[Federal Register Volume 82, Number 139 (Friday, July 21, 2017)]
[Proposed Rules]
[Pages 33950-34203]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-14639]



[[Page 33949]]

Vol. 82

Friday,

No. 139

July 21, 2017

Part II





 Department of Health and Human Services





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 Centers for Medicare & Medicaid Services





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





 Medicare Program; Revisions to Payment Policies Under the Physician 
Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared 
Savings Program Requirements; and Medicare Diabetes Prevention Program; 
Proposed Rule

Federal Register / Vol. 82 , No. 139 / Friday, July 21, 2017 / 
Proposed Rules

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 405, 410, 414, 424, and 425

[CMS-1676-P]
RIN 0938-AT02


Medicare Program; Revisions to Payment Policies Under the 
Physician Fee Schedule and Other Revisions to Part B for CY 2018; 
Medicare Shared Savings Program Requirements; and Medicare Diabetes 
Prevention Program

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

ACTION: Proposed rule.

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SUMMARY: This major proposed rule addresses changes to the Medicare 
physician fee schedule (PFS) and other Medicare Part B payment 
policies.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on September 11, 
2017. (See the SUPPLEMENTARY INFORMATION section of this final rule 
with comment period for a list of provisions open for comment.)

ADDRESSES: In commenting, please refer to file code CMS-1676-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-1676-P, P.O. Box 8016, 
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-1676-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: 
    Jamie Hermansen, (410) 786-2064, for issues related to the 
valuation of anesthesia services and any physician payment issues not 
identified below.
    Lindsey Baldwin, (410) 786-1694, and Emily Yoder, (410) 786-1804, 
for issues related to telehealth services and primary care.
    Roberta Epps, (410) 786-4503, for issues related to PAMA section 
218(a) policy and transition from traditional X-ray imaging to digital 
radiography.
    Isadora Gil, (410) 786-4532, for issues related to the valuation of 
cardiovascular services, bone marrow services, surgical respiratory 
services, dermatological procedures, and payment rates for nonexcepted 
items and services furnished by nonexcepted off-campus provider-based 
departments of a hospital.
    Donta Henson, (410) 786-1947, for issues related to ophthalmology 
services.
    Tourette Jackson, (410) 786-4735, for issues related to the 
valuation of musculoskeletal services, allergy and clinical immunology 
services, endocrinology services, genital surgical services, nervous 
system services, INR monitoring services, injections and infusions, and 
chemotherapy services.
    Ann Marshall, (410) 786-3059, for issues related to primary care, 
chronic care management (CCM), and evaluation and management (E/M) 
services.
    Geri Mondowney, (410) 786-4584, for issues related to malpractice 
RVUs.
    Patrick Sartini, (410) 786-9252, for issues related to the 
valuation of imaging services and malpractice RVUs.
    Michael Soracoe, (410) 786-6312, for issues related to the practice 
expense methodology, impacts, conversion factor, and valuation of 
pathology and surgical procedures.
    Pamela West, (410) 786-2302, for issues related to therapy 
services.
    Corinne Axelrod, (410) 786-5620, for issues related to rural health 
clinics or federally qualified health centers.
    Felicia Eggleston, (410) 786-9287, for issues related to DME 
infusion drugs.
    Rasheeda Johnson, (410) 786-3434, for issues related to initial 
data collection and reporting periods for the clinical laboratory fee 
schedule.
    Edmund Kasaitis, (410) 786-0477, for issues related to biosimilars.
    JoAnna Baldwin, (410) 786-7205, or Sarah Fulton, (410) 786-2749, 
for issues related to appropriate use criteria for advanced diagnostic 
imaging services.
    Alesia Hovatter, (410) 786-6861, for issues related to PQRS.
    Alexandra Mugge, (410) 786-4457, or Elizabeth Holland, (410) 786-
1309, for issues related to the EHR incentive program.
    Rabia Khan or Terri Postma, (410) 786-8084 or [email protected], for 
issues related to the Medicare Shared Savings Program.
    Kimberly Spalding Bush, (410) 786-3232, or Fiona Larbi, (410) 786-
7224, for issues related to Value-based Payment Modifier and Physician 
Feedback Program.
    Wilbert Agbenyikey, (410) 786-4399, for issues related to MACRA 
patient relationship categories and codes.
    Carlye Burd, (410) 786-1972, or Albert Wesley, (410) 786-4204, for 
issues related to diabetes prevention program.

SUPPLEMENTARY INFORMATION:

Table of Contents

I. Executive Summary
II. Provisions of the Proposed Rule for PFS
    A. Background
    B. Determination of Practice Expense Relative Value Units (PE 
RVUs)
    C. Determination of Malpractice Relative Value Units (MRVUs)
    D. Medicare Telehealth Services
    E. Potentially Misvalued Services Under the PFS
    F. Implementation of Reduced Payment for Film-Based Imaging 
Services
    G. Proposed Payment Rates Under the Medicare PFS for Nonexcepted 
Items and Services Furnished by Nonexcepted Off-Campus Provider-
Based Departments of a Hospital

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    H. Proposed Valuation of Specific Codes
    I. Evaluation & Management (E/M) Guidelines and Care Management 
Services
III. Other Provisions of the Proposed Rule
    A. New Care Coordination Services and Payment for Rural Health 
Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
    B. Payment for DME Infusion Drugs
    C. Solicitation of Public Comments on Initial Data Collection 
and Reporting Periods for Clinical Laboratory Fee Schedule
    D. Solicitation of Public Comments on Biosimilars
    E. Appropriate Use Criteria for Advanced Diagnostic Imaging 
Services
    F. Physician Quality Reporting System Criteria for Satisfactory 
Reporting for Individual EPs and Group Practices for the 2018 PQRS 
Payment Adjustment
    G. Medicare EHR Incentive Program
    H. Medicare Shared Savings Program
    I. Value-Based Payment Modifier and Physician Feedback Program
    J. MACRA Patient Relationship Categories and Codes
    K. Medicare Diabetes Prevention Program
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 final rule, we are listing these acronyms 
and their corresponding terms in alphabetical order below:

A1c Hemoglobin A1c
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)
AWV Annual wellness visit
BBA Balanced Budget Act of 1997 (Pub. L. 105-33)
BBRA [Medicare, Medicaid and State Child Health Insurance Program] 
Balanced Budget Refinement Act of 1999 (Pub. L. 106-113)
BLS Bureau of Labor Statistics
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
CoA Certificate of Accreditation
CoC Certificate of Compliance
CoR Certificate of Registration
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 2015 American Medical 
Association. All rights reserved.)
CQM Clinical quality measure
CSW Clinical social worker
CT Computed tomography
CW Certificate of Waiver
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
ED Emergency Department
EHR Electronic health record
E/M Evaluation and management
EMT Emergency Medical Technician
EP Eligible professional
eRx Electronic prescribing
ESRD End-stage renal disease
FAR Federal Acquisition Regulations
FDA Food and Drug Administration
FFS Fee-for-service
FQHC Federally qualified health center
FR Federal Register
FSHCAA Federally Supported Health Centers Assistance Act
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
IPPE Initial preventive physical exam
IPPS Inpatient Prospective Payment System
IQR Inpatient Quality Reporting
ISO Insurance service office
IT Information technology
IWPUT Intensity of work per unit of time
LCD Local coverage determination
MA Medicare Advantage
MAC Medicare Administrative Contractor
MACRA Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 
114-10)
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
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)
PAMPA Patient Access and Medicare Protection Act (Pub. L. 114-115)
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
PPM Provider-Performed Microscopy
PQRS Physician Quality Reporting System
PPIS Physician Practice Expense Information Survey
PPS Prospective Payment System
PT Physical therapy
PT Proficiency Testing
PT/INR Prothrombin Time/International Normalized Ratio
PY Performance year
QA Quality Assessment
QC Quality Control
QCDR Qualified clinical data registry
QRUR Quality and Resources Use Report
RBRVS Resource-based relative value scale
RFA Regulatory Flexibility Act
RHC Rural health clinic
RIA Regulatory impact analysis
RUC American Medical Association/Specialty Society Relative Value 
Scale 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
TCM Transitional Care Management
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

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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 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 2018 PFS Proposed Rule, refer to item 
CMS-1676-P. Readers with questions related to accessing any of the 
Addenda or other supporting documents referenced in this proposed rule 
and posted on the CMS Web site identified above should contact Jamie 
Hermansen at (410) 786-2064.

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 2016 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

A. Purpose

    This major proposed rule proposes to revise payment polices under 
the Medicare PFS and make other policy changes related to Medicare Part 
B payment, applicable to services furnished in CY 2018. In addition, 
this proposed rule includes proposals related to payment policy changes 
that are addressed in section III. of this proposed rule.
1. Summary of the Major Provisions
    The statute 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 statute 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 are proposing to 
establish RVUs for CY 2018 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 Codes.
     Telehealth Services.
     Establishing Values for New, Revised, and Misvalued Codes.
     Establishing Payment Rates under the PFS for Nonexcepted 
Items and Services Furnished by Nonexcepted Off-Campus Provider-Based 
Departments of a Hospital.
     Evaluation & Management (E/M) Guidelines and Care 
Management Services.
     Care Coordination Services and Payment for Rural Health 
Clinics (RHCs) and Federally Qualified Health Centers (FQHCs).
     Payment for DME Infusion Drugs.
     Solicitation of Public Comments on Initial Data Collection 
and Reporting Periods for Clinical Laboratory Fee Schedule.
     Solicitation of Public Comments on Payment for Biosimilar 
Biological Products under Section 1847A of the Act.
     Appropriate Use Criteria for Advanced Diagnostic Imaging 
Services.
     PQRS Criteria for Satisfactory Reporting for Individual 
EPs and Group Practices for the 2018 PQRS Payment Adjustment.
     Medicare EHR Incentive Program.
     Medicare Shared Savings Program.
     Value-Based Payment Modifier and the Physician Feedback 
Program.
     MACRA Patient Relationship Categories and Codes.
     Medicare Diabetes Prevention Program.
2. Summary of Costs and Benefits
    We have determined that this major proposed rule is economically 
significant. For a detailed discussion of the economic impacts, see 
section VI. of this proposed rule.

II. Provisions of the Proposed Rule for PFS

A. Background

    Since January 1, 1992, Medicare has paid for physicians' services 
under section 1848 of the Act, ``Payment for Physicians' Services.'' 
The PFS 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 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 Scale 
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

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submitted to us by the RUC and other public commenters, and the 
rationale for their 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.
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 hospital outpatient department 
(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 5-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, that require the agency to 
periodically identify, review and adjust values for potentially 
misvalued codes.
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 
cause expenditures for the year to change by more than $20 million, we 
make adjustments to ensure that expenditures do not increase or 
decrease by more than $20 million.
2. Calculation of Payments Based on RVUs
    To calculate the payment for each 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.

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The GPCIs reflect the relative costs of work, PE, and MP in an area 
compared to the national average costs for each component.
    RVUs are converted to dollar amounts through the application of a 
conversion factor (CF), which is calculated based on a statutory 
formula by CMS's Office of the Actuary (OACT). The formula for 
calculating the Medicare PFS 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 ensure 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.

B. Determination of Proposed 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 
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 5 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 Medicare Economic Index (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 use crosswalks for specialties 
that did not participate in the PPIS. These crosswalks have been 
generally established through notice and

[[Page 33955]]

comment rulemaking and are available in the file called ``CY 2018 PFS 
Proposed Rule PE/HR'' on the CMS Web site under downloads for the CY 
2018 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.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
    We allocate the indirect costs to the code level on the basis of 
the direct costs specifically associated with a code and the greater of 
either the clinical labor costs or the work RVUs. We also incorporate 
the survey data described earlier in the PE/HR discussion (see section 
II.B.2.b of this proposed rule). 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. That is, 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, represent 25 percent of total costs for the specialties that 
furnish 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 RVU 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 a work RVU of 
4.00 and the clinical labor portion of the direct PE RVU 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 incorporated 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.
(3) Facility and Nonfacility Costs
    For procedures that can be furnished in a physician's office, as 
well as in a facility setting, where Medicare makes a separate payment 
to the facility for its costs in furnishing a service, 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. 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. For this reason, the facility PE RVUs are 
generally lower than the nonfacility PE RVUs.
(4) Services With Technical Components and Professional Components
    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.)
(5) 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). We also direct interested readers to the file called 
``Calculation of PE RVUs under Methodology for Selected Codes'' which 
is available on our Web site under downloads for the CY 2018 PFS 
proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. This 
file contains a table that illustrates the calculation of PE RVUs as 
described in this proposed rule for individual codes.
(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.
    Step 2: Calculate the aggregate pool of direct PE costs for the 
current year. We 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.
    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, use the conversion 
factor to 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 adjustment to the direct costs for each service (as 
calculated in Step 1).

[[Page 33956]]

    Step 5: Convert the results of Step 4 to a RVU scale for each 
service. To do this, divide the results of Step 4 by the conversion 
factor (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 4 and Step 5. Different CFs would result in 
different direct PE scaling adjustments, but this has no effect on the 
final direct cost PE RVUs since changes in the CFs and changes in the 
associated direct scaling adjustments 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.
    We generally use an average of the 3 most recent years of available 
Medicare claims data to determine the specialty mix assigned to each 
code. Prior to implementing that policy, we used the most recent year 
of available claims data to determine the specialty mix assigned to 
each code.
    Under either of these approaches, codes with low Medicare service 
volume require special attention since billing or enrollment 
irregularities for a given year can result in significant changes in 
specialty mix assignment. Prior to adopting the 3-year average of data, 
for low-volume services (fewer than 100 Medicare allowed services), we 
assigned the values associated with the specialty that most frequently 
reported the service in the most recent claims data (dominant 
specialty). For some time, stakeholders, including the RUC, have 
requested that we use a recommended ``expected'' specialty for all low 
volume services instead of the information contained in the claims 
data. Currently, in the development of PE RVUs we use ``expected 
specialty'' overrides for only several dozen services based on several 
code-specific policies we established in prior rulemaking. As we stated 
in the CY 2016 final rule with comment period (80 FR 70894), we hoped 
that the 3-year average would mitigate the need to use dominant or 
expected specialty instead of the specialty identified using claims 
data. Because we incorporated CY 2015 claims data for use in the CY 
2017 proposed rates, we believe that the finalized PE RVUs associated 
with the CY 2017 PFS final rule provided a first opportunity to 
determine whether service-level overrides of claims data are necessary.
    Although we believe that the use of the 3-year average of claims 
data to determine specialty mix has led to an improvement in the 
stability of PE and MP RVUs from year to year, after reviewing the RVUs 
for low volume services, we continue to see possible distortions and 
wide variability from year to year in PE and MP RVUs for low volume 
services. Several stakeholders have suggested that CMS implement 
service-level overrides based on the expected specialty in order to 
determine the specialty mix for these low volume procedures. The RUC 
previously supplied us with a list of nearly 2,000 lower volume codes 
and their suggested specialty overrides. After reviewing the finalized 
PE RVUs for the CY 2017 PFS final rule, we agree that the use of 
service-level overrides for low volume services would help mitigate 
annual fluctuations and provide greater stability in the valuation of 
these services. While the use of the 3-year average of claims data to 
determine specialty mix has helped to mitigate some of the year-to-year 
variability for low volume services, it has not fully mitigated what 
appear to be anomalies for many of these lower volume codes.
    We are, therefore, proposing to use the most recent year of claims 
data to determine which codes are low volume for the coming year (those 
that have fewer than 100 allowed services in the Medicare claims data). 
For codes that fall into this category, instead of assigning specialty 
mix based on the specialties of the practitioners reporting the 
services in the claims data, we are proposing to instead use the 
expected specialty that we identify on a list. For CY 2018, we are 
proposing to use a list that was developed based on our medical review 
of the list most recently recommended by the RUC, in addition to our 
own proposed expected specialty for certain other low-volume codes for 
which we have historically used expected specialty assignments. We 
would display this list as part of the annual set of data files we make 
available as part of notice and comment rulemaking. We propose to 
consider recommendations from the RUC and other stakeholders on changes 
to this list on an annual basis.
    We are also proposing to apply these service-level overrides for 
both PE and MP, rather than one or the other category. We believe that 
this would simplify the implementation of service-level overrides for 
PE and MP, and would also address stakeholder concerns about the year-
to-year variability for low volume services. We are soliciting public 
comment on the proposal to use service-level overrides to determine the 
specialty mix for low volume procedures, as well as on the proposed 
list of expected specialty overrides itself, which is largely based on 
the recommendations submitted by the RUC last year. The proposed list 
of expected specialty assignments for individual low volume services is 
available on our Web site under downloads for the CY 2018 PFS proposed 
rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. Services for 
which the specialty is automatically assigned based on previously 
finalized policies under our established methodology (for example, 
``always therapy'' services) would be unaffected by this proposal.
    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 labor 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 would be allocated 
using the work RVUs, and for the TC service, indirect PEs would 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 the download file 
called ``Calculation of PE RVUs under Methodology for Selected Codes'', 
the formulas were divided into two parts for each service.

[[Page 33957]]

     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 8 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 5 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 sum of steps 
5 and 17 to the proposed aggregate work RVUs scaled by the ratio of 
current aggregate PE and work RVUs. This adjustment ensures that all PE 
RVUs in the PFS account for the fact that certain specialties are 
excluded from the calculation of PE RVUs but included in maintaining 
overall PFS budget neutrality. (See ``Specialties excluded from 
ratesetting calculation'' later in this proposed rule.)
    Step 19: Apply the phase-in of significant RVU reductions and its 
associated adjustment. Section 1848(c)(7) of the Act 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. In implementing the phase-in, we consider a 19 
percent reduction as the maximum 1-year reduction for any service not 
described by a new or revised code. This approach limits the year one 
reduction for the service to the maximum allowed amount (that is, 19 
percent), and then phases in the remainder of the reduction. To comply 
with section 1848(c)(7) of the Act, we adjust the PE RVUs to ensure 
that the total RVUs for all services that are not new or revised codes 
decrease by no more than 19 percent, and then apply a relativity 
adjustment to ensure that the total pool of aggregate PE RVUs remains 
relative to the pool of work and MP RVUs. For a more detailed 
description of the methodology for the phase-in of significant RVU 
changes, we refer readers to the CY 2016 PFS final rule with comment 
period (80 FR 70927 through 70931).
(e) Setup File Information
     Specialties excluded from ratesetting calculation: For the 
purposes of calculating the PE RVUs, we exclude certain specialties, 
such as certain NPPs paid at a percentage of the PFS and low-volume 
specialties, from the calculation. These specialties are included for 
the purposes of calculating the BN adjustment. They are displayed in 
Table 1.

       TABLE 1--Specialties Excluded From Ratesetting Calculation
------------------------------------------------------------------------
      Specialty code                   Specialty description
------------------------------------------------------------------------
49.......................  Ambulatory surgical center.
50.......................  Nurse practitioner.
51.......................  Medical supply company with certified
                            orthotist.
52.......................  Medical supply company with certified
                            prosthetist.
53.......................  Medical supply company with certified
                            prosthetist[dash]orthotist.
54.......................  Medical supply company not included in 51,
                            52, or 53.
55.......................  Individual certified orthotist.
56.......................  Individual certified 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.

[[Page 33958]]

 
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
                                     Physician Assistant.                                  portion.
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 Percentages   Intraoperative
                                                              on the payment files used    portion.
                                                              by Medicare contractors to
                                                              process Medicare claims.
55................................  Postoperative Care only  Postoperative Percentage on  Postoperative portion.
                                                              the payment files used by
                                                              Medicare contractors to
                                                              process Medicare claims.
62................................  Co-surgeons............  62.5%......................  50%.
66................................  Team Surgeons..........  33%........................  33%.
----------------------------------------------------------------------------------------------------------------

    We also make adjustments to volume and time that correspond to 
other payment rules, including special multiple procedure endoscopy 
rules and multiple procedure payment reductions (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.
(6) Equipment Cost per Minute
    The equipment cost per minute is calculated as:

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

Where:


[[Page 33959]]


minutes per year = maximum minutes per year if usage were continuous 
(that is, usage=1); generally 150,000 minutes.
usage = variable, see discussion in this proposed rule.
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 in this proposed rule.

    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.
    Stakeholders have often suggested that particular equipment items 
are used less frequently than 50 percent of the time in the typical 
setting and that CMS should reduce the equipment utilization rate based 
on these recommendations. We appreciate and share stakeholders' 
interest in using the most accurate assumption regarding the equipment 
utilization rate for particular equipment items. However, we believe 
that absent robust, objective, auditable data regarding the use of 
particular items, the 50 percent assumption is the most appropriate 
within the relative value system. We welcome the submission of data 
that illustrates an alternative rate.
    Maintenance: This factor for maintenance was finalized in the CY 
1998 PFS final rule with comment period (62 FR 33164). We continue to 
investigate potential avenues for determining equipment maintenance 
costs across a broad range of equipment items.
    Interest Rate: In the CY 2013 PFS final rule with comment period 
(77 FR 68902), we updated the interest rates used in developing an 
equipment cost per minute calculation (see 77 FR 68902 for a thorough 
discussion of this issue). 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). We 
are not proposing any changes to these interest rates for CY 2018. The 
interest rates are listed in Table 3.

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

3. Changes to Direct PE Inputs for Specific Services
    This section focuses on specific PE inputs. The direct PE inputs 
are included in the CY 2018 direct PE input database, which is 
available on the CMS Web site under downloads for the CY 2018 PFS 
proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
(a) PE Inputs for Digital Imaging Services
    In the CY 2017 PFS final rule (81 FR 80179 through 80184), we 
finalized our proposal to add a professional PACS workstation (ED053) 
used for interpretation of digital images to a series of CPT codes and 
to address costs related to the use of film that had previously been 
incorporated as direct PE inputs for these services. We finalized the 
following criteria for the inclusion of a professional PACS 
workstation:
     We did not add the professional PACS workstation to any 
code that currently lacks a technical PACS workstation (ED050) or lacks 
a work RVU. We continue to believe that procedures that do not include 
a technical workstation, or do not have physician work, would not 
require a professional workstation.
     We did not add the professional PACS workstation to add-on 
codes. Because the base codes include equipment minutes for the 
professional PACS workstation, we continue to believe it would be 
duplicative to add additional equipment time for the professional PACS 
workstation in the add-on code.
     We also did not add the professional PACS workstation to 
image guidance codes where the dominant provider is not a radiologist 
according to the most recent year of claims data, because we believe a 
single technical PACS workstation would be more typical in those cases.
     We agreed with commenters that because the clinical 
utility of the PACS workstation is not necessarily limited to 
diagnostic services, there may be therapeutic codes where it would be 
reasonable to assume its use to be typical. Based on information 
provided by commenters and our own medical review, we stated that we 
believe that the use of the professional PACS workstation is typical 
for many of the specific codes that were identified. We added the 
workstation to many of the therapeutic codes requested by commenters, 
specifically CPT codes listed outside the 70000 series, where we agreed 
that use of the professional PACS workstation was typical.
     For CPT codes in the 80000 and 90000 series, we expressed 
our concerns about whether it is appropriate to include the technical 
PACS workstation in many of these services. PACS workstations were 
created for imaging purposes, but many of these services that include a 
technical PACS workstation do not appear to make use of imaging. 
Although we did not remove the technical PACS workstation from these 
codes at that time, we did not believe that a professional PACS 
workstation should be added to these procedures.
    Prior to the publication of this CY 2018 PFS proposed rule, a 
stakeholder expressed concern about our decision not to include the 
professional PACS workstation in a series of vascular ultrasound codes 
that use technical PACS workstations. The stakeholder indicated that 
the vascular ultrasound codes in question do make use of a professional 
PACS workstation, and that the dominant specialty provider requirement 
(that is, that the code's dominant specialty provider being diagnostic 
radiology) would exclude codes for which the professional PACS 
workstation is typical based on a mistaken assumption. The stakeholder 
stated that to furnish vascular ultrasound services following the 
transition from film to digital imaging, both a technical and a 
professional PACS workstation are required, regardless of whether the 
practitioner furnishing the service is a radiologist, cardiologist, 
neurologist, or vascular surgeon.
    We appreciate the submission of this additional information 
regarding the use of the professional PACS workstation in vascular 
ultrasound codes. Therefore, we seek comments regarding whether or not 
the use of the professional PACS workstation would be typical in the 
following list of CPT and HCPCS codes. The codes brought to our 
attention by the stakeholder are CPT codes 93880, 93882, 93886, 93888, 
93890, 93892, 93893, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 
93965, 93970, 93971, 93975, 93976, 93978, 93979, 93980, 93981, 93990, 
and 76706, and HCPCS code G0365. We will consider information submitted 
in comments to determine whether the professional

[[Page 33960]]

PACS workstation should be included as a direct PE input for these 
codes.
(2) Standardization of Clinical Labor Tasks
    As we noted in the CY 2015 PFS final rule with comment period (79 
FR 67640-67641), we continue to make improvements 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 preservice, service, and 
postservice 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 
would facilitate the identification of the usual numbers of minutes for 
clinical labor tasks and the identification of exceptions to the usual 
values. It would 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 preservice time packages. 
We believe such standards would 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 simultaneously for all codes with the applicable clinical labor 
tasks, instead of waiting for individual codes to be reviewed.
    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. Preservice Clinical Labor for 0-Day and 10-Day Global Services
    Several years ago, the RUC's PE Subcommittee reviewed the 
preservice clinical labor times for CPT codes with 0-day and 10-day 
global periods. The RUC concluded that these codes are assumed to have 
no preservice clinical staff time (standard time of 0 minutes) unless 
the specialty can provide evidence that the preservice time is 
appropriate. In other words, for minor procedures, it is assumed that 
there is no clinical staff time typically spent preparing for the 
specific procedure prior to the patient's arrival. However, we note 
that for CY 2018, 41 of the 53 reviewed codes with 0-day or 10-day 
global periods include preservice clinical labor of some kind, 
suggesting that it is typical for clinical staff to prepare for the 
procedure prior to the patient's arrival. As we review misvalued codes, 
we believe that the general adherence to values that we have 
established as standards supports relativity within the PFS. Because 77 
percent of the reviewed codes for the current calendar year deviate 
from the ``standard,'' we are seeking comment on the value and 
appropriate application of the standard in our review of RUC 
recommendations in future rulemaking. In reviewing the inputs included 
in the direct PE inputs database, we found that for the 1,142 total 0-
day global codes, 741 of them had preservice clinical labor of some 
kind (65 percent). We also noticed a general correlation between 
preservice clinical labor time and the recent review. We are seeking 
comment specifically on whether the standard preservice clinical labor 
time of 0 minutes should be consistently applied for 0-day and 10-day 
global codes in future rulemaking.
b. Obtain Vital Signs Clinical Labor
    The direct PE inputs for each CPT code paid under the PFS include 
minutes assigned to a series of standard clinical labor tasks assumed 
to be typical for the service in question. The minutes assigned to each 
of these tasks for each CPT code have been developed over several 
decades, and what was previously considered to be a standard value in 
the review of the codes has changed over time. Because each year we 
perform a detailed review of all of the inputs for only several hundred 
of the over 7,000 CPT codes paid under the PFS, valuation for 
individual services can be influenced by shifts in review standards 
over time rather than purely based on changes in practice.
    For example, we traditionally assigned a clinical labor time of 3 
minutes for the ``Obtain vital signs'' clinical labor activity, based 
on the amount of time typically required to check a patient's vitals. 
Over time, that number of minutes has increased as codes are reviewed. 
For example, many of the reviewed codes for the current CY 2018 
rulemaking cycle have a recommended clinical labor time of 5 minutes 
for ``Obtain vital signs,'' based on the understanding that these 
services are measuring two additional vital signs: The patient's height 
and weight. We do not have any reason to believe that measuring a 
patient's height and weight is only typical for services described by 
recently reviewed codes. Instead, we believe that the review standards 
have changed, perhaps in conjunction with changes in medical practice, 
and that the change in the minutes assigned for the ``Obtain vital 
signs'' task for newer-reviewed services is detrimental to relativity 
among PFS services.
    Therefore, to preserve relativity among the PFS codes, we are 
proposing to assign 5 minutes of clinical labor time for all codes that 
include the ``Obtain vital signs'' task, regardless of the date of last 
review. We are proposing to assign this 5 minutes of clinical labor 
time for all codes that include at least 1 minute previously assigned 
to this task. We are also proposing to update the equipment times of 
the codes with this clinical labor task accordingly to match the 
changes in clinical labor time. For codes that were not recently 
reviewed and for which we lacked a breakdown of how the equipment time 
was derived from the clinical labor tasks, we could not determine if 
the equipment time included time assigned for the ``Obtain vital 
signs'' task. In these cases, we are proposing to adjust the equipment 
time of any equipment item that matched the clinical labor time of the 
full service period to match the change in the ``Obtain vital signs'' 
clinical labor time. The proposed list of all codes affected by these 
proposed vital signs changes to direct PE inputs is available on the 
CMS Web site under downloads for the CY 2018 PFS proposed rule at 
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
c. Establishment of Clinical Labor Activity Codes
    Historically, the RUC has submitted a ``PE worksheet'' that details 
the recommended direct PE inputs for our use in developing PE RVUs. The 
format of the PE worksheet has varied over time and among the medical 
specialties developing the recommendations. These variations have made 
it difficult for both the RUC's development and our review of code 
values for individual codes. Beginning for the CY 2019 PFS rulemaking 
cycle, we understand that the RUC intends to mandate the use of a new 
PE worksheet for purposes of their recommendation development process 
that standardizes the clinical labor tasks and assigns them a clinical 
labor activity code. We believe the RUC's use of the new PE worksheet 
in developing and submitting recommendations to us would, in turn, help 
us to simplify and standardize the hundreds of different clinical labor 
tasks

[[Page 33961]]

currently listed in our direct PE database.
    To help facilitate this transition to the new clinical labor 
activity codes, we have developed a crosswalk to link the old clinical 
labor tasks to the new clinical labor activity codes. Our crosswalk is 
for informational purposes only, and would not change either the direct 
PE input values or the PE RVUs for codes. Instead, we hope that the 
crosswalk would help us to translate the sprawling, existing data set 
into a condensed version that would significantly improve the 
standardization of clinical labor recommendations and improve the 
ability of commenters to identify concerns with our proposed valuation. 
For CY 2018 rulemaking, we are displaying two versions of the Labor 
Task Detail public use file: One version with the old listing of 
clinical labor tasks, and one with the same tasks as described by the 
new listing of clinical labor activity codes. These lists are available 
on the CMS Web site under downloads for the CY 2018 PFS proposed rule 
at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
(3) Equipment Recommendations for Scope Systems
    During our routine reviews of direct PE input recommendations, we 
have regularly found unexplained inconsistencies involving the use of 
scopes and the video systems associated with them. Some of the scopes 
include video systems bundled into the equipment item, some of them 
include scope accessories as part of their price, and some of them are 
standalone scopes with no other equipment included. It is not always 
clear which equipment items related to scopes fall into which of these 
categories. We have also frequently found anomalies in the equipment 
recommendations, with equipment items that consist of a scope and video 
system bundle recommended, along with a separate scope video system. 
Based on our review, the variations do not appear to be consistent with 
the different code descriptions.
    To promote appropriate relativity among the services and facilitate 
the transparency of our review process, during review of recommended 
direct PE inputs for the CY 2017 PFS proposed rule, we developed a 
structure that separates the scope and the associated video system as 
distinct equipment items for each code. Under this approach, we 
proposed standalone prices for each scope, and separate prices for the 
video systems that are used with scopes. We proposed to define the 
scope video system as including: (1) A monitor; (2) a processor; (3) a 
form of digital capture; (4) a cart; and (5) a printer. We believe that 
these equipment components represent the typical case for a scope video 
system. Our model for this system was the ``video system, endoscopy 
(processor, digital capture, monitor, printer, cart)'' equipment item 
(ES031), which we proposed to re-price as part of this separate pricing 
approach. We obtained current pricing invoices for the endoscopy video 
system as part of our investigation of these issues involving scopes, 
which we proposed to use for this re-pricing. We understand that there 
may be other accessories associated with the use of scopes; we proposed 
to separately price any scope accessories, and individually evaluate 
their inclusion or exclusion as direct PE inputs for particular codes 
as usual under our current policy based on whether they are typically 
used in furnishing the services described by the particular codes.
    We also proposed standardizing refinements to the way scopes have 
been defined in the direct PE input database. We believe that there are 
four general types of scopes: non-video scopes; flexible scopes; semi-
rigid scopes, and rigid scopes. Flexible scopes, semi-rigid scopes, and 
rigid scopes would typically be paired with one of the scope video 
systems, while the non-video scopes would not. The flexible scopes can 
be further divided into diagnostic (or non-channeled) and therapeutic 
(or channeled) scopes. We proposed to identify for each anatomical 
application: (1) A rigid scope; (2) a semi-rigid scope; (3) a non-video 
flexible scope; (4) a non-channeled flexible video scope; and (5) a 
channeled flexible video scope. We proposed to classify the existing 
scopes in our direct PE database under this classification system, to 
improve the transparency of our review process and improve appropriate 
relativity among the services. We planned to propose input prices for 
these equipment items through future rulemaking.
    We proposed these changes only for the reviewed codes for CY 2017 
that made use of scopes, along with updated prices for the equipment 
items related to scopes utilized by these services. But, we did not 
propose to apply these policies to codes with inputs reviewed prior to 
CY 2017. We also solicited comment on this separate pricing structure 
for scopes, scope video systems, and scope accessories, which we could 
consider proposing to apply to other codes in future rulemaking. In 
response to comments, we finalized the addition of a digital capture 
device to the endoscopy video system (ES031) in the CY 2017 PFS final 
rule. We finalized our proposal to price the system at $33,391, based 
on component prices of $9,000 for the processor, $18,346 for the 
digital capture device, $2,000 for the monitor, $2,295 for the printer, 
and $1,750 for the cart. We also finalized a price of $16,843.87 for 
the stroboscopy system scope accessory (ES065). We did not finalize 
price increases for a series of other scopes and scope accessories, as 
the invoices submitted for these components indicated that they are 
different forms of equipment with different product IDs and different 
prices. We did not receive any data to indicate that the equipment on 
the newly submitted invoices was more typical in its use than the 
equipment that we were currently using for pricing.
    We did not make further changes to existing scope equipment in CY 
2017 in order to allow the RUC's PE Subcommittee the opportunity to 
provide feedback. However, we believe there was some miscommunication 
on this point, as the RUC's PE Subcommittee workgroup that was created 
to address scope systems stated that no further action was required 
following the finalization of our proposal. We are making further 
proposals to continue clarifying scope equipment inputs, and seek 
comments regarding the new set of scope proposals. We welcome feedback 
from all stakeholders, including practitioners with direct experience 
in the use of scope equipment.
    We are seeking comment on several potential categories of scope 
system PE inputs. We are considering creating a single scope equipment 
code for each of the five categories detailed in this proposed rule: 
(1) A rigid scope; (2) a semi-rigid scope; (3) a non-video flexible 
scope; (4) a non-channeled flexible video scope; and (5) a channeled 
flexible video scope. Under the current classification system, there 
are many different scopes in each category depending on the medical 
specialty furnishing the service and the part of the body affected. We 
believe that the variation between these scopes is not significant 
enough to warrant maintaining these distinctions, and we believe that 
creating and pricing a single scope equipment code for each category 
would help provide additional clarity. We are seeking public comment on 
the merits of this potential scope organization, as well as any pricing 
information regarding these five new scope categories.

[[Page 33962]]

    For CY 2018, we are proposing two minor changes to PE inputs 
related to scopes. We are proposing to add an LED light source into the 
cost of the scope video system (ES031), which would remove the need for 
a separate light source in these procedures. If this proposal were to 
be finalized, we would remove the equipment time for the separate light 
source from CPT codes that include the scope video system. We are also 
proposing an increase to the price of the scope video system of 
$1,000.00 to cover the expense of miscellaneous small equipment 
associated with the system that falls below the threshold of individual 
equipment pricing as scope accessories (such as cables, microphones, 
foot pedals, etc.) We seek comments on the inclusion of the LED light 
in the scope video system, and the appropriate pricing of the system 
with the inclusion of these additional equipment items.
    We anticipate adopting detailed changes to scope systems at the 
code level through rulemaking for CY 2019, because we believe that 
additional feedback from expert stakeholders will improve the details 
of the proposed changes. We are not proposing any additional pricing 
changes to scope equipment for CY 2018 due to the proposed 
reorganization into a single type of scope equipment for each of the 
five scope categories. However, we would consider updating prices for 
these equipment items through the public request process for price 
updates, or based on information submitted as part of RUC 
recommendations.
(4) Clarivein Kit for Mechanochemical Vein Ablation
    In the CY 2017 PFS final rule, we finalized work RVUs and direct PE 
inputs for two new codes related to mechanochemical vein ablation, CPT 
codes 36473 and 36474. Following the publication of the final rule, 
stakeholders contacted CMS and requested that a Clarivein kit supply 
item (SA122) be added to the direct PE inputs for CPT code 36474, the 
add-on code for ablation of subsequent veins. They stated that the 
Clarivein kit was accidentally omitted from the RUC recommendations, 
and that an additional kit is necessary to perform the service 
described by the add-on procedure. We are soliciting comment regarding 
the use of multiple kits during procedures described by the base and 
add-on codes to determine whether or not this supply should be included 
as a direct PE input for CPT code 36474 for CY 2018.
(5) Removal of Oxygen From Non-Moderate Sedation Post-Procedure 
Monitoring
    After finalizing the creation of separately billable codes for 
moderate sedation during the CY 2017 PFS final rule, we received 
additional recommendations to remove the oxygen gas supply item (SD084) 
from a series of CPT codes that were previously valued with moderate 
sedation as an inherent part of the procedure. Because oxygen gas is 
included in the moderate sedation pack contained within the separately 
billed moderate sedation codes, we believe that the continued inclusion 
of the oxygen gas in these codes is a duplicative supply. We are 
therefore proposing to remove the oxygen gas from the following codes 
(see Table 4):

    Table 4--CY 2018 Proposed Removal of Oxygen (SD084) From Non-Moderate Sedation Post-Procedure Monitoring
----------------------------------------------------------------------------------------------------------------
                                                                                      Current
                     HCPCS                                    NF/F                   (liters)          Cost
----------------------------------------------------------------------------------------------------------------
31622.........................................  NF..............................              90           -0.27
31625.........................................  NF..............................             105           -0.32
31626.........................................  NF..............................             135           -0.41
31627.........................................  NF..............................             150           -0.45
31628.........................................  NF..............................             120           -0.36
31629.........................................  NF..............................             105           -0.32
31632.........................................  NF..............................              54           -0.16
31633.........................................  NF..............................              60           -0.18
31645.........................................  NF..............................             175           -0.53
31652.........................................  NF..............................             180           -0.54
31653.........................................  NF..............................             225           -0.68
31654.........................................  NF..............................              90           -0.27
52647.........................................  NF..............................              10           -0.03
52648.........................................  NF..............................              10           -0.03
90870.........................................  NF..............................             198           -0.59
----------------------------------------------------------------------------------------------------------------

(6) Technical Corrections to Direct PE Input Database and Supporting 
Files
    Subsequent to the publication of the CY 2017 PFS final rule, 
stakeholders alerted us to several clerical inconsistencies in the 
direct PE database. We are proposing to correct these inconsistencies 
as described in this proposed rule and reflected in the CY 2018 
proposed direct PE input database displayed on the CMS Web site under 
downloads for the CY 2018 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
    For CY 2018, we are proposing to address the following 
inconsistencies:
     For CY 2018, we are proposing to make direct PE changes 
for CPT code 96416 (Chemotherapy administration, intravenous infusion 
technique; initiation of prolonged chemotherapy infusion (more than 8 
hours), requiring use of a portable or implantable pump) to improve 
payment accuracy, in response to a stakeholder inquiry regarding the 
use of the ambulatory IV pump equipment for this service. We are 
proposing to add 6 additional minutes of RN/OCN clinical labor (L056A), 
4 minutes for the ``Review charts by chemo nurse regarding course of 
treatment & obtain chemotherapy-related medical hx'' task, and 2 
minutes for the ``Greet patient and provide gowning'' task. We are 
proposing to add 1 quantity of the IV infusion set supply (SC018) and 
proposing to lower the quantity from 2 to 1 of the 20 ml syringe supply 
(SC053). We are proposing to add 1800 minutes for the new ambulatory IV 
pump equipment, and we are proposing to increase the equipment time of 
the medical recliner chair (EF009) from 83 minutes to 89 minutes to 
match the increase in RN/OCN clinical labor. For CY 2018, these

[[Page 33963]]

proposed direct PE changes would be used to calculate the PE RVU for 
CPT code 96416. We seek comments on these proposed direct PE 
refinements.
     We propose to correct an anomaly in the postservice work 
time for CPT code 91200 (Liver elastography, mechanically induced shear 
wave (e.g., vibration), without imaging, with interpretation and 
report) by changing it from 5 minutes to 3 minutes, which also results 
in a refinement in the total work time for the code from 18 minutes to 
16 minutes.
     In the process of making updates to our direct PE 
database, we discovered a series of discrepancies between the finalized 
direct PE inputs and the values entered into the database from previous 
calendar years. To reconcile these discrepancies, we are proposing the 
following direct PE refinements:

                                           Table 5--Direct PE Database Data Discrepancies and Proposed Changes
--------------------------------------------------------------------------------------------------------------------------------------------------------
              HCPCS                     Input code       Input code description            NF/F                 Old             New            Cost
--------------------------------------------------------------------------------------------------------------------------------------------------------
11307............................  SF033..............  scalpel with blade,       NF                                   1               2            0.69
                                                         surgical (#10-20).
11311............................  SG056..............  gauze, sterile 4in x 4in  NF                                   1               2            0.80
                                                         (10 pack uou).
11311............................  SH046..............  lidocaine 1% w-epi inj    NF                                  10               4           -0.38
                                                         (Xylocaine w-epi).
11719............................  L037D..............  Greet patient, provide    NF                                   1               3            0.74
                                                         gowning, ensure
                                                         appropriate medical
                                                         records are available.
11719............................  L037D..............  Provide pre-service       NF                                   1               2            0.37
                                                         education/obtain
                                                         consent.
11719............................  L037D..............  Prepare room, equipment,  NF                                   1               2            0.37
                                                         supplies.
11719............................  L037D..............  Clean room/equipment by   NF                                   1               3            0.74
                                                         physician staff.
17312............................  SL097..............  OCT Tissue-Tek..........  NF                                   8               6           -0.12
17313............................  SF004..............  blade, microtome........  NF                                   1               0           -1.72
17313............................  SF044..............  blade, surgical, super-   NF                                   0               1            4.17
                                                         sharp.
17313............................  SG056..............  gauze, sterile 4in x 4in  NF                                   3               0           -2.39
                                                         (10 pack uou).
17313............................  SG088..............  tape, foam, elastic, 2in  NF                                  10               8           -0.01
                                                         (Microfoam).
17314............................  SG056..............  gauze, sterile 4in x 4in  NF                                   2               0           -1.60
                                                         (10 pack uou).
17314............................  SL097..............  OCT Tissue-Tek..........  NF                                   8               6           -0.12
17315............................  SL078..............  histology freezing spray  NF                                   0             0.2            0.29
                                                         (Freeze-It).
19283............................  L043A..............  Service total costs.....  NF                                  55              54           -0.43
19286............................  L051B..............  Service total costs.....  NF                                  30              31            0.51
19286............................  EL015..............  room, ultrasound,         NF                                  19              20            1.40
                                                         general.
19286............................  EQ168..............  light, exam.............  NF                                  19              20            0.00
23333............................  L037D..............  Post service total costs  F                                   63              90            9.99
28045............................  SC029..............  needle, 18-27g..........  NF                                   2               1           -0.09
32405............................  L041B..............  Service total costs.....  NF                                  52              57            2.05
37765............................  L037D..............  Service total costs.....  NF                                  91              94            1.11
37766............................  L037D..............  Service total costs.....  NF                                 121             124            1.11
45171............................  SJ052..............  swab, procto 16in.......  F                                    2               3            0.12
45172............................  L037D..............  Service total costs.....  F                                    6              12            2.22
45172............................  SJ052..............  swab, procto 16in.......  F                                    2               3            0.12
52214............................  SH047..............  lidocaine 1%-2% inj       NF                                   1              50            1.72
                                                         (Xylocaine).
72120............................  EL012..............  room, basic radiology...  NF                                  16              17            0.48
72148............................  L047A..............  Service total costs.....  NF                                  47              49            0.84
74230............................  L041B..............  Technologist QC's images  NF                                   0               2            0.82
                                                         in PACS, checking for
                                                         all images, reformats,
                                                         and dose page.
91013............................  EF023..............  table, exam.............  NF                                   0               9            0.03
91013............................  EF015..............  mayo stand..............  NF                                   0               9            0.01
91013............................  EQ235..............  suction machine (Gomco).  NF                                   0               9            0.02
91013............................  EQ181..............  manometry system          NF                                   0               9            1.15
                                                         (computer, transducers,
                                                         catheter).
91013............................  EQ339..............  manometry accessory       NF                                   0               9            0.05
                                                         cable.
91013............................  ED050..............  PACS Workstation Proxy..  NF                                   0               9            0.20
91132............................  EQ019..............  EGG monitoring system...  NF                                  22              30            0.83
92227............................  EL006..............  lane, screening (oph)...  NF                                  12               0           -1.07
92227............................  EL005..............  lane, exam (oph)........  NF                                   0              12            1.15
93017............................  L051A..............  Preservice total costs..  NF                                  15               5           -5.10
95819............................  SG079..............  tape, surgical paper 1in  NF                                   6              42            0.07
                                                         (Micropore).
--------------------------------------------------------------------------------------------------------------------------------------------------------

    The proposed PE RVUs displayed in Addendum B on our Web site were 
calculated with the inputs displayed in the CY 2018 proposed direct PE 
input database.
(7) Updates to Prices for Existing Direct PE 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. For CY 2018, 
we are proposing the following price updates for existing direct PE 
inputs.
    We are proposing to update the price of thirteen supplies and one 
equipment item in response to the public submission of invoices. For 
the details of these proposed price updates, please refer to section 
II.H, of this proposed rule, Table 14: Invoices Received for Existing 
Direct PE Inputs.
    We are not proposing to update the price of the blood warmer 
(EQ072), the cell separator system (EQ084), or the photopheresor system 
(EQ206) equipment items. The only pricing information that we received 
for these three equipment items was an invoice that included a hand-
written price over redacted information. We were unable to verify the 
accuracy of this invoice. We are also not proposing to update the price 
of the DNA image analyzer (ACIS) (EP001) equipment item, due to the

[[Page 33964]]

inclusion of many components on the submitted invoice that are not part 
of the price of the DNA image analyzer. We were unable to determine 
which of these components were included in the cost of the DNA image 
analyzer, and which of these components were unrelated types of 
equipment. To price these equipment items accurately, we believe that 
we need additional information. We continue to use the current price 
for these equipment items pending the submission of additional pricing 
information. We welcome the submission of updated pricing information 
regarding these equipment items through valid invoices from commenters 
and other stakeholders.
    We are also proposing to change the name of the ED050 equipment 
from the ``PACS Workstation Proxy'' to the ``Technologist PACS 
workstation.'' In the CY 2017 final rule (81 FR 80180-80182), we 
finalized a policy to add a professional PACS workstation (ED053) to 
the list of approved equipment items, and we believe that renaming 
ED050 to the technologist PACS workstation would help to alleviate 
potential confusion between the two PACS workstations.
    We routinely accept public submission of invoices as part of our 
process for developing payment rates for new, revised, and potentially 
misvalued codes. Often these invoices are submitted in conjunction with 
the RUC-recommended values for the codes. For CY 2018, we note that 
some stakeholders have submitted invoices for new, revised, or 
potentially misvalued codes after the February 10th deadline 
established for code valuation recommendations. To be included in a 
given year's proposed rule, we generally need to receive invoices by 
the same February 10th deadline. However, we would consider invoices 
submitted as public comments during the comment period following the 
publication of the proposed rule, and would consider any invoices 
received after February or outside of the public comment process as 
part of our established annual process for requests to update supply 
and equipment prices.
4. Adjustment to Allocation of Indirect PE for Some Office-Based 
Services
    As we explain in section II.B.2.c.(2) of this proposed rule, we 
allocate indirect costs for each code 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. Indirect expenses include 
administrative labor, office expense, and all other expenses. For PFS 
services priced in both the facility and non-facility settings, the 
difference in indirect PE RVUs between the settings is driven by 
differences in direct PE inputs for those settings since the other 
allocator of indirect PE, the work RVU, does not differ between 
settings. For most services, the direct PE input costs are higher in 
the nonfacility setting than in the facility setting. As a result, 
indirect PE RVUs allocated to these services are higher in the 
nonfacility setting than in the facility setting. When direct PE inputs 
for a service are very low, however, the allocation of indirect PE RVUs 
is almost exclusively based on work RVUs, which results in a very small 
(or no) site of service differential between the total PE RVUs in the 
facility and nonfacility setting.
    Some stakeholders have suggested that for codes in which direct PE 
inputs for a service are very low, this allocation methodology does not 
allow for a site of service differential that accurately reflects the 
relative indirect costs involved in furnishing services in nonfacility 
settings. Among the services most affected by this anomaly are the 
primary therapy and counseling services available to Medicare 
beneficiaries for treatment of behavioral health conditions, including 
substance use disorders. For example, for the most commonly reported 
psychotherapy service (CPT code 90834), the difference between the 
nonfacility and facility PE RVUs is only 0.02 RVUs, which seems 
unlikely to represent the difference in relative resource costs in 
terms of administrative labor, office expense, and all other expenses 
incurred by the billing practitioner for 45 minutes of psychotherapy 
services when furnished in the office setting versus the facility 
setting.
    We agree with these stakeholders that the site of service 
differential for these services that is produced by our PE methodology 
seems unlikely to reflect the relative resource costs for the 
practitioners furnishing these services in nonfacility settings. For 
example, we believe the 0.02 RVUs, which translates to approximately 
$0.72, would be unlikely to reflect the relative administrative labor, 
office rent, and other overhead involved in furnishing the 45 minute 
psychotherapy service in a nonfacility setting. Consequently, we 
believe it would be appropriate to modify the existing methodology for 
allocating indirect PE RVUs in order to better reflect the relative 
indirect PE resources involved in furnishing these kinds of services in 
the nonfacility setting.
    In examining the range of services furnished in the nonfacility 
setting that are most affected by this circumstance, we identified 
HCPCS codes that describe face-to-face services, have work RVUs greater 
than zero, and are priced in both the facility and nonfacility setting. 
From among these codes, we further selected those with the lowest ratio 
between nonfacility PE RVUs and work RVUs. We selected 0.4 as an 
appropriate threshold based on several factors, including the range of 
nonfacility PE RVU to work RVU ratios among the codes identified. Based 
on these criteria, there were fewer than 50 codes that we identified 
with a ratio of less than 0.4 nonfacility PE RVUs for each work RVU, 
most of which are primarily furnished by behavioral health 
professionals, for a potential modification to our indirect PE 
allocation methodology.
    In considering how to address the anomaly and ensure that an 
appropriate number of indirect PE RVUs are allocated to these services 
in the nonfacility setting, we looked at the indirect, nonfacility PE 
RVU for the most commonly billed physician office visit, CPT code 
99213, which is billed by a wide range of physicians and non-physician 
practitioners under the PFS. We believe that the indirect PE costs 
allocated to services reported with CPT code 99213, including 
administrative labor and office rent, would be common for a broad range 
of physicians and non-physician practitioners across the PFS. We 
recognize that the services we seek to address are primarily furnished 
by behavioral health professionals who may be unlikely to incur some of 
the costs incurred by other practitioners furnishing a broader range of 
medical services. For instance, a practitioner furnishing a broader 
range of primary care services likely requires separate office and 
examination room space, and storage for disposable medical supplies and 
equipment. Some costs, however, such as those for office staff and 
records maintenance, would be analogous.
    We looked at the relationship between indirect PE and work RVUs for 
CPT code 99213 as a marker because that is the most commonly and 
broadly reported PFS code that describes face-to-face office-based 
services. We compared the relationship between indirect PE and work 
RVUs for the set of HCPCS codes that we identified using the criteria 
discussed above and found that for the significant majority of codes, 
that ratio was at least 0.4 nonfacility PE RVUs for each work RVU. We 
believe the 0.4 nonfacility PE RVUs can serve as an appropriate marker 
that appropriately reflects the relative resources involved in 
furnishing these services.

[[Page 33965]]

    For the fewer than 50 outlier codes identified using the criteria 
above, we believe it would be appropriate to establish a minimum 
nonfacility indirect PE RVU that would be a better reflection the 
resources involved in furnishing these services. We propose to set the 
nonfacility indirect PE RVUs for these codes using the indirect PE RVU 
to work RVU ratio for the most commonly furnished office-based, face-
to-face service (CPT 99213) as a marker. Specifically, for each of 
these outlier codes, we propose to compare the ratio between indirect 
PE RVUs and work RVUs that result from the preliminary application of 
the standard methodology to the ratio for the marker code, CPT code 
99213. Our proposed change in the methodology would then increase the 
allocation of indirect PE RVUs to the outlier codes to at least one 
quarter of the difference between the two ratios. We believe this 
approach reflects a reasonable minimum allocation of indirect PE RVUs, 
but we do not currently have empirical data that would be useful in 
establishing a more precise number.
    In developing the proposed PE RVUs for CY 2018, we propose to 
implement only one quarter of this proposed minimum value for 
nonfacility indirect PE for the outlier codes. We recognize that this 
change in the PE methodology could have a significant impact on the 
allocation of indirect PE RVUs across all PFS services. In making 
significant changes to the PE methodology in previous years, we have 
implemented such changes using 4 year transitions, based largely on 
concerns that some specialties experience significant payment 
reductions with changes in PE relativity, and a transition period 
allows for a more gradual adjustment for affected practitioners. Under 
the approach we are proposing, we estimate that approximately $40 
million, or approximately 0.04 percent of total PFS allowed charges, 
would shift within the PE methodology for each year of the proposed 4-
year transition, including for CY 2018. We also note that we are 
proposing to exclude the codes directly subject to this proposed change 
from the misvalued code target calculation because the proposed change 
is a methodological change to address an anomaly produced by our 
indirect PE allocation process as opposed to a change to address 
misvalued codes. The PE RVUs displayed in Addendum B on our Web site 
were calculated with the one quarter of the indirect PE adjustment 
factor implemented.

C. Determination of Malpractice Relative Value Units (RVUs)

1. Overview
    Section 1848(c) of the Act requires that each service paid under 
the PFS be composed 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. 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 comprehensive 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).
    To determine MP RVUs for individual PFS services, our MP 
methodology is composed of three factors: (1) Specialty-level risk 
factors derived from data on specialty-specific MP premiums incurred by 
practitioners, (2) service level risk factors derived from Medicare 
claims data of the weighted average risk factors of the specialties 
that furnish each service, and (3) an intensity/complexity of service 
adjustment to the service level risk factor based on either the higher 
of the work RVU or clinical labor RVU. Prior to CY 2016, MP RVUs were 
only updated once every 5 years, except in the case of new and revised 
codes.
    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 
5-year review of MP RVUs were 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 adjusted (or scaled) the 
MP RVU for the new/revised code to reflect the difference in work RVU 
between the source code and the new/revised work RVU (or, if greater, 
the difference in 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 were 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 
was applied for the new/revised code and source code, but the work RVU 
for the new/revised code was used to adjust the MP RVUs for risk.
    In the CY 2016 PFS final rule with comment period (80 FR 70906 
through 70910), we finalized a policy to begin conducting annual MP RVU 
updates to reflect changes in the mix of practitioners providing 
services (using Medicare claims data), and to adjust MP RVUs for risk, 
intensity and complexity (using the work RVU or clinical labor RVU). We 
also finalized a policy to modify the specialty mix assignment 
methodology (for both MP and PE RVU calculations) to use an average of 
the 3 most recent years of data instead of a single year of data. Under 
this approach, for new and revised codes, we generally assign a 
specialty risk factor to individual codes based on the same utilization 
assumptions we make regarding specialty mix we use for calculating PE 
RVUs and for PFS budget neutrality. We continue to use the work RVU or 
clinical labor RVU to adjust the MP RVU for each code for intensity and 
complexity. In finalizing this policy, we stated that the specialty-
specific risk factors would continue to be updated through notice and 
comment rulemaking every 5 years using updated premium data, but would 
remain unchanged between the 5-year reviews.
    In CY 2017, we finalized the eighth GPCI update, which reflected 
updated MP premium data. We did not propose to use the updated MP 
premium data to propose updates for CY 2017 to the specialty risk 
factors used in the calculation of MP RVUs because it was inconsistent 
with the policy we previously finalized in the CY 2016 PFS final rule 
with comment period, whereby we indicated that the specialty-specific 
risk factors would continue to be updated through notice and comment 
rulemaking every 5 years using updated premium data, but would remain 
unchanged between the 5-year reviews. However, we solicited comment on 
whether we should consider doing so, perhaps as early as for CY 2018, 
prior to the fourth review and update of MP RVUs that must occur no 
later than CY 2020. After consideration of the comments received, we 
stated that we would consider the possibility of using the updated MP 
data to update the specialty risk factors used in the calculation of 
the MP RVUs prior to the next 5-year update in future rulemaking (81 FR 
80191 through 80192). Since MP premium data are used to update both the 
MP GPCIs and the MP RVUs, going forward we believe it would be logical 
to align the update of MP premium data used to determine the MP RVUs 
with the update of the MP GPCI. Section 1848(e)(1)(C) of the Act 
requires us to review and, if necessary, adjust the

[[Page 33966]]

GPCIs at least every 3 years. The next review of the GPCIs must occur 
by CY 2020.
    We propose to use the most recent data for the proposed MP RVUs for 
CY 2018 and to align the update of MP premium data and MP GPCIs to once 
every 3 years. We are seeking comment on these proposals, and we are 
also seeking comment on methodologies and sources that we might use to 
improve the next update of MP premium data.
2. Methodology for the Proposed Revision of Resource Based Malpractice 
RVUs
a. General Discussion
    The proposed MP RVUs were calculated based on updated malpractice 
premium data obtained from state insurance rate filings by a CMS 
contractor. The methodology used in calculating the proposed CY 2018 
review and update of resource based MP RVUs largely parallels the 
process used in the CY 2015 update. The calculation requires using 
information on specialty-specific malpractice premiums linked to 
specific services based upon the relative risk factors of the various 
specialties that furnish a particular service. Because malpractice 
premiums vary by state and specialty, the malpractice premium 
information must be weighted geographically and by specialty. 
Accordingly, the proposed MP RVUs are based upon four data sources: CY 
2014 and CY 2015 malpractice premium data; CY 2016 and 2017 Medicare 
payment and utilization data; CY 2017 geographic practice cost indices 
(GPCIs), and CY 2018 proposed work and clinical labor RVUs.
    Similar to the previous update, we calculated the proposed MP RVUs 
using specialty-specific malpractice premium data because they 
represent the actual expense incurred by practitioners to obtain 
malpractice insurance. We obtained malpractice premium data exclusively 
from the most recently available data published in the 2014 and 2015 
Market Share Reports accessed from the National Association of 
Insurance Commissioners (NAIC) Web site. We used information obtained 
from malpractice insurance rate filings with effective dates in 2014 
and 2015. These were the most current data available during our data 
collection process. We collected malpractice insurance premium data 
from all 50 States, and the District of Columbia, and Puerto Rico. Rate 
filings were not available in American Samoa, Guam or the Virgin 
Islands. Premiums were for $1 million/$3 million, mature, claims-made 
policies (policies covering claims made, rather than those covering 
services furnished, during the policy term). A $1 million/$3 million 
liability limit policy means that the most that would be paid on any 
claim is $1 million and the most that the policy would pay for claims 
over the timeframe of the policy is $3 million. We made adjustments to 
the premium data to reflect mandatory surcharges for patient 
compensation funds (funds to pay for any claim beyond the statutory 
amount, thereby limiting an individual physician's liability in cases 
of a large suit) in states where participation in such funds is 
mandatory.
    We included premium information for all physician and NPP 
specialties, and all risk classifications available in the collected 
rate filings. Although we collected premium data from all states, the 
District of Columbia, and Puerto Rico, not all specialties had distinct 
premium data in the rate filings from all states. Additionally, for 
some specialties, MP premiums were not available from the rate filings 
in any state. Therefore, for specialties for which there were not 
premium data for at least 35 states, and specialties for which there 
were not distinct premium data in the rate filings, we crosswalked the 
specialty to a similar specialty, either conceptually or by available 
premium data, for which we did have sufficient and reliable data. These 
specialties and the specialty data that we propose to use are shown in 
Table 6.
    For example, for radiation oncology, data were only available from 
23 states, and therefore this specialty does not meet our 35-state 
threshold, which determines whether or not a specialty is deemed to 
have premium data sufficient to construct a unique risk factor. 
However, based on the 23 states' worth of rate filings for radiation 
oncology, the resource costs for the premiums suggests a similar, 
though slightly lesser average than that of the premiums for diagnostic 
radiology. We developed the proposed MP RVUs for radiation oncology by 
crosswalking the risk factor for diagnostic radiology as a similar 
specialty with similar premium data. We are seeking comment as to the 
appropriateness of this and the other crosswalks used in developing MP 
RVUs.
    For the proposed CY 2018 MP RVU update, sufficient and reliable 
premium data were available for 43 specialty types, representing over 
76 percent of allowed Medicare PFS services, which we used to develop 
specialty specific malpractice risk factors. (See Table 8 for a list of 
these specialties.)

                        Table 6--Proposed Crosswalk of Specialties to Similar Specialties
----------------------------------------------------------------------------------------------------------------
                                                                    Crosswalk
        Specialty code              Medicare specialty name      specialty code        Crosswalk specialty
----------------------------------------------------------------------------------------------------------------
12............................  Osteopathic Manipulative                     03  Allergy/Immunology.
                                 Medicine.
15............................  Speech Language Pathology......              03  Allergy/Immunology.
17............................  Hospice and Palliative Care....              03  Allergy/Immunology.
19............................  Oral Surgery (Dentist only)....              24  Plastic and Reconstructive
                                                                                  Surgery.
23............................  Sports Medicine................              01  General Practice.
27............................  Geriatric Psychiatry...........              26  Psychiatry.
32............................  Anesthesiology Assistant.......              05  Anesthesiology.
35............................  Chiropractic...................              03  Allergy/Immunology.
36............................  Nuclear Medicine...............              30  Diagnostic Radiology.
40............................  Hand Surgery...................              20  Orthopedic Surgery.
41............................  Optometry......................              03  Allergy/Immunology.
42............................  Certified Nurse Midwife........              16  Obstetrics & Gynecology.
43............................  Certified Registered Nurse                   05  Anesthesiology.
                                 Anesthetist (CRNA).
48............................  Podiatry.......................              07  Dermatology.
62............................  Psychologist...................              03  Allergy/Immunology.
64............................  Audiologist....................              03  Allergy/Immunology.
65............................  Physical Therapist in Private                03  Allergy/Immunology.
                                 Practice.
67............................  Occupational Therapist in                    03  Allergy/Immunology.
                                 Private Practice.
68............................  Psychologist, Clinical.........              03  Allergy/Immunology.

