Rule: Medicare: Hospital Outpatient Prospective Payment System and 2007 CY Payment Rates

Friday,
November 24, 2006
Part II
Department of
Health and Human
Services
Centers for Medicare & Medicaid Services
42 CFR Parts 410, 416 et al.

Medicare Program—Revisions to Hospital
Outpatient Prospective Payment System
and Calendar Year 2007 Payment Rates;
Final Rule
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67960 Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations
DEPARTMENT OF HEALTH AND fee-for-service (FFS) claims. This Human Services, Attention: CMS–1506–
HUMAN SERVICES restructuring is directed by section FC, P.O. Box 8011, Baltimore, MD
1874A of the Act, as added by section 21244–1850.
Centers for Medicare & Medicaid 911 of the MMA. The prior separate Please allow sufficient time for mailed
Services Medicare intermediary and Medicare comments to be received before the
carrier contracting authorities under close of the comment period.
42 CFR Parts 410, 416, 419, 421, 485, Title XVIII of the Act have been 3. By express or overnight mail. You
and 488 replaced with the Medicare may send written comments (one
[CMS–1506–FC; CMS–4125–F] Administrative Contractor (MAC) original and two copies) to the following
authority. address ONLY: Centers for Medicare &
RIN 0938–AO15 This final rule continues to Medicaid Services, Department of
implement the requirements of the DRA Health and Human Services, Attention:
Medicare Program; Hospital Outpatient that require that we expand the ‘‘starter CMS–1506–FC, Mail Stop C4–26–05,
Prospective Payment System and CY set’’ of 10 quality measures that we used 7500 Security Boulevard, Baltimore, MD
2007 Payment Rates; CY 2007 Update in FY 2005 and FY 2006 for the hospital 21244–1850.
to the Ambulatory Surgical Center inpatient prospective payment system
Covered Procedures List; Medicare 4. By hand or courier. If you prefer,
(IPPS) Reporting Hospital Quality Data you may deliver (by hand or courier)
Administrative Contractors; and for the Annual Payment Update
Reporting Hospital Quality Data for FY your written comments (one original
(RHQDAPU) program. We began to and two copies) before the close of the
2008 Inpatient Prospective Payment adopt expanded measures effective for
System Annual Payment Update comment period to one of the following
payments beginning in FY 2007. In this addresses: Room 445–G, Hubert H.
Program—HCAHPS Survey, SCIP, and rule, we are finalizing additional quality
Mortality Humphrey Building, 200 Independence
measures for the expanded set of Avenue, SW., Washington, DC 20201; or
AGENCY: Centers for Medicare & measures for FY 2008 payment 7500 Security Boulevard, Baltimore, MD
Medicaid Services (CMS), HHS. purposes. These measures include the 21244–1850.
HCAHPS survey, as well as Surgical If you intend to deliver your
ACTION: Final rule with comment period
Care Improvement Project (SCIP, comments to the Baltimore address,
and final rule.
formerly Surgical Infection Prevention please call telephone number (410) 786–
SUMMARY: This final rule with comment (SIP)), and Mortality quality measures. 7195 in advance to schedule your
period revises the Medicare hospital DATES: Effective Date: The provisions of arrival with one of our staff members.
outpatient prospective payment system these final rules are effective on January (Because access to the interior of the
to implement applicable statutory 1, 2007. Hubert H. Humphrey Building is not
requirements and changes arising from Comment Period: We will consider readily available to persons without
our continuing experience with this comments on the payment classification Federal Government identification,
system, and to implement certain assigned to HCPCS codes identified in commenters are encouraged to leave
related provisions of the Medicare Addendum B with the NI comment their comments in the CMS drop slots
Prescription Drug, Improvement, and code, and other areas specified located in the main lobby of the
Modernization Act (MMA) of 2003 and throughout the preamble, at the building. A stamp-in clock is available
the Deficit Reduction Act (DRA) of appropriate address, as provided below, for persons wishing to retain proof of
2005. In this final rule with comment no later than 5 p.m. January 23, 2007. filing by stamping in and retaining an
period, we describe changes to the Application Deadline—New Class of extra copy of the comments being filed.)
amounts and factors used to determine New Technology Intraocular Lens: Comments mailed to the addresses
the payment rates for Medicare hospital Requests for review of applications for indicated as appropriate for hand or
outpatient services paid under the a new class of new technology courier delivery may be delayed and
prospective payment system. These intraocular lenses must be received by received after the comment period.
changes are applicable to services close of business April 1, 2007.
For information on viewing public
furnished on or after January 1, 2007. In ADDRESSES: In commenting, please refer comments, see the beginning of the
addition, this final rule with comment to file code CMS–1506–FC. Because of SUPPLEMENTARY INFORMATION section.
period implements future CY 2009 staff and resource limitations, we cannot Applications for a new class of new
required reporting on quality measures accept comments by facsimile (FAX) technology intraocular lenses: Requests
for hospital outpatient services paid transmission. for review of applications for a new
under the prospective payment system. You may submit comments in one of class of new technology intraocular
This final rule with comment period four ways (no duplicates, please): lenses must be sent by regular mail to:
revises the current list of procedures 1. Electronically. You may submit ASC/NTIOL, Division of Outpatient
that are covered when furnished in a electronic comments on specific issues Care, Mailstop C4–05–17, Centers for
Medicare-approved ambulatory surgical in this regulation to http:// Medicare and Medicaid Services, 7500
center (ASC), which are applicable to www.cms.hhs.gov/eRulemaking. Click Security Boulevard, Baltimore, MD
services furnished on or after January 1, on the link ‘‘Submit electronic 21244–1850.
2007. comments on CMS regulations with an
This final rule with comment period open comment period.’’ (Attachments FOR FURTHER INFORMATION CONTACT:
revises the emergency medical should be in Microsoft Word, Alberta Dwivedi, (410) 786–0378,
screening requirements for critical WordPerfect, or Excel; however, we Hospital outpatient prospective
access hospitals (CAHs). prefer Microsoft Word.) payment issues.

This final rule with comment period 2. By regular mail. You may mail Dana Burley, (410) 786–0378,
supports implementation of a written comments (one original and two Ambulatory surgery center issues.
restructuring of the contracting entities copies) to the following address ONLY: Suzanne Asplen, (410) 786–4558, Partial
responsibilities and functions that Centers for Medicare & Medicaid hospitalization and community
support the adjudication of Medicare Services, Department of Health and mental health centers issues.
Federal Register / Vol. 71, No. 226 / Friday, November 24, 2006 / Rules and Regulations 67961
Mary Collins, (410) 786–3189, Critical Wide Web; the Superintendent of FAR Federal Acquisition Regulations
access hospital emergency medical Documents’ home page address is FDA Food and Drug Administration
planning issues. http://www.gpoaccess.gov/index.html, FFS Fee-for-service
Sandra M. Clarke, (410) 786–6975, by using local WAIS client software, or FSS Federal Supply Schedule
Medicare Administrative Contractors by telnet to swais.access.gpo.gov, then FY Federal fiscal year
issues. log in as guest (no password required). GAO Government Accountability
Mark Zobel, (410) 786–6905, Medicare Dial-in users should use Office
Administrative Contractors issues. communications software and modem HCPCS Healthcare Common Procedure
Liz Goldstein, (410) 786–6665, FY 2008 to call (202) 512–1661; type swais, then Coding System
IPPS RHQDAPU HCAHPS issues. log in as guest (no password required). HCRIS Hospital Cost Report
Bill Lehrman, (410) 786–1037, FY 2008 Information System
IPPS RHQDAPU HCAHPS issues. Alphabetical List of Acronyms HHA Home health agency
Sheila Blackstock, (410) 786–3506, FY Appearing in the Final Rule HIPAA Health Insurance Portability
2008 IPPS RHQDAPU SCIP and ACEP American College of Emergency and Accountability Act of 1996, Pub.
mortality issues. Physicians L. 104–191
SUPPLEMENTARY INFORMATION: AHA American Hospital Association ICD–9–CM International Classification
Submitting Comments: We welcome AHIMA American Health Information of Diseases, Ninth Edition, Clinical
comments from the public on the Management Association Modification
payment classification and status AMA American Medical Association IDE Investigational device exemption
indicator assigned to HCPCS codes APC Ambulatory payment IOL Intraocular lens
identified in Addendum B of this final classification IPPS [Hospital] Inpatient prospective
rule with comment period with AMP Average manufacturer price payment system
comment indicator NI and on the ASC Ambulatory Surgical Center IVIG Intravenous immune globulin
ambulatory surgical center procedures ASP Average sales price MAC Medicare Administrative
that were not proposed for addition to AWP Average wholesale price Contractors
the ambulatory surgical center list in the BBA Balanced Budget Act of 1997, MedPAC Medicare Payment Advisory
CY 2007 OPPS proposed rule to assist Pub. L. 105–33 Commission
us in fully considering issues and BBRA Medicare, Medicaid, and SCHIP MDH Medicare-dependent, small rural
developing policies. You can assist us [State Children’s Health Insurance hospital
by referencing filed code CMS–1506– Program] Balanced Budget MMA Medicare Prescription Drug,
FC. Refinement Act of 1999, Pub. L. 106– Improvement, and Modernization Act
Inspection of Public Comments: All 113 of 2003, Pub. L. 108–173
comments received before the close of BCA Blue Cross Association MPFS Medicare Physician Fee
the comment period are available for BCBSA Blue Cross and Blue Shield Schedule
viewing by the public, including any Association MSA Metropolitan Statistical Area
personally identifiable or confidential NCCI National Correct Coding
BIPA Medicare, Medicaid, and SCHIP
business information that is included in Initiative
Benefits Improvement and Protection
a comment. We post all comments NCD National Coverage Determination
Act of 2000, Pub. L. 106–554
received before the close of the NTIOL New technology intraocular
CAH Critical access hospital
comment period on the following Web lens
CBSA Core-Based Statistical Area
OCE Outpatient Code Editor
site as soon as possible after they have CCR Cost-to-charge ratio OMB Office of Management and
been received: http://www.cms.hhs.gov/ CMHC Community mental health
Budget
eRulemaking. Click on the link center OPD [Hospital] Outpatient department
‘‘Electronic Comments on CMS CMS Centers for Medicare & Medicaid OPPS [Hospital] Outpatient
Regulations’’ on that Web site to view Services prospective payment system
public comments. CNS Clinical nurse specialist PHP Partial hospitalization program
Comments received timely will also CORF Comprehensive outpatient PM Program memorandum
be available for public inspection as rehabilitation facility PPI Producer Price Index
they are received, generally beginning CPT [Physicians’] Current Procedural PPS Prospective payment system
approximately 3 weeks after publication Terminology, Fourth Edition, 2006, PPV Pneumococcal pneumonia (virus)
of a document, at the headquarters of copyrighted by the American Medical PRA Paperwork Reduction Act
the Centers for Medicare & Medicaid Association QIO Quality Improvement
Services, 7500 Security Boulevard, CRNA Certified registered nurse Organization
Baltimore, MD 21244, on Monday anesthetist RFA Regulatory Flexibility Act
through Friday of each week from 8:30 CY Calendar year RHQDAPU Reporting hospital quality
a.m. to 4:00 p.m. To schedule an DMEPOS Durable medical equipment, data for annual payment update
appointment to view public comments, prosthetics, orthotics, and supplies RHHI Regional home health
phone 1–800–743–3951. DMERC Durable medical equipment intermediary
regional carrier SBA Small Business Administration
Electronic Access DRA Deficit Reduction Act of 2005, SCH Sole community hospital
This Federal Register document is Pub. L. 109–171 SDP Single Drug Pricer
also available from the Federal Register DSH Disproportionate share hospital SI Status indicator
online database through GPO Access, a EACH Essential Access Community TEFRA Tax Equity and Fiscal
service of the U.S. Government Printing Hospital Responsibility Act of 1982, Pub. L.
Office. Free public access is available on E/M Evaluation and management 97–248
a Wide Area Information Server (WAIS) EPO Erythropoietin TOPS Transitional outpatient
through the Internet and via ESRD End-stage renal disease payments
asynchronous dial-in. Internet users can FACA Federal Advisory Committee USPDI United States Pharmacopoeia
access the database by using the World Act, Pub. L. 92–463 Drug Information
In this document, we address three 3. Payment Changes for Devices 1. CY 2007 Proposal
payment systems under the Medicare 4. Payment Changes for Drugs, Biologicals, 2. CY 2007 Final Rule Outlier Calculation
program: the hospital outpatient and Radiopharmaceuticals H. Calculation of the OPPS National
5. Estimate of Transitional Pass-Through Unadjusted Medicare Payment
prospective payment system (OPPS), the Spending in CY 2007 for Drugs, I. Beneficiary Copayments for CY 2007
hospital inpatient prospective payment Biologicals, and Devices 1. Background
system (IPPS), and the ambulatory 6. Brachytherapy Payment Changes 2. Copayment for CY 2007
surgical center (ASC) payment system. 7. Coding and Payment for Drugs 3. Calculation of an Adjusted Copayment
The provisions relating to the OPPS are Administration Amount for an APC Group for CY 2007
included in sections I. through XIII., 8. Hospital Coding and Payments for Visits III. OPPS Ambulatory Payment Classification
XV., XVI., XIX., XXIII., XXIV., XXV., 9. Payment for Blood and Blood Products (APC) Group Policies
10. Payment for Observation Services A. Treatment of New HCPCS and CPT
and XXVI. of the preamble and in
11. Procedures That Will Be Paid Only as Codes
Addenda A, B, C (Addendum C is Inpatient Services 1. Treatment of New HCPCS Codes
available on the Internet only; see 12. Nonrecurring Policy Changes Included in the Second and Third
section XXIII. of the preamble of this 13. Emergency Medical Screening in Quarterly OPPS Updates for CY 2006
final rule with comment period), D1, Critical Access Hospitals (CAHs) 2. Treatment of New CY 2007 Category I
D2, and E of this final rule with 14. Payment Status and Comment Indicator and III CPT Codes and Level II HCPCS
comment period. The provisions related Assignments Codes
to the IPPS are included in sections 15. OPPS Policy and Payment 3. Treatment of New Mid-Year CPT Codes
Recommendations B. Variations Within APCs
XXII. and XXVI.E. of the preamble. The 16. Policies Affecting Ambulatory Surgical 1. Background
provisions related to ASCs are included Centers (ASCs) for CY 2007 2. Application of the 2 Times Rule
in sections XVII. and XXV., and XXVI.C. 17. Revised ASC Payment System for 3. Exceptions to the 2 Times Rule
of the preamble and in Addenda AA of Implementation January 1, 2008 C. New Technology APCs
this final rule with comment period. 18. Medicare Contracting Reform Mandate 1. Introduction
In addition, in this document, we 19. Reporting Quality Data for Improved 2. Movement of Procedures from New
address our implementation of the Quality and Costs Under the OPPS Technology APCs to Clinical APCs
Medicare contracting reform provisions 20. Promoting Effective Use of Health a. Nonmyocardial Positron Emission
Information Technology Tomography (PET) Scans (APC 0308)
of the MMA that replace the prior 21. Health Care Information Transparency b. PET/Computed Tomography (CT) Scans
Medicare intermediary and carrier Initiative (APC 0308)
authorities formerly found in sections 22. Additional Quality Measures and c. Stereotactic Radiosurgery (SRS)
1816 and 1842 of the Act with Medicare Procedures for Hospital Reporting of Treatment Delivery Services (APCs 0065,
administrative contractor (MAC) Quality Data for FY 2008 IPPS Annual 0066, and 0067)
authority under a new section 1874A of Payment Update d. Magnetoencephalography (MEG)
the Act. The provisions relating to 23. Impact Analysis Services (APCs 0038 and 0209)
H. Public Comments Received in Response e. Other Services in New Technology APCs
MACs are included in sections XVIII.
to the CY 2007 OPPS and Reporting (1) Breast Brachytherapy (APCs 0029 and
and XXV.D. of this preamble. To assist Hospital Quality Data for FY 2008 IPPS 0030)
readers in referencing sections Annual Payment Update Program— (2) Radiofrequency Ablation (APCs 0050
contained in this document, we are HCAHPS Survey, SCIP, and Mortality and 0423)
providing the following table of Proposed Rules (3) Extracorporeal Shock Wave Treatment
contents: I. Public Comments Received on the (APC 0050)
November 10, 2005 OPPS Final Rule (4) Insertion of Venuous Access Device
Table of Contents with Comment Period with Two Ports (APC 0623)
I. Background for the OPPS II. Updates Affecting OPPS Payments for CY (5) Stereoscopic X-Ray Guidance (APC
A. Legislative and Regulatory Authority for 2007 0257)
the Hospital Outpatient Prospective A. Recalibration of APC Relative Weights (6) Whole Body Tumor Imaging (APC 0408)
Payment System for CY 2007 (7) Gastroesophageal Reflux Test With pH
B. Excluded OPPS Services and Hospitals 1. Database Construction Electrode (APC 0361)
C. Prior Rulemaking a. Database Source and Methodology (8) Home International Normalized Ratio
D. APC Advisory Panel b. Use of Single and Multiple Procedure (INR) Monitoring (APC 0604)
1. Authority of the APC Panel Claims (9) Tositumomab Administration and
2. Establishment of the APC Panel c. Revised Overall Cost-to-Charge Ratio Supply (APC 0442)
3. APC Panel Meetings and Organizational (CCR) Calculation (10) Summary of Other New Technology
Structure 2. Calculation of Median Costs for CY 2007 Procedures Assigned to Clinical APCs for
E. Provisions of the Medicare Prescription 3. Calculation of Scaled OPPS Payment CY 2007
Drug, Improvement, and Modernization Weights D. APC-Specific Policies
Act of 2003 4. Changes to Packaged Services 1. Radiology Procedures
1. Reduction in Threshold for Separate B. Payment for Partial Hospitalization a. Radiology Procedures (APCs 0333, 0662,
APCs for Drugs 1. Background and Other Imaging APCs)
2. Special Payment for Brachytherapy 2. PHP APC Update for CY 2007 b. Computerized Reconstruction (APC
F. Provisions of the Deficit Reduction Act 3. Separate Threshold for Outlier Payments 0417)
(DRA) of 2005 to CMHCs c. Cardiac Computed Tomography and
1. 3-Year Transition of Hold Harmless C. Conversion Factor Update for CY 2007 Computed Tomographic Angiography
Payments D. Wage Index Changes for CY 2007 (APCs 0282, 0376, 0377, and 0398)
2. Medicare Coverage of Ultrasound E. Statewide Average Default CCRs d. Radiologic Evaluation of Central Venous
Screening for Abdominal Aortic F. OPPS Payments to Certain Rural Access Device (APC 0340)
Aneurysms Hospitals 2. Nuclear Medicine and Radiation
3. Colorectal Cancer Screening 1. Hold Harmless Transitional Payment Oncology Procedures

G. Summary of the Provisions of the CY Changes Made by Pub. L. 109–171 (DRA) a. Myocardial Positron Emission
2007 OPPS Proposed Rule 2. Adjustment for Rural SCHs Implemented Tomography (PET) Scans (APC 0307)
1. Updates to the OPPS Payments for CY in CY 2006 Related to Pub. L. 108–173 b. Complex Interstitial Radiation Source
2007 (MMA) Application (APC 0651)
2. Ambulatory Payment Classification G. CY 2007 Hospital Outpatient Outlier c. Proton Beam Therapy (APCs 0664 and
(APC) Group Policies Payments 0667)
d. Urinary Bladder Residual Study (APC 1. Background 4. Guidelines Based on Patient Complexity
0340) 2. Drugs and Biologicals With Expiring B. CY 2007 Proposed and Final Coding
e. Hyperthermia Treatment (APC 0314) Pass-Through Status in CY 2006 Policies
f. Unlisted Procedure for Clinical 3. Drugs and Biologicals With Pass- 1. Clinic Visits
Brachytherpy (APC 0312) Through Status in CY 2007 2. Emergency Department Visits
3. Cardiac and Vascular Procedures B. Payment for Drugs, Biologicals, and 3. Critical Care Services
a. Electrophysiologic Recording/Mapping Radiopharmaceuticals Without Pass- C. CY 2007 Payment Policy
(APC 0087) Through Status D. CY 2007 Treatment of Guidelines
b. Endovenous Laser Ablation Procedures 1. Background 1. Background
(APC 0092) 2. Criteria for Packaging Payment for 2. Outstanding Concerns with the AHA/
c. Repair/Repositioning of Defibrillator Drugs, Biologicals, and AHIMA Guidelines
Leads (APC 0106) Radiopharmaceuticals a. Three Versus Five Levels of Codes
d. Thrombectomy Procedures (APCs 0103 3. Payment for Drugs, Biologicals, and b. Lack of Clarity for Some Interventions
and 0653) Radiopharmaceuticals Without Pass- c. Treatment of Separately Payable Services
4. Gastrointestinal and Genitourinary Through Status That Are Not Packaged d. Some Interventions Appear Overvalued
Procedures a. Payment for Specified Covered e. Concerns of Specialty Clinics
a. Insertion of Mesh or Other Prosthesis Outpatient Drugs f. American with Disabilities Act
(APC 0195) (1) Background g. Differentiation Between New and
b. Percutaneous Renal Cryoablation (APC (2) Payment Policy for CY 2007 Established Patients and Between
0423) (3) CY 2007 Payment Policy for Standard Visits and Consultations
c. Ultrasound Ablation of Uterine Fibroids Radiopharmaceuticals h. Distinction Between Type A and Type
with Magnetic Resonance Guidance (a) Background and Proposed CY 2007 B Emergency Departments
(MRgFUS) (APCs 0195 and 0202) Radiopharmaceutical Payment Policy X. Payment for Blood and Blood Products
d. Laser Vaporization of Prostate (APC (b) CY 2007 Final Radiopharmaceutical A. Background
0429) Payment Policy B. Policy Changes for CY 2007
e. Gastrointestinal Procedures with Stents b. CY 2007 Payment for Nonpass-Through XI. OPPS Payment for Observation Services
(APC 0384) Drugs, Biologicals, XII. Procedures That Will be Paid Only as
f. Endoscopy with Thermal Energy to Radiopharmaceuticals With HCPCS Inpatient Procedures
Sphincter (APC 0422) Codes, But Without OPPS Hospital A. Background
5. Ocular Procedures Claims Data B. Changes to the Inpatient List
a. Keratoprosthesis (APC 0293) (1) Background C. CY 2007 Payment for Ancillary
(2) CY 2007 Proposed and Final Payment Outpatient Services When Patient
b. Eye Procedures (APCs 0232, 0235, and
Policy for Radiopharmaceuticals With Expires (–CA Modifier)
0241)
HCPCS Codes, But Without Hospital 1. Background
c. Amniotic Membrane for Ocular Surface
Claims Data 2. Policy for CY 2007
Reconstruction
(3) CY 2007 Proposed and Final Payment XIII. Nonrecurring Policy Changes
6. Other Procedures
Policy for Drugs and Biologicals With A. Removal of Comprehensive Outpatient
a. Skin Replacement Surgery and Skin HCPCS Codes, But Without OPPS Rehabilitation Facility (CORF) Services
Substitutes (APC 0025) Hospital Claims Data from the List of Services Paid under the
b. Treatment of Fracture/Dislocation (APCs (4) CY 2007 Proposed and Final Payment OPPS
0062, 0063, and 0064) Policy for Drugs, Biologicals, and B. Addition of Ultrasound Screening for
c. Complex Skin Repair (APC 0024) Radiopharmaceuticals With HCPCS Abdominal Aortic Aneurysms (AAAs)
d. Insertion of Posterior Spinous Process Codes, But Without OPPS Hospital (Section 5112 of Pub. L. 109–171 (DRA))
Distraction Device Claims Data and Without ASP-Related 1. Background
7. Medical Services Data 2. Assignment of New HCPCS Code and
a. Medication Therapy Management VI. Estimate of OPPS Transitional Pass- Payment for Ultrasound Screening for
Services Through Spending in CY 2007 for Drugs, Abdominal Aortic Aneurysm (AAA)
b. Single Allergy Tests (APC 0381) Biologicals, Radiopharmaceuticals, and XIV. Emergency Medical Screening in
c. Hyperbaric Oxygen Therapy (APC 0659) Devices Critical Access Hospitals (CAHs)
d. Guidance for Chemodenervation (APC A. Total Allowed Pass-Through Spending A. Background
0215) B. Estimate of Pass-Through Spending for B. Proposed Policy Change
e. Pathology Services (APC 0344) CY 2007 C. Public Comments Received on the
IV. OPPS Payment Changes for Devices VII. Brachytherapy Source Payment Changes Proposal
A. Treatment of Device-Dependent APCs A. Background D. Final Policy
1. Background B. Government Accountability Office’s XV. OPPS Payment Status and Comment
2. CY 2007 Payment Policy Final Report on Devices of Indicators
3. Devices Billed in the Absence of an Brachytherapy A. CY 2007 Status Indicator Definitions
Appropriate Procedure Code C. Payments for Brachytherapy Sources in 1. Payment Status Indicators to Designate
4. Payment Policy When Devices are CY 2007 Services That Are Paid under the OPPS
Replaced Without Cost or Where Credit VIII. Changes to OPPS Drug Administration 2. Payment Status Indicators to Designate
for a Replaced Device is Furnished to the Coding and Payment for CY 2007 Services That Are Paid under a Payment
Hospital A. Background System Other Than the OPPS
B. Pass-Through Payments for Devices B. CY 2007 Drug Administration Coding 3. Payment Status Indicators to Designate
1. Expiration of Transitional Pass-Through Changes Services That Are Not Recognized under
Payments for Certain Devices C. CY 2007 Drug Administration Payment the OPPS But That May Be Recognized
a. Background Changes by Other Institutional Providers
b. Policy for CY 2007 IX. Hospital Coding and Payment for Visits 4. Payment Status Indicators to Designate
2. Provisions for Reducing Transitional A. Background Services That Are Not Payable by
Pass-Through Payments to Offset Costs 1. Guidelines Based on the Number or Medicare
Packaged into APC Groups Type of Staff Interventions B. CY 2007 Comment Indicator Definitions
a. Background 2. Guidelines Based on the Time Staff XVI. OPPS Policy and Payment
b. Policies for CY 2007 Spent with the Patient Recommendations
V. OPPS Payment Changes for Drugs, 3. Guidelines Based on a Point System A. MedPAC Recommendations
Biologicals, and Radiopharmaceuticals Where a Certain Number of Points Are B. APC Panel Recommendations
A. Transitional Pass-Through Payment for Assigned to Each Staff Intervention C. GAO Recommendations
Additional Costs of Drugs and Based on the Time, Intensity, and Staff XVII. Policies Affecting Ambulatory Surgical
Biologicals Type Required for the Intervention Centers (ASCs) for CY 2007
A. ASC Background b. Intermediary Functions b. Alternatives Considered for

1. Legislative History c. Options Available to Providers and CMS Brachytherapy Source Payments
2. Current Payment Method d. Nomination for Intermediary c. Alternatives Considered for Payment of
3. Published Changes to the ASC List e. Notification of Actions on Nominations, Radiopharmaceuticals
B. ASC List Update Effective for Services Changes to Another Intermediary or to 2. Limitation of Our Analysis
Furnished On or After January 1, 2007 Direct Payment, and Requirements for 3. Estimated Impact of This Final Rule
1. Criteria for Additions To or Deletions Approval of an Agreement with Comment Period on Hospitals
From the ASC List f. Considerations Relating to the Effective 4. Estimated Effect of This Final Rule with
2. Rationale for Payment Assignment and Efficient Administration of the Comment Period on Beneficiaries
3. Response to Comments to the May 4, Medicare Program 5. Conclusion
2005 Interim Final Rule for the ASC g. Assignment and Reassignment of 6. Accounting Statement
Update Providers by CMS C. Effects of Changes to the ASC Payment
4. Procedures Proposed for Additions to h. Designation of National or Regional System for CY 2007
the ASC List Intermediaries and Designation of 1. Alternatives Considered
5. Specific Requests for Payment Group Regional and Alternative Designated 2. Limitations on Our Analysis
Changes Regional Intermediaries for Home Health 3. Estimated Effects of This Final Rule with
6. Requests for Additions to the ASC List Agencies and Hospices Comment Period on ASCs
from Comments to the August 23, 2006 i. Awarding of Experimental Contracts 4. Estimated Effects of This Final Rule with
Proposed Rule XIX. Reporting Quality Data for Improved Comment Period on Beneficiaries
a. Requests Accepted for Additions to the Quality and Costs under the OPPS 5. Conclusion
ASC List for CY 2007 XX. Promoting Effective Use of Health 6. Accounting Statement
b. Requests Not Accepted for Additions to Information Technology D. Effects of the Medicare Contracting
the ASC List for CY 2007 XXI. Health Care Information Transparency Reform Mandate
7. Requests for Payment Increases for Initiative E. Effects of Additional Quality Measures
Procedures on the Current ASC List XXII. Additional Quality Measures and and Procedures for Hospital Reporting of
8. Other Comments on the May 4, 2005 Procedures for Hospital Reporting of Quality Data for IPPS FY 2008
Interim Final Rule Quality Data for the FY 2008 IPPS 1. Alternatives Considered
C. Regulatory Changes for CY 2007 Annual Payment Update 2. Estimated Effects of This Final Rule with
D. Implementation of Section 1834(d) of A. Background Comment Period
the Act B. Additional Quality Measures for FY a. Effects on Hospitals
E. Implementation of Section 5103 of Pub. 2008 b. Effects on Other Providers
L. 109–171 (DRA) 1. Introduction c. Effects on the Medicare and Medicaid
F. Modification of the Current ASC Process 2. HCAHPS Survey and the Hospital Program
for Adjusting Payment for New Quality Initiative F. Executive Order 12866
Technology Intraocular Lenses (NTIOLs) 3. Surgical Care Improvement Project
1. Background (SCIP) Quality Measures Regulation Text
a. Current ASC Payment for Insertion of 4. Mortality Outcome Measures Addenda
IOLs C. General Procedures and Participation
b. Classes of NTIOLs Approved for Requirements for the FY 2008 IPPS Addendum A—OPPS List of Ambulatory
Payment Adjustment RHQDAPU Program Payment Classification (APCs) with
2. Proposed and Final Changes D. HCAHPS Procedures and Participation Status Indicators (SI), Relative Weights,
a. Process for Recognizing IOLs as Requirements for the FY 2008 IPPS Payment Rates, and Copayment
Belonging to an Active IOL Class RHQDAPU Program Amounts—CY 2007
b. Public Notice and Comment Regarding 1. Introduction Addendum AA—List of Medicare Approved
Adjustments of NTIOL Payment 2. HCAHPS Hospital Pledge and Beginning ASC Procedures for CY 2007 With
Amounts Date for Data Collection Additions and Payment Rates; Including
c. Factors CMS Considers in Determining 3. HCAHPS Dry Run Rates That Result From Implementation
Whether an Adjustment of Payment for 4. HCAHPS Data Collection Requirements of Section 5103 of the DRA
Insertion of a New Class of NTIOL is 5. HCAHPS Registration Requirements Addendum B—OPPS Payment Status By
Appropriate 6. Additional Steps for HCAHPS HCPCS Code and Related Information
d. Revision of the Content of a Request to Participation CY 2007
Review 7. HCAHPS Survey Completion Addendum D1—Payment Status Indicators
e. Notice of CMS Determination Requirements Addendum D2—Comment Indicators
f. Payment Adjustment 8. HCAHPS Public Reporting Addendum E—CPT Codes That Are Paid
G. Announcement of CY 2007 Deadline for 9. Reporting HCAHPS Results for Multi- Only As Inpatient Procedures
Submitting Requests for CMS Review of Campus Hospitals Addendum L—Out-Migration Adjustment
Appropriateness of ASC Payment for E. SCIP & Mortality Measure Requirements I. Background for the OPPS
Insertion Following Cataract Surgery of for the FY 2008 RHQDAPU Program
an NTIOL F. Conclusion A. Legislative and Regulatory Authority
XVIII. Medicare Contracting Reform Mandate XXIII. Files Available to the Public Via the for the Hospital Outpatient Prospective
A. Background Internet Payment System
B. CMS’s Vision for Medicare Fee-for- XXIV. Collection of Information
Service and Medicare Administrative Requirements When the Medicare statute was
Contractors (MAC) XXV. Response to Comments originally enacted, Medicare payment
C. Provider Nomination and the Former XXVI. Regulatory Impact Analysis for hospital outpatient services was
Medicare Acquisition Authorities A. Overall Impact based on hospital-specific costs. In an
D. Summary of Changes Made to Section 1. Executive Order 12866 effort to ensure that Medicare and its
1816 of the Act 2. Regulatory Flexibility Act (RFA) beneficiaries pay appropriately for
E. Provisions of the Proposed and Final 3. Small Rural Hospitals services and to encourage more efficient
Regulations 4. Unfunded Mandates delivery of care, the Congress mandated

1. Definitions 5. Federalism
2. Assignments of Providers and Suppliers B. Effects of OPPS Changes in This Final
replacement of the reasonable cost-
to MACs Rule with Comment Period based payment methodology with a
3. Other Technical and Conforming 1. Alternatives Considered prospective payment system (PPS). The
Changes a. Alternatives Considered for Coding and Balanced Budget Act (BBA) of 1997
a. Definition of ‘‘Intermediary’’ Payment Policy for Visits (Pub. L. 105–33), added section 1833(t)
to the Social Security Act (the Act) All services and items within an APC other payment systems. Such excluded
authorizing implementation of a PPS for group are comparable clinically and services include, for example, the
hospital outpatient services (OPPS). with respect to resource use (section professional services of physicians and
The Medicare, Medicaid, and SCHIP 1833(t)(2)(B) of the Act). In accordance nonphysician practitioners paid under
Balanced Budget Refinement Act with section 1833(t)(2) of the Act, the Medicare Physician Fee Schedule
(BBRA) of 1999 (Pub. L. 106–113), made subject to certain exceptions, services (MPFS); laboratory services paid under
major changes in the hospital OPPS. and items within an APC group cannot the clinical diagnostic laboratory fee
The Medicare, Medicaid, and SCHIP be considered comparable with respect schedule; services for beneficiaries with
Benefits Improvement and Protection to the use of resources if the highest end-stage renal disease (ESRD) that are
Act (BIPA) of 2000 (Pub. L. 106–554), median (or mean cost, if elected by the paid under the ESRD composite rate;
made further changes in the OPPS. Secretary) for an item or service in the and, services and procedures that
Section 1833(t) of the Act was also APC group is more than 2 times greater require an inpatient stay that are paid
amended by the Medicare Prescription than the lowest median cost for an item under the hospital inpatient prospective
Drug, Improvement, and Modernization or service within the same APC group payment system (IPPS). We set forth the
Act (MMA) of 2003 (Pub. L. 108–173). (referred to as the ‘‘2 times rule’’). In services that are excluded from payment
The Deficit Reduction Act (DRA) of implementing this provision, we use the under the OPPS in § 419.22 of the
2005 (Pub. L. 109–171), enacted on median cost of the item or service regulations.
February 8, 2006, made additional assigned to an APC group. Under § 419.20(b) of the regulations,
changes in the OPPS. A discussion of Special payments under the OPPS we specify the types of hospitals and
the provisions contained in Pub. L. 109– may be made for new technology items entities that are excluded from payment
171 that are specific to the calendar year and services in one of two ways. Section under the OPPS. These excluded
(CY) 2007 OPPS is included in section 1833(t)(6) of the Act provides for entities include Maryland hospitals, but
II.F. of this preamble. temporary additional payments which only for services that are paid under a
The OPPS was first implemented for we refer to as ‘‘transitional pass-through cost containment waiver in accordance
services furnished on or after August 1, payments’’ for at least 2 but not more with section 1814(b)(3) of the Act;
2000. Implementing regulations for the than 3 years for certain drugs, biological critical access hospitals (CAHs);
OPPS are located at 42 CFR Part 419. agents, brachytherapy devices used for hospitals located outside of the 50
Under the OPPS, we pay for hospital the treatment of cancer, and categories States, the District of Columbia, and
outpatient services on a rate-per-service of other medical devices. For new Puerto Rico; and Indian Health Service
basis that varies according to the technology services that are not eligible hospitals.
ambulatory payment classification for transitional pass-through payments
(APC) group to which the service is C. Prior Rulemaking
and for which we lack sufficient data to
assigned. We use Healthcare Common appropriately assign them to a clinical On April 7, 2000, we published in the
Procedure Coding System (HCPCS) APC group, we have established special Federal Register a final rule with
codes (which include certain Current APC groups based on costs, which we comment period (65 FR 18434) to
Procedural Terminology (CPT) codes) refer to as new technology APCs. These implement a prospective payment
and descriptors to identify and group new technology APCs are designated by system for hospital outpatient services.
the services within each APC group. cost bands which allow us to provide The hospital OPPS was first
The OPPS includes payment for most appropriate and consistent payment for implemented for services furnished on
hospital outpatient services, except designated new procedures that are not or after August 1, 2000. Section
those identified in section I.B. of this yet reflected in our claims data. Similar 1833(t)(9) of the Act requires the
preamble. Section 1833(t)(1)(B)(ii) of the to pass-through payments, an Secretary to review certain components
Act provides for Medicare payment assignment to a new technology APC is of the OPPS not less often than annually
under the OPPS for hospital outpatient temporary; that is, we retain a service and to revise the groups, relative
services designated by the Secretary within a new technology APC until we payment weights, and other adjustments
(which includes partial hospitalization acquire sufficient data to assign it to a to take into account changes in medical
services furnished by community clinically appropriate APC group. practice, changes in technology, and the
mental health centers (CMHCs)) and addition of new services, new cost data,
hospital outpatient services that are B. Excluded OPPS Services and and other relevant information and
furnished to inpatients who have Hospitals factors.
exhausted their Part A benefits or who Section 1833(t)(1)(B)(i) of the Act Since initially implementing the
are otherwise not in a covered Part A authorizes the Secretary to designate the OPPS, we have published final rules in
stay. Section 611 of Pub. L. 108–173 hospital outpatient services that are the Federal Register annually to
added provisions for Medicare coverage paid under the OPPS. While most implement statutory requirements and
of an initial preventive physical hospital outpatient services are payable changes arising from our experience
examination, subject to the applicable under the OPPS, section with this system. We last published
deductible and coinsurance, as an 1833(t)(1)(B)(iv) of the Act excludes such a document on November 10, 2005
outpatient department service, payable payment for ambulance, physical and (70 FR 68516). In that final rule with
under the OPPS. occupational therapy, and speech- comment period, we revised the OPPS
The OPPS rate is an unadjusted language pathology services, for which to update the payment weights and
national payment amount that includes payment is made under a fee schedule. conversion factor for services payable
the Medicare payment and the Section 614 of Pub. L. 108–173 under the CY 2006 OPPS on the basis
beneficiary copayment. This rate is amended section 1833(t)(1)(B)(iv) of the of claims data from January 1, 2004,
divided into a labor-related amount and Act to exclude OPPS payment for through December 31, 2004, and to
a nonlabor-related amount. The labor- screening and diagnostic mammography implement certain provisions of Pub. L.
related amount is adjusted for area wage services. The Secretary exercised the 108–173. In addition, we responded to
differences using the inpatient hospital authority granted under the statute to public comments received on the
wage index value for the locality in exclude from the OPPS those services provisions of November 15, 2004 final
which the hospital or CMHC is located. that are paid under fee schedules or rule with comment period pertaining to
the APC assignment of HCPCS codes Panel, including its charter, Federal E. Provisions of the Medicare
identified in Addendum B of that rule Register notices, meeting dates, agenda Prescription Drug, Improvement, and
with the new interim (NI) comment topics, and meeting reports can be Modernization Act of 2003
indicators; and public comments viewed on the CMS Web site at http:// The Medicare Prescription Drug,
received on the July 25, 2005 OPPS www.cms.hhs.gov/FACA/ Improvement, and Modernization Act
proposed rule for CY 2006 (70 FR 05AdvisoryPanelonAmbulatory (MMA) of 2003, Pub. L. 108–173, made
42674). PaymentClassification changes to the Act relating to the
We published a correction of the Groups.as#TopOFPage. Medicare OPPS. In the January 6, 2004
November 10, 2005 final rule with interim final rule with comment period
3. APC Panel Meetings and
comment period on December 23, 2005 and the November 15, 2004 final rule
Organizational Structure
(70 FR 76176). This correction with comment period, we implemented
document corrected a number of The APC Panel first met on February provisions of Pub. L. 108–173 relating to
technical errors that appeared in the 27, February 28, and March 1, 2001. the OPPS that were effective for services
November 10, 2005 final rule with Since that initial meeting, the APC provided in CY 2004 and CY 2005,
comment period. Panel has held 10 subsequent meetings, respectively. In the November 10, 2005
with the last meeting taking place on final rule with comment period, we
D. APC Advisory Panel
August 23 and 24, 2006. (The APC Panel implemented provisions of Pub. L. 108–
1. Authority of the APC Panel did not meet on August 25, 2006, as 173 relating to the OPPS that went into
Section 1833(t)(9)(A) of the Act, as announced in the meeting notice effect for services provided in CY 2006
amended by section 201(h) of the BBRA, published on June 23, 2006 (71 FR (70 FR 68521). We note below those
requires that we consult with an outside 36118).) Prior to each meeting, we provision of Pub. L. 108–173 that will
panel of experts to review the clinical publish a notice in the Federal Register expire at the end of CY 2006.
integrity of the payment groups and to announce the meeting and, when
necessary, to solicit and announce 1. Reduction in Threshold for Separate
their weights under the OPPS. The Act APCs for Drugs
further specifies that the panel will act nominations for APC Panel
in an advisory capacity. The Advisory membership. Section 621(a)(2) of Pub. L. 108–173
Panel on Ambulatory Payment The APC Panel has established an amended section 1833(t)(16) of the Act
operational structure that, in part, to set a threshold of $50 per
Classification (APC) Groups (the APC
includes the use of three subcommittees administration for the establishment of
Panel), discussed under section I.D.2. of
to facilitate its required APC review separate APCs for drugs and biologicals
this preamble, fulfills these
process. The three current furnished from January 1, 2005, through
requirements. The APC Panel is not
subcommittees are the Data December 31, 2006. Because this
restricted to using data compiled by
Subcommittee, the Observation statutory provision will no longer be in
CMS and may use data collected or
Subcommittee, and the Packaging effect for CY 2007, we have included in
developed by organizations outside the
Subcommittee. The Data Subcommittee section V. of this preamble a discussion
Department in conducting its review.
is responsible for studying the data of the methodology that we will use to
2. Establishment of the APC Panel issues confronting the APC Panel and determine a threshold for establishing
On November 21, 2000, the Secretary for recommending options for resolving separate APCs for drugs and biologicals
signed the initial charter establishing them. The Observation Subcommittee for CY 2007.
the APC Panel. This expert panel, which reviews and makes recommendations to 2. Special Payment for Brachytherapy
may be composed of up to 15 the APC Panel on all issues pertaining
Section 621(b)(1) of Pub. L. 108–173
representatives of providers subject to to observation services paid under the
amended section 1833(t)(16) of the Act
the OPPS (currently employed full-time, OPPS, such as coding and operational
to require that payment for
not as consultants, in their respective issues. The Packaging Subcommittee
brachytherapy devices consisting of a
areas of expertise), reviews and advises studies and makes recommendations on
seed or seeds (or radioactive source)
CMS about the clinical integrity of the issues pertaining to services that are not
furnished on or after January 1, 2004,
APC groups and their weights. For separately payable under the OPPS, but
and before January 1, 2007, be paid
purposes of this Panel, consultants or are bundled or packaged APC payments.
based on the hospital’s charge for each
independent contractors are not Each of these subcommittees was
device furnished, adjusted to cost.
considered to be full-time employees. established by a majority vote of the
Because this statutory provision will no
The APC Panel is technical in nature APC Panel during a scheduled APC
longer be in effect for CY 2007, we
and is governed by the provisions of the Panel meeting and their continuation as
discuss our methodology for payment
Federal Advisory Committee Act subcommittees was approved at the
for brachytherapy devices for CY 2007
(FACA). Since its initial chartering, the August 2006 APC Panel meeting. All
in section VII.B. of this preamble.
Secretary has twice renewed the APC subcommittee recommendations are
Panel’s charter: on November 1, 2002, discussed and voted upon by the full F. Provisions of the Deficit Reduction
and on November 1, 2004. The current APC Panel. Act (DRA) of 2005
charter indicates, among other Discussions of the recommendations The Deficit Reduction Act (DRA) of
requirements, that the APC Panel resulting from the APC Panel’s March 2005, Pub. L. 109–171, enacted on
continues to be technical in nature; is 2006 and August 2006 meetings are February 8, 2006, included three
governed by the provisions of the included in the sections of this provisions affecting the OPPS, as
FACA; may convene up to three preamble that are specific to each discussed below.
meetings per year; has a Designated recommendation. For discussions of

Federal Officer (DFO); and is chaired by earlier APC Panel meetings and 1. 3-Year Transition of Hold Harmless
a Federal official who also serves as a recommendations, we reference Payments
CMS medical officer. previous hospital OPPS final rules or Section 5105 of Pub. L. 109–171
The current APC Panel membership the Web site mentioned earlier in this provides a 3-year transition of hold
and other information pertaining to the section. harmless OPPS payments for hospitals
located in a rural area with not more G. Summary of the Provisions of the CY • The proposed beneficiary
than 100 beds that are not defined as 2007 OPPS Proposed Rule copayment for OPPS services for CY
sole community hospitals (SCHs). This 2007.
On August 23, 2006, we published a
provision provides an increased proposed rule in the Federal Register 2. Ambulatory Payment Classification
payment for such hospitals for covered (71 FR 49506) that set forth proposed (APC) Group Policies
OPD services furnished on or after changes to the Medicare hospital OPPS
January 1, 2006, and before January 1, In the proposed rule, we discussed
for CY 2007 to implement statutory establishing a number of new APCs and
2009, if the OPPS payment they receive requirements and changes arising from
is less than the pre-BBA payment making changes to the assignment of
our continuing experience with the HCPCS codes under a number of
amount that they would have received system and to implement certain
for the same covered OPD services. This existing APCs based on our analyses of
provisions of Pub. L. 109–171 specified Medicare claims data and
provision specifies that, in such cases, in sections II.F.1. and XIII.B. of this
the amount of payment to the specified recommendations of the APC Panel. We
preamble. We also proposed to revise also discussed the application of the 2
hospitals shall be increased by the the standard for critical access hospital times rule and proposed exceptions to
applicable percentage of such personnel that are allowed to perform it; proposed changes for specific APCs;
difference. Section 5105 specifies the emergency medical screenings. In proposed movement of procedures from
applicable percentage as 95 percent for addition, we proposed changes to the the New Technology APCs; and the
CY 2006, 90 percent for CY 2007, and Medicare ASC payment system for CY proposed additions of new procedure
85 percent for CY 2008. This provision 2007 and CY 2008 and to the way we codes to the APC groups.
is discussed in section II.F.1. of the process fee-for-service (FFS) claims
preamble. under Medicare Part A and Part B. 3. Payment Changes for Devices
2. Medicare Coverage of Ultrasound Finally, we set forth a proposed rule In the proposed rule, we discussed
Screening for Abdominal Aortic seeking comments on the RHQDAPU proposed changes to the device-
Aneurysms (AAAs) program under the Medicare hospital dependent APCs and to payment for
IPPS for FY 2008. These changes will be pass-through devices. We also discussed
Section 5112 of Pub. L. 109–171 effective for payments beginning with the proposed payment policy for
amended section 1861 of the Act to FY 2008. The following is a summary of devices that are replaced without cost or
include coverage of ultrasound the major changes included in the CY credit to the hospital for a replaced
screening for abdominal aortic 2007 OPPS proposed rule: device and the proposed related
aneurysms for certain individuals on or regulation under § 419.45.
1. Updates to the OPPS’ Payments for
after January 1, 2007. The provision will 4. Payment Changes for Drugs,
CY 2007
apply to individuals (a) who receive a Biologicals, and Radiopharmaceuticals
referral for such an ultrasound screening In the proposed rule, we set forth—
In the proposed rule, we discussed
as a result of an initial preventive • The methodology used to
proposed payment changes for drugs,
physical examination; (b) who have not recalibrate the proposed APC relative
biologicals, and radiopharmaceuticals.
been previously furnished with an payment weights and the proposed
ultrasound screening under Medicare; median costs for CY 2007. 5. Estimate of Transitional Pass-Through
and (c) who have a family history of • The proposed payment for partial Spending in CY 2007 for Drugs,
abdominal aortic aneurysm or manifest hospitalization, including the proposed Biologicals, and Devices
risk factors included in a beneficiary separate threshold for outlier payments In the proposed rule, we discussed
category recommended for screening (as for CMHCs. the proposed methodology for
determined by the United States • The proposed update to the estimating total pass-through spending
Preventive Services Task Force). conversion factor used to determine and whether there should be a pro rata
Ultrasound screening for abdominal payment rates under the OPPS for CY reduction for transitional pass-through
aortic aneurysm will be included in the 2007. drugs, biologicals,
initial preventive physical examination. • The proposed retention of our radiopharmaceuticals, and categories of
Section 5112 also added ultrasound current policy to apply the IPPS wage devices for CY 2007.
screening for abdominal aortic indices to wage adjust the APC median
aneurysm to the list of services for 6. Brachytherapy Payment Changes
costs in determining the OPPS payment
which the beneficiary deductible does rate and the copayment standardized In the proposed rule, we included a
not apply. These amendments apply to amount for CY 2007. discussion of our proposal concerning
services furnished on or after January 1, • The proposed update of statewide coding and payment for the sources of
2007. See section XIII.B. of this average default cost-to-charge ratios. brachytherapy.
preamble for a detailed discussion of • Proposed changes relating to the 7. Coding and Payment for Drugs
this provision. hold harmless payment provision and Administration
3. Colorectal Cancer Screening § 419.70(d). In the proposed rule, we discussed
• Proposed changes relating to our proposed coding and payment
Section 5113 of Pub. L. 109–171 payment for rural SCHs, including changes for drug administration
amended section 1833(b) of the Act to Essential Access Community Hospitals services.
add colorectal cancer screening to the (EACHs) for CY 2007.
list of services for which the beneficiary • The proposed retention of our 8. Hospital Coding and Payments for
deductible does not apply. This current policy for calculating hospital Visits
provision applies to services furnished outpatient outlier payments for CY In the proposed rule, we discussed
on or after January 1, 2007. See the 2007. our analyses of various guidelines for
Medicare Physician Fee Schedule • Calculation of the proposed coding hospital visits and the proposed
(MPFS) CY 2007 final rule for a detailed national unadjusted Medicare OPPS HCPCS codes and payment policy for
discussion of this provision. payment. those visits.
9. Payment for Blood and Blood 17. Revised ASC Payment System for H. Public Comments Received in
Products Implementation January 1, 2008 Response to the CY 2007 OPPS Proposal
Rule and on the Reporting Hospital
In the proposed rule, we discussed In the proposed rule, we set forth our Quality Data for FY 2008 IPPS Annual
our proposed criteria and coding proposal to revise the current ASC Payment Update Program—HCAHPS
changes for the blood and blood payment system in accordance with Survey, SCIP, and Mortality Proposed
products. Pub. L. 108–173, effective January 1, Rule
10. Payment for Observation Services 2008. We note that we are not finalizing
this proposal in this final rule with We received approximately 1,100
In the proposed rule, we discussed timely items of correspondence
our proposed continuation of applying comment period. Rather, we will issue
a separate document in the Federal containing multiple comments on the
the criteria for separate payment for CY 2007 OPPS proposed rule. We note
observation services and the coding Register that will address public
that we received some comments that
methodology for observation services comments received and finalize the ASC
were outside of the scope of the CY
implemented in CY 2006. payment system effective January 1, 2007 OPPS proposed rule. These
2008. comments are not addressed in the CY
11. Procedures That Will Be Paid Only
as Inpatient Services 18. Medicare Contracting Reform 2007 final rule. We also received
Mandate approximately 20 timely items of
In the proposed rule, we discussed correspondence on Reporting Hospital
the procedures that we proposed to In the proposed rule, we set forth Quality Data for FY 2008 Inpatient
remove from the inpatient list and changes to the way we process FFS Prospective Payment System Annual
assign to APCs. claims under Medicare Part A and Part Payment Update Program—HCAHPS
12. Nonrecurring Policy Changes B. Survey, SCIP, and Mortality proposed
rule. Summaries of the public comments
In the proposed rule, we discussed a 19. Reporting Quality Data for Improved and our responses to those comments
proposed technical change to Quality and Costs Under the OPPS are set forth under the appropriate
§ 419.21(d) of the regulations related to headings.
Comprehensive Outpatient In the proposed rule, we proposed to
Rehabilitation Facility (CORF) services adapt the quality improvement I. Public Comments Received on the
and proposed coding and payment for mechanism provided by the IPPS November 10, 2005 OPPS Final Rule
ultrasound screening for abdominal RHQDAPU program for use under the with Comment Period
aortic aneurysms (AAAs) as a new OPPS.
We received approximately 41 timely
service paid under the OPPS in CY 20. Promoting Effective Use of Health items of correspondence on the
2007. Information Technology November 10, 2005 OPPS final rule with
13. Emergency Medical Screening in comment period, some of which
Critical Access Hospitals (CAHs) In the proposed rule, we discussed contained multiple comments on the
our plans to promote and adopt effective APC assignment of HCPCS codes
In the proposed rule, we discussed use of health information technology to identified with the NI comment
our proposal to revise § 485.618(d) of improve the quality of care for Medicare indicator in Addendum B of that final
the regulations pertaining to the beneficiaries. rule with comment period. Summaries
standards for critical access hospital of those public comments and our
personnel available to perform 21. Health Care Information
responses to those comments are set
emergency medical screening services. Transparency Initiative forth in the various sections under the
14. Payment Status and Comment In the proposed rule, we announced appropriate headings.
Indicator Assignments our plans to launch a major health care II. Updates Affecting OPPS Payments
In the proposed rule, we discussed transparency initiative in 2006. for CY 2007
our list of status indicators assigned to 22. Additional Quality Measures and A. Recalibration of APC Relative
APCs and presented our comment Procedures for Hospital Reporting of Weights for CY 2007
indicators that we proposed to use in
Quality Data for FY 2008 IPPS Annual
this final rule with comment period. 1. Database Construction
Payment Update
15. OPPS Policy and Payment a. Database Source and Methodology
Recommendations In the proposed rule, we discussed
our proposal to expand the IPPS Section 1833(t)(9)(A) of the Act
In the proposed rule, we addressed Reporting Hospital Quality Data for requires that the Secretary review and
recommendations made by MedPAC, Annual Payment program measurement revise the relative payment weights for
the APC Panel, and the GAO regarding APCs at least annually. In the April 7,
set for FY 2008 beyond the measures
the OPPS for CY 2007. 2000 OPPS final rule with comment
adopted for the FY 2007 IPPS update.
period (65 FR 18482), we explained in
16. Policies Affecting Ambulatory
23. Impact Analysis detail how we calculated the relative
Surgical Centers (ASCs) for CY 2007
payment weights that were
In the proposed rule, we discussed In the proposed rule, we set forth an implemented on August 1, 2000, for
changes to the ASC list of covered analysis of the impact that the proposed each APC group. Except for some
procedures for CY 2007; changes will have on affected entities reweighting due to a small number of
implementation of section 5103 of Pub. and beneficiaries. APC changes, these relative payment
L. 108–173; our proposal for modifying weights continued to be in effect for CY
the current ASC process for adjusting 2001. This policy is discussed in the
payment for new technology intraocular November 13, 2000 interim final rule
lenses; and related regulatory changes. (65 FR 67824 through 67827).
In the CY 2007 OPPS proposed rule, most recently submitted cost report data For CY 2003, we created ‘‘pseudo’’
we proposed to use the same basic as reported to the HCRIS system as of single claims by bypassing HCPCS
methodology that we described in the June 30, 2006, to calculate the cost-to- codes 93005 (Electrocardiogram,
April 7, 2000 final rule with comment charge ratios (CCRs) used to reduce the tracing), 71010 (Chest x-ray), and 71020
period to recalibrate the APC relative billed charges to costs for purposes of (Chest x-ray) on a submitted claim.
payment weights for services furnished calculating the median costs on which However, we did not use claims data for
on or after January 1, 2007, and before the CY 2007 OPPS rates are based. the bypassed codes in the creation of the
January 1, 2008. That is, we would After carefully considering all median costs for the APCs to which
recalibrate the relative payment weights comments received, we are finalizing these three codes were assigned because
for each APC based on claims and cost our data source and methodology for the the level of packaging that would have
report data for outpatient services. We recalibration of CY 2007 APC relative remained on the claim after we selected
proposed to use the most recent payment weights as proposed without the bypass code was not apparent and,
available data to construct the database modification, as described in this therefore, it was difficult to determine if
for calculating APC group weights. For section. the medians for these codes would be
the purpose of recalibrating the APC b. Use of Single and Multiple Procedure correct.
relative payment weights for CY 2007, For CY 2004, we created ‘‘pseudo’’
Claims
we used approximately 142.5 million single claims by bypassing these three
final action claims for hospital OPD For CY 2007, we proposed to continue codes and also by bypassing an
services furnished on or after January 1, to use single procedure claims to set the additional 269 HCPCS codes in APCs.
2005, and before January 1, 2006. Of the medians on which the APC relative We selected these codes based on a
142.5 million final action claims for payment weights would be based. We clinical review of the services and
services provided in hospital outpatient have received many requests asking that because it was presumed that these
settings, 110.2 million claims were of we ensure that the data from claims that codes had only very limited packaging
the type of bill potentially appropriate contain charges for multiple procedures and could appropriately be bypassed for
for use in setting rates for OPPS services are included in the data from which we the purpose of creating ‘‘pseudo’’ single
(but did not necessarily contain services calculate the relative payment weights. claims. The APCs to which these codes
payable under the OPPS). Of the 110.2 Requesters believe that relying solely on were assigned were varied and included
million claims, approximately 51.7 single procedure claims to recalibrate mammography, cardiac rehabilitation,
million were not for services paid under APC relative payment weights fails to and Level I plain film x-rays. To derive
the OPPS or were excluded as not take into account data for many more ‘‘pseudo’’ single claims, we also
appropriate for use (for example, frequently performed procedures, split the claims where there were dates
erroneous cost-to-charge ratios or no particularly those commonly performed of service for revenue code charges on
HCPCS codes reported on the claim). in combination with other procedures. that claim that could be matched to a
We were able to use 54.1 million whole They believe that, by depending upon single procedure code on the claim on
claims of the remaining 58.5 million single procedure claims, we base the same date.
claims to set the OPPS APC relative relative payment weights on the least For the CY 2004 OPPS, as in CY 2003,
weights for CY 2007 OPPS. From the costly services, thereby introducing we did not include the claims data for
54.1 million whole claims, we created downward bias to the medians on the bypassed codes in the creation of the
98.5 million single records, of which which the weights are based. APCs to which the 269 codes were
68.5 million were ‘‘pseudo’’ single We agree that, optimally, it is assigned because, again, we had not
claims (created from multiple procedure desirable to use the data from as many established that such an approach was
claims using the process we discuss in claims as possible to recalibrate the APC appropriate and would aid in accurately
this section). relative payment weights, including estimating the median costs for those
As proposed, the final APC relative those with multiple procedures. We APCs. For CY 2004, from approximately
weights and payments for CY 2007 in generally use single procedure claims to 16.3 million otherwise unusable claims,
Addenda A and B to this final rule with set the median costs for APCs because we used approximately 9.5 million
comment period were calculated using we are, so far, unable to ensure that multiple procedure claims to create
claims from this period that had been packaged costs can be appropriately approximately 27 million ‘‘pseudo’’
processed before June 30, 2006, and allocated across multiple procedures single claims. For CY 2005, we
continue to be based on the median performed on the same date of service. identified 383 bypass codes and from
hospital costs for services in the APC However, by bypassing specified codes approximately 24 million otherwise
groups. We selected claims for services that we believe do not have significant unusable claims, we used
paid under the OPPS and matched these packaged costs, we are able to use more approximately 18 million multiple
claims to the most recent cost report data from multiple procedure claims. In procedure claims to create
filed by the individual hospitals many cases, this enables us to create approximately 52 million ‘‘pseudo’’
represented in our claims data. multiple ‘‘pseudo’’ single claims from single claims. For CY 2005, we used the
Comment: Several commenters claims that, as submitted, contained claims data for the bypass codes
supported the use of the most recent multiple separately paid procedures on combined with the single procedure
claims and cost report data to calculate the same claim. For the CY 2007 OPPS, claims to set the median costs for the
the median costs for use in the CY 2007 we proposed to use the date of service bypass codes.
OPPS. on the claims and a list of codes to be For CY 2006, we continued using the
Response: We appreciate the bypassed to create ‘‘pseudo’’ single codes on the CY 2005 OPPS bypass list
commenters’ support and have used the claims from multiple procedure claims, and expanded it to include 404 bypass
claims for services paid under the CY as we did in recalibrating the CY 2006 codes, including 3 bladder
2005 OPPS as processed through the APC relative payment weights. We refer catheterization codes (CPT codes 51701,
common working file as of June 30, to these newly created single procedure 51702, and 51703), which did not meet
2006, in the calculation of the median claims as ‘‘pseudo’’ single claims the empirical criteria discussed below
costs on which the CY 2007 OPPS rates because they were submitted by for the selection of bypass codes. We
are based. In addition, we have used the providers as multiple procedure claims. added these three codes to the CY 2006
bypass list because a decision to change bypass list and to expand it by adding list is contained in the discussion of
their payment status from packaged to codes that, using data presented to the drug administration payment changes in
separately paid would have resulted in APC Panel at its March 2006 meeting, section VIII.C. of this preamble.
a reduction of the number of single bills meet the same empirical criteria as In the CY 2007 OPPS proposed rule,
on which we could base median costs those used in CY 2006 to create the we specifically invited public comment
for other major separately paid bypass list, or which our clinicians on the ‘‘pseudo’’ single process,
procedures that were billed on the same believe would contain minimal including the bypass list and the
claim with these three procedure codes. packaging if the services were correctly criteria.
That is, single bills which contained coded (for example, ultrasound Comment: The commenters urged
other procedures would have become guidance). (Bypass codes shown in CMS to continue to find ways to use all
multiple procedure claims when these Table 1 with an asterisk indicated the data from multiple procedure claims to
bladder catheterization codes were HCPCS codes we proposed to add to the set the median costs on which the
converted to separately paid status. We CY 2006 OPPS listed codes for bypass payment rates are based. Many
believed and continue to believe that in CY 2007.) Our examination of the commenters supported the bypass list as
bypassing these three codes does not data against the criteria for inclusion on a vehicle to enable use of all claims
adversely affect the medians for other the bypass list, as discussed below for data. However, some commenters were
procedures because we believe that the addition of new codes, shows that concerned that placing HCPCS codes on
when these services are performed on the empirically selected codes used for the bypass list would lead to those
the same day as another separately paid bypass for the CY 2006 OPPS generally codes being undervalued because no
service, any packaging that appears on continue to meet the criteria or come packaging from the multiple procedure
the claim would be appropriately very close to meeting the criteria, and bill is attributed to them. These
associated with the other procedure and we have received no comments against commenters urged CMS to validate that
not with these codes. bypassing them. these services were not being
Consequently, for CY 2006, we As proposed, the following empirical systematically undervalued by being
identified 404 bypass codes for use in criteria that we used to determine the bypassed and thus having many units of
creating ‘‘pseudo’’ single claims and additional codes to add to the CY 2006 the service used for median setting with
used some part of 90 percent of the total OPPS bypass list to create the bypass no attribution of packaging to the code.
claims that were eligible for use in list for the CY 2007 OPPS were In many cases, the commenters did not
OPPS ratesetting and modeling in developed by reviewing the frequency offer specific discussion of what
developing the final rule with comment and magnitude of packaging in the packaging they believe would be
period. This process enabled us to use, single claims for payable codes other appropriately attached to the codes on
for the CY 2006 OPPS, 88 million single than drugs and biologicals. We assumed the bypass list. One commenter
bills for ratesetting: 55 million ‘‘pseudo’’ that the representation of packaging on suggested that CMS add CPT code
singles and 34 million ‘‘natural’’ single the single claims for any given code is 77421 (Steroscopic X-ray guidance for
bills (bills that were submitted comparable to packaging for that code in localization of target volume for the
containing only one separately payable the multiple claims: delivery of radiation therapy) to secure
major HCPCS code). (These numbers do • There were 100 or more single more single procedure claims data for
not sum to 88 million because more claims for the code. This number of median setting. Another commenter
than 800,000 single bills were removed single claims ensured that observed asked that CMS add CPT code 88307
when we trimmed at the HCPCS level at outcomes were sufficiently (Level V-Surgical pathology, gross and
+/-3 standard deviations from the representative of packaging that might microscopic examination) to the bypass
geometric mean.) occur in the multiple claims. list because it would be consistent with
For CY 2007, we proposed to continue • Five percent or fewer of the single the inclusion of CPT codes 88304 (Level
using date-of-service matching as a tool claims for the code had packaged costs III-Surgical pathology, gross and
for creation of ‘‘pseudo’’ single claims on that single claim for the code. This microscopic examination) and 88305
and to continue the use of a bypass list criterion results in limiting the amount (Level IV-Surgical pathology, gross and
to create ‘‘pseudo’’ single claims. The of packaging being redistributed to the microscopic examination) on the bypass
process we proposed for the CY 2007 payable procedure remaining on the list.
OPPS resulted in our being able to use claim after the bypass code is removed Response: We agree that the bypass
some part of 92.6 percent of the total and ensures that the costs associated list has been very useful in enabling us
claims that are eligible for use in the with the bypass code represent the cost to use data from multiple procedure
OPPS ratesetting and modeling in of the bypassed service. claims to set median costs for many
developing this final rule with comment • The median cost of packaging services. The use of date of service
period. This process enabled us to use, observed in the single claims was equal stratification and the bypass list enabled
for CY 2007, 68.5 million ‘‘pseudo’’ to or less than $50. This limits the us to create 68.5 million ‘‘pseudo’’
singles and 31.6 million ‘‘natural’’ amount of error in redistributed costs. single claims that would not otherwise
single bills. • The code is not a code for an have been used to set median costs for
We proposed to bypass the 454 codes unlisted service. the CY 2007 OPPS. However, we
identified in Table 1 of the proposed In addition, we proposed to add to the recognize that it is necessary to be
rule (71 FR 49517) to create new single bypass list codes that our clinicians cautious in this approach to minimize
claims and to use the line-item costs believe contain minimal packaging and the possibility that we could mistakenly
associated with the bypass codes on codes for specified drug administration apply packaging on the claim to the
these claims, together with the single services for which hospitals have wrong service. For that reason, each
procedure claims, in the creation of the requested separate payment but for year we investigate the amount of
median costs for the APCs into which which it is not possible to acquire packaging on natural single bills and
they are assigned. Of the codes on this median costs unless we add these codes consider whether changes should be
list, 404 codes were used for bypass in to the bypass list. A more complete made to the bypass list. However, in
CY 2006. We proposed to continue the discussion of the effects of adding these some cases, we know that the natural
use of the codes on the CY 2006 OPPS drug administration codes to the bypass single bills are incorrect, and it is not
reasonable to base a decision on their procedure claims by allocating the median is close to the median for the
level of packaging from what we believe packaging on a claim with multiple ‘‘pseudo’’ single claims. If removing this
are incorrectly coded claims. In these surgical procedures based on the code from the bypass list altogether
cases, we use clinical judgment to currently existing relative weights to results in too few ‘‘pseudo’’ single
determine whether, on a correctly coded create ‘‘pseudo’’ single claims from all claims, the commenter requested that
claim, the packaging would be multiple procedure claims. The CMS calculate the median cost for APC
associated with the code as defined or commenter suggested that if CMS is 0268 using only natural single claims.
whether the packaging would more concerned about that process causing
appropriately be associated with other the weights being calculated to not Response: We agree with the
procedures. For example, a single reflect changes in cost, CMS might use commenter that the median of APC 0268
procedure bill for an ultrasound this process only in cases in which the is higher with the exclusion of
guidance service which is used only for number of units for HCPCS codes on ‘‘pseudo’’ singles that are created from
guidance during an associated surgical natural single bills are below some claims that include CPT code 76942
procedure would not be correctly coded tolerance so that these claims would be than it would be if we only used true
and therefore, clinically, we would not used only on low volume procedures. single claims that include CPT code
expect the packaged costs observed on Response: We are concerned that use 76942. However, we believe that the
these single claims to be correctly of the current relative weights to single bills for CPT code 76942 are
attributed to the guidance procedure. allocate the packaging on multiple miscoded and, therefore,
We believe that the ultrasound guidance procedure claims may cause packaging inappropriately attribute the procedural
procedure itself could not be the service to be allocated inappropriately in some costs (for example, the needle
that required the drugs, devices, or cases. As we indicate above, we are placement for biopsy and injection) to
operating room use that would usually continuing to explore ways that ultrasound guidance rather than the
also be billed on a correctly coded packaging could be allocated on biopsy or aspiration procedures. We
claim. In these cases, we would place multiple procedure claims in such a
note that CPT code 76942 is the code
the ultrasound guidance procedure on way that we would have confidence in
with the highest frequency in APC 0268
the bypass list and attribute the the allocation.
Comment: One commenter requested and, therefore, contributes greatly to the
packaged costs that appear on the same
claim to the surgical procedure on the that CMS remove CPT code 76942 median cost of the APC. The commenter
claim. (Ultrasonic guidance for needle provided no information regarding the
We have been actively investigating placement (eg biopsy, aspiration, specific packaging associated with CPT
options for using all claims data in the injection, localization device), imaging code 76942; therefore, we continue to
establishment of median costs, and we supervision and interpretation) from the believe that its inclusion on the bypass
intend to be ready to discuss our bypass list, because the commenter list, and the resulting calculation of the
findings in the CY 2008 OPPS proposed believed it would raise the median cost APC median cost for APC 0268, is
rule. With respect to the suggestions for for APC 0268, the APC where CPT code appropriate.
additions to the bypass list, we will 76942 is assigned for CY 2007. After carefully considering all public
evaluate the potential for adding CPT According to the commenter, the natural comments received on our proposal, we
codes 77421 and 88307 to the bypass single claims for CPT code 76942 have are adopting as final the proposed
list for purposes of the CY 2008 OPPS a higher median cost than the ‘‘pseudo’’
‘‘pseudo’’ single process and the bypass
ratesetting. single claims. The commenter indicated
codes listed in Table 1.
Comment: One commenter asked that that when all packaged costs are
BILLING CODE 4120–01–P
CMS use all claims data on multiple removed from the natural singles, their
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ER24NO06.004</GPH>
ER24NO06.005</GPH>
ER24NO06.006</GPH>
ER24NO06.007</GPH>
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ER24NO06.009</GPH>
ER24NO06.010</GPH>
BILLING CODE 4120–01–C As stated in the CY 2007 OPPS 03–04, that is, the fiscal intermediary
proposed rule (71 FR 49528), we have calculation, diverged from the
c. Revised Overall Cost-to-Charge Ratio ‘‘traditional’’ overall CCR that we used
discovered that the calculation of the
(CCR) Calculation for modeling. It should be noted that the
overall CCR that the fiscal
We calculate both an overall CCR and intermediaries are using to determine fiscal intermediary overall CCR
cost center-specific cost-to-charge ratios outlier payments and payments for calculation noted in Program
(CCRs) for each hospital. For the CY services paid at charges reduced to cost Transmittal A–03–04 was created with
2007 OPPS, we proposed to change the differs from the overall CCR that we use feedback and input from the fiscal
methodology for calculating the overall to model the OPPS. In Program intermediaries.
CCR. The overall CCR is used in many Transmittal A–03–04 on ‘‘Calculating CMS’ ‘‘traditional’’ calculation
components of the OPPS. We use the Provider-Specific Outpatient Cost-to- consists of summing the total costs from
overall CCR to estimate costs from Charge Ratios (CCRs) and Instructions Worksheet B, Part I (Column 27), after
charges on a claim when we do not have on Cost Report Treatment of Hospital removing the costs for nursing and
an accurate cost center CCR. This does Outpatient Services Paid on a paramedical education (Columns 21 and
not happen very often. For the vast Reasonable Cost Basis’’ (January 17, 24), for those ancillary cost centers that
majority of services, we are able to use 2003), we revised the overall CCR we believe contain most OPPS services,
a cost center CCR to estimate costs from calculation that the fiscal intermediaries summing the total charges from
charges. However, we also use the use in determining outlier and other Worksheet C, Part I (Columns 6 and 7)
overall CCR to identify the outlier cost payments. Until this point, each for the same set of ancillary cost centers,
threshold, to model payments for fiscal intermediary had used an overall and dividing the former by the latter.
services that are paid at charges reduced CCR provided by CMS, or calculated an We exclude selected ancillary cost
to cost, and, during implementation, to updated CCR at the provider’s request centers from our overall CCR
determine outlier payments and using the same calculation. The calculation, such as 5700 Renal Dialysis,
ER24NO06.011</GPH>
payments for other services. calculation in Program Transmittal A– because we believe that the costs and
charges in these cost centers are largely intermediary calculation is attributable overall. As predicted, we observed
paid for under other payment systems. to the inclusion of allied health costs for minor changes in APC median costs
The specific list of ancillary cost the over 700 hospitals with allied health from the adoption of the proposed
centers, both standard and nonstandard, programs. It is inappropriate to include overall CCR calculation. We largely
included in our overall CCR calculation these costs in the overall CCR observed differences of no more than 5
is available on our Web site in the calculation, because CMS already percent in either direction. The median
revenue center-to-cost center crosswalk reimburses hospitals for the costs of overall percent change in APC cost
workbook: http://www.cms.hhs.gov/ these programs through cost report estimates was ¥0.3 percent. We
HospitalOutpatientPPS. settlement. The higher median estimate typically observe comparable changes in
The overall CCR calculation provided and greater variability also is a function APC medians when we update our cost
in Program Transmittal A–03–04, on the of the weighting by Medicare Part B report data. Using updated cost report
other hand, takes the CCRs from charges. Because the fiscal intermediary data for the calculations in this final
Worksheet C, Part I, Column 9, for each overall CCR calculation is higher, on rule with comment period, we estimate
specified ancillary cost center; average, CMS has underestimated the a median overall CCR across all
multiplies them by the Medicare Part B outlier payment thresholds and, hospitals of 0.3015 using the new
outpatient specific charges in each therefore, overpaid outlier payments. overall CCR calculation.
corresponding ancillary cost center from We also have underestimated spending We believe that a single overall CCR
Worksheet D, Part V (Columns 2, 3, 4, for services paid at charges reduced to calculation should be used for all
and 5 and subscripts thereof); and then cost in our budget neutrality estimates. components of the OPPS for both
divides the sum of these costs by the In examining the two different modeling and payment. Therefore, we
sum of charges for the specified calculations, we decided that elements proposed to use the modified overall
ancillary cost centers from Worksheet D, of each methodology had merit. Clearly, CCR calculation as discussed above
Part V (Columns 2, 3, 4, and 5 and as noted above, allied health costs when the hospital-specific overall CCR
subscripts thereof). The elimination of should not be included in an overall is used for any of the following
the reference to Part VI in this final rule CCR calculation. However, weighting by calculations: in the CMS calculation of
with comment period is not a change Medicare Part B charges from Worksheet median costs for OPPS ratesetting, in
from the proposed methodology. We D, Part V, makes the overall CCR the CMS calculation of the outlier
used only data from Worksheet D, Part calculation more specific to OPPS. threshold, in the fiscal intermediary
V of the HCRIS electronic cost report to Therefore, we proposed to adopt a calculation of outlier payments, in the
calculate the overall CCRs for both the single overall CCR calculation that CMS calculation of statewide CCRs, in
proposed rule and final rule with incorporates weighting by Medicare Part the fiscal intermediary calculation of
comment period. We previously B charges but excludes allied health pass-through payments for devices, and
referenced both Part V and Part VI in the costs for modeling and payment. for any other fiscal intermediary
proposed rule and in prior rules because Specifically, the proposed calculation payment calculation in which the
both Part V and Part VI appear on the removes allied health costs from cost current hospital-specific overall CCR
same page in Worksheet D on the paper center CCR calculations for specified may be used now or in the future.
cost report, although no data from Part ancillary cost centers, as discussed Comment: Several commenters
VI on the electronic cost report were above, multiplies them by the Medicare supported the proposed change to the
used in the calculation. Part B charges on Worksheet D, Part V, calculation of the overall CCR to be
Compared with our ‘‘traditional’’ and sums these estimated Medicare weighted by Part B charges and to
overall CCR calculation that has been costs. This sum is then divided by the exclude the costs of nursing and allied
used for modeling OPPS and to sum of the same Medicare Part B health professional education programs.
calculate the median costs, this fiscal charges for the same specified set of One commenter asked that CMS provide
intermediary calculation of overall CCR ancillary cost centers. examples at the line level of how the
fails to remove allied health costs and As we indicated in the proposed rule revenue code to cost center crosswalk is
adds weighting by Medicare Part B (71 FR 49528), using the same cost applied to sample claims to illustrate to
charges. report data in this study, we estimated hospitals how selection of the revenue
In comparing these two calculations, a median overall CCR for the proposed code for any particular item or service
we discovered that, on average, the calculation of 0.3081 (mean 0.3389) controls the resulting cost that is used
overall CCR calculation being used by with a standard deviation of 0.1583. The in median calculation. The commenter
the fiscal intermediaries resulted in similarity to the median and standard also asked that CMS instruct fiscal
higher overall CCRs than under our deviation of the ‘‘traditional’’ overall intermediaries to allow hospitals to
‘‘traditional’’ calculation. Using the CCR calculation noted above (median reclassify expense and revenue
most recent cost report data available for 0.3040 and standard deviation of whenever the hospital believes it is
every provider with valid claims for CY 0.1318) masks some sizeable changes in appropriate, to ensure that the charges
2004 as of November 2005, we overall CCR calculations for specific on the claim result in appropriate costs
estimated the median overall CCR using hospitals due largely to the inclusion of for median setting and order the fiscal
the traditional calculation to be 0.3040 Medicare Part B weighting. intermediaries not to reverse
(mean 0.3223) and the median overall In order to isolate the overall impact reclassification of costs in audit
CCR using the fiscal intermediary of adopting this methodology on APC adjustments. The commenter also
calculation to be 0.3309 (mean 0.3742). medians, we used the first 9 months of suggested that CMS should have fiscal
There also was much greater variability CY 2005 claims data to estimate APC intermediaries conduct a survey of their
in the fiscal intermediary calculation of median costs varying only the two audit staff with regard to the validity of
the overall CCR. The standard deviation methods of determining overall CCR. As the revenue code to cost center
under the ‘‘traditional’’ calculation was stated in the CY 2007 OPPS proposed crosswalk.
0.1318, while the standard deviation rule (71 FR 49528), we expected the Response: We continue to believe that
using the fiscal intermediary’s impact to be limited because the the proposed change to the CCR
calculation was 0.2143. In part, the majority of costs are estimated using a calculation is appropriate, and we have
higher median estimate for the fiscal cost center-specific CCR and not the used the revised formula to calculate the
overall CCRs used to set the medians on instruction to fiscal intermediaries that furnished in Maryland, Guam, and the
which the CY 2007 payment rates are will instruct them to recalculate and use U.S. Virgin Islands, American Samoa,
based. the hospital-specific overall CCR as we and the Northern Marianas because
With respect to the request for have finalized for the above stated hospitals in those geographic areas are
detailed examples to illustrate how purposes. not paid under the OPPS.
selection of a revenue code will control We divided the remaining claims into
the cost that is used in the median 2. Calculation of Median Costs for CY the three groups shown below. Groups
calculation, we believe that hospitals, 2007 2 and 3 comprise the 110 million claims
like any business, are responsible for In this section of the preamble, we that contain hospital bill types paid
performing their own analysis regarding discuss the use of claims to calculate the under the OPPS.
issues that affect their revenue stream. proposed OPPS payment rates for CY 1. Claims that were not bill types 12X,
We have gone to great lengths in the 2007. The hospital outpatient 13X, 14X (hospital bill types), or 76X
preamble of our proposed and final prospective payment page on the CMS (CMHC bill types). Other bill types are
rules to discuss how we derive costs Web site on which this final rule with not paid under the OPPS and, therefore,
from charges and how we crosswalk the comment period is posted provides an these claims were not used to set OPPS
charge from the revenue code reported accounting of claims used in the payment.
for the charge to the cost center on the development of the final rates: http:// 2. Claims that were bill types 12X,
cost report. Moreover, the revenue code www.cms.hhs.gov/ 13X, or 14X (hospital bill types). These
to cost center crosswalk has been on the HospitalOutpatientPPS. The accounting claims are hospital outpatient claims.
CMS Web site for several years, open of claims used in the development of 3. Claims that were bill type 76X
continuously to public comment. We do this final rule with comment period is (CMHC). (These claims are later
not believe it is necessary to create and included on the Web site under combined with any claims in item 2
publish examples at the claim-line level supplemental materials for the CY 2007 above with a condition code 41 to set
to further elaborate on how we convert final rule with comment period. That the per diem partial hospitalization rate
charges to costs for purposes of accounting provides additional detail determined through a separate process.)
establishing median costs. Hospitals regarding the number of claims derived For the CCR calculation process, we
that are interested should have at each stage of the process. In addition, used the same general approach as we
sufficient information available already below we discuss the files of claims that used in developing the final APC rates
on this topic. Moreover, Medicare comprise the data sets that are available for CY 2006 (70 FR 68537), with a
auditing rules have been well- for purchase under a CMS data user change to the development of the
established and standardized over many contract. Our CMS Web site, http:// overall CCR as discussed above. That is,
years, and we rely on our contractors to www.cms.hhs.gov/ we first limited the population of cost
enforce them appropriately. HospitalOutpatientPPS, includes reports to only those for hospitals that
Comment: One commenter suggested information about purchasing the filed outpatient claims in CY 2005
that CMS study the crosswalk that is following two OPPS data files: ‘‘OPPS before determining whether the CCRs
used in the completion of the Provider Limited Data Set’’ and ‘‘OPPS for such hospitals were valid.
Statistical and Reimbursement Report Identifiable Data Set.’’ We then calculated the CCRs at a cost
(PS&R) to determine whether changes to As proposed, we used the following center level and overall for each
the CMS crosswalk of revenue codes to methodology to establish the relative hospital for which we had claims data.
cost centers might be appropriate. weights to be used in calculating the We did this using hospital-specific data
Specifically, the commenter suggested OPPS payment rates for CY 2007 shown from the Healthcare Cost Report
the following revisions: Revenue code in Addenda A and B to this final rule Information System (HCRIS). We used
0413 (hyperbaric oxygen therapy) with comment period. This the most recent available cost report
should be crosswalked to the hospital methodology is as follows: data, in most cases, cost reports for CY
overall CCR; Revenue code 026X (IV We used outpatient claims for the full 2004. As proposed, for this final rule
therapy) could have cost center 5600 CY 2005, processed before June 30, with comment period, we used the most
(Drugs charges to patients) as the 2006, to set the relative weights for CY recently submitted cost report to
secondary default CCR before defaulting 2007. To begin the calculation of the calculate the CCRs to be used to
to the overall CCR; Revenue code 046X relative weights for CY 2007, we pulled calculate median costs for the CY 2007
(Pulmondary therapy) should have cost all claims for outpatient services OPPS. If the most recent available cost
center 4600 (respiratory therapy) as furnished in CY 2005 from the national report was submitted but not settled, we
secondary and cost center 3160 as claims history file. This is not the looked at the last settled cost report to
tertiary; and Revenue code 074X (EEG) population of claims paid under the determine the ratio of submitted to
should have cost center 5400 (EEG) as OPPS, but all outpatient claims settled cost using the overall CCR, and
primary and cost center 3280 (EKG and (including, for example, CAH claims, we then adjusted the most recent
EEG) as secondary. and hospital claims for clinical available submitted but not settled cost
Response: We have not made any laboratory services for persons who are report using that ratio. We calculated
changes in response to the commenter’s neither inpatients nor outpatients of the both an overall CCR and cost center-
suggestions for CY 2007. However, we hospital). specific CCRs for each hospital. We
will carefully examine the commenter’s We then excluded claims with used the final overall CCR calculation
suggestions with regard to the condition codes 04, 20, 21, and 77. discussed in II.A.1.c. of this preamble
calculation of CCRs for the CY 2008 These are claims that providers for all purposes that require use of an
OPPS. submitted to Medicare knowing that no overall CCR.
After carefully considering all the payment will be made. For example, We then flagged CAH claims, which
public comments received, we are providers submit claims with a are not paid under the OPPS, and claims
adopting our proposal for CY 2007 condition code 21 to elicit an official from hospitals with invalid CCRs. The
without modification. As stated in the denial notice from Medicare and latter included claims from hospitals
CY 2007 proposed rule (71 FR 49529), document that a service is not covered. without a CCR; those from hospitals
we will issue a Medicare program We then excluded claims for services paid an all-inclusive rate; those from
hospitals with obviously erroneous services of hospitals and moved them to code was a major code, or a minor code,
CCRs (greater than 90 or less than another file. These claims were or a code other than a major or minor
.0001); and those from hospitals with combined with the 76X claims code. We used those code-specific
CCRs that were identified as outliers (3 identified previously to calculate the determinations to sort claims into these
standard deviations from the geometric partial hospitalization per diem rate. five identified groups. For the CY 2007
mean after removing error CCRs). In We then excluded claims without a OPPS, we proposed to use status
addition, we trimmed the CCRs at the HCPCS code. We also moved claims for indicators, as described above, to sort
cost center level by removing the CCRs observation services to another file. We the claims into these groups. We
for each cost center as outliers if they moved to another file claims that believed that using status indicators was
exceeded ±3 standard deviations from contained nothing but influenza and an appropriate way to sort the claims
the geometric mean. This is the same pneumococcal pneumonia (‘‘PPV’’) into these groups and also to make our
methodology that we used in vaccine. Influenza and PPV vaccines are process more transparent to the public.
developing the final CY 2006 CCRs. For paid at reasonable cost and, therefore, We further believed that this proposed
CY 2007, we proposed to trim at the these claims are not used to set OPPS method of sorting claims would
departmental CCR level to eliminate rates. We note that the two above enhance the public’s ability to derive
aberrant CCRs that, if found in high mentioned separate files containing useful information and become a more
volume hospitals, could skew the partial hospitalization claims and informed commenter on the proposed
medians. We used a four-tiered observation services claims are included rule.
hierarchy of cost center CCRs to match in the files that are available for We note that the claims listed in
a cost center to every possible revenue purchase as discussed above. numbers 1, 2, 3, and 4 above are
code appearing in the outpatient claims, We next copied line-item costs for included in the data files that can be
with the top tier being the most drugs, blood, and devices (the lines stay purchased as described above.
common cost center and the last tier on the claim, but are copied off onto We set aside the single minor,
being the default CCR. If a hospital’s another file) to a separate file. No claims multiple minor claims and the non-
cost center CCR was deleted by were deleted when we copied these OPPS claims (numbers 3, 4, and 5
trimming, we set the CCR for that cost lines onto another file. These line-items above) because we did not use these
center to ‘‘missing,’’ so that another cost are used to calculate a per unit mean claims in calculating median costs. We
center CCR in the revenue center and median and a per day mean and then examined the multiple major
hierarchy could apply. If no other median for drugs, radiopharmaceutical claims for date of service to determine
departmental CCR could apply to the agents, blood and blood products, and if we could break them into single
revenue code on the claim, we used the devices, including but not limited to procedure claims using the dates of
hospital’s overall CCR for the revenue brachytherapy sources, as well as other service on all lines on the claim. If we
code in question. For example, if a visit information used to set payment rates, could create claims with single major
was reported under the clinic revenue including a unit to day ratio for drugs. procedures by using date of service, we
code, but the hospital did not have a We then divided the remaining claims created a single procedure claim record
clinic cost center, we mapped the into the following five groups: for each separately paid procedure on a
hospital-specific overall CCR to the 1. Single Major Claims: Claims with a different date of service (that is, a
clinic revenue code. The hierarchy of single separately payable procedure ‘‘pseudo’’ single).
CCRs is available for inspection and (that is, status indicator S, T, V, or X), We then used the ‘‘bypass codes’’
comment at the CMS Web site: http:// all of which would be used in median listed in Table 1 of the proposed rule
www.cms.hhs.gov/ setting. (71 FR 49517) and discussed in section
HospitalOutpatientPPS. 2. Multiple Major Claims: Claims with II.A.1.b. of this preamble to remove
We then converted the charges to more than one separately payable separately payable procedures that we
costs on each claim by applying the CCR procedure (that is, status indicator S, T, determined contain limited costs or no
that we believed was best suited to the V, or X), or multiple units for one packaged costs, or were otherwise
revenue code indicated on the line with payable procedure. As discussed below, suitable for inclusion on the bypass list,
the charge. Table 2 of the proposed rule some of these can be used in median from a multiple procedure bill. When
(71 FR 49532) contained a list of the setting. one of the two separately payable
allowed revenue codes. Revenue codes 3. Single Minor Claims: Claims with a procedures on a multiple procedure
not included in Table 2 are those not single HCPCS code that is packaged claim was on the bypass code list, we
allowed under the OPPS because their (that is, status indicator N) and not split the claim into two single procedure
services cannot be paid under the OPPS separately payable. claims records. The single procedure
(for example, inpatient room and board 4. Multiple Minor Claims: Claims with claim record that contained the bypass
charges) and thus, charges with those multiple HCPCS codes that are code did not retain packaged services.
revenue codes were not packaged for packaged (that is, status indicator N) The single procedure claim record that
creation of the OPPS median costs. One and not separately payable. contained the other separately payable
exception is the calculation of median 5. Non-OPPS Claims: Claims that procedure (but no bypass code) retained
blood costs, as discussed in section X. contain no services payable under the the packaged revenue code charges and
of this preamble. OPPS (that is, all status indicators other the packaged HCPCS charges.
Thus, we applied CCRs as described than S, T, V, X, or N). These claims are We also removed lines that contained
above to claims with bill types 12X, excluded from the files used for the multiple units of codes on the bypass
13X, or 14X, excluding all claims from OPPS. Non-OPPS claims have codes list and treated them as ‘‘pseudo’’ single
CAHs and hospitals in Maryland, Guam, paid under other fee schedules, for claims by dividing the cost for the
and the U.S. Virgin Islands, American example, durable medical equipment or multiple units by the number of units
Samoa, and the Northern Marianas and clinical laboratory, and do not contain on the line. Where one unit of a single
claims from all hospitals for which either a code for a separately paid separately paid procedure code
CCRs were flagged as invalid. service or a code for a packaged service. remained on the claim after removal of
We identified claims with condition In previous years, we made a the multiple units of the bypass code,
code 41 as partial hospitalization determination of whether each HCPCS we created a ‘‘pseudo’’ single claim
from that residual claim record, which HospitalOutpatientPPS, for this final applicability of the ‘‘2 times’’ rule. As
retained the costs of packaged revenue rule with comment period for further stated previously, section 1833(t)(2) of
codes and packaged HCPCS codes. This explanation. We note that in this final the Act provides that, subject to certain
enabled us to use claims that would rule with comment period, as stated in exceptions, the items and services
otherwise be multiple procedure claims both the proposed rule and here, we within an APC group cannot be
and could not be used. We excluded have excluded those claims that we considered comparable with respect to
those claims that we were not able to believed were not valid reflections of the use of resources if the highest
convert to singles even after applying all hospital resources. median (or mean cost, if elected by the
of the techniques for creation of We also deleted claims for which the Secretary) for an item or service in the
‘‘pseudo’’ singles. charges equal the revenue center group is more than 2 times greater than
We then packaged the costs of payment (that is, the Medicare payment) the lowest median cost for an item or
packaged HCPCS codes (codes with on the assumption that where the charge service within the same group (‘‘the 2
status indicator ‘‘N’’ listed in equals the payment, to apply a CCR to times rule’’). Finally, we reviewed the
Addendum B to this proposed rule) and the charge would not yield a valid medians and reassigned HCPCS codes to
packaged revenue codes into the cost of estimate of relative provider cost. different APCs as deemed appropriate.
the single major procedure remaining on For the remaining claims, we then Section III.B. of this preamble includes
the claim. The list of packaged revenue standardized 60 percent of the costs of a discussion of the HCPCS code
codes was shown in Table 2 of the CY the claim (which we have previously assignment changes that resulted from
2007 OPPS proposed rule (71 FR 49532) determined to be the labor-related examination of the medians and for
and below. portion) for geographic differences in other reasons. The APC medians were
After removing claims for hospitals labor input costs. We made this recalculated after we reassigned the
with error CCRs, claims without HCPCS adjustment by determining the wage affected HCPCS codes. Both the HCPCS
codes, claims for immunizations not index that applied to the hospital that medians and the APC medians were
covered under the OPPS, and claims for furnished the service and dividing the weighted to account for the inclusion of
services not paid under the OPPS, 58.4 cost for the separately paid HCPCS code multiple units of the bypass codes in the
million claims were left. Of these 58.4 furnished by the hospital by that wage creation of pseudo single bills.
million claims, we were able to use index. As has been our policy since the A detailed discussion of the medians
some portion of 54.1 million whole inception of the OPPS, we proposed to for blood and blood products is
claims (92.6 percent of the 58.4 million use the pre-reclassified wage indices for included in section X. of this preamble.
potentially usable claims) to create the standardization because we believed A discussion of the medians for APCs
98.5 million single and ‘‘pseudo’’ single that they better reflect the true costs of that require one or more devices when
claims for use in the CY 2007 median items and services in the area in which the service is performed is included in
development and for ratesetting. the hospital is located than the post- section IV.A. of this preamble. A
We also excluded (1) claims that had reclassification wage indices, and would discussion of the median for observation
zero costs after summing all costs on the result in the most accurate adjusted services is included in section XI. of this
claim and (2) claims containing median costs. preamble, and a discussion of the
packaging flag 3. Effective for services We also excluded claims that were median for partial hospitalization is
furnished on or after July 1, 2004, the outside 3 standard deviations from the included below in section II.B. of this
Outpatient Code Editor (OCE) assigns geometric mean of units for each HCPCS preamble.
packaging flag number 3 to claims on code on the bypass list (because, as We specifically invited public
which hospitals submitted token discussed above, we used claims that comment on the relative benefits of
charges for a service with status contain multiple units of the bypass deleting claims reported with modifier
indicator ‘‘S’’ or ‘‘T’’ (a major separately codes). We then deleted 438,440 single 50 signifying two procedures were
paid service under OPPS) for which the bills reported with modifier 50 that performed versus dividing the costs for
fiscal intermediary is required to were assigned to APCs that contained the two procedures by two to create two
allocate the sum of charges for services HCPCS codes that are considered to be ‘‘pseudo’’ single claims. We received
with a status indicator equaling ‘‘S’’ or conditional or independent bilateral one comment on this issue.
‘‘T’’ based on the weight for the APC to procedures under the OPPS and that are Comment: One commenter supported
which each code is assigned. We do not subject to special payment provisions deletion of the conditional or
believe that these charges, which were implemented through the OCE. Modifier independent bilateral service claims
token charges as submitted by the 50 signifies that the procedure was because the commenter believes that the
hospital, are valid reflections of hospital performed bilaterally. Although these total cost of a bilateral procedure
resources. Therefore, we deleted these are apparently single claims for a (including packaged costs) is generally
claims. In the proposed rule, we deleted separately payable service and although less than 2 times the total cost of a
claims with payment flag 3 (not there is only one unit of the code unilateral procedure, and such cost
packaging flag 3) because we believed reported on the claim, the presence of savings are already reflected in each
that payment flag 3 identified claims for modifier 50 signifies that two services hospital’s CCR. The commenter stated
which the charges were not as were furnished. Therefore, costs that to divide the cost of the bilateral
submitted by the provider as described reported on these claims are for two procedure by two would result in
above. As we were processing claims for procedures and not for a single ‘‘pseudo’’ singles that would
this final rule with comment period, we procedure. Hence, we deleted these underrepresent the full cost of a single
realized that this was not the case and multiple procedure records, which we procedure.
corrected the process to eliminate would have treated as single procedure Response: We have excluded claims
claims which, as described above, have claims in prior OPPS updates. for conditional and independent
charges that are not as submitted by the We used the remaining claims to bilateral procedures from the claims we
provider. See the CY 2007 final rule calculate median costs for each used to calculate the median costs for
claims accounting under supporting separately payable HCPCS code and the CY 2007 OPPS. We will carefully
documentation posted on our Web site, each APC. The comparison of HCPCS consider how to treat these claims for
http://www.cms.hhs.gov/ and APC medians determines the future years.
For the final CY 2007 OPPS APC median from 1 year to the next is response to our proposed rule asked for
ratesetting process, we deleted these often not a valid comparison of the costs more separate payment, less packaging,
claims, as we did for the proposed rule. for the same services. In addition, every and greater service-specific precision in
We received many comments on our year new HCPCS codes that were the calculation of median costs for
proposed CY OPPS data process. A initially assigned to clinical APCs for specifically identified services in the
summary of the comments and our payment purposes may begin to OPPS. We are also often asked to
responses follows: contribute claims data to those APC specifically recalculate median costs by
Comment: The commenters objected median costs, also leading to ill-founded using subsets of claims that meet
to what they view as wide fluctuations comparisons across years. specific criteria or by applying
in the APC payment rates from CY 2006 Moreover, many of the claims we alternative methodologies for identified
to CY 2007, because such variability receive for OPPS services are multiple services. While these special approaches
makes it difficult to plan and budget for procedure claims that must be are generally intended to increase
the services that the hospital will fragmented for use in establishing the payments for their particular services of
provide in the upcoming year. The median costs for single procedures. interest, they likely contribute to less
commenters objected to changes in Unlike other prospective payment stability in the system in general.
proposed OPPS rates that are greater systems in which the costs of multiple Inevitably, such specificity would lead
than 5 percent from the prior year’s services are aggregated into a single to more, not less, volatility as it would
rates and urged CMS to adjust rates so payment for a defined encounter (for reduce the number of claims that can be
that no payment rate in CY 2007 example, inpatient stay and home used to set median costs.
declined by more than 5 percent health episode of care), under the OPPS Lastly, hospital charges and costs are
compared to its payment in CY 2006. the costs that reflect the charges on the foundation of the payment weights,
The commenters stated that more than Medicare claims that contain more than but hospitals change the mix of services
250 APC rates declined compared to a single service on the same date must they furnish and thereby also change
their CY 2006 rates, some by 10 to 20 be fragmented into pieces to provide their cost structure to some extent each
percent or more. In contrast, they noted costs at a unit level, rather than being year. Moreover, hospitals increase,
that over 300 APC rates increased, many aggregated to provide the total cost for sometimes decrease, or hold steady their
substantially and by up to 30 percent a set of services furnished in a single charges each year based on a variety of
compared to their CY 2006 rates. The encounter. The more the costs on claims business reasons, but these changes to
commenters stated that they did not are split to accommodate payment for charges often vary across the different
believe that the changes in the median individual items and services described services they furnish. Thus, hospital
costs were reflective of changes in by HCPCS codes, and the fewer single decisions to change their mix of services
hospital costs, because hospital costs do bills that are available for ratesetting or to change their charges for some
not vary so widely from year to year. because the costs cannot be fragmented services differentially also contribute to
The commenters indicated that they into unique services, the more the volatility in payment rates.
expected that after more than 5 years of variability is introduced into the cost. We recognize that it could be
experience, the rates would no longer Because of the difficulty in assigning the desirable for a payment system’s rates to
show such significant volatility and revenue code charge data that hospitals not vary by a certain percentage from
urged CMS to use more multiple claims submit on multiple procedure claims to the prior year’s payment rates, but there
data to set the median costs. the separately payable HCPCS codes is no reason to believe that limiting the
Response: There are a number of that form the basis of payment in the changes in payment rates to prevent a
factors pertinent to the OPPS that cause OPPS, we must often use small numbers decline by any percentage each year
median costs to change from one year to of claims to set the median costs for would be accurately reflective of
the next. These include reassignment of some services. We believe that the small changes in relative costs. Although the
HCPCS codes to APCs to rectify 2 times numbers of single claims are the source commenters asked that no payment for
violations and to respond to public of much of the volatility in the payment any service decline by more than 5
comments; the need to split costs system. When we examine claims data percent, none addressed a limitation for
derived from claims data among the for APCs like the Visit APCs, for which a payment increase. We do not believe
many different HCPCS codes, which we have large and stable numbers of that it is appropriate to artificially
results in very few usable claims for services, we do not see the median cost impose limits on a payment rate’s
some services; and annual changes in fluctuations that typically occur in those increase or decrease from one year to
reported hospital charges and costs that APCs for which we regularly have small the next, because, as noted above,
provide the source of the cost data on numbers of single bills. comparisons between APC payment
which the system is based. However, we are rarely asked for rates from year to year have little
Although the APC number and title larger APCs that contain more codes or meaning for the many APCs that have
may remain the same from year to year, for more packaging of payment for experienced HCPCS migration.
we routinely reassign HCPCS codes to HCPCS codes into the APC rates, both Moreover, to limit the increases or
different APCs to resolve violations of of which would enable us to use more decreases in payment to a set amount
the 2 times rule as required by law or claims and, we believe, provide more for all services would conflict with the
reconfigure APCs to create more levels stable payment rates. Indeed, payment statutory requirement that at least
in a series. We also reassign codes in in the OPPS has become more specific annually we revise APCs and other
response to public comments when we each year, largely in response to our components of the OPPS using new cost
believe that the requested reassignment willingness to accommodate the data and other relevant information.
will result in improved clinical requests of stakeholders when we Therefore, we are not adjusting the rates
homogeneity and more similar resource believe they are justified and supported as requested to account for a decline of
use for a particular service or group of by the data. Each year, we are asked for more than 5 percent from CY 2006 in
services. To the extent that there has increasingly more APCs that contain the final CY 2007 OPPS payment rates.
been a reassignment either into or out of fewer HCPCS codes, as well as more We will continue to explore ways to use
an APC or a reconfiguration of an APC precise costing of particular services. the data from multiple procedure claims
into multiple levels, a comparison of the Generally, the comments received in because we agree that a high level of
volatility is not desirable in the OPPS, and, therefore, in the related OPPS appropriate payments for new
and we also believe that the most viable payment rates. With regard to the technology services and device-
long term solution to instability is the specific concerns of the commenter, our dependent procedures that we believe
use of all the claims data. However, we responses regarding the rationale for are furnished largely by teaching
also believe that changes in median packaging the revenue code charges for hospitals. We believe this and other
costs from one year to the next are each revenue code of interest follow: (1) payment changes should help ensure
unavoidable in a relative weight Revenue code 274 is one of the revenue adequate and appropriate payment for
payment system which also depends on codes we previously instructed teaching hospitals.
hospital charges and costs and in which hospitals to use to report devices that Comment: One commenter supported
reassignment of HCPCS codes from one had been paid as pass-through devices; CMS’ proposal to discard claims that
APC to another is required by law in (2) Revenue code 280 is packaged contain token charges for packaged
cases of 2 times violations. As the because we believe that it is possible devices but opposed discarding claims
commenters noted, some CY 2007 APC that a hospital could have costs related when there is only one separately paid
payment rates decrease but others to packaged OPPS services for which it procedure on the claim, although there
increase in comparison with the CY would choose not to bill a HCPCS code, are other packaged services billed with
2006 rates, consistent with expectations and we want to ensure that those costs token charges on other lines of the
for a budget neutral payment system are not lost in median calculation; (3) claim.
like the OPPS. Revenue code 290 (DME) is governed by Response: We have not discarded
Comment: One commenter objected to the statute which explicitly states that claims that contain token charges where
the inclusion of charges from the implantable DME provided in hospitals there is only one separately paid
following revenue codes as packaged is paid under the OPPS, and we believe procedure on the claim if there are other
services under the OPPS: (1) Revenue that it is possible that hospitals may packaged services billed with token
code 274 (Prosthetic/orthotic devices) charge for implantable DME but not bill charges on other lines of the claim. We
on the basis that the revenue code is for a HCPCS code for the items; (4) Revenue discarded claims with token charges
nonimplanted devices that require a codes 343 and 344 (diagnostic and only when such claims included token
HCPCS code, are paid under the MPFS, therapeutic radiopharmaceuticals) are charges for devices with procedure
and have a status indicator of ‘‘A’’ under included as hospitals may charge for codes that are assigned to device-
the OPPS; (2) Revenue code 280 these items without placing a HCPCS dependent APCs, because we instructed
(Oncology) on the basis that there is no code on the line; (5) Revenue code 560 hospitals to bill token charges for
oncology service that would not be (Medical Social Services) is included devices that were replaced without cost
coded by a HCPCS code, and, therefore, because hospitals may charge without to the provider due for example, to
any charge without a HCPCS code billing a HCPCS code for the services of warranty, field action or recall. We also
should not be packaged; (3) Revenue a medical social worker that are related discarded claims that, as submitted,
code 290 (Durable Medical Equipment to a visit service and thus would contained token charges for separately
(DME)) on the basis that DME is for use otherwise not be packaged into the paid (not packaged) procedure codes,
in the home and not in the outpatient median cost for the visit. We note that which during claims processing were
setting; (4) Revenue codes 343 and 344 National Uniform Billing Committee converted to imputed charges for
(Diagnostic radiopharmaceuticals and guidelines on use of revenue code 560 purposes of applying the outlier policy
therapeutic radiopharmaceuticals) on recognize that it may be reported by and which came to us through the
the basis that they are required to be hospitals in some circumstances. national claims history with the
billed with a HCPCS code, and, Comment: One commenter asked that imputed charges. These claims are
therefore, charges without a HCPCS CMS implement an indirect medical identified with a packaging flag 3 and
code should not be packaged; and (5) education adjustment under the CY are excluded because the charges shown
Revenue code 560 (Medical Social 2007 OPPS to address what the on the claim we receive were not the
Services) on the basis that they are commenter states is a 23-percent charges submitted by the provider. We
separately billable only by home health shortfall to the market basket for OPPS discuss this in more detail in the CY
agencies and are, therefore, suspect and services. The commenter indicated that 2007 final rule claims accounting on the
should not be packaged. this adjustment was needed to CMS OPPS Web page at http://
Response: With a few limited reimburse hospitals for the higher costs www.cms.hhs.gov/
exceptions, CMS does not specify the incurred by major teaching hospitals to HospitalOutpatientPPS/.
revenue codes hospitals must use to provide outpatient care to Medicare After carefully considering all public
report their charges. Therefore, we beneficiaries. comments received, we are finalizing
selected a generous set of revenue codes Response: We do not believe an the list of packaged services by revenue
to maximize the likelihood that we indirect medical education add-on code shown in Table 2 and our data
would capture all of the costs of a payment is appropriate in a budget process for calculating the median costs
particular service for purposes of neutral payment system where such for OPPS services furnished on or after
calculating the median costs on which changes would result in reduced January 1, 2007, without modification.
the OPPS payment rates are based. To payments to all other hospitals. Table 2 below contains the list of
cease packaging costs under these Moreover, in this final rule with packaged services by revenue code that
revenue codes where there is no HCPCS comment period, we have developed we used in developing the APC relative
code reported on the line may result in payment weights that we believe resolve weights listed in Addenda A and B of
erroneous reductions in median costs many of the public concerns regarding this final rule with comment period.
TABLE 2.—CY 2007 PACKAGED SERVICES BY REVENUE CODE

Revenue code Description
250 .................................................. PHARMACY.
TABLE 2.—CY 2007 PACKAGED SERVICES BY REVENUE CODE—Continued

Revenue code Description
251 .................................................. GENERIC.

252 .................................................. NONGENERIC.
254 .................................................. PHARMACY INCIDENT TO OTHER DIAGNOSTIC.
255 .................................................. PHARMACY INCIDENT TO RADIOLOGY.
257 .................................................. NONPRESCRIPTION DRUGS.
258 .................................................. IV SOLUTIONS.
259 .................................................. OTHER PHARMACY.
260 .................................................. IV THERAPY, GENERAL CLASS.
262 .................................................. IV THERAPY/PHARMACY SERVICES.
263 .................................................. SUPPLY/DELIVERY.
264 .................................................. IV THERAPY/SUPPLIES.
269 .................................................. OTHER IV THERAPY.
270 .................................................. M&S SUPPLIES.
271 .................................................. NONSTERILE SUPPLIES.
272 .................................................. STERILE SUPPLIES.
274 .................................................. PROSTHETIC/ORTHOTIC DEVICES.
275 .................................................. PACEMAKER DRUG.
276 .................................................. INTRAOCULAR LENS SOURCE DRUG.
278 .................................................. OTHER IMPLANTS.
279 .................................................. OTHER M&S SUPPLIES.
280 .................................................. ONCOLOGY.
289 .................................................. OTHER ONCOLOGY.
290 .................................................. DURABLE MEDICAL EQUIPMENT.
343 .................................................. DIAGNOSTIC RADIOPHARMS.
344 .................................................. THERAPEUTIC RADIOPHARMS.
370 .................................................. ANESTHESIA.
371 .................................................. ANESTHESIA INCIDENT TO RADIOLOGY.
372 .................................................. ANESTHESIA INCIDENT TO OTHER DIAGNOSTIC.
379 .................................................. OTHER ANESTHESIA.
390 .................................................. BLOOD STORAGE AND PROCESSING.
399 .................................................. OTHER BLOOD STORAGE AND PROCESSING.
560 .................................................. MEDICAL SOCIAL SERVICES.
569 .................................................. OTHER MEDICAL SOCIAL SERVICES.
621 .................................................. SUPPLIES INCIDENT TO RADIOLOGY.
622 .................................................. SUPPLIES INCIDENT TO OTHER DIAGNOSTIC.
624 .................................................. INVESTIGATIONAL DEVICE (IDE).
630 .................................................. DRUGS REQUIRING SPECIFIC IDENTIFICATION, GENERAL CLASS.
631 .................................................. SINGLE SOURCE.
632 .................................................. MULTIPLE.
633 .................................................. RESTRICTIVE PRESCRIPTION.
681 .................................................. TRAUMA RESPONSE, LEVEL I.
682 .................................................. TRAUMA RESPONSE, LEVEL II.
683 .................................................. TRAUMA RESPONSE, LEVEL III.
684 .................................................. TRAUMA RESPONSE, LEVEL IV.
689 .................................................. TRAUMA RESPONSE, OTHER.
700 .................................................. CAST ROOM.
709 .................................................. OTHER CAST ROOM.
710 .................................................. RECOVERY ROOM.
719 .................................................. OTHER RECOVERY ROOM.
720 .................................................. LABOR ROOM.
721 .................................................. LABOR.
762 .................................................. OBSERVATION ROOM.
810 .................................................. ORGAN ACQUISITION.
819 .................................................. OTHER ORGAN ACQUISITION.
942 .................................................. EDUCATION/TRAINING.
3. Calculation of Scaled OPPS Payment setting. We assigned APC 0601 a relative to reconfigure the APCs where clinic
Weights payment weight of 1.00 and divided the visits are assigned for CY 2007, APC
median cost for each APC by the median 0606 is the middle level clinic visit APC
Using the median APC costs
cost for APC 0601 to derive the relative (that is, Level 3 of five levels). We have
discussed previously, we calculated the
payment weight for each APC. historically used the median cost of the
final relative payment weights for each
APC for CY 2007 shown in Addenda A As proposed, for the CY 2007 OPPS, middle level clinic visit APC (that is
and B of this final rule with comment we scaled all of the relative payment APC 0601 through CY 2006) to calculate
period. In prior years, we scaled all the weights to APC 0606 (Level 3 Clinic unscaled weights because mid-level
relative payment weights to APC 0601 Visits) because we deleted APC 0601, as clinic visits are among the most
(Mid Level Clinic Visit) because it is one part of the reconfiguration of the visit frequently performed services in the
of the most frequently performed APCs. We chose APC 0606 as the hospital outpatient setting. Therefore, to
services in the hospital outpatient scaling base because under our proposal maintain consistency in using a median
for calculating unscaled weights addition to adjusting for increases and bundled into the costs for separately
representing the median cost of some of decreases in weight due the payable procedures on those same
the most frequently provided services, recalibration of APC medians, the scaler claims in establishing payment rates for
we proposed to continue to use the also accounts for any change in the base. the separately payable services. This is
median cost of the middle level clinic The final relative payment weights consistent with the principles of a
APC, proposed APC 0606, to calculate listed in Addenda A and B of this final prospective payment system based upon
unscaled weights. Following our rule with comment period incorporate groupings of services and in contrast to
standard methodology, but using the CY the recalibration adjustments discussed a fee schedule that provides individual
2007 median for APC 0606, we assigned in sections II.A.1. and 2. of this payment for each service billed.
APC 0606 a relative payment weight of preamble. Hospitals may use CPT codes to report
1.00 and divided the median cost of Section 1833(t)(14)(H) of the Act, as any packaged services that were
each APC by the median cost for APC added by section 621(a)(1) of Pub. L. performed, consistent with CPT coding
0606 to derive the unscaled relative 108–173, states that ‘‘Additional guidelines.
payment weight for each APC. The expenditures resulting from this As a result of requests from the
choice of the APC on which to base the paragraph shall not be taken into public, a Packaging Subcommittee to the
relative weights for all other APCs does account in establishing the conversion APC Panel was established to review all
not affect the payments made under the factor, weighting and other adjustment the procedural CPT codes with a status
OPPS because we scale the weights for factors for 2004 and 2005 under indicator of ‘‘N.’’ Providers have often
budget neutrality. paragraph (9) but shall be taken into suggested that many packaged services
account for subsequent years.’’ Section could be provided alone, without any
Section 1833(t)(9)(B) of the Act
1833(t)(14) of the Act provides the other separately payable services on the
requires that APC reclassification and payment rates for certain ‘‘specified claim, and requested that these codes
recalibration changes, wage index covered outpatient drugs.’’ Therefore, not be assigned status indicator ‘‘N.’’ In
changes, and other adjustments be made the cost of those specified covered deciding whether to package a service or
in a manner that assures that aggregate outpatient drugs (as discussed in section pay for a code separately, we consider
payments under the OPPS for CY 2007 V. of this preamble) is now included in a variety of factors, including whether
are neither greater than nor less than the the budget neutrality calculations for CY the service is normally provided
aggregate payments that would have 2007 OPPS. separately or in conjunction with other
been made without the changes. To Under section 1833(t)(16)(C) of the services; how likely it is for the costs of
comply with this requirement Act, as added by section 621(b)(1) of the packaged code to be appropriately
concerning the APC changes, we Pub. L. 108–173, payment for devices of mapped to the separately payable codes
compared aggregate payments using the brachytherapy consisting of a seed or with which it was performed; and
CY 2006 relative weights to aggregate seeds (or radioactive source) is to be whether the expected cost of the service
payments using the CY 2007 final made at charges adjusted to cost for is relatively low.
relative payment weights. Based on this services furnished on or after January 1, The Packaging Subcommittee
comparison, we adjusted the relative 2004, and before January 1, 2007. As we identified areas for change for some
weights for purposes of budget stated in our January 6, 2004 interim packaged CPT codes that it believed
neutrality. The unscaled relative final rule, charges for the brachytherapy could frequently be provided to patients
payment weights were adjusted by sources were not used in determining as the sole service on a given date and
1.364598352 for budget neutrality. We outlier payments, and payments for that required significant hospital
recognize the scaler, or weight scaling these items were excluded from budget resources as determined from hospital
factor, for budget neutrality that we neutrality calculations for the CY 2006 claims data.
proposed for CY 2007 is higher than any OPPS. We excluded these payments Based on the comments received,
previous OPPS weight scaler as a result from budget neutrality calculations, in additional issues, and new data that we
of our proposal to use APC 0606 as the part, because of the challenge posed by shared with the Packaging
base for calculation of relative weights. estimating hospital-specific cost Subcommittee concerning the packaging
Our use of the median cost for APC payment. As proposed, for CY 2007, we status of codes for CY 2007, the
0606 of $83.39 based on final rule with calculated specific payment rates for Packaging Subcommittee reviewed the
comment period data causes the brachytherapy sources, which were packaging status of numerous HCPCS
unscaled weights to be lower than they subjected to scaling for budget codes and reported its findings to the
would have been if we had chosen APC neutrality. (We provide a discussion of APC Panel at its March 2006 meeting.
0605 (Level 2 Clinic Visits; median brachytherapy payment issues, The APC Panel accepted the report of
$60.13 as the scaling base. The CY 2007 including their CY 2007 treatment with the Packaging Subcommittee, heard
median cost of APC 0606 is significantly respect to outlier payments, under several presentations on certain
higher than the CY 2006 median cost of section VII. of this preamble.) Therefore, packaged services, discussed the
APC 0601 for mid-level clinic visits, the costs of brachytherapy sources are deliberations of the Packaging
which was used in CY 2006 and earlier accounted for in the scaler of Subcommittee, and recommended
years to calculate unscaled weights. 1.364598352. that—
Historically, the median cost for APC • CMS pay separately for HCPCS
0601 has been similar to the CY 2007 4. Changes to Packaged Services code 0069T (Acoustic heart sound
proposed median cost for APC 0605. In Payments for packaged services under recording and computer analysis;
order to appropriately scale the total the OPPS are bundled into the payments acoustic heart sound and computer
weight estimated for OPPS in CY 2007 providers receive for separately payable analysis only).
to be similar to the total weight in OPPS services provided on the same day. • CMS maintain the packaged status
for CY 2006, we calculated a scaler of Packaged services are identified by the of HCPCS code 0152T (Computer aided
1.364598352 for this final rule with status indicator ‘‘N.’’ Hospitals include detection with further physician review
comment period, which is higher using charges for packaged services on their for interpretation, with or without
APC 0606 as the base than it would be claims, and the costs associated with digitization of films radiographic
if we used APC 0605 as the base. In these packaged services are then images; chest radiograph(s)).
• CMS maintain the packaged status and reporting) and 75998 (Fluoroscopic images, chest radiograph(s), performed
of CPT code 36500 (Venous guidance for central venous access concurrent with primary interpretation
catheterization for selective blood organ device placement, replacement (catheter (List separately in addition to code for
sampling). only or complete), or removal (includes primary procedure), and 0175T,
• CMS pay separately for CPT code fluoroscopic guidance for vascular Computer aided detection (CAD )
36540 (Collection of blood specimen access and catheter manipulation, any (computer algorithm analysis of digital
from a completely implantable venous necessary contrast injections through image data for lesion detection) with
access device) if there are no separately access site or catheter with related further physician review for
payable OPPS services on the claim. venography radiologic supervision and interpretation and report, with or
• CMS pay separately for CPT code interpretation, and radiographic without digitization of film radiographic
36600 (Arterial puncture; withdrawal of documentation of final catheter images, chest radiograph(s), performed
blood for diagnosis) if there are no position)). remote from primary interpretation).
separately payable OPPS services on the • CMS provide separate payment for + That CMS continue to package
claim. CPT codes 94760 (Noninvasive ear or revised CPT code 0069T (Acoustic heart
• CMS pay separately for CPT code pulse oximetry for oxygen saturation; sound recording and computer analysis;
38792 (Injection procedure for single determination), 94761 acoustic heart sound recording and
identification of sentinel node) if there (Noninvasive ear or pulse oximetry for computer analysis only).
are no separately payable OPPS services oxygen saturation; multiple + That CMS assign CPT code 96523
on the claim. determinations), and 94762 (Irrigation of implanted venous access
• CMS maintain the packaged status (Noninvasive ear or pulse oximetry for device for drug delivery systems) status
of CPT codes 74328 (Endoscopic oxygen saturation by continuous indicator ‘‘Q’’ as a ‘‘special’’ packaged
catheterization of the biliary ductal overnight monitoring) if there are no code.
system, radiological supervision and separately payable OPPS services on the For CY 2007, we proposed to
interpretation), 74329 (Endoscopic claim. maintain CPT code 0069T as a packaged
catheterization of the pancreatic ductal • CMS pay separately for CPT code service and not adopt the APC Panel’s
system, radiological supervision and 96523 (Irrigation of implanted venous March 2006 recommendation to pay
interpretation), and 74330 (Combined access device for drug delivery systems) separately for this code. The service
endoscopic catheterization of the biliary if there are no separately payable OPPS uses signal processing technology to
and pancreatic ductal systems, services on the claim. detect, interpret, and document
radiological supervision and • CMS maintain the packaged status acoustical activities of the heart through
interpretation). of HCPCS code G0269 (Placement of special sensors applied to a patient’s
• CMS pay separately for CPT code occlusive device into either a venous or chest. This code was a new Category III
75893 (Venous sampling through arterial access site). CPT code implemented in the CY 2005
catheter, with or without angiography • CMS pay separately for HCPCS OPPS and assigned a new interim status
(eg, for parathyroid hormone, rennin), code P9612 (Catheterization for indicator of ‘‘N’’ in the CY 2005 OPPS
radiological supervision and collection of specimen, single patient) if final rule with comment period. The
interpretation) if there are no separately there are no separately payable OPPS APC Panel recommended packaging
payable OPPS services on the claim. services on the claim. CPT code 0069T for CY 2006, and we
• CMS continue to separately pay for • CMS bring data to the next APC accepted that recommendation when we
CPT code 76000 (Fluoroscopy (separate Panel meeting that show the following: finalized the status indicator ‘‘N’’
procedures), up to one hour physician (a) how the costs of packaged items and assignment to 0069T for CY 2006. CPT
time, other than 71023 or 71024 (eg, services are incorporated into the code 0069T is an add-on code to an
cardiac fluoroscopy)). median costs of APCs and (b) how the electrocardiography (ECG) service for
• CMS maintain the packaged status costs of these packaged items and CYs 2005 and 2006. However on July 1,
of CPT codes 76001 (Fluoroscopy, services influence payments for 2006, the AMA released to the public a
physician time more than one hour, associated procedures. code descriptor change to remove the
assisting a non-radiologic physician (eg, • The Packaging Subcommittee add-on code designation for CPT code
nephrostolithotomy, ERCP, continue until the next APC Panel 0069T. The effective date of this change
bronchoscopy, transbronchial biopsy)), meeting. is January 1, 2007, at which point the
76003 (Fluoroscopic guidance for At its August 2006 meeting, the descriptor will be ‘‘Acoustic heart
needle placement (eg, biopsy, Packaging Subcommittee further sound recording and computer analysis;
aspiration, injection, localization discussed the packaging status of acoustic heart sound recording and
device)), and 76005 (Fluoroscopic several of the HCPCS codes described computer analysis only.’’ We do not
guidance and localization of needle or above and reported its findings to the include Category III CPT codes that are
catheter tip for spine or paraspinous APC Panel. The APC Panel accepted the released in July of a given year in the
diagnostic or therapeutic injection report of the Packaging Subcommittee, OPPS proposed rule for the following
procedures (epidural, transforaminal heard one presentation, reviewed one calendar year because of timing
epidural, subarachnoid, paravertebral written comment, and discussed the restraints. We include these codes in the
fact joint, paravertebral facet joint nerve deliberations of the Packaging OPPS final rule where they are assigned
or sacroiliac joint), including neurolytic Subcommittee. The APC Panel made the interim comment indicator ‘‘NI’’ to
agent destruction). following recommendations for CY denote that they are open for public
• CMS maintain the packaged status 2007: comment.
of CPT codes 76937 (Ultrasound + That CMS package new CPT codes In its March 2006 presentation to the
guidance for vascular access requiring 0174T, Computer aided detection (CAD) APC Panel, a manufacturer requested
ultrasound evaluation of potential (computer algorithm analysis of digital that we pay separately for CPT code
access sites, documentation of selected image data for lesion detection) with 0069T and assign it to APC 0099
vessel patency, concurrent realtime further physician review for (Electrocardiograms), based on its
ultrasound visualization of vascular interpretation and report, with or estimated cost and clinical
needle entry, with permanent recording without digitization of film radiographic characteristics. The manufacturer stated
that the acoustic heart sound recording always be packaged into payments for CPT codes, 0174T and 0175T. Effective
and analysis service may be provided those other services. Therefore, we January 1, 2007, the descriptor for CPT
with or without a separately reportable believe that CPT code 0069T is code 0174T will be ‘‘Computer aided
electrocardiogram. Members of the APC appropriately packaged because it detection (CAD) (computer algorithm
Panel engaged in extensive discussion would usually be closely linked to the analysis of digital image data for lesion
of clinical scenarios as they considered performance of an ECG, and would detection) with further physician review
whether CPT code 0069T could or could rarely, if ever, be the only OPPS service for interpretation and report, with or
not be appropriately reported alone or provided to a patient. We understand without digitization of film radiographic
in conjunction with several different that the commenter is clarifying that images, chest radiograph(s), performed
procedure codes. this service is not required to be concurrent with primary interpretation
During the August 2006 meeting, the provided in conjunction with an ECG. (List separately in addition to code for
Packaging Subcommittee further However, we continue to believe that it primary procedure) and the descriptor
discussed CMS’s proposal to package is likely that an ECG or other separately for 0175T will be ‘‘Computer aided
CPT 0069T for CY 2007 and the CY payable service would be performed on detection (CAD) (computer algorithm
2007 code descriptor change, and the patient in conjunction with the analysis of digital image data for lesion
ultimately recommended to the APC acoustic heart sound service. Therefore, detection) with further physician review
Panel that CMS continue to package this we believe that it is appropriate to for interpretation and report, with or
code for CY 2007. The APC Panel continue packaging CPT code 0069T for without digitization of film radiographic
accepted this recommendation. CY 2007. In addition, this service is images, chest radiograph(s), performed
Comment: One commenter requested estimated to require only minimal remote from primary interpretation.’’
that CMS pay separately for CPT code hospital resources. Using CY 2005 As indicated above, we do not include
0069T for CY 2007, mapping the code claims that have been updated with Category III CPT codes that are released
to an APC paying between $63 and $97. more recent CCRs, we had only nine in July of a given year in the OPPS
The commenter clarified that this single claims for CPT code 0069T, with proposed rule for the following calendar
service is sometimes provided with an a median line-item cost of $2.45, year because of timing restraints. We
ECG and sometimes provided without consistent with its low expected cost. include these codes in the OPPS final
an ECG, according to its revised Packaging payment for CPT code 0069T rule, where they are assigned new
descriptor for CY 2007. The commenter is consistent with the principles of a interim comment indicator ‘‘NI’’ to
could not explain the low median cost prospective payment system that denote that they are open to comment.
that was calculated from the claims provides payments for groups of In its March 2006 presentation to the
data, but suggested that the nine claims services. To the extent that the acoustic APC Panel, before the AMA had
used to calculate the median were heart sounding recording service may be released the CY 2007 changes to this
miscoded. The commenter estimated the more frequently provided in the future code, the manufacturer requested that
cost of the service to be approximately in association with ECGs or other OPPS we pay separately for this service and
$80 per procedure, significantly higher services as its clinical indications assign it to a New Technology APC with
than the median cost for APC 0099 evolve, we expect that its cost would a payment rate of $15, based on its
(Electrocardiograms), which was $23.60 also be increasingly reflected in the estimated cost, clinical considerations,
based on the CY 2005 data that were median costs for those other services, and similarity to other image post-
used to calculate the CY 2007 proposed particularly ECG procedures. processing services that are paid
median costs. Though the commenter After carefully considering all separately. We proposed to accept the
agreed that it would be rare for the comments received, we are adopting the APC Panel’s recommendation to
acoustic heart sound procedure to be APC Panel’s August 2006 package CPT code 0152T for CY 2007.
performed alone without any other recommendation to continue to package In its August 2006 presentation to the
OPPS services, the commenter disagreed this code for CY 2007. Therefore we are APC Panel, after the AMA had released
that the procedure would be finalizing our proposal without the CY 2007 code changes, the
‘‘associated’’ with other services. modification to maintain CPT code manufacturer requested that we assign
Instead, the commenter clarified that it 0069T as a packaged service for CY both of these two new codes to a New
could be provided with a broad range of 2007. Technology APC with a payment rate of
services, such as an emergency For CY 2007, we proposed to accept $15. The APC Panel members discussed
department visit, clinic visit, chest x- the APC Panel’s recommendation to these codes extensively. They
ray, or ECG. In addition, the commenter maintain the packaged status of CPT considered the possibility of treating
did not expect this service to have a code 0152T. The service involves the CPT code 0175T as a ‘‘special’’
meaningful impact on the median costs application of computer algorithms and packaged code, thereby assigning
of those services because acoustic heart classification technologies to chest x-ray payment to the code only when it was
services are expected to be provided images to acquire and display performed by a hospital without any
infrequently, compared to the total information regarding chest x-ray other separately payable OPPS service
number of emergency department and regions that may contain indications of also provided on the same day. They
clinic visits, chest x-rays, and ECGs. cancer. This code was a new Category questioned the meaning of the word
Response: Despite the change in add- III CPT code implemented in the CY ‘‘remote’’ in the code descriptor for CPT
on status for CPT code 0069T for CY 2006 OPPS and assigned a new interim code 0175T, noting that is was unclear
2007, based on the clinical uses that status indicator of ‘‘NI’’ in the CY 2006 as to whether ‘‘remote’’ referred to time,
were described during the March 2006 OPPS final rule with comment period. geography, or a specific provider. They
APC Panel meeting and in the public For CY 2006, the code is indicated as an thought it was likely that a hospital
comments, we believe that it is highly add-on code to chest x-ray CPT codes, without a CAD system that performed a
unlikely that CPT code 0069T would be according to the AMA’s CY 2006 CPT chest x-ray and sent the x-ray to another
performed in the hospital outpatient book. However, on July 1, 2006, the hospital for performance of the CAD
department as a sole service without AMA released to the public an update would be providing the CAD service
other separately payable OPPS services. that deletes code 0152T for CY 2007 and under arrangement and, therefore,
Payment for CPT code 0069T could replaces it with two new Category III would be providing at least one other
service (chest x-ray) that would be circumstances in which it would be the Using CY 2005 claims, we have
separately paid. Thus, even in these only service provided by a hospital are approximately 200 single claims for CPT
cases, payment for the CAD service also unclear. As discussed by the APC code 75893, with a median cost of
could be appropriately packaged. After Panel if an x-ray were sent to another $269.13. As proposed for CY 2007 and
significant deliberation, the Panel hospital for performance of the CAD, the described below for ‘‘special’’ packaged
recommended that we package both of CAD service would likely be provided codes, when CPT codes 36500 and
the new CPT codes, 0174T and 0175T, under arrangement, in which case the 75893 are billed on a claim with no
for CY 2007. hospital that performed the x-ray would separately payable OPPS services, CPT
Comment: One commenter requested bill for both the x-ray and the CAD code 75893 would become separately
that CMS pay separately for CPT codes service. It is unnecessary to treat CPT payable and would receive payment for
0174T and 0175T, mapping them to code 0175T as a ‘‘special’’ packaged APC 0668. In this circumstance,
New Technology APC 1492, with a code because generally the payment for payment for CPT code 36500 would be
payment rate of $15. The commenter the x-ray CAD would be bundled into packaged into the separate payment for
indicated that there is no basis for the payment for the chest x-ray. While CPT code 75893.
believing that chest x-ray computer- we have no costs from claims data We received no public comments on
aided detection (CAD) will increase the because 0152T was a new CPT code for our proposal. Therefore, we are
number of chest x-rays performed in the CY 2006, and 0174T and 0175T are new finalizing our proposal to accept the
outpatient setting, because chest x-ray codes for CY 2007, we estimate that the APC Panel’s recommendation to
CAD is not a screening tool and should CAD service requires only modest maintain the packaged status of CPT
only be applied to chest x-rays that are resources. We expect that a hospital’s code 36500 without modification.
suspicious for lung cancer. The cost per chest x-ray CAD service would For CY 2007, we proposed to accept
commenter also indicated that separate largely depend on the volume of CAD the APC Panel’s recommendation and
resources are required for chest x-ray services provided. To the extent that pay separately for CPT codes 36540,
CAD that are not required for a standard CAD may be more frequently provided 36600, 38792, 75893, 94762, and 96523
chest x-ray. In addition, the commenter in the future to aid in the review of when any of these codes appear on a
stated that chest x-ray CAD can be diagnostic chest x-rays as its clinical claim with no separately payable OPPS
performed at a different time or location indications evolve, we expect that its services also reported for the same date
or by a different provider than the chest cost would also be increasingly reflected of service. We will refer to this subset
x-ray. In these cases, the commenter in the median costs for chest x-ray of codes as ‘‘special’’ packaged codes.
believed that separate payment would procedures. We acknowledge that there is a cost to
be appropriate. The commenter was After carefully considering all public the hospital associated with registering
concerned that if hospitals are not paid comments received on this proposal, we and treating a patient, regardless of
separately for this technology, they will are accepting the APC Panel’s August whether the specific service provided
not be able to provide it, thereby 2006 recommendation to package new requires minimal or significant hospital
limiting beneficiary access to chest x-ray CPT codes 0174T and 0175T for CY resources. While we continue to believe
CAD. 2007 on an interim final basis. that these ‘‘special’’ packaged codes are
Response: We agree with the APC For CY 2007, we proposed to accept almost always provided along with a
Panel that packaged payment for chest the recommendation of the APC Panel separately payable service, our claims
x-ray CAD under a prospective payment and maintain the packaged status of analyses indicate that there are rare
methodology for outpatient hospital CPT code 36500. As noted in the CY instances when one of these services is
services is appropriate because of the 2007 OPPS proposed rule (71 FR 49535) provided without another separately
close relationship of chest x-ray CAD to we have heard that CPT code 36500 is payable OPPS service on the claim for
chest x-ray services and its projected sometimes billed only with its the same date of service. In these
modest cost. We do not believe that CPT corresponding radiological supervision instances, providers do not currently
code 0174T would ever be performed as and interpretation code, 75893, but with receive any payment. Therefore, we
a sole service without other separately no other separately payable OPPS proposed to provide payment for the
payable OPPS services, based on the services. In those cases, the provider ‘‘special’’ packaged codes listed above
code definition as an add-on service would not receive any payment. For CY when they are billed on a claim without
performed concurrent with the primary 2006, we accepted the APC Panel’s another separately payable OPPS service
interpretation of a chest x-ray. We recommendation to package both CPT on the same date. When any of the
believe that payment for CPT code codes 36500 and 75893 and to examine ‘‘special’’ packaged codes are billed
0174T is appropriately packaged into claims data. Our initial review of several with other codes that are separately
payment for the chest x-ray services it clinical scenarios submitted by the payable under the OPPS on the same
accompanies. Payment for chest x-rays public seemed to suggest that other date of service, the ‘‘special’’ packaged
is provided through APC 0260 (Level I separately payable procedures, such as code would be treated as a packaged
Plain Film Except Teeth), with a CY venography, would likely be billed on code, and the cost of the packaged code
2007 median cost of $43.35. The median the same claim. Our claims data would be bundled into the costs of the
costs for the individual x-ray services indicate that there are usually separately other separately payable services on the
that can be reported with the CAD payable codes that are billed on claims claim. The payments that the provider
technology range from $36.00 to $56.11, with CPT codes 36500 and 75893. receives for the separately payable
easily overlapping the modest However, we acknowledge that these services would include the bundled
additional costs of providing chest x-ray two codes may occasionally be provided payment for the packaged code(s).
CAD services. Although CPT code without any separately payable During the August 2006 APC Panel
0175T applies to chest x-ray CAD that procedures. In these uncommon meeting, the APC Panel reviewed a
is ‘‘remote’’ from the primary instances, the provider historically has request from the public to assign
interpretation, the definition of not received any payment under the payment to CPT code 96523 when it
‘‘remote’’ as used in the code descriptor OPPS. We also understand that there is appears on a claim with no separately
is vague, with respect to time, a cost associated with registering a payable OPPS services also reported for
geography, or a specific provider, so the patient and providing these services. the same date of service. The Panel
recommended that we treat CPT code In the case of a claim with two or discussed below in section IX.A, we
96523 as a ‘‘special’’ packaged code for more ‘‘special’’ packaged codes only would expect that the hospital resources
CY 2007. reported on a single date of service, the associated with a visit would be
We have heard concerns from the PRICER would assign separate payment reflected in the hospital’s internal
public stating that they are unable to only to the ‘‘special’’ packaged code that guidelines used to select the level of
submit claims to CMS that report only would receive the highest payment. The reporting for the visit. The hospital
packaged codes. We note that although other ‘‘special’’ codes would remain should bill the clinic visit code that
these claims are processed by the OCE packaged and would not receive most appropriately describes the service
and are ultimately rejected for payment, separate payment. provided. We acknowledge that
they are received by CMS, and we have Comment: Many commenters Transmittal A–02–129 is based upon
cost data for packaged services based complimented the Packaging our past policy that a hospital could bill
upon these claims. However, we Subcommittee for their efforts to a low level visit code in addition to CPT
recognize that the data used in our improve payment under the OPPS. In code 97602, which was then packaged
analyses to assess the frequencies with addition, the commenters further in CY 2003, at the time of the
which packaged services are provided commended the Packaging instruction. However, beginning in CY
alone and their median costs are Subcommittee and CMS for proposing 2006 we have provided separate
somewhat limited. It is possible that an to provide payment for ‘‘special’’ payment for CPT 97602 when it is
unknown number of hospitals chose not packaged codes under certain performed as a nontherapy service in
to submit claims to CMS when a circumstances. One commenter stated the hospital outpatient setting.
packaged code(s) was provided without that ‘‘special’’ packaged codes further Therefore, the instruction is no longer
other separately payable services on complicate an already complicated relevant and will be revised, because
their claims, realizing that they would system and requested that CMS hospitals are now able to report and be
not receive payment for those claims. consistently either package a code or paid for this wound care service with
While we have been told that some pay separately for a code, but not both. the most specific CPT code available.
Response: We appreciate the This OPPS payment policy for
hospitals may bill for a low-level visit
commenters’ support and plan to nontherapy, nonselective wound care
if a packaged service only is provided so
continue working with the Packaging services will continue for CY 2007. In
that they receive some payment for the
Subcommittee to review other packaged circumstances where there is no
encounter, we note that providers
codes that are brought to our attention applicable HCPCS code to describe a
should bill a low-level visit code in
by the public. While we acknowledge distinct service, hospitals should
such circumstances only if the hospital
that ‘‘special’’ packaged codes add a continue to report the most appropriate
provides a significant, separately layer of complexity to a complicated
identifiable low-level visit in unlisted procedure or unlisted services
payment system, we continue to believe
association with the packaged service. CPT code. In summary, with respect to
that it is appropriate to assign payment
Through OCE logic, the PRICER the billing of low level visit CPT codes,
to ‘‘special’’ codes under certain
would automatically assign payment for as described above, our current policy
circumstances. We note the ‘‘special’’
a ‘‘special’’ packaged service reported dictates that hospitals may only bill a
packaged code policy should impose no
on a claim if there are no other services low-level visit code if the hospital
additional reporting burden on hospital
separately payable under the OPPS on provides a significant, separately
billing staff because the OCE is
the claim for the same date of service. identifiable visit from any other service
automatically programmed to assign
In all other circumstances, the ‘‘special’’ provided.
payment when appropriate.
packaged codes would be treated as Comment: One commenter Comment: One commenter thanked
packaged services. We assign status appreciated that CMS clarified that a CMS for clarifying that CMS receives
indicator ‘‘Q’’ to these ‘‘special’’ hospital cannot bill a CPT E/M code claims with only packaged codes that
packaged codes to indicate that they are simply because the hospital would like may be used for data analysis. The
usually packaged, except for special to receive payment for the packaged commenter also stated that it hoped that
circumstances when they are separately service that was provided. The the ‘‘special’’ packaged codes policy
payable. Through OCE logic, the status commenter asked that CMS also clarify would convince its hospital billing
indicator of a ‘‘special’’ packaged code whether this applies only to packaged department to submit claims with only
would be changed either to ‘‘N’’ or to services, or if it also applies to a service packaged services on them, so that CMS
the status indicator of the APC to which for which there is no applicable HCPCS would have cost data for these codes.
the code is assigned for separate code. Another commenter noted that Other commenters asked that CMS
payment, depending upon the presence CMS is now contradicting Transmittal clarify that it receives claims with only
or absence of other OPPS services also A–02–129, which states that hospitals packaged codes and no separately
reported on the claim for the same date. can bill a low level clinic visit with CPT payable codes.
Table 3 included in the CY 2007 OPPS code 97602 (Removal of devitalized Response: We will clarify again that
proposed rule (71 FR 49536) and shown tissue from wound(s), non-selective claims with only packaged codes are
below listed the proposed status debridement, without anesthesia (eg, received and processed by the OCE. We
indicators and APC assignments for wet-to-moist dressings, enzymatic, can access cost data for all of the
these ‘‘special’’ packaged codes when abrasion), including topical packaged codes on the claim. We
they are separately payable. We note application(s), wound assessment, and encourage hospitals to continue to
that the payment for these ‘‘special’’ instruction(s) for ongoing care, per submit claims to CMS with only
packaged codes is intended to make session) to receive payment. packaged codes because these
payment for all of the hospital costs, Response: Providers should bill a low- submissions will allow us to continue to
which may include patient registration level visit code only if the hospital gather cost data for these codes, and
and establishment of a medical record, provides a significant, separately help us determine whether it would be
in an outpatient hospital setting even identifiable visit from any other service appropriate to add additional packaged
when no separately payable services are provided. This general rule applies to codes to the ‘‘special’’ packaged codes
provided to the patient on that day. any service provided by a hospital. As list.
After carefully considering the public 36540, 36600, 38792, 75893, 94762, and packaged code. The APC assignments
comments received, we are adopting 96523 as ‘‘special’’ packaged codes. We for these codes are shown in Table 3
without modification, our proposal to note that we also are adopting the APC below. These codes are assigned status
accept the APC Panel’s March 2006 Panel’s August 2006 recommendation to indicator ‘‘Q’’ in Addendum B to this
recommendation to treat CPT codes treat CPT code 96523 as a ‘‘special’’ final rule with comment period.
TABLE 3.—STATUS INDICATORS AND APC ASSIGNMENTS FOR ‘‘SPECIAL’’ PACKAGED CPT CODES
Status CY 2007 APC
CPT code Descriptor CY 2007 APC indicator median
36540 .......... Collect blood, venous access device ................................................................... 0624 S .................. $31.44
36600 .......... Arterial puncture; withdrawal of blood for diagnosis ............................................ 0035 T .................. 12.22
38792 .......... Sentinel node identification .................................................................................. 0389 S .................. 84.05
75893 .......... Venous sampling through catheter, with or without angiography, radiological 0668 S .................. 381.71
supervision and interpretation.
94762 .......... Noninvasive ear or pulse oximetry for oxygen saturation by continuous over- 0443 X .................. 63.61
night monitoring.
96523 .......... Irrigation of implanted venous access device ...................................................... 0624 S .................. 31.44
We will monitor and analyze the associated with endoscopic retrograde to continue to pay separately for CPT
claims frequency and claims detail for cholangiopancreatography procedures. code 76000 for OPPS services furnished
situations in which these codes are We received no public comments on on or after January 1, 2007.
billed alone and then separately paid. our proposal. Therefore, we are For CY 2007, we proposed to accept
This will allow us to determine both adopting our proposal to accept the APC the APC Panel’s recommendation to
which providers are billing these codes Panel’s recommendation and maintain continue to package CPT codes 76937
most often and under what the packaged status of CPT codes 74328, and 75998. In the CY 2006 OPPS final
circumstances these codes are billed 74329, and 74330 for CY 2007. rule with comment period (70 FR 68544
For CY 2007, we proposed to accept and 68545), we reviewed in detail the
and separately paid. We expect that
the APC Panel’s recommendation to data related to these two codes and
hospitals scheduling and providing
continue to package CPT codes 76001, promised to share CY 2004 and early CY
services efficiently to Medicare 76003, and 76005 and to continue to 2005 data with the Packaging
beneficiaries will continue to generally pay separately for CPT code 76000. As Subcommittee. We reviewed current
provide these minor services in noted in the CY 2007 proposed rule (71 data with the Packaging Subcommittee,
conjunction with other medically FR 49536), we received a comment and it recommended that we continue to
necessary services. which stated that it was inconsistent to package these codes. In summary, we
For CY 2007, we proposed to accept pay separately for CPT code 76000 but believe that these services would always
the APC Panel’s recommendation and to package CPT code 76001, when CPT be provided with another separately
maintain the packaged status of CPT code 76001 appears to be a similar code, payable procedure, so their costs would
codes 74328, 74329, and 74330. The except that it is for a longer period of be appropriately bundled with the
AMA notes that these radiological physician time. The Packaging definitive vascular access device
supervision and interpretation codes Subcommittee believed that many of the procedures. We found that the costs for
should be reported with procedure CPT claims that listed CPT code 76001 were these guidance procedures are relatively
codes 43260–43272. In fact, our data erroneously billed, as many of the low compared to the CY 2007 proposed
indicate that these supervision and procedure codes that were billed with payment rates for the separately payable
interpretation codes are billed with CPT code 76001 included fluoroscopy services they most frequently
43260–43272 more than 90 percent of as an integral part of the procedure. In accompany. If we were to unpackage
the time, indicating their routine use. other cases, the Packaging CPT codes 76937 and 75998, the single
We believe that some providers may be Subcommittee noted that a procedure- bills available to develop median costs
specific fluoroscopy code should for vascular access device insertion
concerned that although the payment
probably have been billed, instead of services would be significantly reduced.
for the endoscopic procedure includes
CPT code 76001. The Packaging Therefore, we proposed to continue to
the bundled payment for the
Subcommittee believed that CPT code package both CPT codes 76937 and
supervision and interpretation 76000 could often be provided as a sole 75998 for CY 2007.
performed by the radiology department, service, with no other separately CPT code 75998 will be replaced with
the payment for the comprehensive payable procedures. The Packaging CPT code 77001, effective January 1,
service may be directed to the hospital Subcommittee recommended that CMS 2007. The code descriptor will remain
department that performed the continue to pay separately for CPT code the same.
endoscopic procedure, rather than to the 76000, consistent with the AMA’s Comment: Several commenters
radiology department. While we definition of this code, which specifies requested that CMS pay separately for
understand this concern, the OPPS pays that it is a separate procedure, and to CPT code 76937 because they believe
hospital for services provided, and we continue to package CPT codes 76001, that packaged payment creates a
believe that hospitals are responsible for 76003, and 76005. disincentive for use of this technology.
attributing payments to hospital We received no public comments that Three commenters cited a June 2001
departments as they believe appropriate. objected to our proposal. Therefore, we report published by the Agency for
We do not believe that packaging these are adopting our proposal, without Healthcare Research and Quality that
radiological supervision and modification, to accept the APC Panel’s claims that use of ultrasound guidance
interpretation codes leads to inaccurate recommendation to continue to package reduced the relative risk for
payments for the full hospital resources CPT codes 76001, 76003, and 76005 and complications during a central venous
catheter insertion. In addition, two ultrasound guidance in conjunction procedure. Recent data indicate that 94
commenters submitted claims data with central venous access device percent of the time HCPCS code G0269
analyses that suggested that for those repairs and replacements. Our hospital was billed with either CPT code 93510
vascular access procedures that CPT claims data demonstrate that in CY 2004 (Left heart catheterization, retrograde,
code 76937 could be reported with, CPT guidance services were used frequently from the brachial artery, axillary artery
code 76937 was reported, on average, for the insertion of vascular access or femoral artery; percutaneous) or
only 14 percent of the time, with the devices, and we have no evidence that 93526 (Combined right heart
greatest utilization rate no more than 25 patients lacked appropriate access to catheterization and retrograde left heart
percent. The commenters stated that guidance services necessary for the safe catheterization). In addition, the median
these analyses confirmed that insertion of vascular access devices in cost of G0269 is low compared to the
ultrasound guidance is not standard the hospital outpatient setting. To the costs of the procedures with which it is
practice while performing vascular extent that ultrasound guidance may be typically associated.
access procedures. more frequently provided in the future We received no public comments on
Response: We appreciate the data in association with the insertions of our proposal. Therefore, we are
analyses submitted by the commenters. venous access devices or other OPPS finalizing our proposal, without
In fact, we published the results of our services, we expect that its cost would modification, to package HCPCS code
similar analysis in the CY 2006 final also be increasingly reflected in the G0269 for CY 2007.
median costs for those services. For CY 2007, we proposed to continue
rule with comment period (70 FR
Also in the CY 2006 final rule (FR 70 packaging CPT codes 94760 and 94761
68544). To summarize our previous
68544), we reported our analysis of and not adopt the APC Panel’s
analysis, using CY 2004 single claims
claims data related to ultrasound recommendation to provide separate
data, we determined that for the four payment for these services if there are
guidance for vascular access device
most commonly billed venous access no other separately payable OPPS
insertion procedures from another
device insertion codes (CPT codes services on the claim for the same date
perspective. Rather than determining
36556, 36558, 36561, and 36569), one or of service. Our data review revealed that
how often central venous access device
more forms of guidance (fluoroscopic these services are very frequently
insertions were billed with ultrasound
and/or ultrasound) were reported on 41 provided in the OPPS, with over 1.18
guidance, we determined how often
to 64 percent of the single claims million claims in CY 2005 for the single
ultrasound guidance was billed with
utilized for ratesetting. Specifically, central venous access device insertions. pulse oximetry determination service
ultrasound guidance was reported from The OPPS hospital claims data reviewed and over 485,000 claims for the multiple
16 to 34 percent of the time and at that time revealed that out of the total determinations service. These high
fluoroscopic guidance was billed from instances of CPT code 76937 appearing frequencies may actually be understated
29 to 52 percent of the time. Thus, on the claims used for setting payment as both of these services are packaged
overall for these vascular access device rates for CY 2006, CPT code 76937 was codes, and we have been told that some
insertion services, guidance was used in billed with four separately payable hospitals may not report the HCPCS
at least 41 percent of the single claim codes for insertion of central venous codes for services for which they receive
cases, a very significant portion of the access devices 84 percent of the time. no separate payments. Single and
time. We note that all of the commenters This indicated, as might have been multiple pulse oximetry determinations
are specifically concerned about expected, that the costs for CPT code are almost always provided in
unpackaging CPT code 76937 and do 76937 were typically packaged into association with other services that are
not appear to be concerned with the payment for four CPT codes, 36566, separately payable under the OPPS, into
packaged status of CPT 75998. In fact, 36558, 36561, and 36569, the most which their costs may be appropriately
the commenters’ analyses only included commonly billed codes under the OPPS packaged. Specifically, OPPS hospital
ultrasound guidance and did not specify for vascular access device insertion. claims data revealed that out of the total
the number of venous access device Because we believe that ultrasound instances of CPT code 94760 appearing
insertions that involved fluoroscopic guidance would always be provided on claims used for setting payment rates
guidance. We believe that hospital staff with another separately payable for this CY 2007 OPPS final rule with
choose whether to use no guidance or procedure, its costs would be comment period, CPT code 94760 was
fluoroscopic guidance or ultrasound appropriately bundled with the handful billed only 4 percent of the time in
guidance on an individual basis, of vascular access device insertion association with no other separately
depending on the clinical circumstances procedures with which it is most payable OPPS services, with a median
of the vascular access device insertion commonly performed. In addition, cost of $14. Using the same data, CPT
procedure. We also note that the two packaging is also appropriate because code 94761 was billed only 7 percent of
commenters studied the frequency of the cost of ultrasound guidance is the time in association with no other
CPT code 76937 when billed with CPT relatively low compared to the CY 2007 separately payable OPPS services, with
codes 36555–36585, which includes payment rates for the separately payable a median cost of $36. These pulse
central venous access device insertions, services it most frequently accompanies. oximetry services have a relatively low
repairs, and replacements. In fact, the After carefully considering the public cost compared with the OPPS services
study that the commenters reference comments received, we are adopting our they frequently accompany. If we were
indicates that ultrasound guidance is proposal without modification to accept to provide separate payment for these
appropriate for central venous access the APC Panel’s March 2006 pulse oximetry determinations when
device insertions. Interestingly, the data recommendation to continue to package performed as stand alone procedures by
now show that 16 percent of all central CPT codes 76937 and 77001, which hospitals, we are concerned that
venous access device insertions are replaces CPT code 75998. hospitals would lose their incentive to
billed with ultrasound guidance while For CY 2007, we proposed to accept provide these basic, low cost, and brief
only 2 percent of repairs and the APC Panel’s recommendation to services as efficiently as possible,
replacements are billed with ultrasound continue to package HCPCS code generally during the same encounters
guidance. We believe that this indicates G0269. This code should never be billed where they are providing other services
that it may be less useful to use without another separately payable to the same patients. We believe their
appropriate provision as single services ultrasound procedures that must be implement this provision specify that
should be very rare. Therefore, for CY provided with other services, common payments under the OPPS will be made
2007 we proposed not to include these carotid IMT is a stand-alone diagnostic for partial hospitalization services
codes on the list of ‘‘special’’ packaged test because it requires special imaging furnished by CMHCs. Section
codes, so their payment would remain of the arterial wall and quantitative 1883(t)(2)(C) of the Act requires that we
packaged in all circumstances. analysis. The commenter further added establish relative payment weights
We received no public comments on that based on the CPT code book based on median (or mean, at the
our proposal. Therefore, we are instruction for other carotid procedures election of the Secretary) hospital costs
adopting our proposal to continue (that is, CPT codes 93880 and 93882), determined by 1996 claims data and
packaging CPT codes 94760 and 94761 CPT coding does not permit bundling of data from the most recent available cost
and are not adopting the APC Panel’s 0126T with other procedure codes. The reports. Payment to providers under the
March 2006 recommendation to provide commenter urged CMS to pay separately OPPS for PHPs represents the provider’s
separate payment for these services if for common carotid IMT and assign this overhead costs associated with the
there are no other separately payable code to New Technology APC 1504— program. Because a day of care is the
OPPS services on the claim for the same Level IV ($200–$300), with a payment unit that defines the structure and
date of service. rate of $250. scheduling of partial hospitalization
For CY 2007, we proposed to assign Response: We continue to believe that services, we established a per diem
status indicator ‘‘A’’ to HCPCS code it would be unlikely for this code to be payment methodology for the PHP APC,
P9612 and reject the APC Panel’s provided without any other separately effective for services furnished on or
recommendation to pay separately payable services on the same day. after August 1, 2000. For a detailed
under the OPPS for this code when it is However, we also think that the discussion, we refer readers to the April
billed without any separately payable commenter’s suggestion bears closer 7, 2000 OPPS final rule with comment
OPPS services. This code is currently examination. Therefore, we will review period (65 FR 18452).
payable on the clinical lab fee schedule. this code with the Packaging Historically, the median per diem cost
Its status indicator of ‘‘A’’ would Subcommittee of the APC Panel, as is for CMHCs has greatly exceeded the
provide payment for the service our standard procedure for codes that median per diem cost for hospital-based
whenever it is billed, regardless of the we are asked to review during the PHPs and has fluctuated significantly
presence or absence of other reported comment period, and as we have from year to year while the median per
services. In addition, for consistency we previously done for the other services diem cost for hospital-based PHPs has
are proposing to assign status indicator discussed above. We will discuss with remained relatively constant ($200-
‘‘A’’ to HCPCS code P9615 as it is also the Packaging Subcommittee, on an $225). We believe that CMHCs may have
payable on the clinical lab fee schedule. ongoing basis, packaged procedures for increased and decreased their charges in
In general, when a code is payable on which status indicator changes have response to Medicare payment policies.
the clinical lab fee schedule, we defer to been suggested by the public. As discussed in more detail in section
that fee schedule and do not assign We note that the APC Panel Packaging II.B.2. of the preamble of this final rule
payment under the OPPS. Subcommittee remains active, and with comment period and in the CY
We received no public comments on additional issues and new data 2004 OPPS final rule with comment
our proposal. Therefore, we are concerning the packaging status of period (68 FR 63470), we believe that
adopting our proposal without codes will be shared for its some CMHCs manipulated their charges
modification to assign status indicator in order to inappropriately receive
consideration as information becomes
‘‘A’’ to HCPCS code P9612 and reject outlier payments.
available. We continue to encourage
the APC Panel’s recommendation to pay In the CY 2003 OPPS update, the
submission of common clinical
separately under the OPPS for this code difference in median per diem cost for
scenarios involving currently packaged
when it is billed without any separately CMHCs and hospital-based PHPs was so
HCPCS codes to the Packaging
payable OPPS services. great, $685 for CMHCs and $225 for
For CY 2007, we proposed to assign Subcommittee for its ongoing review.
hospital-based PHPs, that we applied an
status indicator ‘‘N’’ to CPT code 0126T Additional detailed suggestions for the
adjustment factor of .583 to CMHC costs
(Common carotid intima-media Packaging Subcommittee should be
to account for the difference between
thickness (IMT) study for evaluation of submitted to APCPanel@cms.hhs.gov,
‘‘as submitted’’ and ‘‘final settled’’ cost
atherosclerotic burden or coronary heart with ‘‘Packaging Subcommittee’’ in the
reports. By doing so, the CMHC median
disease risk factor). We received one subject line.
per diem cost was reduced to $384,
public comment on this proposal. B. Payment for Partial Hospitalization resulting in a combined hospital-based
Comment: One commenter disagreed and CMHC PHP median per diem cost
with our status indicator assignment of 1. Background
of $273. As with all APCs in the OPPS,
‘‘N’’ for CPT code 0126T and stated that Partial hospitalization is an intensive the median cost for each APC was
CMS should pay separately for the outpatient program of psychiatric scaled relative to the cost of a mid-level
common carotid IMT procedure because services provided to patients as an office visit and the conversion factor
this is often the sole service that is alternative to inpatient psychiatric care was applied. The resulting per diem rate
performed in the hospital outpatient for beneficiaries who have an acute for PHP for CY 2003 was $240.03.
setting. As clarified by the commenter, mental illness. A partial hospitalization In the CY 2004 OPPS update, the
common carotid IMT is a standardized program (PHP) may be provided by a median per diem cost for CMHCs grew
ultrasound procedure that enables hospital to its outpatients or by a to $1,038, while the median per diem
physicians to safely and accurately Medicare-certified community mental cost for hospital-based PHPs was again
measure and monitor atherosclerosis, health center (CMHC). Section $225. After applying the .583
which is the underlying cause of heart 1833(t)(1)(B)(i) of the Act provides the adjustment factor in the CY 2004
attacks and stroke. The commenter Secretary with the authority to designate proposed rule to the median CMHC per
reported that this code became effective the hospital outpatient services to be diem cost, the median CMHC per diem
on January 1, 2006. According to the covered under the OPPS. The Medicare cost was $605. Because the CMHC
commenter, unlike certain other regulations at 42 CFR 419.21(c) that median per diem cost exceeded the
average per diem cost of inpatient diem cost of $289 was reduced to adequate payment for a program that
psychiatric care, we proposed a per $281.33. We believed that the reduction often spans 5–6 hours a day. We believe
diem rate for CY 2004 based solely on in the CMHC median per diem cost that 15 percent is an appropriate
hospital-based PHP data. The proposed indicated that the use of updated CCRs reduction because it recognizes
PHP per diem for CY 2004, after scaling, had accounted for the previous increase decreases in median per diem costs in
was $208.95. However, by the time we in CMHC charges, and represented a both the hospital data and the CMHC
published the OPPS final rule with more accurate estimate of CMHC per data, and also reduces the risk of any
comment period for CY 2004, we had diem costs for PHP. adverse impact on access to these
received updated CCRs for CMHCs. For the CY 2006 OPPS final rule with services that might result from a large
Using the updated CCRs significantly comment period, we analyzed 12 single-year rate reduction. However, we
lowered the CMHC median per diem months of the most current claims data adopted this policy as a transitional
cost to $440. As a result, we determined available for hospital and CMHC PHP measure, and stated in the CY 2006
that the higher per diem cost for CMHCs services furnished between January 1, OPPS final rule with comment period
was not due to the difference between 2004, and December 31, 2004. We also that we would continue to monitor
‘‘as submitted’’ and ‘‘final settled’’ cost used the most currently available CCRs CMHC costs and charges for these
reports, but was the result of excessive to estimate costs. The median per diem services and work with CMHCs to
increases in charges which may have cost for CMHCs was $154, while the improve their reporting so that
been done in order to receive higher median per diem cost for hospital-based payments can be calculated based on
outlier payments. Therefore, in PHPs was $201. Based on the CY 2004 better empirical data, consistent with
calculating the PHP median per diem claims data, the average charge per day the approach we have used to calculate
cost for CY 2004, we did not apply the for CMHCs was $760, considerably payments in other areas of the OPPS (70
.583 adjustment factor to CMHC costs to greater than hospital-based per day costs FR 68548).
compute the PHP APC. Using the but significantly lower than what it was To apply this methodology for CY
updated CCRs for CMHCs, the combined in CY 2003 ($1,184). We believed that 2006, we reduced $289 (the CY 2005
hospital-based and CMHC median per a combination of reduced charges and combined unscaled hospital-based and
diem cost for PHP was $303. After slightly lower CCRs for CMHCs resulted CMHC median per diem cost) by 15
scaling, we established the CY 2004 in a significant decline in the CMHC percent, resulting in a combined median
PHP APC of $286.82. median per diem cost between CY 2003 per diem cost of $245.65 for CY 2006.
For CY 2005, the PHP per diem and CY 2004.
amount was based on 12 months of Following the methodology used for 2. PHP APC Update for CY 2007
hospital and CMHC PHP claims data the CY 2005 OPPS update, the CY 2006
For CY 2007, we proposed to
(for services furnished from January 1, OPPS update combined hospital-based
calculate the CY 2007 PHP per diem
2003, through December 31, 2003). We and CMHC median per diem cost was
payment rate using the same update
used data from all hospital bills $161, a decrease of 44 percent compared
methodology that we adopted in CY
reporting condition code 41, which to the CY 2005 combined median per
2006. That is, we proposed to apply an
identifies the claim as partial diem amount. We believed that this
amount was too low to cover the cost for additional 15-percent reduction to the
hospitalization, and all bills from
all PHPs. combined hospital-based and CMHC
CMHCs because CMHCs are Medicare
Therefore, as stated in the CY 2006 median per diem cost that was used to
providers only for the purpose of
OPPS final rule with comment period establish the CY 2006 per diem PHP
providing partial hospitalization
(70 FR 68548 and 68549), we considered payment.
services. We used CCRs from the most
recently available hospital and CMHC the following three alternatives to our As discussed in the CY 2007 OPPS
cost reports to convert each provider’s update methodology for the PHP APC proposed rule (71 FR 49538), we
line-item charges as reported on bills, to for CY 2006 to mitigate this drastic analyzed 12 months of data for hospital
estimate the provider’s cost for a day of reduction in payment for PHP services: and CMHC PHP claims for services
PHP services. Per diem costs were then (1) base the PHP APC on hospital-based furnished between January 1, 2005, and
computed by summing the line-item PHP data alone; (2) apply a different December 31, 2005. We used the most
costs on each bill and dividing by the trimming methodology to CMHC costs currently available CCRs to estimate
number of days on the bill. in an effort to eliminate the effect of costs. Using these CY 2005 claims data,
In a Program Memorandum issued on data for those CMHCs that appeared to the median per diem cost for CMHCs
January 17, 2003 (Transmittal A–03– have excessively increased their charges was $165 and the median per diem cost
004), we directed fiscal intermediaries in order to receive outlier payments; for hospital-based PHPs was $209.
to recalculate hospital and CMHC CCRs and (3) apply a 15-percent reduction to Following the methodology used for the
by April 30, 2003, using the most the combined hospital-based and CMHC CY 2005 update, the CY 2007 combined
recently settled cost reports. Following median per diem cost that was used to hospital-based and CMHC median per
the initial update of CCRs, fiscal establish the CY 2005 PHP APC. (We diem cost is $172.
intermediaries were further instructed refer readers to the CY 2006 OPPS final While the combined hospital-based
to continue to update a provider’s CCR rule with comment period for a full and CMHC median per diem cost is
and enter revised CCRs into the discussion of the three alternatives (70 about $10 higher using the CY 2005 data
outpatient provider-specific file. FR 68548).) After carefully considering compared to the CY 2004 data ($172
Therefore, for CMHCs, we used CCRs these three alternatives and all compared to $161), we believe this
from the outpatient provider-specific comments received on them, we amount is still too low to cover the cost
file. adopted the third alternative for CY for PHPs. As a result, we proposed the
In the CY 2005 OPPS update, the 2006. We adopted this alternative same policy we adopted for CY 2006—
CMHC median per diem cost was $310 because we believed and continue to a 15-percent reduction applied to the
and the hospital-based PHP median per believe that a reduction in the CY 2005 current median cost. Therefore, to
diem cost was $215. No adjustments median per diem cost would strike an calculate the proposed PHP per diem
were determined to be necessary and, appropriate balance between using the rate for CY 2007, we applied an
after scaling, the combined median per best available data and providing additional 15-percent reduction to the
combined hospital-based and CMHC downward trend in data. Although the per diem cost by using combined
median per diem cost. data continue to show a low per diem hospital-based and CMHC median cost
To calculate the proposed CY 2007 cost for PHP, we believe that a transition data and scaled the figure relative to the
APC PHP per diem cost, we reduced to the reduced amount may be more cost of a mid-level office visit and then
$245.65 (the CY 2005 combined appropriate to ensure access for the applied the conversion factor. However,
hospital-based and CMHC median per vulnerable population served in PHPs. in CY 2006, the combined hospital-
diem cost of $289 reduced by 15 We recognize that many CMHCs are based and CMHC median cost data
percent) by 15 percent, which resulted located in areas affected by Hurricanes produced an amount we believed was so
in a proposed combined median per Katrina and Rita where access to low that it would result in too large of
diem cost of $208.80. intensive mental health treatment is a single year rate reduction that we
We received numerous public now limited. We note that the median modified our methodology by limiting
comments in response to our proposal. per diem cost for hospital-based PHPs, this decrease to 15 percent.
A summary of the comments received which has been in the $200 to $225 Comment: One commenter replicated
and responses follow: range since the OPPS was implemented, the CMS methodology and computed
Comment: A number of commenters went from $201 in CY 2004 to $190 in rates very close to the CY 2007 proposed
expressed concern about the magnitude CY 2005, a decrease of 5 percent. We per diem rate, as well as the separate
of the reduction, particularly in light of believe this percentage decrease median per diem costs for CMHCs and
last year’s 15 percent reduction. The provides a valid transitional percentage hospital-based PHPs. The commenter
majority of commenters requested that measure reflecting the downward trend also created a 3-year rolling median cost
CMS freeze the PHP rate at the CY 2006 in PHP cost. that also resulted in a rate similar to the
level. Representatives of CMHCs argued Therefore, for CY 2007, we are making proposed PHP rate. However, the
that their costs are higher than those of a 5-percent reduction to the CY 2006 commenter recommended that CMS use
hospitals, with most in the $300 to $400 median per diem rate. This amount the hospital-specific cost center CCR for
range. Another commenter indicated accounts for the downward direction of partial hospitalization instead of the
that a per-day rate of $325 to $375 was the data and addresses concerns about overall outpatient CCR to calculate PHP
more appropriate than the proposed the magnitude of a 15-percent reduction median costs. The commenter believed
amount. The commenters also suggested in 1 year. To calculate the CY 2007 APC that CMS has understated the PHP
alternatives to calculating the PHP rate, PHP per diem cost, we reduced $245.65 median costs by not using the hospital-
such as including prior years’ CMHC (the CY 2005 combined hospital-based specific CCRs for partial hospitalization.
data trended forward based on medical and CMHC median per diem cost of Response: We note that most hospitals
inflation or market basket update. In $289 reduced by 15 percent) by 5 do not have a cost center for partial
addition, several patients were percent, which resulted in a combined hospitalization; therefore, we have used
concerned that a 15-percent reduction per diem cost of $233.37. If the PHP per the CCR as specific to PHP as possible.
in payment would negatively impact diem cost continues to be low in CY The following link contains the Revenue
their ability to continue therapy. 2008, we expect to continue the Cost to Cost Center Crosswalk: http://
Response: For this CY 2007 final rule transition of decreasing the PHP median www.cms.hhs.gov/
with comment period, we analyzed 12 per diem cost to an amount that is HospitalOutpatientPPS/
months of more current data for hospital reflective of the PHP data. 03_crosswalk.asp#TopOfPage.
and CMHC PHP claims for services Comment: The commenters requested This crosswalk indicates how (and if)
furnished between January 1, 2005 and that CMS better define how it is charges on a claim are mapped to a cost
December 31, 2005. These claims data monitoring and working with CMHCs to center for the purpose of converting
are more current because the data improve their reporting. charges to cost. One or more cost centers
include claims paid through June 30, Response: CMS has provided are listed for every revenue code that is
2006. We also used the most currently guidance to all providers, through used in the OPPS median calculations,
available CCRs to estimate costs. Using transmittals and manuals. In addition, starting with most specific, and ending
these updated data, we recreated the when necessary, CMS has worked with most general. CMS maps the
analysis performed for the CY 2007 closely with fiscal intermediaries to revenue code to the most specific cost
proposed rule to determine if the provide guidance to targeted PHP center with a provider-specific CCR. If
significant factors we used in providers to improve reporting. the hospital does not have a CCR for any
determining the proposed PHP rate had Comment: Several commenters stated of the listed cost centers, the overall
changed. The median per diem cost for that CMS has applied its own hospital CCR is the default. The PHP
CMHCs increased $8 to $173, while the assumptions and methodology on a revenue centers are mapped to a
median per diem cost for hospital-based different basis to compute the PHP rate Primary Cost Center 3550 ‘‘Psychiatric/
PHPs decreased $19 to $190. The CY each year from CY 2003 to CY 2006. The Psychological Services.’’ If that cost
2005 average charge per day for CMHCs commenters also stated that the only center is not available, then the
was $675 similar to the figure noted in years CMS used the same method was Secondary Cost Center is 6000 ‘‘Clinic.’’
the CY 2007 proposed rule ($673) but CY 2006 and CY 2007, when CMS made We use the overall facility CCR for
still significantly lower than what is a simple 15-percent reduction from the CMHCs because PHP is the CMHCs’
noted for CY 2003 ($1,184). previous year’s rate. only Medicare cost and CMHCs do not
Following the 15-percent reduction Response: We do not agree with the have the same cost centers as hospitals.
methodology used for the CY 2005 commenters’ assessment of our Therefore, for CMHCs, we use the CCR
update, the combined hospital-based methodology for computing the PHP from the outpatient provider-specific
and CMHC median per diem cost would median per diem cost. Although a 0.583 file.
be $175, only slightly more than the adjustment factor was applied to CMHC Comment: One commenter stated that
figure noted in the CY 2007 proposed costs in the CY 2003 update, all other its internal computations reflect PHP
rule ($172). We continue to believe this aspects of the methodology that the per diem costs of $262.82 for its facility.
amount is too low to cover the cost of commenter referenced have been the The commenter urged CMS to increase
PHPs. However, we believe that freezing same each year until CY 2006. We have the CY 2006 PHP rate of $245.65 by 6.8
the current rate would not reflect the consistently calculated the PHP median percent so that the commenter’s
program would break even. Another services and representatives from qualified services are presented for a
commenter questioned why CMS did national industry organizations. day of service. The commenters stated
not use actual cost report data to obtain Response: We agree that the payment that if only one or two services are
true costs instead of estimating cost rate for PHP needs to be accurate and assigned a cost and the day is divided
using CCRs applied to charges. A third appropriate to sustain access to care. As into the aggregate data, the cost per day
commenter stated that CMS is required we consider changes to the current is significantly compromised and
to include average costs for all providers methodology, we believe input from the diluted. They claimed that even days
and that CMS claims to utilize data industry is an important part of that that are paid but only have three
representative of the mean of actual process. Therefore, we welcome any services dilute the cost factors on the
operating costs. input and information that the industry calculations.
Response: We appreciate the can provide about the costs of their Response: If a provider has charges on
commenter sharing its facility’s per programs and encourage providers to a bill for which they do not receive
diem costs for its facility. However, PHP submit information on their costs. We payment, this will be reflected in that
providers are paid under the OPPS. note that any significant change in provider’s CCRs. This lower CCR will be
Under the OPPS, we generally payment methodology would require a applied to the larger charges and will
determine rates based on median cost statutory change. result in the appropriate cost per diem.
using charges from bill data and then Comment: A few commenters stated To gauge the effect that days with one
estimate costs using CCRs. The OPPS is that wage index adjustment does not or two services had on the per diem
a PPS and will reflect generally the cost accurately reflect the cost of labor in cost, we trimmed all days with less than
of providing services. A PPS may pay areas affected by Hurricanes Katrina and three services, and the recalculated
more or less than a provider’s costs and Rita. median per diem cost only increased by
Response: The hospital wage data $4.00. As such, we do not believe the
is not a reasonable cost reimbursement
used to compute the FY 2007 hospital calculations are adversely affected by
system.
wage index is from the FY 2003 hospital the inclusion of these days.
Comment: One commenter observed a cost reports for all hospitals. This is the Comment: A few commenters
decline of 19 percent in the number of standard lag timeframe in determining expressed concern that their financial
hospital-based PHPs from CY 2003 to the hospital wage index. It will be status is affected where States limit
CY 2005 and a decline of 21 percent in another 2 years before the FY 2005 data payment of beneficiary coinsurance if
the number of hospital-based PHP will be reflected in the FY 2009 hospital the amount of Medicare payment made
claims. The commenter expected further wage index. The wage index is a relative to a provider exceeds the State’s
reductions in the number of hospital- measure of differences in area hourly payment rate for PHP.
based PHPs if CMS implements the wage levels. It compares a labor Response: This is a Medicaid issue
proposed 15-percent rate cut in CY market’s average hourly wage to the and beyond the scope of this final rule.
2007. national average hourly wage. To the Comment: With respect to the
Response: We do not believe this is an extent that post-hurricane hospital labor methodology used to establish the PHP
appropriate comparison because the costs are higher relative to the national APC amount, commenters were
commenter did not use the complete average, the wage index will reflect the concerned that data from settled cost
year of CY 2005 claims data. Rather, the higher relative labor cost beginning reports fails to include costs reversed on
commenter used CY 2005 claims when the FY 2005 data will be used in appeal. The commenters stated that
processed through December 31, 2005. the FY 2009 IPPS hospital wage index there are inherent problems in using
Using comparable CYs 2003 and 2005 (which will be applied to the CY 2009 claims data from a different time period
data, (both CY 2003 and CY 2005 claims OPPS rate year). In addition, the than the CCRs from settled cost reports.
processed through June 30, 2004 and statutory authority for the OPPS wage The commenters indicated this would
June 30, 2006, respectively), the index policy in section 1833(t)(2)(D) of artificially lower the computed median
declines are 11 percent and 5 percent, the Act requires that wage adjustments costs, even though when cost reports are
respectively. During the same time be made in a budget neutral manner. settled, generally 2 years or more after
period, the number of CMHCs increased Therefore, we cannot raise one wage the actual year of services, as the
13 percent and the number of CMHC area and still maintain budget providers have operated on actual
PHP claims increased 36 percent. While neutrality. revenues of 80 percent of the per diem.
there may have been fewer hospital- Comment: A few commenters Response: We use the best available
based PHPs, the number of CMHCs disagreed with the CMS approach to data in computing the APCs. We issued
increased from 136 in CY 2003 to 179 establishing the median per diem cost a Program Memorandum on January 17,
in CY 2005. In CY 2005, CMHC and by summarizing the line-item costs on 2003 directing fiscal intermediaries to
hospital-based PHPs combined provided each bill and dividing by the number of update the CCRs on an on-going basis
1.2 million days of PHP care, compared days on the bills. The commenters whenever a more recent full year cost
to approximately 0.8 million days of indicated that this calculation can report is available. In this way, we
PHP care in CY 2003. We believe our severely dilute the rate and penalize minimize the time lag between the CCRs
payment rates continue to ensure providers. The commenters stated that and claims data and continue to use the
adequate access to PHP care. all programs are strongly encouraged by best available data.
Comment: Several commenters the fiscal intermediaries to submit all Comment: One commenter stated that
suggested establishing a task force to PHP service days on claims, even when administrative costs for CMHCs
develop a new rate methodology that the patient receives less than three continue to be a major impediment to
captures all relevant data and reflects services. They further stated that operating PHPs for Medicare
the actual costs to providers to deliver programs must report these days to be beneficiaries. The commenter was
PHP services. The commenters able to meet the 57 percent attendance concerned that Medicare does not cover
recommended that the new ratesetting threshold and avoid potential delays in transportation to and from programs and
task force be composed of CMS staff and the claim payment. The commenters does not cover meals. The commenter
a diverse group of stakeholders that were concerned that programs are only stated that almost all programs offer
include front-line providers of PHP paid their per diem when three or more transportation because in most cases
Medicare beneficiaries with serious specify the specific mix of other services better educate the CMHCs in the cost
mental illnesses would not be able to provided and our payment methodology reporting requirements.
access these programs without the reflects the cost per day rather than the Comment: One commenter asked why
transportation. cost of each service furnished within the there are no CMHCs shown in the
Response: The services that are day. We note that CMS does not require impact statement. The commenter asked
covered as part of a PHP are specified a minimum of four services. if this is required by regulation.
in section 1861(ff) of the Act. Meals and Comment: One commenter requested Response: CMHCs do not share the
transportation are specifically excluded that the same provisions given to rural same characteristics as hospitals and do
under section 1861(ff)(2)(I) of the Act. hospital outpatient departments also be not fit into the traditional impact
Comment: Several commenters given to rural CMHCs. categories (like bed size). Therefore, we
summed the payment rate for four Response: We believe the commenter have not included them in the impact
Group Therapy sessions (APC 0325) and may be referring to the statutory hold chart. As PHP is the only Medicare
requested that amount as the minimum harmless provisions. Section service CMHCs provide, the impact is
for a day of PHP (that is, 4 × 1833(t)(7)(D) of the Act authorizes such the percentage change in the APC
$66.40=$265.60). Another commenter payments, on a permanent basis, for amount from year to year. Assuming
presented two different typical days children’s hospitals and cancer that the number days of PHP provided
using proposed CY 2007 rates. Typical hospitals and, through CY 2005, for by CMHCs stays the same as it was in
Day 1 had three Group Therapy sessions rural hospitals having 100 or fewer beds CY 2005, the estimated impact on
(CPT code 90853, APC 0325, 3 × $66.40) and SCHs in rural areas. Section CMHCs as a result of the CY 2007 PHP
and one Individual Psychotherapy 1866(t)(7)(D) of the Act does not payment rate compared to the CY 2006
session (CPT code 90818, APC 0325, authorize hold harmless payments to PHP payment rate is a 5-percent
$105.68). The commenter priced CMHC providers. Section 411 of Pub. L. decrease.
Typical Day 1 at $304.88. Typical Day 108–173 required CMS to determine the
3. Separate Threshold for Outlier
2 had one Group Therapy session (CPT appropriateness of additional payments
Payments to CMHCs
code 90853, APC 0325, $66.40), one for certain rural hospitals. That
Individual Psychotherapy session (CPT authority also does not extend to In the November 7, 2003 final rule
code 90818, APC 0323, $105.68), and CMHCs. with comment period (68 FR 63469), we
one Family Therapy session (CPT code Comment: Representatives of several indicated that, given the difference in
90847, APC 0324, $135.95). The CMHCs claimed that their costs are PHP charges between hospitals and
commenter priced Typical Day 2 at higher because ‘‘hospitals can share and CMHCs, we did not believe it was
$308.03. Based on the commenter’s spread their costs to other appropriate to make outlier payments to
presented material, the commenter departments.’’ The commenters believed CMHCs using the outlier percentage
stated that the typical days yield an that the CMHC patient acuity level is target amount and threshold established
average componentized rate of $306. more intense than that for hospital for hospitals. There was a significant
The commenters questioned how CMS patients because hospital outpatient difference in the amount of outlier
can set rates for APCs 0322 through departments need only provide one or payments made to hospitals and CMHCs
0325, yet are unable to determine a two therapies, yet still receive the full for PHP. In addition, further analysis
payment rate for a day that is comprised PHP per diem. indicated that using the same OPPS
of a minimum of three to four of those Response: CMHCs are required to outlier threshold for both hospitals and
services. Another commenter stated that furnish an array of outpatient services CMHCs did not limit outlier payments
CMS requires a minimum of four including specialized outpatient to high cost cases and resulted in
treatments per day to qualify for a day services for children, the elderly, excessive outlier payments to CMHCs.
of PHP and the proposed per diem rate individuals with a serious mental Therefore, for CYs 2004, 2005, and
of $208.27 for PHP that is less than what illness, and residents of its service area 2006, we established a separate outlier
CMS would pay for four Group Therapy who have been discharged from threshold for CMHCs. For CYs 2004 and
sessions (4 × $66.40=$265.60). inpatient treatment. Accordingly, 2005, we designated a portion of the
Response: We do not believe this is an CMHCs have the same ability to share estimated 2.0 percent outlier target
appropriate comparison. The costs among its programs as needed. amount specifically for CMHCs,
commenter does not use the PHP APC, Further, we believe hospital costs in consistent with the percentage of
APC 0033. The payment rates for APC some areas, for example, capital and 24- projected payments to CMHCs under the
services cited by the commenter (APC hour maintenance costs, likely exceed OPPS in each of those years, excluding
0323, APC 0324 and APC 0325) are not CMHC costs. outlier payments. For CY 2006, we set
computed from PHP bills. As stated Comment: A few commenters stated the estimated outlier target at 1.0
earlier, we used data from PHP that hospitals that offer partial percent and allocated a portion of that
programs (both hospitals and CMHCs) to hospitalization services should not be 1.0 percent, 0.6 percent (or 0.006
determine the median cost of a day of penalized for the instability in data percent of total OPPS payments), to
PHP. PHP is a program of services reporting of CMHCs. Another CMHCs for PHP services. The CY 2006
where savings can be realized by commenter requested that CMS require CMHC outlier threshold is met when the
hospitals and CMHCs over delivering that CMHCs improve their reporting or cost of furnishing services by a CMHC
individual psychotherapy services. have that provider group face economic exceeds 3.40 times the PHP APC
We structured the PHP APC (0033) as consequences. payment amount. The CY 2006 OPPS
a per diem methodology in which the Response: We believe that hospital- outlier payment percentage is 50
day of care is the unit that reflects the based programs may have benefited percent of the amount of costs in excess
structure and scheduling of PHPs and from the inclusion of CMHC data, as of the threshold.
the composition of the PHP APC generally the median calculated from The separate outlier threshold for
consists of the cost of all services hospital outpatient department PHPs CMHCs became effective January 1,
provided each day. Although we require was consistently far less then the 2004, and has resulted in more
that each PHP day include a median amount that is computed for commensurate outlier payments. In CY
psychotherapy service, we do not CMHCs. We have also taken steps to 2004, the separate outlier threshold for
CMHCs resulted in $1.8 million in outlier percentage applicable to costs in rural SCHs, including rural EACHs, of
outlier payments to CMHCs. In CY 2005, excess of the threshold at 50 percent. 0.999975941 result in a standard
the separate outlier threshold for conversion factor for CY 2007 of
C. Conversion Factor Update for CY
CMHCs resulted in $0.5 million in $61.468.
2007 We received many public comments
outlier payments to CMHCs. In contrast,
in CY 2003, more than $30 million was Section 1833(t)(3)(C)(ii) of the Act on the calculation of the proposed
paid to CMHCs in outlier payments. We requires us to update the conversion conversion factor updates for CY 2007
believe this difference in outlier factor used to determine payment rates with regard to the proposal to reduce
payments indicates that the separate under the OPPS on an annual basis. the CY 2007 conversion factor for failure
outlier threshold for CMHCs has been Section 1833(t)(3)(C)(iv) of the Act to report the IPPS RHQDAPU data.
successful in keeping outlier payments provides that, for CY 2007, the update These comments are addressed in
to CMHCs in line with the percentage of is equal to the hospital inpatient market section XIX. of this preamble. We
OPPS payments made to CMHCs. basket percentage increase applicable to received no other comments on the
As discussed in section II.B.2. of this hospital discharges under section proposed conversion factor update for
preamble, we believe the CY 2005 1886(b)(3)(B)(iii) of the Act. CY 2007.
CMHC data produce median per diem The hospital market basket increase
for FY 2007 published in the IPPS final D. Wage Index Changes for CY 2007
cost too low to use for the CY 2007
partial hospitalization payment rate. rule on August 18, 2006 is 3.4 percent Section 1833(t)(2)(D) of the Act
Due to the continued volatility of the (71 FR 48146), the same as the forecast requires the Secretary to determine a
CMHC charge data, we proposed to published in the FY 2007 IPPS proposed wage adjustment factor to adjust, for
maintain the existing outlier threshold rule on April 25, 2006 (71 FR 24148). To geographic wage differences, the portion
for CMHCs for CY 2007 at 3.40 times the set the OPPS proposed conversion factor of the OPPS payment rate and the
APC payment amount and the CY 2007 for CY 2007, we increased the CY 2006 copayment standardized amount
outlier payment percentage applicable conversion factor of $59.511, as attributable to labor and labor-related
to costs in excess of the threshold at 50 specified in the November 10, 2005 final cost. Since the inception of the OPPS,
percent. rule with comment period (70 FR CMS policy has been to wage adjust 60
As noted in section II.G. of this 68551), by 3.4 percent. percent of the OPPS payment, based on
preamble, for CY 2007, we proposed to In accordance with section a regression analysis that determined
continue our policy of setting aside 1.0 1833(t)(9)(B) of the Act, we further that approximately 60 percent of the
percent of the aggregate total payments adjusted the conversion factor for CY costs of services paid under OPPS were
under the OPPS for outlier payments. 2006 to ensure that the revisions we are attributable to wage costs. We did not
We proposed that a portion of that 1.0 making to our updates for a revised propose to revise this policy for CY
percent, an amount equal to 0.25 wage index and expanded rural 2007 OPPS. See section II.H. of this final
percent of outlier payments and 0.0025 adjustment are made on a budget rule with comment period for a
percent of total OPPS payments would neutral basis. We calculated a budget description and example of how the
be allocated to CMHCs for PHP service neutrality factor of 0.999331979 for wage index for a particular hospital is
outliers. As discussed in section II.G. of wage index changes by comparing total used to determine the payment for the
this preamble, we again proposed to set payments from our simulation model hospital.
a dollar threshold in addition to an APC using the FY 2007 IPPS final wage index This adjustment must be made in a
multiplier threshold for OPPS outlier values as finalized to those payments budget neutral manner. As we have
payments. However, because the PHP is using the current (FY 2006) IPPS wage done in prior years, we proposed to
the only APC for which CMHCs may index values. To reflect the inclusion of adopt the IPPS wage indices and extend
receive payment under the OPPS, we essential access community hospitals these wage indices to hospitals that
would not expect to redirect outlier (EACHs) as rural SCHs (discussed in participate in the OPPS but not the IPPS
payments by imposing a dollar section II.F. of this preamble), we (referred to in this section as ‘‘non-
threshold. Therefore, we did not calculated an additional budget IPPS’’ hospitals).
propose to set a dollar threshold for neutrality factor of 0.999975941 for the As discussed in section II.A. of this
CMHC outliers. As noted above, we rural adjustment, including EACHs. For preamble, we standardize 60 percent of
proposed to set the outlier threshold for CY 2007, we estimate that allowed pass- estimated costs (labor-related costs) for
CMHCs for CY 2007 at 3.40 percent through spending would equal geographic area wage variation using the
times the APC payment amount and the approximately $65.6 million, which IPPS wage indices that are calculated
CY 2007 outlier payment percentage represents 0.21 percent of total OPPS prior to adjustments for reclassification
applicable to costs in excess of the projected spending for CY 2007. The to remove the effects of differences in
threshold at 50 percent. final conversion factor also is adjusted area wage levels in determining the
We received no public comments on by the difference between the 0.17 OPPS payment rate and the copayment
our proposal. As discussed in section percent pass-through dollars set-aside in standardized amount.
II.G. of this preamble, using more recent CY 2006 and the 0.21 percent estimate As published in the original OPPS
data for this final rule with comment for CY 2007 pass-through spending. April 7, 2000 final rule with comment
period, we set the target for hospital Finally, payments for outliers remain at period (65 FR 18545), OPPS has
outpatient outlier payments at 1.0 of 1.0 percent of total payments for CY consistently adopted the final IPPS
total OPPS payments. We allocate a 2007. wage indices as the wage indices for
portion of that 1.0 percent, an amount The market basket increase update adjusting the OPPS standard payment
equal to 0.15 percent of outlier factor of 3.4 percent for CY 2007, the amounts for labor market differences.
payments and 0.0015 percent of total required wage index budget neutrality Thus, the wage index that applies to a
OPPS payments to CMHCs for PHP adjustment of approximately particular hospital under the IPPS will
service outliers. For CY 2007, we set the 0.999331979, the adjustment of 0.04 also apply to that hospital under the
outlier threshold for CMHCs for CY percent for the difference in the pass- OPPS. As initially explained in the
2007 at 3.40 percent times the APC through set-aside, and the adjustment September 8, 1998 OPPS proposed rule,
payment amount and the CY 2007 for the rural payment adjustment for we believed and continue to believe that
using the IPPS wage index as the source 108–173. The following is a brief final rule and the October 11, 2006 IPPS
of an adjustment factor for OPPS is summary of the changes in the FY 2005 notice discussed above. Under that final
reasonable and logical, given the IPPS wage indices, continued for FY rule, the wage indices are adjusted 100
inseparable, subordinate status of the 2007, and any adjustments that we are percent for occupational mix. In
hospital outpatient within the hospital applying to the OPPS for CY 2007. We addition, as stated above, the finalized
overall. In accordance with section refer the reader to the FY 2007 IPPS version of the FY 2007 IPPS wage index
1886(d)(3)(E) of the Act, the IPPS wage final rule (71 FR 48005 through 48028) tables and other adjustment factors were
index is updated annually. In the CY for a detailed discussion of the changes published in the October 11, 2006 IPPS
2007 OPPS proposed rule, in to the wage indices. Readers should notice and are applicable to discharges
accordance with our established policy, refer also to our IPPS notice published occurring on or after October 1, 2006.
we proposed to use the FY 2007 final in the Federal Register on October 11, As noted above, for purposes of
version of these wage indices to 2006, for finalized changes to the estimating an adjustment for the OPPS
determine the wage adjustments for the adjusted occupational mix wage indices payment rates to accommodate
OPPS payment rate and copayment and related issues (71 FR 59886). In this geographic differences in labor costs in
standardized amount that would be final rule with comment period, we are this final rule with comment period, we
published in our final rule with not reprinting the FY 2007 IPPS wage have used the finalized FY 2007 IPPS
comment period for CY 2007 which will indices referenced in the discussion wage indices identified in the October
include the finalized wage indices in below, with the exception of the out- 11, 2006 IPPS notice that are fully
effect through March 31, 2007, and migration wage adjustment table adjusted for differences in occupational
those in effect on or after April 1, 2007, (Addendum L of this final rule with mix using the new survey data, effective
to accommodate the expiring comment period). We also refer readers October 1, 2006. As proposed, in all
reclassification provisions under section to the CMS Web site for the OPPS at cases, we are using the finalized FY
508 of Pub. L. 108–173 to determine the http://www.cms.hhs.gov/providers/ 2007 IPPS wage indices, which include
wage adjustments for the OPPS payment hopps. At this Web site, the reader will the wage indices to be in effect through
rate and copayment standardized find a link to the finalized FY 2007 IPPS March 31, 2007, and those to be in effect
amount. wage indices tables. on or after April 1, 2007, with any
On May 17, 2006 (71 FR 28644), in 1. The continued use of the Core subsequent corrections, for calculating
response to a court order in Bellevue Based Statistical Areas (CBSAs) issued OPPS payment in CY 2007.
Hosp. Ctr. v. Leavitt, we published a by the OMB as revised standards for 2. The reclassifications of hospitals to
second IPPS proposed rule that would designating geographical statistical geographic areas for purposes of the
revise the methodology for calculating areas based on the 2000 Census data, to wage index. For purposes of the OPPS
the occupational mix adjustment for FY define labor market areas for hospitals wage index, we proposed to adopt all of
2007. We proposed to replace in full the for purposes of the IPPS wage index. the IPPS reclassifications for FY 2007,
descriptions of the data and The OMB revised standards were including reclassifications that the
methodology that would be used in published in the Federal Register on Medicare Geographic Classification
calculating the occupational mix December 27, 2000 (65 FR 82235), and Review Board (MGCRB) approved under
adjustment discussed in the first FY OMB announced the new CBSAs on the one-time appeal process for
2007 IPPS proposed rule. The second June 6, 2003, through an OMB bulletin. hospitals under section 508 of Pub. L.
proposed rule also states that, because In the FY 2005 IPPS final rule, CMS 108–173. We note that section 508
of the collection of new occupational adopted the new OMB definitions for reclassifications will terminate March
mix data, we would publish the FY wage index purposes. In the FY 2007 31, 2007, and that this expiration, along
2007 occupational mix adjusted wage IPPS final rule, we again stated that with the calendar year operating period
index tables and related impacts on the hospitals located in MSAs will be urban of OPPS, impacts the calculation of the
CMS Web site shortly after we and hospitals that are located in OPPS payment and the budget
published the FY 2007 IPPS final rule, Micropolitan Areas or outside CBSAs neutrality adjustment for the wage
and in advance of October 1, 2006. The will be rural. To help alleviate the index. In the FY 2007 IPPS final rule (71
weights and factors would also be decreased payments for previously FR 48024 and 48025), we finalized the
published on the CMS Web site after the urban hospitals that became rural under procedural rules for hospitals that
FY 2007 IPPS final rule, but in advance the new geographical definitions, we wished to reclassify for the second half
of October 1, 2006 (71 FR 28650). On allowed these hospitals to maintain for of FY 2007 (April 1, 2007, through
October 11, 2006 (71 FR 59886), we the 3-year period from FY 2005 through September 30, 2007) under section
published an IPPS notice in the Federal FY 2007, the wage index of the MSA 1886(d)(10) of the Act. These rules
Register that, in part, finalized the where they previously had been located. essentially provided procedures for
adjusted occupational mix wage indices To be consistent with the IPPS, we will some hospitals to retain section 508
published in the FY 2007 IPPS final continue the policy we began in CY reclassifications for the first half of FY
rule. Readers are directed to refer to the 2005 of applying the same urban-to- 2007 and also be eligible to maintain an
wage index tables that were published rural transition to non-IPPS hospitals approved reclassification under section
on the CMS Web site before October 1, paid under the OPPS. That is, we would 1886(d)(10) for the second half of FY
2006. maintain the wage index of the MSA 2007. Rather than calculating one wage
We note that the FY 2007 IPPS wage where the hospital was previously index that reflected all final
indices continue to reflect a number of located for purposes of determining a reclassification adjustments, we will
changes implemented in FY 2005 as a wage index for CY 2007. Beginning in calculate two separate wage indices for
result of the revised Office of FY 2008, the 3-year transition will end FY 2007, one to be in effect October 1
Management and Budget (OMB) and these hospitals will receive their through March 31, 2007, and one to be
standards for defining geographic statewide rural wage index. However, in effect April 1 through September 30,
statistical areas, the implementation of hospitals paid under the IPPS will be 2007.
an occupational mix adjustment as part eligible to apply for reclassification. These procedural rules also impact a
of the wage index, and new wage For the occupational mix adjustment, hospital’s eligibility to receive the out-
adjustments provided for under Pub. L. we refer readers to the FY 2007 IPPS migration wage adjustment, discussed
in greater detail in section III.I. of the FY with comment period, we have included referenced by CMS in the CY 2006
2007 IPPS final rule (71 FR 48026) and the wage index changes that would OPPS final rule.
under section II.D.4. of this preamble. A result from MGCRB reclassifications, Response: We did not propose a
hospital cannot receive an out-migration implementation of section 505 of Pub. L. change to the labor share, but we do not
wage adjustment if it is reclassified 108–173, and other refinements made in believe that such a change is
under section 1886(d)(10) of the Act. the FY 2007 IPPS final rule, such as the appropriate. The determination to wage
Hospitals declining reclassification hold harmless provision for hospitals adjust 60 percent of the payment of each
status for any part of the year become changing status from urban to rural APC was made based on a regression
eligible to receive the out-migration under the new CBSA geographic analysis at the beginning of the OPPS.
wage adjustment if they are located in statistical area definitions. However, We repeated this analysis as part of the
an adjustment county. We note that section 508 sets aside $900 million to rural adjustment study we performed for
because the OPPS operates on a implement the section 508 the CY 2006 OPPS based on CY 2004
calendar year (January 1 through reclassifications. We considered the claims data. This study examined the
December 31) and not a fiscal year, the increased Medicare payments that the extent to which the body of costs for
expiring reclassification status under section 508 reclassifications would services furnished in the outpatient
section 508 of Pub. L. 108–173 results create in both the IPPS and OPPS when department was split between wage and
in different wage indices for OPPS for we determined the impact of the one- nonwage costs and, based on our most
the first quarter of CY 2007 (January 1, time appeal process. Because the recent findings, we believe that it
2007, through March 31, 2007) and the increased OPPS payments already count remains appropriate to wage adjust 60
last three quarters of CY 2007 (April 1, against the $900 million limit, we did percent of the APC payment (70 FR
2007, through December 31, 2007). not consider these reclassifications 68533).
3. The out-migration wage adjustment when we calculated the OPPS budget Comment: One commenter urged
to the wage index. In FY 2007 IPPS final neutrality adjustment. CMS to postpone the implementation of
rule (71 FR 48026), we discussed the Under the procedural rules described 100 percent of the occupational mix
out-migration adjustment under section under section II.D.3. of this final rule survey adjustment until the DRG
505 of Pub. L. 109–173 for counties with comment period and in section severity refinements can be fully
under this adjustment. Hospitals paid III.H.6. of the FY 2007 IPPS final rule implemented and their possible
under the IPPS located in the qualifying (71 FR 48024) regarding expiring section unrecognized adverse effects on quality
section 505 ‘‘out-migration’’ counties 508 reclassifications, different wage of care and outcomes can be resolved.
receive a wage index increase unless indices may be in effect for the first Another commenter expressed concern
they have already been otherwise quarter of the calendar year and the last about the application of the 100-percent
reclassified. (See the IPPS FY 2007 final three quarters of the calendar year. occupational mix adjustment for CY
rule for further information on out-
These rules have implications for 2007. The commenter encouraged CMS
migration.) For OPPS purposes, we
budget neutrality adjustments. Any to approach Congress for authority to
proposed to continue our policy from
additional payment attributable to transition the occupational mix and to
CY 2006 to allow non-IPPS hospitals
reclassifications due to section 508 repeal the mandate that CMS apply an
paid under the OPPS to qualify for out-
between January 1 and April 1, 2007, occupational mix adjustment to wage
migration adjustment if they are located
must be excluded from a budget indices.
in a section 505 out-migration county.
neutrality adjustment, and all other Response: We appreciate the
Because non-IPPS hospitals cannot
adjustments to the wage index are comments concerning this issue and
reclassify, they are eligible for the out-
subject to budget neutrality. Rather than refer readers to the CMS final rule for
migration wage adjustment. Tables
identifying counties eligible for the out- calculating two different conversion the CY 2007 IPPS ( 71 FR 48006) for a
migration adjustment were published factors, with different budget neutrality discussion of the reasons that CMS
after the FY 2007 IPPS final rule on adjustments, we proposed to calculate adopted a 100 percent occupational mix
October 11, 2006 (71 FR 59886). These one budget neutrality adjustment that adjusted wage index for hospitals
tables reflect updated county listing to reflects the combined adjustments receiving payments under the IPPS. As
reflect changes to the occupation mix required for the first quarter and last first published in the original OPPS
adjustment made in response to three quarters of the calendar year, final rule on April 7, 2000 (65 FR
Bellevue court case discussed above. respectively. We followed the same 18545), the OPPS has consistently
Because we proposed to adopt the final approach in the FY 2007 IPPS final rule adopted the final IPPS wage indices as
FY 2007 IPPS wage index, we are (71 FR 48026). the wage indices for adjusting the OPPS
adopting any changes in a hospital’s We received several comments on the standard payment amounts for labor
classification status that will make them proposed wage index policy for the CY market differences. We continue to
either eligible or ineligible for the out- 2007 OPPS. believe that using the IPPS wage index
migration wage adjustment both through Comment: One commenter urged as the source of an adjustment factor for
March 31, 2007, and on or after April 1, CMS to use the IPPS labor-related the OPPS is reasonable and logical given
2007. adjustment to determine the inseparable, subordinate status of
With the exception of reclassifications reimbursements for outpatient services. the hospital outpatient department
resulting from the implementation of Specifically, the commenter requested within the hospital overall. Therefore,
the one-time appeal process under that the labor-related percentage for the given that a 100 percent occupational
section 508 of Pub. L. 108–173, all OPPS be revised from the 60 percent mix adjusted wage index was adopted
changes to the wage index resulting currently proposed to 69.7 percent, in the IPPS, we will also adopt the same
from geographic labor market area consistent with what is stated in the FY index for the OPPS.
reclassifications or other adjustments 2007 IPPS rule. The commenter further After carefully considering all public
must be incorporated in a budget requested that, at a minimum, CMS comments received, we are finalizing
neutral manner. Accordingly, in update the OPPS labor-related share in our wage index adjustment policy for
calculating the OPPS budget neutrality effect for CY 2007 from 60 percent to 63 the CY 2007 OPPS as proposed without
estimates for CY 2007, in this final rule percent, the labor-related percentage modification.
E. Statewide Average Default CCRs represented data for CY 2004. We have submitted a cost report, hospitals that
CMS uses CCRs to determine outlier since updated the cost report data we have a CCR that falls outside
payments, payments for pass-through use to calculate CCRs with additional predetermined floor and ceiling
submitted cost reports for CY 2005. For thresholds for a valid CCR, and
devices, and monthly interim
this final rule with comment period, hospitals that have recently given up
transitional corridor payments under
66.41 percent of the submitted cost their all-inclusive rate status. Current
the OPPS. Some hospitals do not have
reports utilized in the default ratio OPPS policy also requires hospitals that
a valid CCR. These hospitals include,
calculation were for CY 2004, whereas experience a change of ownership, but
but are not limited to, hospitals that are
34.95 percent were for CY 2005. We that do not accept assignment of the
new and have not yet submitted a cost
only used valid CCRs to calculate these previous hospital’s provider agreement,
report, hospitals that have a CCR that
default ratios. That is, we removed the to use the previous provider’s CCR.
falls outside predetermined floor and
CCRs for all-inclusive hospitals, CAHs, For CY 2007, we proposed to apply
ceiling thresholds for a valid CCR, or
and hospitals in Guam and the U.S. this treatment of using the default
hospitals that have recently given up Virgin Islands because these entities are
their all-inclusive rate status. Last year, statewide CCR to include an entity that
not paid under the OPPS, or in the case has not accepted assignment of an
we updated the default urban and rural of all-inclusive hospitals, because their
CCRs for CY 2006 in our final rule with existing hospital’s provider agreement
CCRs are suspect. We further identified in accordance with § 489.18, and that
comment period published on and removed any obvious error CCRs
November 10, 2005 (70 FR 68553 has not yet submitted its first Medicare
and trimmed any outliers. We limited cost report. We proposed that this
through 68555). As we proposed, in this the hospitals used in the calculation of
final rule with comment period, we policy be effective for hospitals
the default CCRs to those hospitals that experiencing a change of ownership on
have updated the default ratios for CY billed for services under the OPPS
2007 using the most recent cost report or after January 1, 2007. We believed
during CY 2004. that a hospital that has not accepted
data. Finally, we calculated an overall
We calculated the statewide default assignment of an existing hospital’s
average CCR, weighted by a measure of
CCRs using the same overall CCRs that provider agreement is similar to a new
volume for CY 2004, for each State
we use to adjust charges to costs on except Maryland. This measure of hospital that will establish its own costs
claims data. Refer to section II.A.1.c. of volume is the total lines on claims and and charges. We believed that the
this preamble for a discussion of our is the same one that we use in our hospital that has chosen not to accept
revision to the overall CCR calculation. impact tables. For Maryland, we used an assignment may have different costs and
Table 4 published in the CY 2007 OPPS overall weighted average CCR for all charges than the existing hospital.
proposed rule listed the proposed CY hospitals in the Nation as a substitute Furthermore, we believed that the
2007 default urban and rural CCRs by for Maryland CCRs. Very few providers hospital should be provided time to
State and compared them to last year’s in Maryland are eligible to receive establish its own costs and charges.
default CCRs (71 FR 49542 through payment under the OPPS, which limits Therefore, we proposed to use the
49545). These CCRs are the ratio of total the data available to calculate an default statewide CCR to determine
costs to total charges from each accurate and representative CCR. The cost-based payments until the hospital
provider’s most recently submitted cost observed differences between last year’s has submitted its first Medicare cost
report, for those cost centers relevant to default statewide CCRs and the CY 2007 report.
outpatient services weighted by CCRs are a combination of the general We did not receive any public
Medicare Part B charges. We also decline in the ratio between costs and comments concerning the proposed
adjusted these ratios to reflect final charges widely observed in the cost statewide average default CCR.
settled status by applying the report data and the change in the Therefore, we are finalizing the
differential between settled to submitted proposed overall CCR calculation. statewide average default CCRs shown
costs and charges from the most recent As stated above, CMS uses default in Table 4 below for OPPS services
pair of settled to submitted cost reports. statewide CCRs for several groups of furnished on or after January 1, 2007
For the proposed rule, 81.79 percent hospitals, including, but not limited to, without modification.
of the submitted cost reports hospitals that are new and have not yet BILLING CODE 4120–01–P
ER24NO06.012</GPH>
ER24NO06.013</GPH>
BILLING CODE 4120–01–C cost-based payment system to the OPPS 2004, and ends on December 31, 2005.
F. OPPS Payments to Certain Rural system. Cancer hospitals and children’s Accordingly, the authority for making
Hospitals hospitals receive the transitional transitional corridor payments under
corridor payments on a permanent section 1833(t)(7)(D)(i) of the Act, as
1. Hold Harmless Transitional Payment basis. Section 1833(t)(7)(D)(i) of the Act amended by section 411 of Pub. L. 108–
Changes Made by Pub. L. 109–171 originally provided for transitional 173, expired for rural hospitals having
(DRA) corridor payments to rural hospitals 100 or fewer beds and SCHs located in
When the OPPS was implemented, with 100 or fewer beds for covered OPD rural areas on December 31, 2005.
every provider was eligible to receive an services furnished before January 1, Section 5105 of Pub. L. 109–171
additional payment adjustment 2004. However, section 411 of Pub. L. reinstituted the hold harmless
(transitional corridor payment) if the 108–173 amended section transitional outpatient payments (TOPs)
payments it received for covered OPD 1833(t)(7)(D)(i) of the Act to extend for covered OPD services furnished on
services under the OPPS were less than these payments through December 31, or after January 1, 2006, and before
the payments it would have received for 2005, for rural hospitals with 100 or January 1, 2009, for rural hospitals
the same services under the prior fewer beds. Section 411 also extended having 100 or fewer beds that are not
reasonable cost-based system. Section the transitional corridor payments to SCHs. When the OPPS payment is less
1833(t)(7) of the Act provides that the sole community hospitals (SCHs) than the payment the provider would
transitional corridor payments are located in rural areas for services have received under the previous
temporary payments for most providers, furnished during the period that begins reasonable cost-based system, the
with two exceptions, to ease their with the provider’s first cost reporting amount of payment is increased by 95
ER24NO06.014</GPH>
transition from the prior reasonable period beginning on or after January 1, percent of the amount of the difference
between those two payment systems for amount on an annual basis, but that we EACHs, of 7.1 percent and finalizing the
CY 2006, by 90 percent of the amount might review the adjustment in the regulation text at § 419.70(d) without
of that difference for CY 2007, and by future and, if appropriate, would revise modification. We are also revising
85 percent of the amount of that the adjustment. For CY 2007, we § 419.43(g) to clarify that EACHs are
difference for CY 2008. proposed to continue our current policy also eligible for the rural SCH OPPS
For CY 2006, we have implemented of a budget neutral 7.1 percent payment adjustment.
section 5105 of Pub. L. 109–171 through increase for rural SCHs for specified
Transmittal 877, issued on February 24, G. CY 2007 Hospital Outpatient Outlier
services.
2006. We did not specifically address Comment: Many commenters Payments
whether TOPs payments apply to expressed concern that small rural Currently, the OPPS pays outlier
essential access community hospitals hospitals will suffer financially if TOPs payments on a service-by-service basis.
(EACHs), which are considered to be payments continue to decrease each For CY 2006, the outlier threshold is
SCHs under section year, as specified in section 5105 of Pub. met when the cost of furnishing a
1886(d)(5)(D)(iii)(III) of the Act. L. 109–171. The commenters noted that service or procedure by a hospital
Accordingly, under the statute, EACHs patient access to small rural hospitals exceeds 1.75 times the APC payment
are treated as SCHs. Therefore, we could be at risk. One commenter amount and exceeds the APC payment
believe that EACHs are not eligible for supported permanent TOPs for rural rate plus a $1,250 fixed-dollar
TOPs payment under Pub. L. 109–171. SCHs, which currently do not receive threshold. We introduced a fixed-dollar
In the CY 2007 OPPS proposed rule, we any TOPs payments. Several threshold in CY 2005 in addition to the
proposed to update § 419.70(d) to reflect commenters noted their support for a traditional multiple threshold in order
the requirements of Pub. L. 109–171. Senate bill, S.3606, which is known as to better target outliers to those high
the ‘‘Save our Safety Net Act of 2005.’’ cost and complex procedures where a
2. Adjustment for Rural SCHs Response: We share the concerns of very costly service could present a
Implemented in CY 2006 Related to rural hospitals and do not intend to hospital with significant financial loss.
Pub. L. 108–173 (MMA) limit access to health care for Medicare If a provider meets both of these
In the CY 2006 OPPS final rule with beneficiaries in rural areas. However, conditions, the multiple threshold and
comment period (70 FR 68556), we we note that the statute is very specific the fixed-dollar threshold, the outlier
finalized a payment increase for rural and does not provide TOPs payments payment is calculated as 50 percent of
SCHs of 7.1 percent for all services and for entities other than those listed in the the amount by which the cost of
procedures paid under the OPPS, statute. The statute also requires TOPs furnishing the service exceeds 1.75
excluding drugs, biologicals, payments to gradually decrease through times the APC payment rate. For a
brachytherapy seeds, and services paid CY 2008. discussion on CMHC outliers, see
under pass-through payment policy in Comment: Several commenters section II.B.3. of the preamble to this
accordance with section 1833(t)(13)(B) requested that CMS clarify that the 7.1 final rule with comment period.
of the Act, as added by section 411 of percent rural SCH adjustment applies to As explained in the CY 2006 OPPS
Pub. L. 108–173. Section 411 gave the EACHs retroactive to January 1, 2006. final rule with comment period (70 FR
Secretary the authority to make an Response: As stated above, we are 68561), we set our projected target for
adjustment to OPPS payments for rural clarifying that EACHs are treated as aggregate outlier payments at 1.0
hospitals, effective January 1, 2006, if SCHs for purposes of receiving this percent of aggregate total payments
justified by a study of the difference in adjustment, assuming these entities under the OPPS. The outlier thresholds
costs by APC between hospitals in rural otherwise meet the rural adjustment were set so that estimated CY 2006
and urban areas. Our analysis showed a criteria. EACHs are eligible for this aggregate outlier payments would equal
difference in costs only for rural SCHs adjustment effective January 1, 2006, as 1.0 percent of aggregate total payments
and we implemented a payment are all rural SCHs. As stated above, we under the OPPS. In the CY 2006 OPPS
adjustment for those hospitals beginning agree with the commenters and are final rule with comment period (70 FR
January 1, 2006. revising § 419.43(g) to specifically 68563), we also published total outlier
As indicated in the CY 2007 OPPS reflect this clarification. In addition, we payments as a percent of total
proposed rule (71 FR 49547), we will ensure that a retroactive payment expenditures for past years. However,
recently became aware that we did not adjustment occurs. when we published the CY 2007 OPPS
specifically address whether the Comment: Several commenters proposed rule, we did not have a
adjustment applies to EACHs, which are supported the 7.1 percent adjustment complete set of CY 2005 claims data to
considered to be SCHs under section for rural SCHs for CY 2007, but produce this number for CY 2005 and
1886(d)(5)(D)(iii)(III) of the Act. Thus, requested that CMS rerun the analyses stated that we would report on CY 2005
under the statute, EACHs are treated as to possibly provide for an adjustment outlier payments in this CY 2007 OPPS
SCHs. Currently, fewer than 10 for other rural hospitals during CY 2008 final rule with comment period. In the
hospitals are classified as EACHs. As of and CY 2009, when TOPs payments will final set of CY 2005 OPPS claims,
CY 1998, under section 4201(c) of Pub. be further reduced. aggregated outlier payments were 2.39
L. 105–33, a hospital can no longer Response: As stated above, while we percent of aggregated total OPPS
become newly classified as an EACH. will not reestablish the adjustment payments. For CY 2005, the estimated
Therefore, for purposes of receiving this amount nor determine whether other outlier payments were set at 2 percent
rural adjustment, we are clarifying that rural hospitals are eligible for the of the total aggregated OPPS payments.
EACHs are treated as SCHs for purposes adjustment on an annual basis, we may Therefore, for CY 2005, we paid 0.39
of receiving this adjustment, assuming review the adjustment in the future and, percent in excess of the CY 2005 outlier
these entities otherwise meet the rural if appropriate, would revise the target of 2 percent of total aggregated
adjustment criteria. adjustment. OPPS payments.
This adjustment is budget neutral and After carefully considering the
applied before calculating outliers and comments received, we are finalizing 1. CY 2007 Proposal
coinsurance. We also stated that we our policy by continuing a payment For CY 2007, we proposed to continue
would not reestablish the adjustment adjustment for rural SCHs, including our policy of setting aside 1.0 percent of
aggregate total payments under the calculation to raise the outlier the preamble to this final rule with
OPPS for outlier payments. We threshold. comment period.
proposed that a portion of that 1.0 We received many comments on our
2. CY 2007 Final Rule Outlier proposed outlier policy for CY 2007.
percent would be allocated to CMHCs
Calculation Comment: Some commenters were
for partial hospitalization program
service outliers. We proposed that the The claims that we use to model each concerned that the outlier threshold that
portion allocated to CMHCs would be OPPS update lag by 2 years. For this CMS proposed is set too high and will
determined by the amount of estimated final rule with comment period, we result in CMS not spending all of the
outlier payments resulting from the used CY 2005 claims to model the CY money in the projected 1.0 percent
CMHC outlier threshold. 2007 OPPS. In order to estimate CY outlier target. The commenters stated
In order to ensure that estimated CY 2007 outlier payments for this final rule that the estimated outlier target amount
2007 aggregate outlier payments would with comment period, we inflated the has historically been greater than the
equal 1.0 percent of estimated aggregate charges on the CY 2005 claims using the actual need, and they asked that CMS
total payments under the OPPS, we same inflation factor of 1.1642 that we either reduce the set aside amount and
proposed that the outlier threshold be used to estimate the IPPS fixed-dollar retain that money in the OPPS rates or
set so that outlier payments would be outlier threshold for the FY 2007 IPPS reduce the threshold for qualification so
triggered when the cost of furnishing a final rule. For 1 year, the inflation factor that the outlier expenditures are at a
service or procedure by a hospital is 1.079. The methodology for zero balance at the end of each year.
exceeds 1.75 times the APC payment determining this charge inflation factor One commenter asked that CMS limit
amount and exceeds the APC payment was discussed in the FY 2007 IPPS final the increase in the outlier threshold to
rate plus a $1,825 fixed-dollar rule (71 FR 48150). As we stated in the the amount of the market basket update
threshold. CY 2005 OPPS final rule with comment each year, which would mean, for CY
We calculated the fixed-dollar period, we believe that the use of this 2007, that the CY 2006 threshold would
threshold for the CY 2007 proposed rule charge inflation factor is appropriate for be increased by only 3.4 percent.
using the same methodology as we did Response: We believe that the
the OPPS because, with the exception of
in CY 2006, except we used the revised threshold of $1,825 will result in paying
the routine service cost centers,
overall CCR calculation discussed in 1.0 percent of the OPPS expenditures in
hospitals use the same cost centers to
section II.A.1.c. of this preamble. As outliers. As we indicated in the CY 2006
capture costs and charges across
discussed in section II.A.1.c. of this OPPS final rule, in the final set of CY
inpatient and outpatient services (69 FR 2004 OPPS claims, aggregated outlier
preamble, we discovered that the
65845). As also noted in the FY 2006 payments were 2.5 percent of aggregated
calculation of the overall CCR that the
IPPS final rule, we believe that a charge total OPPS payments. Similarly, using
fiscal intermediaries are using to
inflation factor is more appropriate than the final set of CY 2003 OPPS claims,
determine outlier payment and payment
an adjustment to costs because this aggregated outlier payments were 3.1
for services paid at charges reduced to
methodology closely captures how percent of total OPPS payments. As
cost differs from the overall CCR that we
actual outlier payments are made and stated earlier, in the final set of CY 2005
traditionally use to model the outlier
calculated (70 FR 47495). We then claims, aggregated outlier payments
thresholds. We discovered this during
our calculations of the outlier threshold applied the revised overall CCR that we were 2.39 percent of the aggregated total
for the CY 2006 OPPS final rule with calculated from each hospital’s most OPPS payments. For all three years, the
comment period, and we indicated in recent cost report (CMS–2552–96) and, estimated outlier payments were set at
our preamble discussion for that rule, if the cost report was not settled, we 2.0 percent of the total aggregated OPPS
that we might revisit the threshold adjusted it by a settled-to-submitted payments. Hence, our historic
estimate methodology in light of ratio. We simulated aggregated outlier estimation of outlier payments has
identified differences in the overall CCR payments using these costs for several resulted in outlier payments that
calculation. Because, on average, the different fixed-dollar thresholds holding exceeded our target, and we believe that
overall CCR calculation used by the the 1.75 multiple constant until the total our proposed methodology will provide
fiscal intermediaries results in higher outlier payments equaled 1.0 percent of an outlier threshold that will result in
CCRs than those estimated using our aggregated total OPPS payments. We more accurate aggregate program outlier
‘‘traditional’’ CCR sets, the outlier estimate that a threshold of $1,825 payments.
threshold calculated for the CY 2006 combined with the multiple threshold As discussed above, for the proposed
OPPS final rule with comment period is of 1.75 times the APC payment rate rule, we used a charge inflation factor of
too low. The OPPS impact table in would allocate 1.0 percent of aggregated 1.1515 to inflate the charges for CY 2005
section XXVII. of the CY 2007 proposed total OPPS payments to outlier claims to CY 2007 dollars. We then
rule (Table 49; 71 FR 49687) payments. applied the provider’s overall CCR that
demonstrated an estimated payment For CMHCs, in CY 2007 we are we calculate as part of our APC median
differential of 0.25 percent of total projecting that the outlier threshold is estimation process to those inflated
spending for hospital outlier payments met when the cost of furnishing a charges to estimate costs. We compared
in CY 2006 because of the differences in service or procedure by a CMHC these estimated costs to 1.75 times the
overall CCR calculations. The revised exceeds 3.40 times the APC payment proposed APC payment amount and to
overall CCR calculation that we rate. If a CMHC provider meets this the APC payment amount plus a
proposed for CY 2007 aligns the two condition, the outlier payment is number of fixed-dollar thresholds until
CCR calculations by removing allied calculated as 50 percent of the amount we identified a threshold that produced
and nursing health costs for those by which the cost exceeds 3.40 times an estimate of total outlier payments
hospitals with paramedical education the APC payment rate. In the CY 2007 equal to 1.0 percent of total aggregated
programs from the fiscal intermediary’s OPPS proposed rule, we proposed to OPPS payments.
CCR calculation and weighting our continue the same threshold policy for We used the same estimation process
‘‘traditional’’ calculation by total CY 2007 as we have established for CY for this final rule with comment period.
Medicare Part B charges. We expected 2006. An explanation for this proposed We used a complete set of CY 2005
this proposed change in the overall CCR policy is discussed in section II.B.3. of claims, and the updated charge inflation
estimate of 1.1642 percent from the FY of the outlier pool and urged CMS to outlier threshold using this
2007 IPPS final rule and each hospital’s publish the estimated outlier payments methodology results in a fixed-dollar
overall CCR, as calculated for our APC in the proposed rule, based on available outlier threshold of $1,825 and a
median setting process. data, to permit the public to better multiple threshold of 1.75, based on an
Using this methodology, the final comment on the proposed outlier outlier estimate of 1.0 percent of
fixed-dollar threshold for the CY 2007 policy. payments projected to be made under
OPPS is $1,825, and the final multiple Response: The proposed rule the CY 2007 OPPS and outlier payments
threshold is 1.75 times the APC contained considerable discussion of to be made at 50 percent of the amount
payment rate. the methodology we use to create the by which the cost of furnishing the
We did not increase the CY 2007 proposed outlier threshold, as well as service exceeds 1.75 times the APC rate.
outlier threshold by the market basket the projected program expenditure The following is an example of an
update of 3.4 percent because our amount that we use to determine the outlier calculation for CY 2007 under
calculations are intended to best amount of the outlier set aside. our final policy with this modification.
approximate the outlier target of 1.0 Moreover, the claims we used for the A hospital charges $26,000 for a
percent of CY 2007 OPPS expenditures. simulation are available to the public. procedure. The wage adjusted, and rural
As we stated in the CY 2006 OPPS final Indeed, the commenters perform many adjusted, if applicable, APC payment for
rule, we established the projected target different types of analyses and often the procedure is $3,000. The provider’s
for aggregate outlier payments at 1.0 comment in extreme detail based on overall CCR is 0.30. The estimated cost
percent because we believed, consistent their analyses of the claims data and our to the hospital is $7,800 (0.30 ×
with MedPAC’s recommendations, that description of the methodology we use $26,000). To determine whether this
the fairly narrow definitions of APC to calculate the median costs on which provider is eligible for outlier payments
groups make outlier payment less the payment rates are based. Therefore, for this procedure, the provider must
necessary for the OPPS, that multiple the public has every opportunity to determine whether the cost for the
service payments are common for any perform a full and complete analysis of service exceeds both the APC outlier
given claim, and that the susceptibility our outlier projections in preparation for cost threshold (1.75 × APC payment)
to ‘‘gaming’’ through charge inflation commenting on the proposed outlier and the fixed-dollar threshold ($1,825 +
continues (70 FR 68563). Because OPPS policy. APC payment). In this example, the
outlier payments are targeted to Comment: One commenter objected to provider meets both criteria:
services, rather than clinical cases, we the payment of 50 percent of the cost
(1) $7,800 exceeds $5,250 (1.75 ×
believe it is unlikely that any specific that exceeds the threshold and believed
$3,000).
service would be excessively costly, and that CMS should pay 80 percent of the
reducing the outlier threshold to 1.0 cost rather than 50 percent to ameliorate (2) $7,800 exceeds $4,825 ($3,000 +
percent of total OPPS payment the level of losses that major teaching $1,825).
effectively raises the payment for all hospitals incur to provide complex To calculate the outlier payment,
other services. We continue to believe outpatient services and to make outlier which is 50 percent of the amount by
that an outlier target of 1.0 percent of payment under the OPPS consistent which the cost of furnishing the service
total OPPS payment is appropriate for with IPPS outlier payment. exceeds 1.75 times the APC rate,
the OPPS. Response: We disagree with the subtract $5,250 (1.75 × $3,000) from
Comment: One commenter asked that commenter that we should pay 80 $7,800 (resulting in $2,550). The
CMS modify the charge methodology percent of the cost that exceeds the provider is eligible for 50 percent of the
used to set the OPPS outlier threshold threshold to ameliorate the level of difference, in this case $1,275 ($2,550/
to account for the change in CCRs over losses that major teaching hospitals 2). The formula is (cost ¥ (1.75 × APC
time in a manner similar to that used for incur and to make outlier payment payment rate))/2.
the FY 2007 IPPS. The commenter under the OPPS consistent with outlier H. Calculation of the OPPS National
believed that it is appropriate to apply payment under the IPPS. As we have Unadjusted Medicare Payment
an adjustment factor to the CCRs, so that explained, if we increase the percent of
the CCRs CMS would use in simulations the excess over cost, in particular by 30 The basic methodology for
of outlier payments would more closely percent more than our proposed level of determining prospective payment rates
reflect the CCRs that would be used in 50 percent, the threshold would need to for OPD services under the OPPS is set
CY 2007. be greatly increased to avoid paying forth in existing regulations at § 419.31
Response: Given the potential more than the 1.0 percent we have and § 419.32. The payment rate for
difference in cost increases between allowed for outlier payments. Moreover, services and procedures for which
inpatient and outpatient hospital we do not believe that it is appropriate payment is made under the OPPS is the
departments, we do not believe it would to have the same policy governing product of the conversion factor
be appropriate to apply the exact same outlier payment under both the IPPS calculated in accordance with section
CCR adjustment used under the IPPS and the OPPS because of the inherent II.C. of this final rule with comment
without an OPPS-specific analysis. differences in the clinical cases and period and the relative weight
However, it is possible that a similar payment methodologies that determined under section II.A. of this
analysis specific to the OPPS could characterize the two systems. The final rule with comment period.
indicate that it would be appropriate to circumstances giving rise to outlier Therefore, the national unadjusted
apply an OPPS CCR adjustment. We payments under each system are not payment rate for each APC contained in
expect to study this issue further and found in the other system, and therefore Addendum A to this final rule with
would address any changes to the applying the same outlier policies comment period and for HCPCS codes
outlier methodology through future would likely be contrary to the reasons to which payment under the OPPS has
rulemaking. behind each policy. been assigned in Addendum B to this
Comment: Some commenters objected After carefully considering the public final rule with comment period
to the lack of analysis to support the comments received, we are finalizing (Addendum B is provided as a
statement that the proposed outlier our proposed policy for CY 2007 outlier convenience for readers) was calculated
threshold would result in full payment payments. Recalculation of the fixed by multiplying the final CY 2007 scaled
weight for the APC by the final CY 2007 by the amount determined under Step 1 colonoscopy on individual at risk) and
conversion factor. that represents the labor-related portion G0121 (Colorectal cancer screening;
However, to determine the payment of the national unadjusted payment rate. colonoscopy on individual not meeting
that will be made in a calendar year Step 5. Calculate 40 percent (the criteria for high risk), developed in
under the OPPS to a specific hospital for nonlabor-related portion) of the national accordance with our standard OPPS
an APC for a service that has a status unadjusted payment rate and add that ratesetting methodology, would exceed
indicator of ‘‘S,’’ ‘‘T,’’ ‘‘V,’’ or ‘‘X’’ in a amount to the resulting product of Step the ASC payment of $446 for these
circumstance in which the multiple 4. The result is the wage index adjusted procedures. Therefore, for CY 2007, the
procedure discount does not apply, we payment rate for the relevant wage OPPS payment rates for HCPCS codes
take the following steps: index area. G0105 and G0121 that describe
Step 1. Calculate 60 percent (the Step 6. If a provider is a SCH, as screening colonoscopies will be set to
labor-related portion) of the national defined in § 412.92, and located in a equal the CY 2007 ASC rate of $446 for
unadjusted payment rate. Since the rural area, as defined in § 412.63(b), or these services.
initial implementation of the OPPS, we is treated as being located in a rural area
have used 60 percent to represent our under § 412.103 of the Act, multiply the 2. Copayment for CY 2007
estimate of that portion of costs wage index adjusted payment rate by
attributable, on average, to labor. (Refer 1.071 to calculate the total payment. For CY 2007, we proposed to
to the April 7, 2000 final rule with We did not receive any public determine copayment amounts for new
comment period (65 FR 18496 through comments on our proposed and revised APCs using the same
18497) for a detailed discussion of how methodology for calculating the national methodology that we implemented for
we derived this percentage.) unadjusted Medicare payment amount CY 2004. (Refer to the November 7, 2003
Step 2. Determine the wage index area for CY 2007. Therefore, we are finalizing OPPS final rule with comment period,
in which the hospital is located and our proposed methodology for CY 2007 68 FR 63458.) These unadjusted
identify the wage index level that without modification. copayment amounts for services payable
applies to the specific hospital. The under the OPPS that will be effective
wage index values assigned to each area I. Beneficiary Copayments for CY 2007 January 1, 2007, are shown in
reflect the new geographic statistical 1. Background Addendum A and Addendum B of this
areas as a result of revised OMB final rule with comment period.
standards (urban and rural) to which Section 1833(t)(3)(B) of the Act
hospitals are assigned for FY 2007 requires the Secretary to set rules for 3. Calculation of an Adjusted
under the IPPS, reclassifications determining copayment amounts to be Copayment Amount for an APC Group
through the Medicare Classification paid by beneficiaries for covered OPD for CY 2007
Geographic Review Board, section services. Section 1833(t)(8)(C)(ii) of the
1866(d)(8)(B) ‘‘Lugar’’ hospitals, and Act specifies that the Secretary must To calculate the OPPS adjusted
section 401 of Pub. L. 108–173, and the reduce the national unadjusted copayment amount for an APC group,
reclassifications of hospitals under the copayment amount for a covered OPD take the following steps:
one-time appeals process under section service (or group of such services) Step 1. Calculate the beneficiary
508 of Pub. L. 108–173. The wage index furnished in a year in a manner so that payment percentage for the APC by
values include the occupational mix the effective copayment rate dividing the APC’s national unadjusted
adjustment described in section II.D. of (determined on a national unadjusted copayment by its payment rate. For
this final rule with comment period that basis) for that service in the year does example, using APC 0001, $7.00 is 23
was developed for the final FY 2007 not exceed specified percentages. For all percent of $30.21.
IPPS payment rates and finalized in the services paid under the OPPS in CY
2007, and in calendar years thereafter, Step 2. Calculate the wage adjusted
IPPS notice published in the Federal
the specified percentage is 40 percent of payment rate for the APC, for the
Register on October 11, 2006 (71 FR
59886). These finalized FY 2007 IPPS the APC payment rate (section provider in question, as indicated in
wage indices, which are effective 1833(t)(8)(C)(ii)(V) of the Act). Section section II.H. of this preamble. Calculate
October 1, 2007, have been adjusted 100 1833(t)(3)(B)(ii) of the Act provides that, the rural adjustment for eligible
percent for differences in occupational for a covered OPD service (or group of providers as indicated in section I.H. of
mix. As is our practice, we adopt such services) furnished in a year, the this preamble.
changes made to the FY 2007 IPPS wage national unadjusted coinsurance Step 3. Multiply the percentage
index values after they have been amount cannot be less than 20 percent calculated in Step 1 by the payment rate
finalized. of the OPD fee schedule amount. calculated in Step 2. The result is the
Step 3. Adjust the wage index of Sections 1834(d) (2) and (d)(3) of the wage-adjusted copayment amount for
hospitals located in certain qualifying Act further require Medicare to pay the the APC.
counties that have a relatively high lesser of the ASC or OPPS payment rate
The unadjusted copayments for
percentage of hospital employees who for screening flexible sigmoidoscopies
services payable under the OPPS that
reside in the county, but who work in and screening colonoscopies, with
coinsurance equal to 25 percent of the will be effective January 1, 2007, are
a different county with a higher wage
payment amount. We have applied the shown in Addendum A and Addendum
index, in accordance with section 505 of
25-percent coinsurance to all of these B of this final rule with comment
Pub. L. 108–173. Addendum L contains
services since the beginning of the period.
the qualifying counties and the finalized
wage index increase developed for the OPPS. Medicare does not make payment We did not receive any public
FY 2007 IPPS (71 FR 59886). This step to ASCs for screening sigmoidoscopies comments concerning our methodology
is to be followed only if the hospital has so there is no payment comparison to be for calculating the beneficiary
chosen not to accept reclassification made for those services. However, for unadjusted copayment amount.
under Step 2 above. CY 2007, the OPPS payment for Therefore, we are finalizing our
Step 4. Multiply the applicable wage screening colonoscopies, HCPCS codes proposed methodology for CY 2007
index determined under Steps 2 and 3 G0105 (Colorectal cancer screening; without modification.
III. OPPS Ambulatory Payment codes based upon the April 2006 OPPS will be deleted December 31, 2006. We
Classification (APC) Group Policies update were included in Addendum B. note that C-codes are temporary national
In the CY 2007 OPPS proposed rule, we HCPCS codes. To avoid duplication,
A. Treatment of New HCPCS and CPT
proposed to assign the new HCPCS temporary national HCPCS codes, such
Codes
codes for CY 2007 to the appropriate as C, G, K, and Q codes, are generally
1. Treatment of New HCPCS Codes APCs and incorporate them into our deleted once permanent national
Included in the Second and Third final rule with comment period for CY HCPCS codes are created that describe
Quarterly OPPS Updates for CY 2006 2007, which is consistent with our the same item, service, or procedure.
During the second and third quarters annual APC updating policy. Because the four new J-codes describe
of CY 2006, we created a total of four We did not receive any public the same drugs and the same dosages
new Level II HCPCS codes, specifically comments on the APC assignments and that are currently designated by C9227,
C9227, C9228, C9229, and C9230 that status indicators designated for C9227, C9228, C9229, and C9230 and all four
were not addressed in the November 10, C9228, C9229, or C9230 that were
of these drugs will continue with pass-
2005 final rule with comment period implemented in either April 2006 or
through status in CY 2007, we are
that updated the CY 2006 OPPS. We July 2006. However, for CY 2007, the
assigning the J-codes to the same APCs
designated the payment status of these National HCPCS Panel created
permanent J-codes for each of these and status indicators as their
codes and added them either through
drugs. Consistent with our general predecessor C-codes, as shown in Table
the April update (Transmittal 896, dated
policy of using permanent HCPCS codes 5. That is, J2248 will be assigned to the
March 24, 2006) or the July update of
if appropriate rather than C-codes for same APC and status indicator as
the CY 2006 OPPS (Transmittal 970,
dated May 30, 2006). In the CY 2007 the reporting of drugs under the OPPS C9227; J3243 to APC 9228; J1740 to APC
OPPS proposed rule, we also solicited in order to streamline coding, we are 9229; and J0129 to APC 9230. Because
public comments on the status showing the J-codes in Table 5 that we received no public comments on the
indicators and APC assignments of these replaced the C-codes, effective January APC and status indicator assignments
codes, which were listed in Table 5 of 1, 2007. C9227 is replaced with J2248 for the new HCPCS codes that were
that proposed rule (71 FR 49548), and (Injection, micafungin sodium, 1 mg); implemented in April or July 2006, we
now appear in Table 5 of this final rule C9228 with J3243 (Injection, tigecycline, are adopting as final without
with comment period. Because of the 1 mg); C9229 with J1740 (Injection, modification, our proposal to assign
timing of the proposed rule, the codes ibandronate sodium, 1 mg); and C9230 their replacement HCPCS J-codes to the
implemented in the July 2006 OPPS with J0129 (Injection, abatacept, 10 mg). appropriate APCs, as shown in
update were not included in Addendum The J-codes describe the same drugs and Addendum B of this final rule with
B of that proposed rule, while those the same dosages as the C-codes that comment period.
TABLE 5.—NEW HCPCS CODES IMPLEMENTED IN APRIL OR JULY 2006

New HCPCS J- Assigned
HCPCS C-
Code effective Jan- Description status indi- Assigned APC
Code
uary 1, 2007 cator
J2248 ..................... C9227 ......... Injection, micafungin sodium, per 1 mg ....................................................... G ................. 9227
J3243 ..................... C9228 ......... Injection, tigecycline, per 1 mg .................................................................... G ................. 9228
J1740 ..................... C9229 ......... Injection, ibandronate sodium, per 1 mg ..................................................... G ................. 9229
J0129 ..................... C9230 ......... Injection, abatacept, per 10 mg ................................................................... G ................. 9230
2. Treatment of New CY 2007 Category for CY 2007. Therefore, new Category I not available when we developed and
I and III CPT Codes and Level II HCPCS and III CPT codes and new Level II issued the proposed rule. For those new
Codes HCPCS codes, effective January 1, 2007, Category I CPT codes whose descriptors
As has been our practice in the past, are listed in Addendum B of this final were not officially available during the
we implement new Category I and III rule with comment period and comment period and development of
CPT codes and new Level II HCPCS designated using comment indicator the CY 2007 final rule with comment
codes, which are released in the ‘‘NI.’’ The status indicator, the APC period, we do not specifically respond
summer through the fall of each year for assignment, or both, for all such codes to those comments in this final rule
annual updating, effective January 1, in flagged with Comment Indicator ‘‘NI’’ with comment period. For those new
the final rule updating the OPPS for the are open to public comment. As Category III CPT codes that were
following calendar year. These codes are indicated in the CY 2007 OPPS released on July 1, 2006, for
flagged with comment indicator ‘‘NI’’ in proposed rule, we will respond to all implementation January 1, 2007, we
Addendum B of the OPPS final rule to comments received concerning these
respond to those comments in this final
indicate that we are assigning them an codes in a subsequent final rule for the
rule with comment period because those
interim payment status which is subject next calendar year’s OPPS update.
codes were publicly available during the
to public comment following We received some comments to the
comment period to the proposed rule
publication of the final rule that CY 2007 proposed rule regarding
and the development of this final rule
implements the annual OPPS update. individual new HCPCS codes that
with comment period. Both of these
(See the discussion immediately below commenters expected to be

concerning our modified policy for implemented for the first time in the CY groups of codes are flagged with
implementing new Category I and III 2007 OPPS. We could not discuss APC comment indicator ‘‘NI’’ in this final
mid-year CPT codes.) In our CY 2007 and/or status indictor assignments for rule with comment period, as discussed
OPPS proposed rule, we proposed to new CY 2007 HCPCS codes in the above, to signal that they are open to
continue this recognition and process proposed rule because the codes were public comment.
Two new G-codes for CY 2007 that are Category I CPT codes for vaccines for As indicated in the CY 2007 OPPS
assigned comment indicator ‘‘NI’’ in this which FDA approval is imminent, to proposed rule (71 FR 49549), some of
final rule with comment period were ensure timely availability of a code.) the new Category III CPT codes describe
developed to enable clinicians and The AMA establishes these codes to services that we have determined to be
facilities to specifically report allow collection of data specific to the similar in clinical characteristics and
transluminal balloon angioplasty to service described by the code, as these resource use to HCPCS codes in an
existing arteriovenous fistulas or services could otherwise only be existing APC. In these instances, we
prosthetic grafts for hemodialysis reported using a Category I CPT unlisted may assign the Category III CPT code to
access. Currently, there are no CPT or code. The AMA releases Category III the appropriate clinical APC. Other
alphanumeric HCPCS codes on the ASC CPT codes in January, for Category III CPT codes describe services
list that would provide payment to implementation beginning the following that we have determined are not
ASCs for providing this service to July, and in July, for implementation compatible with an existing clinical
Medicare patients with failing or beginning the following January. Prior APC, yet are appropriately provided in
stenotic hemodialysis access fistulas or to CY 2006, we treated new Category III the hospital outpatient setting. In these
grafts. There are no CPT codes that are CPT codes implemented in July of the
specific to this particular service. cases, we may assign the Category III
previous year or January of the OPPS CPT code to what we estimate is an
Therefore, we are creating two Level II update year in the same manner that
HCPCS G-codes for implementation in appropriately priced New Technology
new Category I CPT codes and new
CY 2007: (1) G0392 (Transluminal APC. In other cases, we may assign a
Level II HCPCS codes implemented in
balloon angioplasty, percutaneous, Category III CPT code to one of several
January of the OPPS update year are
hemodialysis access fistula or graft; treated; that is, we provided APC or nonseparately payable status indicators,
arterial) and (2) G0393 (Transluminal status indicator assignments or both in including ‘‘N,’’ ‘‘C,’’ ‘‘B,’’ or ‘‘E,’’ which
balloon angioplasty, percutaneous, the final rule updating the OPPS for the we believe is appropriate for the specific
hemodialysis access fistula or graft; following calendar year. New Category I code. We expect that we will have
venous). We will provide payment for and Category III CPT codes, as well as received applications for new
these G-codes at the same OPPS rates as new Level II HCPCS codes, were flagged technology status for some of the
for CPT codes 35475 (Transluminal with comment indicator ‘‘NI’’ in services described by new Category III
balloon angioplasty, percutaneous; Addendum B of the final rule to CPT codes, which may assist us in
brachiocephalic trunk or branches, each indicate that we assigned them an determining appropriate APC
vessel) and 35476 (Transluminal interim payment status which was assignments. If the AMA establishes a
balloon angioplasty, percutaneous; subject to public comment following Category III CPT code for a service for
venous) through APC 0081 (Non- publication of the final rule that which an application has been
Coronary Angioplasty or Atherectomy), implemented the annual OPPS update. submitted to CMS for new technology
with a CY 2007 final median cost of As discussed in the CY 2006 OPPS status, CMS may not have to issue a
$2,450.64. We will also assign both G- final rule with comment period (70 FR temporary Level II HCPCS code to
codes to payment group 9 for ASC 68567), we modified our process for describe the service, as has often been
payment in CY 2007. The G-codes will implementing the Category III codes that the case in the past when Category III
be used by hospital outpatient the AMA releases each January for CPT codes were only recognized by the
departments and ASCs to report implementation in July to ensure timely OPPS on an annual basis.
transluminal balloon angioplasty of collection of data pertinent to the
hemodialysis access fistulas or grafts in Therefore, for CY 2007, we proposed
services described by the codes; to to include in Addendum B of this final
these settings. ensure patient access to the services the
Beginning in CY 2007, CPT codes rule with comment period, the new
codes describe; and to eliminate
35475 and 35476 should not be reported Category III CPT codes and the new
potential redundancy between Category
for patients undergoing percutaneous Category I CPT codes for vaccines
III CPT codes and some of the C-codes
transluminal balloon angioplasty of released in January 2006 for
hemodialysis access fistulas or grafts. that are payable under the OPPS and
were created by us in response to implementation on July 1, 2006
Both CPT codes will remain active to (through the OPPS quarterly update
report all other clinical services that applications for new technology
services. Therefore, beginning on July 1, process) and the Category III and
would be described by these codes. vaccine Category I CPT codes released
We did not receive any public 2006, we implemented in the OPPS
seven Category III CPT codes that the in July 2006 for implementation on
comments on our proposal to assign a January 1, 2007. However, only those
comment indicator of ‘‘NI’’ in AMA released in January 2006 for
implementation in July 2006. These new Category III CPT codes and the new
Addendum B of the OPPS final rule to vaccine codes implemented effective
the new codes that are open to public codes were shown in Table 6 of the CY
2007 OPPS proposed rule (71 FR January 1, 2007, are flagged with
comment. Therefore, we are finalizing
49549). They were not included in comment indicator ‘‘NI’’ in Addendum
our proposed treatment of new CY 2007
Addendum B of that rule, which was B of this final rule with comment period
Category I and III CPT codes, as well as
the Level II HCPCS codes, without based upon the April 2006 OPPS to indicate that we have assigned them
modification. update. In the CY 2007 OPPS proposed an interim payment status which is
rule, we solicited public comments on subject to public comment. As
3. Treatment of New Mid-Year CPT the status indicators and, if applicable, discussed earlier, Category III CPT codes
Codes the APC assignments of these services. implemented in July 2006, which
Twice each year, the AMA issues We proposed in the CY 2007 OPPS appear in Table 6, were subject to
Category III CPT codes, which the AMA proposed rule to finalize the comment through the CY 2007 OPPS
defines as temporary codes for emerging assignments of these Category III CPT proposed rule and their statuses are
technology, services, and procedures. codes implemented in July 2006 in this finalized in this final rule with
(In addition, the AMA issues mid-year final rule with comment period. comment period.
TABLE 6.—CATEGORY III CPT CODES IMPLEMENTED IN JULY 2006

Proposed CY Final CY
Proposed CY Final CY 2007
CPT code Long descriptor 2007 status 2007 status
2007 APC APC
indicator indicator
0155T .......... Laparoscopy, surgical, implantation or replacement of gastric T .................. 0130 ............ T .................. 0130
stimulation electrodes, lesser curvature (ie, morbid obesity).
0156T .......... Laparoscopy, surgical, revision or removal of gastric stimulation T .................. 0130 ............ T .................. 0130
electrodes, lesser curvature (ie, morbid obesity).
0157T .......... Laparotomy, implantation or replacement of gastric stimulation C.
electrodes, lesser curvature (ie, morbid obesity).
0158T .......... Laparotomy, revision or removal of gastric stimulation elec- C.
trodes, lesser curvature (ie, morbid obesity).
0159T .......... Computer-aided detection, including computer algorithm anal- N.
ysis of MRI image data for lesion detection/characterization,
pharmacokinetic analysis, with further physician review for in-
terpretation, breast MRI.
0160T .......... Therapeutic repetitive transcranial magnetic stimulation treat- X .................. 0340 ............ S .................. 0216
ment planning.
0161T .......... Therapeutic repetitive transcranial magnetic stimulation treat- X .................. 0340 ............ S .................. 0216
ment delivery and management, per session.
We received several public comments performed in the hospital outpatient the technology associated with these
on the proposed APC assignments for setting, are paid according to the MPFS. procedures is currently under review by
Category III CPT codes 0159T, 0160T, Other hospital outpatient imaging the FDA and approval is not expected
and 0161T. A summary of the comments services, such as CPT code 0159T, are until January 2007. The commenter
and our responses follows: paid under the OPPS. We have assigned indicated that these codes describe
Comment: One commenter requested this service packaged payment status therapeutic transcranial magnetic
that CMS assign CPT code 0159T to an under the OPPS for CY 2007, because stimulation (TMS) therapy, which is
APC that is separately payable under the we believe that it is a minor ancillary used for the treatment of major
OPPS because there are additional service that would always be provided depression. The commenter further
resources associated with performing a in association with another separately indicated that TMS therapy represents a
breast MRI with computer-aided payable service (mostly likely an MRI), procedure that involves a complex brain
detection (CAD), which is a significant into which its payment would be mapping and stimulation treatment
advancement in early detection and appropriately packaged. As a process and requires the use of specific
treatment for possible breast cancers. prospective payment system, the OPPS equipment and a specialized operator
The commenter indicated that the makes payment for groups of services skill set. As such, the commenter
procedure described by CPT code 0159T that are clinically coherent with similar concluded that TMS therapy represents
is similar to the CAD procedures that resource utilization and packages a procedure whose hospital resources
are associated with mammography, payment for many items, supplies, and are significantly greater than reflected
which CMS previously recognized and minor associated services into the by the proposed payment rate for APC
allowed separate payment. The payment for the primary service. Our 0340 of about $38. The commenter
commenter urged CMS to pay separately final CY 2007 treatment of CPT code believed that mapping Category III CPT
for CPT code 0159T, if not through the 0159T is the same as our final CY 2007 codes 0160T and 0161T to APC 0340, or
hospital OPPS, then by a separate packaged status for two chest x-ray CAD to any other APCs, is inappropriate at
payment under the MFPS, similar to services, CPT code 0174T (Computer- this time because the costs of these
other hospital-based mammography aided detection (CAD) (computer services are currently not known. The
services. algorithm analysis of digital image data commenter cautioned that assigning
Response: The CAD procedures that for lesion detection) with further these codes to specific APCs would be
the commenter makes reference to are physician review for interpretation and arbitrary and could significantly
described by CPT codes 77051 report, with or without digitization of overcompensate or undercompensate
(Computer-aided detection (computer film radiographic images, chest providers because there are no cost data
algorithm analysis of digital image data radiograph(s), performed concurrent available to appropriately map codes
for lesion detection) with further with primary interpretation) and CPT 0160T and 0161T at this time. The
physician review for interpretation, code 0175T (Computer aided detection commenter acknowledged that not
with or without digitization of film (CAD) (computer algorithm analysis of assigning the two codes to specific APCs
radiographic images; diagnostic digital image data for lesion detection) may result in no payment for TMS
mammography) and 77052 (Computer- with further physician review for therapy performed in hospital
aided detection (computer algorithm interpretation and report, with or outpatient settings for CY 2007 and
analysis of digital image data for lesion without digitization of film radiographic likely limit access for some patients.
detection) with further physician review images, chest radiograph(s), performed However, the commenter indicated that
for interpretation, with or without remote from primary interpretation) that it plans to work with the APC Panel in
digitization of film radiographic images; is discussed further in section II.A.4. of CY 2007 to determine the appropriate
screening mammography). These are this final rule with comment period. mapping for the two codes to ensure
both paid off the MPFS, according to Comment: One commenter requested access for appropriate patients.
specific provisions in the law for that CMS not map Category III CPT Other commenters noted that there
screening and diagnostic mammography codes 0160T and 0161T to APC 0340 was a related Category III code, CPT
that specify that such services, when (Minor Ancillary Procedures) because code 0018T (Delivery of high power,
focal magnetic pulses for direct APCs would be appropriate. Although codes. As discussed earlier, CPT codes
stimulation to cortical neurons) that was our final determination regarding these describe general services that are not
created prior to the full maturation of two codes is to provide assignments to specific to one product, and we believe
the therapeutic TMS procedure and specific APCs with payment rates for CY it is most appropriate to provide APC
related technology. The commenters 2007 as described below, this decision assignments for all new HCPCS codes
noted differences between CPT code does not represent a determination that that would be appropriately separately
0018T and the two new Category III CPT the services described by Category III paid under the OPPS if they were
codes, including its lack of CPT codes 0160T and 0161T are covered. This approach helps ensure
incorporation of the treatment planning reasonable and necessary. Medicare access to services described by these
function, its failure to specify repetitive contractors determine whether the codes for Medicare beneficiaries in the
in the descriptor, and its lack of services described by all HCPCS codes hospital outpatient department and
description of therapeutic treatment with status indicators reflecting their allows us to initiate collection of
delivery. They believed that the potential for payment under the OPPS, hospital cost information as soon as
historical APC assignment of code including Category III CPT codes, meet possible. The commenter indicated that
0018T to APC 0215 (Level I Nerve and all the program requirements for TMS may be safely performed in the
Muscle Tests) was inappropriate, coverage in different clinical hospital outpatient setting. We do not
although one commenter stated that it circumstances. see any reason to provide the Category
was not involved in determining that The Internet listing of Category III III CPT codes for TMS nonpayable
mapping. The commenters pointed out code changes on the AMA Web site status indicators in the OPPS for CY
that there are also two Category I CPT includes a parenthetical note that CPT 2007, when the codes were
codes that incorporate TMS for Code 0018T has been deleted as of July implemented in July 2006 and there are
diagnostic purposes, including CPT 1, 2006, the same date new CPT codes no alternative HCPCS codes to describe
code 95928 (Central motor evoked 0160T and 0161T were first the services. However, we believe that
potential study (transcranial motor implemented. The note also indicates APC 0216 (Level III Nerve and Muscle
stimulation); upper limbs) and CPT that, to report the procedure previously Tests) best represents both the clinical
code 95929 (Central motor evoked described by 0018T, one should see CPT and resource homogeneity of CPT codes
potential study (transcranial motor codes 0160T and 0161T. CPT Changes, 0160T and 0161T for CY 2007,
simulation); lower limbs). The an Insider’s View for CY 2002 when considering all of the information
commenters added that both of these 0018T was created, describes the use of available to us. We note that this APC
codes were proposed for assignment to CPT code 0018T for treatment of a has a status indicator of ‘‘S,’’ so that
APC 0218 (Level II Nerve and Muscle patient with a long history of under the occasional circumstance of
Tests) for CY 2007 with a payment rate depression, incorporating planning and two treatments in one day for a single
of about $74. therapeutic treatment delivery in the patient as described by a commenter,
Response: We appreciate the description of the procedure. In general, payment would not be reduced for the
commenters’ suggestion and background that outline of the service described by second service. We will reevaluate these
information. However, because the CPT CPT code 0018T closely parallels the assignments for future OPPS updates as
code descriptors are general in nature clinical vignettes for CPT codes 0160T additional information becomes
and not specific to a particular product, and 0161T that were provided to us in available to us, including updated
our policy has been to assign an APC to a public comment. Therefore, we do not claims data.
each Category III CPT code if we believe agree with the commenters that our After carefully considering the
that the procedure, if covered, would be historical claims for 0018T must be comments received, we are finalizing
appropriate for separate payment in the instances of miscoding or the use of our general proposal for the treatment of
OPPS. TMS for diagnostic purposes. While we new mid-year CPT codes, with
In addition, as indicated in the CY had no claims for CPT code 0018T for modification only to the CY 2007 APC
2006 OPPS final rule (70 FR 68567), CY 2005, we do have claims data for assignments for Category III CPT codes
some of the new Category III CPT codes this service from CYs 2002 through 0160T and 0161T as described above
may describe services that our medical 2004, although there were fewer than 15 and indicated in Table 6.
advisors determine to be similar in total claims for each of those years. The
clinical characteristics and resource use procedure was assigned to APC 0215 B. Variations Within APCs
to HCPCS codes in an existing APC. In (Level I Nerve and Muscle Tests) with 1. Background
such instances, we may assign the a payment rate of about $35 throughout
Category III CPT code to the appropriate that time period, with no specific Section 1833(t)(2)(A) of the Act
clinical APC. Other Category III CPT comments from the public on this requires the Secretary to develop a
codes may describe services that our assignment during the OPPS proposed classification system for covered
medical advisors determine are not updates for those years. hospital outpatient services. Section
compatible with an existing clinical We understand that the hospital 1833(t)(2)(B) of the Act provides that
APC, yet are appropriately provided in resource costs of specific technologies this classification system may be
the hospital outpatient setting. In these may change over time as those composed of groups of services, so that
cases, we may assign the Category III technologies evolve. In reviewing the services within each group are
CPT code to what we estimate is an clinical aspects of CPT codes 0160T and comparable clinically and with respect
appropriately priced New Technology 0161T, in the context of related codes to the use of resources. In accordance
APC. In the case of CPT codes 0160T and our historical OPPS claims data for with these provisions, we developed a
and 0161T, we believe the services CPT code 0018T and other services, we grouping classification system, referred
described by these active CPT codes agree with the commenter that APC to as the Ambulatory Payment
would be appropriately separately paid 0340 is not the most appropriate Classification Groups (or APCs), as set
under the OPPS if they are covered. We assignment for CPT codes 0160T and forth in § 419.31 of the regulations. We
do not believe the technology used to 0161T for CY 2007. The commenter use Level I and Level II HCPCS codes
provide these services is so new that provided no specific suggestions and descriptors to identify and group
their assignment to New Technology regarding the APC assignments for these the services within each APC. The APCs
are organized such that each group is APC groups and the relative payment clinical homogeneity. We also proposed
homogeneous both clinically and in weights (the APC Panel changes to the status indicators for some
terms of resource use. Using this recommendations for specific services codes that were not specifically and
classification system, we have for CY 2007 OPPS and our responses to separately discussed in the proposed
established distinct groups of surgical, them are discussed in the relevant rule. In these cases, we changed the
diagnostic, and partial hospitalization specific sections throughout this status indicators for some codes because
services, as well as medical visits. We preamble). we believed that another status
also have developed separate APC Finally, as discussed earlier, section indicator more accurately described
groups for certain medical devices, 1833(t)(2) of the Act provides that, their payment status from an OPPS
drugs, biologicals, subject to certain exceptions, the items perspective based on our CY 2007
radiopharmaceuticals, and and services within an APC group proposed policies.
brachytherapy devices. cannot be considered comparable with Addendum B of the CY 2007 OPPS
We have packaged into each respect to the use of resources if the proposed rule identified with a
procedure or service within an APC highest median (or mean cost, if elected comment indicator ‘‘CH’’ those HCPCS
group the costs associated with those by the Secretary) for an item or service codes for which we proposed a change
items or services that are directly related in the group is more than 2 times greater to the APC assignment or status
and integral to performing a procedure than the lowest median cost for an item indicator as assigned in the April 2006
or furnishing a service. Therefore, we do or service within the same group Addendum B update. Addendum B of
not make separate payment for packaged (referred to as the ‘‘2 times rule’’). We this final rule with comment period
items or services. For example, use the median cost of the item or identifies with the ‘‘CH’’ comment
packaged items and services include: (1) service in implementing this provision. indicator the final CY 2007 changes
Use of an operating, treatment, or The statute authorizes the Secretary to compared to the codes’’ status as
procedure room; (2) use of a recovery make exceptions to the 2 times rule in reflected in the October 2006
room; (3) most observation services; (4) unusual cases, such as low-volume Addendum B update.
anesthesia; (5) medical/surgical items and services. We received many public comments
supplies; (6) pharmaceuticals (other 2. Application of the 2 Times Rule regarding the proposed APC and status
than those for which separate payment In accordance with section 1833(t)(2) indicator assignments for CY 2007 for
may be allowed under the provisions of the Act and § 419.31 of the specific HCPCS codes. These are
discussed in section V of this preamble); regulations, we annually review the discussed mainly in sections III.C. and
and (7) incidental services such as items and services within an APC group III.D. of this final rule with comment
venipuncture. Our proposed packaging to determine, with respect to period, and the final action for CY 2007
methodology is discussed in section comparability of the use of resources, if related to each HCPCS code is noted in
II.A. of this preamble. the median of the highest cost item or those sections.
Under the OPPS, we pay for hospital service within an APC group is more
outpatient services on a rate-per-service than 2 times greater than the median of 3. Exceptions to the 2 Times Rule
basis that varies according to the APC the lowest cost item or service within As discussed earlier, we may make
group to which the service is assigned. that same group (‘‘2 times rule’’). We exceptions to the 2 times limit on the
Each APC weight represents the hospital make exceptions to this limit on the variation of costs within each APC
median cost of the services included in variation of costs within each APC group in unusual cases such as low-
that APC relative to the hospital median group in unusual cases such as low- volume items and services. At the time
cost of the services included in APC volume items and services. of the proposed rule, taking into account
0606. The APC weights are scaled to During the APC Panel’s March 2006 the APC changes that we proposed for
APC 0606 because we are proposing it meeting, we presented median cost and CY 2007 based on the APC Panel
to be the middle level clinic visit APC utilization data for services furnished recommendations discussed mainly in
(that is, where the Level III Clinic Visit during the period of January 1, 2005, sections III.C. and III.D. of the preamble,
HCPCS code of five levels of clinic visits through September 30, 2005, about the proposed changes to status
is assigned), and because middle level which we had concerns or about which indicators and APC assignments as
clinic visits are among the most the public had raised concerns identified in Addendum B of the CY
frequently furnished services in the regarding their APC assignments, status 2007 OPPS proposed rule, and the use
outpatient hospital setting. See section indicator assignments, or payment rates. of CY 2005 claims data to calculate the
II.A.3. of this preamble for a complete The discussions of most service-specific median costs of procedures classified in
discussion of the reasons for choosing issues, the APC Panel the APCs, we reviewed all the APCs to
APC 0606 as the basis for scaling the recommendations, if any, and our determine which APCs would not
APC relative weights. proposals for CY 2007 are contained satisfy the 2 times rule. We used the
Section 1833(t)(9)(A) of the Act principally in sections III.C. and III.D. of following criteria to decide whether to
requires the Secretary to review the this preamble. propose exceptions to the 2 times rule
components of the OPPS not less than In addition to the assignment of
for affected APCs:
annually and to revise the groups and specific services to APCs which we • Resource homogeneity
relative payment weights and make discussed with the APC Panel, we also • Clinical homogeneity
other adjustments to take into account identified APCs with 2 times violations • Hospital concentration
changes in medical practice, changes in that were not specifically discussed • Frequency of service (volume)
technology, and the addition of new with the APC Panel but for which we • Opportunity for upcoding and code
services, new cost data, and other proposed changes to their HCPCS codes’ fragments.
relevant information and factors. APC assignments in Addendum B of the For a detailed discussion of these
Section 1833(t)(9)(A) of the Act, as CY 2007 proposed rule. In these cases, criteria, refer to the April 7, 2000 OPPS
amended by section 201(h) of the BBRA to eliminate a 2 times violation, we final rule with comment period (65 FR
of 1999, also requires the Secretary, reassigned the codes to APCs that 18457).
beginning in CY 2001, to consult with contained services that were similar Table 7 published in the CY 2007
an outside panel of experts to review the with regard to both resource use and OPPS proposed rule (71 FR 49551)
listed the APCs that we proposed to We did not receive any general public to APC assignments based on those
exempt from the 2 times rule based on comments related to the list of proposed comments, we analyzed the full CY
the criteria cited above. For cases in exceptions to the 2 times rule. We 2005 data to identify APCs with 2 times
which a recommendation by the APC received a number of specific comments rule violations.
Panel appeared to result in or allow a about some of the procedures assigned Based on those final data, we found
violation of the 2 times rule, we to APCs that we proposed to make that there were 37 APCs with 2 times
generally accepted the APC Panel’s exempt from the 2 times rule for CY rule violations. We applied the criteria
recommendation because those 2007. Those discussions are elsewhere as described earlier to finalize the APCs
recommendations were based on in the preamble, in sections related to that are exceptions to the 2 times rule
explicit consideration of resource use, the types of procedures that were the for CY 2007. The final revised list of
clinical homogeneity, hospital subjects of the comments. APCs that are exceptions to the 2 times
specialization, and the quality of the For the proposed rule, the listed rule for CY 2007 is displayed in Table
data used to determine the APC exceptions to the 2 times rule were 7 below. After careful review of all
payment rates that we proposed for CY based on data from January 1, 2005, public comments on the proposed rule
2007. The median costs for hospital through September 30, 2005. For this and the claims data for the full year, CY
outpatient services for these and all final rule with comment period, we 2005, available to us for this final rule
other APCs which were used in used data from January 1, 2005 through with comment period, we are finalizing
development of the proposed rule can December 1, 2005. Thus, after the list of APCs exempted from the two
be found on the CMS Web site: http:// responding to all of the comments on times rule as displayed in Table 7
www.cms.hhs.gov. the proposed rule and making changes below.
TABLE 7.—APC EXCEPTIONS TO THE 2 TIMES RULE FOR CY 2007

APC APC description
0007 ................... Level II Incision & Drainage.