[[Page 33967]]

 
76............................  Peripheral Vascular Disease....              77  Vascular Surgery.
79............................  Addiction Medicine.............              03  Allergy/Immunology.
80............................  Licensed Clinical Social Worker              03  Allergy/Immunology.
81............................  Critical Care (Intensivists)...              29  Pulmonary Disease.
85............................  Maxillofacial Surgery..........              24  Plastic and Reconstructive
                                                                                  Surgery.
86............................  Neuropsychiatry................              26  Psychiatry.
89............................  Certified Clinical Nurse                     01  General Practice.
                                 Specialist.
92............................  Radiation Oncology.............              30  Diagnostic Radiology.
94............................  Interventional Radiology.......              30  Diagnostic Radiology.
97............................  Physician Assistant............              03  Allergy/Immunology.
98............................  Gynecological Oncology.........              02  General Surgery.
C0............................  Sleep Medicine.................              01  General Practice.
----------------------------------------------------------------------------------------------------------------

b. Steps for Calculating Malpractice RVUs
    Calculation of the proposed MP RVUs conceptually follows the 
specialty-weighted approach used in the CY 2015 final rule with comment 
period (79 FR 67591). The specialty-weighted approach bases the MP RVUs 
for a given service upon a weighted average of the risk factors of all 
specialties furnishing the service. This approach ensures that all 
specialties furnishing a given service are accounted for in the 
calculation of the MP RVUs. The steps for calculating the proposed MP 
RVUs are described below.
    Step (1): Compute a preliminary national average premium for each 
specialty.
    Insurance rating area malpractice premiums for each specialty are 
mapped to the county level. The specialty premium for each county is 
then multiplied by its share of the total U.S. population (from the 
U.S. Census Bureau's 2014 American Community (ACS) estimates). This is 
in contrast to the method used for creating national average premiums 
for each specialty in the 2015 update; in that update, specialty 
premiums were weighted by the total RVU per county, rather than by the 
county share of the total U.S. population. We refer readers to the PFS 
2016 Final Rule with comment period (80 FR 70909) for a discussion of 
why we have adopted a weighting method based on share of total U.S. 
population. This calculation is then divided by the average MP GPCI 
across all counties for each specialty to yield a normalized national 
average premium for each specialty. The specialty premiums are 
normalized for geographic variation so that the locality cost 
differences (as reflected by the GPCIs) would not be counted twice. 
Without the geographic variation adjustment, the cost differences among 
fee schedule areas would be reflected once under the methodology used 
to calculate the MP RVUs and again when computing the service specific 
payment amount for a given fee schedule area.
    Step (2): Determine which premium class(es) to use within each 
specialty.
    Some specialties had premium rates that differed for surgery, 
surgery with obstetrics, and non-surgery. These premium classes are 
designed to reflect differences in risk of professional liability and 
the cost of malpractice claims if they occur. To account for the 
presence of different classes in the malpractice premium data and the 
task of mapping these premiums to procedures, we calculated distinct 
risk factors for surgical, surgical with obstetrics, and nonsurgical 
procedures. However, the availability of data by surgery and non-
surgery varied across specialties. Consistent with the CY 2015 MP RVU 
update, because no single approach accurately addressed the variability 
in premium class among specialties, we employed several methods for 
calculating average premiums by specialty. These methods are discussed 
below.
    (a) Substantial Data for Each Class: For 10 out of 86 specialties, 
we determined that there were sufficient data for surgery and non-
surgery premiums, as well as sufficient differences in rates between 
classes. These specialties are listed in Table 7. Therefore, we 
calculated a national average surgical premium and non-surgical 
premium. We note that, unlike in the CY 2015 MP RVU update, for CY 
2018, there were no specialties that fell under the ``unspecified 
dominates'' specialty/surgery class scenario, therefore we have omitted 
that surgical class category.
    (b) Major Surgery Dominates: For 9 surgical specialties, rate 
filings that included non-surgical premiums were relatively rare. For 
most of these surgical specialties, the rate filings did not include an 
``unspecified'' premium. When it did, the unspecified premium was lower 
than the major surgery rate. For these surgical specialties, we 
calculated only a surgical premium and used the premium for major 
surgery for all procedures furnished by this specialty.
    (c) Blend All Available: For the remaining specialties, there was 
wide variation across the rate filings in terms of whether or not 
premium classes were reported and which categories were reported. 
Because there was no clear strategy for these remaining specialties, we 
blended the available rate information into one general premium rate. 
For these specialties, we developed a weighted average ``blended'' 
premium at the national level, according to the percentage of work RVUs 
correlated with the premium classes within each specialty. For example, 
the surgical premiums for a given specialty were weighted by that 
specialty's work RVUs for surgical services; the nonsurgical premiums 
were weighted by the work RVUs for non-surgical services and the 
unspecified premiums were weighted by all work RVUs for the specialty 
type.
    The three methods for calculating premiums by specialty type are 
summarized in Table 7. (See Table 8: ``Proposed Risk Factors by 
Specialty Type'' for the specialty names associated with the specialty 
codes listed in Table 7.)

    Table 7--Proposed Premium Calculation Approach by Specialty Type
------------------------------------------------------------------------
                  Method                      Medicare specialty codes
------------------------------------------------------------------------
(a) Substantial Data for Each Class (10)..  01, 04, 08, 09, 13, 16, 18,
                                             34, 72, 93.
(b) Major Surgery Dominates (9)...........  02, 14, 20, 24, 28, 33, 77,
                                             78, 91.

[[Page 33968]]

 
(c) Blend all Available (24)..............  03, 05, 06, 07, 10, 11, 22,
                                             25, 26, 29, 30, 37, 38, 39,
                                             44, 46, 50, 66, 71, 82, 83,
                                             84, 90, 99.
------------------------------------------------------------------------

    Step (3): Calculate a risk factor for each specialty.
    The relative differences in national average premiums between 
specialties are expressed in our methodology as a specialty risk 
factor. These risk factors are an index calculated by dividing the 
national average premium for each specialty by the national average 
premium for the specialty with the lowest premiums for which we had 
sufficient and reliable data, allergy and immunology. For specialties 
with sufficient surgical and non-surgical premium data, we calculated 
both a surgical and non-surgical risk factor. For specialties with rate 
filings that distinguished surgical premiums with obstetrics, we 
calculated a separate surgical with obstetrics risk factor. For all 
other specialties we calculated a single risk factor and applied the 
specialty risk factor to both surgery and non-surgery services.
    We note that for determining the risk factor for suppliers of TC-
only services in the CY 2015 update, we updated the premium data for 
independent diagnostic testing facilities (IDTFs) that we used in the 
CY 2010 update. These data were obtained from a survey conducted by the 
Radiology Business Management Association (RBMA) in 2009; we ultimately 
used these data to calculate an updated TC specialty risk factor. We 
applied the updated TC specialty risk factor to suppliers of TC-only 
services. In the CY 2015 final rule with comment period (79 FR 67595), 
RBMA voluntarily submitted updated MP premium information collected 
from independent diagnostic testing facilities (IDTFs) in 2014, and 
requested that we use the data for calculating the CY 2015 MP RVUs for 
TC services. We declined to utilize the data and stated that we believe 
further study is necessary and we would consider this matter and 
propose any changes through future rulemaking. We believe that data for 
a broader set of technical component services are needed, and seek 
comment on appropriate, comparable data sources for such information. 
We also seek comment on whether the data for IDTFs are comparable and 
appropriate as a proxy for the broader set of TC services. We endeavor 
to, in the next update of specialty risk factors, collect more data 
across a broader set of the technical component services, not just for 
radiology (as is currently reflected in the RBMA data), but data for 
services performed by other non-physician practitioners including 
cytotechnologists, and cardiovascular technologists. In the interim, 
for CY 2018, we propose to assign a TC risk factor of 1.0, which 
corresponds to the lowest physician specialty risk factor.
    We assigned the risk factor of 1.0 to the TC services because we do 
not have comparable professional liability premium data for the full 
range of clinicians that furnish these services. In lieu of 
comprehensive, comparable data, we used 1.0 as the default minimum risk 
factor, though we seek information on the best available data sources 
for use in the next update, as well as empirical information that would 
support assignment of an alternative risk factor for these services. 
Table 8 shows the proposed risk factors by specialty type.

                                Table 8--Proposed Risk Factors by Specialty Type
----------------------------------------------------------------------------------------------------------------
                                                                                   Non-surgical    Surgical risk
               Specialty code                      Medicare specialty name          risk factor       factor
----------------------------------------------------------------------------------------------------------------
01.........................................  General Practice...................            1.80            3.72
01.........................................  General Practice w/OB..............  ..............            4.30
02.........................................  General Surgery....................  ..............            6.75
03.........................................  Allergy/Immunology.................            1.00            1.00
04.........................................  Otolaryngology.....................            1.53            4.08
05.........................................  Anesthesiology.....................            2.58            2.58
06.........................................  Cardiovascular Disease (Cardiology)            1.90            1.90
07.........................................  Dermatology........................            2.77            2.77
08.........................................  Family Practice....................            1.67            3.74
08.........................................  Family Practice w/OB...............  ..............            4.31
09.........................................  Interventional Pain Management.....            2.08            2.97
10.........................................  Gastroenterology...................            2.40            2.40
11.........................................  Internal Medicine..................            2.70            2.70
12.........................................  Osteopathic Manipulative Medicine..            1.00            1.00
13.........................................  Neurology..........................            2.46           13.02
14.........................................  Neurosurgery.......................  ..............           10.66
15.........................................  Speech Language Pathology..........            1.00            1.00
16.........................................  Obstetrics & Gynecology............            1.59            4.52
16.........................................  Obstetrics & Gynecology w/OB.......  ..............            8.67
17.........................................  Hospice and Palliative Care........            1.00            1.00
18.........................................  Ophthalmology......................            1.03            2.16
19.........................................  Oral Surgery (Dentist only)........  ..............            4.93
20.........................................  Orthopedic Surgery.................  ..............            6.22
22.........................................  Pathology..........................            1.60            1.60
23.........................................  Sports Medicine....................            1.80            3.72
24.........................................  Plastic and Reconstructive Surgery.  ..............            4.93
25.........................................  Physical Medicine and                          1.49            1.49
                                              Rehabilitation.
26.........................................  Psychiatry.........................            1.27            1.27
27.........................................  Geriatric Psychiatry...............            1.27            1.27
28.........................................  Colorectal Surgery (Proctology)....  ..............            4.19
29.........................................  Pulmonary Disease..................            1.82            1.82
30.........................................  Diagnostic Radiology...............            2.82            2.82
32.........................................  Anesthesiology Assistant...........            2.58            2.58
33.........................................  Thoracic Surgery...................  ..............            6.06
34.........................................  Urology............................            1.66            2.97

[[Page 33969]]

 
35.........................................  Chiropractic.......................            1.00            1.00
36.........................................  Nuclear Medicine...................            2.82            2.82
37.........................................  Pediatric Medicine.................            1.82            1.82
38.........................................  Geriatric Medicine.................            1.52            1.52
39.........................................  Nephrology.........................            1.56            1.56
40.........................................  Hand Surgery.......................  ..............            6.22
41.........................................  Optometry..........................            1.00            1.00
42.........................................  Certified Nurse Midwife............            1.59            4.52
42.........................................  Certified Nurse Midwife w/OB.......  ..............            8.67
43.........................................  Certified Registered Nurse                     2.58            2.58
                                              Anesthetist (CRNA).
44.........................................  Infectious Disease.................            2.03            2.03
46.........................................  Endocrinology......................            1.75            1.75
48.........................................  Podiatry...........................            2.77            2.77
50.........................................  Nurse Practitioner.................            1.95            1.95
62.........................................  Psychologist.......................            1.00            1.00
64.........................................  Audiologist........................            1.00            1.00
65.........................................  Physical Therapist in Private                  1.00            1.00
                                              Practice.
66.........................................  Rheumatology.......................            1.58            1.58
67.........................................  Occupational Therapist in Private              1.00            1.00
                                              Practice.
68.........................................  Psychologist, Clinical.............            1.00            1.00
71.........................................  Registered Dietitian or Nutrition              1.37            1.37
                                              Professional.
72.........................................  Pain Management....................            2.65            3.65
76.........................................  Peripheral Vascular Disease........  ..............            6.67
77.........................................  Vascular Surgery...................  ..............            6.67
78.........................................  Cardiac Surgery....................  ..............            6.87
79.........................................  Addiction Medicine.................            1.00            1.00
80.........................................  Licensed Clinical Social Worker....            1.00            1.00
81.........................................  Critical Care (Intensivists).......            1.82            1.82
82.........................................  Hematology.........................            1.77            1.77
83.........................................  Hematology-Oncology................            1.85            1.85
84.........................................  Preventive Medicine................            1.15            1.15
85.........................................  Maxillofacial Surgery..............  ..............            4.93
86.........................................  Neuropsychiatry....................            1.27            1.27
89.........................................  Certified Clinical Nurse Specialist            1.80            3.72
90.........................................  Medical Oncology...................            1.82            1.82
91.........................................  Surgical Oncology..................  ..............            4.32
92.........................................  Radiation Oncology.................            2.82            2.82
93.........................................  Emergency Medicine.................            2.29            5.03
94.........................................  Interventional Radiology...........            2.82            2.82
97.........................................  Physician Assistant................            1.95            1.95
98.........................................  Gynecological Oncology.............  ..............            6.75
99.........................................  Undefined Physician type...........            1.95            1.95
C0.........................................  Sleep Medicine.....................            1.80            3.72
----------------------------------------------------------------------------------------------------------------

    Step (4): Calculate malpractice RVUs for each HCPCS code.
    Resource-based MP RVUs were calculated for each HCPCS code that has 
work or PE RVUs. The first step was to identify the percentage of 
services furnished by each specialty for each respective HCPCS code. 
This percentage was then multiplied by each respective specialty's risk 
factor as calculated in Step 3. The products for all specialties for 
the HCPCS code were then added together, yielding a specialty-weighted 
service specific risk factor reflecting the weighted malpractice costs 
across all specialties furnishing that procedure. The service specific 
risk factor was multiplied by the greater of the work RVU or PE 
clinical labor index for that service to reflect differences in the 
complexity and risk-of-service between services.
    Low volume service codes: As we discussed in section II.B. of this 
proposed rule, we are proposing to use a list of expected specialties 
instead of the claims-based specialty mix for low volume services in 
order to address stakeholder concerns about the year to year 
variability in PE and MP RVUs for low volume services. We are 
soliciting comments on the proposal to use these service-level 
overrides to determine the specialty for low volume procedures, as well 
as on the list of overrides itself. The proposed list of codes and 
expected specialties is available on our Web site under downloads for 
the CY 2018 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. In previous MP RVU updates, as discussed in the CY 2015 
final rule with comment period (79 FR 40354), we assigned specialty for 
low volume services based on dominant specialty. As discussed in the CY 
2012 final rule with comment period (76 FR 73187 through 73189), we 
applied an additional list of service-level overrides for purposes of 
calculating MP RVUs for a number of cardiothoracic surgery codes. 
Therefore, we note that there are certain codes for which we have 
previously applied expected specialty overrides for purposes of 
calculating MP RVUs based on assumptions regarding low Medicare volume. 
Because we are consolidating policies for low volume service expected 
specialty overrides into a single list for PE and MP, and because we do 
not believe that there is a reason to assume different specialties for 
purposes of calculating PE RVUs than for MP RVUs for any particular 
code, we

[[Page 33970]]

are also proposing to assign the specialty mix solely based on the 
claims data for any code that does not meet the low volume threshold of 
99 allowed services or fewer in the previous year, for the purposes of 
calculating MP RVUs.
    Given that we now annually recalibrate MP RVUs based on claims 
data, and in light of our proposed introduction of the service-level 
specialty override for low volume services, we believe that there would 
no longer be a need to apply service-level MP crosswalks in order to 
assign a specialty-mix risk factor. Contingent on finalizing this 
proposal, we are also proposing to eliminate general use of an MP-
specific specialty-mix crosswalk for new and revised codes. However, we 
would continue to consider, in conjunction with annual recommendations, 
specific recommendations from the public and the RUC regarding 
specialty mix assignments for new and revised codes, particularly in 
cases where coding changes are expected to result in differential 
reporting of services by specialty, or where the new or revised code is 
expected to be low-volume. Absent such information, we would derive the 
specialty mix assumption for the first year for a new or revised code 
from the specialty mix used for purposes of ratesetting. In subsequent 
years when claims data are available, we would assign the specialty 
based on claims data unless the service does not exceed the low volume 
threshold (99 or fewer allowed services). If the service is low volume, 
we would assign the expected specialty, establishing a new expected 
specialty through rulemaking as needed, which is consistent with our 
approach for developing PE RVUs.
    Step (5): Rescale for budget neutrality.
    The statute requires that changes to fee schedule RVUs must be 
budget neutral. Thus, the last step is to adjust for relativity by 
rescaling the proposed MP RVUs so that the total proposed resource 
based MP RVUs are equal to the total current resource based MP RVUs 
scaled by the ratio of current aggregate MP and work RVUs. This scaling 
is necessary in order to maintain the work RVUs for individual services 
from year to year while also maintaining the overall relationship among 
work, PE, and MP RVUs.
    The proposed resource based MP RVUs are shown in Addendum B, which 
is available on the CMS Web site under the downloads section of the CY 
2018 PFS proposed rule at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.
    Because a different share of the resources involved in furnishing 
PFS services is reflected in each of the three fee schedule components, 
implementation of the resource based MP RVU update will have much 
smaller payment effects than implementing updates of resource based 
work RVUs and resource based PE RVUs. On average, work represents about 
50.9 percent of payment for a service under the fee schedule, PE about 
44.8 percent, and MP about 4.3 percent. Therefore, a 25 percent change 
in PE RVUs or work RVUs for a service would result in a change in 
payment of about 11 to 13 percent. In contrast, a corresponding 25 
percent change in MP values for a service would yield a change in 
payment of only about one percent. Estimates of the effects on payment 
by specialty type can be found in section VI. of this proposed rule.
    Additional information on our proposed methodology for updating the 
MP RVUs may be found in our contractor's report, ``Interim Report on 
Malpractice RVUs for the CY 2018 PFS Proposed Rule,'' which is 
available on the CMS Web site under the downloads section of the CY 
2018 PFS proposed rule located at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.
    We are seeking comments on these proposals for calculating the MP 
RVUs for CY 2018.

C. 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 other 
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 professional 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 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 a 
telehealth 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

[[Page 33971]]

telehealth services to the Medicare Administrative Contractors (MACs) 
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 facility fee under the PFS for 
each Medicare telehealth service. The statute specifies both the types 
of entities that can serve as originating sites and the geographic 
qualifications for originating sites. For geographic qualifications, 
our regulation at 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 area (MSA).
    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 Federal Office of Rural Health 
Policy 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 our Web site at https://www.cms.gov/MedicareMedicare-General-Information/Telehealth/index.html.
    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 CY 2003 PFS final rule with comment 
period (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 CY 2012 PFS final 
rule with comment period (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 
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 furnish the service produces 
demonstrated 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.
    The list of telehealth services, including the proposed additions 
described below, is included in the Downloads section to this proposed 
rule at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
    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 2017 will 
be considered for the CY 2019 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, requesters 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 our 
Web site at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html.
3. Submitted Requests To Add Services to the List of Telehealth 
Services for CY 2018
    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 for 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

[[Page 33972]]

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, but also expedite our 
ability to identify codes for the telehealth list that resemble those 
services already on this list.
    We received several requests in CY 2016 to add various services as 
Medicare telehealth services effective for CY 2018. The following 
presents a discussion of these requests, and our proposals for 
additions to the CY 2018 telehealth list. Of the requests received, we 
found that three services were sufficiently similar to services 
currently on the telehealth list to qualify on a category 1 basis. 
Therefore, we are proposing to add the following services to the 
telehealth list on a category 1 basis for CY 2018:
     HCPCS code G0296 (Counseling visit to discuss need for 
lung cancer screening using low dose ct scan (ldct) (service is for 
eligibility determination and shared decision making))
    We found that the service described by HCPCS code G0296 is 
sufficiently similar to office visits currently on the telehealth list. 
We believe that all the components of this service, which include 
assessment of the patient's risk for lung cancer, shared decision 
making, and counseling on the risks and benefits of LDCT, can be 
furnished via interactive telecommunications technology.
     CPT codes 90839 and 90840 (Psychotherapy for crisis; first 
60 minutes) and (Psychotherapy for crisis; each additional 30 minutes 
(List separately in addition to code for primary service))
    We are proposing to add CPT codes 90839 and 90840 on a Category 1 
basis. We found that these services are sufficiently similar to the 
psychotherapy services currently on the telehealth list, even though 
these codes describe patients requiring more urgent care and 
psychotherapeutic interventions to minimize the potential for 
psychological trauma. However, we did identify one specific element of 
the services as described in the CPT prefatory language that we 
concluded may or may not be able to be furnished via telehealth, 
depending on the circumstances of the particular service. The CPT 
prefatory language specifies that the treatment described by these 
codes requires, ``mobilization of resources to defuse the crisis and 
restore safety.'' In many cases, we believe that a distant site 
practitioner would have access (via telecommunication technology, 
presumably) to the resources at the originating site that would allow 
for the kind of mobilization required to restore safety. However, we 
also believe that it would be possible that a distant site practitioner 
would not have access to such resources. Therefore we are proposing to 
add the codes to the telehealth list with the explicit condition of 
payment that the distant site practitioner be able to mobilize 
resources at the originating site to defuse the crisis and restore 
safety, when applicable, when the codes are furnished via telehealth. 
``Mobilization of resources'' is a description used in the CPT 
prefatory language. We believe the critical element of ``mobilizing 
resources'' is the ability to communicate with and inform staff at the 
originating site to the extent necessary to restore safety. We solicit 
comment on whether our assumption that the remote practitioner is able 
to mobilize resources at the originating site to defuse the crisis and 
restore safety is valid.
    Although we did not receive specific requests, we are also 
proposing to add four additional services to the telehealth list based 
on our review of services. All four of these codes are add-on codes 
that describe additional elements of services currently on the 
telehealth list and would only be considered telehealth services when 
billed as an add-on to codes already on the telehealth list. The four 
codes are:
     CPT code 90785 (Interactive complexity (List separately in 
addition to the code for primary procedure))
     CPT codes 96160 and 96161 (Administration of patient-
focused health risk assessment instrument (e.g., health hazard 
appraisal) with scoring and documentation, per standardized instrument) 
and (Administration of caregiver-focused health risk assessment 
instrument (e.g., depression inventory) for the benefit of the patient, 
with scoring and documentation, per standardized instrument))
     HCPCS code G0506 (Comprehensive assessment of and care 
planning for patients requiring chronic care management services (list 
separately in addition to primary monthly care management service))
    In the case of CPT codes 96160 and 96161, and HCPCS code G0506, we 
recognize that these services may not necessarily be ordinarily 
furnished in-person with a physician or billing practitioner. 
Ordinarily, services that are typically not considered to be face-to-
face services do not need to be on the list of Medicare telehealth 
services; however, these services would only be considered Medicare 
telehealth services when billed with a base code that is also on the 
telehealth list and would not be considered Medicare telehealth 
services when billed with codes not on the Medicare telehealth list. We 
believe that by adding these services to the telehealth list it will be 
administratively easier for practitioners who report these services in 
association with a visit code that is furnished via telehealth as both 
the base code and the add-on code would be reported with the telehealth 
place of service.
    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 physical, 
occupational, and speech therapy, initial hospital care, and online E/M 
by physician/qualified healthcare professional to the telehealth list, 
or changing the requirements for ESRD procedure codes furnished via 
telehealth, for the reasons noted in the paragraphs that follow.
a. Physical and Occupational Therapy and Speech-Language Pathology 
Services: CPT Codes--
     CPT code 97001: Now deleted and reported as CPT code 97161 
(Physical therapy evaluation: low complexity, requiring these 
components: A history with no personal factors and/or comorbidities 
that impact the plan of care; An examination of body system(s) using 
standardized tests and measures addressing 1-2 elements from any of the 
following: Body structures and functions, activity limitations, and/or 
participation restrictions; A clinical presentation with stable and/or 
uncomplicated characteristics; and Clinical decision making of low 
complexity using standardized patient assessment instrument and/or 
measurable assessment of functional outcome.)
     CPT code 97002: Now deleted and reported as CPT code 97162 
(Physical therapy evaluation: moderate complexity, requiring these 
components: A history of present problem with 1-2 personal factors and/
or comorbidities that impact the plan of care; An examination of body 
systems using standardized tests and measures in addressing a total of 
3 or more elements from any of the following: Body structures and 
functions, activity limitations, and/or participation restrictions; An 
evolving clinical presentation with changing characteristics; and 
Clinical decision making of moderate complexity using standardized 
patient assessment instrument and/or measurable assessment of 
functional outcome)
     CPT code 97003: Now deleted and reported as CPT code 97165 
(Occupational therapy evaluation, low

[[Page 33973]]

complexity, requiring these components: An occupational profile and 
medical and therapy history, which includes a brief history including 
review of medical and/or therapy records relating to the presenting 
problem; An assessment(s) that identifies 1-3 performance deficits 
(i.e., relating to physical, cognitive, or psychosocial skills) that 
result in activity limitations and/or participation restrictions; and 
Clinical decision making of low complexity, which includes an analysis 
of the occupational profile, analysis of data from problem-focused 
assessment(s), and consideration of a limited number of treatment 
options. Patient presents with no comorbidities that affect 
occupational performance. Modification of tasks or assistance (e.g., 
physical or verbal) with assessment(s) is not necessary to enable 
completion of evaluation component)
     CPT code 97004: Now deleted and reported as CPT code 97166 
(Occupational therapy evaluation, moderate complexity, requiring these 
components: An occupational profile and medical and therapy history, 
which includes an expanded review of medical and/or therapy records and 
additional review of physical, cognitive, or psychosocial history 
related to current functional performance; An assessment(s) that 
identifies 3-5 performance deficits (i.e., relating to physical, 
cognitive, or psychosocial skills) that result in activity limitations 
and/or participation restrictions; and Clinical decision making of 
moderate analytic complexity, which includes an analysis of the 
occupational profile, analysis of data from detailed assessment(s), and 
consideration of several treatment options. Patient may present with 
comorbidities that affect occupational performance. Minimal to moderate 
modification of tasks or assistance (e.g., physical or verbal) with 
assessment(s) is necessary to enable patient to complete evaluation 
component))
     CPT code 97110 (Therapeutic procedure, 1 or more areas, 
each 15 minutes; therapeutic exercises to develop strength and 
endurance, range of motion and flexibility)
     CPT code 97112 (Therapeutic procedure, 1 or more areas, 
each 15 minutes; neuromuscular reeducation of movement, balance, 
coordination, kinesthetic sense, posture, and/or proprioception for 
sitting and/or standing activities)
     CPT code 97116 (Therapeutic procedure, 1 or more areas, 
each 15 minutes; gait training (includes stair climbing))
     CPT code 97535 (Self-care/home management training (e.g., 
activities of daily living (ADL) and compensatory training, meal 
preparation, safety procedures, and instructions in use of assistive 
technology devices/adaptive equipment) direct one-on-one contact, each 
15 minutes)
     CPT code 97750 (Physical performance test or measurement 
(e.g., musculoskeletal, functional capacity), with written report, each 
15 minutes)
     CPT code 97755 (Assistive technology assessment (e.g., to 
restore, augment or compensate for existing function, optimize 
functional tasks and/or maximize environmental accessibility), direct 
one-on-one contact, with written report, each 15 minutes).
     CPT code 97760 (Orthotic(s) management and training 
(including assessment and fitting when not otherwise reported), upper 
extremity(s), lower extremity(s) and/or trunk, each 15 minutes).
     CPT code 97761 (Prosthetic training, upper and/or lower 
extremity(s), each 15 minutes).
     CPT code 97762 (Checkout for orthotic/prosthetic use, 
established patient, each 15 minutes).
    In section 1834(m)(4)(E) of the Act, the statute specifies the 
types of practitioners who may furnish and bill for Medicare telehealth 
services as those practioners under section 1842(b)(18)(C) of the Act. 
Physical therapists, occupational therapists and speech-language 
pathologists are not among the practitioners identified in section 
1842(b)(18)(C) of the Act. We stated in the CY 2017 PFS final rule (81 
FR 80198) that because these services are predominantly furnished by 
physical therapists, occupational therapists and speech-language 
pathologists, we did not believe it would be appropriate to add them to 
the list of telehealth services at this time. In an ensuing submission 
for 2018, the original requester suggested that we might propose these 
services to be added to the list so that they can be furnished via 
telehealth when furnished by eligible distant site practitioners. We 
considered that possibility; however, since the majority of the codes 
are furnished by therapy professionals over 90 percent of the time, we 
believe that adding therapy services to the telehealth list that 
explicitly describe the services of the kinds of professionals not 
included on the statutory list of distant site practitioners could 
result in confusion about who is authorized to furnish and bill for 
these services when furnished via telehealth. We also note that several 
of these services, such as CPT code 97761, require directly physically 
manipulating the beneficiary, which is not possible to do through 
telecommunications technology. Therefore, we are not proposing to add 
these codes to the list of Medicare telehealth services.
b. Initial Hospital Care Services: CPT Codes--
     CPT code 99221 (Initial hospital care, per day, for the 
evaluation and management of a patient, which requires these 3 key 
components: A detailed or comprehensive history; A detailed or 
comprehensive examination; and Medical decision making that is 
straightforward or of low complexity. Counseling and/or coordination of 
care with other physicians, other qualified health care professionals, 
or agencies are provided consistent with the nature of the problem(s) 
and the patient's and/or family's needs. Usually, the problem(s) 
requiring admission are of low severity.)
     CPT code 99222 (Initial hospital care, per day, for the 
evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and 
Medical decision making of moderate complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of 
the problem(s) and the patient's and/or family's needs. Usually, the 
problem(s) requiring admission are of moderate severity.)
     CPT code 99223 (Initial hospital care, per day, for the 
evaluation and management of a patient, which requires these 3 key 
components: A comprehensive history; A comprehensive examination; and 
Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of 
the problem(s) and the patient's and/or family's needs. Usually, the 
problem(s) requiring admission are of high severity.)
    We previously considered a request to add these codes to the 
telehealth list. As we stated in the CY 2011 PFS final rule with 
comment period (75 FR 73315), while initial inpatient consultation 
services are currently on the list of approved telehealth services, 
there are no services on the current list of telehealth services that 
resemble initial hospital care for an acutely ill patient by the 
admitting practitioner who has ongoing responsibility for the patient's

[[Page 33974]]

treatment during the hospital course. Therefore, consistent with prior 
rulemaking, we are not proposing initial hospital care services be 
added to the Medicare telehealth services list on a category 1 basis.
    The initial hospital care codes describe the first visit of the 
hospitalized patient by the admitting practitioner who may or may not 
have seen the patient in the decision-making phase regarding 
hospitalization. Based on the description of the services for these 
codes, we believe it is critical that the initial hospital visit by the 
admitting practitioner be conducted in person to ensure that the 
practitioner with ongoing treatment responsibility comprehensively 
assesses the patient's condition upon admission to the hospital through 
a thorough in-person examination. Additionally, the requester submitted 
no additional research or evidence that the use of a telecommunications 
system to furnish the service produces demonstrated clinical benefit to 
the patient; therefore, we also are not proposing to add initial 
hospital care services to the Medicare telehealth services list on a 
category 2 basis.
    We note that Medicare beneficiaries who are being treated in the 
hospital setting can receive reasonable and necessary E/M services 
using other HCPCS codes that are currently on the Medicare telehealth 
list including those for subsequent hospital care, initial and followup 
telehealth inpatient and emergency department consultations, as well as 
initial and followup critical care telehealth consultations.
    Therefore, we do not propose to add the initial hospital care 
services to the list of Medicare telehealth services for CY 2018.
c. Online E/M by physician/QHP: CPT Code--
     CPT code 99444 (Online evaluation and management service 
provided by a physician or other qualified health care professional who 
may report 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 2016 final rule with comment period (80 
FR 71061), CPT code 99444 is assigned a status indicator of ``N'' (Non-
covered service). 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 non-covered, there would be no Medicare payment 
if this service were furnished without the use of a telecommunications 
system. Because this code is a non-covered service for which no 
Medicare payment may be made under the PFS, we do not propose to add 
online E/M services to the list of Medicare telehealth services for CY 
2018.
d. Monthly Capitation Payment (MCP) for ESRD-Related Services for Home 
Dialysis, by Age: CPT Codes--
     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)
     90967 (End-stage renal disease (ESRD) related services for 
dialysis less than a full month of service, per day; for patients 
younger than 2 years of age); 90968 (End-stage renal disease (ESRD) 
related services for dialysis less than a full month of service, per 
day; for patients 2-11 years of age); and 90969 (End-stage renal 
disease (ESRD) related services for dialysis less than a full month of 
service, per day; for patients 12-19 years of age); and 90970 (End-
stage renal disease (ESRD) related services for dialysis less than a 
full month of service, per day; for patients 20 years of age and 
older).
    In the CY 2004 PFS final rule (68 FR 63216), we established G-codes 
for ESRD monthly capitation payments (MCPs), which were replaced by CPT 
codes in CY 2009 (73 FR 69898). The services described by CPT codes 
90963 through 90966 were added to the Medicare telehealth list in CY 
2005 (69 FR 66276) and CPT codes 90967 through 90970 were added to the 
Medicare telehealth list in the CY 2017 PFS final rule (81 FR 80194); 
however, we specified that the required clinical examination of the 
vascular access site must be furnished face-to-face ``hands on'' 
(without the use of an interactive telecommunications system) by a 
physician, clinical nurse specialist (CNS), nurse practitioner (NP), or 
physician assistant (PA). The American Telemedicine Association (ATA) 
submitted a new request for CY 2018 requesting that we allow telehealth 
coverage of ESRD procedure codes without in-person exam of the catheter 
access site monthly. Our current policy reflects our understanding that 
evaluation of the integrity and functionality of the access site is a 
critical element of the services described by the codes and that this 
element cannot be performed via telecommunications technology. The 
requester did not submit evidence to support the assertation that 
effective examination of the access site can be executed via 
telecommunications technology. Therefore, for CY 2018, we are not 
proposing any changes to the policy requiring that the MCP practitioner 
must furnish at least one face-to-face encounter with the home dialysis 
patient per month for clinical examination of the catheter access site. 
However, we are interested in more information about current clinically 
accepted care practices and to what extent telecommunications 
technology can be used to examine the access site. We are also 
interested in information about the clinical standards of care 
regarding the frequency of the evaluation of the access site.
    In summary, we are proposing to add the following codes to the list 
of Medicare telehealth services beginning in CY 2018 on a category 1 
basis:
     HCPCS code G0296 (Counseling visit to discuss need for 
lung cancer screening using low dose CT scan (ldct) (service is for 
eligibility determination and shared decision making)).
     HCPCS code G0506 (Comprehensive assessment of and care 
planning for patients requiring chronic care management services (list 
separately in addition to primary monthly care management service)).
     CPT code 90785 (Interactive complexity (List separately in 
addision to the code for primary procedure)).
     CPT codes 90839 and 90840 (Psychotherapy for crisis; first 
60 minutes) and (Psychotherapy for crisis; each additional 30 minutes 
(List separately in addition to code for primary procedure)).
     CPT codes 96160 and 96161 (Administration of patient-
focused health risk assessment instrument (e.g., health hazard 
appraisal) with scoring and documentation, per standardized

[[Page 33975]]

instrument) and (Administration of caregiver-focused health risk 
assessment instrument (e.g., depression inventory) for the benefit of 
the patient, with scoring and documentation, per standardized 
instrument).
4. Elimination of the Required Use of the GT Modifier on Professional 
Claims
    Medicare has required distant site practitioners to report one of 
two longstanding HCPCS modifiers when reporting telehealth services. 
Current guidance instructs practitioners to submit claims for 
telehealth services using the appropriate CPT or HCPCS code for the 
professional service along with the telehealth modifier GT (via 
interactive audio and video telecommunications systems). For federal 
telemedicine demonstration programs in Alaska or Hawaii, practitioners 
are instructed to submit claims using the appropriate CPT or HCPCS code 
for the professional service along with the telehealth modifier GQ if 
telehealth services are performed ``via an asynchronous 
telecommunications system.'' By coding and billing these modifiers with 
a service code, practitioners are certifying that both the broad and 
code-specific telehealth requirements have been met.
    In the CY 2017 PFS final rule (81 FR 80201), we finalized payment 
policies regarding Medicare's use of a new Place of Service (POS) Code 
describing services furnished via telehealth. The new POS code became 
effective January 1, 2017, and we believe its use is redundant with the 
requirements to apply the GT modifier for telehealth services. We did 
not propose to implement a change to the modifier requirements during 
CY 2017 rulemaking because at the time of the CY 2017 PFS proposed 
rule, we did not know whether the telehealth POS code would be made 
effective for January 1, 2017. However, we noted in the CY 2017 PFS 
final rule that, like the modifiers, use of the telehealth POS code 
certifies that the service meets the telehealth requirements.
    Because a valid POS code is required on professional claims for all 
services, and the appropriate reporting of the telehealth POS code 
serves to indicate both the provision of the service via telehealth and 
certification that the requirements have been met, we believe that it 
is unnecessary to also require the distant site practitioner report the 
GT modifier on the claim. Therefore, we are proposing to eliminate the 
required use of the GT modifier on professional claims. Because 
institutional claims do not use a POS code, we propose for distant site 
practitioners billing under CAH Method II to continue to use the GT 
modifier on institutional claims. For purposes of the federal 
telemedicine demonstration programs in Alaska or Hawaii, we propose to 
retain the GQ modifier to maintain the distinction between synchronous 
and asynchronous telehealth services, as reflected in statute.
5. Comment Solicitation on Medicare Telehealth Services
    We have received numerous requests from stakeholders to expand 
access to telehealth services. As noted above, Medicare payment for 
telehealth services is restricted by statute, which establishes the 
services initially eligible for Medicare telehealth and limits the use 
of telehealth by defining both eligible originating sites (the location 
of the beneficiary) and the distant site practitioners who may furnish 
and bill for telehealth services. Originating sites are limited both by 
geography and provider setting. We have the authority to add to the 
list of eligible services based on our annual process, but cannot 
change the limitations relating to geography, patient setting, or type 
of furnishing practitioner because these requirements are specified in 
statute. For CY 2018, we are seeking information regarding ways that we 
might further expand access to telehealth services within the current 
statutory authority and pay appropriately for services that take full 
advantage of communication technologies.
6. Comment Solicitation on Remote Patient Monitoring
    In addition to the broad comment solicitation regarding Medicare 
telehealth services, we are also specifically seeking comment on 
whether to make separate payment for CPT codes that describe remote 
patient monitoring. We note that remote patient monitoring services 
would generally not be considered Medicare telehealth services as 
defined under section 1834(m) of the Act. Rather, like the 
interpretation by a physician of an actual electrocardiogram or 
electroencephalogram tracing that has been transmitted electronically, 
these services involve the interpretation of medical information 
without a direct interaction between the practitioner and beneficiary. 
As such, they are paid under the same conditions as in-person 
physicians' services with no additional requirements regarding 
permissible originating sites or use of the telehealth place of service 
code.
    We are particularly interested in comments regarding CPT code 99091 
(Collection and interpretation of physiologic data (e.g., ECG, blood 
pressure, glucose monitoring) digitally stored and/or transmitted by 
the patient and/or caregiver to the physician or other qualified health 
care professional, qualified by education, training, licensure/
regulation (when applicable) requiring a minimum of 30 minutes of 
time). This code is currently assigned a procedure status of B 
(bundled). As with many other bundled codes, we currently assign RVUs 
for this code based on existing RUC recommendations, even though we 
have considered the services described by the code to be bundled with 
other services. In addition to comments on the payment status and 
valuation for this code (the RUC-recommended value, specifically) we 
are seeking information about the circumstances under which this code 
might be reported for separate payment, including how to differentiate 
the time related to these services from other services, including care 
management services. For example, PFS payment for analysis of patient-
generated health data is considered included in chronic care management 
(CCM) services (CPT codes 99487, 99489, and 99490) to the extent that 
this activity is medically necessary and performed as part of CCM (see 
the CY 2015 PFS final rule (79 FR 67727), CY 2016 PFS final rule (81 FR 
80244), and the CMS FAQ available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf.). We also seek comment from 
beneficiaries and beneficiary advocacy organizations on the value of 
such services and what protections might be necessary to assure that 
beneficiaries are properly informed that they are receiving a remote 
monitoring service, since beneficiaries would be required to pay 
standard cost sharing for such services. Finally, regarding CPT code 
99091, we are seeking available information regarding potential 
utilization assumptions we might make for the service for purposes of 
PFS ratesetting, were we to make it payable for CY 2018 or in the 
future; since making such asumptions would be necessary to implement 
separate payment. We note that since the PFS is a budget neutral 
system, any increase in payment made for particular services would 
result in decreases in payment for other services, and the degree of 
that decrease would depend, in large part, on the utilization 
assumptions.
    We are also seeking comment on other existing codes that describe 
extensive use of communications technology for

[[Page 33976]]

consideration for future rulemaking, including CPT code 99090 (Analysis 
of clinical data stored in computers (e.g., ECGs, blood pressures, 
hematologic data)). CPT code 99090 is also assigned a procedure status 
of B (bundled). However, we do not have RUC recommended values for this 
service, and therefore, currently do not assign RVUs.

E. Proposed 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 II.H. 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 as authorized by 
law. We may also consider analyses of work time, work RVUs, or direct 
PE inputs using other data sources, such as Department of Veteran 
Affairs (VA), National Surgical Quality Improvement Program (NSQIP), 
the Society for Thoracic Surgeons (STS), and the Physician Quality 
Reporting System (PQRS) databases. In addition to considering the most 
recently available data, we assess the results of physician surveys and 
specialty recommendations submitted to us by the RUC for our review. 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 and requires us to take into account the results of 
consultations with organizations representing physicians who provide 
the services. In accordance with section 1848(c) of the Act, we 
determine and make appropriate adjustments to the RVUs.
    In its March 2006 Report to the Congress (http://www.medpac.gov/documents/reports/Mar06_EntireReport.pdf?sfvrsn=0), MedPAC discussed 
the importance of appropriately valuing physicians' services, noting 
that misvalued services can distort the market for physicians' 
services, as well as for other health care services that physicians 
order, such as hospital services. In that same report MedPAC postulated 
that physicians' services under the PFS can become misvalued over time. 
MedPAC stated, ``When a new service is added to the physician fee 
schedule, it may be assigned a relatively high 0l value because of the 
time, technical skill, and psychological stress that are often required 
to furnish that service. Over time, the work required for certain 
services would be expected to decline as physicians become more 
familiar with the service and more efficient in furnishing it.'' We 
believe services can also become overvalued when PE declines. This can 
happen when the costs of equipment and supplies fall, or when equipment 
is used more frequently than is estimated in the PE methodology, 
reducing its cost per use. Likewise, services can become undervalued 
when physician work increases or PE rises.
    As MedPAC noted in its March 2009 Report to Congress (http://www.medpac.gov/documents/reports/march-2009-report-to-congress-medicare-payment-policy.pdf?sfvrsn=0), in the intervening years since 
MedPAC made the initial recommendations, CMS and the RUC have taken 
several steps to improve the review process. Also, 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 
physician fee schedule.
     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

[[Page 33977]]

(including using existing processes for consideration of coding 
changes) that may include consolidation of individual services into 
bundled codes for payment under the physician fee schedule.
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 approximately 
1,700 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 
through 73055). In the CY 2012 PFS final rule with comment period (76 
FR 73055 through 73958), we finalized our policy to consolidate the 
review of physician work and PE at the same time, and established a 
process for the annual public nomination of potentially misvalued 
services.
    In the CY 2013 PFS 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 (73 FR 38589), 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. In the fourth Five-Year Review (76 FR 32410), we 
requested recommendations from the RUC to aid in our review of Harvard-
valued codes with annual utilization of greater than 30,000. In the CY 
2013 PFS final rule with comment period, we identified specific 
Harvard-valued services with annual allowed charges that total at least 
$10,000,000 as potentially misvalued. In addition to the Harvard-valued 
codes, in the CY 2013 PFS 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 that have listed work time).
    In the CY 2016 PFS final rule with comment period, we finalized for 
review a list of potentially misvalued services, which included eight 
codes in the neurostimulators analysis-programming family (CPT 95970-
95982). We also finalized as potentially misvalued 103 codes identified 
through our screen of high expenditure services across specialties.
    In the CY 2017 PFS final rule, we finalized for review a list of 
potentially misvalued services, which included eight codes in the end-
stage renal disease home dialysis family (CPT codes 90963-90970). We 
also finalized as potentially misvalued 19 codes identified through our 
screen for 0-day global services that are typically billed with an 
evaluation and management (E/M) service with modifier 25.
3. CY 2018 Identification and Review of Potentially Misvalued Services
    In the CY 2012 PFS final rule with comment period (76 FR 73058), we 
finalized a process for the public to nominate potentially misvalued 
codes. The public and stakeholders may nominate potentially misvalued 
codes for review by submitting the code with supporting documentation 
by February 10 of each year. Supporting documentation for codes 
nominated for the annual review of potentially misvalued codes may 
include the following:
     Documentation in 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.
     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.
    We evaluate the supporting documentation submitted with the 
nominated codes 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. The public has the opportunity to 
comment on these and all other proposed potentially misvalued codes. In 
that year's final rule, we finalize our list of potentially misvalued 
codes.
    After we issued the CY 2017 PFS final rule, we received a 
nomination and supporting documentation for one code to be considered 
as potentially misvalued. We evaluated the supporting documentation for 
this nominated code to ascertain whether the submitted information 
demonstrated that the code should be proposed as potentially misvalued.
    CPT code 27279 (Arthrodesis, sacroiliac joint, percutaneous or 
minimally invasive (indirect visualization), with image guidance, 
includes obtaining bone graft when performed, and placement of 
transfixing device) was nominated for review as a potentially misvalued 
code because the current work RVU is potentially undervalued and 
stakeholders recommend that it should be increased to 14.23. We are 
proposing this code as a potentially misvalued code. In the CY 2017 PFS 
final rule, we noted that some assertions regarding appropriate values 
for the dialysis vascular access codes newly created in CY 2017 (CPT 
codes 36901 through 36909) did not include data that would warrant 
increases to the work RVUs. However, we urged interested stakeholders 
to consider

[[Page 33978]]

submitting robust data regarding costs for these and other services (81 
FR 80294). We have continued to receive feedback from stakeholders 
regarding the work valuation of these codes. Stakeholders have 
expressed concerns regarding the typical patient for these procedures 
as reflected in the information included in the RUC recommendations for 
CY 2017 and the importance of appropriate payment for ensuring access 
to care for Medicare beneficiaries. Therefore, we are seeking 
additional comment and continuing to request robust data regarding the 
potentially misvalued work RVUs for CPT codes 36901 through 36909 and 
considering alternate work valuations for CY 2018, such as the RUC-
recommended work RVUs from CY 2017, or other potential values based on 
submission of data through the public comment process. We note that the 
RUC recommended work RVUs for these services are displayed in the CY 
2017 PFS final rule (81 FR 80290 through 80296). We have received 
conflicting information about the direct PE inputs for CPT codes 88184 
(Flow cytometry, cell surface, cytoplasmic, or nuclear marker, 
technical component only; first marker) and 88185 (Flow cytometry, cell 
surface, cytoplasmic, or nuclear marker, technical component only; each 
additional marker (List separately in addition to code for first 
marker)), and we are proposing these codes as potentially misvalued so 
that they can be reviewed again because some stakeholders have 
suggested the clinical labor and supplies that were previously 
finalized are no longer accurate.
    We have received information suggesting that the work RVUs for 
emergency department visits may not appropriately reflect the full 
resources involved in furnishing these services. Specifically, 
stakeholders have expressed concerns that the work RVUs for these 
services have been undervalued given the increased acuity of the 
patient population and the heterogeneity of the sites, such as 
freestanding and off-campus emergency departments, where emergency 
department visits are furnished. We are, therefore, seeking comment on 
whether CPT codes 99281-99385 (Emergency department visits for the 
evaluation and management of a patient) should be reviewed under the 
misvalued code initiative.
    For over a decade, CMS has collaborated with the RUC to regularly 
prioritize codes for review by using the categories specified in the 
statute or as determined appropriate. We generally have referred to 
these categories as ``misvalued code screens.'' To supplement ongoing 
RUC identification of potentially misvalued codes through established 
screens, CMS regularly uses PFS rulemaking to identify other screens 
for use in identifying potentially misvalued codes. For example, in 
recent years, CMS has prioritized the following screens:
     Codes with low work RVUs commonly billed in multiple units 
per single encounter.
     Codes with high volume and low work RVUs.
     Codes with site-of-service-anomalies.
     E/M codes.
     PFS high expenditure services.
     Services with standalone PE procedure time.
     Services with anomalous time.
     Contractor Medical Director identified potentially 
misvalued codes.
     Codes with higher total Medicare payments in office than 
in hospital or ASC.
     Publicly nominated potentially misvalued codes.
     0-day global services that are typically billed with an 
evaluation and management (E/M) service with modifier 25.
    Although we are not proposing a new screen for CY 2018, we continue 
to believe that it is important to prioritize codes for review under 
the misvalued code initiative. As a result, we are seeking public 
comment on the best approach for developing screens, as well as what 
particular new screens we might consider. We will consider these 
comments for future rulemaking.

F. Payment Incentive for the Transition From Traditional X-Ray Imaging 
to Digital Radiography and Other Imaging Services

    Section 502(a)(1) of Division O, Title V of the Consolidated 
Appropriations Act of 2016 (Pub. L. 114-113) amended section 1848(b) of 
the Act by establishing a new paragraph (9) of subsection (b). Section 
1848(b)(9)(B) of the Act provides for a 7 percent reduction in payments 
for the technical component (TC) for imaging services made under the 
PFS that are X-rays (including the technical component portion of a 
global service) taken using computed radiography technology furnished 
during CYs 2018, 2019, 2020, 2021, or 2022, and for a 10 percent 
reduction for the technical component of such imaging services 
furnished during CY 2023 or a subsequent year. Computed radiography 
technology is defined for purposes of this paragraph as cassette-based 
imaging that utilizes an imaging plate to create the image involved. 
Section 1848(b)(9) of the Act also requires implementation of the 
reduction in payments through appropriate mechanisms, which can include 
the use of modifiers. In accordance with section 1848(c)(2)(B)(v)(X) of 
the Act, the adjustments under section 1848(b)(9)(A) of the Act are 
exempt from the budget neutrality requirement.
    We stated in the CY 2017 PFS proposed rule that because the 
required reductions in PFS payment for the TC of imaging services 
(including the TC portion of a global service) that are X-rays taken 
using computed radiography technology did not apply for CY 2017, we 
would address implementation of section 1848(b)(9)(B) of the Act in 
future rulemaking. Therefore, to implement the provisions of section 
1848(b)(9)(B) of the Act relating to the payment reduction for the TC 
(including the TC portion of a global service) of X-rays taken using 
computed radiography technology during CY 2018 or subsequent years, we 
are proposing to establish a new modifier to be used on claims for 
these services.
    We are proposing that beginning January 1, 2018, this modifier 
would be required to be used when reporting imaging services for which 
payment is made under the PFS that are X-rays (including the X-ray 
component of a packaged service) taken using computed radiography 
technology. The modifier would be required on claims for the technical 
component of the X-ray service, including when the service is billed 
globally because the PFS payment adjustment is made to the technical 
component regardless of whether it is billed globally, or billed 
separately using the TC modifier. The modifier must be used to report 
the specific services that are subject to the payment reduction and 
accurate use is subject to audit. The use of this proposed modifier to 
indicate an X-ray taken using computed radiography would result in a 7 
percent reduction for CYs 2018 through 2022 and a 10 percent reduction 
for CY 2023 or a subsequent calendar year to the payments for the TC 
for such imaging services furnished as specified under section 
1848(b)(9)(B) of the Act.

G. Proposed Payment Rates Under the Medicare Physician Fee Schedule for 
Nonexcepted Items and Services Furnished by Nonexcepted Off-Campus 
Provider-Based Departments of a Hospital

1. Background
    Sections 1833(t)(1)(B)(v) and (t)(21) of the Act require that 
certain items and services furnished by certain off-campus

[[Page 33979]]

provider-based departments (PBDs) (collectively referenced here as 
nonexcepted items and services furnished by nonexcepted off-campus 
PBDs) shall not be considered covered OPD services for purposes of 
payment under the OPPS, and payment for those nonexcepted items and 
services furnished on or after January 1, 2017 shall be made under the 
applicable payment system. In the CY 2017 OPPS/ASC final rule with 
comment period (81 FR 79713), we finalized the PFS as the ``applicable 
payment system'' for most nonexcepted items and services furnished by 
off-campus PBDs.
    As part of that discussion, we indicated that, in response to 
public comments received on the proposed payment policies for 
nonexcepted items and services, we would issue an interim final rule 
with comment period (the CY 2017 interim final rule, 81 FR 79720 
through 79729) to establish payment policies under the PFS for 
nonexcepted items and services furnished on or after January 1, 2017. 
In the following paragraphs, we propose the payment policies under the 
PFS for nonexcepted items and services furnished during CY 2018. The CY 
2017 interim final rule can be found on the Internet at https://www.gpo.gov/fdsys/pkg/FR-2016-11-14/pdf/2016-26515.pdf. We anticipate 
responding to public comments and finalizing the CY 2017 interim final 
rule in future PFS rulemaking.
2. Payment Mechanism
    Coding and payment policies under the PFS have long recognized the 
differences between the portions of services for which direct costs 
generally are incurred by practitioners and the portions of services 
for which direct costs generally are incurred by facilities. At 
present, the coding and RVUs established for particular groups of 
services under the PFS generally reflect such direct cost differences. 
As described in section II.B of this proposed rule, we establish 
separate nonfacility and facility RVUs for many HCPCS codes describing 
particular services paid under the PFS. For many other services, we 
establish separate RVUs for the professional component and the 
technical component of the service described by the same HCPCS code. 
For other services, we establish RVUs for the different HCPCS codes 
that segregate and describe the discrete professional and technical 
aspects of particular services.
    Because hospitals with nonexcepted off-campus PBDs that furnish 
nonexcepted items and services are likely to furnish a broader range of 
services than other provider or supplier types for which there is a 
separately valued technical component under the PFS, for CY 2017, we 
established a new set of payment rates under the PFS that reflected the 
relative resource costs of furnishing the technical component of a 
broad range of services to be paid under the PFS specific to the off-
campus PBD of a hospital with packaging (bundling) rules that are 
unique to the hospital outpatient setting under the OPPS.
    In principle, the coding and billing mechanisms required to make 
appropriate payment to hospitals for nonexcepted items and services 
furnished by nonexcepted off-campus PBDs are parallel to those used to 
make payment for the technical component services for a range of 
supplier types paid under the PFS. That is, payments to hospitals are 
made for the technical aspect of services, while physicians and other 
practitioners report the professional aspect of these same services. In 
some cases, the entities reporting the technical aspect of services use 
the same coding that is used by the individuals reporting the 
professional services. In other cases, different coding applies. We are 
proposing to maintain this mechanism for CY 2018.
3. Establishment of Payment Rates
    Using the relativity among OPPS payments to establish rates for the 
nonexcepted items and services furnished by nonexcepted off-campus PBDs 
and billed by hospitals under the PFS was only one aspect of 
establishing the necessary relativity of these services under the PFS 
more broadly. It was necessary to estimate the relativity of these 
services compared to PFS services furnished in other settings. For CY 
2017, we used our best estimate of the more general relativity between 
the technical component of PFS services furnished in nonexcepted off-
campus PBDs and all other PFS services furnished in other settings 
using the limited information available to us at that time. As 
described in the CY 2017 interim final rule (81 FR 79722 through 
79726), we estimated that for CY 2017, scaling the OPPS payment rates 
by 50 percent would strike an appropriate balance that avoided 
potentially underestimating the relative resources involved in 
furnishing services in nonexcepted off-campus PBDs as compared to the 
services furnished in other settings for which payment was made under 
the PFS. Specifically, we established site-specific rates under the PFS 
for the technical component of the broad range of nonexcepted items and 
services furnished by nonexcepted off-campus PBDs to be paid under the 
PFS that was based on the OPPS payment amount for the same items and 
services, scaled downward by 50 percent. We called this adjustment the 
``PFS Relativity Adjuster.'' The PFS Relativity Adjuster refers to the 
percentage of the OPPS payment amount paid under the PFS for a 
nonexcepted item or service to the non-excepted off-campus PBD under 
this policy.
a. Methodology for Establishing CY 2017 PFS Relativity Adjuster
    In developing the CY 2017 interim final rule, we began by analyzing 
hospital outpatient claims data from January 1 through August 26, 2016, 
that contained the ``PO'' modifier signifying that they were billed by 
an off-campus department of a hospital paid under the OPPS other than a 
remote location, a satellite facility, or a dedicated emergency 
department (ED). We noted that the use of the ``PO'' modifier was a new 
mandatory reporting requirement for CY 2016. We limited our analysis to 
those claims billed on the 13X Type of Bill because those claims were 
used for Medicare Part B billing under the OPPS. We then identified the 
top (most frequently billed) 25 major codes that were billed by claim 
line; that is, items and services that were separately payable or 
conditionally packaged. Specifically, we restricted our analysis to 
codes with OPPS status indicators ``J1'', ``J2'', ``Q1'', ``Q2'', 
``Q3'', ``S'', ``T'', or ``V''. We did not include separately payable 
drugs or biologicals in this analysis because those drugs or 
biologicals were not paid under the PFS under the CY 2017 interim final 
rule. As such, under the CY 2017 interim final rule, the PFS Relativity 
Adjuster did not apply to separately payable drugs and biologicals 
furnished by a nonexcepted PBD. Similarly, we excluded codes assigned 
an OPPS status indicator ``A'' because the services described by those 
codes were already paid at a rate under a fee schedule other than the 
OPPS and payment for those nonexcepted items and services was not 
changed by the rates established under the CY 2017 interim final rule. 
Next, for the same major codes (or analogous codes in the rare instance 
that different coding applies under the OPPS than the PFS), we compared 
the CY 2016 payment rate under the OPPS to a CY 2016 payment rate under 
the PFS attributable to the nonprofessional relative resource costs 
involved in furnishing the services.
    The most frequently billed service with the ``PO'' modifier was 
described by HCPCS code G0463 (Hospital outpatient clinic visit for 
assessment and management of a patient), which is paid under APC 5012; 
the total number

[[Page 33980]]

of CY 2016 claim lines for that service was approximately 6.7 million 
as of August 2016. In CY 2016, the OPPS payment rate for APC 5012 was 
$102.12. Because there were multiple CPT codes (CPT codes 99201 through 
99215) used under the PFS for billing that service, an exact comparison 
between the $102.12 OPPS payment rate for APC 5012 and the payment rate 
for a single CPT code billed under the PFS was not possible. However, 
for purposes of the analysis, we examined the difference between the 
nonfacility payment rates and the facility payment rates under the PFS 
for CPT codes 99213 and 99214, which were the billing codes for a Level 
III and a Level IV office visit. While we did not have data to 
precisely determine the equivalent set of PFS visit codes to use for 
the comparison, we believed that, based on the distribution of services 
billed for the visit codes under the PFS and the distribution of the 
visit codes under the OPPS from the last time period the CPT codes were 
used under the OPPS in CY 2014, those two codes provided reliable 
points of comparison. For CPT code 99213, the difference between the 
nonfacility payment rate and the facility payment rate under the PFS in 
CY 2016 was $21.86, which was 21 percent of the OPPS payment rate for 
APC 5012 of $102.12. For CPT code 99214, the difference between the 
nonfacility payment rate and the facility payment rate under the PFS in 
CY 2016 was $29.02, which was 28 percent of the OPPS payment rate for 
APC 5012. However, we recognized that, due to the more extensive 
packaging that occurred under the OPPS for services provided along with 
clinic visits relative to the more limited packaging that occurred 
under the PFS for office visits, those payment rates were not entirely 
comparable.
    We then assessed the next 24 major codes most frequently billed on 
the 13X claim form by hospitals. We removed HCPCS code 36591 
(Collection of blood specimen from a completely implantable venous 
access device) because, under current PFS policies, the code is used 
only to pay separately under the PFS when no other service was on the 
claim. We also removed HCPCS code G0009 (Administration of Pneumococcal 
Vaccine) because there was no payment for the code under the PFS. For 
the remaining 22 major codes most frequently billed, we estimated the 
amount that would have been paid to the physician in the office setting 
under the PFS for practice expenses not associated with the 
professional component of the service. As indicated in Table 9, this 
amount reflected (1) the difference between the PFS nonfacility payment 
rate and the PFS facility rate, (2) the technical component, or (3) in 
instances where payment would have been made only to the facility or 
only to the physician, the full nonfacility rate. This estimate ranged 
from zero percent to 137.8 percent of the OPPS payment rate for a code. 
Overall, the average (weighted by claim line volume times rate) of the 
nonfacility payment rate estimate for the PFS compared to the estimate 
for the OPPS for the 22 remaining major codes was 45 percent.

Table 9--Comparison of CY 2016 OPPS Payment Rate to CY 2016 PFS Payment Rate for Top Hospital Codes Billed Using
                                               the ``PO'' Modifier
----------------------------------------------------------------------------------------------------------------
                                                                    CY 2016
                                                                applicable PFS   Col (5) as a
 HCPCS code   Code description    Total claim    CY 2016 OPPS      technical      percent of      PFS estimate
                                     lines       payment rate   payment amount       OPPS
                                                                    estimate
(1)           (2).............             (3)             (4)             (5)                  (6)
----------------------------------------------------------------------------------------------------------------
96372.......  Injection                338,444          $42.31          $25.42            60.1  Single rate paid
               beneath the                                                                       exclusively to
               skin or into                                                                      either
               muscle for                                                                        practitioner or
               therapy,                                                                          facility: Full
               diagnosis, or                                                                     nonfacility
               prevention.                                                                       rate.
71020.......  X-ray of chest,          333,203           60.80           16.83            27.7  Technical
               2 views, front                                                                    component: Full
               and side.                                                                         nonfacility
                                                                                                 rate.
93005.......  Routine                  318,099           55.94            8.59            15.4  Technical
               electrocardiogr                                                                   component: Full
               am (EKG) with                                                                     nonfacility
               tracing using                                                                     rate.
               at least 12
               leads.
96413.......  Infusion of              254,704          280.27          136.41            48.7  Single rate paid
               chemotherapy                                                                      exclusively to
               into a vein up                                                                    either
               to 1 hour.                                                                        practitioner or
                                                                                                 facility: Full
                                                                                                 nonfacility
                                                                                                 rate.
93798.......  Physician                203,926          103.92           11.10            10.7  Nonfacility
               services for                                                                      rate--Facility
               outpatient                                                                        rate.
               heart
               rehabilitation
               with continuous
               EKG monitoring
               per session.
96375.......  Injection of             189,140           42.31           22.56            53.3  Single rate paid
               different drug                                                                    exclusively to
               or substance                                                                      either
               into a vein for                                                                   practitioner or
               therapy,                                                                          facility: Full
               diagnosis, or                                                                     nonfacility
               prevention.                                                                       rate.
93306.......  Ultrasound               179,840          416.80          165.77            39.8  Technical
               examination of                                                                    component: Full
               heart including                                                                   nonfacility
               color-depicted                                                                    rate.
               blood flow
               rate,
               direction, and
               valve function.
77080.......  Bone density             155,513          100.69           31.15            30.9  Technical
               measurement                                                                       component: Full
               using dedicated                                                                   nonfacility
               X-ray machine.                                                                    rate.
77412.......  Radiation                137,241          194.35          267.86           137.8  Technical
               treatment                                                                         component (Full
               delivery.                                                                         nonfacility
                                                                                                 rate) based on
                                                                                                 weighted
                                                                                                 averages for
                                                                                                 the following
                                                                                                 PFS codes:
                                                                                                 G6011; G6012;
                                                                                                 G6013; and
                                                                                                 G6014.