0010 ................... Level I Destruction of Lesion.
0019 ................... Level I Excision/ Biopsy.
0024 ................... Level I Skin Repair.
0040 ................... Percutaneous Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve.
0043 ................... Closed Treatment Fracture Finger/Toe/Trunk.
0058 ................... Level I Strapping and Cast Application.
0060 ................... Manipulation Therapy.
0081 ................... Non-Coronary Angioplasty or Atherectomy.
0093 ................... Vascular Reconstruction/Fistula Repair without Device.
0105 ................... Revision/Removal of Pacemakers, AICD, or Vascular.
0111 ................... Blood Product Exchange.
0112 ................... Apheresis, Photopheresis, and Plasmapheresis.
0203 ................... Level IV Nerve Injections.
0204 ................... Level I Nerve Injections.
0215 ................... Level I Nerve and Muscle Tests.
0245 ................... Level I Cataract Procedures without IOL Insert.
0251 ................... Level I ENT Procedures.
0252 ................... Level II ENT Procedures.
0274 ................... Myelography.
0303 ................... Treatment Device Construction.
0307 ................... Myocardial Positron Emission Tomography (PET) Imaging.
0312 ................... Radioelement Applications.
0323 ................... Extended Individual Psychotherapy.
0330 ................... Dental Procedures.
0340 ................... Minor Ancillary Procedures.
0367 ................... Level I Pulmonary Test.
0381 ................... Single Allergy Tests.
0397 ................... Vascular Imaging.
0409 ................... Red Blood Cell Tests.
0418 ................... Insertion of Left Ventricular Pacing Elect.
0432 ................... Health and Behavior Services.
0437 ................... Level II Drug Administration.
0604 ................... Level I Clinic Visits.
0621 ................... Level I Vascular Access Procedures.
0664 ................... Level I Proton Beam Radiation Therapy.
0676 ................... Thrombolysis and Thrombectomy.
C. New Technology APCs services within New Technology APC New Technology APC for more than 3
groups until we gather sufficient claims years if sufficient data upon which to
1. Introduction
data to enable us to assign the service base a decision for reassignment have
In the November 30, 2001 final rule to a clinically appropriate APC. This not been collected. More recently, at its
(66 FR 59903), we finalized changes to policy allows us to move a service from August 2006 meeting the APC Panel
the time period a service was eligible for a New Technology APC in less than 2 recommended that when CMS assigns a
payment under a New Technology APC. years if sufficient data are available. It new service to a New Technology APC,
Beginning in CY 2002, we retain also allows us to retain a service in a the service should remain there for at
least 2 years until sufficient claims data share of the costs of procedures based a. Nonmyocardial Positron Emission
are collected. In general, services remain on Medicare beneficiary projected Tomography (PET) Scans (APC 0308)
in New Technology APCs for at least 2 utilization and does not set its payment Positron emission tomography (PET)
years consistent with the APC Panel’s rates based on initial projections of low is a noninvasive diagnostic imaging
recommendation. However, we do not utilization for services that require procedure that assesses the level of
fully accept the APC Panel’s expensive capital equipment. For the metabolic activity and perfusion in
recommendation. While we agree with OPPS, we rely on hospitals to make various organ systems of the human
the APC Panel that we need sufficient informed business decisions regarding body. PET serves an important role in
claims data to move services from New the acquisition of high cost capital the clinical care of many Medicare
Technology APCs to clinical APCs, we equipment, taking into consideration beneficiaries. We recognize that PET is
also continue to believe that it their knowledge about their entire a useful technology in many instances
occasionally may be appropriate to patient base (Medicare beneficiaries and want to ensure that the technology
move a service from a New Technology included) and an understanding of remains available to Medicare
APC to a clinical APC in less than 2 Medicare’s and other payers’ payment beneficiaries when medically necessary.
years if the data are robust and there is policies. Since August 2000, nonmyocardial PET
an appropriate clinical APC for its We note that in a budget neutral procedures have been assigned to a New
assignment. environment, payments may not fully
We note that the cost bands for New Technology APC in the OPPS. As a
cover hospitals’ costs, including those result of our collection of 5 full years of
Technology APCs range from $0 to $50 for the purchase and maintenance of
in increments of $10, from $50 to $100 hospital claims data, in the CY 2007
capital equipment. We rely on providers proposed rule (71 FR 49566 through
in increments of $50, from $100 through to make their decisions regarding the
$2,000 in intervals of $100, and from 49567) we indicated that we believed
acquisition of high cost equipment with that we had sufficient data to assign
$2,000 through $6,000 in intervals of the understanding that the Medicare
$500. These intervals, which are in two nonmyocardial PET scans to a clinically
program must be careful to establish its appropriate APC for CY 2007. We assign
parallel sets of New Technology APCs, initial payment rates for new services
one with status indicator ‘‘S’’ and the a service to a New Technology APC only
that lack hospital claims data based on when we do not have adequate claims
other with status indicator ‘‘T,’’ allow us realistic utilization projections for all
to price new technology services more data upon which to determine the
such services delivered in cost-efficient median cost of performing the
appropriately and consistently. hospital outpatient settings. As the
Every year we receive many requests procedure, and we expect that the
OPPS acquires claims data regarding service’s clinical or resource
for higher payment amounts for specific
hospital costs associated with new characteristics will differ from all other
procedures under the OPPS because
they require the use of expensive procedures, we will regularly examine procedures already assigned to clinical
equipment. We are taking this the claims data and any available new APCs. Each New Technology APC
opportunity to reiterate our response in information regarding the clinical represents a particular cost band (for
general to the issue of hospitals’ capital aspects of new procedures to confirm example, $1,400–1,500), and we assign
expenditures as they relate to the OPPS that our OPPS payments remain procedures to these APCs based on our
and Medicare. appropriate for procedures as they analysis of the costs of the procedures.
Under the OPPS, one of our goals is transition into mainstream medical Payment for items assigned to a New
to make payments that are appropriate practice. Technology APC is the midpoint of the
for the services that are necessary for the 2. Movement of Procedures From New band (for example, $1,450). We move a
treatment of Medicare beneficiaries. The Technology APCs to Clinical APCs service from a New Technology APC to
OPPS, like other Medicare payment a clinical APC when we have adequate
systems, is budget neutral and so, As we explained in the November 30, claims data upon which to base its
although we do not pay full hospital 2001 final rule (66 FR 59897), we future payment rate. As noted in the CY
costs for procedures, we believe that our generally keep a procedure in the New 2007 proposed rule, in the case of
payment rates generally reflect the costs Technology APC to which it is initially nonmyocardial PET services, we
that are associated with providing care assigned until we have collected data believed that we had sufficient data to
to Medicare beneficiaries in cost- sufficient to enable us to move the assign them to a clinically appropriate
efficient settings. Further, we believe procedure to a clinically appropriate APC.
that our rates are adequate to assure APC. However, in cases where we find For CY 2006, we maintained the APC
access to services for most beneficiaries. that our original New Technology APC payment methodologies from CY 2005
For many emerging technologies there assignment was based on inaccurate or for nonmyocardial PET services.
is a transitional period during which inadequate information, or where the According to that methodology,
utilization may be low, often because New Technology APCs are restructured, payment was based on a 50/50 blend of
providers are first learning about the we may, based on more recent resource their median cost based on CY 2003
techniques and their clinical utility. utilization information (including claims data and the payment rate of the
Quite often, the requests for higher claims data) or the availability of refined CY 2004 New Technology APC to which
payment amounts are for new New Technology APC bands, reassign they were assigned. Therefore,
procedures in that transitional phase. the procedure or service to a different nonmyocardial PET scans were assigned
These requests, and their accompanying New Technology APC that most to New Technology APC 1513 (New
estimates for expected Medicare appropriately reflects its cost. Technology—Level XIII ($1100–$1200))
beneficiary or total patient utilization, The procedures presented below for a blended payment rate of $1,150.
often reflect very low rates of patient represent services assigned to New For CY 2007, we proposed the
use, resulting in high per use costs for Technology APCs for CY 2006 for which assignment of nonmyocardial PET
which requesters believe Medicare at the time of developing the proposed procedures to a clinically appropriate
should make full payment. Medicare rule we believed we had sufficient data APC as we now have several years of
does not, and we believe should not, to reassign them to clinically robust and stable claims data upon
assume responsibility for more than its appropriate APCs for CY 2007. which to determine the median cost of
performing these procedures. Based on for them to be able to continue to modification to provide payment for
analysis of the Medicare claims data, the provide the service in their nonmyocardial PET scans through APC
median costs for nonmyocardial PET communities. A number of other 0308.
scans have ranged between commenters opposed proposed payment
b. PET/Computed Tomography (CT)
approximately $852 and $924 for claims reductions for PET imaging services that
Scans (APC 0308)
submitted from CY 2002 through CY they believed were essential to ensuring
2005. However, our payment rates have appropriate treatment of patients with Since August 2000, we have paid
been significantly higher than the cancer and providing necessary patient separately for PET and CT scans. In CY
median costs throughout this same time access. 2004, the payment rate for
period. We have observed significant Response: We are sensitive to the nonmyocardial PET scans was $1,450,
growth in the number of nonmyocardial obstacles that rural providers face in while it was $193 for typical diagnostic
PET scans performed on Medicare trying to provide some services to CT scans. Prior to CY 2005,
beneficiaries, from about 48,000 in CY Medicare beneficiaries. However, we nonmyocardial PET and the PET portion
2002, to 68,000 in CY 2003, and to have years of stable and consistent data of PET/CT scans were described by G-
121,000 in CY 2004, the year when we that indicate that Medicare will now be codes for billing to Medicare. Several
first reduced the OPPS nonmyocardial paying more accurately for the scans at commenters on the November 15, 2004
PET scan payment rates from $1,450 to the proposed clinical APC rate. We final rule with comment period (69 FR
$1,150. For the CY 2007 OPPS proposed believe this rate will ensure the 65682) urged us to replace the G-codes
rule, we had about 45,000 single PET necessary patient access to PET services. for nonmyocardial PET and PET/CT
claims from CY 2005, yielding a stable Comment: Several commenters scan procedures with the established
median cost for PET procedures of about requested that, instead of assigning CPT CPT codes. These commenters stated
$867. Although the CY 2005 claims data code 78608 (Brain imaging, positron that movement to the established CPT
were not complete when we published emission tomography (PET); metabolic codes would greatly reduce the burden
the CY 2007 OPPS proposed rule, we evaluation), to APC 0308 with the CPT on hospitals of tracking and billing the
noted that the apparent decline in codes for tumor PET scans, CMS should G-codes that were not recognized by
numbers of claims for nonmyocardial assign this single code to a separate other payers and would allow for more
PET scans alone in the CY 2005 claims clinical APC. The commenters had no uniform hospital billing of these scans.
data was likely related to the large objections to assignment of PET services We agreed with the commenters that
number of claims for PET/CT scans to clinical APCs, with payment rates movement from the G-codes to the
observed in CY 2005, when codes for based on the APCs’ median costs. The established CPT codes for
that combined service were first commenters believed that assignment of nonmyocardial PET and PET/CT scans
available for billing. In fact, the total the CPT code for brain PET scans to its would allow for more uniform billing of
number of PET scans provided to own APC would be more appropriate these scans. As a result of a Medicare
Medicare beneficiaries in CY 2005, because the brain PET scans are not national coverage determination
defined as PET scans and PET/CT scans, clinically homogenous with the other (Publication 100–3, Medicare Claims
continued to climb to almost 128,000 tumor PET scans assigned to APC 0308. Processing Manual section 220.6) that
based upon the CY 2005 claims data Response: The brain PET scan was made effective January 28, 2005, we
available for the proposed rule, in services have been assigned to the same discontinued numerous G-codes that
comparison to final claims for CY 2004 New Technology APC with the same described myocardial PET and
of approximately 121,000 for PET scans. payment rate as the other nonmyocardial PET procedures and
Therefore, we proposed to assign nonmyocardial PET services for a replaced them with the established CPT
nonmyocardial PET scans, in particular, number of years. The CY 2005 median codes. The CY 2005 payment rate for
CPT codes 78608, 78811, 78812, and cost for the brain PET CPT code of $886 concurrent PET/CT scans using CPT
78813, to new APC 0308 is very similar to the median costs for codes 78814, 78815, and 78816 was
(Nonmyocardial Positron Emission the two tumor PET CPT codes of $873 $1,250, which was $100 higher than the
Tomography (PET) Imaging) with a and $762, indicating that all three of payment rate for PET scans alone. These
median cost of $865.30 for CY 2007. We these related PET services require PET/CT CPT codes were placed in New
noted we were confident that in the face comparable hospital resources. We are Technology APC 1514 (New
of our stable median costs for not convinced that separating Technology—Level XIV ($1,200–
nonmyocardial PET scans over the past nonmyocardial PET scans according to $1,300)) for CY 2005. We continued
4 years, their additional 2-year period of the body site being examined is with these coding and payment
receiving New Technology APC necessary for clinical homogeneity, and methodologies in CY 2006.
payments at the blended rate of $1,150 the result of such a distinction would be For CY 2007, we proposed the
for CY 2005 and CY 2006 as we a single CPT code in one APC and two assignment of concurrent PET/CT scans,
transitioned the services to a clinical CPT codes in another APC. The OPPS specifically CPT codes 78814, 78815,
APC would ensure continued is a prospective payment system that and 78816, to a clinically appropriate
availability of this technology now that provides payment for groups of services APC because we believed that we had
its services would be paid through a that share clinical and resource use adequate claims data from CY 2005
clinical APC in CY 2007, like most other characteristics. We believe that PET upon which to determine the median
OPPS services. scans for tumor imaging and brain cost of performing these procedures. At
Comment: A few commenters imaging are similar in both respects and the time of the proposed rule, based on
representing rural providers stated that are appropriately assigned to the same our analysis of CY 2005 single claims,
they would no longer be able to provide clinical APC. Therefore, we are the median cost of PET/CT scans was
PET scans to their patients who are finalizing our proposal to assign CPT $865 from almost 70,000 single claims.
Medicare beneficiaries if Medicare code 78608 to APC 0308, along with Comparison of the median cost of
lowered its payment for the services. CPT codes 78811, 78812, and 78813. nonmyocardial PET procedures of $867
They stated that, because they relied on After carefully considering the with the median cost of concurrent PET/
more costly, mobile units, the proposed comments, we are adopting our CT scans demonstrated that the median
payment amount would not be adequate proposal for CY 2007 without costs of PET scans with or without
concurrent CT scans for attenuation payment at the proposed level would recommendation and all of the
correction and anatomical localization not cover the costs of providing the information provided in the comments
were about the same. This result was services; the APC Panel recommended received regarding the proposed APC
not unexpected because many newer during its August 2006 meeting that assignment and payment amount for
PET scanners also had the capability of CMS retain PET/CT services in New PET/CT scans for CY 2007. We remain
rapidly acquiring CT images for Technology APC 1514 for another year confident that our CY 2005 data for
attenuation correction and anatomical so that more CPT-coded claims upon conventional nonmyocardial PET
localization, sometimes with which to base a decision about the services are accurate reflections of
simultaneous image acquisition. appropriate APC assignment for the hospital costs for those services, in spite
To explore the possibility that the services would be available; PET/CT of the CY 2005 coding changes.
similarity in median costs for PET and services are a clinically distinct Similarly, our review of the hospital
PET/CT procedures could be related to technology from conventional PET data provided in one of the public
different groups of hospitals billing the procedures and should not be assigned comments shows that the average cost
two types of PET services based on their to the same APC; PET/CT services are per hospital for PET/CT for one set of
available equipment, rather than the more costly to provide than are other hospitals was $829 and for the other
true comparability of hospital resources nonmyocardial PET services and there group was $912. We are encouraged that
required for the two types of services, must be a payment differential to these mean costs are so similar to our
we analyzed claims from a subset of recognize that; and a 30-percent median cost for the services, and these
hospitals billing both PET and PET/CT payment decrease would result in data serve to increase our confidence in
scans in CY 2005. This analysis looked decreased Medicare beneficiary access the CY 2005 claims data.
at 362 providers that billed a PET to the services. The commenters However, we recognize that there are
HCPCS code and a PET/CT CPT code at reported that the higher costs associated other factors to consider related to
least one time each during CY 2005. The with PET/CT were due to requirements hospital charging practices for PET/CT
median cost from this subset of claims for specially-trained, licensed services. For instance, prior to
for nonmyocardial PET scans was $890, technicians, more costly capital institution of the specific CPT codes for
in comparison with $863 for the PET/CT equipment, and higher equipment PET/CT scans, hospitals were reporting
scans. Thus, we observed the same close maintenance costs. a diagnostic CT scan charge in addition
relationship between median costs of Most commenters recommended that to the appropriate G-code charge for the
PET and PET/CT procedures from PET/CT should remain in its current PET scan. Therefore, the transition to
hospitals billing both sets of services as New Technology APC 1514 with a the new CPT codes was not a simple
we did for all OPPS CY 2005 claims payment rate of $1,250 for CY 2007. coding crosswalk for the PET/CT
available for the proposed rule for these Some of the commenters believed that services because it required the hospital
scans. We believed that our claims data CMS’ proposal to assign PET/CT scans to change from reporting two charges for
accurately reflected the comparable to a clinical APC was premature because the service to only one charge that was
hospital resources required to provide CMS did not have a full year of reliable to include the costs of the entire service.
PET and PET/CT procedures, and the cost data for PET/CT. They made that We are aware that making that
scans had obvious clinical similarity as assertion because the CPT codes used to adjustment may have been difficult for
well. Therefore, for CY 2007 we report the services were newly some hospitals.
proposed to assign the CPT codes for recognized by the OPPS in April 2005 After considering the information and
PET/CT scans, along with the CPT codes and, therefore, only 9 months of claims opinions provided to us in the
for PET scans, to the same new APC data were available for the CY 2007 comments, particularly with respect to
0308 (Nonmyocardial Positron Emission OPPS update. The commenters observed our data that are limited to 9 months of
Tomography (PET) Imaging) with a that if PET/CT scans were moved to a claims (although there are over 76,000
proposed median cost of $865.30. clinical APC for CY 2007, they would single claims from that time period), we
At its August 2006 meeting, the APC have been assigned to a New are persuaded that there are valid
Panel recommended that CMS retain Technology APC for only 21 months, reasons to assign PET/CT services to a
PET/CT scans in New Technology APC while the APC Panel recommended at different APC than the conventional
1514 with a payment rate of $1,250 for its August 2006 meeting that services PET services for CY 2007. We are
CY 2007. assigned to New Technology APCs convinced that, in this instance, we
We note that we have been paying should remain there for at least 2 years. should wait for a full year of CPT-coded
separately for fluorodeoxyglucose Further, because hospitals often do not claims data prior to assigning the PET/
(FDG), the radiopharmaceutical update their chargemasters more than CT services to a clinical APC and that
described by HCPCS code A9552 once per year, the commenters believed maintaining a modest payment
(Fluorodeoxyglucose F–18 FDG, that true hospital costs were not differential between PET and PET/CT
diagnostic, per study dose, up to 45 reflected in the CY 2005 data that CMS procedures is warranted for CY 2007.
millicuries) that is commonly considered when developing its For these reasons, we are assigning
administered during nonmyocardial proposal for CY 2007. PET/CT to a different APC than
PET and PET/CT procedures. For CY One of the commenters provided conventional PET services for CY 2007,
2007, we proposed to continue paying limited hospital-level average cost data based on our continued expectation of
separately for FDG, according to the for PET and PET/CT scans, as well as a the appropriate relative cost difference
methodology described in section V. of cost analysis model for PET/CT services. between the two types of services. When
the preamble of the CY 2007 proposed Those data covered the 6-month period we first recognized PET/CT CPT codes
rule. of July through December and display for payment in CY 2005, we established
Comment: A number of commenters average cost and charge data for two sets their payment rate at $100 more than
disagreed with the proposal to assign of hospitals, separated according to two the payment rate for PET scans.
PET/CT services to APC 0308. Among different methods of reducing their Although the commenters to the CY
the reasons provided by commenters charges to costs. 2007 proposed rule did not provide
that PET/CT services should not be Response: We have carefully specific information regarding an
assigned to APC 0308 were that: considered the APC Panel appropriate differential between
payments for PET and PET/CT scans, Second, we received comments on changes to the coding or APC placement
the commenters generally did not HCPCS code G0242 which requested of SRS treatment delivery HCPCS codes
oppose our proposed payment for PET that we modify the code descriptor to G0173, G0243, G0251, G0339, and
scans through a clinical APC with a avoid confusion and misuse of the code, G0340 for CY 2006. In addition,
payment rate of about $850. and also to appropriately describe presenters to the APC Panel described
Historically, when both PET and PET/ treatment planning for both linear ongoing deliberations among interested
CT scans were assigned to New accelerator-based and Cobalt 60-based professional societies around the
Technology APCs with a $100 payment SRS treatments. In response, for CY descriptions and coding for SRS. The
difference for CYs 2005 and 2006, we 2004, we created HCPCS code G0338 to APC Panel and presenters suggested that
received few public comments distinguish linear accelerator-based SRS CMS wait for the outcome of these
indicating that payment difference was treatment planning from Cobalt 60- deliberations before making any
inappropriate. Therefore, we are based SRS treatment planning. We significant changes to SRS delivery
assigning PET/CT scans to New placed HCPCS code G0338 in APC 1516 coding or payment rates. As indicated in
Technology APC 1511 (New at a payment rate of $1,450. the CY 2007 OPPS proposed rule, we
Technology—Level XI ($900–$1,000)) In CY 2005, there were no changes to did not receive a report from
with a payment of $950 for CY 2007 to the coding or New Technology APC participating professional societies as to
maintain the approximately $100 payment rates for the SRS planning or the outcome of such deliberations prior
difference between payments these treatment delivery codes from CY 2004. to publishing that rule (71 FR 49554).
services and nonmyocardial PET scans, We stated in the CY 2005 OPPS final In response to comments for CY 2006
which will be assigned to APC 0308 rule with comment period (69 FR regarding the mature technology and
with a median cost of about $850 for CY 65711) that any SRS code changes stable median costs associated with
2007. In this way, the differential would be premature without cost data to Cobalt 60-based SRS treatment delivery
payment between conventional PET and support a code restructuring. Therefore, described by HCPCS code G0243, we
PET/CT scans will be preserved at an we maintained HCPCS codes G0173, reassigned G0243 from a New
appropriate level, the payment decrease G0242, G0243, G0251, G0338, G0339, Technology APC to new clinical APC
for PET/CT procedures will be and G0340 in their respective New 0127 (Stereotactic Radiosurgery), with a
moderated as the services transition to Technology APCs for CY 2005. We payment rate of $7,305 established
payment based on their costs in a further stated that until we had based on the CY 2004 median cost of
clinical APC, and CMS will be able to completed an analysis of claims for G0243. We made no changes for CY
consider a full 12 months of CPT-coded these procedure codes, we would 2006 to the New Technology APC
claims prior to making the assignment continue to maintain HCPCS codes assignments of the other four SRS
of PET/CT scans to a clinical APC. G0173, G0242, G0243, G0251, G0338, treatment codes, specifically, G0173,
G0339, and G0340 in their respective G0251, G0339, and G0340.
c. Stereotactic Radiosurgery (SRS) New Technology APCs for CY 2005 as Since we first established the full
Treatment Delivery Services (APCs we considered the adoption of CPT group of SRS treatment delivery codes
0065, 0066, and 0067) codes to describe all SRS procedures for in CY 2004, we now have 2 years of
For the past several years, we have CY 2006. hospital claims data reflecting the costs
collected hospital costs associated with At its February 2005 meeting, the APC of each of these services. Based on our
the planning and delivery of stereotactic Panel discussed the clinical and proposed rule analysis of our claims
radiosurgery services (hereafter referred resource cost similarities between data from CY 2004 and CY 2005, the
to as SRS). As new technology emerged planning for Cobalt 60-based and linear median costs for linear accelerator-
in the field of SRS, public commenters accelerator-based SRS. The APC Panel based SRS treatment delivery
urged us to recognize cost differences also discussed the use of CPT codes procedures as described by HCPCS
associated with the various methods of instead of specific G-codes to describe codes G0173, G0251, G0339, and G0340
SRS planning and delivery. Beginning the services involved in SRS planning, have been stable and generally lower
in CY 2001, we established G-codes to noting the clinical similarities in than our New Technology APC payment
capture any such cost variations radiation treatment planning regardless rates in effect from CY 2004 through CY
associated with the various methods of of the mode of treatment delivery. Given 2006. Specifically, the payment rate for
planning and delivery of SRS. For CY the APC Panel’s deliberations about the HCPCS code G0173, a complete course
2004, based on comments received possible need for CMS to separately of non-image guided, non-robotic linear
regarding the G-codes used for SRS, we track planning for SRS, the APC Panel accelerator-based SRS treatment, has
made some modifications to the coding eventually recommended that CMS been set at $5,250, yet our claims data
(68 FR 63431 and 63432). First, we create a single HCPCS code to indicate a median cost of $2,802 from
received comments regarding the encompass both Cobalt 60-based and CY 2004 claims and $3,665 from our
descriptors for HCPCS codes G0173 and linear accelerator-based SRS planning. proposed rule CY 2005 claims, based
G0251, indicating that these codes did Because we had no programmatic need upon hundreds of single claims from
not distinguish image-guided robotic to separately track SRS planning each year. For HCPCS code G0251,
SRS systems from other forms of linear services, in the CY 2006 OPPS final rule fractionated non-image guided, non-
accelerator-based SRS systems to with comment period (70 FR 68585), we robotic linear accelerator-based SRS
account for the cost variation in discontinued HCPCS codes G0242 and treatment, the corresponding median
delivering these services. In response, G0338 for the reporting of charges for costs have been $1,028 and $1,386
for CY 2004 we created two new G- SRS planning and instructed hospitals based upon over 1,000 single claims
codes (G0339 and G0340) to describe to bill charges for SRS planning, from each year, and relatively consistent
complete and fractionated image-guided regardless of the mode of treatment with the procedure’s New Technology
robotic linear accelerator-based SRS delivery, using all of the available CPT APC payment of $1,150. With respect to
treatment. We placed HCPCS code codes that most accurately reflect the the complete course of therapy in one
G0339 in APC 1528 at a payment rate services provided. session or first fraction of image-guided,
of $5,250, and HCPCS code G0340 in Furthermore, the APC Panel robotic linear accelerator-based SRS,
APC 1525 at a payment rate of $3,750. recommended that CMS make no described by HCPCS code G0339, its
median costs have been $4,917 and indicators, APC assignments, and CY 2005. The fact that image-guided
$4,809 for CY 2004 and CY 2005 median costs for these services. robotic SRS centers have grown in
respectively, based upon over 500 single We received many comments on our number and service volume over the
bills in each year, in comparison with proposal from hospitals, health most recent 2 years of claims
the procedure’s payment rate of $5,250 professionals, and various healthcare submissions is expected for new
for those years. Lastly, the median costs associations. A summary of the technology and other OPPS services.
of HCPCS code G0340, the second comments and our responses follow: Many OPPS services are only provided
through fifth sessions of image-guided, Comment: Several commenters in a small subset of hospitals paid under
robotic linear accelerator-based SRS objected to our use of the CY 2005 the OPPS, and we routinely establish
treatment, have been $2,502 for CY 2004 claims data in setting the CY 2007 APC median costs based on Medicare
and $2,917 for CY 2005 as determined payment rates, specifically with regards OPPS claims from the hospitals that
to the image-guided robotic SRS were providing the services 2 years
by over 1,000 single bills during each
services, as described by HCPCS codes prior to the OPPS update year. We
year, significantly lower than its
G0339 and G0340. They indicated that recognize that our claims data evolve
payment rate of $3,750. Unquestionably,
the claims data used to set the proposed over time, in part because the pool of
the claims data from CY 2004 and CY payment rates for HCPCS codes G0339 hospitals providing certain procedures
2005 for linear accelerator-based SRS and G0340 were based on a flawed may change significantly.
treatment delivery services revealed methodology because several centers The information provided in the
highly stable median costs from year to providing these services submitted comments did not convince us that the
year based on significant claims volume. claims to CMS for less than a full year proposed payment rates for HCPCS code
Based on the above findings, in the during CY 2004 and CY 2005. Because G0339 and G0340 were based on
CY 2007 proposed rule we indicated centers that provided image-guided SRS inadequate claims data that did not
that we believed that we had adequate grew in number significantly over the represent the costs of the procedures for
claims data to assign the SRS treatment past 2 years, the commenters believed the hospitals providing the services in
delivery procedures to clinically that CMS did not have meaningful data CY 2005. Based on our final CY 2005
appropriate APCs, and we believed that over 2 years from a large number of claims data, we found 1,535 single (of
such movement was appropriate. For institutions providing the services upon 1,655 total) claims for HCPCS code
CY 2007, we proposed to create several which to base the proposed changes. G0339 and 2,716 single (of 2,798 total)
new SRS clinical APCs of different They believed that new technology claims for HCPCS code G0340. We
levels to assign the HCPCS codes services should have a minimum of 2 believe that the single claims data for
describing linear accelerator-based SRS years of claims data before moving them both procedures are sufficiently robust
treatment, G0173, G0251, G0339, and to clinical APCs. These commenters for ratesetting purposes.
G0340, based on their clinical and urged CMS to maintain HCPCS code Comment: Several commenters agreed
hospital resource similarities and G0339 in its current New Technology with CMS that the hospital claims data
differences. In particular, we proposed APC 1528 with a payment rate of from the past 2 years for the SRS
to assign HCPCS codes G0339 and $5,250, and to also maintain HCPCS services have been relatively stable and
G0173 to the same Level III SRS APC, G0340 in its current New Technology based on at least several hundreds of
because we believed that these codes APC 1525 with a payment rate of claims both years. However, these
that describe the complete or first $3,750. commenters expressed concern about
Response: In the November 30, 2001 our proposal to assign HCPCS codes
fraction of all types of linear accelerator-
final rule (66 FR 59903), we finalized G0173 and G0339 to the same APC,
based SRS treatments had substantial changes to the time period a service was specifically APC 0067 (Level III
hospital resource and clinical similarity, eligible for payment under a New Stereotactic Radiosurgery). The
as observed in their median costs and Technology APC. Beginning in CY 2002, commenters opposed assignment of the
recognized previously in their we noted that we would retain services two procedures to the same APC
equivalent New Technology APC within New Technology APC groups because they believed that our claims
payments. The codes describing until we gathered sufficient claims data data clearly showed that the median
subsequent fractions of image-guided, to enable us to assign the service to a cost of G0339 has been significantly
robotic and non-image guided, non- clinically appropriate APC. There is no higher than the median cost of G0173
robotic linear accelerator-based SRS requirement for a minimum number of for both CY 2004 and CY 2005.
treatments were each assigned to their claims or years of claims data before Response: Both services have been
own clinical APCs in our proposal, as services may be moved from New assigned to the same New Technology
they demonstrated significant Technology APCs to clinical APCs. APC 1528 for the past 3 years because
differences in resource utilization as In the case of the image-guided of our initial expectation that the costs
reflected in their median costs. Their robotic SRS services, specifically G0339 of the first or complete session of linear
previous assignments to different New and G0340, we continue to believe that accelerator-based SRS would be similar,
Technology APCs anticipated these we have adequate claims data from CY regardless of whether or not the SRS
resource distinctions. We proposed to 2005 upon which to base our payments procedure was an image-guided robotic
continue our assignment of HCPCS code for CY 2007. Both HCPCS codes G0339 service. While we have observed that
G0243 for Cobalt 60-based SRS and G0340 were effective for reporting their costs are somewhat different, we
treatment delivery to clinical APC 0127, beginning January 1, 2004, under the believe that they are sufficiently
renamed Level IV Stereotactic OPPS, and consequently, we have 2 full comparable to warrant placement of the
Radiosurgery. Our proposed years worth of hospital claims data for SRS services in the same clinical APC,
reassignments of SRS services from New these services. As we noted earlier, the given the comparable clinical
Technology APCs to clinical APCs were median costs for both procedures have characteristics of the services. The OPPS
listed in Table 8 of the CY 2007 OPPS been reasonably stable over the past 2 provides payments based on APC
proposed rule (71 FR 49554), which has years based upon substantial numbers of groups of services that share clinical
been reproduced as Table 8 below, single claims, and there was similar and resource characteristics, and the
amended with the final status growth in both services from CY 2004 to median of the highest cost service
within an APC group should not be describe the services they provide. We hospital OPPS because the code will be
more than 2 times greater than the believe that the current HCPCS code deleted and replaced with CPT code
median cost of the lowest cost service descriptors adequately distinguish 77371, effective January 1, 2007. CPT
within that same group. The final CY image-guided robotic linear accelerator- code 77371 is assigned to the same APC
2005 median cost of G0173 is $3,407.53, based SRS from other types of SRS. We and status indicator as its predecessor
and the final CY 2005 median cost of observe significant difference in the code (G0243). That is, for CY 2007, CPT
G0339 is $4,126.46. These median costs costs of G0251 and G0340 that describe code 77371 is assigned to APC 0127
are quite comparable, and APC 0067, the later fractions of non-image-guided (Level IV Stereotactic Radiosurgery)
configured as proposed, does not violate and image-guided SRS respectively, so with a status indicator of ‘‘S’’.
the 2 times limit on the variation of that they require assignment to two • CPT code 77372 describes a single
costs within the APC. separate clinical APCs. We have no session, complete course of treatment,
Therefore, for CY 2007, both HCPCS evidence that hospitals are not linear accelerator-based procedure.
codes G0339 and G0173 are reassigned accurately reporting these services During CY 2006, this procedure was
to clinical APC 0067 with a median cost based on the technology utilized to reported under one of two HCPCS
of $3,872.87, and HCPCS code G0340 is provide SRS in their institutions. codes, depending on the technology
reassigned to clinical APC 0066, with a For CY 2007, the CPT Editorial Panel used, specifically, G0173 (Linear
median cost of $2,629.53. created four new SRS Category I CPT accelerator based stereotactic
Comment: Several organizations codes in the Radiation Therapy section radiosurgery, complete course of
supported our proposed clinical APC of the 2007 CPT manual. Specifically, therapy in one session) and G0339
assignments but were concerned by the the CPT Editorial Panel created CPT (Image-guided robotic linear accelerator-
extent of the payment reductions for codes 77371 (Radiation treatment based stereotactic radiosurgery,
certain services. The commenters delivery, stereotactic radiosurgery (SRS) complete course of therapy in one
expressed concern regarding the 23- (complete course of treatment of session or first session of fractionated
percent reduction in payment for cerebral lesion[s] consisting of 1 treatment). Because HCPCS codes
HCPCS codes G0173 and G0339. They session); multi-source Cobalt 60 based)), G0173 and G0339 are more specific in
urged CMS to review the cost 77372 (Radiation treatment delivery, their descriptors than CPT code 77372,
calculations for all SRS services and use stereotactic radiosurgery (SRS) we have decided to continue using
the most current claims data available (complete course of treatment of G0173 and G0339 under the OPPS for
for the CY 2007 OPPS final rule. cerebral lesion[s] consisting of 1 CY 2007. Therefore, for CY 2007, we
Response: We thank the commenters session); linear accelerator based)), have assigned CPT code 77372 to status
for their suggestion. The payment rates 77373 (Stereotactic body radiation indicator ‘‘B’’ under the OPPS.
reflected in Table 8 are based on the therapy, treatment delivery, per fraction • CPT code 77373 describes a
latest and most complete CY 2005 to 1 or more lesions, including image fractionated session linear accelerator-
claims data, with CY 2007 payment guidance, entire course not to exceed 5 based procedure. During CY 2006, CPT
rates based upon APC median costs fractions), and 77435 (Stereotactic body code 77373 was reported under one of
calculated according to the standard radiation therapy, treatment three HCPCS codes depending on the
OPPS methodology. Almost all of the management, per treatment course, to circumstances and technology used,
claims are single claims; therefore, we one or more lesions, including image specifically, G0251 (Linear accelerator-
are confident that the observed costs in guidance, entire course not to exceed 5 based stereotactic radiosurgery, delivery
the claims data are representative of the fractions). For CY 2007, we will including collimator changes and
costs of the SRS services provided in CY continue our recent practice of not custom plugging, fractionated treatment,
2005. recognizing established CPT code 61793 all lesions, per session, maximum five
Comment: Several commenters (Stereotactic radiosurgery (particle sessions per course of treatment), G0339
requested that CMS modify the beam, gamma ray or linear accelerator), (Image-guided robotic linear accelerator-
descriptors for HCPCS codes G0339 and one or more sessions) under the OPPS based stereotactic radiosurgery,
G0340 to be more precise and reflect the because the OPPS will utilize more complete course of therapy in one
technology accurately. The commenters specific SRS codes to provide session or first session of fractionated
provided their proposed language, and appropriate payment for the facility treatment), and G0340 (Image-guided
indicated that not refining the resources associated with specific types robotic linear accelerator-based
descriptors would make it virtually of SRS treatment delivery. Below is our stereotactic radiosurgery, delivery
impossible to determine appropriate discussion of the new SRS CPT codes, including collimator changes and
APC payment rates for image-guided and our assignments for the codes under custom plugging, fractionated treatment,
robotic SRS services in the future. They the OPPS. all lesions, per session, second through
also urged CMS to work with the centers • CPT code 77371 describes a cobalt- fifth sessions, maximum five sessions
providing these specialized services to based SRS procedure for a single, per course of treatment). Because
establish accurate and appropriate complete treatment session of one or HCPCS codes G0251, G0339, and G0340
payments for image-guided robotic SRS. more cerebral lesions. Under the OPPS, are more specific in their descriptors
Response: The recommended this procedure has been separately than CPT code 77373 and these HCPCS
language provided by the commenters is payable under HCPCS code G0243 codes are assigned to different clinical
very specific and may cause more (Multi-source photon stereotactic APCs for CY 2007, we have decided to
confusion for hospitals and coders. Long radiosurgery, delivery including continue using G0251, G0339, and
descriptors of HCPCS codes that collimator changes and custom G0340 under the OPPS for CY 2007.
describe services and procedures are plugging, complete course of treatment, Therefore, for CY 2007, we have
usually more general and not specific to all lesions) since January 1, 2002. We assigned CPT code 77373 to status
a particular specialty or product. We do believe this single CPT code may be indicator ‘‘B’’ the hospital OPPS.
not establish HCPCS codes that are appropriately reported in all clinical • CPT code 77435 also describes
specific to certain technologies. Instead, situations of cobalt-based SRS treatment management for a full
we rely on hospitals to select the most treatment. For CY 2007, HCPCS G0243 treatment course of linear accelerator-
specific HCPCS codes that accurately will no longer be reportable under the based SRS. During CY 2006, CPT code
77435 was described under CPT code indicator that was assigned to its data are sufficient for us to move these
0083T (Stereotactic body radiation predecessor Category III CPT code. services to clinical APCs. Therefore, for
therapy, treatment management, per After carefully considering all the CY 2007, HCPCS codes G0173 and
day), which was assigned to status comments and concerns raised by the G0339 are assigned to clinical APC
indicator ‘‘N’’ in the OPPS. The CPT commenters, we are finalizing our 0067, with a median cost of $3,872.87,
Editorial Panel has decided to delete proposal as shown in Table 8 without HCPCS code G0251 to clinical APC
CPT code 0083T on December 31, 2006, modification. Given the ample cost 0065, with a median cost of $1,241.89,
and replaced it with CPT code 77435. information reflected in the CY 2005 and HCPCS code G0340 to clinical APC
Because the costs of SRS treatment claims data for the SRS services and 0066 with a median cost of $2,629.53.
management are already packaged into given the fact that these services have As described above, despite new CPT
the OPPS payment rates for SRS been in New Technology APCs for 3 full codes for SRS treatment delivery in CY
treatment delivery, for CY2007 we have years, since they were first assigned to 2007, coding for linear accelerator-based
assigned CPT code 77435 to status New Technology APCs beginning SRS treatment delivery services will not
indicator ‘‘N’’, which is the same status January 1, 2004, we believe our claims change in the CY 2007 OPPS.
TABLE 8.—FINAL APC ASSIGNMENTS FOR SRS TREATMENT DELIVERY SERVICES FOR CY 2007
Final CY 2007
HCPCS CY 2006 pay- Final CY Final CY 2007
Short descriptor CY 2006 SI CY 2006 APC APC median
code ment rate 2007 SI APC cost
G0173 .... Linear acc stereo radsur com .. S .................. 1528 $5,250.00 S .................. 0067 $3,872.87
G0251 .... Linear acc based stero radio .... S .................. 1513 1,150.00 S .................. 0065 1,241.89
G0339 .... Robot lin-radsurg com, first ...... S .................. 1528 5,250.00 S .................. 0067 3,872.87
G0340 .... Robt lin-radsurg fractx 2–5 ....... S .................. 1525 3,750.00 S .................. 0066 2,629.53
d. Magnetoencephalography (MEG) assigned to only one level as their the commenters, and the APC Panel
Services (APCs 0038 and 0209) required hospital resources differ recommendation for CY 2006 that we
Magnetoencephalography (MEG) is a significantly. They further stated that retain the MEG procedures in New
noninvasive diagnostic tool that assists our data did not represent the true costs Technology APCs. As a result of this
surgeons in the presurgical period by of the procedures because MEG analysis, we determined that using a 50/
measuring and mapping brain activity. procedures are performed on very few 50 blend of the code-specific median
It may be used for epilepsy and brain Medicare patients. costs from our most recent CY 2004
tumor patients. Since CY 2002, the MEG Analysis of our hospital data for hospital claims data and the CY 2005
procedures described by CPT codes claims submitted from CY 2002 through New Technology APC code-specific
95965 (Magnetoencephalography CY 2005 indicated that these procedures payment amounts as the basis for
(MEG), recording and analysis; for are rarely performed on Medicare assignment of the procedures for CY
spontaneous brain magnetic activity (eg, beneficiaries. For claims submitted from 2006 would be an appropriate way to
epileptic cerebral cortex localization)), CY 2002 through CY 2005, our single recognize both the current payment
95966 (Magnetoencephalography claims data showed that there were rates for the procedures, which were
(MEG), recording and analysis; for annually only between 2 and 23 claims originally based on the theoretical costs
evoked magnetic fields, single modality submitted for CPT code 95965, between to hospitals of providing MEG services,
(e.g., sensory, motor, language, or visual 3 and 7 claims for CPT code 95966, and and the median costs based upon our
cortex localization)), and 95967 only 1 claim for CPT code 95967. In hospital claims data regarding actual
(Magnetoencephalography (MEG), addition, the hospital claims median MEG services provided to Medicare
recording and analysis; for evoked costs for these codes have varied beneficiaries by hospitals. Therefore,
magnetic fields, each additional widely, perhaps due to our small CPT codes 95965, 95966, and 95967
modality (e.g., sensory, motor, language, volume of claims. The median cost for were assigned to different New
or visual cortex localization)) have been CPT code 95965 has ranged from $332 Technology APCs for CY 2006 based on
assigned to New Technology APCs. In using CY 2002 claims to $3,166 based this blended methodology, with
the CY 2006 proposed rule (70 FR upon CY 2005 claims. The median cost payment rates of $2,750, $1,250, and
42709), we proposed to reassign MEG for CPT code 95966 has varied widely $850 respectively.
procedures to clinical APC 0430 using from CY 2002 to CY 2005. For single At the March 2006 APC Panel
CY 2004 claims data to establish median claims submitted during CY 2002, the meeting, the Panel recommended that
costs on which the CY 2006 payment median cost was $1,949, while it was CMS move CPT codes 95965 (MEG,
rates would be based. This proposal $507 for CY 2003, $1,435 for CY 2004, spontaneous), 95966 (MEG, evoked,
involved the reassignment of the three and $701 from 3 single claims for CY single), and 95967 (MEG, evoked, each
MEG procedures, specifically CPT codes 2005. The median cost for CPT code additional) from their CY 2006 New
95965, 95966, and 95967, from three 95967 based upon 1 single claim from Technology APCs which were assigned
separate New Technology APCs into one CY 2005 claims was $217. As noted in based on the blended methodology
new clinical APC with a status indicator our CY 2007 OPPS proposed rule (71 FR described above to clinical APC(s) for
of ‘‘T.’’ The commenters on the CY 2006 49555), we had no hospital median cost CY 2007. Following that meeting,
proposal believed that their assignment data for CPT code 95967 prior to CY interested parties provided us with CY
to clinical APC 0430 would be 2005. 2005 charge and cost information from
inappropriate because the proposed In the November 10, 2005 final rule six hospitals that provided MEG
payment level of $674 was inadequate with comment period (70 FR 68579), we services. These external data showed
to cover the costs of the procedures, and stated that we carefully considered our wide variation in hospitals’ costs and
because the procedures should not be claims data, information provided by charges for MEG procedures, with
generally higher values for CPT code activity of the brain over a significant hospital claims data for MEG
95965 and lower values for CPT codes time period, and our hospital claims procedures and because MEG is no
95966 and 95967 but no consistent data showed that their hospital longer a new technology, we believe
proportionate relationship among those resources were also relatively that the proposed APC assignment for
costs and charges. In some cases, the comparable. MEG procedures and their CPT code 95966 is appropriate. If we
charges and costs for CPT codes 95966 CY 2007 proposed APC assignments were to assign CPT code 95966 to its
and 95967 were quite similar for the two were displayed in Table 9 published in own clinical APC, the median cost of
related services, one of which describes the CY 2007 OPPS proposed rule (71 FR that APC would be the median cost of
MEG for a single modality of evoked 49556), which has been reproduced in CPT code 95966 of $709 from CY 2005
magnetic fields and the other that Table 9 of this final rule with comment claims data, quite consistent with the
describes MEG for each additional period and updated to include the final median cost of APC 0209. We do not
modality of evoked magnetic fields. The status indicators, APC assignments, and assign payment rates for clinical APCs
individual hospital cost and charge data APC median costs for CY 2007. based upon speculative relationships of
for specific services demonstrated Comment: Most of the commenters the costs of its services to payments for
significant variations of up to six fold agreed with the APC assignments for other services. Instead, the standard
across the hospitals, with an apparent both CPT codes 95965 and 95967 but OPPS methodology to develop the
inverse relationship between the requested that CMS reconsider the APC median cost of a clinical APC upon
numbers of services provided and the assignment for CPT code 95966. The which a specific procedure’s payment is
costs of the procedures. This finding commenters supported the based is to establish the APC median
was not unexpected, given the establishment of a separate APC for CPT from claims data for all of the services
dependence of MEG procedures on the code 95965 and its proposed payment assigned to the APC. As we have
use of expensive capital equipment. As rate. They also agreed that CPT code indicated above, while the volumes of
we have previously stated, our OPPS 95967 is an add-on code that is always MEG procedures are low, almost all
payment rates generally reflect the costs used in conjunction with CPT codes procedures, including those with very
that are associated with providing care 95965 or 95966 and is less costly to low Medicare volume, are assigned to
to Medicare beneficiaries in cost- perform. They generally agreed with the clinical APCs under the OPPS, with
efficient settings. For emerging proposed APC assignment and payment their payment rates based on the median
technologies, we establish payment rate for CPT code 95967, despite the costs of their assigned APCs. Taking
rates for new services that lack hospital very low volume of OPPS claims for the into consideration our hospital claims
claims data based on realistic utilization procedure. The commenters disagreed data for CPT code 95966 from the last
projections for all such services with the proposed APC and payment several years, we continue to believe
delivered in cost-efficient hospital rate for CPT code 95966. They indicated that its assignment to APC 0209 is
outpatient settings. In the CY 2007 that MEG is a highly specialized service appropriate, and that the service is
OPPS proposed rule, we indicated that performed in a limited number of sufficiently similar to other diagnostic
since we now had 4 years of hospital hospitals in the U.S. Because the service procedures also residing in the APC.
claims data for MEG procedures and is not commonly performed, the Therefore, for CY 2007, we are assigning
because MEG was no longer a new commenters acknowledged that CPT code 95965 to APC 0038, with a
technology, we did not believe these Medicare beneficiaries represent only a final CY 2007 median cost of $3,270,
small number of patients who receive and CPT codes 95966 and 95967 to APC
external data from six hospitals that
MEG services because epilepsy surgery 0209, with a final CY 2007 median cost
performed MEG services in CY 2005
is rarely performed on elderly patients, of $687.
provided a better estimate of the
which further explains the very low Comment: One commenter indicated
hospital resources used in MEG
volume of these services in the that the claims data cited in the CY 2007
procedures during the care of Medicare
Medicare claims data. While the OPPS proposed rule for CPT codes
beneficiaries than our standard OPPS
commenters agreed with the proposed 95965, 95966, and 95967 were based
historical claims methodology.
APC assignments for CPT codes 95965 both on incomplete and inaccurate
We agreed with the APC Panel and and 95967, they believed that the claims data. The commenter submitted
proposed to accept their resources required to perform 95966 copies of paid Medicare claims from CY
recommendation to move the MEG CPT were significantly higher than the 2005 for CPT code 95965, which
codes into clinical APCs for CY 2007. payment rate reflected in APC 0209, its included nine claims that reflected 5
While the volumes for the MEG proposed assignment for CY 2007. The months of data, each representing total
procedures are low, almost all commenters indicated that the costs of charges greater than the CY 2007
procedures, including those with very MEG services were substantially higher proposed payment rate for CPT code
low Medicare volume, are assigned to than the EEG or sleep study services 95965. The commenter requested that
clinical APCs under the OPPS, with that are also assigned to APC 0209. As CMS consider these claims in
their payment rates based on the median such, the commenters believed that CPT determining the appropriate APC
costs of their assigned APCs. Therefore, code 95966 should be assigned to its assignments for the MEG services.
we proposed to assign CPT code 95965 own APC at a rate equal to 50 percent Response: We confirmed that the
to new clinical APC 0038 (Spontaneous of the payment rate for CPT code 95965, claims data submitted to us are
MEG), with a proposed median cost of or approximately $1,550. They believed accurately reflected in the CY 2005
$3,166.30, and to assign both CPT codes that this payment rate was supported by claims data used for the CY 2007 OPPS
95966 and 95967 to APC 0209 (Level II the hospital cost data for the six update. Consequently, we believe that
MEG, Extended EEG Studies, and Sleep hospitals providing a high volume of our claims data adequately reflect the
Studies), with a proposed median cost MEG services, which were provided to costs associated with providing the
of $709.36. We believed that the CMS and discussed in the CY 2007 MEG service identified by CPT code
assignment of CPT codes 95966 and OPPS proposed rule. 95965. In determining a hospital’s cost
95967 to APC 0209 was appropriate Response: We appreciate the for a service, we take the individual
because MEG studies were similar to commenters’ input and suggestions. hospital’s departmental CCR and
EEGs and sleep studies in measuring However, given that we have 4 years of multiply this by the total charge on a
single claim for that service. In the event code 95965 of about $3,165, consistent according to our standard OPPS
there is no applicable departmental with the final CY 2007 median cost of methodology.
CCR, we use the overall hospital- APC 0038 of about $3,270. This median After carefully reviewing the data and
specific CCR. For this CY 2007 OPPS cost provides the basis for establishing considering the public comments
update, the average overall hospital CCR the procedure’s payment rate. Overall, received, we are finalizing our proposal
is 0.30142. Multiplying this average we believe the claims provided by the
for APC assignment for MEG as shown
CCR by the typical MEG procedure commenter help to validate our final CY
in Table 9 without modification.
charge of about $10,500 on the claims 2007 APC 0038 assignment of CPT code
provided to us yields a cost for CPT 95965, with its payment rate calculated
TABLE 9.—CY 2007 APC ASSIGNMENT FOR MEG

Final CY 2007
HCPCS CY 2006 pay- Final CY 2007
Short descriptor CY 2006 SI CY 2006 APC CY 2007 SI APC median
code ment rate APC cost
95965 ..... Meg, spontaneous .................... S .................. 1523 $2,750.00 S .................. 0038 $3,270.35
95966 ..... Meg, evoked, single ................. S .................. 1514 1,250.00 S .................. 0209 687.26
95967 ..... Meg, evoked, each additional .. S .................. 1510 850.00 S .................. 0209 687.26
e. Other Services in New Technology application following partial which had a proposed median cost of
APCs mastectomy, includes imaging guidance; $3,012.92 and a CY 2006 title of ‘‘Breast
Other than the PET, PET/CT, SRS, concurrent with partial mastectomy) Reconstruction with Prosthesis.’’ As to
and MEG new technology services from New Technology APC 1523 (New our proposed CY 2007 APC
discussed in section III.C.2.a. through d. Technology Level XXIII—($2500– assignments, for these codes, the
of this preamble, there are 23 $3000)) to clinical APC 0029 (Level II commenters indicated that the other
procedures currently assigned to New Breast Surgery), with a proposed procedures in APCs 0030 and 0029 did
Technology APCs for CY 2007 for which median cost of $1,738.75. not use high cost devices, and the
we believed we also had data that were Comment: Numerous commenters median costs of the various procedures
adequate to support their assignment to requested that CMS maintain CPT code assigned to these APCs violated the 2
clinical APCs. For CY 2007, we 19296 and CPT code 19297 in New times rule when the device-dependent
proposed to reassign these procedures to Technology APCs 1524 and 1523, median costs of CPT codes 19296 and
clinically appropriate APCs, applying respectively, for another year so that 19297 were considered. The
their CY 2005 claims data to develop more claims data could be collected for commenters further added that the
their clinical APC median costs upon both services. They were concerned procedures within these APCs were not
which payments would be based. These about the proposed significant payment clinically homogeneous and
procedures and their proposed APC decreases for CPT codes 19296 and recommended that we reassign CPT
assignments were displayed in Table 10 19297 that ranged from -23 percent to codes 19296 and 19297 to APC 0648
of the CY 2007 OPPS proposed rule. -37 percent. The commenters also (Breast Reconstruction with Prosthesis),
This table has been reproduced as Table indicated that the number of hospital which contained procedures that were
10 at the end of this section and outpatient claims for both codes were more similar to the brachytherapy
updated with the final status indicators, low and thus inadequate to support catheter insertion procedures in terms of
APC assignments, and median costs. their assignment to appropriate clinical their clinical characteristics and use of
We received many comments APCs. The commenters indicated that in costly devices.
concerning the proposed reassignment developing the proposed rule, CPT code Response: As we have stated
of other new technology procedures 19296 had a total of 491 single claims previously, we retain services within
listed in Table 10 to clinical APCs for for CY 2005, and only 36 single claims New Technology APC groups until we
CY 2007. A summary of the comments were available for CPT code 19297. One gather sufficient claims data to enable
and our responses follow: commenter was surprised that CMS us to assign the services to clinically
would consider moving CPT code 19297 appropriate APCs. This policy allows us
(1) Breast Brachytherapy (APCs 0029 to a clinical APC with only 36 single to move services from New Technology
and 0030) claims, while CPT code 19298 (Place APCs in less than 2 years if sufficient
For CY 2007, we proposed to reassign breast rad tube/caths), with 49 single data are available. It also permits us to
CPT code 19296 (Placement of claims for CY 2005, would continue to retain services in New Technology APCs
radiotherapy afterloading balloon be assigned to New Technology APC for more than 3 years if sufficient data
catheter into the breast for interstitial 1524. upon which to base a decision for
radioelement application following The commenters generally urged CMS reassignment have not been collected. In
partial mastectomy, includes imaging to reevaluate the proposed clinical APCs the case of CPT codes 19296 and 19297,
guidance; on date separate from partial for these procedures, and, if necessary, the predecessor codes for these services
mastectomy) from New Technology APC place them in more appropriate APCs were created in April 2004. CPT code
1524 (New Technology Level XIV— that accurately reflected the costs and 19296 was previously described by
($3000-$3500)) to clinical APC 0030 clinical characteristics of these services. HCPCS code C9715 (Placement of
(Level III Breast Surgery) with a Many commenters requested that CMS balloon catheter into the breast for
proposed median cost of $2,516.94. We either continue to assign CPT codes interstitial radiation therapy following a
also proposed to reassign CPT code 19296 and 19297 to their current CY partial mastectomy; delayed), and CPT
19297 (Placement of radiotherapy 2006 New Technology APCs for CY code 19297 was described by HCPCS
afterloading balloon catheter into the 2007, or place them in APC 0648, code C9714 (Placement of balloon
breast for interstitial radioelement retitled ‘‘Level IV Breast Surgery,’’ catheter into the breast for interstitial
radiation therapy following a partial performed in a single session. As for mastectomy and placement of
mastectomy; concurrent/immediate). CPT code 19298, because there was no brachytherapy catheter procedures are
Both predecessor codes were assigned to predecessor code to describe this performed in a single operative session.
New Technology APCs when the codes procedure, which was new in CY 2005, According to the CPT manual, CPT code
were announced in the April update of we only have 1 year of claims data. 19297 would be reported with CPT code
the CY 2004 OPPS (Transmittal 132, Therefore, we are continuing to assign 19160 (Mastectomy, partial (e.g.,
dated March 30, 2004). Specifically, this code to New Technology APC 1524 lumpectomy, tylectomy,
HCPCS code C9715 was assigned to for CY 2007 to enable us to collect quadrantectomy, segmentectomy)) or
New Technology APC 1524 and HCPCS additional data for appropriate 19162 (Mastectomy, partial (e.g.,
code C9714 was assigned to New ratesetting in the future. lumpectomy, tylectomy,
Technology APC 1523. Consequently, Comment: Several commenters quadrantectomy, segmentectomy); with
we believe we have sufficient data from indicated that the procedure associated axillary lymphadenectomy). These
almost 3 years of hospital claims to with CPT codes 19296 and 19297 codes are assigned to APCs 0028 (Level
assign both CPT codes 19296 and 19297 requires the use of a specialized catheter I Breast Surgery), with a final CY 2007
to clinically appropriate APCs. We that has a list price of $2,750, which is median cost of $1,178.12, and 0693
recognize that, in the case of CPT code more costly than the proposed payment (Breast Reconstruction), with a final CY
19297 which is an add-on code to a rate for APC 0030 or APC 0029. One 2007 median cost of $2,260.98,
partial mastectomy service, single bills commenter added that hospitals do not respectively. In cases where the partial
would likely always be miscoded and receive discounts or rebates on the mastectomy is performed with
available in only small numbers, unique catheters, and that regardless of concurrent placement of a
because the correctly coded claims whether the procedure is performed at brachytherapy balloon catheter into the
would be multiple procedure claims the time of lumpectomy or during future breast, payment for the nondevice-
that we could not use for ratesetting. surgery, the cost of the catheter is still dependent partial mastectomy
However, in light of the comments the same in both cases. procedure would be appropriately
received and our review of all the Response: As noted above, after reduced by 50 percent, while full
information provided by the carefully considering all the public payment would be provided for the
commenters, we reconsidered the comments received, we have reassigned device-dependent procedure described
proposed APC assignments for CPT CPT codes 19296 and 19297 to APC by CPT code 19297, consistent with the
codes 19296 and 19297. We agree with 0648, a device-dependent APC, for CY expected resource efficiencies when
the commenters that the clinical APC 2007. The final median cost for this these procedures are performed in a
assignments for CPT codes 19296 and device-dependent APC was calculated single session.
19297 should accurately reflect the costs using only claims that contained After carefully considering all public
of the procedures, as well as their appropriate device HCPCS codes for all comments received, we are finalizing
clinical features. We note that the final the procedures assigned to it with our CY 2007 proposal with modification
CY 2005 median cost for CPT code nontoken charges for the devices as to reassign CPT codes 19296 and 19297
19296 is $3,041.58 based on 537 (of 860 discussed in section IV.A.2 of this from New Technology APCs to clinical
total) single claims, and the final CY preamble. The median cost from the APC 0648, retitled ‘‘Level IV Breast
2005 median cost for CPT code 19297 is subset of claims reporting a device Procedures,’’ with a final CY 2007
$1,322.03 based on 36 single claims (of HCPCS code for the brachytherapy median cost of $3,130.45. We also are
443 total claims). As noted previously, catheter was $3,469.85 for CPT code implementing appropriate procedure-to-
we do not believe the median cost of 19296 and $3,379.97 for CPT code device edits for both of these
CPT code 19297 is calculated based 19297. We believe that payment for APC procedures.
upon correctly coded claims. Therefore, 0648 accurately reflects the resources
and costs associated with performing (2) Radiofrequency Ablation (APCs 0050
after full consideration of the public
these device-dependent brachytherapy and 0423)
comments received, we believe it is
appropriate for CY 2007 to assign both catheter insertion procedures. To ensure For CY 2007, we proposed to reassign
services to clinical APC 0648 with an that their future claims include charges CPT code 20982 (Ablation, bone
APC title of ‘‘Level IV Breast Surgery’’ for the necessary devices to assist in tumor(s) (e.g., osteoid osteoma,
and a final median cost of $3,130.45. We ratesetting, we will implement metastasis), radiofrequency,
believe this is the most appropriate procedure-to-device edits for both of percutaneous, included computed
assignment for both procedures, when these services in CY 2007. In order to tomographic guidance) from New
we consider their clinical and resource receive payment for the two procedures Technology APC 1557 (New
characteristics in the context of other to insert brachytherapy balloon Technology—Level XX ($1800–$1900))
procedures also assigned to APC 0648. catheters, hospitals will be required to to APC 0050 (Level II Musculoskeletal
APC 0648 is assigned status indicator report the appropriate device HCPCS Procedures Except Hand and Foot), with
‘‘T,’’ which means that when a service code or their claims will be returned to a proposed median cost of $1,535.66.
assigned to it is reported with a lower them for correction. We also proposed that CPT code
priced service (for example, a Comment: Several commenters were 50592 (Ablation, one or more renal
mastectomy procedure) that is also concerned about the proposed tumor(s), percutaneous, unilateral
assigned status indicator ‘‘T,’’ payment assignment of status indicator ‘‘T’’ to radiofrequency), which was a new CPT
for the lower priced service would be both CPT codes 19296 and 19297. They code for CY 2006, and CPT code 47382
reduced by 50 percent. This reduction observed that the indicator would (Ablation, one or more liver tumor(s),
in payment reflects the efficiencies that always reduce the payment for CPT percutaneous, radiofrequency) continue
occur when a lower paid service is code 19297 by 50 percent. to be assigned to APC 0423 (Level II
performed during the same operative Response: Based on the final CY 2007 Percutaneous Abdominal and Biliary
session as a higher paid surgical assignment of CPT code 19297 to APC Procedures), with a proposed median
procedure. We believe this reduction is 0648, we believe this reduction is cost of $2,410.33.
appropriate due to efficiencies that may appropriate due to efficiencies that may Comment: One commenter objected to
be gained when both services are be gained when both the partial the proposed payment for APC 0423 and
the placement of CPT codes 47382 and code 47382 based on clinical and wave, high energy, performed by a
50592 in APC 0423 because the resource considerations. Therefore, it is physician, requiring anesthesia other
commenter believed that the proposed most appropriately assigned to the same than local, including ultrasound
payment was too low to adequately clinical APC. Moreover, because CPT guidance, involving the plantar fascia)
compensate hospitals for the required code 47382 uses devices that never had and CPT code 0102T (Extracorporeal
radiofrequency electrode and the pass-through status, we have not placed shock wave, high energy, performed by
necessary services. One commenter also any of the CPT codes for radiofrequency a physician, requiring anesthesia other
asked that CPT code 20982 be ablation procedures in specialized than local, involving lateral humeral
reassigned to APC 0051 (Level III APCs, nor do we consider their APCs to epicondyle) from New Technology APC
Musculoskeletal Procedures Except be device-dependent. Because the 1547 (New Technology—Level X ($800–
Hand and Foot) to pay a more device is well-established in its use for $900)) to clinical APC 0050 (Level II
appropriate amount. The commenter radiofrequency ablation of liver tumors, Musculoskeletal Procedures Except
provided a comparison to the MPFS we believe that hospital charges for the Hand and Foot), which had a proposed
practice expense inputs that showed procedure contain the charges the payment rate of $1,542.47.
that the supply, clinical time, and hospital considers are appropriate for Comment: One commenter on our CY
capital expense for performing CPT the electrode and other required 2006 final rule with comment period
code 20982 was about $2,100. Moreover, supplies. This is similar to our was concerned that our assignment of
the commenter asked that CMS ensure treatment of CPT code 66984 new CPT code 28890 to APC 1547 may
that a forthcoming CPT code for ablation (Extracapsular cataract removal with be insufficient to appropriately pay for
of a lung tumor be assigned to an APC insertion of intraocular lens prosthesis the costs associated with its
that would make appropriate payment (one stage procedure), manual or performance and facility costs in the
for both the electrode and the services. mechanical technique (e.g., irrigation outpatient setting. The commenter
The commenter stated that the and aspiration or phacoemulsification)). admitted that it did not have actual cost
electrodes used in these services This is a well-established service that data for supplies and equipment used in
typically cost from $900 to $2,500, with predates the OPPS and that uses a the hospital outpatient setting.
an approximate average of $1,500. The device that was never a pass-through Nevertheless the commenter was
commenter asked that CMS grant its device. We also do not consider its APC concerned that the $850 payment rate
pass-through device category to be device-dependent. for services assigned to APC 1547 may
application, establish a new device We also are assigning new CPT code be insufficient for this service the OPD.
category code for radiofrequency 32998 (Ablation therapy for reduction or The commenters on our CY 2007 OPPS
electrodes for pass-through payment, eradication of one or more pulmonary proposed rule believed that our
and designate APCs 0423, 0132 (Level tumor(s) including pleura or chest wall proposed reassignment of CPT codes
III Laparoscopy), and 0050 as device- when involved by tumor extension, 28890 and 0102T to APC 0050 was
dependent APCs and implement percutaneous, radiofrequency, appropriate for CY 2007 until the
appropriate procedure-to-device edits. unilateral) to APC 0423 because we Medicare hospital claims data become
have no reason to believe that the more robust. Several commenters
Response: The MPFS is a different resources required for the newly coded supported our proposal to reassign CPT
payment system that establishes service differ in any substantive way code 28890 and CPT code 0102T from
payment rates based on a methodology from the resources required for New Technology APC 1547 to clinical
that is wholly unrelated to the OPPS longstanding CPT code 49382. This new APC 0050. The commenters believed
setting of relative weights, so its practice CPT code’s assignment is open to that APC 0050 appropriately reflects the
expense costs are not applicable to the comment in this final rule with true costs and clinical resources
OPPS. However, in this final rule with comment period. We do not make pass- associated with CPT code 0102T. One
comment period, we are reassigning through device category determinations commenter indicated that the costs of
CPT code 20982 to APC 0051 for CY through rulemaking, nor do we create the procedures currently classified
2007 because we agree, based on review new device category codes outside of under clinical APC 0050 are not
of our historical claims data and final the pass-through process. Because there dissimilar to the median cost of its
CY 2005 claims, that CPT code 20982 is is no specific device code to describe predecessor code, specifically, HCPCS
more appropriately assigned to APC the radiofrequency ablation electrode, code C9720 (High-energy (greater than
0051 than to APC 0050 from hospital we are unable to implement procedure- 0.22mj/mm2) extracorporeal shock wave
resource and clinical perspectives. to-device edits for any of these (ESW) treatment for chronic lateral
However, we are retaining CPT codes procedures. epicondylitis (tennis elbow)), and
47382 and 50592 in APC 0423, with a After carefully considering the public therefore, agreed with our proposed
median cost established based upon our comments received, we are finalizing assignment. However, one commenter
standard OPPS methodology, because our proposal with modification. CPT believed that the true resource costs of
we believe that we have sufficient code 20982 is reassigned to APC 0051 CPT codes 28890 and 0102T are not
claims data for CPT code 47382, which for CY 2007, with a median cost of fully reflected in the CY 2005 claims
was created in CY 2002. We have 4 $2,510.95. CPT codes 47382 and 50592 data upon which CY 2007 payment rates
years of claims data for this procedure, continue to be assigned to APC 0423 for are based. Therefore, the commenter
with hundreds of single claims from CY CY 2007, with a median cost of recommended that CMS adopt the
2005 that reflect a stable code-specific $2,283.08. New CPT code 32998 is also proposed assignments of these CPT
median cost in comparison with CY assigned to APC 0423 for CY 2007, and codes to APC 0050, but that CMS
2004 claims. For CY 2007, CPT code this assignment is open to comment in continue to track and evaluate its claims
47382 is the only code assigned to APC this final rule with comment period. data as additional claims data become
0423 that contributes claims data to the available.
median cost calculation for the APC. We (3) Extracorporeal Shock Wave However, the commenter questioned
also believe that CPT code 50592, which Treatment (APC 0050) our assignment of CPT code 0101T
has no CY 2005 claims data because it For CY 2007, we proposed to reassign (Extracorporeal shock wave involving
was new for CY 2006, is similar to CPT CPT code 28890 (Extracorporeal shock musculoskeletal system, not otherwise
specified, high energy) to APC 0050, centrally inserted central venous access reported on the claim. We have
stating that this code describes a variety device, requiring two catheters via two calculated the median cost of APC 0625
of unspecified procedures for which we separately venous access sites: with for CY 2007 using only claims that
have no CY 2005 claims data. The subcutaneous port(s)) from New contain nontoken charges for HCPCS
commenter recommended that we not Technology APC 1564 (New code C1881.
assign CPT code 0101T to APC 0050 or Technology—Level XXVII ($4500– After carefully considering the public
to any inappropriately low-priced New $5000)), to APC 0623 (Level III Vascular comments received, we are finalizing
Technology APC. Access Procedures), with a proposed our CY 2007 proposal with
Response: Concerning the comment to median cost of $1,703.94. At its August modification. We are assigning CPT
our CY 2006 assignment of CPT code 2006 meeting, the APC Panel code 36566 to APC 0625, with a median
28890, we note that the OPPS payment recommended that this procedure be cost of $5,100.26, and establishing an
is for the technical or facility portion of moved to an APC with a payment rate appropriate procedure-to-device edit for
the payment only. The physician no less than that of New Technology CY 2007.
performing the procedure would also APC 1524 (New Technology—Level (5) Stereotactic X-ray Guidance (APC
bill CMS for the professional services in XXIV ($3000–$3500)) and more than 0257)
providing the procedure. Therefore, the that of New Technology APC 1564 (New
CY 2006 OPPS payment for APC 1547 Technology—Level XXVII ($4500– For CY 2007, we proposed to reassign
was not for both the performance and $5000)). The APC Panel also CPT code 77421 (Stereoscopic x-ray
facility fee as suggested by the recommended that CMS establish a guidance) from New Technology APC
commenter. Nevertheless, in our procedure-to-device edit for the service. 1502 (New Technology—Level II ($50–
proposed rule for CY 2007, we proposed Comment: Some commenters objected $100)) to clinical APC 0257 (Level I
reassigning CPT code 28890 to APC to the proposed payment rate for CPT Therapeutic Radiologic Procedures),
0050, Level II Musculoskeletal code 36566. The commenters asked that with a proposed median cost of $60.
Procedures Except Hand and Foot, with CMS establish the median cost for this Comment: Some commenters
a proposed payment rate of $1,542.47. code based only on claims that contain expressed concern about our proposal to
Prior to the introduction of this CPT HCPCS code C1881 (Dialysis access reassign CPT code 77421 from New
code in CY 2006, hospitals reported system, implantable) and that we add a Technology APC 1502 to clinical APC
HPCPS code C9721 (High-energy device edit that requires that hospitals 0257. The commenters indicated that
(greater than 0.22mj/mm2) must bill for HCPCS code C1881 as a the proposed payment rate of $60.14 for
extracorporeal shock wave (ESW) condition of being paid for CPT code APC 0257 was insufficient and did not
treatment for chronic plantar fasciitis), 36566. They indicated that two devices, adequately cover the actual costs
to describe the service. This C-code had totaling $3,500, are required for the associated with providing the guidance
a median cost of about $1,794 based on procedures. service described by CPT code 77421. In
CY 2005 claims, consistent with the Response: We agree that CPT code addition, the commenters believed that
proposed payment rate for APC 0050. 36566, created in CY 2004, should be the other services currently assigned to
We appreciate the support for our assigned to a device-dependent APC, APC 0257 were significantly different
proposed reassignment of ESWT CPT and we calculated median costs for from CPT code 77421. The commenters
codes 28890 and 0102T to APC 0050 for device-dependent APCs in CY 2007 stated that the stereotactic x-ray
CY 2007. Concerning the objection to based upon claims that passed the guidance procedure is considerately
assigning CPT code 0101T to APC 0050 device edits and contained nontoken more sophisticated and technologically
due to the lack of claims data, we device charges as described in section more complex, and thus, more resource
believe that the clinical characteristics IV.A.2 of this preamble. When we intensive, than the procedures in APC
and expected resource use for CPT code calculated the median cost of CPT 0257. Furthermore, the commenters
0101T will be similar to other ESWT 36566 based only on that subset of cited the global payment rate of $151.59
treatments such as those described by claims with HCPCS code C1881, its for CPT code 77421 under the MPFS,
CPT codes 28890 and CPT 0102T. As median cost was $5,100.26. We are and requested that we take into
indicated in our CY 2007 OPPS generally accepting the APC Panel’s consideration the MPFS practice
proposed rule (71 FR 49549), some of recommendation to assign CPT code expense information for ratesetting
the new Category III CPT codes describe 36566 to an APC with an appropriate rather than relying on very limited
services that we have determined to be payment rate and to establish a hospital claims data. Some commenters
similar in clinical characteristics and procedure-to-device edit for CY 2007. requested that CMS reassign CPT code
resource use to HCPCS codes in an For CY 2007, we have placed CPT code 77421 to APC 0296 (Level II Therapeutic
existing APC. In these instances, we 36566 in new APC 0625 (Level IV Radiologic Procedures), which had a
may assign the Category III CPT code to Vascular Access Procedures) because proposed median cost of $167, to more
the appropriate clinical APC. In the case there is no currently existing clinical accurately reflect the true costs
of CPT code 0101T, we believe this APC where CPT code 36566 could associated with providing this service.
procedure is similar in clinical appropriately be reassigned based on The commenters further indicated that
characteristics and resource use to CPT clinical and resource considerations. We the other services assigned to APC 0296
code 28890 and CPT code 0102T. have established APC 0625 as a device- were similar clinically and resource-
After carefully considering the public dependent APC because the APCs for wise to the stereotactic x-ray guidance
comments received, we are finalizing the vascular access device services that procedure. Other commenters requested
our proposal without modification to require devices of significant cost that CMS maintain CPT code 77421 in
assign CPT codes 28890, 0102T, and generally have been considered device- New Technology APC 1502 with a
0101T to APC 0050 for CY 2007. dependent since the inception of the payment rate of $75 for CY 2007, until
OPPS. We have established a device CMS has more experience with the CPT
(4) Insertion of Venous Access Device edit, effective for services on or after code. Some commenters noted that CMS
With Two Ports (APC 0623) January 1, 2007, that will not provide may have mistakenly cross-walked CY
For CY 2007, we proposed to reassign payment for CPT code 36566 unless an 2005 claims data for C9722
CPT code 36566 (Insertion of tunneled appropriate device HCPCS code is also (Stereoscopic kilovolt x-ray imaging
with infrared tracking for localization of Comment: Several commenters gastroesophageal reflux test; with
target volume) to CPT code 77421, based disagreed with the proposed mucosal attached telemetry ph electrode
on the belief that both codes described reassignment of CPT code 78804, which placement, recording, analysis and
the same services. describes a whole body study that interpretation) from New Technology
Response: While CPT code 77421 was requires multiple days of imaging, from APC 1506 (New Technology—Level VI
made effective on January 1, 2006, New Technology APC 1508 to the same ($400–$500)) to clinical APC 0361
under the OPPS stereoscopic kV x-ray new clinical APC 0408 as the (Level II Alimentary Tests) with a
guidance was previously reported with assignment of CPT code 78806 proposed payment of $242.
HCPCS code C9722, which was made (Radiopharmaceutical localization of Comment: One commenter disagreed
effective January 1, 2005, and deleted on inflammatory process; whole body), with our proposal to reassign CPT code
December 31, 2005, according to our which describes a single day whole 91035 from New Technology APC 1506
usual practice when services previously body imaging study. While the to clinical APC 0361. The commenter
described by a C-code can be reported commenters acknowledged that the two believed that the proposed payment
with a CPT code. Based on our claims procedures use similar resources for a level of $242 for APC 0361 did not
data, we found 14,794 single claims (out day of imaging, they stated that the adequately reflect the cost of providing
of 15,367 total claims) for HCPCS code clinical time and work involved in the service and that it did not
C9722 in the CY 2005 data upon which performing a multiple day imaging appropriately differentiate between the
we are basing the CY 2007 relative study is significantly more intensive two types of pH monitoring for
weights. We believe that services than a single day study; therefore, detection of gastroesophageal reflux
previously reported with HCPCS code hospitals incur additional costs. As disease (GERD): capsule-based and
C9722 may now be reported with CPT such, the commenters disagreed with catheter-based. (CPT code 91035
code 77421, although CPT code 77421 our proposal to assign the single and describes the capsule-based pH
may allow reporting of a broader set of multiple day study CPT codes to the monitoring service while CPT code
technologies. We also believe this CY same clinical APC because the hospital 91034 describes the catheter-based pH
2005 volume of services is sufficient to resources are not homogeneous for these monitoring procedure.) The commenter
justify setting a relative weight based on clinically similar studies. The believed that the resource costs for the
claims-based cost information rather commenters urged CMS to maintain the two procedures are significantly
than keeping the service in a New single day study as described by CPT different, and as such, each procedure
Technology APC for another year. In code 78806 in its current APC should be placed in a separate APC to
addition, our claims information is not assignment, specifically APC 0406 accurately reflect the costs of providing
consistent with a payment for the (Level I Tumor/Infection Imaging), and the services. The commenter indicated
service through clinical APC 0296, to create a new APC for CPT code 78804 that the average cost of the capsule is
which has a final median cost of about for assignment of the multiple day about $184, which is significantly
$164. We note that, of the claims study. Furthermore, the commenters higher than the cost of the catheter used
available for ratesetting for APC 0257, recommended that the payment rate for for pH monitoring that is priced at about
almost 90 percent of them were for CPT code 78804 be based on the current $45. In addition, the commenter
HCPCS code C9722; therefore, we are claims data for the procedure. requested that CPT code 91035 be
confident that the median cost of APC Response: After further review of our designated as a device-dependent
0257 appropriately reflects the costs of CY 2005 claims data and consideration procedure, and also requested that CMS
stereoscopic x-ray imaging. We also of the clinical characteristics of CPT establish a C-code for the capsule to
believe the other imaging services code 78804, we agree with the appropriately track its cost. The
assigned to APC 0257 share sufficient commenters’ recommendation to commenter also requested that CMS
clinical and resource similarity with maintain the single day study, which is compare the costs of single claims with
CPT code 77421 to support their described by CPT code 78806, in its claims that include an endoscopy
assignment to the same clinical APC. current CY 2006 APC 0406. We further procedure, with which the pH capsule
Moreover, we again note that the MPFS agree with the commenters’ assignment procedure is very commonly performed,
practice expense information for this of CPT code 78804 to a separate APC to ensure that all costs were captured
service is not relevant to the setting of established as Level II Tumor/Infection and based on the most likely clinical
relative weights under OPPS. Imaging, and therefore, have decided to scenario when determining the
After considering all the public keep this code as the only code assigned appropriate payment rate for CPT code
comments received, for CY 2007, we are to APC 0408 for CY 2007. Based on our 91035.
adopting as final without modification final revised policy, the CY 2007 Response: Since April 2004, the
our proposal to reassign CPT code median cost of APC 0408 is $362.05. procedure described by CPT code 91035
77421 from New Technology APC 1502 The separate APC assignments for the has been designated as a new
to clinical APC 0257, which has a final single and multiple day tumor/infection technology service under the OPPS.
CY 2007 median cost of $67.06. imaging studies adequately achieve both While CPT code 91035 was not effective
clinical and resource coherence for the for reporting until January 1, 2005, its
(6) Whole Body Tumor Imaging (APC predecessor code, specifically HCPCS
services in both APCs. Therefore, we are
0408) code C9712 (Insertion of a pH capsule
finalizing our proposed CY 2007 APC
For CY 2007, we proposed to reassign assignment of CPT code 78804 to new for measurement and monitoring of
CPT code 78804 (Radiopharmaceutical clinical APC 0408 for CY 2007, with gastroesophageal reflux disease,
localization of tumor or distribution of modification to the proposal through includes data collection and
radiopharmaceutical agent(s); whole reconfiguration of APC 0408 as interpretation) was designated as a new
body, requiring two or more days described above. technology service and assigned to New
imaging) from New Technology APC Technology APC 1506 from April 2004
1508 (New Technology—Level VIII (7) Gastroesophageal Reflux Test With until December 31, 2004, when the code
($600–$700)) to clinical APC 0408 pH Electrode (APC 0361) was deleted and replaced with CPT
(Level II Tumor/Infection Imaging) with For CY 2007, we proposed to reassign code 91035. CPT code 91035 was then
a proposed median cost of $309. CPT code 91035 (Esophagus, assigned to the same New Technology
APC for CY 2005, with a payment rate procedures, and these services are of other services also proposed for
of $450. As usual, in determining the clinically similar, we are finalizing our assignment to APC 0604.
initial payment level for this service, we assignment of CPT code 91035 to APC During the August 2006 APC Panel
took into consideration the costs 0361 for CY 2007 without modification. meeting, one presenter recommended
associated with the procedure, that we either continue to assign G0248
(8) Home International Normalized and G0249 to a New Technology APC or
including the necessary capsule device.
We do not believe that our claims data Ratio (INR) Monitoring (APC 0604) move them to an appropriate clinical
from CYs 2004 and 2005 demonstrate Since CY 2002, home INR monitoring APC consistent with the clinical and
that the resources associated with a services have been described by two G- resource cost characteristics of
capsule-based pH monitoring procedure codes, specifically G0248 and G0249, providing these services. This
are significantly greater than those and have been assigned to New technology is used in monitoring the
required for a catheter-based pH Technology APCs. These codes were adequacy of anticoagulation in patients
monitoring procedure, leading to their created effective July 2002 in the taking warfarin to prevent major
inappropriate assignments to the same context of a National Coverage thromboembolic events. The presenter
clinical APC. Based on our CY 2005 Determination (NCD) that covers home indicated that providers have been slow
claims data, the median costs for each INR monitoring for patients with to adopt the technology because they
procedure are relatively comparable: mechanical heart valves on warfarin must purchase the monitors and
$260 for CPT code 91034 (based on that have been anticoagulated for at materials. The presenter requested that
2,982 single claims) and $300 for CPT least 3 months, who undergo an the codes remain in New Technology
code 91035 (based on 1,160 single educational program on anticoagulation APCs or be reassigned to clinical APCs
claims). We believe that both management and use of the device prior that appropriately make payments for
procedures are fairly similar in terms of to its use in the home, and who perform the costs of providing the services, so
device cost, clinical staff time, and other self-testing no more than once a week. that use of this technology increases and
facility resources required for The G-codes have been assigned to New more data can be collected. The Panel
performing the procedures. We note that Technology APCs for 5 years. Generally, agreed that providing payment at an
the median cost for CPT code 91035 was codes remain in New Technology APCs appropriate rate would encourage more
based upon 1,160 single claims out of until we can determine an appropriate use of home INR monitoring, which
4,777 total claims for the procedure. clinical APC, based on the median cost would actively engage patients in their
While we understand that capsule-based and clinical characteristics of the own care. The Panel recommended that
pH monitoring is often initiated in services described by the code. This we assign G0248 and G0249 to APC
association with an endoscopy usually ranges from approximately 2 to 0421 (Prolonged Physiologic
procedure, we have no reason to believe 3 years. Monitoring) for CY 2007.
that our median cost from single claims In CY 2002, G0248 and G0249 were Comment: One commenter expressed
calculated according to our standard assigned to a New Technology APC with concern regarding our proposal to move
OPPS methodology understates the cost a payment rate of $75. In CY 2003, these home INR monitoring from New
of the procedure. Indeed, we would codes were reassigned to a New Technology APC 1503 (New
expect that the resources could be less Technology APC with a payment rate of Technology—Level III ($100–$200)) to
if the service were performed in $150, and they have remained there clinical APC 0604. The commenter was
association with another surgical since that time. particularly concerned that the
procedure because of efficiencies, Our analysis of hospital data for proposed clinical APC 0604, which has
although there would be no payment Medicare single and multiple claims a payment rate of $49.75, would not
reduction because APC 0361 has a submitted from CY 2002 through CY compensate for the costs incurred in
status indicator of ‘‘X.’’ 2005 indicates that these procedures are delivering this service. While the
With respect to designation of the rarely performed by hospital outpatient commenter understood the reason for
procedure as device-dependent, we facilities. For claims submitted from CY assigning these codes to a clinical APC
typically have only designated APCs as 2002 through CY 2005, our single claims because these codes have been assigned
device-dependent in the context of data show that there were zero claims to a New Technology APC since July
historical payment adjustments submitted during CYs 2002, 2003, and 2002 (these codes were made effective
provided for these APCs. Many device- 2004, and in CY 2005, only nine single in July 2002 and announced through the
intensive procedures appropriately claims for G0248 and only seven for OPPS July 2002 update, specifically
reside in clinical APCs along with G0249 are available for ratesetting. Transmittal A–02–050, dated June 17,
procedures that do not require Looking at total claims, from 2002 2002), the commenter stated that the
expensive devices. Currently device through 2004, we had fewer than 20 technology is fairly new with only a
HCPCS codes are only established when claims for each of the specific services. small number of hospital claims, which
new pass-through device categories are In addition, the median costs for these could therefore warrant its continued
approved. Therefore, we will not create codes are $95 for G0248 and $128 for assignment to the current New
a new device code to track charges for G0249 based on CY 2005 claims. Technology APC 1503. The commenter
this particular device that has not had Because we received no single claims also indicated that the assignments of
pass-through status. We expect that between CY 2002 and CY 2004 for these HCPCS codes G0248 and G0249 to
hospitals will include their charges for codes, we have no prior median cost clinical APC 0604 were neither
the cost of the capsule either in the line- data. economically nor clinically coherent
item charge for the pH monitoring In the CY 2007 OPPS proposed rule because none of the other procedures
procedure or under a separate revenue (71 FR 49556), we proposed to assign also proposed for assignment to APC
code line on their claims. both G0248 and G0249 to clinical APC 0604 involved the furnishing of
Because we believe that the median 0604 (Level I Clinic Visits), with a equipment and supplies to patients for
cost of APC 0361 appropriately proposed median cost of $49.93. We use in their homes or involved care
represents the costs and resources believe these assignments were extended over a 4-week period.
involved in performing both capsule- appropriate based on both clinical and Therefore, the commenter urged CMS to
based and catheter-based pH monitoring resource considerations, in the context maintain home INR monitoring services
in New Technology APC 1503 with a product and the administration of the tositumomab, which would not then
payment rate of $150 for at least one product itself since the WAC for the receive separate payment. Rather, we
more year. Alternatively, the commenter tositumomab product was will continue to make separate payment
requested that CMS assign these codes approximately $2,189. They requested for the administration of tositumomab
to clinical APC 0421, which had a that CMS maintain the current payment through G3001, and payment for the
proposed payment rate of $101.47, rate for G3001 of $2,250 for CY 2007. supply of unlabeled tositumomab is
because the reimbursement rate more Furthermore, one commenter packaged into the administration
closely corresponded with the costs of recommended that HCPCS code G3001, payment.
providing the services, and also with the currently applicable to both doses of the Based on our CY 2005 claims data
clinical characteristics of the other non-radioactive component of therapy that show a final median cost of $1,367
procedure already assigned to this same and its administration, be amended to for APC 0442, which contains only the
APC. apply only to the unlabeled service described by G3001, we had 148
Response: As we indicated above, the tositumomab product. The commenter single claims for the service. The
APC Panel also recommended that these urged CMS to assign a specific code that median cost of G3001 from CY 2004
two HCPS codes be assigned to APC describes the unlabeled tositumomab to claims is $1,210 based on 69 single
0421 for CY 2007. We agree with both enable appropriate payment for the claims. We expect the annual volume of
the commenter and the APC Panel’s product. The commenter added that this service to Medicare beneficiaries to
recommendation to assign these codes unlabeled tositumomab alone is only remain modest. By CY 2007, G3001
to APC 0421. FDA approved as part of the overall service will have been assigned to a
Therefore, we are finalizing our BEXXAR therapeutic regimen, and New Technology APC for 3 years,
proposed movement of HCPCS codes therefore cannot be used other than as providing two full years of claims data
G0248 and G0249 from New Technology part of BEXXAR therapy. The for our analysis. We believe that the
APC 1503 to a clinical APC for CY 2007 commenter also recommended CMS final CY 2007 median cost of APC 0442
with modification. Effective January 1, permit hospitals to use a CPT code for accurately reflects the hospital resources
2007, HCPCS codes G0248 and G0249 the 1-hour administration of the required to perform the administration
will be assigned to APC 0421, with a nonradioactive component of BEXXAR. and supply of tositumomab service, and
final median cost of $99.43. Response: We first established G3001 that our data are sufficient at this point
in CY 2003. As we stated in the CY 2004 to support movement of G3001 out of a
(9) Tositumomab Administration and OPPS final rule with comment period New Technology APC and into an
Supply (APC 0442) (68 FR 63443), unlabeled tositumomab appropriate clinical APC for CY 2007.
For CY 2007, we proposed to assign is not approved as either a drug or a Consequently, we are finalizing the
HCPCS code G3001 (Administration and radiopharmaceutical, but it is a supply proposed CY 2007 reassignment of
supply of tositumomab, 450 mg) from that is required as part of the BEXXAR HCPCS code G3001 from New
New Technology APC 1522 (New treatment regimen. We do not make Technology APC 1522 to clinical APC
Technology—Level XXII ($2000–$2500)) separate payment for supplies used in 0442, without modification.
to clinical APC 0442 (Dosimetric Drug services provided under the OPPS.
Administration), which had a proposed Payments for necessary supplies are (10) Summary of Other New Technology
median cost of $1,515.80. packaged into payments for the Procedures Assigned to Clinical APCs
Comment: Several commenters, separately payable services provided by for CY 2007
including a pharmaceutical company, the hospital. Administration of After carefully considering all of the
expressed concern with the CMS unlabeled tositumomab is a complete public comments received, we are
proposal to assign HCPCS code G3001 service that qualifies for separate adopting our proposal to reassign the
from New Technology APC 1522 with a payment under its own APC. This new technology procedures to clinically
payment rate of $2,250 to clinical APC complete service is currently described appropriate APCs with modification to
0442. The commenters were concerned by HCPCS code G3001. Therefore, we the final APC assignments for CPT
that the payment rate of $1,510.52 that do not agree with the commenter’s codes 19296, 19297, 20982, 36566, and
was proposed for APC 0442 would not recommendation that we assign a 78804 as shown in Table 10 below.
adequately cover both the cost of the separate code to the supply of unlabeled BILLING CODE 4120–01–P
BILLING CODE 4120–01–C angiography (CTA) procedures to ensure OPPS proposed rule (71 FR 49567), over
D. APC-Specific Policies that their payment rates are the past 7 months, we have conducted
comparatively consistent and that they additional studies of our hospital claims
1. Radiology Procedures accurately reflect resource use. data for single and multiple diagnostic
a. Radiology Procedures (APCs 0333, • Recommended that CMS invite imaging procedures, and our analyses
0662, and Other Imaging APCs) comments on ways that hospitals can support continued deferral for CY 2007
uniformly and consistently report of implementation of a multiple imaging
At its March 2006 meeting, the APC
charges and costs related to radiology procedure payment reduction policy in
Panel made three recommendations
services. the OPPS. Therefore, we accepted the
regarding radiology services. These
APC Panel’s recommendation to not
included the following: In the CY 2006 OPPS final rule with adopt such a policy for CY 2007
• Reaffirmed the CY 2005 comment period (70 FR 68707), we pending the results of further analyses.
recommendation that CMS postpone indicated that, based on the APC Panel’s Depending upon the findings from such
implementation of the multiple recommendations and public comments studies, in a future rulemaking we may
procedure reduction policy for imaging received, we decided not to finalize our propose revisions to the structure of our
services as included in the CY 2006 CY 2006 proposal to reduce OPPS rates to further refine these rates in the
OPPS proposed rule for CY 2007, to payments for some second and context of additional study findings.
allow CMS to gather more data on the subsequent diagnostic imaging
efficiencies associated with multiple procedures performed in the same We received numerous public
imaging procedures that may already be session. Our analyses did not disprove comments concerning our proposal. A
reflected in the OPPS payment rates for the commenters’ contentions that there summary of the comments and
imaging services. are efficiencies already reflected in their responses follow:
• Recommended that CMS review hospital costs, and, therefore, in their Comment: Numerous commenters
payment rates for computed tomography CCRs and the median costs for the supported the CMS proposal to defer
ER24NO06.015</GPH>
(CT) and computed tomographic procedures. As noted in the CY 2007 implementing a multiple imaging
procedure payment reduction policy in case for the past several years, the 0282 (Miscellaneous Computerized
the OPPS for CY 2007. A number of proposed median costs associated with Axial Tomography), which had a
commenters reiterated that CMS should these two APCs were virtually identical proposed payment rate of $95.72.
never implement such a policy in the to one another and were also quite Alternatively, the commenters suggested
OPPS, based on the inherent consistent with their historical costs that CMS reassign the CTA procedures
characteristics of the standard from prior years of claims data. The CY from APC 0662 to an existing APC that
methodology that is used to establish 2007 proposed median costs for APCs more closely reflected the resource costs
OPPS payment rates that already 0333 and 0662 were based on about of performing the procedures.
captures the efficiencies of these 500,000 and 150,000 single claims, Response: While we acknowledge the
multiple services in the CCRs used to respectively. The stability of these APC commenters’ concerns, we believe that
convert charges to costs on hospital median costs, based on large numbers of our claims data accurately reflect the
claims. They argued that such single claims, was consistent with our resource costs associated with providing
discounting is not needed and belief that the median costs of these the CTA services. As we stated in the
unwarranted, because discounting has APCs accurately reflected hospitals’ November 15, 2004 final rule with
already been considered in setting the resource use. From CY 2004 to CY 2005, comment period (69 FR 65722) and
APC weights. the number of CTA procedures further reiterated in the November 10,
Response: We continue to be performed in the outpatient department 2005 final rule with comment period (70
concerned about making appropriate increased by 50 percent, whereas the FR 68597), accurate cost information
payments for imaging services in the number of CT procedures that included about the costs of image reconstruction
common circumstances where multiple a scan without contrast followed by a for CTA specifically, and for CT alone
procedures using the same imaging scan with contrast to complete each full as utilized with CTA, would be required
modality are provided in the same study increased by only about 1 percent. in order to implement one commenter’s
encounter. We will continue to study The large annual increases in the OPPS suggestion that we make the payment
our single and multiple outpatient frequencies of CTA procedures through rate for CTA (APC 0662) equal to the
hospital claims for diagnostic imaging CY 2005 provided no evidence that sum of the rates for CT alone (APC
procedures and consider refinements to Medicare beneficiaries were 0333) plus image reconstruction (APC
our payment rates for these services if experiencing difficulty accessing these 0282). However, such cost information
results from the analyses suggest that services in the hospital outpatient is still not available.
changes to our payment policies would setting. CTA procedures were being We have had several years of robust
provide more accurate payments for more commonly performed for various claims data for CTA procedures, whose
these services. clinical indications, likely resulting in code descriptors by definition include
After carefully considering the public more consistent and efficient use of the the required CT scans and image
comments received, we are adopting our associated image postprocessing postprocessing, and have no reason to
proposal to defer implementation of a technology. Accordingly, it is not doubt these data. Based on the full year
multiple imaging procedure payment surprising that the hospital costs of of CY 2005 data, we note that the
reduction for CY 2007, without typical CTA procedures in median cost of $295.80 for APC 0333
modification. contemporary medical practice were (CT) is almost equal to the median cost
As indicated in the CY 2007 OPPS very similar to the hospital costs of the of $296.70 for APC 0662 (CTA).
proposed rule (71 FR 49568), we also more involved and resource-intensive Moreover, for specific reasons cited in
accepted the APC Panel’s complex CT services that, like CTA the CY 2006 OPPS final rule (70 FR
recommendation to review the CY 2007 procedures, included scans without 68599), we are not reassigning the CTA
proposed payment rates for CT and CTA contrast material, followed by scans procedures to any other clinical APC(s)
procedures to ensure that their rates with contrast. Thus, we indicated in the for CY 2007. We believe that APC 0662
were comparatively consistent and CY 2007 proposed rule that we believed is quite homogeneous and see no other
accurately reflective of hospitals’ that our CY 2007 proposed payment clinical APC where these services could
resource costs. Presenters at the March rates for CT and CTA procedures were be appropriately assigned based on
2006 APC Panel meeting indicated to generally consistent with one another clinical and resource considerations. We
the Panel that hospital resources for and accurately reflective of hospitals’ will apply the same standard OPPS
CTA procedures were similar to those resource costs. ratesetting methodology for CY 2007
for CT procedures that included scans We received several comments that we used for CY 2006 in establishing
without contrast followed by scans with concerning our proposal. A summary of the payment rate for CTA procedures
contrast, but additional resources were the comments and our responses residing in APC 0662.
required for the 3-dimensional follows: After carefully considering the public
reconstruction that was part of the CTA Comment: Several comments on our comments received, we are finalizing
procedures. As a result of this image proposed payment rate of $302.85 for our proposal for payment of APCs 0333
postprocessing, CTA scans displayed the CTA procedures placed in APC 0662 and 0662 based on their median costs
the vasculature in a 3-dimensional (CT Angiography) indicated that the established according to the standard
format rather than in the 2-dimensional CTA procedures were reimbursed at a OPPS methodology, without
cross-sectional images of conventional lower rate than conventional CT modification.
CT scans. As indicated in our CY 2007 procedures, although the utilization With respect to the APC Panel’s
proposed rule (71 FR 49568), based costs of CTA exceeded conventional CT. recommendation regarding the reporting
upon CY 2005 claims data, the CY 2007 The commenters urged CMS to set the of costs and charges for radiology
proposed median cost for APC 0333 for payment for APC 0662 at a rate equal to services, as we noted in the proposed
CT procedures that included scans the sum of APC 0333 (Computerized rule, CMS requires hospitals to report
without contrast material, followed by Axial Tomography and Computerized their costs and charges through the cost
contrast scans to complete the studies Angiography without Contrast followed report with sufficient specificity to
was $309, and the CY 2007 proposed by Contrast), which had a proposed support CMS’ use of cost report data for
median cost for APC 0662 for CTA payment rate of $307.88, and the monitoring and payment. Within
procedures was $304. As has been the postprocessing APC, specifically, APC generally accepted principles of cost
accounting, we allow providers hospitals can uniformly and on refining the OPPS payment system to
flexibility to accommodate the unique consistently report charges and costs pay more accurately for outpatient
attributes of each institution’s related to all cost centers, not just hospital services.
accounting systems. For example, radiology, that also acknowledge the For CY 2007, we did not propose to
providers must match the generally ubiquitous tradeoff between greater make any changes from CY 2006 in our
intended meaning of the line-item cost precision in developing CCRs and proposed APC assignments of CT,
centers, both standard and nonstandard, administrative burden associated with magnetic resonance imaging (MRI), and
to the unique configuration of reduced flexibility in hospital magnetic resonance angiography (MRA)
department and service categories used accounting practices. services, preserving the longstanding
by each hospital’s accounting system. We received a number of public APC groupings of these services. In
Also, while the cost report provides comments concerning this APC Panel particular, CT services were assigned to
recommended bases of allocation for the recommendation. A summary of the APCs 0332 (Computed Tomography
general services cost centers, a provider comments and our responses follows: without Contrast), 0283 (Computed
is permitted, within specified Comment: Several commenters agreed Tomography with Contrast Material),
guidelines, to use an alternative basis that any steps taken to ensure greater and 0333 (Computed Tomography
for a general service cost if it can justify uniformity in the reporting of costs and without contrast followed by Contrast)
to its fiscal intermediary that the charges would have to carefully balance based upon their nature as studies
alternative is more accurate than the the additional administrative burden without contrast, with contrast, and
recommended basis. This approach and loss of flexibility in hospitals’ without contrast followed by contrast,
creates internal consistency between a accounting practices. They noted that respectively. MRI and MRA procedures
hospital’s accounting system and the the difficulty in applying CCRs to arrive were assigned to APCs 0336 (Magnetic
cost report, but cannot guarantee the at hospital costs is that this requires Resonance Imaging and Magnetic
precise comparability of costs and assumptions of consistency in the Resonance Angiography without
charges for individual cost centers relationship of HCPCS codes and Contrast), 0284 (Magnetic Resonance
across institutions. revenue codes to revenue center service Imaging and Magnetic Resonance
However, in the CY 2007 proposed categories on the cost report. However, Angiography with Contrast), and 0337
rule, we indicated that we believed that the cost report recognizes service (Magnetic Resonance Imaging and
achieving greater uniformity by, for categories that reflect the general Magnetic Resonance Angiography
example, specifying the exact descriptions of a hospital’s service without Contrast followed by Contrast)
components of individual cost centers, categories, but services that were at one based upon their characteristics as
would be very burdensome for hospitals time performed in a specific department studies without contrast, with contrast,
and auditors. Hospitals would need to of the hospital may now be performed and without contrast followed by
tailor their internal accounting systems in many departments of hospitals. The contrast, respectively.
to reflect a national definition of a cost commenters noted that inconsistencies Comment: One commenter requested
center. It was not clear that the marginal occur when determining the cost of a that CMS revise the established CT,
improvement in precision created by service if the CCR utilized in the MRI, and MRA APC groupings to create
such a requirement would justify the calculation is from a different cost greater internal clinical and resource
additional administrative burden. We report service category than where the consistency. The commenter believed
believed that the current hospital service was actually performed. The that diagnostic services performed in
practice of matching costs to the general commenters also urged CMS to the same anatomical region have similar
intended meaning of a cost center recognize the limitations and resource utilization and should,
ensures that most services in the cost inconsistencies in the preparation of therefore, be assigned to the same APC
center would be comparable across hospital cost reports, attributable to both grouping. The commenter
providers, even if the precise hospital and fiscal intermediary recommended that CMS differentiate
composition of a cost center among behavior. They urged CMS to proceed among these services based on two body
hospitals differed. Further, every with care in instructing hospitals regions, the core (including the head,
hospital provides a different mix of because hospitals need the flexibility to neck, thorax, spine, chest, abdomen,
services. Even if CMS specified the set charges and allocate costs in a and pelvis) and the extremities
components of each cost center, costs manner that makes the most sense for (including the orbit/ear/fossa,
and charges on the cost report would the particular hospital based on the mix maxillofacial region, upper extremity,
continue to reflect each individual of services it provides. The commenters and lower extremity). The commenter
hospital’s mix of services. At the same noted that even small changes in argued that because the OPPS was being
time, internal consistency is very practice and procedures require used as the benchmark established by
important to the OPPS. Costs are significant systems changes, and that the DRA to limit payment for imaging
estimated on claims by matching CCRs CMS should allow time for services under the MPFS, this
for a given hospital to their own claims dissemination of any such changes, refinement would assist in ensuring
data through a cost center-to-revenue coupled with significant provider even greater resource similarity of
code crosswalk. OPPS relative weights education. procedures within imaging APCs to
are based on the median cost for all Response: We appreciate the establish more accurate payment rates
services in an APC. The components commenters’ observations. We will under both the OPPS and the MPFS.
resulting in CCRs for a given revenue continue to reflect on the delicate Response: We examined the current
code would have to be dramatically balance between greater accuracy in APC structure for CT, MRI, and MRA
different for the providers contributing developing CCRs to convert charges to services and observed that there were no
the majority of claims used to calculate costs under the OPPS and the needs of violations of the 2 times rule in any of
an APC’s median cost in order to impact hospitals for flexibility in their the APCs. The median costs of the
relative weights. accounting practices. services assigned to each APC were
We accepted the APC Panel’s After carefully considering the public relatively close, and we did not identify
recommendation and specifically comments received, we will continue to any code-specific patterns of
invited comments on ways that seek input on this balance as we work significantly increased or decreased
costs based on the specific anatomical to APC 0417 (Computerized payment rates over the last several
region of the body imaged. We believe Reconstruction) for CY 2007, with a years, the number of total procedures
these APCs as currently structured proposed median cost of $192.34. This billed under the OPPS for HCPCS code
contain services that are quite was the same APC assignment as CY G0288 has risen steadily from 2,065 in
homogeneous with respect to their 2006, and this service is the only service CY 2002, to 4,733 in CY 2003, to 8,421
clinical and resource characteristics. assigned to the APC. in CY 2004, and most recently to 9,395
The OPPS provides payments for APC Comment: One commenter strongly in CY 2005. We have no evidence that
groups of closely related procedures, opposed the proposed payment amount Medicare beneficiaries are having
and the current imaging groups provide for CY 2007 for HCPCS code G0288. The trouble accessing this service based on
appropriate payments for these services commenter stated that the OPPS our hospital claims information. We
in a manner that is consistent with the proposed payment amount was not believe that it is appropriate for us to
payment policies of the OPPS. nearly enough to cover the hospital’s use our historical hospital cost data as
Accordingly, we see no reason to further costs for providing this important the basis for the CY 2007 payment
distinguish CT, MRI, and MRA service. The commenter believed that amount. Therefore, we are finalizing our
procedures into even smaller, more implementation of the proposed CY 2007 payment rate for APC 0417
refined groupings. We also do not payment would jeopardize the quality of based on a median cost of $197.95.
believe it would be appropriate to adjust the HCPCS code G0288 procedures that
c. Cardiac Computed Tomography and
these APC groups in order to affect the are performed, limit beneficiary access
Computed Tomographic Angiography
payments for CT, MRI, and MRA to the services, and result in
(APCs 0282, 0376, 0377, and 0398)
procedures under the MPFS. postoperative complications due to
After carefully considering the public implantation of poorly fitting stents. In Addendum B of the CY 2007
comment received, we are finalizing our Response: The payment amount proposed rule (71 FR 49832), we
CY 2007 proposal for payment of CT, proposed for the APC 0417, to which proposed to assign the eight cardiac
MRI, and MRA procedures, without HCPCS code G0288 is the only service computed tomography (CCT) and
modification. b. Computerized assigned, is based on the median cost computed tomographic angiography
Reconstruction (APC 0417) from 6,028 single claims for this one (CCTA) Category III CPT codes to the
We proposed to assign HCPCS code service. We are confident that these data APCs as shown in Table 11 below.
G0288 (Reconstruction, computed provide an accurate representation of These services were new for CY 2006,
tomographic angiography of aorta for hospital costs for providing the service. and we did not propose any changes to
surgical planning for vascular surgery) We note that despite reductions in their APC assignments for CY 2007.
TABLE 11.—PROPOSED CY 2007 APC ASSIGNMENTS FOR CCT AND CCTA CATEGORY III CPT CODES
Proposed CY
Proposed CY 2007 APC as-
CPT code Descriptor 2007 APC assignment pay-
signment ment rate
0144T ............................................... CT heart wo dye; qual calc ....................................................................... 0398 $261.66

0145T ............................................... CT heart w/wo dye funct ........................................................................... 0376 306.34
0146T ............................................... CCTA w/wo dye ........................................................................................ 0376 306.64
0147T ............................................... CCTA w/wo, quan calcium ........................................................................ 0376 306.34
0148T ............................................... CCTA w/wo, strxr ...................................................................................... 0377 415.12
0149T ............................................... CCTA w/wo, strxr quan calcium ................................................................ 0377 415.12
0150T ............................................... CCTA w/wo, disease strxr ......................................................................... 0398 261.66
0151T ............................................... CT heart funct add-on ............................................................................... 0282 95.72
Comment: Several commenters 2006. We received no public comments APC. In other cases, we may assign a
requested that CMS remove the APC on their interim final APC assignments Category III CPT code to one of several
assignments for the eight CCT and published in Addendum B of the CY nonseparately payable status indicators,
CCTA procedures because these codes 2006 OPPS final rule with comment including ‘‘N,’’ ‘‘C,’’ ‘‘B,’’ or ‘‘E,’’ which
fall within the Category III CPT code period. As we indicated in our CY 2007 we believe is appropriate for the specific
section, and because they are carrier- OPPS proposed rule (71 FR 49549), code. We believe that CCT and CCTA
priced and not assigned any relative some Category III CPT codes describe procedures are appropriate for separate
value units under the MPFS. The services that we have determined to be payment under the OPPS should local
commenters believed that the Deficit similar in clinical characteristics and contractors provide coverage for these
Reduction Act MPFS provisions should procedures, and, therefore, they warrant
resource use to HCPCS codes in an
not apply to these procedures. status indicator and APC assignments
Response: As we stated in a section existing APC. In these instances, we
that would provide separate payment
III.A.2. of this CY 2007 OPPS final rule may assign the Category III CPT code to under the OPPS. MPFS concerns
with comment period, we implement the appropriate clinical APC. Other regarding payment limitations for these
Category III codes that are released by Category III CPT codes describe services procedures are outside the scope of this
the AMA in July of a given year for that we have determined are not final rule with comment period.
implementation in January of the next compatible with an existing clinical Comment: Many commenters
year by providing them with new APC, yet are appropriately provided in expressed their appreciation of our
interim assignments in the OPPS final the hospital outpatient setting. In these recognition of the CPT codes as
rule for the next update year. These CCT cases, we may assign the Category III separately payable services under the
and CCTA codes were released in July CPT code to what we estimate is an OPPS; however, they believed that the
2005 for implementation in January appropriately priced New Technology CCTA Category III CPT codes (0144T
through 0151T) should be moved from assign CPT codes 0144T through 0151T tomography (PET), perfusion; single
APCs 0282, 0376, 0377, and 0398, to to APCs 0282, 0376, 0377, and 0398, all study at rest or stress) under the OPPS.
appropriate New Technology APCs so with status indicator ‘‘S.’’ Public comments on the CY 2006 OPPS
that adequate hospital claims data could proposed rule suggested that the HCPCS
d. Radiologic Evaluation of Central
be gathered. They provided specific codes describing multiple myocardial
Venous Access Device (APC 0340)
recommendations for the New PET scans should be assigned to a
Technology APC assignments of these For CY 2006, new CPT code 36598 separate APC from single study codes
services. These same commenters added (Contrast injection(s) for radiologic because their hospital resource costs are
that once CMS has acquired adequate evaluation of existing central venous significantly higher than single scans.
claims data, pricing information could access device, including fluoroscopic Review of the CY 2004 claims data for
be used to separate and incorporate the guidance) was assigned to APC 0340 myocardial PET scans revealed a
various Category III CCTA CPT codes (Minor Ancillary Procedures) on an median cost of $2,482 for the 9 G-codes
into clinical APCs. Some commenters interim final basis. The proposed that describe multiple myocardial PET
were also concerned that CCT and assignment of the code for CY 2007 was scans, based upon 978 single claims of
CCTA procedures were not clinically unchanged. 2,001 total claims for multiple scan
homogeneous with other procedures Comment: One commenter requested procedures. The CY 2004 claims data
currently assigned to APCs 0282, 0376, that CMS assign new CPT code 36598 to showed a median cost of $800 for the 6
0377, and 0398, noting that the last APC 0263 (Level I Miscellaneous G-codes describing single PET studies,
three APCs previously contained only Radiology Procedures) for CY 2007. The based on 391 single claims of 575 total
nuclear medicine cardiac imaging commenter stated that the procedure claims. A review of CY 2003 claims data
procedures. reported by CPT code 36598 is very showed a similar pattern of significantly
Response: We appreciate the similar to that which is coded using higher hospital costs for multiple
suggestions submitted by the CPT code 76080 (Radiologic myocardial PET studies in comparison
commenters. However, as we indicated examination, abscess, fistula or sinus with single studies, although there were
above, some of the new Category III CPT tract study, radiological supervision and fewer claims for the procedures in CY
codes describe services that we have interpretation), which is assigned to 2003 in comparison with CY 2004. In
determined to be similar in clinical APC 0263 for CY 2006. Further, the response to the comments received and
characteristics and resource use to commenter stated that the use of based on this claims information,
HCPCS codes in an existing APC. In contrast and fluoroscopy makes CPT myocardial PET services were assigned
these instances, we may assign the code 36598 more resource intensive to two clinical APCs for the CY 2006
Category III CPT code to the appropriate than the other procedures assigned to OPPS. HCPCS codes for single scans
clinical APC. In the case of these eight APC 0340, where CMS assigned it with were assigned to APC 0306 with a
CCT and CCTA procedures, we believe an interim final status for CY 2006. payment rate of $800.55, and HCPCS
that their clinical characteristics and Response: We will not have data upon codes for the multiple scan procedures
resource use are similar to the other which to base our decisions about the were assigned to APC 0307 (Myocardial
procedures assigned to APCs 0282, APC assignment for this procedure until Positron Emission Tomography (PET)
0376, 0377, and 0398. We have not next year. However, based on our data Imaging) with a payment rate of
limited APCs 0376, 0377, and 0398 for many procedures that we believe are $2,484.88.
solely to nuclear medicine cardiac similar to that coded by CPT code
imaging services. We believe that Analysis of the CY 2005 claims data
36598, we believe that assignment to for myocardial PET scans for the CY
cardiac imaging services using different APC 0340 is appropriate and do not
modalities may be appropriate for 2007 proposed rule revealed that the
believe that it is appropriate to reassign APC median costs for the single and
assignment to the same clinical APCs, it to another APC at this time.
based on their clinical and resource multiple myocardial PET codes were
We are maintaining the assignment of $836 and $680 respectively, based on
characteristics. The OPPS is a CPT code 36598 to APC 0340 for CY
prospective payment system that 296 single claims for single studies and
2007 and will reevaluate that 1,150 single claims for multiple scan
provides payment for services based on assignment when data become available.
their assignment to APC groups, and, as procedures. Despite more CY 2005
such, we think the proposed APC 2. Nuclear Medicine and Radiation single claims for multiple scan
assignments for these CCT and CCTA Oncology Procedures procedures, the median cost of these
services, which are the same as their CY procedures declined significantly from
a. Myocardial Positron Emission CY 2004 to CY 2005, dropping below
2006 interim final assignments, are Tomography (PET) Scans (APC 0307)
appropriate. While we understand that the median cost of single studies. As
use of CCT and CCTA to image the heart From August 2000 to December 31, indicated earlier, there was a significant
are relatively new applications of 2005, under the OPPS we assigned to coding change for myocardial PET
specifically refined technology, cardiac one clinical APC all myocardial services in CY 2005, with the reporting
imaging using other modalities is positron emission tomography (PET) of a single CPT code for multiple studies
already well-established, as is the scan procedures, which were reported (CPT code 78492), in comparison with
noncardiac use of CT and CTA. with multiple G-codes through March nine G-codes in CY 2004. We examined
Therefore, for CY 2007, we are 31, 2005. Effective April 1, 2005, the single bills for multiple scan
continuing with our proposal to assign myocardial PET scans were reported procedures from CY 2004 and noted 17
Category III CPT codes 0144T through with three CPT codes, specifically CPT hospitals were represented, with the
0151T to clinical APCs 0282, 0376, codes 78492 (Myocardial imaging, majority of those claims from a single
0377, and 0398. We expect to have positron emission tomography (PET), hospital. In contrast, in the CY 2005
claims data for these procedures perfusion; multiple studies at rest and/ claims, 25 hospitals were represented in
available for the CY 2008 OPPS update. or stress), 78459 (Myocardial imaging, the single bills for multiple scan
After carefully considering the public positron emission tomography (PET), procedures, and no single hospital
comments received, we are finalizing metabolic evaluation), and 78491 contributed a majority of claims to the
our proposal without modification to (Myocardial imaging, positron emission median cost calculation. We also
examined differences in charges services was about $727, very similar to based on whether they are single or
associated with G-codes versus the CPT the $703 median cost of their single CY multiple.
code to determine if hospitals had 2005 clinical APC. Therefore, for CY The commenters recommended that
adjusted the charge for the CPT code to 2007, we proposed to assign CPT codes CMS retain the multiple scan
reflect the termination of the multiple 78459, 78491, and 78492 to a single procedures in a separate APC as in CY
study G-codes. However, the individual APC, specifically, APC 0307. We 2006, and that the payment rate
charging practices of hospitals did not believed that the assignment of these decrease be dampened to mitigate the
appear to vary with the use of a G-code three CPT codes to APC 0307 was potential for underpayment, as we have
versus the CPT code in either the CY appropriate, as the CY 2005 claims data in the past for device-dependent and
2004 or the CY 2005 claims. Greater revealed that more hospitals were blood product APCs. One commenter
volume of claims and consistent providing multiple myocardial PET scan suggested that CMS dampen payment
charging for both the G-codes and CPT services, most myocardial PET scans for the multiple scans APC by 15
code by hospitals suggested that the were multiple studies, and the hospital percent each year for the next 2 to 3
median appropriately captured the resource costs of single and multiple years to moderate the large payment
greater variability in relative hospital studies were similar. We believed that decrease for the multiple myocardial
costs for multiple myocardial PET the proposed median cost appropriately PET scans.
studies in the CY 2005 claims data. reflected the hospital resources Response: We understand the
Based on these claims data, we associated with providing myocardial commenters’ objections to the median
believe that it is apparent that the use PET scans to Medicare beneficiaries in cost for the multiple myocardial PET
of myocardial PET scan technology had cost-efficient settings. Further, we scans, but see no reason to modify our
become more widely prevalent in believed that the proposed rates were proposal to assign them to the same
hospitals, and as a result, we had more adequate to ensure appropriate access to APC with the single scans. We do not
data to support our proposed payment these services for Medicare believe that our data are erroneous.
rates. We believed that the median costs beneficiaries. We specifically invited Myocardial PET scans are not new
from our CY 2005 claims data for comments on our proposal to provide a procedures and the data across years,
myocardial PET scan services, single payment rate for all myocardial except for the CY 2004 claims data, have
calculated based upon our standard PET scans in CY 2007. The myocardial been relatively consistent with regard to
OPPS methodology and based on almost PET scan CPT codes and their CY 2007 median costs, while the frequency of
1,600 single claims, for both the single proposed APC assignments were multiple scans has been growing
and multiple scans, were reflective of displayed in Table 17 of the CY 2007 consistently. As described above, we
the hospital resources required to OPPS proposed rule (71 FR 49567). explored many aspects of the CY 2005
provide the services to Medicare claims data in an attempt to explain the
Comment: A number of commenters decreased costs reported for the
beneficiaries in the outpatient hospital
requested that CMS not finalize our multiple scans and to assure ourselves
setting. Based on those data, we
proposed APC assignments for CPT and the public that the data were
concluded in the CY 2007 proposed rule
codes 78492, 78459, and 78491. The reliable. Our additional investigations
that the differential median costs of the
commenters stated that it is included analyses of claims to
single and multiple study procedures
inappropriate to assign multiple scan determine whether they were submitted
did not support the two-level APC
procedures to the same APC with single by only a few hospitals and whether any
payment structure. Although we
acknowledged that some individuals scan procedures as we proposed, of the hospitals accounted for an
may believe that multiple scan because CPT code 78492 requires more unusually high number of the multiple
procedures should require increased hospital resources than do CPT codes scan claims or for unusually low costs.
resources at some hospitals in 78459 and 78491. The commenters We also examined the claims in an
comparison with single scans, stated that multiple scans require attempt to detect whether there were
particularly because of the longer scan significantly greater hospital resources differences in billing practices for the
times required for multiple studies, we due to much longer scan times, and CPT code compared to the predecessor
noted that our data did not support a believed that our median cost data were G-codes for multiple myocardial PET
resource differential that would seriously flawed. scans. There was no indication that the
necessitate the placement of these single The commenters objected to the data are erroneous in any regard. Claims
and multiple scan procedures into two proposal to assign the multiple scan were submitted by at least 25 hospitals
separate APCs. As myocardial PET procedures to the same APC as the (compared to 17 in the CY 2004 claims
scans are being provided more single scans because they believed the data), and no hospital was responsible
frequently at a greater number of APC assignment creates a 2 times for a disproportionate number of claims
hospitals than in the past, we believed violation for APC 0306; the proposed (in contrast to what was found in the CY
that it was possible that most hospitals payment for the multiple scan 2004 claims) or for unusually low costs.
performing multiple PET scans were procedures decreases by 71 percent No systematic hospital coding
particularly efficient in their delivery of between CYs 2006 and 2007; if payment irregularities were discovered. Further,
higher volumes of these services and, is allowed to decrease to the level the number of single claims for the
therefore, incurred hospital costs that proposed by CMS, beneficiary access to multiple scan procedures increased
were similar to those of single scans, these important diagnostic procedures from 872 in the proposed rule data to
which were provided less commonly. In (CPT code 78492) will be seriously 983 in the final rule data and the
fact, the CPT code for multiple scans restricted; the Medicare program will median cost remained stable, increasing
had a lower median cost than either of have to spend more for diagnostic by only $5.00, still lower than the
the CPT codes for single procedures. procedures such as cardiac median cost for single scans.
When all myocardial PET scan catheterizations if hospitals cannot Our data do not support a resource
procedure codes were combined into a afford to offer the multiple scan differential that warrants assignment of
single clinical APC, as they were prior myocardial PET procedures; and CMS the multiple myocardial scan
to CY 2006, the CY 2007 proposed rule does assign other cardiac nuclear procedures to an APC separate from the
APC median cost for myocardial PET medicine studies to separate APCs single scans. Single and multiple scan
procedures are closely related from a myocardial PET scans, we are To the contrary, with the exception of
clinical perspective, and their hospital maintaining the clinical and resource the CY 2004 claims data, we found that
resources required, as reflected in our use homogeneity in APC 0307, where costs from the CY 2005 claims are
claims data, appear comparable in terms the APC payment will be slightly higher relatively consistent with costs
of cost. The 2 times violation for CY for the multiple scans than it would calculated from claims for myocardial
2007 in APC 0307 results from the have been if we retained the multiple PET scans provided in years before CY
inclusion of limited data from one G- scans in a separate APC. 2004. We believe that our CY 2006 APC
code for multiple scan procedures that Similarly, we do not believe that there assignments for multiple and single
was reported for the first 3 months of is a basis for dampening the payment
myocardial PET scans to separate APCs
CY 2005. The median cost for that G- decrease for a separate multiple
were based on data that were unduly
code is $1,840, based on 129 single myocardial PET scan APC. Although we
have adjusted payment amounts for affected by one hospital’s unusually
claims. However, the code was deleted
in CY 2005, and the median cost for the device-dependent and blood product high charges for multiple scans.
CPT code that replaced it is only $665, APCs in the past, as noted by the Without evidence that the claims data
based on 983 single claims. We utilized commenters, we generally have done so for CPT codes 78459, 78491, and 78492
the data from the predecessor G-code in to moderate the effects on payment are too flawed to use as a basis for
developing the median cost for APC resulting from inaccurate claims data setting weights, we believe it is prudent
0307 (where it would be likely to affect that failed to fully capture the costs to establish the CY 2007 payment rate
the APC median cost by raising it). The associated with the procedures in ways for APC 0307 using the standard OPPS
fact that data from a deleted code are that we could partially identify. In some methodology for developing payment
responsible for the violation leads us to of these situations, we had very few rates.
conclude that the violation is not single claims, contributing to the
significant. Therefore, based on clinical problem of unstable payment rates, but After carefully considering the public
and resource homogeneity, we are myocardial PET scans have significant comments received, we are finalizing
excepting APC 0307 from the 2 times numbers of single claims. We have the APC assignments for the myocardial
rule for CY 2007. examined the claims data thoroughly PET procedures as shown in Table 12
By assigning the multiple and single and found nothing to indicate below without modification.
scans to the same clinical APC for inaccuracy for myocardial PET scans.
TABLE 12.—CY 2007 APC ASSIGNMENT FOR MYOCARDIAL PET

CY 2007
CY 2007 CY 2007 CY 2007 Final APC
HCPCS code Short descriptor SI APC median cost 307 median
cost
78459 ................................... Heart muscle imaging (PET) .......................................... S 0307 $784.42 $726.98
78491 ................................... Heart image (pet), single ............................................... S 0307 1,014.61 726.98
78492 ................................... Heart image (pet), multiple ............................................ S 0307 665.42 726.98
b. Complex Interstitial Radiation Source 77778 have not been stable since the the related service CPT code 55859
Application (APC 0651) inception of the OPPS, and that (Transperitoneal placement of needles
instability has been a source of concern or catheters into the prostate for
APC 0651 (Complex Interstitial to hospitals that furnish the service and application of brachytherapy sources)
Radiation Source Application) contains to specialty societies. The vast majority were displayed in Table 14 of the CY
only one code, CPT code 77778 of claims for interstitial brachytherapy 2007 OPPS proposed rule (71 FR
(Complex interstitial application of are for the treatment of patients with a 49564), and are reproduced below in
brachytherapy sources). The coding, diagnosis of prostate cancer. The Table 13.
APC assignment, median cost, and historical coding, APC assignments, and BILLING CODE 4120–01–P
resulting payment rate for CPT code payment rates for CPT code 77778 and
BILLING CODE 4120–01–C At the March 2006 APC Panel their claims were more likely to report
We have frequently been informed by meeting, presenters urged the Panel to complete charges for the associated
the public that the instability in our recommend that CMS use only single brachytherapy procedure than hospitals
payment rates for APC 0651 creates procedure claims that contained charges that did not report the separately
difficulty in planning and budgeting for for brachytherapy sources on the same payable brachytherapy sources.
hospitals. Moreover, we have been claim with CPT code 77778 to set the The APC Panel recommended that
informed that, in this case, reliance on median cost for APC 0651. Presenters CMS reevaluate the proposed payment
single procedure claims results in use of also urged that CMS adopt a process for for brachytherapy services in APC 0651
only incorrectly coded claims for using multiple procedure claims to set for CY 2007. The APC Panel also
prostate brachytherapy because, for the median for APC 0651 that would recommended that CMS formally work
application to the prostate, which is sum the costs on multiple procedure with the Coalition for the Advancement
estimated to be 85 percent of all claims containing CPT codes 77778 and of Brachytherapy, the American
occurrences of CPT code 77778, a 55859 (and no other separately payable Brachytherapy Society, and the
correctly coded claim is a multiple services not on the bypass list) and, American Society for Therapeutic
procedure claim. Specifically, we have excluding the costs of sources, split the Radiology and Oncology to evaluate the
been advised that a correctly coded resulting aggregate median cost on the methodology for setting brachytherapy
claim for prostate brachytherapy should multiple procedure claim according to a service payment rates in APC 0651.
include, for the same date of service, preestablished attribution ratio between
CPT codes 77778 and 55859. The In response to the APC Panel
both CPT codes 55859 and 77778,
presenters also urged CMS to provide recommendations, we explicitly
brachytherapy sources reported with C-
hospitals with education on correct analyzed the standard OPPS
codes, and typically separately coded
coding of brachytherapy services and methodology that we used in
imaging and radiation therapy planning
services. We have been further advised devices of brachytherapy required to determining our CY 2007 proposed
that, in the cases of complex interstitial perform brachytherapy procedures. payment rate for APC 0651 in the
brachytherapy where sources are placed They indicated that any claim for a context of alternative multiple bill
in sites other than the prostate, the brachytherapy service that did not also methodologies.
charges for both placing the needles or report a brachytherapy source should be The organizations that the APC Panel
catheters and for applying the sources considered to be incorrectly coded and asked us to work with have frequently
may be reported by CPT code 77778 thus not reflective of the hospital’s brought their concerns to our attention
alone because there are no other specific resources required for the interstitial through the rulemaking process and
CPT codes for placement of needles or source application procedure. The otherwise. As stated in the CY 2007
catheters in those sites. In other cases, presenters believed that these claims OPPS proposed rule, we will consider
the placement of needles or catheters should be excluded from use in the input of any individual or
may be reported with not otherwise establishing the median cost for APC organization to the extent allowed by
classified codes specific to the treated 0651. They believed that hospitals that Federal law, including the
ER24NO06.016</GPH>
body area. reported the brachytherapy sources on Administrative Procedure Act (APA)
and the Federal Advisory Committee the 381 single bills upon which the final codes, which have repeatedly appeared
Act (FACA) (71 FR 49564). APC 0651 median cost was calculated as common procedures that are reported
We establish the OPPS rates through for CY 2006. However, only 6 of these on the same claim with CPT codes
regulations. We are required to consider 1,123 single and ‘‘pseudo’’ single claims 55859 and 77778: 76000, 76965, or
the timely comments of interested data used in calculating the proposed 77290. We then calculated median costs
organizations, establish the payment median cost also included for interstitial prostate brachytherapy in
policies for the forthcoming year, and brachytherapy sources used in complex two different ways: (1) Bypassing the
respond to the timely comments of all interstitial brachytherapy source line item charges for these three
public commenters in the final rule in application, and the median cost for ancillary codes; and (2) packaging the
which we establish the payments for the these 6 claims at $600.68 was costs of these three ancillary codes. We
forthcoming year. significantly less than the median cost applied this methodology both (1) to all
For the CY 2007 OPPS proposed rule, for all single claims. It was unclear why claims that met these criteria with and
we developed a median cost for APC so many of these claims did not contain without sources; and (2) to claims that
0651 using single procedure claims and brachytherapy sources, which were met the criteria and also separately
the general OPPS methodology, but we separately paid at cost in CY 2005. reported brachytherapy sources that
also looked at multiple procedure Because we proposed to pay separately would be expected to be reported with
claims that contained the most common
for brachytherapy sources again for CY CPT code 77778. See Tables 15 and 16
combinations of codes used with APC
2007, we saw no reason to believe that published in the CY 2007 OPPS
0651. In the proposed rule, our single
these few claims for brachytherapy proposed rule (71 FR 49565) and shown
procedure claims process using CY 2005
services that included sources, which below as Table 14–A and Table 14–B for
data resulted in using 1,123 claims to
also did not report CPT code 55859 for the results of this investigation.
calculate a proposed median cost of
$1,028.93 for APC 0651. We added CPT placement of needles or catheters into In the proposed rule, we found 10,571
code 76965, a CPT code for ultrasound the prostate, were more correctly coded multiple procedure claims with CPT
guidance that commonly appeared on than those claims that did not separately codes 55859 and 77778 reported on the
claims for complex interstitial report brachytherapy sources. We claim, including those both with and
brachytherapy, to the bypass list for CY believed it was possible that hospitals without separately reported sources. We
2007 after close clinical review because billing CPT code 77778 and not the found that 7,181 of the 10,571 claims in
we believed that it would typically have associated brachytherapy sources may the proposed rule’s data contained any
little associated packaging. We believed have bundled their charges for the combination of the three ancillary codes
that this change, along with brachytherapy sources into their charge (76000, 76965, or 77290). Table 14–A
maintenance of CPT code 77290 for for CPT code 77778. shows the results of bypassing and
complex therapeutic radiology We also identified multiple procedure packaging the line-item costs of the
simulation-aided field setting on the claims that contained both CPT codes three ancillary procedures based on the
bypass list, was responsible for the 55859 and 77778 and also included any data used to construct the proposed
growth in single procedure claims from one or more of the following procedure rule.
TABLE 14–A.—MULTIPLE PROCEDURE CLAIMS INCLUDING CPT CODES 55859 AND 77778 PROPOSED RULE DATA
Minimum Maximum
Frequency Mean cost Median cost
cost cost
Ancillary Codes Packaged ........................ 7180 (1 lost to trimming) .......................... $828.46 $11,202.81 $3,326.50 $3,062.99
Ancillary Codes Bypassed ........................ 7181 .......................................................... 811.95 11,203.81 3,300.16 3,030.01
We found 9,791 multiple procedure brachytherapy sources that would be codes. Table 14-B shows the results of
claims in the proposed rule’s data with used with CPT code 77778. We found bypassing and packaging the line-item
CPT codes 55859 and 77778 reported on that 6,748 of the 9,791 claims contained costs of the three ancillary procedures,
the claim that also included any combination of the three ancillary using the proposed rule’s data.
TABLE 14–B.—MULTIPLE PROCEDURE CLAIMS INCLUDING CPT CODES 55859 AND 77778 AND ONE OR MORE
BRACHYTHERAPY SOURCES—PROPOSED RULE DATA
Minimum Maximum Mean Median
Frequency cost cost cost cost
Ancillary Codes Packaged ....................................................................... 6,748 $890.56 $10,224.17 $3,240.13 $3,026.62

Ancillary Codes Bypassed ....................................................................... 6,748 $912.81 $10,307.37 $3,215.75 $2,992.60
We found that the claims containing with the procedure codes. Moreover, Moreover, when we calculated the
CPT codes 55859 and 77778 and any most of the multiple procedure claims total median cost from single bills for
combination of the three identified we identified contained sources. This the APCs for the two major procedures
ancillary codes had mean and median led us to conclude that the presence of codes from the proposed rule’s data
costs that were very close to one sources on the claim did not make a without regard to the separate payments
another, regardless of whether the significant difference in the median cost that would be made for CPT codes
hospital billed separately for the of the combined service. 76000, 76965, and 77290, the sum of the
brachytherapy sources on the claim CY 2007 proposed medians for APC
0651 and APC 0163 was $3,197.07, median cost for APC 0163 of $2,134.32, proton therapy. In addition, this is the
which was greater than the combination and separate payment for each source second year in which we have exempted
medians, even when the three ancillary applied (section VII. of this preamble), APC 0664 from its violation of the 2
services were packaged into the we believe that the OPPS will make times rule. We also observe that the
combination median. Under our appropriate payment for brachytherapy payment rates for the two proton
proposed policies for CY 2007, hospitals services in CY 2007. therapy APCs are quite close for CY
would also be paid separately for After carefully considering the public 2007, with only a small differential
brachytherapy sources, guidance comments received, we are finalizing between Levels I and II of therapy. As
services, and radiation therapy planning our proposal to develop a median cost such, we will continue to monitor our
services that may be provided in for APC 0651 using single procedure claims data for proton beam therapy in
support of services reported with CPT claims and the general OPPS the future to assess the appropriateness
codes 55859 and 77778. methodology as discussed above of the current APC structure. We are
Therefore, as indicated in the CY 2007 without modification. generally concerned about APCs that
OPPS proposed rule (71 FR 49565), we chronically violate the 2 times rule,
c. Proton Beam Therapy (APCs 0664 and
believed that the summed median cost especially when those APCs contain few
0667)
for APC 0651 and APC 0163 results in services and we have no specific data
an appropriate level of full payment for For CY 2007, we proposed to pay for concerns regarding the services assigned
the dominant type of service provided the following four CPT codes that to them.
under APC 0651, interstitial prostate describe proton beam therapy: 77520 With respect to the commenters’
brachytherapy. We proposed to use the (Proton treatment delivery; simple, request regarding consistent payment
median cost of $1,028.93, as derived without compensation), 77522 (Proton for proton therapy under the MPFS and
from all single bills for APC 0651 treatment delivery; simple, with the OPPS, we note the MPFS and the
according to our standard OPPS compensation), 77523 (Proton treatment OPPS are completely separate payment
methodology, to establish the median delivery; intermediate), and 77525 systems, whose rates are established
for that APC. (Proton treatment delivery; complex). based on different methodologies.
We recognized that prostate We proposed to assign the simple After careful consideration of the
brachytherapy was not the sole use of proton beam therapy procedures to APC public comments received, we are
CPT code 77778, although it was the 0664 (Level I Proton Beam Radiation finalizing without modification our CY
predominant use. Costs attributable to Therapy), with a proposed median cost 2007 proposal to provide payment for
the placement of needles and catheters of $1,141, and the intermediate and proton beam therapy through APCs
and to the interstitial application of complex proton beam therapy 0664 and 0667, with their payment rates
brachytherapy sources to sites other procedures to APC 0667 (Level II Proton based on the final APC median costs of
than the prostate may also be reported Beam Radiation Therapy), with a $1,154 and $1,381, respectively.
on claims whose data map to APC 0651. proposed median cost of $1,365. These
proposed assignments were unchanged d. Urinary Bladder Residual Study (APC
As we noted in the proposed rule, this
from CY 2006. The proposed payment 0340)
clinically driven variability in the
claims data was difficult to assess rates for proton beam therapy were At its February 2005 meeting, the APC
without adding additional levels of based on CY 2005 claims data and Panel recommended that we move CPT
complexity to the issue by considering showed an increase of about 20 percent code 78730 (Urinary bladder residual
diagnoses in establishing payments over the CY 2006 payment rates. study) from APC 0340 (Minor Ancillary
rates. However, recognizing that a Comment: Several commenters Procedures) to APC 0404 (Level I Renal
prospective payment system is a system supported our CY 2007 proposed APC and Genitourinary Studies) for CY 2006,
based on averages and, to the extent that assignments and payment rates for because the Panel believed that the CY
claims for all types of complex proton beam therapy. The commenters 2003 data for CPT code 78730 may have
interstitial brachytherapy source also supported our proposing APC 0664 been derived from incorrectly coded
application were included in the body as an exception to the 2 times rule for hospital claims. Based on reasons
of claims used to set the median cost for CY 2007. They were generally discussed in detail in the CY 2006 OPPS
APC 0651, we believed that the payment concerned about the payment for the final rule with comment period (70 FR
for these services as proposed for CY same services furnished in freestanding 68602), we maintained the assignment
2007 was appropriate. proton therapy centers located in of CPT code 78730 in APC 0340 for CY
We received several public comments several States because the OPPS 2006. For CY 2007, we proposed
concerning our proposal. A summary of payment rates were very different from assignment of CPT code 78370 to APC
the comments and our responses follow: the carrier-priced payments for these 0340 once again.
Comment: The commenters generally services. The commenters requested that Comment: Several commenters
supported the proposed median cost for CMS establish consistent payments for requested that CMS move CPT code
APC 0651. One commenter encouraged these services under the OPPS and the 78730 from APC 0340 to APC 0399
CMS to consider calculating a packaged MPFS because the significant capital (Nuclear Medicine Add-on Imaging).
combination median cost for both CPT costs required to provide proton beam Some commenters indicated that in CY
codes 55859 and 77778 and splitting the therapy treatments do not vary across 2005 they disagreed with our APC
cost between the two codes, should the delivery settings. assignment of APC 0340 for CPT code
median cost for APC 0651 drop by a Response: We appreciate the 78730. One commenter added that the
significant percent in future years as it commenters’ support for our CY 2007 data for CPT code 78730 may have been
has sometimes done in the past. OPPS proposed payment rates for derived from incorrectly coded hospital
Response: The median cost for APC proton therapy. We note that the OPPS claims. The commenters indicated that
0651 calculated using CY 2005 claims payment rates for these services have the CPT Editorial Panel would be
data as updated for this final rule with increased significantly over the past revising the service’s code descriptor for
comment period is $1,029.47, virtually several years, although we understand CY 2007 to more specifically indicate
the same as the proposed rule median that there are only a small number of the performance of a nuclear medicine
cost of $1,028.93. Together with the active hospital-based centers providing procedure.
Response: In the November 15, 2004 applicators); 77615 (Hyperthermia, CCRs were outside of the allowed range,
final rule with comment period (69 FR generated by interstitial probe(s) more or the reporting hospital was a CAH or
65705), we stated that CPT code 78730 than 5 interstitial applicators); and an otherwise excluded hospital (as
was originally created and valued for 77620 (Hyperthermia generated by explained in section II. of this final rule
the MPFS as a procedure requiring the intracavitary probe(s)). The CY 2007 with comment period).
services of a nuclear medicine proposed median cost for APC 0314 was We exclude claims from the data to be
technician, but that the use of the code $225.96. used for calculation of median costs
subsequently had changed to be used Comment: Several commenters every year to ensure that the claims we
primarily by urologists rather than by reported that the proposed APC 0314 use are accurate and valid
nuclear medicine physicians. While we CY 2007 payment rate was 32 percent representations of claims for the
reassigned CPT code 78730 to APC 0340 less than the CY 2006 payment rate of services. The method for identifying
for CY 2005 based on robust CY 2003 $332.31 and suggested that the decrease claims that meet the criteria for
claims data, we solicited other was due to the use of inaccurate CMS inclusion in the median cost
physician specialties to submit resource claims data. development process for CY 2007 was
data for us to review in the context of The commenters believed that the performed similarly to the methodology
our hospital claims data so that we flaws in the CMS claims data were due applied for past OPPS updates and
could reexamine the appropriate APC to a few factors: The variation in should not have had a disproportionate
placement of CPT code 78730 for CY hospitals’ cost allocation methodologies; effect on hyperthermia procedures.
2006. While we acknowledge the CMS’ use of hospital CCRs derived from As noted by the commenters, median
commenters’ repeated concern that the those varying hospital allocation costs for the hyperthermia procedures
median cost for CPT code 78730 may practices and which they reported have been somewhat unstable across the
reflect miscoded claims, commenters varied dramatically (from 15 to 50 years due to low volume and the small
again provided no supporting evidence percent) across hospitals that provided number of facilities reporting the
for either CY 2006 or CY 2007 of what hyperthermia therapies; and low procedures. For CY 2007, the decrease
they believe to be the true resource costs utilization among the few hospitals that is more pronounced than changes in
associated with CPT code 78730. In fact, reported the services. Further, the past years and we appreciate the
a relatively stable number of single commenters expressed an additional providers’ concerns. We note that these
procedure claims has generated a concern for one of the procedures, CPT historical changes have served both to
consistent median cost for CPT code code 77605, for which there were no increase and decrease payments for the
78730 over the past 5 years (that is, claims in the CY 2005 data that CMS treatments over time. We agree with the
ranging from $39 based on the CY 2001 used for the CY 2007 median commenters’ observation about the
claims data to $42 based on the CY 2005 calculation proposal. The commenters relative median cost instability for these
claims data) and supports our added that in past years, the procedure procedures and the probable reasons for
assignment of CPT code 78730 to APC had been one of the more frequently that, but given that we do not observe
0340 with an APC median cost of $37, reported therapies, and they believed specific inaccuracies in our claims data
as opposed to APC 0399 with an APC that having no cases in the claims data that are used in the standard OPPS
median cost of $92. We are aware that used to calculate the medians for APC methodology, it appears these
the code descriptor and parenthetical 0314 was indicative of inaccurate data fluctuations are in keeping with the
language in the CPT manual for CPT and also contributed to the historical charges.
code 78730 indicating other CPT codes inappropriately low proposed median The median costs for the individual
to be reported for certain bladder cost. procedures assigned to APC 0314 vary
studies will be modified for CY 2007. The commenters submitted some from approximately $194 to $431. The
However, we do not know if these estimated hospital costs of hyperthermia median for the APC overall is
additional instructions will lead to treatment for five hospitals, and significantly lower than the highest
differences in hospital reporting that recommended three options that CMS service-specific median because 195 of
result in a significant change in the could use to moderate the proposed CY the 225 single claims for the APC are for
procedure’s cost. Therefore, we are 2007 payment decrease for APC 0314. CPT code 77600, which has a median
maintaining CPT code 78730 in APC The three options are as follows: That cost of $194. In the past, CPT code
0340 for CY 2007. CMS could use external hospital survey 77605 has contributed a significant
After carefully considering the public data to establish a payment rate of number of claims to the number of
comments received, we are finalizing $1,005 for APC 0314; that CMS could single claims in the APC and has also
our proposal to assign CPT code 78730 apply an average cost for CPT code had a higher median than CPT 77600.
to APC 0340 for CY 2007, with a median 77605 using the medians calculated for Thus, the lack of claims for that
cost of $37.29. CY 2004 through CY 2006 to establish procedure may have contributed to the
a more appropriate payment amount for lower APC median for CY 2007, but the
e. Hyperthermia Treatment (APC 0314) CY 2007; or that CMS could maintain median cost calculated for the APC is
We did not propose any APC the CY 2006 payment rate for CY 2007. accurate and reflects costs for those
assignment changes for CY 2007 for the Response: In our analysis, we found services based upon the CY 2005 claims
CPT codes used to report hyperthermia that there were 55 claims reported for data that meet our criteria for use in
treatments. The following five CPT code 77605 in the CY 2005 data, calculating APC medians. We have no
hyperthermia treatment CPT codes are but that all were excluded from the data reason to doubt the accuracy of those
the only codes that we proposed to because they did not meet the criteria data and, therefore, have no basis for
assign to APC 0314 (Hyperthermic for use in calculating the median costs diverging from the established method
Therapies) for CY 2007: 77600 due to any number of factors. Included of calculating the median cost for APC
(Hyperthermia, externally generated; among the reasons for removing the 0314.
superficial); 77605 (Hyperthermia, claims for CPT 77605 from the CY 2005 For these reasons, we will not accept
externally generated; deep); 77610 data that were used to calculate median any of the options recommended to us
(Hyperthermia, generated by interstitial costs were that the reporting hospitals’ by the commenters and are finalizing
probe(s); 5 or fewer interstitial claims were excluded because their the CY 2007 payment rate for APC 0314
based on its median cost of $204, epicardial and endocardial pacing and Comment: A few commenters
calculated using our CY 2005 claims mapping to localize zone of slow requested that CMS retain CPT codes
data as proposed. conduction for surgical correction) be 36478 and 36479 in APC 0091 for CY
removed from APC 0087. The presenter 2007 instead of assigning them to APC
f. Unlisted Procedure for Clinical
asked the APC Panel to recommend that 0092, as we proposed. The commenters
Brachytherapy (APC 0312) these codes be placed in APC 0086 believed that the percutaneous laser
For CY 2007, we proposed to move (Ablate Heart Dysrhythm Focus) for procedures should be assigned to the
CPT code 77799 (Unlisted procedure, improved clinical and resource same APC as CPT codes 36475
clinical brachytherapy) from APC 0313 alignment. The presenter indicated that (Endovenous ablation therapy of
(Brachytherapy) to APC 0312 the median costs for these CPT codes incompetent vein, extremity, inclusive
(Radioelement Applications) for the CY were more than two times the median of all imaging guidance and monitoring,
2007 OPPS. cost of the least costly HCPCS code in percutaneous, radiofrequency; first vein
Comment: Several commenters APC 0087 and, therefore, constituted a treated); and 36476 (Endovenous
objected to the proposal to reassign CPT 2 times rule violation. The presenter ablation therapy of incompetent vein,
code 77799 from APC 0313 to APC 0312 also indicated that the median cost of extremity, inclusive of all imaging
for CY 2007. The commenters stated APC 0087 had declined in recent years, guidance and monitoring, percutaneous,
that APC 0312 is titled ‘‘Radioelement and argued that the payment rate for radiofrequency; second and subsequent
Applications,’’ while APC 0313 is titled APC 0087 was too low to adequately veins treated in a single extremity, each
‘‘Brachytherapy,’’ and that it is in compensate providers for these services. through separate access sites), because
keeping with the intent of APC The APC Panel did not recommend the hospital costs for both types of
classification to group procedures that that CMS move these codes from APC procedures are very similar. The
are similar in clinical characteristics 0087 to APC 0086, but instead proposed APC assignment for CPT
and resource use. Therefore, the recommended that CMS maintain the codes 36475 and 36476 was to APC
commenters believed that because APC three codes in APC 0087 for CY 2007. 0091.
0313 was the lowest payment level The APC Panel noted that, due to the Response: In our review of APCs for
brachytherapy APC, it would be most low volume of these and other services the CY 2007 proposed rule, we found
appropriate to continue to assign CPT assigned to APC 0087, under the CMS’ that the procedures assigned to APCs
code 77799 to APC 0313 with other rules there was no 2 times violation in 0091 and 0092 were appropriate
brachytherapy procedures. APC 0087. Moreover, the APC Panel clinically, but that the median costs
Response: We disagree. CPT code found that the services under discussion within both of the APCs had become
77799 has no meaningful definition that were cardiac electrophysiologic heterogeneous so there was not
would enable us to place it accurately mapping services like other procedures significant differentiation between the
in one brachytherapy APC versus also assigned to APC 0087, and were, medians for the two levels of vascular
another APC based on clinical therefore, clinically coherent with other APCs. In addition, CPT codes 36475
homogeneity or resource considerations. services in APC 0087. The APC Panel through 36479 were new in CY 2005
While the APC title for APC 0312 does did not believe that these three cardiac and, as such, their median costs were
not contain the term brachytherapy electrophysiologic mapping procedures available to us for the first time in our
explicitly, all of the procedures assigned were similar clinically or from a development of the CY 2007 proposed
to APC 0312 are from the section of the resource perspective to the intracardiac rule.
CPT manual called ‘‘Clinical catheter ablation procedures residing in In order to remedy the heterogeneity
Brachytherapy.’’ Furthermore, APC APC 0086. We agreed with the APC within APCs 0091 and 0092, we
Panel’s assessment and accepted this reconfigured them to achieve greater
0312, not APC 0313, is the lowest
APC Panel recommendation. Therefore, differentiation between the median
payment level brachytherapy procedure
we proposed that CPT codes 93609, costs of the two APCs and to improve
APC. In CY 2005, we finalized the OPPS
93613, and 93631 remain assigned to internal homogeneity. In that
policy of assigning all unlisted or ‘‘not
APC 0087 for CY 2007. reconfiguration, CPT codes 36478 and
otherwise classified’’ HCPCS codes to
We did not receive any public 36479 were assigned to APC 0092, with
the lowest level APC that is appropriate
comments concerning our proposal. other procedures with similar resource
to the clinical nature of the service (69
Therefore, we are adopting our CY 2007 requirements. The median costs for CPT
FR 65725). Therefore, we believe that
proposal as final without modification. codes 36478 and 36479 are $1,521 and
our reassignment of CPT code 77799 to
$1,241, respectively, and the median
APC 0312 is appropriate. b. Endovenous Laser Ablation
cost for APC 0092 is $1,520. There are
After carefully considering the public Procedures (APC 0092)
more than 800 single claims for CPT
comments received, we are finalizing We proposed to reassign CPT codes code 36478, and we are confident that
our CY 2007 proposal for the 36478 (Endovenous ablation therapy of the data reflect hospital costs for the
assignment of CPT code 77799 to APC incompetent vein, extremity, inclusive procedure. We believe that these
0312, without modification. of all imaging guidance and monitoring, procedures fit appropriately into the
3. Cardiac and Vascular Procedures percutaneous laser; first vein treated;) APC 0092.
and 36479 (Endovenous ablation In contrast, CPT codes 36475 and
a. Electrophysiologic Recording/ therapy of incompetent vein, extremity, 36476 were assigned to APC 0091,
Mapping (APC 0087) inclusive of all imaging guidance and which has a median cost of $2,122. The
At its March 2006 meeting, the APC monitoring, percutaneous laser; second median costs for those procedures are
Panel heard testimony from a presenter and subsequent veins treated in a single $2,295 and $3,017, respectively, and
who asked that the Panel recommend extremity, each through separate access there are more than 900 single claims
that CPT codes 93609 (Intraventricular sites) from APC 0091 (Level II Vascular for CPT code 36475. Although the
and/or intra-atrial mapping of Ligation) for CY 2007 to APC 0092 endovenous ablation procedures
tachycardia, add-on); 93613 (Level I Vascular Ligation), with a described by CPT codes 34675 through
(Intracardiac electrophysiologic 3–D proposed median cost of $1,518.22 for 36479 are clinically related, we do not
mapping); and 93631 (Intra-operative CY 2007. believe that they belong in the same
APC. In this case, there exist separate and intraprocedural pharmacological We believe the reassignments provide
APCs into which each procedure type is thrombolytic injection(s); initial vessel); more accurate payment for these
appropriately assigned to reflect more 37187 (Percutaneous transluminal thrombectomy procedures.
similar usage. mechanical thrombectomy, vein(s), After careful consideration of the
The reconfiguration resulted in including intraprocedural public comment received, we are
improved differentiation between the pharmacological thrombolytic finalizing our proposal for the APC
two APCs. For CY 2006, the difference injection(s) and fluoroscopic guidance); assignments of CPT codes 37184, 37185,
between the APC median costs was only and 37188 (Percutaneous transluminal 37186, 37187, and 37188 with
about $140. For CY 2007, that difference mechanical thrombectomy, vein(s), modification. All five procedures are
is about $600, and the internal including intraprocedural assigned to APC 0088 for CY 2007.
homogeneity in each APC is improved. pharmacological thrombolytic
For these reasons we are finalizing injection(s) and fluoroscopic guidance, 4. Gastrointestinal and Genitourinary
our proposal to assign CPT codes 36478 repeat treatment on subsequent day Procedures
and 36479 to APC 0092 for CY 2007. during course of thrombolytic therapy) a. Insertion of Mesh or Other Prosthesis
were provided interim final assignments (APC 0195)
c. Repair/Repositioning of Defibrillator
to APC 0653 (Vascular Reconstruction/
Leads (APC 0106) During the March 2006 APC Panel
Fistula Repair with Device). New CPT
For CY 2007, we proposed to assign codes 37185 (Primary percutaneous meeting, a presenter requested that we
CPT code 33218 (Repair of single transluminal mechanical thrombectomy, reassign CPT code 57267 (Insertion of
transvenous electrode for a single noncoronary, arterial or arterial bypass mesh or other prosthesis for repair of
chamber, permanent pacemaker or graft, including fluoroscopic guidance pelvic floor defect, each site (anterior,
single chamber pacing cardioverter- and intraprocedural pharmacological posterior compartment), vaginal
defibrillator), and CPT code 33220 thrombolytic injection(s); second and all approach) to a more clinically and
(Repair of two transvenous electrodes subsequent vessel(s) within the same resource-appropriate APC than its CY
for a dual chamber permanent vascular family) and 37186 (Secondary 2006 assignment to APC 0154 (Hernia/
pacemaker or dual chamber pacing percutaneous transluminal Hydrocele Procedures). The presenter
cardioverter-defibrillator) to APC 0106 thrombectomy (e.g., nonprimary expressed concern that the procedure
(Insertion/Replacement/Repair of mechanical, snare basket, suction was currently assigned to an APC with
Pacemaker and/or Electrodes), with a technique), noncoronary, arterial or a ‘‘T’’ status indicator and stated that
proposed median cost of $2,754.86. arterial bypass graft, including payment would be more accurate if it
These procedures were both assigned to fluoroscopic guidance and were assigned to an APC that has an ‘‘S’’
APC 0106 for CY 2006. intraprocedural pharmacological status indicator. The mesh insertion
Comment: Several commenters asked thrombolytic injections, provided in procedure is a CPT add-on code and is,
CMS to reassign CPT codes 33218 and conjunction with another percutaneous by definition, performed at the same
33220 from APC 0106 to APC 0105 intervention other than primary time as certain other procedures and
(Revision/Removal of Pacemakers, mechanical thrombectomy) were will, therefore, be discounted every time
AICD, or Vascular Devices) because provided interim final assignments to it is performed. The presenter objected
these two codes do not require a device APC 0103 (Miscellaneous Vascular to our assignment of CPT code 57267 to
like other codes in APC 0106 and their Procedures). The proposed assignments an APC that was subject to the multiple
median costs are closer to the proposed of these codes for CY 2007 were procedure discount because it was
median cost of APC 0105 of $1,449.44. unchanged. always a secondary procedure, and the
Response: We agree and have moved Comment: One commenter who discounted payment amount was not
CPT codes 33218 and 33220 out of APC addressed our CY 2006 APC adequate to pay even for the cost of the
0106 and into APC 0105 for CY 2007. assignments for CPT codes 37184, implantable mesh. The presenter also
The final rule median cost for APC 0106 37187, and 37188 believed that all of the believed that its assignment to an APC
is $3,596.86. new codes should have been assigned to where hernia and hydrocele procedures
After carefully considering the public APC 0088 (Thrombectomy). The were also assigned was clinically
comments received, we are finalizing commenter stated that the procedures inappropriate.
our CY 2007 proposal with modification reported by the new CPT codes were
to reassign CPT codes 33218 and 33220 The APC Panel recommended that
very similar to the procedures reported
from APC 0106 to APC 0105. We also CMS reassign CPT code 57267 to a more
by CPT code 92973 (Percutaneous
are modifying the titles of these APCs to transluminal coronary thrombectomy), clinically and resource-appropriate
reflect their new composition. APC 0106 that was assigned to APC 0088 because APC.
is retitled ‘‘Insertion/Replacement of they required the use of a costly As stated in the CY 2007 OPPS
Pacemaker Leads and/or Electrodes.’’ mechanical thrombectomy catheter. The proposed rule, in the CY 2005 claims
APC 0105 is retitled ‘‘Repair/Revision/ commenter stated that the procedures data, the median cost for CPT code
Removal of Pacemakers, AICDs, or coded with CPT codes 37184 through 57267 was $529.14, the lowest by far for
Vascular Devices.’’ The final median 37188 also required the use of costly procedures in APC 0154, which had a
cost of APC 0106 is $3,596.87, and the catheters and were clinically more proposed APC median cost of $1,821 for
final median cost of APC 0105 is similar to the other procedures assigned CY 2007 (71 FR 49562). However, the
$1,565.27. to APC 0088 than to those assigned to proposed median cost of CPT code
either APC 0103 or APC 0653. 57267 was based on only 6 single claims
d. Thrombectomy Procedures (APCs Response: Although we will not have of the total 1,038 claims submitted for
0103 and 0653) data for these procedures until next the service. Because the procedure
For CY 2006, new CPT codes 37184 year, based on the information in the always was performed in addition to
(Primary percutaneous transluminal comment and our further review, we other related procedures, we expected
mechanical thrombectomy, agree with the commenter that a more that claims for this service would be
noncoronary, arterial or arterial bypass appropriate assignment for the multiple claims. Therefore, we were not
graft, including fluoroscopic guidance procedures is APC 0088 for CY 2007. confident that the procedure’s median
cost based upon the six single claims item median cost of the mesh and the HCPCS codes C1762 and C1763, as well
was accurate. median single claims cost of CPT code as those with device code C1781 that we
Therefore, at the time of the proposed 57267 (which explicitly included the presented in the proposed rule. We
rule, in order to obtain more implantable mesh) reflected in our analyzed all single and ‘‘pseudo’’ single
information about the cost of the claims data. claims and multiple claims for CPT
procedure, we performed additional We agreed with the APC Panel that code 57267 reported with one of the 3
analyses of CY 2005 claims data in an the procedure should be assigned to a device codes (C1762, C1763, and C1781)
attempt to specifically explore the cost more clinically appropriate APC, and and examined the line-item cost for
of the mesh implant packaged into the therefore, we proposed to accept its each of the three devices, based upon
payment for CPT code 57267. We recommendation and reassign CPT code our belief that the cost of the add-on
believe that a significant portion of the 57267 to APC 0195 (Level IX Female repair procedure was principally due to
procedural cost should be related to the Reproductive Procedures), with status the device cost. The results of our study
cost of the mesh, based on information indicator ‘‘T’’ for CY 2007. The showed that the median line-item costs
presented at the March 2006 APC Panel proposed median cost of APC 0195 was for device codes C1762 and C1763 on
meeting. We looked at all claims that $1,777 for CY 2007, very comparable to claims for the pelvic floor repair
included charges for the HCPCS code the CY 2006 median cost of APC 0154, procedure were $810.72 and $503.71,
for implantable mesh (C1781) and either where CPT code 57267 was assigned for respectively, compared to $352.20 for
CPT code 57267 or 49568 (Implantation CY 2006. The median cost for the device code C1781.
of mesh or other prosthesis for procedure remained very low in Although the commenters stated that
incisional or ventral hernia repair). We comparison with other procedures the graft insertion procedure to repair
examined the bills for CPT code 49568 assigned to APC 0195; therefore, we the pelvic floor was performed using
in addition to those for CPT code 57267 believe that payment for the service only the connective tissue products
because it was a high volume procedure when the multiple procedure reduction coded by device codes C1762 and
that also used implantable mesh, and was applied would be appropriate. C1763, there is no guidance with regard
we expected that the extra volume While not affecting the procedure’s to use of the CPT code 57267 that
would improve our chances of payment significantly, this reassignment specifically restricts the type of device
identifying meaningful charge data. improved the clinical homogeneity of that may be reported with that code. In
We found 210 claims with charges APCs 0154 and 0195. the list of device category codes and
reported for both CPT code 57267 and Comment: The commenters generally their definitions posted on the CMS
HCPCS code C1781 on the same day and believed that CPT code 57267 should be Web site, we indicate that device code
6,345 claims with reported charges for assigned to APC 0202 (Level X Female C1781 is defined as, ‘‘A mesh implant
both CPT code 49568 and HCPCS code Reproductive Procedures), which is a or synthetic patch composed of
C1781 on the same day. Costs developed device-dependent APC and for which absorbable or non-absorbable material
from these two claims subsets included the proposed CY 2007 median cost is that is used to repair hernias, support
the cost of the implanted mesh device $2,534.46. They stated that the analyses weakened or attenuated tissue, cover
that was used in performing the that CMS performed for the proposed tissue defects, etc.’’ We also note in the
procedure. Table 13 published in the CY rule to identify costs for the procedure definition that other device codes
2007 OPPS proposed rule displayed the described by CPT code 57267 when should be used for reporting connective
median costs from those claims (71 FR billed with the HCPCS code C1781 for tissue when used to treat urinary
49562). The costs shown in the column the mesh implant were incorrect incontinence. There are far more CY
titled ‘‘Line-item Median Cost’’ of Table because the mesh devices that are used 2005 claims for CPT code 57267 with
13 were those we obtained by looking at in pelvic floor repair are best described device code C1781 than with either of
all CY 2005 OPPS claims upon which by HCPCS codes C1762 (Connective the device codes presented by the
charges for both the procedure code tissue, human (includes fascia lata)) and commenters. Therefore, the CY 2005
(either CPT code 57267 or 49568) and C1763 (Connective tissue, non-human claims data for the procedure are more
the code for the implantable mesh (includes synthetic)). One commenter reflective of the use of the mesh
(HCPCS code C1781) were reported. The provided data showing the costs of four reported with device code C1718 than of
costs shown in the column titled procedures, including CPT codes 57240 the mesh the commenters believed was
‘‘Single Claims Median Cost’’ were the (Anterior colporrhaphy, repair of most often used. Table 15 displays the
median costs calculated using only cystocele with or without repair of numbers of claims and the median costs
single procedure claims for the specific urethrocele) and 57250 (Posterior found in our analyses.
procedure that also included the C-code colporrhaphy, repair of rectocele with or We continue to believe that
for the mesh. without perineorrhaphy), when assignment of CPT code 57267 to APC
Our additional data analysis performed with and without the graft 0195 is appropriate and ensures
supported the APC Panel presenter’s insertion procedure, CPT code 57267. adequate payment for the procedure,
assertion that the cost of the mesh was Their data indicated that the median even when the multiple procedure
greater than 50 percent of the total cost cost for CPT code 57267, including the discount is taken. Based on the typical
of CPT code 57267, but it also indicated device (C1762 or C1763), ranged from cost of any one of the mesh/connective
that the mesh cost was far less than 50 $946 to $1,465, and that, on average, the tissue devices that are used in the
percent of the payment amount for APC cost was $1,254. service, 50 percent of the payment for
0154. In CY 2006, the payment rate for Response: In response to the APC 0195, based on its CY 2007 median
APC 0154 was $1,704.59, and the comments, we performed additional cost of $1742.20, should be appropriate.
payment when the multiple procedure analyses of claims for CPT code 57267 Assignment to APC 0202, with a median
discount was taken was $852.30, which that included the two types of mesh/ cost of $2,534.46, would result in
was much greater than both the line- connective tissues devices coded with overpayment for the procedures.
TABLE 15.—MEDIAN COSTS OF HCPCS CODES C1762, C1763 AND C1781 AND 57267
CY 2005 CY 2005
HCPCS code Short descriptor frequency of line-item me-
total claims dian cost
C1762 (billed with 57267) ............................................ Conn tiss, human (inc fascia) ....................................... 22 $810.72
C1763 (billed with 57267) ............................................ Conn tissue, non-human .............................................. 55 503.71
C1781 (billed with 49568) ............................................ Mesh (implantable) ....................................................... 175 352.20
After carefully considering the public Comment: Several commenters 0423 upon which the payment rate for
comments received, we are finalizing approved of the proposed reassignment CPT code 0135T is based is $2,283.08.
our proposal to reassign CPT code of CPT code 0135T from APC 0163 to We believe that this payment will be
57267 to APC 0195 without APC 0423 for CY 2007 because this sufficient to ensure access to this service
modification. move placed the percutaneous for Medicare beneficiaries.
cryoablation procedure with other Comment: Several commenters
b. Percutaneous Renal Cryoablation similar procedures. However, the acknowledged that cryoablation and
(APC 0423) commenters were concerned that the radiofrequency percutaneous ablation
During the March 2006 APC Panel payment rate for CPT code 0135T was procedures for renal tumors were
meeting, a presenter requested that we inadequate and did not reflect the total clinically similar; however, there were
reassign CPT code 0135T (Ablation cost incurred by hospitals in providing major resource differences in the
renal tumor(s), unilateral, percutaneous, this service. The commenters also required equipment and the technology-
cryotherapy) from APC 0163 (Level IV indicated that the payment rate for CPT specific probes. One commenter
Cystourethroscopy and other code 0135T was not based on timely indicated that the radiofrequency
Genitourinary Procedures) to APC 0423 data or accurate hospital claims. The ablation procedure involves the use of
(Level II Percutaneous Abdominal and commenters believed that the proposed only one probe, while the cryoablation
Biliary Procedures). The presenter payment rate would not cover the costs procedure requires, on average, 2.5
provided information about the costs of of the expensive cryoablation probes probes.
performing these procedures and used in performing the procedures. One Response: We believe that CPT code
compared the resource requirements for commenter indicated that the average 0135T is appropriately assigned to APC
the procedures to those for CPT code cost of one probe was about $1,000, and 0423 because it is placed with other
47382 (Ablation, one or more liver the average procedure used between 2.3 procedures that share clinical and
tumor(s), percutaneous, and 2.5 probes. Another commenter resource homogeneity. If hospitals use
radiofrequency), which is currently submitted copies of invoices showing more than one probe in performing the
assigned to APC 0423. The presenter the costs of the probes. The commenter renal cryoablation procedure, we expect
proposed reassignment of CPT code urged CMS to reevaluate the payment hospitals to report this information on
0135T to APC 0423 because that was for APC 0423, because an underpayment the claim and adjust their charges
where CPT code 47382 was assigned, could result in hospitals not offering accordingly. Hospitals should report the
and stated that the costs of the two this procedure, thereby creating an number of cyroablation probes used to
procedures were very similar. access barrier for Medicare patients. perform CPT code 0135T as the units of
Several commenters requested that CMS HCPCS code C2618 (Probe,
Based on the information presented,
use all available data, including external cryoablation), which describes these
the APC Panel recommended that we
data, to determine the appropriate devices, with their charges for the
reassign CPT code 0135T from APC
payment rate for APC 0423. probes. Since CY 2005, we have
0163 to APC 0423 for CY 2007. Response: We reviewed the data for required hospitals to report device
CPT code 0135T is new for CY 2006 APC 0423, considered the comments, HCPCS codes for all devices used in
and, therefore, we had no claims data and examined all available information procedures if there are appropriate
upon which to base our APC assignment regarding the procedure described by HCPCS codes available. In this way, we
decision. The procedure currently has CPT code 0135T, as well as other can be confident that hospitals have
an interim assignment to APC 0163, procedures that are separately payable included charges on their claims for
with a CY 2006 payment amount of under the OPPS and for which we have costly devices used in procedures when
$1,999.35. claims data. In addition, we reviewed they submit claims for those procedures.
In the CY 2007 OPPS proposed rule, the recommendation of the APC Panel Comment: Several commenters
we proposed to accept the APC Panel’s from its March 2006 meeting that was indicated that in the CY 2007 OPPS
recommendation to reassign CPT code based upon the request of a presenter. proposed rule we acknowledged the
0135T to APC 0423 for CY 2007. We Based on our evaluation, we believe that lack of claims data to set the payment
believed that assignment of CPT code we have appropriately assigned CPT rate for the renal cryoablation procedure
0135T to APC 0423 was clinically code 0135T to APC 0423 for CY 2007 reported with CPT code 0135T. They
appropriate, and the CY 2007 proposed based on clinical and resource believed that CMS should assign CPT
median cost of APC 0423 of $2,410.33 homogeneity considerations. Under the code 0135T to a New Technology APC
was reasonably close to our expectations standard OPPS methodology, the APC and base its payment on the actual cost
regarding the resource requirements for payment rate is established based on CY of performing the procedure. One
the renal cryoablation procedure. The 2005 claims data for those services for commenter reported that the renal
APC Panel did not discuss this which there are data. One service also cryoablation procedure was a relatively
procedure again at its August 2006 assigned to APC 0423 has significant new procedure that had only rarely been
meeting, nor were there any public claims volume, and its median costs performed in the outpatient setting. The
presentations on this issue at that have been stable over the past several commenter also noted that assigning
meeting. years. The final median cost of APC CPT code 0135T to a New Technology
APC would allow CMS time to obtain We made those reassignments in imaging (MRI) and ultrasound services.
meaningful outpatient cost information response to public comments to our The use of focused ultrasound for
for the procedure, so that CMS could proposed rule of July 25, 2005, in which thermal tissue ablation has been in
eventually place the procedure in an we had proposed to assign the development for decades, and the recent
appropriate clinical APC. The procedures to APC 0193 (Level V application of MRI to focused
commenter added that prior to January Female Reproductive Procedures) for ultrasound therapy provides monitoring
1, 2006, there was no specific HCPCS CY 2006. These services had been capabilities that may make the therapy
code that accurately described the renal assigned to APC 0193 since their more clinically useful. We believe that
cryoablation procedure, and, as a result, implementation in the OPPS in CY MRgFUS therapy is a new and
the service was reported by those 2005. We proposed no changes to their integrated application of existing
hospitals performing the procedure final CY 2006 assignments for CY 2007. technologies (MRI and ultrasound) and
under the general unlisted CPT code Comment: Although our assignments that the technology used in this service
53899. Because of the use of the of the procedures were to separate, fits as well into existing clinical APCs
unlisted CPT code, the commenter higher paying APCs for CY 2006 than for female reproductive services, as do
indicated that it would be impossible to their assignments for CY 2005, many other modalities that are currently
identify the historical hospital commenters on the CY 2007 proposed assigned to those clinical groups.
outpatient claims that were related to rule believed that the procedures’ Retaining them in clinical APCs with
percutaneous renal cryotherapy. assignments still resulted in significant other female reproductive procedures
Response: While we previously underpayment. The commenters will enable us both to set accurate
acknowledged the lack of claims data in asserted that while MRgFUS treats payment amounts and to maintain
setting the payment rate for CPT code anatomical sites that are similar to other appropriate clinical homogeneity of the
0135T, we have commonly assigned a procedures assigned to APCs 0195 and APCs.
new service or procedure without 0202, the resources utilized differ The similarity of the charges for
claims data to a clinical APC that we dramatically. Further, they stated that MRgFUS and SRS as reflected in the
believed appropriately reflected the cost treatment of uterine fibroids using the examples provided by one commenter
and clinical features of the procedure. MRgFUS procedure is more cost does not convince us that the level of
We often have relevant information effective for the Medicare program and hospital resources used to provide
available to us based on claims data for for beneficiaries because the recovery MRgFUS is the same as for SRS. APC
other services historically paid under time is shorter, and beneficiaries would assignments are made based on
the OPPS, as well as data provided to us be spared the need for hysterectomies. consideration of both hospital resources
by the public. In the case of CPT code The commenters indicated that the and clinical homogeneity. There are
0135T specifically, the APC Panel at its most appropriate assignment for the many OPPS claims with similar charges,
March 2006 meeting recommended that MRgFUS procedures would be APC but where the reported procedures have
we reassign this code from APC 0163 to 0127 (Level IV Stereotactic nothing in common with one another
APC 0423 for CY 2007. Based on this Radiosurgery) based on their analyses of clinically. We do not assign those
recommendation and our the procedures’ resource use and procedures to the same clinical APC.
comprehensive review of the procedures clinical characteristics. The similarities In our CY 2005 claims data, there are
assigned to APC 0423, we believe that between the two technologies that were two claims for CPT code 0071T but
we have assigned the renal cryoablation presented by the commenters included none for CPT code 0072T and 3,346
procedure to an appropriate clinical their clinical indication to treat non- claims for the single SRS service
APC, specifically APC 0423, which invasive tumors by using focused assigned to APC 0127. Those data show
reflects clinical homogeneity and ionizing radiation (stereotactic the median cost for SRS is $8,461 and
comparable resource costs among the radiosurgery) or acoustic waves the median cost for the two MRgFUS
procedures assigned to the APC for CY (MRgFUS) to destroy the tumor tissue. claims is $1,026. We realize the limited
2007. We note that we expect to have Further, the commenters argued that nature of the data from which to draw
claims data for CPT code 0135T the procedures require similar hospital any conclusions about cost, but because
available for the CY 2008 OPPS update. resources: planning prior to treatment; treatment of uterine fibroids is most
After carefully considering all the specialized equipment housed in common among women younger than
public comments received, we are treatment rooms; continuous monitoring 65 years of age, we do not expect that
reassigning CPT code 0135T to APC during treatment; and 120 to 300 there ever will be many Medicare claims
0423, as proposed, without minutes to perform the treatment. for those procedures. Nevertheless, we
modification. The final APC 0423 One commenter sent data that do not see a compelling reason to except
median cost is $2,283.08. compared the hospital charges for three MRgFUS from our established policy to
MRgFUS cases to those for five rely on our claims as the basis for
c. Ultrasound Ablation of Uterine stereotactic radiosurgery (SRS) weight-setting under the OPPS.
Fibroids with Magnetic Resonance procedures. Those data showed charges Further, and in contrast with SRS, the
Guidance (MRgFUS) (APCs 0195 and for CPT code 0071T of $18,215 and for MRI equipment used to provide the
0202) 0072T, $22,122 and $23,463, and for MRgFUS therapy can also be used to
We received many public comments SRS, charges ranging from $21,360 to perform conventional MRI procedures
concerning the APC assignments for $28,790. In addition, many of the and does not necessarily represent an
HCPCS codes 0071T and 0072T. commenters reported that their additional capital expense for the
In the CY 2006 final rule we assigned hospitals charge between $18,000 and hospital. Those costs should be
magnetic resonance guided focused $24,000 for each MRgFUS treatment. allocated accordingly so that
ultrasound ablation of uterine fibroids Response: As we stated in the amortization will be shared by those
(MRgFUS) procedures, CPT codes November 10, 2005 final rule, we other tests. In addition, we remind
0071T and 0072T, to APCs 0195 (Level believe that MRgFUS treatment bears a commenters that the OPPS was
IX Female Reproductive Procedures) significant relationship to technologies originally set up to be budget neutral to
and 0202 (Level X Female Reproductive already in widespread use in hospitals, the prior system, which under several
Procedures), respectively, for CY 2006. in particular magnetic resonance provisions of the statute, paid
approximately 82 percent of reported assignments of CPT codes 071T and claims that pass the device edits and
hospital outpatient department costs as 072T, without modification. which do not contain token charges for
shown on the cost reports. Therefore, the device HCPCS codes on the claims.
d. Laser Vaporization of Prostate (APC
payment rates for individual services The proposed rule median cost of APC
0429)
are set, in effect, to reflect relative 0384 was $1,400.71.
resource use within a payment system For CY 2007, we proposed to assign Comment: The commenters asked that
that pays, on average, at what was a CPT code 52648 (Laser vaporization of CMS calculate the median by applying
discount of approximately 18 percent. prostate, including control of the same device edits for CPT codes
Because the OPPS is a prospective postoperative bleeding, complete 43268 (Endoscopic retrograde
payment system as well, payment may (vasectomy, meatotomy, cholangiopancreatography (ECRP); with
be more or less than a provider’s costs cystourethroscopy, urethral calibration retrograde insertion of tube or stent into
in any specific case. We expect that our and/or dilation, internal urethrotomy bile or pancreatic duct); 43269
payment rates generally will reflect the and transurethral resection of prostate (Endoscopic retrograde
costs that are associated with providing are included if performed)) to APC 0429 cholangiopancreatography (ECRP); with
care to Medicare beneficiaries in cost- (Level V Cystourethroscopy and other retrograde removal of foreign body and/
efficient settings. Genitourinary Procedures), with a or change of tube or stent); and 43219
Prior to assigning CPT codes 0071T proposed median cost of $2,651.79. The (Esophagoscopy, rigid or flexible; with
and 0072T to APCs 0195 and 0202 procedure was assigned to APC 0429 for insertion of plastic tube or stent) that
respectively, we compared the CY 2006. were applied to calculate the CY 2006
Comment: One commenter indicated OPPS median cost. The commenters
necessary hospital resources for the
that the proposed assignment of CPT stated that CMS used only claims
MRgFUS procedures, including
code 52648 to APC 0429 seemed containing stent device codes to
specialized equipment, MRI/procedure
appropriate but asked CMS to use only calculate the median cost for APC 0384
room time, personnel, anesthesia and
claims for CPT code 52648 that also for CY 2006 OPPS. They believed that
other required resources, to various
contained HCPCS code C9713 the CY 2007 OPPS median cost for APC
other procedures for which we have
(Noncontact laser vaporization of 0384 would be significantly higher if
historical hospital claims data. In
prostate, including coagulation control only claims that contained the stent
addition, we took into consideration
of intraoperative and postoperative device codes were used in the
projected costs for the MRgFUS
bleeding) to calculate the median cost calculation.
procedures submitted to us, and other
for APC 0429. The commenter believed Response: We have not calculated the
available information regarding the
that by using single bills that did not CY 2007 median cost for APC 0384
clinical characteristics and costs of
also contain HCPCS code C9713, CMS using only claims that contain the
those services. We do not believe that
may have excluded the correctly coded HCPCS codes for stents for the
there are significant clinical similarities
claims. procedures reported under CPT codes
between MRgFUS and the multi-source Response: We agree that assignment 43268 and 43219, because the
photon SRS procedure assigned to APC of CPT code 52648 to APC 0429 is procedures may be performed with
0127. This SRS procedure is generally appropriate, but we disagree that we tubes rather than stents. There are no
performed on intracranial lesions, and should require HCPCS code C9713 to be device HCPCS codes for the tubes that
requires immobilization of the patient’s on all claims for CPT code 52648 as may be used. Similarly, the procedure
head in a frame that is screwed into the either a condition of payment for CPT identified by CPT code 43269 may or
skull. Several hundred converging code 52648 or to calculate the median may not use either a stent or a tube, and,
beams of gamma radiation are applied to cost of APC 0429. HCPCS code C9713 therefore, it would be erroneous to
the target lesion, requiring their accurate was created to describe the service for require that a stent be reported on the
placement to the fraction of a laser vaporization of the prostate claim. We assume that where a stent
millimeter. In contrast, during MRgFUS, because we did not believe that CPT HCPCS code is not reported on the
MRI guidance is utilized to confirm code 52648, as defined before January 1, claim, the charge for the procedure
tissue heating, while multiple 2006, described the same service, and incorporates the charge for the tube if
sonications at various points in the HCPCS code C9713 should not have one was used in the case of CPT codes
fibroid treatment area are executed until been included on any claims with CPT 43268 and 43219, or in the case of CPT
the entire target volume has been code 52648. HCPCS code C9713 was code 43269, we assume that no stent or
treated. Therefore, we do not think these deleted effective December 31, 2005, as tube was used at all. It is also possible
two types of procedures are clinically a result of the change to the descriptor that if the hospital inserted a tube, the
similar, nor do we believe they require of CPT code 52648. Hospitals that billed hospital provided a charge for the tube
comparable hospital resources based on both codes on the same claim in CY under a revenue code with no HCPCS
the considerations described previously 2005 were billing incorrectly, as HCPCS code. The other CPT codes in the APC
that went into our CY 2006 APC code C9713 did not describe the device require the use of a stent (and make no
assignments for MRgFUS and SRS used to furnish the service. provision for substitution of a tube) and,
procedures. After carefully considering the public therefore, we require that a stent HCPCS
We continue to believe that the comment received, we are finalizing our C-code be reported on the claims for
assignments of CPT codes 071T and CY 2007 proposal to assign CPT code those services. This is the same
072T for MRgFUS procedures to APCs 52648 to APC 0429 for CY 2007. The CY methodology and the same set of device
0195 and 0202 respectively for CY 2007 2007 final median cost of APC 0429 is edits for these procedures that were
will make appropriate OPPS payments $2,633.85. applied to calculate the median cost of
for MRgFUS services, thereby ensuring APC 0384 to establish its CY 2006 OPPS
access for Medicare beneficiaries who e. Gastrointestinal Procedures with payment rate. Our discussion of our
need them. Stents (APC 0384) final policy for setting the payment rates
After careful consideration of the For CY 2007, we proposed to for device-dependent APCs, including
public comments received, we are calculate the median cost of APC 0384 APC 0384, is included in section IV.A.2.
finalizing our proposed CY 2007 APC (GI Procedures with Stents) using only of this final rule with comment period.
See the OPPS device edits at http:// CMS should recalculate the median cost $1,573.89. Furthermore, with regard to
www.cms.hhs.gov/ for CPT code 43257 to ensure that all the commenter’s analogy to a new APC
HospitalOutpatientPPS/ under claims contributing to the median for vascular access devices, such a
‘‘downloads’’ for the device edits in reflect the resources of the endoscopic comparison was misplaced as we did
place for this APC for each calendar procedures that are part of this not propose to create a new APC for
quarter since October 2005. procedure. vascular access devices in the CY 2007
After carefully considering the public Response: The commenters cited the OPPS proposed rule.
comments received, we are finalizing CY 2004 claims as part of their Comment: One commenter requested
our CY 2007 proposal for APC 0384 objection. However, we used claims that CMS recompute the median cost for
without modification. The final median data from CY 2005 for all services, CPT code 43257, and suggested two
cost for APC 0384 is $1,402.31. including CPT code 43257, in specific options for determining a
determining the payment rates for CY revised median cost. One option
f. Endoscopy With Thermal Energy to
2007. As we stated in the CY 2007 OPPS suggested by the commenter was that
Sphincter (APC 0422)
proposed rule, median costs for the CY CMS add the median cost for CPT code
CPT code 43257 (Upper 2007 OPPS update were based on the 43235 to the cost of all claims for
gastrointestinal endoscopy, including CY 2005 hospital claims data. APC HCPCS code C9701 (CPT code 43257 in
esophagus, stomach, and either the assignments are based on clinical CY 2005) that did not also contain at
duodenum and/or jejunum as homogeneity and comparable resource least one unit of an endoscopy code on
appropriate; with delivery of thermal utilization for all CPT and HCPCS codes the claim. The commenter indicated
energy to the muscle of lower within an APC. In the case of APC 0422, that these inflated claims costs would
esophageal sphincter and/or gastric we believe that the procedures assigned then be combined with all claims for
cardia, for treatment of gastroesophageal to this APC are similar in costs and HCPCS code C9701 that also contain at
reflux disease), effective January 1, resource consumption, with median least one unit of an endoscopy code and
2005, is used for esophagoscopy with costs for the significant procedures with the claims for CPT code 0008T to
delivery of thermal energy to the muscle assigned to the APC of $1,475 to $2,084, set the median cost for the APC they
of the lower esophageal sphincter and/ well within the 2 times rule limits. wanted CMS to create. The commenter
or gastric cardia for the treatment of Comment: Several commenters suggested that another option would be
gastresophageal reflux disease. This requested that CMS create a new APC to use only claims that contained both
code describes the Stretta procedure, that includes both CPT codes 43257 and HCPCS code C9701 and CPT codes
including use of the Stretta System and 0008T (Upper gastrointestinal 43234, 42235, or any other endoscopy
all endoscopies associated with the endoscopy, including esophagus, code to calculate the median cost,
Stretta procedure. Prior to CY 2005, the stomach, and either the duodenum and/ which the commenter admitted would
Stretta procedure was recognized under or jejunum as appropriate, with suturing not yield as robust a set of claims for
HCPCS code C9701 from January 1, of the esophagogastric junction) to setting medians.
2004, through December 31, 2004, in the appropriately cover the costs associated Response: We no longer have a need
OPPS. For the CY 2005 OPPS, HCPCS with performing these procedures. One for special calculations to develop the
code C9701 was deleted and CPT code commenter requested that CMS create a median cost of CPT code 43257 because
43257 was utilized for the Stretta new APC to which CMS would assign
procedure. In CY 2005, the Stretta the code itself was reported by hospitals
CPT codes 43257 and 0008T, and that
procedure was transitioned from a New in CY 2005 and includes all
CMS use a different methodology to
Technology APC to clinical APC 0422 endoscopies. In addition, HCPCS code
calculate the median cost. The
(Level II Upper GI Procedures) based on C9701 was deleted for CY 2005 so we
commenter indicated that because CPT
several years of hospital cost data. have no claims for the service from that
codes 43228 and 43830 have higher
Procedures within APC 0422 were year. Further, as we indicated in the CY
volumes but lower costs, the inclusion
similar to the Stretta procedure in terms 2006 OPPS final rule with comment
of them in the same APC as CPT code
of clinical characteristics and resource period that addressed this same issue
43257 does not lead to payment of CPT
use. For both CYs 2005 and 2006, we and similar comment (70 FR 68606), we
code 43257 at a level that is appropriate
specifically calculated the median cost see no reason to create a new APC for
to pay the costs of the service. The same
for the Stretta procedure reported with commenter indicated that the continued CPT codes 43257 and 0008T. We believe
CPT code 43257 taking into account the inclusion of CPT codes 43228 and that the procedures in APC 0422 contain
codes that hospitals billed for the 43830 decrease the payment rate for similar procedures for the treatment of
service in CYs 2003 and 2004, which many of the procedures placed in APC gastroesophageal reflux disease, and
included HCPCS code C9701 and one 0422. The commenter believed that therefore, the APC is appropriately
unit of endoscopy service. For CY 2007, creating the new APC was analogous to structured based on clinical
we proposed to continue with the what CMS proposed to do for vascular homogeneity and resource use.
current APC assignment for the Stretta access devices in the proposed rule. After carefully considering the public
procedure, with no need for a special Response: We disagree with the comments received, we are finalizing
median cost calculation. commenters. We believe that the our proposal for assignment of CPT code
We received several public comments procedures in APC 0422 contain similar 43257 to APC 0422 for CY 2007, with
in response to the CY 2007 proposed procedures for the treatment of a median cost of $1,573.89.
payment rate for the Stretta procedure, gastroesophageal reflux disease, and 5. Ocular Procedures
in particular with a focus on the median these services are, therefore,
appropriately assigned based on clinical a. Keratoprosthesis (APC 0293)
cost methodology.
Comment: Some commenters objected homogeneity and resource use. Thus, for CPT code 65770 (Keratoprosthesis) is
to the APC assignment of the Stretta CY 2007, CPT code 43257 will remain a surgical procedure for implantation of
procedure to APC 0422 and cited the in APC 0422. CPT code 0008T will be a keratoprosthesis, an artificial cornea.
use of the CY 2004 claims data in deleted as of January 1, 2007. For the CY In the CY 2007 proposed rule, we
determining its median cost for CY 2007 OPPS, the payment for APC 0422 indicated that we believed that the
2007. The commenters indicated that is based on the final median cost of keratoprosthesis device that is required
for the implantation is described by external data for these procedures to two-part keratoprosthesis not described
HCPCS code C1818 (Integrated validate whether the claims used for by HCPCS code C1818, it would not be
keratoprosthesis), a device category that ratesetting were properly coded and appropriate for us to use only claims
received transitional pass-through make appropriate adjustments to the reporting HCPCS code C1818 to
payment under the OPPS from July 2003 OPPS payment rate if necessary. calculate the median cost for CPT code
through December 2005. When the pass- Further, the Panel recommended that 65770. If we were to follow the
through status for the device expired for CMS implement a device edit that recommendation of the commenter, we
CY 2006 and the costs of the device would ensure that the device code could be systematically and incorrectly
were packaged into the implantation (HCPCS code C1818) is included on excluding claims for CPT code 65770
procedure, CPT code 65770 continued claims for the keratoprosthesis that may have been correctly coded at
to be assigned to APC 0244 (Corneal procedure. the time by hospitals implanting a two-
Transplant), with a payment rate of The commenters provided hospital part keratoprosthesis with a lower
about $2,275, despite an increase in the data that showed that many hospitals device cost than the cost of the one-
median cost of the implantation that performed the procedure which piece device coded by CPCS code
procedure of about $1,200 associated may be reported for implantation of the C1818.
with the packaging of the device. There costly biointegratable artificial cornea The OPPS is a prospective payment
is no 2 times violation in APC 0244 for described by HCPCS code C1818 did not system that pays based on the median
CY 2006. report charges for the device on their cost of procedures assigned to APC
At the March 2006 meeting of the bills to Medicare. Further, one groups, and to the extent that various
APC Panel, following a presentation commenter performed analyses of devices with dissimilar costs may be
regarding the procedure to implant a Medicare hospital outpatient claims used to provide the same procedure,
keratoprosthesis that described the data and found that if CMS used only those different device costs are
clinical and hospital resource single procedure claims that included packaged into the procedural payment
characteristics of CPT code 65770, the HCPCS code C1818 and CPT code 65770 in relationship to their utilization in the
Panel recommended moving CPT code to establish the median cost for APC procedure. Therefore, we do not believe
65770 to a more appropriate APC in 0293, it would be more than $10,000 the 47 single claims from CY 2005 used
order to make appropriate payment. We and would result in a payment rate that for ratesetting for APC 0293 were
agreed with the recommendation of the would be adequate to cover the costs of miscoded, and we do not believe
APC Panel. At the time of the proposed implantation of the integrated adjustments to the payment rate for APC
rule, claims data from CY 2005 keratoprosthesis device. 0293 established based on the standard
demonstrated that the median cost for Response: In response to the OPPS methodology are needed for CY
implantation of a keratoprosthesis of comments and the APC Panel’s 2007.
$3,127.51 remained significantly higher recommendations, we performed Where there are device HCPCS codes
than the median costs of other additional analyses of our claims data. for all possible devices that could be
procedures assigned to APC 0244, We noted that a new alphanumeric used to perform a procedure that always
although there was no 2 times violation. HCPCS code L8609 (Artificial cornea) requires a device and the APC is
In addition, CPT code 65770 was established in CY 2006, but there designated a device-dependent APC, we
contributed less than 1 percent of the would not have been any claims have commonly instituted device edits
single claims in the APC available for reported for this code in the CY 2005 that prevent payment of claims that do
ratesetting, and it was likely to continue claims data used for this CY 2007 OPPS not include both the procedure and an
to be an uncommon procedure among update. We found that only 8 of the 47 acceptable device code. In that way,
Medicare beneficiaries, resulting in its single claims for CPT code 65770 hospitals become aware of the proper
persistent small contribution to the included the HCPCS device code C1818. coding requirements, and we can be
median cost of APC 0244. Therefore, for The median cost for those few claims confident that our procedure claims
CY 2007, we proposed to create a new was $10,715.30, consistent with the include charges for the necessary
APC 0293 (Level V Anterior Segment commenter’s data analyses. devices so we can establish appropriate
Eye Procedures) with a median cost of Upon further exploration of the payment rates for those procedures.
$3,127.51 and to move CPT code 65770 background of HCPCS device code Because there was a new, more
into that APC in order to more C1818, we noted that we had provided general HCPCS L-code (L8609) created
appropriately pay for the procedure and specific guidance concerning the device for the artificial cornea in CY 2006 that
the related device. CPT code 65770 was code in the June 2003 Transmittal A– may be used to report all
the only code proposed for assignment 03–051, explaining, ‘‘The device is keratoprostheses not already described
to that APC. composed of a flexible, one-piece by HCPCS code C1818, we are accepting
Comment: One commenter and a biocompatible polymer * * *.’’ We are the APC Panel’s recommendation
presenter to the APC Panel during its aware of at least one other device that regarding the establishment of device
August 2006 meeting requested that the may be inserted during the procedure edits for CPT code 65770. We will
procedure be paid at a higher rate than described by CPT code 65770, and that establish a device edit in CY 2007 for
the proposed payment rate. They keratoprosthesis is a two-part device CPT code 65770 that requires reporting
believed that our cost data were that would not be appropriately of an appropriate device HCPCS code to
inaccurate and understated the cost of described by HCPCS code C1818. We ensure that all claims for CPT code
the implantable device, HCPCS code have been told that the device is 65770 in CY 2007 and future years
C1818. The commenters reported that significantly less costly than the device include charges for a required device.
the device, a biointegratable artificial described by HCPCS code C1818, the However, to the extent that devices with
cornea, costs approximately $7,000, far one-piece biointegratable different costs are used to provide the
more than the proposed $3,116.62 OPPS keratoprosthesis. Because there are at keratoprosthesis procedure, unless the
payment rate for the procedure to least two devices with different costs CPT code descriptor for the service is
implant the device. that could have been used in CY 2005 revised or more specific CPT codes are
At its August 2006 meeting, the APC to perform CPT code 65770, but there developed, our claims data will
Panel recommended that CMS consider was no HCPCS code in CY 2005 for the continue to reflect highly variable costs
for the services that are provided using While the payment rates for many APCs ocular reconstructive procedure. The
the full spectrum of keratoprosthesis remain stable over time, in the absence commenters requested that CMS
devices. of APC reconfiguration, it is not unusual reassign HCPCS code V2790 from status
After carefully considering the for the payment rates for certain APCs indicator ‘‘N’’ to status indicator ‘‘F’’ for
comments received, we are adopting our to vary modestly from year to year, CY 2007.
proposal without modification to assign similar to the approximately 10-percent Response: We appreciate the
CPT code 65770 to APC 0293, with a decrease in median costs observed for commenters’’ interest in payment for
median cost of $3,177.05 for CY 2007. APCs 0232 and 0235 for CY 2007. tissues used in ocular treatments. The
We are also assigning a procedure-to- However, as the commenters noted, OPPS has provided separate payment
device edit for CPT code 65770 with other eye procedure APCs also had for corneal tissue acquisition at
APC 0293. proposed increases for CY 2007. The CY reasonable cost since the beginning of
b. Eye Procedures (APCs 0232, 0235, 2007 median costs for APCs 0232 and the OPPS, due to the highly variable
and 0241) 0235 have been calculated based upon corneal tissue processing fees required
CY 2005 claims using the standard for eye banks to provide safe corneal
In Addendum B of the CY 2007 OPPS methodology. In the case of APC tissue from donors as needed for
proposed rule (71 FR 49702), we 0241, the commenter is mistaken to transplant, through special distribution
proposed to assign a payment rate of believe that the CY 2006 OPPS payment channels. These costs may vary
$368.07 for APC 0232 (Level I Anterior rate for the APC was $1,806.03. The CY substantially and unpredictably,
Segment Eye Procedures), a payment 2006 OPPS payment rate for APC 0241 depending on philanthropic and in-kind
rate of $250.82 for APC 0235 (Level I was $1,378.76. Therefore, the proposed service contributions to eye banks that
Posterior Segment Eye Procedures), and payment rate of $1,529.55 for APC 0241 vary from community to community
a payment rate of $1,529.55 for APC was a proposed payment rate increase and from year to year. Our
0241 (Level IV Repair and Plastic Eye for CY 2007. understanding is that amniotic
Procedures). After carefully considering the public membrane retrieved from donated
Comment: Several commenters comments received, we are finalizing placental tissues is a processed,
questioned the reasoning behind the our CY 2007 proposal for APCs 0232, cryopreserved, and commercially
payment reductions for APCs 0232, 0235, and 0241 without modification, marketed product used for ocular
0235, and 0241 when their facilities with final median costs of $370.77, reconstruction that may be stocked and
experienced increased costs for the $240.36, and $1,543.32, respectively.
procedures assigned to these APCs. stored by hospitals. Therefore, there is
Specifically, the commenters questioned c. Amniotic Membrane for Ocular no need for HCPCS code V2790 to be
why the payment rate for APC 0232 Surface Reconstruction paid based on reasonable cost outside of
declined from $411.84 for CY 2006 to the OPPS. Instead, like many items
In Addendum B of the CY 2007
the proposed payment rate of $368.07 under the OPPS used in surgical
proposed rule (71 FR 49845), we
for CY 2007; why the payment rate for procedures, its prospective payment is
proposed to assign HCPCS code V2790
APC 0235 declined from $285.21 for CY appropriately packaged into payment
(Amniotic membrane for surgical
2006 to the proposed payment rate of reconstruction, per procedure) to status for the procedures in which it is used.
$250.82 for CY 2007; and why the After consideration of the public
indicator ‘‘N’’ (packaged).
payment rate for APC 0241 declined Comment: Several commenters comments received, we are finalizing
from $1,806.03 for CY 2006 to the requested that CMS consider assigning our proposed CY 2007 payment policies
proposed payment rate of $1,529.55 for status indicator ‘‘F’’ (paid at reasonable without modification for HCPCS codes
CY 2007. At the same time, several cost) to HCPCS code V2790 rather than V2785 and V2790 as reflected in their
commenters supported the proposed status indicator ‘‘N’’. One commenter assigned status indicators.
payment increases for APCs 0242 (Level indicated a discrepancy in payment 6. Other Procedures
V Repair and Plastic Eye Procedures), policy and status indicator assignment
a. Skin Replacement Surgery and Skin
0245 (Level I Cataract Procedures for two types of tissues currently used
Substitutes (APC 0025)
without IOL Insert), 0247 (Laser Eye for ocular surface transplants; that is,
Procedures Except Retinal), 0248 (Laser HCPCS code V2785 (Processing, For CY 2006, the AMA made
Retinal Procedures), 0673 (Level IV preserving and transporting corneal comprehensive changes, including code
Anterior Segment Eye Procedures), and tissue), which is assigned to status additions, deletions, and revisions,
0699 (Level IV Eye Tests and indicator ‘‘F’’ and HCPCS code V2790, accompanied by new and revised
Treatment). The commenters requested which is assigned to status indicator introductory language, parenthetical
that CMS reexamine the proposed ‘‘N,’’ are not treated similarly with notes, subheadings and cross-references,
payments for APCs 0232, 0235, and regard to status indicator assignments to the Integumentary, Repair (Closure)
0241. and OPPS payment policy. The subsection of surgery in the CPT book
Response: Each year, we reevaluate commenters added that payment for to facilitate more accurate reporting of
APC assignments for procedures, items and services assigned to status skin grafts, skin replacements, skin
services, and items paid under the indicator ‘‘N’’ is packaged into payment substitutes, and local wound care. In
hospital OPPS based on claims data for the associated procedures, while particular, the section of the CPT book
paid by Medicare to set annual payment payment for items and services assigned previously titled ‘‘Free Skin Grafts’’ and
rates. Based on our analyses, we make to status indicator ‘‘F’’ is made at containing codes for skin replacement
changes to the APC assignments when reasonable cost, not under the OPPS. and skin substitute procedures was
necessary. As we stated in the CY 2007 The commenters believed this renamed, reorganized, and expanded.
OPPS proposed rule (71 FR 49514), we discrepancy could create a competitive New and existing CPT codes related to
used approximately 50.7 million whole disadvantage and financial disincentive skin replacement surgery and skin
claims that reflected services furnished for hospitals to promote the treatment of substitutes were organized into five
on or after January 1, 2005, and before ocular surface diseases using amniotic subsections: Surgical Preparation,
January 1, 2006, to recalibrate the APC membrane tissue, and ultimately Autograft/Tissue Cultured Autograft,
relative payment weights for CY 2007. impede beneficiary access to this unique Acellular Dermal Replacement,
Allograft/Tissue Cultured Allogeneic additional one percent of body area of body area of infants and children, or
Skin Substitute, and Xenograft. infants and children, or part thereof) part thereof).
As part of the CY 2006 CPT code • CPT code 15320 (Allograft skin for The CY 2006 interim final APC
update in the newly named ‘‘Skin temporary wound closure, face, scalp, assignments of these codes, the
Replacement Surgery and Skin eyelids, mouth neck, ears, orbits, recommendations made by the APC
Substitutes’’ section, certain codes were genitalia, hands, feet and/or multiple Panel at its March 2006 meeting, and
deleted that previously described skin digits; first 100 sq cm or less, or one our proposed placement of the codes for
allograft and tissue cultured and percent of body area of infants and CY 2007 were listed in Table 11 of the
acellular skin substitute procedures, children) CY 2007 OPPS proposed rule (71 FR
including CPT code 15342 (Application • CPT code 15321 (Allograft skin for 49557). As noted in the proposed rule,
of bilaminate skin substitute/ temporary wound closure, face, scalp, in general, biological skin substitutes
neodermis; 25 sq cm), CPT code 15343 eyelids, mouth neck, ears, orbits, and replacements used in procedures
(Application of bilaminate skin genitalia, hands, feet and/or multiple described by these CPT codes were
substitute/neodermis; each additional digits; each additional 100 sq cm, or proposed for separate payment under
25 sq cm), CPT code 15350 (Application each additional one percent of body area the OPPS for CY 2007, according to the
of allograft, skin; 100 sq cm or less), and of infants and children, or part thereof) methodology outlined in section V. of
CPT code15351 (Application of • CPT code 15340 (Tissue cultured the preamble of the proposed rule (71
allograft, skin; each additional 100 sq allogeneic skin substitute; first 25 sq cm FR 49557) and discussed in this
cm). Thirty-seven new CPT codes were or less) preamble.
created in the ‘‘Skin Replacement • CPT code 15341 (Tissue cultured As we indicated in the proposed rule
Surgery and Skin Substitutes’’ section, allogeneic skin substitute; each (71 FR 49558), we reviewed the
and these codes received interim final additional 25 sq cm) presentations to the APC Panel; the APC
status indicators and APC assignments • CPT code 15360 (Tissue cultured Panel’s recommendations; the CPT code
in the CY 2006 final rule with comment allogeneic dermal substitute; trunk, descriptors, introductory explanations,
period and were subject to comment. At arms, legs; first 100 sq cm or less, or one cross-references, and parenthetical
its March 2006 meeting, the APC Panel percent of body area of infants and notes; the clinical characteristic of the
heard several presentations on some of children) procedures; and the code-specific
the new CY 2006 CPT codes for skin • CPT code 15361 (Tissue cultured median costs for all related CPT codes
replacement and skin substitute allogeneic dermal substitute; trunk, available from our CY 2005 claims data.
procedures, and CMS has received arms, legs; each additional 100 sq cm, While we agreed with the APC Panel
additional information from the public or each additional one percent of body that the codes currently placed in APC
regarding a number of these services. In area of infants and children, or part 0024 (Level I Skin Repair) should be
particular, 18 new CPT codes that were thereof) assigned to an APC with a higher
created to more specifically describe • CPT code 15365 (Tissue cultured median cost for CY 2007, we disagreed
skin allograft, skin replacement, and allogeneic dermal substitute, face, scalp, that these procedures should be placed
skin substitute procedures were the eyelids, mouth neck, ears, orbits, in APC 0027 (Level IV Skin Repair). The
subject of the APC Panel discussion and genitalia, hands, feet and/or multiple APC Panel presenters reasoned that
recommendations. These codes are as digits; first 100 sq cm or less, or one some of the codes (CPT codes 15170,
follows: percent of body area of infants and 15175, 15320, 15340, 15360, 15365,
• CPT code 15170 (Acellular dermal children) 15420, and 15430) for the first
replacement, trunk, arms, legs; first 100 • CPT code 15366 (Tissue cultured increment of body surface area treated
sq cm or less, or one percent of body allogeneic dermal substitute, face, scalp, should be placed in APC 0027 because
area of infants and children) eyelids, mouth neck, ears, orbits, they are similar to CPT code 15300
• CPT code 15171 (Acellular dermal genitalia, hands, feet and/or multiple (Allograft skin for temporary wound
replacement, trunk, arms, legs; each digits; first 100 sq cm or less, or one closure, trunk, arms, legs; first 100 sq
additional 100 sq cm, or each additional percent of body area of infants and cm or less, or one percent of body area
one percent of body area of infants and children) of infants and children). Upon further
children, or part thereof) • CPT code 15420 (Xenograft skin review of the clinical and expected
• CPT code 15175 (Acellular dermal (dermal), for temporary wound closure, hospital resource characteristics of CPT
replacement, face, scalp, eyelids, mouth face, scalp, eyelids, mouth neck, ears, code 15300, we asserted in the proposed
neck, ears, orbits, genitalia, hands, feet orbits, genitalia, hands, feet and/or rule that this procedure was not
and/or multiple digits; first 100 sq cm multiple digits; first 100 sq cm or less, appropriately placed in APC 0027.
or less, or one percent of body area of or one percent of body area of infants Split-thickness and full thickness skin
infants and children) and children) autograft procedures currently assigned
• CPT code 15176 (Acellular dermal • CPT code 15421 (Xenograft skin to APC 0027 were likely to require
replacement, face, scalp, eyelids, mouth (dermal), for temporary wound closure, greater hospital resources, including
neck, ears, orbits, genitalia, hands, feet face, scalp, eyelids, mouth neck, ears, additional operating room time and
and/or multiple digits; each additional orbits, genitalia, hands, feet and/or special equipment, in comparison to
100 sq cm, or each additional one multiple digits; each additional 100 sq application of a separately paid allograft
percent of body area of infants and cm, or each additional one percent of skin product. Instead, for CY 2007 we
children, or part thereof) body area of infants and children, or proposed to reassign CPT code 15300 to
• CPT code 15300 (Allograft skin for part thereof) APC 0025 (Level II Skin Repair), with an
temporary wound closure, trunk, arms, • CPT code 15430 (Acellular APC median cost of $314.58. We agreed,
legs; first 100 sq cm or less, or one xenograft implant; first 100 sq cm or in principle, that other CPT codes for
percent of body area of infants and less, or one percent of body area of the first increment of body surface area
children) infants and children) treated with a skin replacement or skin
• CPT code 15301 (Allograft skin for • CPT code 15431 (Acellular substitute were similar clinically and
temporary wound closure; trunk, arms, xenograft implant; each additional 100 from a hospital resource perspective to
legs; each additional 100 sq cm, or each sq cm, or each additional one percent of CPT code 15300 and, therefore, we
proposed to assign these procedures to appropriate payment for the costs of services, described by CPT codes 15170
APC 0025 as well for CY 2007. surgical debridement of the wound to through 15176, and about temporary
Similarly, presenters reasoned that prepare it properly for application of the wound closure by allograft services,
the related add-on codes (CPT codes allogeneic skin substitute. Several described by CPT codes 15300 through
15171, 15176, 15321, 15342, 15361, commenters on the CY 2007 proposed 15321. In contrast to our proposal, the
15366, 15421, and 15431) for rule supported our proposal to assign commenters believed that, based on the
procedures to treat additional body new CPT codes 15340 and 15341 to APC clinical characteristics and expected
surface areas are similar to CPT code 0025. One commenter noted that the costs including anesthesia, procedure
15301 (Allograft skin for temporary proposed assignments of these CPT room time, supplies, and preparation of
wound closure, trunk, arms, legs; each codes for tissue cultured allogeneic skin the products for application, these
additional 100 sq cm, or each additional substitutes to APC 0025 for CY 2007 services would be most appropriately
one percent of body area of infants and would correct substantial reductions in assigned to APC 0686 (Level III Skin
children, or part thereof) in terms of payment for application of one product Repair). They believed that CMS had
required hospital resources. CPT code that occurred with the assignment of underestimated the resources required
15301 is assigned to APC 0025 for CY these CPT codes to APC 0024 for CY to perform these procedures.
2006. We proposed to maintain the 2006. The commenter believed that our
Response: While the commenters
assignment of CPT code 15301 to APC proposal represented a significant step
provided comparisons among the
0025 for CY 2007 and to reassign the toward the appropriate payment for
expected relative costs of various
other add-on codes to this APC. Note these services. The commenter further
procedures, the commenter provided no
that APC 0025 has a status indicator of claimed that its external analyses of
specific cost analyses to persuade us to
‘‘T,’’ so that the add-on codes would Medicare claims data supported the
assign CPT codes 15170 through 15176
experience the standard OPPS multiple change, with a median cost for new CPT
and 15300 through 15321 to a skin
surgical procedure reduction when code 15340 that was higher than the
repair APC that would provide payment
properly billed with the first body median cost of APC 0025 but lower than
at two and a half times the proposed
surface area treatment codes that are the median cost of APC 0027.
payment rate for these services. We do
assigned to the same clinical APC. We Response: We appreciate the
not agree that the clinical and resource
asserted in the proposed rule that this recognition from the commenter that the
distinctions between these procedures
reduction in payment for the procedural proposed assignments of CPT codes
and other services also assigned to APC
resources associated with the add-on 15340 and 15341 to APC 0025 provides
0025 would warrant their reassignment
services was appropriate. (71 FR 49558). more appropriate payment for these
to APC 0686, with its significantly
The APC Panel did not hear any services.
Comment: A commenter supported higher payment rate than their CY 2007
presentations or make any
our CY 2007 proposed assignments of proposed payment rate. We note that we
recommendations regarding skin
CPT codes 15170 through 15176, will have claims data for all of these
substitutes or skin replacement codes
15300–15321, 15340–15366, and 15420– CPT codes available for the CY 2008
and APCs at its August 2006 meeting.
Comment: One commenter on the CY 15431 to APC 0025. One commenter OPPS update.
2006 final rule requested that we agreed that skin substitute or After carefully considering the public
reassign CPT codes 15340 and 15341 to replacement add-on codes (CPT codes comments received, we are finalizing
APC 0025, where the services would be 15171, 15176, 15301, 15321, 15341, our proposed assignments of skin
grouped with clinically related services 15361, 16366, 15421, and 15431) should substitute and skin replacement
that require comparable hospital be placed in APC 0025. Another procedures as shown in Table 16 below
resources. In particular, the commenter commenter provided significant clinical without modification.
noted that APC 0024 did not provide detail about dermal replacement BILLING CODE 4120–01–P
BILLING CODE 4120–01–C

high of about $3,893. We received fixation at that time but we
b. Treatment of Fracture/Dislocation comments to the CY 2006 proposed rule acknowledged that we had treated APC
(APCs 0062, 0063, and 0064) (70 FR 42674) requesting that we 0046 as an exception to the 2 times rule
distinguish procedures containing ‘‘with for several years. For CY 2006, we again
APC 0046 (Open/Percutaneous
Treatment Fracture or Dislocation) was or without external fixation’’ in their treated APC 0046 as an exception to the
a large clinical APC to which many descriptors to provide greater payments 2 times rule, but noted we would ask
procedures related to the percutaneous when external fixation is used to treat the APC Panel to consider whether this
or open treatment of fractures and fractures. The commenters explained APC could be reconfigured to improve
dislocations are assigned for CY 2006. that when external fixation devices are its clinical and resource homogeneity.
Most of the approximately 100 used, the costs of the procedures At the March 2006 meeting of the
procedures in the APC are relatively low increase, and, therefore, the current APC APC Panel, we asked the Panel to
volume, with even fewer single bills placement significantly underpays those consider a possible reconfiguration of
available for ratesetting. The median procedures in those instances. In the CY APC 0046 based on partial year CY 2005
costs of the significant procedures in 2006 final rule with comment period (70 claims data. The reconfiguration would
this APC as configured for CY 2006 FR 68607), we declined to reassign create three new APCs and would
ER24NO06.017</GPH>
range from a low of about $1,415 to a procedures that could include external divide the codes in APC 0046 among
them. The APC Panel recommended area), was not clinically coherent with requiring manipulation, with or without
that CMS continue to evaluate the the other procedures in APC 0046, and external fixation) for CY 2007, replacing
refinement of APC 0046 into at least we proposed to reassign this procedure it with CPT code 25606 (Percutaneous
three APC levels, with consideration of outside of the Fracture/Dislocation skeletal fixation of distal radial fracture
a fourth level should data support this series to APC 0050 (Level II or epiphyseal separation). AMA’s CPT
additional level. We accepted the APC Musculoskeletal Procedures Except Editorial Panel has also deleted CPT
Panel’s recommendation and proposed Hand and Foot) for CY 2007. code 25620 (Open treatment of distal
for CY 2007 to split APC 0046 into three We received two supportive radial fracture (e.g., Colles or Smith
new APCs: APC 0062 (Level I Treatment comments on our proposed type) or epiphyseal separation, with or
Fracture/Dislocation); APC 0063 (Level reconfiguration of APC 0046. A without fracture of ulnar styloid, with or
II Treatment Fracture/Dislocation); and summary of the comments and our without internal or external fixation) for
APC 0064 (Level III Treatment Fracture/ response follow: CY 2007, replacing it with three CPT
Dislocation). To ensure clinical and Comment: A few commenters codes as refinements: CPT code 25607
resource homogeneity in the new APCs, supported our proposal to move from (Open treatment of distal radial
their proposed configurations were one APC (0046) to three APCs (0062, extraarticular fracture or epiphyseal
based on the procedure code 0063, and 0064) for services that treat separation, with internal fixation); CPT
descriptors, clinical considerations fractures and dislocations. The code 25608 (Open treatment of distal
specific to each procedure, and service- commenters noted that three APCs radial intraarticular fracture or
specific hospital resource utilization as better recognize the differences in epiphyseal separation; with internal
shown in the claims data from CY 2005. hospital resource utilization. The fixation of two fragments); and CPT
Restructuring APC 0046 into these three commenters noted that OPPS payments code 25609 (Open treatment of distal
new APCs eliminated 2 times rule would increase significantly for the radial intraarticular fracture or
violations in the Fracture/Dislocation highest level of fracture and dislocation epiphyseal separation; with internal
series. treatment, decrease for the lowest level, fixation of three or more fragments).
The APC Panel did not hear any and remain relatively stable for the These changes are effective January 1,
presentations or make any medium treatment level. 2007. The interim final APC
recommendations regarding APC 0046 Response: We appreciate the assignments of the new CY 2007 CPT
or our proposed APCs 0062, 0063, and acknowledgement that we are codes for fracture treatments are
0064 at its August 2006 meeting. attempting to better recognize the included in Table 17 below.
We did not propose a fourth APC differences in hospital resource After carefully considering the
level in the Fracture/Dislocation series utilization for fracture and dislocation comments received, we are finalizing
because we did not believe our claims procedures. our proposal without modification to
data were sufficiently robust and We note that AMA’s CPT Editorial reconfigure CY 2006 APC 0046 for
consistent from year to year to support Panel has deleted CPT 25611 fracture and dislocation procedures into
differential payment for another service (Percutaneous skeletal fixation of distal three new APCs for CY 2007, APCs
level. One code, CPT 27615 (Radical radial fracture (e.g., Colles or Smith 0062, 0063, and 0064, as displayed in
resection of tumor (e.g., malignant type) or epiphyseal separation, with or Table 17, and to reassign CPT code
neoplasm), soft tissue of leg or ankle without fracture of ulnar styloid, 27615 to APC 0050.
TABLE 17.—RECONFIGURATION OF APC 0046

HCPCS CY 2007
Description
code APC
21336 ........................................................... Treat nasal septal fracture ................................................................................................ 0063

21805 ........................................................... Treatment of rib fracture .................................................................................................... 0062
23515 ........................................................... Treat clavicle fracture ........................................................................................................ 0064
23530 ........................................................... Treat clavicle dislocation ................................................................................................... 0063
23585 ........................................................... Treat scapula fracture ....................................................................................................... 0064
23615 ........................................................... Treat humerus fracture ...................................................................................................... 0064
23660 ........................................................... Treat shoulder dislocation ................................................................................................. 0063
23670 ........................................................... Treat dislocation/fracture ................................................................................................... 0064
23680 ........................................................... Treat dislocation/fracture ................................................................................................... 0063

24586 ........................................................... Treat elbow fracture .......................................................................................................... 0064
24615 ........................................................... Treat elbow dislocation ...................................................................................................... 0064
24665 ........................................................... Treat radius fracture .......................................................................................................... 0063
TABLE 17.—RECONFIGURATION OF APC 0046—Continued

HCPCS CY 2007
Description
code APC
24666 ........................................................... Treat radius fracture .......................................................................................................... 0064

24685 ........................................................... Treat ulnar fracture ............................................................................................................ 0063
25515 ........................................................... Treat fracture of radius ...................................................................................................... 0063
25545 ........................................................... Treat fracture of ulna ......................................................................................................... 0063
25574 ........................................................... Treat fracture radius & ulna .............................................................................................. 0064
25575 ........................................................... Treat fracture radius/ulna .................................................................................................. 0064
25606 (25611 deleted) ................................ Treat fx distal radial ........................................................................................................... 0062
25607 (25620 deleted) ................................ Treat fx rad extra-articul .................................................................................................... 0064
25608 (25620 deleted) ................................ Treat fx rad intra-articul ..................................................................................................... 0064
25609 (25620 deleted) ................................ Treat fx radial 3+ frag ........................................................................................................ 0064
25628 ........................................................... Treat wrist bone fracture ................................................................................................... 0063
25645 ........................................................... Treat wrist bone fracture ................................................................................................... 0063
25651 ........................................................... Pin ulnar styloid fracture .................................................................................................... 0062
25652 ........................................................... Treat fracture ulnar styloid ................................................................................................ 0063
25670 ........................................................... Treat wrist dislocation ........................................................................................................ 0062
25671 ........................................................... Pin radioulnar dislocation .................................................................................................. 0062
25685 ........................................................... Treat wrist fracture ............................................................................................................ 0062
26608 ........................................................... Treat metacarpal fracture .................................................................................................. 0062
26615 ........................................................... Treat metacarpal fracture .................................................................................................. 0063
26650 ........................................................... Treat thumb fracture .......................................................................................................... 0062
26665 ........................................................... Treat thumb fracture .......................................................................................................... 0063
26676 ........................................................... Pin hand dislocation .......................................................................................................... 0062
26685 ........................................................... Treat hand dislocation ....................................................................................................... 0063
26686 ........................................................... Treat hand dislocation ....................................................................................................... 0064
26715 ........................................................... Treat knuckle dislocation ................................................................................................... 0063
26727 ........................................................... Treat finger fracture, each ................................................................................................. 0062
26756 ........................................................... Pin finger fracture, each .................................................................................................... 0062
26776 ........................................................... Pin finger dislocation ......................................................................................................... 0062
26785 ........................................................... Treat finger dislocation ...................................................................................................... 0062
27202 ........................................................... Treat tail bone fracture ...................................................................................................... 0063
27509 ........................................................... Treatment of thigh fracture ................................................................................................ 0062
27524 ........................................................... Treat kneecap fracture ...................................................................................................... 0063
27566 ........................................................... Treat kneecap dislocation ................................................................................................. 0063
27615 ........................................................... Remove tumor, lower leg .................................................................................................. 0050
27756 ........................................................... Treatment of tibia fracture ................................................................................................. 0062
27766 ........................................................... Treatment of ankle fracture ............................................................................................... 0063
27784 ........................................................... Treatment of fibula fracture ............................................................................................... 0063
27826 ........................................................... Treat lower leg fracture ..................................................................................................... 0063
27829 ........................................................... Treat lower leg joint ........................................................................................................... 0063
27832 ........................................................... Treat lower leg dislocation ................................................................................................ 0063
27846 ........................................................... Treat ankle dislocation ...................................................................................................... 0063
27848 ........................................................... Treat ankle dislocation ...................................................................................................... 0063
28406 ........................................................... Treatment of heel fracture ................................................................................................. 0062
28415 ........................................................... Treat heel fracture ............................................................................................................. 0063
28420 ........................................................... Treat/graft heel fracture ..................................................................................................... 0063
28445 ........................................................... Treat ankle fracture ........................................................................................................... 0063
28456 ........................................................... Treat midfoot fracture ........................................................................................................ 0062
28465 ........................................................... Treat midfoot fracture, each .............................................................................................. 0063
28476 ........................................................... Treat metatarsal fracture ................................................................................................... 0062

28485 ........................................................... Treat metatarsal fracture ................................................................................................... 0063
28496 ........................................................... Treat big toe fracture ......................................................................................................... 0062
28505 ........................................................... Treat big toe fracture ......................................................................................................... 0063
28525 ........................................................... Treat toe fracture ............................................................................................................... 0063
28531 ........................................................... Treat sesamoid bone fracture ........................................................................................... 0063
28545 ........................................................... Treat foot dislocation ......................................................................................................... 0062
TABLE 17.—RECONFIGURATION OF APC 0046—Continued