[[Page 33981]]

 
90853.......  Group                    123,282           69.65            0.36             0.5  Nonfacility
               psychotherapy.                                                                    rate--Facility
                                                                                                 rate.
96365.......  Infusion into a          122,641          173.18           69.82            40.3  Nonfacility
               vein for                                                                          rate--Facility
               therapy,                                                                          rate.
               prevention, or
               diagnosis up to
               1 hour.
20610.......  Aspiration and/          106,769          223.76           13.96             6.2  Nonfacility
               or injection of                                                                   rate--Facility
               large joint or                                                                    rate.
               joint capsule.
11042.......  Removal of skin           99,134          225.55           54.78            24.3  Nonfacility
               and tissue                                                                        rate--Facility
               first 20 sq cm                                                                    rate.
               or less.
96367.......  Infusion into a           98,930           42.31           30.79            72.8  Single rate paid
               vein for                                                                          exclusively to
               therapy                                                                           either
               prevention or                                                                     practitioner or
               diagnosis                                                                         facility: Full
               additional                                                                        nonfacility
               sequential                                                                        rate.
               infusion up to
               1 hour.
93017.......  Exercise or drug-         96,312          220.35           39.74            18.0  Technical
               induced heart                                                                     component: Full
               and blood                                                                         nonfacility
               vessel stress                                                                     rate.
               test with EKG
               tracing and
               monitoring.
77386.......  Radiation                 81,925          505.51          347.30            68.7  Technical
               therapy                                                                           component:
               delivery.                                                                         Nonfacility
                                                                                                 rate for CPT
                                                                                                 code G6015
                                                                                                 (analogous code
                                                                                                 used under the
                                                                                                 PFS).
78452.......  Nuclear medicine          79,242        1,108.46          412.82            37.2  Technical
               study of                                                                          component: Full
               vessels of                                                                        nonfacility
               heart using                                                                       rate.
               drugs or
               exercise
               multiple
               studies.
74177.......  CT scan of                76,393          347.72          220.20            63.3  Technical
               abdomen and                                                                       component: Full
               pelvis with                                                                       nonfacility
               contrast.                                                                         rate.
71260.......  CT scan chest             75,052          236.86          167.21            70.6  Technical
               with contrast.                                                                    component: Full
                                                                                                 nonfacility
                                                                                                 rate.
71250.......  CT scan chest...          74,570          112.49          129.61           115.2  Technical
                                                                                                 component: Full
                                                                                                 nonfacility
                                                                                                 rate.
73030.......  X-ray of                  71,330           60.80           19.33            31.8  Technical
               shoulder,                                                                         component: Full
               minimum of 2                                                                      nonfacility
               views.                                                                            rate.
90834.......  Psychotherapy,            70,524          125.04            0.36             0.3  Nonfacility
               45 minutes with                                                                   rate--Facility
               patient and/or                                                                    rate.
               family member.
----------------------------------------------------------------------------------------------------------------
Weighted Average (claim line volume*rate) of the PFS payment compared to OPPS payment for the   45%
 22 major codes:
----------------------------------------------------------------------------------------------------------------

    As noted with the clinic visits, we recognized that there were 
limitations to our data analysis, including that OPPS payment rates 
include the costs of packaged items or services billed with the 
separately payable code, and therefore the comparison to rates under 
the PFS was not a one-to-one comparison. Also, we included only a 
limited number of services, and noted that additional services may have 
different patterns than the services described. After considering the 
payment differentials for major codes billed by off-campus departments 
of hospitals with the ``PO'' modifier and based on the data limitations 
of our analysis, we adopted, with some exceptions noted below, a set of 
PFS payment rates that were based on a 50-percent PFS Relativity 
Adjuster to the OPPS payment rates (inclusive of packaging) for 
nonexcepted items and services furnished by nonexcepted off-campus PBDs 
in the CY 2017 interim final rule. Generally speaking, we arrived at 
the 50 percent PFS Relativity Adjuster by examining the 45-percent 
comparison noted above, the ASC payment rate--which was roughly 55 
percent of the OPPS payment rate on average--and the payment rate 
differential for the large number of OPPS and PFS evaluation and 
management services, as described above. We recognized that the 
equivalent PFS nonfacility rates may be higher or lower on a code-
specific basis than the rates that result from applying the overall PFS 
Relativity Adjuster to the OPPS payment rates on a code specific basis. 
However, we believed that, on the whole, the percentage reduction did 
not underestimate the overall relativity between the OPPS and the PFS 
based on the limited data that was available. We were concerned, 
however, that the 50 percent PFS Relativity Adjuster might overestimate 
PFS nonfacility payments relative to OPPS payments. For example, if we 
were able at the time to sufficiently estimate the effect of the 
packaging differences between the OPPS and PFS, we suspected that the 
equivalent portion of PFS payments for evaluation and management codes, 
and for PFS services on average, would likely have been less than 50 
percent for the same services. We considered the 50 percent PFS 
Relativity Adjuster for CY 2017 to be a transitional policy until such 
time that we had more precise data to better

[[Page 33982]]

identify and value nonexcepted items and services furnished by 
nonexcepted off-campus PBDs and billed by hospitals.
    We established several significant exceptions to the application of 
the 50 percent PFS Relativity Adjuster. For example, we did not apply 
the 50 percent PFS Relativity Adjuster to services that are currently 
paid under the OPPS based on payment rates from other Medicare fee 
schedules (including the PFS) on an institutional claim. The items and 
services that are assigned status indicator ``A'' in Addendum B to the 
CY 2017 OPPS/ASC final rule with comment period (available on the CMS 
Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1656-FC.html) continue to be reported on an 
institutional claim and paid under the PFS, the CLFS, or the Ambulance 
Fee Schedule (ASC) without a payment reduction. Similarly, drugs and 
biologicals that are separately payable under the OPPS (identified by 
status indicator ``G'' or ``K'' in Addendum B to the CY 2017 OPPS/ASC 
final rule with comment period) are paid in accordance with section 
1847A of the Act (that is, typically ASP + 6 percent), consistent with 
payment rules in the physician office setting. Drugs and biologicals 
that are unconditionally packaged under the OPPS and are not separately 
payable (that is, those drugs and biologicals assigned status indicator 
of ``N'' in Addendum B to the CY 2017 OPPS/ASC final rule with comment 
period) are bundled into the PFS payment and are not separately paid to 
hospitals billing for nonexcepted items and services furnished by 
nonexcepted off-campus PBDs. The full range of exceptions and 
adjustments to the otherwise applicable OPPS payment rate that were 
adopted in the new PFS site-of-service payment rates in the CY 2017 
interim final rule can be found on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/CMS-1656-FC-2017-OPPS-Status-Indicator.zip.
    All nonexcepted items and services furnished by nonexcepted off-
campus PBDs and billed by a hospital on an institutional claim with 
modifier ``PN'' (Nonexcepted service provided at an off-campus, 
outpatient, provider-based department of a hospital) are currently paid 
under the PFS at the rate established in the CY 2017 interim final 
rule. Specifically, nonexcepted off campus PBDs must report modifier 
``PN'' on each UB-04 claim line to indicate a nonexcepted item or 
service, and otherwise continue to bill as they currently do. Further 
billing instructions on the PN modifier can be found in the January 
2017 OPPS Quarterly Update (transmittal 3685, Change Request 9930) 
released December 22, 2016, available on the CMS Web site at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3685CP.pdf.
b. PFS Relativity Adjuster
    As noted in the CY 2017 interim final rule, we considered the CY 
2017 50 percent PFS Relativity Adjuster to be a transitional policy 
until such time that we had more precise data to better identify and 
value nonexcepted items and services furnished by nonexcepted off-
campus PBDs and billed by hospitals. At present, we do not have more 
precise data than were available when we established the PFS Relativity 
Adjuster in the CY 2017 interim final rule, and we do not anticipate 
having such data until after the end of CY 2017, at the earliest. 
However, in developing a proposed policy for CY 2018, we have continued 
to explore options for modifying the calculation of the CY 2018 PFS 
Relativity Adjuster.
    There is no consensus among stakeholders regarding the appropriate 
PFS Relativity Adjuster. Many stakeholders have suggested that making 
separate facility fee payments to hospitals under the PFS for all 
services that are separately paid under the OPPS itself undermines 
site-neutral payment because practitioners are only paid a single 
combined fee for many services when furnished in an office setting, 
while there are two separate fees (professional and facility) paid when 
the service is furnished in the hospital setting. We acknowledge that 
there are many cases where single fees are paid to practitioners for 
services furnished in an office setting while fees for comparable 
services when furnished in the hospital setting are paid to both the 
professional and facility entities. However, we do not agree that this 
necessarily means that overall payment cannot be site neutral. We point 
out that the sum of the professional and the facility portions of 
payment for a service furnished in a nonexcepted off-campus PBD or in a 
different institutional setting could be equivalent to a single fee 
paid to the professional in the office setting. In the case of some 
services, in fact, the single payment made under the PFS at the 
nonfacility rate exceeds the sum of the separate payments Medicare 
makes to the professional at the facility rate under the PFS and to the 
facility under the OPPS. We also note that there are many separately 
reportable services under the PFS (for example, the vast majority of 
services described by add-on codes) for which separate payment is made 
to physician offices but no separate payment is made under either the 
OPPS or under the site-specific PFS payments made to hospitals billing 
for nonexcepted items and services furnished by nonexcepted off-campus 
PBDs. For these reasons, we believe that the overall total payment made 
for services is more relevant to the goal of site neutrality than the 
quantity of individual payments made. Nonetheless, we continue to 
recognize and share stakeholders' concerns regarding the importance of 
equivalent overall payment for services, regardless of setting.
    In considering the appropriate PFS Relativity Adjuster for CY 2018, 
we continue to believe that claims data from CY 2017, which are not yet 
available, are needed to guide potential changes to our general 
approach. In the absence of such data, however, we have continued to 
consider the appropriate PFS Relativity Adjuster based on the 
information that is available. In the analysis we used to establish the 
PFS Relativity Adjuster for CY 2017, we attempted to identify the 
appropriate value by comparing OPPS and PFS payment rates for services 
frequently reported in PBDs and described by the same codes under the 
two payment systems. As we acknowledged in the CY 2017 interim final 
rule, that data analysis did not include the most frequently billed 
service furnished in nonexcepted off-campus hospital PBDs, outpatient 
visits. Outpatient visits are reported using a single code under the 
OPPS and by one of ten different codes under the PFS.
    Consistent with our previously stated concern that the PFS 
Relativity Adjuster for CY 2017 might be too small, generally resulting 
in greater overall payments to hospitals for services furnished by 
nonexcepted off-campus PBDs than would otherwise be paid under the PFS 
in the non-facility setting, we believe it is appropriate to propose 
changing the PFS Relativity Adjuster in order to ensure that payment 
made to these nonexcepted PBDs better aligns with these services that 
are the most frequently furnished in this setting.
    For CY 2018, we propose to revise the PFS Relativity Adjuster for 
nonexcepted items and services furnished by nonexcepted off-campus PBDs 
to be 25 percent of the OPPS payment rate. We arrived at this proposed 
PFS Relativity Adjuster by making a code-level comparison for the 
service most

[[Page 33983]]

commonly billed in the off-campus PBD setting under the OPPS: A clinic 
visit reported using HCPCS code G0463. In order to determine the 
analogous payment for the technical aspects of this service under the 
PFS in nonfacility settings, we compared the CY 2017 OPPS national 
payment rate for HCPCS code G0463 ($102.12) to the difference between 
the nonfacility and facility PFS payment amounts under the PFS using CY 
2017 rates for the weighted average of outpatient visits (CPT codes 
99201-99205 and CPT codes 99211-99215) billed by physicians and other 
professionals in an outpatient hospital place of service.
    This proposed 25 percent PFS Relativity Adjuster is based solely on 
the comparison for the visit services that reflect greater than 50 
percent of services billed in off-campus PBDs. We continue to recognize 
that the comparison between the OPPS and PFS rates for other services 
varies greatly, and that there are other factors, including the 
specific mix of services furnished by non-excepted PBDs, policies 
related to packaging of codes under OPPS, and payment adjustments like 
MPPRs and bundling under the PFS that rely on empirical information 
about whether or not codes are billed on the same day, that contribute 
to the differences in aggregate payment amounts for a broader range of 
services. However, for CY 2018, as for CY 2017, we must set the PFS 
Relativity Adjuster prior to studying the CY 2017 claims data that 
might allow us to consider and incorporate many more factors, including 
the ones stated above. When we established the 50 percent PFS 
Relativity Adjuster for CY 2017, we stated that we did so with the goal 
of ensuring adequate payment but remained concerned that the resulting 
reduction was too small. For CY 2018, we are focused on ensuring that 
we do not overestimate the appropriate overall payments for these 
services. Until we are able to study claims data, we believe that the 
comparison between PFS and OPPS payment for the most common services 
furnished in off-campus PBDs, outpatient visits, is a better proxy than 
our previous approach.
    We welcome stakeholder input with regard to this analysis and the 
resulting rate. We also request comment on whether we should adopt a 
different PFS Relativity Adjuster, such as 40 percent, that represents 
a relative middle ground between the CY 2017 PFS Relativity Adjuster, 
selected to ensure adequate payment to hospitals and our proposed CY 
2018 PFS Relativity Adjuster, selected to ensure that hospitals are not 
paid more than others would be paid through the PFS nonfacility rate. 
We intend to continue to study this issue and welcome comments 
regarding potential future refinements to payment rates for non-
excepted items and services furnished by non-excepted off-campus PBDs 
as we gain more experience with these new site-of-service PFS rates.
    Finally, we note that for CY 2018, as in recent years, the proposed 
annual update to OPPS payments exceeds the proposed annual update to 
PFS payments. Because we are proposing to make a single, across-the-
board and, by necessity, imprecise adjustment to OPPS payment rates to 
establish PFS payment rates for nonexcepted items and services 
furnished by nonexcepted off-campus PBDs, we expect that the actual 
difference between OPPS and PFS payment rates for nonexcepted items and 
services furnished by nonexcepted off-campus PBDs falls in a range 
which includes our proposed PFS Relativity Adjuster (that is, the 
actual differential may differ from our proposed PFS Relativity 
Adjuster). As such, taking into account the differential between the 
OPPS and PFS annual updates by making an adjustment to the PFS 
Relativity Adjuster our proposal for CY 2018 would presume a level of 
precision in our estimates that is simply not present in our analysis. 
Therefore, we will not adjust our proposal to reflect the relative 
updates to PFS and OPPS between CY 2017 and CY 2018, and instead note 
that the differential between the OPPS and PFS payment update for CY 
2018 is a factor that suggests that the proposed PFS Relativity 
Adjuster may overestimate PFS nonfacility payment relative to OPPS 
payments; in future years, we intend to more precisely account for any 
differential between these two update factors.
c. Geographic Adjustments
    For CY 2017, we established class-specific geographic practice cost 
indices (GPCIs) under the PFS exclusively used to adjust these site-
specific, technical component rates for nonexcepted items and services 
furnished in nonexcepted off-campus PBDs. These class-specific GPCIs 
are parallel to the geographic adjustments made under the OPPS based on 
the hospital wage index. We believed it was appropriate to adopt the 
hospital wage index areas for purposes of geographic adjustment because 
non-excepted off-campus PBDs are still considered to be part of a 
hospital, and the PFS payments to these entities will be limited to the 
subset of PFS services furnished by hospitals. We also believed it was 
appropriate, as an initial matter for CY 2017, to adopt the actual wage 
index values for these hospitals in addition to the wage index areas. 
The PFS GPCIs that would otherwise currently apply are not based on the 
hospital wage index areas. For CY 2018, we are proposing to continue 
using the authority under section 1848(e)(1)(B) of the Act to maintain 
a class-specific set of GPCIs for these site-specific technical 
component rates that are based both on the hospital wage index areas 
and the hospital wage index value themselves. For purposes of payment 
to hospitals, this means that the geographic adjustments used under the 
OPPS continue to apply.
d. Coding Consistency
    For most services, the same HCPCS codes are used to describe 
services paid under both the PFS and the OPPS. There are two notable 
exceptions that describe high-volume services. The first is the set of 
codes that describe evaluation and management (E/M) services which are 
reported under the PFS using the 5 levels of CPT codes describing new 
or established patient visits (for a total of 10 codes). However, since 
CY 2014, these visits have been reported under the OPPS using the 
single HCPCS code G0463 (Hospital Outpatient Clinic Visit) (see 78 FR 
75042). We are proposing to maintain the current PFS payment rate for 
HCPCS code G0463 based on the OPPS payment rate modified by the PFS 
Relativity Adjuster.
    The second is a set of radiation treatment delivery and imaging 
guidance services that are reported using different codes under the PFS 
and the OPPS. CMS established HCPCS Level II G codes to describe 
radiation treatment delivery services when furnished in the physician 
office setting (see 79 FR 67666 through 67667). However, these HCPCS G 
codes are not recognized under the OPPS; rather, CPT codes are used to 
describe these services when furnished in the HOPD. Both sets of codes 
were implemented for CY 2015 and were maintained for CY 2016. Under the 
PFS, there is a particular statutory provision under section 
1848(c)(2)(K) of the Act that required maintenance of the CY 2016 
coding and payment inputs for these services for CY 2017 and also for 
CY 2018. Accordingly, the proposed CY 2018 PFS rates for these services 
are calculated based on the maintenance of the CY 2016 coding and 
payment inputs. Because non-excepted items and services furnished by a 
nonexcepted off-campus PBD are paid under the PFS, and we are required 
to maintain the CY 2016 coding and payment inputs for these services 
under

[[Page 33984]]

the CY 2018 PFS, we are proposing to maintain payment amounts for 
nonexcepted items and services furnished by a nonexcepted off-campus 
PBD consistent with the payments that would be made to other facilities 
under the PFS. That is, nonexcepted off-campus PBDs submitting claims 
for these nonexcepted items and services will continue to bill the 
HCPCS G codes established under the PFS to describe radiation treatment 
delivery services. Under this proposal, the nonexcepted off-campus PBD 
must append modifier PN to each applicable claim line for these 
nonexcepted items and services, even though the PFS Relativity Adjuster 
will not apply. The payment amount for these services would be set to 
reflect the technical component rate for the code under the PFS.
4. OPPS Payment Adjustments
    In the CY 2017 interim final rule, we adopted the packaging payment 
rates and multiple procedure payment reduction (MPPR) percentage that 
applied under the OPPS to establish the PFS payment rates for 
nonexcepted items and services furnished by nonexcepted off-campus PBDs 
and billed by hospitals. That is, the claims processing logic that was 
used for payments under the OPPS for comprehensive APCs (C-APCs), 
conditionally and unconditionally packaged items and services, and 
major procedures, was incorporated into the newly established PFS 
rates. We continue to believe it is necessary to incorporate the OPPS 
payment policies for C-APCs, packaged items and services, and the MPPR 
in order to maintain the integrity of the PFS Relativity Adjuster 
because the adjuster is intended in part to account for the 
methodological differences between the OPPS and the PFS rates that 
would otherwise apply. We also direct interested stakeholders to 
related proposed policies under the OPPS, since prospective changes in 
the applicable adjustments and policies would generally apply to non-
excepted items and services furnished by nonexcepted off-campus PBDs 
for CY 2018. We are interested in comments regarding the applicability 
of particular prospective OPPS adjustments to non-excepted items and 
services.
    In order to apply these OPPS payment policies and adjustments to 
non-excepted items and services, we propose that hospitals continue to 
bill on an institutional claim form that will pass through the 
Outpatient Code Editor and into the OPPS PRICER for calculation of 
payment. This approach will yield data based on claims for non-excepted 
items and services furnished by nonexcepted off-campus PBDs, which can 
be used to refine PFS payment rates for these services in future years.
    There were several OPPS payment adjustments that we did not adopt 
in the CY 2017 interim final rule, including, but not limited to, 
outlier payments, the rural sole community hospital (SCH) adjustment, 
the cancer hospital adjustments, transitional outpatient payments, the 
hospital outpatient quality reporting payment adjustment, and the 
inpatient hospital deductible cap to the cost-sharing liability for a 
single hospital outpatient service. We believed these payment 
adjustments were expressly authorized for, and should be limited to, 
hospitals that are paid under the OPPS for covered OPD services in 
accordance with section 1833(t) of the Act. We continue to believe that 
these policies should not apply to non-excepted items and services 
furnished by nonexcepted off-campus PBDs, and are not proposing that 
they apply for CY 2018.
5. Partial Hospitalization Services
    With respect to partial hospitalization programs (PHP) (intensive 
outpatient psychiatric day treatment programs furnished to patients as 
an alternative to inpatient psychiatric hospitalization or as a 
stepdown to shorten an inpatient stay and transition a patient to a 
less intensive level of care), section 1861(ff)(3)(A) of the Act 
specifies that a PHP is a program furnished by a hospital, to its 
outpatients, or by a CMHC. In the CY 2017 OPPS/ASC proposed rule (81 FR 
45690), in the discussion of the proposed implementation of section 603 
of Public Law 114-74, we noted that because CMHCs also furnish PHP 
services and are ineligible to be provider-based to a hospital, a 
nonexcepted off-campus PBD would be eligible for PHP payment if the 
entity enrolls and bills as a CMHC for payment under the OPPS. We 
further noted that a hospital may choose to enroll a nonexcepted off-
campus PBD as a CMHC, provided it meets all Medicare requirements and 
conditions of participation.
    Commenters expressed concern that without a clear payment mechanism 
for PHP services furnished by nonexcepted off-campus PBDs, access to 
partial hospitalization services would be limited, and pointed out the 
critical role PHPs play in the continuum of mental health care. Many 
commenters believed that Congress did not intend for partial 
hospitalization services to no longer be paid for by Medicare when such 
services are furnished by nonexcepted off-campus PBDs. Several 
commenters disagreed with the notion of enrolling as a CMHC in order to 
receive payment for PHP services. These commenters stated that 
hospital-based PHPs and CMHCs are inherently different in structure, 
operation, and payment, and noted that the conditions of participation 
for hospital departments and CMHCs are different. Several commenters 
requested that CMS find a mechanism to pay hospital-based PHPs in 
nonexcepted off-campus PBDs.
    Because we shared the commenters' concerns, in the CY 2017 OPPS/ASC 
final rule with comment period and the CY 2017 interim final rule (81 
FR 79727), we adopted payment for partial hospitalization items and 
services furnished by nonexcepted off-campus hospital-based PBDs under 
the PFS. When billed in accordance with the CY 2017 interim final rule, 
these partial hospitalization services are paid at the CMHC per diem 
rate for APC 5853, for providing three or more partial hospitalization 
services per day (81 FR 79727).
    In the CY 2017 OPPS/ASC proposed rule (81 FR 45681), the CY 2017 
OPPS/ASC final rule with comment period, and the CY 2017 interim final 
rule (81 FR 79727), we noted that when a beneficiary receives 
outpatient services in an off-campus department of a hospital, the 
total Medicare payment for those services is generally higher than when 
those same services are provided in a physician's office. Similarly, 
when partial hospitalization services are provided in a hospital-based 
PHP, Medicare pays more than when those same services are provided by a 
CMHC. Our rationale for adopting the CMHC per diem rate for APC 5853 as 
the PFS payment amount for nonexcepted off-campus PBDs providing PHP 
services is because CMHCs are freestanding entities that are not part 
of a hospital, but they provide the same PHP services as hospital-based 
PHPs (81 FR 79727). This is similar to the differences between 
freestanding entities paid under the PFS that furnish other services 
also provided by hospital-based entities. Similar to other entities 
currently paid for their technical component services under the PFS, we 
believe CMHCs would typically have lower cost structures than hospital-
based PHPs, largely due to lower overhead costs and other indirect 
costs such as administration, personnel, and security. We believe that 
paying for nonexcepted hospital-based partial hospitalization services 
at the lower CMHC per diem rate aligns with section 603 of Pubic Law 
114-74, while also preserving access to PHP services. In addition, 
nonexcepted off-campus PBDs will not be required to enroll as CMHCs

[[Page 33985]]

in order to bill and be paid for providing partial hospitalization 
services. However, a nonexcepted off-campus PBD that wishes to provide 
PHP services may still enroll as a CMHC if it chooses to do so and 
meets the relevant requirements. Finally, we recognize that because 
hospital-based PHPs are providing partial hospitalization services in 
the hospital outpatient setting, they can offer benefits that CMHCs do 
not have, such as an easier patient transition to and from inpatient 
care, and easier sharing of health information between the PHP and the 
inpatient staff. We are not proposing to require these PHPs to enroll 
as CMHCs but instead we are proposing to continue to pay non-excepted 
off-campus PBDs providing PHP items and services under the PFS. 
Further, we are proposing to continue to adopt the CMHC per diem rate 
for APC 5853 as the PFS payment amount for nonexcepted off-campus PBDs 
providing three or more PHP services per day in CY 2018.
6. Supervision Rules
    The supervision rules that apply for hospitals continue to apply 
for nonexcepted off-campus PBDs that furnish nonexcepted items and 
services. The amendments made by section 603 of the Bipartisan Budget 
Act of 2015 (Pub. L. 114-74, enacted November 2, 2015) did not change 
the status of these PBDs, only the status of, and payment mechanism 
for, the services they furnish. These supervision requirements are 
specified in Sec.  410.27.
7. Beneficiary Cost-Sharing
    Under the PFS, the beneficiary copayment is generally 20 percent of 
the fee schedule amount, unless there is an applicable exception in 
accordance with the statute. All cost-sharing rules that apply under 
the PFS in accordance with section 1848(g) of the Act and section 
1866(a)(2)(A) of the Act continue to apply for all nonexcepted items 
and services furnished by nonexcepted off-campus PBDs, regardless of 
the cost-sharing obligation under the OPPS.
8. CY 2019 and Future Years
    We continue to believe the amendments made to the statute by 
section 603 of the Bipartisan Budget Act of 2015 intended to eliminate 
the Medicare payment incentive for hospitals to purchase physician 
offices, convert them to off-campus PBDs, and bill under the OPPS for 
items and services they furnish there. Therefore, we continue to 
believe the payment policy under this provision should ultimately 
equalize payment rates between nonexcepted off-campus PBDs and 
physician offices to the greatest extent possible, while allowing 
nonexcepted off-campus PBDs to bill in a straight-forward way for 
services they furnish.
    We note that a full year of claims data regarding the mix of 
services reported using the ``PN'' modifier (from CY 2017) will first 
be available for use in PFS ratesetting for CY 2019. Under the current 
methodology, we would expect to use that data in order to ensure that 
Medicare payment to hospitals billing for non-excepted items and 
services furnished by nonexcepted off-campus PBDs under the PFS would 
reflect the relative resources involved in furnishing the items and 
services relative to other PFS services. We recognize that under our 
current approach, the payment rates would not be equal on a procedure-
by-procedure basis, application of the PFS Relativity Adjuster would 
move toward equalizing payment rates in the aggregate between physician 
offices and nonexcepted off-campus PBDs to the extent appropriate. 
Therefore, for certain specialties, service lines, and nonexcepted off-
campus PBD types, total Medicare payments for the same services might 
be either higher or lower when furnished by a nonexcepted off-campus 
PBD rather than in a physician office.
    Depending on the mix of services for particular off-campus PBDs, we 
remain concerned that such specialty-specific patterns in payment 
differentials could result in continued incentives for hospitals to buy 
certain types of physician offices and convert them to nonexcepted off-
campus PBDs; these are the incentives we believe Congress intended to 
avoid. However, continuing a policy similar to the one we are proposing 
in this proposed rule would allow hospitals to continue billing through 
a facility claim form and would allow for continuation of the packaging 
rules and cost report-based relative payment rate determinations under 
OPPS, which we believe are preferable to using the current valuation 
methodologies under the PFS that are not well-suited for nonexcepted 
items and services furnished by nonexcepted off-campus PBDs. Therefore, 
for CY 2019 and for future years, we intend to examine the claims data 
in order to determine not only the appropriate PFS Relativity 
Adjuster(s), but also to determine whether additional adjustments to 
the methodology are appropriate--especially with the goal of attaining 
site neutral payments to promote a level playing field under Medicare 
between physician office settings and nonexcepted off-campus PBD 
settings, without regard to the kinds of services furnished by 
particular off-campus PBDs. We solicit comments on potential changes to 
our methodology that would better account for these specialty-specific 
patterns.

H. Proposed Valuation of Specific Codes

1. Background: Process for Valuing New, Revised, and Potentially 
Misvalued Codes
    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 make sure 
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 5-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 5-year review process, revisions in RVUs were proposed 
and finalized via rulemaking. In addition to the 5-year reviews, 
beginning with CY 2009, CMS and the RUC have identified a number of 
potentially misvalued codes each year using various identification 
screens, as discussed in section II.E.4 of this proposed rule. 
Historically, when we received RUC recommendations, our process had 
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 for a year. Then, during the 60-day period 
following the publication of the final rule, we accepted public comment 
about those valuations. For services furnished during the calendar year 
following the publication of interim final rates, we paid for services 
based upon the interim final values established in the final rule. In 
the final rule with comment period for the subsequent year, we 
considered and responded to public comments received on the interim 
final values, and typically made any appropriate adjustments and 
finalized those values.
    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. Beginning with the 
CY 2017 PFS proposed rule, the new process was applicable to all codes, 
except for new codes that describe truly new services.

[[Page 33986]]

For CY 2017, we proposed new values in the CY 2017 PFS proposed rule 
for the vast majority of new, revised, and potentially misvalued codes 
for which we received complete RUC recommendations by February 10, 
2016. To complete the transition to this new process, for codes where 
we established interim final values in the CY 2016 PFS final rule with 
comment period, we reviewed the comments received during the 60-day 
public comment period following release of the CY 2016 PFS final rule 
with comment period, and re-proposed values for those codes in the CY 
2017 PFS proposed rule.
    We considered public comments received during the 60-day public 
comment period for the proposed rule before establishing final values 
in the CY 2017 PFS final rule. As part of our established process we 
will adopt interim final values only 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 2017, we 
were not aware of any new codes that described such wholly new 
services. Therefore, we did not establish any code values on an interim 
final basis.
2. Methodology for Proposing Work RVUs
    We conduct a review of each code identified in this section and 
review the current work RVU (if any), RUC-recommended work RVU, 
intensity, time to furnish the preservice, intraservice, and 
postservice activities, as well as other components of the service that 
contribute to the value. Our reviews of recommended work RVUs and time 
inputs have generally included, but have not been limited to, a review 
of information provided by the RUC, the Health Care Professionals 
Advisory Committee (HCPAC), and other public commenters, medical 
literature, and comparative databases, as well as a comparison with 
other codes within the PFS, consultation with other physicians and 
health care professionals within CMS and the federal government, as 
well as Medicare claims data. We have 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, crosswalks 
to key reference or similar codes, and magnitude estimation (see the CY 
2011 PFS final rule with comment period (75 FR 73328 through 73329) for 
more information). When referring to a survey, unless otherwise noted, 
we mean the surveys conducted by specialty societies as part of the 
formal RUC process. We have used the building block methodology to 
construct, or deconstruct, the work RVU for a CPT code based on 
component pieces of the code.
    Components that we have used in the building block approach may 
have included 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 work that determines the appropriate work 
RVU for a service by gauging the total amount of work for that service 
relative to the work for a similar service across the PFS without 
explicitly valuing the components of that work. In addition to these 
methodologies, we have frequently utilized an incremental methodology 
in which we value a code based upon its incremental difference between 
another code and another family of codes. The statute specifically 
defines the work component as the resources in time and intensity 
required in furnishing the service. Also, the published literature on 
valuing work has recognized the key role of time in overall work. For 
particular codes, we have refined the work RVUs in direct proportion to 
the changes in the best information regarding the time resources 
involved in furnishing particular services, either considering the 
total time or the intraservice time.
    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 preservice time packages for 
services typically furnished in the facility setting (for example: 
Preservice time packages reflecting the different combinations of 
straightforward or difficult procedure, and straightforward or 
difficult patient). Currently, there are three preservice time packages 
for services typically furnished in the nonfacility setting.
    We 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 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. Our longstanding adjustments have 
reflected a broad assumption 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 
have believed that the RUC has not adequately accounted for the 
overlapping activities in the recommended work RVU and/or times, we 
have adjusted 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 multiplied by 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 have removed 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 have also 
removed a work RVU of 0.09 (4 minutes x 0.0224 IWPUT) if we have not 
believed the overlap in time had already been accounted for in the work 
RVU. The RUC has recognized this valuation policy and, in many cases, 
now addresses the overlap in time and work when a service is typically 
furnished on the same day as an E/M service.
    We note that many commenters and stakeholders have expressed 
concerns with our ongoing adjustment of work RVUs based on changes in 
the best information we have had regarding the time resources involved 
in furnishing individual services. We have been particularly concerned 
with the RUC's and various specialty societies' objections to our 
approach given the significance of their recommendations to our process 
for valuing services and since much of the information we have used to 
make the adjustments is derived from their survey process. We are 
statutorily obligated to consider both time and intensity in 
establishing work RVUs for PFS services. As explained in the CY 2016 
PFS final rule with comment period (80 FR 70933), we recognize that 
adjusting work RVUs for changes in time is not always a straightforward 
process, so we have applied various methodologies to identify several 
potential work values for individual codes.

[[Page 33987]]

    We have observed that for many codes reviewed by the RUC, 
recommended work RVUs have appeared to be incongruous with recommended 
assumptions regarding the resource costs in time. This has been the 
case for a significant portion of codes for which we have recently 
established or proposed work RVUs that are based on refinements to the 
RUC-recommended values. When we have adjusted work RVUs to account for 
significant changes in time, we have begun by looking at the change in 
the time in the context of the RUC-recommended work RVU. When the 
recommended work RVUs have not appeared to account for significant 
changes in time, we have employed the different approaches to identify 
potential values that reconcile the recommended work RVUs with the 
recommended time values. Many of these methodologies, such as survey 
data, building block, crosswalks to key reference or similar codes, and 
magnitude estimation have long been used in developing work RVUs under 
the PFS. In addition to these, we have sometimes used the relationship 
between the old time values and the new time values for particular 
services to identify alternative work RVUs based on changes in time 
components.
    In so doing, rather than ignoring the RUC-recommended value, we 
have used the recommended values as a starting reference and then 
applied one of these several methodologies to account for the 
reductions in time that we believe had not otherwise been reflected in 
the RUC-recommended value. When we have believed that such changes in 
time have already been accounted for in the RUC recommendation, then we 
have not made such adjustments. Likewise, we have not arbitrarily 
applied time ratios to current work RVUs to calculate proposed work 
RVUs. We have used the ratios to identify potential work RVUs and 
considered these work RVUs as potential options relative to the values 
developed through other options.
    We do not imply that the decrease in time as reflected in survey 
values must equate to a one-to-one or linear decrease in newly valued 
work RVUs. Instead, we have believed that, since the two components of 
work are time and intensity, absent an obvious or explicitly stated 
rationale for why the relative intensity of a given procedure has 
increased, significant decreases in time should be reflected in 
decreases to work RVUs. If the RUC recommendation had appeared to 
disregard or dismiss the changes in time, without a persuasive 
explanation of why such a change should not be accounted for in the 
overall work of the service, then we have generally used one of the 
aforementioned referenced methodologies to identify potential work 
RVUs, including the methodologies intended to account for the changes 
in the resources involved in furnishing the procedure.
    Several stakeholders, including the RUC, in general have objected 
to our use of these methodologies and deemed our actions in adjusting 
the recommended work RVUs as inappropriate; other stakeholders have 
also expressed concerns with CMS refinements to RUC recommended values 
in general. In the CY 2017 PFS final rule (81 FR 80272 through 80277) 
we responded in detail to several comments that we received regarding 
this issue. In the CY 2017 PFS proposed rule, we requested comments 
regarding potential alternatives to making adjustments that would 
recognize overall estimates of work in the context of changes in the 
resource of time for particular services; however, we did not receive 
any specific potential alternatives as requested.
    In developing proposed values for new, revised, and potentially 
misvalued codes for CY 2018, we considered the lack of alternative 
approaches to making the adjustments, especially since many 
stakeholders have routinely urged us to propose and finalize the RUC 
recommended values. We also considered the RUC's consistent reassurance 
that these kinds of concerns (regarding changes in time, for example) 
had already been considered, and either incorporated or dismissed, as 
part of the development of their recommended values. These have led us 
to shift our approach to reviewing RUC recommendations, especially as 
we believe that the majority of practitioners paid under the PFS, 
though not necessarily those in any particular specialty, would prefer 
CMS rely more heavily on RUC recommended values in establishing payment 
rates under the PFS.
    For CY 2018, we have generally proposed RUC-recommended work RVUs 
for new, revised, and potentially misvalued codes. We are proposing 
these values based on our understanding that the RUC generally 
considers the kinds of concerns we have historically raised regarding 
appropriate valuation of work RVUs. During our review of these 
recommended values, however, we identified some concerns similar to 
those we have recognized in prior years. Given the relative nature of 
the PFS and our obligation to ensure that the RVUs reflect relative 
resource use, we have included descriptions of potential approaches we 
might have taken in developing work RVUs that differ from the RUC 
recommended values. We are seeking comment on both the RUC-recommended 
values as well as the alternatives considered.
    Table 10 contains a list of codes for which we proposed work RVUs; 
this includes all codes for which we received RUC recommendations by 
February 10, 2017. The proposed work RVUs, work time and other payment 
information for all proposed CY 2018 payable codes are available on the 
CMS Web site under downloads for the CY 2018 PFS proposed rule at 
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. Table 10 also 
contains the CPT code descriptors for all proposed, new, revised, and 
potentially misvalued codes discussed in this section.
3. Methodology for Proposing the Direct PE Inputs To Develop PE RVUs
a. Background
    On an annual basis, the RUC provides us 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 PFS, and consultation with 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's recommendations appropriately estimate the 
direct PE inputs (clinical labor, disposable supplies, and medical 
equipment) required for the typical service, are 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 inputs 
includes many refinements that are common

[[Page 33988]]

across codes, as well as refinements that are specific to particular 
services. Table 11 details our proposed 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 proposed impact on direct costs for that 
service. We note that, on average, in any case where the impact on the 
direct cost for a particular refinement is $0.30 or less, the 
refinement has no impact on the proposed 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 proposed refinements listed in Table 
11 result in changes under the $0.30 threshold and are unlikely to 
result in a change to the proposed RVUs.
    We also note that the proposed direct PE inputs for CY 2018 are 
displayed in the CY 2018 direct PE input database, available on the CMS 
Web site under the downloads for the CY 2018 PFS proposed rule at 
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html. The inputs 
displayed there have also been used in developing the proposed CY 2018 
PE RVUs as displayed in Addendum B.
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. The direct PE input recommendations generally 
correspond to the work time values associated with services. We believe 
that inadvertent discrepancies between work time values and direct PE 
inputs should be refined or adjusted in the establishment of proposed 
direct PE inputs to resolve the discrepancies.
(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 over several years of rulemaking, 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 preservice 
or postservice tasks performed by clinical labor staff on the day of 
the procedure (the clinical labor service period) and are typically 
available for other patients even when one member of the clinical staff 
may be occupied with a preservice or postservice 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 since any items in the room in question would be available if the 
room is not being occupied by a particular patient. For additional 
information, we refer readers to our discussion of these issues 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, 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, we review 
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 conform to the standard times 
for those tasks. In addition, in cases when a service is typically 
billed with an E/M service, we remove the preservice clinical labor 
tasks to avoid duplicative inputs and to reflect the resource costs of 
furnishing the typical service.
    We refer readers to section II.B. of this proposed rule for more 
information regarding the collaborative work of CMS and the RUC in 
improvements in standardizing clinical labor tasks.
(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 or that cannot be allocated to 
individual services or patients. We have addressed these kinds of 
recommendations in previous rulemaking (78 FR 74242), and we do not use 
items included in these recommendations as direct PE inputs in the 
calculation of PE RVUs.
(5) 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, however, include 
supply or equipment items that are not currently in the direct PE input 
database. In these cases, the RUC has historically recommended that a 
new item be created and has facilitated our pricing of that item by 
working with the specialty societies to provide us copies of sales 
invoices. For CY 2018, we received invoices for several new supply and 
equipment items. Tables 13 and 14 detail the invoices received for new 
and existing items in the direct PE database. As discussed in section 
II.B. of this proposed rule, we encourage stakeholders to review the 
prices associated with these new and existing

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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 during the 60-day public comment period for 
this proposed rule. We expect that invoices received outside of the 
public comment period would be submitted by February 10th of the 
following year for consideration in future rulemaking, similar to our 
new process for consideration of RUC recommendations.
    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 13 and 14 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. A single invoice may not be reflective of 
typical costs and we 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 use 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.
(6) Service Period Clinical Labor Time in the Facility Setting
    Generally speaking, our proposed inputs did not include clinical 
labor minutes assigned to the service period 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. 
We address proposed code-specific refinements to clinical labor in the 
individual code sections.
(7) Procedures Subject to the Multiple Procedure Payment Reduction 
(MPPR) and the OPPS Cap
    We note that the public use files for the PFS proposed and final 
rules for each year display both the services subject to the MPPR lists 
on diagnostic cardiovascular services, diagnostic imaging services, 
diagnostic ophthalmology services and therapy services and the list of 
procedures that meet the definition of imaging under section 
1848(b)(4)(B) of the Act, and therefore, are subject to the OPPS cap 
for the upcoming calendar year. The public use files for CY 2018 are 
available on the CMS Web site under downloads for the CY 2018 PFS 
proposed rule at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html For more 
information regarding the history of the MPPR policy, we refer readers 
to the CY 2014 PFS final rule (78 FR 74261-74263). For more information 
regarding the history of the OPPS cap, we refer readers to the CY 2007 
PFS final rule (71 FR 69659-69662).
4. Proposed Valuation of Specific Codes for CY 2018
(1) Anesthesia Services for Gastrointestinal (GI) Procedures (CPT codes 
007X1, 007X2, 008X1, 008X2, and 008X3)
    In the CY 2016 PFS proposed rule (80 FR 41686), we discussed that 
in reviewing Medicare claims data, a separate anesthesia service is 
typically reported more than 50 percent of the time that various 
colonoscopy procedures are reported. We discussed that given the 
significant change in relative frequency with which anesthesia codes 
are reported with colonoscopy services, we believed the relative values 
of the anesthesia services should be reexamined and proposed to 
identify CPT codes 00740 (Anesth upper gi visualize) and 00810 (Anesth 
low intestine scope) as potentially misvalued. For CY 2018, the CPT 
Editorial Panel is deleting CPT codes 00740 and 00810 and creating new 
codes for anesthesia services furnished in conjunction with and in 
support of gastrointestinal endoscopic procedures: Two codes for upper 
GI procedures (007X1 and 007X2), two codes for lower GI procedures 
(008X1 and 008X2), and one code for upper and lower GI procedures 
(008X3).
    For CY 2018, we are proposing the RUC-recommended base units 
without refinement for CPT codes 007X1 (5.00 base units), 007X2 (6.00 
base units), 008X1 (4.00 base units), 008X2 (4.00 base units) and 008X3 
(5.00 base units). We considered 3.00 base units (the 25th percentile 
survey result) for CPT code 008X2 (Anesthesia for lower intestinal 
endoscopic procedures, endoscope introduced distal to duodenum; 
screening colonoscopy), based on our comparison of the surveyed post-
induction anesthesia-intensity allocation for CPT code 008X2 to codes 
with similar allocations (CPT code 01382 (Anesth dx knee arthroscopy)). 
We found that CPT code 01382, which was also valued with 3.00 base 
units, had similar allocations compared to the survey results for CPT 
code 008X2. We are seeking comment on our proposed and alternative 
value for CPT code 008X2.
(2) Acne Surgery (CPT code 10040)
    CPT code 10040 was identified as potentially misvalued on a screen 
of Harvard-valued codes with utilization over 30,000 in CY 2014. We are 
proposing the RUC-recommended work RVU of 0.91 for CPT code 10040 and 
the RUC-recommended work time values. We considered using the current 
number of 0.5 post-procedure office visits of CPT code 99212 (Office/
outpatient visit est) rather than the RUC-recommended number of 1.0 
post-procedure office visits. For CPT code 10040, the RUC states that 
it is a low intensity service that can be performed by a nurse under a 
physician's supervision, and that the average number of office visits 
in the follow-up period of acne surgery is 0.4. We are seeking public 
comments regarding the typical number of postoperative visits for this 
code, considering there have been no changes made to the code 
descriptor and we have not found evidence of changes to the typical 
patient population.
    We are proposing the RUC-recommended direct PE inputs for CPT code 
10040 without refinement. We considered refinements to the clinical

[[Page 33990]]

labor for ``Assist physician in performing procedure'' from 10 minutes 
to 3 minutes. CPT code 10040 previously used about one third of the 
intraservice work time for this clinical labor activity (5 minutes out 
of 14 minutes), and the RUC-recommended value of 10 minutes would have 
increased this to 100 percent of the intraservice work time without 
rationale for the change. We considered 3 minutes for this clinical 
labor activity, which is about one third of the intraservice work time 
(3 minutes out of 10 minutes) and would have maintained the current 
ratio between clinical labor time and work time.
    For CY 2018, we are proposing the RUC-recommended work RVUs and 
direct PE inputs for CPT code 10040 and are seeking comment on our 
proposed and alternative values.
(3) Muscle Flaps (CPT codes 15734, 15736, 15738, 157X1, and 157X2)
    CPT codes 15732 and 15736 were identified via a screen of high 
level E/M visits included in their global periods. This screen 
identified that a CPT code 99214 office visit was included for CPT 
codes 15732 and 15736 but not included in the other codes in this 
family. During the review process for this family of codes, CPT code 
15732 was deleted and replaced with two new codes, CPT codes 157X1 and 
157X2, to better differentiate and describe the work of large muscle 
flaps performed on patients with head and neck cancer depending on the 
site where the service was performed.
    For CY 2018, we are proposing the RUC-recommended work RVUs for CPT 
codes 15734 (a work RVU of 23.00), 15736 (a work RVU of 17.04), 15738 
(a work RVU of 19.04), 157X1 (a work RVU of 13.50), and 157X2 (a work 
RVU of 15.68). For CPT code 157X1, we considered a work RVU of 12.03, 
crosswalking to CPT code 36830 (Creation of arteriovenous fistula by 
other than direct arteriovenous anastomosis (separate procedure); 
nonautogenous graft (eg, biological collagen, thermoplastic graft)). We 
have concerns because the RUC-recommended work RVU of 13.50 would 
represent nearly double the intensity of CPT codes 15734 through 15738, 
as well as nearly double the intensity of deleted CPT code 15732. The 
RUC-recommended work RVU for CPT code 157X1 is also based on a direct 
crosswalk to CPT code 36832 (Revision, open, arteriovenous fistula; 
without thrombectomy, autogenous or nonautogenous dialysis graft 
(separate procedure)), which has the same intraservice time, but with 
20 additional minutes of total time. We considered a potential 
crosswalk to another code in the same family, CPT code 36830, which 
also shares the same intraservice time with CPT code 157X1 but differs 
by only 8 minutes of total time. However, we seek comment on whether 
the RUC recommendation is appropriate given the significant variation 
in intensity among these services.
    We considered a work RVU of 14.63 for CPT code 157X2 (survey 25th 
percentile), crosswalking to CPT code 36833 (Revision, open, 
arteriovenous fistula; with thrombectomy, autogenous or nonautogenous 
dialysis graft (separate procedure)), which has the same intraservice 
time, 1 minute of additional total time, and a work RVU of 14.50. We 
are seeking comment on the effect that an alternative work RVU of 14.50 
would have on relativity among the codes in this family.
    We considered refining the clinical labor time for ``Check 
dressings & wound/home care instructions'' for CPT code 157X1 from 10 
minutes to 5 minutes. We are seeking comment on the typical time input 
for checking dressings, and whether removing and replacing dressings, 
would typically take place during the intraservice or postservice 
period.
    We are also seeking comments regarding the use of the new ``plate, 
surgical, mini-compression, 4 hole'' (SD189) supply included in CPT 
code 157X1, including whether use of this supply would be typical, and 
if so, whether it should be included in the work description. We note 
that SD189 is mentioned in the direct PE recommendations, but the 
supply does not appear in the work description. In the work 
description, the fixation screws are applied to the orbital rim and 
lateral nasal wall, not the surgical plate.
(4) Application of Rigid Leg Cast (CPT code 29445)
    CPT code 29445 appeared on a high growth screen of all services 
with total Medicare utilization of 10,000 or more that increased by at 
least 100 percent from 2008 through 2013. This screen also indicated 
that the code was last surveyed more than 10 years previously, and that 
the dominant specialty had changed during that time.
    For CY 2018, we are proposing the RUC-recommended work RVU of 1.78 
for CPT code 29445. For the direct PE inputs, we are proposing to 
refine the clinical labor time for ``Check dressings & wound/home care 
instructions'' from 5 minutes to 3 minutes. We believe that the 
additional 2 minutes of clinical labor time that we are proposing to 
remove would take place during the monitoring time following the 
procedure and be accounted for in that clinical labor time.
    We also considered refining the clinical labor time for ``Remove 
cast'' from 22 minutes to 11 minutes: 1 minute for room prep, 10 
minutes for assisting the physician, and 0 minutes for the additional 
activities described in the RUC recommendations, which would have only 
taken place during the initial casting. We have concerns that the RUC-
recommended clinical labor regarding the ``remove cast'' task is based 
only on an initial visit where a new cast would be applied and 22 
minutes may be an appropriate length of time. However, the RUC 
recommendations suggest that four to twelve cast changes are common for 
patients, and we are seeking comment on whether the initial application 
of a new cast would be typical for CPT code 29445. We reviewed the 
Medicare claims data for CPT code 29445 and found that three or more 
castings took place for 52 percent of beneficiaries, which suggests 
that three or more castings may be the typical case. A single casting 
only took place for 30 percent of services reported with CPT code 
29445.
(5) Strapping Multi-Layer Compression (CPT codes 29580 and 29581)
    The RUC reviewed CPT code 29580 since it appeared on the screen for 
high expenditure services and reviewed CPT code 29581 as part of this 
family of codes. For CY 2018, the CPT Editorial Panel is deleting two 
additional codes in the family: CPT codes 29582 (Application of multi-
layer compression system; thigh and leg, including ankle and foot, when 
performed) and 29583 (Application of multi-layer compression system; 
upper arm and forearm).
    For CY 2018, we are proposing the RUC-recommended work RVUs for CPT 
code 29580 (a work RVU of 0.55) and CPT code 29581 (a work RVU of 
0.60).
    However, we are concerned about the changes in preservice time 
reflected in the specialty surveys compared to the RUC-recommended work 
RVUs. For instance, for CPT code 29580, we considered a work RVU of 
0.46, crosswalking to CPT code 98925 (Osteopathic manipulative 
treatment (OMT); 1-2 body regions involved)), which has a work RVU of 
0.46 and shares a similar intraservice time. Compared to the specialty 
survey times, the RUC recommended a slight decrease (9 minutes) in 
preservice time for CPT code 29580, with the intraservice and immediate 
postservice times remaining unchanged.

[[Page 33991]]

    For CPT code 29581, we considered a work RVU of 0.5 by using the 
RUC-recommended work RVU increment between CPT codes 29580 and 29581 
(+0.05), added to the work RVU we considered for CPT code 29580 (0.46), 
and crosswalking to CPT code 97597 (Debridement (eg, high pressure 
waterjet with/without suction, sharp selective debridement with 
scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized 
epidermis and/or dermis, exudate, debris, biofilm), including topical 
application(s), wound assessment, use of a whirlpool, when performed 
and instruction(s) for ongoing care, per session, total wound(s) 
surface area; first 20 sq cm or less)), which has similar intraservice 
and total times to the RUC-recommended services times for CPT code 
29581. We are seeking comment on whether a work RVU of 0.51 would 
improve relativity among the codes in this family.
    For CY 2018, we are proposing the RUC-recommended work RVUs for CPT 
codes 29580 and 29581 and are seeking comment on whether the 
alternative values we considered would be more appropriate.
(6) Resection Inferior Turbinate (CPT Code 30140)
    CPT code 30140 was identified as potentially misvalued on a screen 
of Harvard-valued codes with utilization over 30,000 in CY 2014. During 
the review process, the RUC re-surveyed the code as a 0-day global 
period, based on the presence of a negative intensity value in the 
initial survey and highly variable postoperative office visits.
    For CY 2018, we are proposing the RUC-recommended work RVU of 3.00 
for CPT code 30140 as a 0-day global code. We also considered a work 
RVU of 2.68 for CPT code 30140 and are seeking comment on changes in 
practice patterns since the code was previously reviewed, service times 
of comparable services, and whether a work RVU of 2.68 would better 
maintain relativity among similar codes. We note that the RUC-
recommended work RVU of 3.0 nearly doubles the derived intensity of the 
code as currently valued. We note that the RUC recommendations 
referenced services that had similar service times to CPT code 30140 
(CPT code 31240 (Nasal/sinus endoscopy, surgical; with concha bullosa 
resection), with a work RVU of 2.61; and CPT code 31295 (Nasal/sinus 
endoscopy, surgical; with dilation of maxillary sinus ostium (eg, 
balloon dilation), transnasal or via canine fossa), with a work RVU of 
2.70).
    We note that the initial survey for CPT code 30140 as a 90-day 
global resulted in a RUC-recommended work RVU of 3.57, while the second 
survey for the code as a 0-day global resulted in a RUC-recommended 
work RVU of 3.00, despite the removal of two postoperative office 
visits of CPT code 99212 and a half discharge visit of CPT code 99238. 
These removed postoperative visits have a total work RVU of 2.58, which 
is notably higher than the difference in the RUC-recommended work RVU 
between the two surveys.
    We are also proposing to create equipment codes for three new 
equipment items based on invoices submitted with the RUC 
recommendations for CPT code 30140. We are proposing to create three 
new equipment codes based on the invoices submitted for this code 
family: the 2mm reusable shaver blade (EQ383) at a price of $790, the 
microdebrider handpiece (EQ384) at a price of $4,760, and the 
microdebrider console (EQ385) at a price of $9,034.
(7) Control Nasal Hemorrhage (CPT Codes 30901, 30903, 30905, and 30906)
    For CY 2018, we are proposing the RUC-recommended work RVUs for CPT 
codes 30901 (a work RVU of 1.10), 30903 (a work RVU of 1.54), 30905 (a 
work RVU of 1.97), and 30906 (a work RVU of 2.45). We are also 
proposing to use the RUC-recommended direct PE inputs for CPT codes 
30901, 30903, 30905, and 30906, with standard refinements to the 
equipment times to account for patient monitoring times. We noted that 
as part of its recommendation, the RUC informed us that the specialty 
societies presented evidence stating that the 1995 valuations for these 
services factored in excessive times, specifically to account for 
infection control procedures that were necessary at that time due to 
the prevalence of HIV/AIDS. The specialty societies also noted that 
increased availability and use of blood thinner medications compared to 
those available in 1995, has increased the difficulty and intensity of 
these procedures. We are seeking additional information regarding the 
presumption that the relative resource intensity of these services, 
specifically, would be affected by the commercial availability of 
additional blood thinner medications. We believe that blood thinner 
medications were widely available before 1995 when these codes were 
last valued. Additionally, we seek comments on the prevalence of HIV/
AIDS and whether the work related to infection control procedures would 
be relative across many PFS services or specifically related to nasal 
hemorrhage control procedures.
    For CPT code 30901 (Control nasal hemorrhage, anterior, simple 
(limited cautery and/or packing) any method), we considered a work RVU 
of 1.00 (the 25th percentile survey result), crosswalking to CPT code 
20606 (Drain/inj joint/bursa w/us), which has similar service times. 
The median survey total time (24 minutes) dropped by 2 minutes (from 
preservice time), to 24 minutes compared to the existing total time. 
The difference in total time reflected a small decrease in preservice 
time, with no change in intraservice time (10 minutes). Among codes 
with similar service times, we found only three codes that had a higher 
work RVU than the RUC-recommended value.
    For CPT code 30903 (Control nasal hemorrhage, anterior, complex 
(extensive cautery and/or packing) any method), we considered a work 
RVU of 1.30 (the 25th percentile survey result), which would have been 
further supported by CPT codes 36584 and 51710 which have similar 
service times to the median survey results. The RUC recommended a 
decreased total time of 39 minutes compared to the existing total time 
(70 minutes), with intraservice time dropping from 30 to 15 minutes.
    For CPT code 30905 (Control nasal hemorrhage, posterior, with 
posterior nasal packs and/or cautery, any method; initial), we 
considered a work RVU of 1.73, using the RUC-recommended work RVU 
increment between CPT code 30903 and CPT code 30905 (0.43), added to 
the work RVU we considered for CPT code 30903 (1.30), and crosswalking 
to CPT code 45321 (Proctosigmoidoscopy volvul), which has similar 
service times. The surveyed intraservice time dropped from 48 minutes 
to 20 minutes. The RUC recommendations indicated that surveyed service 
times for CPT code 30905 are longer than for CPT code 30903 since the 
service is performed to control an arterial posterior bleed. According 
to the specialty society, arterial posterior bleeds are more difficult 
to treat and require a more extensive procedure in comparison to 
services reported with CPT code 30903. We considered using the RUC-
recommended work RVU increment between CPT code 30903 and CPT code 
30905 (0.43), added to the work RVU we considered for CPT code 30903 
(1.30), resulting in a work RVU of 1.73. We are seeking comment on 
whether a work RVU of 1.73 would potentially affect relativity among 
the codes in this family.