HCPCS CY 2007
Description
code APC

28555 ........................................................... Repair foot dislocation ....................................................................................................... 0063
28636 ........................................................... Treat toe dislocation .......................................................................................................... 0062
28645 ........................................................... Repair toe dislocation ........................................................................................................ 0063
28666 ........................................................... Treat toe dislocation .......................................................................................................... 0062
28675 ........................................................... Repair of toe dislocation .................................................................................................... 0063
c. Complex Skin Repair (APC 0024) codes and recommend appropriate APC device to remain on pass-through status
assignments for them for CY 2007. through CY 2008 and, therefore, be paid
In the CY 2007 OPPS proposed rule, separately through that time. However,
Comment: Some commenters
we proposed to assign CPT code 13151 the commenter expressed concern that
indicated that CMS should place new
(Repair, complex, eyelids, nose, ears once the device is no longer paid
procedure codes 0171T and 0172T into
and/or lip, 1.1 cm to 2.5 cm, to APC separately under pass-through payment,
clinical APC 0051 (Level III
0024 (Level I Skin Repair) with a the device costs, which would be a
Musculoskeletal Procedures Except
payment rate of $91.86. substantial percentage of total
Hand and Foot). Although the level of
Comment: One commenter asked why resources used in performing CPT code procedural costs, would be packaged
CPT code 13151 (Repair, complex, 0172T (second and subsequent level into payment for the procedural APC
eyelids, nose, ears and/or lips; 1.1 cm to implants) is less than those used for and adjusted by the wage index that is
2.5 cm) was assigned to APC 0024, CPT code 0171T (the single level applied to 60 percent of the payment
rather than to APC 0025 (Level II Skin implant of the device), the commenters rate. The commenter requested that
Repair). The commenter pointed out believed that APC 0051 is also CMS address this issue, so that once
that the smaller skin repair represented appropriate for 0172T because APC payment for the spinous process
by CPT code 13150 was assigned to APC 0051 is subject to the multiple distraction device is packaged into the
0025 with other more complex skin procedure discount. CPT code 0172T is procedural APC payment, hospitals
repair procedures. an add-on code to the primary with wage indices below 1.0 would be
Response: We agree with the procedure reported with CPT code able to continue offering the procedure
commenter that CPT code 13151 would 0171T; therefore, payment for 0172T to patients.
be more appropriated assigned to APC would always be reduced by 50 percent. Another commenter stated that it had
0025 and are making that reassignment One commenter stated that the resource performed four spinous process
effective January 1, 2007. elements they outlined specifically for distraction device cases over the past
CPT code 0172T are all costs incurred year. All four cases had similar
d. Insertion of Posterior Spinous Process
separately and in addition to the costs utilization patterns and outcomes. The
Distraction Device
of the single level procedure, CPT code commenter claimed to have evaluated
The AMA released two new Category 0171T. The commenter believed it the time and resources needed to
III codes on July 1, 2006, for insertion would be inappropriate to place CPT complete the procedure, and compared
of a posterior spinous process code 0172T into an APC based on the the costs to other procedures, for
distraction device, namely: 0171T claimed resources, and then reduce the example, laminectomies and
(Insertion of posterior spinous process payment rate by 50 percent when a diskectomies, performed at the hospital,
distraction device (including necessary multiple procedure discount applies to and also extracted single procedure
removal of bone or ligament for every case that is correctly coded. The costs for all cases performed in APCs
insertion and imaging guidance), commenter provided charge data from 0049 through 0052. The commenter
lumbar; single level); and 0172T seven claims for six different facilities determined that the costs of the four
(Insertion of posterior spinous process that performed the single level spinous process distraction device cases
distraction device (including necessary procedure (CPT code 0171T). The were most consistent with the costs of
removal of bone or ligament for commenter calculated a ‘‘median’’ of other services assigned to APC 0051.
insertion and imaging guidance), these charges reduced to cost of $2,727, Response: The commenters provided
lumbar; each additional level (List which the commenter asserted was their recommendation based on their
separately in addition to code for within the range of median costs of limited cost studies that relied on
primary procedure)). These two new other procedures assigned to APC 0051. information from a few hospitals with
codes are effective January 1, 2007. The commenter stated that it was unable experience implanting spinous process
Moreover, we have created a new device to obtain any facility charge or cost data distraction devices. This is not unusual
category for transitional pass-through for CPT code 0172T. The commenter for new procedures, such as CPT
payment, effective January 1, 2007, acknowledged that CMS had also Category III codes. We examined the
C1821 (Interspinous process distraction granted transitional pass-through procedural resource information
device (implantable)), which we expect payment status for spinous process provided by commenters as well as
to be reported with these procedures. At distraction devices effective January 1, considered CY 2005 claims data for
its August 2006 meeting, the APC Panel 2007. other musculoskeletal procedures in the
recommended that CMS review the One commenter indicated that it OPPS. We believe that both of the
resources required for these new CPT expected the spinous process distraction procedures describe by CPT codes
0171T and 0172T would be most assignment in July 2006, if possible, or medication therapy management
appropriately assigned to APC 0050 otherwise in CY 2007; and provide services were imbedded as a component
(Level II Musculoskeletal Procedures guidance to hospitals on how and when within our claims data, we were
Except Hand and Foot), based on both these codes should be reported. As confident that our CY 2005 claims data
clinical and expected resource indicated in the CY 2007 OPPS reflected the costs of pharmacist
considerations. Their assignment to the proposed rule (71 FR 49563), we did not medication management services
same clinical APC for CY 2007 will accept the APC Panel’s provided to hospital outpatients who
ensure appropriate payment for CPT recommendations. Rather, we proposed were receiving hospital services.
code 0172T when the multiple to continue to assign status indicator We received a large number of public
procedure payment reduction is ‘‘B’’ to CPT codes 0115T, 0116T, and comments concerning our proposal for
applied. We note that the device cost of 0117T for CY 2007. CPT codes 0115T, 0116T, and 0117. A
HCPCS code C1821 (Interspinous According to the AMA, the purpose of summary of the comments and our
process distraction device Category III CPT codes is to facilitate responses follows:
(implantable)), will be paid separately data collection on and assessment of Comment: Most commenters
under the OPPS for at least 2 and not new services and procedures. requested that Medicare pay separately
more than 3 years of pass-through Medication therapy management for medication therapy management
payment. After that period, payment for services are not new services in the because it is difficult for the hospital to
the cost of the device would be OPPS, as they have been provided to provide this service without receiving
packaged into the procedural APC patients by hospitals in the past as any payment. One commenter
payments for its implantation, most components of a wide variety of services elaborated on the emerging role of a
likely CPT codes 0171T and 0172T. At provided by hospitals, including clinic pharmacist and the increasing scope of
that time, we will further evaluate the and emergency room visits, procedures, services provided by the pharmacist to
most appropriate APC assignments for and diagnostic tests. As such, in the CY the patient, including proactive
these procedures, as we will each year. 2007 proposed rule, we noted that we assessments rather than simply reactive
For a discussion about application of believe their associated hospital responses. This commenter stated that
the wage index to payments for APCs resource costs were already although the historical resource costs of
that have significant device costs, see incorporated into the OPPS payments the pharmacist’s services may be
section IV.A.2 of this final rule with for these other services that are based on captured in the claims data, it was
comment period. historical hospital claims data. The unlikely that the resource costs of the
After carefully considering the public three Category III CPT codes specifically new responsibilities are represented in
comments received, we are accepting describe medication therapy the data. Another commenter quoted
the APC Panel’s recommendation and management services provided by a statistics that estimated that, in 2004,
assigning CPT codes 0171T and 0172T pharmacist. We indicated that we had only 30 percent of hospitals had
to APC 0050 with status indicator ‘‘T’’ no need to distinguish medication pharmacists who were involved in
for CY 2007. These assignments are therapy management services provided ambulatory care. Of those who were
interim final, and, therefore, open to by a pharmacist in a hospital from involved, only 50 percent had
medication therapy management involvement in medication therapy
comment in this final rule with
services provided by other hospital staff, management services. Therefore,
comment period.
as the OPPS only makes payments for although there may be cost data
7. Medical Services services provided incident to embedded in the claims, the fact that
a. Medication Therapy Management physicians’ services. Hospitals these services have historically been
Services providing medication therapy provided infrequently means that the
management services incident to costs of these services have minimal
Following a presentation at its March physicians’ services may choose a impact on our median cost data. Many
2006 meeting, the APC Panel made two variety of staffing configurations to commenters noted that these pharmacist
recommendations regarding Category III provide those services, taking into services reduce costs in the long run by
CPT codes for pharmacist medication account other relevant factors such as improving the health of patients. One
therapy management services that were State and local laws and hospital commenter agreed that these services
new for CY 2006. These services include policies. are already accounted for in the claims
CPT codes 0115T (medication therapy In the CY 2007 proposed rule, we data and further agreed that there is no
management services provided by a explained that in general, we do not need to distinguish between services
pharmacist, individual, face-to-face with establish new clinical APCs for new provided by pharmacists and other
patient, initial 15 min., w/ assessment codes and set payment rates for those providers. One commenter suggested
and intervention if provided; initial APCs when we have no cost data for any that medication therapy management
encounter), 0116T (medication therapy services populating the APCs. New could be provided to a patient on the
management; subsequent encounter), codes for which we believe that there same day as a laboratory test and
and 0117T (medication therapy are no existing clinical APCs compatible requested that CMS clarify the
management; additional 15 min.). These with their expected clinical and hospital appropriate billing technique under
codes were assigned status indicator resource characteristics are often such circumstances. Another
‘‘B’’ in the CY 2006 OPPS final rule with assigned to New Technology APCs until commenter specifically asked if it was
comment period, indicating that they we have sufficient cost data to appropriate to bill CPT code 99211, the
are not recognized by the OPPS when determine appropriate clinical APC lowest level clinic visit, if the only
submitted on an outpatient hospital Part assignments. However, these medication service provided to a patient is
B bill type, with comment indicator therapy management codes would not medication therapy management by a
‘‘NI’’ to identify them as subject to be eligible to map to New Technology pharmacist. One commenter agreed that
comment. The APC Panel recommended APCs because they are not new services these services are not technically new,
that CMS create a new APC, with a that are unrepresented in historical but suggested that CMS map them to
nominal payment, to which we would hospital claims data. As stated earlier, New Technology APCs because they are
assign these codes; implement the because we believe the costs of new in the sense that they are now more
readily available independent of a inappropriate. A hospital may bill a CY 2007 APC 0381 median cost
physician’s service or clinic procedure. visit code, based on the hospital’s own calculated based upon 382 single
One pharmacy association objected to coding guidelines which must claims, using the methodology as
our statement that these services can be reasonably relate the intensity of proposed, is $16.43.
provided by staff other than hospital resources to the different levels
c. Hyperbaric Oxygen Therapy (APC
pharmacists. The association notes that of HCPCS codes. Services furnished
0659)
pharmacists have distinct training, must be medically necessary and
skills, and abilities to perform these documented. When hyperbaric oxygen therapy
services, which are reflected in the new After carefully considering the (HBOT) is prescribed for promoting the
Category III codes. comments received, we are continuing healing of chronic wounds, it typically
Response: We agree with the to assign status indicator ‘‘B’’ to CPT is prescribed for 90 minutes and billed
commenters that medication therapy codes 0115T, 0116T, and 0117T for CY using multiple units of HBOT on a
management services are important 2007 and finalizing our proposed policy single line or multiple occurrences of
services provided to patients and that without modification. HBOT on a claim. In addition to the
providers should receive payments for therapeutic time spent at full hyperbaric
b. Single Allergy Tests (APC 0381) oxygen pressure, treatment involves
these services. We would expect the
hospital charges for the services We proposed to continue with our additional time for achieving full
provided to the patient to include methodology of differentiating single pressure (descent), providing air breaks
charges for all hospital resource costs allergy tests (‘‘per test’’) from multiple to prevent neurological and other
associated with the patient’s care, allergy tests (‘‘per visit’’) by assigning complications from occurring during the
including medication therapy these services to two different APCs to course of treatment, and returning the
management services, if appropriate. As provide accurate payments for these patient to atmospheric pressure (ascent).
we stated above, medication therapy tests in CY 2007. Multiple allergy tests The OPPS recognizes HCPCS code
management services are not new are assigned to APC 0370 (Allergy Tests) C1300 (Hyperbaric oxygen under
services, and they have been provided with a median cost calculated based on pressure, full body chamber, per 30
in the past as components of a wide the standard OPPS methodology. We minute interval) for HBOT provided in
variety of services provided by provided billing guidance in CY 2006 in the hospital outpatient setting.
hospitals, including clinic and Transmittal 804 (issued on January 3, In the CY 2005 final rule with
emergency room visits, procedures, and 2006) specifically clarifying that comment period (69 FR 65758 through
diagnostic tests. Although we do not hospitals should report charges for the 65759), we finalized a ‘‘per unit’’
make separate payment for medication CPT codes that describe single allergy median cost calculation for APC 0659
therapy management provided by a tests to reflect charges ‘‘per test’’ rather (Hyperbaric Oxygen) using only claims
pharmacist, the costs for this service are than ‘‘per visit’’ and should bill the with multiple units or multiple
included in the costs of other services appropriate number of units of these occurrences of HCPCS code C1300
furnished by the hospital on the same CPT codes to describe all of the tests because delivery of a typical HBOT
day. Therefore, we continue to believe provided. However, our CY 2005 claims service requires more than 30 minutes.
that the costs for these services are data available for the CY 2007 proposed We observed that claims with only a
embedded in our claims data, and are rule did not yet reflect the improved single occurrence of the code were
reflected in our payment rates, thereby and more consistent hospital billing anomalies, either because they reflected
providing payments for these important practices of ‘‘per test’’ for single allergy terminated sessions or because they
services. While we acknowledge tests. Some claims for single allergy were incorrectly coded with a single
commenters’ concerns that hospitals are tests still appeared to provide charges unit. In the same rule, we also
providing medication therapy that represented a ‘‘per visit’’ charge, established that HBOT would not
management services more frequently rather than a ‘‘per test’’ charge. generally be furnished with additional
than in the past, we continue to disagree Therefore, consistent with our payment services that might be packaged under
that they are new and should be policy for CY 2006, we proposed to the standard OPPS APC median cost
assigned to a New Technology APC. To calculate a ‘‘per unit’’ median cost for methodology. This enabled us to use
the extent that medical management APC 0381, based upon 349 claims claims with multiple units or multiple
services evolve over time to require containing multiple units or multiple occurrences. Finally, we also used each
more facility resources due to their occurrences of a single CPT code, where hospital’s overall CCR to estimate costs
greater complexity, we expect those packaging on the claims was allocated for HCPCS code C1300 from billed
higher costs to be reflected in hospitals’ equally to each unit of the CPT code. charges rather than the CCR for the
charges for the associated services, Using this methodology, we calculated respiratory therapy cost center.
which will then provide the basis for a median cost of $13.29 for APC 0381 Comments on the CY 2005 proposed
future ratesetting under the OPPS. for CY 2007. As indicated in the CY rule effectively demonstrated that
To clarify our billing requirements, if 2007 OPPS proposed rule (71 FR hospitals report the costs and charges
the only service provided to a patient is 49566), we were hopeful that the better for HBOT in a wide variety of cost
a laboratory test to determine and more accurate hospital reporting centers. We used this methodology to
medication levels, the laboratory test is and charging practices for these single estimate payment for HBOT in CYs 2005
all that should be billed. If a hospital allergy test CPT codes beginning in CY and 2006. For CY 2007, we proposed to
provides a distinct, separately 2006 would allow us to calculate the continue using the same methodology to
identifiable service in addition to the median cost of APC 0381 using the estimate a ‘‘per unit’’ median cost for
test, the hospital is responsible for standard OPPS process in future OPPS HCPCS code C1300. Using 50,311
billing the HCPCS code that most updates. claims with multiple units or multiple
closely describes the service provided. We did not receive any public occurrences, we estimated a median
Billing a visit code in addition to comments concerning our proposed cost of $98.36 for CY 2007.
another service merely because the methodology for differentiating single Comment: One commenter agreed
patient interacted with hospital staff or allergy tests from multiple allergy tests with CMS’ approach to determining the
spent time in a room for that service is for OPPS payment in CY 2007. The final median costs for HCPCS code C1300
(HBOT) to the extent that it eliminated adjusted the CCR used in the conversion One commenter cautioned that the cost
services that were obviously billed of charges to costs for these services so differential between the hospital OPPS
incorrectly. The commenter believed that claims data would more accurately and the MPFS would result in a site-of-
that use of the hospital’s overall CCR reflect the relative costs of the services. service differential. The commenter
appeared to be the best option at this The median costs of HBOT calculated submitted a table showing differences in
time. However, the commenter asked using this methodology have been payments between the OPPS and the
that hospitals be allowed to bill these reasonably stable for the last 3 years. We MPFS. The commenter believed that the
services with multiple revenue codes believe that this adjustment through use payment levels for these laboratory
(not just respiratory therapy), so that of the hospitals’ overall CCRs is all that services should be the same as or equal
hospitals could bill the services under is necessary to yield a valid median cost under both Medicare payment systems.
the revenue code that was most closely for establishing a scaled weight for The commenter asked that CMS
linked to the cost center where the HBOT services. establish payment equity for the same
services were furnished. The commenter After carefully considering the public service furnished in these respective
also requested that the revenue code to comments received, we are finalizing settings. Several commenters urged
cost center crosswalk be revised to our proposed methodology for CMS to review the payment rate for APC
reflect the use of the hospital’s overall estimating a ‘‘per unit’’ median cost for 0344, and assign a payment rate that
CCR for HBOT. HCPCS code C1300, assigned to APC reflects the complexity and resource
In contrast, another commenter was 0659, without modification for CY 2007. costs associated with providing these
concerned that CMS’ claims data do not services.
accurately reflect the costs of this d. Guidance for Chemodenervation Response: The statutory method for
therapy because of potential hospital (APC 0215) calculating payment for physicians’
miscoding. The commenter believed For CY 2006, new CPT codes 95873 practice expenses under the MPFS
that the use of hospitals’ overall CCRs (Electrical stimulation for guidance in differs from the general statutory
did not reflect the relationship between conjunction with chemodenervation) method we use for establishing payment
costs and charges specific to HBOT. The and 95874 (Needle electromyography rates in the hospital outpatient setting.
commenter believed that the payment for guidance in conjunction with Consequently, the application of the
rate for HCPCS code C1300 continued to chemodenervation) were provided different methodologies results in
be inadequate as proposed for CY 2007 interim final assignments to APC 0215 different payment amounts in the two
and asked that the rate be increased (Level I Nerve and Muscle Tests). The settings.
based on the external data provided by proposed APC assignments of the codes Payment for services assigned to APC
an association to the APC Panel. for CY 2007 were unchanged. 0344 for CY 2007 will be made based
Another commenter objected to Comment: One commenter requested upon the median cost of the APC,
erratic payment rates for HBOT over a that CMS reevaluate the APC established according to the standard
period of years, particularly a drop in assignments for CPT codes 95873 and OPPS methodology from CY 2005
payment between CYs 2004 and 2005. 95874 when data become available. The hospital outpatient claims. The median
The commenter attributed this commenter believed that it would be costs of individual services assigned to
instability both to the confusion of appropriate to assign the codes to two APC 0344 do not violate the 2 times
hospitals regarding proper coding of different payment levels based on their rule. The claims data used to establish
treatment units and to CMS’ inability to different resource requirements, but the the APC median cost are stable and
determine an appropriate CCR for HBOT commenter understood the CMS robust, and the APC is appropriately
because hospitals reported their costs decision to assign them both to one APC structured to include only those
under many cost centers. The pending data development. procedures with common clinical and
commenter recommended that CMS use Response: We appreciate the resource features.
an external analysis that it indicated commenter’s request, and we will After carefully considering the public
reproduces an accurate CCR for HBOT, reevaluate the assignment for both of the comments received, we are finalizing
calculated using a consistent and new codes for the CY 2008 update to the the APC 0344 structure as proposed
transparent methodology. OPPS. without modification. The final CY 2007
Response: We believe that the final After carefully considering the public median cost of APC 0344 is $48.44,
median cost for APC 0659 ($97.20 per comment received, we are finalizing our upon which its payment rate is based.
unit) is an appropriate relative cost to be proposal to assign CPT codes 95873 and
used to set the weights upon which the IV. OPPS Payment Changes for Devices
95874 to APC 0215 for CY 2007, without
HBOT payment will be based. modification. A. Treatment of Device-Dependent APCs
CY 2007 is the third year in which we
have used a special methodology to e. Pathology Services (APC 0344) 1. Background
develop the median cost for HBOT In Addendum B of the CY 2007 Device-dependent APCs are
services that removed obviously proposed rule (71 FR 49709), we populated by HCPCS codes that usually,
erroneous claims and deviated from our proposed to assign a payment rate of but not always, require that a device be
standard methodology of using $49.90 to APC 0344 (Level IV Pathology implanted or used to perform the
departmental CCRs, when available, to Services). procedure. For the CY 2002 OPPS, we
convert hospitals’ charges to costs. Prior Comment: Many commenters used external data, in part, to establish
to CY 2005, our inclusion of significant considered the proposed payment rate the device-dependent APC medians
numbers of miscoded claims in the for APC 0344 to be low, especially when used for weight setting. At that time,
median calculation for HBOT and our compared with the MPFS payment for many devices were eligible for pass-
exclusion of the claims for multiple these same laboratory CPT codes that through payment. For the CY 2002
units of treatment, the typical scenario, are assigned to APC 0344. Several OPPS, we estimated that the total
resulted in payment rates that were commenters indicated that the payment amount of pass-through payments
artificially elevated. As explained rate of $49.90 was far below the level of would far exceed the limit imposed by
earlier, beginning in CY 2005 and payment necessary for performing these statute. To reduce the amount of a pro
continuing through the present, we have tests in the hospital outpatient settings. rata adjustment to all pass-through
items, we packaged 75 percent of the APCs for CY 2006 at the highest of: (1) For example, we removed the
cost of the devices, using external data The median cost of all single bills; (2) requirement for device codes for APC
furnished by commenters on the August the median cost calculated using only 0080 (Diagnostic Cardiac
24, 2001 proposed rule and information claims that contained pertinent device Catheterization) based on the
furnished on applications for pass- codes and for which the device cost is information provided by hospitals that
through payment, into the median costs greater than $1; or (3) 90 percent of the the codes assigned to this APC do not
for the device-dependent APCs payment median that was used to set always require a device for which there
associated with these pass-through the CY 2005 payment rates. We set 90 is an appropriate HCPCS code.
devices. The remaining 25 percent of percent of the CY 2005 payment median Therefore, we no longer consider this
the cost was considered to be pass- as a floor rather than 85 percent as APC to be device-dependent and have
through payment. proposed, in consideration of public removed it from the list of device-
In the CY 2003 OPPS, we determined comments that stated that a 15-percent dependent APCs. In the case of some
APC medians for device-dependent reduction from the CY 2005 payment procedures assigned to other device-
APCs using a three-pronged approach. median was too large of a transitional dependent APCs, where we determined
First, we used only claims with device step. We noted in our CY 2006 proposed that no device was required to provide
codes on the claim to set the medians rule that we viewed our proposed 85 a particular service or where there were
for these APCs. Second, we used percent payment adjustment as a no HCPCS codes that described all
external data, in part, to set the medians transitional step from the adjusted devices that could be used to furnish the
for selected device-dependent APCs by medians of past years to the use of service, we removed the requirement for
blending that external data with claims unadjusted medians based solely on a device code for the individual
data to establish the APC medians. hospital claims data with device codes procedure code but retained the device
Finally, we also adjusted the median for in future years (70 FR 42714). We also requirement for other procedure codes
any APC (whether device-dependent or incorporated, as part of our CY 2006 assigned to that device-dependent APC.
not) that declined more than 15 percent. methodology, the recommendation of At its February 2006 meeting, the APC
In addition, in the CY 2003 OPPS we commenters to base payment on Panel recommended that CMS consider
deleted the device codes (‘‘C’’ codes) medians that were calculated using only calculating the median costs for APCs
from the HCPCS file because we claims that passed the device edits. As
0107 (Insertion of Cardioverter
believed that hospitals would include stated in the CY 2006 OPPS final rule
Defibrillator) and 0108 (Insertion/
the charges for the devices on their with comment period (70 FR 68620), we
claims, notwithstanding the absence of Replacement/Repair of Cardioverter-
believed that this policy provided a
specific codes for devices used. Defibrillator Leads) by bypassing the
reasonable transition to full use of
In the CY 2004 OPPS, we used only line-item costs of CPT code 33241
claims data in CY 2007, which would
claims containing device codes to set (Subcutaneous removal of single or dual
include device coding and device
the medians for device-dependent APCs chamber pacing cardioverter-
editing, while better moderating the
and again used external data in a 50/50 defibrillator pulse generator) and
amount of decline from the CY 2005
blend with claims data to adjust packaging the line item-costs of CPT
OPPS payment rates.
medians for a few device-dependent codes 93640 (Electrophysiological
codes when it appeared that the 2. CY 2007 Payment Policy evaluation of single or dual chamber
adjustments were important to ensure For CY 2007, we proposed to base the pacing cardioverter-defibrillator leads
access to care. However, hospital device device-dependent APC medians on CY including defibrillation threshold
code reporting was optional. 2005 claims, the most current data evaluation (induction of arrhythmia,
In the CY 2005 OPPS, which was available. As stated earlier, in CY 2005 evaluation of sensing and pacing for
based on CY 2003 claims data, there we reinstated the use of device codes arrhythmia termination) at time of
were no device codes on the claims and, and made the reporting of device codes initial implantation or replacement) and
therefore, we could not use device- mandatory where an appropriate code 93641 (Electrophysiological evaluation
coded claims in median calculations as exists to describe a device utilized. In of single or dual chamber pacing
a proxy for completeness of the coding CY 2005, we also implemented HCPCS cardioverter-defibrillator leads
and charges on the claims. For the CY code edits to facilitate complete including defibrillation threshold
2005 OPPS, we adjusted device- reporting of the charges for the devices evaluation (induction of arrhythmia,
dependent APC medians for those used in the procedures assigned to the evaluation of sensing and pacing for
device-dependent APCs for which the device-dependent APCs. We arrhythmia termination) at time of
CY 2005 OPPS payment median was implemented the first set of device edits initial implantation or replacement;
less than 95 percent of the CY 2004 on April 1, 2005, for those APCs for with testing of single or dual chamber
OPPS payment median. In these cases, which the CY 2005 payment rate was pacing cardioverter-defibrillator) when
the CY 2005 OPPS payment median was based on an adjusted median cost. We these codes, separately or in
adjusted to 95 percent of the CY 2004 continued to take public comment on combination, are reported on the same
OPPS payment median. We also the remaining device edits after April 1, claim with HCPCS codes G0297
reinstated the device codes and made 2005, and implemented device edits for (Insertion of single chamber pacing
the use of the device codes mandatory the remaining device-dependent APCs cardioverter defibrillator pulse
where an appropriate code exists to on October 1, 2005. Subsequent to the generator), G0298 (Insertion of dual
describe a device utilized in a implementation of the device edits, we chamber pacing cardioverter
procedure. In addition, we implemented received public comments that caused defibrillator pulse generator), G0299 (
HCPCS code edits to facilitate complete us to remove the requirement for edits Insertion or repositioning of electrode
reporting of the charges for the devices for several APCs on the basis that the lead for single chamber pacing
used in the procedures assigned to the services in them do not always require cardioverter defibrillator and insertion
device-dependent APCs. the use of a device, or there may be no of pulse generator), and G0300
In the CY 2006 OPPS, which was suitable device codes available for (Insertion or repositioning of electrode
based on CY 2004 claims data, we set reporting all devices that may be used lead(s) for dual chamber pacing
the median costs for device-dependent to perform the procedures. cardioverter defibrillator and insertion
of pulse generator), which are assigned reported with the procedures in APCs generators in CY 2005 for which the
to APCs 0107 and 0108. The APC Panel 0107 and 0108. manufacturers provided replacement
recommended bypassing the line-item However, CPT codes 93640 and 93641 devices without cost to the beneficiary
costs for CPT code 33241 because are always performed during an or hospital. We also found that there
members believed that when a pacing operative procedure for ICD initial were other devices for which the charge
cardioverter-defibrillator (ICD) pulse implantation or replacement or with was less than $1.01, and we removed
generator removal is performed in the implantation, revision or replacement of those claims also.
same operative session as the insertion leads, and, therefore, we believed that it As expected, the median costs
of a new pulse generator described by a would be appropriate to package them calculated using all single procedure
procedure code assigned to APC 0107 or into the surgical procedure with which bills, including both bills that lacked
APC 0108, the packaging on the claim they are performed. Moreover, as a appropriate device codes (where there
is appropriately assigned to the result of the descriptors of the lead are edits) and bills with token charges
procedure code in APC 0107 or APC evaluation CPT codes, they should for devices, were in many cases less
0108. Moreover, CPT codes 93640 and never be billed as single procedure than the medians calculated using only
93641 may only be correctly coded claims, and packaging them would also claims that contained appropriate
when the electrophysiologic evaluation resolve the problem of setting their device codes without token charges for
of ICD leads is performed at the time of payment rates in part on the basis of the devices. In some cases, the medians
initial implantation or replacement of claims that reflect erroneous coding. As were significantly different when claims
an ICD pulse generator and/or leads, we noted in the CY 2007 proposed rule, either without device codes or which
with or without testing of the pulse packaging the costs of intraoperative had only token device charges were
generator. Thus, the APC Panel electrophysiologic testing of the ICD removed. In the CY 2007 proposed rule,
expected that the costs of the leads yielded many more single bills on we noted that we believed that the
evaluations of the ICD leads (CPT codes which to set median costs and also claims that reflected the best estimated
93640 and 93641) could be increased the median costs for APCs costs for these APCs, including the costs
appropriately packaged with the 0106, 0107, 0108, and 0418. Therefore, of the devices, were those claims that
procedure codes that describe the we proposed to package CPT codes contain appropriate device codes
insertion of ICD generators, which are 93640 and 93641 for CY 2007. without token charges for devices. (See
assigned to APCs 0107 and 0108, or the Furthermore, the APC Panel, at its section IV.A.4. below for our discussion
insertion of ICD leads assigned to APCs August 2006 meeting, recommended of payments when the hospital incurs
0106 (Insertion/Replacement/Repair of that CMS use readily available external no cost for the principal device required
Pacemaker and/or Electrodes), 0108, data to validate the costs derived from for the service.)
claims data. While CMS reviews all Therefore, we proposed to base the
and 0418 (Insertion of Left Ventricular
information that comes to our attention, payment rates for CY 2007 for these
Pacing Elect). Because APCs 0107 and
we have not systematically used device-dependent APCs on median
0108 have typically had very few single
external data to validate the median costs calculated using claims with
bills on which the medians have been
costs derived from our claims data, appropriate device codes with no token
based, and because the APC Panel
because external data are typically charges for devices reported on the
indicated that it believed that we could
furnished by parties with special claim. We did not believe that
use many more claims if we bypassed
interest in a particular item or service. adjustment of these median costs was
CPT code 33241 and packaged CPT
Therefore, it is of limited usefulness in necessary to provide adequate payment
codes 93640 and 93641, we calculated
determining the relative cost of all items for these services, and, therefore, we did
median costs for APCs 0107 and 0108 and services paid under the OPPS. In a not propose to adjust the median costs
using these rules. We excluded claims system of relative weights, it is the for these APCs to moderate any
that did not meet the device edits, and relativity of the costs of services to one decreases in medians from CY 2006 to
we also excluded token claims. another, as derived from a standardized CY 2007. However, we noted in the
The effect of packaging CPT codes system that uses standardized inputs proposed rule that, notwithstanding the
93640 and 93641 into claims that both and a consistent methodology, that is device edits, it may continue to be
passed the device edits and contained the foundation of the system. The necessary for purposes of median cost
no token charges for devices were relationship between the actual calculations to remove claims that do
shown in Table 19 of the CY 2007 OPPS acquisition cost of a particular item or not contain devices because it is likely
proposed rule (71 FR 49573) and below. service compared to the relative cost that there would be incidental
This affected APCs 0106, 0107, 0108, derived from the standard system for a occurrences of interrupted procedures
and 0418. Bypassing the line-item cost single item or service is of little value. in which a device is not used and does
of CPT code 33241 could not be done For the proposed rule, we calculated not appear on the claim. (The
for all claims on which this CPT code the median cost for device-dependent interrupted procedure modifier nullifies
was reported because there are clinical APCs using two different sets of claims. the device edit.) Moreover, we noted
circumstances in which the ICD pulse We first calculated a median cost using that there are likely to continue to be
generator is removed and no new device all single procedure claims for the incidental occurrences of token charges
is implanted. Therefore, the APC procedure codes in those APCs. We also for devices as a result of devices that are
assignment of CPT code 33241 and the calculated a second median cost using replaced without cost by the
payment for that code need to reflect the only claims that contain allowed device manufacturer. However, each of these
packaging associated with the procedure codes and also for which charges for all circumstances could cause the
when it is performed alone. Because of device codes were in excess of $1.00 procedure code median cost to
this problem with assigning packaging (nontoken charge device claims). We underrepresent the cost of the complete
in all of the circumstances in which the excluded claims for which the charge procedure, including the device cost,
procedure may be reported, we decided for a device was less than $1.01, in part, where the hospital purchases the
against proposing to bypass CPT code to recognize hospital charging practices device.
33241, either in general for all due to a recall of cardioverter Therefore, we proposed that use of
procedures or selectively, when it is defibrillator and pacemaker pulse claims that met the device edits and that
did not contain token charges for dependent APCs would set payments at use of the hospital’s CCR, even at the
devices were the appropriate claims to such a low level that hospitals were departmental level, results in computed
use to set the median costs for the likely to cease furnishing these services costs and relative weights that may be
device-dependent APCs, ensuring that so that beneficiaries would no longer more or less than the actual costs for
the costs of the principal devices were have access to needed care. The items in specific cases. We believe that
included in the APC medians. In commenters urged CMS to use external this average is appropriate and inherent
addition, we proposed that, with our data in place of median costs derived in PPS. One of the principles behind the
proposed changes to the OPPS from claims data and to protect all such use of median costs for weight setting in
packaging status of two codes for external data used for ratesetting from a budget neutral payment system like
electrophysiologic evaluation of ICD public disclosure. the OPPS is to determine the
leads, no special payment policies Response: We continue to believe that appropriate relativity in resource use
would be needed to establish payment it is appropriate to calculate the median among services, thus allowing fair and
rates that correctly reflect the relative costs to be used for establishing the equitable distribution of payment
costs of these procedures to other payment rates in CY 2007 for device- among hospitals based on their mix of
procedures paid under the OPPS. dependent APCs using only claims that services provided to Medicare
We received a number of public do not contain token charges for devices beneficiaries. The median costs are not
comments concerning our CY 2007 and that contain the devices that are intended to represent the actual
proposed payment policies for device- appropriate for the procedure code, acquisition costs of the services being
dependent APCs. where there are HCPCS codes for such furnished. They are estimated relative
Comment: The commenters supported costs that are converted to relative
devices. We proposed to exclude all
limiting the set of claims used to weights, scaled for budget neutrality
claims containing token charges because
calculate median costs for device- and then multiplied by a conversion
dependent APCs to claims that passed there were a number of actions in CY
2005 (the year of claims being used for factor to derive a payment under a PPS
the device edits and did not contain and are not intended to pay reasonable
device charges less than $1.01 to the CY 2007 OPPS update) that caused
hospitals to replace devices that they costs. For this reason, we believe that it
calculate median costs. In addition, is not appropriate to use external
some commenters asked CMS to remove received without cost from
manufacturers, and we advised pricing information in place of the costs
claims with residual charges in cases in derived from the claims and Medicare
which recalled devices were replaced by hospitals to report a token charge for
these devices. We will reassess whether cost report data, because we believe that
upgraded devices or a different type of to do so would distort the relativity that
device, as was done when we removed exclusion of token charges is necessary
for future years because, effective is so important to the system’s integrity.
token charge claims, so that the full cost Similarly, we do not believe that it is
of the device would be wholly January 1, 2006, devices furnished
without cost to the provider will be appropriate to remove specific claims
represented in the procedure claims
identified with modifier ‘‘FB’’ and from contributing to ratesetting if the
used for ratesetting. Several commenters
exclusion of claims with token charges hospital charge for a particular item
objected to the proposed payment rates
may no longer be necessary. We does not exceed an established
on the basis that hospitals report the
proposed to exclude claims that did not threshold.
units and charges for devices
incorrectly, leading to incomplete and contain appropriate devices, as defined However, we recognize that there may
inaccurate claims data. They also by the device edits on the CMS Web be value in exploring the extent to
believed that the CMS methodology of site, to maximize the likelihood that we which the estimated relative costs
applying CCRs to charges for device- would be basing the median costs for derived from claims and cost report data
intensive services results in median device-dependent APCs on claims that deviate so substantially from acquisition
costs that do not reflect the true relative contained the full charge for the service, costs that payment adjustments may be
costs of those services. They believed including the device. However, we did appropriate. Therefore, we are
that hospitals do not mark up their not exclude claims that contained interested in further studying the
charges for high cost items sufficiently residual charges for upgrades of analytic technique suggested in the
to result in the actual cost of the item, replaced devices for which hospitals comments that would involve the use of
a phenomenon generally known as received credits from manufacturers a regression analysis to identify
‘‘charge compression.’’ The commenters because it was not possible to identify adjustments that could be made to the
stated that hospitals are inhibited by them systematically. Moreover, because CCRs to account for charge
market and other forces from charging at we are calculating a median cost and compression. We note that the
a level necessary for the application of commenters inform us that upgraded regression model furnished with some
the CCR to result in an accurate estimate devices represent only 10 to 15 percent comments was only applied to
of the cost of the device. Some of cases in which devices are replaced expensive medical supplies and
commenters offered specific statistical without cost or with credit for the devices. It was not applied uniformly to
strategies for calculation of adjustment replaced device, we believe that those develop potential adjustments that
factors that could be applied to the claims would have minimal influence could be made to costs and charges
charges for devices to overcome the on the calculation of the device- across all revenue codes and cost
effects of charge compression. The dependent APC median cost used for centers that could potentially be subject
commenters urged CMS to examine ratesetting. By basing weights on the to charge compression. If such a model
these strategies for their potential median cost where the median is the were to be applied in the OPPS, we
application to calculation of median 50th percentile of the array, a relatively believe further analysis would have to
costs and to use the charge compression small number of unusually low values be undertaken to determine whether it
analysis currently underway for (as would likely be represented by 10 to should apply to all costs and cost
Medicare inpatient billings to initiate a 15 percent of a relatively small number centers. At this time, we intend to study
similar analysis for Medicare outpatient of devices replaced without any or full whether a rigorous model could provide
hospital payments. They indicated that cost) is not likely to significantly affect a payment adjustment for charge
the proposed payment rates for device- the median cost. We recognize that the compression to the extent it exists.
We recognize that the issues the token charges for devices or 90 percent rate than charges for other items and
commenters raise regarding charge of the CY 2006 payment median because services. As such, the median cost of
compression apply both to the OPPS to do otherwise would result in any particular item or service is largely
weight setting and to the setting of the discontinuation of some services that a function of both its costs and the
DRG weights that are an important require high cost devices. Other various charging practices of the
determinant of payment under the IPPS commenters urged CMS to set the hospitals that bill the services. Hospitals
for inpatient hospital services. median cost at no less than 100 percent have now had 6 years experience with
Accordingly, CMS has awarded a 1-year of the CY 2006 median cost plus the the OPPS, 4 of which were after the
contract to RTI International to study market basket update for CY 2007. Some expiration of pass-through payments for
methods of improving estimates of the commenters believed CMS should use most devices. We believe that hospitals
cost of Medicare inpatient hospital only claims on which the charges for make thoughtful decisions regarding
discharges used in constructing the DRG their devices equaled or exceeded how they want to report and charge for
relative weights. The RTI contract will minimum thresholds that would be set device-dependent procedures in the
focus on methods of improving the based on amounts they specified. In context of the effects of those decisions
accuracy of the adjustment of charges to several cases, the commenters asked on their payments by Medicare and
cost to account for the fact that hospitals that CMS do this due to the billing of other payers.
tend to mark up high cost items to a residual charges for upgraded devices Comment: Some commenters objected
lesser extent than they mark up low cost that replaced recalled devices. In other to the application of the wage index to
items, the phenomenon known as cases, they recommended thresholds the payment for device-dependent
charge compression. The study will also because they believed that hospital APCs. They argued that it creates
examine how charge compression charges for devices were too low, inequities for hospitals that have low
interacts with other variables in the thereby resulting in inadequate APC wage indices, due to the application of
construction of the DRG relative median costs for establishing the CY the wage adjustment to 60 percent of the
weights, such as the number of cost 2007 payment rates for device- APC rate, even though the cost of the
centers included and whether hospital- dependent procedures and their device is often much more than 60
specific relative values are used. To the packaged devices. percent of the APC payment and the
extent that we find charge compression device costs are the same regardless of
Response: We do not believe that it is
exists, we will further study potential the location of the facility. The
necessary or appropriate to set the commenters objected to hospitals in
models that could adjust for it so we
median cost for these device-dependent high cost areas receiving a premium for
might develop a more accurate system
APCs at 100 percent of the CY 2006 providing these service, and hospitals in
of cost-based weights to better reflect
payment median plus the update factor low cost areas receiving what they
the relative costs of the different types
or at 90 percent of the CY 2006 payment viewed as a payment penalty for
of services provided under the OPPS.
median, or to otherwise override the furnishing these services. The
We plan to fully involve appropriate
estimated median costs derived from the commenters asked that the wage index
stakeholders in future analysis of this
claims process proposed, using only be applied only to 20 percent, rather
issue to the extent feasible. Before
implementing such an adjustment, we claims that contained device codes than the current 60 percent, of the
would thoroughly describe our analysis where appropriate and that did not payment for certain device-dependent
and a potential proposed adjustment as contain token charges. Because the APCs, specifically 0039, 0107, 0108,
part of the OPPS rulemaking process. devices that are required for many of 0222, 0224, 0225, 0226, 0227, 0315,
Further, we intend to use the charge these services came off pass-through 0418, 0654, 0655, and 0656.
compression study that we will conduct payment in CY 2003, we have Response: The immediate effect of
over the next year as an opportunity to implemented device edits to maximize changing the application of the wage
better understand the costs of medical the likelihood that the charges for the index from 60 percent to 20 percent for
devices. devices are included on the claim. Over these APCs is likely to lower payments
With regard to the comment that the past several years, we provided for to hospitals in high cost areas, which we
providers are ceasing to provide services adjustments to the median costs of believe likely provide the higher
that require devices, we have no data device-dependent APCs where the cost volumes of these services, and to raise
that causes us to believe that there is a data for the OPPS update resulted in a payments in low cost areas that likely
problem with access to care. In fact, the decline in the median from one year to furnish fewer services. Therefore, we
volume and intensity of OPPS services the next. We indicated in the CY 2006 believe that such a change would
are growing significantly each year. As final rule (70 FR 68620) that we fully actually result in lower overall OPPS
we indicated in section XIX. of this final expected to be able to transition to full payment for the procedures. Moreover,
rule with comment period, Medicare use of the claims data without any such suggested change could not be
program payment under the OPPS is adjustment for CY 2007. We see no done in isolation. At the beginning of
expected to reach $32.54 billion in CY reason why we should limit the the OPPS, we performed a regression
2007, an increase of approximately 9 decrease in CY 2007 median cost for analysis resulting in a determination to
percent from the projected program those APCs for which the median cost wage adjust 60 percent of the payment
payment of $29.809 billion in CY 2006. declines compared to the adjusted CY for each APC. This analysis examined
Comment: A number of commenters 2006 payment median cost. The nature the extent to which the body of costs for
urged CMS to make adjustments to the of a payment system that is based on services furnished in the outpatient
CY 2007 payment rates for device- relative weights is that the weights vary department was split between wage and
dependent APCs to account for charge from year to year. Any change in the nonwage costs. We determined that 60
compression. Specifically, some median cost for an APC, whether one percent is an average across all service
commenters recommended that CMS set with a high device cost or not, is a types, many of which have significant
the APC payment rates based on the function of many complex factors, labor costs (for example, visits, drug
higher of the median cost calculated including, but not limited to, the extent administration services, and diagnostic
using only claims that contain to which hospitals increase charges for tests). We reaffirmed the
appropriate devices and do not contain some items and services at a different appropriateness of applying the wage
index to 60 percent of the APC payment because this approach greatly increased manner, separate payment for the
during our development of the CY 2006 the number of single bills that were procedure provides payment for the
OPPS (70 FR 68533). By definition, as available for calculating the median packaged HCPCS code as well. Because
an average across all services, a standard costs of APCs 0107 and 0108. Other of the enormous number of HCPCS
wage adjustment could not be linked to commenters objected to the packaging of codes, it is not practical to include logic
specific services, particularly the least these CPT codes where they appeared that specifies that a particular HCPCS
expensive and most expensive services. on a claim unless the claim also code is packaged with specified services
To change the application of the wage contained a HCPCS code assigned to but not with others. We rely upon
index for certain device-dependent APCs 0107, 0108, and 0106. Some hospitals to correctly code the claims
APCs as commenters request would commenters also objected to packaging they report to Medicare because they
require reassessing the application of 93640 and 93641 into services assigned have significant incentives to do so
the wage index to all services. In the CY to APC 0418 because they believed that (such as, payment and audit concerns).
2006 OPPS final rule, we committed to the packaged services were not After carefully considering the public
assessing the effects of the wage index performed at the time that procedures in comments received, we are finalizing
on the device-dependent APCs. We are APC 0418 were performed. They were our proposed payment policies for
continuing our efforts in this area. concerned that packaging these testing device-dependent APCs for CY 2007.
Comment: Some commenters fully codes inappropriately raised the median The CY 2007 payment rates for device-
supported packaging CPT codes 93640 cost of APC 0418. dependent APCs are based on their
(Electrophysiological evaluation of Response: We continue to believe that median costs calculated from CY 2005
single or dual chamber pacing the costs of CPT codes 93640 and 93641 nontoken claims that passed the device
cardioverter-defibrillator leads are appropriately packaged because they edits, without application of a
including defibrillation threshold are performed only during the course of maximum payment reduction floor in
evaluation) and 93641 identifiable surgical procedures. Under comparison with CY 2006 payment
(Electrophysiological evaluation of the OPPS data development process, the medians. Discussions of HCPCS code
single or dual chamber pacing cost of a packaged HCPCS code on a and APC-specific issues for device-
cardioverter-defibrillator leads claim is added to the cost of the single dependent APCs are found in section
including defibrillation threshold major procedure code that is reported III.D of this preamble, where other APC-
evaluation; with testing of single or dual on the same claim, along with other specific policies are also discussed.
chamber cardioverter defibrillator) packaged costs also on the claim. In that BILLING CODE 4120–01–P
ER24NO06.018</GPH>
BILLING CODE 4120–01–C a device code but failed to also bill any the billing of devices with incorrect
3. Devices Billed in the Absence of an procedure code with which the device procedure codes with the APC Panel at
Appropriate Procedure Code could be used correctly. These errors in its March 2006 meeting, and the APC
billing have led to the costs of the Panel recommended that we explore the
As we discussed in the proposed rule device being packaged with an incorrect extent to which it would be appropriate
(71 FR 49573), in the course of procedure code and also have caused to establish edits for HCPCS device
examining claims data for creation of the hospital to be paid incorrectly for codes to ensure that hospitals also bill
the payment rates for the CY 2007 OPPS the service furnished if the device was procedures in which the devices would
proposed rule, we identified appropriately reported. We discussed be used on the same claim.
ER24NO06.019</GPH>
circumstances in which hospitals billed
As we stated in the proposed rule, we TABLE 19.—DEVICES WHICH MUST BE taking several steps to assist in the early
examined our CY 2005 claims data and BILLED WITH ASSOCIATED PROCE- recognition and analysis of patterns of
found that incorrect billing occurred DURE CODES—Continued device problems to minimize the
more often with some devices than with potential for harmful device-related
others. As noted in the CY 2007 OPPS Device Description effects on the health of Medicare
proposed rule (71 FR 49573), we beneficiaries and the public in general.
expected to implement device to C1786 ............ Pmkr, single, rate-resp. In recent years, CMS has recognized
procedure code edits for the specified C1820 ............ Generator, neuro rechg bat the importance of data collection as a
devices and their associated procedures, sys. condition of Medicare coverage for
that we believed must be reported on a C1882 ............ AICD, other than sing/dual. selected services. In 2005, CMS issued
claim with the specified device for the C1895 ............ Lead, AICD, endo dual coil. a National Coverage Determination
C1896 ............ Lead, AICD, non sing/dual. (NCD) that expanded coverage of ICDs
claim to be correctly coded and the C1897 ............ Lead, neurostim test kit.
device costs properly attributed to C1898 ............ Lead, pmkr, other than trans.
and required registry participation when
procedures with which they were used. C1899 ............ Lead, pmkr/AICD combina- the devices were implanted for certain
The devices for which we expected to tion. clinical indications. The NCD included
implement edits are shown below in C1900 ............ Lead, coronary venous. this requirement in order to ensure that
Table 19, as well as in Table 20 of the C2619 ............ Pmkr, dual, non rate-resp. the care received by Medicare
proposed rule (71 FR 49573 and 49574), C2620 ............ Pmkr, single, non rate-resp. beneficiaries was reasonable and
and are posted on the CMS outpatient C2621 ............ Pmkr, other than sing/dual. necessary and, therefore, appropriately
hospital Web site, along with our initial reimbursed. Presently, the American
draft of all the procedures with which 4. Payment Policy When Devices Are College of Cardiology—National
they could be appropriately used and Replaced Without Cost or Where Credit Cardiovascular Data Registry (ACC–
thus reported. As noted in the proposed for a Replaced Device Is Furnished to NCDR) in partnership with the Heart
rule (71 FR 49573), we believed that the the Hospital Rhythm Society collects these data and
establishment of claims edits reflected maintains the registry.
As we discuss above in the context of In addition to ensuring appropriate
merely standard operational and the calculation of median costs for ICDs
administrative practice. However, as the payment of claims, collection, and
and pacemakers, in recent years there ongoing analysis of ICD implantation,
public may assist in establishing have been several field actions and
appropriate edits, we, therefore, asked data can speed public health action in
recalls with regard to failure of these the event of future device recalls. The
that comments regarding the specific devices. In many of these cases, the
associations of device codes and systematic recording of device
manufacturers have offered replacement manufacturer and model number can
procedure codes be provided to the
devices without cost to the hospital or enhance patient and provider
following email address:
credit for the device being replaced if notification. Analysis of registry data
OutpatientPPS@cms.hhs.gov. This is the
the patient required a more expensive may uncover patterns in complication
same email address to which comments
device. In some circumstances rates (for example, device malfunction,
on the existing procedure to device edits
manufacturers have also offered, device-related infection, and early
should be directed. Comments
through a warranty package, to pay battery depletion) associated with
submitted on this issue to this mail box
specified amounts for unreimbursed particular devices that signify the need
were not comments on the proposed
expenses to persons who had for a more specific investigation.
rule and as stated in our proposed rule
(71 FR 49573), we are not responding to replacement devices implanted. In Patterns found in registry data may
them in this CY 2007 OPPS final rule. addition, we noted in the proposed rule identify problems earlier than the
However, we are taking this that we believed that incidental device currently available mechanisms, which
opportunity to advise the public that we failures that are covered by do not systematically collect such
will implement these edits effective manufacturer warranties occur detailed information surrounding
with the January 2007 OCE. The edits routinely. While we understood that procedures.
will be posted on the OPPS Web site at some device malfunctions might be As we indicated in the proposed rule,
http://www.cms.hhs.gov/ inevitable as medical technology grows we encouraged the medical community
HospitalOutpatientPPS/, and as with increasingly sophisticated, we believed to work to develop additional registries
the device edits currently in place, we that early recognition of problems for implantable devices, so that timely
will continue to accept comments on would reduce the number of people and comprehensive information is
them indefinitely at the email address with the potential to be adversely available regarding devices, recipients
identified above. affected by these device problems. We of those devices, and their health status
indicated our belief that the medical and outcomes. While participation in an
TABLE 19.—DEVICES WHICH MUST BE community needs heightened and early ICD registry is required as a condition
BILLED WITH ASSOCIATED PROCE- awareness of patterns of device failures, of coverage for ICD implantation for
DURE CODES
voluntary field actions, and recalls so certain clinical conditions, we believe
that they can take appropriate action to that the potential benefits of registries
Device Description care for our beneficiaries. Systematic extend well beyond their application in
efforts must be undertaken by all Medicare’s specific national coverage
C1721 ............ AICD, dual chamber. interested and involved parties, determinations. As medical technology
C1722 ............ AICD, single chamber. including manufacturers, insurers, and continues to swiftly advance, data
C1767 ............ Generator, neuro non- the medical community, to ensure that collection regarding the short and long
recharg. device problems are recognized and term outcomes of new technologies, and
C1777 ............ Lead, AICD, endo single
addressed as early as possible so that especially concerning implanted
coil.
C1778 ............ Lead, neurostimulator. people’s health is protected and high devices that may remain in the bodies
C1779 ............ Lead, pmkr, transvenous quality medical care is provided. As of patients for their lifetimes, will be
VDD. indicated in the CY 2007 OPPS essential to the timely recognition of
C1785 ............ Pmkr, dual, rate-resp. proposed rule (71 FR 49574), we are specific problems and patterns of
complications. This information will proposed to revise the existing packaged cost of the device is a
facilitate early interventions to mitigate regulations by adding new § 419.45, relatively modest part of the APC
harm and improve the quality and Payment and copayment reduction for payment for the procedure into which
efficiency of health care services. replaced devices. This proposed the device cost is packaged. In the case
Moreover, data from registries may regulation was intended to cover certain of devices of modest cost, we believed
help further the development of high devices for which credit for the replaced that the averaging nature of payments
quality, evidence-based clinical practice device is given or which are replaced as under the OPPS based on the
guidelines for the care of patients who a result of or pursuant to a warranty, conversion of charges to costs with
may receive device-intensive field action, voluntary recall, CCRs would incorporate any significant
procedures. In turn, widespread use of involuntary recall, and certain devices savings from a warranty replacement,
evidence-based guidelines may reduce which are provided free of charge. As field action, or recall into the payment
variation in medical practice, leading to proposed, it would provide for a rate for the associated procedural APC
improved personal and public health. reduction in the APC payment rate and that no specific adjustment would
Registry information may also when we determine that the device is be necessary or appropriate. However,
contribute to the development of more replaced without cost to the provider or in other cases, such as implantation of
comprehensive and refined quality beneficiary or when the provider an ICD, the cost of the device is the
metrics that may be used to receives full credit for the cost of a majority of the cost of the APC and
systematically assess and then improve replaced device. We proposed that the payment at the full payment rate for the
the safety and quality of health care. amount of the reduction to the APC procedural APC would pay the hospital
Such improvements in the quality of payment rate would be calculated in the much in excess of its incurred cost for
care that result in better personal health same manner as the offset amount that the service.
will require the sustained commitment would be applied if the implanted As we discuss above, we proposed to
of industry, payers, health care device assigned to the APC had pass- set the APC payment rates for device-
providers, and others towards that goal, through status as defined under dependent APCs for the CY 2007 OPPS
along with excellent and open § 419.66. We also proposed that the using only claims that contain
communication and rapid system-wide beneficiary’s copayment amount would appropriate devices to ensure that we
responses in a comprehensive effort to be calculated based on the reduced APC make appropriate full payment when
protect and enhance the health of the payment rate. the hospital initially incurs the full cost
public. We look forward to further We indicated that we believed that of the device. Beginning in CY 2005, we
discussions with the public about new this would be appropriate because in required that device codes be billed for
strategies to recognize device problems these cases the full cost of the replaced devices used and specifically required
early and how to definitively address device would not be incurred and, that hospitals bill certain device codes
them, in order to minimize both the therefore, we believed that an for some services. We are using the CY
harmful health effects and increased adjustment to the APC payment would 2005 claims to set the payment rates for
health care costs that may result. be necessary to remove the cost of the the CY 2007 OPPS. Currently, where the
In addition, in the proposed rule we device. We also indicated that we device is furnished without cost to the
stated that we believed that the routine believe that the averaging nature of the hospital, we have authorized hospitals
identification of Medicare claims where calculation of the amount of the to charge less than $1.01.
hospitals identify and then adjustment would cause it to be We authorized this charge because the
appropriately report selected services appropriately applied to cases of credit CMS device edits require that the
performed under the OPPS when for the replaced device, regardless of hospital must report an appropriate
devices are replaced without cost to the whether there is a residual cost due to device if they bill for certain codes that
hospital or with full credit to the the implantation of a more expensive cannot be performed without a device or
hospital for the cost of the replaced device. the claim will be returned. Moreover,
device, should provide comprehensive Moreover, we stated that we also the Fiscal Intermediary Standard
information regarding the outpatient believe that the proposed adjustment System will not accept the claim unless
hospital experiences of Medicare was consistent with section 1862(a)(2) there is a charge for each HCPCS code
beneficiaries with certain devices that of the Act, which excludes from billed. In addition, we were seeking a
are being replaced. Because Medicare Medicare coverage an item or service for means of identifying these recall cases
beneficiaries are common recipients of which neither the beneficiary nor in the data. Therefore, by authorizing
implanted devices, this claims anyone on his or her behalf has an hospitals to charge less than $1.01 for
information may be particularly helpful obligation to pay. Payment of the full the device we enabled the claim to be
in identifying patterns of device APC payment rate in these cases in paid and also provided a mechanism for
problems early in their natural history which the device was replaced under identifying devices for which the
so that appropriate strategies to reduce warranty or in which there was a full hospital incurred no expense.
future problems may be developed. credit for the price of the recalled or Where we set the payment rates for
In addition to our concern for the failed device effectively results in these device-dependent APCs using
public health, we also noted that we Medicare payment for a noncovered only claims that contain the full costs of
have a fiduciary responsibility to the item. Moreover, it results in creation of devices when they are purchased by
Medicare trust fund to ensure that a beneficiary liability for the copayment hospitals and exclude claims for which
Medicare pays only for covered services. associated with the device for which the there is no appropriate device code or
Therefore, we proposed, effective for beneficiary has no liability. Therefore, a charge for the device of less than
services furnished on or after January 1, we proposed to adjust the APC payment $1.01, the proposed APC payments into
2007, to reduce the APC payment and rate in these circumstances under the which the full costs of the devices have
beneficiary copayment for selected authority of section 1833(t)(2)(E) of the been packaged would result in excessive
APCs in cases in which an implanted Act, which permits us to make equitable program payments and beneficiary
device is replaced without cost to the adjustments to the OPPS payment rates. copayments for the services being
hospital or with full credit for the As we indicated in the proposed rule, furnished if the devices were provided
removed device. Specifically, we we recognized that in many cases, the without cost to hospitals. To avoid
excessive payments in these catheter that was used, and there would For purposes of making the proposed
circumstances, as noted previously we be no savings to the hospital from that adjustment, we proposed to adapt the
proposed to adjust the APC payment procedure. The hospital would likely methodology that we have employed to
rates when implanted devices have been charge for both the defective device and establish an offset for the device costs
replaced without cost to the hospital or the device used to complete the incorporated into APCs in cases where
beneficiary or where full credit for such procedure because both catheters were a pass-through device is also being
a device has been given because the used to provide the full service. We billed. We currently calculate the offset
replacement device was of greater cost believed that if a replacement catheter amount by first calculating a median
than the originally implanted device. was furnished to the hospital under including device costs and then
We proposed that the adjustment warranty from the manufacturer, it calculating a median excluding device
would be limited to the APCs listed in would be used at a much later date on costs using single bills that contain
Table 21, of the CY 2007 OPPS a different patient, it would most likely devices. We then divide the ‘‘without
proposed rule (71 FR 49577) but only be charged to that patient account, and device’’ median by the ‘‘with device’’
when the purpose of the procedure was it would be unlikely to be specifically median and subtract the percent from
to replace a device that was reported by identified as being furnished without 100 to acquire the percent of cost
a HCPCS code in Table 22 of that rule cost to the hospital. In these cases, we attributable to devices in the APC. We
(71 FR 71 FR 49578), which was expected that any cost savings from the apply this percent to the payment rate
furnished without cost or at full credit replacement devices such as these (for of the APC to determine the offset
by the manufacturer. We proposed that example, catheters) that are furnished amount. For example, this is the
the following three criteria must each be without cost would be incorporated into methodology we used to calculate the
met for an APC to be subject to the the median costs for the procedures in offset amount for APC 0222
adjustment. We selected the APCs in the normal course of the data process (Implantation of Neurological Device)
Table 21 of the proposed rule on the through application of the CCRs when current pass-through device
basis of these three criteria. generated from the cost reports. C1820 (Generator, neuro rechg bat sys)
The first criterion we proposed was The third criterion we proposed was is billed on the same claim. We
that all procedures assigned to the that the offset percent for the APC (that indicated in the proposed rule that we
selected APCs must require implantable is, the median cost of the APC without believed that it was appropriate to apply
devices that would be reported if device device costs divided by the median cost this same methodology in circumstances
replacement procedures were of the APC with devices) must be when we needed to remove the cost of
performed. Therefore, the device being significant. For this purpose, we defined the device from the APC payment, not
replaced must be necessary for the a significant offset percent as exceeding because the device was being paid
service to be furnished and without the 40 percent. We believed that this under pass-through but because the
devices, the services assigned to the percent was appropriate because our hospital was either not incurring the
APCs could not be performed. For studies have shown that approximately cost for the replaced device or had been
services, and, therefore, their assigned 60 percent of the cost of OPPS services given full credit for the replaced device
APCs, where a device was not needed is wage-related, and that approximately (71 FR 49576). In both cases, the intent
or where it might or might not be 40 percent of the cost of OPPS services was to remove the cost of the device
needed to perform a procedure, we did is not wage related. This is why we from the APC payment rate.
not believe that reducing the payment wage adjust 60 percent of the APC Using this methodology, we
for the APCs would be appropriate payment rates for all APCs, including calculated the proposed offset amounts
because the charges for the devices were APCs for which a greater percentage of by first calculating an APC median cost
unlikely to be a significant factor in the APC payment is for the cost of a including device costs and then
establishing the rates for the APCs. device. calculating a median cost excluding
The second criterion we proposed We believed that once the device device costs, using only single bills that
was that the required devices must be share of an APC exceeded the 40 met our device edits and did not have
surgically inserted or implanted devices percent we attribute to costs other than token charges for devices. We then
that remain in the patient’s body after wage costs (for example, device costs, divided the ‘‘without device’’ median
the conclusion of the procedures, at capital costs, plant costs, and supplies cost by the ‘‘with device’’ median cost
least temporarily. We believed this was other than devices), the device cost is a and subtracted the percent from 100 to
necessary to establish that the significant part of the APC cost. acquire the percent of cost attributable
replacement device was a direct Therefore, where the device costs in an to devices in the APC. We next applied
replacement for the device being APC exceed 40 percent, which is the this percent to the payment rate for the
removed. In cases of failures of devices average of all types of nonwage-related APC to determine the offset amount.
that were surgically inserted or costs across all APCs, we proposed to The following is an example of the
implanted but did not remain in the define the device costs as ‘‘significant’’ payment reduction we proposed in the
patient’s body after the conclusion of for purposes of this proposed policy. case of replacement of an ICD under
procedures, we believe that it was We recognized in the proposed rule warranty. Where the cardioverter
highly likely that the replacement that it might be appropriate to define defibrillator pulse generator described
device was not specifically used to care ‘‘significant’’ for this purpose at a by HCPCS code C1721 (AICD, dual
for the patient on whom the original different percentage of the APC cost chamber) is replaced under warranty
defective device was used and that, because there are costs other than during a procedure described by HCPCS
where a defective device of this type device costs (for example, capital costs code G0298 (Insertion of dual chamber
was used, there was no savings to the and other supply costs) in the 40 pacing cardioverter defibrillator pulse
hospital. For example, if a vascular percent of service costs to which the generator), the hospital would report
catheter failed during a procedure, we wage adjustment does not apply. We HCPCS code G0298 with a specified
believed that the physician would indicated that we would reassess for modifier and would also report HCPCS
probably use another similar catheter to future years whether it is appropriate to code C1721 with a token charge for the
finish the procedure. In these cases the define ‘‘significant’’ for this purpose at device. Assuming the hospital had a
hospital would correctly charge for the a level other than 40 percent. wage index of 1, based upon CY 2007
proposed rule data the payment rate for this was appropriate in the case of potential APC payment adjustment
APC 0107 after adjustment would be payment for pass-through devices scenarios.
$1862.27. That is, the adjusted payment because the hospital incurred costs for We noted in the proposed rule that we
rate would equal the unadjusted both the service and the device, and believed that our proposed policy
payment rate for APC 0107 ($17,185.34) Medicare paid for both the service would accomplish three important
less the warranty reduction percentage through the full APC payment and for goals. First and foremost, it would
(Table 21 of the proposed rule at 71 FR the incremental cost of the pass-through advise us of the extent to which devices
49577) of 89.13 percent ($15,317.29). device above the costs of associated are being replaced due to device failures
Because the adjustment amount is set devices already reflected in the APC so that, if patterns are identified, we
for the APC, the same adjustment payment at charges reduced to cost by could explore them to see if there are
amount would be removed if devices a CCR. The pass-through payment systemic problems with certain devices.
reported under HCPCS code C1722 or amount was reduced only to prevent the We believed that the reporting of a
C1882 were reported with HCPCS code program from making duplicate specific modifier with certain procedure
G0297. This would be identical to the payment for a portion of the device, codes would allow us to examine
amount of adjustment that would apply once as part of the APC payment and patterns of delivery of specific hospital
to the payment for a pass-through once through the pass-through payment. services when implanted devices are
device if there were, hypothetically, a We proposed to implement the replaced without cost or with full credit
new ICD to which we had given pass- adjustment through the use of an for the cost of a device by the
through status (no ICD currently has appropriate modifier specific to a device manufacturer, in comparison with
pass-through status) and if the reduction replacement without cost or crediting of publicly available information about
amount in Table 21 of the proposed rule the cost of a device by the manufacturer. problematic devices. We also stated that
were the appropriate reduction amount. We proposed that hospitals would be we believed that analysis of outpatient
We proposed to both adjust the APC required to report the modifier hospital claims would serve as an
payment to remove payment for the appended to a specific procedure on additional source of information to the
device furnished without cost to the claims for services when two conditions medical community about patterns of
hospital or beneficiary and also to are met. The first condition was that the device failures, voluntary field actions,
decrease the beneficiary copayment in procedure was assigned to one of the and recalls, contributing to improved
proportion to the reduced APC payment APCs in Table 21 of the proposed rule. awareness and understanding of
so that the beneficiary would, in many We have discussed above the criteria problems.
but not all cases, share in the cost that we employed for selecting the APCs Secondly, we explained that we
savings attributable to the provision of to which we proposed that this policy believed that it would ensure equitable
the device without cost by the would apply. We proposed that the adjustment to the payments for surgical
manufacturer. We proposed that when a second condition would be that the procedures to replace problematic
device was replaced without cost to the device for which the manufacturer devices by providing payments to
hospital under warranty or recall or a furnished a replacement device (or hospitals only for the nondevice-related
credit was provided for the cost of a provided credit for the device being procedural costs when a device is
failed or recalled device (unlike cases of replaced) would be one of the devices replaced without cost to the hospital for
offset for a pass-through device), the included in Table 22 of the proposed the device or with full credit for the
beneficiary’s copayment would be rule. We proposed to restrict the devices removed device. Thirdly, we noted that
calculated based on the reduced APC to which the adjustment would apply to we believed that it would also identify
payment rate, maintaining the same those included in Table 22 of the those claims that contained reduced
percentage copayment as would apply proposed rule in order to ensure that the device charges due to the full credit
to the unadjusted APC payment if the adjustment would not be triggered by provided by the manufacturer for a
inpatient deductible were not exceeded. the replacement of an inexpensive replaced device so that in the future we
We proposed this because we believed device whose cost would not constitute could assess the impact of these claims
that it was appropriate to reduce the a significant proportion of the total on median costs for the services into
beneficiary copayment in these cases payment rate for an APC. which the device costs are packaged.
because the device was being furnished We also proposed that the presence of We proposed that the policy would be
or credited by the manufacturer without the modifier would trigger the effective for services furnished on or
obligation on the part of the beneficiary. adjustment in payment for the APCs in after January 1, 2007. We believed that
We noted, however, that in the case of Table 21 of the proposed rule. While we this proposed policy was necessary to
some high cost APCs, making the recognized that this would create a enable us to secure claims data that
payment adjustment in a recall or reporting burden for hospitals, we might be used to identify trends in
warranty situation might not result in indicated that we believed that the device problems that led to device
reduction of the copayment because the reporting requirement would be replacements, and that it would also be
copayment, although based on the unavoidable. Only hospitals could necessary to fulfill our fiduciary
reduced payment rate, might continue report whether the circumstances for responsibility to the Medicare program
to exceed the inpatient deductible and, reduced payment as described above by not providing payments for items
therefore, would continue to be set at were met and, therefore, we saw no that were excluded from coverage under
the inpatient deductible. option other than to have hospitals Medicare law because neither the
As we discussed in the proposed rule, report this information to us. We beneficiary nor any party on his or her
this contrasted with the case of pass- recognized that the current FB modifier behalf had an obligation to pay.
through devices, where the beneficiary (‘‘Item furnished without cost to At its August 2006 meeting, the APC
was liable for the copayment on the full provider, supplier or practitioner’’) Panel recommended that CMS evaluate
APC amount (which, in the case of high might not be appropriate in cases in the proposed percentage adjustments in
cost APCs, was limited to the Medicare which the replacement device was a cases in which the device is furnished
inpatient deductible) but paid no more expensive device than the device without cost or with credit for the
copayment for the incremental cost of being removed and that it might need to replaced device to ensure that they have
the pass-through device. We stated that be changed to expand its use for all taken into account the administrative
resources required for hospitals to to the hospital, the hospital nevertheless relevant full offset amount. We believe
provide the replacement devices. In incurs costs due to the special handling that making the full APC payment
reviewing this recommendation, we of the billing and accounting for the would result in significant overpayment
have carefully considered the issue of device. One commenter proposed that because we are specifically establishing
administrative costs involved in CMS reduce the APC payment by 70 to our CY 2007 payment rates based on
furnishing the replacement devices and 80 percent of the offset amount rather claims where hospitals incur device
have concluded that the residual than by the entire offset amount. costs, and in most cases those claims
payment for the procedure should Another commenter agreed with the would include the full device costs. If
adequately compensate the provider for proposed policy, provided that CMS we were to take no APC payment
all administrative costs of furnishing the excludes claims for these APCs that are reduction in upgrade cases, such an
services, whether the device is reported with condition code 50 from approach would favor device upgrades,
furnished with or without cost to the the median cost calculation because rather than replacement with a
provider. We elaborate on our responses including them would understate the comparable device, in warranty or recall
to this recommendation in the device costs that should be packaged. cases where the surgical procedure to
discussion below. Some commenters objected to the
replace the device with an upgraded
We received a number of comments application of the policy in the case of
device is only medically necessary
on our discussion of data collection and upgraded devices in which the hospital
the potential use of that data from a is given a credit for the device that is because of the original defective device,
public health perspective. We agree covered under warranty but the hospital for which the manufacturer bears
with commenters that only data must pay the difference between the responsibility.
elements required to answer predefined manufacturer’s charge for the replaced As discussed above, we calculated the
questions should be collected. In device and the upgraded device being CY 2007 payment rates for the APCs
addition to serving a public health role, inserted and in the case of replacement subject to the reduction policy using
we agree that data collection in under warranty in which there is a only claims which contained
registries may offer transparency once partial credit because the warranty does appropriate devices and for which there
devices are on the market. not cover the full replacement cost of were no token charges for the devices.
We also agree with commenters that the device. The commenters indicated We used this methodology to maximize
registry data may not be sufficient to that the same issue arises when one type the probability that we captured all of
develop clinical practice guidelines, and of device is replaced with a different the costs of the devices in these APCs
we believe that the process in place by type of device (for example, a in all situations where hospitals
many medical professional societies pacemaker being replaced under incurred costs to provide the devices.
appropriately establishes guidelines warranty by an ICD), whose procedural Therefore, in our median cost
based on the strength of evidence in payment may be provided through a calculations for these device-dependent
which evidence from controlled clinical different APC than the procedural APC APCs, we used both claims where the
trials would be stronger than registry associated with the device being hospital bore the full cost of the device
data. replaced. The commenters argued that and those where the hospital bore a
We received a number of public these cases should be exempt from any partial device cost due to a
comments regarding Coverage with reduction, notwithstanding that the manufacturer credit in an upgrade
Evidence Development (CED) and hospital receives a credit for the device situation. The amounts by which we
registry funding that are outside the being replaced. Other commenters urged will reduce the payment for these APCs
scope of this rule; therefore, we are not CMS to reduce the amount of the are calculated using the device costs
responding to them in this final rule adjustment to the APC payment rate in
with comment period. that are found in the very same set of
these cases. They offered to work with claims on which we calculated the
We received several public comments CMS to develop the amount of the
concerning our proposal for CY 2007. A median costs for the device-dependent
reduction that would apply in such
summary of the comments and our APCs. As such, we believe that the
situations.
responses follow. Response: We continue to believe that percentages represent the best estimate
Comment: Some commenters it is appropriate to reduce the amount of costs attributable to the devices, for
supported the proposed policy in cases of the APC payment by the full which in most cases the hospital incurs
in which the hospital incurs no cost for estimated percentage of device cost, no cost or, in the case of upgraded
the device being replaced under both in cases in which the hospital devices or partial credits, a reduced
warranty or otherwise without cost by receives the device without cost and in cost, and those costs are packaged into
the manufacturer. However, other cases in which the hospital receives a the APC payments. Moreover,
commenters stated that the proposal to credit toward an upgrade for the device commenters told us that upgrades
remove 100 percent of the cost of the that is being replaced. We are concerned account for only 10 to 15 percent of the
devices is not appropriate because of the about a payment policy that would cases where devices are replaced under
acquisition, handling, and apply a smaller APC payment warranty or recall. Thus, we believe it
administrative costs associated with the percentage reduction in upgrade cases, is appropriate to use the same device
acquisition of the replacement device. because we have no way of estimating percentage for the APC payment
The commenters indicated that although an appropriate offset amount based on reduction in both cases of device
the hospital does not pay for the device, the CY 2005 claims data. We are unable replacement without cost to the hospital
the hospital must record the special ‘‘no to identify upgrade cases in our CY 2005 and device upgrade with a manufacturer
charge’’ status of the device, advise the claims data, and we will not be able to credit. We recognize that in some cases
finance and patient accounts identify such claims until our CY 2007 the estimated amount of device cost,
departments how to charge for it, and data are available for the CY 2009 OPPS and therefore the amount of the
report to Medicare that the procedure update. In the meantime, we believe payment reduction, will be more or less
involves replacement of a defective that our two alternatives would be than the hospital cost of the device in
device. They pointed out that although either to provide the full APC payment a specific clinical circumstance, but as
the device may be acquired without cost or reduce the APC payment by the averaging is inherent in a prospective
payment system, we do not believe that so that CMS could exclude those claims times the unadjusted payment rate. We
it is inappropriate. from the calculation of the median cost intend to publish the actual adjustment
As described below in reference to the for the devices and more accurately amounts on the CMS website after
use of modifier FB in CY 2007, once we apply an appropriate reduction in these publication of this final rule with
have CY 2007 claims data we expect cases. The commenters also questioned comment period. If the FB modifier is
that we would be able to examine the how the multiple procedure discount assigned to a procedure code that is not
costs of device upgrades in recall or would apply when the procedure is on Table 21, then no adjustment will be
warranty replacement cases to see if reported with an FB modifier, signifying taken. The adjustment will occur before
they are typically significantly greater that the device was replaced or credited wage adjustment and before the
than the costs of replacement of a device under warranty. Specifically, assessment to determine if a multiple
without cost to the hospital. However, commenters indicated that all of the procedure reduction applies. There may
until we have data available that permit APCs for which we proposed this policy be cases where, after removal of the
examination of the differential average have status indicator ‘‘T’’ and that, device cost, the remaining payment for
costs in these two situations, we intend therefore, their payment would be the service is less than the payment for
to provide payment of procedures where reduced by 50 percent if there was a another procedure with a status
a manufacturer credit is provided higher paid service on the same date of indicator of ‘‘T,’’ and the multiple
toward an upgraded device at the same service. The commenters objected to a procedure reduction would apply. We
rate we would pay if a replacement policy that would first reduce the believe this multiple procedure
device were provided by the payment for the APC due to a recall and reduction continues to be appropriate
manufacturer at no cost, by applying the then also reduce the payment rate if even after the APC payment adjustment
same APC payment reduction in both there was a more costly procedure on to remove payment for the device costs,
situations. In this way, we will avoid the claim with a status indicator of ‘‘T.’’ because there would still be the
significant overpayments while we Response: Effective January 1, 2007, expected efficiencies in performing the
collect claims data for future the definition of the FB modifier will procedure if it were provided in the
examination to see if an alternative read: ‘‘Item Provided Without Cost to same operative session as another
payment policy could be warranted. Provider, Supplier, or Practitioner or surgical procedure. Thus, it would be
Moreover, we do not believe that it is credit received for replaced device appropriate for the remaining
necessary to reduce the amount of the (Examples, but not limited to: Covered procedural payment to be reduced by 50
adjustment for administrative costs in under warranty, replaced due to defect, percent, consistent with our well-
these cases, as we believe that these free sample).’’ Hospitals will be established multiple surgical procedure
costs are part of the payment that instructed to append the modifier to the reduction policy. Similarly, if the
remains for the services furnished. HCPCS code for the procedure in which procedure is interrupted before
Administrative costs vary significantly, the device was inserted on claims when administration of anesthesia and
with more resource-intensive the device that was replaced under appended with modifier 73 or if the
administrative actions occasionally warranty, recall or field action is one of reduced services modifier 52 appears on
required even for the simplest services the devices in Table 21 below. Claims the line with the procedure code, the 50
at times. Hence, we believe that the containing the FB modifier will not be percent reduction will be taken from the
averaging nature of the payment that accepted unless the modifier is on a adjusted payment amount as well. We
remains for the hospital procedural procedure code with status indicator believe that it is appropriate to treat the
services should provide fair and ‘‘S,’’ ‘‘T,’’ ‘‘V’’ or ‘‘X.’’ In cases in which service subject to the APC payment
adequate payment for these routine the device being replaced is replaced reduction in cases of devices replaced
costs. without cost, the provider will report a without cost or with a full credit
With regard to the comment that we token device charge. In cases in which received like any other service and to
should exclude claims reported with the device being inserted is an upgrade apply the standard reduction policies.
condition code 50 from the median cost (either of the same type of device or to Comment: One commenter objected to
calculation because including them a different type of device), the provider the application of a different offset
would understate the device costs that will report as the device charge the percentage to APC 0385 (Level I
should be packaged, we do not agree. difference between its usual charge for Prosthetic Urology) than for APC 0386
Condition code 50, ‘‘Product the device being replaced and the credit (Level II Prosthetic Urology) for
replacement for known recall of a for the replacement device. CMS will be purposes of the adjustment when a
product—Manufacturer or FDA has able to identify whether the device was device is replaced without cost or with
identified the product for recall and replaced without cost by the presence of credit for the device being replaced. The
therefore replacement,’’ is placed on the the token charge. Where there is not a commenter stated that the ratio of
claim at a claim level, not at a line level, token charge for the device but there is device costs to overall procedure costs
and thus does not provide the level of an FB modifier on a HCPCS code, CMS is basically identical for both ,and,
specificity that the FB modifier will assume that an upgrade occurred. therefore, the offset percent should be
provides. We expect to use the presence Therefore, we believe that with the 60 percent for both.
of the FB modifier on the line with the change in the definition of the FB Response: We disagree. The APC 0385
procedure code, as discussed below, to modifier as of January 2007, we have no device percentage is 46.86 percent and
determine which claims should be need to establish a second modifier for the APC 0386 percentage is 61.16
removed from the set of claims used for device replacement situations where a percent. Therefore, we conclude that the
calculation of the median cost. manufacturer provides a credit toward device cost in APC 0386 is significantly
Comment: Several commenters asked an upgraded device. higher than the device code in APC 385,
how the FB modifier would apply in If the APC to which the procedure and it would not be appropriate to
cases of a credit for an upgrade in a code is assigned is one of the APCs assign the same percentage to both.
warranty or recall situation. The listed in Table 20 below, the fiscal After carefully considering the public
commenters asked CMS to create a intermediary will reduce the unadjusted comments received, we are finalizing
second modifier for use when there is a payment rate for the procedure by an our proposed CY 2007 policy for
device upgrade or change in device type amount equal to the percent in Table 20 reduction of APC payments in cases of
device replacement without cost or APC payment in cases of devices under warranty or as a result of recall.
when a full credit is received without replaced without cost or where full The revised title to section 419.45 is
modification. We are also making a credit is received. The title of the ‘‘Payment and copayment reduction for
technical change to the title of the proposed regulation does not reflect the devices replaced without cost or full
regulation at new section 419.45 to entire policy as proposed or finalized as credit is received.’’
better reflect our policy to reduce the it references only devices replaced
TABLE 20.—ADJUSTMENTS TO APCS IN CASES OF DEVICES REPORTED WITHOUT COST OR FOR WHICH FULL CREDIT IS
RECEIVED
CY 2007
APC SI APC group title offset
percent
0039 ................... S Level I Implantation of Neurostimulator .......................................................................................................... 78.85

0040 ................... S Percutaneous Implantation of Neurostimulator Electrodes, Excluding Cranial Nerve ................................... 54.06
0061 ................... S Laminectomy or Incision for Implantation of Neurostimulator Electrodes, Excludin ...................................... 60.06
0089 ................... T Insertion/Replacement of Permanent Pacemaker and Electrodes ................................................................. 77.11
0090 ................... T Insertion/Replacement of Pacemaker Pulse Generator ................................................................................. 74.74
0106 ................... T Insertion/Replacement/Repair of Pacemaker and/or Electrodes .................................................................... 41.88
0107 ................... T Insertion of Cardioverter-Defibrillator .............................................................................................................. 90.44
0108 ................... T Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads ................................................................. 89.40
0222 ................... T Implantation of Neurological Device ............................................................................................................... 77.65
0225 ................... S Implantation of Neurostimulator Electrodes, Cranial Nerve ............................................................................ 79.04
0227 ................... T Implantation of Drug Infusion Device .............................................................................................................. 80.27
0229 ................... T Transcatherter Placement of Intravascular Shunts ......................................................................................... 46.17
0259 ................... T Level VI ENT Procedures ............................................................................................................................... 84.61
0315 ................... T Level II Implantation of Neurostimulator ......................................................................................................... 76.03
0385 ................... S Level I Prosthetic Urological Procedures ........................................................................................................ 83.19
0386 ................... S Level II Prosthetic Urological Procedures ....................................................................................................... 61.16
0418 ................... T Insertion of Left Ventricular Pacing Elect. ....................................................................................................... 87.32
0654 ................... T Insertion/Replacement of a permanent dual chamber pacemaker ................................................................. 77.35
0655 ................... T Insertion/Replacement/Conversion of a permanent dual chamber pacemaker ............................................. 76.59
0680 ................... S Insertion of Patient Activated Event Recorders .............................................................................................. 76.40
0681 ................... T Knee Arthroplasty ............................................................................................................................................ 73.37
TABLE 21.—DEVICES FOR WHICH THE TABLE 21.—DEVICES FOR WHICH THE the BIPA. Prior to pass-through device
FB MODIFIER MUST BE REPORTED FB MODIFIER MUST BE REPORTED categories, Medicare payments for pass-
WITH THE PROCEDURE CODE WHEN WITH THE PROCEDURE CODE WHEN through devices under the OPPS were
FURNISHED WITHOUT COST OR AT FURNISHED WITHOUT COST OR AT made on a brand-specific basis. All of
the initial 97 category codes that were
FULL CREDIT FOR A REPLACED DE- FULL CREDIT FOR A REPLACED DE- established as of April 1, 2001, have
VICE VICE—Continued expired; 95 categories expired after CY
2002, and 2 categories expired after CY
Device Description Device Description
2003. In addition, nine new categories
C1721 ............ AICD, dual chamber. C1900 ............ Lead coronary venous. have expired since their creation. We
C1722 ............ AICD, single chamber. C2619 ............ Pmkr, dual, non rate-resp. currently have no category codes for
C1764 ............ Event recorder, cardiac. C2620 ............ Pmkr, single, non rate-resp. pass-through devices that will expire
C1767 ............ Generator, neurostim, imp. C2621 ............ Pmkr, other than sing/dual. January 1, 2007. We created one new
C1771 ............ Rep dev, urinary, w/sling. C2622 ............ Prosthesis, penile, non-inf. category effective January 1, 2006, for
C1772 ............ Infusion pump, program- C2626 ............ Infusion pump, non-prog, C1820 (Generator, neurostimulator
mable. temp. (implantable), with rechargeable battery
C1776 ............ Joint device (implantable). C2631 ............ Rep dev, urinary, w/o sling. and charging system), which we
C1777 ............ Lead, AICD, endo single L8614 ............. Cochlear device/system.
proposed to continue to pay under the
coil.
pass-through provision in CY 2007
C1778 ............ Lead, neurostimulator. B. Pass-Through Payments for Devices
C1779 ............ Lead, pmkr, transvenous
under the OPPS. This category was
VDD. 1. Expiration of Transitional Pass- created after we published
C1785 ............ Pmkr, dual, rate-resp. Through Payments for Certain Devices modifications to our criteria in the CY
C1786 ............ Pmkr, single, rate-resp. 2006 OPPS final rule with comment
a. Background period on November 10, 2005 (70 FR
C1813 ............ Prosthesis, penile, inflatab.
C1815 ............ Pros, urinary sph, imp. Section 1833(t)(6)(B)(iii) of the Act 68628 through 68631), allowing CMS to
C1820 ............ Generator, neuro rechg bat requires that, under the OPPS, a refine previous pass-through category
sys. category of devices be eligible for descriptions that would have prevented
C1882 ............ AICD, other than sing/dual. transitional pass-through payments for us from making pass-through payments
C1891 ............ Infusion pump, non-prog, at least 2, but not more than 3, years. for a new technology that otherwise met
perm.
This period begins with the first date on our criteria. These modifications
C1895 ............ Lead, AICD, endo dual coil.
C1896 ............ Lead, AICD, non sing/dual. which a transitional pass-through amended the original criteria and
C1897 ............ Lead, neurostim, test kit. payment is made for any medical device process for creating additional device
C1898 ............ Lead, pmkr, other than trans. that is described by the category. The categories for pass-through payment that
C1899 ............ Lead, pmkr/AICD combina- device category codes became effective we published on November 2, 2001 (66
tion. April 1, 2001, under the provisions of FR 55850 through 55857). Under our
established policy, we base the reflected the portion of the APC costs associated with the device. We
expiration dates for the category codes payment amount that we determined continued our existing methodology for
on the date on which a category was was associated with the cost of the determining the offset amount,
first eligible for pass-through payment. device, as required by section described earlier. We were able to use
In the November 1, 2002 OPPS final 1833(t)(6)(D)(ii) of the Act. In the this methodology to establish the device
rule, we established a policy for November 1, 2002 interim final rule offset amounts for CY 2004 because
payment of devices included in pass- with comment period, we published the providers reported device codes
through categories that are due to expire applicable offset amounts for CY 2003 (generally C-codes) on the CY 2002
(67 FR 66763). For CY 2003 through CY (67 FR 66801). claims used for the CY 2004 OPPS
2006, we packaged the costs of the For the CY 2002 and CY 2003 OPPS update. For the CY 2005 update to the
devices no longer eligible for pass- updates, to estimate the portion of each OPPS, our data consisted of CY 2003
through payments into the costs of the APC payment rate that could reasonably claims that did not contain device codes
procedures with which the devices were be attributed to the cost of an associated and, therefore, for CY 2005, we utilized
billed in the claims data used to set the device eligible for pass-through the device percentages as developed for
payment rates for those years. payment, we used claims data from the CY 2004. In the CY 2004 OPPS update,
Brachytherapy sources, which are now period used for recalibration of the APC we reviewed the device categories
separately paid in accordance with rates. That is, for CY 2002 OPPS eligible for continuing pass-through
section 1833(t)(2)(H) of the Act, are an updating, we used CY 2000 claims data, payment in CY 2004 to determine
exception to this established policy and for CY 2003 OPPS updating, we whether the costs associated with the
(with the exception of brachytherapy used CY 2001 claims data. For CY 2002, device categories were packaged into
sources for prostate brachytherapy, we used median cost claims data based the existing APCs. Based on our review
which were packaged in the CY 2003 on specific revenue centers used for of the data for the device categories
OPPS only). device-related costs because C-code cost existing in CY 2004, we determined that
data were not available until CY 2003. there were no close or identifiable costs
b. Policy for CY 2007 For CY 2003, we calculated a median associated with the devices relating to
As we stated earlier, currently we cost for every APC based on single the respective APCs that were normally
have one effective device category for claims with device codes but without billed with them. Therefore, for those
pass-through payment, C1820, which packaging the costs of associated C- device categories, we set the offset
we created for pass-through payment codes for device categories that were amount to $0 for CY 2004. We
effective January 1, 2006. For CY 2007, billed with the APC. We then calculated continued this policy of setting the
we proposed to continue to make a median cost for every APC based on offset amount to $0 for the device
payment under the pass-through single claims with the costs of the categories that continued to receive
provisions for category C1820. We associated device category C-codes that pass-through payment in CY 2005.
proposed that this category would were billed with the APC packaged into
the median. Comparing the median APC For the CY 2006 OPPS update, CY
expire from pass-through payment after 2004 hospital claims were available for
December 31, 2007 (71 FR 49578). This cost without device packaging to the
median APC cost, including device analysis. Hospitals billed device C-
would provide the category transitional codes in CY 2004 on a voluntary basis.
pass-through payment status for a 2-year packaging, developed from the claims
with device codes also reported enabled We reviewed our CY 2004 data and
period, in accordance with the statutory found that the numbers of claims for
requirement that no category be paid as us to determine the percentage of the
median APC cost that was attributable services in many of the APCs for which
a pass-through device for less than 2 we calculated device percentages using
years, nor more than 3 years. to the associated pass-through devices.
By applying those percentages to the CY 2004 data were quite small. We also
We did not receive any public found that many of these APCs already
comments concerning this proposal. APC payment rates, we determined the
applicable amount to be deducted from had relatively few single claims
Therefore, we are finalizing our available for median calculations
proposal to expire category C1820, the pass-through payment, the ‘‘offset’’
amount. We created an offset list compared with the total bill frequencies
Generator, neurostimulator because of our inability to use many
(implantable), with rechargeable battery comprised of any APC for which the
device cost was at least 1 percent of the multiple bills in establishing median
and charging system, from pass-through costs for all APCs. In addition, we found
APC’s cost.
payment after December 31, 2007 that our claims demonstrated that
The offset list that we published for
without modification. CY 2002 through CY 2004 was a list of relatively few hospitals specifically
2. Provisions for Reducing Transitional offset amounts associated with those coded for devices utilized in CY 2004.
Pass-Through Payments to Offset Costs APCs with identified offset amounts Thus, we were not confident that CY
Packaged Into APC Groups developed using the methodology 2004 claims reporting device HCPCS
described above. As a rule, we do not codes represented the typical costs of all
a. Background hospitals providing the services.
know in advance which procedures
In the November 30, 2001 OPPS final residing in certain APCs may be billed Therefore, we did not use CY 2004
rule, we explained the methodology we with new device categories. Therefore, claims with device codes to calculate
used to estimate the portion of each an offset amount is applied only when CY 2006 device offset amounts. In
APC payment rate that could reasonably a new device category is billed with a addition, we did not use the CY 2005
be attributed to the cost of the HCPCS procedure code that is assigned methodology, for which we utilized the
associated devices that are eligible for to an APC appearing on the offset list. device percentages as developed for CY
pass-through payments (66 FR 59904). For CY 2004, we modified our policy 2004. Two years had passed since we
Beginning with the implementation of for applying offsets to device pass- developed the device offsets for CY
the CY 2002 OPPS quarterly update through payments. Specifically, we 2004, and the device offsets originally
(April 1, 2002), we deducted from the indicated that we would apply an offset calculated from CY 2002 hospitals’
pass-through payments for the to a new device category only when we claims data may either have
identified devices an amount that could determine that an APC contains overestimated or underestimated the
contributions of device costs to total described earlier and first used for the offset greater than $0 is appropriate for
procedural costs in the outpatient CY 2003 OPPS to determine an any new category that we create, we
hospital environment of CY 2006. In appropriate device offset percentage for proposed to announce the offset amount
addition, a number of the APCs on the those APCs with which the new in the program transmittal that
CY 2004 and CY 2005 device offset category would be reported. announces the new category.
percentage lists were either no longer in We did not publish a list of APCs In summary, for CY 2007, we
existence or were so significantly with device percentages as a transitional proposed to use CY 2005 hospital
reconfigured that the past device offsets policy for CY 2006 because of the claims data to calculate device
likely did not apply. previously discussed limitations of the percentages and potential offsets for CY
For CY 2006, we reviewed the single CY 2004 OPPS data with respect to 2007 applications for new device
new device category established thus device costs associated with procedures. categories. We proposed to publish,
far, C1820, to determine whether device We stated in the CY 2006 final rule with through quarterly program transmittals,
costs associated with the new category comment period (70 FR 68628) that we any new or updated offsets that we
were packaged into the existing APC expected to reexamine our previous calculate for CY 2007, corresponding to
structure based on partial CY 2005 methodology for calculating the device newly created categories or existing
claims data. Under our established percentages and offset amounts for the categories, respectively.
policy, if we determine that the device CY 2007 OPPS update, which would be After the CY 2007 proposed OPPS
costs associated with the new category based on CY 2005 hospital claims data rule was published and prior to the
are closely identifiable to device costs where device HCPCS code reporting publication of this final rule with
packaged into existing APCs, we set the was required. comment period, we determined that we
offset amount for the new category to an would establish two new device
b. Policies for CY 2007 categories for transitional pass-through
amount greater than $0. Our review of
the service indicated that the median For CY 2007, we proposed to continue payment. Therefore, we are announcing
cost for the applicable APC 0222 to review each new device category on our offset policy for these two device
contained costs for neurostimulators a case-by-case basis as we have done in categories, whose coding and payment
that were similar to neurostimulators CY 2004, CY 2005, and CY 2006, to information is found in Addenda A and
described by the new device category determine whether device costs B. We have established device
C1820. Therefore, we determined that a associated with the new category are categories L8690 (Auditory
device offset would be appropriate. We packaged into the existing APC osseointegrated device, external sound
announced an offset amount for that structure. If we determine that, for any processor, replacement) and C1821
category in Program Transmittal No. new device category, no device costs (Interspinous process distraction device
804, dated January 3, 2006. associated with the new category are (implantable)) for pass-through
For CY 2006, we are using available packaged into existing APCs, we payment, effective January 1, 2007. As
partial year CY 2005 hospital claims proposed to continue our current policy stated earlier, beginning in CY 2004 and
data to calculate device percentages and of setting the offset amount for the new now continuing through CY 2007, we
potential offsets for CY 2006 category to $0 for CY 2007. There is apply an offset to a new device category
applications for new device categories. currently one new device category that only when we determine that an APC
Effective January 1, 2005, we require will continue for pass-through payment contains costs associated with a related
hospitals to report device HCPCS codes in CY 2007. This category, described by device. We have determined that we
and their charges when hospitals bill for HCPCS code C1820, currently has an cannot identify device-related costs in
services that utilize devices described offset amount of $8,647.81, which is the procedural APCs we expect will be
by the existing device codes. In applied to APC 0222. We proposed to billed with either of the new categories
addition, during CY 2005, we update this offset for CY 2007 based on L8690 or C1821, that is, in APC 0256 or
implemented device edits for many the full year of claims data for CY 2005, APC 0050, respectively. Therefore, we
services that require devices and for the claims data year for our CY 2007 are setting the offset amount to $0 for
which appropriate device HCPCS codes OPPS update. Based on full year CY device categories L8690 and C1821 for
exist. Therefore, we expected that the 2005 claims data used for this final rule CY 2007.
number of claims that included device with comment period, the offset amount We did not receive any public
codes and their respective costs to be for C1820 is 77.65 percent of the final comments concerning our CY 2007
much more robust and representative CY 2007 payment rate for APC 0222. proposals for calculating device
for CY 2005 than for CY 2004. We (See Addendum A of this CY 2007 percentages and potential offset
believe that use of the most current OPPS final rule with comment period amounts. Therefore, we are finalizing
claims data to establish offset amounts for a listing of the final CY 2007 APC our proposals without modification, and
when they are needed to ensure payment rates.) specifically applying them to device
appropriate payment is consistent with We proposed to continue our existing categories C1820, L8690, and C1821, as
our stated policy; therefore, we policy of establishing new categories in discussed above.
proposed to continue to do so for the CY any quarter when we determine that the
2007 OPPS. Specifically, if we create a criteria for granting pass-through status V. OPPS Payment Changes for Drugs,
new device category for payment in CY for a device category are met. If we Biologicals, and Radiopharmaceuticals
2007, to calculate potential offsets we create a new device category and A Transitional Pass-Through Payment
proposed to examine the most current determine that our CY 2005 claims data for Additional Costs of Drugs and
available claims data, including device contain a sufficient number of claims Biologicals
costs, to determine whether device costs with identifiable costs associated with
associated with the new category are the new category of devices in any APC, 1. Background
already packaged into the existing APC we proposed to reduce the transitional Section 1833(t)(6) of the Act provides
structure, as indicated earlier. If we pass-through payment for the device by for temporary additional payments or
conclude that some related device costs the related procedural APC offset ‘‘transitional pass-through payments’’
are packaged into existing APCs, we amount if the offset amount is greater for certain drugs and biological agents.
proposed to use the methodology than $0. If we determine that a device As originally enacted by the Medicare,
Medicaid, and SCHIP Balanced Budget Section 1833(t)(6)(D)(i) of the Act also how CMS determines the Part B drug
Refinement Act (BBRA) of 1999 (Pub.L. states that if a drug or biological is CAP rate.
106–113), this provision requires the covered under a competitive acquisition Response: As discussed above, the
Secretary to make additional payments contract under section 1847B of the Act, statutory language requires that if a drug
to hospitals for current orphan drugs, as the payment rate is equal to the average or biological is covered under a
designated under section 526 of the price for the drug or biological for all competitive acquisition contract under
Federal Food, Drug, and Cosmetic Act competitive acquisition areas and the section 1847B of the Act, the OPPS
(Pub. L. 107–186); current drugs and year established as calculated and pass-through payment rate is equal to
biological agents and brachytherapy adjusted by the Secretary. Section the average price for the drug or
sources used for the treatment of cancer; 1847B of the Act, as added by section biological for all competitive acquisition
and current radiopharmaceutical drugs 303(d) of Pub. L. 108–173, establishes areas and the year established as
and biological products. For those drugs the payment methodology for Medicare calculated and adjusted by the
and biological agents referred to as Part B drugs and biologicals under the Secretary. As of the time of this final
‘‘current,’’ the transitional pass-through competitive acquisition program (CAP). rule with comment period, the Part B
payment began on the first date the The Part B drug CAP was implemented drug CAP includes one national
hospital OPPS was implemented (before July 1, 2006, and includes competitive acquisition area and one
enactment of the Medicare, Medicaid, approximately 180 of the most common national vendor. Therefore, the average
and SCHIP Benefits Improvement and Part B drugs provided in the physician payment across all competitive
Protection Act BIPA of 2000 (Pub. L. office setting. The list of drugs and acquisition areas at this time is also
106–554), on December 21, 2000). biologicals covered under the Part B equal to the rate paid to the national
Transitional pass-through payments drug CAP, their associated payment vendor. We refer the public to the CY
are also required for certain ‘‘new’’ rates and the Part B drug CAP pricing 2006 MPFS final rule (70 FR 70236) for
drugs and biological agents that were methodology can be found at http:// a full description of the Part B CAP.
www.cms.hhs.gov/ Comment: Commenters stated that
not being paid for as a hospital
CompetitiveAcquisforBios. pass-through payments were required
outpatient department service as of
For CY 2007, we proposed to pay for by law to be paid on a drug-by-drug
December 31, 1996, and whose cost is
drugs and biologicals that are granted basis, and therefore a payment based on
‘‘not insignificant’’ in relation to the
pass-through status under the OPPS and the Part B drug CAP process that
OPPS payments for the procedures or
that are included in the Part B drug CAP incorporates many drugs across several
services associated with the new drug or
at a payment rate equal to the rate these vendors would violate this drug-specific
biological. Under the statute,
drugs would be paid under the Part B requirement.
transitional pass-through payments can Response: We disagree that these
drug CAP. We had several comments
be made for at least 2 years but not more statutory requirements pose a conflict.
about this proposal.
than 3 years. Proposed pass-through Comment: Commenters expressed The Part B drug CAP program payment
drugs and biologicals are assigned status concern that Part B drug CAP rates are determination is performed on a drug-
indicator ‘‘G’’ in Addenda A and B of insufficient to cover the costs hospitals by-drug basis and complements the
the CY 2007 OPPS proposed rule. The incur for drugs, as the CAP rate is an provisions of the pass-through concept.
pass-through application and review average of eligible approved CAP (For more information on the Part B
process is explained on the CMS Web vendor bids, and hospitals are not able drug CAP payment rate methodology,
site at http://www.cms.hhs.gov. to obtain drugs at the CAP rates because see section II.C.3. of the Interim Rule
Section 1833(t)(6)(D)(i) of the Act sets they are statutorily excluded from the entitled ‘‘Competitive Acquisition of
the payment rate for pass-through CAP program. The commenters Outpatient Drugs and Biologicals Under
eligible drugs (assuming that no pro rata suggested that the rate for all pass- Part B’’ which was published at the
reduction in pass-through payment is through drugs should, therefore, be set Federal Register on July 6, 2005 (70 FR
necessary) as the amount determined to the ASP methodology, regardless of 39069) and section II.H.6. of the final
under section 1842(o) of the Act. This the drug’s inclusion in the Part B drug rule entitled ‘‘Revisions to Payment
payment methodology is set forth in CAP. Policies Under the Physician Fee
§ 419.64 of the regulations. Section Response: As discussed above, our Schedule for Calendar Year 2006 and
1847A of the Act, as added by section proposed methodology for setting Certain Provisions Related to the
303(c) of Pub. L. 108–173, establishes payment rates for pass-through drugs Competitive Acquisition Program of
the use of the average sales price (ASP) that are also a part of the Part B drug Outpatient Drugs and Biologicals Under
methodology as the basis for payment CAP program is mandated by section Part B’’ which was published in the
for drugs and biologicals described in 1833(t)(6)(D)(i) of the Act. In addition, Federal Register on November 21, 2005
section 1842(o)(1)(C) of the Act that are we note that, for the two pass-through (70 FR 70236).)
furnished on or after January 1, 2005. drugs that we proposed to pay at the For the reasons set forth in the section
The ASP methodology uses several Part B drug CAP rate in CY 2007, the above, we are finalizing our proposed
sources of data as a basis for payment, Part B drug CAP rate exceeds the rate policy to pay for drugs and biologicals
including ASP, wholesale acquisition resulting from the October update of the with pass-through status in CY 2007
cost (WAC), and average wholesale ASP methodology for both drugs. that are also covered under the Part B
price (AWP). In this final rule with Therefore, we disagree that the Part B drug CAP at the rate each drug would
comment period, the terms ‘‘ASP drug CAP rate undermines hospitals’ be paid under the Part B drug CAP.
methodology’’ and ‘‘ASP-based’’ are ability to procure drugs that are paid at
inclusive of all data sources and this rate while on pass-through. 2. Drugs and Biologicals With Expiring
methodologies described therein. Comment: Commenters requested that Pass-Through Status in CY 2006
Additional information on the ASP CMS clarify the amount that we would Section 1833(t)(6)(C)(i) of the Act
methodology can be found at http:// pay for pass-through drugs and specifies that the duration of
www.cms.hhs.gov/ biologicals that are also included as part transitional pass-through payments for
McrPartBDrugAvgSalesPrice/ of the Part B drug CAP. Specifically, the drugs and biologicals must be no less
01_overview.asp#TopOfPage. commenters asked for clarification of than 2 years and no longer than 3 years.
In Table 23 of the CY 2007 OPPS section V.B of this final rule with C9220, and that HCPCS code J7346
proposed rule (71 FR 49580), we comment period. (Injectable human tissue) appropriately
proposed to allow the expiration of the Based on our review of the existing describes the product reported under
pass-through status for 12 drugs and permanent HCPCS codes available at the HCPCS code C9222 as shown in Table
biologicals on December 31, 2006. We time of the CY 2007 OPPS proposed 23 of the CY 2007 OPPS proposed rule.
also proposed to delete temporary CY rule, we determined that HCPCS code Therefore, in accordance with the policy
2006 C-codes if an alternate permanent J7344 (Nonmetabolic active tissue) described above, we are deleting HCPCS
HCPCS code was available for purposes appropriately described the product codes C9220 and C9222, and instructing
reported under HCPCS code C9221 in hospitals to use HCPCS codes J7319 and
of OPPS billing and payment in CY
the CY 2006 OPPS. We proposed to J7346, respectively, for services
2007.
delete HCPCS code C9221 and instruct furnished on or after January 1, 2007.
There are seven pass-through drugs, hospitals to use HCPCS code J7344 for
identified with an asterisk (*) in services furnished on or after January 1, We did not receive any public
Table22 below, that are paid under the 2007. We did not receive any comments comments concerning our proposed
OPPS for CY 2006 at the rate established on this proposal. Therefore, we are policy for CY 2007. Therefore, we are
by the Part B drug CAP. In CY 2007, finalizing our proposal without finalizing our proposal to discontinue
these drugs, in accordance with OPPS modification. pass-through status as of December 31,
policy for all non-pass through drugs, Since the publication of the proposed 2006, for the 12 drugs and biologicals
biologicals, and radiopharmaceuticals, rule, we have determined that HCPCS shown in Table 22 below. In addition,
are subject to the established OPPS code J7319 (Sodium hyaluronate Table 22 indicates the final CY 2007
payment methodologies discussed in injection) appropriately describes the coding changes for these drugs and
product reported under HCPCS code biologicals.
TABLE 22.—LIST OF DRUGS AND BIOLOGICALS FOR WHICH PASS-THROUGH STATUS EXPIRES DECEMBER 31, 2006
CY 2007 CY 2006 CY 2007 CY 2007 short descriptor
HCPCS HCPCS APC
J7319 .............................................................. C9220 0896 Sodium hyaluronate injection

J7344 .............................................................. C9221 9156 Nonmetabolic active tissue
J7346 .............................................................. C9222 9222 Injectable human tissue
J0128* ............................................................. .................... 9216 Abarelix injection
J0878* ............................................................. .................... 9124 Daptomycin injection
J2357* ............................................................. .................... 9300 Omalizumab injection
J2783 .............................................................. .................... 0738 Rasburicase
J2794* ............................................................. .................... 9125 Risperidone, long acting
J7518 .............................................................. .................... 9219 Mycophenolic acid
J9035* ............................................................. .................... 9214 Bevacizumab injection
J9055* ............................................................. .................... 9215 Cetuximab injection
J9305* ............................................................. .................... 9213 Pemetrexed injection
* Indicates that the drug was paid at a rate determined by the Part B drug CAP methodology while identified as pass-through under the OPPS.
3. Drugs and Biologicals With Pass- Comment: Many commenters However, drugs are paid through their
Through Status in CY 2007 supported our proposal to provide own drug specific APCs, typically at a
payment in CY 2007 for drugs and rate that is based on the ASP
In the CY 2007 OPPS proposed rule, biologicals with pass-through status at methodology that reflects recent market
we proposed to continue pass-through the rate these drugs and biologicals prices. Payment rates for separately
status in CY 2007 for the nine drugs and would receive in the physician office payable drugs are updated quarterly and
biologicals listed in Table 24 (71 FR setting. However, one commenter stated do not rely on the most recent set of
49582) that had received pass-through that the purpose of pass-through OPPS hospital claims data that results
status as of April 1, 2006. We also payments is to recognize additional in the 2-year difference between
assigned these APCs and HCPCS codes costs that hospitals incur when hospital claims and OPPS payment rates
status indicator ‘‘G’’ in Addenda A and providing new and expensive drugs and experienced by other APCs. Therefore,
B of the CY 2007 proposed rule. biologicals that are not yet reflected in we do not believe that pass-through
We proposed to pay for drugs and the OPPS APC payment rates. Therefore, drugs require a separate methodology or
biologicals that are not included in the the commenter added, pass-through payments above the methodology used
Part B drug CAP at a rate equal to the drugs and biologicals should be subject to set payment rates for other drugs.
payment these drugs and biologicals to a methodology that provides an As discussed in section V.A.1. of this
would receive in the physician office additional payment, above the payment preamble, pass-through payments for
setting in CY 2007, where payment will methodology provided to non-pass CY 2007 are made under the OPPS for
be determined by the methodology through drugs and biologicals. drugs and biologicals that are also
described in § 414.904 and generally be Response: We appreciate the included in the Part B drug CAP at the
equal to ASP+6 percent. commenters’ support for our proposed rate established by the Part B drug CAP.
We received several comments on our policy. In addition, we agree that the At the time of the proposed rule, two
proposal to pay for pass-through drugs purpose of pass-through payments is to drugs (HCPCS codes J2503 (Pegaptanib
and biologicals that are not included in recognize and support hospitals that sodium injection) and J9264 (Paclitaxel
the Part B drug CAP at the rate these provide innovative and expensive protein bound)) were approved for pass-
drugs would receive in the physician therapies before these costs are reflected through payments in CY 2007 that were
office setting. in the OPPS APC payment amounts. also covered under the Part B drug CAP.
As we have established above, payment a prospective WAC-based payment rule with comment period. We received
for these drugs will be amounts methodology for pass-through no comments on this proposal.
determined under the Part B drug CAP, radiopharmaceuticals in CY 2007. We Therefore, we have updated the
which will be at a rate slightly different believe it is appropriate to align our payment rates for budget neutrality
than the rate determined under the ASP payment methodologies, whenever estimates, impact analyses, and
methodology. Pass-through rates for all possible, within the OPPS. Therefore, completion of Addenda A and B of this
other CY 2007 pass-through drugs will for CY 2007, we are finalizing our final rule with comment period to
be at a rate equal to the rate paid in the payment policy for pass-through reflect payment rates based on ASP data
physician office setting, as determined radiopharmaceuticals as follows: For CY effective October 1, 2006, as this is the
by the ASP methodology. This 2007, hospitals will receive payment for most recent data available at the time of
information is updated quarterly as part radiopharmaceuticals that are granted this final rule with comment period.
of the ASP methodology process, and pass-through status in CY 2007 at the In addition, to be consistent with the
OPPS payment rates are adjusted hospital’s charge for the ASP-based payments that would be
accordingly. Additional information on radiopharmaceutical adjusted to the made when these drugs and biologicals
this ASP methodology is available at cost, using the hospital’s overall CCR. are furnished in physician offices, we
http://www.cms.hhs.gov/ This methodology will provide payment proposed to make any appropriate
McrPartBDrugAvgSalesPrice/. for radiopharmaceuticals granted pass- adjustments to the amounts shown in
Currently, there are no through status in CY 2007 based on the Addenda A and B on a quarterly basis
radiopharmaceuticals that would have same payment methodology that will be on the CMS Web site during CY 2007 if
pass-through status in CY 2007. In the used to provide payment for separately later quarter ASP methodology
event that a new radiopharmaceutical payable nonpass-through calculations indicate that adjustments to
agent receives pass-through status in CY radiopharmaceuticals in CY 2007 in the the payment rates for these pass-through
2007, we proposed to base its payment OPPS. drugs and biologicals are necessary, or
on the WAC for the product as ASP data We discuss in section V.B.3.b. of this in the event that they become covered
for radiopharmaceuticals are not final rule with comment period that we under the competitive acquisition
available. In addition, we proposed to are making separate payment in CY program. The payment rate for a
calculate payment for the 2007 for new drugs and biologicals with radiopharmaceutical with pass-through
radiopharmaceutical at 95 percent of its a HCPCS code, consistent with the status would also be adjusted
most recent AWP if WAC information provisions of section 1842(o) of the Act, accordingly.
was also not available. We proposed to at a rate that is equivalent to the
In Table 24 of the proposed rule, we
adopt this interim payment payment they would receive in a
listed the drugs and biologicals for
methodology in order to be consistent physician office setting (or under
which we proposed that pass-through
with how we pay for new drugs, section 1847B of the Act, if the drug or
status continue in CY 2007 (71 FR
biologicals, and radiopharmaceuticals biological is covered under a
49581). We assigned pass-through status
without HCPCS codes, as discussed in competitive acquisition contract),
to these drugs and biologicals as of
the CY 2006 OPPS final rule with whether or not we have received a pass-
April 1, 2006 and identified them in
comment period (70 FR 68669). We through application for the item.
Addenda A and B of the proposed rule
received several comments on this Accordingly, in CY 2007 the pass-
with status indicator ‘‘G.’’
proposal. through payment amount would equal
Comment: Several commenters zero for those new drugs and biologicals Comment: One commenter supported
requested that CMS pay separately for that we determine have pass-through our pass-through determination for
all radiopharmaceuticals at hospital status. That is, when we subtract the C9228 (Injection, tigecycline), and one
charges reduced to cost using the amount to be paid for pass-through commenter supported our pass-through
hospital specific overall CCR. drugs and biologicals under section determination for Q4079 (Natalizumab
Response: Comments received 1842(o) of the Act (or section 1847B of injection) for CY 2007.
relating to nonpass-through the Act, if the drug or biological is Response: We appreciate the
radiopharmaceuticals are addressed in covered under a competitive acquisition commenters’ support of our pass-
section V.B.3. of this preamble, and contract), from the portion of the through decisions for these drugs.
comments received regarding our otherwise applicable fee schedule Since the time of the proposed rule,
proposed payment methodology for amount or the APC payment rate we have granted pass-through status in
nonpass-through drugs, biologicals and associated with the drug or biological CY 2007 to an additional nine drugs and
radiopharmaceuticals without claims that would be the amount paid for drugs biologicals. In addition, in accordance
data are discussed in section V.B.3.b. of and biologicals under section 1842(o) of with the established policy discussed
this preamble. the Act (or section 1847B of the Act, if above, we are deleting six temporary CY
Our CY 2007 proposal to pay for pass- the drug or biological is covered under 2006 C-codes because we have
through radiopharmaceuticals at WAC a competitive acquisition contract), the identified an alternate permanent
was closely aligned with our proposal to resulting difference is equal to zero. HCPCS code that is available for
pay for separately payable nonpass- In the proposed rule, we used purposes of OPPS billing and payment
through radiopharmaceuticals based on payment rates based on the ASP data in CY 2007. These temporary codes, and
mean unit costs calculated from CY from the fourth quarter of CY 2005 for their permanent HCPCS replacement
2005 hospital claims data. As we budget neutrality estimates, impact codes, are listed in Table 23 along with
discuss in section V.B.3. of this analyses, and completion of Addenda A all drugs and biologicals that we are
preamble, after careful consideration of and B of the proposed rule because finalizing for pass-through payments in
all comments received, we are not these were the most recent data CY 2007 under the OPPS. In addition,
finalizing this proposal for separately available to us during the development we have identified with an asterisk (*)
payable nonpass-through of the proposed rule. We proposed to those pass-through drugs for CY 2007
radiopharmaceuticals. Therefore, we are update this data with the most recent OPPS that are also included in the Part
also not finalizing our proposal to use data available for purposes of the final B drug CAP.
TABLE 23.—LIST OF DRUGS AND BIOLOGICALS WITH PASS-THROUGH STATUS IN CY 2007

CY 2007 CY 2007 proposed
final APC Short descriptor
rule HCPCS
HCPCS
C9232 ............................................................................................... ** 9232 Injection, idursulfase.

C9233 ............................................................................................... ** 9233 Injection, ranibizumab.
C9350 ............................................................................................... ** 9350 Porous collagen tube per cm.
C9351 ............................................................................................... ** 9351 Acellular derm tissue percm2.
J0129 ................................................................................................ C9230** 9230 Abatacept injection.
J0348 ................................................................................................ ** 0760 Anadulafungin injection.
J0894 ................................................................................................ C9231** 9231 Decitabine injection.
J1740 ................................................................................................ C9229** 9229 Injection ibandronate sodium.
J2248 ................................................................................................ C9227 9227 Micafungin sodium injection.
J2278 ................................................................................................ J2278 1694 Ziconotide injection.
J2503* .............................................................................................. J2503 1697 Pegaptanib sodium injection.
J3243 ................................................................................................ C9228 9228 Tigecycline injection.
J3473 ................................................................................................ ** 0806 Hyaluronidase recombinant.
J7311 ................................................................................................ C9225 9225 Fluocinolone acetonide implt.
J8501 ................................................................................................ J8501 0868 Oral aprepitant.
J9027 ................................................................................................ J9027 1710 Clofarabine injection.
J9264* .............................................................................................. J9264 1712 Paclitaxel protein bound.
Q4079 ............................................................................................... Q4079 9126 Natalizumab injection.
* Indicates that the drug is included in the Part B drug CAP and will be paid at this methodology in 2007.
** Pass-through status was granted after publication of the CY 2007 OPPS proposed rule.
B. Payment for Drugs, Biologicals, and resources with maximum flexibility. biological, and radiopharmaceutical
Radiopharmaceuticals Without Pass- Notwithstanding our commitment to HCPCS codes to be recognized under
Through Status package as many costs as possible, we the OPPS, as opposed to our current
are aware that packaging payments for policy that does not recognize some
1. Background
certain drugs, biologicals, and codes because they are not the lowest
Under the CY 2006 OPPS, we radiopharmaceuticals, especially those dosage unit HCPCS code available for an
currently pay for drugs, biologicals, and that are particularly expensive or rarely item.
radiopharmaceuticals that do not have used, might result in insufficient Response: We appreciate these
pass-through status in one of two ways: payments to hospitals, which could comments, as well as the efforts of the
packaged payment within the payment adversely affect beneficiary access to commenters to identify specific drugs
for the associated service or separate medically necessary services. where the OPPS currently recognizes
payment (individual APCs). We Section 1833(t)(16)(B) of the Act, as only one of several HCPS codes. As is
explained in the April 7, 2000 OPPS added by section 621(a)(2) of Pub. L. our longstanding interest, we are
final rule with comment period (65 FR 108–173, set the threshold for considerate of situations where
18450) that we generally package the establishing separate APCs for drugs hospitals may experience an
cost of drugs and radiopharmaceuticals and biologicals at $50 per administrative burden that could
into the APC payment rate for the administration for CYs 2005 and 2006. possibly be reduced with a change in
procedure or treatment with which the Therefore, for CY 2006, we paid OPPS policy. In general, the current
products are usually furnished. separately for drugs, biologicals, and practice of the HCPCS National Panel is
Hospitals do not receive separate radiopharmaceuticals whose per day to establish only one HCPCS code for a
payment from Medicare for packaged cost exceeds $50 and packaging the particular drug with a single appropriate
items and supplies, and hospitals may costs of drugs, biologicals, and dose descriptor for reporting all doses,
not bill beneficiaries separately for any radiopharmaceuticals whose per day whereas historically more than one
packaged items and supplies whose cost is less than $50 into the procedures HCPCS code may have been created
costs are recognized and paid within the with which they are billed. In addition, with different dose descriptors for the
national OPPS payment rate for the we extended an exception to this same drug. Typically, under the OPPS,
associated procedure or service. packaging policy for oral and injectable we have only recognized a single
(Program Memorandum Transmittal A– 5HT3 forms of anti-emetic treatments HCPCS code with the lowest dose
01–133, issued on November 20, 2001, (70 FR 68635 through 68638) for CY descriptor, as this approach assists us in
explains in greater detail the rules 2006. data collection for OPPS ratesetting
regarding separate payment for At the August 2006 APC Panel purposes and allows hospitals to
packaged services.) meeting, the Panel recommended that accurately reflect all doses administered
Packaging costs into a single aggregate CMS allow providers to use all available by billing a variety of units in relation
payment for a service, procedure, or HCPCS codes for reporting drugs in the to the drug’s dose descriptor.
episode of care is a fundamental OPPS to reduce the administrative Our current practice is to make a
principle that distinguishes a burden associated with reporting drugs packaging determination based on
prospective payment system from a fee using only HCPCS codes with the historical hospital claims data for each
schedule. In general, packaging the costs lowest increments in their code drug, biological, and
of items and services into the payment descriptors. We include our response to radiopharmaceutical HCPCS code that
for the primary procedure or service this recommendation in the discussion we recognize under the OPPS.
with which they are associated below. Therefore, we generally determine the
encourages hospital efficiencies and Comment: Several commenters packaging status for the lowest dose
also enables hospitals to manage their recommended that CMS allow all drug, descriptor that exists for a particular
drug, as other doses are typically eliminate the drug packaging threshold multiple claims to be significantly less
assigned status indictor ‘‘B’’ (Not for all drugs and radiopharmaceuticals than the comparable percentage for
recognized under OPPS; alternate code with HCPCS codes. We include our single claims for drug administration
may be available). If we were to response to the Panel’s recommendation services. In addition, much of the
recognize all the HCPCS codes that may in our discussion below. packaged drug costs on multiple
exist for a single drug, we would need In addition to the APC Panel’s procedure claims might be more
to consider the ramifications of such a recommendation, we received several accurately associated with services
substantial change on our ratesetting comments requesting that we pay other than drug administration services.
methodology. For example, we would separately for all drugs, biologicals and Thus, we are unsure about the
need to consider whether to adjust our radiopharmaceuticals (or combination appropriate methodology and the
methodology to provide packaging thereof) with HCPCS codes that are ultimate utility of studies to examine
decisions based upon a particular drug, provided in the hospital outpatient drug, biological, and
rather than making a determination for department and payable under the radiopharmaceutical packaging on
each HCPCS code. If we did not adjust OPPS. multiple claims. In section VIII.C. of this
our methodology, we could have Comment: Two commenters preamble, we provide a preliminary
variable packaging determinations for acknowledged that unpackaging all analysis of a study we performed in
multiple HCPCS codes that described drugs, biologicals and response to the APC Panel’s March 2006
the same drug, and it is not clear radiopharmaceuticals is inconsistent recommendation to further explore how
whether this would be appropriate. with the concept of a prospective packaged drug, biological, and
Therefore, we are not accepting the payment system. However, one of these radiopharmaceutical costs are
recommendation of the APC Panel and commenters contended that packaged accounted for within the OPPS
the commenters to recognize all items may not be fully accounted for in ratesetting methodology so that their
available HCPCS codes in the CY 2007 the OPPS ratesetting process, and these costs are incorporated into payment
OPPS. However, we will further explore costs therefore may not appear in the rates for associated drug administration
the issues surrounding such an final payment rates established for the procedures. The same analysis provides
approach for the future, to further primary service. For this reason, the a preliminary response to the APC
develop our understanding of the commenter believed that the OPPS Panel’s August 2006 recommendation
implications of such a change. We should pay separately for all drugs, that CMS provide claims analysis of the
continue to believe that the current biologicals, and radiopharmaceuticals. contributions of packaged costs
HCPCS codes recognized under the The commenter further asserted that the (considering packaged drugs and other
OPPS allow hospitals to accurately OPPS’ inability to use multiple packaging) to the median cost of each
report all doses of the drugs, biologicals, procedure bills exacerbates the problem drug administration service.
and radiopharmaceuticals they because multiple procedure claims are Comment: Several commenters
administer. more likely to include packaged drugs, asserted that separate payment for all
biologicals, and radiopharmaceuticals. drugs and biologicals under the OPPS
2. Criteria for Packaging Payment for Response: We agree that unpackaging was appropriate in the light of CMS’s
Drugs, Biologicals, and all drugs, biologicals and efforts to align payments across the
Radiopharmaceuticals radiopharmaceuticals is inconsistent physician office and hospital outpatient
As indicated above, in accordance with the concept of a prospective settings, for example, by adopting the
with section 1833(t)(16)(B) of the Act, payment system. We have not been ASP methodology in both settings. The
the threshold for establishing separate presented with any data that support the commenters stated that continuing a
APCs for drugs and biologicals was set commenter’s assertion that multiple policy of packaging certain items in the
to $50 per administration during CYs procedure claims would be more likely hospital outpatient setting would
2005 and 2006. As this provision to include packaged drugs, biologicals, continue an inequality in payment
expires at the end of CY 2006, we and radiopharmaceuticals. Multiple between these settings. We also received
provided a discussion in the proposed procedure claims contain a variety of several comments specifically against
rule of four packaging level options that services, including surgical procedures, our proposal to set the packaging
were considered for the CY 2007 OPPS diagnostic imaging tests, visits, and threshold for radiopharmaceuticals at
update. laboratory procedures that also could $55. These commenters requested that
One of the packaging options we have significant associated packaging in we pay separately for all
considered for the CY 2007 OPPS addition to drugs, biologicals, and radiopharmaceuticals.
update was to pay separately for all radiopharmaceuticals, such as devices, Response: While we believe that
drugs, biologicals, and minor ancillary procedures, anesthesia, payment parity is appropriate for certain
radiopharmaceuticals with a HCPCS operating room time, and recovery room items in order to provide appropriate
code. We determined that this would be time. As we have previously indicated, access to care without undesirable site
a straightforward policy that would we are unable to use these claims for of service shifts, the OPPS and MPFS
speed the creation of procedural APC ratesetting because we cannot attribute are fundamentally different payment
medians; however, we expressed the packaging appropriately to the systems with essential differences in
concern that this policy would be individual services on the claims. their payment policies. Specifically, the
inconsistent with OPPS packaging However, we would not expect the OPPS is a prospective payment system,
principles, would reduce hospitals’ amount of drug, biological, and based on the concept of paying for
incentives for economy and efficiency, radiopharmaceutical packaging to be groups of services that share clinical
and would increase hospitals’ proportionately higher for these and resource characteristics. Payment is
administrative burden related to multiple procedure claims compared to made in the OPPS according to
separate billing for more drugs, the amount of drug packaging contained prospectively established payment rates
biologicals, and radiopharmaceuticals. on the single drug administration claims that are related to the relative costs of
During the August 2006 meeting of we use for ratesetting. In fact, we might hospital resources for services. The
the APC Panel, the Panel endorsed this expect that the percentage of total costs MPFS is a fee schedule that generally
option and recommended that CMS related to packaged drugs on these provides payment for each individual
component of a service. Differences in of paying separately for all drugs, Price Index (PPI) for prescription
the degrees of packaged payment and biologicals, and radiopharmaceuticals preparations. As described in the
separate payment between these two for CY 2007. Accordingly, we also are proposed rule, we calculated an
systems are only to be expected. In not adopting the August 2006 APC adjusted packaging threshold for CY
general, we do not believe that our Panel recommendation presented above. 2007 by using the four quarter moving
packaging methodology under the OPPS The second option we presented in average PPI levels for prescription
creates issues that result in limiting the CY 2007 proposed rule was to preparations to trend the $50 threshold
beneficiary access to care. In those rare increase the packaging threshold to a forward from the third quarter of CY
circumstances where we believe a level much higher than the current $50 2005 (when the Pub. L. 108–173-
situation may cause problems with threshold. As we discussed, we believed mandated threshold became effective) to
beneficiary access or where our that this option would be more the third quarter of CY 2007. We
packaging methodology may unduly consistent with OPPS packaging proposed to apply an annual inflation
influence physicians’ treatment principles by packaging more drugs, adjustment factor that would be
decisions, in the best interest of biologicals, and radiopharmaceuticals. consistent with the practices of many
Medicare beneficiaries, we have In addition, we stated that we believed health care payment policy areas, and
modified our packaging methodology, as this option would also provide greater many other areas of government policy,
is the case for 5HT3 anti-emetics. At this administrative simplicity for hospitals. that acknowledge real costs by using an
time there is neither sufficient reason, However, we expressed concern that inflation adjustment factor instead of
nor have we been presented with implementation of this option might static dollar values. We discussed our
information, that leads us to consider result in circumstances where drug concern that in the absence of a
modifying our packaging policy for administration payments could be less mechanism to update the threshold, we
radiopharmaceuticals. than the cost of the packaged drugs, as believed that current relatively
Comment: Several commenters relatively expensive drugs, biologicals, inexpensive drugs would begin to
disagreed with our assertion that and radiopharmaceuticals could become receive separate payment over time.
unpackaging all drugs and biologicals packaged under this option. The PPI for prescription preparations
with HCPCS codes would increase the We received no comments on this reflects price changes at the wholesale
burden on hospitals, as many hospitals option and we are not adopting this or manufacturer stage. Because OPPS
are following CMS’ request to report methodology for CY 2007. payment rates for drugs and biologicals
charges for all drugs, biologicals, and The third option we presented in the are generally based on the average sales
radiopharmaceuticals with HCPCS CY 2007 proposed rule was to maintain price (ASP) data that are reported by
codes, regardless of the packaging status the packaging threshold at $50. We their manufacturers, in the proposed
of the particular item. However, another discussed that maintaining the rule we indicated that we believed that
commenter agreed with our statement threshold would provide stability to the the PPI for prescription preparations
and explained that eliminating the payment system, as the packaging would be an appropriate price index to
packaging threshold for drugs, threshold has been set at $50 since CY use to update the packaging threshold
biologicals and radiopharmaceuticals 2004. We also noted that this policy for CY 2007 and beyond.
would not only increase the option would be consistent with the Specifically, we proposed to adjust
administrative burden of hospitals, but March 2006 APC Panel recommendation the packaging threshold by the PPI for
that this change would lead to to maintain the packaging threshold at prescription drugs each year, and round
unexpected payment decreases for other $50 in CY 2007. However we discussed the adjusted dollar amount to the
services payable under the OPPS, our concern that this policy would not nearest $5 increment to identify the
because the OPPS is a budget neutral take into account price inflation and updated packaging threshold. We
payment system. would, therefore, not be representative calculated the adjusted amount for CY
Response: We appreciate these of real dollars in future years. We 2007 at $55.99, rounded to $55.
comments. We understand that the received one comment specifically on Therefore, for CY 2007 and beyond, we
impact of increased coding this option and a number of comments proposed to package all drugs,
responsibilities that would accompany a requesting this option if we decided to biologicals, and radiopharmaceuticals
change in our packaging policy would continue with a packaging methodology whose per day cost is less than or equal
likely vary from hospital to hospital. We for the OPPS for CY 2007. to $55 into the procedures with which
appreciate the efforts of hospitals to Comment: One commenter supported they are billed.
include data for packaged services on the March 2006 APC Panel We explained that we believed that
their claims as it continues to provide recommendation to retain the $50 this proposal was consistent with the
us with a robust data set which we can packaging threshold because it would APC Panel’s March 2006
use for both future ratesetting and help ensure adequate payments for recommendation to continue the $50
development of OPPS payment policies. hospitals, preserve stability in the packaging threshold in CY 2007,
We note that in CYs 2005 and 2006, payment policy, and continue to because the real dollar value would be
the statutorily mandated drug packaging provide beneficiary access to care. held constant during the calendar year
threshold was set at $50, and we believe Response: We appreciate the in which it would be in effect. Our
it is appropriate to continue a modest commenter’s support of the adequacy of response to this recommendation is
drug packaging threshold for the CY the $50 threshold for drugs, biologicals, included in the discussion presented
2007 OPPS, consistent with the and radiopharmaceuticals. However, we below.
framework provided in the law. have chosen to not to adopt this option, We received several comments on our
Therefore, because of our continued for the reasons discussed below. proposal to provide an annual update of
belief that packaging is a fundamental The final option discussed in the CY the packaging threshold using the four-
component of a prospective payment 2007 proposed rule was a variation of quarter moving average PPI.
system that contributes to important the previous option, where we proposed Comment: Most commenters, in
flexibility and efficiency in the delivery an annual update of the packaging general, disagreed with an increase to
of high quality outpatient hospital threshold for inflation using an inflation the packaging threshold. However, one
services, we are not adopting the option adjustment factor based on the Producer commenter disagreed with our use of
the PPI as a basis for our annual To determine their CY 2007 proposed determine the final per day costs of
packaging threshold update. The packaging status, we calculated the per drugs, biologicals, and
commenter explained that as the PPI day cost of all drugs, biologicals, and radiopharmaceuticals and their
includes information for all prescription radiopharmaceuticals that had a HCPCS packaging status in CY 2007. As
medications, it includes information for code in CY 2005 and were paid (via discussed in section V.B.3. of this
drugs that are not covered under Part B packaged or separate payment) under preamble, for this CY 2007 final rule
benefits and may inaccurately represent the OPPS using claims data from determination of packaging status we
the amount of inflation for Part B drugs. January 1, 2005 to December 31, 2005. are also altering the payment rate used
The commenter recommended that CMS In CY 2005, multisource drugs and for the determination to reflect a
calculate an inflation index using radiopharmaceuticals had two HCPCS payment rate of ASP+6 percent, based
manufacturers’ quarterly ASP data codes that distinguished the innovator on our final CY 2007 policy, rather than
submissions. multisource (brand) drug or the proposed rate of ASP+5 percent.
Response: We appreciate the radiopharmaceutical from the Because the data we used in the
commenter’s analysis of the noninnovator multisource (generic) drug proposed rule to calculate per day costs,
applicability of the PPI and their or radiopharmaceutical. We aggregated and the payment rates applied to that
proposed alternative methodology. claims for both the brand and generic data, have been updated for the final
There are a wide array of drugs that are HCPCS codes in our packaging analysis rule packaging status determination, the
covered under Part B of Medicare, and of these multisource products. In order packaging status of certain drugs,
these drugs are used to treat a broad to calculate the per day cost for drugs, biologicals, and radiopharmaceuticals
spectrum of clinical conditions in the biologicals, and radiopharmaceuticals to
may have changed. Under such
hospital outpatient setting. These drugs determine their packaging status in CY
circumstances, we proposed to apply
range from monoclonal antibody agents, 2007, we proposed to use the
to complex chemotherapeutic agents, to the following policies to these drugs,
methodology that was described in
antiemetics, to antibiotics, to narcotics, biologicals, and radiopharmaceuticals
detail in the CY 2006 OPPS proposed
and to analgesics. The ASP system is whose relationship to the $55 threshold
rule (70 FR 42723 through 42724) and
relatively new, and we have only changed based on the final updated
finalized in the CY 2006 OPPS final rule
limited experience in following changes data:
with comment period (70 FR 68636
in manufacturers’ data submissions over through 68638). • Drugs, biologicals, and
time. While we understand that the PPI In our calculation of per day costs for radiopharmaceuticals that were paid
includes drugs that may not be payable the CY 2007 OPPS proposed rule we separately in CY 2006 (which were
as a Part B benefit, we continue to used the manufacturer-submitted ASP proposed for separate payment in CY
believe that the PPI is a mature, well- data from the fourth quarter of CY 2005 2007), and then have per day costs less
established, and widely available index (rates that were used for payment than $55 based on the updated ASPs
already used by Medicare that provides purposes in the physician office setting and hospital claims data used for the CY
the most accurate estimate of Part B effective April 1, 2006) and a payment 2007 final rule with comment period,
drug inflation for purposes of updating rate of ASP+5 percent, as our proposal would continue to receive separate
the OPPS drug packaging threshold each was to pay for drugs and biologicals at payment in CY 2007.
year. We intend to evaluate the ASP+5 percent for CY 2007. For items • Drugs, biologicals, and
applicability of the PPI as the drug that did not have an ASP-based radiopharmaceuticals that were
packaging inflation adjustment factor as payment rate, we used their mean unit packaged in CY 2006, (which were
needed. cost derived from the CY 2005 hospital proposed for separate payment in CY
Because we believe that packaging claims data to determine their per day 2007), and then have per day costs less
certain items is a fundamental cost. For the proposed rule, we than $55 based on the updated ASPs
component of a prospective payment identified the items with per day cost and hospital claims data used for the CY
system, that packaging these items does less than or equal to $55 as packaged 2007 final rule with comment period,
not lead to beneficiary access issues and and identified items with per day cost would remain packaged in CY 2007.
does not create a problematic site of greater than $55 as separately payable.
service differential, that a minimum $50 Our policy during previous cycles of • Drugs, biologicals, and
packaging threshold is reasonable based the OPPS has been to use updated data radiopharmaceuticals for which we
on its initial establishment in law for to establish final determinations of the proposed packaged payment in CY 2007
the CY 2005 OPPS, that updating the packaging status of drugs, biologicals, but then had per day costs greater than
$50 threshold is consistent with and radiopharmaceuticals. We note it is $55 based on the updated ASPs and
industry and government practices, and also our policy to make an annual hospital claims data used for the CY
that the PPI is an appropriate packaging determination at the time of 2007 final rule with comment period,
mechanism to gauge Part B drug the final rule. Only items that are would receive separate payment in CY
inflation, we are finalizing our proposal identified as separately payable will be 2007.
to calculate an annual update to the subject to quarterly updates as We received no comments on the
OPPS packaging threshold using the discussed in section V.B.3. of this methodology we proposed to use in the
proposed methodology without preamble. Items that are finalized as event that the packaging status of a drug
modification. Therefore, for CY 2007 packaged will be eligible for had changed due to the data update
and beyond, drugs, biologicals and consideration of separate payment only between the proposed and final rules.
radiopharmaceuticals that are not new for the next update of the OPPS. We Therefore, we are finalizing this
and do not have pass-through status will proposed to use the ASP data from the proposal without modification. Table 24
be packaged if their calculated per day first quarter of CY 2006 (reflected in below indicates those drugs, biologicals
cost is equal to or less than $55 for CY payment rates in the physician office and radiopharmaceuticals that have
2007 or equal to or less than the setting effective July 1, 2006) as a basis changed packaging status between the
updated threshold established, rounded for our annual packaging determination proposed rule and the final rule, and
to the nearest $5 increment, for the for CY 2007, along with updated indicates their final CY 2007 packaging
relevant update year. hospital claims data from CY 2005, to status.
TABLE 24.—DRUGS, BIOLOGICALS AND RADIOPHARMACEUTICALS THAT EXPERIENCED A STATUS CHANGE BETWEEN THE
PROPOSED AND FINAL CY 2007 OPPS RULES
CY 2007 CY 2007 CY 2007 CY 2007
Short description
HCPCS proposed SI final SI final APC
J0580 .................................................... Penicillin g benzathine inj ..................................................... K N

J1205 .................................................... Chlorothiazide sodium inj ..................................................... N K 0747
J2354 .................................................... Octreotide inj, non-depot ...................................................... K N
J3320 .................................................... Spectinomycn di-hcl inj ........................................................ N K 0753
J8600 .................................................... Melphalan oral 2 MG ............................................................ K N
J9040 .................................................... Bleomycin sulfate injection ................................................... N K 0748
J9120 .................................................... Dactinomycin actinomycin d ................................................. N K 0752
J9130 .................................................... Dacarbazine 100 mg inj ....................................................... N K 0746
J9230 .................................................... Mechlorethamine hcl inj ....................................................... N K 0751
For CY 2007, we also included a TABLE 25.—ANTI-EMETICS EXEMPTED • During CYs 2004 and 2005, an
proposal to continue exempting the oral FROM $55 PACKAGING REQUIRE- orphan drug (as designated by the
and injectable 5HT3 anti-emetic MENT—Continued Secretary).
products from packaging, thereby Section 1833(t)(14)(A)(iii) of the Act,
making separate payment for all of the HCPCS code Short description as added by section 621(a)(1) of Pub. L.
5HT3 anti-emetic products. As stated in 108 173, requires that payment for
the CY 2005 OPPS final rule with J2405 ................. Ondansetron HCl injec- specified covered outpatient drugs in
comment period (69 FR 65779 through tion. CY 2006 and subsequent years be equal
65780), it is our understanding that J2469 ................. Palonosetron HCl. to the average acquisition cost for the
chemotherapy is very difficult for many Q0166 ................ Granisetron HCl 1 mg
drug for that year as determined by the
patients to tolerate, as the side effects oral.
Q0179 ................ Ondansetron HCl 8 mg Secretary subject to any adjustment for
are often debilitating. In order for oral. overhead costs and taking into account
Medicare beneficiaries to achieve the Q0180 ................ Dolasetron mesylate oral. the hospital acquisition cost survey data
maximum therapeutic benefit from collected by the Government
chemotherapy and other therapies with 3. Payment for Drugs, Biologicals, and Accountability Office (GAO) in CYs
side effects of nausea and vomiting, Radiopharmaceuticals Without Pass- 2004 and 2005. If hospital acquisition
anti-emetic use is often an integral part Through Status That Are Not Packaged cost data are not available, the law
of the treatment regimen. In the requires that payment be equal to
proposed rule, we stated that we a. Payment for Specified Covered payment rates established under the
believed that we should continue to Outpatient Drugs methodology described in section
ensure that Medicare payment rules do (1) Background 1842(o), section 1847A, or section
not impede a beneficiary’s access to the 1847B of the Act as calculated and
particular anti-emetic that is most Section 1833(t)(14) of the Act, as adjusted by the Secretary as necessary.
effective for him or her as determined added by section 621(a)(1) of Pub. L. For CY 2006, we adopted a policy of
by the beneficiary and his or her 108–173, requires special classification paying for the acquisition and overhead
physician. of certain separately paid costs of separately paid drugs and
We received several supportive radiopharmaceuticals, drugs, and biologicals at a combined rate of ASP+6
comments on this proposed policy for biologicals and mandates specific percent. To calculate the ASP+6 percent
CY 2007. payments for these items. Under section payment rate, we evaluated the three
Comment: Commenters commended 1833(t)(14)(B)(i) of the Act, a ‘‘specified data sources that were available to us for
CMS on the CY 2007 proposal to covered outpatient drug’’ is a covered setting the CY 2006 payment rates for
continue to pay separately for all 5HT3 outpatient drug, as defined in section drugs and biologicals. As described in
antiemetics. 1927(k)(2) of the Act, for which a the CY 2006 OPPS final rule with
Response: We appreciate the support separate APC exists and that either is a comment period (70 FR 68639 through
for our proposal, and we continue to radiopharmaceutical agent or is a drug 68644), these data sources were the
believe that separate payment for these or biological for which payment was GAO reported average purchase prices
items is warranted for the reasons made on a pass-through basis on or for 55 specified covered outpatient drug
discussed above. before December 31, 2002.
Therefore, we are finalizing our categories for the period July 1, 2003, to
Under section 1833(t)(14)(B)(ii) of the June 30, 2004, collected via a survey of
proposal to exempt the 5HT3 Act, certain drugs and biologicals are
antiemetics from the packaging 1,400 acute care Medicare-certified
designated as exceptions and are not hospitals; ASP data; and mean costs
threshold. As a result, the anti-emetics included in the definition of ‘‘specified
listed in Table 25 will receive separate derived from CY 2004 hospital claims
covered outpatient drugs.’’ These data. For the CY 2006 final rule with
payment status under the OPPS for CY exceptions are—
2007. comment period, we used ASP data
• A drug or biological for which from the second quarter of CY 2005,
payment is first made on or after which were used to set payment rates
TABLE 25.—ANTI-EMETICS EXEMPTED
January 1, 2003, under the transitional for drugs and biologicals in the
FROM $55 PACKAGING REQUIREMENT pass-through payment provision in physician office setting effective
section 1833(t)(6) of the Act. October 1, 2005.
HCPCS code Short description
• A drug or biological for which a In our data analysis for the CY 2006
J1260 ................. Dolasetron mesylate. temporary HCPCS code has not been OPPS final rule with comment period,
J1626 ................. Granisetron HCl injection. assigned. we compared the payment rates for
drugs and biologicals using data from all 1847B of the Act as calculated and inclusive of both acquisition costs and
three sources described above. We adjusted by the Secretary as necessary. pharmacy handling costs for the
estimated aggregate expenditures for all Additionally, section 1833(t)(14)(E)(ii) particular drug. Therefore, for CY 2007,
drugs and biologicals that would be authorizes the Secretary to adjust APC we proposed a policy of paying for the
separately payable in CY 2006 and for weights for specified covered outpatient acquisition and overhead costs of
the 55 drugs and biologicals reported by drugs to take into account the MedPAC separately paid drugs and biologicals at
the GAO using mean costs from the report relating to overhead and related a combined rate of ASP+5 percent.
claims data, the GAO mean purchase expenses, such as pharmacy services We received several comments on our
prices, and the ASP-based payment and handling costs. proposal to use these two data sources
amounts (ASP+6 percent in most cases), For the CY 2007 OPPS proposed rule, to calculate an average ASP-based
and then calculated the equivalent we evaluated the two data sources that payment rate for separately payable
average ASP-based payment rate under were available to us for ratesetting drugs and biologicals in the hospital
each of the three payment purposes for drugs and biologicals in CY outpatient department for CY 2007.
methodologies. We excluded 2007. The first source presented in the Comment: We received mixed
radiopharmaceuticals in our analysis proposed rule was based on the ASP comments about our proposal to
because they were paid at hospital methodology and included data from continue to base OPPS payment rates for
charges reduced to cost during CY 2006. the fourth quarter of CY 2005, which drugs and biologicals relative to the ASP
The results based on updated ASP and were also the data used for payments in methodology. A few commenters
claims data were published in Table 24 the physician office setting effective expressed their dissatisfaction with
of the CY 2006 OPPS final rule with April 1, 2006. We stated that we have certain aspects of the ASP system, and
comment period. For a full discussion of prices for approximately 500 drugs and as a result, our use of a payment rate
our reasons for using these data, refer to biologicals (including contrast agents) relative to ASP. These commenters
section V.B.3.a. of the CY 2006 OPPS payable under the OPPS using the ASP expressed concern that ASP rates reflect
final rule with comment period (70 FR methodology (ASP+6 percent in most prompt pay discounts that hospitals do
68639 through 68644). cases); however, we did not have any not experience, that the data
As we noted in the CY 2006 OPPS data from this source for represented by ASP reporting do not
final rule with comment period, radiopharmaceutical products. indicate hospital-specific prices, and
findings from a MedPAC survey of The second source of cost data for that the inclusion of 340B prices skews
hospital charging practices indicated drugs, biologicals, and ASP data because only a limited number
that hospitals set charges for drugs, radiopharmaceuticals discussed in the of hospitals are eligible to receive these
biologicals, and radiopharmaceuticals OPPS proposed rule available for reduced prices. Other commenters who
high enough to reflect their pharmacy ratesetting purposes was CY 2005 disagreed with our proposal to use the
handling costs as well as their hospital claims data, used to calculate ASP methodology suggested that we
acquisition costs. In consideration of mean and median costs for these items. conduct a survey to collect data on
this information, we stated in the CY As section 1833(t)(14)(A)(iii) of the Act hospital acquisition costs and include
2006 OPPS final rule that payment rates clearly specifies that payment for factors such as size and type of hospital.
derived from hospital claims data also specified covered outpatient drugs in However, other commenters expressed
included acquisition and pharmacy CY 2007 be equal to the ‘‘average’’ support of our continued use of the
handling costs because they are derived acquisition cost for the drug, we limited ASP-based methodology in the OPPS.
directly from hospital charges. our analysis to the mean costs of drugs Response: We note that the ASP
Therefore, in CY 2006, we finalized a determined using the hospital claims methodology has been established
policy of providing payment to hospital data. through rulemaking, and specific
outpatient departments for drugs, To determine our proposed payment requests regarding methodological
biologicals and associated pharmacy rates for drugs and biologicals for CY changes to this established system are
handling costs at a rate of ASP+6 2007, we compared estimated aggregate outside the scope of this final rule with
percent. expenditures for all drugs and comment period. In addition, we note
biologicals (excluding that we received numerous supportive
(2) Payment Policy for CY 2007 radiopharmaceuticals) that would be comments regarding our proposal to use
The provision in section separately payable in CY 2007 using ASP as the basis for hospital payments
1833(t)(14)(A)(iii) of the Act, as data from both sources described above. in the OPPS for CY 2006. At that time,
described above, continues to be We then used the OPPS proposed commenters generally supported the use
applicable to determining payments for conversion factor to calculate weights of ASP as a payment methodology
specified covered outpatient drugs for for each separately payable drug and because these rates are updated
CY 2007. This provision requires that in biological HCPCS code and developed quarterly and are therefore more
CY 2007 payment for specified covered an equivalent average ASP-based reflective of current market conditions
outpatient drugs be equal to the average payment rate under both payment that influence hospital purchasing
acquisition cost for the drug for that methodologies. The result of this prices than hospital claims data, and
year as determined by the Secretary analysis indicated that using mean unit payment equity across the hospital and
subject to any adjustment for overhead cost to set the payment rates for the physician office settings offers
costs and taking into account the drugs and biologicals that would be administrative benefits and does not
hospital acquisition cost survey data separately payable in CY 2007 would be create a site-of-service difference.
collected by the Government equivalent to basing payment rates for Furthermore, comparison of the ASP
Accountability Office (GAO) in CYs these drugs and biologicals, on average, data to our hospital claims data serves
2004 and 2005. If hospital acquisition at ASP+5 percent. We again stated that to ensure that we are paying for drugs
cost data are not available, the law this payment rate was representative of in the OPPS in general at rates that are
requires that payment be equal to both hospital acquisition costs and reflective of hospitals costs for
payment rates established under the pharmacy handling costs, as this ASP- acquisition and overhead. For these
methodology described in section based rate was calculated using hospital reasons, we continue to believe that
1842(o), section 1847A, or section charge data, and hospital charges are ASP is an appropriate proxy of the
average acquisition and pharmacy preamble. To include the costs of process; however, those drugs and
overhead costs for drug and biologicals packaged drugs in both our APC biologicals that we determine will be
administered in the hospital outpatient ratesetting process (for associated separately payable during the next
setting. procedures present on the same claim) calendar year will receive quarterly
Comment: Several commenters also and during our ratesetting process to updates to their ASP-based payment
addressed our methodology for establish a relative ASP-based payment rates, as is the current process in both
determining the specific ASP-based amount for drugs and biologicals would the OPPS and physician office setting.
payment rate including acquisition costs give this data disproportionate emphasis We indicated that in CY 2007, we will
and pharmacy handling costs for in the OPPS system by skewing our continue to post these quarterly
separately payable drugs and biologicals analyses, as the costs of these packaged payment rate changes on our Web site.
that would equate to payment of drugs items would be, in effect, counted twice. During the March 2006 meeting of the
and biologicals based on their mean Once we determined our final CY 2007 APC Panel, the Panel recommended that
costs from claims data. Some packaging policy for drugs, biologicals, CMS examine pharmacy overhead costs
commenters were confused about how and radiopharmaceuticals at a issues and work with appropriate
our methodology resulted in a proposed packaging threshold of $55 or less per associations to study how to measure
payment at ASP+5 percent for CY 2007, day, we included the costs of these pharmacy overhead costs. The Panel
while others disagreed with our packaged drugs and biologicals in the also recommended that CMS solicit
methodology to only include separately standard OPPS calculation of feedback on how pharmacy overhead
payable drugs and biologicals in our procedural APC median costs. costs should be reimbursed in the
calculations. The commenters theorized Accordingly, we are not implementing future.
that due to hospital charge compression, the suggestion from commenters that we In the proposed rule, we responded to
pharmacy overhead costs for include all packaged and separately these recommendations by stating that
inexpensive drugs that are typically payable drugs and biologicals when we would continue to work on issues
packaged under the OPPS exhibit a establishing an average ASP-based rate related to pharmacy overhead costs, and
higher pharmacy handling cost relative to provide payment for the hospital we specifically requested public
to their acquisition cost because acquisition and pharmacy handling comments on methodologies that could
hospitals disproportionately load their costs of drugs and biologicals. However, be used when considering pharmacy
pharmacy overhead costs in their we remind commenters that because the overhead cost issues in future years. We
charges for less costly drugs. Therefore, costs of packaged drugs, including their again note that we regularly accept
while hospitals may attribute costs pharmacy overhead costs, are packaged requests from interested organizations to
associated with pharmacy services into the payments for the procedures in discuss their views about OPPS
across all drugs, the costs associated which they are administered, the OPPS payment policy issues, including
with a particular drug do not necessarily provides payment for both the drugs pharmacy handling issues. As stated in
encompass that drug’s total pharmacy and the associated pharmacy overhead our CY 2007 OPPS proposed rule (71 FR
handling costs. The commenters costs through the applicable procedural 49585), we consider the input of any
believed that this results in an APC payments. individual or organization to the extent
inaccurate ASP-based estimate for drugs We noted that ASP data were allowed by Federal law, including the
and biologicals in the OPPS, because unavailable for some drugs and Administrative Procedure Act (APA)
these lower cost packaged drugs that biologicals at the time of the proposed and the Federal Advisory Committee
have proportionately greater pharmacy rule, and some remain unavailable at Act (FACA). In addition, we establish
overhead costs in their charges are not the time of this final rule. For these the OPPS rates through regulations, and
used in our calculation, which is based drugs and biologicals, we proposed to as such we are required to consider the
only on those drugs with per day costs use their mean unit costs from the CY timely comments of interested
greater than the $55 packaging 2005 hospital claims data to determine organizations, establish the payment
threshold. their packaging status for ratesetting. In policies for the forthcoming year, and
Response: We included a detailed addition, we proposed to base payment respond to the timely comments of all
explanation of the methodology we used for these drugs and biologicals on their public commenters in the final rule in
to determine our proposed average CY mean cost calculated from CY 2005 which we establish the payments for the
2007 ASP-based payment inclusive of hospital claims data until ASP-based forthcoming year.
acquisition and pharmacy handling rates become available for these items. The APC Panel recommended at its
costs in the proposed rule (71 FR Comment: One commenter requested August 2006 meeting that CMS work
49584), and we again discussed this that CMS use a drug’s WAC or AWP with stakeholders to better understand
methodology relative to the CY 2007 data in order to determine an item’s the costs involved in the preparation of
final ratesetting process above. We packaging status when ASP data are pharmaceutical agents for
began our analysis by identifying those unavailable. chemotherapy, and that CMS work to
drugs and biologicals that we have Response: We follow the established develop a new payment methodology
determined will receive separate ASP methodology, and the ASP that acknowledges and provides
payment in CY 2007. (See section V.B.2. methodology incorporates several appropriate payment for those costs.
of this final rule with comment period sources, such as WAC and AWP, as well The Panel requested a report on our
for a discussion of the methodology we as ASP data submitted by findings at their next meeting. We will
used to determine the packaging status manufacturers. Additional information provide an update to the Panel on all
for drugs, biologicals, and on the ASP methodology can be found the information that has been shared
radiopharmaceuticals for CY 2007.) We at: http://www.cms.hhs.gov/ with us at their next meeting.
do not include packaged drugs and McrPartBDrugAvgSalesPrice/ We received many comments in

biologicals in this analysis because cost 01_overview.asp#TopOfPage. response to our request for information
data for these items are already We noted in the proposed rule that we related to hospital outpatient
accounted for within the APC rates determine the packaging status of each department pharmacy overhead costs.
setting process through the methodology drug or biological for the following year Comment: A number of commenters
discussed in section II.A. of this only once during the annual update expressed dissatisfaction with the
amount of pharmacy handling costs services. We understand that not every hospitals for both types of costs. This
represented in the methodology that hospital will be able to acquire all drugs averaging methodology is fully
resulted in an aggregate payment for for the same price, and to that end, we consistent with the principles of a
drug acquisition and pharmacy use aggregate amounts when prospective payment system like the
handling costs at ASP+6 percent in CY determining the average ASP-based OPPS.
2006. The commenters noted increased amount that applies across all drugs. We Comment: One commenter suggested
pharmacy costs, such as unfunded also acknowledge that different types of that CMS develop a survey for hospitals
mandates, increased staff training in drugs likely have very disparate and instruct fiscal intermediaries to
order to handle complex drugs, and pharmacy handling costs. administer, collate, and transmit this
multiple demands on the time of In the CY 2006 proposed rule, we data back to CMS where this
pharmacists, including quality proposed creating a set of HCPCS codes information could then be used as the
verification requirements and patient or that hospitals would be able to use to basis for an additional pharmacy add-on
physician consultations, that contribute indicate the relative resource levels of or separate APC payments for pharmacy
to pharmacy handling costs that are pharmacy handling involved in services.
above the amount represented by the preparing a reported drug, biological, or Response: We appreciate the
ASP+6 methodology after subtracting radiopharmaceutical for administration. commenter’s suggestions for gathering
drug acquisition costs. Several of these This methodology would have allowed information regarding pharmacy
commenters expressed disappointment us to begin collecting data on pharmacy overhead costs. We are not sure,
that CMS had not implemented an overhead costs for possible use in future however, that it would be
administratively simple methodology ratesetting calculations. We did not administratively feasible and reasonable
for collecting hospital pharmacy finalize this proposal for CY 2006 due from a resource perspective to develop
overhead cost data that could be used as to the overwhelming response from the and update information regarding
the basis for providing additional hospital community citing the pharmacy overhead costs through a
payments for pharmacy handling costs. tremendous administrative burden hospital survey administered by fiscal
Several commenters also expressed reporting these pharmacy handling intermediaries. We are also concerned
concern that the proposed payment of codes would have placed on hospital that such a survey could be quite
ASP+5 percent for CY 2007 would not resources. Hospitals have now had 1 burdensome for hospitals. We will
be adequate to cover both the year to fully consider this proposal and continue to work with the hospital
acquisition costs and pharmacy it appears that there may be greater industry to better understand the costs
handling costs associated with drug support for the creation of these associated with pharmacy overhead and
services provided in a hospital pharmacy HCPCS codes, or another drug handling, and we welcome
outpatient department setting. One methodology to collect this data. We are additional suggestions for alternative
commenter suggested that CMS should, reluctant to proceed with the approaches to gathering cost
at a minimum, implement the two implementation of our CY 2006 information to inform our policy
percent add-on payment that was proposal until we are confident that development.
discussed in the CY 2006 OPPS there is not another feasible, less Comment: One commenter requested
proposed rule. Others suggested various burdensome alternative or there is much that CMS convene an APC Panel
add-on payments, with amounts ranging broader support in the hospital meeting specific to the topics of
from $10 for every billed drug, to community for this proposal. Therefore, pharmacy handling issues and charge
inflating OPPS payment rates for we are not adopting this methodology compression.
separately payable drugs and biologicals for CY 2007. However, we again Response: We appreciate the
to ASP+39 percent. specifically request comments regarding commenter’s suggestion. However, at
MedPAC expressed concern that our hospital outpatient department this time, we do not believe that a
proposal to pay for drugs and pharmacy costs and request ideas and special meeting of the APC panel on
biologicals at ASP+5 percent, a methodologies that we may consider for pharmacy overhead costs is necessary,
proportional payment methodology, future data collection purposes under since the topic has been included on the
could result in inaccurate payments for the OPPS. agenda of several recent Panel meetings,
individual drugs because it does not As we stated in our discussion of the and has been the subject of extended
effectively account for large differences average ASP-based methodology in CY discussions in the course of these
in pharmacy overhead costs among 2006, and as we have reiterated above, meetings. Furthermore, the APC Panel’s
drugs. MedPAC recommended that it is our understanding that pharmacy 2004 charter specifically states that the
payment for pharmacy overhead costs handling costs are included in hospital issue of cost compression is outside of
should reflect methods recommended in charges for drugs and biologicals. the scope of the Panel. Additional
their June 2005 Report to Congress to Therefore, we continue to believe that information on the purpose and scope of
collect drugs into APC groups based on without more information regarding the the APC Panel is available at: http://
attributes that affect overhead costs and specific required resources and their www.cms.hhs.gov/FACA/
establish payment rates for the APCs associated costs for providing hospital 05_AdvisoryPanelonAmbulatory
based on hospital claims data. MedPAC outpatient department pharmacy PaymentClassificationGroups.asp.
encouraged us to revisit this issue and handling services associated with In its final report on the hospital
develop a method that recognizes and particular groups of drugs, it is not acquisition cost survey of specified
pays more specifically for the pharmacy reasonable to provide differential, covered outpatient drugs entitled
overhead costs of different classes of identifiable payments for pharmacy ‘‘Medicare Hospital Pharmaceuticals:
drugs. handling services that are separate from Survey Shows Price Variation and
Response: We appreciate these our payments for the average acquisition Highlights Data Collection Lessons and
comments and recognize the concerns costs of drugs. We believe that generally Outpatient Rate-Setting Challenges for
that were expressed related to our methodology of providing a single CMS,’’ the GAO recommended that the
identifying and providing accurate payment level for drug acquisition and Secretary validate, on an occasional
payments for hospital outpatient pharmacy overhead costs provides, in basis, manufacturers’ reported drug
department costs for pharmacy handling aggregate, appropriate payment to ASPs as a measure of hospitals’
acquisition costs using a survey of Comment: The majority of comments drugs and biologicals and their
hospitals or other method that CMS we received regarding our CY 2007 associated pharmacy handling costs in
determines to be similarly accurate and OPPS payment policy for drugs and the hospital outpatient department at a
efficient. As we indicated in our written biologicals expressed concern over the combined rate of ASP+6 percent for CY
comments to the GAO on its draft proposed rate of ASP+5 percent. Most 2007. In addition, we are also finalizing
report, we will continue to consider the commenters requested that we continue our proposal to pay for separately
best approach for setting payment rates the ASP+6 percent methodology, or payable drugs and biologicals without
for drugs and biologicals in light of this increase the ASP-based payment ASP-based data at their mean cost
recommendation. We also indicated that amount for separately payable drugs and calculated from CY 2005 hospital claims
we would continue to analyze the biologicals under the OPPS for CY 2007. data. We have adopted this final policy
adequacy of ASP-based pricing in light The commenters stated that the for CY 2007 for the reasons noted below.
of our hospital claims data. proposed ASP-based rate of ASP+5 We continue to believe the MedPAC
In its October 31, 2005 letter of percent was inadequate, citing finding that pharmacy overhead costs
comment on proposed 2006 SCOD rates difficulties obtaining drugs at this price are included in the hospital’s charge for
titled ‘‘Comments on Proposed 2006 and challenges identifying the portion a drug, whether we treat the payment
SCOD Rates,’’ the GAO recommended of payment that was to account for for the drug and its handling as
that in order to approximate hospitals’ pharmacy handling costs associated packaged or separately payable. While
acquisition costs of SCODs better, the with these items. In addition, several our final rule analysis indicated an
Secretary should reconsider the level of commenters expressed that a difference average ASP-based payment of ASP+4
proposed payment rates for drug in payment rates for drugs and percent, we note that this is the same
SCODs, in relation to survey data on biologicals across the hospital relative ASP-based amount that was
average purchase price, the role of outpatient and physician office settings comparable to the GAO purchase price
rebates in determining acquisition costs, may result in an unexpected site of data for a subset of drugs reviewed in
and the desirability of setting payment service shift that may be problematic for our CY 2006 final rule with comment
rates for SCODs at average acquisition beneficiaries. period, which did not include pharmacy
costs. In the CY 2006 OPPS proposed The vast majority of commenters overhead costs. This factor furthered our
rule (70 FR 42726), we noted that the recommended that CMS retain the CY conclusion that a final payment
comparison between the GAO purchase 2006 rate of ASP+6 percent for drugs, determination of ASP+6 percent was a
price data and the ASP data indicated biologicals and their associated reasonable level of payment for both the
that the GAO data on average were pharmacy handling costs for CY 2007. hospital acquisition and pharmacy
Response: We appreciate these overhead costs of drugs and biologicals
equivalent to ASP+3 percent. For the CY
comments. In analyzing data for the CY in CY 2007. We further believe
2006 OPPS final rule with comment
2007 final rule, we again performed the maintaining stability in the payment
period, we found that the comparison
analysis described in the CY 2007 levels for drug and biologicals should be
between the GAO purchase price data proposed rule comparing aggregate
and the ASP data indicated that the considered in light of the inherent
expenditures for separately payable complexity in determining how to best
GAO data on average were equivalent to drugs and biologicals to the ASP-based
ASP+4 percent, and using mean unit account for pharmacy overhead costs.
payment rates, weighting these HCPCS We also understand the commenters’
cost from hospital claims to set the codes by their OPPS volumes, and concerns about providing appropriate
payment rates for the drugs and calculating an ASP-based average OPPS payment for the costs of
biologicals that would be separately payment rate for drugs and biologicals pharmacy overhead and drug handling,
payable in CY 2006 would be equivalent provided in hospital outpatient but believe a better understanding of the
to basing their payment rates, on departments for CY 2007. As we did for full nature and magnitude of hospitals
average, at ASP+6 percent. Because our final rule analysis to determine the costs related to these important
pharmacy overhead costs are already final packaging status for each drug, we activities is needed. Therefore, we will
built into the charges for drugs, used updated CY 2005 hospital claims continue to work with the hospital
biologicals, and radiopharmaceuticals, data, including updated CCRs and industry to examine the difficult and
we noted in the CY 2006 OPPS final complete year CY 2005 mean unit costs complex issues concerning pharmacy
rule with comment period that our and drug volumes. The result of our overhead in the hospital outpatient
claims data indicated that payment for final analysis using updated hospital department.
drugs and biologicals and their claims data for the full CY 2005 year Therefore, for these reasons, we are
pharmacy overhead at a combined and updated CCRs indicates that the not finalizing our proposal to pay for
ASP+6 percent rate served as the best ASP-based average payment rate for drugs and biologicals at ASP+5 percent.
proxy for the combined acquisition and separately payable drugs and Instead, after carefully considering all
overhead costs of each of these biologicals, including pharmacy comments and the recommendations of
products. handling costs, would be the equivalent the APC Panel, we are accepting the
During the August meeting of the APC of ASP+4 percent for CY 2007. Thus, if Panel’s recommendation to continue to
Panel, the Panel recommended that we were to follow the methodology that pay for separately payable drugs,
CMS maintain the payment rate for we employed for establishing the biologicals and their associated
drugs and biologicals at ASP+6 percent payment rate for drugs and biologicals pharmacy handling in the hospital
in the hospital outpatient setting for CY under the OPPS in the CY 2006 final outpatient department for CY 2007 at a
2007. We discuss our responses to these rule and the CY 2007 proposed rule, we combined rate of ASP+6 percent to
recommendations below. would set the CY 2007 payment rate for maintain the stability of our payments.
We received a number of comments these items at ASP+4 percent. We believe that this rate will ensure
on our proposal to set the ASP-based However, we have decided to accept suitable payment for the hospital
payment for separately payable drugs the recommendation of the APC Panel pharmacy overhead costs associated
and biologicals provided in CY 2007 in and the recommendation of many with drugs and biologicals, while we
the hospital outpatient setting at ASP+5 commenters to continue to pay for the continue to work with the hospital
percent. acquisition costs of separately payable industry to understand the complex
issues related to capturing and Response: We recognize the IVIG preadministration-related services
evaluating these overhead costs. Full importance of IVIG to patients who need payment into CY 2007 to help ensure
consideration of the potential benefits it, and we are concerned about reports continued patient access to IVIG. We
and challenges associated with of problems with IVIG access and will continue to review IVIG access
alternative OPPS payment availability. Since 2005, CMS has taken during CY 2007 as additional
methodologies for hospitals’ pharmacy several specific actions that are within information becomes available, and we
overhead and drug handling costs that our statutory authority in response to will discontinue this temporary
are associated with administering drugs the IVIG concerns that have been raised, preadministration-related services
and biologicals in the hospital including creating separate HCPCS payment during CY 2007 through
outpatient department is an important codes to report lyophilized and non- rulemaking if we determine it is no
part of this ongoing work. lyophilized IVIG in April 2005, having longer warranted.
During the March 2006 meeting of the discussions with manufacturers about Therefore, after our assessment of the
APC Panel, the Panel included several their ASP data to confirm that their comments, we are also accepting the
recommendations regarding intravenous ASPs have been developed in March 2006 recommendation of the
immune globulin (IVIG) including: that accordance with applicable guidance, APC Panel and the suggestion of several
CMS work with the Plasma Protein and for CY 2006 establishing a commenters to continue the IVIG
Therapeutics Association and other temporary additional payment for IVIG preadministration-related services
stakeholders to develop appropriate preadministration-related services to payment as long as it remains
payments for IVIG; that CMS maintain compensate physicians and hospital appropriate in CY 2007. Consequently,
separate payment for IVIG outpatient departments for extra Medicare will temporarily allow a
preadministration-related services as resources expended on locating and separate payment in CY 2007 for each
long as it remains appropriate, and that obtaining appropriate IVIG products and day of IVIG administration to physicians
CMS reevaluate payments for IVIG on scheduling patients’ infusions during and hospital outpatient departments
administration, especially considering a period where there may be temporary that administer IVIG to Medicare
the resource intensity of IVIG infusions. market instability. In addition, we beneficiaries. This payment is for the
Our responses to these continue to work with manufacturers, extra resources expended on locating
recommendations are included in our patient groups, and stakeholders to and obtaining appropriate IVIG products
discussion below. understand the present situation and to and on scheduling patients’ infusions
Comment: Several commenters urged assess potential actions that could help during this time when there may
the continuation of the one-year ensure an adequate supply of IVIG and continue to be transient disruptions in
temporary preadministration-related patients receiving appropriate, high the marketplace. This
services fee for IVIG that we established quality care. We believe that these preadministration-related service
for CY 2006. The commenters stated ongoing efforts will continue to assist us payment will continue to be billed
that there continue to be concerns with in developing future payment policies under the same HCPCS code as CY
IVIG access and availability and that that continue to adapt to the IVIG 2006: G0332 (Preadministration-related
eliminating the fee will have an adverse marketplace. Therefore, we accept the services for intravenous infusion of
impact on beneficiary access to care. Panel’s recommendation to work with immunoglobulin, per infusion
Furthermore, some indicated that CMS external stakeholders to develop encounter). We are continuing our CY
provided little rationale in the proposed appropriate payments for IVIG and 2006 placement of HCPCS code G0332
rule for why the fee was no longer related services. in New Technology APC 1502 (status
needed. As these efforts are ongoing, we do indicator ‘‘S’’) with a payment rate of
A number of commenters expressed not believe that specific adjustments to $75 at this time. The payment for
concerns about the adequacy of the ASP-based payment rates for IVIG preadministration-related services is in
Medicare’s drug and drug are appropriate or necessary at this time. addition to the separate payments
administration payment rates for IVIG, We remain confident that our ASP data Medicare makes for the IVIG product
and made some suggestions for changes reflect current market pricing for all of itself and its administration.
to these payment rates that they have the brands of IVIG, and that our CY We believe that continuation of this
previously expressed to us. For 2007 final payment rates are appropriate temporary separate payment provided
example, some urged CMS to take for these therapies. Furthermore, there through G0332 for the physician office
actions such as establishing separate are currently two studies underway in and hospital outpatient resources
HCPCS codes for each IVIG product, the Department of Health and Human associated with additional IVIG
increasing payment for IVIG Services (HHS) concerning IVIG. The preadministration-related services will
administration and instituting a HHS Assistant Secretary for Planning help facilitate beneficiary access to care
payment adjustment to the ASP-based and Evaluation has commissioned a in this current period where there may
payment rates for IVIG. study to better understand the market be continuing market fluctuations for
One commenter provided information for IVIG and evaluate the demand, IVIG products. At the same time, we
from a survey conducted of 800 patients supply, and access to IVIG. The HHS will continue to work with the IVIG
with primary immune deficiency Office of Inspector General is also community, manufacturers, providers,
syndrome. The commenter, a patient conducting a study on availability and and other stakeholders, and will be
advocacy group, stated that since the pricing of IVIG. We anticipate that these monitoring IVIG market developments
beginning of 2005, Medicare patients studies will provide more information and access to care closely.
receiving IVIG have been more likely on IVIG supply, demand, and pricing. Additionally, regarding comments
than patients with other types of With several studies on IVIG not yet requesting the establishment of brand-
insurance to report a shift in site of care, completed and with comments from specific HCPCS codes for IVIG products,
increased intervals between infusions, stakeholders suggesting that some we again remind the commenters that
reduced IVIG dosages, and adverse beneficiaries are experiencing IVIG Level II HCPCS codes describe
health effects, and they believe that this access issues such as delayed treatments categories of similar items. The code set
is the result of Medicare reimbursement and site of service shifts, we believe it is not intended to be an exhaustive
issues. is appropriate to continue the temporary listing of all brands on the market. In CY
2006, we stated that we do not see a the OPPS at ASP+6 percent and In the CY 2007 OPPS, we proposed to
compelling reason to override that included payment for the furnishing fee continue our CY 2006 policy of
standard; this conclusion also holds true that is also a part of the payment for providing payment for blood clotting
for CY 2007. (For further discussion of blood clotting factors furnished in factors at a rate of ASP+5 percent plus
HCPCS coding procedures, see http:// physician offices under Medicare Part B. an additional furnishing fee.
www.cms.hhs.gov/medicare/hcpcs/ In the CY 2006 OPPS final rule with We received four comments on our
codpayproc.asp.) comment period (70 FR 68661), we proposal regarding blood clotting
Commenters expressed concern indicated that we would update the factors.
regarding OPPS payment for both IVIG furnishing fee (based on the consumer Comment: All commenters
drugs and their administration. price index) and the payment amount commended us on proposing to
Typically, IVIG administration requires for this furnishing fee each calendar continue to pay the furnishing fee and
a multiple hour infusion and frequent year so that the furnishing fee is equal urged us to continue providing payment
monitoring by qualified hospital staff. to the amount noted in the MPFS final for blood clotting factors under the
As discussed above, the APC Panel rule. OPPS at a rate equal to ASP+6 in CY
recommended that we reevaluate IVIG Comment: One commenter requested 2007.
administration payments, taking into that CMS establish brand-specific Three of these commenters
consideration the additional resources HCPCS codes for each available sodium additionally expressed concern that the
associated with this type of therapy. We hyaluronate product. In addition, they proposed ASP-based rate for blood
accepted this APC Panel requested that each brand-specific clotting factors would also be applied to
recommendation and reevaluated the HCPCS code be assigned to an the inpatient hospital setting. These
IVIG administration payments, along individual APC, with assigned APC commenters requested that if payment
with our general review of drug payment rates based on product-specific rates were adjusted in the outpatient
administration methodology. We believe ASP data. The commenter concluded setting that we not apply these rates to
that our final drug administration that they believe that there is no the inpatient hospital setting as well.
payment policy for CY 2007, as scientific justification for the current Response: We appreciate these
discussed in section VIII. of this final three HCPCS code structure that assigns comments. As we proposed an ASP-
rule with comment period, will provide two products to individual HCPCS based payment rate for CY 2007 of
more accurate payments for extended codes while other products are grouped ASP+5 percent for separately payable
infusions, including IVIG infusions. together in a single HCPCS code. drugs, biologicals and blood clotting
Finally, we received several Response: We appreciate this factors in CY 2007, and we have since
comments requesting that we classify comment, and the National HCPCS finalized a payment rate of ASP+6
IVIG therapy as a biological response Panel agreed that a reconfiguration of percent for separately payable drugs and
modifier. We note that the term these codes was warranted. The biologicals in this final rule, we are
‘‘biological response modifier’’ is used National HCPCS Panel has examined taking this opportunity to finalize a
in the text preceding CY 2006 CPT the sodium hyaluronate codes payment rate for separately payable
codes, and as such, we refer referenced by this comment and has blood clotting factors in the outpatient
commenters to the AMA CPT Editorial concluded that all sodium hyaluronate setting at ASP+6 percent plus the
Panel, as they are the creators and products will be reported in CY 2007 updated CY 2007 furnishing fee of
maintainers of CPT codes and CPT code with the single HCPCS code J7319 $0.15. Issues concerning inpatient
instructions. (Hyaluronan (Sodium hyaluronate) or hospital rates are outside the scope of
In CY 2005, we applied an equitable derivative, intra-articular injection, per
this final rule with comment period,
adjustment to determine the payment injection). As we discuss in reference to
and we refer the commenters to the
rate for darbepoetin alfa (HCPCS code pass-through drugs and biologicals in
annual IPPS rulemaking process to note
Q0137) pursuant to section 1833(t)(2)(E) section V.A.3. of this final rule with
these concerns.
of the Act. However, for CY 2006 we comment period, it is our practice to
transitioned to ASP-based payment rates adopt a national HCPCS code for (3) CY 2007 Payment Policy for
for OPPS drugs and biologicals and reporting drugs when available, with the Radiopharmaceuticals
stated that it was our intent to permit exception of certain pass-through drug (a) Background and Proposed CY 2007
market forces to determine the situations. Therefore, for services Radiopharmaceutical Payment Policy
appropriate payment rate for this furnished on or after January 1, 2007,
biological. We received a few comments hospitals are to use the single HCPCS Section 303(h) of Public Law 108–173
on our proposal to continue with an code for sodium hyaluronate products, exempted radiopharmaceuticals from
ASP-based payment rate for this J7319, status indicator ‘‘K,’’ to report all ASP pricing in the physician office
biological. sodium hyaluronate intra-articular setting. In both the CY 2005 and CY
Comment: Commenters commended injections provided in hospital 2006 OPPS final rules with comment
CMS on our decision to not exercise our outpatient departments. period, the OPPS exempted
equitable adjustment authority for any As there is a single national HCPCS radiopharmaceutical manufacturers
drug or biological in CY 2007. code, and there are no sodium from reporting ASP data for payment
Response: We appreciate the support hyaluronate products with pass-through purposes under the OPPS for reasons
of these commenters. As we discussed status in CY 2007, this single HCPCS discussed in those rules (69 FR 65811
in CY 2006, we believe that as long as code will be assigned to a single APC for and 70 FR 68655, respectively).
the market price for darbepoetin alfa is OPPS payment purposes. Therefore, for Consequently, we did not have ASP
consistent with a payment rate derived CY 2007, HCPCS code J7319 is assigned data for radiopharmaceuticals for
using a clinically appropriate to APC 0896 (Sodium Hyaluronate consideration for CY 2007 ratesetting in
conversion ratio, invoking our equitable Injection). We have calculated a the OPPS.
adjustment authority would not lead to reference October 2006 ASP-based Pursuant to section 1833(t)(14)(B)(i)(I)
a different result. payment rate for this single code at of the Act, radiopharmaceuticals are
During CY 2006, we provided $124.68, as shown in Addenda A and B classified under the OPPS as specified
payment for blood clotting factors under of this final rule with comment period. covered outpatient drugs (SCODs).
Accordingly, payments for comment and feedback on how we may become packaged. At the same time, we
radiopharmaceuticals are to be made at be able to improve on our methodology also note the GAO’s comment in
average acquisition cost as determined in future years. We note that we reference to the CY 2006 OPPS
by the Secretary and subject to any received relatively little feedback in proposed rule that a methodology that
adjustment for overhead costs. response to our CY 2006 requests for includes packaging all
Radiopharmaceuticals are also subject to comments on methodologies we could radiopharmaceutical costs into the
the policies affecting all similarly consider during the development of a payments for the nuclear medicine
classified OPPS drugs and biologicals, methodology for radiopharmaceutical procedures may result in payments that
such as pass-through payments and payments in the hospital outpatient exceed hospitals’ acquisition costs for
packaging determinations, as discussed setting in preparation for the CY 2007 certain radiopharmaceuticals as there
earlier in this final rule with comment proposed rule. We again specifically may be more than one
period. invite feedback on this issue and request radiopharmaceutical that may be used
For CY 2006, we used CY 2004 mean comments for our consideration during for one particular procedure. We were
unit cost data from hospital claims to the development of our proposal for CY also concerned that with such divergent
determine each items’ packaging status, 2008 radiopharmaceutical payments. outcomes, this payment policy could
and we implemented a 1-year temporary We considered a number of provoke a treatment decision that may
policy to pay for separately payable alternative methodologies for not reflect the most clinically
radiopharmaceuticals based on the radiopharmaceutical payment policy appropriate radiopharmaceutical for a
hospital’s charge for each under the OPPS in CY 2007. One of the particular nuclear medicine procedure.
radiopharmaceutical adjusted to cost We also considered maintaining the CY
options we considered for CY 2007 (71
using the hospital’s overall cost-to- 2006 policy of paying for
FR 49587) was to package additional
charge ratio. This temporary radiopharmaceuticals at charges
radiopharmaceuticals, either through
methodology was finalized as an interim converted to cost.
increasing the packaging threshold for
proxy for average acquisition cost For CY 2007, our proposed
radiopharmaceuticals from a cost of $55
because of the unique circumstances methodology included a packaging
per day to a higher amount or through
associated with providing threshold equal to that of other drugs
a policy that would package payments
radiopharmaceutical products to and biologicals proposed for CY 2007
for all radiopharmaceuticals with
Medicare beneficiaries. We clearly and established prospective payment
payments for the services with which
stated in the CY 2006 OPPS final rule rates for separately payable
with comment period that we did not they are reported. All nuclear medicine radiopharmaceuticals using mean costs
intend to maintain the CY 2006 procedures require the use of at least derived from the CY 2005 claims data,
methodology permanently (70 FR one radiopharmaceutical, and while where the costs were determined using
68656), and that we would actively seek many separately payable drugs may our standard methodology of applying
other methodologies for setting share the same drug administration hospital-specific departmental CCRs to
payments for radiopharmaceuticals in HCPCS code, there are only a few radiopharmaceutical charges, defaulting
CY 2007. radiopharmaceuticals that may be to hospital-specific overall CCRs only if
In the CY 2006 final rule, we also appropriately billed with the same appropriate departmental CCRs were
discussed the various data sources nuclear medicine procedure. A policy to unavailable. This proposed payment
available to us, as well as the challenges package additional methodology included both the
associated with developing an radiopharmaceuticals would be acquisition and pharmacy handling
acceptable mechanism to identify consistent with OPPS packaging costs of radiopharmaceuticals
average costs for radiopharmaceutical principles and would provide greater determined to be separately payable for
products. In addition, we stated that we administrative simplicity for hospitals. CY 2007. As we have noted previously,
agreed with MedPAC’s assessment that We noted that while examining CY 2005 we agree with the MedPAC finding that
hospitals include associated preparation hospital claims data, we identified a hospitals include overhead costs in their
and handling costs in their charges for significant number of nuclear medicine charges for the associated
the radiopharmaceutical. We strongly procedure claims that were missing radiopharmaceutical. We believe this
encouraged hospitals and the HCPCS codes for the associated methodology provides for an
radiopharmaceutical community to radiopharmaceutical. We believed that appropriate proxy for the average
assist us as we began developing a there could be two reasons for the acquisition cost of the
viable long-term prospective payment presence of these claims in the data. radiopharmaceutical along with its
methodology for these products under One reason could be that the handling cost. We noted that this
OPPS. radiopharmaceutical used for the proposed methodology would be an
During the March 2006 meeting of the procedure was packaged under the appropriate long-term
APC Panel, the Panel recommended that OPPS and therefore would not be billed radiopharmaceutical payment policy
CMS work with stakeholders to on the claim with a HCPCS code and an that would allow us to consistently
continue to develop a methodology to associated charge. The second reason establish prospective OPPS payment
pay for radiopharmaceuticals. While could be that the hospitals may have rates for the acquisition and overhead
Federal law, including the incorporated the costs of the costs of separately payable
Administrative Procedure Act (APA) radiopharmaceutical into their charges radiopharmaceuticals. We also proposed
and the Federal Advisory Committee for these nuclear medicine procedures. to update the packaging threshold
Act (FACA), govern the forum by which We did not propose this methodology consistent with the methodology
we receive input of stakeholders, we for CY 2007 because we were concerned discussed above.
have met with interested organizations that payments for certain nuclear We noted in the proposed rule that
to discuss the numerous complexities medicine procedures could potentially the National HCPCS Panel implemented
associated with developing be less than the costs of some of the changes to many radiopharmaceutical
radiopharmaceutical payments under packaged radiopharmaceuticals, and codes and their descriptors effective
the OPPS, and in the CY 2007 OPPS that relatively expensive and high January 1, 2006. In some instances,
proposed rule, we again invited volume radiopharmaceuticals could these changes were relatively minor; in
others, code descriptors changed from hospital CCR. In addition, the Panel overhead costs, consistent with the
‘‘per unit’’ to ‘‘per study dose.’’ The recommended that we consider using August 2006 recommendation of the
hospital claims data used for our external data to evaluate the proposed APC Panel. Although we do believe that
proposed rule included payment rate for HCPCS code A9600 the costs unique to
radiopharmaceutical HCPCS codes that (Sr89 strontium) because of concerns radiopharmaceuticals are recognized in
were in effect during CY 2005. Because about hospital miscoding of this several departmental cost-to-charge
there were significant changes in radiopharmaceutical. We include our ratios, similar to the costs of many other
HCPCS code descriptors for several responses to these Panel items and services paid prospectively
radiopharmaceuticals from CY 2005 to recommendations in the discussion under the OPPS, consistent with the CY
CY 2006, implementation of the presented below. 2006 methodology, we will again
proposed payment methodology for In addition to these Panel calculate payment using each hospital’s
radiopharmaceuticals required us to recommendations, we received many overall cost-to-charge ratio in CY 2007.
propose a crosswalk to map the CY 2005 comments on our proposed payment As stated in the CY 2006 final rule, we
hospital claims data to updated CY 2006 methodology for radiopharmaceuticals believe that using hospitals’ overall
codes that we expected to be in effect in CY 2007. CCRs to determine payments could
during CY 2007. Out of the 39 Comment: Several commenters result in an overstatement of
radiopharmaceutical HCPCS codes that supported our proposal to establish a radiopharmaceutical costs, which are
we proposed to pay separately for in CY prospective payment methodology for likely reported in several cost centers
2007, we were able to directly crosswalk radiopharmaceuticals, but noted that, such as diagnostic radiology that have
the CY 2005 cost data to 31 of these prior to the CY 2006 final rule with lower CCRs than hospitals’ overall
codes. The descriptors for the remaining comment period, many hospitals were CCRs. We note that it is still our
eight codes changed from per unit of unaware that charges for the preparation intention to move toward a prospective
radioactivity in CY 2005 to new and handling should be included in the payment methodology for
descriptors based on per study doses in charge for the associated radiopharmaceuticals in the OPPS, and
CY 2006. Therefore, we proposed to use radiopharmaceutical. Therefore, these that we generally employ departmental
the per day costs based on the CY 2005 commenters claimed that the CY 2005 CCRs in setting payment rates for most
claims data as proxies for the per study data used to establish proposed mean- items and services that are paid
dose costs for this subset of based payment rates for CY 2007 are separately in the OPPS. We expect that
radiopharmaceutical HCPCS codes to be inaccurate. In addition, commenters for the CY 2008 OPPS update, hospitals
reported in CY 2007. (We refer readers noted that several radiopharmaceutical will have adapted to the CY 2006 coding
to the CY 2007 proposed rule for a more HCPCS codes were updated in CY 2006 changes and responded to our
detailed description of our proposed to standardize hospital coding for instructions to include their charges for
crosswalk methodology.) radiopharmaceuticals, and that CY 2005 radiopharmaceutical handling in their
We also noted in the proposed rule data are unreliable because hospitals charges for the radiopharmaceutical
that there were three cases where two were not using the CY 2005 products. We anticipate, as do our
CY 2005 HCPCS codes were mapped to radiopharmaceutical HCPCS codes commenters, that our CY 2006 claims
the same new CY 2006 HCPCS code that uniformly. Other commenters noted that data should be much more
would be reported in CY 2007. These using a methodology that incorporates a comprehensive and accurate in
three CY 2006 HCPCS codes were departmental CCR is not appropriate for reflecting the full hospital costs for
A9550 (Tc99m gluceptate), A9553 (Cr51 radiopharmaceuticals because the radiopharmaceutical products and their
chromate), and A9559 (Co57 cyano). unique costs associated with overhead. Because of the coding
Because of the complicated nature of radiopharmaceuticals are not properly changes for CY 2006 to simplify
crosswalking the cost data for two accounted for within any department. radiopharmaceutical reporting, hospital
predecessor HCPCS codes with different For these reasons, commenters data from that time should also reflect
units in their descriptors to each of requested that CMS extend the more consistent and correct coding
these new HCPCS codes, we proposed temporary CY 2006 methodology of because the HCPCS code units for
to crosswalk the cost data only from the paying for separately payable reporting have been aligned with the
predecessor HCPCS codes with the most radiopharmaceuticals at charges clinical uses of the
claims volume in CY 2005 to each of reduced to cost, where payment is radiopharmaceuticals.
these three HCPCS codes to be used for determined using each hospital’s overall Comment: One commenter suggested
CY 2007 ratesetting purposes. CCR. that CMS require ASP reporting for
Table 26 of the CY 2007 proposed rule Response: We understand the radioimmunotherapy
(71 FR 49589) listed all of the CY 2007 commenters’ concerns regarding the radiopharmaceutical manufacturers.
separately payable data that are represented in the CY 2005 The commenter suggested that this data
radiopharmaceuticals and the hospital claims, especially in light of the could be used in conjunction with a
predecessor HCPCS codes whose claims reports of confusion resulting from new HCPCS code for compounding
data were used to set the CY 2007 coding changes. We also acknowledge services related to these
proposed payment rates and noted the that the preparation and handling costs radiopharmaceuticals. The commenter
crosswalk methodology used for the associated with administering suggested that CMS assign the
proposed rates. radiopharmaceuticals are significant compounding HCPCS code to its own
and should be fully captured in claims APC and set the payment rate between
(b) CY 2007 Final Radiopharmaceutical data used to establish prospective $2,000 and $3,000.
Payment Policy payments rates. At this time, we believe Response: We appreciate these
During the August 2006 meeting of that there is sufficient reason to extend comments, but we do not believe that
the APC Panel, the Panel recommended the temporary policy of paying for the complex issues relating to the
that CMS continue the 1-year temporary radiopharmaceuticals at charges collection of ASP data for
policy of paying for reduced to cost for one additional year radiopharmaceuticals, as discussed at
radiopharmaceuticals at charges as the best proxy for length in the CY 2006 OPPS final rule
reduced to cost, using the overall radiopharmaceutical acquisition and with comment period (70 FR 68655),
have been resolved. Therefore, we Response: We appreciate these that this final payment policy addresses
believe that implementation of the comments, and we continue to the concerns of the APC Panel regarding
collection of ASP data for these encourage comments and suggestions on HCPCS code A9500. Therefore, we are
products remains premature. However, methodologies we may consider during accepting this Panel recommendation
we will consider this comment during the development of our CY 2008 and we have applied the packaging
the development of future updates to proposed radiopharmaceutical payment methodology for radiopharmaceuticals,
the OPPS. policy. as described above, and determined that
Comment: One commenter requested We also received several comments HCPCS code A9500 will be separately
that CMS instruct hospitals to include on the amount of pharmacy handling payable in the OPPS in CY 2007. As
radiopharmaceutical handling costs in involved with compounding such, payment will be at a hospital’s
the charge for the associated nuclear radiopharmaceuticals and preparing charge for the radiopharmaceutical
medicine procedure. them for administration. reduced to cost, using the overall
Response: We appreciate this Comment: Commenters proposed hospital CCR. We again reiterate our
comment. However, we believe that several methodologies for intent to develop a suitable prospective
hospitals appropriately include these implementation in the OPPS to provide payment methodology for
handling charges in their charges for additional payment for radiopharmaceutical products paid
drugs, biologicals, and radiopharmaceutical pharmacy under the OPPS in future years,
radiopharmaceuticals. As such, we handling costs. Additional payments are beginning in CY 2008. We generally do
believe that these costs are already being warranted, commenters noted, because not make payments under the OPPS for
captured through hospital charges for radiopharmaceutical products require items and services at cost, particularly
these items, which require preparation substantial preparation and handling if we do not expect the costs of the
and handling for their administration. In prior to administration, and these services to vary substantially and
addition, for hospitals that were not services are unique to unpredictably over time and if we have
clear where these handling costs should radiopharmaceuticals. In addition, hospital claims data available. Paying
be represented on a claim, we provided commenters cite concerns regarding the for radiopharmaceuticals at cost
specific instructions in the CY 2006 effects of charge compression for these provides hospitals with no incentive to
final rule with comment period (70 FR high cost items with substantially supply radiopharmaceuticals in the
68654). As we stated for CY 2006, and higher pharmacy handling costs (see most efficient manner. However, we are
reiterate here for CY 2007, it is section V.B.III.a.2. of this preamble for encouraged by recent reports of ongoing
appropriate for hospitals to set charges additional discussion on the issue of discussions within the
for radiopharmaceuticals based on all charge compression). Commenters radiopharmaceutical community to
costs associated with the acquisition, included suggestions ranging from develop a viable, ongoing methodology
preparation, and handling of these inflating proposed payment amounts to
for OPPS radiopharmaceutical
products so that their payments under providing a fixed add-on payment
ratesetting and recent meetings with
the OPPS can accurately reflect all of amount.
Response: As we noted in the CY members of the radiopharmaceutical
the actual costs associated with
2006 final rule with comment period (70 community. We again specifically
providing these products to hospital
FR 68654), we believe that hospitals solicit comments on alternative
outpatients. If necessary, we believe that
have the ability to set charges for items methodologies and data sources that
hospitals can appropriately adjust their
properly so that charges converted to may be used to set radiopharmaceutical
charges for radiopharmaceuticals so that
costs can appropriately account fully for payment rates in the OPPS.
the calculated costs from applying
hospitals’ overall CCRs to their acquisition and overhead costs. As While payments for drugs, biologicals
radiopharmaceutical charges on claims noted previously, commenters urged us and radiopharmaceuticals are taken into
properly reflect their actual costs. We do to delay implementation of our account when calculating budget
not believe it is appropriate to provide proposed CY 2007 radiopharmaceutical neutrality, we proposed to make
different instructions in this final rule payment methodology based on CY payments for drugs, biologicals, and
with comment period, when we have 2005 mean unit costs calculated from radiopharmaceuticals without scaling
many comments reflecting hospitals’ hospital claims data because, they these payment amounts. Section
efforts to respond to our CY 2006 claimed, hospitals had only begun 1833(t)(14)(A)(iii)(I) requires that,
instruction. including associated overhead charges beginning in CY 2006, we pay for a
We received a few comments that in response to our CY 2006 final rule, separately payable drug on the basis of
included specific suggestions for and these preparation and handling ‘‘the average acquisition cost of the
consideration during the future costs were not included in the CY 2005 drug.’’ As we stated in the CY 2006
development of our proposed CY 2008 claims data. As we are continuing our OPPS final rule with comment period
radiopharmaceutical payment policy. CY 2006 methodology of paying for (70 FR 42728), we believe that the best
Comment: Commenters suggested that radiopharmaceuticals at a hospital’s interpretation of the specific
CMS consider establishing a buffering charges for the radiopharmaceutical requirement that we pay for such drugs
mechanism when radiopharmaceuticals reduced to costs, based upon the on the basis of average acquisition cost
are transitioned to a prospective hospital’s overall CCR, we do not is that these payments themselves
payment methodology; that we continue believe that an additional payment should not be adjusted as part of
to use the overall hospital CCR to specific to overhead costs for meeting the statutory budget neutrality
calculate costs, regardless of any future radiopharmaceutical products is requirement. If we were to apply a
radiopharmaceutical payment warranted at this time. budget neutrality scalar to these
methodology; that we consider a unique Therefore, for CY 2007, we have payments, we would no longer be
data trimming methodology for concluded that our final payment paying the average acquisition cost, but
radiopharmaceuticals; and that we methodology provides an acceptable rather an adjusted average acquisition
consider using the PPI as a basis for proxy for the average acquisition cost of cost for separately payable drugs,
annual radiopharmaceutical payment the radiopharmaceutical along with its biologicals, and radiopharmaceuticals.
updates. handling cost. In addition, we believe We believe that these amounts, without
a budget neutrality scalar applied, are and A9502 (Tc99m tetrofosmin) are data in line with our payment
the best proxies we have for the comparable in terms of safety and methodologies for newly established
aggregate average acquisition and efficacy, and as such, there should be no HCPCS codes that are granted pass-
pharmacy overhead and handling costs difference in OPPS payment rates. It through status under the OPPS. (Section
of drugs, biologicals, and suggested that factors such as V.A. of this final rule with comment
radiopharmaceuticals. manufacturer rebates and incomplete period provides additional details on
Comment: A few commenters hospital reporting may have contributed our final policies for CY 2007 pass-
requested the implementation of edits to inaccurate CY 2005 claims data. It through drugs, biologicals, and
similar to procedure to device edits that suggested that the payment rates for radiopharmaceuticals.) In Addendum B
would require hospitals to include a these products be averaged and that the of the CY 2007 proposed rule, we
radiopharmaceutical HCPCS code resulting rate be used for both products. assigned status indicator ‘‘K’’ to these
whenever a nuclear medicine procedure Response: We believe the concerns new CY 2007 HCPCS codes for drug,
is billed. expressed by this commenter are no biological, and radiopharmaceutical
Response: We understand that coding longer applicable in light of the items without pass-through status.
accurately for the variety of services finalized payment methodology for
provided across a hospital setting can be (2) CY 2007 Proposed and Final
radiopharmaceutical products in CY Payment Policy for
challenging, as can be keeping current 2007 discussed above.
on changes to codes, modifiers and Radiopharmaceuticals With HCPCS
updated billing instructions. However, b. CY 2007 Payment for Nonpass- Codes, But Without OPPS Hospital
we do not believe that the appropriate Through Drugs, Biologicals, and Claims Data
solution to complex billing is the Radiopharmaceuticals With HCPCS In section V.B.3.a.(3) of this final rule
implementation of edits for a large Codes, But Without OPPS Hospital with comment period, we discuss our
number of services. As discussed above, Claims Data proposed methodology to base payment
during our review of claims for the CY (1) Background rates for radiopharmaceuticals with CY
2007 ratesetting process we identified a 2005 hospital claims data at their mean
large number of claims without Pub. L. 108–173 does not address the costs for CY 2007. We also proposed to
associated radiopharmaceuticals OPPS payment in CY 2005 and after for use WAC as a basis for ratesetting for
reported with nuclear medicine new drugs, biologicals, and new radiopharmaceuticals without
procedures. We believe that this may be radiopharmaceuticals that have assigned hospital claims data that have been
due to hospitals using packaged HCPCS codes, but that do not have a assigned HCPCS codes as of January 1,
radiopharmaceuticals, or because reference AWP or approval for payment 2007, without regard to their pass-
hospitals have already packaged the as pass-through drugs or biologicals. through status. If WAC data were
costs of the associated Because there is no statutory provision unavailable, we proposed to use 95
radiopharmaceutical into the cost of the that dictated payment for such drugs percent of the most recent AWP, and to
nuclear medicine procedure. If this is and biologicals in CY 2005, and because implement payment rate adjustments
the case, we do not believe that we had no hospital claims data to use resulting from the quarterly update
implementing procedure to in establishing a payment rate for them, process accordingly.
radiopharmaceutical edits would be an we investigated several payment options We received numerous comments on
appropriate mechanism for us to use in for CY 2005 and discussed them in our proposed payment methodologies
order to get additional data for detail in the CY 2005 OPPS final rule for radiopharmaceutical products, and
radiopharmaceutical products. We do with comment period (69 FR 65797 one comment specific to HCPCS code
not mandate hospital charging practices through 65799). A9567 (Technetium TC–99m aerosol).
for specific items, and implementing For CYs 2005 and 2006, we finalized Comment: One commenter objected to
edits would be contrary to our general our policy to provide separate payment our proposed packaged status for
concept of encouraging hospitals to for new drugs, biologicals, and HCPCS code A9567. The commenter
develop their charges, revenue centers radiopharmaceuticals with HCPCS recommended that in the absence of
and internal practices as they find codes, but which did not have pass- data providing payment information, we
appropriate. In addition, edits do not through status at a rate that was assign HCPCS code A9567 status
necessarily ensure quality data. Most equivalent to the payment they received indicator ‘‘H’’ and provide payment in
importantly, we generally implement in the physician office setting, CY 2007 at charges reduced to cost.
edits to ensure that high cost items with established in accordance with the ASP In addition, other commenters
packaged payment are reported on methodology. remarking on our proposed
appropriate claims, so that the As discussed in the CY 2005 OPPS radiopharmaceutical policies requested
procedural payment rates fully final rule with comment period (69 FR that we continue our CY 2006 payment
incorporate the costs of these items that 65797), and the CY 2006 OPPS final rule methodology for separately payable
are required for the procedures. We with comment period (70 FR 68666), radiopharmaceuticals (see section
have no need to edit for the presence of new drugs, biologicals, and V.B.3.a.(3) of this preamble). That is,
radiopharmaceutical HCPCS codes on radiopharmaceuticals may be expensive, commenters requested that we continue
claims for nuclear medicine procedures and we are concerned that packaging to pay for radiopharmaceuticals at the
when we will be paying separately in these new items might jeopardize hospital’s charge for the
CY 2007 for all radiopharmaceuticals beneficiary access to them. In addition, radiopharmaceutical adjusted to the
with per day costs greater than $55. we do not want to delay separate cost, using the hospital’s overall CCR.
Therefore, we are not accepting this payment for these items solely because Response: We believe it is appropriate
commenter’s proposal to implement a pass-through application was not to align our payment methodologies,
procedure to radiopharmaceutical edits submitted. Therefore, we developed our whenever possible, within the OPPS.
at this time. proposed CY 2007 payment Therefore, for CY 2007, we are finalizing
Comment: The manufacturer of a methodologies for drugs, biologicals, our payment policy for nonpass-through
radiopharmaceutical product stated that and radiopharmaceuticals with HCPCS radiopharmaceuticals without hospital
HCPCS codes A9500 (Tc99m sestamibi) codes but without OPPS hospital claims claims data that have been assigned
HCPCS codes as of January 1, 2007, as (3) CY 2007 Proposed and Final In the rare circumstance that a drug
follows: For CY 2007, hospitals will Payment Policy for Drugs and does not have a Part B drug CAP rate or
receive payment for nonpass-through Biologicals With HCPCS Codes, But data available for use for the ASP
radiopharmaceuticals without hospital Without OPPS Hospital Claims Data methodology, we proposed to make
claims data that have been assigned payment at 95 percent of the product’s
HCPCS codes as of January 1, 2007, at (a) New Drugs Without Hospital Claims
most recent AWP in order to be
the hospital’s charge for the Data
consistent with how we pay for new
radiopharmaceutical adjusted to cost, For CY 2007, we proposed to continue drugs, biologicals, and
using the hospital’s overall cost-to- payment for new drugs and biologicals radiopharmaceuticals without HCPCS
charge ratio. This methodology will with HCPCS codes as of January 1, 2007, codes, as discussed in the CY 2006
provide payment for nonpass-through OPPS final rule with comment period
but without pass-through status, at a
radiopharmaceuticals using the same (70 FR 68669). We noted in our proposal
rate that is equivalent to the payment
payment methodology that we have that it was our intent to adjust payment
they would receive in the physician
finalized for pass-through rates through the quarterly update
radiopharmaceuticals in CY 2007, as office setting, unless the drug or
biological was also covered under the process for items paid under a
discussed in section V.B.3.a.(3) of this methodology other than ASP once ASP
final rule with comment period. As we Part B drug CAP. If the drug or
biological was covered under the Part B data became available and to make
discuss above, we are aware that due to
drug CAP, then we proposed to set the appropriate adjustments to the payment
the additional costs associated with new
OPPS rate equal to the Part B drug CAP rates for new drugs and biologicals in
radiopharmaceuticals that a decision to
rate. If not, then we proposed to set the the event that they become covered
package these items may affect
beneficiary access. Therefore, when we OPPS payment rate at a rate equal to the under the Part B drug CAP in the future.
are unable to determine the appropriate payment rate established in accordance Table 26 below lists the new CY 2007
packaging status (as outlined in section with the ASP methodology described in HCPCS codes for drugs, biologicals, and
V.B.2. of this preamble) for a the CY 2006 MPFS final rule, where radiopharmaceuticals that were not
radiopharmaceutical in CY 2007 due to payment will generally be equal to available during development of the
the lack of hospital claims data, we are ASP+6 percent. Additional information proposed rule. In addition, we note that
finalizing a policy to provide payment on the ASP methodology can be found these codes are included in Addendum
for these items at the hospital’s charge at http://www.cms.hhs.gov/ B this final rule with comment period
for the radiopharmaceutical adjusted to McrPartBDrugAvgSalesPrice/ and are identified with comment
cost, using the hospital’s overall CCR. 01_overview.asp#TopOfPage. indicator ‘‘NI.’’.
TABLE 26.—CY 2007 HCPCS CODES WITHOUT OPPS CLAIMS DATA AND WITHOUT PASS-THROUGH STATUS
HCPCS Short description CY 2007 SI CY 2007 APC
code
C9234 .. Inj, alglucosidase alfa ............................................................................................................................ K 9234

C9235 .. Injection, panitumumab ......................................................................................................................... K 9235
J0364 ... Apomorphine hydrochloride .................................................................................................................. K 0766
J1324 ... Enfuvirtide injection ............................................................................................................................... K 0767
J1562 ... Immune globulin subcutaneous ............................................................................................................ K 0804
J2170 ... Mecasermin injection ............................................................................................................................. K 0805
J2315 ... Naltrexone, depot form .......................................................................................................................... K 0759
J8650 ... Nabilone oral ......................................................................................................................................... K 0808
J9261 ... Nelarabine injection ............................................................................................................................... K 0825
(b) Established Drugs Without Hospital We proposed to use the same CY 2007 final rule, as is the process for all other
Claims Data packaging methodology as was drugs, biologicals, and
proposed for other drugs, biologicals, radiopharmaceuticals.
As we discussed in the CY 2007 and radiopharmaceuticals. Specifically, We specifically requested comments
proposed rule, there are several drugs, we proposed that items with a per on our proposed payment policies for
biologicals, and radiopharmaceuticals administration cost of less than or equal drugs and biologicals with HCPCS codes
which are not new for CY 2007, but for to $55 would be packaged and items but without hospital claims data that do
which we do not have CY 2005 hospital with an estimated per administration not have pass-through status as of
claims data. In order to determine the cost greater than $55 would receive January 1, 2007.
packaging status of these items for the separate payment at a proposed rate of We received one comment specific to
CY 2007 proposed rule, we estimated ASP+5 percent, using the ASP our packaging determination for HCPCS
the per day cost of each item by methodology, subject to adjustments as code J2805 (Sincalide injection) as a
multiplying the proposed payment rate updates became available through the result of our proposal.
of ASP+5 for each product by an quarterly process. As we discussed in Comment: One commenter objected to
estimated average number of units the proposed rule, we used the most our proposed packaging determination
typically furnished to a patient during
recent data available at the time of the for HCPCS code J2805. This commenter
one administration in the hospital proposed rule to determine both the stated that in absence of data, codes
outpatient setting. We included our packaging status and payment rates for should not automatically be packaged;
estimated average number of units in these drugs. We update these rates and rather, J2805 should be assigned status
Table 27 of the CY 2007 OPPS proposed reevaluate our proposed status indicator ‘‘K’’ with a payment rate at
rule (71 FR 49595). indicators and payment rates for the ASP+6 percent for CY 2007.
Response: As we noted in the CY HCPCS codes but without CY 2005 one administration in the hospital
2007 proposed rule, we have an ASP- hospital claims data and without pass- outpatient setting as published in Table
based amount for HCPCS code J2805, through status. (For a discussion of the 27 of the proposed rule (71 FR 49595).
however we do not have CY 2005 comments and our responses to these For those drugs and biologicals that
hospital claims data available. issues, see sections V.B.2. and V.B.3. of have been classified as separately
Therefore, in absence of aggregate totals this final rule with comment period.) payable using this final methodology,
for the number of units and the number For the reasons cited in sections V.B.2. payment will be determined using the
of days this code was billed on hospital and V.B.3. of this final rule with methodology finalized in section V.B.3.
claims in CY 2005, we estimated an comment period, and because we of this final rule with comment period.
average number of units that would be believe it is appropriate to align our Therefore, drugs that have been
clinically appropriate for one payment methodologies whenever identified as separately payable in CY
administration of this drug to a typical possible within the OPPS, we are 2007 will be paid under the ASP-based
hospital outpatient. Our estimate was finalizing our policy for drugs and methodology at a rate of ASP+6 percent,
included in Table 27 of the OPPS biologicals that have HCPCS codes but and will be subject to adjustments
proposed rule (70 FR 49595). In order to do not have pass-through status, and through the quarterly update process.
determine the packaging status of this those that also do not have CY 2005 Table 27 below shows our final
drug, we multiplied the ASP-based hospital claims data as follows: determinations using the methodology
payment rate by our estimated number Packaging status will be determined finalized above for drugs and biologicals
of units per administration. We using the threshold finalized in section that do not have CY 2005 hospital
proposed to package HCPCS code J2805 V.B.2. of this final rule with comment claims data and are not new for CY
because its cost per administration was period. That is, for CY 2007, items with 2007. We note that since the time of the
below our proposed packaging a per administration cost of less than or proposed rule, we have received claims
threshold. The final packaging equal to $55 would be packaged and data for two codes that were previously
determination for CY 2007 for this code items with an estimated per listed in Table 27 of the proposed rule.
can be found in Table 27. administration cost greater than $55 These codes are J0200 (Alatrofloxacin
In addition to this code-specific would receive separate payment. mesylate) and J0288 (Ampho b
comment, we believe that the general Estimating the per day costs for each cholesteryl sulfate). Accordingly, these
comments received regarding our item will be determined by multiplying codes have been removed from the table
proposed packaging methodology and the final payment rate (described in and their packaging and payment rates
the comments received regarding our section V.B.3. of this final rule with determined under our final OPPS policy
proposed payment rate of ASP+5 for comment period) for each product by as noted in section V.B.1. of this final
nonpass-through drugs and biologicals the estimated average number of units rule with comment period.
also apply to this group of drugs with typically furnished to a patient during BILLING CODE 4120–01–P
BILLING CODE 4120–01–C biologicals in the OPPS for CY 2007, Technetium TC–99m aerosol), we
In addition, we note that HCPCS which in general will be equal to ASP+6 proposed to package them in CY 2007.
codes Q9945-Q9954 for low osmolar percent, subject to adjustments based on We specifically invited comments on
contrast material of various iodine the quarterly update process. This final our proposed policies for determining
concentrations were activated in the CY 2007 methodology for separately the per administration cost of the drugs,
OPPS in CY 2006 and replaced several payable drugs and biologicals is biologicals, and radiopharmaceuticals
CY 2005 HCPCS A-codes that defined discussed further in section V.B.3 of this that are payable under the OPPS, but do
different sets of units in their final rule with comment period. not have any CY 2005 claims data.
descriptors. As we have no CY 2005 We received a few public comments
(4) CY 2007 Proposed and Final
hospital claims data for the Q-codes, we concerning our proposed CY 2007
Payment Policy for Drugs, Biologicals,
used the CY 2005 data from the HCPCS policies for drugs, biologicals, and
and Radiopharmaceuticals With HCPCS
A-codes (HCPCS mean, number of units, radiopharmaceuticals with HCPCS
Codes, But Without OPPS Hospital
and days) to determine the packaging codes, but without OPPS hospital
Claims Data and Without ASP-Related
status of the corresponding set of claims data and without ASP-related
Data
HCPCS Q-codes for CY 2007. All of our data.
estimated per-day administration rate In addition to the drugs, biologicals, Comment: Commenters suggested that
determinations for the HCPCS A-codes and radiopharmaceuticals without CY ASP pricing data are available for one or
were above the final OPPS CY 2007 2005 claims data identified in Table 27 more of these items. Another
packaging threshold of $55, as discussed of the proposed rule (71 FR 49595), we commenter requested that we use
in section V.B.2. of this final rule with identified three HCPCS codes for which alternative data sources, such as WAC
comment period. Therefore, we are there were no available data to support or AWP, to determine the CY 2007
determining that the corresponding set the ASP methodology and no available packaging status of the three items listed
of CY 2007 HCPCS Q-codes will be paid hospital claims data from CY 2005. As above as ASP information is not
separately in CY 2007. As there are ASP we were unable to estimate the per available.
data available for these HCPCS Q-codes, administration cost of these three Response: We appreciate these
they will be paid at the same rate as HCPCS codes (90393,Vaccina ig, im; comments. During the data update
ER24NO06.020</GPH>
other separately payable drugs and 90693, Typhoid vaccine, akd, sc; A9567, process we perform between the CY
2007 proposed and final rules, we again J0190. Therefore, for purposes of impact entails estimating spending for two
queried for ASP-related data for these estimates and for publication of groups of items. The first group consists
three items, including other sources Addenda A and B of this final rule with of those items for devices that were
such as WAC and AWP. Again, we were comment period, we have used the CY eligible for pass-through payment in CY
unsuccessful in identifying this 2005 mean as it is the only pricing 2005 and/or CY 2006 and that would
information. However, in the course of source available to us at this time. continue to be eligible for pass-through
our research for updated pricing data, Also, based upon CY 2005 hospital payment in CY 2007. The second group
we discovered that HCPCS code 90693 claims mean unit cost data and the contains items that we know are newly
(Typhoid vaccine, akd, sc) is not methodology described in section V.B.2. eligible, or project would be newly
available for purchase by hospitals. of this final rule with comment period, eligible, for pass-through payment
Therefore, we are assigning status we have determined that HCPCS code beginning in CY 2007.
indicator ‘‘B’’ (Codes that are not A9566 (Tc99m fanolesomab) is B. Estimate of Pass-Through Spending
recognized by OPPS when submitted on separately payable in CY 2007. for CY 2007
an outpatient hospital Part B bill type However, we do not have CY 2004
(12x and 13x)). hospital claims data available for this As we proposed, in this final rule
After carefully considering the code as its predecessor code, C1093, with comment period, we are setting the
comments received, we are finalizing was not reported under the OPPS until applicable percentage cap at 2.0 percent
our CY 2007 proposed policy to package January 1, 2005. Therefore, similar to of the total OPPS projected payments for
HCPCS code 90393 (Vaccina ig, im), as HCPCS code J0190 described above, we CY 2007. As we discuss in section IV.B.
we remain unable to determine pricing are using the CY 2005 mean unit cost for of this preamble, there is one device
information for this item. Finally, this code for purposes of impact category receiving pass-through
HCPCS code A9567 (Technitium TC– estimates. We note that there will be no payment in CY 2006 that will continue
99m aerosol) is a radiopharmaceutical, payment rate information for this code for payment during CY 2007. In cases
and as such, we are finalizing a policy included in Addenda A or B of this final where we have relevant claims data for
to pay for this item in CY 2007 as we rule with comment period because this the procedures associated with a device
will pay for all new code is a radiopharmaceutical and will category, we often project these data
radiopharmaceuticals without claims be paid according to the methodology forward using inflation and utilization
data, regardless of pass-through status. described in section V.B.3.a.(3) of the factors based on total growth in OPPS
Therefore, for CY 2007, we will pay for preamble of this final rule with services as projected by CMS’ Office of
HCPCS code A9567 at the hospital’s comment period. the Actuary (OACT) to estimate the
charge for the radiopharmaceutical upcoming year’s pass-through spending
adjusted to cost, using the hospital’s VI. Estimate of OPPS Transitional Pass- for this first group of device categories.
overall CCR. Through Spending in CY 2007 for As we stated in the CY 2007 OPPS
In addition, HCPCS code J0190 (Inj Drugs, Biologicals, proposed rule (71 FR 49596), we may
biperiden lactate/5 mg) was packaged Radiopharmaceuticals, and Devices use an alternate growth factor for any
for CYs 2005 and 2006. As discussed in specific device category based on our
A. Total Allowed Pass-Through
section V.B.2. of this final rule with claims data or the device’s clinical
Spending
comment period, to determine the CY characteristics, or both. Based on our
2007 final packaging status of drugs, Section 1833(t)(6)(E) of the Act limits historical claims data for the procedures
biologicals, and radiopharmaceuticals the total projected amount of associated with the current device
we used ASP data from the first quarter transitional pass-through payments for category continuing for pass-through
of CY 2006 (reflected in payment rates drugs, biologicals, payment into CY 2007 and the device’s
in the physician office setting effective radiopharmaceuticals, and categories of clinical characteristics, we estimate
July 1, 2006), along with updated devices for a given year to an pass-through spending attributable to
hospital claims data from CY 2005. ‘‘applicable percentage’’ of projected the first group (that is, one category for
Under this methodology, we determined total Medicare and beneficiary CY 2007) described above to be $44.0
that for CY 2007, HCPCS code J0190 payments under the hospital OPPS. For million for CY 2007.
will be separately payable. We note that a year before CY 2004, the applicable To estimate CY 2007 pass-through
for impact estimates and for purposes of percentage was 2.5 percent; for CY 2004 spending for device categories in the
publication of Addenda A and B of this and subsequent years, we specify the second group, that is, items that we
final rule with comment period, we use applicable percentage up to 2.0 percent. know at the time of development of this
payment rates for drugs, biologicals, and If we estimate before the beginning of final rule with comment period would
radiopharmaceuticals that are effective the calendar year that the total amount be newly eligible for pass-through
in the OPPS for October 2006. These of pass-through payments in that year payment in CY 2007 or contingent
rates are developed through the would exceed the applicable percentage, projections for new categories in the
methodologies discussed in the CY 2006 section 1833(t)(6)(E)(iii) of the Act second through fourth quarters of CY
final rule with comment period (70 FR requires a uniform reduction in the 2007, we used the following approach.
68631), and generally reflect ASP data amount of each of the transitional pass- In general, as described for the first
from the second quarter of CY 2006, through payments made in that year to group of device categories above, if we
hospital claims data from CY 2004, or ensure that the limit is not exceeded. have relevant claims data we may
rates paid under the Part B drug CAP. We make an estimate of pass-through project these data forward using OACT
This methodology essentially provides spending to determine not only whether inflation and utilization factors based on
comparable payment rates across payments exceed the applicable total growth in OPPS services, or we
HCPCS codes at a specific point in time, percentage, but also to determine the may use an alternate growth factor for
and therefore enables consistency when appropriate reduction to the conversion any specific new device category based
calculating impact estimates. Under this factor for the projected level of pass- on our claims data or the device’s
methodology, we do not have ASP through spending in the following year. clinical characteristics, or both. As we
based data or CY 2004 claims-based For devices, developing an estimate of indicated in the proposed rule (71 FR
mean unit cost data for HCPCS code pass-through spending in CY 2007 49596), we anticipated that any new
categories for January 1, 2007 would be the pass-through payment amount for radiopharmaceuticals in CY 2007 will
determined after the publication of the new drugs and biologicals that we be significant enough to materially
proposed rule, but before publication of determine to have pass-through status affect our estimate of total pass-through
this final rule with comment period. For will equal zero. Therefore, in this final spending in CY 2007. Therefore, we are
the two additional device categories that rule with comment period, our estimate not including radiopharmaceuticals in
have now been approved for pass- of pass-through spending for drugs and our final estimate of pass-through
through status as of January 1, 2007, we biologicals with pass-through status in spending for CY 2007. We discuss the
used price information and utilization CY 2007 equals zero. methodology for determining the CY
estimates from manufacturers, because In the CY 2005 OPPS final rule with
2007 payment amount for
we did not have any relevant CY 2005 comment period (69 FR 65810), we
radiopharmaceuticals with pass-through
claims data upon which to base a indicated that we are accepting pass-
through applications for new status in section V.B.3.b. of this
spending estimate for CY 2007. To
account for the contingency of new radiopharmaceuticals that are assigned a preamble.
device categories that we project could HCPCS code on or after January 1, 2005. In accordance with the methodology
become eligible for pass-through status (Prior to this date, radiopharmaceuticals described above, we estimate that total
in the second, third, or fourth quarters were not included in the category of pass-through spending for both device
of CY 2007, we used the general drugs paid under the OPPS, and categories that are continuing into CY
methodology as described above, while therefore, were not eligible for pass- 2007 and those that first become eligible
also considering the most recent OPPS through status.) There are no for pass-through status during CY 2007
experience in approving new pass- radiopharmaceuticals that were eligible will equal approximately $65.6 million,
through device categories. Therefore, as for pass-through payment in CY 2005 or which represents 0.21 percent of total
indicated in our proposed rule (71 FR at the time of publication of this final OPPS projected payments for CY 2007.
49596), the estimate of pass-through rule with comment period in CY 2006. This figure includes an estimate for the
spending in this CY 2007 OPPS final In addition, we have no information
current device category continuing into
rule with comment period incorporates identifying new radiopharmaceuticals to
CY 2007, which equals approximately
both CY 2007 estimates of pass-through which a HCPCS code might be assigned
on or after January 1, 2007, for which $44.0 million, in addition to projections
spending for device categories made
pass-through payment status would be for both categories that were approved
effective January 1, 2007, and estimates
for those projected to be approved sought. We also have no data regarding after publication of the OPPS proposed
during subsequent quarters of CY 2007. payment for new radiopharmaceuticals rule effective January 1, 2007, and
With respect to CY 2007 pass-through with pass-through status under the discussed in section IV.B. of the
spending for drugs and biologicals, as methodology that we specified in the preamble of this final rule with
noted in the proposed rule (71 FR CY 2005 OPPS final rule with comment comment period, and new categories
49596) and explained in section V.A.3. period. However, we do not believe that that may become eligible during the
of this final rule with comment period, pass-through spending for new subsequent quarters of CY 2007.
TABLE 28.—ESTIMATE OF CY 2007 TRANSITIONAL PASS-THROUGH SPENDING FOR CURRENT PASS-THROUGH CATEGORY
CONTINUING INTO CY 2007
CY 2007 esti-
CY 2007 estimated pass-
HCPCS APC Existing pass-through device category mated utiliza- through pay-
tion ments
C1820 1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system 5,483 $43,974,519
Because we estimate that pass- separately from other services or groups devices may not be used in determining
through spending in CY 2007 will not of services. The additional groups must any outlier payments under the OPPS
amount to 2.0 percent of total projected reflect the number, isotope, and for that period of payment. Consistent
OPPS CY 2007 spending, we will return radioactive intensity of the devices of with our practice under the OPPS to
1.79 percent of the pass-through pool to brachytherapy furnished, including exclude items paid at cost from budget
adjust the conversion factor, as we separate groups for palladium-103 and neutrality consideration, these items
discuss in section II.C. of this preamble. iodine-125 devices. In accordance with have been excluded from budget
Accordingly, we are finalizing our this provision, since CY 2004 we have neutrality for that time period as well.
proposed methodology for estimating established four new brachytherapy
CY 2007 OPPS pass-through spending source codes and descriptors. In the OPPS interim final rule with
for drugs, biologicals, and categories of comment period published on January
Section 1833(t)(16)(C) of the Act, as 6, 2004 (69 FR 827), we implemented
devices. Our final total pass-through added by section 621(b)(1) of Pub. L.
estimate for CY 2007 is $65.6 million. sections 621(b)(1) and (b)(2)(C) of Pub.
108–173, established payment for L. 108–173. In that rule, we stated that
VII. Brachytherapy Source Payment devices of brachytherapy consisting of a
we would pay for the brachytherapy
Changes seed or seeds (or radioactive source)
sources listed in Table 4 of the interim
based on a hospital’s charges for the
final rule with comment period (69 FR
A. Background service, adjusted to cost. The period of

Section 1833(t)(2)(H) of the Act, as payment under this provision is for 828) on a cost basis, as required by the
added by section 621(b)(2)(C) of Pub. L. brachytherapy sources furnished from statute. Since January 1, 2004, we have
108–173, mandated the creation of January 1, 2004, through December 31, used status indicator ‘‘H’’ to denote
separate groups of covered OPD services 2006. Under section 1833(t)(16)(C) of nonpass-through brachytherapy sources
that classify brachytherapy devices the Act, charges for the brachytherapy paid on a cost basis, a policy that we
finalized in the CY 2005 final rule with paid by 121 hospitals, from July 1, 2003, differential pricing by source
comment period (69 FR 65838). through June 30, 2004. These hospitals characteristics, such as configuration or
Furthermore, we adopted a standard were carefully selected to be radioactivity level. While the GAO
policy for brachytherapy code representative of all hospitals providing stated that its survey data were
descriptors, beginning January 1, 2005. these sources in CY 2002. The GAO insufficient to reliably identify any price
We included ‘‘per source’’ in the HCPCS used a regression model to identify differences by source characteristics, it
code descriptors for all those stratification factors that would concluded that any price variation
brachytherapy source descriptors for maximize the difference in mean should be reflected in its survey data
which units of payment were not purchase price among strata of the because hospitals were to report all their
already delineated. sample. It grouped hospitals into major purchases during the survey period. The
B. Government Accountability Office’s teaching hospitals, nonmajor teaching GAO indicated that its results could be
Final Report on Devices of hospitals, urban nonteaching hospitals, appropriately generalized to the
Brachytherapy and rural nonteaching hospitals. The approximately 950 hospitals providing
GAO placed small hospitals into a these sources in the outpatient
Section 621(b)(3) of Pub. L. 108–173 separate stratum to ensure that they department that met the sampling
required the Government Accountability were appropriately represented. criteria, and stated that the sampling
Office (GAO) to conduct a study to For iodine and palladium sources, the frame contained 98 percent of the
determine appropriate payment survey requested reporting of the name hospitals submitting OPPS claims for
amounts for devices of brachytherapy, of the manufacturer, the number of the three brachytherapy sources in CY
and to submit a report on its study to sources, the price per source, and 2002.
the Congress and the Secretary, certain characteristics of the sources Only 19 hospitals responded to the
including recommendations. This report purchased, such as radioactivity level survey with iridium information, but 11
was due to Congress and to the and configuration. For iridium, it did not provide the number of
Secretary no later than January 1, 2005. requested reporting of the name of the treatments and/or reported questionable
The GAO’s final report, ‘‘Medicare manufacturer, the number of treatments source prices, resulting in the GAO’s
Outpatient Payments: Rates for Certain delivered, the source price, and its inability to estimate the cost per
Radioactive Sources Used in rebate eligibility. The GAO survey had treatment in these cases. For the other
Brachytherapy Could Be Set an overall response rate of 51 percent, eight hospitals, there were also data
Prospectively’’ (GAO–06–635), which and the GAO was able to calculate the inconsistencies. Because the GAO could
was published on July 24, 2006, was not mean and median purchase prices for not establish a unit cost for iridium, it
available in time for review and iodine and palladium. Few hospitals could not assess if the unit cost of
discussion in the CY 2007 OPPS reported receiving rebates. iridium varied substantially and
proposed rule. Therefore, we are To estimate the hospitals’ mean and unpredictably over time in a way that
summarizing and discussing the report’s median purchase prices for iodine and would make establishing a prospective
findings and recommendations in this palladium sources, the sample payment rate inappropriate.
final rule with comment period. The hospitals’ purchase price data were The GAO report concluded that CMS
GAO report principally recommends weighted to make them representative of could set prospective payment rates
that we use OPPS historical claims data the sample frame of hospitals from based on claims data for iodine and
to determine prospective payment rates which the sample was drawn. The GAO palladium sources, because the sources’
for two of the most frequently used used standard statistical trimming unit costs are generally stable, both
brachytherapy sources, iodine-125 and principles, which resulted in the sources have identifiable unit costs that
palladium-103, and also recommends exclusion of only 2 percent of the do not vary substantially and
that we consider using claims data for reported purchase prices of iodine and unpredictably over time, and reasonably
the third source studied, high dose rate exclusion of none of the reported accurate claims data are available. On
(HDR) iridium-192. During the GAO purchase prices of palladium. It the other hand, the GAO report
hospital purchase price study period, estimated the mean price per source as explained that it was not able to
separate device codes were not available $29.54 (median $25.37) for iodine from determine a suitable methodology for
to specifically distinguish high activity data submitted by 52 hospitals and paying separately for HDR iridium. The
and low activity iodine and palladium $45.35 (median $45.46) for palladium report noted that iridium is reused
sources. Therefore, in addition to from data submitted by 40 hospitals, across multiple patients, making its unit
establishing prospective payment rates with very low price variability across cost more difficult to determine.
for iodine-125 (C1718) and palladium- hospitals. Specifically, the coefficients However, the report also indicated that
103 (C1720) based on claims data, the of variation for the mean estimates were CMS has outpatient claims data from all
GAO states that it expects CMS to have 1.59 percent for the iodine purchase hospitals that have used iridium and
data available to set prospective price data and 0.68 percent for the that in order to identify a suitable
payment rates for high activity iodine- palladium purchase price data. This methodology for separate payment, CMS
125 (C2634) and palladium-103 (C2635) shows a remarkably low degree of would be able to use these data to
sources in CY 2007 as well. These two variability within the data for the establish an average cost and evaluate
codes were created in CY 2005 as a purchase prices of iodine and palladium whether that cost varies substantially
result of the Medicare Modernization brachytherapy sources during the and unpredictably.
Act (MMA) requirement that the OPPS survey period.
establish brachytherapy device The GAO found this price information C. Payments for Brachytherapy Sources
payments that account for the to be reasonably consistent with cost in CY 2007
radioactive intensity of the sources. data calculated from historical OPPS As indicated above, the provision to
The GAO studied 3 of the 12 specific claims for the sources. It speculated pay for brachytherapy sources at charges
sources currently paid separately under that, to the extent that price variation in reduced to cost expires after December
the OPPS: palladium-103, iodine-125, the survey data existed across either 31, 2006, in accordance with section
and HDR iridium-192. The GAO palladium or iodine sources, this 1833(t)(16)(C) of the Act. However,
conducted a survey of purchase prices variation could be attributed to under section 1833(t)(2)(H) of the Act,
CMS is still required to create APC conditions under treatment, other than erroneous, because it showed the costs
groupings that classify devices of through differences in the numbers of of low activity iodine and palladium
brachytherapy separately from other sources utilized, which would be sources to be higher than the costs of
services or groups of services in a accounted for in our proposed per high activity sources of iodine and
manner reflecting the number, isotope, source payment methodology. We also palladium, a result that contradicted
and radioactive intensity of the devices believed that the proposed prospective their expectations. The commenters
of brachytherapy furnished. payment methodology would promote believed that the use of median costs
In the CY 2007 OPPS proposed rule, efficiency in the provision of sources, was not valid because median costs can
we proposed to pay separately for each while continuing to provide payments result in a single claim or hospital being
of the sources listed in Table 29 of that that reflect the wide clinical variation in the determinant of the median cost.
rule (71 FR 49597) on a prospective the use of brachytherapy sources related Therefore, they concluded that basing
basis for CY 2007, with payment rates to many factors, including tumor type brachytherapy source payment on a
to be determined using the CY 2005 and stage, patient anatomy, and planned median cost did not fully represent the
claims-based median unit cost per brachytherapy dose. In addition, under costs of all hospitals.
source for each brachytherapy device the proposal we would continue to pay Response: In contrast to the
(with the exception of Ytterbium-169, as for brachytherapy sources separately commenters’ opinions, we believe that
discussed below). Consistent with our using the same C-codes and descriptors both the GAO survey information and
policy regarding APC payments made that hospitals have reported for the last CMS’ claims data provide sufficient
on a prospective basis, we proposed that several years. valid information on which to base
the cost of brachytherapy sources be We received numerous comments prospectively established payment rates
subject to the outlier provisions of regarding our CY 2007 proposed for brachytherapy sources. The findings
section 1833(t)(5) of the Act. As payment methodology for of the GAO survey and CMS’ claims
indicated in section II.A.2. of this brachytherapy sources. data are sufficiently similar and stable
preamble, for CY 2007 we proposed Comment: A number of commenters to justify the use of claims data in
specific payment rates for objected to CMS’ proposal to set setting prospective payment rates for
brachytherapy sources, which would be prospective payment rates based on brachytherapy sources. We do not view
subject to scaling for budget neutrality. median unit costs of sources because the delay in the publication of the GAO
Table 29 of the proposed rule they believed that there was no valid, report as causing its contents to be
included a complete listing of the useful source of data for brachytherapy outdated. In fact, the law that required
HCPCS codes, long descriptors, APC sources upon which to base prospective the survey was passed on December 23,
assignments, APC titles, and status payment rates for CY 2007. The 2003. Instead of choosing to survey
indicators that we currently use for commenters stated that the GAO survey hospital costs only from CY 2003 or
brachytherapy sources paid under the data were fundamentally flawed and before, GAO, after seeking the views of
OPPS in CY 2006, and that we proposed should be disregarded by CMS, and that stakeholders, chose to survey for the
to use for CY 2007. The brachytherapy CMS’ claims data also did not reflect the period, July 1, 2003, through June 30,
sources and related information in Table true hospital costs of brachytherapy 2004, in order to acquire the most
29 were the same sources and sources. Specifically with regard to the current information available at the time
information as those listed in Table 28 GAO survey, they believed that the data that the survey was performed.
of the OPPS CY 2006 final rule with collected by the GAO were outdated, We found the GAO survey to provide
comment period (70 FR 68676). No and that the survey response rate was credible information based on a
additional brachytherapy sources have inadequate as the basis for conclusions stratified sample of all relevant
been added since the CY 2006 final rule regarding the costs of sources. They categories of hospitals furnishing
with comment period. stated that the GAO survey failed to brachytherapy sources. We noted that
As indicated in the CY 2007 OPPS provide data sufficient for analyses by there was remarkably little variation
proposed rule (71 FR 49597), we source configuration (specifically, loose within the cost data elements for the
believed there were a number of sources versus stranded sources) and iodine and palladium sources, the two
advantages to this proposed payment type of hospital (specifically, rural most commonly billed sources under
method. The OPPS is a prospective versus urban), both of which they the OPPS. The GAO survey was
payment system under which payment believed should be taken into account in performed using standard survey
rates are generally established based on setting prospective payment rates for techniques, and the statistics were
median costs from historical hospital brachytherapy sources. calculated using standard statistical
claims. Under our proposal, The commenters also stated that the methods. The coefficients of variation
brachytherapy sources would be paid CMS claims data were not valid because demonstrated a remarkable amount of
using the same basic median cost they were not available by source stability for the data which were
methodology as the overall OPPS. We configuration (that is, loose sources gathered from a wide range of provider
believed that the payment of sources versus stranded sources), which types. We agree with the GAO that the
based on this approach would thus be commenters viewed as an important response to the survey, while not
an integral part of the OPPS, rather than distinction with respect to clinically sufficiently robust to provide
a separate cost-based payment meaningful characteristics and costs. information by source configuration or
methodology within the OPPS. In They observed that the CMS cost data other characteristics of sources, is
addition, we proposed this option showed significant variation in unit sufficient to provide a valid measure of
because we believed that consistent and costs across hospitals, and that the the purchase price for iodine and
predictable prospectively established number of claims containing source palladium sources. We do not believe
payment rates under the OPPS for charges was inadequate. They objected that the information from the survey
brachytherapy sources would be to reliance on CMS’ cost data because was insufficient to yield valid estimates
appropriate. We doubted that the they stated that two-thirds of the source of hospital costs. Moreover, the median
hospital resource costs associated with APCs have fewer than 50 hospitals costs provided by the GAO survey are
specific brachytherapy sources would reporting cost data for sources. They remarkably consistent with the median
vary greatly across hospitals or clinical concluded that the CMS data must be costs derived from Medicare claims data
over the years as discussed below and for other uses. Moreover, before CY brachytherapy sources to be relevant to
shown in Table 29. 2003 the sources were paid separately the calculation of sources’ median costs.
The GAO report recommended that under the transitional pass-through We have, as the law specified,
we use OPPS claims data to determine payment methodology as pass-through established source codes for purposes of
prospective payment rates for two of the devices. Therefore, hospitals have now separate payments that take into
most frequently utilized brachytherapy had 6 years of experience in billing the account the number, isotope, and
sources, iodine-125 and palladium-103. sources separately to receive payment radioactive intensity of the sources. As
In addition, the GAO report stated that for these relatively costly items. Due to with other medical devices, there will
it was unable to determine a suitable their pass-through payments in CYs always be incremental improvements in
methodology for paying separately for 2000 through 2002 and payments at the technology. We consider the
HDR iridium because the survey charges reduced to costs for CYs 2004 configuration of sources as loose or
provided insufficient data to identify through 2006, hospitals have stranded to be an incremental change,
and evaluate iridium’s average unit cost historically had a strong incentive to bill whose potential differential costs would
across hospitals. However, the GAO for sources at charges that reflected the be reflected in source cost data as the
observed that CMS has historical costs of the sources. Therefore, to the change penetrates the market for the
outpatient claims data from all hospitals extent that the commenters believed product. As such, the impact of differing
that have provided iridium sources. The that our data show rank order anomalies
GAO concluded that CMS should be configurations would become apparent
or inadequate charges or wide variations in hospital claims data over time as a
able to use its data to establish an in charges, we must assume that the
average unit cost for HDR iridium, matter of natural course. Based on the
charges reflect the hospitals’ historical technological evolution in
which could then be evaluated for perceptions of the relative costs of the
suitability as the basis for separate stranded brachytherapy sources, we
sources, and hospitals alone choose the expect that our CY 2005 median costs
payment, specifically considering charges they submit to Medicare and to
whether the source cost varies for sources already reflect their partial
all other payers.
substantially and unpredictably. market penetration, as indicated in the
With regard to the use of the median comments and discussed later in this
We do not believe the absence of data
cost, we note that the use of median section. Moreover, we do not agree that
by configuration or type of hospital is
relevant to the validity of the median costs for sources of brachytherapy is special action is necessary to prevent
costs of iodine and palladium sources identical to the basis of payments for all disincentives to the use of improved
that resulted from the survey. We services paid under the OPPS, other products. We believe that hospitals and
discuss the issue of changes in source than drugs and biologicals, pass-through physicians balance the additional
configuration in more detail below in devices, and some new technology benefit to patients of improved products
the context of the CMS data. With services. The nature of basing weights
with the additional costs, if any, of
respect to the absence of statistics by on median costs is that the volume of
those products. One of the functions of
type of facility, we believe that the services, by definition, controls the
a prospective payment system is to
consistency between the GAO survey median cost because the median is the
encourage wise purchasing while
purchase prices and the CMS data 50th percentile of the array of data.
simultaneously making appropriate
(which are based on billing by all However, use of the median cost also
simultaneously eliminates the influence payments for the services being
hospitals regardless of type) shows that furnished. We believe that payments
the lack of response by rural hospitals of not only the highest but also the
lowest values in the array. Moreover, as based on the median unit costs of
to the GAO survey is not meaningful. brachytherapy sources support this goal.
We believe that there are sufficient the OPPS is a budget neutral relative
and valid CMS claims data upon which weight system, it is the relativity of the Our review of the GAO findings and
to base prospective payment rates per medians that is important and not the examination of OPPS claims data
source for each of the brachytherapy specific median itself. Therefore, it is support use of the median costs from
sources with available historical claims important that the same measure of CMS’’ claims data as the basis for the
information. Sources of brachytherapy central tendency (in this case the CY 2007 payment rates for
have been separately paid for virtually median cost) be used to establish the brachytherapy sources. In Table 29
all of the history of the OPPS, with weights for all OPPS services to which below, we have summarized available
packaging of iodine and palladium the conversion factor applies to historical OPPS information for the
sources only for prostate brachytherapy calculate their payment rates. iodine and palladium sources studied
in CY 2003, when there was separate We also do not consider the absence by the GAO, in the context of our CY
payment in that year for these sources of data specific to loose versus stranded 2007 final rule median unit costs.
TABLE 29.—MEDIAN COSTS, PAYMENT RATES, AND GAO STUDY FINDINGS FOR IODINE AND PALLADIUM BRACHYTHERAPY
SOURCES
CY 2003 CY 2004 GAO survey Estimated CY CY 2007 final
Source payment proposed median 2006 median rule median
rate* rate** price @ payment # unit cost
Iodine-125 .................................................................................... $31.33 $36.35 $25.37 $32.63 $36.12

Palladium-103 .............................................................................. 43.96 44.00 45.46 48.92 48.53
* Based on median from CY 2001 claims.

** Based on median from CY 2002 claims.
@ Purchase price between July 2003 and June 2004.
# Based on charges reduced to cost method.
While the CY 2007 final rule median for cesium-131, ytterbium-169, and acknowledge that the relatively low
costs are established as median unit linear palladium-102, and had not yet volume of claims from a small number
costs calculated using the standard distinguished high activity iodine-125 of hospitals for the high activity iodine
OPPS methodology of applying specific and palladium-103 sources. source from CY 2005 may contribute to
departmental CCRs, if available, to While we have relatively low CY 2005 the variability in its median cost, but we
claims’ charges, and defaulting to days and units for several of these 8 see no reason to believe that its median
overall hospital CCRs only if sources, we have at least 320 units for cost would not be appropriately
departmental CCRs are unavailable, each one. We estimate that half of these reflective of the costs to hospitals
estimated CY 2006 payments are devices would experience an increase in providing the source in CY 2005. The
calculated according to the cost-based payment of 4 percent to 38 percent GAO also noted that it expected us to
payment methodology in effect during under the CY 2007 final rule have claims data from CY 2005 that
CY 2006, which reduces charges to costs methodology compared with their could be used to establish a prospective
using overall hospital-specific CCRs. median payments under the CY 2006 payment rate for the high activity
The table shows great consistency of cost-based methodology, while the iodine-25 source.
OPPS claims data for these sources over others would experience decreases of 17 Comment: Two commenters objected
the past 5 years, yielding reasonably percent to 38 percent. This variation to our proposal to pay for sources of
stable median costs, with their reflects the numerous different brachytherapy based on the median cost
associated payment rates, as either departmental CCRs that are used to and asked that CMS set a prospective
proposed or finalized over time. The CY calculate costs for brachytherapy from per source payment rate base on the
2007 final rule median costs for iodine, the relatively small number of hospitals mean cost derived from our claims data.
although based on claims for services reporting charges for many of the One commenter believed that sources of
provided approximately 1 to 2 years sources, in comparison with their brachytherapy should be paid based on
later than the dates of service for the overall hospital CCRs. We can identify prospectively set mean costs because
survey data collected by the GAO no specific problems with the data for they should be paid on the same basis
regarding hospital purchase prices, are these eight sources that would cause us as radiopharmaceuticals, for which we
significantly higher than the median to question the accuracy of the CY 2007 proposed to pay based on mean cost
GAO purchase prices. For palladium, final rule payment rates based on the because both brachytherapy sources and
the final rule median cost is about 8 sources’ median costs from CY 2005 radiopharmaceuticals contain
percent higher. On average, the CY 2007 claims data. Therefore, we believe that radioactive material, are regulated by
median cost for iodine sources would be the median cost per source from CY the Nuclear Regulatory Commission,
about 11 percent greater than the 2005 Medicare claims data provides a and have the same storage, handling,
median payment under the CY 2006 sufficient and valid basis to establish a and disposal requirements.
cost-based methodology, while for prospective payment rate for each
Response: We disagree that sources of
palladium sources it would be about the brachytherapy source with available CY
brachytherapy should be paid
same. Thus, we are relatively confident 2005 claims data.
Comment: A few commenters identically to radiopharmaceuticals.
that the CY 2007 final rule Radiopharmaceuticals are defined by
questioned our median costs published
brachytherapy source median unit costs MMA as drugs and drugs are, by law,
in the CY 2007 OPPS proposed rule for
from CY 2005 claims that are the basis paid based on hospital average
high activity iodine-125 source (C2634),
of the CY 2007 payment rates for acquisition cost. Sources of
pointing out the proposed payment rate
sources are reasonably accurate and brachytherapy are not required by law
for C2634 was $25.68, which is lower
should ensure continued access by than the proposed payment rate for the to be paid at average acquisition cost,
Medicare beneficiaries to brachytherapy iodine-125 source (C1718) at $35.42. and therefore we are setting the CY 2007
services delivered with these commonly One commenter indicated that this payment for these items based on
used iodine and palladium sources. reflected a rank order anomaly in median costs derived from our claims
We also found that, for the eight other proposed payments for high activity data, like most other OPPS services that
brachytherapy sources for which we brachytherapy sources, and added that are not drugs. We refer readers to the
have hospital claims data from CY 2005, high activity iodine-125 sources always discussion below, in response to a
hospital costs for these sources do not cost more, and typically may be many comment, concerning our policy for
vary more significantly than for the two times more expensive than the payment of the handling and storage
sources previously discussed. Of these corresponding low activity sources. The costs of brachytherapy sources.
eight sources, gold-198 (C1716), non- commenter stated that this error in the Comment: A few commenters asserted
HDR iridium-192 (C1719), and yttrium- payment for high activity sources must that CMS did not provide an estimate of
90 (C2616) were established sources in be corrected for the sources to be the effect on payments for
CY 2003, the only previous year where clinically available. brachytherapy sources due to the
the OPPS provided separate payments Response: While the median cost of proposed change from a payment
for some brachytherapy sources (other C2634 for this CY 2007 final rule with methodology of charges reduced to cost
than pass-through payments in years comment period, $32.49, is still lower to a median cost methodology. They
prior to CY 2003). Their CY 2003 than the median cost for C1718, at recommended that CMS evaluate the
payment rates were $22.74, $27.29, and $36.12, the median cost for the high impact of any proposed changes in
$6,485.37, respectively, relatively activity source is somewhat higher than payment methodologies for
consistent with our CY 2007 final rule proposed, and the gap between the brachytherapy sources and
median costs of $36.61, $23.01, and median costs of the two sources has radiopharmaceuticals.
$10,525.13, respectively, based on CY narrowed. The commenters did not Response: In fact, we did consider the
2005 claims data. Iodine-125 provide data supporting their assertion impact of the proposed brachytherapy
brachytherapy solution (C2632) was that the cost of the high activity iodine- source payment methodology and
paid in CY 2003 as a pass-through 125 source is typically many times alternatives as discussed in section
device, without a prospective payment greater than the cost of the traditional XXVII.B.1.b. of the CY 2007 proposed
rate. In CY 2003, the OPPS did not pay low activity iodine-125 source. We rule (71 FR 49681).
Comment: One commenter disagreed is particularly variable, depending on brachytherapy source, factors in the
with our proposal that the cost of the number of treatments provided by a clinical variability in the number of
brachytherapy sources should be subject hospital in a given calendar quarter treatments per day with this source.
to the outlier provisions of the OPPS, before the source must be renewed. HDR iridium is a radioactive source
indicating that historically They believed that HDR iridium was, with a 90-day life span that is purchased
brachytherapy sources have not been therefore, unlike most other OPPS and used multiple times in numerous
subject to additional outlier payments. services, for which hospital costs did patients over its life. During a treatment
The commenter also stated that services not typically vary as greatly in with HDR iridium, the radioactive
assigned to status indicator ‘‘K’’ status relationship to service volume. They source is briefly inserted into each
have not been eligible for outlier argued that providing payment at temporary treatment catheter that has
payments for the past 2 years. The charges reduced to costs for this source, been placed into a patient’s treatment
commenter indicated that these types of in particular, was important to ensuring area and then removed. It never comes
changes are burdensome on hospitals patient access to HDR iridium treatment in direct contact with the patient so it
and believed that brachytherapy sources in their communities where the service may be used for multiple patients. We
should be excluded from outlier volume may be low, such as at rural believe that the cost of the radioactive
calculations, like separately paid drugs hospitals. Partial breast irradiation, with source per treatment procedure is the
and devices receiving pass-through closely spaced treatments provided over same, irrespective of how many dwell
payments. a short time period in comparison with positions or source runs are provided in
Response: Unlike separately paid traditional treatment with external beam the variable numbers of catheters placed
drugs and devices eligible for pass- radiation therapy over many weeks, was in patients. However, we also
through payments, our proposal for cited as an important example of the understand that a per day payment
brachytherapy sources is to pay for them value of HDR iridium in improving the methodology that does not take into
based on median costs, which the care and quality of life for patients consideration the number of treatments
commenter supports. Therefore, we are undergoing treatment for breast cancer. per day could be problematic, because
merely making our policy for The commenters expressed concern the total day’s source cost when more
brachytherapy sources consistent with that the proposed payment of $134.93 than one treatment is provided on a day
our policy regarding other APC per fraction may provide inadequate for the same Medicare beneficiary
payments based on median costs, payment, particularly to hospitals that would be significantly greater than if
including that they be subject to the do not provide a high volume of HDR only one treatment was performed on
outlier provisions of section 1833(t)(5) brachytherapy, notably smaller and that day. We believe that a per source
of the Act. We are finalizing our mid-sized hospitals. Some of the payment, which equates to a per
proposal to make prospectively paid commenters agreed with our concern treatment payment, for HDR iridium as
brachytherapy sources subject to the that hospitals may not be reporting proposed is appropriate, given these
outlier provisions of section 1833(t)(5) accurate units and charges for this considerations.
of the Act. We note that we reusable source. The commenters Because HDR iridium has a fixed
inadvertently did not show the recommended that HDR iridium should active life and must be replaced every
necessary conforming regulation text in continue to be paid on a per treatment 90 days, we agree with commenters that
the proposed rule. Accordingly, we are or per fraction basis, and not be paid per hospitals’ costs for the source will be
making a conforming technical change treatment day, due to the significant highly dependent on the number of
to the regulation text at § 419.43(f) to variations among different treatment treatments provided by a hospital
delete brachytherapy sources from the protocols. Therefore, the commenters during that time period. The source cost
services and groups excluded from concluded that CMS should continue to must be amortized over the life of the
outlier payments. pay for HDR iridium per fraction. sources so, in establishing their charges
We noted in the proposed rule that A few commenters indicated that for the HDR iridium source, we expect
HDR iridium-192 (code C1717) is a there is great variability in the cost of that hospitals would project the number
reusable source across treatment HDR iridium treatments, with such of treatments that would be provided
sessions and across patients. We variations occurring because of the over the life of the source and establish
believed that it was unclear whether treatment site (for example, breast, their charges accordingly. In this
hospitals had been reporting the number uterus, prostate). These treatment respect, HDR iridium is similar to
of units provided accurately, in variations result in differences in the capital equipment that hospitals buy to
accordance with our instructions to resources needed, such as the number of perform procedures and that has a
report one unit per treatment. Thus, source runs for each case. The limited lifespan. Hospitals’ costs for
while we proposed that HDR iridium be commenters also indicated that our such equipment must be spread over
paid separately on the basis of the claims data for HDR iridium-192 their charges for the procedures
median cost per source as we proposed presented huge variations in cost per performed, so the cost per procedure
to pay for the other brachytherapy unit source on claims and across would vary significantly depending on
sources, we invited comments on hospitals, with costs ranging from $0 to the number of services provided.
alternatives to using this methodology $4,746. In addition, the commenters For most such OPPS services, our
for this source in particular, such as on pointed out that the GAO report made practice is to establish prospective
the basis of median cost per treatment no definitive recommendations payment rates based on the median
day from hospital claims. regarding payment for the HDR iridium hospital costs as calculated from claims
We received a large number of source. A number of commenters stated data, to provide incentives for efficient
comments specifically addressing the that CMS should continue to pay for and cost-effective delivery of these
CY 2007 OPPS proposal for payment of HDR iridium based on the charges hospital services. We examined our full
HDR iridium, including suggestions for reduced to cost payment methodology. year CY 2005 claims data for HDR
alternatives to payment based on the Response: Our proposal to pay for iridium, as suggested by the GAO, and
median unit cost of the source. HDR iridium-192 on a per source basis, found the hospital costs for this source
Comment: A number of commenters which is equivalent to a per treatment did not vary much more than for the
noted that the unit cost of HDR iridium or per fraction payment for this other brachytherapy sources, including
iodine and palladium. We note that, paying hospitals ‘‘based on use of the correct unit of billing, which
based on our analysis, on average the HDR Iridium-192 source,’’ but that CMS undermines the accuracy of data on
CY 2007 final rule median cost for HDR establish a maximum charge for HDR which CMS relies. One commenter
of $141.75 based on the source’s median Iridium, that is, $700 per fraction. The stated that the ‘‘actual hospital charge’’
unit cost from CY 2005 claims would be commenter also suggested that each of a 1 mL vial of I–125 solution is
about 7 percent higher than under the provider continue to establish a charge $5,900, which at the rate of 150 mCi per
CY 2006 cost-based methodology, which based upon the source costs per year vial is $39.33 per mCi, while our
yields an estimated median payment of divided by the number of fractions, thus proposed payment rate was $19.32 per
$132.30, similar to the pattern observed allowing low volume HDR facilities to mCi.
for iodine and palladium sources. While offer the service, while not overpaying This commenter also mentioned that
we recognize that the average unit cost high volume facilities. the APC Panel report from the March
of an iridium source purchased by a Response: We do not instruct 2006 Panel meeting noted that some
hospital would be related to the number hospitals on establishing charges or brachytherapy sources, including
of treatments provided with the source restrict hospital charges for items billed C2632, ‘‘demonstrate relatively
and that hospitals must bill Medicare to Medicare. Hospitals establish charges inconsistent mean and median numbers
based on projections of their unit cost, based on many factors, including, but of sources used,’’ and that CMS staff
we have no reason to believe that our not limited to, the costs of items and pointed out concerns about variability
CY 2007 final rule payment rate based services and the market conditions in of the mean and median statistics. The
on the median unit cost for HDR iridium the communities that they serve. commenter contracted an outside
would place continued access to this Moreover, the OPPS is not a system that consultant to analyze CY 2005 OPPS
source at risk. Like many services under pays hospital charges. The OPPS rates claims data for C2632. The contractor
the OPPS for which hospitals purchase generally are based upon relative concluded that there are wide variations
reusable equipment and supplies, weights calculated from Medicare in how hospitals billed for units of I–
hospitals’ unit costs for iridium sources claims data and converted to payment 125 solution, which points to unreliable
would vary based on the number of rates by a conversion factor. Prospective cost data on which to base payments for
treatments a hospital provides before payment rates under the OPPS are based CY 2007.
the source must be renewed, thus on the median cost for each APC from Response: The commenters did not
incurring additional costs. Again, under historical hospital claims, with establish why payment based on the
a PPS methodology, payments generally trimming of claims data only at the median unit cost for the I–125 liquid
account for the average costs of services, extremes to eliminate those claims of brachytherapy solution is insufficient.
and do not specifically account for exceptionally high or low cost from Most commenters did not provide any
varying circumstances. We believe that contributing to APC median cost information on the cost of a one mL vial
hospitals understand this prospective development. The commenter did not of I–125 solution or sufficient further
payment methodology and should indicate how a maximum charge would information supporting their claim that
recognize that a PPS could pay more or alleviate problems associated with the proposed payment rate is
less than the cost of delivering a specific making appropriate payments for HDR insufficient. The commenter who stated
service in an individual case. iridium to hospitals, or any goals such that the ‘‘actual hospital charge’’ for a 1
Regarding the comment that the GAO a policy would accomplish. mL vial of I–125 solution is $5,900 is a
report made no definitive Additionally, the commenter did not manufacturer of equipment that uses the
recommendations regarding payment for provide the basis of its recommendation I–125 solution for its brain cancer
the HDR iridium source, this that the maximum charge should be treatments and was the only commenter
recommendation was based on the lack capped at $700 per fraction. to provide some information on the cost
of data produced by the GAO’s own Comments: A large number of of the I–125 solution. We note that we
survey, and the report indicated that it commenters requested that iodine-125 proposed to pay for the I–125 solution
was the GAO’s opinion that CMS has liquid brachytherapy solution, C2632 on a per mCi basis. This per source
outpatient claims data from all hospitals (which will be paid under A9527, payment methodology is designed to
that have used iridium. The GAO effective January 1, 2007, as stated capture the variability in costs per
recommended that, in order to identify elsewhere in this section), which is used treatment, depending on the radiation
a suitable methodology for separate in patients with brain cancer, continue dose. We also observe that the typical
payment for HDR iridium, CMS would to be paid on the basis of charges treatment of 150–450 mCi cited would
be able to establish an average cost and reduced to cost. The commenters receive payments between $2,898 and
evaluate whether that cost varies claimed that the proposed payment is $8,694 per treatment, at the proposed
substantially and unpredictably. In the insufficient to meet the cost of the payment rate of $19.32 per mCi.
efficient delivery of high dose rate iodine-125 (I–125) solution, along with We have issued instructions on the
brachytherapy services, our claims data handling and other administrative costs correct OPPS billing for the
provide no evidence that the hospital associated with the source. The brachytherapy solution. Transmittal
costs associated with HDR iridium vary commenters stated that hospitals must 132, Change Request 3154, dated March
greatly and unpredictably, so we believe continue to be able to offer this vital 30, 2004, notes how to account for the
that our CY 2005 claims provide an brain cancer radiotherapy option. cost of handling and supervision related
appropriate basis upon which to Several commenters believed that the to radiation sources. The commenters
establish the CY 2007 prospective proposed payment of $19.32 is not claimed that hospitals are confused
payment rate for HDR iridium for each sufficient to cover the cost of one mCi, regarding the number of units of I–125
treatment. This rate should help ensure the 150–200 mCi in a 1 mL vial of I–125 solution per vial. Our payment has
that hospitals continue to operate solution, or the usual 150–450 mCi historically been made on a per mCi
efficiently in providing HDR required for a typical case. One basis, and this approach will continue
brachytherapy treatments to Medicare commenter noted that while appropriate for CY 2007, consistent with the
beneficiaries. coding requires reporting one unit per predecessor C-code unit (C2632) and,
Comment: One commenter mCi, or 150 units per 1 mL vial, for CY 2007, the permanent A-code unit
recommended that CMS continue hospitals are confused regarding the (A9527). Therefore, when a vial of I–125
solution contains 150 mCi, there are 150 being packaged into payments for CY 2006 cost-based payment
billing units of I–125 solution per vial, brachytherapy procedures. methodology for CY 2007, but no public
resulting in an OPPS payment, if all Comment: Some commenters asked presentation was heard. While we
billing units are used, of $2,898 based that CMS continue to pay for acknowledge the Panel’s
on the CY 2007 proposed payment rate. brachytherapy sources on the basis of recommendation, we note that the Panel
CMS staff did point out to the APC charges reduced to cost because the APC did not provide specific rationale for its
Panel at the March 2006 meeting our Panel and Practicing Physicians recommendation, nor did it provide an
concerns about variability in statistics Advisory Council (PPAC) recommended explanation of what it perceived to be
for numbers of sources used and it. They also stated that continuation of the problem with the proposed median
wondered whether significant payment based on charges reduced to costs. Accordingly, we do not choose to
differences between the median and cost would ensure that there are no adopt the Panel’s recommendation.
mean mCi reported per day could point barriers to access and would avoid their We also acknowledge that the PPAC
to coding confusion regarding the concerns with CMS data. The recommended that CMS abandon the
correct billing of units for individual commenters stated that payment based proposal to pay for brachytherapy
cases. We asked the Panel members to on this methodology has worked well sources based on median unit costs
respond and provide any for the past 2 years and should be calculated from claims data and
recommendations. Individual Panel continued for at least CY 2007 and CY reexamine its claims data for sources
members familiar with brachytherapy 2008. Noting the GAO report was due (see recommendation 57 H.1 in the
source costs, as well as the Data no later than January 1, 2005, the summary of the August 2006 PPAC
Subcommittee in general, believed that commenters believed that the intent of meeting at http://www.cms.hhs.gov/
the median costs per unit appeared to Congress in section 621(b) of the MMA FACA/). The Panel’s discussion of the
generally be reasonable for the most was to provide 2 years of payments for issue at its August 2006 meeting
commonly furnished sources, but that brachytherapy sources based on charges centered on its belief that hospitals
erroneous billing of the units of sources reduced to cost after the publication of incorrectly reported HCPCS codes and
could affect the median unit costs of the GAO study to allow no less than 2 charges for brachytherapy sources.
some sources, including C2632. We are years for Congress, CMS, and the public However, as discussed in detail
continuing to study the variability of to further analyze brachytherapy device previously, we observe significant
brachytherapy source data, and note cost and payment information, and the stability of claims-based costs for the
that there are significantly greater units findings of the GAO survey in most commonly used sources over time,
for some sources, such as C2632, based particular, before payment based on and hospitals have generally had 6 years
on full year CY 2005 data, than were charges reduced to cost would cease. of experience with reporting the codes
They believed that CMS should and charges for brachytherapy sources,
included in the partial CY 2005 data the
continue payment based on charges upon which their specific source
Panel reviewed in March 2006. We
reduced to cost for CY 2007 and CY payments were based throughout that
believe it is appropriate to treat I–125
2008 to comply with what they viewed time period. Therefore, as we do not
solution like all other brachytherapy
as the intent of Congress, because the agree with the underlying rationale
sources for CY 2007 and establish its
GAO report was not released until July behind PPAC’s recommendation, we are
payment rate based on its median unit
2006, about 18 months after its due date likewise not accepting its
cost from CY 2005 claims data.
of January 1, 2005, for publication. recommendation.
Comment: One commenter did not One commenter supported the We also note that the statute requires
believe we had factored into the cost of concept of prospective payment for payment based on charges reduced to
brachytherapy the need for special brachytherapy sources when the cost for sources furnished between
handling of sources by nuclear payment rates can be based on data that January 1, 2004, and December 31, 2006.
physicists and sought payment are stable over time and reasonably The law is clear as to the timeframe for
consideration for these handling costs. accurate. The commenter believed that this payment approach and is not linked
Response: We explicitly consider the the GAO report was sound, and it to the issuance of the GAO report, as
special handling of brachytherapy supported the GAO’s recommendations commenters suggested was the intent of
sources by nuclear physicists in our regarding payment of C1718, iodine- Congress. Moreover, we have
ratesetting policies. We instructed 125, per source and C1720, palladium- considered the GAO’s findings in setting
providers, in Transmittal 132, Change 103, per source. For other sources, the prospective payment rates for sources of
Request 3154, dated March 30, 2004, to commenter recommended that CMS brachytherapy, which we believe is
report charges for the supervision, continue to pay on the basis of charges fully consistent with the provisions of
handling, and loading of radiation reduced to cost. The commenter the MMA.
sources, including brachytherapy believed this was especially important Comment: A few commenters
sources, in one of two ways: report the for HDR iridium, which entails recommended that CMS institute
charge separately using CPT 77790, in particular data challenges in developing mandatory device code edits for
addition to reporting the associated an accurate per treatment or per fraction brachytherapy procedures assigned to
HCPCS procedure code(s) for median cost. APCs 0312, 0313, and 0651, requiring
application of the radiation source; or Response: We recognize that at its the reporting of alphanumeric HCPCS
include the charge as part of the charge August 2006 APC Panel meeting, the codes for brachytherapy sources, which
reported with the HCPCS procedure Panel recommended that CMS continue are always required for the delivery of
code(s) for application of the radiation the current methodology of charges brachytherapy. More generally, the
source. (We further noted in that reduced to cost using the overall commenters stated that they support
transmittal that providers should not hospital CCR for payment of expanding the CY 2007 device edit
bill a separate charge for brachytherapy brachytherapy sources for 1 year (see policy to all device-related APCs. They
source storage costs, which are treated recommendations of the APC Panel at also remarked that the CMS source data
as part of the department’s overhead http://www.cms.hhs.gov/FACA/). The were insufficiently representative of
costs.) Reporting in either of these ways Panel reviewed a letter of comment on actual source costs because many
results in the costs of special handling this issue requesting continuation of the hospitals that charged for brachytherapy
procedures did not include codes and sources in the charges for the prospective payment rate for A9527
charges for sources on the claims for procedures in which they are applied, a based on our CY 2005 claims for C2632.
these procedures, which could not have requirement for reporting of codes for Table 30 in this final rule with comment
been performed without the use of the sources could result in these period contains the median costs of
brachytherapy sources. The commenters hospitals billing token charges, thus brachytherapy sources from CY 2005
asked that CMS require hospitals to bill undermining the correct determination claims data and the HCPCS codes to be
the alphanumeric HCPCS codes for of the unit cost per source. used in CY 2007 to report these devices.
sources as a condition of being paid for As required by the law, we currently
Therefore, we are finalizing our
the brachytherapy procedures that are paying separately for brachytherapy
proposed payment methodology for
cannot be performed without sources, in sources, as we have been for most
sources every year since the beginning brachytherapy sources based upon their
order to promote correct coding and to
of the OPPS in CY 2000. We will be median unit costs from CY 2005 claims
improve the quality of the claims data.
paying for sources separately in CY data for CY 2007 without modification.
The commenter also believed that
hospitals should be educated regarding 2007 as well. Because payments are While this methodology is fully
how to report charges for brachytherapy provided separately for brachytherapy consistent with the statutory
sources used in the outpatient sources reported with specific HCPCS requirement of separate payment for
department. codes, device edits are not needed to brachytherapy sources based on their
Response: Device edits are ensure appropriate payments for number, isotope, and radioactive
appropriate for APCs that have the costs brachytherapy procedures. The intensity, it will also provide hospitals
of the relevant devices packaged into reporting of brachytherapy source with an incentive to operate efficiently
the costs of the procedural APCs. We HCPCS codes is required for hospitals to in providing brachytherapy services to
require device edits for certain APCs in receive payment for brachytherapy Medicare beneficiaries.
order to ensure that charges for the sources, and this should be sufficient Because brachytherapy sources will
required devices are included on the incentive for providers to report no longer be paid on the basis of their
claims, so that payments for device brachytherapy source codes. charges reduced to cost, we proposed to
costs are appropriately packaged into After consideration of the comments discontinue our use of payment status
the payments for the procedures that received, as well as the indicator ‘‘H’’ for APCs assigned to
use the devices. Moreover, we impose recommendations of the APC Panel, the brachytherapy sources. We proposed to
device edits in association with specific PPAC, and the GAO, we have decided use status indicator ‘‘K’’ for all
procedures only when an item is of to base payment for all sources of brachytherapy source APCs for CY 2007.
significant cost whose payment is brachytherapy for which we have CY We also proposed for CY 2007 to change
packaged into the APC payment for the 2005 claims on their median unit costs the definition of status indicator ‘‘K’’ to
procedure. We do not impose claims derived from CY 2005 OPPS claims ensure that ‘‘K’’ appropriately describes
edits for items, such as brachytherapy data. We refer readers to Addendum B brachytherapy source APCs. Payment
sources, that are separately paid and for of this final rule with comment period status indicators are discussed in
which hospitals have a very strong for the CY 2007 national payment rates section XV.A. of the preamble of this
incentive to bill Medicare. Specifically, and copayments for the sources of final rule with comment period.
APCs 0312, 0313, and 0651 do not have brachytherapy. We note that there is a
payment for the costs of brachytherapy new permanent Level II alphanumeric We did not receive any public
sources packaged into the procedural HCPCS codes for iodine-125 comments specific to the proposal to
APC payments. We believe that brachytherapy solution for CY 2007. change the status indicator definitions
hospitals that furnish brachytherapy The new code, A9527, has a long for brachytherapy sources. Therefore,
services either bill us for the sources descriptor, Iodine I–125, sodium iodide we are adopting as final for CY 2007,
separately using their alphanumeric solution, therapeutic, per millicurie, without modification our proposed
HCPCS codes or apparently choose to that describes the same brachytherapy changes to the definitions of status
package the charges for the sources into source as the predecessor C-code, indicators ‘‘H’’ and ‘‘K’’ to address CY
charges for the services in which they C2632, Brachytherapy solution, iodine 2007 brachytherapy source payment.
are applied and not seek separate 125, per mci, for which we are currently Table 30 below provides a complete
payment for the sources. The latter making separate payment under the listing of the HCPCS codes, long
reporting practice would lead to our OPPS. As of January 1, 2007, with the descriptors, APC assignments, median
overestimation of the costs of effective date of HCPCS code A9527, we costs, and status indicators that we will
brachytherapy procedures. In addition, will delete C2632. We will crosswalk use for brachytherapy sources paid
if hospitals include the charges for the claims data and establish the separately under the OPPS in CY 2007.
TABLE 30.—SEPARATELY PAYABLE BRACHYTHERAPY SOURCES FOR CY 2007