[[Page 33992]]

    For CPT code 30906 (Control nasal hemorrhage, posterior, with 
posterior nasal packs and/or cautery, any method; subsequent), we 
considered a work RVU of 2.21, using the RUC-recommended work RVU 
increment between CPT codes 30905 and 30906 (0.48), added to the work 
RVU we considered for CPT code 30905 (1.73), and crosswalking to 
services with similar service times (CPT codes 19281 (Perq device 
breast 1st imag), 51727 (Cystometrogram w/up), 49185 (Sclerotx fluid 
collection), and 62305 (Myelography lumbar injection)). The surveyed 
median intraservice time dropped from 60 minutes to 30 minutes. We are 
seeking comment on whether a work RVU of 2.21 would potentially improve 
relativity among the codes in this family.
    Given the RUC's consensus for CY 2018, we are proposing the RUC-
recommended work RVUs for each code in this family and seeking comment 
on whether our alternative values would be more appropriate.
(8) Nasal Sinus Endoscopy (CPT Codes 31254, 31255, 31256, 31267, 31276, 
31287, 31288, 31295, 31296, 31297, 31XX1, 31XX2, 31XX3, 31XX4, and 
31XX5)
    In October 2016, the CPT Editorial Panel created five new codes 
(CPT codes 31XX1, 31XX2, 31XX3, 31XX4 and 31XX5) and revised CPT codes 
31238, 31254, 31255, 31276, 31287, 31288, 31296, and 31297. CPT codes 
31XX2--31XX5 are newly bundled services representing services that are 
frequently reported together. CPT code 31XX1 represents a new service. 
The RUC reviewed this family of codes at their January 2017 meeting. 
For CY 2018, we are proposing the RUC-recommended work RVUs for all 15 
CPT codes in this family as follows: 4.27 for CPT code 31254, 5.75 for 
CPT code 31255, 3.11 for CPT code 31256, 4.68 for CPT code 31267, 6.75 
for CPT code 31276, 3.50 for CPT code 31287, 4.10 for CPT code 31288, 
2.70 for CPT code 31295, 3.10 for CPT code 31296, 2.44 for CPT code 
31297, 8.00 for CPT code 31XX1, 9.00 for CPT code 31XX2, 8.00 for CPT 
code 31XX3, 8.48 for CPT code 31XX4, and 4.50 for CPT code 31XX5.
    For CPT code 31296, we considered a work RVU of 2.82, supported by 
a crosswalk to CPT code 36901 (Intro cath dialysis circuit) with an 
intraservice time of 25 minutes and total time of 66 minutes, similar 
to the service times for CPT code 31296. We are concerned about the 
decrease in service time compared to the work RVU and we seek comment 
on whether or not a work RVU of 2.82 might improve relativity with 
other PFS services.
    For CPT code 31256, we considered a work RVU of 2.80, supported by 
a crosswalk to CPT code 43231 (Esophagoscopy, flexible, transoral; with 
endoscopic ultrasound examination), which has 30 minutes of 
intraservice time and 81 minutes of total time, similar to the RUC-
recommended service times. We are concerned about the difference in 
total time between CPT code 31256 and the RUC-recommended crosswalk to 
CPT code 43247. CPT code 43247 has 30 minutes intraservice time and 58 
minutes total time), and CPT code 31256 (30 minutes intraservice time 
and 83 minutes total time).
    For CPT code 31254, we note the RUC's explanation that this service 
is more intense than the functional endoscopic sinus surgery on the 
maxillary or sphenoid sinuses due to the risk of major complications 
such as injury to the eye muscles, bleeding into the eye or brain fluid 
leak and, consequently, that the RUC concluded that it should be valued 
higher than either CPT code 31256 or CPT code 31287. Since CPT code 
31256 has the same total time (30 minutes) and intraservice time (30 
minutes) as CPT code 31254, we considered whether the incremental 
difference recommended by the RUC between these two codes (work RVU of 
1.16) would reflect the intensity of the service. We considered a work 
RVU of 2.80 for CPT code 31256, and also considered an alternative work 
RVU of 3.97 for CPT code 31254.
    For CPT code 31287, we considered a work RVU of 3.19 based on the 
difference between the RUC-recommended work RVU for the maxillary sinus 
surgery (CPT code 31256) and the sphenoid sinus surgery (CPT code 
31287) (difference = 0.28) added to the work RVU that we considered for 
the base code (CPT code 31256, a work RVU of 2.80). We note that the 
magnitude of decreases in service times are greater than those for the 
work RVU, which potentially could affect relativity among PFS services.
    For CPT code 31255, we considered a work RVU of 5.30, based on a 
crosswalk to CPT codes 36475 (Endovenous rf 1st vein) and 36478 
(Endovenous laser 1st vein) since both of these services have the same 
intraservice times, total times, and work RVUs). We note that there are 
several CPT codes with similar total and intraservice times that have 
lower work RVUs than the crosswalk to CPT code 36246 (Ins cath abd/l-
ext art 2nd) noted by the RUC, which has 45 minutes intraservice and 96 
minutes total time, has work RVU of 5.02; CPT code 36475 (Endovenous rf 
1st vein) has 94 minutes intraservice and 94 minutes total time and has 
work RVU of 5.30).
    For CPT code 31276 (Nasal/sinus endoscopy, surgical; with frontal 
sinus exploration, including removal of tissue from frontal sinus, when 
performed), we considered a work RVU of 6.30, which is similar to other 
functional endoscopic surgeries. We note that the services reported 
with CPT code 31276 are the most intense and complex of the functional 
endoscopic surgeries due to the risks of working in the narrow confines 
in the frontal recess. However, we have concerns that a crosswalk to 
CPT code 52352 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy; 
with removal or manipulation of calculus (ureteral catheterization is 
included)), and we seek comment on whether the RUC-recommended decrease 
in service times is appropriate since CPT code 52352 has 20 minutes 
more total time than CPT code 31276.
    For CPT 31XX1 (nasal/sinus endoscopy, surgical; with ligation of 
Sphenopalatine artery), we have concerns and seek comment regarding the 
accuracy and applicability of the surveys as the RUC indicated that the 
specialty society did not use the survey instrument that contains 
questions about the number and types of visits and that this service 
requires a half day discharge day management as the patients typically 
stay overnight to be monitored for further bleeding. We seek comment on 
whether inclusion of a half day discharge day visit is typical for this 
service since services assigned 0-day global periods do not typically 
include discharge visits. We considered reducing the total time from 
142 minutes to 123 minutes by removing the half day discharge. Using 
the alternative total time of 123 minutes, we found services with 
similar total and intraservice time (60 minutes) and total time (123 
minutes).
    We considered a work RVU of 7.30 for CPT code 31XX1, supported by a 
direct crosswalk to CPT code 36253 (Superselective catheter placement 
(one or more second order or higher renal artery branches) renal artery 
and any accessory renal artery(s) for renal angiography, including 
arterial puncture, catheterization, fluoroscopy, contrast injection(s), 
image postprocessing, permanent recording of images, and radiological 
supervision and interpretation, including pressure gradient 
measurements when performed, and flush aortogram when performed; 
unilateral), since CPT code 36253 has a similar total time compared to 
our alternative total time.
    For CPT code 31XX3, we considered a work RVU of 7.30, based on a 
crosswalk to CPT code 36253 (Superselective catheter placement (one

[[Page 33993]]

or more second order or higher renal artery branches) renal artery and 
any accessory renal artery(s) for renal angiography, including arterial 
puncture, catheterization, fluoroscopy, contrast injection(s), image 
postprocessing, permanent recording of images, and radiological 
supervision and interpretation, including pressure gradient 
measurements when performed, and flush aortogram when performed; 
unilateral). We have similar concerns regarding the service times for 
this service, including the cited reference codes, compared to the 
recommended work RVU. We are seeking comment on whether a work RVU of 
7.30 for CPT code 31XX3 would improve consistency among the combined 
CPT codes in this family.
    CPT code 31XX4 is a new code representing a combination of the 
services previously described by CPT codes 31255 and 31288. We note the 
changes in overall service times compared to other codes in this family 
and other PFS services. We considered a work RVU of 7.85 for CPT code 
31XX4, crosswalking to CPT code 93461 (R&l hrt art/ventricle angio), 
which has identical intraservice times. We are seeking comment on the 
effect that this alternative work RVU might have on consistency and 
rank order compared to the other bundled codes in this family.
    CPT code 31XX5 represents a combination of CPT codes 31296 and 
31297. We have concerns about the use of CPT codes 47532 and 58558, 
which were used by the RUC as comparison codes, due to differences in 
both intraservice and total time compared to the service times for CPT 
code 31XX5. We considered a work RVU of 4.10 for CPT code 31XX5, 
crosswalking to CPT code 44406 (Colonoscopy w/ultrasound), which has 
similar service times.
    For CY 2018, we are proposing the RUC-recommended work RVUs for 
each code in this family and are seeking comment on our alternative 
values.
    Regarding the recommended direct PE inputs, we are concerned about 
one of the supply items used in furnishing services for several CPT 
codes in this family:, ``sinus surgery balloon (maxillary, frontal, or 
sphenoid) kit'' (SA106). In the current recommendations, half of one 
kit (each kit has sufficient supply for two sinuses) is included in the 
practice expense inputs for CPT codes 31295, 31296, and 31297. The new 
CPT code 31XX5 has one full kit, reflecting a service consisting of two 
sinuses, according to the RUC's explanation. The price of the full kit 
(two sinuses) of this disposable supply is $2599.06. Our analysis of 
2016 Medicare claims data indicates that 48 percent of the time one of 
the three CPT codes (31295, 31296, and 31297) is billed, it is reported 
on a claim with either one or both of the other codes. Ten percent of 
the time one of the three CPT codes is billed, it is reported on a 
claim with both of the other two codes. Effectively, 10 percent of 
claims reporting these CPT codes are being paid for three sinuses.
    We are seeking comments on the number of units of this supply item 
that are used for each service. We welcome suggestions about improved 
methodologies for identifying the quantity of this disposable supply 
used during these procedures and will continue to monitor utilization 
and reporting of these services.
    In reviewing the RUC recommendations for this family of CPT codes, 
we note that CPT codes in this family are subject to the standard 
payment adjustment for multiple surgeries. In our analysis of the 
claims data, we noted that the average number of HCPCS codes in this 
family reported together on a claim line is approximately 2.89. In 
addition, about 15 percent of claims have two of the newly bundled CPT 
codes reported together on a claim line. We are concerned about the 
frequency with which the nasal sinus endoscopy CPT codes in this family 
are billed together. We are seeking comments on whether we should 
consider the endobase code adjustments as a better approach to 
adjusting payment for these services instead of the current multiple 
procedure reduction. For additional information about the payment 
adjustment under the special rule for multiple endoscopic services, we 
refer readers to the Medicare Claims Processing Manual, Chapter 23 
(available on the CMS Web site at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf.).
    We note that in developing the utilization crosswalk we use for 
purposes of PFS ratesetting, for this complex set of newly bundled 
codes, we adopted ratios that differ significantly from the ratios 
accompanying the RUC recommendations to better account for the 
reductions in overall reporting frequency. We direct readers to the 
file called ``CY 2017 Analytic Crosswalk to CY 2018'' on the CMS Web 
site under downloads for the CY 2018 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
(9) Tracheostomy (CPT Codes 31600, 31601, 31603, 31605, and 31610)
    CPT code 31600 was identified as part of a screen of high 
expenditure services with Medicare allowed charges of $10 million or 
more that had not been recently reviewed. CPT codes 31601, 31603, 
31605, and 31610 were added and reviewed as part of the code family.
    We are proposing the RUC-recommended work RVUs for all five codes 
in this family. We are proposing a work RVU of 5.56 for CPT code 31600, 
a work RVU of 8.00 for CPT code 31601, a work RVU of 6.00 for CPT code 
31603, a work RVU of 6.45 for CPT code 31605, and a work RVU of 12.00 
for CPT code 31610.
    We considered a work RVU of 6.50 for CPT code 31601. We seek 
comment on the effect that this alternative value would have on 
relativity compared to other PFS services, especially since the survey 
data does not suggest an increase in the time required to perform the 
procedure.
    We considered a work RVU of 4.77 for CPT code 31605, based on the 
survey 25th percentile from the combined survey total. We also 
considered an intraservice work time of 15 minutes, based on the median 
intraservice work time from the combined survey total for CPT code 
31605. We are seeking comments on the methodology used to determine the 
RUC-recommended work RVU and intraservice work time. We are concerned 
that the number of respondents (20) is below the threshold typically 
required for submission of a survey, and the effect of using survey 
results only from physicians who had personal experience performing the 
procedure (20 respondents). CPT code 31605 has a lower intraservice and 
total time, but a higher work RVU than comparable codes under the PFS. 
We note that the next highest 0-day global code with 20 minutes of 
intraservice time is CPT code 16035 (Escharotomy; initial incision) at 
a work RVU of 3.74. All other 0-day global codes with a work RVU of 
6.45 or greater have at least 40 minutes of intraservice time. We are 
seeking comment on the effect that an alternative work RVU of 4.77 
would have on the relativity of this service compared to other services 
in this family of codes and compared to other PFS services, taking into 
account that CPT code 31605 describes a difficult and dangerous life-
threatening emergency procedure.
    We considered a work RVU of 6.50 for CPT code 31610 based on a 
direct crosswalk to CPT code 31601 (Incision of windpipe). We 
understand that the RUC considered the possibility of

[[Page 33994]]

recommending this code be assigned a 0-day global period based on 
concerns about negative derived intensity. We share the RUC's concerns 
with the current construction of CPT code 31610, particularly with the 
242 minutes of work time included in the postoperative visits, which is 
an unusually large amount for a procedure with only 45 minutes of 
intraservice time. We did not identify any other comparable codes under 
the PFS with 45 minutes of intraservice time and more than 300 minutes 
of total time. We seek comment on whether the unusual volume of 
physician work time included in the postoperative visits for CPT code 
31610 contributed to the negative derived intensity reported by the 
survey data. Considering that the other codes in this family have 0-day 
global periods, we considered and are seeking comment on whether a 0-
day global period should be assigned to CPT code 31610. Removal of the 
postoperative E/M visits from CPT code 31610 would result in an 
intraservice time of 45 minutes and a total time of 125 minutes, 
similar to CPT code 31601 with 45 minutes of intraservice time and 135 
minutes of total time.
    We are proposing the RUC-recommended direct PE inputs for all five 
CPT codes in this family without refinements. As discussed earlier, we 
considered a 0-day global period for CPT code 31610, which would also 
have resulted in removal of the clinical labor associated with the 
postoperative E/M visits, along with the supplies and equipment 
utilized during those visits.
    While we remain concerned about the global period assigned to CPT 
code 31610 and the changes in service times reflected in the specialty 
surveys compared to the RUC-recommended work RVUs, for CY 2018, we are 
proposing the RUC-recommended work RVUs and direct PE inputs for each 
code in this family and are seeking comment on our proposed and 
alternative values.
(10) Bronchial Aspiration of Tracheobronchial Tree (CPT Codes 31645 and 
31646)
    CPT code 31645 was identified as potentially misvalued on a screen 
of Harvard-valued codes with utilization over 30,000 in CY 2014. CPT 
code 31646 was added for review as part of the family of codes, and 
both were revised to reflect recent changes in how the services are 
typically performed. For CY 2018, we are proposing the RUC-recommended 
work RVU of 2.88 for CPT code 31645 and the RUC-recommended work RVU of 
2.78 for CPT code 31646.
    We considered a work RVU of 2.72 for CPT code 31645, crosswalking 
to CPT code 45347 (Sigmoidoscopy, flexible; with placement of 
endoscopic stent). We have concerns regarding the decrease in 
intraservice and total time compared to the current values (we also 
believe that it is important to note how these related codes have been 
affected by the creation of separately billable codes for moderate 
sedation (see CY 2017 PFS final rule (81 FR 80339)). The RUC-
recommended values CPT code 31645 higher than CPT code 31622 
(Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when 
performed; diagnostic, with cell washing, when performed), which is the 
base procedure for this wider group of codes. We agree that CPT code 
31645 should be valued at a higher work RVU than CPT code 31622, 
however, we are seeking comment on whether the work of moderate 
sedation was inadvertently included in the development of the 
recommended work RVU. We note that as part of the CY 2017 PFS final 
rule (81 FR 80339), we finalized separate payment for moderate 
sedation.
    Following the creation of separately billable codes for moderate 
sedation, CPT code 31622 is currently valued at a work RVU of 2.53, not 
2.78 as it was previously valued, and we do not believe it would be 
appropriate to continue to value CPT code 31645 as though moderate 
sedation was still an inherent part of the work of this service. As a 
result, we considered a direct crosswalk to CPT code 45347, which has 
the same intraservice time and 8 additional minutes of total time, at a 
work RVU of 2.72.
    We considered a work RVU of 2.53 for CPT code 31646, crosswalking 
to CPT code 31622 (Dx bronchoscope/wash). The RUC recommendation for 
CPT code 31646 indicated that the code was comparable to CPT code 
31622, since they share the same intraservice time and similar total 
time, and that the recommended work RVU of 2.78 for CPT code 31646 was 
equal to the work RVU of CPT code 31622 before the CY 2017 changes to 
reporting of moderate sedation. We agree with the survey participants 
that these two codes are comparable to one another, but have concerns 
about valuation of CPT code 31646 using a cross reference to a code 
that included moderate sedation. We considered crosswalking CPT code 
31646 (Bronchoscopy reclear airway) using the current CY 2017 valuation 
for CPT code 31622 (a work RVU of 2.53).
    For the direct PE inputs, we are proposing to remove the oxygen gas 
(SD084) from CPT code 31645. This supply is included in the separately 
billable moderate sedation codes, and we are proposing to remove the 
oxygen gas as recommended by the RUC's PE Subcommittee as part of the 
removal of oxygen from non-moderate sedation post-procedure monitoring 
codes. We are proposing to remove the equipment time for the IV 
infusion pump (EQ032) from CPT code 31645. We do not agree that there 
would typically be a need for a separate infusion pump in CPT code 
31645, as the infusion pump is contained in the separately reportable 
moderate sedation codes. We are also proposing to remove the equipment 
time for the CO2 respiratory profile monitor (EQ004) and the 
mobile instrument table (EF027) from CPT code 31645. These equipment 
items are not contained in the current composition of the code, and 
there was no rationale provided in the RUC recommendations for their 
inclusion. As a result, we do not believe that their use would be 
typical for CPT code 31645.
    We are proposing to increase the equipment time for the flexible 
bronchoscopy fiberscope (ES017) for CPT code 31645 consistent with 
standard equipment times for scopes. We are also proposing to increase 
the equipment time for the Gomco suction machine (EQ235) and the power 
table (EF031) consistent with standard equipment times for non-highly 
technical equipment.
    For CY 2018, we are proposing the RUC-recommended work RVUs for 
both codes in this family and are seeking comment on whether we should 
finalize refined values consistent with the implementation of 
separately billable codes for moderate sedation.
(11) Cryoablation of Pulmonary Tumor (CPT Codes 32998 and 32X99)
    For CY 2018, the CPT Editorial Panel modified the descriptor for 
CPT code 32998 (Ablation therapy for reduction or eradication of 1 or 
more pulmonary tumor(s) including pleura or chest wall when involved by 
tumor extension, percutaneous, including imaging guidance when 
performed, unilateral; radiofrequency) to include imaging guidance. In 
addition, the panel deleted Category III CPT Code 0304T and replaced it 
with a new CPT code 32X99, to describe ablation therapy for reduction 
of pulmonary tumor using cryoablation with imaging guidance. For CY 
2018, we are proposing the RUC-recommended work RVUs for CPT codes 
32998 (a work RVU of 9.03) and 32X99 (a work RVU of 9.03).
    However, we have concerns about the descriptions of the codes and 
the recommended valuations assuming that imaging guidance is inherent 
to the

[[Page 33995]]

procedure. Based on our analysis of claims data from 2014, existing CPT 
code 32998 is currently reported with one of the three imaging guidance 
codes (CPT codes 76940, 77013, or 77022) less than 50 percent of the 
time. We seek comment on whether there is additional information that 
would help explain why the codes are being bundled despite what is 
reflected in the Medicare claims data. We considered a work RVU of 7.69 
for CPT code 32998, that included approximately one half the value of 
the imaging guidance in the new codes that describe the work of both 
the procedure and the image guidance (that is, the sum of the current 
work RVU for CPT code 32998 and one-half of the work RVU for CPT code 
77013 (the imaging guidance code most frequently billed with CPT code 
32998 according to 2014 claims data)). We applied the same general 
rationale regarding the use of imaging guidance for new CPT code 32X99. 
Since the RUC recommended identical work RVUs for these codes, we also 
considered a work RVU of 7.69 for CPT 32X99.
    For CPT codes 32998 and 32X99, we are proposing to use the RUC-
recommended direct PE inputs with standard refinements.
    For CY 2018, we are proposing the RUC-recommended work RVUs and 
direct PE inputs for both codes and are seeking comment on our proposed 
and alternative values.
(12) Artificial Heart System Procedures (CPT Codes 339X1, 339X2, and 
339X3)
    For CY 2018, the CPT Editorial Panel deleted Category III CPT Codes 
0051T through 0053T and created CPT codes 339X1, 339X2, and 339X3 to 
report artificial heart system procedures. We are proposing the RUC-
recommended work RVU of 49.00 for CPT code 339X1, and proposing to 
assign contractor-priced status to CPT codes 339X2 and 339X3 as 
recommended by the RUC.
    We considered assigning contractor-priced status for CPT code 
339X1. We have concerns regarding the accuracy of the RUC-recommended 
work valuation for CPT code 339X1, due to its low utilization and the 
resulting difficulties in finding enough practitioners with direct 
experience of the procedure for the specialty societies to survey. We 
seek comment on the sufficiency of the survey data, especially since 
new technologies and those with lower utilization are typically 
contractor-priced. For CY 2018, we are proposing the RUC-recommended 
work RVUs for CPT code 339X1. We are seeking comment on alternative 
pricing for this CPT code 339X1.
    We are not proposing any direct PE inputs, as we did not receive 
RUC-recommended PE information for CPT codes 339X1, 339X2, and 339X3. 
These three codes will be placed on the RUC's new technology list and 
will be re-reviewed by the RUC in 3 years.
(13) Endovascular Repair Procedures (CPT Codes 34X01, 34X02, 34X03, 
34X04, 34X05, 34X06, 34X07, 34X08, 34X09, 34X10, 34X11, 34X12, 34X13, 
34812, 34X15, 34820, 34833, 34834, 34X19, and 34X20)
    The CPT/RUC joint workgroup on codes recommended in October 2015 to 
bundle endovascular abdominal aortic aneurysm repair (EVAR) codes 
together with radiologic supervision and interpretation codes, since 
these codes were typically reported together at least 50 percent of the 
time. The CPT Editorial Panel bundled these services together in 
September 2016, creating 16 new codes, revising four existing codes, 
and deleting 14 other codes related to endovascular repair procedures.
    We are proposing the RUC-recommended work RVUs for all 20 codes in 
this family. We are proposing a work RVU of 23.71 for CPT code 34X01, a 
work RVU of 36.00 for CPT code 34X02, a work RVU of 26.52 for CPT code 
34X03, a work RVU of 45.00 for CPT code 34X04, a work RVU of 29.58 for 
CPT code 34X05, a work RVU of 45.00 for CPT code 34X06, a work RVU of 
22.28 for CPT code 34X07, a work RVU of 36.50 for CPT code 34X08, a 
work RVU of 6.50 for CPT code 34X09, a work RVU of 15.00 for CPT code 
34X10, a work RVU of 6.00 for CPT code 34X11, a work RVU of 12.00 for 
CPT code 34X12, a work RVU of 2.50 for CPT code 34X13, a work RVU of 
4.13 for CPT code 34812, a work RVU of 5.25 for CPT code 34X15, a work 
RVU of 7.00 for CPT code 34820, a work RVU of 8.16 for CPT code 34833, 
a work RVU of 2.65 for CPT code 34834, a work RVU of 6.00 for CPT code 
34X19, and a work RVU of 7.19 for CPT code 34X20.
    We are also proposing the RUC-recommended direct PE inputs without 
refinement for all 20 codes in the family.
    We considered a work RVU of 32.00 for CPT code 34X02 based on the 
survey 25th percentile, and further supported with a crosswalk to CPT 
code 48000 (Placement of drains, peripancreatic, for acute 
pancreatitis), which has the same intraservice time of 120 minutes and 
a work RVU of 31.95. When we compared the RUC-recommended work RVU to 
similar codes valued under the PFS, we were unable to find any 90-day 
global services with 120 minutes of intraservice time and approximately 
677 minutes of total time that had a work RVU greater than 36.00.
    We considered a work RVU of 40.00 for CPT code 34X04 based on the 
survey 25th percentile, crosswalking to CPT code 33534 (Coronary artery 
bypass, using arterial graft(s); 2 coronary arterial grafts) which has 
a work RVU of 39.88. CPT code 33534 has 193 minutes of intraservice 
time, but a lower total time of 717 minutes. When we compared the RUC-
recommended work RVU for CPT code 34X04 to similar codes paid under the 
PFS, we were unable to find any 90-day global services with 180 minutes 
of intraservice time and approximately 737 minutes of total time that 
had a work RVU greater than 45.00.
    We considered a work RVU of 40.00 for CPT code 34X06 based on the 
survey 25th percentile. CPT code 34X06 has nearly identical time values 
to CPT code 34X04, with 2 fewer minutes of intraservice time and total 
time, and the RUC-recommended work RVU was the same for both of these 
codes. The survey respondents also believe that these two codes had a 
comparable amount of work, as the survey 25th percentile work RVU is 
40.00 for both codes.
    We considered a work RVU of 30.00 for CPT code 34X08 based on the 
survey 25th percentile and seek comment on whether a work RVU of 30.00 
would improve relativity among the codes in this family. CPT code 34X08 
has identical intraservice and total times as CPT code 34X02. However, 
we note that the RUC-recommended work RVU of 36.50 for CPT code 34X08 
is higher than the RUC-recommended work RVU of 36.00 for CPT code 
34X02. This is the inverse of the relationship between CPT codes 34X07 
and 34X01, which describe the same procedures in a non-emergent state 
when a rupture does not take place. CPT code 34X07 has a RUC-
recommended work RVU of 22.28 while CPT code 34X01 has a RUC-
recommended work RVU of 23.71. We seek comment on whether the RUC-
recommended work RVUs would create a rank order anomaly within the 
family by reversing the relationship between these paired codes when 
performed in an emergent state. We note that if CPT codes 34X08 and 
34X02 were valued at the survey 25th percentile, this potential rank 
order anomaly disappears; in this scenario, we considered valuing CPT 
code 34X08 at a work RVU of 30.00 and CPT code 34X02 at a work RVU of 
32.00. We seek comment on whether these alternative work values would 
improve relativity with the RUC-recommended work RVUs for CPT code 
34X07 (22.28) and CPT code 34X01 (23.71), with an increment of

[[Page 33996]]

approximately 1.50 to 2.00 RVUs between the two code pairs.
    For the eight remaining codes that describe endovascular access 
procedures, we considered assignment of a 0-day global period, instead 
of the RUC-recommended add-on (ZZZ) global period and subsequently 
adding back the preservice and immediate postservice work time, and 
increasing the work RVU of each code accordingly using a building block 
methodology. We note that as add-on procedures, these eight codes would 
not be subject to the multiple procedure payment discount. We are 
concerned that the total payment for these services will be increasing 
in the aggregate based on changes in coding that alter MPPR 
adjustments, despite the information in the surveys that reflects a 
decrease in the intraservice time required to perform the procedures, 
and a decrease in their overall intensity as compared to the current 
values.
    We considered a work RVU of 3.95 for CPT code 34X13, based on the 
RUC-recommended work RVU of 2.50 plus an additional 1.45 work RVUs. 
This additional work results from the addition of 38 total minutes of 
preservice work time and 30 minutes of postservice work time based on a 
crosswalk to CPT code 37224 (Revascularization, endovascular, open or 
percutaneous, femoral, popliteal artery(s), unilateral; with 
transluminal angioplasty) as valued by using the building block 
methodology. Using the same method, we considered a work RVU of:
     6.48 for CPT code 34812 based on maintaining the current 
75 minutes of preservice work time and the current 30 minutes of 
postservice work time, with a total work RVU of 2.35, added to the RUC-
recommended work RVU of 4.13;
     7.53 for CPT code 34X15 with the addition of 75 minutes of 
preservice work time and 27 minutes of postservice work time to match 
CPT code 34833;
     9.46 for CPT code 34820 based on maintaining the current 
80 minutes of preservice work time and the current 30 minutes of 
postservice work time;
     10.44 for CPT code 34833 based on maintaining the current 
75 minutes of preservice work time and the current 27 minutes of 
postservice work time;
     5.00 for CPT code 34834 based on maintaining the current 
70 minutes of preservice work time and the current 35 minutes of 
postservice work time;
     8.35 for CPT code 34X19 with the addition of 70 minutes of 
preservice work time and 35 minutes of postservice work time to match 
CPT code 34834; and
     9.47 for CPT code 34X20 with the addition of 75 minutes of 
preservice work time and 27 minutes of postservice work time to match 
CPT code 34833.
(14) Selective Catheter Placement (CPT Codes 36215, 36216, 36217, and 
36218)
    CPT code 36215 was identified as potentially misvalued on a screen 
of Harvard-valued codes with utilization over 30,000 in CY 2014, as 
well as on a screen of high expenditure services across specialties 
with Medicare allowed charges of over $10 million. CPT codes 36216, 
36217, and 36218 were added to the family to be reviewed together with 
CPT code 36215.
    We are proposing the RUC-recommended work RVUs for each code in 
this family as follows: A work RVU of 4.17 for CPT code 36215, a work 
RVU of 5.27 for CPT code 36216, a work RVU of 6.29 for CPT code 36217, 
and a work RVU of 1.01 for CPT code 36218.
    We also considered refinements to the intraservice work time for 
CPT code 36217 from 60 minutes to 50 minutes, consistent with the RUC's 
usual use of the survey median intraservice work time. We have concerns 
that the use of the recommended survey 75th percentile intraservice 
work time will not be clinically appropriate for this code, as the 75th 
percentile time was identical for both CPT code 36216 and 36217, and 
therefore, the use of this value would not preserve the incremental, 
linear consistency between the work RVU and the intraservice time 
within the family.
    For the direct PE inputs, we are proposing to refine the clinical 
labor time for the ``Post-procedure doppler evaluation (extremity)'' 
activity from 3 minutes to 1 minute for CPT codes 36215, 36216, and 
36217. We believe that 1 minute would be more typical for this task, as 
the practitioner would be able to quickly evaluate if there was an 
issue with the extremity because there would be visual signs of 
arterial insufficiency resulting from the procedure.
    We are proposing to remove the equipment time for the mobile 
instrument table (EF027) from CPT codes 36215, 36216, and 36217. We 
believe that the mobile instrument table would be used for moderate 
sedation, which was removed from these procedures in CY 2017 (see CY 
2017 PFS final rule (81 FR 80339)). While we recognize that 180 minutes 
of post-procedure monitoring time remains in these codes during which 
the stretcher (EF018), IV infusion pump (EQ032), and 3-channel ECG 
(EQ011) would remain in use, we do not agree that the mobile instrument 
table would typically be in use during this period of monitoring. As a 
result, we are proposing to remove this equipment time from these three 
codes.
    While we remain concerned about the use of the survey 75th 
percentile intraservice work time for CPT code 36217, for CY 2018, we 
are proposing the RUC-recommended work RVUs for each code in this 
family and seek comment on whether our alternative values would be more 
appropriate.
(15) Treatment of Incompetent Veins (CPT Codes 36470, 36471, 364X3, 
364X4, 364X5, and 364X6)
    In September 2016, the CPT Editorial Panel created four new codes 
to describe the treatment of incompetent veins, and revised existing 
CPT codes 36470 and 36471. These six codes were reviewed together as 
part of the same family of procedures. For CY 2018, we are proposing 
the RUC-recommended work RVU for all six codes as follows: A work RVU 
of 0.75 for CPT code 36470, a work RVU of 1.50 for CPT code 36471, a 
work RVU of 3.50 for CPT code 364X3, and a work RVU of 1.75 for CPT 
code 364X4, a work RVU of 2.35 for CPT code 364X5, and a work RVU of 
3.00 for CPT code 364X6.
    We considered a work RVU of 4.38 for CPT code 364X3, which would 
have been based on the RUC-recommended work RVU of 3.50 plus half of 
the RUC-recommended work RVU of CPT code 364X4. We also considered 
assigning CPT code 364X4 a status indicator of ``bundled.'' The 
services that would be reported using CPT codes 364X3 and 364X4 in CY 
2018, are currently reported with unlisted CPT code 37799 (Unlisted 
procedure, vascular surgery). We have concerns about the frequency that 
the current services include treatment of an initial vein (CPT code 
364X3) as compared to the treatment of initial and subsequent veins 
(CPT codes 364X3 and 364X4 together). It may be more accurate to 
describe these services through the use of a single code, as in the 
rest of this code family, instead of a base code and add-on code pair. 
Under this potential scenario, we looked at the RUC-recommended 
crosswalk and noted that the add-on CPT code 364X4 was estimated to be 
billed 50 percent of the time together with CPT code 364X3. We 
therefore considered adding half of the RUC-recommended work RVU of CPT 
code 364X4 (0.88) to the RUC-recommended work RVU of CPT code 364X3 
(3.50), resulting in a work RVU of 4.38.
    We are proposing to remove the 2 minutes of clinical labor for the 
``Setup scope'' (CA015) activity and add the same 2 minutes of clinical 
labor for the ``Prepare room, equipment and

[[Page 33997]]

supplies'' (CA013) activity for CPT codes 364X3, 364X5, and 364X6. The 
RUC-recommended materials stated that these 2 minutes were a proxy for 
setting up the ultrasound machine, and we believe that this 2 minutes 
is more accurately described by the ``Prepare room, equipment and 
supplies'' (CA013) activity code, since there is no scope equipment 
utilized in these procedures. We are proposing to maintain the Vascular 
Tech (L054A) clinical labor type for these 2 minutes. We are also 
proposing to refine the clinical labor for the ``Check dressings, 
catheters, wounds'' (CA029) activity for CPT codes 36470, 36471, 364X3, 
364X5, and 364X6, consistent with the standard times for this clinical 
labor activity.
    We are proposing to remove the six individual 4x4 sterile gauze 
(SG055) supplies and replace them with a 4x4 sterile gauze pack of 10 
(SG056) for CPT codes 36470, 36471, 364X3, 364X5, and 364X6. The pack 
of 10 sterile gauze is cheaper than six individual pieces of sterile 
gauze, and we do not agree that it would be typical to pay a higher 
cost for fewer supplies. We are also proposing to create three new 
supply codes in response to the invoices submitted for this family of 
codes. We are proposing to establish a price of $1495 for the Venaseal 
glue (SD323) supply, a price of $3195 for the Varithena foam (SD324) 
supply, and a price of $40 for the Varithena admin pack (SA125) supply.
    We are proposing to adjust the equipment times for the surgical 
light (EF014), the power table (EF031), and the portable ultrasound 
unit (EQ250) for CPT codes 364X3, 364X5, and 364X6 consistent with the 
standards for non-highly technical equipment and to reflect the changes 
in the clinical labor described in this section of the proposed rule.
    While we remain concerned about the creation of a base code and 
add-on code pairing (CPT codes 364X3 and 364X4) out of services that 
are currently reported using an unlisted code, for CY 2018, we are 
proposing the RUC-recommended work RVUs for each code in this family 
and are seeking comment on whether our alternative values would be more 
appropriate.
(16) Therapeutic Apheresis (CPT Codes 36511, 36512, 36513, 36514, 
36516, and 36522)
    CPT code 36516 was nominated as potentially misvalued in the CY 
2016 PFS proposed rule. The CPT Editorial Panel deleted CPT code 36515 
and made revisions to CPT code 36516 to include immunoabsorption. CPT 
codes 36511, 36512, 36513, 36514, and 36522 were added to CPT code 
36516 to be reviewed together as part of the therapeutic apheresis 
family.
    For CY 2018, we are proposing the RUC-recommended work RVU for all 
six codes in the family as follows: A work RVU of 2.00 for CPT code 
36511, a work RVU of 2.00 for CPT 36512, a work RVU of 2.00 for CPT 
code 36513, a work RVU of 1.81 for CPT code 36514, a work RVU of 1.56 
for CPT code 36516, and a work RVU of 1.75 for CPT code 36522.
    We are proposing to use the RUC-recommended direct PE inputs for 
these codes without refinement. We considered refining the clinical 
labor time for the ``Prepare room, equipment, supplies'' activity from 
20 minutes to 10 minutes for CPT codes 36514 and 36522, and from 30 
minutes to 10 minutes for CPT code 36516. We also considered refining 
the clinical labor for the ``Prepare and position patient/monitor 
patient/set up IV'' activity from 15 minutes to 10 minutes for these 
same three codes. In both cases, we considered maintaining the current 
clinical labor time for CPT codes 36514 and 36516, and adjusting the 
clinical labor time for CPT code 36522 to match the other two codes in 
the family. We have concerns about the lack of a rationale provided for 
these changes in clinical labor time, and whether these clinical labor 
tasks would typically require this additional time.
    We are proposing the RUC-recommended work RVUs and to use the RUC-
recommended direct PE inputs for each code in this family and seeking 
comment on whether our alternative values would be more appropriate. We 
are also seeking comment on whether these procedures are creating a new 
point of venous access or utilizing a previously placed access.
(17) Insertion of Catheter (CPT Codes 36555, 36556, 36620, and 93503)
    CPT code 36556 was identified as part of a screen of high 
expenditure services with Medicare allowed charges of $10 million or 
more that had not been recently reviewed. CPT codes 36555, 36620, and 
93503 were added for review as part of the code family. We are 
proposing the RUC-recommended work RVUs for each code in this family as 
follows: A work RVU of 1.93 for CPT code 36555, a work RVU of 1.75 for 
CPT code 36556, a work RVU of 1.00 for CPT code 36620, and a work RVU 
of 2.00 for CPT code 93503.
    We are proposing to remove the clinical labor time for the 
``Monitor pt. following procedure'' activity and the equipment time for 
the 3-channel ECG (EQ011) for CPT code 36555. CPT code 36555 no longer 
includes moderate sedation as part of the procedure (see CY 2017 PFS 
final rule (81 FR 80339). We are proposing to remove the direct PE 
inputs related to moderate sedation from CPT code 36555 as they would 
now be included in the separately reported moderate sedation services. 
We are also proposing to refine the equipment times for the exam table 
(EF023) and the exam light (EQ168) to reflect changes in the clinical 
labor time.
(18) Insertion of PICC Catheter (CPT Code 36569)
    CPT code 36569 was identified as part of a screen of high 
expenditure services with Medicare allowed charges of $10 million or 
more that had not been recently reviewed. For CY 2018, we are proposing 
the RUC-recommended work RVU of 1.70 for CPT code 36569.
    We are proposing to remove the equipment time for the exam table 
(EF023), as this equipment item is a component part of the 
radiographic-fluoroscopic room (EL014) included in CPT code 77001 
(Fluoroscopic guidance for central venous access device placement, 
replacement (catheter only or complete), or removal). Because CPT code 
36569 is typically billed together with CPT code 77001, we believe that 
the additional equipment time for the exam table would be duplicative.
(19) Bone Marrow Aspiration (CPT Codes 38220, 38221, 382X3, and 2093X)
    CPT code 38221 was identified as part of a screen of high 
expenditure services with Medicare allowed charges of $10 million or 
more that had not been recently reviewed. The descriptors for CPT codes 
38220 and 38221 were revised to reflect changes in practice patterns, 
and two new CPT codes (382X3 and 2093X) were created to more accurately 
describe new services that are now available. For CY 2018, we are 
proposing the RUC-recommended work RVUs for each code in this family as 
follows: A work RVU of 1.20 for CPT code 38220, a work RVU of 1.28 for 
CPT code 38221, a work RVU of 1.44 for CPT code 382X3, and a work RVU 
of 1.16 for CPT code 2093X.
    We also received a recommendation from the RUC to change the global 
period for CPT codes 38220, 38221, and 382X3 from XXX global periods to 
0-day global periods, even though these codes were surveyed under the 
XXX global period. We agree with the recommendation that for these 
three particular codes, their services are more accurately described 
when assigned 0-day global periods as opposed to the XXX global status. 
Therefore, we propose to assign a 0-day global period

[[Page 33998]]

to all three codes in this family. We note, however, that we believe 
that global period changes must be addressed on an individual basis, 
especially when the routine survey methodologies rely on assumptions 
regarding global periods for particular codes. Subsequently, we are 
proposing to refine the preservice work time from 15 minutes of 
evaluation time to 9 minutes of evaluation time, 1 minute of 
positioning time, and 5 minutes of scrub, dress, and wait time. We are 
proposing these refinements to the work times for these three codes to 
more closely align with the preservice times of other recently reviewed 
0-day global procedures, such as CPT code 30903 (Control nasal 
hemorrhage, anterior, complex (extensive cautery and/or packing) any 
method). We also note that given our proposal to value CPT code 382X3, 
we are proposing to eliminate payment using HCPCS code G0364 for CY 
2018 since the changes to the set of CPT codes will now accurately 
describe the services currently reported by G0364. For CPT code 2093X, 
we considered a work RVU of 1.00 based on a direct crosswalk to CPT 
codes 64494 (Injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that 
joint) with image guidance (fluoroscopy or CT), lumbar or sacral; 
second level) and 64495 (Injection(s), diagnostic or therapeutic agent, 
paravertebral facet (zygapophyseal) joint (or nerves innervating that 
joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third 
and any additional level(s)). CPT code 2093X is a global ZZZ add-on 
code for CPT code 38220, and we are concerned with maintaining 
relativity among PFS services, considering that an add-on code 
typically has significantly less intraservice time and total time 
compared to the base code. We considered an alternative crosswalk to 
CPT codes 64494 and 64495, which share the same intraservice and total 
time with CPT code 2093X and have a work RVU of 1.00.
    We are also proposing to refine the clinical labor for ``Lab Tech 
activities'' from 12 minutes to 9 minutes for CPT code 38220, from 7.5 
minutes to 7 minutes for CPT code 38221, and from 12.5 minutes to 10 
minutes for CPT code 382X3. We are maintaining the current time value 
for the two existing codes, as we have no reason to believe that the 
typical duration has increased for these lab activities. We are 
assigning 10 minutes for CPT code 382X3 based on the statement in the 
RUC-recommended materials for the direct PE inputs that this activity 
takes 0.5 minutes longer than it does in the current version of CPT 
code 38220. We are also proposing to remove the breakout lines for the 
lab activities. We believe that the breakout of activities into 
numerous subactivities generally tends to inflate the total time 
assigned to clinical labor activities and results in values that are 
not consistent with the analogous times for other PFS services.
    We considered refining the clinical labor for ``Provide preservice 
education/obtain consent'' for CPT codes 38220, 38221, and 382X3 from 
12 minutes to 6 minutes. We have concerns regarding whether 12 minutes 
would be typical for education and consent prior to these procedures, 
as much of the patient education takes place following the procedure, 
in the clinical labor activity described under the ``Check dressings & 
wound/home care instructions'' heading.
    We are proposing the RUC-recommended work RVUs for each code in 
this family and are seeking comment on whether our alternative values 
would be more appropriate.
(20) Esophagectomy (CPT Codes 43107, 43112, 43117, 432X5, 432X6, and 
432X7)
    CPT codes 432X5, 432X6, and 432X7 were created by the CPT Editorial 
Panel to report esophagectomy via laparoscopic and thoracoscopic 
approaches. CPT codes 43107, 43112, and 43117 were also reviewed as 
part of the family with the three new codes. CPT code 43112 was revised 
to clarify the nature of the service being performed. We are proposing 
the RUC-recommended work RVUs and work times for all six codes in the 
family as follows: A work RVU of 52.05 for CPT code 43107, a work RVU 
of 62.00 for CPT code 43112, a work RVU of 57.50 for CPT code 43117, a 
work RVU of 55.00 for CPT code 432X5, a work RVU of 63.00 for CPT code 
432X6, and a work RVU of 66.42 for CPT code 432X7.
    We are also proposing the RUC-recommended work times for all six 
codes in this family. We considered removing 20 minutes from the 
preservice evaluation work time from all six of the codes in this 
family. We have concerns as to whether this additional evaluation time 
should be included for surgical procedures, due to the lack of evidence 
indicating that it takes longer to review outside imaging and lab 
reports for surgical services than for non-surgical services. We also 
considered refining the preservice positioning work time and the 
immediate postservice work time for all six of the codes in this family 
consistent with standard preservice and postservice work times 
allocated to other PFS services.
    We have concerns about the presence of two separate surveys 
conducted for the three new codes. We note that CPT codes 432X5, 432X6, 
and 432X7 were surveyed initially in January 2016, and then were 
surveyed again in October 2016 together with CPT codes 43107, 43112, 
and 43117 due to concerns about the description of the typical patient 
in the original vignette and a change in the codes on the reference 
service list (RSL). We note that CPT codes 432X5 and 432X6 had the same 
median intraservice time on both surveys, while CPT code 432X7 had a 
median intraservice time that was an hour longer on its second survey 
(420 minutes) as compared to its first survey (360 minutes). We also 
note that the total survey time for CPT code 432X5 decreased from 1058 
minutes in the first survey to 972 minutes in the second survey, while 
the median work RVU increased from 50.00 to 65.00. We do not understand 
how the survey median intraservice time could increase so significantly 
from the first survey to the second survey for CPT code 432X7, or how 
the surveyed times for CPT code 432X5 could be decreasing while the 
work RVU was simultaneously increasing by 15.00 work RVUs.
    Based on our analysis, it appears that the accompanying RSL is the 
main difference between the two surveys; the codes on the initial RSL 
had a median work RVU of 44.18, while the codes on the second RSL had a 
median work RVU of 59.64. This increase of 15.00 work RVUs between the 
two RSLs that accompanied the surveys appears to account for the 
increase in the work RVUs for the three new codes. We are concerned 
that the second survey may have overestimated the work required to 
perform these procedures, as the 25th percentile work RVU of the second 
survey is higher than the median work RVU of the initial survey for all 
three codes, despite no change in the median intraservice work time for 
CPT codes 432X5 and 432X6.
    Given these concerns, we considered a work RVU of 50.00 for CPT 
code 432X5, a work RVU of 60.00 for CPT code 432X6, and a work RVU of 
61.00 for CPT code 432X7, by using the survey median work RVU from the 
first survey for the three new codes. For CPT codes 43107 and 43117, we 
considered employing the intraservice time ratio between the 
laparoscopic version of the procedure represented by the new code and 
the open version of the same procedure represented by the existing 
code.

[[Page 33999]]

    We considered a work RVU of 45.00 for CPT code 43107 based on the 
intraservice time ratio with CPT code 432X5 and a work RVU of 55.00 for 
CPT code 43117 based on the intraservice time ratio with CPT code 
432X6. CPT code 43107 has 270 minutes of intraservice time as compared 
with 300 minutes of intraservice time for CPT code 432X5, which 
produces a ratio of 0.9, and when multiplied by a work RVU of 50.00 
(CPT code 432X5), results in the proposed work RVU of 45.00. We 
considered using the same methodology for CPT codes 43117 and 432X6.
    Finally, we considered a work RVU of 58.94 for CPT code 43112 based 
on a direct crosswalk to CPT code 46744 (Repair of cloacal anomaly by 
anorectovaginoplasty and urethroplasty, sacroperineal approach). We 
note that the intraservice time ratio when applied to CPT codes 43112 
and 432X7, the paired McKeown esophagectomy procedures, would have 
produced a potential work RVU of 52.29, creating a rank order anomaly 
within the family by establishing a higher work RVU for CPT code 43117 
than CPT code 43112, and are concerned with whether this is an 
appropriate valuation for the code. We are seeking comment on whether 
the alternative work RVUs that we considered may reflect the relative 
difference in work more accurately between the six codes in the family. 
We note, for example, that these valuations correct the rank order 
anomaly between CPT codes 43112 and 43121 as noted in the RUC 
recommendations.
    We are proposing the RUC-recommended direct PE inputs for all six 
codes in the family without refinement. We considered changing the 
preservice clinical labor type for all six codes from an RN (L051) to 
an RN/LPN/MTA blend (L037D). We have concerns about whether the use of 
RN clinical labor would be typical for filling out referral forms or 
for scheduling space and equipment in the facility. We also considered 
removing the additional clinical labor time for the ``Additional 
coordination between multiple specialties for complex procedures (eg, 
tests, meds, scheduling)'' activity, consistent with preservice 
standards for codes with 90-day global periods. We are concerned that 
this time would not typically be included in non-surgical procedures 
performed by other specialties even when additional coordination is 
required.
    We are seeking comment regarding the changes in the valuation 
between the two surveys, the preservice and immediate postservice work 
times, and the RN staffing type employed for routine preservice 
clinical labor.
(21) Transurethral Electrosurgical Resection of Prostate (CPT Code 
52601)
    CPT code 52601 appeared on a screen of potentially misvalued codes 
which indicated that it was performed less than 50 percent of the time 
in the inpatient setting, yet included inpatient hospital E/M services 
within the global period. For CY 2018, we are proposing the RUC-
recommended work RVU of 13.16 for CPT code 52601 and proposing to use 
the RUC-recommended direct PE inputs without refinements.
    We considered a work RVU of 12.29 for CPT code 52601 based on a 
direct crosswalk to CPT code 58541 (Laparoscopy, surgical, 
supracervical hysterectomy, for uterus 250 g or less), which is one of 
the reference codes. CPT code 58541 may potentially be a more accurate 
crosswalk for CPT code 52601 than the RUC-recommended direct crosswalk 
to CPT code 29828 (Arthroscopy, shoulder, surgical; biceps tenodesis). 
Although all three of these codes share the same intraservice time of 
75 minutes, CPT code 58541 is a closer match in terms of the total time 
at only 10 minutes difference. CPT code 58541 also shares the same 
postoperative office visits as CPT code 52601, a pair of CPT code 99213 
office visits, while CPT code 29828 also contains two CPT code 99212 
office visits that are not present in the reviewed code.
    We note that if we were to use a reverse building block methodology 
for CPT code 52601 and subtract out the value of the E/M visits being 
removed, the proposed work RVU would be 11.21. We are not proposing 
this work RVU, however, because as we noted in the CY 2017 PFS final 
rule (81 FR 80274), we agree that the per-minute intensity of work is 
not necessarily static over time or even necessarily during the course 
of a procedure. Instead, we utilize time ratios and building block 
methodologies to identify potential values that account for changes in 
time and compare these values to other PFS services for estimates of 
overall work. When the values we develop reflect a similar derived 
intensity, we agree that our values are the result of our assessment 
that the relative intensity of a given service has remained similar. 
For CPT code 52601, we are concerned as to how the RUC-recommended 
derived intensity of the procedure could be increasing by 30 percent 
over the current derived intensity, while at the same time the typical 
site of service is changing from inpatient to outpatient status. In 
other words, if it is now typical for CPT code 52601 to be performed on 
an outpatient basis, then we would generally expect the intensity of 
the procedure to be decreasing, not increasing. We considered a work 
RVU of 12.29 for CPT code 52601 based on a direct crosswalk to CPT code 
58541 (Lsh uterus 250 g or less), and seek comment on whether this 
alternative value might better reflect relativity.
(22) Peri-Prostatic Implantation of Biodegradable Material (CPT Code 
55X87)
    In October 2016, the CPT Editorial Panel deleted CPT Category III 
code 0438T and created a new CPT code 55X87 (Transperineal placement of 
biodegradable material, peri-prostatic, single or multiple 
injection(s), including image guidance, when performed). For CY 2018, 
we are proposing the RUC-recommended work RVU of 3.03 for CPT code 
55X87.
    In reviewing the RUC recommendations, we noted a decrease in 
preservice time (30 minutes) compared to the current value. In order to 
account for this change in time, we considered calculating the 
intraservice time ratio between the key reference code (CPT code 
49411), which has an intraservice time of 40 minutes, and the RUC-
recommended intraservice time (30 minutes) and multiplying that against 
the work RVU for CPT code 49411 (3.57), which would have resulted in a 
work RVU of 2.68. A work RVU of 2.68 would have been further supported 
by a bracket of two crosswalk codes, CPT code 65779 (Placement of 
amniotic membrane on the ocular surface; single layer, sutured) which 
has a work RVU of 2.50 and CPT code 43252 (Esophagogastroduodenoscopy, 
flexible, transoral; with optical endomicroscopy), which has a work RVU 
of 2.96. Compared with CPT code 55X87, these codes have identical 
intraservice and similar total times. We are seeking comment on whether 
these alternative values should be considered, especially given the 
changes in time reflected in the survey data.
    We received invoices with pricing information regarding two new 
supply items: ``endocavity balloon'' and ``biodegradeable material 
kit--periprostatic''. The invoice for endocavity balloon was $399.00 
and the input price on the PE spreadsheet for this supply item was 
noted as such. We believe the input price noted on the PE spreadsheet 
was an error, given that the invoice noted that the price of $399.00 
was for a box of ten and the specialty society requested a single unit 
of this supply item. Therefore, we are proposing to use this 
information to propose for supply item ``endocavity balloon'' a price 
of $39.90. The invoice

[[Page 34000]]

for the ``biodegradeable material kit--periprostatic'' totaled 
$2850.00. We are proposing to use this information to propose for the 
supply item ``biodegradeable material kit--periprostatic'' a price of 
$2850.00. We also received an invoice with pricing information 
regarding the new equipment item ``endocavitary US probe'' which 
totaled $16,146.00. We are proposing to use this information to propose 
for equipment item ``endocavitary US probe'', a per-minute price of 
$0.0639. We question, given an invoice price of $29,999.00 for this 
existing equipment item EQ250 (portable ultrasound unit), whether this 
equipment item includes probes. We are seeking public comments related 
to whether equipment item EQ250 (portable ultrasound) includes probes.
(23) Colporrhaphy With Cystourethroscopy (CPT Codes 57240, 57250, 57260 
and 57265)
    In October 2015, CPT code 57240 was identified by analysis of the 
Medicare data from 2011-2013 that indicated that services reported with 
CPT code 57240 were performed less than 50 percent of the time in the 
inpatient setting, yet include inpatient hospital E/M services within 
the global period. The RUC recommended that CPT codes 57240 (Anterior 
colporrhaphy, repair of cystocele with or without repair of 
urethrocele), 57250 (Posterior colporrhaphy, repair of rectocele with 
or without perineorrhaphy), 57260 (Combined anteroposterior 
colporrhaphy), and 57265 (Combined anteroposterior colporrhaphy; with 
enterocele repair) be referred to the CPT Editorial Panel. In September 
2016, the CPT Editorial Panel revised 57240, 57260 and 57265 to 
preclude separate reporting of follow up cystourethroscopy after 
colporrhaphy (CPT code 52000).
    For CY 2018, we are proposing the RUC-recommended work RVUs for CPT 
code 57240 (a work RVU of 10.08), CPT code 57250 (a work RVU of 10.08), 
CPT code 57260 (a work RVU of 13.25), and CPT code 57265 (a work RVU of 
15.00).
    We note that there were changes in service times reflected in the 
specialty surveys compared to the RUC-recommended work RVUs for CPT 
code 57240. Specifically, we note that the RUC recommended a 48 minute 
decrease in total time, compared to the specialty survey total time of 
259 minutes. The difference in total time reflected a decrease in 
preservice time (29 minutes) and inpatient visits (0.5 visits = 19 
minutes). We considered a work RVU of 9.77 for CPT code 57240, 
crosswalking to CPT code 50590 (Lithotripsy, extracorporeal shock 
wave), which has similar service times. We are seeking comment on 
whether CPT code 57250 would be a relevant comparator for CPT code 
57240, based on the described elements of each service and existing or 
surveyed service times, compared to CPT code 57240.
    We considered a work RVU of 11.47 for CPT code 57265, crosswalking 
to CPT code 47563 (Laparoscopy, surgical; cholecystectomy with 
cholangiography) with similar service times. We seek comment on how an 
alternative work RVU of 11.47 for CPT code 57265 would affect 
relativity among PFS services, and on whether CPT code 57260 is a 
relevant comparator for CPT code 57265, considering differences in the 
described procedures and service times.
    We are proposing the RUC-recommended direct PE inputs for CPT codes 
57240, 57250, 57260 and 57265 without refinements.
(24) Nerve Repair With Nerve Allograft (CPT Codes 64910, 64911, 64X91 
and 64X92)
    The CPT Editorial Panel created two new CPT Category I codes (64X91 
and 64X92) to report the repair of a nerve using a nerve allograft. CPT 
codes 64910 and 64911 were also reviewed as part of this code family. 
CPT codes 64X91 and 64X92 will be placed on the new technology list to 
be re-reviewed by the RUC in 3 years to ensure correct valuation and 
utilization assumptions.
    For CY 2018, we are proposing the RUC-recommended work RVUs for the 
following codes: A work RVU of 10.52 for CPT code 64910, a work RVU of 
14.00 for CPT code 64911, a work RVU of 12.00 for CPT code 64X91, and a 
work RVU of 3.00 for CPT code 64X92.
    We noted a decrease in preservice time (7 minutes) for CPT code 
64910 and considered an alternate work RVU of 10.15, crosswalking to 
CPT code 15120 (Split-thickness autograft, face, scalp, eyelids, mouth, 
neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; 
first 100 sq cm or less, or 1 percent of body area of infants and 
children (except 15050)), which has similar service times. We seek 
comments on whether an alternative work RVU of 10.15 for CPT code 64910 
would better reflect relativity among PFS services with similar service 
times.
    For CPT code 64911 (Nerve repair; with autogenous vein graft 
(includes harvest of vein graft), each nerve)), we considered a work 
RVU of 13.50, crosswalking to CPT code 31591 (Laryngoplasty, 
medicalization, unilateral), which has similar service times. We seek 
comments on whether a work RVU of 13.50 for CPT code 64911 would better 
reflect relativity among other PFS services with similar service times.
    The new coding structure for these services increases granularity 
by including add-on codes that describe each strand of nerve repair. 
While we recognize that additional granularity may be important and 
useful for purposes of data collection, the advantages to Medicare for 
such granularity for purposes of payment are unclear, especially since 
we are unaware of a payment-related reason for such coding complexity. 
We considered proposing a bundled status to the new add-on codes and 
incorporating the relative resources in furnishing the add-on code (CPT 
code 64X92) into the base code (CPT code 64X91) based on the 
utilization assumptions that accompanied the RUC recommendations. The 
RUC estimated that CPT code 64X91 would have 750 Medicare allowed 
services in CY 2018, and that the corresponding add-on CPT code 64X92 
would have 150 Medicare allowed services in CY 2018. Therefore, the RUC 
estimates that CPT code 64X91 will be billed without add-on CPT code 
64X92 for 80 percent (750/900) of the Medicare allowed services, and 
that CPT code 64X91 will be billed with add-on CPT code time 64X92 for 
20 percent (150/900) of the Medicare allowed services in CY 2018. To 
account for the additional work involved in 20 percent of the allowed 
services, we added a work RVU of 0.60 (20 percent of a work RVU of 3.00 
for CPT code 64X92) to the work RVU of 12.00 for CPT code 64X91, to get 
to an alternate work RVU of 12.60 for CPT code 64X91 and increased the 
intraservice time by 6 minutes to account for the bundling of services 
from CPT code 64X92. The alternative work RVU of 12.60 would have been 
further supported by a crosswalk to CPT code 14301 (Adjacent tissue 
transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm), 
which has similar intraservice and total times.
    We are proposing the RUC-recommended direct PE inputs for CPT codes 
64910, 64911, 64X91 and 64X92 without refinements.
(25) CT Soft Tissue Neck (CPT Codes 70490, 70491, and 70492)
    CPT codes 70490 and 70492 were identified through the high 
expenditure services across specialties with Medicare allowed charges 
of $10 million or more screen. CPT code 70491 was also included for 
review as part of this code family. For CY 2018, we are proposing the 
RUC-recommended work RVUs of 1.28 for CPT code 70490, 1.38

[[Page 34001]]

for CPT code 70491, and 1.62 for CPT code 70492.
    For CPT code 70490, we considered a work RVU of 1.07 based on a 
crosswalk to CPT code 72125 (Computed tomography, cervical spine; 
without contrast material). CPT code 72125 is a non-contrast CT service 
on a similar anatomical area and has identical intraservice and total 
times to those recommended by the RUC for CPT code 70490. We also 
considered work RVUs of 1.17 for CPT code 70491 and 1.41 for CPT code 
70492. We are seeking comment on how relativity among other CT services 
paid under the PFS would be affected by applying the alternative work 
RVUs described above for CPT codes in this family.
(26) Magnetic Resonance Angiography (MRA) Head (CPT Codes 70544, 70545, 
and 70546)
    CPT code 70544 was identified by a screen of services across 
specialties with Medicare allowed charges of $10 million or more. 
Subsequently, CPT codes 70545 and 70546 were also reviewed as part of 
this code family. We are proposing the RUC-recommended work RVUs of 
1.20 for CPT code 70544, 1.20 for CPT code 70545, and 1.48 for CPT code 
70546.
    We are also proposing the following refinements to the RUC-
recommended direct PE inputs. For the service period clinical labor 
activity ``Provide preservice education/obtain consent,'' we are 
proposing 5 minutes for CPT code 70544, 7 minutes for CPT code 70545, 
and 7 minutes for CPT code 70546 so that the times for this activity 
are consistent with other magnetic resonance (MR) services performed 
without-contrast materials, with-contrast materials, and without-and-
with contrast materials, respectively. For the clinical labor task 
``Acquire images,'' we are proposing to use the RUC-recommended 
clinical time of 26 minutes for CPT code 70544. We considered proposing 
20 minutes of clinical time to maintain the relativity among the three 
codes in this family and for consistency with other MRA and magnetic 
resonance imaging (MRI) codes, which do not typically assign more 
clinical labor time to this task for services without contrast material 
than for services with contrast material. We seek comments as to the 
appropriate time value for this clinical labor task.
(27) Magnetic Resonance Angiography (MRA) Neck (CPT Codes 70547, 70548, 
and 70549)
    CPT code 70549 was identified through a high expenditure screen. 
CPT codes 70547 and 70748 were also reviewed as part of this family of 
codes. We are proposing the RUC-recommended work RVUs of 1.20 for CPT 
code 70547, 1.50 for CPT code 70548, and 1.80 for CPT code 70549.
    We are also proposing several refinements to the RUC-recommended 
direct PE inputs for these services. For the service period clinical 
labor activity ``Provide preservice education/obtain consent'', we are 
proposing 5 minutes for CPT code 70547, 7 minutes for CPT code 70548, 
and 7 minutes for CPT code 70549 so that the times for this activity 
are consistent with other MR services performed without contrast 
material, with contrast material, and without-and-with contrast 
material, respectively.
    For the intraservice clinical labor task acquire images, for CPT 
code 70547, we are proposing to use the RUC-recommended 26 minutes. We 
considered applying 20 minutes to this clinical labor task, which would 
have maintained consistency with the 20 minutes recommended by the RUC 
for CPT code 70548 (the service that includes with-contrast material). 
We are concerned about the lack of evidence that a non-contrast MRA 
would require more clinical labor time than the with-contrast MRA 
service. We are seeking comment as to the appropriate time value for 
this clinical labor task.
(28) CT Chest (CPT Codes 71250, 71260, and 71270)
    CMS identified this code family through the high expenditures 
screen. We are proposing the RUC-recommended work RVUs of 1.16 for CPT 
code 71250, 1.24 for CPT code 71260, and 1.38 for CPT code 71270.
    For CPT code 71250, we considered maintaining the CY 2017 work RVU 
of 1.02. We are concerned with the lack of evidence that the physician 
time or intensity of furnishing this service has changed since it was 
last valued. In addition, a comparison to other CT codes indicates that 
the RUC-recommended work values could be overvalued relative to other 
CT services and compared to similar, non-contrast CT studies such as 
CPT codes 72131 (Computed tomography, lumbar spine; without contrast 
material) and 73700 (Computed tomography, lower extremity; without 
contrast material), both of which have work RVUs of 1.00.
    For CPT code 71260, we considered proposing a work RVU of 1.10 by 
applying the RUC-recommended increment between CPT code 71250 and 71260 
(0.08) to CPT code 71260. For CPT code 71270, we considered a work RVU 
of 1.24 by applying the RUC-recommended increment between CPT codes 
71260 and 71270 (0.22) to CPT code 71270. In addition to maintaining 
relatively among the codes in this family, we considered further 
supporting these alternative values based on a comparison to other CT 
studies, such as with-contrast material CT studies, and without-and-
with contrast CT studies.
    While we have concerns about the RUC-recommended work RVUs for 
these codes, for CY 2018, we are proposing the RUC recommended work 
RVUs for CPT code 71250, 71260, and 71270 and are seeking comment on 
whether our alternative values would improve relativity.
(29) MRI of Abdomen and Pelvis (CPT Codes 72195, 72196, 72197, 74181, 
74182, and 74183)
    CPT codes 74182 and 72196 were identified as part of the screen of 
high expenditure services across specialties with Medicare allowed 
charges of $10 million or more. CPT codes 74181, 74183, 72195, and 
72197 were also reviewed as part of this code family. We are proposing 
the RUC-recommended work RVUs of 1.46 for CPT code 72195, 1.73 for CPT 
code 72196, 2.20 for CPT code 72197, 1.46 for CPT code 74181, 1.73 for 
CPT code 74182, and 2.20 for CPT code 74183.
    While we are proposing the RUC-recommended direct PE inputs, we 
considered 30 minutes for clinical labor task ``Acquire images'' for 
CPT codes 74181 and 74182, which appears to be more consistent with the 
codes in this family and more consistent with other MR codes. We also 
note that for CPT codes 74181 and 74182, the clinical labor time for 
acquired images appears to have been developed through a consensus 
panel from the specialty society over 15 years ago. Given that these 
times are estimates based on expert panel consensus rather than survey 
data, we seek comments on whether using a structure that matches other 
MR code families would be more appropriate to value these clinical 
labor times.
(30) MRI Lower Extremity (CPT Codes 73718, 73719, and 73720)
    CPT codes 73718 and 73720 were identified as part of the screen of 
high expenditure services, and CPT code 73719 was included for review 
as part of the code family. We are proposing the RUC-recommended work 
RVUs of 1.35 for CPT code 73718, 1.62 for CPT code 73719, and 2.15 for 
CPT code 73720.
    We are also proposing the following refinements to the RUC-
recommended direct PE inputs. For the service period clinical labor 
activity ``Provide preservice education/obtain consent,''

[[Page 34002]]

we are proposing 5 minutes for CPT code 73718, 7 minutes for CPT code 
73719, and 7 minutes for CPT code 73720. Likewise, for the service 
period task ``Prepare room, equipment, supplies,'' we are proposing 3 
minutes for CPT code 73718, 5 minutes for CPT code 73719, and 5 minutes 
for CPT code 73720. We are proposing these changes to maintain 
consistency with other MR services without contrast materials, with 
contrast materials, and without-and-with contrast materials, 
respectively.
(31) Abdominal X-ray (CPT Codes 74022, 740X1, 740X2, and 740X3)
    CPT codes 74000 (Radiologic examination, abdomen; single 
anteroposterior view) and 74022 (Radiologic examination, abdomen; 
complete acute abdomen series, including supine, erect, and/or 
decubitus views, single view chest) were identified via a high 
expenditure screen. The CPT Editorial Panel created CPT codes 740X1, 
740X2, and 740X3 to replace CPT codes 74000, 74010, and 74020. For CY 
2018, we are proposing the RUC-recommended work values for these codes.
    As part of their recommendations, the RUC's utilization crosswalk 
suggests that 25 percent of services currently reported with CPT code 
74010 will be reported with CPT code 740X2 and 75 percent will be 
reported with CPT code 740X3; and 75 percent of services currently 
reported with CPT code 74020 will be reported with CPT code 740X2 and 
25 percent will be reported with CPT code 740X3. However, we did not 
identify evidence or a rationale for these assumptions. For purposes of 
calculating the proposed RVUs, we used an even distribution of services 
previously reported as CPT codes 74010 and 74020 to CPT codes 740X2 and 
740X3 instead of the RUC-recommended distribution because we think that 
the services previously reported with codes 74010 and 74020 will be 
reported in equal volume between the code representing two views and 
the code representing three views. We seek comment on information that 
would help us improve on this distribution for purposes of developing 
final RVUs, including rationale for the distribution reflected in the 
RUC's utilization crosswalk.
(32) Angiography of Extremities (CPT Codes 75710 and 75716)
    This code family was identified through the $10 million or more 
screen of high expenditure services. We are proposing the RUC-
recommended work RVUs of 1.75 for CPT code 75710 and 1.97 for CPT code 
75716. We are also proposing to use the RUC-recommended direct PE 
inputs for both CPT codes 75710 and 75716, with the following 
refinements. For the clinical labor task ``Technologist QC's images in 
PACS, checking for all images, reformats, and dose page,'' we are 
proposing refinements consistent with the standard clinical labor times 
for tasks associated with the PACS Workstation.
    We are also proposing to refine the clinical labor by removing the 
2 minutes associated with the task ``prepare room, equipment, and 
supplies.'' CPT codes 75710 and 75716, which represent radiological 
supervision and interpretation, are billed with codes that include 
activities such as needle placement and imaging, and the ``prepare 
room, equipment, supplies,'' activity will be accounted for with the 
codes that are billed with these interpretation codes.
(33) Ophthalmic Biometry (CPT Codes 76516, 76519, and 92136)
    In the CY 2016 PFS final rule with comment period, CMS identified 
CPT codes 76519 and 92136 as potentially misvalued on the high 
expenditure screen. For CY 2018, we are proposing the RUC-recommended 
work RVUs for each code in this family as follows: A work RVU of 0.40 
for CPT code 76516, a work RVU of 0.54 for CPT code 76519, and a work 
RVU of 0.54 for CPT code 92136.
    For both CPT codes 76519 and 92136, the RUC recommended adding an 
additional 8 minutes of immediate postservice time for dictating the 
report of the procedure for the medical record, review and sign report, 
communicate results to the patient, discussing lens implant options for 
desired post-operative refractive result, and entering an order for the 
intraocular lens implant. We considered time and work values that would 
not include the additional 8 minutes of immediate postservice time in 
either of these codes, due to the concern that the additional time may 
not reflect the typical case. Were we to not include those 8 minutes, 
each of these procedures would have a total time of 14 minutes. We 
considered applying the total time ratio (decrease from 17 minutes to 
14 minutes; ratio of 0.824) to the RUC-recommended work RVU of 0.54, 
which would have resulted in a work RVU of 0.44 for both CPT codes 
76519 and 92136. We are seeking comment on whether these alternative 
values would improve relativity.
(34) Ultrasound of Extremity (CPT Codes 76881 and 76882)
    The RUC identified CPT codes 76881 and 76882 for review of PE 
inputs. For CPT code 76881, we are proposing the recommended inputs 
with refinements. We are proposing to remove 1 minute from the clinical 
labor task ``Exam documents scanned into PACS. Exam completed in RIS 
system to generate billing process and to populate images into 
Radiologist work queue,'' because this code does not include any 
equipment time for the PACS workstation proxy or professional PACS 
workstation. We note that the RUC-recommended inputs shift the general 
ultrasound room from the PE inputs for CPT code 76881 to the PE inputs 
for CPT code 76882. We are proposing to make this change, consistent 
with the RUC recommendations. We are also seeking comment on whether a 
portable ultrasound unit would be a more accurate PE input for both 
codes, given that the dominant specialty for both of these services is 
podiatry based on available 2016 Medicare claims data. However, we are 
proposing that these codes would not be subject to the phase-in of 
significant RVU reductions given the significance of this shift of 
resource costs between codes in the same family. In the CY 2016 PFS 
final rule (80 FR 70927 through 70931), we finalized a policy to 
identify services that are not subject to the phase-in because they are 
new or revised codes. We excluded 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. 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. Moving the general ultrasound room input from CPT code 
76881 to CPT code 76882 as recommended by the RUC would represent a 
significant shift in direct PE due to the high cost nature of this 
equipment item. As a result, these codes describe different services in 
the update year than in the current year, producing a substantial 
revision in the valuation of the coding. We are seeking comment on this 
proposed application of the phase-in policy.
(35) Radiation Therapy Planning (CPT Codes 77261, 77262, and 77263)
    CPT code 77263 was identified through a screen of high expenditure 
services across specialties. CPT codes 77261 and 77262 were included 
for review. For CY 2018, we are proposing the RUC-recommended work RVUs 
of