CY 2007
CY 2007 CY 2005
HCPCS code Long descriptor status
APC median cost indicator
C1716 ............... Brachytherapy source, Gold 198, per source ...................................................... 1716 $36.61 K
C1717 ............... Brachytherapy source, High Dose Rate Iridium 192, per source ........................ 1717 141.75 K
C1718 ............... Brachytherapy source, Iodine 125, per source .................................................... 1718 36.12 K
C1719 ............... Brachytherapy source, Non-High Dose Rate Iridium 192, per source ................ 1719 23.01 K
C1720 ............... Brachytherapy source, Palladium 103, per source .............................................. 1720 48.53 K
C2616 ............... Brachytherapy source, Yttrium-90, per source .................................................... 2616 10,525.13 K
A9527 (C2632 Iodine I–125, sodium iodide solution, therapeutic, per millicurie ......................... 2632 20.30 K
deleted).
C2633 ............... Brachytherapy source, Cesium-131, per source .................................................. 2633 90.31 K
TABLE 30.—SEPARATELY PAYABLE BRACHYTHERAPY SOURCES FOR CY 2007—Continued

CY 2007
CY 2007 CY 2005
HCPCS code Long descriptor status
APC median cost indicator
C2634 ............... Brachytherapy source, High Activity, Iodine-125, greater than 1.01 mCi (NIST), 2634 32.49 K
per source.
C2635 ............... Brachytherapy source, High Activity, Palladium-103, greater than 2.2 mCi 2635 54.25 K
(NIST), per source.
C2636 ............... Brachytherapy linear source, Palladium-103, per 1MM ....................................... 2636 39.28 K
As indicated in our CY 2007 OPPS provision will expire for the CY 2007 prospective payment rate based on
proposed rule (71 FR 49598), there was OPPS. In addition, this methodology external data provided to us regarding
one source for which we had no claims would be inconsistent with the the expected cost of the source to
data or payment information from the prospective payment methodologies we hospitals. If we were provided reliable
CY 2005 claims data available for the use to provide payments for other new and relevant cost information for the
development of the proposed rule, and items and services under the OPPS for source, we could establish its payment
this statement remains true based on our which we do not yet have claims data. rate based on that information and our
recent analysis of complete CY 2005 A second option was to assign the review of other pertinent
claims data for this final rule with code to its own APC or to a New considerations, as we do for new
comment period. We added Ytterbium- Technology APC with a payment rate technology services under the OPPS.
169 (HCPCS code C2637) for payment set at or near the lowest CY 2007 Under this option, in the absence of
effective October 1, 2005, because it met payment rate for any source of external cost information, we would not
the requirements of section 1833(t)(2)(H) brachytherapy paid on a per source recognize HCPCS code C2637 under the
of the Act as a separate brachytherapy basis (as opposed, for example, to per OPPS for CY 2007 until we received
source. It was our understanding at the mci), for CY 2007. However, we had no such information and could establish a
time of development of the proposed claims data or other information payment rate in a quarterly OPPS
rule that this source, which is for use in regarding the cost of HCPCS code C2637 update. We provided the brachytherapy
HDR brachytherapy, was not yet to hospitals. This payment policy would source Ytterbium-169 a HCPCS code in
marketed by the manufacturer, although resemble our policy regarding the APC CY 2005 at the manufacturer’s request,
it had been approved by the Food and assignment of not otherwise classified based on the belief that the source
Drug Administration (FDA). Therefore, codes, which are assigned to the lowest would be marketed shortly. However,
we had no claims data for this level APC in their clinically compatible the product has not yet been marketed.
brachytherapy source in order to series. However, HCPCS code C2637 is Therefore, we recognize a HCPCS code
develop a prospective payment rate, as a specifically defined brachytherapy for an item that is not currently
we did for the other brachytherapy source, and such a payment rate would available to hospitals. We do not
sources for CY 2007. In addition, it was not recognize the clinical distinctions typically issue and maintain as payable
our understanding that no price for the among brachytherapy sources, including a HCPCS code for an item that is not
product existed, as it had not yet been their differences in isotopes and marketed. Under this option, if the
marketed. Thus, we also had no external radioactive intensities, that are relevant source were marketed mid-quarter in CY
information regarding the cost of this to their clinical uses in low dose rate 2007 and cost information was provided
source to hospitals. We weighed our (LDR) versus HDR brachytherapy. The to us, there would be no payment
payment options for CY 2007 for solid brachytherapy source with the available for the source until the next
brachytherapy sources for which we had lowest final median cost for CY 2007 is OPPS quarterly update, which would
no payment or claims information, such HCPCS code C1719, for non-HDR establish the payment rate for HCPCS
as the present case with Ytterbium-169. Iridium-192, with a median cost of code C2637 and its effective date.
This included considering our CY 2007 $23.01 per source, which is implanted After weighing the above options, we
payment options for other new in LDR brachytherapy. proposed the second option discussed,
brachytherapy sources that come to our A third option was to assign HCPS that is, to assign C2637 to its own APC
attention, which historically have been code C2637 to its own APC or to a New or a New Technology APC with a
newly recognized under the OPPS on a Technology APC with a payment rate payment rate set at or near the lowest
quarterly basis. We discussed these established at or near the proposed proposed payment rate for any source of
payment options in our CY 2007 OPPS payment rate for HCPCS code C1717, brachytherapy paid on a per source
proposed rule (71 FR 49598 and 49599), which describes HDR Iridium-192. Like basis. This option resembled our policy
and they are reviewed below. HCPCS code C2637, HCPCS code C1717 regarding the APC assignment of not
One option for CY 2007 was to pay for is used for HDR brachytherapy, and otherwise classified codes, in the
the currently existing HCPCS code HCPCS code C1717 is the most absence of any data currently available.
C2637 for Ytterbium-169 at charges commonly used source for HDR Once we had claims data, or obtain
converted to cost. However, this would brachytherapy under the OPPS. external data, we could consider
be inconsistent with our final policy However, this approach would not take movement to another APC, if warranted.
with regard to payment for into consideration significant We specifically invited comments on
brachytherapy sources under differences in the two sources, how we should establish the CY 2007
prospectively established payment rates. including their radioactive isotopes and payment amount for Ytterbium-169
The law specifically required us to pay energy levels. (HCPCS code C2637), especially with
for all brachytherapy sources based The fourth option was to assign consideration of the four options
upon charges converted to cost for CYs HCPCS code C2637 to its own APC or discussed above, and on how we should
2004 through 2006. However, that to a New Technology APC with a generally proceed in the future to set
payment amounts for established or new currently available sources, could that commenters provide a detailed
brachytherapy sources eligible for provide payments for new sources that rationale to support recommended new
separate payment under section were too low to permit continued new sources and send recommendations to
1833(t)(2)(H) of the Act, for which we developments in brachytherapy us. We noted that we would continue
have no claims-based cost data. technology. Therefore, after weighing our endeavor to add new brachytherapy
We received a number of public the comments and the four options, we source codes and descriptors to our
comments concerning our four proposed are adopting as final the fourth option systems for payment on a quarterly basis
CY 2007 payment options for discussed for CY 2007. That is, we (71 FR 49599). We specified that such
Ytterbium-169 and/or other new would assign future new HCPCS codes recommendations should be directed to
brachytherapy sources without hospital for new brachytherapy sources to their the Division of Outpatient Care, Mail
costs from claims data. A summary of own APCs, with prospective payment Stop C4–05–17, Centers for Medicare &
the comments and our responses follow. rates set based on our consideration of Medicaid Services, 7500 Security
Comment: A few commenters external data and other relevant Boulevard, Baltimore, MD 21244.
recommended that we pay for information regarding the expected As indicated in the CY 2007 OPPS
ytterbium, and other new or established costs of the sources to hospitals. This proposed rule (71 FR 49599), we had
brachytherapy sources when no hospital approach is consistent with our usual considered the definition of the term
claims data are available, at charges treatment of new technologies under the ‘‘brachytherapy source’’ in the context
reduced to cost, which was generally OPPS. We do not pay for new of current medical practice, and in light
the commenters’ recommendation on technologies, other than pass-through of the language in section 1833(t)(2)(H)
payment for all sources. Several devices, under the OPPS at charges of the Act. We proposed to define a
commenters claimed that ytterbium adjusted to cost. Instead, for new device of brachytherapy eligible for
would be available to hospitals in CY technology services we utilize external separate payment under the OPPS as a
2007. The commenters noted that data and other information available to ‘‘seed or seeds (or radioactive source)’’
ytterbium is an HDR source with unique us, including claims data on related as indicated in section 1833(t)(2)(H) of
characteristics and that, as described in services, to establish appropriate New the Act, which refers to sources that are
its original request to CMS for a HCPCS Technology APC assignments for new themselves radioactive, meaning that
code, ytterbium has a shorter half-life services until we have costs from claims the sources contain a radioactive
than HDR Iridium-192, requiring data specific to the new services. We isotope. Therefore, for example, we
replacement every 32 days versus 90 would not assign a brachytherapy proposed that we would not consider
days for HDR iridium. The commenters source to a New Technology APC specific devices that did not utilize
also noted different shielding and target because such APCs contain only radioactive isotopes to deliver radiation
activity for ytterbium in comparison services, and, according to the statute, to be radioactive sources as envisioned
with HDR iridium. Because there are no by the statute.
we are to establish separate groups for
other sources comparable to ytterbium, We received numerous public
payment of brachytherapy sources
some commenters believed the most comments in response to our request for
reflecting their number, isotope, and
appropriate payment methodology was new brachytherapy source
radioactive intensity. Therefore, when
charges reduced to cost for a minimum recommendations and our proposed
we establish HCPCS codes for new
of 2 years, while CMS collects claims definition of the term ‘‘brachytherapy
brachytherapy sources, we will utilize
data. The commenters believed that sources.’’ A summary of the comments
external data and other information
CMS should similarly employ the and our responses follow.
available to us to establish a prospective Comment: A large number of
payment methodology of charges
payment rate specific to the source, for commenters disagreed with our
reduced to cost for other new sources
when there are no hospital claims data use until we have hospital costs from proposed definition of brachytherapy
available. A number of commenters claims data. Consistent with this sources for separate payment for a
recommended that CMS pay for new practice, although we solicited specific variety of reasons. Several commenters
sources on the basis of charges reduced comments on payment for the ytterbium stated that our definition based on
to cost for a period of 3 years. source in the CY 2007 proposed rule, to section 1833(t)(2)(H) of the Act was too
Reponse: The commenters presented date we have received no cost data and narrow, and should be broadened to
no compelling arguments that new have no other information that we could include new and innovative
sources for which there are no claims use to establish an informed prospective nonradioactive sources, such as
data need to be paid at charges reduced payment rate for the source. Therefore, ‘‘electronic’’ brachytherapy sources. The
to cost. Such an approach is contrary to we are assigning C2637 the nonpayable commenters indicated that
the way we generally pay for other new status indicator ‘‘B’’ for January 1, 2007, brachytherapy sources do not need to be
nonpass-through items and services because we have no claims information radioactive to deliver therapeutic doses
based on prospective payment rates or external cost data that would allow of brachytherapy. They recommended
through their APCs in the OPPS. We us to assign C2637 to its own APC with that CMS consider all new technologies
note that none of the commenters, a prospective payment rate. Should we now FDA-cleared for brachytherapy and
including the manufacturer of later receive relevant information, we broaden our definition for separate
ytterbium, provided the cost of that could establish a payable status payment to include innovative
source when it reportedly will be indicator and appropriate payment rate radioactive and nonradioactive sources.
marketed in CY 2007. However, we for the ytterbium source in a future Many commenters believed that
agree with the commenters that we need OPPS quarterly update. adopting the proposed definition of
to pay appropriately for new In our CY 2007 OPPS proposed rule, brachytherapy sources for separate
brachytherapy sources in order to we again invited the public to submit payment would prevent Medicare
ensure continued developments in the recommendations for new HCPCS codes beneficiary access to care and hamper
technology. We have determined that to describe new brachytherapy sources the development of new cancer
our proposed option, to pay for new in a manner reflecting the number, therapies, such as ‘‘electronic’’
brachytherapy sources based upon the isotope, and radioactive intensity of the brachytherapy. Some commenters
lowest per source payment rate of sources (71 FR 49599). We requested indicated that brachytherapy is not
defined by the type of source used to bisphosphonate, and a device of separate payment, given that the statute
treat the cancer, but by the treatment brachytherapy * * *’’ and cited section also requires separate payment groups
that is delivered to the patient. A few 1833(t)(6) of the Act as authority for that for brachytherapy sources to reflect the
commenters stated that, through definition. The commenters then stated number, isotope, and radioactive
discussions with legislators, it was their that this definition did not require that intensity of the sources. We also remind
understanding that the intent of the a device of brachytherapy consist of a the commenters that payment for
legislation was to provide separate seed or seeds or radioactive sources, as devices under the OPPS, other than
payment for all devices of we proposed, and that section 1833(t)(6) brachytherapy devices and those
brachytherapy and not to exclude any of the Act allegedly clearly indicated devices described by categories with
devices. ‘‘but not limited to,’’ such that this list active pass-through status, is packaged
Reponse: As indicated in the CY 2007 was not exclusionary. Another advocate into the procedural APC payments for
OPPS proposed rule (71 FR 49599) and of creating a new source code for those services in which they are used.
reiterated in this preamble above, we ‘‘electronic’’ brachytherapy, cited Comment: A few commenters
considered the definition of section 1833(t)(2)(B) of the Act, which supported our definition of
‘‘brachytherapy source’’ in the context generally indicated that the Secretary brachytherapy source.
of current medical practice and in may establish groups of services within Reponse: We appreciate the support
regard to the language in section the classification system that are for our proposal.
1833(t)(2)(H) of the Act, which refers to comparable clinically and with respect Comment: Another commenter
brachytherapy sources as ‘‘a seed or to resources. Therefore, the commenters requested a clarification regarding the
seeds (or radioactive source).’’ We believed CMS should be able to group definition of ‘‘source,’’ claiming that the
continue to believe that this provision of ‘‘electronic’’ brachytherapy with other word source leaves unclear whether
the Act mandating separate payment sources, if they are comparable. multiple brachytherapy seeds would
refers to sources that are themselves constitute multiple sources, or, because
Reponse: The commenters miscite the they are all implanted at one time, they
radioactive, meaning that the source
statute, erroneously implying it is part would constitute a single source.
contains a radioactive isotope.
of section 1833(t)(2)(H) of the Act. Reponse: Multiple brachytherapy
Furthermore, the statutory language is
Section 1833(t)(6)(A)(ii) of the Act is the seeds implanted during a single
likewise clear that devices of
source of the commenters’ quote and treatment session constitute multiple
brachytherapy paid for separately must
does not deal with separate payment of sources for billing on the claim to
reflect ‘‘the number, isotope, and
radioactive intensity of such devices brachytherapy sources. Rather, the Medicare. For example, if 50
furnished’.’’ Accordingly, we further context of the quote is pass-through brachytherapy seeds are implanted, a
believe that section 1833(t)(2)(H) of the treatment of cancer therapies current hospital should report on its claim to
Act applies only to radioactive devices when the Balanced Budget Refinement CMS that it used 50 units of the source.
of brachytherapy. Act (Pub. L. 106–113) was enacted. The Comment: Several commenters
We point out that forms of radiation statutory authority mandating separate recommended that CMS establish new
delivery such as nonradioactive groups for payment discussed above is HCPCS codes and descriptors for
brachytherapy, which was used by based on section 1833(t)(2)(H) of the separate payment of additional
commenters as the principal example of Act. Specifically, section 1833(t)(2)(H) brachytherapy sources. Specifically,
other forms of brachytherapy, do not of the Act clearly states: ‘‘With respect several commenters recommended that
constitute a brachytherapy source as to devices of brachytherapy consisting CMS establish new codes for stranded
contemplated by the statute. In addition of a seed or seeds (or radioactive sources, namely Iodine-125, Palladium-
to not containing a radioactive isotope, source), the Secretary shall create 103, RAPID Strand Iodine-125 (a brand
these forms of radiation delivery are additional groups of covered OPD of iodine-125), and cesium-131 sources
dependent on external equipment to services that classify such in CY 2007. Possible new codes and
deliver therapeutic radiation to the [brachytherapy] devices separately from descriptors suggested for two of the
treatment sites within the body. the other services * * * in a manner stranded sources were: C26xx,
Therefore, we will not consider reflecting the number, isotope, and Brachytherapy device, Stranded Iodine-
specific devices, beams of radiation, or radioactive intensity of such devices 125, per source; and C26xx,
equipment that do not constitute furnished * * *.’’ We believe that Brachytherapy device, Stranded
separate sources that utilize radioactive Congress clearly limited any Palladium-103, per source. One
isotopes to deliver radiation to be requirement for separate payment of commenter recommended that CMS
brachytherapy sources for separate brachytherapy sources to those which create a new source code for separate
payment, as such items do not meet the reflect the number, isotope, and payment based on its product name:
statutory requirements provided in radioactive intensity of the sources and C26xx, Brachytherapy device, RAPID
section 1833(t)(2)(H) of the Act. to a ‘‘seed or seeds (or radioactive Strand Iodine-125, per source.
Comment: A few commenters claimed source)’’ as stated in section A few commenters recommended that
that section 1833(t)(2)(H) of the statute 1833(t)(2)(H) of the Act. Furthermore, CMS establish a new source code for
does not limit CMS to consider as new while section 1833(t)(2)(B) of the Act separate payment as follows:
brachytherapy sources seeds or provides the authority to create new Brachytherapy device, Stranded
radioactive sources that are themselves APCs to group similar services together Cesium-131, per source. The
radioactive. Some commenters cited or distinguish new and/or different commenters described stranded
section 1833(t)(2)(H) of the Act, while services to group together in terms of brachytherapy sources as embedded
others defined current cancer therapies clinical characteristics and resource into the stranded suture material and
as ‘‘a drug or biological that is used in costs, it must be read in conjunction separated within the strand by material
cancer therapy, including (but not with the requirements given in section of an absorbable nature at specified
limited to) a chemotherapeutic agent, an 1833(t)(2)(H) of the Act. We do not intervals. They claimed that this
antiemetic, a hematopoietic growth believe that nonradioactive devices that approach ensured the initial and long-
factor, a colony stimulating factor, a deliver radiation are appropriately term position of each source when
biological response modifier, a grouped with brachytherapy sources for implanted in and around tumors. The
commenters claimed that stranded separate, measurement, per millimeter, separate payment under section
sources were different from as opposed to per source (that is, seed). 1833(t)(2)(H) of the Act as previously
‘‘traditional’’ sources in a number of We agree that it is probable that indicated in our discussion of the
ways, such as improved patient safety thousands of Medicare patients received definition of brachytherapy sources
and clinical outcomes in the treatment stranded iodine and palladium in CY eligible for separate payment. Consistent
of prostate cancer; increased production 2006, and further agree that stranded with our discussion of the definition of
costs; requirements for separate FDA iodine and palladium are likely well- a brachytherapy source, we are not
clearances; and potential for permitting represented in our historical claims creating a new brachytherapy source
greater radioactive intensity for data, such that stranded source costs code for separate payment for
treatment of specific patients because of and utilization are reflected in the ‘‘electronic’’ brachytherapy.
their more precise positioning. The source codes for iodine and palladium, Comment: One commenter, the
commenters further claimed that C1718 and C1720, respectively. manufacturer of the Intrabeam system,
stranded sources could be placed at the Therefore, their use should be well- recommended that CMS designate the
periphery of the prostate or outside the represented in the respective median radiation source used in the Intrabeam
prostate gland, permitting treatment of costs for these C-codes in our CY 2005 procedure as a brachytherapy device
extra-prostatic extension of cancer data used to establish CY 2007 payment and provide separate payment for the
without the potential for migration into rates. The GAO drew similar source. The commenter claimed the
another body organ. The commenters conclusions in its study of radiation from the Intrabeam system is
also pointed out that CMS has brachytherapy source purchase prices, delivered directly into a tumor cavity,
separately coded differences in where they believed that their purchase and therefore, by definition, is a form of
configurations of previously established price data reflected information across brachytherapy. The commenter also
isotopes among brachytherapy source the full spectrum of brachytherapy claimed that the Intrabeam radiation
codes (that is, linear palladium-103 is source configurations provided by source is a point source that is similar
separately coded as C2636). Some hospitals during the study period. to other brachytherapy sources, such as
commenters claimed that thousands of Neither the GAO data nor the CY 2005 seeds or pellets. The commenter stated
Medicare patients received stranded Medicare claims data reflect significant that the wording of section 1833(t)(2)(H)
iodine and palladium in CY 2006, variation in the hospital costs of iodine of the Act, ‘‘with respect to devices of
whose specific costs would not have and palladium sources. Our preferred brachytherapy consisting of a seed or
been reflected through separate codes treatment of iodine, palladium, and seeds (or radioactive source), the
for these source variants. cesium sources is consistent with our Secretary shall create additional groups
general expectation that, as technology of services * * *’’ to establish separate
Some commenters asserted that the
evolves and grows in utilization, the brachytherapy source payment would
lack of separate coding results in no
costs of the newer technologies will include the Intrabeam brachytherapy
separate data on the clinical practice for
increasingly be reflected in the claims source within that definition of a
stranded sources. They claimed that
data used to establish prospective source. The commenter argued that the
CMS’ CY 2005 data do not reflect
payment rates for future services. temporarily activated gold of the
important new clinical protocols that Accordingly, we are not creating new Intrabeam system is a radioactive source
have emerged over the past few years, brachytherapy source codes for separate as described in the statute. The
which have resulted in increased payment for stranded iodine-125, commenter claimed that the statutory
clinical use of stranded and ‘‘custom- stranded palladium-103, RAPID Strand language does not limit brachytherapy
stranded’’ sources for the treatment of Iodine-125, or stranded cesium-131 sources to only radioactive isotopes, as
prostate cancer. The commenters sources. is evidenced by the more general
indicated that absence of data Comment: A number of commenters language ‘‘or radioactive source.’’
concerning stranded brachytherapy recommended that CMS establish a new Response: Based on the commenter’s
sources was a significant flaw in CMS’ brachytherapy source code and description, the Intrabeam system relies
current data because stranded sources descriptor for ‘‘electronic’’ upon a miniature x-ray source, where
were distinct from traditional brachytherapy, effective January 1, electron beams travel to strike a gold
brachytherapy sources. 2007, with the following recommended target and x-rays are then emitted to
Reponse: Section 1833(t)(2)(H) of the code descriptor: C26xx, Brachytherapy treat the tissue surrounding a tumor
Act requires the creation of separate device, High Dose Rate X-ray radiation, cavity. The Intrabeam procedure uses
APC groups for brachytherapy sources per source. The commenters made no external equipment to generate the
that reflect the number, isotope, and recommendation on how to define ‘‘per electron beam, and the gold target is not
radioactive intensity of the source.’’ The commenters stated that itself a radioactive isotope used to
brachytherapy devices (sources) technological advances demonstrate that provide radiation treatment. As noted
furnished. Stranding of existing sources nonradioactive sources can deliver a previously, such forms of brachytherapy
of a certain isotope, such as iodine or therapeutic radiation dose similar to a do not constitute a brachytherapy
palladium, is a specific clinical radioactive source or seed. They source as contemplated by the statute.
configuration that does not affect the claimed that brachytherapy treatment In addition to not containing a
number, isotope, and radioactive does not define the type of source; radioactive isotope, such forms of
intensity of the brachytherapy sources, instead, it defines a type of treatment radiation delivery are dependent on
and thus would not lead to a separate and there may be many kinds of sources external equipment to deliver
APC grouping. While we created a new used in such treatments. therapeutic radiation to the treatment
source code, C2636, linear palladium- Response: We agree that sites within the body. The statute
103, per 1 mm, even though a code nonradioactive sources may be capable requires us to establish separate
already existed for palladium-103 of delivering a therapeutic radiation payment groups for brachytherapy
(C1720), we determined that the linear dose similar to a radioactive source or sources that classify them separately
palladium source led to a change in the seed. However, we believe that based on their number, isotope, and
number of sources used, because it nonradioactive sources do not meet the radioactive intensity. We do not believe
required a different, and therefore definition of brachytherapy sources for the concept of an isotope applies to the
Intrabeam system. Therefore, we are not codes allowed for more specific preview of CPT drug administration
creating a new brachytherapy source reporting of services, especially coding guidelines developed by the CPT
code for separate payment for the regarding the number of hours for an Editorial Panel, in the hospital
radiation source used in the Intrabeam infusion, and provided consistency in community of the multiple implications
system. coding between Medicare and other associated with adopting the newly
After carefully considering the public payers. However, we did not have any introduced CPT concepts of initial,
comments received, we are not data to revise the CY 2005 per-visit APC sequential, and concurrent services.
accepting any of the recommendations payment structure for infusion services. Upon review of the completed
provided above by commenters for the In order to collect data for future revisions to our proposed CY 2006
establishment of new HCPCS codes to ratesetting purposes, we implemented methodology, and following a
describe new brachytherapy sources for claims processing logic that collapsed comprehensive assessment of all public
CY 2007. However, consistent with our payments for drug administration comments, we implemented 20 of the 33
general practice, we will consider services and paid a single APC amount CY 2006 drug administration CPT codes
recommendations submitted by the for those services for each visit, unless that did not reflect the concepts of
public for new brachytherapy sources a modifier was used to identify drug initial, sequential, and concurrent
during CY 2007, as discussed earlier. In administration services provided in a services, and we created six new HCPCS
addition, we are adopting as final our separate encounter on the same day. C-codes that generally paralleled the CY
proposed definition of the term Hospitals were instructed to bill all 2005 CPT codes for the same services.
‘‘brachytherapy source’’ without applicable CPT codes for drug We chose not to implement the full set
modification. administration services provided in a of CY 2006 CPT codes because of our
hospital outpatient department, without concerns regarding the interface
VIII. Changes to OPPS Drug regard to whether or not the CPT code between the complex claims processing
Administration Coding and Payment would receive a separate APC payment logic required for correct payments and
for CY 2007 during OPPS claims processing. hospitals’ challenges in correctly coding
A. Background While hospitals were just adopting their claims to receive accurate
CPT codes for outpatient drug payments for these services. In addition,
From the start of the OPPS until the administration services in CY 2005, numerous commenters indicated that
end of CY 2004, three HCPCS codes physicians paid under the MPFS were implementing certain CPT codes in a
were used to bill drug administration using HCPCS G-codes in CY 2005 to fashion consistent with the code
services provided in the hospital report office-based drug administration descriptors would present hospitals
outpatient department: services. These G-codes were developed with difficult operational and
• Q0081 (Infusion therapy, using in anticipation of substantial revisions administrative challenges, because
other than chemotherapeutic drugs, per to the drug administration CPT codes by concepts integral to the codes were
visit) the CPT Editorial Panel that were inconsistent with the clinical patterns of
• Q0083 (Chemotherapy expected for CY 2006. drug administration services provided
administration by other than infusion In CY 2006, as anticipated, the CPT in hospital outpatient departments. In
technique only, per visit) Editorial Panel revised its coding addition to coding changes, CY 2006
• Q0084 (Chemotherapy structure for drug administration payment rates for drug administration
administration by infusion technique services, incorporating new concepts services were updated based upon CY
only, per visit). such as initial, sequential, and 2004 claims, and we continued the
A fourth OPPS drug administration concurrent services into a structure that claims processing logic that required
HCPCS code, Q0085 (Administration of previously distinguished services based hospitals providing drug administration
chemotherapy by both infusion and on type of administration services to report all applicable drug
another route, per visit), was active from (chemotherapy/nonchemotherapy), administration HCPCS codes, despite
the beginning of the OPPS through the method of administration (injection/ some codes being collapsed into one
end of CY 2003. infusion/push), and for infusion APC for payment purposes.
Each of these four HCPCS codes services, first hour and additional hours.
mapped to an APC (that is, Q0081 For CY 2006, we proposed a crosswalk B. CY 2007 Drug Administration Coding
mapped to APC 0120, Q0083 mapped to that mapped the expected CY 2006 CPT Changes
APC 0116, Q0084 mapped to APC 0117, codes (represented by CY 2005 G-codes In the CY 2007 OPPS proposed rule,
and Q0085 mapped to APC 0118), and used in the physician office setting, the we proposed to continue the CY 2006
the APC payment rates for these codes closest proxy at the time) to the APC OPPS drug administration coding
were made on a per-visit basis. The per- payment structure implemented in CY structure, which combined CPT codes
visit payment included payment for all 2005. Our crosswalk was reviewed by with several alphanumeric HCPCS C-
hospital resources (except separately the APC Panel at both the February and codes. However, we solicited comments
payable drugs) associated with the drug August 2005 meetings, and was from hospitals regarding their
administration procedures. For CY included in the CY 2006 OPPS proposed experiences in implementing, for
2004, we discontinued using HCPCS rule. During the proposed rule comment purposes of reporting to other payers,
code Q0085 to identify drug period, we received a number of the CY 2006 CPT codes reflecting the
administration services and moved to a comments that prompted several concepts of initial, sequential, and
combination of HCPCS codes Q0083 revisions to our proposed crosswalk, concurrent services.
and Q0084 that allowed more accurate including the development of complex Due to the discrepancies between
calculations when determining OPPS claims processing logic to assign correct APC payments (based on per-visit
payment rates. payment for certain drug administration hospital claims data) and per-service
In CY 2005, in response to the services that would vary based on other CPT/HCPCS coding in CY 2005 and CY
recommendations made by commenters drug administration services provided 2006, we provided special instructions
and the hospital industry, OPPS during the same patient visit. These to hospitals regarding the appropriate
transitioned to the use of CPT codes for revisions were a result of the growing use of modifier 59 in relation to OPPS
drug administration services. These CPT understanding, facilitated by the drug administration services in order to
ensure proper OPPS payments and applicable CPT guidelines. received on the CY 2007 OPPS proposed
consistent with our claims processing However, even those commenters rule, we have decided to adopt the full
logic. As the need no longer existed, for favoring adoption of the full set of drug set of CPT codes for CY 2007 for use
CY 2007 we proposed to instruct administration CPT codes under OPPS. Therefore, we are
hospitals to apply modifier 59 to drug acknowledged that some outstanding accepting the August 2006
administration services using the same questions remain regarding billing recommendation of the APC Panel to
correct coding principles that they scenarios using the CPT codes, and they use only CPT codes for the reporting of
generally use for other OPPS services. requested additional guidance from drug administration services in the CY
At its August 2006 meeting, the APC CMS on these issues. Nevertheless, 2007 OPPS. Table 31 lists the
Panel recommended that CMS recognize commenters were overwhelmingly in alphanumeric HCPCS codes that were
only the AMA’s CPT codes for favor of reporting the same codes to all created to replace the CPT codes
outpatient hospital reporting of drug payers. reflecting the concepts of initial,
administration services in CY 2007. We Response: In the CY 2006 OPPS final sequential, and concurrent, that are
discuss our response to this rule with comment period (70 FR deleted effective December 31, 2006.
recommendation along with our 68679), we indicated that we decided
response to comments presented below. not to recognize 13 of the 33 CPT drug TABLE 31.—DRUG ADMINISTRATION C-
We received numerous comments administration codes in an effort to CODES THAT WILL NO LONGER BE
from individual hospitals, health minimize the administrative and REPORTABLE UNDER THE OPPS IN
systems, university medical centers, operational burden hospitals would CY 2007
physicians, community cancer centers, have reportedly faced if we had adopted
pharmaceutical companies, specialty all 33 of the CY 2006 drug HCPCS
societies, and various healthcare administration CPT codes. In particular, Long description
Code
associations, on our proposal to many hospitals expressed concern
continue with the existing CY 2006 regarding significant administrative C8950 ...... Intravenous infusion for therapy/
OPPS drug administration coding problems in implementing the subset of diagnosis; up to 1 hour.
structure for CY 2007, which combined CY 2006 CPT drug administration codes C8951 ...... Intravenous infusion for therapy/
CPT codes with several C-codes, as well diagnosis; each additional
that incorporated the concepts of initial, hour (List separately in addi-
as comments on the use of the CPT sequential, and concurrent. At that time, tion to C8950).
codes. a substantial number of commenters C8952 ...... Therapeutic, prophylactic or di-
Comment: A few commenters requested that, if CMS were to agnostic injection; intravenous
requested that CMS continue with the implement the full set of CY 2006 CPT push of each new substance/
current CY 2006 coding scheme of using codes in the hospital outpatient setting, drug.
CPT and C-codes for CY 2007, while in order for the codes to be applicable C8953 ...... Chemotherapy administration,
many others requested that CMS use the to the hospital setting, CMS would need intravenous; push technique.
CPT codes. The commenters supportive to direct hospitals to disregard elements C8954 ...... Chemotherapy administration,
of our CY 2007 proposal indicated that intravenous; infusion tech-
of the code descriptors. As it is not our
the CY 2006 CPT drug administration nique, up to one hour.
practice to alter CPT codes in order to C8955 ...... Chemotherapy administration,
codes were not applicable in the apply them to a particular site of intravenous; infusion tech-
hospital setting because these codes service, we decided not to implement nique, each additional hour
were created specifically for physician the full set of CPT codes at that time. (List separately in addition to
use. Several commenters urged CMS to Instead, we developed alphanumeric C8954).
work with the CPT Editorial Panel and HCPCS C-codes for the hospital setting
others to make revisions to the existing to replace those CY 2006 CPT drug Comment: We received a few
CPT codes so they are more reflective of administration codes with the comments requesting that we retain
hospital services. problematic concepts of initial, HCPCS code C8957 (Intravenous
Overall, the vast majority of sequential, and concurrent. infusion for therapy/diagnosis;
commenters requested that CMS adopt During CY 2006, we received initiation of prolonged infusion (more
the full set of CPT codes for drug anecdotal information related to than 8 hours), requiring the use of
administration services in CY 2007, as hospitals’ experience implementing the portable or implantable pump), if we
many hospitals have been using these full set of CY 2006 CPT codes for non- finalize a policy to transition to the full
codes for non-Medicare payers for the Medicare payers. While yet another set of CPT codes for CY 2007. These
past year. Several commenters indicated transition to new drug administration commenters expressed appreciation for
that the use of the CPT codes would codes was frustrating, these CMS’ development of the Level II
reduce hospital’s current operational commenters, like commenters HCPCS code, as there is currently no
burden related to charging different responding to our CY 2007 proposed CPT code that describes this service.
payers with different code sets, rule request for information, noted that Response: We appreciate the support
including the burden of maintaining the operational issues were no longer a of commenters in the development of
two very different sets of codes for primary concern with drug this code, and we agree that there is no
essentially the same services. They administration coding, and they had comparable CPT code for this service.
added that OPPS use of the full set of gained valuable experience over the past As such, we are retaining HCPCS code
CPT codes would also promote year reporting these codes to non- C8957 for use in the CY 2007 OPPS
consistency and transparency across Medicare payers. Instead, their concern because there is no comparable CPT
sites of service and payment systems. was the time, effort, and administrative code available to report this service.
The commenters also noted that, costs associated with maintaining two Table 32 lists drug administration
contrary to last year’s substantial code sets for one group of services. HCPCS codes, associated status
concerns regarding the operational After considering the indicators, and CY 2007 APC
aspects of implementing these codes, recommendation of the APC Panel assignments, where applicable, for CPT
they have now adopted the full CPT discussed above, and after carefully codes that will be newly recognized
code set, including full code descriptors considering all the public comments under the OPPS for reporting drug
administration services provided in hospital outpatient departments on or

after January 1, 2007.
TABLE 32.—CY 2007 NEWLY RECOGNIZED DRUG ADMINISTRATION CPT CODES*

2007 CPT 2007 CY 07
2007 description
code APC SI
90760 ....... Intravenous Infusion, hydration; initial, up to one hour ......................................................................................... 0440 S
90761 ....... Intravenous Infusion, hydration; each additional hour (list separately in addition to code for primary proce- 0437 S
dure).
90765 ....... Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); initial, up to one 0440 S
hour.
90766 ....... Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); each additional hour 0437 S
(List separately in addition to code for primary procedure).
90767 ....... Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); additional sequential 0437 S
infusion, up to 1 hour (List separately in addition to code for primary procedure).
90768 ....... Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); concurrent infusion — N
(List separately in addition to code for primary procedure).
90774 ....... Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or ini- 0438 S
tial substance/drug.
90775 ....... Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intra- 0438 S
venous push of a new substance/drug (List separately in addition to code for primary procedure).
96409 ....... Chemotherapy administration; intravenous, push technique, single or initial substance/drug ............................. 0439 S
96411 ....... Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately 0439 S
in addition to code for primary procedure).
96413 ....... Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug ... 0441 S
96415 ....... Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addi- 0438 S
tion to code for primary procedure).
96417 ....... Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different 0438 S
substance/drug), up to 1 hour.
* Current Procedural Terminology (CPT) codes and descriptors are copyrighted by the American Medical Association (AMA).
For CY 2007, we reiterate our CY 2006 hyperimmune IVIG, and DNA- or RNA- same day as a procedure that includes
final rule statement reminding hospitals based therapies. Specifically, the a drug administration service.
that they are expected to report all drug commenters requested that CMS Response: We continue to believe that
administration CPT codes in a manner identify these items as biological CCI edits for drug administration
consistent with their descriptors, CPT response modifiers and instruct services are appropriate for the hospital
instructions, and correct coding hospitals to report chemotherapy outpatient department setting. We refer
principles. As we have done in the past, administration codes for these services commenters with questions and
we will release instructions separately in recognition of the significant concerns related to particular CCI edits
from this final rule with comment resources incurred by hospitals that to the National Correct Coding Initiative
period that will provide additional provide them. Policy Manual for Medicare Services at
OPPS-specific guidance for hospital Response: CPT instructions for the CY http://www.cms.hhs.gov/
outpatient departments providing drug 2006 CPT code set included a statement NationalCorrectCodInitEd/.
administration services in CY 2007. that chemotherapy administration codes
C. CY 2007 Drug Administration
Comment: A few commenters are appropriate for chemotherapy
Payment Changes
requested that, if CMS implement the services but also apply to ‘‘parenteral
full set of CPT codes, CMS should also administration of non-radionuclide anti- Prior to CY 2005, hospitals were
provide hospitals with specific neoplastic drugs; and also to anti- reporting per-day drug administration
instructions on how to bill for CPT neoplastic agents provided for treatment codes under the OPPS. These codes did
codes 90761, 90766, and 96415, as their of noncancer diagnoses (for example, not distinguish between the number of
CY 2006 code descriptors included a cyclophosphamide for auto-immune services, types of service, or duration of
statement that they were to be billed for conditions) or to substances such as services provided. Hospitals received
each hour ‘‘up to 8 hours’’ or ‘‘1 to 8 monocolonal antibody agents, and other per-day APC payments for
hours.’’ The commenters requested biologic response modifiers.’’ As is our chemotherapy infusions, non-
OPPS billing instructions in the event longstanding practice, we defer chemotherapy infusions, and
that infusions reported with these codes questions about CPT code definitions to chemotherapy other than infusion. With
lasted longer than 8 hours. the AMA CPT Editorial Panel as they the implementation of CPT codes in CY
Response: As indicated in Table 32, are the creators and maintainers of the 2005, hospitals began reporting separate
the CPT Editorial Panel has removed the CPT code set. codes and associated charges for many
reference to ‘‘up to 8 hours’’ and ‘‘1 to Comment: Several commenters drug administration services for
8 hour’’ in the code descriptors for these requested that CMS remove various purposes of the OPPS. The CY 2007
three infusion service for CY 2007. National Correct Coding Initiative (CCI) update process offered us the first
Therefore, we do not believe any edits related to drug administration opportunity to consider this data for
additional guidance is required for codes. These commenters expressed purposes of ratesetting.
hospitals at this time. frustration about the increased For the CY 2007 proposed rule, we
Comment: Several commenters administrative burden associated with explained that we expected codes for
requested additional instructions identifying separate instances of drug additional hours of infusion to be
regarding the administration of IVIG, administration services provided on the reported with codes for the first hour of
infusion. This would result in a drug administration claims data for costs to multiple different services due
substantial set of claims that were purposes of calculating these proposed to the limitations of our claims data. In
unusable for ratesetting purposes APC median costs. the proposed rule, we indicated that we
because multiple services would be As we explained in the CY 2007 believed this proposed methodology
present on the same bill. (See section proposed rule, bypassing these three took into account all of the packaging on
II.A. of this preamble for a further CPT codes and developing additional claims for drug administration services
discussion of multiple bills and our ‘‘per unit’’ claims provided a and provided a reasonable framework
ratesetting methodology). In order to use methodology to calculate median costs for developing median costs for drug
these claims, we explained our process for these previously packaged drug administration services that were often
of adding three CY 2005 drug administration services and to attribute provided in combination with one
administration CPT codes 90781 all of their cost data to their assigned another.
(Intravenous infusion for therapy/ APCs. However, this methodology After calculating HCPCS code median
diagnosis, administered by physician or allocates all packaging on the claim costs for all drug administration
under direct supervision of physician; related to drug administration to the services, including injections and
each additional hour, up to eight (8) associated first hour drug antigen therapy services, we created a
hours); 96412 (Chemotherapy administration code. Because these comprehensive set of new APC
administration, intravenous; infusion additional hours of infusion codes were groupings of CY 2005 HCPCS codes for
technique, one to 8 hours, each always reported with other drug drug administration services and based
additional hour); and 96423 administration services, we expected our assignments upon hospital
(Chemotherapy administration, intra- that the packaging related to additional resources utilized as reflected in HCPCS
arterial; infusion technique, one to 8 hours of infusion would be code median costs and clinical
hours, each additional hour) to the appropriately assigned to the drug coherence. The result of this analysis
bypass list in the CY 2007 proposed rule administration services on the same was the development of six proposed
in order to create ‘‘pseudo’’ single claim. While we stated our belief that drug administration APC levels based
claims that would be useable for OPPS there are some packaged costs that are on CY 2005 claims data for the CY 2007
ratesetting purposes. After creation of clinically related to the second and OPPS. The proposed structure was
these ‘‘pseudo’’ single claims, we subsequent hours of infusion, especially displayed in Table 30–1 of the CY 2007
applied the standard OPPS methodology for infusions of packaged drugs OPPS proposed rule, and a refined table,
to calculate HCPCS median costs for spanning several hours, we were not reflective of the complete updated CY
these three drug administration codes able for purposes of the CY 2007 2005 hospital claims data, is shown
and mapped their respective data to the proposed rule to accurately assign below in Table 33.
APCs to which we assigned CY 2005 representative portions of packaged BILLING CODE 4120–01–P
BILLING CODE 4120–01–C In the proposed rule, we noted that drug administration HCPCS codes into
proposed placement of the CY 2005 the six APC levels followed logical,
ER24NO06.021</GPH>
clinically coherent principles, and was administration services at its August We identified CY 2005 single claims
consistent with both expected and 2006 meeting in addition to the (including ‘‘pseudo’’ single claims
observed differences in hospital recommendation, discussed above, that derived from the process detailed in
resource costs, both across levels and CMS adopt the full set of CPT drug section II.A.1. of this preamble) for drug
within each level. For example, the first administration codes for CY 2007 OPPS administration services. We used all
hour of chemotherapy infusion was purposes. First, the Panel recommended active CY 2005 drug administration
assigned to Level VI, while additional that if CMS does not recognize only the codes, but excluded the additional hour
hours of chemotherapy infusion were AMA CPT codes for drug administration infusion codes (as these hours were not
assigned to Level III. This structure was services for CY 2007, CMS should allow separately payable in CY 2005). In
mirrored by the nonchemotherapy codes hospitals to separately bill and receive addition, their treatment as codes on the
that showed the first hour of payments for therapeutic infusions and bypass list results in no packaging being
nonchemotherapy infusion assigned to hydration infusions provided in the attributed to their ‘‘pseudo’’ single
Level V, while additional hours of same encounter. We do not believe that claims. Correct coding results in their
nonchemotherapy infusion were a response to this recommendation is claims always being multiple claims, so
assigned to Level II. required, as we have adopted the full set we have no correctly coded natural
Using this structure as a base, we of CPT codes for CY 2007, as discussed single claims for these procedures.
assigned the CY 2006 OPPS drug above. Second, the Panel recommended We identified 16 separate revenue
administration codes to the six-level that CMS make payment for a second or codes where we expected hospitals
APC structure based on their clinical subsequent intravenous push of the would associate packaged drugs—
and expected hospital resource same drug by instituting a modifier, namely, those revenue codes that are in
characteristics. This general structure developing a new HCPCS code for the the 250 series (Pharmacy), 260 series (IV
was presented to the APC Panel during procedure, or implementing another Therapy) and 630 series (Drugs Require
the March 2006 meeting and was our methodology in CY 2007. We discuss Specific ID). We assumed that, for
proposed structure for CY 2007. The this recommendation along with purposes of this analysis, packaged drug
Panel recommended using the bypass comments on this issue in further detail costs were included on claims with
methodology as described above for the below. Third, the Panel recommended revenue codes listed above or with a
three additional hours of infusion codes that CMS provide payment for all drug HCPCS code that in CY 2005 was
to develop their median costs and intravenous pushes and therapeutic assigned status indicator ‘‘N.’’ We also
supported separate payment for each injections for pain management and assumed that hospitals reported the
additional hour of infusion for CY 2007. other clinical conditions, regardless of charges for the packaged drugs on the
In the proposed rule, we accepted the the setting (for example, post-operative same claim on which they reported the
APC Panel’s recommendation for CY anesthesia care unit, cardiac drug administration code, with the same
2007 to use the proposed structure with catheterization laboratory). Again, we date of service.
the bypass and ‘‘per unit’’ methodology discuss this issue in greater detail We calculated both the median and
as described above as it established a below. Finally, the Panel recommended mean percentages on these single and
drug administration payment structure that CMS provide claims analyses of the ‘‘pseudo’’ single claims for: (1) All
that included a methodology to pay for contribution of packaged costs packaged costs (drug or not); and (2) the
infusion services by the hour. (considering packaged drugs and other subset of packaged drug/pharmacy costs
Hospitals’ cooperation during CY packaging) to the median cost of each (defined as a code for either a drug
2005 in reporting all drug drug administration service. revenue code cost or a packaged drug
administration services, whether or not During the March and August 2006 HCPCS code). We calculated the median
separate payments were made for all meetings of the APC Panel, the Panel costs by calculating the percentages for
such services, allowed us to develop recommended that we provide each single bill (including ‘‘pseudo’’
robust median costs for individual additional information specific to the singles), arraying them, and calculating
services so that we had sufficient costs of packaged items that are the 50th percentile of the array. We
information to propose this more represented in drug administration APC calculated the mean costs by summing
specific APC payment structure for drug rates. Specifically, the Panel the packaged costs of each type for the
administration services for CY 2007. In recommended that: code and dividing each by the sum of
the proposed rule, we indicated that we • CMS provide the Panel with data all total costs for the code.
believed that this structure would make that indicate the costs of packaged drugs Our initial analysis indicates that, for
appropriate payments for the hospital that are incorporated into drug the highest volume drug administration
resources required to provide drug administration payment rates (March codes, there is a significant amount of
administration services, as we had large 2006). drug packaging costs on their claims
numbers of claims for many specific • CMS provide claims analysis of the that are used for ratesetting. For
drug administration services that contributions of packaged costs example, CPT code 90780 for the first
revealed significant and differential (considering packaged drugs and other hour of nonchemotherapy intravenous
costs. In particular, we noted that using packaging) to the median cost of each infusion has a median of 27 percent of
the six-level APC structure should allow drug administration service (August packaging of any type and a median of
us to make more accurate payments to 2006). 15 percent of drug/pharmacy packaging,
hospitals for complex and lengthy drug We have performed a preliminary showing clearly that the cost of
administration services furnished to analysis on a subset of CY 2005 claims packaged drugs is reflected in the
Medicare beneficiaries for many data (the data that was used in median for the code. Its respective mean
medical conditions, while also preparation for the CY 2007 proposed amounts are 30 percent and 22 percent.
providing accurate payments for rule). We intend to provide a more Similarly, for CPT code 6410, used to
individual services when they were complete analysis based on CY 2005 report the first hour of chemotherapy
provided alone. final rule data to the APC Panel during intravenous infusion, the median
The APC Panel made a number of its next meeting; this preliminary amount of packaging of any type is 21
additional recommendations regarding analysis only serves as a brief summary percent, and the median amount of
payment for CY 2007 OPPS drug of our initial findings. drug/pharmacy packaging is 13 percent.
Its mean amounts are 27 percent and 20 Response: We appreciate the 96450 to higher paying APCs, create a
percent respectively. The findings are commenters’ support for our proposal to new APC group with a significantly
also similar for CPT code 96422 for the pay for drug administration services higher payment rate for them, or
first hour of an intra-arterial through a six-level APC structure for CY instruct providers to report both the
chemotherapy infusion. Its median 2007, with separate payment to be surgical procedures and the related drug
amount of packaging is 51 percent, and provided for each hour of drug infusion. administration codes as separate line
the median amount of drug/pharmacy We remind commenters that our APC items for the single service.
packaging is 34 percent. rates are based upon median costs Response: We will not instruct
We expect to replicate this study calculated from historical hospital hospitals to report CPT codes in a
using final rule data for presentation to claims, and hospitals reporting multiple manner that is inconsistent with their
the APC Panel at its first meeting in CY hours of infusion service were code descriptors, such as would be the
2007 and to present our results in more instructed to report the costs for these case if we asked hospitals to separately
detail. However, we believe that these hours beginning in CY 2005. report the minor surgical procedures
findings demonstrate that the costs of Comment: Several commenters required to administer the
packaged drugs are reflected in the expressed their concerns regarding the chemotherapy services, when those
payment for the services with which low proposed payment rates for three puncture procedures are included in
they are furnished, contributing chemotherapy administration codes these drug administration code
significant costs to establishment of the described by CPT codes 96440 descriptors. We also note that the final
ultimate drug administration services (Chemotherapy administration into median costs for these procedures are
payment rates. We note that in many pleural cavity, requiring and including $160.03 for CPT code 96450 based on
cases in which drug administration thoracentesis); 96445 (Chemotherapy 394 single claims, $37.12 for CPT code
codes are billed, Medicare also pays for administration into peritoneal cavity, 96440 based upon 38 single claims, and
separately paid drugs at ASP+6 percent. requiring and including $61.98 for CPT code 96445 based upon
Therefore, the total payment for the peritoneocentesis); and 96450 43 single claims are related to the
drugs administered in an encounter is (Chemotherapy administration, into median costs of their proposed APCs.
the sum of payment for separately paid CNS (e.g., intrathecal), requiring and We carefully reviewed all the comments
drugs and the portion of the APC including spinal puncture). In received and our CY 2005 claims data,
payment for drug administration particular, commenters disagreed with in the context of the clinical
services that reflects the packaged costs our proposed APC assignments for CPT characteristics of these three services, as
of drugs/pharmacy. As mentioned codes 96440 and 96445 to APC 0439 well as considered the low volume of
above, we intend to present this study, (Level IV Drug Administration), which claims for their single year of hospital
with updated data, to the APC Panel at had a proposed payment rate of $97.50, cost data.
the next Panel meeting. Therefore, we and CPT code 96450 to APC 0441 (Level As we proposed, we continue to
are specifically requesting feedback VI Drug Administration), which had a believe these services should be
regarding the usefulness of this proposed payment rate of $154.31. assigned to drug administration APCs
information to the hospital community. These commenters reported that the because they are best characterized as
We received numerous comments on chemotherapy administration services chemotherapy administration services,
our payment proposal for drug described by these three CPT codes are albeit with special methods of delivery.
administration services in the CY 2007 far more intensive and require more However, we are reassigning CPT codes
OPPS proposed rule. facility resources than the other drug 96440 and 96445 from APC 0439 to APC
Comment: A number of commenters administration services currently 0441 (Level VI Drug Administration),
believed that the assignments of CY assigned to the same APCs. which has a final median cost of
2005 cost data to the six APCs to The commenters further illustrated $151.86 as the highest paying CY 2007
develop their proposed median costs that when CPT code 96440 or CPT code drug administration APC. If we were to
were appropriate. Many commenters 96445 is reported, hospitals cannot create another drug administration APC
were extremely supportive of the CY report separately the surgical procedure specifically for these three services, its
2007 proposal to pay separately for each that is required for the drug median cost from CY 2005 claims for
hour of drug infusion, indicating that administration service, such as CPT the special chemotherapy
this payment methodology would code 32000 (Thoracentesis, puncture of administration services would be less
provide appropriate payment for pleural cavity for aspiration, initial or than the median cost of APC 0441 for
infusions whose resources varied subsequent) or CPT code 49080 CY 2007. In addition, based on our CY
depending on the length of the (Peritoneocentesis, abdominal 2005 claims data from almost 400 single
infusions. Several commenters noted paracentesis, or peritoneal lavage claims, we believe that the proposed
that the current CY 2006 methodology (diagnostic or therapeutic); initial). They APC assignment for CPT code 96450 is
of paying for drug administration observed that the proposed payments accurate and reflects the resource costs
services does not pay separately for the for both surgical procedures were associated with performing the
second and subsequent hours of drug $224.20, and they believed that procedure. We will monitor our claims
administration, and instead, packages payments for the more extensive drug data in the future to see if additional
them into payment for the first hour of administration services should, changes are warranted to the APC
drug administration. One commenter therefore, be significantly higher than assignments of these chemotherapy
suggested that the packaging of the $224.20. The commenters strongly services. Therefore, for CY 2007, we are
second and subsequent hours for drug urged CMS to reevaluate the APC assigning CPT codes 96440 and 96445
administration resulted in inadequate assignments for these chemotherapy from APC 0439 to APC 0441, which has
reimbursement to hospitals because the administration codes. One commenter a final median cost of $151.86, and we
payment did not reflect the true cost of proposed three options for how CMS are finalizing our proposal without
providing the service, particularly in could make changes to the APC modification to assign CPT code 96450
those instances that involved patients assignments for the three CPT codes. to APC 0441.
who received chemotherapy infusions Specifically, they requested that CMS Comment: Several commenters
that last 2 or more hours. reassign CPT codes 96440, 96445, and expressed concern about the decrease in
payment for the ‘‘first hour of infusion’’ and requested clarification on our or drug); intravenous push, single or
codes from CY 2006 to their proposed methodology. The commenter indicated initial substance/drug) and 90775
CY 2007 rates. They asked that CMS that providers reported CPT code 90784 (Therapeutic, prophylactic or diagnostic
verify that our calculations were correct in CY 2005 with multiple units when injection (specify substance or drug);
and that the proposed rates were more than one IV push injection was each additional sequential intravenous
appropriate. provided, along with a dollar charge push of a new substance/drug) through
Response: Based on our CY 2006 reflecting each injection. The APC 0438 (Level III Drug
payment methodology, we made one commenter requested clarification as to Administration) is appropriate.
payment per day for administration of a whether CMS factored the multiple After carefully considering the public
particular type of infusion, regardless of units into its payment rate calculation, comments related to our proposed six-
its length, and packaged payment for and whether CMS discarded these level APC structure for drug
additional hours of infusion of the same claims from the ratesetting process administration services, we are
type. For example, the CY 2006 because they may have been considered finalizing our proposal with
payment of $189.04 for CPT code 96410 as multiple procedure claims. modification to assign all CY 2007
(Chemotherapy administration, Response: We were unable to use HCPCS codes for drug administration
intravenous; infusion technique, up to claims reporting multiple units of CPT services to six new drug administration
one hour), reflected a payment for the code 90784 on the same date of service APCs, as listed in Table 34, with
median chemotherapy infusion, for ratesetting, because we had no way payment rates based on median costs for
regardless of the number of hours of to attribute the packaging on the claims the APCs as calculated from CY 2005
infusion. In contrast, for CY 2007 we to the appropriate unit of the code. We claims data. We note that because our
proposed to pay separately for each also had no way of discerning from the CY 2007 proposal reflected our
hour of infusion. In the case of CY 2005 claims whether multiple units assignment of CPT codes and C-codes to
chemotherapy infusions, we proposed of CPT code 90784 were reported for these APCs consistent with our drug
to pay $154.31 for the first hour, CPT more than one intravenous push of the administration coding proposal for CY
code 96413, and $48.58 for each same drug, or multiple pushes of 2007, we are finalizing our assignment
additional hour of infusion, CPT code different drugs were provided. CPT code of the newly recognized CPT codes to
96415. We have confirmed that our 90784 was deleted for CY 2006, and the APCs where their related C-codes
calculations were correct for both the replaced by CPT codes 90774 were proposed for assignment. In the
proposed rule and this final rule with (Therapeutic, prophylactic or diagnostic case of CPT code 90768 (Intravenous
comment period. The apparent decrease injection (specify substance or drug); infusion, for therapy, prophylaxis, or
in payment for the first hour of infusion intravenous push, single or initial diagnosis (specify substance or drug);
is a direct result of our proposal to substance/drug) and 90775 concurrent infusion), we are packaging
unpackage payment for the additional (Therapeutic, prophylactic or diagnostic its payment for CY 2007 to maintain
hours of infusion and provide separate injection (specify substance or drug); consistency, because concurrent
payment for each hour as opposed to a each additional sequential intravenous infusions were not previously separately
per-day payment. Because many push of a new substance/drug (List reported in the OPPS and their costs are
chemotherapy infusions take place over separately in addition to code for already packaged into our CY 2007
more than one hour, the payment for the primary procedure)). The situations payments. We believe that this approach
first hour appeared to decrease. As discussed by the commenter would be provides consistency and will allow us
discussed earlier in this section, in our reported and paid differently in the CY to collect hospital claims data over the
methodology we also assigned all 2007 OPPS based upon the CY 2007 next two years to assess whether
packaging on the drug administration CPT code descriptors for IV push changes to the APC assignments for
claims to the first hour of infusion codes injections. According to our standard these newly recognized CPT codes
to allow us to use multiple claims for OPPS methodology as proposed based should be considered. Because the
ratesetting. We believe this payment on median costs from single claims, we newly recognized CPT codes
methodology will provide more accurate used only single claims for CPT code discriminate among services more
payment to hospitals for the specific 90784 for ratesetting for APC 0438 as specifically than the CY 2006 C-codes,
drug administration services they shown in Table 33 above. However, we as was the case when the OPPS
provide in CY 2007. examined our claims data and found transitioned from more general Q-codes
Comment: One commenter expressed that in over two-thirds of the cases, to more specific CPT codes for the
concern over the methodology used in hospitals billed only a single unit of reporting of drug administration
calculating the CY 2005 median cost for CPT code 90784 per day for an IV push services in CY 2005, for a period of 2
the non-chemotherapy intravenous (IV) injection. Therefore, we believe that our years drug administration services will
push injection services, specifically CPT payment rate for the CY 2007 be paid based on the costs of their
code 90784 (Therapeutic, prophylactic intravenous push injection CPT codes predecessor HCPCS codes until updated
diagnostic or diagnostic injection 90774 (Therapeutic, prophylactic or data are available for review.
(specify material injected); intravenous), diagnostic injection (specify substance BILLING CODE 4120–01–P

ER24NO06.022</GPH>
Comment: In addition to the APC appropriate to services performed under TABLE 35.—CY 2006 CPT CODES
Panel recommendation introduced the OPPS. More information regarding USED TO REPORT CLINIC AND
above, a number of commenters these edits may be found in the National EMERGENCY DEPARTMENT VISITS
requested that CMS pay separately for Correct Coding Initiative Policy Manual AND CRITICAL CARE SERVICES
multiple pushes of the same drugs, for Medicare Services as referenced
specifically for a second or subsequent earlier in this section. CPT
IV push performed during the same Descriptor
Therefore, we are not accepting the Code
episode of care, to cover the resource
costs associated with providing the recommendation of the APC Panel to CPT Evaluation and Management Codes
additional injections and drugs. Similar pay separately for all intravenous
to the recommendation of the APC pushes and injections for pain 99201 ... Office or other outpatient visit for
Panel, commenters suggested several management and other clinical the evaluation and management
options on how CMS could implement conditions. Consistent with our current of a new patient (Level 1).
such a policy. payment policy, in some cases their 99202 ... Office or other outpatient visit for
the evaluation and management
Response: We thank the commenters payment is packaged into payment for
of a new patient (Level 2).
for their suggestions. However, the associated procedures. 99203 ... Office or other outpatient visit for
consistent with our policy for reporting Comment: Several commenters the evaluation and management
intravenous pushes of the same drug requested that CMS allow hospitals to of a new patient (Level 3).
only once in CY 2006 and consistent 99204 ... Office or other outpatient visit for
bill separately and receive payments for
with the definition of the CPT codes the evaluation and management
the first hour of therapeutic infusions
that will be used in CY 2007 to report of a new patient (Level 4).
these services, we will continue to and hydration infusions when provided 99205 ... Office or other outpatient visit for
provide payment for an intravenous in the same encounter. the evaluation and management
push of each drug only once during a Response: With the use of CPT codes of a new patient (Level 5).
hospital encounter in CY 2007. In for the reporting of drug administration 99211 ... Office or other outpatient visit for
addition, we do not believe it would be services under the CY 2007 OPPS, the evaluation and management
appropriate to unbundle procedures by of an established patient (Level
hospitals may bill for therapeutic drug 1).
creating a new HCPCS code for an administration and hydration services 99212 ... Office or other outpatient visit for
element of a service that should be provided in the same encounter. the evaluation and management
reported with existing CPT codes when However, as mentioned above, we of an established patient (Level
they are used in the CY 2007 OPPS. We expect hospitals to adhere to CPT 2).
also see no need to develop a modifier coding instructions and instructions for 99213 ... Office or other outpatient visit for
to identify these situations. We expect the use of these codes. We do not the evaluation and management
that hospitals will adjust their charges of an established patient (Level
believe that allowing hospitals to submit 3).
for the CPT codes used to report IV push
claims for, and receive separate 99214 ... Office or other outpatient visit for
injections accordingly, based on their
experiences with providing intravenous payment for, the first hour of a the evaluation and management
injections of drugs in the outpatient therapeutic infusion and the first hour of an established patient (Level
of a hydration infusion provided in one 4).
setting.
Therefore, we are not accepting the encounter through a single vascular 99215 ... Office or other outpatient visit for
access site would be consistent with the evaluation and management
recommendation of the APC Panel to of an established patient (Level
make payment for multiple pushes of CPT coding principles. Therefore, we 5).
the same drug in a single hospital are not adopting the commenters’ 99241 ... Office consultation for a new or es-
encounter. proposal. tablished patient (Level 1).
Comment: In addition to the APC We note that in the CY 2007 OPPS 99242 ... Office consultation for a new or es-
Panel recommendation introduced tablished patient (Level 2).
proposed rule we discussed HCPCS
above, several commenters advised CMS 99243 ... Office consultation for a new or es-
code G0332 (Preadministration-related
to provide payments for all intravenous tablished patient (Level 3).
pushes and therapeutic injections for services for intravenous infusion of 99244 ... Office consultation for a new or es-
pain management and other clinical immunoglobulin, per infusion tablished patient (Level 4).
conditions, regardless of the setting in encounter (This service is to be billed in 99245 ... Office consultation for a new or es-
which they are administered. conjunction with administration of tablished patient (Level 5).
Response: The OPPS is a prospective immunoglobulin)) in this section of the
preamble. However, for the CY 2007 Emergency Department Visit CPT Codes
payment system that provides payment
for groups of services that are similar OPPS final rule with comment period,
99281 ... Emergency department visit for the
both clinically and in terms of resource we discuss this code and other issues evaluation and management of a
use. We package into payment for each relating to IVIG in section V.B.III. of this patient (Level 1).
procedure or service within an APC preamble. 99282 ... Emergency department visit for the
group the costs associated with items or evaluation and management of a
IX. Hospital Coding and Payments for patient (Level 2).
services that are directly related to
performing a procedure or furnishing a Visits 99283 ... Emergency department visit for the
service. Drug administration services are evaluation and management of a
A. Background
only paid separately in conjunction patient (Level 3).
Currently, CMS instructs hospitals to 99284 ... Emergency department visit for the
with many other procedures performed
evaluation and management of a
on the same day if they are distinct use the CY 2006 CPT codes used by
patient (Level 4).
procedural services that are reported in physicians and listed in Table 35 to 99285 ... Emergency department visit for the
a manner consistent with the principles report clinic and emergency department evaluation and management of a
of correct coding. We apply National (ED) visits and critical care services on patient (Level 5).
Correct Coding Initiative edits as claims paid under the OPPS.
TABLE 35.—CY 2006 CPT CODES the intensity of hospital resources to the provided (in addition to baseline care),
USED TO REPORT CLINIC AND different levels of effort represented by whether other similarly complex
EMERGENCY DEPARTMENT VISITS the codes. interventions were also provided, or
During the January 2002 APC Panel whether other interventions of less
AND CRITICAL CARE SERVICES—
meeting, the APC Panel recommended complexity were also provided. The
Continued that CMS adopt the American College of intervention model is based on
Emergency Physicians (ACEP) emergency department/clinic resource
CPT
Code Descriptor intervention-based guidelines for use, is simple, reflects the care given to
facility coding of emergency department the patient, and does not require
Critical Care Services CPT Codes visits and develop guidelines for clinic additional facility documentation.
visits that are modeled on the ACEP However, we expressed concern that the
99291 ... Critical care, evaluation and man- guidelines. intervention model may provide an
agement of the critically ill or In the August 9, 2002 OPPS proposed incentive to provide unnecessary
critically injured patient; first 30– rule, we proposed 10 new G-codes services and that it is susceptible to
74 minutes. (Levels 1–5 Facility Emergency Services
99292 ... Each additional 30 minutes.
upcoding. In addition, it is not
and Levels 1–5 Facility Clinic Services) particularly focused on measuring and
for use in the OPPS to report hospital appropriately reporting a code reflecting
The majority of CPT code descriptors
visits. We also asked for public total hospital resources used in a visit.
are applicable to both physician and
comments regarding national guidelines Furthermore, the ACEP model requires
facility resources associated with
for hospital coding of emergency extrapolation from a set of examples
specific services. However, we have
department and clinic visits. We that could make it prone to variability
acknowledged from the beginning of the
discussed various types of models, across hospitals.
OPPS that we believe that CPT reflecting on the advantages and
Evaluation and Management (E/M) disadvantages of each. We reviewed in 2. Guidelines Based on the Time Staff
codes were defined to reflect the detail the considerations around various Spent With the Patient
activities of physicians and do not discrete types of specific guidelines, Under this model, the level of service
describe well the range and mix of including guidelines based on staff would be determined based on the
services provided by hospitals during interventions, based upon staff time amount of time hospital staff spent with
visits of clinic and emergency spent with the patient, based on a patient. The underlying assumption is
department patients and critical care resource intensity point scoring, and that staff time spent with the patient is
encounters. Presently, CPT indicates based on severity acuity point scoring an appropriate proxy for total hospital
that office or other outpatient visit codes related to patient complexity. We note resource consumption. In this model, if
are used to report E/M services provided below our analysis of the various only baseline care (as described above)
in the physician’s office or in an models. were provided, a Level 1 service would
outpatient or other ambulatory facility. be reported. Higher levels of service
For OPPS purposes, we refer to these as 1. Guidelines Based on the Number or would be reported based on increments
clinic visit codes. CPT also indicates Type of Staff Interventions
of staff time beyond baseline care. For
that emergency department visit codes Under this model, the level of service example, Level 2 could be reported for
are used to report E/M services provided reported would be based on the number 11 to 20 minutes beyond baseline care,
in the emergency department, defined and/or type of interventions performed and Level 3 could be reported for 21 to
as an ‘‘organized hospital-based facility by nursing or ancillary staff. In the 30 minutes beyond baseline care. This
for the provision of unscheduled intervention model, baseline care model is simple, correlates with total
episodic services to patients who (including registration, triage, initial hospital resource use, and provides an
present for immediate medical nursing assessment, periodic vital signs objective standard for all hospitals to
attention. The facility must be available as appropriate, simple discharge follow. However, we observed that this
24 hours a day.’’ For OPPS purposes, we instructions, and examination room set model would require additional,
refer to these as emergency department up/clean up) and possibly a single potentially burdensome documentation
visit codes. CPT defines critical care minor intervention (for example, suture of staff time, could provide an incentive
services as the ‘‘direct delivery by a removal, rapid strep test, or visual to work slowly or use less efficient
physician(s) of medical care for a acuity) would be reported by the lowest personnel, and has the potential for
critically ill or critically injured level of service. Higher levels of service upcoding and gaming.
patient.’’ It also states that ‘‘critical care would be reported as the number and/
is usually, but not always, given in a or complexity of staff interventions 3. Guidelines Based on a Point System
critical care area, such as * * * the increased. Where a Certain Number of Points Are
emergency care facility.’’ The most commonly recommended Assigned to Each Staff Intervention
In the April 7, 2000 OPPS final rule intervention-based guidelines were the Based on the Time, Intensity, and Staff
(65 FR 18434), CMS instructed hospitals facility-coding guidelines developed by Type Required for the Intervention
to report facility resources for clinic and the ACEP. The ACEP model uses In this model, points or weights are
emergency department visits using CPT examples of interventions to illustrate assigned to each facility service and/or
E/M codes and to develop internal appropriate coding. Coders extrapolate intervention provided to a patient in the
hospital guidelines to determine what from these examples to determine the clinic or emergency department. The
level of visit to report for each patient. correct level of service to report. The level of service is determined by the
While awaiting the development of a ACEP model uses the types of sum of the points for all services/
national set of facility-specific codes interventions rather than the number of interventions provided. Commenters on
and guidelines, we have advised that interventions to determine the the August 9, 2002 proposed rule
each hospital’s internal guidelines appropriate level of service. This means recommended various approaches to a
should follow the intent of the CPT code that the single most complex point system, including point systems
descriptors, in that the guidelines intervention determines the level of that assigned points based on the
should be designed to reasonably relate service, whether it was the only service amount of staff time spent with the
patient, the number of activities CY 2007 proposed rule, we indicated representatives observed the meetings.
performed during the visit, and a that we were reconsidering this On June 24, 2003, the AHA and AHIMA
combination of patient condition and perspective. We discuss this issue submitted their recommended
activities performed. A point system further below. guidelines, hereafter referred to as the
would correlate with facility resource In the November 1, 2002 OPPS final AHA/AHIMA guidelines, for reporting
consumption and provide an objective rule, we specified that we would not three levels of hospital clinic and
standard. In addition, it is not as easily create new codes to replace existing emergency department visits and a
gamed because time-based interventions CPT E/M codes for reporting hospital single level of critical care services to
can be assigned a set number of points. visits until national guidelines have CMS, with the hope that CMS would
However, we noted that a point system been developed, in response to publish the guidelines in the CY 2004
could present a significant burden for commenters who were concerned about proposed rule. The AHA and AHIMA
hospitals in terms of requiring implementing code definitions without acknowledged that ‘‘continued
additional, clinically unnecessary national guidelines. We noted that an refinement will be required as in all
documentation. Point systems that are independent panel of experts would be coding systems. The Panel * * * looks
complex could require dedicated staff to an appropriate forum to develop codes forward to working with CMS to
monitor and maintain them. and guidelines that are simple to incorporate any recommendations
understand and implement, and that are raised during the public comment
4. Guidelines Based on Patient compliant with HIPAA requirements. period’’ (AHA/AHIMA guidelines
Complexity We explained that organizations such as report, page 9). The AHA and AHIMA
Several variations were recommended the American Hospital Associations indicated that the guidelines were field-
in comments on the August 9, 2002 (AHA) and the American Health tested several times by panel members
proposed rule, including assignment of Information Management Association at different stages of their development.
levels of service based on ICD–9–CM (AHIMA) had such expertise and would The guidelines are based on an
(International Classification of Diseases, be capable of creating hospital visit intervention model, where the levels are
Ninth Edition, Clinical Modification) guidelines and providing ongoing determined by the numbers and types of
diagnosis codes, based on complexity of education of providers. We also interventions performed by nursing or
medical decision making, or based on articulated a set of principles that any ancillary hospital staff. Higher levels of
presenting complaint or medical national guidelines for facility visit services are reported as the number and/
problem. The premise for these coding should satisfy, including that or complexity of staff interventions
guideline systems is that many coding guidelines should be based on increase.
emergency departments follow facility resources, should be clear to Although we did not publish the
established protocols based on patients’ facilitate accurate payments and be guidelines, the AHA and AHIMA
presenting complaints and/or diagnoses. usable for compliance purposes and released the guidelines through their
Therefore, assigning a level of service audits, should meet HIPAA Web sites. Consequently, we received
based on patient diagnosis should requirements, should only require numerous comments from providers
correlate with facility resource documentation that is clinically and associations, some in favor and
consumption. These systems may necessary for patient care, and should some opposed to the guidelines. We
require the use of a coding ‘‘grid,’’ not facilitate upcoding or gaming. We undertook a critical review of the
which lists more than 100 examples of stated that the distribution of codes recommendations from the AHA and
patient conditions and diagnoses and should result in a normal curve. We AHIMA and made some modifications
assigns a level of service to each concluded that we believed the most to the guidelines based on comments we
example. When the patient presents appropriate forum for development of received from outside hospitals and
with a condition that does not appear on code definitions and guidelines was an associations on the AHA/AHIMA
the grid, the coder must extrapolate independent expert panel that would guidelines, clinical review, and
from the grid to the individual patient. make recommendations to CMS. changing payment policies in the OPPS
We expressed concern that these The AHA and AHIMA originally regarding some separately payable
systems are extremely complex, demand supported the ACEP model for services.
significant interpretive work on the part emergency department visit coding, but In an attempt to validate the modified
of the coder (who may not have clinical we expressed concern that the ACEP AHA/AHIMA guidelines and examine
experience), and are subject to guidelines allowed counting of the distribution of services that would
variability across hospitals. While no separately payable services in result from their application to hospital
clinically unnecessary documentation determining a service level, which clinic and emergency department visits
would be required because the system is could result in the double counting of paid under the OPPS, we contracted a
based on diagnoses that are already hospital resources in establishing visit study that began in September 2004 and
reported on claims, there is a significant payment rates and payment rates for concluded in September 2005 to
potential for upcoding and gaming. those separately payable services. retrospectively code, under the
In the August 9, 2002 OPPS proposed Subsequently, on their own initiative, modified AHA/AHIMA guidelines,
rule, we also stated that we were the AHA and AHIMA formed an hospital visits by reviewing hospital
concerned about counting separately independent expert panel, the Hospital visit medical chart documentation
paid services (for example, intravenous Evaluation and Management Coding gathered through the Comprehensive
infusions, x-rays, electrocardiograms, Panel, comprised of members with Error Rate Testing (CERT) work. While
and laboratory tests) as ‘‘interventions’’ coding, health information management, a review of documentation and
or including their associated ‘‘staff documentation, billing, nursing, assignment of visit levels based on the
time’’ in determining the level of finance, auditing, and medical modified AHA/AHIMA guidelines to
service. We believed that the level of experience. This panel included 12,500 clinic and emergency
service should be determined by representatives from the AHA, AHIMA, department visits was initially planned,
resource consumption that is not ACEP, Emergency Nurses Association, the study was terminated after a pilot
otherwise captured in payments for and American Organization of Nurse review of only 750 visits. The contractor
other separately payable services. In the Executives. CMS and AMA identified a number of elements in the
guidelines that were difficult for coders guidelines should be designed to perspective to distinguish between the
to interpret, poorly defined, nonspecific, reasonably relate the intensity of two types of visits. The proposed codes
or regularly unavailable in the medical hospital resources to the different levels are listed in Table 36 below.
records. The contractor’s coders were of effort represented by the codes.
unable to determine any level for about In the November 1, 2002 OPPS final TABLE 36.—CY 2007 PROPOSED
25 percent of the clinic cases and about rule, we specified that we would not HCPCS CODES TO BE USED TO
20 percent of the emergency cases create new codes to replace existing REPORT CLINIC VISITS
reviewed. The only agreement observed CPT E/M codes for reporting hospital
between the levels reported on the visits until national guidelines have HCPCS Short descriptor Long descriptor
claims and levels according to the been developed, in response to code
modified AHA/AHIMA guidelines was commenters who were concerned about
the classification of Level 1 services, implementing code definitions without Gxxx1 Level 1 hosp Level 1 hospital
national guidelines. While we do not yet clinic visit. clinic visit.
where the review supported the level on Gxxx2 Level 2 hosp Level 2 hospital
the claims 54–70 percent of the time. In have a formal set of guidelines that we clinic visit. clinic visit.
addition, the vast majority of the clinic believe may be appropriately applied Gxxx3 Level 3 hosp Level 3 hospital
and emergency department visits nationally to report different levels of clinic visit. clinic visit.
reviewed were assigned to Level 1 hospital clinic and emergency Gxxx4 Level 4 hosp Level 4 hospital
during the review. Based on these department visits and to report critical clinic visit. clinic visit.
findings, we believed that it was not care services, we have made significant Gxxx5 Level 5 hosp Level 5 hospital
necessary to review additional records progress in developing potential clinic visit. clinic visit.
after the initial sample. The contractor guidelines. Therefore, in the CY 2007
advised that multiple terms in the OPPS proposed rule (71 FR 49604– Comment: Although a few
guidelines required clearer definition 49618), we proposed for CY 2007 the commenters were in favor of creating G-
and believed that more examples would establishment of HCPCS codes to codes for CY 2007, numerous
be helpful. Although we believe that all describe hospital clinic and emergency commenters requested that CMS
of the visit documentation for each case department visits and critical care postpone creation of G-codes until
was available for the contractor’s services. Prior to our implementation of national guidelines are implemented.
review, we were unable to determine national guidelines for the new hospital Almost all of these commenters stated
definitively that this was the case. Thus, visit HCPCS codes, we proposed that that it would be extremely time
there is some possibility that the hospitals might continue to use their consuming to train staff in the new
contractor’s assignments would have existing internal guidelines to determine coding system, only to retrain them 1 to
differed if additional documentation the visit levels to be reported with these 2 years later, when national guidelines
from the medical records were available codes. We anticipated that many were implemented. They believed that if
for the visits. In summary, while testing providers would choose to use their national guidelines were established for
of the modified AHA/AHIMA existing guidelines for reporting visits CY 2007, hospitals could justify the
guidelines was helpful in illuminating with CPT codes. We did not expect a time commitment and training expense.
areas of the guidelines that would substantial workload for a provider that They added that prior to the
benefit from refinement, we were unable chose to adjust its guidelines to reflect establishment of national guidelines,
to draw conclusions about the our policies. however, there is little incentive for
relationship between the distribution of We acknowledged that it could be hospitals to transition to G-codes.
current hospital reporting of visits using burdensome for providers to bill G- Several commenters noted that there
CPT E/M codes that are assigned codes rather than CPT codes. In this would be no benefit of improved data if
according to each hospital’s internal case, because current CPT E/M codes do hospitals transitioned to G-codes
guidelines and the distribution of not describe hospital visit resources, we without guidelines because the median
coding under the AHA/AHIMA saw no alternative other than to create cost data captured from the G-codes
guidelines, nor were we able to new G-codes. CPT has not yet created would parallel current data because
demonstrate a normal distribution of clinic and emergency department visit hospitals would still be using their own
visit levels under the modified AHA/ and critical care services codes that internal guidelines. It was implicit in
AHIMA guidelines. describe hospital resource utilization. It many comments that once national
is important to note that G-codes may be guidelines are established, hospitals
B. CY 2007 Proposed and Final Coding recognized by other payers. would agree to transition to G-codes.
Policies However, other commenters objected to
As discussed above, the majority of all 1. Clinic Visits the G-codes because other payors either
CPT code descriptors are applicable to For clinic visits, we proposed to fail to accept them or do not assign
both physician and facility resources establish five new codes to replace proper payment to them. Several
associated with specific services. hospitals’ reporting of the CPT clinic commenters suggested that a proposal
However, we believe that CPT E/M visit E/M codes for new and established be submitted to the AMA requesting
codes were defined to reflect the patients and consultations listed in hospital-specific Category I visit codes.
activities of physicians and do not Table 35. Providers have been reporting Response: In response to the
describe well the range and mix of five levels of CPT codes through CY numerous comments related to creation
services provided by hospitals during 2006, and we believed that it would be of G-codes, we are postponing finalizing
visits of clinic and emergency fairly easy to crosswalk current internal G-codes for clinic visits until national
department patients and critical care hospital guidelines to these five new guidelines have been established, when
encounters. While awaiting the codes. Commenters to prior rules have we will again consider their possible
development of a national set of facility- stated that the hospital resources used utility. We are responding to the
specific codes and guidelines, we have for new and established patients to requests of many commenters who
advised that each hospital’s internal provide a specific level of service are stated that it would be too difficult for
guidelines should follow the intent of very similar, and that it is unnecessary them to first transition to G-codes and
the CPT code descriptors, in that the and burdensome from a coding then to transition to national guidelines
shortly thereafter. Most commenters patient is considered an established be a distinction between new and
indicated a preference for training their patient to the hospital. The same patient established visits and consultations. We
staff once, for both coding and could be ‘‘new’’ to the physician, but an continue to be interested in the opinions
guidelines, even if it means that the ‘‘established’’ patient to the hospital. of hospital staff and others who are
training would be significant. In the The opposite could be true if the familiar with these codes. Further
meantime, as discussed further below, physician has a longstanding discussion of these codes appears in
we will to continue work to develop relationship with the patient, in which section IX.C. of this preamble.
national guidelines. For CY 2007, case the patient would be an Comment: A few commenters
providers should continue to use CPT ‘‘established’’ patient with respect to the requested that CMS clarify whether a
codes to bill for clinic visits. physician and a ‘‘new’’ patient to the hospital can bill several clinic visits for
Comment: Several commenters hospital. services provided to a patient who is
compared hospital resource cost Because hospitals will be reporting seen in one clinic by several clinicians
differences between new and CPT codes for CY 2007, they must on the same day, although not at the
established patient visits and discussed continue to distinguish between new same time. The commenters stated that,
whether it was necessary to distinguish and established patients, according to in oncology clinics, it is common for
between the two types of visits. The the CPT code descriptor. However, it patients to have several scheduled visits
commenters were divided as to whether may be unnecessary for hospitals to on one day, provided by an oncologist,
this distinction was necessary or useful. report consultation CPT codes if either physicians trained in other specialties,
While some commenters stated that it the new or established patient visit code therapists, or others, depending on the
would be appropriate to continue using accurately describes the service patients’ needs. They added that, in
different codes for new and established provided. To simplify billing, as many some instances, the oncology clinic
patients because of the observed median commenters requested, we are now allows the patient to remain in one
cost differences, other commenters considering whether consultation codes clinic room, while asking the various
found it cumbersome to bill a different are necessary, or if hospitals could bill clinicians to meet the patient in the
code for each type of visit. One either a new patient visit or an oncology clinic. One commenter noted
commenter speculated that hospitals established patient visit, instead of a that the patient usually consumes few
often choose a new versus an consultation, as appropriate in these hospital resources other than use of the
established visit code based upon which cases. We could assign status indicator clinic room. These commenters also
code the physician bills, instead of ‘‘B’’ to the consultation codes and indicated that HCPCS code G0175
choosing a code based on whether the instruct hospitals to bill a new or (Scheduled interdisciplinary team
patient is new or established at that established visit code. While developing conference (minimum of three exclusive
particular hospital. One commenter the proposal to create G-codes in place of patient care nursing staff) with
suggested that the additional resources of the clinic visit CPT E/M codes for CY patient present) would only apply if the
for new patients be reflected in the 2007, we determined that hospitals patient was seen by all the clinicians at
guidelines, rather than in the coding. could report G-code levels that reflect the same time. According to the
Yet another commenter indicated that their resources used, by applying their commenters, the hospital could bill
new patients did not necessarily use guidelines, without the need for codes multiple clinic visits if the patient was
more hospital resources than that differentiate among new, seen in several different clinics on the
established patients, and questioned established, or consultation visits. same day. They believed that the
whether both types of codes were However, because hospitals will current policy penalizes oncology
necessary. continue to use CPT E/M codes for CY clinics for offering services in an
Response: We initially solicited 2007, which distinguish between new, efficient manner. One of the
comment as to whether a distinction established, and consultation visits, we commenters requested that CMS change
between new and established visits was invite further input on this issue, the descriptor of G0175 so that it would
necessary because we were planning to specifically as to whether the apply when a patient was treated by
transition to G-codes and did not want consultation codes are necessary for several clinicians on one day, in one
to unnecessarily create codes for both hospitals to report, or whether it would clinic, but not necessarily at the same
new and established visits. However, be simpler for hospitals to report either time. The commenter noted that an
because hospitals will continue to bill a new patient visit or established patient appropriate payment for the service
CPT codes for CY 2007, they must visit, as appropriate in each would be at a rate comparable to the
continue to distinguish between new circumstance. We are particularly critical care payment rate.
and established patients, according to interested to know whether consultation Response: We expect the hospital
the CPT code descriptor. Therefore, codes are a useful measure of hospital resources associated with an extended
these codes will continue to be payable resource use under the OPPS, and how clinic visit involving multiple clinicians
under the OPPS for CY 2007. The AMA they are different, from a hospital to be reflected in the hospital’s internal
defines an established patient as ‘‘one resource perspective, from new patient guidelines used to select the level for
who has received professional services visits and established patient visits. reporting of the visit. The hospital
from the physician or another physician In summary, for CY 2007, providers should bill the clinic visit code that
of the same specialty who belongs to the should continue to use CPT codes to bill most appropriately describes the service
same group practice, within the past for clinic visits. The CPT codes for new provided. We will maintain the same
three years.’’ To apply this definition to and established visits and consultations code descriptor for G0175 for CY 2007
hospital visits, we stated in the April 7, will continue to be payable under the because we believe it is appropriate to
2000 final rule with comment period OPPS. Prior to implementation of pay specifically for interdisciplinary
that the meanings of ‘‘new’’ and national guidelines, we are considering team conferences that contribute to
‘‘established’’ pertain to whether or not whether it would be appropriate for well-coordinated, high quality care,
the patient already has a hospital hospitals to bill a new or established E/ particularly for patients with severe or
medical record number. If the patient M visit code instead of a consultation complex medical conditions. We note
has a hospital medical record that was code. In the national guidelines, we still that payment for G0175 will be made
created within the past 3 years, that need to determine whether there should through APC 0608 (Level V Clinic
Visits) at the highest payment level for held out to the public (by name, posted those of emergency departments that
clinic visits in CY 2007. signs, advertising, or other means) as a meet the CPT definition than they are to
place that provides care for emergency the resource costs of clinics.
2. Emergency Department Visits
medical conditions on an urgent basis Representatives of such facilities have
As described above, CPT defines an without requiring a previously argued that emergency department visit
emergency department as ‘‘an organized scheduled appointment; or (3) During payments are more appropriate, on the
hospital-based facility for the provision the calendar year immediately grounds that their facilities treat
of unscheduled episodic services to preceding the calendar year in which a patients with emergency conditions
patients who present for immediate determination under the regulations is whose costs exceed the resources
medical attention. The facility must be being made, based on a representative reflected in the clinic visit APC
available 24 hours a day.’’ Under the sample of patient visits that occurred payments, even though these emergency
OPPS, we have restricted the billing of during that calendar year, it provides at departments are not available 24 hours
emergency department CPT codes to least one-third of all of its outpatient per day. In addition, these hospital
services furnished at facilities that meet visits for the treatment of emergency representatives indicated that their
this CPT definition. Facilities open less medical conditions on an urgent basis facilities have EMTALA obligations and
than 24 hours a day should not use the without requiring a previously should, therefore, be able to receive
emergency department codes. scheduled appointment. emergency department visit payments.
Sections 1866(a)(1)(I), 1866(a)(1)(N), We believe that every emergency While these emergency departments
and 1867 of the Act impose specific department that meets the CPT may provide a broader range and
obligations on Medicare-participating definition of emergency department also intensity of hospital services and
hospitals and CAHs that offer qualifies as a DED under EMTALA.
require significant resources to assure
emergency services. These obligations However, we are aware that there are
their availability and capabilities in
concern individuals who come to a some departments or facilities of
comparison with typical hospital
hospital’s dedicated emergency hospitals that meet the definition of a
outpatient clinics, the fact that they do
department (DED) and request DED under the EMTALA regulations but
not operate with all capabilities full-
examination or treatment for medical that do not meet the more restrictive
time suggests that hospital resources
conditions, and apply to all of these CPT definition of an emergency
associated with visits to emergency
individuals, regardless of whether or not department. For example, a hospital
they are beneficiaries of any program department or facility that meets the departments or facilities available less
under the Act. Section 1867(h) of the definition of a DED may not be available than 24 hours a day may not be as great
Act specifically prohibits a delay in 24 hours a day, 7 days a week. as the resources associated with
providing required screening or Nevertheless, hospitals with such emergency departments or facilities that
stabilization services in order to inquire departments or facilities incur EMTALA are available 24 hours a day and that
about the individual’s payment method obligations with respect to an individual fully meet the CPT definition.
or insurance status. Section 1867(d) of who presents to the department and To determine whether visits to
the Act provides for the imposition of requests, or has requested on his or her emergency departments or facilities
civil monetary penalties on hospitals behalf, examination or treatment for an (referred to as Type B emergency
and physicians responsible for failing to emergency medical condition. However, departments) that incur EMTALA
meet the provisions listed above. These because they do not meet the CPT obligations but do not meet more
provisions, taken together, are requirements for reporting emergency prescriptive expectations that are
frequently referred to as the Emergency visit E/M codes, these facilities must bill consistent with the CPT definition of an
Medical Treatment and Labor Act clinic visit codes for the services they emergency department (referred to as
(EMTALA). EMTALA was passed in furnish. We have no way to distinguish Type A emergency departments) have
1986 as part of the Consolidated in our hospital claims data the costs of different resource costs than visits to
Omnibus Budget Reconciliation Act of visits provided in DEDs that do not meet either clinics or Type A emergency
1985, Public Law 99–272 (COBRA). the CPT definition of emergency departments, we proposed in the CY
Section 489.24 of the EMTALA department from the costs of clinic 2007 OPPS proposed rule (71 FR 49608)
regulations defines ‘‘dedicated visits. to establish a set of five G-codes for use
emergency department’’ as any Some hospitals have requested that by all entities that meet the definition of
department or facility of the hospital, they be permitted to bill emergency a DED under the EMTALA regulations
regardless of whether it is located on or department visit codes under the OPPS in § 489.24 but that are not Type A
off the main hospital campus, that meets for services furnished in a facility that emergency departments, as described in
at least one of the following meets the CPT definition for reporting Table 33 of the proposed rule and as
requirements: (1) It is licensed by the emergency department visit E/M codes, finalized as Table 37 below in this final
State in which it is located under except that they are not available 24 rule with comment period. These codes
applicable State law as an emergency hours a day. These hospitals believe that are called ‘‘Type B emergency
room or emergency department; (2) It is their resource costs are more similar to department visit codes.’’
TABLE 37.—CY 2007 FINAL HCPCS CODES TO BE USED TO REPORT EMERGENCY DEPARTMENT VISITS PROVIDED IN
TYPE B EMERGENCY DEPARTMENTS
HCPCS Short descriptor Long descriptor
code
G0380 Lev 1 hosp type B ED visit .. Level 1 hospital emergency department visit provided in a Type B emergency department. (The ED
must meet at least one of the following requirements: (1) It is licensed by the State in which it is lo-
cated under applicable State law as an emergency room or emergency department; (2) It is held out
to the public (by name, posted signs, advertising, or other means) as a place that provides care for
emergency medical conditions on an urgent basis without requiring a previously scheduled appoint-
ment; or (3) During the calendar year immediately preceding the calendar year in which a determina-
tion under this section is being made, based on a representative sample of patient visits that oc-
curred during that calendar year, it provides at least one-third of all of its outpatient visits for the
treatment of emergency medical conditions on an urgent basis without requiring a previously sched-
uled appointment).
uled appointment).
uled appointment).
uled appointment).
uled appointment).
For CY 2007, we proposed to create advertising, or other means) as a place department visit codes. We believed
five G-codes to be reported by the subset that provides care for emergency that this definition of Type A emergency
of provider-based emergency medical conditions on an urgent basis departments would neither narrow nor
departments or facilities of the hospital, without requiring a previously broaden the group of emergency
called Type A emergency departments, scheduled appointment. These codes departments or facilities that may bill
that are available to provide services 24 are called ‘‘Type A emergency visit the Type A emergency department visit
hours a day, 7 days per week and meet codes’’ and were proposed to replace codes in comparison with those that are
one or both of the following hospitals’ current reporting of the CPT currently correctly billing CPT
requirements related to the EMTALA emergency department visit E/M codes emergency department visit E/M codes.
definition of DED, specifically: (1) It is listed in Table 35. Our intention was to Rather, our proposal refined and
licensed by the State in which it is allow hospital-based emergency clarified the definition for use in the
located under the applicable State law departments or facilities that are hospital context. We believed that
as an emergency room or emergency currently appropriately reporting CPT because the concepts employed in the
department; or (2) It is held out to the emergency department visit E/M codes definition of a DED for EMTALA
public (by name, posted signs, to bill these new Type A emergency purposes are already familiar to
hospitals, it is appropriate to employ provided by hospitals during visits of departments of the hospital is that Type
those concepts, rather than the concepts emergency department patients. We A emergency departments do not
employed in the CPT definition of believed that these new codes for generally provide scheduled care, but
emergency department, for purposes of reporting emergency department visits rather regularly operate to provide
defining these new G-codes. As we have to Type A emergency departments are immediately available unscheduled
previously noted, the CPT codes were more specific to the hospital context. services.
defined to reflect the activities of For example, one feature that
physicians and do not always describe distinguishes Type A hospital The new codes that we proposed for
well the range and mix of services emergency departments from other CY 2007 are listed in Table 38 below.
TABLE 38.—CY 2007 PROPOSED HCPCS CODES TO BE USED TO REPORT EMERGENCY DEPARTMENT VISITS PROVIDED
IN TYPE A EMERGENCY DEPARTMENTS

code
Gyyy1 Lev 1 hosp type A ED visit .. Level 1 hospital emergency department visit provided in a Type A hospital-based facility or visit depart-
ment. (The facility or department must be open 24 hours a day, 7 days a week and meet at least one
of the following requirements: (1) It is licensed by the State in which it is located under applicable
State law as an emergency room or emergency department; or (2) It is held out to the public (by
name, posted signs, advertising, or other means) as a place that provides care for emergency med-
ical conditions on an urgent basis without requiring a previously scheduled appointment).
Gyyy5 Lev 5 hosp type A ED visit .. Level 5 hospital emergency department visit type provided in a Type A hospital-based facility or visit
department. (The facility or department must be open 24 hours a day, 7 days a week and meet at
least one of the following requirements: (1) It is licensed by the State in which it is located under ap-
plicable State law as an emergency room or emergency department; or (2) It is held out to the public
(by name, posted signs, advertising, or other means) as a place that provides care for emergency
medical conditions on an urgent basis without requiring a previously scheduled appointment).
Comment: As discussed above in being made, based on a representative person’’ (as defined in the EMTALA
section IX.B.1. of this preamble sample of patient visits that occurred regulations) during operating hours.
describing coding for clinic visits, during that calendar year, it provides at One commenter requested that CMS
numerous commenters requested that least one-third of all of its outpatient revise the description of an emergency
CMS postpone adoption of G-codes visits for the treatment of emergency department by replacing the words
until CMS has established national medical conditions on an urgent basis ‘‘licensed by the State’’ with
guidelines. We will not re-summarize or without requiring a previously ‘‘authorized or permitted by the State’’
re-respond to those comments in this scheduled appointment.’’ This to allow for States that do not license
section. commenter suggested that urgent care emergency departments.
As to our proposed coding for centers that operated primarily with Several providers were concerned that
emergency department visits, the scheduled appointments be required to CMS has used and is continuing to
majority of commenters agreed with our bill clinic visit codes. Many other piggyback on the AMA’s requirement
general distinction between Type A and commenters stated that our Type B that an emergency department must be
Type B emergency departments. One emergency department definition was open 24 hours a day in order to bill
commenter believed that our definition too narrow and would apply to only a emergency department codes. They
for Type B emergency departments was few emergency departments. One believed that if CPT codes do not
too broad because many urgent care commenter requested that CMS add two describe hospital resources, CMS should
centers would meet the definition of additional requirements for dedicated not follow the CPT rules when billing
Type B emergency department based on Type B emergency departments: (1) these CPT codes. One commenter stated
the EMTALA criterion that ‘‘During the They must have transfer agreements that the operating hours of an
calendar year immediately preceding with local and/or regional full service emergency department was irrelevant,
the calendar year in which a hospitals; and (2) they must have the and that the resource costs of the
determination under this section is presence of a ‘‘qualified medical services provided should instead
determine selection of the appropriate we acknowledge the comments that emergency departments, it is necessary
code. In other words, the commenter requested that we amend the definition to create a new set of codes to be billed
indicated, if a Type B emergency of a Type B emergency department, we by Type B emergency departments. We
department that was available less than will continue to use the EMTALA will consider whether further
24 hours a day provided a highly definition of a dedicated emergency instructions are necessary in the future
resource-intensive service, that Type B department as defined in 42 CFR 489.24 to enhance our data collection.
emergency department should bill a because, as stated above, we believed Comment: Several commenters
Type A emergency department code and that because the concepts employed in requested that CMS clarify whether
be paid at the Type A emergency the definition of a DED for EMTALA Type A emergency department codes,
department rate. purposes are already familiar to Type B emergency department codes, or
Several commenters requested that hospitals. clinic visit codes apply in specific
CMS distinguish between Type A and While we understand the reservations situations. One questioned whether a
Type B emergency departments using a expressed by the commenters about the Type A emergency department that has
method other than coding, as it would use of G-codes, we believe the creation a separate adjacent space that is
be burdensome for providers to choose of G-codes for Type B emergency organizationally part of the Type A
the correct code. In addition, one departments is necessary because there emergency department, but treats less
commenter that specializes in coding currently are no CPT codes that fully severe patients and is often closed at
indicated that it is more appropriate for describe this type of facility. If we were night, would be eligible to bill the Type
a code to describe services provided to continue instructing Type B A emergency department visit codes.
rather than the facility type. Several emergency departments to bill clinic The commenter clarified that the
commenters suggested that providers visit codes, we would have no way to primary emergency area is fully staffed
instead bill Type B emergency track resource costs for Type B 24 hours a day. Several commenters
department services under a different emergency department visits as distinct questioned whether services provided at
revenue code than Type A emergency from clinic visits. These new G-codes a satellite emergency department that is
department services. will serve as a vehicle to capture open less than 24 hours a day, located
Response: In response to the median cost and resource differences at a different location than the main
numerous public comments received, among visits provided by Type A campus, could bill the Type A
and as discussed in detail in section emergency departments, Type B emergency department visit codes.
IX.B.1. of this preamble on clinic visit emergency departments, and clinics. Again the commenter clarified that the
coding, we are postponing finalizing G- Further, we acknowledge that some primary emergency department was
codes for Type A emergency department providers prefer that we not distinguish available 24 hours a day. Yet another
visits until national guidelines have between providers that are open 24 commenter requested clarification about
been established, when we will again hours a day and those that are not. a Type A emergency department that
consider their possible utility. For CY However, we continue to believe that operated subunits or locations within a
2007, providers should continue to use hours of operation significantly impact Type A emergency department, that are
CPT codes to bill for Type A emergency hospital resource costs. It is necessarily closed part of the day or night, based on
department visits. However, we are more costly to operate a department fluctuations in patient loads. This
finalizing the definition of Type A with full capabilities 24 hours a day commenter noted that these subunits are
emergency departments to distinguish it than to operate with full capabilities 12 sometimes referred to as ‘‘Fast Track
from Type B emergency departments. hours a day. Emergency departments areas.’’
As stated above, we believe that this that are open 24 hours a day serve as a Response: We are aware that hospitals
definition of Type A emergency crucial safety net of our health care operate many types of facilities which
departments will neither narrow nor system, and we are concerned with they view in aggregate as an integrated
broaden the group of emergency ensuring that necessary emergency healthcare system. For purposes of
departments or facilities that may bill department services are available to determining EMTALA obligations,
the Type A emergency department visit Medicare beneficiaries. We are under § 489.24(b) of the regulations,
codes in comparison to those that are concerned that if we allow emergency each hospital is evaluated individually
currently correctly billing CPT departments that are open less than 24 to determine its own particular
emergency department visit E/M codes. hours a day to bill Type A emergency obligations. As we have discussed
Rather, we are refining and clarifying department codes, the result would be previously, hospital facilities or
the definition for use in the hospital to dilute the median costs associated departments of the hospital that meet
context. A Type A emergency with the provision of services by the definition of a dedicated emergency
department is a hospital-based facility emergency departments that are open 24 department consistent with the
or department that must be open 24 hours a day, 7 days a week. EMTALA regulations may bill Type A
hours a day, 7 days a week and meet at We note the commenters’ concerns emergency department codes (CPT
least one of the following requirements: that G-codes may not allow accurate emergency department visit codes) or
(1) It is licensed by the State in which data collection because services for both Type B emergency department codes
it is located under applicable State law Type A and Type B emergency (HCPCS G-codes), depending on
as an emergency room or emergency department services may be reported whether or not the dedicated emergency
department; or (2) It is held out to the under one revenue code. However, we department meets the definition of a
public (by name, posted signs, expect hospitals to adjust their charges Type A emergency department, which
advertising, or other means) as a place appropriately to reflect differences in includes operating 24 hours per day, 7
that provides care for emergency Type A and Type B emergency days a week. For purposes of
medical conditions on an urgent basis departments. The current revenue codes determining whether to bill Type A or
without requiring a previously do not distinguish between Type A and Type B emergency department codes,
scheduled appointment). We were Type B emergency departments. each hospital must be evaluated
pleased that most commenters agreed Therefore, to track the resource costs individually and should make a
with our distinction between the two differences between clinics, Type A decision specific to each area of the
types of emergency departments. While emergency departments, and Type B hospital to determine which codes
would be appropriate. Where a hospital services in such facilities or areas to adopting the G-codes in Table 38 for
maintains a separately identifiable area evaluate the status of those areas and Type A emergency departments, but we
or part of a facility which does not bill accordingly. In general, it is not are adopting the G-codes in Table 37 for
operate on the same schedule (that is, 24 appropriate to consider a satellite Type B emergency departments.
hours per day, 7 days a week) as its emergency department or an area of the
3. Critical Care Services
emergency department, that area or emergency department as if it were
facility would not be considered an available 24 hours a day simply because For critical care services, we proposed
integral part of the emergency the main emergency department is in the CY 2007 OPPS proposed rule (71
department that operates 24 hours per available 24 hours a day. It may be FR 49610) to create two new codes to
day, 7 days a week for purposes of appropriate for a Type A emergency replace hospitals’ reporting of the CPT
determining its emergency department department to ‘‘carve out’’ portions of E/M critical care codes listed in Table
type for reporting emergency visit the emergency department that are not 35 above. Providers have been reporting
services. Instead, the facility or area available 24 hours a day, where visits two CPT codes through CY 2006, and
would be evaluated separately to would be more appropriately billed we believed that it would be fairly easy
determine whether it is a Type A with Type B emergency department to crosswalk current internal hospital
emergency department, Type B codes. guidelines to these two new codes. The
emergency department, or clinic. We For CY 2007, we are finalizing our proposed new codes are listed in Table
would expect the hospital providing proposal with modification. We are not 39 below.
TABLE 39.—CY 2007 PROPOSED HCPCS CODES TO BE USED TO REPORT CRITICAL CARE SERVICES
code
Gccc1 Hosp critical care, 30–74 Hospital critical care services, first 30–74 minutes.
min.
Gccc2 Hosp critical care, add 30 Hospital critical care services, each additional 30 minutes.
min.
Comment: In addition to the many commenters asked us to clarify how a that critical care services with trauma
comments we received about G-codes in hospital should count time. They asked: activation require a significantly higher
general, we received many comments on Does it start when the patient is level of hospital resources than critical
the proposed G-codes specific to critical admitted? Should each provider of care care services alone. In particular, one
care. Most comments fell under one of measure his own minutes, after which commenter who made a presentation
two categories: (1) Remove the the hospital would add together all the during the August 2006 APC Panel
minimum time requirement for critical minutes from all the providers meeting suggested that CMS use
care services; or (2) create one G-code involved? In addition, several revenue codes in the 68x series reported
for critical care without trauma commenters referenced page 18452 of on the same date as a critical care
activation and one G-code for critical the April 7, 2000 final rule preamble service to determine whether a trauma
care with trauma activation. language, which has been interpreted by response was activated in association
Many commenters requested that commenters to mean that the 30-minute with critical care services in order to
CMS allow hospitals to bill critical care minimum for critical care does not facilitate selection of appropriate claims
without a minimum time requirement. apply under the OPPS. One commenter to establish differential payment rates
The commenters indicated that it was requested that CMS remove the 30- for critical care services with and
extremely difficult to measure time minute minimum requirement because without trauma activation. The APC
while providing critical care services it creates a disincentive to provide Panel recommended that CMS analyze
because of the intensity of the services critical care services in an efficient cost data to determine if additional
provided. These commenters also manner. Several commenters indicated payment for trauma response was
indicated that it is easier and more that critical care should be the highest appropriate.
appropriate to use time when measuring level visit code, regardless of time. One Response: We responded to the
physician resources rather than facility commenter suggested that critical care general comments regarding the use of
resources. They did not believe that be paid at a flat rate, rather than G-codes in section IX.B.1. of this
time is an appropriate proxy for involving time. Another commenter preamble on clinic visit coding. Under
measuring hospital resource utilization indicated that its State Medicaid agency this response, we address the comments
when providing hospital critical care did not accept critical care as a payable specific to critical care coding.
services because the hospital may have service and would only pay for the First, we would like to respond to the
its highest resource use in the first 10 highest level emergency department apparent confusion concerning the
minutes of critical care, much earlier visit code. April 7, 2000 response to a comment
than the 30-minute minimum required Many commenters requested CMS to that we pay separately instead of
in the code descriptor. However, finalize the proposal to create G-codes packaging CPT code 99292 (each
because the proposed G-code indicates for critical care, but that, in doing so, additional 30 minutes of critical care
a minimum of 30 minutes of critical CMS create one G-code for critical care time). Apparently, many commenters
care services before the critical care without trauma activation and one G- misinterpreted the preamble language in
code can be billed, the commenters code for critical care associated with that final rule and believed that it was
indicated that the hospital would not be trauma activation. They also requested not necessary to apply a 30-minute
able to bill for the critical care services that CMS pay differentially for critical minimum before billing a critical care
it provided. In case we still continued care provided with and without trauma code. However, in response to a request
to require a 30-minute minimum, the activation. The commenters suggested to pay separately for CPT code 99292,
we responded that ‘‘We do not believe first implemented in October 2002. The differentially for critical care when there
that paying hospitals for incremental revenue codes series 68x can only be is trauma activation associated with the
time as critical care would better reflect used by trauma centers/hospitals as critical care and when there is no
facility resources. The most resource- licensed or designated by the state or trauma activation. This will improve the
intensive period for the hospital is local government authority authorized accuracy of payments as related to
generally the first hour of critical care. to do so, or as verified by the American resource use. Trauma centers provide
In addition, we believe it would be College of Surgeons. Different important local and regional health
burdensome for hospitals to keep track subcategory codes are reported by the services and serve valuable roles in their
of minutes for billing purposes. designated Level 1–4 hospital trauma communities through their well-
Therefore, we will pay for critical care centers. Only patients for whom there developed emergency capabilities.
as the most resource-intensive visit has been prehospital notification based In response to commenters’ concern
possible as defined by CPT code on triage information by prehospital about G-codes, we will continue to
99291.’’ In this context, it is clear that caregivers, who meet either local, state, instruct providers to bill CPT codes
our response did not deal with the or American College of Surgeons field 99291 and 99292 for critical care. In
application of a 30-minute minimum triage criteria, or are delivered by addition, we are creating one new G-
time in the OPPS. Rather, our response interhospital transfers, and are given the code, G0390 (Trauma response team
dealt only with the issue involved; the appropriate team response can be billed activation associated with hospital
packaging of payment for CPT code a trauma activation charge. critical care service), effective January 1,
99292. Specifically, we indicated that We analyzed CY 2005 claims for 2007, which is assigned to APC 0618
we package CPT code 99292 because it critical care services, dividing claims (Critical Care with Trauma Response),
is burdensome for hospitals to track into two groups: Those with trauma with a median cost of $491.66. When
each additional 30-minute increment of revenue code 68x on the same date of critical care is provided without trauma
time. Instead of requiring this tracking service as CPT code 99291 for the first activation, the hospital will bill CPT
of all minutes of critical care services, period of critical care and those without code 99291 (and 99292, if appropriate)
we package payment for CPT code trauma revenue code 68x on the same as usual, and receive payment for APC
99292 into the payment for CPT code date of service as the critical care code. 0617 (Critical Care), which has a median
99291. Our response did not indicate The median cost for critical care with a cost of $402.67, calculated from that
that the 30-minute minimum trauma revenue code charge is subset of single claims for CPT code
requirement does not apply to CPT code approximately $894, and the median 99291 without revenue code 68x
99291. In fact, the 30-minute minimum cost for claims for critical care without reported on the same day. If trauma
requirement has always applied and a trauma revenue code charge is activation occurs under the
will continue to apply for CY 2007 and approximately $403. The proposed CY circumstances described by the National
beyond. As is currently the case, the 2007 median cost for critical care was Uniform Billing Committee guidelines
hospital can bill the appropriate clinic $495. that would permit reporting a charge
We further reviewed the list of under 68x, the hospital may also bill
or emergency department visit code if
providers who billed critical care with one unit of G-code G0390, reported with
fewer than 30 minutes of critical care is
a trauma revenue code. We noted that revenue code 68x on the same date of
provided. We may provide more
of all the 2,200 hospitals that billed a service, thereby paying the hospital
specific billing guidance at a later point
critical care code during CY 2005, less $491.66 under APC 0618. The CY 2007
in time. As described below, for CY
than 2 percent of these hospitals billed median cost for APC 0618 was
2007, clinic and emergency department
a trauma revenue code on the same date established based on the difference in
visits will be paid at five levels, rather of service as CPT code 99291 one or median costs from the two subsets of
than three levels, which will ensure more times on an OPPS claim. In single claims for CPT code 99291
more accurate payments for these visits. addition, many of the hospitals that representing the reporting of critical
Five payment levels will increase the billed critical care with a trauma care services with and without revenue
payment rates for the highest level revenue code also billed critical care code 68x reported on the same day. The
clinic and emergency department visits, without a trauma revenue code. We OCE will edit to ensure that G0390
which should benefit hospitals that further investigated whether providers appears with revenue code 68x on the
provide these high-level services. that billed critical care with a trauma same date of service and that only one
In response to the commenters who revenue code on the same date of unit of G0390 is billed. We believe that
requested that we pay differentially for service had higher median costs in trauma activation is a one-time
critical care associated with trauma general than providers that billed occurrence in association with critical
response, as well as the critical care without a trauma revenue care services, and therefore, we will
recommendation of the APC Panel, we code. We re-ran the median cost of only pay for one unit of G0390 per day.
performed several studies to determine critical care without a trauma revenue CPT code 99292 remains packaged for
whether critical care associated with code on the same date of service using CY 2007. We will monitor usage of the
trauma response was costlier than only claims from the subset of providers CPT codes for critical care services and
critical care without trauma response. that had billed critical care with the new G-code to ensure that their
As suggested by the commenter, we revenue code 68x to determine if it was utilization remains at anticipated levels.
used revenue codes in the 68x series different than the $403 median cost that For CY 2007, we are not adopting the
reported on the same date as a critical was calculated using all providers. Our proposed HCPCS G-codes in Table 39
care service to determine whether a results showed that providers that billed for critical care services but we are
trauma response was activated in critical care with revenue code 68x had adopting one new G-code (G0390) for
association with critical care services in very similar critical care resource costs trauma activation and response in
order to facilitate selection of to other hospitals. association with critical care services.
appropriate claims. There are specific Therefore, for CY 2007, because we
National Uniform Billing Committee see meaningful cost differences between C. CY 2007 Payment Policy
guidelines related to the reporting of critical care when billed with and Since the implementation of the
trauma revenue codes in the 68x series, without trauma activation, we will pay OPPS, outpatient visits provided by
hospitals have been paid at three minutes in duration, it is to be billed as data indicate that the cost of providing
payment levels for both clinic and either a clinic visit or an emergency a visit of the same level is generally
emergency department visits, even department visit CPT code. Because the significantly higher for emergency
though hospitals have been reporting three payment rates for clinic and department visits in comparison with
five resource-based coding levels of emergency department visits are based clinic visits, with the differential
clinic and emergency department visits on five levels of CPT codes as listed in increasing at higher levels of services.
using CPT E/M codes. Critical care Table 40, in general the two lowest
services have been paid at one level, levels of CPT codes (1 and 2) have been Based upon CY 2005 claims data
with separate payment for the first 30 to assigned to the low-level visit APC and processed through December 31, 2005,
74 minutes of care and bundling of the two highest levels of CPT codes (4 the median costs of clinic visit,
payment for all additional 30 minute and 5) have been assigned to the high- emergency department visit, and critical
increments of critical care services into level visit APC, with the single middle care APCs as configured for CY 2006 are
payment for the first 30–74 minutes. If CPT level CPT code (3) assigned to the listed below.
the critical care service is less than 30 mid-level visit APC. Hospital claims
TABLE 40.—MEDIAN COSTS OF CLINIC AND EMERGENCY DEPARTMENT VISIT AND CRITICAL CARE APCS AS CONFIGURED
FOR CY 2006
APC Title APC Median Levels of CPT Codes Assigned to APC
Clinic Visits
Low Level Clinic Visits .............................. $53.14 Level 1 Clinic Visit, Level 2 Clinic Visit.
Mid Level Clinic Visits ............................... 61.89 Level 3 Clinic Clinic Visit.
High Level Clinic Visits ............................. 89.09 Level 4 Clinic Visit, Level 5 Clinic Visit.
Emergency Department Visits
Low Level Emergency Visits ..................... $74.44 Level 1 ED Visit, Level 2 ED Visit.
Mid Level Emergency Visits ..................... 129.25 Level 3 ED Visit.
High Level Emergency Vists ..................... 230.52 Level 4 ED Visit, Level 5 ED Visit.
Critical Care Services
Critical Care .............................................. $478.04 Critical care, first hour.
However, historical hospitals claims Therefore, we proposed to create five data from the CY 2005 CPT E/M codes
data have generally reflected payment levels for clinic and emergency and other HCPCS codes currently
significantly different median costs for department visits and one payment assigned to the clinic visit APCs to 11
the two levels of services assigned to the level for critical care services. new APCs, 5 for clinic visits, 5 for
low and high level visit APCs. While the As discussed in section IX.B. of this emergency department visits, and 1 for
median costs of these services do not preamble, we are not adopting our critical care services as shown in Table
violate the 2 times rule within their proposal to replace all visit and critical 41 to develop median costs for these
assigned APCs, this may not be the most care E/M CPT codes with G-codes, but APCs. We mapped the CPT E/M codes
we are creating five new G-codes to
accurate method of payment for these and other HCPCS codes to the new
describe Type B emergency department
very common hospital levels of visits APCs based on median costs and
visits and one new G-code to describe
which clearly demonstrate differential critical care services associated with clinical considerations. The table,
hospital resources. In particular, trauma activation and response in which is reprinted below, is relevant for
because of the relatively low volume of association with critical care services. calculating median costs at five
the highest levels of services in the In the proposed rule, to determine payment levels, regardless of whether
clinic and emergency department, our appropriate payment rates for the hospitals use CPT codes or G-codes.
payment rates may be especially low. proposed new G-codes, we mapped the BILLING CODE 4120–01–P
BILLING CODE 4120–01–C In the case of the CPT E/M codes for assignment of data for the proposed rule
emergency department visits, the from five levels of coding to five levels
ER24NO06.023</GPH>
of payment was straightforward. services under the OPPS over the past five levels because its experience has
However, in some cases of the data for several years. We collected hospital shown that providers tend to choose the
CPT clinic visit E/M codes, we assigned claims data for specific detailed services middle level automatically. One
a code to an appropriate clinic visit APC using CPT and HCPCS codes for CYs commenter preferred three levels to five
level based upon resource and clinical 2005 and 2006, while making payments levels to distinguish it from physician
homogeneity considerations, and that based on claims data available to us for coding. Several commenters requested
APC assignment did not correspond to the less specific HCPCS codes billed by that CMS continue paying at three
the visit level described by the code. For hospitals prior to CY 2005. We payment levels until CMS established
example, CPT 99213 is a Level 3 clinic recognize that reporting specific drug national guidelines. These commenters
visit code for an established patient, administration services for which also requested that CMS not transition
which would seem to logically map to hospitals received no separate or to G-codes until national guidelines
the Level 3 Clinic Visit APC. However, additional payments created some were established. They preferred to
because CPT 99213 has a median cost of additional administrative burden on maintain the status quo until national
$60.70, it maps more appropriately to hospitals for a period of time, but the guidelines were established, at which
the Level 2 Clinic Visit APC, which has resource information collected through point they believed it would be more
an overall median cost of $60.13. In the claims submissions has been critical appropriate to also revise the coding
general, CPT codes for established to the development of our proposal of and payment structure. The commenters
patient visits had lower median costs more refined drug administration believed that it would be simpler to
than new patient visit or consultation payment policies. The hospital claims make the changes all at once, rather
codes of the same E/M level, and that data based upon the CY 2005 drug than making incremental changes,
variability was reflected in their administration coding structure now leading up to the establishment of
respective proposed APC data form the foundation of our final CY national guidelines.
assignments for CY 2007. 2007 policy for drug administration Several commenters favored moving
For CY 2007, we proposed to assign services as described in section VIII. of to five payment levels before national
the five new Type A emergency the preamble of this final rule with guidelines were established, and
department visit codes for services comment period. encouraged CMS to finalize the number
provided in a Type A emergency In the proposed rule, we noted that of payment levels before continuing
department to the five new Emergency we were particularly concerned with work on national guidelines. The
Visit APCs, 0609, 0613, 0614, 0615, and ensuring that necessary emergency commenters believed that, if the cost
0616. department services are available to data showed that five payment levels
For CY 2007, we proposed to assign rural Medicare beneficiaries. We would lead to a more accurate
the five new Type B emergency recognize that rural emergency distribution of payment, they were in
department visit codes for services departments may be disproportionately favor of the change.
provided in a Type B emergency likely to offer essential emergency While most comments favored the
department to the five new Clinic Visit department services less than 24 hours distinction between Type A and Type B
APCs, 0604, 0605, 0606, 0607, and 0608. per day, 7 days a week because of the emergency departments, several
This payment policy for Type B limited demand for those services and commenters believed that Type B
emergency department visits is similar the high costs and inefficiencies emergency department visits should be
to our current policy which requires associated with providing full paid at Type A emergency department
services furnished in emergency emergency department availability rates, rather than clinic visit rates. The
departments that have an EMTALA during times when few patients present commenters believed that, although
obligation but do not meet the CPT for emergency care. We believe that our these facilities were open less than 24
definition of emergency department to OPPS payment policies for Type A and hours a day, the services provided more
be reported using CPT clinic visit E/M Type B emergency department visits closely resemble emergency department
codes, resulting in payments based should support the ability of hospitals services than clinic services, and
upon clinic visit APCs. As mentioned to provide their communities with therefore, their resource costs were
above, CPT and CMS require an essential and appropriate emergency higher than clinics. Other commenters
emergency department to be open 24 department services efficiently and believed it was appropriate and
hours per day in order for it to be effectively. We also believe that the reasonable to pay for Type B emergency
eligible to bill emergency department E/ payment policies should present no departments at clinic visit rates until
M codes. While maintaining the same payment incentive for hospitals to cost data was collected. One commenter
payment policy for Type B emergency provide necessary emergency services was concerned that ‘‘unfettered
department visits in CY 2007, the less than 24 hours per day, 7 days per proliferation of less than full-service
reporting of specific G-codes for week, which could result in limited emergency departments could reduce
emergency department visits provided access to emergency services for access for many individuals who need
in Type B emergency departments will Medicare beneficiaries, thereby leading emergency care after hours when Type
permit us to specifically collect and to adverse effects on their health. B emergency departments are closed.
analyze the hospital resource costs of Comment: The commenters were We do not want these facilities to have
visits to these facilities in order to divided as to whether to continue with financial incentives to locate in areas
determine in the future whether a three payment levels or to move to five where the population is more affluent
proposal of an alternative payment payment levels for clinic and emergency and largely insured, leaving full-service
policy may be warranted. The OPPS department visits. Several commenters hospital emergency departments with
rulemaking cycle for CY 2009 will be noted that five payment levels is better an even larger financial burden to care
the first year that we will have cost data because it is similar to the payment for the uninsured and underinsured
for these new Type B emergency structure of other payors, while others after hours.’’ The commenter favored
department HCPCS codes available for noted that three levels was more the distinction between the two types of
analysis. This approach to more refined appropriate because it is difficult to emergency departments, but believed
data collection is similar to our distinguish among four or five levels. the costs of Type B emergency
approach to drug administration Another commenter opposed creation of departments is closer to the cost of Type
A emergency department visits than to receive care in the most cost-efficient We re-assessed the APC assignments
clinic visits. The commenter was unsure setting. for the HCPCS codes in Table 41 using
of the direct impact this payment policy As discussed in section IX.B.3. of this updated final rule data. Because
will have on Type B emergency preamble on coding, we received a hospitals will be reporting CPT codes
departments, recognizing that these significant number of comments for clinic visits for CY 2007, they must
facilities improve patient access to regarding payment for critical care continue to distinguish between new
emergency care. In particular, the services associated with trauma and established patients and
commenter wondered how many activation. We summarized and consultations according to the CPT code
hospital-based Type B emergency responded to those comments in that descriptor. However, it may be
departments exist and how many of section. unnecessary for hospitals to report
them are currently billing at emergency Response: While we acknowledge the consultation CPT codes if either the new
department rates. One commenter noted concern of several commenters that it is or established patient visit code
that emergency departments are best to remain at status quo until accurately describes the service
suffering financially, and that CMS national guidelines are developed, we provided. We do not want to create an
should pay them at higher rates to continue to believe that five payment incentive for hospitals to bill a
ensure continued access. Several levels are now appropriate for both consultation code instead of a new or
commenters suggested that CMS pay clinic and emergency department visits established patient code because we do
Type B emergency departments at a rate based on median cost data. This will not believe that consultation codes
somewhere in between the Type A allow us to more accurately distribute necessarily reflect different resource
emergency department rates and clinic clinic and emergency department utilization than either new or
visit rates until complete cost data are payments, as also noted by several established patient codes. Therefore,
collected. commenters. because consultation codes may be
Several commenters responded to our Five payment levels will increase the reported by hospitals during CY 2007,
concern that rural hospitals may be payment rates for the highest level we re-reviewed the resource costs for
disproportionately likely to offer clinic and emergency department visits, the consultation codes, as well as the
essential emergency department which will benefit hospitals that clinical homogeneity of the APCs to
services less than 24 hours per day, 7 provide these high-level services. In which we proposed to map them. As a
days a week. Specifically, one addition, we do not anticipate that result of this review, we have moved the
commenter confirmed through hospitals will need to update their consultation codes to the same APC as
conversations with State associations internal guidelines to reflect this the established patient code, for each
and hospitals that few emergency change, as it affects payment, not level of service. For example, CPT code
departments are open less than 24 hours coding. While we have heard 99242, the level 2 consultation code is
a day. In particular, the commenter anecdotally that some hospitals only bill mapped to APC 0605 (Level 2 Clinic
indicated many rural hospitals are level 1, level 3, and level 5 clinic and Visits), which is where CPT code 99212,
designated as CAHs, for which the emergency department visit CPT codes the level 2 established patient code, is
Medicare CAH conditions of to simplify their internal coding, our mapped. In addition, we mapped the
participation require that emergency data indicates a fairly normal data for the deleted confirmatory
services are available 24 hours a day. distribution, suggesting that overall, consultation CPT codes, 99271–99275,
While the commenter had heard of a providers are billing all five levels of to the same APC as the corresponding
few emergency departments that were codes. In any case, general coding rules consultation code. Moving the
open less than 24 hours a day, it did not dictate that providers should bill the consultation codes to the same APC as
believe that any rural emergency code that most appropriately describes the corresponding established patient
departments were open less than 24 the service provided. Therefore, for CY visit code eliminates the incentive for
hours a day. 2007, we will finalize our proposal to hospitals to bill a consultation code
One commenter suggested that CMS pay clinic and emergency department instead of a new or established patient
adjust the copayments so that the Level visits at five levels, rather than three code. Table 42 shows the assignment of
1 clinic copayment becomes levels. We will pay for critical care claims data from the CY 2005 CPT E/M
significantly less than the Level 1 services at two payment rates as well, as codes and other codes in the Visit APCs
emergency department visit, to provide described in section IX.B.3. of this to the new Visit APCs for CY 2007.
an incentive for Medicare beneficiaries preamble on coding. BILLING CODE 4120–01–P
ER24NO06.024</GPH>
BILLING CODE 4120–01–C precise data on how many Type B APC unless a statutory provision states
We have reviewed all of the public emergency departments currently exist, that the standard formula does not
comments carefully and continue to but we believe that they are currently apply. Because there is no statutory
believe that it is appropriate to pay Type billing the clinic visit CPT codes, as provision that excludes these visit APCs
B emergency department visits at clinic required under the OPPS, and thus this from the standard formula, we cannot
visit rates, until we collect enough data policy would have little impact on ensure a specific relationship between
to better determine their resource costs. current billing practices and payments. the clinic and emergency department
We have no hospital resource data that Therefore, for CY 2007, we are finalizing visit copayments.
would support how to establish our proposal to pay Type B emergency For CY 2007, we are finalizing
appropriate payment rates for Type B departments at clinic visit rates. without modification our proposal to
emergency department visits at rates We appreciate the efforts of the create five payment levels for clinic and
between clinic and Type A emergency commenters that responded to our emergency department visits. We are
department rates. The fact that they do concern about access to rural emergency finalizing with modification our
not operate with all capabilities full- departments. As most rural emergency proposal to create one payment level for
time suggests that hospital resources departments are open 24 hours a day, critical care, by providing an additional
associated with visits to DEDs may not we believe Medicare beneficiaries in payment when critical care is associated
be as great as those for full-time hospital rural areas should continue to have with trauma activation and response.
emergency departments. Paying clinic access to emergency care. D. CY 2007 Treatment of Guidelines
rates for visits to Type B emergency In response to the commenter that
departments would be consistent with suggested that the copayment for 1. Background
current OPPS policy and CPT guidelines emergency department visits be set at a As described in section IX.A. of the
that a facility that does not meet the higher rate than the copayment for preamble of this final rule with
CPT definition of emergency clinic visits, we note that the statute and comment period, since April 7, 2000,
department cannot bill emergency regulation set a general formula that we we have instructed hospitals to report
department CPT codes and, therefore, use to calculate copayments. As stated facility resources for clinic and
cannot receive emergency department in 42 CFR 419.41, for CY 2007, a emergency department outpatient
visit payments. We agree with the copayment cannot be lower than 20 hospital visits using the CPT E/M codes
commenter that was concerned about percent of the payment rate or greater and to develop internal hospital
creating incentives for emergency than 40 percent of the payment rate. In guidelines for reporting the appropriate
departments to be open less than 24 addition, we have established through visit level. In the CY 2003 OPPS final
hours a day, which could thereby place rulemaking a detailed formula that we rule with comment period (67 FR
additional burden on the emergency use to calculate copayments. We do not 66792), we noted that an independent
ER24NO06.025</GPH>
health care system. We do not have artificially adjust copayments for any panel of experts would be an
appropriate forum to develop codes and guidelines for use in the OPPS of which We continue to commit that we will
guidelines. In that final rule with we are aware. Our particular interest in provide a minimum of 6–12 months
comment period, we also articulated a these guidelines is based upon the notice to hospitals prior to
set of principles that any national broad-based input into their implementation of national guidelines
guidelines for facility visit coding development, the need for CMS to move to provide sufficient time for providers
should satisfy, including that coding definitively to promulgate national to make the necessary systems changes
guidelines should be based on facility outpatient hospital visit coding and educate their staff.
resources, should be clear to facilitate guidelines in the near future, and full
accurate payments and be usable for 2. Outstanding Concerns with the AHA/
consideration of the characteristics of
compliance purposes and audits, should AHIMA Guidelines
alternative types of guidelines. We also
meet the HIPAA requirements, should believe that hospitals will react a. Three Versus Five Levels of Codes
only require documentation that is favorably to guidelines developed and The AHA/AHIMA guidelines describe
clinically necessary for patient care, and supported by the AHA and AHIMA, three levels of codes for clinic and
should not facilitate upcoding or national organizations that have great emergency department visits, rather
gaming. We stated that the distribution interest in hospital coding and payment than the five levels of codes that
of codes should result in a normal issues, and possess significant medical, currently exist for clinic and emergency
curve. technical and practical expertise due to department visits. We believe that it is
Subsequently, as described above, the their broad membership, which difficult to pay at five levels using these
AHA and AHIMA formed an includes hospitals and health
independent expert panel, the Hospital guidelines, unless the guidelines were
information management professionals. revised, because hospitals would not
Evaluation and Management Coding Anecdotally, we have been told that a
Panel, and submitted the AHA/AHIMA have guidelines that applied to the
number of hospitals are successfully Level 2 and Level 4 visits. As discussed
guidelines for reporting three levels of utilizing the AHA/AHIMA guidelines to
hospital clinic and emergency above, our claims data indicate that five
report levels of hospital visits. However, payment levels are justified for both
department visits and a single level of other organizations have expressed
critical care services to CMS. The clinic and Type A emergency
concern that the AHA/AHIMA department visits, and, therefore, we are
guidelines are based on an intervention guidelines may result in a significant
model, where the levels are determined finalizing five levels of clinic and
redistribution of hospital visits to higher emergency department visit payments
by the numbers and types of levels, reducing the ability of the OPPS
interventions performed by nursing or so that providers may code at five visit
to discriminate among the hospital levels and receive payments at five
ancillary hospital staff. We undertook a resources required for various different
critical review of the recommendations levels as well. In fact, the materials
levels of visits. We, too, remain explaining the AHA/AHIMA guidelines
and made some modifications to the concerned about the potential
guidelines based on comments we state that one of the reasons that the
redistributive effect on OPPS payments model includes only three coding levels
received from outside hospitals and for other services or among levels of
associations, clinical review, and is because CMS only paid at three
hospital visits when national guidelines payment levels. We will now pay at five
changing payment policies in the OPPS for outpatient visit coding are adopted.
regarding some separately payable payment levels for CY 2007 and believe
We recognize that there may be the AHA/AHIMA guidelines may need
services. In addition, as previously difficulty crosswalking historical
stated, we contracted a study to to be revised to reflect five visit levels.
hospital claims data from current CPT
retrospectively code, under the b. Lack of Clarity for Some Interventions
E/M codes reported based on individual
modified AHA/AHIMA guidelines,
internal hospital guidelines to payments Some interventions are vague,
hospital visits by reviewing hospital
for any new coding system developed, unclear, or nonspecific, without
visit medical chart documentation
in order to provide appropriate payment sufficient examples of documentation in
gathered through CERT work. In
levels for hospital visits reported based the medical record that may support
summary, while the testing of the
on national guidelines in the future. those interventions. For instance, it is
modified AHA/AHIMA guidelines was
helpful in illuminating areas of the There are several types of problems unclear what documentation for the
guidelines that would benefit from with the AHA/AHIMA guidelines that intervention stated as ‘‘Patient
refinement, we were unable to draw have been identified based upon registration, room setup, patient use of
conclusions about the relationship extensive staff review and contractor room, room cleaning’’ and assigned in
between the distribution of current use of the guidelines during the the AHA/AHIMA guidelines to a low-
hospital reporting of visits using CPT E/ validation study. We believe the AHA/ level clinic visit would be necessary to
M codes that are assigned according to AHIMA guidelines require short-term support all aspects of that intervention.
each hospital’s internal guidelines and refinement prior to their full adoption In another case, the intervention
the distribution of code levels under the by the OPPS, as well as continued ‘‘Frequent monitoring/assessment as
AHA/AHIMA guidelines, nor were we refinement over time after their evidenced by two sets of vital sign
able to demonstrate a normal implementation. Our modified version measurements or assessments’’ that is
distribution of visit levels under the of the AHA/AHIMA guidelines provides attributable to a mid-level emergency
modified AHA/AHIMA guidelines. some possibilities for addressing certain department visit in the guidelines
Despite the inconclusive findings issues. Our eight general areas of explains that this may include
from the validation study, after concern regarding the AHA/AHIMA assessment of cardiovascular,
reviewing the AHA/AHIMA guidelines, model are listed below. In addition, we pulmonary, or neurological status.
as well as approximately a dozen other have posted to the CMS Web site both However, it is unclear exactly what
guidelines for outpatient visits the original AHA/AHIMA guidelines coders should look for in the medical
submitted by various hospitals and and our modified draft version. In the record to support this intervention and
hospital associations, we believe that CY 2007 OPPS proposed rule (71 FR whether narrative hospital staff
the AHA/AHIMA guidelines are the 49616), we sought public input before descriptions of patient status would be
most appropriate and well-developed we adopt national guidelines. considered to be assessments. These
examples, and others, were identified by separately payable, provided certain interventions in the guidelines, with the
the contractor engaged in medical chart conditions were met. If the guidelines goal of differentiating five levels of
reviews as part of the guidelines strictly excluded all separately payable services in a normal distribution, based
validation study. The AHA/AHIMA services, the guidelines could also on their respective hospital resources.
guidelines may benefit from revisions to change from year to year, possibly
e. Concerns of Specialty Clinics
clarify some interventions and/or requiring additional education of
provide additional examples based hospital staff on an annual basis. An The AHA/AHIMA guidelines are
upon questions that arose during field extremely ill emergency department unlikely to sufficiently address the
testing of the guidelines or that are patient who may need a significant concerns of various specialty clinics (for
raised by hospitals reviewing the AHA/ number of separately payable example, pain management clinics,
AHIMA guidelines and the modified procedures, but only one or two minor oncology clinics, and wound care
version posted on our Web site. interventions that are not separately centers). Anecdotally, we have heard
payable, may require significant time that the interventions listed in the AHA/
c. Treatment of Separately Payable AHIMA guidelines do not include many
and attention from hospital staff that is
Services of the interventions commonly
unrelated to the hospital resources
CMS and the APC Panel stated that generally required for the separately performed in specialty clinics and that
separately payable services should be payable procedures. The guidelines may some of the interventions in the
excluded from the guidelines because of indicate that a low level emergency guidelines would never be performed in
their concern over the potential for department visit code should be billed, certain types of clinics. Currently, each
double payment for hospital resources while, in fact, the patient may require provider has its own set of guidelines,
attributed to visit services when those significantly more hospital resources and we believe that some specialty
resources were actually used to provide than a mildly ill patient who received clinics have customized guidelines to
the separately payable services. the same two minor interventions. In facilitate coding their visits at different
Consistent with this policy, at the time the proposed rule, we indicated that we levels based upon the specific hospital
of their development, the AHA/AHIMA are open to further discussion and resources commonly used in visits to
guidelines excluded all services welcomed public comments on the their clinics. While we prefer to have
separately payable under the OPPS from exclusion of separately payable services one model that can be applied
the list of interventions. For policy from the national visit guidelines and nationally to each level of clinic visit
consistency, in our modified draft whether their inclusion could pose a code for which we make a specific
version of the guidelines, we removed risk of attributing the same hospital OPPS payment, we are unsure as to
interventions that have now become resources to both visits and separately whether one model can adequately
separately payable under the OPPS payable services, potentially resulting in characterize visit levels for all types of
through CY 2006, such as bladder duplicate payments for those resources. clinics. For example, we have been told
catheterizations and some wound care that the most appropriate proxy for
services. However, upon further d. Some Interventions Appear facility resource consumption in cancer
reflection as we move forward to Overvalued care is staff time due to the intensive
implement national guidelines, in the Several interventions that we believe staff interactions required to care for
proposed rule, we indicated that we are may be minor are valued at a high level patients with cancer, regardless of the
open to reconsidering whether the in the guidelines. This could result in reasons for their clinic visits. In the
inclusion of some separately payable visits with relatively less resource proposed rule, we expressed interest in
services in guidelines to determine visit intensive interventions being coded as receiving comments regarding the
levels could serve as a proxy for the high level visits, leading to an overall feasibility of applying national
resources that the patient will consume visit distribution that was skewed guidelines to specialty clinic visits
and that should be attributable to the toward the high end. Claims data then while ensuring appropriate OPPS
hospital visit, not the separately payable would fail to reflect the differential payments for those services and
services. In such cases, consideration of hospital resources associated with suggestions for revisions to the
separately payable services in reporting hospital visits of five levels. For guideline models posted that could
visit levels may not result in double example, the AHA/AHIMA guidelines improve their utility in reporting such
payment for components of those consider oxygen administration, visits.
separately payable services. There may described as initiation and/or
be hospital resources used in visits that adjustment from a baseline oxygen f. Americans With Disabilities Act
are not captured in the AHA/AHIMA regimen, to be a mid-level emergency We are concerned that the AHA/
guidelines’ limited number of department intervention, while we AHIMA guidelines’ intervention related
interventions that are not separately believe that the associated hospital to the special needs of certain patients
payable. We believe that, in general, a resources could be more consistent with may be in violation of the Americans
patient with high medical acuity will its characterization as a low-level with Disabilities Act, as it may increase
consume more hospital resources in the emergency department intervention. In the visit level reported, thereby
visit than a patient with moderate another example, the AHA/AHIMA increasing a patient’s copayment. Even
acuity. However, when separately guidelines consider specimen if additional hospital resources are
payable interventions are removed from collection(s), other than venipuncture required to treat patients with
the model, it may be difficult for the and other separately payable services, to disabilities, patients must not have
limited interventions remaining in the be a mid-level clinic intervention, while additional financial liability for those
guidelines for each visit level to capture we believe this may be more consistent services based on their disabilities.
the acuity level of the patient. In with other low-level clinic