[[Page 34003]]

1.30 for CPT code 77261, 2.00 for CPT code 77262, and 3.14 for CPT code 
77263.
    However, we have concerns regarding the RUC-recommended work RVUs 
given the decreases in service times as recommended by the RUC and 
reflected in the survey data compared to the current values. For CPT 
code 77263, we considered a work RVU of 2.60 based on a crosswalk to 
CPT code 96111 (Developmental testing, (includes assessment of motor, 
language, social, adaptive, and/or cognitive functioning by 
standardized developmental instruments) with interpretation and 
report), which has an identical intraservice time, and similar total 
time to the RUC-recommended time values for CPT code 77263. We are 
concerned that despite a 15 minute decrease in intraservice time, the 
RUC did not recommend a work RVU decrease.
    We note that the majority of the utilization among the codes in 
this family would be reported with CPT code 77263. Therefore, we 
considered using a work RVU of 2.60 for CPT code 77263 as a base for 
alternative valuations for CPT codes 77261 and 77262 by applying the 
ratio of the crosswalk work RVU of CPT code 96111 (Developmental test 
extend) to the RUC-recommended work RVU of CPT code 77263 (that is, 
2.60/3.14 = 0.83) to the RUC-recommended work RVU for CPT code 77261 
(that is, 0.83 x 1.30 = 1.08) and CPT code 77262 (that is, 0.83 x 2.0 = 
1.66), which would have resulted in work RVUs of 1.08 for CPT code 
77261 and 1.66 for CPT code 77262. We seek comments on whether the 
alternative valuation would be more appropriate for these codes.
(36) Pathology Consultation during Surgery (CPT Codes 88333 and 88334)
    CPT codes 88333 and 88334 were surveyed for both work and PE for 
the CY 2018 rule cycle. We are proposing the RUC-recommended work RVU 
of 1.20 for CPT code 88333 and the RUC-recommended work RVU of 0.73 for 
CPT code 88334. For the direct PE inputs, we are proposing to remove 
the clinical labor for the ``Prepare room. Filter and replenish stains 
and supplies (including setting up grossing station with colored 
stains)'' activity from CPT code 88333. This clinical labor is not 
currently included in the direct PE inputs for CPT code 88333, and we 
continue to believe that this is a form of indirect PE that is not 
individually allocable to a particular patient for a particular 
service. While we agree that replenishing stains and supplies is a 
necessary task, under the established methodology, it is more 
appropriately classified as indirect PE.
    We are proposing to refine the clinical labor time for ``Clean 
room/equipment following procedure'' activity for CPT code 88333, 
consistent with the standard clinical labor time assigned for room 
cleaning when used by laboratory services. We seek comments related to 
the equipment time assigned to the ``grossing station w-heavy duty 
disposal'' (EP015) for both CPT codes 88333 and 88334. Although the 
recommended equipment time of 10 minutes maintains the current 
equipment time assigned to the grossing station, and we have no reason 
to believe that this time is incorrect, it is unclear to us how this 
equipment time is derived.
(37) Tumor Immunohistochemistry (CPT Codes 88360 and 88361)
    CPT codes 88360 and 88361 appeared on a high expenditure services 
screen across specialties with Medicare allowed charges of over $10 
million. We are proposing the RUC-recommended work RVU of 0.85 for CPT 
code 88360 and the RUC-recommended work RVU of 0.95 for CPT code 88361. 
We are proposing to refine the clinical labor time for the ``Enter 
patient data, computational prep for antibody testing, generate and 
apply bar codes to slides, and enter data for automated slide stainer'' 
activity for both codes, consistent with the standard time for this 
clinical labor activity across different pathology services. For CPT 
code 88361, we are also proposing to remove the 1 minute of clinical 
labor time from the ``Performing instrument calibration, instrument qc 
and start up and shutdown'' and the ``Gate areas to be counted by the 
machine'' activities. These clinical labor activities do not appear in 
other recently reviewed computer-assisted pathology codes. We believe 
that these clinical labor activities would not be typical for CPT code 
88361 and are already included in the allocation of indirect PE 
consistent with our established methodology.
    We are proposing to remove the clinical labor time for ``Clean 
room/equipment following procedure'' for CPT codes 88360 and 88361, as 
we believe that this clinical labor is duplicative of the 4 minutes of 
clinical labor assigned to ``Clean equipment and work station in 
histology lab''. We are also proposing to remove the clinical labor 
time for the ``Verify results and complete work load recording logs'' 
and the ``Recycle xylene from tissue processor and stainer'' activities 
for CPT codes 88360 and 88361. As we have stated in previous rules, 
such as in the CY 2017 PFS final rule (81 FR 80319), we believe these 
clinical labor activities to be already included in the allocation of 
indirect PE consistent with our established methodology.
    We are proposing to refine the equipment time for the ``Benchmark 
ULTRA auto slide prep & E-Bar Label system'' (EP112) from 18 minutes to 
16 minutes for both codes. The RUC-recommended equipment time of 18 
minutes was an increase of 3 minutes from the current EP112 equipment 
time to incorporate the equipment time of the ``E-Bar II Barcode Slide 
Label System'' (EP113), which the recommended materials have clarified 
is part of the EP112 equipment item. We are proposing to add 1 minute 
over the current value of 15 minutes to the EP112 equipment time to 
reach the aforementioned 16 minutes, as we believe that this would be 
more typical for the slide labeling taking place.
    For CPT code 88361, we are proposing to maintain the current price 
of $195,000.00 for the DNA image analyzer (EP001) equipment, as the 
submitted invoice contains a series of unrelated items that have been 
crossed out, making it difficult to determine the cost of the 
equipment. We considered refining the equipment time for the DNA image 
analyzer from 30 minutes to 5 minutes. The equipment literature for the 
DNA image analyzer states that the machine can run 50 slides per hour, 
and CPT code 88361 only requires 3 slides per procedure. This works out 
to 3.6 minutes of equipment usage (3 slides divided by 50 slides per 
hour multiplied by 60 minutes in an hour), to which we considered 
adding 1 minute for preparing the slides. The resulting figure of 4.6 
minutes would then round up to 5 minutes, which we considered as the 
potential equipment time for EP001 assigned to CPT code 88361. We seek 
comments on additional pricing information for the EP001 DNA image 
analyzer equipment, specifically invoices solely for this equipment 
containing a rationale for each component part, as well as the 
appropriate equipment time typically required for use in CPT code 
88361.
(38) Cardiac Electrophysiology Device Monitoring Services (CPT Codes 
93279, 93281, 93282, 93283, 93284, 93285, 93286, 93287, 93288, 93289, 
93290, 93291, 93292, 93293, 93294, 93295, 93296, 93297, 93298, and 
93299)
    As part of the CY 2016 PFS final rule (80 FR 70914), several 
services in this family (reported with CPT codes 93288, 93293, 93294, 
93295, and 93296) were identified as potentially misvalued through the 
high expenditure by

[[Page 34004]]

specialty screen. Seven of the 21 services in this family involve 
remote monitoring of cardiovascular devices, and two of these services 
(reported with CPT codes 93296 and 93299) are valued for practice 
expense only. For CY 2018, we are proposing the RUC-recommended work 
RVUs for the 19 CPT codes in this family that are valued with physician 
work as follows: 0.65 for CPT code 93279, 0.77 for CPT code 93280, 0.85 
for CPT code 93281, 0.85 for CPT code 93282, 1.15 for CPT code 93283, 
1.25 for CPT code 93284, 0.52 for CPT code 93285, 0.30 for CPT code 
93286, 0.45 for CPT code 93287, 0.43 for CPT code 93288, 0.75 for CPT 
code 93289, 0.43 for CPT code 93290, 0.37 for CPT code 93291, 0.43 for 
CPT code 93292, 0.31 for CPT code 93293, 0.60 for CPT code 93294, 0.74 
for CPT code 93295, 0.52 for CPT code 93297, and 0.52 for CPT code 
93298.
    For CPT code 93293, we considered a work RVU of 0.91 (25th 
percentile survey result) and seek comment on whether this alternative 
work RVU for this service would better maintain relativity between 
single and dual lead pacemaker systems and cardioverter defibrillator 
services. We considered reducing the work RVU for CPT code 93282 by 
0.11 work RVUs and seek comments on whether this alternative value 
would better reflect relativity between the single and dual lead 
systems that exist within pacemaker services and within cardioverter 
defibrillator services. We also noted that there is a difference of 
0.10 work RVUs between the RUC-recommended values for CPT codes 93289 
and 93282. Therefore, we considered a proportionate reduction for CPT 
code 93289 to a work RVU of 0.69. For CPT code 93283, we considered a 
work RVU of 0.91, consistent with the 25th percentile from the survey 
results, and seek comment on whether this value would improve 
relativity.
    As noted in this section of the proposed rule, several of the CPT 
codes (99392, 99294, 99295, 99297, and 99298) reviewed by the RUC in 
January 2017 involve remote monitoring services for cardiac devices. We 
agree with the RUC that these services are difficult to value 
considering that the monitoring duration (number of days between 30 and 
90) and the average number of transmissions vary. We also note that 
these codes were surveyed twice, and in both cases the intraservice and 
total times were considered by the specialty societies to be 
inconsistent with existing times. The RUC explained that they 
extrapolated total and intraservice time data for these codes and 
warned against making comparisons. Without additional information about 
the methods and sources used for extrapolation, however, we have no 
basis for assuming the imputed values are of higher quality and/or 
accuracy than those from the survey. We do not agree, therefore, that 
survey results should not be used as a point of comparison in the 
context of other factors, particularly when they are used to support 
other considerations.
    Although we are proposing the RUC-recommended work RVUs for each of 
these CPT codes, we considered alternative values. The RUC recommended 
a work RVU of 0.31 for CPT code 93293, which is 0.01 work RVUs lower 
than the existing work RVU for this code. We have concerns that the 
amount of the reduction in the work RVU recommended by the RUC may not 
be consistent with the decrease in total time of 7 minutes. We 
considered an alternative crosswalk for CPT code 93293 (Pm phone r-
strip device eval) (5 minutes intraservice time and 13 minutes total 
time) to CPT code 94726 (Pulm funct tst plethysmograp), which has 5 
minutes intraservice time and 15 minutes total time and a work RVU of 
0.26. We seek comments our proposed and alternative valuations for this 
code.
    For CPT code 93294, we considered a work RVU of 0.55, crosswalking 
from CPT code 76706 (Us abdl aorta screen aaa), and we seek comments on 
whether it would better align with the RUC-recommended service times. 
We are concerned that a work RVU of 0.60 may not account for the 
difference between existing service times and the RUC-recommended 
service times. Similarly, the RUC recommended a work RVU for CPT code 
93294 of 0.60, which is 0.05 work RVUs less than the existing work RVU. 
The total time for furnishing services reported with CPT code 93294 
decreased by 10 minutes, however, and we believe this reduction in time 
may not be appropriately reflected by a decrease of 0.05 work RVUs. 
Compared to services with similar total and intraservice times, we 
identified CPT code 76706 (Us abdl aorta screen aaa) as potentially a 
more appropriate crosswalk. CPT code 76706 has identical intraservice 
and total service times as CPT code 93294, with a work RVU of 0.55. We 
seek comments on whether our alternative value would better reflect the 
time and intensity involved in furnishing this service.
    For CPT code 93295, we considered a work RVU of 0.69, crosswalking 
to CPT code 76586, which has identical intraservice and total times 
compared to CPT code 93295. We considered using a work RVU of 0.69 to 
maintain the differential between CPT code 93295 and the work RVU we 
considered for the previous code in this family (a work RVU of 0.11 for 
CPT code 93295). We are concerned about the decrease in service time 
compared to the work RVU. We note that the existing intraservice time 
is 22.5 minutes, compared to the RUC-recommended intraservice time of 
10 minutes. We seek comments on whether our alternative value would 
better reflect the time and intensity involved in furnishing this 
service.
    For CPT code 93298, the RUC recommended a work RVU of 0.52, which 
is unchanged from the current work RVU for this code. We are concerned 
about that recommendation given the reduction in both intraservice and 
total time for this service. The intraservice time decreased from 24 to 
7 minutes, while total time decreased from 44 to 17 minutes. We 
acknowledge that the current times for this CPT code and others in this 
family are extrapolations. However, without additional information 
about the extrapolation of data from survey results, we question 
whether the survey results should be excluded from consideration 
altogether. We considered a work RVU of 0.37 for CPT code 93297, 
crosswalking to CPT code 96446 (Chemotx admn prtl cavity). We also 
considered a work RVU of 0.37 for CPT code 93298 based on a crosswalk 
to CPT code 96446, since the RUC indicated that the work RVUs for CPT 
codes 93297 and 93298 should be the same. We are seeking comment on our 
proposed valuation and whether our alternative valuation would be more 
appropriate for this code.
    We propose the RUC-recommended direct PE inputs with the following 
refinements. We propose to remove 2 minutes for ``review charts'' from 
CPT codes 93279, 93281, 93282, 93283, 93284, 93285, 93286, 93287, 
93288, 93289, 93290, 93291, and 93292 to maintain relativity since it 
is not typically incorporated for similar PFS codes. We also propose 
removing 2 minutes for ``complete diagnostic forms, lab & X-ray 
requisitions'' for the labor category ``med tech/asst'' (L026A) for 
these services because we believe the same activity is being performed 
by labor category RN/LPN/MTA (L037D). We seek comments regarding 
whether this row was included in error. Also for the same group of CPT 
codes, we also propose standard refinements for the time for equipment 
items EF023 and EQ198.
    We propose to use the RUC-recommended direct practice expense 
inputs and times for all other CPT codes in this family (CPT codes 
93293, 93294,

[[Page 34005]]

93295, 93296, 93297, 93298, and 93299) without refinement.
(39) Transthoracic Echocardiography (TTE) (CPT Codes 93306, 93307, and 
93308)
    In the CY 2016 PFS final rule with comment period (80 FR 70914), 
CMS identified CPT code 93306 through the high expenditures screen. 
Subsequently, the RUC reviewed CPT codes 93307 and 93308, in addition 
to CPT code 93306 as part of this family of codes that describe 
transthoracic echocardiograms. For CY 2018, we are proposing the RUC-
recommended work RVUs for CPT codes 99306 (a work RVU of 1.50), 99307 
(a work RVU of 0.92), and 99308 (a work RVU of 0.53), and proposing the 
RUC-recommended direct PE inputs for CPT codes 93306, 93307, and 93308 
without refinement.
    For CPT code 93306 (Echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed, 
complete, with spectral Doppler echocardiography, and with color flow 
Doppler echocardiography), we considered maintaining the CY 2017 work 
RVU of 1.30. The surveyed total time for this code dropped slightly due 
to changes in the immediate postservice time. The median preservice and 
intraservice time remained unchanged.
    For CPT code 93307 (Echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed, 
complete, without spectral or color Doppler echocardiography), we 
considered a work RVU of 0.80, crosswalking to services with similar 
service times (CPT codes 93880 (Extracranial bilat study), 93925 (Lower 
extremity study), 93939, 93976 (Vascular study), and 93978 (Vascular 
study)). The surveyed total time dropped 3 minutes (from the 
intraservice time) compared to the existing service times for this 
code.
    For CPT code 93308 (Echocardiography, transthoracic, real-time with 
image documentation (2D), includes M-mode recording, when performed, 
follow-up or limited study), we considered a work RVU of 0.43, 
crosswalking to CPT code 93292 (Wcd device interrogate) based on 
similar service times. The surveyed total time dropped by 5 minutes 
(from the intraservice time) compared to the existing service times for 
this code.
    For CY 2018, we are proposing the RUC-recommended work RVUs for CPT 
codes 93306, 93307, and 93308 and seek comments on whether our 
alternative values would better reflect the time and intensity of these 
services.
(40) Stress Transthoracic Echocardiography (TTE) Complete (CPT Codes 
93350 and 93351)
    CPT code 93351 was identified as potentially misvalued and the RUC 
reviewed CPT code 93350 as part of the same code family. For CY 2018, 
we are proposing the RUC-recommended work RVUs for CPT codes 93350 (a 
work RVU of 1.46) and 93351 (a work RVU of 1.75).
    We are proposing the following refinements to the RUC-recommended 
direct PE inputs for CPT codes 93350 and 93351. For both codes, we 
applied the standard formula in developing the minutes for equipment 
item ED053 (professional PACS workstation), which results in 18 minutes 
for CPT code 93350 and 25 minutes for CPT code 93351. We are also 
proposing standard clinical labor times for providing preservice 
education/obtaining consent. We are not proposing to include clinical 
labor time for the task setup scope since there is no scope used in the 
procedure and we do not agree with the RUC's statement that this 
replicates 5 minutes in CPT code 93015 when the RN prepares patients 
for 10-lead ECG. We have found that there is no corresponding time of 5 
minutes for setup scope in the PE inputs for CPT code 93015. We are 
proposing refinements to the equipment time for ED050 (PACS workstation 
proxy) for CPT code 93351, consistent with our standard equipment times 
for PACS Workstation Proxy.
(41) Peripheral Artery Disease (PAD) Rehabilitation (CPT Code 93668)
    We have issued a national coverage determination (NCD) for Medicare 
coverage of supervised exercise therapy (SET) for the treatment of 
peripheral artery disease (PAD). Information regarding the NCD can be 
found on the CMS Web site at https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=287. For the remainder of 
CY 2017, we anticipate that CPT code 93668, currently assigned PROCSTAT 
N (noncovered service by Medicare), will be payable before the end of 
CY 2017, retroactive to the effective date of the NCD to implement 
payment under the NCD.
    For CY 2018, we are proposing to make payment for Medicare-covered 
SET for the treatment of PAD, consistent with the NCD, reported with 
CPT code 93668. For CPT code 93668, we are proposing to use the most 
recent RUC-recommended work and direct PE inputs. We are also seeking 
comment on the coding structure and valuation assumptions. Since the 
RUC has not reviewed CPT code 93668 since 2001, we seek comments on the 
direct PE inputs assigned to the code, which appear in the direct PE 
input database. We also note that CPT code 93668 is a PE only code and 
does not include physician work.
    CPT prefatory language states that CPT code 93668 may be separately 
reported with appropriate E/M services, including office and/or 
outpatient services (CPT codes 99201 through 99215), initial hospital 
care (CPT codes 99221 through 99223), subsequent hospital care (CPT 
codes 99231 through 99233), and critical care services (CPT codes 99291 
through 99292). Our understanding of CPT's prefatory language is that 
these E/M codes may only be billed when review or exam of the patient 
is medically indicated and must conform to all existing E/M 
documentation requirements. E/M visit codes should not be billed to 
account for supervision of SET for the treatment of PAD by a physician 
or other qualified healthcare practitioner. We seek comments on whether 
to develop professional coding to reflect the supervision of clinical 
staff, and on the potential overlap with CPT code 99211 (Office or 
other outpatient visit for the evaluation and management of an 
established patient, that may not require the presence of a physician 
or other qualified health care professional. Usually, the presenting 
problem(s) are minimal. Typically, 5 minutes are spent performing or 
supervising these services.) and any distinctions between time spent by 
clinical staff for CPT code 99211 and time spent by clinical staff for 
CPT code 93668.
(42) Pulmonary Diagnostic Tests (CPT Codes 94621, 946X2, and 946X3)
    CPT code 94620 was identified as part of a screen of high 
expenditure services with Medicare allowed charges of $10 million or 
more that had not been recently reviewed. CPT code 94621 was added to 
the family for review. The CPT Editorial Panel deleted CPT code 94620 
and split it into two new codes, CPT codes 946X2 and 946X3, to describe 
two different tests commonly performed for evaluation of dyspnea. We 
are proposing the RUC-recommended work RVUs of 1.42 for CPT code 94621, 
0.70 for CPT code 946X2, and 0.48 for CPT code 946X3.
    We are proposing to refine the clinical labor time for the 
``Provide preservice education/obtain consent'' activity from 10 
minutes to 5 minutes for CPT code 94621, which is the current time 
assigned for this task. While we agree that CPT code 94621 requires 
additional time above the standard for this clinical

[[Page 34006]]

labor activity, we do not believe that double the current time would be 
typical for this procedure. We are also proposing to refine the 
clinical labor time for the ``Prepare and position patient/monitor 
patient/set up IV'' activity from 5 minutes to 3 minutes for the same 
code. The standard time for this activity is 2 minutes, and we are 
proposing a value of 3 minutes to reflect 1 minute of additional 
preparation time above the standard. We believe that additional 
clinical labor time used for preparation would be included under the 10 
minutes assigned to the ``Prepare room, equipment, supplies'' activity 
for this code.
    We are proposing to refine the clinical labor time for the 
``Complete diagnostic forms, lab & X-ray requisitions'' activity, 
consistent with the standard clinical labor time for this activity. We 
also propose to refine the equipment times for CPT codes 94621 and 
946X2 to account for 1:4 patient monitoring time, and to refine the 
equipment times for CPT code 946X3 consistent with standards for non-
highly technical equipment.
    We considered refining the clinical labor time for the ``pre 
exercise ECG, VC, Min Vent. Calculation'' activity from 27 minutes to 
15 minutes for CPT code 94621. We considered proposing this value of 15 
minutes based on assigning 5 minutes apiece for the ECG, the MVV, and 
the spirometry. We believe that each of these three components of this 
clinical labor activity would typically take no longer than 5 minutes 
based on a comparison to the use of these tasks in other CPT codes. We 
also considered refining the clinical labor time for the ``Clinical 
staff performs procedure'' activity from 55 minutes to 35 minutes for 
CPT code 946X2 and from 14 minutes to 12 minutes for CPT code 94621. 
The RUC-recommended materials for the PE inputs state that this 
clinical labor task consists of performing 5 spirometries at 9 minutes 
each plus 10 minutes of exercise time for CPT code 946X2; we believe 
that the spirometries typically take 5 minutes each, which would reduce 
this activity from 55 minutes to 35 minutes. For CPT code 94621, we 
considered maintaining the current value of 12 minutes due to a lack of 
justification for increasing the time to 14 minutes.
    While we remain concerned about the intraservice period clinical 
labor times, for CY 2018, we are proposing the RUC-recommended work 
RVUs for each code in this family and seek comment on whether our 
alternative clinical labor times would better reflect the work and 
times for these services.
(43) Percutaneous Allergy Skin Tests (CPT Code 95004)
    In the CY 2016 PFS proposed rule (80 FR 41706), CPT code 95004 was 
identified through the high expenditures screen as potentially 
misvalued. The RUC suggested in its comments on the CY 2016 PFS 
proposed rule (80 FR 41706), that CPT code 95004 should be removed from 
the list of potentially misvalued codes because it has a work RVU of 
0.01 and that it would serve little purpose to survey physician work 
for this code. The RUC and CMS previously determined that there is 
physician work involved in providing this service since the physician 
must interpret the test and prepare a report. In the CY 2016 PFS final 
rule with comment period (80 FR 70913), CMS reiterated an interest in 
the review of work and PE for this service. We note that our interest 
in stakeholder review of a particular code should not be considered a 
directive for survey under the RUC process. We intend to more clearly 
state our interests in the future, so that under similar circumstances, 
such effort need not be undertaken based on a mistaken impression. To 
reiterate, we believe that whether or not a code should be surveyed in 
response to our interest in receiving recommendations regarding the 
work RVUs should be at the RUC and the specialties' discretion. In many 
cases, we have used recommendations developed through means other than 
surveys in developing RVUs. For example, for many PFS services, the 
direct PE inputs are the primary drivers of overall RVUs and Medicare 
payment. In most of these cases, the recommended inputs are not derived 
from survey data. In some cases, especially for resource-intensive and 
highly technical services, we have expressed some concern about the 
lack of survey or other broad-based data that we have relied on in 
developing rates across the PFS for many years.
    For CY 2018, we are proposing the RUC-recommended work RVU of 0.01 
for CPT code 95004.
    Regarding direct PE inputs, we are proposing to refine the 
equipment times for exam table (EF023) and mayo stand (EF015) to 79 
minutes each to account for clinical 1:4 patient monitoring time. We 
received invoices with new pricing information for two supplies: SH101 
``negative control, allergy test'' ($5.17) and SH102 ``positive 
control, allergy test'' ($26.12). Using this information, we are 
proposing a price of $0.03 per test for supply item SH101 and a price 
of $0.13 per test for supply item SH102.
(44) Continuous Glucose Monitoring (CPT Codes 95250 and 95251)
    CPT codes 95250 (Ambulatory continuous glucose monitoring of 
interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 
hours; sensor placement, hook-up, calibration of monitor, patient 
training, removal of sensor, and printout of recording) and 95251 
(Ambulatory continuous glucose monitoring of interstitial tissue fluid 
via a subcutaneous sensor for a minimum of 72 hours; interpretation and 
report) are used to report the technical and professional component for 
continuous glucose monitoring. In April 2013, CPT code 95251 was 
identified through the high volume growth services screen and 
subsequently this code family was reviewed at the RUC's October 2016 
meeting.
    For CY 2018, we are proposing the RUC-recommended work RVU of 0.70 
for CPT code 95251. However, we are concerned and seek comments on 
whether the 2 minutes of physician preservice time is necessary. Since 
CPT code 95251 is typically billed with an E/M service on the same day, 
we believe the 2 minutes of preservice time may be duplicative. 
Furthermore, we seek comment on whether it would be typical for the 
physician to spend 2 minutes to obtain the CGM reports for review since 
we believe the report would typically be obtained by clinical staff on 
behalf of the physician.
    For the direct PE inputs, the RUC submitted 19 invoices to update 
the price of the medical supply item ``glucose monitoring 
(interstitial) sensor'' (SD114) for CPT code 95250. We are proposing to 
use these invoice prices for the glucose monitoring (interstitial) 
sensor (SD114), with an average cost of $53.08. Therefore, we are 
proposing to use the average price of $53.08 for this supply item.
    As part of our review of this service, we obtained publicly 
available pricing information for the CGM system (EQ125). We reviewed 
the information provided in a study titled, ``The cost-effectiveness of 
continuous glucose monitoring in type 1 diabetes,'' (Huang, SE., 
O'Grady, M., Basu, A. et al., Diabetes Care. June 2010), which 
indicated the price of CGM technology (without sensors) from 3 
different vendors, reflective of full retail prices with no insurer 
discounts, to be $600.00, $1119.00, and $1250.00, which equated to an 
average cost of $1016.00 for the CGM system. In addition, we obtained 
publicly available pricing information for two vendors. This 
information indicated the price of a

[[Page 34007]]

CGM system to be $1061.90 and $1279.17, which equated to an average 
cost of $1170.54. For CY 2018, we are proposing to price supply items 
SD114 at $53.08 and EQ125 at $1170.54. We seek comments on current 
pricing for equipment item ``continuous glucose monitoring system'' 
(EQ125).
(45) Parent, Caregiver-Focused Health Risk Assessment (CPT Codes 96160 
and 96161)
    In the CY 2017 PFS final rule (81 FR 80330), we discussed that in 
October 2015, the CPT Editorial Panel created two new PE-only codes, 
CPT code 96160 (Administration of patient focused health risk 
assessment instrument (e.g., health hazard appraisal) with scoring and 
documentation, per standardized instrument) and CPT code 96161 
(Administration of caregiver-focused health risk assessment instrument 
(e.g., depression inventory) for the benefit of the patient, with 
scoring and documentation, per standardized instrument). We assigned an 
active payment status to both codes for CY 2017 and finalized use of 
the RUC-recommended values for these codes. We also assigned an add-on 
code status to both of these services. As add-on codes, CPT codes 96160 
and 96161 describe additional resource components of a broader service 
furnished to the patient that are not accounted for in the valuation of 
the base code.
    The RUC submitted updated recommendations for the direct PE inputs 
for CPT codes 96160 and 96161 after reviewing new specialty society 
surveys. The RUC recommended 7 total minutes of clinical staff time, 
and we are proposing to adopt this number of minutes in valuing the 
services. The PE worksheet included several distinct tasks with minutes 
for each; however, in keeping with the standardization of clinical 
labor tasks, we are proposing to designate all 7 minutes under 
``administration, scoring, and documenting results of completed 
standardized instrument'' rather than dividing the minutes into the 
four categories as shown in the RUC recommendations.
(46) Chemotherapy Administration (CPT codes 96401, 96402, 96409, and 
96411)
    In the CY 2016 PFS proposed rule, CPT codes 96401 (Chemotherapy 
administration, subcutaneous or intramuscular; non-hormonal anti-
neoplastic), 96402 (Chemotherapy administration, subcutaneous or 
intramuscular; hormonal anti-neoplastic), 96409 (Chemotherapy 
administration; intravenous, push technique, single or initial 
substance/drug), and 96411 (Chemotherapy administration; intravenous, 
push technique, each additional substance/drug (List separately in 
addition to code for primary procedure)) were identified through the 
high expenditure services screen across specialties with Medicare 
allowed charges of over $10 million.
    For CY 2018, we are proposing the RUC-recommended work RVUs for CPT 
code 96401 (a work RVU of 0.21), CPT code 96402 (a work RVU of 0.19), 
CPT code 96409 (a work RVU of 0.24) and CPT code 96411 (a work RVU of 
0.20).
    For CPT code 96402, we are proposing the RUC-recommended equipment 
times with refinements for the biohazard hood (EP016) and exam table 
(EF023) from 31 minutes to 34 minutes to reflect the service period 
time associated with this code. We are proposing the RUC-recommended 
direct PE inputs for CPT codes 96401, 96409, and 96411 without 
refinements.
(47) Photochemotherapy (CPT Code 96910)
    CPT code 96910 appeared on a high expenditure services screen 
across specialties with Medicare allowed charges of over $10 million, 
which is a PE-only code that does not have work RVUs.We are proposing 
to refine the clinical labor time for the ``Provide preservice 
education/obtain consent'' from 3 minutes to 1 minute for CPT code 
96910. We believe that 1 minute would be typical for patient education, 
as CPT code 96910 is a repeat procedure where there would not be a need 
to obtain consent again. We are also proposing to remove the 2 minutes 
of clinical labor for the ``Complete diagnostic forms, lab & X-ray 
requisitions'' activity, as this item is considered indirect PE 
consistent with our established methodology. We are also proposing to 
create a new supply code (SB054) for the sauna suit, and proposing to 
price at $9.99 based on the submitted invoice. Finally, we are also 
proposing to adjust the equipment times to reflect changes in the 
clinical labor for CPT code 96910.
    We are proposing the RUC-recommended clinical labor time of 15 
minutes for the ``Prepare and position patient/monitor patient/set up 
IV'' activity, the RUC-recommended clinical labor time of 16 minutes 
for the ``Monitor patient during procedure'' activity, and the RUC-
recommended clinical labor time of 15 minutes for the ``Clean room/
equipment by physician staff'' activity, but seeking additional 
information regarding the rationale for these values. Given the lack of 
explanation, we considered using the current clinical labor time of 7 
minutes for the ``Prepare and position patient/monitor patient/set up 
IV'' activity, the current clinical labor time of 4 minutes for the 
``Monitor patient during procedure'' activity, and the current clinical 
labor time of 10 minutes for the ``Clean room/equipment by physician 
staff'' activity. We seek comment on whether maintaining the current 
values would improve relativity.
    We considered removing the ``Single Patient Discard Bag, 400 ml'' 
(SD236) supply and replacing it with the ``biohazard specimen transport 
bag'' (SM008). We are concerned about whether the single patient 
discard bag is the appropriate size for storing the sauna suit used in 
this procedure, and whether use of a biohazard specimen transport bag 
would be typical. We seek comments on our proposed and alternative 
values for these direct PE inputs.
(48) Photodynamic Therapy (CPT Codes 96567, 96X73, and 96X74)
    CPT code 96567 was identified as potentially misvalued through a 
CMS screen for codes with high expenditures. This code describes a 
service furnished by clinical staff and does not include physician 
work. For CY 2018, the CPT Editorial Panel created two new codes, CPT 
codes 96X73 and 96X74, to describe photodynamic therapy by external 
application of light to destroy premalignant skin lesions, including 
the physician work involved in furnishing the service. CPT codes 96567, 
96X73, and 96X74 were reviewed during the RUC's January 2017 meeting.
    For CY 2018, we are proposing the RUC-recommended work RVUs for CPT 
code 96X73 (a work RVU of 0.48) and CPT code 96X74 (a work RVU of 
1.01).
    We are proposing the RUC-recommended PE inputs with refinements due 
to inconsistencies between the stated description of clinical 
activities and the submitted spreadsheets. First, we propose to add 
assist physician clinical staff time to CPT codes 96X73 (10 minutes) 
and 96X74 (16 minutes), which is equivalent to the physician 
intraservice times for these services. For both CPT codes 96X73 and 
96X74, we propose a reduction from 35 minutes to 17 minutes for 
clinical activity in the postservice time, consistent with the 
description of clinical work in the summary of recommendations, which 
states that the patient receives activation of the affected area with 
the BLU-U Photodynamic Therapy Illuminator for approximately 17 
minutes. For CPT codes 96X73 and 96X74, we are

[[Page 34008]]

proposing to refine equipment formulas for two items: Power table 
(EF031) and LumaCare external light with probe set (EQ169), consistent 
with standards for nonhighly technical equipment. An explanation of the 
standards and formulas for equipment related to direct PE inputs is in 
the CY 2014 PFS final rule with comment period (79 FR 67557).
    We identified several vendors with publically available prices 
available for supply item LMX 4 percent cream (SH092) for significantly 
less than the existing $1.60 per gram. Based on our research of 
vendors, we are proposing to set the price of supply item SH092 to 
$0.78 per gram. Other CPT codes affected by the proposed change in the 
price of supply item LMX 4 percent cream (SH092) are: CPT code 46607 
(Anoscopy; with high-resolution magnification (HRA) (eg, colposcope, 
operating microscope) and chemical agent enhancement, with biopsy, 
single or multiple), CPT code 17000 (Destruction (eg, laser surgery, 
electrosurgery, cryosurgery, chemosurgery, surgical curettement), 
premalignant lesions (eg, actinic keratoses); first lesion), CPT code 
17003 (Destruction (eg, laser surgery, electrosurgery, cryosurgery, 
chemosurgery, surgical curettement), premalignant lesions (eg, actinic 
keratoses); second through 14 lesions, each (List separately in 
addition to code for first lesion)), and CPT code 17004 (Destruction 
(eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical 
curettement), premalignant lesions (eg, actinic keratoses), 15 or more 
lesions)).
    In addition, the RUC forwarded an invoice for a new supply item, 
safety goggles, at $6.00 and requested three goggles each for CPT codes 
96X73 and 96X74. Because we do not have a basis for distinguishing the 
requested new goggles from the existing UV-blocking goggles, we 
consider this invoice to be an additional price point for SJ027 rather 
than an entirely new item. We propose a price of $4.10 for supply item 
SJ027 (the average of the two prices for this supply item ($2.30 + 
$6.00)/2=$4.10)). Other CPT codes affected by the proposed change in 
the price of supply item UV-blocking goggles (SJ027) are: CPT code 
36522 (Photopheresis, extracorporeal), CPT code 96910 
(Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or 
petrolatum and ultraviolet B), CPT code 96912 (Photochemotherapy; 
psoralens and ultraviolet A (PUVA)), and CPT code 96913 
(Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive 
dermatoses requiring at least 4-8 hours of care under direct 
supervision of the physician (includes application of medication and 
dressings)), CPT code 96920 (Laser treatment for inflammatory skin 
disease (psoriasis); total area less than 250 sq cm), CPT code 96921 
(Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm 
to 500 sq cm), and CPT code 96922 (Laser treatment for inflammatory 
skin disease (psoriasis); over 500 sq cm). We seek comments on our 
proposed PE refinements, including our proposed supply item prices.
(49) Physical Medicine and Rehabilitation (PM&R) (CPT Codes 97012, 
97016, 97018, 97022, 97032, 97033, 97034, 97035, 97110, 97112, 97113, 
97116, 97140, 97530, 97533, 97535, 97537, 97542, and HCPCS code G0283)
    In our CY 2015 PFS final rule (79 FR 67576) and CY 2016 PFS final 
rule (80 FR 70917), we identified a total of ten codes through the high 
expenditure by specialty screen for services primarily furnished by 
physical and occupational therapists: CPT codes 97032, 97035, 97110, 
97112, 97113, 97116, 97140, 97530, 97535, and HCPCS code G0283. An 
additional nine codes in this PM&R family were identified for review by 
the physical therapy (PT) and occupational therapy (OT) specialty 
societies: CPT codes 97012, 97016, 97018, 97022, 97033, 97034, 97533, 
97537, and 97542. Many of these code values had not been reviewed since 
they were established in 1994, 1995 or 1998.
    After review during its January 2017 meeting, the HCPAC submitted 
recommendations for all 19 codes. While the HCPAC included 
recommendations for CPT code 97014, we note that this is a code we have 
not recognized for PFS payment since 2002 when we implemented our wound 
care electrical stimulation policies. For payment under the PFS, 
instead of CPT code 97014, we recognize HCPCS code G0281 for wound care 
electrical stimulation and HCPCS code G0283 for all other electrical 
stimulation scenarios, when covered. For CY 2018, we are proposing the 
HCPAC recommendations for CPT code 97014, HCPCS code G0283, and HCPCS 
code G0281.
    CMS considers all 19 codes as ``always therapy'' which means they 
are always considered to be furnished under a physical therapy (PT), 
occupational therapy (OT), or speech-language pathology (SLP) plan of 
care regardless of who furnishes them and the payment amounts are 
counted towards the appropriate statutory therapy cap--either the 
therapy cap for PT and SLP services combined, or the single therapy cap 
for OT services. These always therapy codes are also subject to the 
therapy MPPR.
    For CY 2018, we are proposing the HCPAC's recommended work RVUs for 
CPT codes 97012, 97016, 97018, 97022, 97032, 97033, 97533, 97034, 
97035, 97110, 97112, 97113, 97116, 97140, 97530, 97533, 97535, 97537, 
97542, and G0283 (97014).
    For supervised modality services reported with CPT codes 97012, 
97016, 97018, and 97022, and HCPCS code G0283 (97014), we considered 
maintaining the current values for these codes rather than the HCPAC 
recommendations. We note that the work times recommended by the HCPAC 
reflect use of the survey data even though the HCPAC explained in its 
recommendations that the survey results were not deemed credible 
because of a lack of evidence to support higher work RVUs of each 
survey's 25th percentile or median values. We note total time decreases 
among these codes ranging from 1 to 8 minutes.
    While we are proposing the HCPAC-recommended work RVUs and work 
times for each code in this family, we seek comments on whether 
maintaining the current times, given the HCPAC's lack of confidence in 
the survey data, would better reflect the work times for these 
services.
    We are proposing to maintain the existing CY 2017 PE inputs for all 
19 codes. We note that section 1848(b)(7) of the Act requires a 50 
percent therapy MPPR instead of the 25 percent therapy MPPR established 
during CY 201l PFS rulemaking. One of the primary rationales for the 
MPPR policy developed through the rulemaking process was that the 
direct PE inputs for these services did not fully recognize the 
redundant inputs when these services were furnished together, or in 
multiple units. After reviewing the recommended direct PE inputs, it is 
evident that they were developed based on an acknowledgement of the 
efficiencies of services typically furnished together as well as codes 
billed in multiple units. Given this assessment, we believe that were 
we to use the recommended inputs to develop the PE RVUs, the 50 percent 
MPPR on the PE for these services, as required by current law, would 
functionally duplicate the payment adjustments to account for 
efficiencies that had already been addressed through code-level 
valuation. Therefore, for CY 2018, we are proposing to retain the 
existing CY 2017 PE inputs for these services and seek comments on 
whether there is an

[[Page 34009]]

alternative approach that would avoid duplicative downward payment 
adjustments while still allowing for the direct PE inputs to be updated 
to better reflect current practice.
    We note that we believe that the always therapy codes subject to 
the therapy MPPR on PE are unique from other therapeutic and diagnostic 
procedure codes paid under the PFS and subject to MPPRs. For example, 
unlike most surgical services, these ``always therapy'' codes are 
typically billed either with other therapy codes or in multiple units, 
or both. Generally, MPPRs are used when codes are often, but not 
typically, furnished with other particular codes. When full sets of 
related codes are almost all typically billed with other codes, or 
billed in multiple units, coding and valuation have changed to reflect 
these practices. For example, new codes have been introduced to 
describe combined services or some related services are described by 
add-on codes. In other cases, the MPPR is considered in the valuation 
for individual services.
(50) Management and/or Training: Orthotics and Prosthetics (CPT Codes 
97760, 97761, and 977X1)
    For CY 2018, the CPT Editorial Panel revised the set of codes that 
comprise the CPT manual's PM&R subsection for orthotic management and 
prosthetic management at its September 2016 meeting. According to the 
CPT Editorial Panel, these revisions were made at the request of the 
specialty societies representing physical and occupational therapists 
to differentiate between the initial and subsequent encounters and to 
describe the ongoing management and/or training that is involved in 
subsequent encounters. These changes include:
     Revising the code descriptors by adding the term ``initial 
encounter'' to CPT code 97760 (Orthotic(s) management and training 
(including assessment and fitting when not otherwise reported), upper 
extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) 
encounter, each 15 minutes), and CPT code 97761 (Prosthetic(s) 
training, upper and/or lower extremity(ies), initial prosthetic(s) 
encounter, each 15 minutes);
     Creating a new CPT code 977X1 (Orthotic(s)/prosthetic(s) 
management and/or training, upper extremity(ies), lower extremity(ies), 
and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 
minutes); and
     Deleting CPT code 97762 (checkout for orthotic/prosthetic 
use, established patient, each 15 minutes).
    Intended for the management and/or training of patients with 
orthotics and/or prosthetics, CPT codes 97760 and 97761 were previously 
used to report both the initial and subsequent encounters, that, when 
furnished under the Medicare outpatient therapy services benefit, 
included services occurring during the same PT or OT episode of care. 
CPT code 97762 was used to separately report the assessment and fitting 
(including any adjustments) of an orthotic or prosthetic for an 
established patient when these services were not bundled into another 
code or service. For CY 2018, CPT codes 97760 and 97761 are intended to 
be reported only for the initial encounter, and CPT code 977X1 is 
intended to be reported for all other orthotic and/or prosthetic 
services for an established patient that occur on a ``subsequent 
encounter'' or a different date of service from that of the initial 
encounter service.
    The HCPAC submitted work and PE recommendations for CPT codes 
97760, 97761, and 977X1 from their January 2017 meeting. For CY 2018, 
we propose the HCPAC recommended work RVU of 0.5 for CPT code 97760, a 
work RVU of 0.5 for CPT code 97761, and a work RVU of 0.48 for CPT code 
977X1. We note that for budget neutrality purposes, the HCPAC 
recommendations also included utilization crosswalks for each of the 
three codes that were each assigned a one-to-one crosswalk to the 
utilization of the prior codes: All the prior services of CPT codes 
97760 and 97761 were each crosswalked to the same newly revised codes; 
and, all the utilization from CPT code 97762 was crosswalked to the new 
CPT code 977X1.
    For CPT code 977X1, we considered a work RVU of 0.33, crosswalking 
to CPT code 92508 (Speech/hearing therapy), which has a similar total 
therapist time (22 minutes). We are concerned and seek comments on the 
HCPAC one-to-one utilization crosswalk recommendations for all three 
codes in this family since the utilization assumptions are potentially 
flawed when viewed in the context of the new CPT code descriptors. For 
instance, for CPT code 977X1, the new descriptor indicates that the 
services inherent to CPT code 97762 (over 14,000 in 2015), as well as 
the new services for subsequent encounters previously reported via CPT 
codes 97760 and 97761 will also be encompassed, although it is 
difficult to estimate the number of additional services the latter 
represents. We are concerned that the HCPAC's valuation is inconsistent 
with the submitted information regarding how services will be reported 
under the new coding. We seek comments on our proposed and alternative 
values for CPT code 977X1. We are also interested in receiving comments 
from stakeholders and clinicians with expertise in furnishing these 
orthotic management and/or prosthetics training services about the 
utilization and types of services that would be furnished under the new 
CPT coding structure, particularly those of the newly created CPT code 
977X1 and how these services differ from the services reported with the 
predecessor CPT code 97762.
    We propose to maintain the current PE inputs for CPT codes 97760, 
97761, and 977X1, as we discussed in our proposals for the PM&R codes 
discussed above; the same therapy MPPR applies. We are proposing the 
current direct PE inputs for CPT code 97762 and for new CPT code 977X1, 
though we are seeking comment as to whether or not a different 
crosswalk or other adjustment would be appropriate given the change in 
code descriptor.
    We also note that these codes are designated as always therapy, 
meaning that they always represent therapy services regardless of who 
furnishes them; and that a GO or GP therapy modifier is always required 
to indicate that the services are furnished under an OT or PT plan of 
care, respectively. As always therapy, these codes are subject to the 
therapy MPPR and the statutory therapy caps.
(51) Cognitive Function Intervention (CPT Code 97X11)
    We received HCPAC recommendations for new CPT code 97X11 that 
describes services currently reported under CPT code 97532 (Development 
of cognitive skills to improve attention, memory, problem solving 
(includes compensatory training), direct (one-on-one) patient contact, 
each 15 minutes). CPT code 97532 is scheduled to be deleted for CY 2018 
and replaced by CPT code 97X11.
    The existing code is reported per 15 minutes and the new code is 
reported once. Under current coding, Medicare utilization for these 
services is heterogeneous and indicates that practitioners of different 
disciplines incur significantly different resource costs (especially in 
time) when furnishing these services to Medicare beneficiaries. As 
described by both the existing and new code, the service might be 
appropriately furnished both by therapists under the outpatient therapy 
(OPT) services benefit (includes physical therapy (PT), occupational 
therapy (OT) or speech-language pathology (SLP)); and outside the 
therapy benefit by physicians, certain

[[Page 34010]]

NPPs, and psychologists. As an OPT service, it can (1) be billed by 
physicians, certain NPPs, or private practice therapists including 
physical therapists (PT-PPs), occupational therapists (OT-PPs) and 
speech-language pathologists (SLP-PPs) in private practice, or (2) be 
billed by institutional providers (for example, skilled nursing 
facilities, rehabilitation agencies, outpatient hospitals, etc.) when 
furnished by therapists working for the institutional providers.
    According to the HCPAC, professional claims data indicate that CPT 
code 97532 was most often billed in 4 units. The HCPAC recommended a 
work RVU of 1.50 for CPT code 97X11, which is only 3.4 times greater 
than the work RVU for the predecessor code (0.44). Assuming 
professional billing patterns remain the same, the recommended coding 
and valuation could result in a significant reduction in overall 
Medicare payment under the PFS.
    However, our analysis of the claims data indicates that the number 
of units typically reported for the current code suggests a significant 
difference in the amount of time spent with the patient, depending on 
which discipline (and implicitly under which benefit) bills Medicare 
for services described by this single code.
    Based on our review of claims data by specialty, SLP-PPs, OT-PPs 
and PT-PPs furnishing the same services under the OPT benefit would 
receive overall payment increases due simply to the change in coding 
because they typically bill for fewer than 4 units, while overall 
payment for clinical psychologists furnishing therapeutic interventions 
for cognitive function would decrease because they typically bill in 
units of four or more.
    We are seeking additional information regarding the potential 
impact of this coding and payment change prior to proposing its use 
under the PFS. For CY 2018, we are proposing to maintain the current 
coding and valuation for these cognitive function services. If the CPT 
Editorial Panel deletes the existing CPT code for CY 2018, we would 
effectuate this proposal through use of a new a G-code, GXXX1, which 
would maintain the descriptor and values from existing CPT code 97532. 
Under this proposal, new CPT code 97X11 would be given a procedure 
status of ``I'' (Invalid for Medicare).
    We also note that this change in coding and payment could have 
significant impact for payment to Medicare institutions for OPT 
services. Under section 1834(k) of the Act, when reported by Medicare 
institutional providers, OPT services are paid at PFS non-facility 
payment rates. Institutional claims data for CPT code 97532 when 
furnished by the three therapist disciplines show a much higher 
utilization overall than that for professional claims but significantly 
fewer 15 minute units reported. This suggests that professionals 
generally spend significantly less time with patients in the 
institutional setting. Use of the new CPT code could therefore result 
in significant additional expenditure to the Medicare program, as well 
as other payers, including Medicaid programs, based on the change in 
coding alone.
(52) INR Monitoring (CPT Codes 993X1 and 993X2)
    In October 2015, AMA staff assembled a list of all services with 
total Medicare utilization of 10,000 or more that have increased by at 
least 100 percent from 2008 through 2013 and these services were 
identified on that list. The RUC recommended that HCPCS codes G0248, 
G0249 and G0250, which describe related INR monitoring services, be 
referred to the CPT Editorial Panel to create Category I codes to 
describe these services. For CY 2018, the CPT Editorial Panel is 
deleting CPT codes 99363 and 99364 and creating new CPT codes 993X1 
(Patient/caregiver training for initiation of home INR monitoring under 
the direction of a physician or other qualified health care 
professional, including face-to-face, use and care of the INR monitor, 
obtaining blood sample, instructions for reporting home INR test 
results, and documentation of patient's/caregiver's ability to perform 
testing and report results) and 993X2 (Anticoagulant management for a 
patient taking warfarin, must include review and interpretation of a 
new home, office, or lab International Normalized Ratio (INR) test 
result, patient instructions, dosage adjustment (as needed), and 
scheduling of additional test(s) when performed). CPT code 993X1 is a 
technical component-only code. With the creation CPT codes 993X1 and 
993X2, the RUC recommended that CMS delete HCPCS codes G0248, G0249 and 
G0250.
    For CPT code 993X2, we are proposing the RUC-recommended work RVU 
of 0.18. Because HCPCS codes G0248, G0249 and G0250 are used to report 
related services under a national coverage determination, we do not 
intend to delete the G-codes.
    In reviewing the recommended PE inputs for these services, we 
obtained updated invoices for prices for particular items. We are 
proposing to use the invoices to update the price of the supply ``INR 
test strip'' (SJ055). We obtained publically available pricing 
information from two vendors. The pricing from one vendor indicated the 
price for a box of 24 of supply item SJ055 item (INR test strip) to be 
$150.00, which equated to a unit price of $6.25. Pricing from a second 
vendor indicated the price of a box of 48 of the supply item SJ055 to 
be $233.00, which equated to a unit price of $5.06. The average price 
of these two unit prices is $5.66.
    Therefore, we are proposing to re-price SJ055 from $21.86 to $5.66 
for CPT code 993X1. We are seeking public comments on current pricing 
for the INR test strip supply.
(53) Psychiatric Collaborative Care Management Services (CPT Codes 
994X1, 994X2, 994X3, and HCPCS Code G0507)
    In the CY 2017 PFS final rule (81 FR 80230), we established 
separate payment for three services (HCPCS codes G0502, G0503, and 
G0504) under the psychiatric collaborative care model that paralleled 
CPT codes that were being created to report these services as well as a 
G-code for general behavioral health integration (BHI) services (HCPCS 
code G0507).
    For CY 2018, the CPT Editorial Panel is creating CPT codes 994X1, 
994X2, 994X3, and 99XX5 to describe these services. We are proposing 
the RUC-recommended work RVUs for each of these services, which are 
identical to the current values for HCPCS codes G0502, G0503, G0504, 
and G0507.
    We are proposing the RUC-recommended PE inputs, with one 
refinement. The RUC-recommended values included clinical labor inputs 
in the facility setting, but we are not proposing to include these 
minutes in developing the facility PE RVUs.
    Were we to develop facility PE RVUs for these services that 
included clinical staff time, when a practitioner working in a 
provider-based department of a hospital was furnishing these services, 
both the professional and the hospital would be paid for the same 
clinical labor costs. We presume that this aspect of the RUC's 
recommendation reflects the circumstance where the patient receiving 
the services spends a significant period of time in a facility setting, 
but the billing practitioner is nonetheless incurring the cost 
associated with the non-face-to-face clinical staff time over the 
course of a month. We recognize that the binary site of service 
differential may not recognize the different models of this kind of 
care and may not be appropriate in some cases. We seek comments on how 
to best address this valuation issue for these and other monthly care

[[Page 34011]]

management services. We could consider a range of options for future 
rulemaking, including allowing separate billing for the professional, 
technical, and global components of these services to allow 
practitioners to bill the component of the service they furnish.
    We stated in the CY 2017 PFS final rule (81 FR 80236) that the 
general BHI code (CPT code 99XX5) may be used to report a range of 
models of BHI services and that we expected this code to be refined 
over time as we receive more information about other BHI models in use. 
We remain interested in how this code is being used and look forward to 
hearing from stakeholders regarding its use in reporting different 
models of BHI services. Additionally, we have received inquiries from 
stakeholders about whether or not professionals who cannot report E/M 
services to Medicare might nonetheless serve as a primary hub for BHI 
services. For example, stakeholders have suggested that a clinical 
psychologist might serve as the primary practitioner that integrates 
medical care and psychiatric expertise. For purposes of future 
rulemaking, we are seeking comment on the circumstances under which 
this model of care is happening and whether additional coding would be 
needed to accurately describe and value other models of care.
(54) Hyperbaric Oxygen Therapy (HCPCS Code G0277)
    In the CY 2016 PFS final rule (80 FR 71005), we discussed the CY 
2015 valuation of hyperbaric oxygen therapy services (79 FR 67677). 
Prior to CY 2015, CPT code 99183 was used to report both the 
professional attendance and supervision, and the costs associated with 
treatment delivery were included in the nonfacility direct PE inputs 
for the code. We created HCPCS code G0277 to be used to report the 
treatment delivery separately, consistent with the OPPS coding 
mechanism, to allow the use of the same coding structure across 
settings. In establishing interim final direct PE inputs for HCPCS code 
G0277, we used the RUC-recommended direct PE inputs for CPT code 99183, 
which assumed a 120-minute treatment interval and adjusted them to 
align with the 30-minute treatment interval of HCPCS code G0277. We 
observed that the quantity of oxygen increased significantly relative 
to the previous inputs for CPT code 99183.
    To better understand why the oxygen supply increased, we reviewed 
the instruction manual for the Sechrist Model 3600E Hyperbaric Chamber, 
which was the model noted on the invoice that was included with the RUC 
recommendations for use in pricing the capital equipment. The 
instruction manual for the Sechrist 3600E model provided guidance 
regarding the quantity of oxygen to be used in furnishing the service 
described by HCPCS code G0277. Based on our review at that time, we 
determined that 12,000 liters, rather than 47,000 liters, was the 
typical number of units for the oxygen gas. Therefore, in aligning the 
direct PE inputs as described in this section of the proposed rule, we 
first adjusted the units of oxygen to 12,000 liters for the recommended 
120 minute time, and subsequently adjusted it to align with the 30-
minute G-code by dividing by 4. We stated that we agreed that an 
initial high purge flow rate is needed to reach maximum pressure/
O2; however, we still had not seen data that demonstrated 
the need to continue the high purge flow rate throughout the entire 
session. According to the manufacturer's instruction manual for this 
model, ``once the nitrogen has been purged from the chamber and the 
internal oxygen concentration has exceeded 95 percent, high flows are 
no longer needed to maintain the patient's saturation level.'' The 
manual also stated that ``the plateau purge flow can be set to 80 
liters per minute (lpm).'' We calculated that 13 minutes at 400 lpm 
plus 120 minutes at 80 lpm equals 14,800 liters of oxygen. We stated 
that based on information in the manufacturer's manual that was 
publicly available at the time, we believed that this represented the 
typical usage for a 120-minute treatment. That amount represented an 
increase from the interim final amount of 12,000 liters. We aligned 
this total oxygen requirement to the 30-minute G-code by dividing 
14,800 liters of oxygen by 4 and stated we were updating the direct PE 
inputs to 3,700 liters of oxygen for HCPCS code G0277.
    For CY 2018, we received requests from stakeholders to update the 
direct PE inputs for HCPCS code G0277. In the CY 2016 PFS final rule 
(80 FR 71005), we explained that we had previously established values 
for this service based on information suggesting that the Sechrist 
Model 3600E Hyperbaric Chamber was typically used in furnishing the 
service in the non-facility setting. As we noted in that rule, we 
established the amount of oxygen used in furnishing the service based 
on use of the equipment item described as part of the RUC 
recommendation, instead of the RUC-recommended amount of oxygen, which 
appeared to be based on use of a different equipment product, the 
Sechrist Model 3200. Based on information received from stakeholders, 
we are proposing to update both the equipment item and the amount of 
oxygen so that the amount of oxygen conforms to the RUC-recommended 
value of 47,600 liters of oxygen, which we divided by 4 to conform to 
the 30-minute service period for HCPCS code G0277, and that the 
equipment item is consistent with that recommendation. The proposed 
direct PE inputs for HCPCS code G0277 are displayed in the proposed CY 
2018 direct PE input database, available on the CMS Web site under the 
downloads for the CY 2018 PFS proposed rule at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.
    We are also proposing to exclude this change in direct PE inputs 
from calculation of the misvalued code target since we view this 
proposed change as a refinement of a single recommendation over several 
years. Since the initial recommendation (79 FR 67677) was undertaken in 
a year without the misvalued code target, we believe it would be 
consistent with our previously established policy (80 FR 70923) to 
exclude this change from the calculation. We note that this change 
would represent an increase from the current PE RVUs for this service.
(55) Physician Coding for Insertion and Removal of Subdermal Drug 
Implants for the Treatment of Opioid Addiction (HCPCS Codes GDDD1, 
GDDD2, and GDDD3)
    We met with representatives from the American Society of Addiction 
Medicine (ASAM) in April 2016 to discuss the possibility of making 
separate payment for insertion and removal of buprenorphine 
hydrochloride, formulated as a 4-rod, 80 mg, long-acting subdermal drug 
implant for the treatment of opioid addiction. There are existing CPT 
codes that broadly describe the insertion and removal of non-
biodegradable drug delivery implants (CPT codes 11981 through 11983). 
However, ASAM contended that the resources associated with the 
administration of this particular drug are greater than that of other 
drug delivery implants, stating that the physician must insert four 
rods using a newly designed applicator and obturator and use a 
specially designed clamp to remove the four rods, which in some cases 
requires careful shaving of tissue that has attached to the rods during 
the 6-month period that the rods have been inserted. They noted that 
these procedures can have unique

[[Page 34012]]

challenges associated with treating patients with opioid addiction, who 
often have complications and/or co-morbidities. They also noted that 
the FDA has recognized the complexity of the technology and patient 
needs by establishing regulatory standards to adhere to the protocol 
and imposing special training requirements on physicians. ASAM 
indicated that they would pursue an application to the CPT Editorial 
Panel for new CPT codes.
    ASAM informed CMS that the CPT Editorial Panel did not approve 
their application; therefore, they repeated their request that CMS 
establish separate payment for the insertion, removal, and removal with 
reinsertion of the buprenorphine subdermal implants.
    To improve payment accuracy, for CY 2018, we are proposing to make 
separate payment for the insertion, removal, and removal with 
reinsertion of Buprenorphine subdermal implants using HCPCS G codes:
     HCPCS code GDDD1: Insertion, non-biodegradable drug 
delivery implants, 4 or more.
     HCPCS code GDDD2: Removal, non-biodegradable drug delivery 
implants, 4 or more.
     HCPCS code GDDD3: Removal with reinsertion, non-
biodegradable drug delivery implants, 4 or more.
    For HCPCS code GDDD1, ASAM states that performing the procedure 
according to the FDA-required Risk Evaluation and Mitigation Strategies 
(REMS) program takes approximately 23-25 minutes for the a physician 
who is not a trainer/proctor for this procedure. They state that in 
developing crosswalk recommendations for physician work values, they 
used a total time of 35-40 minutes, which is based on a preservice time 
of 10 minutes, an intraservice time of 20-25 minutes, and a postservice 
time of 5 minutes. Based on ASAM's recommendations, we are proposing a 
work RVU of 1.82 for HCPCS code GDDD1, which is supported by a direct 
crosswalk to CPT code 64644 (Chemodenervation of one extremity; 5 or 
more muscles).
    For HCPCS code GDDD2, ASAM states that data from physicians who 
perform this procedure indicated that it takes approximately 15-20 
additional minutes compared to the insertion procedure (HCPCS code 
GDDD1) based on the FDA-required REMS program for removal of the 
implant. They note that this procedure is of a higher intensity 
compared to CPT code 11982 as this service requires identification and 
removal of multiple subdermal implants. They state that in developing 
crosswalk recommendations for physician work values, they used a total 
time of 45-60 minutes, which is based on a preservice time of 10 
minutes, an intraservice time of 30-45 minutes, and a postservice time 
of 5 minutes. Based on ASAM's recommendations, we are proposing a work 
RVU of 2.10 for HCPCS code GDDD2, which is supported by a direct 
crosswalk to CPT code 96922 (Laser treatment for inflammatory skin 
disease (psoriasis); over 500 sq cm).
    For HCPCS code GDDD3, ASAM indicated that there is minimal 
consolidation of effort since the removal of the implants from one arm 
is followed by insertion of a new set of implants in the contralateral 
arm. Physician data from those who have performed this procedure 
indicated that it takes approximately 70 minutes of total intra-service 
time. They state that in developing crosswalk recommendations for 
physician work values, they assumed a preservice evaluation time of 10 
minutes (7 minutes for removal and 3 minutes for insertion), 
positioning of 4 minutes (2 minutes for each arm), and wait time of 2 
minutes (1 minute for each arm). They state that using the multiple 
surgical procedure rule, they calculated an intraservice time of 40-58 
minutes based on 100 percent of the intraservice time for HCPCS code 
GDDD2 (30-45 minutes) and 50 percent of the intraservice time for HCPCS 
code GDDD1 (0.5 x (20 - 25) = 10 - 13). They used a postservice time of 
8 minutes based on 100 percent of the postservice time for the removal 
arm and 50 percent of the postservice time for the insertion arm, 
equaling a total time of 58-76 minutes. Based on ASAM's 
recommendations, we are proposing a work RVU of 3.55 for HCPCS code 
GDDD3, which is supported by a direct crosswalk to CPT code 31628 
(Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when 
performed; with transbronchial lung biopsy(s), single lobe).
    We are proposing to use the direct PE inputs requested by ASAM for 
HCPCS codes GDDD1, GDDD2, and GDDD3, which are reflected in the Direct 
PE Inputs public use files for clinical labor, supplies, and equipment, 
available on the CMS Web site at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.
    In addition to seeking comment on the proposal to make separate 
payment for these services using HCPCS G codes, we are also seeking 
comment on the appropriateness and accuracy of our proposed work RVUs 
and direct PE inputs.
(56) Superficial Radiation Treatment Planning and Management (HCPCS 
Code GRRR1)
    In the CY 2015 PFS final rule with comment period (79 FR 67666 
through 67667), we noted that changes to the CPT prefatory language 
limited the codes that could be reported when describing services 
associated with superficial radiation treatment (SRT) delivery, 
described by CPT code 77401 (radiation treatment delivery, superficial 
and/or ortho voltage, per day). The changes effectively meant that many 
other related services were bundled with CPT code 77401, instead of 
being separately reported. For example, CPT guidance clarified that 
certain codes used to describe clinical treatment planning, treatment 
devices, isodose planning, physics consultation, and radiation 
treatment management cannot be reported when furnished in association 
with superficial radiation treatment. Stakeholders stated that these 
changes to the CPT prefatory language prohibited them from billing 
Medicare for codes that were previously frequently billed in addition 
to CPT code 77401. We solicited comments as to whether the coding for 
SRT allowed for accurate reporting of the associated services.
    In the CY 2016 PFS final rule with comment period (80 FR 70955), we 
noted that the RUC 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 the bundling of associated 
services. In addition, we solicited recommendations from stakeholders 
regarding whether or not it would be appropriate to add physician work 
for this service, even though physician work is not included in other 
radiation treatment services. As commenters were not in agreement as to 
whether the service should be valued with physician work, we introduced 
the possibility of creating a HCPCS G code to describe total work 
associated with the course of treatment for these services.
    The 2016 National Correct Coding Initiative (NCCI) Policy Manual 
for Medicare Services states that radiation oncology services may not 
be separately reported with E/M codes. While this edit is no longer 
active, stakeholders have stated that MACs have denied claims for E/M 
services associated with SRT based on the NCCI policy manual language. 
According to stakeholders, the bundling of services associated with 
SRT, as well as the confusion regarding the appropriate use of E/M 
coding to report associated physician work, means

[[Page 34013]]

that practitioners are not being accurately paid for planning and 
treatment management associated with furnishing SRT.
    In recognition of these concerns, we are proposing to make separate 
payment for the professional planning and management associated with 
SRT using HCPCS code GRRR1 (Superficial radiation treatment planning 
and management related services, including but not limited to, when 
performed, clinical treatment planning (for example, 77261, 77262, 
77263), therapeutic radiology simulation-aided field setting (for 
example, 77280, 77285, 77290, 77293), basic radiation dosimetry 
calculation (for example, 77300), treatment devices (for example, 
77332, 77333, 77334), isodose planning (for example, 77306, 77307, 
77316, 77317, 77318), radiation treatment management (for example, 
77427, 77431, 77432, 77435, 77469, 77470, 77499), and associated 
evaluation and management per course of treatment). We intend for this 
code to describe the range of professional services associated with a 
course of SRT, including services similar to those not otherwise 
separately reportable under CPT guidance and the NCCI manual.
    To value this code, we are including the physician work and work 
time associated with radiation management-related services that we 
think would be typical for a course of SRT treatment. These services 
include: CPT code 77261 (Therapeutic radiology treatment planning; 
simple), CPT code 77280 (Therapeutic radiology simulation-aided field 
setting; simple), CPT code 77300 (Basic radiation dosimetry 
calculation, central axis depth dose calculation, TDF, NSD, gap 
calculation, off axis factor, tissue inhomogeneity factors, calculation 
of non-ionizing radiation surface and depth dose, as required during 
course of treatment, only when prescribed by the treating physician), 
CPT code 77306 (Teletherapy isodose plan; simple (1 or 2 unmodified 
ports directed to a single area of interest), includes basic dosimetry 
calculation(s)), CPT code 77332 (Treatment devices, design and 
construction; simple (simple block, simple bolus)), and CPT code 77427 
(Radiation treatment management, 5 treatments). Therefore, for CY 2018, 
we are proposing a work RVU of 7.93 for HCPCS code GRRR1.
    To develop the proposed direct PE inputs for this code, we are 
proposing to use the RUC-recommended direct PE inputs from the 
aforementioned codes with several adjustments. We are proposing to 
apply the staff type ``RN/LPN/MTA'' for all of the clinical labor 
inputs for this code because we believe that the typical office 
performing SRT will be staffed with this labor type, rather than with 
another clinical labor type such as radiation therapists, and we seek 
comments as to the appropriateness of the staff type ``RN/LPN/MTA'' for 
this SRT-related service. Some stakeholders have suggested that many 
services related to SRT are personally performed by the billing 
practitioner rather than by clinical staff.
    We are proposing to remove the supply items ``gown, patient'' and 
``pillow case'' that are associated with CPT code 77280, as these items 
are included in the minimum multi-specialty visit pack that is 
associated with CPT code 77427. We are not proposing to include the 
equipment items ``radiation virtual simulation system,'' ``room, CT'' 
and ``PACS Workstation Proxy'' that are associated with CPT code 77280, 
as we do not believe that a typical office furnishing SRT uses this 
kind of equipment. Instead, we are including additional time for the 
capital equipment used in delivering SRT in the proposed direct PE 
inputs. For ``radiation dose therapy plan,'' we are proposing to apply 
the clinical labor time that is associated with CPT code 77300 to HCPCS 
code GRRR1 for purposes of developing a proposed value, but we seek 
comments as to whether the clinical staff would typically perform the 
radiation dose therapy planning for this service, or if the physician 
would perform this and/or other tasks, and, in the case of the latter, 
what the appropriate physician time would be. Likewise, we are 
soliciting comment as to whether the clinical labor associated with the 
teletherapy isodose plan would be performed by the physician. We are 
proposing to assign 14 minutes each to the equipment items ``radiation 
therapy dosimetry software (Argus QC)'', ``computer workstation'', and 
``3D teletherapy treatment planning'' as these are the times assigned 
to these equipment items for CPT code 77300.
    We are not proposing to include inputs related to radiation physics 
consultation, described by CPT code 77336, as we think that a typical 
course of SRT would not require this service, and the typical 
practitioner providing SRT would not be performing physics 
consultation, and we are seeking comment as to whether inputs 
associated with this code or other inputs used in furnishing analogous 
services should be included. We are not proposing to include the post-
operative office visits included in the valuation of CPT code 77427, as 
we do not believe that a typical course of SRT will require post-
operative visits; however, we are seeking comment regarding the amount 
of face-to-face time typically spent by the practitioner with the 
patient for radiation treatment management associated with SRT.
    As discussed in the CY 2016 PFS final rule (80 FR 70924 through 
70927), in the case of new codes that describe services that were 
previously included in the payment for other codes, we finalized the 
policy that these new codes are excluded from the misvalued code target 
when they were previously bundled into a set of broadly reported E/M 
codes and services that include E/M visits. We noted that we did not 
believe that the change to separate payment for these kinds of services 
should be counted as increases that are included in calculating ``net 
reductions'' in expenditure attributable to adjustments for misvalued 
codes. Therefore, we are proposing to exclude HCPCS code GRRR1 from the 
misvalued code target.
(57) Payment Accuracy for Prolonged Preventive Services (HCPCS Codes 
GYYY1 and GYYY2)
    Most services paid under the PFS are coded to reflect differential 
resource costs associated with different levels of care. However, this 
level of granularity is not applied evenly across the PFS. For example, 
there are far fewer Evaluation and Management (E/M) visit codes than 
there are codes that describe procedures. While not a comprehensive 
solution to address the differential resource costs of certain E/M 
visits, prolonged services codes can be used to report medically 
necessary E/M visits that require additional amounts of time. Like E/M 
visit codes, many of the Medicare-covered preventive services codes 
describe a service that has an atypically broad range of potential 
resource costs, including differential amounts of time required to 
furnish services. However, unlike for most E/M visit codes, there are 
not prolonged services codes that apply to Medicare-covered preventive 
services.
    Some stakeholders have expressed concerns to CMS that there is no 
coding mechanism for practitioners to report the additional time 
sometimes required to appropriately furnish care to a patient receiving 
a Medicare-covered preventive service. We note that Medicare covers a 
broad range of preventive services, such as a ``Welcome to Medicare 
Preventive Visit'', yearly wellness visits, cancer screenings, and many 
types of counseling. Medicare beneficiary coinsurance and deductible 
payments are not applicable for certain Medicare-covered preventive 
services. Additional information about preventive services

[[Page 34014]]

covered under Medicare, including whether beneficiary coinsurance or 
deductible apply, is available on the CMS Web site at https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-QuickReferenceChart-1TextOnly.pdf. To more accurately reflect the 
differential resource costs when additional time is required to furnish 
a Medicare-covered preventive service, we are proposing to make payment 
for prolonged preventive services using two new HCPCS G codes that 
could be billed along with the Medicare-covered preventive service 
codes, when a clinician provides a prolonged Medicare-covered 
preventive service.
     GYYY1: Prolonged preventive service(s) (beyond the typical 
service time of the primary procedure) in the office or other 
outpatient setting requiring direct patient contact beyond the usual 
service; first 30 minutes (List separately in addition to code for 
preventive service)), and
     GYYY2: Prolonged preventive service(s) (beyond the typical 
service time of the primary procedure) in the office or other 
outpatient setting requiring direct patient contact beyond the usual 
service; each additional 30 minutes (List separately in addition to 
code for preventive service)). These proposed services (HCPCS codes 
GYYY1 and GYYY2) are only permitted to be billed with Medicare-covered 
preventive services. Beneficiary coinsurance and deductible would not 
be applicable for HCPCS codes GYYY1 and GYYY2 because the codes can 
only be reported to describe prolonged portions of services where 
beneficiary coinsurance and deductible are not applicable.
    We are proposing to use prolonged services codes in 30-minute 
increments instead of the 60-minute increments that apply for the 
parallel office/outpatient prolonged services codes, since some 
Medicare-covered preventive services have a shorter duration than E/M 
visits. For purposes of valuation for both initial and additional 30 
minute codes, we are proposing to use one half of the current work RVUs 
and direct PE inputs for CPT code 99354 (Prolonged evaluation and 
management or psychotherapy service(s) beyond the typical service time 
of the primary procedure) in the office or other outpatient setting 
requiring direct patient contact beyond the usual service; first hour 
(List separately in addition to code for office or other outpatient 
Evaluation and Management or psychotherapy service)). CPT code 99354 
has a total time of 60 minutes and a work RVU of 2.33. Therefore, we 
are proposing a work RVU of 1.17 and 30 minutes of total work time for 
HCPCS codes GYYY1 and GYYY2. We are proposing to use one half of the 
direct PE inputs for CPT code 99354, which results in a proposal of 7 
minutes of clinical labor type L037D (RN/LPN/MTA) and 15 minutes for 
equipment type EF031 (table, power) for HCPCS code GYYY1 and HCPCS code 
GYYY2 as the best reflection of typical direct PE costs. We understand 
that these specific clinical labor and equipment types may be 
functioning as proxy inputs for some Medicare-covered preventive 
services.
    As described in this section of the rule, we propose that HCPCS 
codes GYYY1 and GYYY2 be billed for prolonged preventive services 
beyond the typical service time of the primary procedure. For 
preventive services with both physician work and practice expense, we 
are considering the typical service time of the primary procedure to be 
the intraservice work time used for the purposes of ratesetting. For 
Medicare-covered preventive services with no face-to-face physician 
work, the typical time is the service period clinical staff time that 
best represents the face-to-face time with the patient. The counted 
time requirements (derived from the typical times assumed for 
ratesetting) for all eligible companion Medicare-covered preventive 
services are available in the file called ``CY 2018 Preventive Services 
Billed with Prolonged Preventives Code'' on the CMS Web site under 
downloads for the CY 2018 PFS proposed rule at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices.html.

              Table 10--Proposed CY 2018 Work RVUs for New, Revised and Potentially Misvalued Codes
----------------------------------------------------------------------------------------------------------------
                                                        Current    RUC work   CMS work
          HCPCS                    Descriptor           work RVU     RVU        RVU       CMS time  refinement
----------------------------------------------------------------------------------------------------------------
007X1....................  Anesthesia for upper              NEW       0.00       0.00  No.
                            gastrointestinal
                            endoscopic procedures,
                            endoscope introduced
                            proximal to duodenum; not
                            otherwise specified.
007X2....................  Anesthesia for upper              NEW       0.00       0.00  No.
                            gastrointestinal
                            endoscopic procedures,
                            endoscope introduced
                            proximal to duodenum;
                            endoscopic retrograde
                            cholangiopancreatography
                            (ERCP).
008X1....................  Anesthesia for lower              NEW       0.00       0.00  No.
                            intestinal endoscopic
                            procedures, endoscope
                            introduced distal to
                            duodenum; not otherwise
                            specified.
008X2....................  Anesthesia for lower              NEW       0.00       0.00  No.
                            intestinal endoscopic
                            procedures, endoscope
                            introduced distal to
                            duodenum; screening
                            colonoscopy.
008X3....................  Anesthesia for combined           NEW       0.00       0.00  No.
                            upper and lower
                            gastrointestinal
                            endoscopic procedures,
                            endoscope introduced both
                            proximal to and distal to
                            the duodenum.
10040....................  Acne surgery (e.g.,              1.21       0.91       0.91  No.
                            marsupialization, opening
                            or removal of multiple
                            milia, comedones, cysts,
                            pustules).
15734....................  Muscle, myocutaneous, or        19.86      23.00      23.00  No.
                            fasciocutaneous flap;
                            trunk.
15736....................  Muscle, myocutaneous, or        17.04      17.04      17.04  No.
                            fasciocutaneous flap;
                            upper extremity.
15738....................  Muscle, myocutaneous, or        19.04      19.04      19.04  No.
                            fasciocutaneous flap;
                            lower extremity.
157X1....................  Midface flap (i.e.,               NEW      13.50      13.50  No.
                            zygomaticofacial flap)
                            with preservation of
                            vascular pedicle(s).
157X2....................  Muscle, myocutaneous, or          NEW      15.68      15.68  No.
                            fasciocutaneous flap;
                            head and neck with named
                            vascular pedicle (i.e.,
                            buccinators,
                            genioglossus, temporalis,
                            masseter,
                            sternocleidomastoid,
                            levator scapulae).
192X1....................  Preparation of tumor              NEW       3.00       3.00  No.
                            cavity with placement of
                            a radiation therapy
                            applicator for
                            intraoperative radiation
                            therapy (IORT) concurrent
                            with partial mastectomy.
19303....................  Mastectomy, simple,             15.85      15.00      15.00  No.
                            complete.
2093X....................  Bone marrow aspiration for        NEW       1.16       1.16  No.
                            bone grafting, spine
                            surgery only, through
                            separate skin or fascial
                            incision.
29445....................  Application of rigid total       1.78       1.78       1.78  No.
                            contact leg cast.
29580....................  Strapping; Unna boot......       0.55       0.55       0.55  No.
29581....................  Application of multi-layer       0.25       0.60       0.60  No.
                            compression system; leg
                            (below knee), including
                            ankle and foot.
30140....................  Submucous resection              3.57       3.00       3.00  No.
                            inferior turbinate,
                            partial or complete, any
                            method.
30901....................  Control nasal hemorrhage,        1.10       1.10       1.10  No.
                            anterior, simple (limited
                            cautery and/or packing)
                            any method.
30903....................  Control nasal hemorrhage,        1.54       1.54       1.54  No.
                            anterior, complex
                            (extensive cautery and/or
                            packing) any method.
30905....................  Control nasal hemorrhage,        1.97       1.97       1.97  No.
                            posterior, with posterior
                            nasal packs and/or
                            cautery, any method;
                            initial.

[[Page 34015]]

 
30906....................  Control nasal hemorrhage,        2.45       2.45       2.45  No.
                            posterior, with posterior
                            nasal packs and/or
                            cautery, any method;
                            subsequent.
31XX1....................  Nasal/sinus endoscopy,            NEW       8.00       8.00  No.
                            surgical; with ligation
                            of sphenopalatine artery.
31XX2....................  Nasal/sinus endoscopy,            NEW       9.00       9.00  No.
                            surgical with
                            ethmoidectomy; total
                            (anterior and posterior),
                            including frontal sinus
                            exploration, with removal
                            of tissue from frontal
                            sinus, when performed.
31XX3....................  Nasal/sinus endoscopy,            NEW       8.00       8.00  No.
                            surgical with
                            ethmoidectomy; total
                            (anterior and posterior),
                            including sphenoidotomy.
31XX4....................  Nasal/sinus endoscopy,            NEW       8.48       8.48  No.
                            surgical with
                            ethmoidectomy; total
                            (anterior and posterior),
                            including sphenoidotomy,
                            with removal of tissue
                            from the sphenoid sinus.
31XX5....................  Nasal/sinus endoscopy,            NEW       4.50       4.50  No.
                            surgical; with dilation
                            of frontal and sphenoid
                            sinus ostia (e.g.,
                            balloon dilation).
31254....................  Nasal/sinus endoscopy,           4.64       4.27       4.27  No.
                            surgical with
                            ethmoidectomy; partial
                            (anterior).
31255....................  Nasal/sinus endoscopy,           6.95       5.75       5.75  No.
                            surgical with
                            ethmoidectomy; total
                            (anterior and posterior).
31256....................  Nasal/sinus endoscopy,           3.29       3.11       3.11  No.
                            surgical, with maxillary
                            antrostomy.
31267....................  Nasal/sinus endoscopy,           5.45       4.68       4.68  No.
                            surgical, with maxillary
                            antrostomy; with removal
                            of tissue from maxillary
                            sinus.
31276....................  Nasal/sinus endoscopy,           8.84       6.75       6.75  No.
                            surgical, with frontal
                            sinus exploration,
                            including removal of
                            tissue from frontal
                            sinus, when performed.
31287....................  Nasal/sinus endoscopy,           3.91       3.50       3.50  No.
                            surgical, with
                            sphenoidotomy.
31288....................  Nasal/sinus endoscopy,           4.57       4.10       4.10  No.
                            surgical, with
                            sphenoidotomy; with
                            removal of tissue from
                            the sphenoid sinus.
31295....................  Nasal/sinus endoscopy,           2.70       2.70       2.70  No.
                            surgical; with dilation
                            of maxillary sinus ostium
                            (e.g., balloon dilation),
                            transnasal or canine
                            fossa.
31296....................  Nasal/sinus endoscopy,           3.29       3.10       3.10  No.
                            surgical; with dilation
                            of frontal sinus ostium
                            (e.g., balloon dilation).
31297....................  Nasal/sinus endoscopy,           2.64       2.44       2.44  No.
                            surgical; with dilation
                            of sphenoid sinus ostium
                            (e.g., balloon dilation).
31600....................  Tracheostomy, planned            7.17       5.56       5.56  No.
                            (separate procedure).
31601....................  Tracheostomy, planned            4.44       8.00       8.00  No.
                            (separate procedure);
                            younger than 2 years.
31603....................  Tracheostomy, emergency          4.14       6.00       6.00  No.
                            procedure; transtracheal.
31605....................  Tracheostomy, emergency          3.57       6.45       6.45  No.
                            procedure; cricothyroid
                            membrane.
31610....................  Tracheostomy, fenestration       9.38      12.00      12.00  No.
                            procedure with skin flaps.
31645....................  Bronchoscopy, rigid or           2.91       2.88       2.88  No.
                            flexible, including
                            fluoroscopic guidance,
                            when performed with
                            therapeutic aspiration of
                            tracheobronchial tree,
                            initial.
31646....................  Bronchoscopy, rigid or           2.47       2.78       2.78  No.
                            flexible, including
                            fluoroscopic guidance,
                            when performed with
                            therapeutic aspiration of
                            tracheobronchial tree,
                            subsequent, same hospital
                            stay.
32998....................  Ablation therapy for             5.68       9.03       9.03  No.
                            reduction or eradication
                            of 1 or more pulmonary
                            tumor(s) including pleura
                            or chest wall when
                            involved by tumor
                            extension, percutaneous,
                            including imaging
                            guidance when performed,
                            unilateral;
                            radiofrequency.
32X99....................  Ablation therapy for              NEW       9.03       9.03  No.
                            reduction or eradication
                            of 1 or more pulmonary
                            tumor(s) including pleura
                            or chest wall when
                            involved by tumor
                            extension, percutaneous,
                            including imaging
                            guidance when performed,
                            unilateral; cryoablation.
339X1....................  Implantation of a total           NEW      49.00      49.00  No.
                            replacement heart system
                            (artificial heart) with
                            recipient cardiectomy.
339X2....................  Removal and replacement of        NEW          C          C  No.
                            total replacement heart
                            system (artificial heart).
339X3....................  Removal of a total                NEW          C          C  No.
                            replacement heart system
                            (artificial heart) for
                            heart transplantation.
34812....................  Open femoral artery              6.74       4.13       4.13  No.
                            exposure for delivery of
                            endovascular prosthesis
                            by groin incision,
                            unilateral.
34820....................  Open iliac artery exposure       9.74       7.00       7.00  No.
                            for delivery of
                            endovascular prosthesis
                            or iliac occlusion by
                            abdominal or
                            retroperitoneal incision,
                            unilateral.
34833....................  Open iliac artery exposure      11.98       8.16       8.16  No.
                            with creation of conduit
                            for delivery of
                            endovascular prosthesis
                            or for establishment of
                            cardiopulmonary bypass,
                            by abdominal or
                            retroperitoneal incision,
                            unilateral.
34834....................  Open brachial artery             5.34       2.65       2.65  No.
                            exposure for delivery of
                            endovascular prosthesis
                            unilateral.
34X01....................  Endovascular repair of            NEW      23.71      23.71  No.
                            infrarenal aorta by
                            deployment of an aorto-
                            aortic tube endograft
                            including pre-procedure
                            sizing and device
                            selection, all
                            nonselective
                            catheterization(s), all
                            associated radiological
                            supervision and
                            interpretation, all
                            endograft extension(s)
                            placed in the aorta from
                            the level of the renal
                            arteries to the aortic
                            bifurcation, and all
                            angioplasty/stenting
                            performed from the level
                            of the renal arteries to
                            the aortic bifurcation;
                            for other than rupture
                            (e.g., for aneurysm,
                            pseudoaneurysm,
                            dissection, penetrating
                            ulcer).
34X02....................  Endovascular repair of            NEW      36.00      36.00  No.
                            infrarenal aorta by
                            deployment of an aorto-
                            aortic tube endograft
                            including pre-procedure
                            sizing and device
                            selection, all
                            nonselective
                            catheterization(s), all
                            associated radiological
                            supervision and
                            interpretation, all
                            endograft extension(s)
                            placed in the aorta from
                            the level of the renal
                            arteries to the aortic
                            bifurcation, and all
                            angioplasty/stenting
                            performed from the level
                            of the renal arteries to
                            the aortic bifurcation;
                            for rupture including
                            temporary aortic and/or
                            iliac balloon occlusion
                            when performed (e.g., for
                            aneurysm, pseudoaneurysm,
                            dissection, penetrating
                            ulcer, traumatic
                            disruption).
34X03....................  Endovascular repair of            NEW      26.52      26.52  No.
                            infrarenal aorta and/or
                            iliac artery(ies) by
                            deployment of an aorto-
                            uniiliac endograft
                            including pre-procedure
                            sizing and device
                            selection, all
                            nonselective
                            catheterization(s), all
                            associated radiological
                            supervision and
                            interpretation, all
                            endograft extension(s)
                            placed in the aorta from
                            the level of the renal
                            arteries to the iliac
                            bifurcation, and all
                            angioplasty/stenting
                            performed from the level
                            of the renal arteries to
                            the iliac bifurcation;
                            for other than rupture
                            (e.g., for aneurysm,
                            pseudoaneurysm,
                            dissection, penetrating
                            ulcer).
34X04....................  Endovascular repair of            NEW      45.00      45.00  No.
                            infrarenal aorta and/or
                            iliac artery(ies) by
                            deployment of an aorto-
                            uniiliac endograft
                            including pre-procedure
                            sizing and device
                            selection, all
                            nonselective
                            catheterization(s), all
                            associated radiological
                            supervision and
                            interpretation, all
                            endograft extension(s)
                            placed in the aorta from
                            the level of the renal
                            arteries to the iliac
                            bifurcation, and all
                            angioplasty/stenting
                            performed from the level
                            of the renal arteries to
                            the iliac bifurcation;
                            for rupture including
                            temporary aortic and/or
                            iliac balloon occlusion
                            when performed (e.g., for
                            aneurysm, pseudoaneurysm,
                            dissection, penetrating
                            ulcer, traumatic
                            disruption).

[[Page 34016]]

 
34X05....................  Endovascular repair of            NEW      29.58      29.58  No.
                            infrarenal aorta and/or
                            iliac artery(ies) by
                            deployment of an aorto-
                            biiliac endograft
                            including pre-procedure
                            sizing and device
                            selection, all
                            nonselective
                            catheterization(s), all
                            associated radiological
                            supervision and
                            interpretation, all
                            endograft extension(s)
                            placed in the aorta from
                            the level of the renal
                            arteries to the iliac
                            bifurcation, and all
                            angioplasty/stenting
                            performed from the level
                            of the renal arteries to
                            the iliac bifurcation;
                            for other than rupture
                            (e.g., for aneurysm,
                            pseudoaneurysm,
                            dissection, penetrating
                            ulcer).
34X06....................  Endovascular repair of            NEW      45.00      45.00  No.
                            infrarenal aorta and/or
                            iliac artery(ies) by
                            deployment of an aorto-
                            biiliac endograft
                            including pre-procedure
                            sizing and device
                            selection, all
                            nonselective
                            catheterization(s), all
                            associated radiological
                            supervision and
                            interpretation, all
                            endograft extension(s)
                            placed in the aorta from
                            the level of the renal
                            arteries to the iliac
                            bifurcation, and all
                            angioplasty/stenting
                            performed from the level
                            of the renal arteries to
                            the iliac bifurcation;
                            for rupture including
                            temporary aortic and/or
                            iliac balloon occlusion
                            when performed (e.g., for
                            aneurysm, pseudoaneurysm,
                            dissection, penetrating
                            ulcer, traumatic
                            disruption).
34X07....................  Endovascular repair of            NEW      22.28      22.28  No.
                            iliac artery by
                            deployment of an ilio-
                            iliac tube endograft
                            including pre-procedure
                            sizing and device
                            selection, all
                            nonselective
                            catheterization(s), all
                            associated radiological
                            supervision and
                            interpretation, and all
                            endograft extension(s)
                            proximally to the aortic
                            bifurcation and distally
                            to the iliac bifurcation,
                            and treatment zone
                            angioplasty/stenting when
                            performed, unilateral;
                            for other than rupture
                            (e.g., for aneurysm,
                            pseudoaneurysm,
                            dissection, arteriovenous
                            malformation).
34X08....................  Endovascular repair of            NEW      36.50      36.50  No.
                            iliac artery by
                            deployment of an ilio-
                            iliac tube endograft
                            including pre-procedure
                            sizing and device
                            selection, all
                            nonselective
                            catheterization(s), all
                            associated radiological
                            supervision and
                            interpretation, and all
                            endograft extension(s)
                            proximally to the aortic
                            bifurcation and distally
                            to the iliac bifurcation,
                            and treatment zone
                            angioplasty/stenting when
                            performed, unilateral;
                            for rupture including
                            temporary aortic and/or
                            iliac balloon occlusion
                            when performed (e.g., for
                            aneurysm, pseudoaneurysm,
                            dissection, arteriovenous
                            malformation, traumatic
                            disruption).
34X09....................  Placement of extension            NEW       6.50       6.50  No.
                            prosthesis(es) distal to
                            the common iliac
                            artery(ies) or proximal
                            to the renal artery(ies)
                            for endovascular repair
                            of infrarenal abdominal
                            aortic or iliac aneurysm,
                            false aneurysm,
                            dissection, penetrating
                            ulcer, including pre-
                            procedure sizing and
                            device selection, all
                            nonselective
                            catheterization(s), all
                            associated radiological
                            supervision and
                            interpretation, and
                            treatment zone
                            angioplasty/stenting when
                            performed, per vessel
                            treated.
34X10....................  Delayed placement of              NEW      15.00      15.00  No.
                            distal or proximal
                            extension prosthesis for
                            endovascular repair of
                            infrarenal abdominal
                            aortic or iliac aneurysm,
                            false aneurysm,
                            dissection, endoleak, or
                            endograft migration,
                            including pre-procedure
                            sizing and device
                            selection, all
                            nonselective
                            catheterization(s), all
                            associated radiological
                            supervision and
                            interpretation, and
                            treatment zone
                            angioplasty/stenting when
                            performed; initial vessel
                            treated.
34X11....................  Delayed placement of              NEW       6.00       6.00  No.
                            distal or proximal
                            extension prosthesis for
                            endovascular repair of
                            infrarenal abdominal
                            aortic or iliac aneurysm,
                            false aneurysm,
                            dissection, endoleak, or
                            endograft migration,
                            including pre-procedure
                            sizing and device
                            selection, all
                            nonselective
                            catheterization(s), all
                            associated radiological
                            supervision and
                            interpretation, and
                            treatment zone
                            angioplasty/stenting when
                            performed; each
                            additional vessel treated.
34X12....................  Transcatheter delivery of         NEW      12.00      12.00  No.
                            enhanced fixation
                            device(s) to the
                            endograft (e.g., anchor,
                            screw, tack) and all
                            associated radiological
                            supervision and
                            interpretation.
34X13....................  Percutaneous access and           NEW       2.50       2.50  No.
                            closure of femoral artery
                            for delivery of endograft
                            through a large sheath
                            (12 French or larger),
                            including ultrasound
                            guidance, when performed,
                            unilateral.
34X15....................  Open femoral artery               NEW       5.25       5.25  No.
                            exposure with creation of
                            conduit for delivery of
                            endovascular prosthesis
                            or for establishment of
                            cardiopulmonary bypass,
                            by groin incision,
                            unilateral.
34X19....................  Open axillary/subclavian          NEW       6.00       6.00  No.
                            artery exposure for
                            delivery of endovascular
                            prosthesis by
                            infraclavicular or
                            supraclavicular incision,
                            unilateral.
34X20....................  Open axillary/subclavian          NEW       7.19       7.19  No.
                            artery exposure with
                            creation of conduit for
                            delivery of endovascular
                            prosthesis or for
                            establishment of
                            cardiopulmonary bypass,
                            by infraclavicular or
                            supraclavicular incision,
                            unilateral.
36215....................  Selective catheter               4.67       4.17       4.17  No.
                            placement, arterial
                            system; each first order
                            thoracic or
                            brachiocephalic branch,
                            within a vascular family.
36216....................  Selective catheter               5.27       5.27       5.27  No.
                            placement, arterial
                            system; initial second
                            order thoracic or
                            brachiocephalic branch,
                            within a vascular family.
36217....................  Selective catheter               6.29       6.29       6.29  No.
                            placement, arterial
                            system; initial third
                            order or more selective
                            thoracic or
                            brachiocephalic branch,
                            within a vascular family.
36218....................  Selective catheter               1.01       1.01       1.01  No.
                            placement, arterial
                            system; additional second
                            order, third order, and
                            beyond, thoracic or
                            brachiocephalic branch,
                            within a vascular family.
36470....................  Injection of sclerosant;         1.10       0.75       0.75  No.
                            single incompetent vein
                            (other than
                            telangiectasia).
36471....................  Injection of sclerosant;         1.65       1.50       1.50  No.
                            multiple incompetent
                            veins (other than
                            telangiectasia), same leg.
364X3....................  Endovenous ablation               NEW       3.50       3.50  No.
                            therapy of incompetent
                            vein, extremity, by
                            transcatheter delivery of
                            a chemical adhesive
                            (e.g., cyanoacrylate)
                            remote from the access
                            site, inclusive of all
                            imaging guidance and
                            monitoring, percutaneous;
                            first vein treated.
364X4....................  Endovenous ablation               NEW       1.75       1.75  No.
                            therapy of incompetent
                            vein, extremity, by
                            transcatheter delivery of
                            a chemical adhesive
                            (e.g., cyanoacrylate)
                            remote from the access
                            site, inclusive of all
                            imaging guidance and
                            monitoring, percutaneous;
                            subsequent vein(s)
                            treated in a single
                            extremity, each through
                            separate access sites.
364X5....................  Injection of non-                 NEW       2.35       2.35  No.
                            compounded foam
                            sclerosant with
                            ultrasound compression
                            maneuvers to guide
                            dispersion of the
                            injectate, inclusive of
                            all imaging guidance and
                            monitoring; single
                            incompetent extremity
                            truncal vein (e.g., great
                            saphenous vein, accessory
                            saphenous vein).
364X6....................  Injection of non-                 NEW       3.00       3.00  No.
                            compounded foam
                            sclerosant with
                            ultrasound compression
                            maneuvers to guide
                            dispersion of the
                            injectate, inclusive of
                            all imaging guidance and
                            monitoring; multiple
                            incompetent truncal veins
                            (e.g., great saphenous
                            vein, accessory saphenous
                            vein), same leg.
36511....................  Therapeutic apheresis; for       1.74       2.00       2.00  No.
                            white blood cells.
36512....................  Therapeutic apheresis; for       1.74       2.00       2.00  No.
                            red blood cells.
36513....................  Therapeutic apheresis; for       1.74       2.00       2.00  No.
                            platelets.
36514....................  Therapeutic apheresis; for       1.74       1.81       1.81  No.
                            plasma pheresis.

[[Page 34017]]

 
36516....................  Therapeutic apheresis;           1.22       1.56       1.56  No.
                            with extracorporeal
                            selective adsorption or
                            selective filtration and
                            plasma reinfusion.
36522....................  Photopheresis,                   1.67       1.75       1.75  No.
                            extracorporeal.
36555....................  Insertion of non-tunneled        2.43       1.93       1.93  No.
                            centrally inserted
                            central venous catheter;
                            younger than 5 years of
                            age.
36556....................  Insertion of non-tunneled        2.50       1.75       1.75  No.
                            centrally inserted
                            central venous catheter;
                            age 5 years or older.
36569....................  Insertion of peripherally        1.82       1.70       1.70  No.
                            inserted central venous
                            catheter (PICC), without
                            subcutaneous port or
                            pump; age 5 years or
                            older.
36620....................  Arterial catheterization         1.15       1.00       1.00  No.
                            or cannulation for
                            sampling, monitoring or
                            transfusion (separate
                            procedure); percutaneous.
38220....................  Diagnostic bone marrow;          1.08       1.20       1.20  Yes.
                            aspiration(s).
38221....................  Diagnostic bone marrow;          1.37       1.28       1.28  Yes.
                            biopsy(ies).
382X3....................  Diagnostic bone marrow;           NEW       1.44       1.44  Yes.
                            biopsy(ies) and
                            aspiration(s).
3857X....................  Laparoscopy, surgical;            NEW      20.00      20.00  No.
                            with bilateral total
                            pelvic lymphadenectomy
                            and peri-aortic lymph
                            node sampling peritoneal
                            washings, peritoneal
                            biopsy(s), omentectomy,
                            and diaphragmatic
                            washings, including
                            biopsy(s) when performed.
43107....................  Total or near total             44.18      52.05      52.05  No.
                            esophagectomy, without
                            thoracotomy; with
                            pharyngogastrostomy or
                            cervical
                            esophagogastrostomy, with
                            or without pyloroplasty
                            (transhiatal).
43112....................  Total or near total             47.48      62.00      62.00  No.
                            esophagectomy, with
                            thoracotomy; with
                            pharyngogastrostomy or
                            cervical
                            esophagogastrostomy, with
                            or without pyloroplasty
                            (i.e., McKeown
                            esophagectomy, or tri-
                            incisional esophagectomy).
43117....................  Partial esophagectomy,          43.65      57.50      57.50  No.
                            distal two-thirds, with
                            thoracotomy and separate
                            abdominal incision, with
                            or without proximal
                            gastrectomy; with
                            thoracic
                            esophagogastrostomy, with
                            or without pyloroplasty
                            (Ivor Lewis).
432X5....................  Esophagectomy, total or           NEW      55.00      55.00  No
                            near total, with
                            laparoscopic mobilization
                            of the abdominal and
                            mediastinal esophagus and
                            proximal gastrectomy,
                            with laparoscopic pyloric
                            drainage procedure if
                            performed, with open
                            cervical
                            pharyngogastrostomy or
                            esophagogastrostomy
                            (i.e., laparoscopic
                            transhiatal
                            esophagectomy).
432X6....................  Esophagectomy, distal two-        NEW      63.00      63.00  No.
                            thirds, with laparoscopic
                            mobilization of the
                            abdominal and lower
                            mediastinal esophagus and
                            proximal gastrectomy,
                            with laparoscopic pyloric
                            drainage procedure if
                            performed, with separate
                            thoracoscopic
                            mobilization of the
                            middle and upper
                            mediastinal esophagus and
                            thoracic
                            esophagogastrostomy
                            (i.e., laparoscopic
                            thoracoscopic
                            esophagectomy, Ivor Lewis
                            esophagectomy).
432X7....................  Esophagectomy, total or           NEW      66.42      66.42  No.
                            near total, with
                            thoracoscopic
                            mobilization of the
                            upper, middle, and lower
                            mediastinal esophagus,
                            with separate
                            laparoscopic proximal
                            gastrectomy, with
                            laparoscopic pyloric
                            drainage procedure if
                            performed, with open
                            cervical
                            pharyngogastrostomy or
                            esophagogastrostomy
                            (i.e., thoracoscopic,
                            laparoscopic and cervical
                            incision esophagectomy,
                            McKeown esophagectomy,
                            tri-incisional
                            esophagectomy).
51798....................  Measurement of post-             0.00       0.00       0.00  No.
                            voiding residual urine
                            and/or bladder capacity
                            by ultrasound, non-
                            imaging.
52601....................  Transurethral                   15.26      13.16      13.16  No.
                            electrosurgical resection
                            of prostate, including
                            control of postoperative
                            bleeding, complete
                            (vasectomy, meatotomy,
                            cystourethroscopy,
                            urethral calibration and/
                            or dilation, and internal
                            urethrotomy are included).
55X87....................  Transperineal placement of        NEW       3.03       3.03  No.
                            biodegradable material,
                            peri-prostatic, single or
                            multiple injection(s),
                            including image guidance,
                            when performed.
57240....................  Anterior colporrhaphy,          11.50      10.08      10.08  No.
                            repair of cystocele with
                            or without repair of
                            urethrocele, including
                            cystourethroscopy, when
                            performed.
57250....................  Posterior colporrhaphy,         11.50      10.08      10.08  No.
                            repair of rectocele with
                            or without perineorrhaphy.
57260....................  Combined anteroposterior        14.44      13.25      13.25  No.
                            colporrhaphy, including
                            cystourethroscopy, when
                            performed.
57265....................  Combined anteroposterior        15.94      15.00      15.00  No.
                            colporrhaphy, including
                            cystourethroscopy, when
                            performed; with
                            enterocele repair.
5857X....................  Laparoscopy, surgical,            NEW      32.60      32.60  No.
                            total hysterectomy; with
                            or without salpingo-
                            oophorectomy, unilateral
                            or bilateral, with
                            resection of malignancy
                            (tumor debulking), with
                            omentectomy.
64418....................  Injection, anesthetic            1.32       1.10       1.10  No.
                            agent; suprascapular
                            nerve.
64553....................  Percutaneous implantation        2.36       6.13       6.13  No
                            of neurostimulator
                            electrode array; cranial
                            nerve.
64555....................  Percutaneous implantation        2.32       5.76       5.76  No.
                            of neurostimulator
                            electrode array;
                            peripheral nerve
                            (excludes sacral nerve).
64910....................  Nerve repair; with              11.39      10.52      10.52  No.
                            synthetic conduit or vein
                            allograft (e.g., nerve
                            tube), each nerve.
64911....................  Nerve repair; with              14.39      14.00      14.00  No
                            autogenous vein graft
                            (includes harvest of vein
                            graft), each nerve.
64X91....................  Nerve repair; with nerve          NEW      12.00      12.00  No.
                            allograft, each nerve,
                            first strand (cable).
64X92....................  Nerve repair; with nerve          NEW       3.00       3.00  No.
                            allograft, each
                            additional strand.
67820....................  Correction of trichiasis;        0.71       0.32       0.32  No.
                            epilation, by forceps
                            only.
70490....................  Computed tomography, soft        1.28       1.28       1.28  No.
                            tissue neck; without
                            contrast material.
70491....................  Computed tomography, soft        1.38       1.38       1.38  No.
                            tissue neck; with
                            contrast material(s).
70492....................  Computed tomography, soft        1.45       1.62       1.62  No.
                            tissue neck; without
                            contrast material
                            followed by contrast
                            material(s) and further
                            sections.
70544....................  Magnetic resonance               1.20       1.20       1.20  No.
                            angiography, head;
                            without contrast
                            material(s).
70545....................  Magnetic resonance               1.20       1.20       1.20  No.
                            angiography, head; with
                            contrast material(s).
70546....................  Magnetic resonance               1.80       1.48       1.48  No.
                            angiography, head;
                            without contrast
                            material(s), followed by
                            contrast material(s) and
                            further sequences.
70547....................  Magnetic resonance               1.20       1.20       1.20  No.
                            angiography, neck;
                            without contrast
                            material(s).
70548....................  Magnetic resonance               1.20       1.50       1.50  No.
                            angiography, neck; with
                            contrast material(s).
70549....................  Magnetic resonance               1.80       1.80       1.80  No.
                            angiography, neck;
                            without contrast
                            material(s), followed by
                            contrast material(s) and
                            further sequences.
710X1....................  Radiologic examination,           NEW       0.18       0.18  No.
                            chest; single view.
710X2....................  Radiologic examination,           NEW       0.22       0.22  No.
                            chest; 2 views.
710X3....................  Radiologic examination,           NEW       0.27       0.27  No.
                            chest; 3 views.
710X4....................  Radiologic examination,           NEW       0.31       0.31  No.
                            chest; 4 or more views.
71100....................  Radiologic examination,          0.22       0.22       0.22  No.
                            ribs, unilateral; 2 views.
71101....................  Radiologic examination,          0.27       0.27       0.27  No.
                            ribs, unilateral;
                            including posteroanterior
                            chest, minimum of 3 views.
71110....................  Radiologic examination,          0.27       0.29       0.29  No.
                            ribs, bilateral; 3 views.
71111....................  Radiologic examination,          0.32       0.32       0.32  No.
                            ribs, bilateral;
                            including posteroanterior
                            chest, minimum of 4 views.

[[Page 34018]]

 
71250....................  Computed tomography,             1.02       1.16       1.16  No.
                            thorax; without contrast
                            material.
71260....................  Computed tomography,             1.24       1.24       1.24  No.
                            thorax; with contrast
                            material(s).
71270....................  Computed tomography,             1.38       1.38       1.38  No.
                            thorax; without contrast
                            material, followed by
                            contrast material(s) and
                            further sections.
72195....................  Magnetic resonance (e.g.,        1.46       1.46       1.46  No.
                            proton) imaging, pelvis;
                            without contrast
                            material(s).
72196....................  Magnetic resonance (e.g.,        1.73       1.73       1.73  No.
                            proton) imaging, pelvis;
                            with contrast material(s).
72197....................  Magnetic resonance (e.g.,        2.26       2.20       2.20  No.
                            proton) imaging, pelvis;
                            without contrast
                            material(s), followed by
                            contrast material(s) and
                            further sequences.
73100....................  Radiologic examination,          0.16       0.16       0.16  No.
                            wrist; 2 views.
73110....................  Radiologic examination,          0.17       0.17       0.17  No.
                            wrist; complete, minimum
                            of 3 views.
73120....................  Radiologic examination,          0.16       0.16       0.16  No.
                            hand; 2 views.
73130....................  Radiologic examination,          0.17       0.17       0.17  No.
                            hand; minimum of 3 views.
73140....................  Radiologic examination,          0.13       0.13       0.13  No.
                            finger(s), minimum of 2
                            views.
73718....................  Magnetic resonance (e.g.,        1.35       1.35       1.35  No.
                            proton) imaging, lower
                            extremity other than
                            joint; without contrast
                            material(s).
73719....................  Magnetic resonance (e.g.,        1.62       1.62       1.62  No.
                            proton) imaging, lower
                            extremity other than
                            joint; with contrast
                            material(s).
73720....................  Magnetic resonance (e.g.,        2.15       2.15       2.15  No.
                            proton) imaging, lower
                            extremity other than
                            joint; without contrast
                            material(s), followed by
                            contrast material(s) and
                            further sequences.
74022....................  Radiologic examination,          0.32       0.32       0.32  No.
                            abdomen; complete acute
                            abdomen series, including
                            supine, erect, and/or
                            decubitus views, single
                            view chest.
740X1....................  Radiologic examination,           NEW       0.18       0.18  No.
                            abdomen; 1 view.
740X2....................  Radiologic examination,           NEW       0.23       0.23  No.
                            abdomen; 2 views.
740X3....................  Radiologic examination,           NEW       0.27       0.27  No.
                            abdomen; 3 or more views.
74181....................  Magnetic resonance (e.g.,        1.46       1.46       1.46  No.
                            proton) imaging, abdomen;
                            without contrast
                            material(s).
74182....................  Magnetic resonance (e.g.,        1.73       1.73       1.73  No.
                            proton) imaging, abdomen;
                            with contrast material(s).
74183....................  Magnetic resonance (e.g.,        2.26       2.20       2.20  No.
                            proton) imaging, abdomen;
                            without contrast
                            material(s), followed by
                            with contrast material(s)
                            and further sequences.
75635....................  Computed tomographic             2.40       2.40       2.40  No.
                            angiography, abdominal
                            aorta and bilateral
                            iliofemoral lower
                            extremity runoff, with
                            contrast material(s),
                            including noncontrast
                            images, if performed, and
                            image postprocessing.
75710....................  Angiography, extremity,          1.14       1.75       1.75  No.
                            unilateral, radiological
                            supervision and
                            interpretation.
75716....................  Angiography, extremity,          1.31       1.97       1.97  No.
                            bilateral, radiological
                            supervision and
                            interpretation.
76510....................  Ophthalmic ultrasound,           1.55       0.70       0.70  No.
                            diagnostic; B-scan and
                            quantitative A-scan
                            performed during the same
                            patient encounter.
76511....................  Ophthalmic ultrasound,           0.94       0.64       0.64  No.
                            diagnostic; quantitative
                            A-scan only.
76512....................  Ophthalmic ultrasound,           0.94       0.56       0.56  No.
                            diagnostic; B-scan (with
                            or without superimposed
                            non-quantitative A-scan).
76516....................  Ophthalmic biometry by           0.54       0.40       0.40  No.
                            ultrasound echography, A-
                            scan.
76519....................  Ophthalmic biometry by           0.54       0.54       0.54  No.
                            ultrasound echography, A-
                            scan; with intraocular
                            lens power calculation.
76881....................  Ultrasound, extremity,           0.63       0.63       0.63  No.
                            nonvascular, real-time
                            with image documentation;
                            complete.
76882....................  Ultrasound, extremity,           0.49       0.49       0.49  No.
                            nonvascular, real-time
                            with image documentation;
                            limited, anatomic
                            specific.
77261....................  Therapeutic radiology            1.39       1.30       1.30  No.
                            treatment planning;
                            simple.
77262....................  Therapeutic radiology            2.11       2.00       2.00  No.
                            treatment planning;
                            intermediate.
77263....................  Therapeutic radiology            3.14       3.14       3.14  No.
                            treatment planning;
                            complex.
78300....................  Bone and/or joint imaging;       0.62       0.62       0.62  No.
                            limited area.
78305....................  Bone and/or joint imaging;       0.83       0.83       0.83  No.
                            multiple areas.
78306....................  Bone and/or joint imaging;       0.86       0.86       0.86  No.
                            whole body.
88333....................  Pathology consultation           1.20       1.20       1.20  No.
                            during surgery; cytologic
                            examination (e.g., touch
                            prep, squash prep),
                            initial site.
88334....................  Pathology consultation           0.73       0.73       0.73  No.
                            during surgery; cytologic
                            examination (e.g., touch
                            prep, squash prep), each
                            additional site.
88360....................  Morphometric analysis,           1.10       0.85       0.85  No.
                            tumor
                            immunohistochemistry
                            (e.g., Her-2/neu,
                            estrogen receptor/
                            progesterone receptor),
                            quantitative or
                            semiquantitative, per
                            specimen, each single
                            antibody stain procedure;
                            manual.
88361....................  Morphometric analysis,           1.18       0.95       0.95  No.
                            tumor
                            immunohistochemistry
                            (e.g., Her-2/neu,
                            estrogen receptor/
                            progesterone receptor),
                            quantitative or
                            semiquantitative, per
                            specimen, each single
                            antibody stain procedure;
                            using computer-assisted
                            technology.
92136....................  Ophthalmic biometry by           0.54       0.54       0.54  No.
                            partial coherence
                            interferometry with
                            intraocular lens power
                            calculation.
93279....................  Programming device               0.65       0.65       0.65  No.
                            evaluation (in person)
                            with iterative adjustment
                            of the implantable device
                            to test the function of
                            the device and select
                            optimal permanent
                            programmed values with
                            analysis, review and
                            report by a physician or
                            other qualified health
                            care professional; single
                            lead pacemaker system.
93280....................  Programming device               0.77       0.77       0.77  No.
                            evaluation (in person)
                            with iterative adjustment
                            of the implantable device
                            to test the function of
                            the device and select
                            optimal permanent
                            programmed values with
                            analysis, review and
                            report by a physician or
                            other qualified health
                            care professional; dual
                            lead pacemaker system.
93281....................  Programming device               0.90       0.85       0.85  No.
                            evaluation (in person)
                            with iterative adjustment
                            of the implantable device
                            to test the function of
                            the device and select
                            optimal permanent
                            programmed values with
                            analysis, review and
                            report by a physician or
                            other qualified health
                            care professional;
                            multiple lead pacemaker
                            system.
93282....................  Programming device               0.85       0.85       0.85  No.
                            evaluation (in person)
                            with iterative adjustment
                            of the implantable device
                            to test the function of
                            the device and select
                            optimal permanent
                            programmed values with
                            analysis, review and
                            report by a physician or
                            other qualified health
                            care professional; single
                            lead transvenous
                            implantable defibrillator
                            system.
93283....................  Programming device               1.15       1.15       1.15  No.
                            evaluation (in person)
                            with iterative adjustment
                            of the implantable device
                            to test the function of
                            the device and select
                            optimal permanent
                            programmed values with
                            analysis, review and
                            report by a physician or
                            other qualified health
                            care professional; dual
                            lead transvenous
                            implantable defibrillator
                            system.

[[Page 34019]]

 
93284....................  Programming device               1.25       1.25       1.25  No.
                            evaluation (in person)
                            with iterative adjustment
                            of the implantable device
                            to test the function of
                            the device and select
                            optimal permanent
                            programmed values with
                            analysis, review and
                            report by a physician or
                            other qualified health
                            care professional;
                            multiple lead transvenous
                            implantable defibrillator
                            system.
93285....................  Programming device               0.52       0.52       0.52  No.
                            evaluation (in person)
                            with iterative adjustment
                            of the implantable device
                            to test the function of
                            the device and select
                            optimal permanent
                            programmed values with
                            analysis, review and
                            report by a physician or
                            other qualified health
                            care professional;
                            implantable loop recorder
                            system.
93286....................  Peri-procedural device           0.30       0.30       0.30  No.
                            evaluation (in person)
                            and programming of device
                            system parameters before
                            or after a surgery,
                            procedure, or test with
                            analysis, review and
                            report by a physician or
                            other qualified health
                            care professional;
                            single, dual, or multiple
                            lead pacemaker system.
93287....................  Peri-procedural device           0.45       0.45       0.45  No.
                            evaluation (in person)
                            and programming of device
                            system parameters before
                            or after a surgery,
                            procedure, or test with
                            analysis, review and
                            report by a physician or
                            other qualified health
                            care professional;
                            single, dual, or multiple
                            lead implantable
                            defibrillator system.
93288....................  Interrogation device             0.43       0.43       0.43  No.
                            evaluation (in person)
                            with analysis, review and
                            report by a physician or
                            other qualified health
                            care professional,
                            includes connection,
                            recording and
                            disconnection per patient
                            encounter; single, dual,
                            or multiple lead
                            pacemaker system.
93289....................  Interrogation device             0.92       0.75       0.75  No.
                            evaluation (in person)
                            with analysis, review and
                            report by a physician or
                            other qualified health
                            care professional,
                            includes connection,
                            recording and
                            disconnection per patient
                            encounter; single, dual,
                            or multiple lead
                            transvenous implantable
                            defibrillator system,
                            including analysis of
                            heart rhythm derived data
                            elements.
93290....................  Interrogation device             0.43       0.43       0.43  No.
                            evaluation (in person)
                            with analysis, review and
                            report by a physician or
                            other qualified health
                            care professional,
                            includes connection,
                            recording and
                            disconnection per patient
                            encounter; implantable
                            cardiovascular monitor
                            system, including
                            analysis of 1 or more
                            recorded physiologic
                            cardiovascular data
                            elements from all
                            internal and external
                            sensors.
93291....................  Interrogation device             0.43       0.37       0.37  No.
                            evaluation (in person)
                            with analysis, review and
                            report by a physician or
                            other qualified health
                            care professional,
                            includes connection,
                            recording and
                            disconnection per patient
                            encounter; implantable
                            loop recorder system,
                            including heart rhythm
                            derived data analysis.
93292....................  Interrogation device             0.43       0.43       0.43  No.
                            evaluation (in person)
                            with analysis, review and
                            report by a physician or
                            other qualified health
                            care professional,
                            includes connection,
                            recording and
                            disconnection per patient
                            encounter; wearable
                            defibrillator system.
93293....................  Transtelephonic rhythm           0.32       0.31       0.31  No.
                            strip pacemaker
                            evaluation(s) single,
                            dual, or multiple lead
                            pacemaker system,
                            includes recording with
                            and without magnet
                            application with
                            analysis, review and
                            report(s) by a physician
                            or other qualified health
                            care professional, up to
                            90 days.
93294....................  Interrogation device             0.65       0.60       0.60  No.
                            evaluation(s) (remote),
                            up to 90 days; single,
                            dual, or multiple lead
                            pacemaker system with
                            interim analysis,
                            review(s) and report(s)
                            by a physician or other
                            qualified health care
                            professional.
93295....................  Interrogation device             1.29       0.74       0.74  No.
                            evaluation(s) (remote),
                            up to 90 days; single,
                            dual, or multiple lead
                            implantable defibrillator
                            system with interim
                            analysis, review(s) and
                            report(s) by a physician
                            or other qualified health
                            care professional.
93296....................  Interrogation device             0.00       0.00       0.00  No.
                            evaluation(s) (remote),
                            up to 90 days; single,
                            dual, or multiple lead
                            pacemaker system or
                            implantable defibrillator
                            system, remote data
                            acquisition(s), receipt
                            of transmissions and
                            technician review,
                            technical support and
                            distribution of results.
93297....................  Interrogation device             0.52       0.52       0.52  No.
                            evaluation(s), (remote)
                            up to 30 days;
                            implantable
                            cardiovascular monitor
                            system, including
                            analysis of 1 or more
                            recorded physiologic
                            cardiovascular data
                            elements from all
                            internal and external
                            sensors, analysis,
                            review(s) and report(s)
                            by a physician or other
                            qualified health care
                            professional.
93298....................  Interrogation device             0.52       0.52       0.52  No.
                            evaluation(s), (remote)
                            up to 30 days;
                            implantable loop recorder
                            system, including
                            analysis of recorded
                            heart rhythm data,
                            analysis, review(s) and
                            report(s) by a physician
                            or other qualified health
                            care professional.
93299....................  Interrogation device             0.00       0.00       0.00  No.
                            evaluation(s), (remote)
                            up to 30 days;
                            implantable
                            cardiovascular monitor
                            system or implantable
                            loop recorder system,
                            remote data
                            acquisition(s), receipt
                            of transmissions and
                            technician review,
                            technical support and
                            distribution of results.
93306....................  Echocardiography,                1.30       1.50       1.50  No.
                            transthoracic, real-time
                            with image documentation
                            (2D), includes M-mode
                            recording, when
                            performed, complete, with
                            spectral Doppler
                            echocardiography, and
                            with color flow Doppler
                            echocardiography.
93307....................  Echocardiography,                0.92       0.92       0.92  No.
                            transthoracic, real-time
                            with image documentation
                            (2D), includes M-mode
                            recording, when
                            performed, complete,
                            without spectral or color
                            Doppler echocardiography.
93308....................  Echocardiography,                0.53       0.53       0.53  No.
                            transthoracic, real-time
                            with image documentation
                            (2D), includes M-mode
                            recording, when
                            performed, follow-up or
                            limited study.
93350....................  Echocardiography,                1.46       1.46       1.46  No.
                            transthoracic, real-time
                            with image documentation
                            (2D), includes M-mode
                            recording, when
                            performed, during rest
                            and cardiovascular stress
                            test using treadmill,
                            bicycle exercise and/or
                            pharmacologically induced
                            stress, with
                            interpretation and report.
93351....................  Echocardiography,                1.75       1.75       1.75  No.
                            transthoracic, real-time
                            with image documentation
                            (2D), includes M-mode
                            recording, when
                            performed, during rest
                            and cardiovascular stress
                            test using treadmill,
                            bicycle exercise and/or
                            pharmacologically induced
                            stress, with
                            interpretation and
                            report; including
                            performance of continuous
                            electrocardiographic
                            monitoring, with
                            supervision by a
                            physician or other
                            qualified health care
                            professional.
93503....................  Insertion and placement of       2.91       2.00       2.00  No.
                            flow directed catheter
                            (e.g., Swan-Ganz) for
                            monitoring purposes.
93613....................  Intracardiac                     6.99       5.23       5.23  No.
                            electrophysiologic 3-
                            dimensional mapping.
93668....................  Peripheral arterial                 N       0.00       0.00  No.
                            disease (PAD)
                            rehabilitation, per
                            session.
94621....................  Cardiopulmonary exercise         1.42       1.42       1.42  No.
                            testing, including
                            measurements of minute
                            ventilation, CO2
                            production, O2 uptake,
                            and electrocardiographic
                            recordings.
946X2....................  Exercise test for                 NEW       0.70       0.70  No.
                            bronchospasm, including
                            pre- and post-spirometry
                            and pulse oximetry.
946X3....................  Pulmonary stress testing          NEW       0.48       0.48  No.
                            (e.g., 6-minute walk
                            test), including
                            measurement of heart
                            rate, oximetry, and
                            oxygen titration, when
                            performed.
95004....................  Percutaneous tests               0.01       0.01       0.01  No.
                            (scratch, puncture,
                            prick) with allergenic
                            extracts, immediate type
                            reaction, including test
                            interpretation and
                            report, specify number of
                            tests.

[[Page 34020]]

 
95250....................  Ambulatory continuous            0.00       0.00       0.00  No.
                            glucose monitoring of
                            interstitial tissue fluid
                            via a subcutaneous sensor
                            for a minimum of 72
                            hours; sensor placement,
                            hook-up, calibration of
                            monitor, patient
                            training, removal of
                            sensor, and printout of
                            recording.
95251....................  Ambulatory continuous            0.85       0.70       0.70  No.
                            glucose monitoring of
                            interstitial tissue fluid
                            via a subcutaneous sensor
                            for a minimum of 72
                            hours; interpretation and
                            report.
95930....................  Visual evoked potential          0.35       0.35       0.35  No.
                            (VEP) testing central
                            nervous system except
                            glaucoma, checkerboard or
                            flash, with
                            interpretation and report.
96160....................  Administration of patient-       0.00       0.00       0.00  No.
                            focused health risk
                            assessment instrument
                            (e.g., health hazard
                            appraisal) with scoring
                            and documentation, per
                            standardized instrument.
96161....................  Administration of                0.00       0.00       0.00  No.
                            caregiver-focused health
                            risk assessment
                            instrument (e.g.,
                            depression inventory) for
                            the benefit of the
                            patient, with scoring and
                            documentation, per
                            standardized instrument.
96360....................  Intravenous infusion,            0.17       0.17       0.17  No.
                            hydration; initial, 31
                            minutes to 1 hour.
96361....................  Intravenous infusion,            0.09       0.09       0.09  No.
                            hydration; each
                            additional hour.
96372....................  Therapeutic, prophylactic,       0.17       0.17       0.17  No.
                            or diagnostic injection
                            (specify substance or
                            drug); subcutaneous or
                            intramuscular.
96374....................  Therapeutic, prophylactic,       0.18       0.18       0.18  No.
                            or diagnostic injection
                            (specify substance or
                            drug); intravenous push,
                            single or initial
                            substance/drug.
96375....................  Therapeutic, prophylactic,       0.10       0.10       0.10  No.
                            or diagnostic injection
                            (specify substance or
                            drug); each additional
                            sequential intravenous
                            push of a new substance/
                            drug.
96377....................  Application of on-body           0.00       0.17       0.17  No.
                            injector (includes
                            cannula insertion) for
                            timed subcutaneous
                            injection.
96401....................  Chemotherapy                     0.21       0.21       0.21  No.
                            administration,
                            subcutaneous or
                            intramuscular; non-
                            hormonal anti-neoplastic.
96402....................  Chemotherapy                     0.19       0.19       0.19  No.
                            administration,
                            subcutaneous or
                            intramuscular; hormonal
                            anti-neoplastic.
96409....................  Chemotherapy                     0.24       0.24       0.24  No.
                            administration;
                            intravenous, push
                            technique, single or
                            initial substance/drug.
96411....................  Chemotherapy                     0.20       0.20       0.20  No.
                            administration;
                            intravenous, push
                            technique, each
                            additional substance/drug.
96910....................  Photochemotherapy; tar and       0.00       0.00       0.00  No.
                            ultraviolet B (Goeckerman
                            treatment) or petrolatum
                            and ultraviolet B.
96X73....................  Photodynamic therapy by           NEW       0.48       0.48  No.
                            external application of
                            light to destroy
                            premalignant lesions of
                            the skin and adjacent
                            mucosa with application
                            and illumination/
                            activation of
                            photosensitizing drug(s),
                            per day.
96X74....................  Debridement of                    NEW       1.01       1.01  No.
                            premalignant
                            hyperkeratotic lesion(s)
                            (i.e., targeted
                            curettage, abrasion)
                            followed with
                            photodynamic therapy by
                            external application of
                            light to destroy
                            premalignant lesions of
                            the skin and adjacent
                            mucosa with application
                            and illumination/
                            activation of
                            photosensitizing drug(s),
                            per day.
97012....................  Application of a modality        0.25       0.25       0.25  No.
                            to 1 or more areas;
                            traction, mechanical.
97014....................  Application of a modality        0.18       0.18       0.18  No.
                            to 1 or more areas;
                            electrical stimulation
                            (unattended).
97016....................  Application of a modality        0.18       0.18       0.18  No.
                            to 1 or more areas;
                            vasopneumatic devices.
97018....................  Application of a modality        0.06       0.06       0.06  No.
                            to 1 or more areas;
                            paraffin bath.
97022....................  Application of a modality        0.17       0.17       0.17  No.
                            to 1 or more areas;
                            whirlpool.
97032....................  Application of a modality        0.25       0.25       0.25  No.
                            to 1 or more areas;
                            electrical stimulation
                            (manual), each 15 minutes.
97033....................  Application of a modality        0.26       0.26       0.26  No.
                            to 1 or more areas;
                            iontophoresis, each 15
                            minutes.
97034....................  Application of a modality        0.21       0.21       0.21  No.
                            to 1 or more areas;
                            contrast baths, each 15
                            minutes.
97035....................  Application of a modality        0.21       0.21       0.21  No.
                            to 1 or more areas;
                            ultrasound, each 15
                            minutes.
97110....................  Therapeutic procedure, 1         0.45       0.45       0.45  No.
                            or more areas, each 15
                            minutes; therapeutic
                            exercises to develop
                            strength and endurance,
                            range of motion and
                            flexibility.
97112....................  Therapeutic procedure, 1         0.45       0.50       0.50  No.
                            or more areas, each 15
                            minutes; neuromuscular
                            reeducation of movement,
                            balance, coordination,
                            kinesthetic sense,
                            posture, and/or
                            proprioception for
                            sitting and/or standing
                            activities.
97113....................  Therapeutic procedure, 1         0.44       0.48       0.48  No.
                            or more areas, each 15
                            minutes; aquatic therapy
                            with therapeutic
                            exercises.
97116....................  Therapeutic procedure, 1         0.40       0.45       0.45  No.
                            or more areas, each 15
                            minutes; gait training
                            (includes stair climbing).
97140....................  Manual therapy techniques        0.43       0.43       0.43  No.
                            (e.g., mobilization/
                            manipulation, manual
                            lymphatic drainage,
                            manual traction), 1 or
                            more regions, each 15
                            minutes.
97530....................  Therapeutic activities,          0.44       0.44       0.44  No.
                            direct (one-on-one)
                            patient contact (use of
                            dynamic activities to
                            improve functional
                            performance), each 15
                            minutes.
97533....................  Sensory integrative              0.44       0.48       0.48  No.
                            techniques to enhance
                            sensory processing and
                            promote adaptive
                            responses to
                            environmental demands,
                            direct (one-on-one)
                            patient contact, each 15
                            minutes.
97535....................  Self-care/home management        0.45       0.45       0.45  No.
                            training (e.g.,
                            activities of daily
                            living (ADL) and
                            compensatory training,
                            meal preparation, safety
                            procedures, and
                            instructions in use of
                            assistive technology
                            devices/adaptive
                            equipment) direct one-on-
                            one contact, each 15
                            minutes.
97537....................  Community/work                   0.45       0.48       0.48  No.
                            reintegration training
                            (e.g., shopping,
                            transportation, money
                            management, avocational
                            activities and/or work
                            environment/modification
                            analysis, work task
                            analysis, use of
                            assistive technology
                            device/adaptive
                            equipment), direct one-on-
                            one contact, each 15
                            minutes.
97542....................  Wheelchair management            0.45       0.48       0.48  No.
                            (e.g., assessment,
                            fitting, training), each
                            15 minutes.
97760....................  Orthotic(s) management and       0.45       0.50       0.50  No.
                            training (including
                            assessment and fitting
                            when not otherwise
                            reported), upper
                            extremity(ies), lower
                            extremity(ies) and/or
                            trunk, initial
                            orthotic(s) encounter,
                            each 15 minutes.
97761....................  Prosthetic(s) training,          0.45       0.50       0.50  No.
                            upper and/or lower
                            extremity(ies), initial
                            prosthetic(s) encounter,
                            each 15 minutes.
977X1....................  Orthotic(s)/prosthetic(s)         NEW       0.48       0.48  No.
                            management and/or
                            training, upper
                            extremity(ies), lower
                            extremity(ies), and/or
                            trunk, subsequent
                            orthotic(s)/prosthetic(s)
                            encounter, each 15
                            minutes.
97X11....................  Therapeutic interventions         NEW       1.50          I  Yes.
                            that focus on cognitive
                            function (e.g.,
                            attention, memory,
                            reasoning, executive
                            function, problem
                            solving, and/or pragmatic
                            functioning) and
                            compensatory strategies
                            to manage the performance
                            of an activity (e.g.,
                            managing time or
                            schedules, initiating,
                            organizing and sequencing
                            tasks, direct (one-on-
                            one) patient contact (do
                            not report 97X11 in
                            conjunction with 0364T,
                            0365T, 0368T, 0369T)
                            (report 97X11 only once
                            per day).
993X1....................  Patient/caregiver training        NEW       0.00       0.00  No.
                            for initiation of home
                            INR monitoring under the
                            direction of a physician
                            or other qualified health
                            care professional,
                            including face-to-face,
                            use and care of the INR
                            monitor, obtaining blood
                            sample, instructions for
                            reporting home INR test
                            results, and
                            documentation of
                            patient's/caregiver's
                            ability to perform
                            testing and report
                            results.

[[Page 34021]]

 
993X2....................  Anticoagulant management          NEW       0.18       0.18  No.
                            for a patient taking
                            warfarin, must include
                            review and interpretation
                            of a new home, office, or
                            lab International
                            No.rmalized Ratio (INR)
                            test result, patient
                            instructions, dosage
                            adjustment (as needed),
                            and scheduling of
                            additional test(s) when
                            performed.
994X1....................  Initial psychiatric               NEW       1.70       1.70  No.
                            collaborative care
                            management, first 70
                            minutes in the first
                            calendar month of
                            behavioral health care
                            manager activities, in
                            consultation with a
                            psychiatric consultant,
                            and directed by the
                            treating physician or
                            other qualified health
                            care professional, with
                            the following required
                            elements: Outreach to and
                            engagement in treatment
                            of a patient directed by
                            the treating physician or
                            other qualified health
                            care professional;
                            initial assessment of the
                            patient, including
                            administration of
                            validated rating scales,
                            with the development of
                            an individualized
                            treatment plan; review by
                            the psychiatric
                            consultant with
                            modifications of the plan
                            if recommended; entering
                            patient in a registry and
                            tracking patient follow-
                            up and progress using the
                            registry, with
                            appropriate
                            documentation, and
                            participation in weekly
                            caseload consultation
                            with the psychiatric
                            consultant; and provision
                            of brief interventions
                            using evidence-based
                            techniques such as
                            behavioral activation,
                            motivational
                            interviewing, and other
                            focused treatment
                            strategies.
994X2....................  Subsequent psychiatric            NEW       1.53       1.53  No.
                            collaborative care
                            management, first 60
                            minutes in a subsequent
                            month of behavioral
                            health care manager
                            activities, in
                            consultation with a
                            psychiatric consultant,
                            and directed by the
                            treating physician or
                            other qualified health
                            care professional, with
                            the following required
                            elements: Tracking
                            patient follow-up and
                            progress using the
                            registry, with
                            appropriate
                            documentation;
                            participation in weekly
                            caseload consultation
                            with the psychiatric
                            consultant; ongoing
                            collaboration with and
                            coordination of the
                            patient's mental health
                            care with the treating
                            physician or other
                            qualified health care
                            professional and any
                            other treating mental
                            health providers;
                            additional review of
                            progress and
                            recommendations for
                            changes in treatment, as
                            indicated, including
                            medications, based on
                            recommendations provided
                            by the psychiatric
                            consultant; provision of
                            brief interventions using
                            evidence-based techniques
                            such as behavioral
                            activation, motivational
                            interviewing, and other
                            focused treatment
                            strategies; monitoring of
                            patient outcomes using
                            validated rating scales;
                            and relapse prevention
                            planning with patients as
                            they achieve remission of
                            symptoms and/or other
                            treatment goals and are
                            prepared for discharge
                            from active treatment.
994X3....................  Initial or subsequent             NEW       0.82       0.82  No.
                            psychiatric collaborative
                            care management, each
                            additional 30 minutes in
                            a calendar month of
                            behavioral health care
                            manager activities, in
                            consultation with a
                            psychiatric consultant,
                            and directed by the
                            treating physician or
                            other qualified health
                            care professional.
99XX3....................  Assessment of and care            NEW       3.44       3.44  No.
                            planning for a patient
                            with cognitive
                            impairment, requiring an
                            independent historian, in
                            the office or other
                            outpatient, home or
                            domiciliary or rest home,
                            with all of the following
                            required elements:
                            Cognition-focused
                            evaluation including a
                            pertinent history and
                            examination; Medical
                            decision making of
                            moderate or high
                            complexity; Functional
                            assessment (e.g., Basic
                            and Instrumental
                            Activities of Daily
                            Living), including
                            decision-making capacity;
                            Use of standardized
                            instruments for staging
                            of dementia (e.g.,
                            Functional Assessment
                            Staging Test [FAST],
                            Clinical Dementia Rating
                            [CDR]); Medication
                            reconciliation and review
                            for high-risk
                            medications; Evaluation
                            for neuropsychiatric and
                            behavioral symptoms,
                            including depression,
                            including use of
                            standardized screening
                            instrument(s); Evaluation
                            of safety (e.g., home),
                            including motor vehicle
                            operation; Identification
                            of caregiver(s),
                            caregiver knowledge,
                            caregiver needs, social
                            supports, and the
                            willingness of caregiver
                            to take on caregiving
                            tasks; Development,
                            updating or revision, or
                            review of an Advance Care
                            Plan; Creation of a
                            written care plan,
                            including initial plans
                            to address any
                            neuropsychiatric
                            symptoms, neuro-cognitive
                            symptoms, functional
                            limitations, and referral
                            to community resources as
                            needed (e.g.,
                            rehabilitation services,
                            adult day programs,
                            support groups) shared
                            with the patient and/or
                            caregiver with initial
                            education and support.
                            Typically, 50 minutes are
                            spent face-to-face with
                            the patient and/or family
                            or caregiver.
99XX5....................  Care management services          NEW       0.61       0.61  No.
                            for behavioral health
                            conditions, 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: Initial
                            assessment or follow-up
                            monitoring, including the
                            use of applicable
                            validated rating scales;
                            Behavioral health care
                            planning in relation to
                            behavioral/psychiatric
                            health problems,
                            including revision for
                            patients who are not
                            progressing or whose
                            status changes;
                            Facilitating and
                            coordinating treatment
                            such as psychotherapy,
                            pharmacotherapy,
                            counseling and/or
                            psychiatric consultation;
                            and Continuity of care
                            with a designated member
                            of the care team.
G0283....................  Electrical stimulation           0.18       0.18       0.18  No.
                            (unattended), to one or
                            more areas for
                            indication(s) other than
                            wound care, as part of a
                            therapy plan of care.
GDDD1....................  Insertion, non-                   NEW  .........       1.82  No.
                            biodegradable drug
                            delivery implants, 4 or
                            more.
GDDD2....................  Removal, non-biodegradable        NEW  .........       2.10  No.
                            drug deliver implants, 4
                            or more.
GDDD3....................  Removal with reinsertion,         NEW  .........       3.55  No.
                            non-biodegradable drug
                            delivery implants, 4 or
                            more.
GRRR1....................  Superficial radiation             NEW  .........       7.93  No.
                            treatment planning and
                            management related
                            services, including but
                            not limited to, when
                            performed, clinical
                            treatment planning (e.g.,
                            77261, 77262, 77263),
                            therapeutic radiology
                            simulation-aided field
                            setting (e.g., 77280,
                            77285, 77290, 77293),
                            basic radiation dosimetry
                            calculation (e.g.,
                            77300), treatment devices
                            (e.g., 77332, 77333,
                            77334), isodose planning
                            (e.g., 77306, 77307,
                            77316, 77317, 77318),
                            radiation treatment
                            management (e.g., 77427,
                            77431, 77432, 77435,
                            77469, 77470, 77499), and
                            associated evaluation and
                            management per course of
                            treatment.
GXXX1....................  Therapeutic interventions         NEW  .........       0.44  No.
                            that focus on cognitive
                            function (e.g.,
                            attention, memory,
                            reasoning, executive
                            function, problem
                            solving, and/or pragmatic
                            functioning) and
                            compensatory strategies
                            to manage the performance
                            of an activity (e.g.,
                            managing time or
                            schedules, initiating,
                            organizing and sequencing
                            tasks, direct (one-on-
                            one) patient contact.
GYYY1....................  Prolonged preventive              NEW  .........       1.17  No.
                            service(s), initial 30
                            minutes.
GYYY2....................  Prolonged preventive              NEW  .........       1.17  No.
                            service(s), first 30
                            minutes.
----------------------------------------------------------------------------------------------------------------


[[Page 34022]]


                                                     Table 11--CY 2018 Proposed Codes With Direct PE Input Recommendations With Refinements
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                      RUC             CMS                               Direct
                          HCPCS code                                 Input code       Nonfacility (NF)/     Labor activity     recommendation or   refinement                           costs
    HCPCS code           description           Input code           description          Facility (F)     (where applicable)     current value      (min or           Comment         change (in
                                                                                                                                  (min or qty)        qty)                             dollars)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
157X1.............  Mdfc flap w/prsrv      ED050               Technologist PACS      NF                 ....................                115          117  E15: Refined                $0.04
                     vasc pedcl.                                workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
157X1.............  Mdfc flap w/prsrv      EF014               light, surgical......  NF                 ....................                115          117  E15: Refined                 0.02
                     vasc pedcl.                                                                                                                                equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
157X1.............  Mdfc flap w/prsrv      EF031               table, power.........  NF                 ....................                115          117  E15: Refined                 0.03
                     vasc pedcl.                                                                                                                                equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
157X1.............  Mdfc flap w/prsrv      EQ011               ECG, 3-channel (with   NF                 ....................                115          117  E15: Refined                 0.03
                     vasc pedcl.                                SpO2, NIBP, temp,                                                                               equipment time to
                                                                resp).                                                                                          conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
157X1.............  Mdfc flap w/prsrv      EQ110               electrocautery-        NF                 ....................                115          117  E15: Refined                 0.01
                     vasc pedcl.                                hyfrecator, up to 45                                                                            equipment time to
                                                                watts.                                                                                          conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
157X1.............  Mdfc flap w/prsrv      EQ138               instrument pack,       NF                 ....................                127          129  E15: Refined                 0.01
                     vasc pedcl.                                medium ($1500 and                                                                               equipment time to
                                                                up).                                                                                            conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
157X1.............  Mdfc flap w/prsrv      L038A               COMT/COT/RN/CST......  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.76
                     vasc pedcl.                                                                                                                                standard for this
                                                                                                                                                                clinical labor task.
29445.............  Apply rigid leg cast.  EF031               table, power.........  NF                 ....................                 69           67  E15: Refined                -0.03
                                                                                                                                                                equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
29445.............  Apply rigid leg cast.  EQ080               cast cart............  NF                 ....................                 69           67  E15: Refined                -0.02
                                                                                                                                                                equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
29445.............  Apply rigid leg cast.  EQ168               light, exam..........  NF                 ....................                 69           67  E15: Refined                -0.01
                                                                                                                                                                equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
29445.............  Apply rigid leg cast.  L037D               RN/LPN/MTA...........  NF                 Check dressings &                     5            3  L1: Refined time to         -0.74
                                                                                                          wound/home care                                       standard for this
                                                                                                          instructions/                                         clinical labor task.
                                                                                                          coordinate office
                                                                                                          visits/
                                                                                                          prescriptions.

[[Page 34023]]

 
29580.............  Application of paste   EF023               table, exam..........  NF                 ....................                 35           34  E15: Refined                 0.00
                     boot.                                                                                                                                      equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
29580.............  Application of paste   EQ168               light, exam..........  NF                 ....................                 35           34  E15: Refined                 0.00
                     boot.                                                                                                                                      equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
29580.............  Application of paste   L037D               RN/LPN/MTA...........  NF                 Provide pre-service                   3            2  L1: Refined time to         -0.37
                     boot.                                                                                education/obtain                                      standard for this
                                                                                                          consent.                                              clinical labor task.
29581.............  Apply multlay comprs   EF023               table, exam..........  NF                 ....................                 37           36  E15: Refined                 0.00
                     lwr leg.                                                                                                                                   equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
29581.............  Apply multlay comprs   EQ168               light, exam..........  NF                 ....................                 37           36  E15: Refined                 0.00
                     lwr leg.                                                                                                                                   equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
29581.............  Apply multlay comprs   L037D               RN/LPN/MTA...........  NF                 Provide pre-service                   3            2  L1: Refined time to         -0.37
                     lwr leg.                                                                             education/obtain                                      standard for this
                                                                                                          consent.                                              clinical labor task.
30140.............  Resect inferior        EF008               chair with headrest,   NF                 ....................                 98          100  E15: Refined                 0.02
                     turbinate.                                 exam, reclining.                                                                                equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
30140.............  Resect inferior        EQ137               instrument pack,       NF                 ....................                102          104  E15: Refined                 0.00
                     turbinate.                                 basic ($500-$1499).                                                                             equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
30140.............  Resect inferior        EQ170               light, fiberoptic      NF                 ....................                 98          100  E15: Refined                 0.02
                     turbinate.                                 headlight w-source.                                                                             equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
30140.............  Resect inferior        EQ234               suction and pressure   NF                 ....................                 98          100  E15: Refined                 0.02
                     turbinate.                                 cabinet, ENT (SMR).                                                                             equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
30140.............  Resect inferior        EQ383               reusable shaver        NF                 ....................                102          104  E15: Refined                 0.01
                     turbinate.                                 blade, 2mm.                                                                                     equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.

[[Page 34024]]

 
30140.............  Resect inferior        EQ384               Microdebrider          NF                 ....................                 98          100  E15: Refined                 0.03
                     turbinate.                                 handpiece.                                                                                      equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
30140.............  Resect inferior        EQ385               Microdebrider console  NF                 ....................                 98          100  E15: Refined                 0.06
                     turbinate.                                                                                                                                 equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
30140.............  Resect inferior        L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     turbinate.                                                                                                                                 standard for this
                                                                                                                                                                clinical labor task.
30901.............  Control of nosebleed.  EF008               chair with headrest,   NF                 ....................                 22           26  E1: Refined                  0.04
                                                                exam, reclining.                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30901.............  Control of nosebleed.  EQ137               instrument pack,       NF                 ....................                 29           33  E5: Refined                  0.01
                                                                basic ($500-$1499).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                surgical instrument
                                                                                                                                                                packs.
30901.............  Control of nosebleed.  EQ170               light, fiberoptic      NF                 ....................                 22           26  E1: Refined                  0.03
                                                                headlight w-source.                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30901.............  Control of nosebleed.  EQ234               suction and pressure   NF                 ....................                 22           26  E1: Refined                  0.04
                                                                cabinet, ENT (SMR).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30903.............  Control of nosebleed.  EF008               chair with headrest,   NF                 ....................                 27           31  E1: Refined                  0.04
                                                                exam, reclining.                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30903.............  Control of nosebleed.  EQ110               electrocautery-        NF                 ....................                 27           31  E1: Refined                  0.01
                                                                hyfrecator, up to 45                                                                            equipment time to
                                                                watts.                                                                                          conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30903.............  Control of nosebleed.  EQ137               instrument pack,       NF                 ....................                 34           38  E5: Refined                  0.01
                                                                basic ($500-$1499).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                surgical instrument
                                                                                                                                                                packs.

[[Page 34025]]

 
30903.............  Control of nosebleed.  EQ170               light, fiberoptic      NF                 ....................                 27           31  E1: Refined                  0.03
                                                                headlight w-source.                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30903.............  Control of nosebleed.  EQ234               suction and pressure   NF                 ....................                 27           31  E1: Refined                  0.04
                                                                cabinet, ENT (SMR).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30905.............  Control of nosebleed.  EF008               chair with headrest,   NF                 ....................                 32           62  E1: Refined                  0.32
                                                                exam, reclining.                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30905.............  Control of nosebleed.  EQ110               electrocautery-        NF                 ....................                 32           62  E1: Refined                  0.08
                                                                hyfrecator, up to 45                                                                            equipment time to
                                                                watts.                                                                                          conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30905.............  Control of nosebleed.  EQ137               instrument pack,       NF                 ....................                 39           69  E5: Refined                  0.07
                                                                basic ($500-1499).                                                                              equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                surgical instrument
                                                                                                                                                                packs.
30905.............  Control of nosebleed.  EQ170               light, fiberoptic      NF                 ....................                 32           62  E1: Refined                  0.24
                                                                headlight w-source.                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30905.............  Control of nosebleed.  EQ234               suction and pressure   NF                 ....................                 32           62  E1: Refined                  0.28
                                                                cabinet, ENT (SMR).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30906.............  Repeat control of      EF008               chair with headrest,   NF                 ....................                 42           72  E1: Refined                  0.32
                     nosebleed.                                 exam, reclining.                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30906.............  Repeat control of      EQ110               electrocautery-        NF                 ....................                 42           72  E1: Refined                  0.08
                     nosebleed.                                 hyfrecator, up to 45                                                                            equipment time to
                                                                watts.                                                                                          conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.

[[Page 34026]]

 
30906.............  Repeat control of      EQ137               instrument pack,       NF                 ....................                 49           79  E5: Refined                  0.07
                     nosebleed.                                 basic ($500-$1499).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                surgical instrument
                                                                                                                                                                packs.
30906.............  Repeat control of      EQ170               light, fiberoptic      NF                 ....................                 42           72  E1: Refined                  0.24
                     nosebleed.                                 headlight w-source.                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
30906.............  Repeat control of      EQ234               suction and pressure   NF                 ....................                 42           72  E1: Refined                  0.28
                     nosebleed.                                 cabinet, ENT (SMR).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31254.............  Nsl/sins ndsc w/prtl   EF008               chair with headrest,   NF                 ....................                 47           52  E1: Refined                  0.05
                     ethmdct.                                   exam, reclining.                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31254.............  Nsl/sins ndsc w/prtl   EF015               mayo stand...........  NF                 ....................                 47           52  E1: Refined                  0.01
                     ethmdct.                                                                                                                                   equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31254.............  Nsl/sins ndsc w/prtl   EQ138               instrument pack,       NF                 ....................                 59           64  E5: Refined                  0.03
                     ethmdct.                                   medium ($1500 and                                                                               equipment time to
                                                                up).                                                                                            conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                surgical instrument
                                                                                                                                                                packs.
31254.............  Nsl/sins ndsc w/prtl   EQ167               light source, xenon..  NF                 ....................                 47           52  E1: Refined                  0.14
                     ethmdct.                                                                                                                                   equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31254.............  Nsl/sins ndsc w/prtl   EQ170               light, fiberoptic      NF                 ....................                 47           52  E1: Refined                  0.04
                     ethmdct.                                   headlight w-source.                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31254.............  Nsl/sins ndsc w/prtl   EQ234               suction and pressure   NF                 ....................                 47           52  E1: Refined                  0.05
                     ethmdct.                                   cabinet, ENT (SMR).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.

[[Page 34027]]

 
31254.............  Nsl/sins ndsc w/prtl   EQ383               reusable shaver        NF                 ....................                 47           52  E1: Refined                  0.02
                     ethmdct.                                   blade, 2mm.                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31254.............  Nsl/sins ndsc w/prtl   EQ384               Microdebrider          NF                 ....................                 47           52  E1: Refined                  0.06
                     ethmdct.                                   handpiece.                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31254.............  Nsl/sins ndsc w/prtl   EQ385               Microdebrider console  NF                 ....................                 47           52  E1: Refined                  0.15
                     ethmdct.                                                                                                                                   equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31254.............  Nsl/sins ndsc w/prtl   ES005               endoscope              NF                 ....................                 37           51  E4: Refined                  0.85
                     ethmdct.                                   disinfector, rigid                                                                              equipment time to
                                                                or fiberoptic, w-                                                                               conform to
                                                                cart.                                                                                           established
                                                                                                                                                                policies for scopes.
31254.............  Nsl/sins ndsc w/prtl   ES031               video system,          NF                 ....................                 47           44  E19: Refined                -0.39
                     ethmdct.                                   endoscopy                                                                                       equipment time to
                                                                (processor, digital                                                                             conform to
                                                                capture, monitor,                                                                               established
                                                                printer, cart).                                                                                 policies for scope
                                                                                                                                                                accessories.
31254.............  Nsl/sins ndsc w/prtl   ES040               PROXY endoscope,       NF                 ....................                 37           51  E4: Refined                  0.11
                     ethmdct.                                   rigid, sinoscopy (0                                                                             equipment time to
                                                                degrees).                                                                                       conform to
                                                                                                                                                                established
                                                                                                                                                                policies for scopes.
31254.............  Nsl/sins ndsc w/prtl   L037D               RN/LPN/MTA...........  NF                 Complete pre-service                  3            0  L1: Refined time to         -1.11
                     ethmdct.                                                                             diagnostic and                                        standard for this
                                                                                                          referral forms.                                       clinical labor task.
31254.............  Nsl/sins ndsc w/prtl   L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     ethmdct.                                                                                                                                   standard for this
                                                                                                                                                                clinical labor task.
31254.............  Nsl/sins ndsc w/prtl   L037D               RN/LPN/MTA...........  NF                 Provide pre-service                   3            0  L1: Refined time to         -1.11
                     ethmdct.                                                                             education/obtain                                      standard for this
                                                                                                          consent.                                              clinical labor task.
31254.............  Nsl/sins ndsc w/prtl   L037D               RN/LPN/MTA...........  NF                 Complete pre-                         3            0  L1: Refined time to         -1.11
                     ethmdct.                                                                             procedure phone                                       standard for this
                                                                                                          calls and                                             clinical labor task.
                                                                                                          prescription.
31295.............  Sinus endo w/balloon   EF008               chair with headrest,   NF                 ....................                 37           42  E1: Refined                  0.05
                     dil.                                       exam, reclining.                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31295.............  Sinus endo w/balloon   EF015               mayo stand...........  NF                 ....................                 37           42  E1: Refined                  0.01
                     dil.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.

[[Page 34028]]

 
31295.............  Sinus endo w/balloon   EQ138               instrument pack,       NF                 ....................                 49           54  E5: Refined                  0.03
                     dil.                                       medium ($1500 and                                                                               equipment time to
                                                                up).                                                                                            conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                surgical instrument
                                                                                                                                                                packs.
31295.............  Sinus endo w/balloon   EQ167               light source, xenon..  NF                 ....................                 37           42  E1: Refined                  0.14
                     dil.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31295.............  Sinus endo w/balloon   EQ170               light, fiberoptic      NF                 ....................                 37           42  E1: Refined                  0.04
                     dil.                                       headlight w-source.                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31295.............  Sinus endo w/balloon   EQ234               suction and pressure   NF                 ....................                 37           42  E1: Refined                  0.05
                     dil.                                       cabinet, ENT (SMR).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31295.............  Sinus endo w/balloon   EQ383               reusable shaver        NF                 ....................                 37           42  E1: Refined                  0.02
                     dil.                                       blade, 2mm.                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31295.............  Sinus endo w/balloon   EQ384               Microdebrider          NF                 ....................                 37           42  E1: Refined                  0.06
                     dil.                                       handpiece.                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31295.............  Sinus endo w/balloon   EQ385               Microdebrider console  NF                 ....................                 37           42  E1: Refined                  0.15
                     dil.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31295.............  Sinus endo w/balloon   ES005               endoscope              NF                 ....................                 27           41  E4: Refined                  0.85
                     dil.                                       disinfector, rigid                                                                              equipment time to
                                                                or fiberoptic, w-                                                                               conform to
                                                                cart.                                                                                           established
                                                                                                                                                                policies for scopes.
31295.............  Sinus endo w/balloon   ES031               video system,          NF                 ....................                 37           34  E19: Refined                -0.39
                     dil.                                       endoscopy                                                                                       equipment time to
                                                                (processor, digital                                                                             conform to
                                                                capture, monitor,                                                                               established
                                                                printer, cart).                                                                                 policies for scope
                                                                                                                                                                accessories.
31295.............  Sinus endo w/balloon   ES040               PROXY endoscope,       NF                 ....................                 27           41  E4: Refined                  0.11
                     dil.                                       rigid, sinoscopy (0                                                                             equipment time to
                                                                degrees).                                                                                       conform to
                                                                                                                                                                established
                                                                                                                                                                policies for scopes.

[[Page 34029]]

 
31295.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Provide pre-service                   3            0  L1: Refined time to         -1.11
                     dil.                                                                                 education/obtain                                      standard for this
                                                                                                          consent.                                              clinical labor task.
31295.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Complete pre-                         3            0  L1: Refined time to         -1.11
                     dil.                                                                                 procedure phone                                       standard for this
                                                                                                          calls and                                             clinical labor task.
                                                                                                          prescription.
31295.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     dil.                                                                                                                                       standard for this
                                                                                                                                                                clinical labor task.
31295.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Complete pre-service                  3            0  L1: Refined time to         -1.11
                     dil.                                                                                 diagnostic and                                        standard for this
                                                                                                          referral forms.                                       clinical labor task.
31296.............  Sinus endo w/balloon   EF008               chair with headrest,   NF                 ....................                 40           45  E1: Refined                  0.05
                     dil.                                       exam, reclining.                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31296.............  Sinus endo w/balloon   EF015               mayo stand...........  NF                 ....................                 40           45  E1: Refined                  0.01
                     dil.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31296.............  Sinus endo w/balloon   EQ138               instrument pack,       NF                 ....................                 52           57  E5: Refined                  0.03
                     dil.                                       medium ($1500 and                                                                               equipment time to
                                                                up).                                                                                            conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                surgical instrument
                                                                                                                                                                packs.
31296.............  Sinus endo w/balloon   EQ167               light source, xenon..  NF                 ....................                 40           45  E1: Refined                  0.14
                     dil.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31296.............  Sinus endo w/balloon   EQ170               light, fiberoptic      NF                 ....................                 40           45  E1: Refined                  0.04
                     dil.                                       headlight w-source.                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31296.............  Sinus endo w/balloon   EQ234               suction and pressure   NF                 ....................                 40           45  E1: Refined                  0.05
                     dil.                                       cabinet, ENT (SMR).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31296.............  Sinus endo w/balloon   EQ383               reusable shaver        NF                 ....................                 40           45  E1: Refined                  0.02
                     dil.                                       blade, 2mm.                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.

[[Page 34030]]

 
31296.............  Sinus endo w/balloon   EQ384               Microdebrider          NF                 ....................                 40           45  E1: Refined                  0.06
                     dil.                                       handpiece.                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31296.............  Sinus endo w/balloon   EQ385               Microdebrider console  NF                 ....................                 40           45  E1: Refined                  0.15
                     dil.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31296.............  Sinus endo w/balloon   ES005               endoscope              NF                 ....................                 32           44  E4: Refined                  0.73
                     dil.                                       disinfector, rigid                                                                              equipment time to
                                                                or fiberoptic, w-                                                                               conform to
                                                                cart.                                                                                           established
                                                                                                                                                                policies for scopes.
31296.............  Sinus endo w/balloon   ES031               video system,          NF                 ....................                 40           37  E19: Refined                -0.39
                     dil.                                       endoscopy                                                                                       equipment time to
                                                                (processor, digital                                                                             conform to
                                                                capture, monitor,                                                                               established
                                                                printer, cart).                                                                                 policies for scope
                                                                                                                                                                accessories.
31296.............  Sinus endo w/balloon   ES040               PROXY endoscope,       NF                 ....................                 32           44  E4: Refined                  0.09
                     dil.                                       rigid, sinoscopy (0                                                                             equipment time to
                                                                degrees).                                                                                       conform to
                                                                                                                                                                established
                                                                                                                                                                policies for scopes.
31296.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Complete pre-service                  3            0  L1: Refined time to         -1.11
                     dil.                                                                                 diagnostic and                                        standard for this
                                                                                                          referral forms.                                       clinical labor task.
31296.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Provide pre-service                   3            0  L1: Refined time to         -1.11
                     dil.                                                                                 education/obtain                                      standard for this
                                                                                                          consent.                                              clinical labor task.
31296.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     dil.                                                                                                                                       standard for this
                                                                                                                                                                clinical labor task.
31296.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Complete pre-                         3            0  L1: Refined time to         -1.11
                     dil.                                                                                 procedure phone                                       standard for this
                                                                                                          calls and                                             clinical labor task.
                                                                                                          prescription.
31297.............  Sinus endo w/balloon   EF008               chair with headrest,   NF                 ....................                 37           42  E1: Refined                  0.05
                     dil.                                       exam, reclining.                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31297.............  Sinus endo w/balloon   EF015               mayo stand...........  NF                 ....................                 37           42  E1: Refined                  0.01
                     dil.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31297.............  Sinus endo w/balloon   EQ138               instrument pack,       NF                 ....................                 49           54  E5: Refined                  0.03
                     dil.                                       medium ($1500 and                                                                               equipment time to
                                                                up).                                                                                            conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                surgical instrument
                                                                                                                                                                packs.

[[Page 34031]]

 
31297.............  Sinus endo w/balloon   EQ167               light source, xenon..  NF                 ....................                 37           42  E1: Refined                  0.14
                     dil.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31297.............  Sinus endo w/balloon   EQ170               light, fiberoptic      NF                 ....................                 37           42  E1: Refined                  0.04
                     dil.                                       headlight w-source.                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31297.............  Sinus endo w/balloon   EQ234               suction and pressure   NF                 ....................                 37           42  E1: Refined                  0.05
                     dil.                                       cabinet, ENT (SMR).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31297.............  Sinus endo w/balloon   EQ383               reusable shaver        NF                 ....................                 37           42  E1: Refined                  0.02
                     dil.                                       blade, 2mm.                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31297.............  Sinus endo w/balloon   EQ384               Microdebrider          NF                 ....................                 37           42  E1: Refined                  0.06
                     dil.                                       handpiece.                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31297.............  Sinus endo w/balloon   EQ385               Microdebrider console  NF                 ....................                 37           42  E1: Refined                  0.15
                     dil.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31297.............  Sinus endo w/balloon   ES005               endoscope              NF                 ....................                 27           41  E4: Refined                  0.85
                     dil.                                       disinfector, rigid                                                                              equipment time to
                                                                or fiberoptic, w-                                                                               conform to
                                                                cart.                                                                                           established
                                                                                                                                                                policies for scopes.
31297.............  Sinus endo w/balloon   ES031               video system,          NF                 ....................                 37           34  E19: Refined                -0.39
                     dil.                                       endoscopy                                                                                       equipment time to
                                                                (processor, digital                                                                             conform to
                                                                capture, monitor,                                                                               established
                                                                printer, cart).                                                                                 policies for scope
                                                                                                                                                                accessories.
31297.............  Sinus endo w/balloon   ES040               PROXY endoscope,       NF                 ....................                 27           41  E4: Refined                  0.11
                     dil.                                       rigid, sinoscopy (0                                                                             equipment time to
                                                                degrees).                                                                                       conform to
                                                                                                                                                                established
                                                                                                                                                                policies for scopes.
31297.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     dil.                                                                                                                                       standard for this
                                                                                                                                                                clinical labor task.
31297.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Complete pre-                         3            0  L1: Refined time to         -1.11
                     dil.                                                                                 procedure phone                                       standard for this
                                                                                                          calls and                                             clinical labor task.
                                                                                                          prescription.

[[Page 34032]]

 
31297.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Complete pre-service                  3            0  L1: Refined time to         -1.11
                     dil.                                                                                 diagnostic and                                        standard for this
                                                                                                          referral forms.                                       clinical labor task.
31297.............  Sinus endo w/balloon   L037D               RN/LPN/MTA...........  NF                 Provide pre-service                   3            0  L1: Refined time to         -1.11
                     dil.                                                                                 education/obtain                                      standard for this
                                                                                                          consent.                                              clinical labor task.
31645.............  Brnchsc w/ther aspir   EF027               table, instrument,     NF                 ....................                 57            0  G1: See preamble            -0.08
                     1st.                                       mobile.                                                                                         text.
31645.............  Brnchsc w/ther aspir   EF031               table, power.........  NF                 ....................                 57           58  E1: Refined                  0.02
                     1st.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31645.............  Brnchsc w/ther aspir   EQ004               CO2 respiratory        NF                 ....................                 57            0  G1: See preamble            -1.47
                     1st.                                       profile monitor.                                                                                text.
31645.............  Brnchsc w/ther aspir   EQ032               IV infusion pump.....  NF                 ....................                 57            0  G1: See preamble            -0.36
                     1st.                                                                                                                                       text.
31645.............  Brnchsc w/ther aspir   EQ235               suction machine        NF                 ....................                 57           58  E1: Refined                  0.00
                     1st.                                       (Gomco).                                                                                        equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31645.............  Brnchsc w/ther aspir   ES017               fiberscope, flexible,  NF                 ....................                 72           82  E4: Refined                  0.82
                     1st.                                       bronchoscopy.                                                                                   equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for scopes.
31645.............  Brnchsc w/ther aspir   ES031               video system,          NF                 ....................                 42           55  E19: Refined                 1.68
                     1st.                                       endoscopy                                                                                       equipment time to
                                                                (processor, digital                                                                             conform to
                                                                capture, monitor,                                                                               established
                                                                printer, cart).                                                                                 policies for scope
                                                                                                                                                                accessories.
31645.............  Brnchsc w/ther aspir   SD084               gas, oxygen..........  NF                 ....................                175            0  G1: See preamble            -0.53
                     1st.                                                                                                                                       text.
31XX5.............  Nsl/sins ndsc w/sins   EF008               chair with headrest,   NF                 ....................                 59           64  E1: Refined                  0.05
                     dilat.                                     exam, reclining.                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31XX5.............  Nsl/sins ndsc w/sins   EF015               mayo stand...........  NF                 ....................                 59           64  E1: Refined                  0.01
                     dilat.                                                                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31XX5.............  Nsl/sins ndsc w/sins   EQ138               instrument pack,       NF                 ....................                 71           76  E5: Refined                  0.03
                     dilat.                                     medium ($1500 and                                                                               equipment time to
                                                                up).                                                                                            conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                surgical instrument
                                                                                                                                                                packs.
31XX5.............  Nsl/sins ndsc w/sins   EQ167               light source, xenon..  NF                 ....................                 59           64  E1: Refined                  0.14
                     dilat.                                                                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.

[[Page 34033]]

 
31XX5.............  Nsl/sins ndsc w/sins   EQ170               light, fiberoptic      NF                 ....................                 59           64  E1: Refined                  0.04
                     dilat.                                     headlight w-source.                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31XX5.............  Nsl/sins ndsc w/sins   EQ234               suction and pressure   NF                 ....................                 59           64  E1: Refined                  0.05
                     dilat.                                     cabinet, ENT (SMR).                                                                             equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31XX5.............  Nsl/sins ndsc w/sins   EQ383               reusable shaver        NF                 ....................                 59           64  E1: Refined                  0.02
                     dilat.                                     blade, 2mm.                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31XX5.............  Nsl/sins ndsc w/sins   EQ384               Microdebrider          NF                 ....................                 59           64  E1: Refined                  0.06
                     dilat.                                     handpiece.                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31XX5.............  Nsl/sins ndsc w/sins   EQ385               Microdebrider console  NF                 ....................                 59           64  E1: Refined                  0.15
                     dilat.                                                                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
31XX5.............  Nsl/sins ndsc w/sins   ES005               endoscope              NF                 ....................                 57           73  E4: Refined                  0.97
                     dilat.                                     disinfector, rigid                                                                              equipment time to
                                                                or fiberoptic, w-                                                                               conform to
                                                                cart.                                                                                           established
                                                                                                                                                                policies for scopes.
31XX5.............  Nsl/sins ndsc w/sins   ES031               video system,          NF                 ....................                 59           56  E19: Refined                -0.39
                     dilat.                                     endoscopy                                                                                       equipment time to
                                                                (processor, digital                                                                             conform to
                                                                capture, monitor,                                                                               established
                                                                printer, cart).                                                                                 policies for scope
                                                                                                                                                                accessories.
31XX5.............  Nsl/sins ndsc w/sins   ES040               PROXY endoscope,       NF                 ....................                 57           73  E4: Refined                  0.12
                     dilat.                                     rigid, sinoscopy (0                                                                             equipment time to
                                                                degrees).                                                                                       conform to
                                                                                                                                                                established
                                                                                                                                                                policies for scopes.
31XX5.............  Nsl/sins ndsc w/sins   L037D               RN/LPN/MTA...........  NF                 Complete pre-service                  3            0  L1: Refined time to         -1.11
                     dilat.                                                                               diagnostic and                                        standard for this
                                                                                                          referral forms.                                       clinical labor task.
31XX5.............  Nsl/sins ndsc w/sins   L037D               RN/LPN/MTA...........  NF                 Provide pre-service                   3            0  L1: Refined time to         -1.11
                     dilat.                                                                               education/obtain                                      standard for this
                                                                                                          consent.                                              clinical labor task.
31XX5.............  Nsl/sins ndsc w/sins   L037D               RN/LPN/MTA...........  NF                 Complete pre-                         3            0  L1: Refined time to         -1.11
                     dilat.                                                                               procedure phone                                       standard for this
                                                                                                          calls and                                             clinical labor task.
                                                                                                          prescription.
31XX5.............  Nsl/sins ndsc w/sins   L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     dilat.                                                                                                                                     standard for this
                                                                                                                                                                clinical labor task.

[[Page 34034]]

 
32998.............  Ablate pulm tumor      ED050               Technologist PACS      NF                 ....................                133          112  E18: Refined                -0.46
                     perq rf.                                   workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
32998.............  Ablate pulm tumor      EL007               room, CT.............  NF                 ....................                 98           96  E2: Refined                 -9.73
                     perq rf.                                                                                                                                   equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for highly
                                                                                                                                                                technical equipment.
32998.............  Ablate pulm tumor      EQ168               light, exam..........  NF                 ....................                 98          107  E1: Refined                  0.04
                     perq rf.                                                                                                                                   equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
32998.............  Ablate pulm tumor      EQ214               radiofrequency         NF                 ....................                 98           96  E2: Refined                 -0.25
                     perq rf.                                   generator (NEURO).                                                                              equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for highly
                                                                                                                                                                technical equipment.
32X99.............  Ablate pulm tumor      ED050               Technologist PACS      NF                 ....................                138          117  E18: Refined                -0.46
                     perq crybl.                                workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
32X99.............  Ablate pulm tumor      EL007               room, CT.............  NF                 ....................                103          101  E2: Refined                 -9.73
                     perq crybl.                                                                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for highly
                                                                                                                                                                technical equipment.
32X99.............  Ablate pulm tumor      EQ168               light, exam..........  NF                 ....................                103          112  E1: Refined                  0.04
                     perq crybl.                                                                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
32X99.............  Ablate pulm tumor      EQ302               cryosurgery system     NF                 ....................                103          101  E2: Refined                 -0.19
                     perq crybl.                                (for tumor ablation).                                                                           equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for highly
                                                                                                                                                                technical equipment.
36215.............  Place catheter in      ED050               Technologist PACS      NF                 ....................                 61           59  E15: Refined                -0.04
                     artery.                                    workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
36215.............  Place catheter in      EF027               table, instrument,     NF                 ....................                180            0  G1: See preamble            -0.25
                     artery.                                    mobile.                                                                                         text.

[[Page 34035]]

 
36215.............  Place catheter in      L037D               RN/LPN/MTA...........  NF                 Other Clinical                        3            1  G1: See preamble            -0.74
                     artery.                                                                              Activity--specify:                                    text.
                                                                                                          Post-procedure
                                                                                                          doppler evaluation
                                                                                                          (extremity).
36216.............  Place catheter in      ED050               Technologist PACS      NF                 ....................                 76           74  E15: Refined                -0.04
                     artery.                                    workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
36216.............  Place catheter in      EF027               table, instrument,     NF                 ....................                180            0  G1: See preamble            -0.25
                     artery.                                    mobile.                                                                                         text.
36216.............  Place catheter in      L037D               RN/LPN/MTA...........  NF                 Other Clinical                        3            1  G1: See preamble            -0.74
                     artery.                                                                              Activity--specify:                                    text.
                                                                                                          Post-procedure
                                                                                                          doppler evaluation
                                                                                                          (extremity).
36217.............  Place catheter in      ED050               Technologist PACS      NF                 ....................                 91           89  E15: Refined                -0.04
                     artery.                                    workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
36217.............  Place catheter in      EF027               table, instrument,     NF                 ....................                180            0  G1: See preamble            -0.25
                     artery.                                    mobile.                                                                                         text.
36217.............  Place catheter in      L037D               RN/LPN/MTA...........  NF                 Other Clinical                        3            1  G1: See preamble            -0.74
                     artery.                                                                              Activity--specify:                                    text.
                                                                                                          Post-procedure
                                                                                                          doppler evaluation
                                                                                                          (extremity).
36217.............  Place catheter in      L037D               RN/LPN/MTA...........  NF                 Circulator (25%)....                 12           15  G1: See preamble             1.11
                     artery.                                                                                                                                    text.
36470.............  Njx sclrsnt 1          L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     incmptnt vein.                                                                                                                             standard for this
                                                                                                                                                                clinical labor task.
36470.............  Njx sclrsnt 1          L037D               RN/LPN/MTA...........  NF                 Check dressings,                      5            3  L1: Refined time to         -0.74
                     incmptnt vein.                                                                       catheters, wounds.                                    standard for this
                                                                                                                                                                clinical labor task.
36470.............  Njx sclrsnt 1          SG055               gauze, sterile 4in x   NF                 ....................                  6            0  S7: Supply item             -0.95
                     incmptnt vein.                             4in.                                                                                            replaced by another
                                                                                                                                                                item; see preamble
                                                                                                                                                                SG056.
36470.............  Njx sclrsnt 1          SG056               gauze, sterile 4in x   NF                 ....................                  0            1  S8: Supply item              0.80
                     incmptnt vein.                             4in (10 pack uou).                                                                              replaces another
                                                                                                                                                                item; see preamble
                                                                                                                                                                SG055.
36471.............  Njx sclrsnt mlt        L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     incmptnt vn.                                                                                                                               standard for this
                                                                                                                                                                clinical labor task.
36471.............  Njx sclrsnt mlt        L037D               RN/LPN/MTA...........  NF                 Check dressings,                      5            3  L1: Refined time to         -0.74
                     incmptnt vn.                                                                         catheters, wounds.                                    standard for this
                                                                                                                                                                clinical labor task.
36471.............  Njx sclrsnt mlt        SG055               gauze, sterile 4in x   NF                 ....................                  6            0  S7: Supply item             -0.95
                     incmptnt vn.                               4in.                                                                                            replaced by another
                                                                                                                                                                item; see preamble
                                                                                                                                                                SG056.
36471.............  Njx sclrsnt mlt        SG056               gauze, sterile 4in x   NF                 ....................                  0            1  S8: Supply item              0.80
                     incmptnt vn.                               4in (10 pack uou).                                                                              replaces another
                                                                                                                                                                item; see preamble
                                                                                                                                                                SG055.

[[Page 34036]]

 
364X3.............  Endoven ther chem      EF014               light, surgical......  NF                 ....................                 58           53  E1: Refined                 -0.05
                     adhes 1st.                                                                                                                                 equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
364X3.............  Endoven ther chem      EF031               table, power.........  NF                 ....................                 58           53  E1: Refined                 -0.08
                     adhes 1st.                                                                                                                                 equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
364X3.............  Endoven ther chem      EQ250               ultrasound unit,       NF                 ....................                 58           53  E1: Refined                 -0.58
                     adhes 1st.                                 portable.                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
364X3.............  Endoven ther chem      L037D               RN/LPN/MTA...........  NF                 Check dressings,                      5            3  L1: Refined time to         -0.74
                     adhes 1st.                                                                           catheters, wounds.                                    standard for this
                                                                                                                                                                clinical labor task.
364X3.............  Endoven ther chem      L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     adhes 1st.                                                                                                                                 standard for this
                                                                                                                                                                clinical labor task.
364X3.............  Endoven ther chem      L054A               Vascular Technologist  NF                 Prepare room,                         0            2  G1: See preamble             1.08
                     adhes 1st.                                                                           equipment and                                         text.
                                                                                                          supplies.
364X3.............  Endoven ther chem      L054A               Vascular Technologist  NF                 Setup scope                           2            0  G1: See preamble            -1.08
                     adhes 1st.                                                                           (nonfacility                                          text.
                                                                                                          setting only).
364X3.............  Endoven ther chem      SG055               gauze, sterile 4in x   NF                 ....................                  6            0  S7: Supply item             -0.95
                     adhes 1st.                                 4in.                                                                                            replaced by another
                                                                                                                                                                item; see preamble
                                                                                                                                                                SG056.
364X3.............  Endoven ther chem      SG056               gauze, sterile 4in x   NF                 ....................                  0            1  S8: Supply item              0.80
                     adhes 1st.                                 4in (10 pack uou).                                                                              replaces another
                                                                                                                                                                item; see preamble
                                                                                                                                                                SG055.
364X5.............  Njx noncmpnd sclrsnt   EF014               light, surgical......  NF                 ....................                 48           43  E1: Refined                 -0.05
                     1 vein.                                                                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
364X5.............  Njx noncmpnd sclrsnt   EF031               table, power.........  NF                 ....................                 48           43  E1: Refined                 -0.08
                     1 vein.                                                                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
364X5.............  Njx noncmpnd sclrsnt   EQ250               ultrasound unit,       NF                 ....................                 48           43  E1: Refined                 -0.58
                     1 vein.                                    portable.                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
364X5.............  Njx noncmpnd sclrsnt   L037D               RN/LPN/MTA...........  NF                 Check dressings,                      5            3  L1: Refined time to         -0.74
                     1 vein.                                                                              catheters, wounds.                                    standard for this
                                                                                                                                                                clinical labor task.

[[Page 34037]]

 
364X5.............  Njx noncmpnd sclrsnt   L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     1 vein.                                                                                                                                    standard for this
                                                                                                                                                                clinical labor task.
364X5.............  Njx noncmpnd sclrsnt   L054A               Vascular Technologist  NF                 Setup scope                           2            0  G1: See preamble            -1.08
                     1 vein.                                                                              (nonfacility                                          text.
                                                                                                          setting only).
364X5.............  Njx noncmpnd sclrsnt   L054A               Vascular Technologist  NF                 Prepare room,                         0            2  G1: See preamble             1.08
                     1 vein.                                                                              equipment and                                         text.
                                                                                                          supplies.
364X5.............  Njx noncmpnd sclrsnt   SG055               gauze, sterile 4in x   NF                 ....................                  6            0  S7: Supply item             -0.95
                     1 vein.                                    4in.                                                                                            replaced by another
                                                                                                                                                                item; see preamble
                                                                                                                                                                SG056.
364X5.............  Njx noncmpnd sclrsnt   SG056               gauze, sterile 4in x   NF                 ....................                  0            1  S8: Supply item              0.80
                     1 vein.                                    4in (10 pack uou).                                                                              replaces another
                                                                                                                                                                item; see preamble
                                                                                                                                                                SG055.
364X6.............  Njx noncmpnd sclrsnt   EF014               light, surgical......  NF                 ....................                 58           53  E1: Refined                 -0.05
                     mlt vn.                                                                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
364X6.............  Njx noncmpnd sclrsnt   EF031               table, power.........  NF                 ....................                 58           53  E1: Refined                 -0.08
                     mlt vn.                                                                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
364X6.............  Njx noncmpnd sclrsnt   EQ250               ultrasound unit,       NF                 ....................                 58           53  E1: Refined                 -0.58
                     mlt vn.                                    portable.                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
364X6.............  Njx noncmpnd sclrsnt   L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     mlt vn.                                                                                                                                    standard for this
                                                                                                                                                                clinical labor task.
364X6.............  Njx noncmpnd sclrsnt   L037D               RN/LPN/MTA...........  NF                 Check dressings,                      5            3  L1: Refined time to         -0.74
                     mlt vn.                                                                              catheters, wounds.                                    standard for this
                                                                                                                                                                clinical labor task.
364X6.............  Njx noncmpnd sclrsnt   L054A               Vascular Technologist  NF                 Setup scope                           2            0  G1: See preamble            -1.08
                     mlt vn.                                                                              (nonfacility                                          text.
                                                                                                          setting only).
364X6.............  Njx noncmpnd sclrsnt   L054A               Vascular Technologist  NF                 Prepare room,                         0            2  G1: See preamble             1.08
                     mlt vn.                                                                              equipment and                                         text.
                                                                                                          supplies.
364X6.............  Njx noncmpnd sclrsnt   SG055               gauze, sterile 4in x   NF                 ....................                  6            0  S7: Supply item             -0.95
                     mlt vn.                                    4in.                                                                                            replaced by another
                                                                                                                                                                item; see preamble
                                                                                                                                                                SG056.
364X6.............  Njx noncmpnd sclrsnt   SG056               gauze, sterile 4in x   NF                 ....................                  0            1  S8: Supply item              0.80
                     mlt vn.                                    4in (10 pack uou).                                                                              replaces another
                                                                                                                                                                item; see preamble
                                                                                                                                                                SG055.
36555.............  Insert non-tunnel cv   EF023               table, exam..........  NF                 ....................                 68           38  E1: Refined                 -0.09
                     cath.                                                                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.

[[Page 34038]]

 
36555.............  Insert non-tunnel cv   EQ011               ECG, 3-channel (with   NF                 ....................                 68            0  G1: See preamble            -0.95
                     cath.                                      SpO2, NIBP, temp,                                                                               text.
                                                                resp).
36555.............  Insert non-tunnel cv   EQ168               light, exam..........  NF                 ....................                 68           38  E1: Refined                 -0.13
                     cath.                                                                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
36555.............  Insert non-tunnel cv   L037D               RN/LPN/MTA...........  NF                 Monitor pt.                         7.5            0  L11: Removed                -2.78
                     cath.                                                                                following procedure/                                  clinical labor
                                                                                                          check tubes,                                          associated with
                                                                                                          monitors, drains,                                     moderate sedation;
                                                                                                          multitasking 1:4.                                     moderate sedation
                                                                                                                                                                not typical for
                                                                                                                                                                this procedure.
36569.............  Insert picc cath.....  EF023               table, exam..........  NF                 ....................                 30            0  G1: See preamble            -0.09
                                                                                                                                                                text.
36569.............  Insert picc cath.....  EQ168               light, exam..........  NF                 ....................                 30           32  E15: Refined                 0.01
                                                                                                                                                                equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
36569.............  Insert picc cath.....  L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                                                                                                                                                                standard for this
                                                                                                                                                                clinical labor task.
38220.............  Dx bone marrow         EF023               table, exam..........  NF                 ....................                 84           82  E1: Refined                 -0.01
                     aspirations.                                                                                                                               equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
38220.............  Dx bone marrow         L033A               Lab Technician.......  NF                 Other Clinical                       12            9  G1: See preamble            -0.99
                     aspirations.                                                                         Activity--specify:L                                   text.
                                                                                                          ab Tech activities.
38221.............  Dx bone marrow         EF023               table, exam..........  NF                 ....................                 83           82  E1: Refined                  0.00
                     biopsies.                                                                                                                                  equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
38221.............  Dx bone marrow         L033A               Lab Technician.......  NF                 Other Clinical                      7.5            7  G1: See preamble            -0.17
                     biopsies.                                                                            Activity--specify:L                                   text.
                                                                                                          ab Tech activities.
382X3.............  Dx bone marrow bx &    EF023               table, exam..........  NF                 ....................                 95           92  E1: Refined                 -0.01
                     aspir.                                                                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
382X3.............  Dx bone marrow bx &    L033A               Lab Technician.......  NF                 Other Clinical                     12.5           10  G1: See preamble            -0.83
                     aspir.                                                                               Activity--specify:L                                   text.
                                                                                                          ab Tech activities.
55X87.............  Tprnl plmt             EF031               table, power.........  NF                 ....................                 63           65  E15: Refined                 0.03
                     biodegrdabl matrl.                                                                                                                         equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.

[[Page 34039]]

 
55X87.............  Tprnl plmt             EQ250               ultrasound unit,       NF                 ....................                 48           50  E15: Refined                 0.23
                     biodegrdabl matrl.                         portable.                                                                                       equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
55X87.............  Tprnl plmt             EQ386               Endocavitary US probe  NF                 ....................                 48           50  E15: Refined                 0.13
                     biodegrdabl matrl.                                                                                                                         equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
55X87.............  Tprnl plmt             ER061               stepper, stabilizer,   NF                 ....................                 48           50  E15: Refined                 0.12
                     biodegrdabl matrl.                         template (for                                                                                   equipment time to
                                                                brachytherapy                                                                                   conform to changes
                                                                treatment).                                                                                     in clinical labor
                                                                                                                                                                time.
55X87.............  Tprnl plmt             ER062               stirrups (for          NF                 ....................                 48           50  E15: Refined                 0.02
                     biodegrdabl matrl.                         brachytherapy table).                                                                           equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
55X87.............  Tprnl plmt             L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     biodegrdabl matrl.                                                                                                                         standard for this
                                                                                                                                                                clinical labor task.
5857X.............  Laps tot hyst resj     EQ168               light, exam..........  F                  ....................                142          125  E7: Refined                 -0.07
                     mal.                                                                                                                                       equipment time to
                                                                                                                                                                conform to office
                                                                                                                                                                visit duration.
5857X.............  Laps tot hyst resj     SA051               pack, pelvic exam....  F                  ....................                  4            3  G1: See preamble            -1.17
                     mal.                                                                                                                                       text.
67820.............  Revise eyelashes.....  EL006               lane, screening (oph)  NF                 ....................                 11            5  G1: See preamble            -0.54
                                                                                                                                                                text.
67820.............  Revise eyelashes.....  L038A               COMT/COT/RN/CST......  F                  Coordinate pre-                       3            0  L1: Refined time to         -1.14
                                                                                                          surgery services.                                     standard for this
                                                                                                                                                                clinical labor task.
67820.............  Revise eyelashes.....  L038A               COMT/COT/RN/CST......  F                  Provide pre-service                   3            0  L1: Refined time to         -1.14
                                                                                                          education/obtain                                      standard for this
                                                                                                          consent.                                              clinical labor task.
67820.............  Revise eyelashes.....  L038A               COMT/COT/RN/CST......  F                  Schedule space and                    3            0  L1: Refined time to         -1.14
                                                                                                          equipment in                                          standard for this
                                                                                                          facility.                                             clinical labor task.
67820.............  Revise eyelashes.....  L038A               COMT/COT/RN/CST......  F                  Complete pre-service                  3            0  L1: Refined time to         -1.14
                                                                                                          diagnostic and                                        standard for this
                                                                                                          referral forms.                                       clinical labor task.
67820.............  Revise eyelashes.....  L038A               COMT/COT/RN/CST......  F                  Follow-up phone                       3            0  L1: Refined time to         -1.14
                                                                                                          calls and                                             standard for this
                                                                                                          prescriptions.                                        clinical labor task.
70544.............  Mr angiography head w/ ED050               Technologist PACS      NF                 ....................                 72           69  E15: Refined                -0.07
                     o dye.                                     workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
70544.............  Mr angiography head w/ ED053               Professional PACS      NF                 ....................                 17           15  E18: Refined                -0.12
                     o dye.                                     Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.

[[Page 34040]]

 
70544.............  Mr angiography head w/ EL008               room, MR.............  NF                 ....................                 39           38  E15: Refined                -3.38
                     o dye.                                                                                                                                     equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
70544.............  Mr angiography head w/ L047A               MRI Technologist.....  NF                 Technologist QCs                      4            3  L1: Refined time to         -0.47
                     o dye.                                                                               images in PACS,                                       standard for this
                                                                                                          checking all                                          clinical labor task.
                                                                                                          images, reformats,
                                                                                                          and dose page.
70544.............  Mr angiography head w/ L047A               MRI Technologist.....  NF                 Provide pre-service                   7            5  G1: See preamble            -0.94
                     o dye.                                                                               education/obtain                                      text.
                                                                                                          consent.
70545.............  Mr angiography head w/ ED050               Technologist PACS      NF                 ....................                 75           74  E15: Refined                -0.02
                     dye.                                       workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
70545.............  Mr angiography head w/ ED053               Professional PACS      NF                 ....................                 17           15  E18: Refined                -0.12
                     dye.                                       Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
70545.............  Mr angiography head w/ EL008               room, MR.............  NF                 ....................                 37           36  E15: Refined                -3.38
                     dye.                                                                                                                                       equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
70545.............  Mr angiography head w/ L047A               MRI Technologist.....  NF                 Technologist QCs                      4            3  L1: Refined time to         -0.47
                     dye.                                                                                 images in PACS,                                       standard for this
                                                                                                          checking all                                          clinical labor task.
                                                                                                          images, reformats,
                                                                                                          and dose page.
70545.............  Mr angiography head w/ L047A               MRI Technologist.....  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.94
                     dye.                                                                                                                                       standard for this
                                                                                                                                                                clinical labor task.
70545.............  Mr angiography head w/ L047A               MRI Technologist.....  NF                 Provide pre-service                   9            7  G1: See preamble            -0.94
                     dye.                                                                                 education/obtain                                      text.
                                                                                                          consent.
70546.............  Mr angiograph head w/  ED050               Technologist PACS      NF                 ....................                116          115  E15: Refined                -0.02
                     o&w/dye.                                   workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
70546.............  Mr angiograph head w/  ED053               Professional PACS      NF                 ....................                 20           18  E18: Refined                -0.12
                     o&w/dye.                                   Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
70546.............  Mr angiograph head w/  EL008               room, MR.............  NF                 ....................                 58           57  E15: Refined                -3.38
                     o&w/dye.                                                                                                                                   equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.

[[Page 34041]]

 
70546.............  Mr angiograph head w/  L047A               MRI Technologist.....  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.94
                     o&w/dye.                                                                                                                                   standard for this
                                                                                                                                                                clinical labor task.
70546.............  Mr angiograph head w/  L047A               MRI Technologist.....  NF                 Technologist QCs                      4            3  L1: Refined time to         -0.47
                     o&w/dye.                                                                             images in PACS,                                       standard for this
                                                                                                          checking all                                          clinical labor task.
                                                                                                          images, reformats,
                                                                                                          and dose page.
70546.............  Mr angiograph head w/  L047A               MRI Technologist.....  NF                 Provide pre-service                   9            7  G1: See preamble            -0.94
                     o&w/dye.                                                                             education/obtain                                      text.
                                                                                                          consent.
70547.............  Mr angiography neck w/ ED050               Technologist PACS      NF                 ....................                 72           69  E15: Refined                -0.07
                     o dye.                                     workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
70547.............  Mr angiography neck w/ ED053               Professional PACS      NF                 ....................                 17           15  E18: Refined                -0.12
                     o dye.                                     Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
70547.............  Mr angiography neck w/ EL008               room, MR.............  NF                 ....................                 39           38  E15: Refined                -3.38
                     o dye.                                                                                                                                     equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
70547.............  Mr angiography neck w/ L047A               MRI Technologist.....  NF                 Technologist QCs                      4            3  L1: Refined time to         -0.47
                     o dye.                                                                               images in PACS,                                       standard for this
                                                                                                          checking all                                          clinical labor task.
                                                                                                          images, reformats,
                                                                                                          and dose page.
70547.............  Mr angiography neck w/ L047A               MRI Technologist.....  NF                 Provide pre-service                   7            5  G1: See preamble            -0.94
                     o dye.                                                                               education/obtain                                      text.
                                                                                                          consent.
70548.............  Mr angiography neck w/ ED050               Technologist PACS      NF                 ....................                 75           74  E15: Refined                -0.02
                     dye.                                       workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
70548.............  Mr angiography neck w/ ED053               Professional PACS      NF                 ....................                 20           18  E18: Refined                -0.12
                     dye.                                       Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
70548.............  Mr angiography neck w/ EL008               room, MR.............  NF                 ....................                 37           36  E15: Refined                -3.38
                     dye.                                                                                                                                       equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
70548.............  Mr angiography neck w/ L047A               MRI Technologist.....  NF                 Technologist QCs                      4            3  L1: Refined time to         -0.47
                     dye.                                                                                 images in PACS,                                       standard for this
                                                                                                          checking all                                          clinical labor task.
                                                                                                          images, reformats,
                                                                                                          and dose page.

[[Page 34042]]

 
70548.............  Mr angiography neck w/ L047A               MRI Technologist.....  NF                 Provide pre-service                   9            7  G1: See preamble            -0.94
                     dye.                                                                                 education/obtain                                      text.
                                                                                                          consent.
70548.............  Mr angiography neck w/ L047A               MRI Technologist.....  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.94
                     dye.                                                                                                                                       standard for this
                                                                                                                                                                clinical labor task.
70549.............  Mr angiograph neck w/  ED050               Technologist PACS      NF                 ....................                116          115  E15: Refined                -0.02
                     o&w/dye.                                   workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
70549.............  Mr angiograph neck w/  ED053               Professional PACS      NF                 ....................                 25           23  E18: Refined                -0.12
                     o&w/dye.                                   Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
70549.............  Mr angiograph neck w/  EL008               room, MR.............  NF                 ....................                 58           57  E15: Refined                -3.38
                     o&w/dye.                                                                                                                                   equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
70549.............  Mr angiograph neck w/  L047A               MRI Technologist.....  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.94
                     o&w/dye.                                                                                                                                   standard for this
                                                                                                                                                                clinical labor task.
70549.............  Mr angiograph neck w/  L047A               MRI Technologist.....  NF                 Provide pre-service                   9            7  G1: See preamble            -0.94
                     o&w/dye.                                                                             education/obtain                                      text.
                                                                                                          consent.
70549.............  Mr angiograph neck w/  L047A               MRI Technologist.....  NF                 Technologist QCs                      4            3  L1: Refined time to         -0.47
                     o&w/dye.                                                                             images in PACS,                                       standard for this
                                                                                                          checking all                                          clinical labor task.
                                                                                                          images, reformats,
                                                                                                          and dose page.
71250.............  Ct thorax w/o dye....  ED053               Professional PACS      NF                 ....................                 20           18  E18: Refined                -0.12
                                                                Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
71260.............  Ct thorax w/dye......  ED053               Professional PACS      NF                 ....................                 21           19  E18: Refined                -0.12
                                                                Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
71270.............  Ct thorax w/o & w/dye  ED053               Professional PACS      NF                 ....................                 25           23  E18: Refined                -0.12
                                                                Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
72195.............  Mri pelvis w/o dye...  ED053               Professional PACS      NF                 ....................                 25           23  E18: Refined                -0.12
                                                                Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.

[[Page 34043]]

 
72196.............  Mri pelvis w/dye.....  ED050               Technologist PACS      NF                 ....................                 64           66  E15: Refined                 0.04
                                                                workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
72196.............  Mri pelvis w/dye.....  ED053               Professional PACS      NF                 ....................                 30           28  E18: Refined                -0.12
                                                                Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
72196.............  Mri pelvis w/dye.....  L047A               MRI Technologist.....  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.94
                                                                                                                                                                standard for this
                                                                                                                                                                clinical labor task.
72197.............  Mri pelvis w/o & w/    ED050               Technologist PACS      NF                 ....................                 79           81  E15: Refined                 0.04
                     dye.                                       workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
72197.............  Mri pelvis w/o & w/    ED053               Professional PACS      NF                 ....................                 32           30  E18: Refined                -0.12
                     dye.                                       Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
72197.............  Mri pelvis w/o & w/    L047A               MRI Technologist.....  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.94
                     dye.                                                                                                                                       standard for this
                                                                                                                                                                clinical labor task.
73718.............  Mri lower extremity w/ ED050               Technologist PACS      NF                 ....................                 55           53  E15: Refined                -0.04
                     o dye.                                     workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
73718.............  Mri lower extremity w/ ED053               Professional PACS      NF                 ....................                 20           18  E18: Refined                -0.12
                     o dye.                                     Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
73718.............  Mri lower extremity w/ EL008               room, MR.............  NF                 ....................                 44           42  E15: Refined                -6.76
                     o dye.                                                                                                                                     equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
73718.............  Mri lower extremity w/ L047A               MRI Technologist.....  NF                 Prepare room,                         5            3  G1: See preamble            -0.94
                     o dye.                                                                               equipment, supplies.                                  text.
73719.............  Mri lower extremity w/ ED050               Technologist PACS      NF                 ....................                 62           64  E15: Refined                 0.04
                     dye.                                       workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
73719.............  Mri lower extremity w/ ED053               Professional PACS      NF                 ....................                 25           23  E18: Refined                -0.12
                     dye.                                       Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.

[[Page 34044]]

 
73719.............  Mri lower extremity w/ EL008               room, MR.............  NF                 ....................                 48           46  E15: Refined                -6.76
                     dye.                                                                                                                                       equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
73719.............  Mri lower extremity w/ L047A               MRI Technologist.....  NF                 Provide pre-service                   5            7  G1: See preamble             0.94
                     dye.                                                                                 education/obtain                                      text.
                                                                                                          consent.
73719.............  Mri lower extremity w/ L047A               MRI Technologist.....  NF                 Prepare room,                         7            5  G1: See preamble            -0.94
                     dye.                                                                                 equipment, supplies.                                  text.
73719.............  Mri lower extremity w/ L047A               MRI Technologist.....  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.94
                     dye.                                                                                                                                       standard for this
                                                                                                                                                                clinical labor task.
73720.............  Mri lwr extremity w/   ED050               Technologist PACS      NF                 ....................                 77           79  E15: Refined                 0.04
                     o&w/dye.                                   workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
73720.............  Mri lwr extremity w/   ED053               Professional PACS      NF                 ....................                 29           27  E18: Refined                -0.12
                     o&w/dye.                                   Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
73720.............  Mri lwr extremity w/   EL008               room, MR.............  NF                 ....................                 63           61  E15: Refined                -6.76
                     o&w/dye.                                                                                                                                   equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
73720.............  Mri lwr extremity w/   L047A               MRI Technologist.....  NF                 Prepare room,                         7            5  G1: See preamble            -0.94
                     o&w/dye.                                                                             equipment, supplies.                                  text.
73720.............  Mri lwr extremity w/   L047A               MRI Technologist.....  NF                 Provide pre-service                   5            7  G1: See preamble             0.94
                     o&w/dye.                                                                             education/obtain                                      text.
                                                                                                          consent.
73720.............  Mri lwr extremity w/   L047A               MRI Technologist.....  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.94
                     o&w/dye.                                                                                                                                   standard for this
                                                                                                                                                                clinical labor task.
74181.............  Mri abdomen w/o dye..  ED053               Professional PACS      NF                 ....................                 25           23  E18: Refined                -0.12
                                                                Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
74182.............  Mri abdomen w/dye....  ED050               Technologist PACS      NF                 ....................                 74           76  E15: Refined                 0.04
                                                                workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
74182.............  Mri abdomen w/dye....  ED053               Professional PACS      NF                 ....................                 30           28  E18: Refined                -0.12
                                                                Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
74182.............  Mri abdomen w/dye....  L047A               MRI Technologist.....  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.94
                                                                                                                                                                standard for this
                                                                                                                                                                clinical labor task.

[[Page 34045]]

 
74183.............  Mri abdomen w/o & w/   ED050               Technologist PACS      NF                 ....................                 79           81  E15: Refined                 0.04
                     dye.                                       workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
74183.............  Mri abdomen w/o & w/   ED053               Professional PACS      NF                 ....................                 35           33  E18: Refined                -0.12
                     dye.                                       Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
74183.............  Mri abdomen w/o & w/   L047A               MRI Technologist.....  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.94
                     dye.                                                                                                                                       standard for this
                                                                                                                                                                clinical labor task.
75635.............  Ct angio abdominal     ED050               Technologist PACS      NF                 ....................                119          124  E18: Refined                 0.11
                     arteries.                                  workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
75635.............  Ct angio abdominal     ED053               Professional PACS      NF                 ....................                 49           44  E18: Refined                -0.29
                     arteries.                                  Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
75635.............  Ct angio abdominal     EL007               room, CT.............  NF                 ....................                 71           70  E15: Refined                -2.70
                     arteries.                                                                                                                                  equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
75635.............  Ct angio abdominal     L046A               CT Technologist......  NF                 Technologist QCs                      4            3  L1: Refined time to         -0.46
                     arteries.                                                                            images in PACS,                                       standard for this
                                                                                                          checking all                                          clinical labor task.
                                                                                                          images, reformats,
                                                                                                          and dose page.
75710.............  Artery x-rays arm/leg  ED050               Technologist PACS      NF                 ....................                 52           49  E15: Refined                -0.07
                                                                workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
75710.............  Artery x-rays arm/leg  ED053               Professional PACS      NF                 ....................                 55           48  E18: Refined                -0.41
                                                                Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
75710.............  Artery x-rays arm/leg  L041B               Radiologic             NF                 Technologist QCs                      4            3  L1: Refined time to         -0.41
                                                                Technologist.                             images in PACS,                                       standard for this
                                                                                                          checking all                                          clinical labor task.
                                                                                                          images, reformats,
                                                                                                          and dose page.
75710.............  Artery x-rays arm/leg  L041B               Radiologic             NF                 Prepare room,                         2            0  G1: See preamble            -0.82
                                                                Technologist.                             equipment, supplies.                                  text.
75716.............  Artery x-rays arms/    ED050               Technologist PACS      NF                 ....................                 62           59  E15: Refined                -0.07
                     legs.                                      workstation.                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.

[[Page 34046]]

 
75716.............  Artery x-rays arms/    ED053               Professional PACS      NF                 ....................                 65           58  E18: Refined                -0.41
                     legs.                                      Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
75716.............  Artery x-rays arms/    L041B               Radiologic             NF                 Prepare room,                         2            0  G1: See preamble            -0.82
                     legs.                                      Technologist.                             equipment, supplies.                                  text.
75716.............  Artery x-rays arms/    L041B               Radiologic             NF                 Technologist QCs                      4            3  L1: Refined time to         -0.41
                     legs.                                      Technologist.                             images in PACS,                                       standard for this
                                                                                                          checking all                                          clinical labor task.
                                                                                                          images, reformats,
                                                                                                          and dose page.
76881.............  Us xtr non-vasc        EF031               table, power.........  NF                 ....................                  8            7  E1: Refined                 -0.02
                     complete.                                                                                                                                  equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
76881.............  Us xtr non-vasc        EQ250               ultrasound unit,       NF                 ....................                  8            7  E1: Refined                 -0.12
                     complete.                                  portable.                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
76881.............  Us xtr non-vasc        L026A               Medical/Technical      NF                 Exam document                         1            0  G1: See preamble            -0.26
                     complete.                                  Assistant.                                scanned into PACS.                                    text.
                                                                                                          Exam completed in
                                                                                                          RIS system to
                                                                                                          generate billing
                                                                                                          process and to
                                                                                                          populate images
                                                                                                          into Radiologist
                                                                                                          work queue.
78300.............  Bone imaging limited   ED053               Professional PACS      NF                 ....................                 15           13  E18: Refined                -0.12
                     area.                                      Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
78305.............  Bone imaging multiple  ED053               Professional PACS      NF                 ....................                 15           13  E18: Refined                -0.12
                     areas.                                     Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
78306.............  Bone imaging whole     ED053               Professional PACS      NF                 ....................                 78           13  E18: Refined                -3.76
                     body.                                      Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
88333.............  Intraop cyto path      L033A               Lab Technician.......  NF                 Prepare room. Filter                 10            0  G6: Indirect                -3.30
                     consult 1.                                                                           and replenish                                         Practice Expense
                                                                                                          stains and                                            input and/or not
                                                                                                          supplies.                                             individually
                                                                                                          (including OCT                                        allocable to a
                                                                                                          blocks, set up                                        particular patient
                                                                                                          grossing station                                      for a particular
                                                                                                          with colored                                          service.
                                                                                                          stains).

[[Page 34047]]

 
88333.............  Intraop cyto path      L037B               Histotechnologist....  NF                 Clean room/equipment                  5            1  L1: Refined time to         -1.48
                     consult 1.                                                                           following procedure                                   standard for this
                                                                                                          (including any                                        clinical labor task.
                                                                                                          equipment
                                                                                                          maintenance that
                                                                                                          must be done after
                                                                                                          the procedure).
88360.............  Tumor immunohistochem/ EP112               Benchmark ULTRA        NF                 ....................                 18           16  G1: See preamble            -1.14
                     manual.                                    automated slide                                                                                 text.
                                                                preparation system.
88360.............  Tumor immunohistochem/ L033A               Lab Technician.......  NF                 Recycle xylene from                   1            0  G6: Indirect                -0.33
                     manual.                                                                              tissue processor                                      Practice Expense
                                                                                                          and stainer.                                          input and/or not
                                                                                                                                                                individually
                                                                                                                                                                allocable to a
                                                                                                                                                                particular patient
                                                                                                                                                                for a particular
                                                                                                                                                                service.
88360.............  Tumor immunohistochem/ L037B               Histotechnologist....  NF                 Clean room/equipment                  1            0  L2: Clinical labor          -0.37
                     manual.                                                                              following procedure                                   task redundant with
                                                                                                          (including any                                        clinical labor task
                                                                                                          equipment                                             Clean equipment and
                                                                                                          maintenance that                                      work station in
                                                                                                          must be done after                                    histology lab.
                                                                                                          the procedure).
88360.............  Tumor immunohistochem/ L037B               Histotechnologist....  NF                 Verify results and                    1            0  G6: Indirect                -0.37
                     manual.                                                                              complete work load                                    Practice Expense
                                                                                                          recording logs.                                       input and/or not
                                                                                                                                                                individually
                                                                                                                                                                allocable to a
                                                                                                                                                                particular patient
                                                                                                                                                                for a particular
                                                                                                                                                                service.
88360.............  Tumor immunohistochem/ L037B               Histotechnologist....  NF                 Enter patient data,                   5            1  L1: Refined time to         -1.48
                     manual.                                                                              computational prep                                    standard for this
                                                                                                          for antibody                                          clinical labor task.
                                                                                                          testing, generate
                                                                                                          and apply bar codes
                                                                                                          to slides, and
                                                                                                          enter data for
                                                                                                          automated slide
                                                                                                          stainer.
88361.............  Tumor immunohistochem/ EP112               Benchmark ULTRA        NF                 ....................                 18           16  G1: See preamble            -1.14
                     comput.                                    automated slide                                                                                 text.
                                                                preparation system.
88361.............  Tumor immunohistochem/ L033A               Lab Technician.......  NF                 Recycle xylene from                   1            0  G6: Indirect                -0.33
                     comput.                                                                              tissue processor                                      Practice Expense
                                                                                                          and stainer.                                          input and/or not
                                                                                                                                                                individually
                                                                                                                                                                allocable to a
                                                                                                                                                                particular patient
                                                                                                                                                                for a particular
                                                                                                                                                                service.

[[Page 34048]]

 
88361.............  Tumor immunohistochem/ L037B               Histotechnologist....  NF                 Verify results and                    1            0  G6: Indirect                -0.37
                     comput.                                                                              complete work load                                    Practice Expense
                                                                                                          recording logs.                                       input and/or not
                                                                                                                                                                individually
                                                                                                                                                                allocable to a
                                                                                                                                                                particular patient
                                                                                                                                                                for a particular
                                                                                                                                                                service.
88361.............  Tumor immunohistochem/ L037B               Histotechnologist....  NF                 Performing                            1            0  G1: See preamble            -0.37
                     comput.                                                                              instrument                                            text.
                                                                                                          calibration,
                                                                                                          instrument qc and
                                                                                                          start up and
                                                                                                          shutdown..
88361.............  Tumor immunohistochem/ L037B               Histotechnologist....  NF                 Gate areas to be                      1            0  G1: See preamble            -0.37
                     comput.                                                                              counted by the                                        text.
                                                                                                          machine.
88361.............  Tumor immunohistochem/ L037B               Histotechnologist....  NF                 Enter patient data,                   5            1  L1: Refined time to         -1.48
                     comput.                                                                              computational prep                                    standard for this
                                                                                                          for antibody                                          clinical labor task.
                                                                                                          testing, generate
                                                                                                          and apply bar codes
                                                                                                          to slides, and
                                                                                                          enter data for
                                                                                                          automated slide
                                                                                                          stainer.
88361.............  Tumor immunohistochem/ L037B               Histotechnologist....  NF                 Clean room/equipment                  1            0  L2: Clinical labor          -0.37
                     comput.                                                                              following procedure                                   task redundant with
                                                                                                          (including any                                        clinical labor task
                                                                                                          equipment                                             Clean equipment and
                                                                                                          maintenance that                                      work station in
                                                                                                          must be done after                                    histology lab.
                                                                                                          the procedure).
93279.............  Pm device progr eval   EF023               table, exam..........  NF                 ....................                 33           26  E1: Refined                 -0.02
                     sngl.                                                                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93279.............  Pm device progr eval   EQ198               pacemaker follow-up    NF                 ....................                 33           26  E1: Refined                 -0.53
                     sngl.                                      system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93279.............  Pm device progr eval   L026A               Medical/Technical      NF                 Complete diagnostic                   2            0  L2: Clinical labor          -0.52
                     sngl.                                      Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93279.............  Pm device progr eval   L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     sngl.                                                                                Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.
93280.............  Pm device progr eval   EF023               table, exam..........  NF                 ....................                 38           31  E1: Refined                 -0.02
                     dual.                                                                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.

[[Page 34049]]

 
93280.............  Pm device progr eval   EQ198               pacemaker follow-up    NF                 ....................                 38           31  E1: Refined                 -0.53
                     dual.                                      system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93280.............  Pm device progr eval   L026A               Medical/Technical      NF                 Complete diagnostic                   2            0  L2: Clinical labor          -0.52
                     dual.                                      Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93280.............  Pm device progr eval   L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     dual.                                                                                Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.
93281.............  Pm device progr eval   EF023               table, exam..........  NF                 ....................                 39           31  E1: Refined                 -0.02
                     multi.                                                                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93281.............  Pm device progr eval   EQ198               pacemaker follow-up    NF                 ....................                 39           31  E1: Refined                 -0.61
                     multi.                                     system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93281.............  Pm device progr eval   L026A               Medical/Technical      NF                 Complete diagnostic                   2            0  L2: Clinical labor          -0.52
                     multi.                                     Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93281.............  Pm device progr eval   L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     multi.                                                                               Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.
93281.............  Pm device progr eval   L037D               RN/LPN/MTA...........  NF                 Assist physician in                  16           15  L15: Refined                -0.37
                     multi.                                                                               performing                                            clinical labor time
                                                                                                          procedure.                                            to match
                                                                                                                                                                intraservice work
                                                                                                                                                                time.
93282.............  Prgrmg eval            EF023               table, exam..........  NF                 ....................                 35           28  E1: Refined                 -0.02
                     implantable dfb.                                                                                                                           equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93282.............  Prgrmg eval            EQ198               pacemaker follow-up    NF                 ....................                 35           28  E1: Refined                 -0.53
                     implantable dfb.                           system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93282.............  Prgrmg eval            L026A               Medical/Technical      NF                 Complete diagnostic                   2            0  L2: Clinical labor          -0.52
                     implantable dfb.                           Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93282.............  Prgrmg eval            L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     implantable dfb.                                                                     Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.

[[Page 34050]]

 
93283.............  Prgrmg eval            EF023               table, exam..........  NF                 ....................                 38           31  E1: Refined                 -0.02
                     implantable dfb.                                                                                                                           equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93283.............  Prgrmg eval            EQ198               pacemaker follow-up    NF                 ....................                 38           31  E1: Refined                 -0.53
                     implantable dfb.                           system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93283.............  Prgrmg eval            L026A               Medical/Technical      NF                 Complete diagnostic                   2            0  L2: Clinical labor          -0.52
                     implantable dfb.                           Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93283.............  Prgrmg eval            L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     implantable dfb.                                                                     Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.
93284.............  Prgrmg eval            EF023               table, exam..........  NF                 ....................               40.5         33.5  E1: Refined                 -0.02
                     implantable dfb.                                                                                                                           equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93284.............  Prgrmg eval            EQ198               pacemaker follow-up    NF                 ....................               40.5         33.5  E1: Refined                 -0.53
                     implantable dfb.                           system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93284.............  Prgrmg eval            L026A               Medical/Technical      NF                 Complete diagnostic                   2            0  L2: Clinical labor          -0.52
                     implantable dfb.                           Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93284.............  Prgrmg eval            L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     implantable dfb.                                                                     Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.
93285.............  Ilr device eval progr  EF023               table, exam..........  NF                 ....................                 30           25  E1: Refined                 -0.01
                                                                                                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93285.............  Ilr device eval progr  EQ198               pacemaker follow-up    NF                 ....................                 30           25  E1: Refined                 -0.38
                                                                system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93285.............  Ilr device eval progr  L026A               Medical/Technical      NF                 Complete diagnostic                   1            0  L2: Clinical labor          -0.26
                                                                Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93285.............  Ilr device eval progr  L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                                                                                                          Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.

[[Page 34051]]

 
93286.............  Peri-px pacemaker      EF023               table, exam..........  NF                 ....................                 27           20  E1: Refined                 -0.02
                     device evl.                                                                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93286.............  Peri-px pacemaker      EQ198               pacemaker follow-up    NF                 ....................                 27           20  E1: Refined                 -0.53
                     device evl.                                system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93286.............  Peri-px pacemaker      L026A               Medical/Technical      NF                 Complete diagnostic                   2            0  L2: Clinical labor          -0.52
                     device evl.                                Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93286.............  Peri-px pacemaker      L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     device evl.                                                                          Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.
93287.............  Peri-px device eval &  EF023               table, exam..........  NF                 ....................                 27           20  E1: Refined                 -0.02
                     prgr.                                                                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93287.............  Peri-px device eval &  EQ198               pacemaker follow-up    NF                 ....................                 27           20  E1: Refined                 -0.53
                     prgr.                                      system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93287.............  Peri-px device eval &  L026A               Medical/Technical      NF                 Complete diagnostic                   2            0  L2: Clinical labor          -0.52
                     prgr.                                      Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93287.............  Peri-px device eval &  L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     prgr.                                                                                Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.
93288.............  Pm device eval in      EF023               table, exam..........  NF                 ....................                 33           26  E1: Refined                 -0.02
                     person.                                                                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93288.............  Pm device eval in      EQ198               pacemaker follow-up    NF                 ....................                 33           26  E1: Refined                 -0.53
                     person.                                    system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93288.............  Pm device eval in      L026A               Medical/Technical      NF                 Complete diagnostic                   2            0  L2: Clinical labor          -0.52
                     person.                                    Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93288.............  Pm device eval in      L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     person.                                                                              Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.

[[Page 34052]]

 
93289.............  Interrog device eval   EF023               table, exam..........  NF                 ....................                 33           26  E1: Refined                 -0.02
                     heart.                                                                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93289.............  Interrog device eval   EQ198               pacemaker follow-up    NF                 ....................                 33           26  E1: Refined                 -0.53
                     heart.                                     system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93289.............  Interrog device eval   L026A               Medical/Technical      NF                 Complete diagnostic                   2            0  L2: Clinical labor          -0.52
                     heart.                                     Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93289.............  Interrog device eval   L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     heart.                                                                               Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.
93290.............  Icm device eval......  EF023               table, exam..........  NF                 ....................                 28           24  E1: Refined                 -0.01
                                                                                                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93290.............  Icm device eval......  EQ198               pacemaker follow-up    NF                 ....................                 28           24  E1: Refined                 -0.30
                                                                system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93290.............  Icm device eval......  L026A               Medical/Technical      NF                 Complete diagnostic                   1            0  L2: Clinical labor          -0.26
                                                                Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93290.............  Icm device eval......  L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                                                                                                          Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.
93291.............  Ilr device             EF023               table, exam..........  NF                 ....................                 27           22  E1: Refined                 -0.01
                     interrogate.                                                                                                                               equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93291.............  Ilr device             EQ198               pacemaker follow-up    NF                 ....................                 27           22  E1: Refined                 -0.38
                     interrogate.                               system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93291.............  Ilr device             L026A               Medical/Technical      NF                 Complete diagnostic                   1            0  L2: Clinical labor          -0.26
                     interrogate.                               Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93291.............  Ilr device             L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     interrogate.                                                                         Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.

[[Page 34053]]

 
93292.............  Wcd device             EF023               table, exam..........  NF                 ....................                 30           25  E1: Refined                 -0.01
                     interrogate.                                                                                                                               equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93292.............  Wcd device             EQ198               pacemaker follow-up    NF                 ....................                 30           25  E1: Refined                 -0.38
                     interrogate.                               system (incl                                                                                    equipment time to
                                                                software and                                                                                    conform to
                                                                hardware) (Paceart).                                                                            established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93292.............  Wcd device             L026A               Medical/Technical      NF                 Complete diagnostic                   1            0  L2: Clinical labor          -0.26
                     interrogate.                               Assistant.                                forms, lab, X-ray                                     task redundant with
                                                                                                          requisitions.                                         clinical labor task
                                                                                                                                                                L037D.
93292.............  Wcd device             L037D               RN/LPN/MTA...........  NF                 Other Clinical                        2            0  L1: Refined time to         -0.74
                     interrogate.                                                                         Activity--specify:                                    standard for this
                                                                                                          Review charts.                                        clinical labor task.
93350.............  Stress tte only......  ED053               Professional PACS      NF                 ....................                 20           18  E18: Refined                -0.12
                                                                Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
93351.............  Stress tte complete..  ED050               Technologist PACS      NF                 ....................                104          114  E18: Refined                 0.22
                                                                workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
93351.............  Stress tte complete..  ED053               Professional PACS      NF                 ....................                 30           25  E18: Refined                -0.29
                                                                Workstation.                                                                                    equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for PACS
                                                                                                                                                                Workstations.
93351.............  Stress tte complete..  EQ078               cardiac monitor w-     NF                 ....................                104           91  E1: Refined                 -0.49
                                                                treadmill (12-lead                                                                              equipment time to
                                                                PC-based ECG).                                                                                  conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
93351.............  Stress tte complete..  L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                                                                                                                                                                standard for this
                                                                                                                                                                clinical labor task.
93351.............  Stress tte complete..  L037D               RN/LPN/MTA...........  NF                 Provide pre-service                   3            2  L1: Refined time to         -0.37
                                                                                                          education/obtain                                      standard for this
                                                                                                          consent.                                              clinical labor task.
93351.............  Stress tte complete..  L051A               RN...................  NF                 Setup scope (non                      5            0  G1: See preamble            -2.55
                                                                                                          facility setting                                      text.
                                                                                                          only).
94621.............  Cardiopulm exercise    EQ042               Vmax 29c (cardio-pulm  NF                 ....................                127          115  E6: Refined                 -1.98
                     testing.                                   stress test equip,                                                                              equipment time to
                                                                treadmill, computer                                                                             conform to
                                                                system).                                                                                        established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.

[[Page 34054]]

 
94621.............  Cardiopulm exercise    EQ211               pulse oximeter w-      NF                 ....................                127          115  E6: Refined                 -0.05
                     testing.                                   printer.                                                                                        equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.
94621.............  Cardiopulm exercise    L047C               RN/Respiratory         NF                 Prepare and position                  5            3  G1: See preamble            -0.94
                     testing.                                   Therapist.                                pt/monitor pt/set                                     text.
                                                                                                          up IV.
94621.............  Cardiopulm exercise    L047C               RN/Respiratory         NF                 Provide pre-service                  10            5  G1: See preamble            -2.35
                     testing.                                   Therapist.                                education/obtain                                      text.
                                                                                                          consent.
94621.............  Cardiopulm exercise    L047C               RN/Respiratory         NF                 Complete diagnostic                   5            3  L1: Refined time to         -0.94
                     testing.                                   Therapist.                                forms, lab, X-ray                                     standard for this
                                                                                                          requisitions.                                         clinical labor task.
946X2.............  Exercise tst brncspsm  EQ043               Vmax 29s (spirometry   NF                 ....................                 87           83  E6: Refined                 -0.31
                                                                testing equip,                                                                                  equipment time to
                                                                computer system).                                                                               conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.
946X2.............  Exercise tst brncspsm  EQ078               cardiac monitor w-     NF                 ....................                 87           83  E6: Refined                 -0.15
                                                                treadmill (12-lead                                                                              equipment time to
                                                                PC-based ECG).                                                                                  conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.
946X2.............  Exercise tst brncspsm  EQ211               pulse oximeter w-      NF                 ....................                 87           83  E6: Refined                 -0.02
                                                                printer.                                                                                        equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.
946X2.............  Exercise tst brncspsm  L047C               RN/Respiratory         NF                 Complete diagnostic                   4            3  L1: Refined time to         -0.47
                                                                Therapist.                                forms, lab, X-ray                                     standard for this
                                                                                                          requisitions.                                         clinical labor task.
946X3.............  Pulmonary stress       EQ211               pulse oximeter w-      NF                 ....................                 17           15  E1: Refined                 -0.01
                     testing.                                   printer.                                                                                        equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
946X3.............  Pulmonary stress       L047C               RN/Respiratory         NF                 Complete diagnostic                   2            3  L1: Refined time to          0.47
                     testing.                                   Therapist.                                forms, lab, X-ray                                     standard for this
                                                                                                          requisitions.                                         clinical labor task.
95004.............  Percut allergy skin    EF015               mayo stand...........  NF                 ....................               1.28         1.58  E6: Refined                  0.00
                     tests.                                                                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.
95004.............  Percut allergy skin    EF023               table, exam..........  NF                 ....................               1.28         1.58  E6: Refined                  0.00
                     tests.                                                                                                                                     equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.

[[Page 34055]]

 
96160.............  Pt-focused hlth risk   L026A               Medical/Technical      NF                 Explain purpose of                    2            0  G1: See preamble            -0.52
                     assmt.                                     Assistant.                                assessment to                                         text.
                                                                                                          patient/caregiver
                                                                                                          and answer
                                                                                                          questions.
96160.............  Pt-focused hlth risk   L026A               Medical/Technical      NF                 Remain in exam room                   2            0  G1: See preamble            -0.52
                     assmt.                                     Assistant.                                with patient/                                         text.
                                                                                                          caregiver exclusive
                                                                                                          to completion of
                                                                                                          assessment.
96160.............  Pt-focused hlth risk   L026A               Medical/Technical      NF                 Collate and score                     1            0  G1: See preamble            -0.26
                     assmt.                                     Assistant.                                data elements on                                      text.
                                                                                                          assessment in
                                                                                                          advance of
                                                                                                          physician exam.
96160.............  Pt-focused hlth risk   L026A               Medical/Technical      NF                 Scan assessment or                    2            0  G1: See preamble            -0.52
                     assmt.                                     Assistant.                                enter data elements                                   text.
                                                                                                          and total score
                                                                                                          into electronic
                                                                                                          health record.
96160.............  Pt-focused hlth risk   L026A               Medical/Technical      NF                 Administration,                       0            7  G1: See preamble             1.82
                     assmt.                                     Assistant.                                scoring, and                                          text.
                                                                                                          documenting results
                                                                                                          of completed
                                                                                                          standardized
                                                                                                          instrument.
96161.............  Caregiver health risk  L026A               Medical/Technical      NF                 Explain purpose of                    2            0  G1: See preamble            -0.52
                     assmt.                                     Assistant.                                assessment to                                         text.
                                                                                                          patient/caregiver
                                                                                                          and answer
                                                                                                          questions.
96161.............  Caregiver health risk  L026A               Medical/Technical      NF                 Remain in exam room                   2            0  G1: See preamble            -0.52
                     assmt.                                     Assistant.                                with patient/                                         text.
                                                                                                          caregiver exclusive
                                                                                                          to completion of
                                                                                                          assessment.
96161.............  Caregiver health risk  L026A               Medical/Technical      NF                 Collate and score                     1            0  G1: See preamble            -0.26
                     assmt.                                     Assistant.                                data elements on                                      text.
                                                                                                          assessment in
                                                                                                          advance of
                                                                                                          physician exam.
96161.............  Caregiver health risk  L026A               Medical/Technical      NF                 Scan assessment or                    2            0  G1: See preamble            -0.52
                     assmt.                                     Assistant.                                enter data elements                                   text.
                                                                                                          and total score
                                                                                                          into electronic
                                                                                                          health record.
96161.............  Caregiver health risk  L026A               Medical/Technical      NF                 Administration,                       0            7  G1: See preamble             1.82
                     assmt.                                     Assistant.                                scoring, and                                          text.
                                                                                                          documenting results
                                                                                                          of completed
                                                                                                          standardized
                                                                                                          instrument.
96360.............  Hydration iv infusion  EF023               table, exam..........  NF                 ....................                 16           24  E6: Refined                  0.02
                     init.                                                                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.

[[Page 34056]]

 
96360.............  Hydration iv infusion  EQ032               IV infusion pump.....  NF                 ....................                 16           24  E6: Refined                  0.05
                     init.                                                                                                                                      equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.
96360.............  Hydration iv infusion  L056A               RN/OCN...............  NF                 Obtain vital signs..                  3            5  L1: Refined time to          1.58
                     init.                                                                                                                                      standard for this
                                                                                                                                                                clinical labor task.
96361.............  Hydrate iv infusion    EF023               table, exam..........  NF                 ....................                  7            9  E15: Refined                 0.01
                     add-on.                                                                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
96361.............  Hydrate iv infusion    EQ032               IV infusion pump.....  NF                 ....................                  7            9  E15: Refined                 0.01
                     add-on.                                                                                                                                    equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
96361.............  Hydrate iv infusion    L056A               RN/OCN...............  NF                 Obtain vital signs..                  3            5  L1: Refined time to          1.58
                     add-on.                                                                                                                                    standard for this
                                                                                                                                                                clinical labor task.
96372.............  Ther/proph/diag inj    EF023               table, exam..........  NF                 ....................                 12            9  E15: Refined                -0.01
                     sc/im.                                                                                                                                     equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
96372.............  Ther/proph/diag inj    EQ189               otoscope-              NF                 ....................                 12            9  E15: Refined                -0.01
                     sc/im.                                     ophthalmoscope (wall                                                                            equipment time to
                                                                unit).                                                                                          conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
96372.............  Ther/proph/diag inj    L037D               RN/LPN/MTA...........  NF                 Complete medical                      1            0  G6: Indirect                -0.37
                     sc/im.                                                                               record                                                Practice Expense
                                                                                                          documentation.                                        input and/or not
                                                                                                                                                                individually
                                                                                                                                                                allocable to a
                                                                                                                                                                particular patient
                                                                                                                                                                for a particular
                                                                                                                                                                service.
96372.............  Ther/proph/diag inj    L037D               RN/LPN/MTA...........  NF                 Document lot number                   1            0  L3: Refined clinical        -0.37
                     sc/im.                                                                               and expiration date.                                  labor time to
                                                                                                                                                                conform with
                                                                                                                                                                identical labor
                                                                                                                                                                activity in other
                                                                                                                                                                codes in the family.
96372.............  Ther/proph/diag inj    L037D               RN/LPN/MTA...........  NF                 Clean room/equipment                  1            0  G8: Input removed;          -0.37
                     sc/im.                                                                               by physician staff.                                   code is typically
                                                                                                                                                                billed with an E/M
                                                                                                                                                                or other evaluation
                                                                                                                                                                service.
96374.............  Ther/proph/diag inj    EF023               table, exam..........  NF                 ....................                 23           31  E6: Refined                  0.02
                     iv push.                                                                                                                                   equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.

[[Page 34057]]

 
96374.............  Ther/proph/diag inj    EQ189               otoscope-              NF                 ....................                 23           31  E6: Refined                  0.01
                     iv push.                                   ophthalmoscope (wall                                                                            equipment time to
                                                                unit).                                                                                          conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.
96374.............  Ther/proph/diag inj    L056A               RN/OCN...............  NF                 Complete medical                      1            0  G6: Indirect                -0.79
                     iv push.                                                                             record                                                Practice Expense
                                                                                                          documentation.                                        input and/or not
                                                                                                                                                                individually
                                                                                                                                                                allocable to a
                                                                                                                                                                particular patient
                                                                                                                                                                for a particular
                                                                                                                                                                service.
96375.............  Tx/pro/dx inj new      EF023               table, exam..........  NF                 ....................                 12           17  E6: Refined                  0.01
                     drug addon.                                                                                                                                equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.
96375.............  Tx/pro/dx inj new      EQ189               otoscope-              NF                 ....................                 12           17  E6: Refined                  0.01
                     drug addon.                                ophthalmoscope (wall                                                                            equipment time to
                                                                unit).                                                                                          conform to
                                                                                                                                                                established
                                                                                                                                                                policies for
                                                                                                                                                                equipment with 4x
                                                                                                                                                                monitoring time.
96375.............  Tx/pro/dx inj new      L056A               RN/OCN...............  NF                 Complete medical                      1            0  G6: Indirect                -0.79
                     drug addon.                                                                          record                                                Practice Expense
                                                                                                          documentation.                                        input and/or not
                                                                                                                                                                individually
                                                                                                                                                                allocable to a
                                                                                                                                                                particular patient
                                                                                                                                                                for a particular
                                                                                                                                                                service.
96377.............  Applicaton on-body     EF023               table, exam..........  NF                 ....................                 12           11  E15: Refined                 0.00
                     injector.                                                                                                                                  equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
96377.............  Applicaton on-body     EQ189               otoscope-              NF                 ....................                 12           11  E15: Refined                 0.00
                     injector.                                  ophthalmoscope (wall                                                                            equipment time to
                                                                unit).                                                                                          conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
96377.............  Applicaton on-body     L056A               RN/OCN...............  NF                 Complete medical                      1            0  G6: Indirect                -0.79
                     injector.                                                                            record                                                Practice Expense
                                                                                                          documentation.                                        input and/or not
                                                                                                                                                                individually
                                                                                                                                                                allocable to a
                                                                                                                                                                particular patient
                                                                                                                                                                for a particular
                                                                                                                                                                service.
96910.............  Photochemotherapy      EF023               table, exam..........  NF                 ....................                 67           65  E15: Refined                -0.01
                     with uv-b.                                                                                                                                 equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.

[[Page 34058]]

 
96910.............  Photochemotherapy      EQ168               light, exam..........  NF                 ....................                 67           65  E15: Refined                -0.01
                     with uv-b.                                                                                                                                 equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
96910.............  Photochemotherapy      EQ204               phototherapy unit,     NF                 ....................                 67           65  E15: Refined                -0.01
                     with uv-b.                                 hand-foot, UVA-UVB.                                                                             equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
96910.............  Photochemotherapy      EQ205               phototherapy unit,     NF                 ....................                 67           65  E15: Refined                -0.07
                     with uv-b.                                 whole body, UVA-UVB.                                                                            equipment time to
                                                                                                                                                                conform to changes
                                                                                                                                                                in clinical labor
                                                                                                                                                                time.
96910.............  Photochemotherapy      L037D               RN/LPN/MTA...........  NF                 Complete diagnostic                   2            0  G6: Indirect                -0.74
                     with uv-b.                                                                           forms, lab & X-ray                                    Practice Expense
                                                                                                          requisitions, and                                     input and/or not
                                                                                                          documentation.                                        individually
                                                                                                                                                                allocable to a
                                                                                                                                                                particular patient
                                                                                                                                                                for a particular
                                                                                                                                                                service.
96910.............  Photochemotherapy      L037D               RN/LPN/MTA...........  NF                 Provide pre-service                   3            1  G1: See preamble            -0.74
                     with uv-b.                                                                           education/obtain                                      text.
                                                                                                          consent.
96910.............  Photochemotherapy      L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     with uv-b.                                                                                                                                 standard for this
                                                                                                                                                                clinical labor task.
96X73.............  Pdt dstr prmlg les     EF031               table, power.........  NF                 ....................                230           52  E1: Refined                 -2.91
                     phys/qhp.                                                                                                                                  equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
96X73.............  Pdt dstr prmlg les     EQ169               light, external PDT,   NF                 ....................                 20           52  E1: Refined                  1.12
                     phys/qhp.                                  w-probe set                                                                                     equipment time to
                                                                (LumaCare).                                                                                     conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
96X73.............  Pdt dstr prmlg les     L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     phys/qhp.                                                                                                                                  standard for this
                                                                                                                                                                clinical labor task.
96X73.............  Pdt dstr prmlg les     SJ027               goggles, uv-blocking.  NF                 ....................                  0            3  S8: Supply item             12.30
                     phys/qhp.                                                                                                                                  replaces another
                                                                                                                                                                item; see preamble.
96X74.............  Dbrdmt prmlg les w/    EF031               table, power.........  NF                 ....................                232           54  E1: Refined                 -2.91
                     pdt.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.

[[Page 34059]]

 
96X74.............  Dbrdmt prmlg les w/    EQ168               light, exam..........  NF                 ....................                 52           54  E1: Refined                  0.01
                     pdt.                                                                                                                                       equipment time to
                                                                                                                                                                conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
96X74.............  Dbrdmt prmlg les w/    EQ169               light, external PDT,   NF                 ....................                 20           54  E1: Refined                  1.19
                     pdt.                                       w-probe set                                                                                     equipment time to
                                                                (LumaCare).                                                                                     conform to
                                                                                                                                                                established
                                                                                                                                                                policies for non-
                                                                                                                                                                highly technical
                                                                                                                                                                equipment.
96X74.............  Dbrdmt prmlg les w/    L037D               RN/LPN/MTA...........  NF                 Obtain vital signs..                  3            5  L1: Refined time to          0.74
                     pdt.                                                                                                                                       standard for this
                                                                                                                                                                clinical labor task.
96X74.............  Dbrdmt prmlg les w/    SJ027               goggles, uv-blocking.  NF                 ....................                  0            3  S8: Supply item             12.30
                     pdt.                                                                                                                                       replaces another
                                                                                                                                                                item; see preamble.
97012.............  Mechanical traction    EQ241               traction system (hi-   NF                 ....................                 13           15  G1: See preamble             0.03
                     therapy.                                   low table, digital                                                                              text.
                                                                unit, accessories).
97012.............  Mechanical traction    L023A               Physical Therapy Aide  NF                 Clean room/equipment                  1            2  G1: See preamble             0.23
                     therapy.                                                                             by physician staff.                                   text.
97012.............  Mechanical traction    L023A               Physical Therapy Aide  NF                 Assist therapist....                  2            0  G1: See preamble            -0.46
                     therapy.                                                                                                                                   text.
97012.............  Mechanical traction    L023A               Physical Therapy Aide  NF                 Other clinical                        0            1  G1: See preamble             0.23
                     therapy.                                                                             Activity--specify:                                    text.
                                                                                                          post-treatment
                                                                                                          assistance.
97012.............  Mechanical traction    L023A               Physical Therapy Aide  NF                 Prepare room,                         1            0  G1: See preamble            -0.23
                     therapy.                                                                             equipment, supplies.                                  text.
97012.............  Mechanical traction    L023A               Physical Therapy Aide  NF                 Prepare and position                  1            0  G1: See preamble            -0.23
                     therapy.                                                                             patient.                                              text.
97012.............  Mechanical traction    L039B               Physical Therapy       NF                 Check dressings &                     0            1  G1: See preamble             0.39
                     therapy.                                   Assistant.                                wound/home care                                       text.
                                                                                                          instructions/
                                                                                                          coordinate office
                                                                                                          visits/
                                                                                                          prescriptions.
97012.............  Mechanical traction    L039B               Physical Therapy       NF                 Assist therapist....                  0            5  G1: See preamble             1.95
                     therapy.                                   Assistant.                                                                                      text.
97012.............  Mechanical traction    SB022               gloves, non-sterile..  NF                 ....................                  1            0  G1: See preamble            -0.08
                     therapy.                                                                                                                                   text.
97012.............  Mechanical traction    SB026               gown, patient........  NF                 ....................                  1            0  G1: See preamble            -0.53
                     therapy.                                                                                                                                   text.
97012.............  Mechanical traction    SG039               dressing, 5in x 9in    NF                 ....................                  0            1  G1: See preamble             0.27
                     therapy.                                   (ABD-Combine).                                                                                  text.
97012.............  Mechanical traction    SK082               towel, paper (Bounty)  NF                 ....................                  2            0  G1: See preamble            -0.01
                     therapy.                                   (per sheet).                                                                                    text.
97012.............  Mechanical traction    SM012               disinfectant spray     NF                 ....................                  2            0  G1: See preamble            -0.06
                     therapy.                                   (Transeptic).                                                                                   text.
97014.............  Electric stimulation   EF028               table, mat, hi-lo, 6   NF                 ....................                 10           15  G1: See preamble             0.05
                     therapy.                                   x 8 platform.                                                                                   text.
97014.............  Electric stimulation   EQ116               electrotherapy         NF                 ....................                 10           15  G1: See preamble             0.03
                     therapy.                                   stimulator, high                                                                                text.
                                                                volt, 2 channel.
97014.............  Electric stimulation   L023A               Physical Therapy Aide  NF                 Prepare room,                         1            0  G1: See preamble            -0.23
                     therapy.                                                                             equipment, supplies.                                  text.
97014.............  Electric stimulation   L023A               Physical Therapy Aide  NF                 Assist therapist....                  2            0  G1: See preamble            -0.46
                     therapy.                                                                                                                                   text.

[[Page 34060]]

 
97014.............  Electric stimulation   L023A               Physical Therapy Aide  NF                 Clean room/equipment                  1            2  G1: See preamble             0.23
                     therapy.                                                                             by physician staff.                                   text.
97014.............  Electric stimulation   L023A               Physical Therapy Aide  NF                 Other clinical                        0            1  G1: See preamble             0.23
                     therapy.                                                                             Activity--specify:                                    text.
                                                                                                          post-treatment
                                                                                                          assistance.
97014.............  Electric stimulation   L023A               Physical Therapy Aide  NF                 Prepare and position                  1            0  G1: See preamble            -0.23
                     therapy.                                                                             patient.                                              text.
97014.............  Electric stimulation   L039B               Physical Therapy       NF                 Assist therapist....                  0            3  G1: See preamble             1.17
                     therapy.                                   Assistant.                                                                                      text.
97014.............  Electric stimulation   L039B               Physical Therapy       NF                 Check dressings &                     0            1  G1: See preamble             0.39
                     therapy.                                   Assistant.                                wound/home care                                       text.
                                                                                                          instructions/
                                                                                                          coordinate office
                                                                                                          visits/
                                                                                                          prescriptions.
97014.............  Electric stimulation   SB026               gown, patient........  NF                 ....................                  1            0  G1: See preamble            -0.53
                     therapy.                                                                                                                                   text.
97014.............  Electric stimulation   SJ024               electrolyte coupling   NF                 ....................                  0            1  G1: See preamble             0.02
                     therapy.                                   gel.                                                                                            text.
97014.............  Electric stimulation   SK068               razor................  NF                 ....................                  0            1  G1: See preamble             0.39
                     therapy.                                                                                                                                   text.
97014.............  Electric stimulation   SK082               towel, paper (Bounty)  NF                 ....................                  1            0  G1: See preamble            -0.01
                     therapy.                                   (per sheet).                                                                                    text.
97014.............  Electric stimulation   SM012               disinfectant spray     NF                 ....................                  1            0  G1: See preamble            -0.03
                     therapy.                                   (Transeptic).                                                                                   text.
97016.............  Vasopneumatic device   EF028               table, mat, hi-lo, 6   NF                 ....................                 11           20  G1: See preamble             0.09
                     therapy.                                   x 8 platform.                                                                                   text.
97016.............  Vasopneumatic device   EQ263               vasopneumatic          NF                 ....................                 11           20  G1: See preamble             0.02
                     therapy.                                   compression system.                                                                             text.
97016.............  Vasopneumatic device   L023A               Physical Therapy Aide  NF                 Other clinical                        0            2  G1: See preamble             0.46
                     therapy.                                                                             Activity--specify:                                    text.
                                                                                                          post-treatment
                                                                                                          assistance.
97016.............  Vasopneumatic device   L023A               Physical Therapy Aide  NF                 Prepare room,                         1            0  G1: See preamble            -0.23
                     therapy.                                                                             equipment, supplies.                                  text.
97016.............  Vasopneumatic device   L023A               Physical Therapy Aide  NF                 Clean room/equipment                  1            2  G1: See preamble             0.23
                     therapy.                                                                             by physician staff.                                   text.
97016.............  Vasopneumatic device   L023A               Physical Therapy Aide  NF                 Prepare and position                  1            0  G1: See preamble            -0.23
                     therapy.                                                                             patient.                                              text.
97016.............  Vasopneumatic device   L023A               Physical Therapy Aide  NF                 Assist therapist....                  2            0  G1: See preamble            -0.46
                     therapy.                                                                                                                                   text.
97016.............  Vasopneumatic device   L039B               Physical Therapy       NF                 Assist therapist....                  0           10  G1: See preamble             3.90
                     therapy.                                   Assistant.                                                                                      text.
97016.............  Vasopneumatic device   L039B               Physical Therapy       NF                 Check dressings &                     0            5  G1: See preamble             1.95
                     therapy.                                   Assistant.                                wound/home care                                       text.
                                                                                                          instructions/
                                                                                                          coordinate office
                                                                                                          visits/
                                                                                                          prescriptions.
97016.............  Vasopneumatic device   L039B               Physical Therapy       NF                 Obtain vital signs..                  0            2  G1: See preamble             0.78
                     therapy.                                   Assistant.                                                                                      text.
97016.............  Vasopneumatic device   SB026               gown, patient........  NF                 ....................                  1            0  G1: See preamble            -0.53
                     therapy.                                                                                                                                   text.
97018.............  Paraffin bath therapy  EQ200               paraffin bath, hand-   NF                 ....................                 11           15  G1: See preamble             0.03
                                                                foot (institutional).                                                                           text.

[[Page 34061]]

 
97018.............  Paraffin bath therapy  L023A               Physical Therapy Aide  NF                 Prepare room,                         1            3  G1: See preamble             0.46
                                                                                                          equipment, supplies.                                  text.
97018.............  Paraffin bath therapy  L023A               Physical Therapy Aide  NF                 Other clinical                        0            1  G1: See preamble             0.23
                                                                                                          Activity--specify:                                    text.
                                                                                                          post-treatment
                                                                                                          assistance.
97018.............  Paraffin bath therapy  L023A               Physical Therapy Aide  NF                 Clean room/equipment                  1            2  G1: See preamble             0.23
                                                                                                          by physician staff.                                   text.
97018.............  Paraffin bath therapy  L023A               Physical Therapy Aide  NF                 Assist therapist....                  2            0  G1: See preamble            -0.46
                                                                                                                                                                text.
97018.............  Paraffin bath therapy  L023A               Physical Therapy Aide  NF                 Prepare and position                  1            3  G1: See preamble             0.46
                                                                                                          patient.                                              text.
97018.............  Paraffin bath therapy  L039B               Physical Therapy       NF                 Check dressings &                     0            1  G1: See preamble             0.39
                                                                Assistant.                                wound/home care                                       text.
                                                                                                          instructions/
                                                                                                          coordinate office
                                                                                                          visits/
                                                                                                          prescriptions.
97018.............  Paraffin bath therapy  L039B               Physical Therapy       NF                 Assist therapist....                  0            5  G1: See preamble             1.95
                                                                Assistant.                                                                                      text.
97018.............  Paraffin bath therapy  SA048               pack, minimum multi-   NF                 ....................                  0          0.5  G1: See preamble             0.57
                                                                specialty visit.                                                                                text.
97022.............  Whirlpool therapy....  EF012               lift, hydraulic,       NF                 ....................                 26            4  G1: See preamble            -0.28
                                                                chair.                                                                                          text.
97022.............  Whirlpool therapy....  EF036               whirlpool, lo-boy      NF                 ....................                 26           24  G1: See preamble            -0.02
                                                                tank (whole body).                                                                              text.
97022.............  Whirlpool therapy....  L023A               Physical Therapy Aide  NF                 Prepare and position                  2            3  G1: See preamble             0.23
                                                                                                          patient.                                              text.
97022.............  Whirlpool therapy....  L023A               Physical Therapy Aide  NF                 Assist therapist....                  2            0  G1: See preamble            -0.46
                                                                                                                                                                text.
97022.............  Whirlpool therapy....  L023A               Physical Therapy Aide  NF                 Other clinical                        0            3  G1: See preamble             0.69
                                                                                                          Activity--specify:                                    text.
                                                                                                          post-treatment
                                                                                                          assistance.
97022.............  Whirlpool therapy....  L039B               Physical Therapy       NF                 Assist therapist....                  0            5  G1: See preamble             1.95
                                                                Assistant.                                                                                      text.
97022.............  Whirlpool therapy....  L039B               Physical Therapy       NF                 Check dressings &                     0            1  G1: See preamble             0.39
                                                                Assistant.                                wound/home care                                       text.
                                                                                                          instructions/
                                                                                                          coordinate office
                                                                                                          visits/
                                                                                                          prescriptions.
97022.............  Whirlpool therapy....  SB022               gloves, non-sterile..  NF                 ....................                  1            0  G1: See preamble            -0.08
                                                                                                                                                                text.
97022.............  Whirlpool therapy....  SB024               gloves, sterile......  NF                 ....................                  0            1  G1: See preamble             0.84
                                                                                                                                                                text.
97022.............  Whirlpool therapy....  SB033               mask, surgical.......  NF                 ....................                  0            1  G1: See preamble             0.20
                                                                                                                                                                text.
97022.............  Whirlpool therapy....  SG017               bandage, Kling, non-   NF                 ....................                  0            1  G1: See preamble             0.36
                                                                sterile 2in.                                                                                    text.
97022.............  Whirlpool therapy....  SG027               cast, stockinette 4in  NF                 ....................                  0            1  G1: See preamble             0.46
                                                                                                                                                                text.
97022.............  Whirlpool therapy....  SG055               gauze, sterile 4in x   NF                 ....................                  0            5  G1: See preamble             0.80
                                                                4in.                                                                                            text.
97022.............  Whirlpool therapy....  SG079               tape, surgical paper   NF                 ....................                  0           12  G1: See preamble             0.02
                                                                1in (Micropore).                                                                                text.
97022.............  Whirlpool therapy....  SJ046               silver nitrate         NF                 ....................                  0            1  G1: See preamble             0.07
                                                                applicator.                                                                                     text.
97032.............  Electrical             EF028               table, mat, hi-lo, 6   NF                 ....................                 18           15  G1: See preamble            -0.03
                     stimulation.                               x 8 platform.                                                                                   text.
97032.............  Electrical             EQ116               electrotherapy         NF                 ....................                 18           15  G1: See preamble            -0.02
                     stimulation.                               stimulator, high                                                                                text.
                                                                volt, 2 channel.

[[Page 34062]]

 
97032.............  Electrical             L023A               Physical Therapy Aide  NF                 Prepare room,                         1            0  G1: See preamble            -0.23
                     stimulation.                                                                         equipment, supplies.                                  text.
97032.............  Electrical             L023A               Physical Therapy Aide  NF                 Prepare and position                  1            0  G1: See preamble            -0.23
                     stimulation.                                                                         patient.                                              text.
97032.............  Electrical             L023A               Physical Therapy Aide  NF                 Other clinical                        0            1  G1: See preamble             0.23
                     stimulation.                                                                         Activity--specify:                                    text.
                                                                                                          post-treatment
                                                                                                          assistance.
97032.............  Electrical             L023A               Physical Therapy Aide  NF                 Clean room/equipment                  1            2  G1: See preamble             0.23
                     stimulation.                                                                         by physician staff.                                   text.
97032.............  Electrical             L039B               Physical Therapy       NF                 Assist therapist....                  0            3  G1: See preamble             1.17
                     stimulation.                               Assistant.                                                                                      text.
97032.............  Electrical             L039B               Physical Therapy       NF                 Check dressings &                     0            1  G1: See preamble             0.39
                     stimulation.                               Assistant.                                wound/home care                                       text.
                                                                                                          instructions/
                                                                                                          coordinate office
                                                                                                          visits/
                                                                                                          prescriptions.
97032.............  Electrical             SB022               gloves, non-sterile..  NF                 ....................                  1            0  G1: See preamble            -0.08
                     stimulation.                                                                                                                               text.
97032.............  Electrical             SB026               gown, patient........  NF                 ....................                  1            0  G1: See preamble            -0.53
                     stimulation.                                                                                                                               text.
97032.............  Electrical             SD055               electrode, electrical  NF                 ....................                  0            2  G1: See preamble             2.62
                     stimulation.                               stimulation.                                                                                    text.
97032.............  Electrical             SG079               tape, surgical paper   NF                 ....................                  0            6  G1: See preamble             0.01
                     stimulation.                               1in (Micropore).                                                                                text.
97032.............  Electrical             SJ020               electrode conductive   NF                 ....................                  0            5  G1: See preamble             0.08
                     stimulation.                               gel.                                                                                            text.
97032.............  Electrical             SJ053               swab-pad, alcohol....  NF                 ....................                  1            2  G1: See preamble             0.01
                     stimulation.                                                                                                                               text.
97032.............  Electrical             SK068               razor................  NF                 ....................                  0            1  G1: See preamble             0.39
                     stimulation.                                                                                                                               text.
97032.............  Electrical             SK082               towel, paper (Bounty)  NF                 ....................                  1            0  G1: See preamble            -0.01
                     stimulation.                               (per sheet).                                                                                    text.
97032.............  Electrical             SM012               disinfectant spray     NF                 ....................                  1            0  G1: See preamble            -0.03
                     stimulation.                               (Transeptic).                                                                                   text.
97033.............  Electric current       EF028               table, mat, hi-lo, 6   NF                 ....................                 20           15  G1: See preamble            -0.05
                     therapy.                                   x 8 platform.                                                                                   text.
97033.............  Electric current       EQ141               iontophoresis machine  NF                 ....................                 20           15  G1: See preamble            -0.01
                     therapy.                                                                                                                                   text.
97033.............  Electric current       L023A               Physical Therapy Aide  NF                 Other clinical                        0            1  G1: See preamble             0.23
                     therapy.                                                                             Activity--specify:                                    text.
                                                                                                          post-treatment
                                                                                                          assistance.
97033.............  Electric current       L023A               Physical Therapy Aide  NF                 Prepare room,                         2            3  G1: See preamble             0.23
                     therapy.                                                                             equipment, supplies.                                  text.
97033.............  Electric current       L023A               Physical Therapy Aide  NF                 Clean room/equipment                  1            3  G1: See preamble             0.46
                     therapy.                                                                             by physician staff.                                   text.
97033.............  Electric current       L039B               Physical Therapy       NF                 Other Clinical                        0            1  G1: See preamble             0.39
                     therapy.                                   Assistant.                                Activity--specify:                                    text.
                                                                                                          Obtain measurements.
97033.............  Electric current       SG055               gauze, sterile 4in x   NF                 ....................                  0            1  G1: See preamble             0.16
                     therapy.                                   4in.                                                                                            text.
97033.............  Electric current       SK068               razor................  NF                 ....................                  0            1  G1: See preamble             0.39
                     therapy.                                                                                                                                   text.
97034.............  Contrast bath therapy  L023A               Physical Therapy Aide  NF                 Clean room/equipment                  2            5  G1: See preamble             0.69
                                                                                                          by physician staff.                                   text.
97034.............  Contrast bath therapy  L023A               Physical Therapy Aide  NF                 Prepare room,                         2            3  G1: See preamble             0.23
                                                                                                          equipment, supplies.                                  text.
97034.............  Contrast bath therapy  L023A               Physical Therapy Aide  NF                 Prepare and position                  1            2  G1: See preamble             0.23
                                                                                                          patient.                                              text.

[[Page 34063]]

 
97034.............  Contrast bath therapy  L039B               Physical Therapy       NF                 Assist therapist....                  0            3  G1: See preamble             1.17
                                                                Assistant.                                                                                      text.
97034.............  Contrast bath therapy  L039B               Physical Therapy       NF                 Check dressings &                     0            3  G1: See preamble             1.17
                                                                Assistant.                                wound/home care                                       text.
                                                                                                          instructions/
                                                                                                          coordinate office
                                                                                                          visits/
                                                                                                          prescriptions.
97034.............  Contrast bath therapy  SB022               gloves, non-sterile..  NF                 ....................                  1            0  G1: See preamble            -0.08
                                                                                                                                                                text.
97034.............  Contrast bath therapy  SB026               gown, patient........  NF                 ....................                  1            0  G1: See preamble            -0.53
                                                                                                                                                                text.
97035.............  Ultrasound therapy...  EF028               table, mat, hi-lo, 6   NF                 ....................                 16           15  G1: See preamble            -0.01
                                                                x 8 platform.                                                                                   text.
97035.............  Ultrasound therapy...  EQ251               ultrasound unit,       NF                 ....................                 16            8  G1: See preamble            -0.03
                                                                therapeutic.                                                                                    text.
97035.............  Ultrasound therapy...  L023A               Physical Therapy Aide  NF                 Prepare and position                  1            0  G1: See preamble            -0.23
                                                                                                          patient.                                              text.
97035.............  Ultrasound therapy...  L023A               Physical Therapy Aide  NF                 Prepare room,                         1            0  G1: See preamble            -0.23
                                                                                                          equipment, supplies.                                  text.
97035.............  Ultrasound therapy...  L023A               Physical Therapy Aide  NF                 Other clinical                        0            1  G1: See preamble             0.23
                                                                                                          Activity--specify:                                    text.
                                                                                                          post-treatment
                                                                                                          assistance.
97035.............  Ultrasound therapy...  L039B               Physical Therapy       NF                 Assist therapist....                  0            3  G1: See preamble             1.17
                                                                Assistant.                                                                                      text.
97035.............  Ultrasound therapy...  SB022               gloves, non-sterile..  NF                 ....................                  1            0  G1: See preamble            -0.08
                                                                                                                                                                text.
97035.............  Ultrasound therapy...  SB026               gown, patient........  NF                 ....................                  1            0  G1: See preamble            -0.53
                                                                                                                                                                text.
97035.............  Ultrasound therapy...  SJ024               electrolyte coupling   NF                 ....................                  0            1  G1: See preamble             0.02
                                                                gel.                                                                                            text.
97035.............  Ultrasound therapy...  SJ062               ultrasound             NF                 ....................                 30            0  G1: See preamble            -0.39
                                                                transmission gel.                                                                               text.
97035.............  Ultrasound therapy...  SK082               towel, paper (Bounty)  NF                 ....................                  1            0  G1: See preamble            -0.01
                                                                (per sheet).                                                                                    text.
97035.............  Ultrasound therapy...  SM012               disinfectant spray     NF                 ....................                  1            0  G1: See preamble            -0.03
                                                                (Transeptic).                                                                                   text.
97110.............  Therapeutic exercises  EF028               table, mat, hi-lo, 6   NF                 ....................                 22           10  G1: See preamble            -0.12
                                                                x 8 platform.