addition, the list of HCPCS codes that interventions, depending upon the g. Differentiation Between New and
are packaged can change annually. For numbers and types of different Established Patients and Between
example, in the CY 2006 OPPS, bladder specimens collected. In the proposed Standard Visits and Consultations
catheterization services, which had been rule, we encouraged specific comments The AHA/AHIMA guidelines do not
packaged in prior years, were first made on the levels assigned to various differentiate between new versus
established patients or consultations h. Distinction Between Type A and guidelines, but a few commenters
versus standard visits for clinic visits. Type B Emergency Departments preferred to continue using the internal
During the summer 2002 APC Panel There are no AHA/AHIMA guidelines guidelines that they had been using for
meeting, the APC Panel recommended for the reporting of visits to Type B several years. Some hospitals had
that CMS not differentiate among visit emergency departments that meet the successfully implemented the original
types, specifically new, established, and EMTALA definition of a DED, but do AHA/AHIMA model, while others had
consultation visits, for the purposes of not meet the proposed definition of a success with diagnosis-related models
clinic visit facility coding. Therefore, in Type A emergency department, as and resource intensity point scoring
the August 9, 2002 OPPS proposed rule, discussed above. When the AHA and models. One commenter indicated that
we proposed to accept the APC Panel’s AHIMA created these guidelines, a diagnosis-based model is not as
recommendation to create five new G- emergency departments that did not complicated as we described. The
codes to replace the CPT new and meet the CPT definition of emergency commenter’s hospital had great success
established clinic visit and consultation department were instructed to bill CPT training its staff and now has little
E/M codes. We did not finalize the clinic visit E/M codes. There was no coding variability among its coders. One
codes for CY 2003 because of concerns distinction in CPT reporting between developer of national guidelines noted
then about creating new G-codes emergency departments that, as DEDs, that many hospitals had success with
without national guidelines. had an EMTALA obligation but did not problem-based guidelines that it had
During CY 2006 and earlier, there has meet the CPT definition of emergency created. The developer noted that its
not been a payment difference between department and outpatient hospital system was easy to use, produced
new and established patient visits of the clinics that did not provide emergency consistent coding decisions with a
same level, as generally both were services. For the new G-codes that we normal distribution of visits, and even
mapped to the same APC. The created in this final rule with comment served as a tool to track effectiveness
information describing the AHA/ period for CY 2007 for Type B and efficiency. One hospital asked if it
AHIMA guidelines indicates that only emergency departments to use in was permitted to continue using its own
one set of guidelines was developed for reporting visits, in the short run internal guidelines if CMS had
five levels of codes for clinic visits, hospitals will use internal guidelines to indicated some concerns with that
regardless of a patient’s status as a new determine their visit levels for Type B particular type of guidelines. Several
or established patient or the provision of emergency department visits, as they hospitals asked us to clarify whether a
a consultation visit. This approach may will for visits to both clinics and Type normal distribution would be expected
have been related to the lack of a A emergency departments. However, nationally, across all hospitals, or for an
payment differential for different types with the implementation of national individual hospital. The commenter
of clinic visits of the same level under hospital visit guidelines, we will need suggested that it would be appropriate
the OPPS when those guidelines were to specify those guidelines to be used for a trauma center to have a curve that
developed. However, several years of for the purposes of Type B emergency was skewed to the right, toward higher
hospital claims data regarding the department visit reporting. The AHA level visit codes. Another commenter
median costs of the specific CPT clinic and AHIMA have not yet had the suggested that hospitals be instructed to
visit E/M codes consistently indicate opportunity to consider the issue of bill the same level code that is billed on
that new patients generally are more Type B emergency department visit the physician side, to simplify coding
resource intensive than existing patients reporting in their guidelines, and in the and reduce excess documentation. The
across all visit levels, and that proposed rule we welcomed public commenter noted that then there would
consultations are more resource comments to provide additional be no concern about redistributive
intensive than standard visits, but perspectives on the appropriate impact because we could simply study
similar in terms of resources to new guidelines for reporting visit levels in the physician E/M code distribution.
patient visits. For example, based upon these Type B emergency departments. One commenter requested that the final
the final CY 2005 claims used by the We received a large number of guidelines use criteria and/or
OPPS for CY 2007 ratesetting, CPT code comments related to national guidelines interventions that would be available in
99213, the level 3 clinic visit code for for clinic and emergency department electronic medical records, to ease
established patients, has a median cost visits and critical care services, some of guideline implementation for hospitals
of $60.70. CPT code 99203, the level 3 which described general questions and with this technology. The same
clinic visit code for new patients, has a concerns about using a national model commenter suggested that the
median cost of $72.33. CPT code 99243, and others with specific suggestions for guidelines should be very specific and
the level 3 consultation visit code, has improving the AHA/AHIMA model. As serve as detailed coding instructions
a median cost of $72.89. Finally, CPT noted in the CY 2007 proposed rule, we rather than just ‘‘guidelines,’’ which
code 99273, the level 3 confirmatory sought broad public input regarding our would make training easier and reduce
consultation visit code that was deleted discussion of national guidelines to the number of questions directed at the
for CY 2006 had a median cost of inform our guidelines development fiscal intermediaries. The commenter
$98.24. In the proposed rule, we efforts at this point in time, but we suggested that the guidelines include
encouraged public comments that made no specific proposal for CY 2007. details, with regulation citations such as
discuss the potential differences in Therefore, the comments below are ‘‘the patient must be a registered
hospital clinic resource consumption for summarized to reflect the breadth and outpatient of the hospital’’ as defined in
new patient visits, established patient depth of thoughtful input provided by a particular regulation. Several
visits, and consultations. If there are the public, and we will continue to commenters requested that we clarify
significant additional hospital resources consider these comments and additional that the clinic guidelines are intended to
required to provide new patient visits or public input as we work to develop be used by any outpatient area that is
consultations, we are unsure whether national guidelines for future not an emergency department, even if
the interventions in the AHA/AHIMA implementation. that outpatient area is not a true clinic
guidelines would reliably capture these Comment: Most commenters strongly and suggested that the guidelines
additional resources. supported creation of national should be titled ‘‘Outpatient visit
guidelines’’ instead of ‘‘Clinic visit measure quantitative items such as precautions, drug/alcohol influence,
guidelines.’’ One commenter gave blood pressure, heart rate, and pain prepping for surgery, postmortem care,
examples of outpatient areas that are not threshold scoring, and like items. dietary planning, pain management, and
clinics, which included outpatient Most commenters believed that others. Although pre-authorization is
infusion centers, outpatient oncology separately payable interventions should not required for Medicare beneficiaries,
centers, wound care centers, and be included in the guidelines because some commenters noted that hospitals
outpatient maternity services. they serve as a proxy for resource use. will use these guidelines for all payors,
We received many specific comments One commenter noted that the so it may be appropriate to include this
about the AHA/AHIMA model. The American College of Emergency intervention. One commenter agreed
AHA and AHIMA were pleased that we Physicians’ guidelines have an excellent that continuous irrigation of the eye
are working on their model and look list of interventions, some of which are should not be a Level 5 visit. The AHA
forward to reconvening the expert panel separately payable. One commenter and AHIMA stated that its expert Panel
to continue work on this project. They suggested that we assign a modifier to looked carefully at each intervention.
noted that the model was an initial a code that is separately paid so that it They noted that their criteria for
attempt with a short turnaround time, would not be counted toward placement included hospital staff time
and that it was never intended to be calculating a visit level. The AHA and involved, complexity of intervention,
used as a stand-alone document. They AHIMA aptly noted that not all number of hospital staff members
anticipated creating educational separately payable services reflect required to perform the intervention,
supplemental materials that would patient acuity, so it would be necessary and the skill level, qualifications, or
accompany the guidelines. Several for the Panel to determine which credentialing needed to perform the
organizations expressed interest in services are appropriate for inclusion. intervention. Other commenters noted
working with CMS as well as the AHA/ One commenter asked that we continue that the interventions were focused on
AHIMA expert panel in the to exclude separately payable services to interventions performed by nurses,
development of national guidelines, avoid double billing and confusion. rather than by assorted clinicians and
including the American College of Some commenters indicated that most technicians. One hospital expressed
Emergency Physicians and Lynx interventions in the original AHA/ interest in submitting further
Medical Systems. AHIMA model were appropriately suggestions after the comment period
Several commenters agreed that it was placed, with some interventions that ended.
appropriate to continue with five levels were valued too low and a few that were We received a few comments about
of coding to achieve consistency with valued too high. Other commenters applying one set of guidelines to all
other payors. Other commenters agreed disagreed with several CMS-suggested clinics, including specialty clinics,
that retaining five coding levels was revisions. For example, in the revised suggesting that it was unnecessary to
appropriate if five payment rates model, if emergency department staff create multiple guidelines. Several
existed. One commenter believed that performed a body assessment, pain commenters suggested that any
three levels was simpler and measurement, vitals, and an x-ray, that differences could be addressed with
distinguished hospital coding from service would no longer reach a level 1 time as an element, which is the single
physician coding, which has five coding visit, while under the original AHA/ biggest resource that varies among
levels. The AHA and AHIMA noted that AHIMA guidelines, the service would clinics. For example, a diabetic patient
the guidelines originally used three be coded as a Level 1 visit. Several with limited eyesight requires
levels because the expert panel found it commenters argued that oxygen additional training time to learn to read
hard to distinguish between five levels administration should not be moved to glucose levels and give the proper
when separately payable services were a low level because it is resource- amount of insulin. A cancer association
excluded. However, if separately intensive in terms of staff time and submitted an additional example,
payable services or other factors such as resource use. One commenter stated that explaining that a simple blood draw can
time could be included, the model specimen collection was appropriately be time consuming when performed on
could be modified to account for five assigned as a Level 1 intervention in a an oncology patient, whose veins may
levels. They requested clear guidance clinic setting but should be higher in the be damaged from the effects of
from CMS before proceeding. emergency department because staff chemotherapy. One commenter
Many commenters agreed that often need to assist patients who are suggested that if more than 50 percent
multiple interventions were unclear and anxious and having trouble of a visit is used for counseling and care
could be interpreted in several ways. concentrating. Another commenter coordination, the visit level should be
Other commenters asked CMS to clarify suggested Level 1 assignment for one to increased by one level. Several
exactly which interventions were two specimen collections and Level 3 associations stated that it is unlikely
unclear. One commenter noted that over for three or more collections. Two that one set of guidelines could apply to
time, after the guidelines are hospitals speculated that their all specialty clinics. Specifically, one
implemented, the ambiguities will emergency department payment would wound care association recommended
decrease as staff becomes familiar with decrease by 30 to 40 percent as a result that all wound care clinics use the
the model. Several commenters of transitioning to the AHA/AHIMA guidelines developed by that particular
suggested that specific examples of guidelines. There were additional association. Another wound care
patient acuity or symptoms would be suggestions that specific interventions association developed an acuity scoring
useful. (We noted above that the AHA move from one level to another. Several system that has been successfully
and AHIMA anticipated that they would commenters suggested additional implemented by wound care clinics.
provide significant supplemental interventions that should be included, One commenter suggested that in a
materials.) Several commenters asked such as restroom assistance, memory time-based model, there would be no
that we clarify the difference between testing, reviewing medications, American with Disabilities Act (ADA)
‘‘triage’’ and the medical screening obtaining insurance authorization, violation. Another commenter suggested
exam required under EMTALA psychological and spiritual counseling, setting a flat copayment rate for all
provisions. One commenter suggested emotional support, time with the family, clinic and all emergency department
that CMS only use interventions that discharge instructions, seizure visits to avoid an ADA violation. The
AHA and AHIMA clarified that their that we intend for these national eight areas of concern that are discussed
intention was not to increase the guidelines to be used by any outpatient above, as well as the other issues
beneficiary copayment but was intended hospital department, even if it is not reviewed above that have been brought
to reflect resource utilization. called a clinic. to our attention by the public. We plan
We discuss in sections IX.B. and C. of We would expect these national to communicate progress on the
this preamble the comments that we guidelines to provide for five levels of development of OPPS visit guidelines
received about the distinction among coding, to parallel the five payment through updates to the OPPS Web site
‘‘new’’ and ‘‘established’’ visits and levels that are finalized in this final rule at: http://www.cms.hhs.gov/
‘‘consultations.’’ A few commenters with comment period. It would be
HospitalOutpatientPPS/ and we may
suggested that a new patient could be a impossible to code at three levels and
post other versions of draft guidelines in
contributing factor in the guidelines. pay at five levels. As described above,
We also discuss in sections IX.B of we believe that paying at five levels will order to solicit additional public input
this preamble the comments that we allow a more accurate payment for during CY 2007. When we post
received about Type A versus Type B clinic and emergency department visits. additional materials to the Web site for
emergency departments. We received no We agree with commenters that there purposes of providing information or
comments on this topic that were may be advantages to including soliciting further comments regarding
specific to the AHA/AHIMA guidelines. separately payable interventions in the national guidelines, we will update the
One organization noted that some guidelines as examples, because a public through all means practically
revisions may have been necessary due measure of acuity may be lost in the available to us, including
to changes in clinical practice since the absence of recognition of these communications with professional
guidelines were developed 3 years ago. procedures. We also agree with the AHA associations, list-serves, and other
Another commenter noted that several and AHIMA that it might be easier to broad-based communication forums.
Level 1 emergency department distinguish among five levels of coding
interventions, such as first aid, are Level While we understand the interest of
if separately payable interventions are
3 clinic interventions, which leads to some hospitals in our moving quickly to
included as examples.
emergency departments receiving less We appreciate all of the specific promulgate national guidelines that will
payment for the same service, even comments about interventions that may ensure standardized reporting of
though emergency departments are not be appropriately assigned to levels outpatient hospital visit levels, we
costlier. in the guidelines. We acknowledge that believe that the issues we have
The AHA and AHIMA requested that the guidelines are still being developed identified and others that may arise are
CMS release the detailed analysis of the and require additional testing. While it important and require serious
Iowa Foundation for Medical Care would be impossible for every single consideration prior to the
review of the AHA/AHIMA model so hospital to agree about the placement of implementation of national guidelines.
that they can review all concerns. They every single intervention in the Because of our commitment to provide
also requested that CMS clarify the guidelines, we anticipate that the hospitals with 6–12 months notice prior
rationale for the other modifications. interventions will be assigned in a way to implementation of national
For example, it sometimes appeared to that best reflects the resource use of the guidelines, we expect that we would not
them as if CMS measured physician services provided such that few implement national guidelines prior to
time rather than facility resources or providers will have objections. We CY 2008. We acknowledge that, once
hospital staff time. For example, patient remind providers that under a relative implemented, the guidelines will
education by hospital staff was removed system, if a service is listed as a Level require periodic review and updating
but physician counseling of more than 1 intervention, it does not mean that based on factors such as changing
60 minutes was added. very few hospital resources are
Response: We appreciate all the medical practices, hospital experiences
involved. Instead, it means that the
comments we received from the public, in reporting the codes, new payment
resources used in that service must be
and we encourage continued policies under the OPPS, and median
considered relative to the other
submission of comments at any time interventions in the model. costs for levels of services calculated
that will assist us, the AHA/AHIMA While most commenters believed that from claims data. We are hopeful that
expert panel, and other stakeholders one set of guidelines could apply to all the information received from the AHA,
interested in the development of specialty clinics, it may be necessary to AHIMA and others on such reviews
national guidelines. Until national incorporate time into the guidelines as would permit us to effectively, and in a
guidelines are established, hospitals well. The AHA and AHIMA expert timely manner, address emerging
should continue using their own panel has considered this issue as well. guideline implementation issues, as
internal guidelines, even if we have We will determine whether the Iowa well as develop desirable future
expressed reservations about the type of Foundation for Medical Care study of modifications to the guidelines based on
guidelines that a hospital is currently the modified AHA/AHIMA model can hospitals’ experiences reporting
using. As commenters stated, we would be released to the public. commonly provided visits. We believe
not expect individual hospitals to The public comments that we that this ongoing and evolving system
experience a normal distribution of visit received on this guidelines section of should provide the most successful
levels, although we would expect a the proposed rule are publicly available approach to ensuring that OPPS
normal distribution across all hospitals to the AHA and AHIMA and their national visit guidelines continue to
after national guidelines are established. expert panel, as well as other interested facilitate consistent and standardized
We would expect that a small parties, along with comments that we reporting of outpatient hospital visits, in
community hospital may provide more received on the two versions of the
a manner that is resource-based and
low-level services than high-level guidelines posted on the CMS Web site
supportive of appropriate OPPS
services, while an academic medical at: http://www.cms.hhs.gov. We hope to
center or trauma center may provide receive additional input from the AHA payments for the efficient and effective
more high-level services than low-level and AHIMA and other stakeholders over provision of visits in hospital outpatient
services. The commenters are correct the upcoming months to address the settings.
X. Payment for Blood and Blood that public comments on previous OPPS 2005 adjusted median costs for some
Products rules had stated that the CCRs that were specific blood products. For the CY
used to adjust charges to costs for blood 2006 OPPS, we adopted a payment
A. Background
products in past years were too low. adjustment policy that limited
Since the implementation of the OPPS Past commenters indicated that this significant decreases in APC payment
in August 2000, separate payments have approach resulted in an rates for blood and blood products from
been made for blood and blood products underestimation of the true hospital the CY 2005 OPPS to the CY 2006 OPPS
through APCs rather than packaging costs for blood and blood products. In to not more than 5 percent. We applied
them into payments for the procedures response to these comments and APC this adjustment to 11 blood and blood
with which they were administered. Panel recommendations from its product APCs for the CY 2006 OPPS,
Hospital payments for the costs of blood February 2004 and September 2004 which we identified in Table 33 of the
and blood products, as well as the costs meetings, we conducted a thorough CY 2006 OPPS final rule with comment
of collecting, processing, and storing analysis of the CY 2003 claims (used to period. For the CY 2006 OPPS, we set
blood and blood products, are made calculate the CY 2005 APC payment the final median costs for blood and
through the OPPS payments for specific rates) to compare CCRs between those blood products at the greater of: (1) The
blood product APCs. On April 12, 2001, hospitals reporting a blood-specific cost simulated median costs calculated from
CMS issued the original billing center and those hospitals defaulting to the CY 2004 claims data; or (2) 95
guidance for blood products to hospitals the overall hospital CCR in the percent of the CY 2005 OPPS adjusted
(Program Transmittal A–01–50). In conversion of their blood product median costs for these products, as
response to requests for clarification of charges to costs. As a result of this reflected in Table 33 published in the
these instructions, CMS issued Program analysis, we observed a significant CY 2006 OPPS final rule with comment
Transmittal 496 on March 4, 2005. The difference in CCRs utilized for period.
comprehensive billing guidelines in the conversion of blood product charges to
Program Transmittal also addressed B. Policy Changes for CY 2007
costs for those hospitals with and
specific concerns and issues related to without blood-specific cost centers. The In the CY 2007 OPPS proposed rule,
billing for blood-related services, which median hospital blood-specific CCR was we proposed to base CY 2007 payment
the public had brought to our attention. almost two times the median overall rates for blood and blood products on
In the CY 2000 OPPS, payments for hospital CCR. As discussed in the their median costs from CY 2005 claims
blood and blood products were November 15, 2004 final rule with data, calculated using a special
established based on external data comment period, we applied a methodology to simulate blood-specific
provided by commenters due to limited methodology for hospitals not reporting CCRs if hospitals did not have such
Medicare claims data. From the CY 2000 a blood-specific cost center, which specific CCRs. After hearing several
OPPS to the CY 2002 OPPS, payment simulated a blood-specific CCR for each public presentations at the August 2006
rates for blood and blood products were hospital that we then used to convert APC Panel meeting, the Panel engaged
updated for inflation. For the CY 2003 charges to costs for blood products. in considerable deliberation and
OPPS, as described in the November 1, Thus, we developed simulated medians recommended that CMS reconsider its
2002 final rule with comment period (67 for all blood and blood products based methodology to develop payment rates
FR 66773), we applied a special on CY 2003 hospital claims data (69 FR for blood and blood products to more
adjustment methodology to blood and 65816). accurately reflect the true costs of blood
blood products that had significant For the CY 2005 OPPS, we also and blood products to hospitals,
reductions in payment rates from the CY identified a subset of blood products including using external data. We
2002 OPPS to the CY 2003 OPPS, when that had less than 1,000 units billed in include our response to this
median costs were first calculated from CY 2003. For these low-volume blood recommendation in the discussion
hospital claims. Using the adjustment products, we based the CY 2005 OPPS below.
methodology, we limited the decrease in payment rate on a 50/50 blend of the CY We received a number of public
payment rates for blood and blood 2004 OPPS product-specific OPPS comments regarding this proposal. A
products to approximately 15 percent. median costs and the CY 2005 OPPS summary of the comments and our
For the CY 2004 OPPS, as recommended simulated medians based on the responses follows:
by the APC Panel, we froze payment application of blood-specific CCRs to all Comment: A number of commenters
rates for blood and blood products at CY claims. We were concerned that, given objected to our proposal to base
2003 levels as we studied concerns the low frequency in which these payments for blood and blood products
raised by commenters and presenters at products were billed, a few occurrences on their simulated median unit costs.
the August 2003 and February 2004 of coding or billing errors may have led They stated that the proposed payments
APC Panel meetings. to significant variability in the median are inadequate to compensate hospitals
For the CY 2005 OPPS, we established calculation. The claims data may not for the full acquisition costs of blood
new APCs that allowed each blood have captured the complete costs of and blood products. Some commenters
product to be assigned to its own these products to hospitals as fully as said that they appreciated CMS’ work to
separate APC, as several of the previous possible. This low-volume adjustment calculate more appropriate payment
blood product APCs contained multiple methodology also allowed us to further rates for blood and blood products, but
blood products with no clinical study the issues raised by commenters urged CMS to use external data, rather
homogeneity or whose product-specific and by presenters at the September 2004 than claims-based data, as a measure of
median costs may not have been similar. APC Panel meeting, without putting the appropriateness of the median costs
Some of the blood product HCPCS beneficiary access to these low-volume derived from the claims process.
codes were reassigned to the new APCs blood products at risk. Specifically, the commenters asked
(Table 34 of the November 15, 2004 Overall, median costs from CY 2003 CMS to set the payments for four blood
final rule with comment period (69 FR (used for the CY 2005 OPPS) to CY 2004 products at 110 percent of the average
65819)). (used for the CY 2006 OPPS) were hospital purchase price for four blood
We also noted in the November 15, relatively stable, with a few significant products, specifically, P9016, RBC
2004 final rule with comment period, increases and decreases from the CY Leukocytes reduced; P9017, Plasma 1
donor frz w/in 8 hr; P9019, and including the average amounts hospitals rates for these products tend to volatile
Platelets; P9035, Platelet pheresis paid for the four blood products in CY even with an entire year of claims data,
leukoreduced as determined from data 2004, is available in the journal because they are furnished in very low
submitted by 1600 hospitals in response ‘‘Transfusion,’’ 2006 volume 46 volume in outpatient hospital settings.
to a survey of 2004 blood costs that was Supplement (page 188A). We reviewed We also are not setting median costs for
conducted by the Department of Health the limited information that is currently the product without processing and
and Human Services under a contract available from the survey for these four establishing separate median costs for
with the American Association of Blood blood products. However, we are unable each different type of processing.
Banks (AABB). The commenters to determine the extent to which the Hospitals generally acquire the product
believed that the 10 percent increase survey findings could be useful in processed as specified in the definition
over the survey purchase price findings evaluating the methodology and of the product they report, and we do
was necessary to update the amounts to resulting median costs that were the not believe that they would be able to
reflect what they thought would be the basis for our CY 2007 proposal of charge separately for the unprocessed
costs to hospitals for these blood payment rates for all blood and blood product (for example, red blood cells)
products in CY 2007. They stated that products. Our payment methodology for and also charge separately for the
the amounts that resulted were very blood and blood products has processing that occurred before they
conservative because they reflected only historically been based upon median acquired the already processed product.
the cost of the blood and its processing, hospital costs (consistent with the Instead, for the CY 2007 OPPS, we are
without including a hospital allowance standard OPPS claims-based finalizing our proposal to establish
for the costs of overhead, storage, methodology for establishing payment payment rates for blood and blood
handling, and waste due to shelf-life rates), and the survey reported average products by using the same simulation
limitations. Other commenters asked hospital purchase prices, rather than methodology described in the November
CMS to set the blood median costs for median costs. Moreover, this 15, 2004 final rule with comment period
CY 2007 at 12 percent higher than the information was not available to the (69 FR 65816), which utilizes hospital-
proposed rule median costs, because public at the beginning of the comment specific actual or simulated CCRs for
such an increase would result in a period of the CY 2007 OPPS proposed blood cost centers to convert hospital
significant improvement in rule, and hence we were not able to charges for blood and blood products to
reimbursement for products for which request and consider public comments costs. We continue to believe that using
the OPPS claims data understated true on it. The OPPS methodology to blood-specific CCRs applied to hospital
acquisition costs and would help to establish relative weights requires claims data will result in payments that
ensure continued beneficiary access to standardized cost finding applied to a more fully reflect hospitals’ true costs of
the nation’s blood supply. Some standardized source of data to ensure providing blood and blood products
commenters asked that CMS set the that the relative weights for the items than our general methodology of
payment for blood at the charge and services paid under the system are defaulting to the overall hospital CCR
established by large suppliers of blood in the correct relationship to one when more specific CCRs are
products. Several commenters requested another. To select four blood products unavailable. However, for CY 2007 we
that CMS calculate the median costs for for treatment outside of the standard are providing a payment transition for
blood and blood products using only methodology, substituting external data those blood products for which the
difference between their CY 2006
claims with dates of service after July 1, for claims data, may not result in
adjusted median cost and their CY 2007
2005, so that the only claims used in weights that are appropriately relative to
simulated median cost is greater than 25
median calculation for these products one another. Accordingly, we are not
percent. Specifically, we are setting the
would be claims that were submitted using the AABB survey data in
CY 2007 median costs upon which
after the billing guidance and coding determining the payment rates for blood
payments for blood and blood products
edits of CMS Program Transmittal 496 and blood products for the CY 2007
are based at the higher of the CY 2007
went into effect on July 1, 2005. Other OPPS.
unadjusted simulated median cost or 75
commenters suggested that we establish We also are not adopting one percent of the CY 2006 adjusted median
median costs for basic blood products suggestion of the commenters to cost on which the CY 2006 payment is
and, separately, for different types of establish rates based upon the amounts based. This results in adjustment to the
additional blood processing (for charged by the largest suppliers of simulated median costs for CY 2007 for
example, irradiation and blood, because as described earlier 7 of the 34 blood products. See Table 43
leukoreduction) to ensure that there regarding use of the AABB survey data, below.
would be no rank order anomalies in the to do so would be contrary to the The median costs for blood and blood
medians derived from claims data. methodology of the OPPS that is based products in this final rule with
Response: In developing this CY 2007 on a system of relative weights. comment period are derived from the
final rule with comment period, we are Similarly, we do not believe it would be CY 2005 claims data and have the
accepting the APC Panel’s appropriate to increase the final median benefit of reflecting, in part, the
recommendation to review our costs of blood and blood products by 12 clarifications about reporting that were
methodology for developing payment percent over their proposed CY 2007 provided through CMS Program
rates for blood and blood products. We median costs because little justification Transmittal 496, dated March 4, 2005.
have also considered the only recent was provided by the commenters for the This instruction articulated and
external data of which we are aware that increase. Lastly, we do not believe we clarified many questions that had been
was mentioned by several commenters. should calculate median costs for this raised by hospitals and others about
The recent survey by the AABB final rule using only claims submitted how hospitals should report charges for
included reporting of the hospital on or after the July 1, 2005, effective blood and blood products. The
purchase prices related to providing 4 of date of the blood instructions in instruction went into effect for services
the 34 blood and blood products for Transmittal 496, because to do so would furnished on or after July 1, 2005, and
which we have specific HCPCS codes. greatly reduce the number of claims for therefore, was in effect for the last 6
An abstract of the resulting report, the low volume blood products. The months of CY 2005. Thus, we expect
that the reporting of charges and units the total units of blood products simulated median costs represent only
for blood and blood products in CY furnished in the CY 2005 OPPS claims 0.37 percent of the total units of blood
2005 has improved over past years, data. products reflected in the CY 2005
especially with respect to hospitals’ However, we recognize that for some claims data.
inclusion of all charges related to the blood products, including one product
In summary, we are setting the final
acquisition, processing, and handling of that is not of low volume, the difference
payment rates for blood and blood
blood and blood products as specifically between the CY 2006 adjusted
products for CY 2007 based on the
described in each of the relevant HCPCS simulated median cost on which CY
unadjusted simulated median costs for
P-code descriptors. We believe that the 2006 payment is based is greater than 25
blood and blood products that are
median costs for blood and blood percent. Therefore, we are providing a
transitional payment for CY 2007 by derived from CY 2005 claims data as we
products from the CY 2005 claims data
limiting the amount of the decrease for have described, with the exception of
reflect this improved reporting of
CY 2007 compared to CY 2006 to no the seven products for which we are
charges and units for these products,
particularly with regard to the most more than 25 percent. We believe that providing a payment adjustment to
commonly furnished blood and blood this is a necessary and appropriate step smooth their transition to full claims-
products. in the transition to payments for blood based payment in the future. We believe
Of the 34 blood products, median and blood products based fully on that, in most cases, the unadjusted
costs per unit (calculated using the claims data. median unit costs developed by this
simulated blood-specific CCR Fewer blood products actually process are valid reflections of the
methodology) for CY 2007 rise for 23 of experience increases in their median estimated median costs of furnishing
them compared to their CY 2006 costs from CY 2006 to their final CY these specific blood products, and that
unadjusted simulated median unit costs. 2007 median costs because we adjusted no adjustment is required to result in
These 23 products account for about 82 the CY 2006 median costs for blood and appropriate payments for blood and
percent of all units of blood products blood products. Of the 34 blood blood products in CY 2007. Under this
furnished to Medicare beneficiaries in products, median costs rise for 18 of policy, based on the CY 2005 claims
the hospital outpatient department in them compared to the CY 2006 OPPS data, the projected payments will rise
our CY 2005 claims data. As has been adjusted simulated median costs on for approximately 81 percent of the
the case in the past, the low volume which the CY 2006 payments are based blood product units paid under the
products (which we have historically (and which were adjusted to no less OPPS if patterns of furnishing blood
defined as fewer than 1,000 units per than 95 percent of the CY 2005 payment products in CY 2007 remain similar to
year) show the most volatility. Of the 11 medians). These 18 products account for those in CY 2005. The low volume
low volume products, 6 products show 81 percent of all units of blood products products whose simulated median costs
increases in their unit costs compared to furnished in our CY 2005 claims data. decline compared to their CY 2006
their CY 2006 unadjusted simulated Of the 11 low volume products, 3 show adjusted simulated median costs are
median unit costs, and 5 products show increases in their median unit costs furnished very rarely and by very few
decreases in their median unit costs compared to the CY 2006 OPPS adjusted providers because, in part, more
compared to their CY 2006 unadjusted simulated median unit costs, and 8 commonly available products may be
simulated median unit costs. The low show decreases compared to their CY used for similar clinical indications. In
volume products for which the median 2006 OPPS adjusted simulated median addition, the median costs of several
costs decline compared to their unit costs. The low volume products low volume blood products show a
unadjusted simulated median costs in that show a decline in medians significant increase for CY 2007.
CY 2006 represent only 0.48 percent of compared to their CY 2006 adjusted BILLING CODE 4120–01–P

ER24NO06.026</GPH>
XI. OPPS Payment for Observation reflect the CY 2006 changes and to when certain procedures that are
Services provide additional guidance to assigned status indicator ‘‘T’’ are
Observation care is a well-defined set contractors and hospitals. reported on the same claim with an
During the APC Panel’s March 2006 emergency department visit and
of specific, clinically appropriate
meeting, the Observation Subcommittee observation services, and all other
services that include ongoing short-term
did not make any recommendations to criteria for separate observation
treatment, assessment, and reassessment
the Panel other than to request its payment are met.
before a decision can be made regarding
review of additional data on observation Response: We intend to perform a
whether patients will require further
services at the Panel’s 2007 winter series of analyses over the upcoming
treatment as hospital inpatients or if
meeting. The APC Panel adopted the year to explore the potential effects of
they are able to be discharged from the
Observation Subcommittee’s report and adding syncope and dehydration as
hospital. Observation status is
recommended no changes to the criteria qualifying diagnoses for separately
commonly assigned to patients with
for separate payment for observation payable observation services, as well as
unexpectedly prolonged recovery after services or to the coding and payment the possibility of allowing separate
surgery and to patients who present to methodology for observation services. observation payment for claims for
the emergency department and who During the APC Panel’s August 2006 observation services that also include
then require a significant period of meeting, the Observation Subcommittee specific minor or routine procedures
treatment or monitoring before a made several recommendations that have ‘‘T’’ status indicators. We will
decision is made concerning their next regarding observation services. The first continue to work with the APC Panel
placement. of these was that CMS should consider Observation Subcommittee over the
For CY 2006, we adopted two coding adding syncope and dehydration as coming months in response to these
changes that affect how observation diagnoses for which observation recommendations. We expect to have
services are reported, and we made services would qualify for separate preliminary results of the analyses in
changes in the OCE to shift from payment. Second, the Observation time for discussion with the full Panel
individual providers to the OPPS claims Subcommittee recommended that CMS at the next APC Panel meeting in the
processing systems the determination of perform claims analyses and present winter of 2007.
whether or not observation services are data that would allow it to consider For CY 2007, as we proposed, we are
separately payable or packaged. revising criteria for separately payable continuing to apply the criteria for
Observation services reported using observation services when certain separate payment for observation
HCPCS code G0378 (Hospital procedures that are assigned status services and the coding and payment
observation services, per hour) that are indicator ‘‘T,’’ for example, insertion of methodology for observation services
eligible for separate payment map to a bladder catheter or laceration repair, that were implemented in CY 2006,
APC 0339 (Observation). The CY 2006 are reported on the same claim with an with one exception. In section IX. of this
payment rate for APC 0339 is $425.08. emergency department visit and preamble, we are making final changes
In the CY 2007 proposed rule, we observation services, and all other in APC assignments and payments for
proposed a CY 2007 median cost for criteria for separate observation clinic and emergency department visits.
APC 0339 of $442.16. This reflected payment (for example, qualifying As part of those changes, low level
relative stability in hospital costs for diagnosis code, number of hours) are clinic visits are being moved from APC
separately payable observation care. met. 0600 (Low Level Clinic Visits) to APC
Direct admission to observation (HCPCS Comment: A few commenters 0604 (Level 1 Clinic Visits), with a final
code G0379), when separately payable, expressed ongoing support for the CY 2007 median cost of $50.37. Under
is currently assigned for payment to improved processing of observation the circumstances where direct
APC 0600 (Low Level Clinic Visit) with claims through use of the OCE to assign admission to observation is separately
a CY 2006 payment rate of $52.37. As separate or packaged status to payable, we are finalizing our
discussed below, for CY 2007, we observation services depending on assignment of HCPCS code G0379 to
proposed to assign direct admission to whether the criteria for separate APC 0604, consistent with its CY 2006
observation, when separately payable, to payment were met, an approach that placement in the APC for Low Level
APC 0604 (Low Level Clinic Visit). The CMS implemented for CY 2006. The Clinic Visits.
proposed CY 2007 median cost for APC commenters suggested that now that Comment: One commenter suggested
0604 was $49.93. CMS has simplified the process for that CMS adopt ‘‘midnight’’ as a
As we stated in the CY 2006 OPPS ensuring separate payment for covered defining measure of an overnight stay in
final rule with comment period (70 FR outpatient observation services in hospital outpatient departments. The
68688), the changes that we adopted for specific circumstances, CMS should commenter believed that CMS proposed
CY 2006 were intended to ensure more consider adding syncope and to apply that definition of an overnight
consistent hospital billing for dehydration as diagnoses that qualify stay in ASCs so beneficiaries in ASCs at
observation services in order to guide for separate observation payment. The midnight would be transferred at that
our future analyses of payment for commenters did not request CY 2007 time to hospital outpatient departments
observation care and to simplify how implementation, but, rather, their for continuing care. The commenter
observation services are reported and suggestions were consistent with the stated that those patients would be
paid. We refer readers to the CY 2006 APC Panel recommendation that CMS unlikely to meet acuity and severity
OPPS final rule with comment period should explore this expansion to the list requirements for inpatient admission
for a detailed discussion of the G-codes of diagnoses for which observation may and would be admitted to observation
for observation services and the OCE be separately paid. and that the hospital would be able to
logic changes implemented for CY 2006 Also related to the APC Panel bill for the initial care with G0379
(70 FR 68688), and to Program recommendations, one commenter because the patient was a direct
Transmittal 787, issued on December recommended that CMS perform claims admission. The commenter expressed
16, 2005, in which we updated Chapter and data analysis that would enable concern about the payment inequity
4, Section 290 of the Medicare Claims CMS to consider revising the criteria for between the situation in which a patient
Processing Manual (Pub. 100–04) to separately payable observation services is transferred to observation from the
ASC (and the hospital can bill for direct department. The proposal is still open decisions can be and are routinely made
admission to observation) compared to for comment and, therefore, we will in less than 24 hours, regarding whether
that for patients who are transferred make no final decision about the to release a beneficiary from the hospital
from the hospital’s own outpatient proposal at this time. following resolution of the reason for
department into observation (and the As the commenter pointed out, in the the outpatient visit or whether to admit
hospital cannot bill). circumstances where a patient is the beneficiary as an inpatient. Again, as
The commenter suggested that CMS transferred from an ASC to a hospital for we have stated repeatedly, all hospital
consider a new source of admission observation, the hospital may report observation services, regardless of the
code for ‘‘transfer from ASC’’ to be used HCPCS code G0379 (Direct admission of duration of the observation care, that are
by hospitals. The commenter believed patient for hospital observation care) for medically reasonable and necessary are
that CMS would benefit from collection the direct admission to observation
covered by Medicare, and hospitals
of that data. service, along with HCPCS code G0378
Response: We believe the commenter receive either packaged or separate
for the hours of observation care.
has misinterpreted our proposed use of However, unless the observation OPPS payment for these covered
midnight to define an overnight stay in services meet our criteria for separate observation services. Similar to CY
ASCs for CY 2008. There is no payment, the hospital would only 2006, in calculation of the CY 2007
requirement for an ASC to transfer a receive separate payment for HCPCS median cost for APC 0339, we used all
patient who continues to require care at code G0379 through APC 0604 (Level 1 claims for G0244 (Observation care
and beyond midnight. For Clinic Visits), with a CY 2007 median provided by a facility to a patient with
implementation in CY 2008, we cost of about $50. Similarly, if a patient CHF, chest pain, or asthma, minimum
proposed to include on the list of has an outpatient surgical procedure eight hours), the HCPCS code that
procedures for which an ASC facility fee performed in a hospital and requires hospitals used in CY 2005 to report hour
would be allowed any procedure that outpatient observation care after the of separately payable observation under
may be safely performed in the ASC and recovery period, the hospital may report the circumstances described by the
that does not require an overnight stay. the hours of observation using HCPCS code. Because this code was only to be
We proposed to exclude from payment code G0379, with payment for the reported for observation care that
of an ASC facility fee any procedure for observation care packaged into payment spanned a minimum of 8 hours, we
which prevailing medical practice for the surgical procedure. We believe used all claims for G0244 in our median
dictates that the beneficiary would that the current policy is reasonable cost calculation for APC 0339 for CY
typically be expected to require active because, in both cases, hospitals will 2007, regardless of the number of units
medical monitoring at midnight receive a separate payment for their of G0244 reported.
following the procedure (71 FR 49638). services, into which payment for the As we stated in Program Transmittal
Therefore, midnight with respect to an hours of observation care is packaged.
A–02–129 released in January 2003, we
overnight stay is used solely for Comment: One commenter sought
determining which procedures are clarification on whether the CY 2007 will continue to include in the October
eligible to be included on the Medicare median cost calculation for APC 0339 quarterly update of the OPPS any
ASC list and, thus, payment of an ASC included claims with more than 48 changes to the list of ICD–9–CM codes
facility fee would be allowed. There is hours of observation. The commenter required for separate payment of HCPCS
no requirement to transfer patients out also sought clarification about whether code G0378 resulting from the October
of the ASC at midnight. all hours of observation care beyond 48 1 annual update of ICD–9–CM codes.
Our proposed use of midnight to hours are noncovered. The applicable ICD–9–CM codes for
define overnight stay for purposes of Response: As we have stated before in separate payment for observation
evaluating procedures for inclusion on reference to the appropriate duration of services under the CY 2007 OPPS are
the Medicare ASC list has no payment observation services, we believe that in listed in Table 44 below.
implications for the hospital outpatient the overwhelming majority of cases, BILLING CODE 4120–01–P
ER24NO06.027</GPH>

ER24NO06.028</GPH>
XII. Procedures That Will Be Paid Only • The simplest procedure described public. The APC Panel recommended
as Inpatient Procedures by the code may be performed in most that one of the procedures (CPT code
outpatient departments. 21181, Reconstruction by contouring of
A. Background • The procedure is related to codes benign tumor of cranial bones,
Section 1833(t)(1)(B)(i) of the Act that we have already removed from the extracranial) be removed from the list,
inpatient list. and that we solicit approval from the
gives the Secretary broad authority to In the November 1, 2002 final rule
determine the services to be covered relevant physician specialty societies
with comment period (67 FR 66741), we prior to proposing removal of the other
and paid for under the OPPS. Before removed 43 procedures from the
implementation of the OPPS in August six procedures. For CY 2007, we
inpatient list for payment under OPPS. ultimately proposed to remove a total of
2000, Medicare paid reasonable costs for We also added the following criteria for
services provided in the outpatient eight procedures from the inpatient list.
use in reviewing procedures to
department. The claims submitted were determine whether they should be Consistent with our established policy
subject to medical review by the fiscal removed from the inpatient list and for removing procedures from the
intermediaries to determine the assigned to an APC group for payment inpatient list, we rely on our utilization
appropriateness of providing certain under the OPPS: data and clinical staff input in
services in the outpatient setting. We • We have determined that the determining which procedures are
did not specify in regulations those procedure is being performed in candidates for removal. We believe that
services that were appropriate to numerous hospitals on an outpatient our policy of proposing the procedures
provide only in the inpatient setting and basis; or for removal and soliciting comments
that, therefore, should be payable only • We have determined that the from the public, which includes
when provided in that setting. procedure can be appropriately and physician specialty societies, is the most
safely performed in an ambulatory appropriate process to receive input
In the April 7, 2000 final rule with surgical center (ASC) and is on the list from the public on this issue. Rather
comment period, we identified of approved ASC procedures or than solicit approval from a select group
procedures that are typically provided proposed by us for addition to the ASC (for example, specific physician
only in an inpatient setting and, list. specialty societies), in the CY 2007
therefore, would not be paid by We believe that these additional proposed rule we solicited comments
Medicare under the OPPS (65 FR criteria help us to identify procedures from all interested parties consistent
18455). These procedures comprise that are appropriate for removal from with meeting our obligation to the
what is referred to as the ‘‘inpatient the inpatient list. public regarding outpatient services
list.’’ The inpatient list specifies those provided by hospitals.
B. Changes to the Inpatient List
services that are only paid when
For the CY 2007 OPPS, we used the During the APC Panel meeting in
provided in an inpatient setting because
same methodology as described in the August 2006, a presenter requested that
of the nature of the procedure, the need
November 15, 2004 final rule with the Panel recommend to CMS removal
for at least 24 hours of postoperative
comment period (69 FR 65835) to of 10 procedures from the inpatient list
recovery time or monitoring before the
identify a subset of procedures currently for CY 2007, in addition to those
patient can be safely discharged, or the
on the inpatient list that are being presented in the proposed rule. The 10
underlying physical condition of the
widely performed on an outpatient procedure codes and their descriptors
patient. As we discussed in the April 7,
basis. These procedures were then are displayed in Table 45 below. The
2000 final rule with comment period (65 APC Panel recommended that CMS
clinically reviewed for possible removal
FR 18455) and the November 30, 2001 remove the procedures from the
from the inpatient list. We solicited
final rule (66 FR 59856), we use the inpatient list and assign them to
input from the APC Panel on the
following criteria when reviewing appropriateness of the removal of seven appropriate clinical APCs for payment
procedures to determine whether or not procedures from the inpatient list at the beginning in CY 2007, including
they should be moved from the March 1, 2006 APC Panel meeting. Prior considering their assignment to APCs
inpatient list and assigned to an APC to publishing the CY 2007 OPPS for female reproductive procedures such
group for payment under the OPPS: proposed rule, we had not received any as APCs 0194 (Level VIII Female
• Most outpatient departments are other candidate HCPCS codes for Reproductive Proc), 0195 (Level IX
equipped to provide the services to the removal from the OPPS inpatient list Female Reproductive Proc), and 0202
Medicare population. based on recommendations from the (Level X Female Reproductive Proc).
TABLE 45.—ADDITIONAL PROCEDURES RECOMMENDED BY THE APC PANEL FOR REMOVAL FROM THE INPATIENT LIST FOR
CY 2007
HCPCS Long Descriptor
Code
57282 .............................................. Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus).

57283 .............................................. Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy).
58260 .............................................. Vaginal hysterectromy, for uterus 250 grams or less.
58262 .............................................. Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s).
58263 .............................................. Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s), and/or ovary(s), with repair of
enterocele.
58270 .............................................. Vaginal hysterectomy, for uterus 250 grams or less; with repair of enterocele.
58290 .............................................. Vaginal hysterectomy, for uterus greater than 250 grams.
58291 .............................................. Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s).
58292 .............................................. Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s), with re-
pair of enterocele.
TABLE 45.—ADDITIONAL PROCEDURES RECOMMENDED BY THE APC PANEL FOR REMOVAL FROM THE INPATIENT LIST FOR
CY 2007—Continued
HCPCS Long Descriptor
Code
58294 .............................................. Vaginal hysterectomy, for uterus greater than 250 grams; with repair of enterocele.
We received numerous comments on performed in the outpatient department are provided are still on the inpatient
our inpatient list proposal for the CY was on the inpatient list. list.
2007 OPPS. A summary of the public Response: We appreciate these Response: We proposed to remove
comments and our responses follow: comments and thoughtful suggestions. CPT code 22851 because we believed
Comment: Several commenters We continue to believe that the that it was being performed safely in the
supported the APC Panel’s inpatient list is a valuable tool that is outpatient setting. CPT code 22851 is
recommendation made during its appropriate for the OPPS, and we will not used exclusively with the CPT codes
August 2006 meeting to remove the 10 not eliminate it at this time. We believe cited by the commenter. In fact, in our
procedures listed in Table 45 above. there are many surgical procedures that consultation with physician experts, we
Response: Although the most recent are never safely performed for typical found that it is being performed safely
physician utilization data indicate that Medicare beneficiaries in the hospital in the outpatient setting, but not with
the procedures are performed on an outpatient setting, so that it would be the procedures that are on the inpatient
inpatient basis 80 to 95 percent of the inappropriate for us to assign them list.
time, most of them have low volumes. separately payable status indicators and We are confident after our additional
We agree with the presenter and the establish payment rates in the OPPS. medical consultation that proposing to
APC Panel that they are performed However, we welcome the commenters’ remove CPT code 22851 from the
predominantly for the younger women suggestions to provide more education inpatient list was appropriate.
in our beneficiary population and, to physicians about the list and its
Therefore, we are finalizing our
therefore, we believe they may be safely proposal, without modification, to
purpose. We intend to put those
performed in the outpatient department. remove CPT code 22851 from the
suggestions into practice. However, we
Therefore, we are removing the inpatient list for CY 2007.
will not implement an appeals process We have received no comments prior
procedures as listed in Table 45 above
at this time. to this year requesting that we put CPT
from the OPPS inpatient list and
assigning them to appropriate clinical Comment: One commenter codes 22612 and 22614 back on the
APCs for CY 2007 as noted in Table 46 recommended that CMS not remove inpatient list. Both of the procedures are
of this final rule with comment period. CPT code 22851 (Application of performed 99 percent of the time in the
Comment: Many commenters intervertebral biomechanical inpatient setting, even though they are
recommended elimination of the device(s)(eg, synthetic cage(s), threaded no longer on the inpatient list. We have
inpatient list altogether. Some of the bone dowel(s), methylmethacrylate) to a small number of outpatient hospital
commenters suggested that CMS rely on vertebral defect or interspace), 22612 claims for both CPT codes from CY
the Quality Improvement Organizations (Arthrodesis, posterior or posterolateral 2005. We have not seen significant
(QIOs) to handle issues related to care technique, single level; lumbar), or growth in the outpatient performance of
provided in inappropriate settings 22614 (Arthrodesis, posterior or these procedures since they were
instead of maintaining the inpatient list, posterolateral technique, single level; removed the inpatient list several years
and all of the commenters believed that each additional vertebral segment) from ago. This is consistent with our belief
the decision to admit a beneficiary to the inpatient list. The commenter stated that these procedures are being
the hospital should be left to the that CPT code 22851 should not be performed in the most appropriate
physician. They explained that the removed as CMS proposed because the setting, and we see no reason to reassign
inpatient list causes confusion for primary procedures with which it is them to the inpatient list. Therefore, we
hospitals when they are trying to make performed (CPT codes 22325 (Open are finalizing our proposal without
decisions about the medical necessity of treatment and/or reduction of vertebral modification and are not adding CPT
admission for beneficiaries. fracture(s) and/or dislocation(s), codes 22612 and 22614 to the inpatient
In addition, the commenters posterior approach, one fractured list for CY 2007.
suggested that, if CMS does not vertebrae or dislocated segment; Comment: One commenter requested
eliminate the list, CMS should post the lumbar); 22326 (Open treatment and/or that CMS not finalize the proposal to
inpatient list and an explanation of its reduction of vertebral fracture(s) and/or remove CPT code 61720 (Creation of
purpose on CMS’ Web page for dislocation(s), posterior approach, one lesion by stereotactic method, including
physicians and carriers, and that CMS fractured vertebrae or dislocated burr hole(s) and localizing and
present that same educational segment; cervical); and 22327 (Open recording techniques, single or multiple
information during the Physician Open treatment and/or reduction of vertebral stages; globus pallidus or thalamus).
Door Forum. Further, a number of the fracture(s) and/or dislocation(s), The commenter stated that they have
commenters suggested that CMS posterior approach, one fractured received feedback from physicians that
consider implementing an appeals vertebrae or dislocated segment; it would not be clinically appropriate to
process to allow providers to submit thoracic) are still on the inpatient list. perform the procedure in an outpatient
documentation about physician intent, The commenters believed that, even setting. The commenter stated that
patient clinical condition, and the though CPT codes 22612 and 22614 requiring at least an overnight stay is the
circumstances that allowed the patient were removed from the list in 2003, they standard of care for the procedure. The
to be sent home safely without an should be put back on the inpatient list commenter noted that the APC Panel
inpatient admission after payment has because the autologous and allograft recommended that CMS consult with
been denied because the procedure bone graft procedures with which they the relevant specialty society to confirm
the appropriateness of removing the colostomy); and 61624 (Transcatheter Response: We reviewed the outpatient
code from the inpatient list and stated permanent occlusion or embolization hospital claims data and Part B
that it was not clear in the proposed rule (eg, tumor destruction, to achieve physician bill data for CPT codes 60502
whether that confirmation was made. hemostasis, to occlude a vascular and 60520. According to the Part B bill
Response: In our proposed rule, we malformation), percutaneous, any data, CPT code 60502 was performed 43
clearly stated that we were interested in method; central nervous system percent of the time in the hospital
comments from the public on our (intracranial, spinal cord)) from the outpatient setting in CY 2005, and CPT
proposals to remove codes from the inpatient list. The commenter provided code 65020 was performed 27 percent of
inpatient list. We also stated that our no rationale for requesting the removal the time in that setting. Although there
solicitation of comments from the of those procedures. were very few single procedure claims
public includes physician specialty Response: The utilization data for in the OPPS data for these two
societies. Further, we explained that these codes show that all of them are procedure codes, we did find 12 single
rather than solicit approval from a select performed more than 80 percent of the procedure claims for CPT code 60502
group (physician specialty societies), we time on an inpatient basis. While we
with a median cost of approximately
believed that solicitation of comments first removed the CPT code for the
$2,715.
from interested parties was more revision TIPS procedure (CPT code
consistent with meeting our obligation 37183) from the inpatient list for CY Taking into account the utilization
to the public. 2006, our decision was based, in part, information, hospital data, cost data,
We note that aside from this one on a recommendation of the APC Panel and the advice of our medical advisors,
comment, we received no other to do so. We will be following OPPS we believe that it is appropriate to
responses to our proposal. We would claims data for that procedure based remove the two procedures from the
have expected that the physicians who upon its newly payable status under the inpatient list. Therefore, for CY 2007 we
were concerned enough about our OPPS. However, without specific will assign CPT codes 60502 and 60520
proposed removal of CPT code 61720 clinical evidence that the initial TIPS to APC 0256 (Level V ENT Procedures),
from the inpatient list that they procedure and the other procedures the same APC to which CPT code 60500
discussed it with the commenter would recommended by the commenter may be is assigned. We will monitor utilization
have conveyed their concerns directly to safely performed in the hospital and evaluate the assignments of these
us as well. Thus, we have no other outpatient setting, we believe that it is codes to APC 0256 as data become
information outside of the commenter’s appropriate to retain those procedures available to us (in time for the CY 2009
assertion to confirm this procedure on the inpatient list. Therefore, we are proposed rule) and as we do for all
requires an inpatient stay. finalizing our CY 2007 proposal, procedures after making changes in
The procedure coded as CPT code without modification, to retain these their APC assignments.
61720 is performed only 26 percent of three services on the inpatient list.
the time in the inpatient setting. We Comment: One commenter requested Consistent with our CY 2007
continue to believe that removing the that CMS remove two procedures, CPT proposal, the utilization data and
procedure from the inpatient list is codes 60502 ( Parathyroidectomy or clinical review findings for the eight
appropriate, and we are finalizing our exploration of thyroid(s); re-exploration) procedures support our removal of them
proposal to do so, without modification. and 60520 (Thymectomy, partial or from the inpatient list. We also are
Comment: One commenter requested total; transcervical approach), from the accepting the APC Panel’s
that CMS remove three additional OPPS inpatient list. The commenter recommendation regarding the removal
procedures, CPT code 37182 (Insertion stated that those procedures are often of 10 additional procedures from the
of transvenous intrahepatic performed in the same operative session inpatient list for CY 2007 and the public
portosystemic shunt(s)(TIPS)(includes with CPT code 60500 comment requests that we remove 2
venous access, hepatic and portal vein (Parathyroidectomy or exploration of other procedures. Therefore, we are
catheterization, portography with thyroid(s)), which is not included on the removing a total of 20 procedures from
hemodynamic evaluation, intrahepatic inpatient list. The commenter believed the inpatient list and assigning them to
tract formation/dilatation, stent that the two procedures (CPT codes clinically appropriate APCs, as shown
placement and all associated imaging 60502 and 60520) may be safely in Table 46. The changes to the
guidance and documentation)); 45563 performed in the hospital outpatient inpatient list will be effective for
(Exploration, repair, and presacral department and should be removed services furnished on or after January 1,
drainage for rectal injury; with from the inpatient list. 2007.
TABLE 46.—PROCEDURE CODES REMOVED FROM INPATIENT LIST AND NEW APC ASSIGNMENTS, EFFECTIVE JANUARY 1,
2007
CY 2007 CY 2007
HCPCS Long Descriptor APC Status
code Assignment Indicator
16035 ............................................... Escharotomy; initial incision ...................................................................... 0016 T

21181 ............................................... Reconstruction by contouring of benign tumor of cranial bones, 0254 T
extracranial.
22851 ............................................... Apply spine prosth device ......................................................................... 0049 T
57282 ............................................... Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, 0202 T
iliococcygeus).
57283 ............................................... Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator 0202 T
myorrhaphy).
57292 ............................................... Construction of artificial vagina; with graft ................................................ 0195 T
57335 ............................................... Vaginoplasty for intersex state .................................................................. 0195 T
58260 ............................................... Vaginal hysterectromy, for uterus 250 grams or less ............................... 0195 T
TABLE 46.—PROCEDURE CODES REMOVED FROM INPATIENT LIST AND NEW APC ASSIGNMENTS, EFFECTIVE JANUARY 1,
2007—Continued
CY 2007 CY 2007
HCPCS Long Descriptor APC Status
code Assignment Indicator
58262 ............................................... Vaginal hysterectomy, for uterus 250 grams or less; with removal of 0195 T
tube(s) and/or ovary(s).
58263 ............................................... Vaginal hysterectomy, for uterus 250 grams or less; with removal of 0195 T
tube(s), and/or ovary(s), with repair of enterocele.
58270 ............................................... Vaginal hysterectomy, for uterus 250 grams or less; with repair of 0195 T
enterocele.
58290 ............................................... Vaginal hysterectomy, for uterus greater than 250 grams ....................... 0202 T
58291 ............................................... Vaginal hysterectomy, for uterus greater than 250 grams; with removal 0202 T
of tube(s) and/or ovary(s).
58292 ............................................... Vaginal hysterectomy, for uterus greater than 250 grams; with removal 0202 T
of tube(s) and/or ovary(s), with repair of enterocele.
58294 ............................................... Vaginal hysterectomy, for uterus greater than 250 grams; with repair of 0202 T
enterocele..
60502 ............................................... Parathyroidectomy or exploration of thyroid(s); re-exploration ................. 0256 T
60520 ............................................... Thymectomy, partial or total; transcervical approach ............................... 0256 T
61720 ............................................... Creation of lesion by stereotactic method, including burr holes and lo- 0221 T
calizing and recording techniques, single of multiple stages; globus
pallidus or thalamus.
62000 ............................................... Elevation of depressed skull fracture; simple extradural .......................... 0254 T
64804 ............................................... Sympathectomy, cervicothoracic ............................................................... 0220 T
C. CY 2007 Payment for Ancillary created APC 0375 (Ancillary Outpatient APC 0375 for the services that met the
Outpatient Services When Patient Services When Patient Expires) to pay specific conditions discussed in
Expires (–CA Modifier) for services furnished on the same date previous rules for using modifier –CA.
1. Background as a procedure with SI ‘‘C’’ and billed In the CY 2006 final rule with
with the modifier –CA (68 FR 63467) comment period (70 FR 68700), we
In the November 1, 2002 final rule because we were concerned that discussed our concern about the large
with comment period (67 FR 66798), we payment under a New Technology APC increase in the volume of hospital
discussed the creation of a new HCPCS would not result in an appropriate claims billed with modifier –CA from
modifier –CA to address situations payment. Payment under a New CY 2003 to CY 2004, growing from 18
where a procedure on the OPPS Technology APC is a fixed amount that to 300 claims over that 1-year time
inpatient list must be performed to does not have a relative payment weight period. We acknowledged that because
resuscitate or stabilize a patient (whose and, therefore, is not subject to modifier –CA was first introduced for
status is that of an outpatient) with an recalibration based on hospital costs. In CY 2003, the use of the modifier in CYs
emergent, life-threatening condition, the absence of hospital claims data to 2003 and 2004 may have reflected such
and the patient dies before being determine costs, the clinical APC 0375 an increase due to hospitals’ learning
admitted as an inpatient. In Transmittal payment rate for CY 2004 was set at curve with respect to the modifier’s
A–02–129, issued on January 3, 2003, $1,150, which was the payment amount appropriate use on claims for services
we instructed hospitals on the use of for the newly structured New payable under the OPPS. We also
this modifier when submitting a claim Technology APC that replaced APC expressed some concern that numerous
on bill type 13x for a procedure that is 0977.
on the inpatient list and assigned the claims reflected unanticipated examples
payment status indicator (SI) ‘‘C’’ (to For CYs 2005 and 2006, the payment of ‘‘C’’ status procedures reported with
indicate inpatient services that are not rates for APC 0375 for services billed on modifier –CA that may not have been
paid under the OPPS). Conditions to be the same date as a ‘‘C’’ status procedure provided to patients with emergency life
met for hospital payment for a claim appended with modifier –CA were threatening conditions, where the
reporting a service billed with modifier established in accordance with the same inpatient procedure was performed on
–CA include a patient with an emergent, methodology we followed to set an emergency basis to resuscitate or
life-threatening condition on whom a payment rates for the other procedural stabilize the patient. We promised to
procedure on the inpatient list is APCs in those years, based on the monitor CY 2005 claims data for similar
performed on an emergency basis to relative payment weight calculated for increases.
resuscitate or stabilize the patient. For APC 0375. For APC 0375 specifically, Our review of the CY 2005 claims
CY 2003, a single payment for otherwise we calculated the relative payment data available for the CY 2007 proposed
payable outpatient services billed on a weight from all claims reporting a ‘‘C’’ rule revealed a decrease in the use of
claim with a procedure appended with status procedure appended with modifier –CA in comparison with CY
this new –CA modifier was made under modifier –CA, using charge data from 2004 claims. In the final CY 2005 data
APC 0977 (New Technology Level VIII, the relevant calendar year claims for available for this final rule with
$1,000–$1,250), due to the lack of line items with a HCPCS code and comment period, there were 260 claims
available claims data to establish a status indicator ‘‘V,’’ ‘‘S,’’ ‘‘T,’’ ‘‘X,’’ submitted reporting modifier –CA.
payment rate based on historical ‘‘N,’’ ‘‘K,’’ ‘‘G,’’ and ‘‘H,’’ in addition to Because of the diverse individual
hospital costs. charges for revenue codes without a clinical scenarios where modifier –CA
As discussed in the November 7, 2003 HCPCS code. We continued to make one may be appropriately reported, we
final rule with comment period, we payment in CYs 2005 and 2006 under expect some variation from year to year
in the number of OPPS claims reporting OPPS and, by its definition, should rule. We refer readers to that document
the modifier and in light of the growth always be limited in its use. for a full and complete explanation of
in outpatient claims overall, it is We did not receive any public this coverage provision.
encouraging that the level of claims comments on our proposed payment
policy for ancillary outpatient services 2. Assignment of New HCPCS Code and
with –CA modifier decreased compared
when a patient expires. Therefore, we Payment for Ultrasound Screening for
to CY 2004. It would appear that the
are finalizing our proposal without AAAs
hospital learning curve regarding use of
modifier –CA may have been completed modification for CY 2007. When we published the CY 2007
over the past 3-year period, and that we OPPS proposed rule, there was no
XIII. Nonrecurring Policy Changes current CPT code that specifically
may expect relatively consistent
reporting of this modifier in future A. Removal of Comprehensive described an ultrasound screening for
years. We note that not only was there Outpatient Rehabilitation Facility AAA. In that same rule, we proposed to
no increase in the number of claims (CORF) Services From the List of establish the following HCPCS code,
reporting modifier –CA in CY 2005, but Services Paid Under the OPPS GXXXX (Ultrasound, B-scan and or real
there were also fewer apparently In the CY 2007 OPPS proposed rule time with image documentation; for
inappropriate instances of use. Our CY (71 FR 49623), we proposed to make a abdominal aortic aneurysm (AAA)
2005 claims data show the majority of technical change to the regulations at 42 screening) to be used to bill for the new
reporting of modifier –CA was in CFR 419.21(d) to remove from the list of service under both the Medicare
association with what were likely to services paid under the OPPS certain Physician Fee Schedule and the OPPS.
have been urgent interventions, services furnished by a comprehensive In this final rule with comment period,
including the insertion of intra-aortic outpatient rehabilitation facility (CORF) we are assigning HCPCS code G0389
balloon assist devices and exploratory when they are provided outside the (Ultrasound, B-scan and/or real time
laparotomies. We believe that the data patient’s plan of care (for example, with image documentation; for
support our speculation that much of hepatitis B vaccine). Section 1834(k) of abdominal aortic aneurysm (AAA)
the increase in reporting of the modifier the Act, as added by section 4541(a) of screening) to be reported on or after
observed in CY 2004 data was a result Public Law 105–33 (BBA), requires that January 1, 2007, to describe an
of hospitals’ learning curve regarding CORF services be paid using the lesser ultrasound screening test for AAA. As
the appropriate use of the modifier. of actual charges or a fee schedule required by the statute, Medicare will
allow payment for a one-time only
2. Policy for CY 2007 amount. We instructed fiscal
screening examination, and this
intermediaries to use the MPFS for
In the CY 2007 OPPS proposed rule screening test will be available even if
payments to CORFs. We have not
(71 FR 49622), we did not propose any the qualifying patient does not present
required CORF cost reports, or paid
change to our policies regarding signs or symptoms of disease or illness.
CORFs under the OPPS, since 2001. The
reporting of modifier –CA for CY 2007, In addition, this code does not include
revision of the regulation to delete
or to our payment policy regarding APC any other preventive services that are
certain CORF services from the list of
0375. Therefore, for CY 2007, as we currently separately covered and paid
specified services paid under the OPPS
proposed, we are specifying that under the Medicare Part B screening
is necessary to conform the regulations
hospitals continue reporting modifier benefits. When these other preventive
to the statutory requirement.
–CA only under circumstances services are performed, they should be
We did not receive any public
described in section VI. of Transmittal reported using the existing appropriate
comments on this issue. Therefore, we
A–02–129, which provided specific codes.
are adopting as final, without We noted previously that ultrasound
billing guidance for the use of modifier
modification, the technical change to screening for AAA is also addressed in
–CA. In addition, we will continue to
§ 419.21(d) to remove from the list of detail in our final rule to update the
make one payment under APC 0375 for
services paid under the OPPS certain MPFS for CY 2007. We are responding
the services that meet the specific
services furnished by a CORF when they to all comments regarding the elements
conditions discussed in previous rules
are provided outside the patient’s plan required for the ultrasound screening for
for using modifier –CA, based on
calculation of the relative payment of care (for example, hepatitis B AAA, whether the examination is
weight for APC 0375 as described above. vaccine). performed in a physician’s office or an
We applaud hospitals’ improved billing B. Addition of Ultrasound Screening for outpatient hospital setting, and the
practices and as before, will continue to Abdominal Aortic Aneurysms (AAAs) exception from the Part B annual
monitor use of modifier –CA. (Section 5112 of Public Law 109–171 deductible, in the CY 2007 MPFS final
The CY 2007 proposed APC 0375 (DRA)) rule.
median cost was $3,539, significantly In the CY 2007 OPPS proposed rule,
increased from the $2,527 median cost 1. Background we proposed that payment for this
in the CY 2006 proposed rule and the Section 5112 of the Deficit Reduction service be made at the same level as
CY 2006 final median cost of $2,717. Act of 2005, Public Law 109–171 (DRA), CPT code 76775 (Ultrasound,
The CY 2007 final APC 0375 median amended section 1861 and related retroperitoneal (eg, renal aorta modes),
cost is $3,549. This variation in median provisions of the Act to provide for B-scan and/or real time with image
costs is expected because the specific coverage under Medicare Part B of documentation; limited).
cases that populate the claims data for ultrasound screening for abdominal We received several comments on this
APC 0375 likely exhibit only limited aortic aneurysms (AAAs), effective for payment proposal. In particular, the
clinical and resource homogeneity services furnished on or after January 1, commenters supported the payment
among all the claims attributable to that 2007, subject to certain eligibility and assignment of HCPCS code G0389. The
APC in a given year and across different other limitations. The final rule commenters agreed that the hospital
years for the same APC. Such cost governing this new Part B coverage is costs associated with the screening
variation for APC 0375 from year to year being established through a separate study described by HCPCS code G0389
is generally anticipated and accepted document, specifically the CY 2007 are very similar to those of the limited
because APC 0375 is unique in the Medicare Physician Fee Schedule final retroperitoneal ultrasound diagnostic
examination, which is described by CPT department of a CAH are more stringent not have an emergency medical
code 76775. Therefore, in this final rule than for general hospitals. condition.
with comment period, we are finalizing The provider community recently Although EMTALA also applies to
this assignment for CY 2007. That is, we requested that we change the emergency CAHs, the CoP for CAH emergency
are basing the CY 2007 payment for on-call personnel requirements for services (§ 485.618(d)) states that a
HCPCS code G0389 on equivalent CAHs to conform to the regulatory physician, a physician assistant, a nurse
hospital resources and intensity to those changes published in the Federal practitioner, or a clinical nurse
contained in CPT code 76775, which is Register on September 9, 2003 (68 FR specialist, with training or experience in
assigned to APC 0266 (Level II 53262). In response to this request, in emergency care, must be on call and
Diagnostic and Screening Ultrasound) the proposed rule published in the available onsite at a CAH within a
under the OPPS for CY 2007. We believe Federal Register on August 23, 2006 (71 specified timeframe. Therefore, under
that the hospital costs associated with FR 49623), we proposed to revise the this CAH CoP, these are the only CAH
the screening study are very similar to current CAH CoPs to align the personnel who are currently permitted
those of the limited retroperitoneal emergency medical screening to conduct an appropriate medical
ultrasound diagnostic examination and, requirements in CAHs with those screening to determine that an
therefore, the screening and diagnostic applicable to acute care hospitals. We individual, who presents in the manner
studies should be assigned to the same proposed to allow registered nurses, in described above, does not have an
clinical APC for reasons of clinical and addition to the personnel currently emergency medical condition (as
resource homogeneity. Thus, we are required at § 485.618(d), to serve as required under § 489.24(c)). In contrast,
assigning G0389 to APC 0266 with a qualified medical personnel to screen the emergency services CoP for acute
median cost of $95.37 for CY 2007. individuals who present to the CAH care hospitals at § 482.55 does not
Consistent with the statute, no Medicare emergency room if the nature of the specify the type of personnel who must
beneficiary deductible will be applied to patient’s request is within the registered be available to provide emergency
payment for this AAA screening service. nurse’s scope of practice under State services and who would, therefore,
law and such screening is permitted by perform assessments and screenings.
XIV. Emergency Medical Screening in The regulation states only that the
the CAH’s bylaws. This proposed
Critical Access Hospitals (CAHs) services must be organized and
change would effectively eliminate the
need for a doctor or nonphysician supervised under the direction of a
A. Background
practitioner to report to the emergency qualified member of the medical staff
Section 1820 of the Act, as amended department to attend to a nonemergent and that there must be adequate medical
by section 4201 of the Balanced Budget request for medical care if a registered and nursing personnel qualified in
Act of 1997, provides for the emergency care to meet the written
nurse is on site at the CAH and has
establishment of Medicare Rural emergency procedures and needs
made a determination that the care
Hospital Flexibility Programs anticipated by the facility. Therefore, an
needed is of a nonemergent nature.
(MRHFPs), under which individual acute care hospital may, if it chooses,
The EMTALA statute at section 1867 have protocols that permit a registered
States may designate certain facilities as of the Act states that a hospital in this
critical access hospitals (CAHs). nurse to conduct specific emergency
context must provide an appropriate medical screenings if the nature of the
Facilities that are so designated and (suitable for the symptoms presented)
meet the CAH conditions of individual’s request for examination
medical screening examination within and treatment is within the scope of
participations (CoPs) under 42 CFR Part the capability of the hospital’s
485, Subpart F, will be certified as practice of a registered nurse. For
emergency department to determine emergencies that are outside of a
CAHs by CMS. The MRHFP replaced whether or not an emergency medical
the Essential Access Community registered nurse’s scope of practice,
condition exists (section 1866(a)(1)(I) of another qualified medical personnel
Hospital (EACH)/Rural Primary Care the Act imposes the section 1867
Hospital (RPCH) program. (operating within his or her scope of
requirements on a CAH). The EMTALA practice under State law) would
B. Proposed Policy Change regulations at § 489.24(a) state that the conduct the emergency medical
examination must be conducted by screening.
Existing regulations governing CAHs qualified medical personnel. These We proposed to revise the CAH
at § 485.618(d) require on-call doctors qualified medical personnel designated standard at § 485.618(d) to allow a CAH,
and nonphysician practitioners who to perform medical screening if applicable, the flexibility of including
may be attending to urgent/acute examinations must be determined a registered nurse, with training and
medical problems in other areas of the qualified by the hospital’s bylaws or experience in emergency care and who
CAH or outside the CAH to report to the rules and regulations and must be is on site at the CAH, as one of the
CAH’s emergency room within 30 practicing within the scope of practice qualified medical personnel available
minutes (60 minutes if the CAH is under State law. for emergency services, particularly
located in a frontier or remote area or The regulations at § 489.24(c) relating emergency medical screenings, if the
permissible under the State’s rural to the use of a dedicated emergency nature of the individual’s request for
health care plan) to see a patient in the department for nonemergency services medical care is within the registered
emergency room of a CAH. Often, these were added in September 2003 (68 FR nurse’s scope of practice and is
patients do not have emergency medical 53262) to state that if an individual goes consistent with applicable State laws. If
conditions. With changes to the to a hospital’s dedicated emergency the registered nurse begins the
regulations at § 489.24 that implement department to request medical emergency medical screening and
the Emergency Medical Treatment and treatment, and the nature of the request determines that the nature of the
Labor Act (EMTALA) over the past few makes it clear that the medical individual’s conditions is outside his or
years, some practitioners have noted to condition is not of an emergency nature, her scope of practice under State law,
CMS that the requirements regarding the hospital is required only to perform the physician, physician assistant, nurse
who should respond to calls to see such screening as would be appropriate practitioner or a clinical nurse specialist
patients who present to the emergency to determine that the individual does must be contacted to see the patient
within 30 or 60 minutes to conduct the Comment: Several commenters applicable, the flexibility of utilizing a
emergency medical screening and pointed out an inconsistency between registered nurse, with training and
provide stabilizing treatment. If the the preamble language in the proposed experience in emergency care, to
registered nurse knows initially that the rule, which notes that medical screening conduct specific medical screening
medical screening for the presenting examinations by a registered nurse examinations only if the registered
complaint is outside the applicable would be allowed only if such nurse is on site and immediately
scope of practice under State law, the screenings were permitted by the CAH’s available at the CAH when a patient
physician or other nonphysician bylaws, and the proposed regulation requests medical care and if the nature
practitioner must see the individual text, which does not mention the of the individual’s request is within the
within the 30 or 60 minute timeframes bylaws. registered nurse’s scope of practice and
(as currently specified in Response: We appreciate the consistent with applicable State laws
§ 485.618(d)(1)). commenters bringing this inadvertent and the CAH’s bylaws or rules and
We recognize that not all CAHs will omission to our attention. We are regulations. As noted above, we have
be able to utilize this flexibility. Some revising the regulatory text at revised the regulatory text to include
State licensure boards have stated that § 485.618(d)(2)(ii) in this final rule to language regarding the CAH’s bylaws,
it is not within the authorized scope of indicate that the nature of a patient’s rules, and regulations. The revised
practice for a registered nurse to request for medical care must be within regulatory text is now consistent with
independently perform an appropriate the scope of practice and consistent the preamble language contained in
emergency medical screening for the with applicable State laws and the both the proposed rule and this final
purpose of determining if an emergency CAH’s bylaws or rules and regulations rule, and with the language in the
medical condition exists. However, the in order for a registered nurse to EMTALA regulations at § 489.24(a).
licensure boards in these States further conduct a medical screening
examination. This revision to the XV. OPPS Payment Status and
maintain that it is within the scope of
language is also consistent with the Comment Indicators
practice for a registered nurse to assess
the health status of an individual to EMTALA regulations at § 489.24(a)(1)(i), A. CY 2007 Status Indicator Definitions
determine a nonemergent condition and which refer to hospital ‘‘bylaws or rules
to provide nursing care or to refer the and regulations.’’ The OPPS payment status indicators
Comment: One commenter questioned (SIs) that we assign to HCPCS codes and
individual to appropriate medical
the impact that this change may have on APCs play an important role in
resources. Therefore, based on State
payment and encouraged CMS to ensure determining payment for services under
law, some CAHs will not be able to
that it does not adversely affect the the OPPS. They indicate whether a
designate registered nurses as qualified
payment that CAHs receive for service represented by a HCPCS code is
medical personnel under our proposed
screening services. payable under the OPPS or another
revision to the regulations governing Response: The change being made
CAHs. However, as we wished to payment system and also whether
affects only the CAH CoPs and does not particular OPPS policies apply to the
provide flexibility to CAHs and to be revise the CAH payment regulations,
consistent with existing EMTALA code. Our CY 2007 final status indicator
which are codifed at 42 CFR 413.70. assignments for APCs and HCPCS codes
policy, we proposed the revision to the Comment: One commenter noted that,
regulation at § 485.618(d). are shown in Addendum A and
in the FY 2007 IPPS proposed rule for Addendum B, respectively. We are
C. Public Comments Received on the EMTALA false labor certifications, care using the status indicators and
Proposal roles and responsibilities were to be
definitions that are listed in Addendum
documented in the ‘‘the medical staff
We received 12 comments on our D1, which we discuss below in greater
bylaws or rules and regulations,’’ while
proposal. Our response follows each detail.
under the FY 2007 IPPS final rule, these
comment summary. roles and responsibilities are to be 1. Payment Status Indicators To
Comment: All of the commenters documented in ‘‘medical staff bylaws.’’ Designate Services That Are Paid Under
supported the proposed revision of the The commenter requested a clarification the OPPS
current CoP to allow registered nurses on this issue due to concern that the
with training and experience in final rule imposed a more restrictive The table of proposed status
emergency care to conduct specific requirement than was proposed by indicators in section XV. of the
medical screening examinations under limiting documentation to the bylaws proposed rule (71 FR 49625)
certain provisions. Several of the only. inadvertently listed
commenters commended CMS for Response: The FY 2007 final IPPS radiopharmaceuticals under status
proposing a rule change that would rule is outside the scope of this rule and indicator ‘‘H’’ rather than under status
afford CAHs the staffing flexibility cannot be addressed here. We will indicator ‘‘K.’’ Consistent with our CY
needed to maintain access and to address this comment in a future 2007 proposed payment policy for
provide efficient emergency and urgent document. radiopharmaceuticals (as discussed in
care services for their patients. section V.B.3.a.(3) of this preamble) and
Response: We appreciate the support D. Final Policy their associated status indicators as
of the provider community and believe After consideration of the public correctly listed in Addenda A and B of
that this revision to the current CoP will comments received on the proposed the CY 2007 proposed rule, the list of
most likely decrease the regulatory rule, we are adopting the proposed status indicators, the items, and their
burden for CAHs by allowing them change to § 485.618(d), with minor OPPS payment status descriptions are
greater staffing flexibility. modifications, to allow a CAH, if noted in the corrected table below.
CY 2007 PROPOSED PAYMENT STATUS INDICATORS (CORRECTED)

Indicator Item/code/service OPPS payment status
G .......................................... Pass-Through Drugs and Biologicals ............................. Paid under OPPS; Separate APC payment includes
pass-through amount.
H ........................................... Pass-Through Device Categories ................................... Separate cost-based pass-through payment; Not sub-
ject to coinsurance.
K ........................................... (1) Non-Pass-Through Drugs, Biologicals, and Radio- (1) Paid under OPPS; Separate APC payment.
pharmaceutical Agents.
(2) Brachytherapy Sources ............................................. (2) Paid under OPPS; Separate APC payment.
(3) Blood and Blood Products ......................................... (3) Paid under OPPS; Separate APC payment.
N ........................................... Items and Services Packaged into APC Rates .............. Paid under OPPS; Payment is packaged into payment
for other services, including outliers. Therefore, there
is no separate APC payment.
P ........................................... Partial Hospitalization ...................................................... Paid under OPPS; Per diem APC payment.
Q .......................................... Packaged Services Subject to Separate Payment Paid under OPPS; Addendum B displays APC assign-
Under OPPS Payment Criteria. ments when services are separately payable.
(1) Separate APC payment based on OPPS payment
criteria.
(2) If criteria are not met, payment is packaged into
payment for other services, including outliers. There-
fore, there is no separate APC payment.
S ........................................... Significant Procedure, Not Discounted when Multiple .... Paid under OPPS; Separate APC payment.
T ........................................... Significant Procedure, Multiple Reduction Applies ......... Paid under OPPS; Separate APC payment.
V ........................................... Clinic or Emergency Department Visit ............................ Paid under OPPS; Separate APC payment.
X ........................................... Ancillary Services ............................................................ Paid under OPPS; Separate APC payment.
2. Payment Status Indicators To

Designate Services That Are Paid Under
a Payment System Other Than the OPPS
A ........................................... Services furnished to a hospital outpatient that are paid Not paid under OPPS. Paid by fiscal intermediaries
under a fee schedule or payment system other than under a fee schedule or payment system other than
OPPS, for example: OPPS.
∑ Ambulance Services ...................................................
∑ Clinical Diagnostic Laboratory Services .....................
∑ Non-Implantable Prosthetic and Orthotic Devices ......
∑ EPO for ESRD Patients ..............................................
∑ Physical, Occupational, and Speech Therapy ............
∑ Routine Dialysis Services for ESRD Patients Pro-
vided in a Certified Dialysis Unit of a Hospital.
∑ Diagnostic Mammography ..........................................
∑ Screening Mammography ...........................................
C ........................................... Inpatient Procedures ....................................................... Not paid under OPPS. Admit patient. Bill as inpatient.
F ........................................... Corneal Tissue Acquisition; Certain CRNA Services; Not paid under OPPS. Paid at reasonable cost.
and Hepatitis B Vaccines.
L ........................................... Influenza Vaccine; Pneumococcal Pneumonia Vaccine Not paid under OPPS. Paid at reasonable cost; Not
subject to deductible or coinsurance.
M .......................................... Items and Services Not Billable to the Fiscal Inter- Not paid under OPPS.
mediary.
Y ........................................... Non-Implantable Durable Medical Equipment ................ Not paid under OPPS. All institutional providers other
than home health agencies bill to DMERC.

Designate Services That Are Not
Recognized Under the OPPS But That
May Be Recognized by Other
Institutional Providers
B ........................................... Codes that are not recognized by OPPS when sub- Not paid under OPPS.
mitted on an outpatient hospital Part B bill type (12x ∑ May be paid by intermediaries when submitted on a
and13x). different bill type, for example, 75x (CORF), but not
paid under OPPS.
∑ An alternate code that is recognized by OPPS when
submitted on an outpatient hospital Part B bill type
(12x and13x) may be available.

Designate Services That Are Not Payable
by Medicare
D ........................................... Discontinued Codes ........................................................ Not paid under OPPS or any other Medicare payment
system.
E ........................................... Items, Codes, and Services: ........................................... Not paid under OPPS or any other Medicare payment
∑ That are not covered by Medicare based on statutory system.
exclusion.
∑ That are not covered by Medicare for reasons other
than statutory exclusion.
∑ That are not recognized by Medicare but for which
an alternate code for the same item or service may
be available.
∑ For which separate payment is not provided by Medi-
care.
We received several public comments that were assigned the suggested new appropriately specific, while
regarding our general use of status status indicator ‘‘Z.’’ maintaining the administrative
indicators. Response: The OPPS has no simplicity associated with a modest
Comment: Some commenters operational need to split the definition number of status indicators.
of status indicator ‘‘B’’ and to establish We are unable to develop and publish
suggested that each status indicator
a new status indicator ‘‘Z’’ as suggested an addendum that lists the alternative
definition should be ‘‘pure’’ and have
by the commenters. As discussed codes that should be used for payment
only one meaning. Specifically, they
previously, our status indicators exist under the OPPS when a HCPCS code is
recommended that the current OPPS
for purposes of assisting in determining not recognized under the OPPS because
status indicator ‘‘B’’ be split into two payment, and a single status indicator an alternate code may be available.
different status indicators, with ‘‘B’’ is sufficient for both circumstances Although the commenters suggested
descriptions that uniquely reflect the when codes may be paid by that alternative codes are Level II
two situations in which ‘‘B’’ is currently intermediaries when submitted on a HCPCS codes, in some cases alternate
assigned. In CY 2006, the assignment of different bill type but would not be paid codes are CPT codes that describe
status indicator ‘‘B,’’ which identifies under the OPPS or an alternate code specific portions of a service. In other
codes that are not recognized by the might be recognized under the OPPS. In cases, there may be multiple alternative
OPPS when submitted on an outpatient either situation, there is no payment codes that could be used to report
hospital Part B bill type (12X and 13X), effect that would require the differential complete services or portions of services
reflects two possible reasons for its use of two separate status indicators. that were provided, and we have no way
assignment to any specific HCPCS code: There are currently 19 different status to determine in any given situation the
(1) Not paid under OPPS but may be indicators in Addendum B that are used specific services a hospital provided for
paid by intermediaries when submitted to indicate whether a service described which an alternative code or codes
on a different bill type, for example 75X by a HCPCS code is payable under the might be available. Therefore, we
(CORF); or (2) Not paid under OPPS but OPPS or another payment system and believe that it is appropriate for
an alternate code that is recognized by whether particular OPPS payment hospitals that provide a specific service
OPPS when submitted on an outpatient policies apply to the code. Two new to determine, in situations where they
hospital Part B bill type (12X and 13X) status indicators, ‘‘M’’ and ‘‘Q,’’ were believe a HCPCS code with a status
may be available. The commenters established in CY 2006 for purposes of indicator of ‘‘B’’ would be their choice
recommended that CMS continue to identifying the OPPS payment status of for reporting, whether that code could
assign status indicator ‘‘B’’ to codes not certain HCPCS codes. We believe that be reported on a different bill type and
paid under the OPPS for the first reason only a limited number of status be paid, and, if not, determine if the
and develop new status indicator ‘‘Z’’ indicators in the OPPS are needed to service provided may be correctly
for assignment to codes not recognized convey the necessary payment-related reported with one or more other HCPCS
for the second reason. information, and that additional codes that are recognized for payment
The commenters also recommended indicators should only be created at this under the OPPS. For some HCPCS codes
that CMS publish a separate addendum point when policy necessitates further not recognized under the OPPS, the
as part of the OPPS rule that lists the refinements in this area. We also believe determination of an appropriate
alternative HCPCS Level II codes for the that with 19 status indicators for CY alternate code or codes is
OPPS that should be used for all codes 2007, the set of indicators is straightforward, and we believe
hospitals have already developed such absolutely vital to the eye banking V.B.3.a.(3) of this preamble, we will
crosswalks for their own use based on system, a network that was established continue to assign them to status
the services they provide. for the single purpose of procuring and indicator ‘‘H’’ as indicated in the table
Comment: One commenter stated that providing donated human eye tissue for set forth below and in Addendum D1 of
the community supported the CMS sight restoring transplantation this final rule with comment period,
proposal to continue paying for the procedures. rather than to status indicator ‘‘K’’ as
acquisition of corneal tissue as status Response: We appreciate the proposed. We also note we are finalizing
indicator ‘‘F’’ as an item or service not commenter’s support. our proposed description of status
paid under OPPS and paid at reasonable We are finalizing our status indicator
indicator ‘‘K’’ to include brachytherapy
cost. The commenter believed that the definitions to be consistent with the
sources because, as discussed in section
adoption and implementation of an final CY 2007 OPPS payment policies.
appropriate payment policy for the Because separately payable VII.B. of this final rule with comment
acquisition of corneal tissue for radiopharmaceuticals will continue to period, these sources will be paid based
procedures provided in a hospital be paid on a cost-based methodology in on payment rates through brachytherapy
outpatient department setting was CY 2007 as discussed in section source-specific APCs in CY 2007.
CY 2007 FINAL PAYMENT STATUS INDICATORS TO DESIGNATE SERVICES THAT ARE PAID UNDER THE OPPS
G .......................................... Pass-Through Drugs and Biologicals ............................. Paid under OPPS; Separate APC payment includes
pass-through amount.
H ........................................... (1) Pass-Through Device Categories ............................. (1) Separate cost-based pass-through payment; Not
subject to coinsurance.
(2)Radiopharmaceutical Agents ...................................... (2) Separate cost-based non-pass-through payment.
K ........................................... (1) Non-Pass-Through Drugs and Biologicals ................ (1) Paid under OPPS; Separate APC payment.
(2) Brachytherapy Sources ............................................. (2) Paid under OPPS; Separate APC payment.
(3) Blood and Blood Products ......................................... (3) Paid under OPPS; Separate APC payment.
N ........................................... Items and Services Packaged into APC Rates .............. Paid under OPPS; Payment is packaged into payment
for other services, including outliers. Therefore, there
is no separate APC payment.
P ........................................... Partial Hospitalization ...................................................... Paid under OPPS; Per diem APC payment.
Q .......................................... Packaged Services Subject to Separate Payment Paid under OPPS; Addendum B displays APC assign-
Under OPPS Payment Criteria. ments when services are separately payable.
(1) Separate APC payment based on OPPS payment
criteria.
(2) If criteria are not met, payment is packaged into
payment for other services, including outliers. There-
fore, there is no separate APC payment.
S ........................................... Significant Procedure, Not Discounted when Multiple .... Paid under OPPS; Separate APC payment.
T ........................................... Significant Procedure, Multiple Reduction Applies ......... Paid under OPPS; Separate APC payment.
V ........................................... Clinic or Emergency Department Visit ............................ Paid under OPPS; Separate APC payment.
X ........................................... Ancillary Services ............................................................ Paid under OPPS; Separate APC payment.
To make the published Addendum B an OPPS final rule the assignment status We implemented comment indicator
more relevant to the update of the of a specific HCPCS code to an APC and ‘‘CH’’ to designate a change in payment
OPPS, we are displaying in Addendum the timeframe when comments on the status indicator and/or APC assignment
B of this final rule with comment period HCPCS APC assignment would be for HCPCS codes in Addendum B of the
those HCPCS codes that describe items accepted. These two comment CY 2006 final rule with comment
or services that are payable under the indicators are listed below. period. We also stated that codes flagged
OPPS, as well as nonpayable codes for • ‘‘NF’’—New code, final APC with the ‘‘CH’’ indicator in that final
which we are making a final change in assignment; comments were accepted rule would not be open to comment
status for CY 2007. The final status on a proposed APC assignment in the because the changes generally were
indicators for items and services that are proposed pule; APC assignment is no previously subject to comment during
paid under the OPPS are listed in the longer open to comment. the proposed rule comment period. As
table above. • ‘‘NI’’—New code, interim APC we proposed, we are continuing that
A complete listing of HCPCS codes assignment; comments will be accepted policy in this CY 2007 OPPS final rule
with final OPPS payment status on the interim APC assignment for the with comment period. When used in an
indicators and APC assignments for CY new code. OPPS final rule, the ‘‘CH’’ indicator is
2007 is available electronically on the In the November 10, 2005 final rule only intended to facilitate the public’s
CMS Web site http://www.cms.hhs.gov/ with comment period (70 FR 68702 and review of changes made from one
HospitalOutpatientPPS/HORD/ 68703), we adopted a new comment calendar year to another. We are using
list.asp#TopOfPage. indicator, with the final CY 2007 the ‘‘CH’’ indicator in this CY 2007 final
definition as listed below: rule with comment period to indicate
B. CY 2007 Comment Indicator
• ‘‘CH’’—Active HCPCS code in HCPCS codes for which the status

Definitions current and next calendar year; status indicator and/or APC assignment will
In the November 15, 2004 final rule indicator and/or APC assignment has change in CY 2007 and to indicate
with comment period (69 FR 65827 and changed; or active HCPCS code that is HCPCS codes that are discontinued at
65828), we made final our policy to use discontinued at the end of the current the end of the current calendar year.
two comment indicators to identify in calendar year. However, only HCPCS codes with
comment indicator ‘‘NI’’ in this CY 2007 Response: Comment indicator ‘‘NI’’ 05_AdvisoryPanelonAmbulatory
OPPS final rule with comment period flags HCPCS codes that are new for the PaymentClassificationGroups.asp.
will be subject to comment during the CY 2007 OPPS final rule with comment The APC Panel met on August 23–24,
comment period for this final rule with period and that did not appear in the CY 2006 to discuss the CY 2007 OPPS
comment period. 2007 OPPS proposed rule. Codes with proposed rule and to hear testimony
In the proposed rule, we used the comment indicator ‘‘NI’’ in Addendum from concerned members of the public.
‘‘CH’’ indicator to call attention to B are open to comment in this CY 2007 The minutes of the meeting are available
changes in payment status indicators final rule with comment period. The at: http://www.cms.hhs.gov/FACA/
and/or APC assignments in the comment period for the OPPS final rule 05_AdvisoryPanelonAmbulatory
proposed rule to update the OPPS for for a specific calendar year is specified PaymentClassification
CY 2007. We believed that using the as noted in the final rule. After the close Groups.asp#TopOfPage.
‘‘CH’’ indicator in the proposed rule of the final rule comment period, ‘‘NI’’
facilitated the public’s review of the has no relevance, and it would not be C. GAO Recommendations
changes that we proposed to make final applied to the same HCPCS codes for A discussion of the October 31, 2005
in CY 2007. Use of the ‘‘CH’’ indicator the next OPPS update year. The ‘‘NI’’ GAO letter of comment on proposed
in the proposed rule was significant comment indicator is not used in the 2006 specified covered outpatient drug
because it highlighted changes that were OPPS proposed rule because the status (SCOD) rates (GAO–06–17R ‘‘Comments
subject to comment during the proposed indicators and APC assignments of all on Proposed 2006 SCOD Rates’’) was
rule comment period. HCPCS codes that appear in the contained in section V.3.B.a. of the CY
The three comment indicators that we proposed rule are open for public 2007 OPPS proposed rule (71 FR
are implementing in CY 2007 and their comment. 49584). The letter is referenced in
definitions are listed in Addendum D2 After carefully considering the public section V.B. of this final rule with
of this final rule with comment period. comments received, we are comment.
We received several public comments implementing the comment indicators
regarding the use of the proposed CY A discussion of the April 2006 GAO
as proposed for CY 2007, with report entitled ‘‘Medicare Hospital
2007 comment indicators. modification to the definition of
Comment: Several commenters Pharmaceuticals: Survey Shows Price
comment indicator ‘‘CH’’ to include Variation and Highlights Data Collection
recommended that the comment
active HCPCS codes that are Lessons and Outpatient Rate-setting
indicator ‘‘CH’’ be limited to only a
discontinued at the end of the current Challenges for CMS’’ (GAO–06–372)
single change. Currently, ‘‘CH’’ is
assigned to indicate one of two possible calendar year. was contained in section V.3.B.a. of the
changes. It can signify that the HCPCS XVI. OPPS Policy and Payment CY 2007 OPPS proposed rule (71 FR
code has had a status indicator change, Recommendations 49584). The report is referenced in
and it can also indicate that the HCPCS section V.B. of this final rule with
code has had an APC reassignment. The A. MedPAC Recommendations comment period.
commenters argued that limiting ‘‘CH’’ The Medicare Payment Advisory A discussion of the July 26, 2006 GAO
to a single change would readily Commission (MedPAC) submits reports report entitled ‘‘Medicare Outpatient
facilitate the identification of the to Congress in March and June that Payments: Rates for Certain Radioactive
HCPCS code changes and would summarize payment policy Sources Used in Brachytherapy Could
minimize the need for visual recommendations. The March 2006 be Set Prospectively’’ (GAO 06–635) is
comparison of two separate Addendum MedPAC report included the following contained in section VII.B. of this final
B files to determine what has actually recommendation relating specifically to rule with comment period.
changed. the hospital OPPS: These GAO reports are available for
Response: The designation of HCPCS Recommendation 2A: The Congress review in their entirety at: http://
codes with comment indicator ‘‘CH’’ is should increase payment rates for the www.GAO.gov.
a new process that we initiated in the acute inpatient and outpatient XVII. Policies Affecting Ambulatory
CY 2006 OPPS final rule to facilitate the prospective payment systems in 2007 by Surgical Centers (ASCs) for CY 2007
public’s review of changes that were the projected increase in the hospital
proposed or finalized from one calendar market basket index less half of the A. ASC Background
year to another. We believe the specific Commission’s expectation for 1. Legislative History
reasoning behind the change is not productivity growth. A discussion of the
necessary, as our intent is to merely flag MedPAC recommendation regarding Section 1832(a)(2)(F)(i) of the Act
the changes from our proposed rule to updates to the market basket was provides that benefits under the
our final rule. We appreciate the included in section II.C. (‘‘OPPS Medicare Supplementary Medical
comment and will consider possible Conversion Factor Update for 2007’’) of Insurance program (Part B) include
refinements to comment indicators in the proposed rule (71 FR 49539). payment for facility services furnished
the future that could assist the public in There have been no subsequent in connection with surgical procedures
recognizing and identifying proposed MedPAC recommendations with regard the Secretary specifies that are
and final changes to OPPS payment to Medicare payment under the OPPS. performed in an ambulatory surgical
policies regarding specific items and center (ASC). To participate in the
B. APC Panel Recommendations Medicare program as an ASC, a facility
services of interest.
Comment: Several commenters asked Recommendations made by the APC must meet the standards specified in
CMS to clarify the use of status Panel at its March and August 2006 section 1832(a)(2)(F)(i) of the Act; in 42
indicator ‘‘NI’’ and the length of time meetings are discussed in sections of CFR 416, subpart B of our regulations,
allowed for public comment regarding this preamble that correspond to topics which sets forth general conditions and
HCPCS codes with comment indicator addressed by the APC Panel. Minutes of requirements for ASCs; and in 42 CFR
‘‘NI.’’ They also asked at exactly what the APC Panel’s March 1–2, 2006 416, subpart C of our regulations, which
point in time the ‘‘NI’’ designation meeting are available online at: http:// provides specific conditions for
would be removed. www.cms.hhs.gov/FACA/ coverage for ASCs.
The ASC services benefit was enacted intraocular lenses (NTIOLs). In section 626(b)(1) of Public Law 108–173
by Congress through the Omnibus XVII.G. of this preamble, we announce amended section 1833(i)(2)(A)(i) of the
Reconciliation Act of 1980 (Pub. L. 96– the CY 2007 deadline for submitting Act to require us to take into account
499). For a detailed discussion of the requests for CMS review of the audited costs incurred by ASCs to
legislative history related to ASCs, we appropriateness of ASC payment for perform a procedure, in accordance
refer readers to the June 12, 1998 insertion following cataract surgery of with a survey. Except for screening
proposed rule (63 FR 32291). an NTIOL. flexible sigmoidoscopy and screening
Section 626(b) of Public Law 108–173 In section XVIII. of the preamble of colonoscopy services, payment for ASC
repealed the requirement formerly the CY 2007 OPPS proposed rule (71 FR facility services is subject to the usual
found in section 1833(i)(2)(A) of the Act 49635), we proposed a revised payment Medicare Part B deductible and
that the Secretary conduct a survey of system for ASCs to be implemented coinsurance requirements and the
ASC costs for purposes of updating ASC effective January 1, 2008, including amounts paid by Medicare must be 80
payment rates and, instead, requires the revisions to the ASC list for CY 2008, percent of the standard fee.
Secretary to implement a revised ASC the ratesetting method, and the Section 1833(i)(1) of the Act requires
payment system, to be effective not later applicable ASC regulations to us to specify, in consultation with
than January 1, 2008. In section XVIII. incorporate the requirements and appropriate medical organizations,
of the CY 2007 OPPS proposed rule (71 payments for ASC facility services surgical procedures that are
FR 49635), we set forth our proposal for under the proposed revised ASC system. appropriately performed on an inpatient
a revised ASC payment system that We will be addressing the public basis in a hospital but that can be safely
would be implemented on January 1, comments received and implementing performed in an ASC and to review and
2008. We are in the process of receiving the revised ASC payment system in a update the list of ASC procedures at
and analyzing public comments on this separate final rule that we expect to be least every 2 years.
proposal and we expect to issue a published separately in 2007. Section 141(b) of the Social Security
separate final rule for the revised ASC Act Amendments of 1994, Public Law
2. Current Payment Method 103–432, requires us to establish a
payment system sometime in the spring
of 2007 to be effective January 1, 2008. There are two primary elements in the process for reviewing the
Section 5103 of Public Law 109–171 total cost of performing a surgical appropriateness of the payment amount
amended section 1833(i)(2) of the Act by procedure: (a) The cost of the provided under section 1833(i)(2)(A)(iii)
adding a new subparagraph (E) to place physician’s professional services to of the Act for intraocular lenses (IOLs)
a limitation on payments for surgical perform the procedure; and (b) the cost for a class of new technology IOLs
procedures in ASCs. If the standard of items and services furnished by the (NTIOLs). That process was the subject
overhead amount under section facility where the procedure is of a separate final rule entitled
1833(i)(2)(A) of the Act for a facility performed (for example, surgical ‘‘Adjustment in Payment Amounts for
service for such procedure, without supplies, equipment, and nursing New Technology Intraocular Lenses
application of any geographic services). Payment for the first element Furnished by Ambulatory Surgical
adjustment exceeds the Medicare OPPS is made under the MPFS. In the Centers,’’ published in the June 16, 1999
payment amount for the service for that proposed rule and in this final rule with Federal Register (64 FR 32198). As
year, without application of any comment period, we address the second stated earlier, in section XVII.E. of the
geographic adjustment, the Secretary element, the payment of facility fees for preamble of this final rule with
shall substitute the OPPS payment ASC services. We also address the comment period, we discuss the
amount for the ASC standard overhead coverage of ASC services in the changes that we are making to that
amount. This provision applies to proposed rule and in this final rule with process.
surgical procedures furnished in ASCs comment period. A summary of changes to ASC
on or after January 1, 2007, and before Under the current ASC facility payment rates made prior to CY 1998
the effective date of the revised ASC services payment system, the ASC may be found in the June 12, 1998
payment system. payment rate is a standard overhead proposed rule (63 FR 32292). The 1998
We discuss in section XVII.B. of this amount established on the basis of our rule proposed to rebase the ASC
preamble additions to and deletions estimate of a fee that takes into account payment rates using cost, charge, and
from the list of Medicare-approved ASC the costs incurred by ASCs generally in utilization data collected by a 1994
procedures to be implemented January providing facility services in connection survey of ASCs. In that proposed rule,
1, 2007, prior to implementation of the with performing a specific procedure. we also proposed to refine the
revised ASC payment system. In section The report of the Conference Committee ratesetting methodology that was
XVII.C. of this preamble, we discuss the accompanying section 934 of the implemented in the February 8, 1990
regulatory changes that we are making Omnibus Reconciliation Act of 1980 Federal Register (55 FR 4577). However,
for our current ASC payment system. In (ORA), Public Law 96–499, which the changes that were proposed for the
section XVII.D. of this preamble, we enacted the ASC benefit in December ratesetting methodology were not
address the provisions of sections 1980, states that this overhead amount implemented because of a combination
1834(d)(2) and (d)(3) of the Act is expected to be calculated on a of circumstances resulting in the
regarding payment amounts and prospective basis using sample survey delayed publication of a final rule.
beneficiary coinsurance amounts for data and similar techniques to establish Those circumstances included several
screening flexible sigmoidoscopy and reasonable estimated overhead extensions to the comment period
screening colonoscopy. In section allowances, which take into account which ended July 30, 1999, Year 2000
XVII.E. of this preamble, we address the volume (within reasonable limits), for (Y2K) Medicare systems compliancy
changes in payment to ASCs mandated each of the listed procedures. (H.R. Rep. considerations, and legislative changes
by section 5103 of Public Law 109–171. No. 96–1479, at 134–35 (1980).) required by the Medicare, Medicaid,
In addition, in section XVII.F. of this To establish those reasonable and SCHIP Balanced Budget Refinement
preamble, we are making changes in the estimated allowances for services Act of 1999 (BBRA), Public Law 106–
process to review payment adjustments furnished prior to implementation of the 113, and the Medicare, Medicaid, and
for insertion of new technology revised ASC payment system, section SCHIP Benefits Improvement and
Protection Act of 2000 (BIPA), Public 12, 1998 proposed rule (63 FR 32292). expensive ASC setting without
Law 106–554. Readers may refer to the Subsequently, in accordance with encouraging the migration of procedures
March 28, 2003 ASC List Update final § 416.65(c), we published updates of the from the generally less expensive
rule (68 FR 15268–69) for a detailed ASC list in the Federal Register on physician’s office setting to the ASC. We
discussion of these circumstances and March 28, 2003 (68 FR 15268) and May applied these quantitative standards not
the legislative changes. 4, 2005 (70 FR 23690). only to codes proposed for addition to
During years when we have not the ASC list, but also to the codes that
3. Published Changes to the ASC List updated the ASC list in the Federal were currently on the list, to delete
Section 1833(i)(1)(A) of the Act Register, we have revised the list to be codes that did not meet the thresholds.
requires the Secretary to specify surgical consistent with annual calendar year The trend towards performing surgery
procedures that, although appropriately changes to HCPCS and CPT codes. on an ambulatory or outpatient basis
performed in an inpatient hospital These annual coding updates have been grew steadily and, by 1995, we
setting, can also be performed safely on implemented through program discovered that a number of procedures
an ambulatory basis in an ASC, a CAH, instructions to the carriers that process that were on the ASC list at the time fell
or a hospital outpatient department. The ASC claims. The most recent update to short of the 20 percent and 50 percent
report accompanying the legislation the list to conform to CPT and HCPCS thresholds, even though the procedures
explained that the Congress intended coding changes was published in were obviously appropriate in the ASC
procedures currently performed on an Transmittal R–720–CP, Change Request setting. The most notable of these was
ambulatory basis in a physician’s office 4082, on October 21, 2005. The cataract extraction with intraocular lens
that do not generally require the more transmittal may be found on our Web insertion that were already being
elaborate facilities of an ASC not be site at: http://www.cms.hhs.gov/ performed predominately in outpatient
included in the list of ASC covered Transmittals/. settings by the early 1990s, although
procedures (H.R. Rep. No. 96–1167, at more than 20 percent were also
390–91, reprinted in 1980 U.S.C.C.A.N. B. ASC List Update Effective for Services performed as inpatient procedures. The
5526, 5753–54). In a final rule published Furnished On or After January 1, 2007 thresholds would also have excluded
August 5, 1982, in the Federal Register 1. Criteria for Additions to or Deletions from the ASC list certain newer
(47 FR 34082), we established From the ASC List procedures, such as CPT code 66825
regulations that included criteria for (Repositioning of intraocular lens
In April 1987, we adopted prosthesis, requiring an incision
specifying which surgical procedures quantitative criteria for identifying
were to be included for purposes of (separate procedure)), that were rarely
procedures that were commonly performed on a hospital inpatient basis
implementing the ASC facility benefit. performed either in a hospital inpatient
Section 416.65(a) of the regulations but that were appropriate for the ASC
setting or in a physician’s office. setting. Strict adherence to the same 20
specifies general standards for
Collectively, commenters responding to percent and 50 percent thresholds both
procedures on the ASC list. ASC
a notice published on February 16, to add and remove procedures did not
procedures are those surgical and other
1984, in the Federal Register (49 FR provide latitude for minor fluctuations
medial procedures that are—
• Commonly performed on an 6023) had recommended that virtually in utilization across settings or errors
inpatient basis but may be safely every surgical CPT code be included on that could occur in the site-of-service
performed in an ASC; the ASC list. Our medical staff reviewed data drawn from the National Claims
• Not of a type that are commonly the recommended additions to the list, History File that we were then using for
performed or that may be safely in consultation with other specialist analysis.
performed in physicians offices; physicians and medical organizations, In an effort to avoid these anomalies
• Limited to procedures requiring a as appropriate, to determine which code but still retain a relatively objective
dedicated operating room or suite and or series of codes were appropriately standard for determining which
generally requiring a post-operative performed on an ambulatory basis procedures should comprise the ASC
recovery room or short-term (not within the framework of the regulatory list, we adopted in the Federal Register
overnight) convalescent room; and criteria in § 416.65. However, when we notice with comment period published
• Not otherwise excluded from arrayed the proposed procedures by the on January 26, 1995 (60 FR 5185), a
Medicare coverage. site where they were most frequently modified standard for deleting
Specific standards in § 416.65(b) limit performed according to our claims procedures already on the list. We
covered ASC procedures to those that payment data files (1984 Part B deleted from the list only those
do not generally exceed 90 minutes Medicare Data (BMAD)), we found that procedures whose combined hospital
operating time and a total of 4 hours many procedures were not commonly inpatient, hospital outpatient, and ASC
recovery or convalescent time. If performed on an inpatient basis or were site-of-service volume was less than 46
anesthesia is required, the anesthesia performed in a physician’s office the percent of the procedure’s total volume
must be local or regional anesthesia, or majority of the time, and, thus, would and that were either performed 50
general anesthesia of not more than 90 not meet the standards in our percent of the time or more in the
minutes duration. regulations. Therefore, we decided that physician’s office or 10 percent of the
Section 416.65(b)(3) of the regulations if a procedure was performed on an time or less in an inpatient hospital
excludes from the ASC list procedures inpatient basis 20 percent of the time or setting. We retained the 20 percent and
that generally result in extensive blood less, or in a physician’s office 50 percent 50 percent standard to determine which
loss, that require major or prolonged of the time or more, it would be procedures would be appropriate
invasion of body cavities, that directly excluded from the ASC list. (April 21, additions to the ASC list.
involve major blood vessels, or that are 1987 (52 FR 13176)). In the CY 2007 OPPS proposed rule,
generally emergency or life-threatening At the time, we believed that these we did not propose changes to the
in nature. utilization thresholds best reflected the criteria for adding or deleting items
A detailed history of published legislative objectives of moving from the ASC list effective January 1,
changes to the ASC list and ASC procedures from the more expensive 2007. However, in section XVIII.B. of
payment rates may be found in the June hospital inpatient setting to the less the proposed rule, we did discuss
proposed changes in the context of payment groups as indicated in Table 41 manipulation) because we believe that
developing a revised ASC payment of the 2007 OPPS proposed rule (71 FR facility costs are similar for the two
system to be effective January 1, 2008. 49629), set out below as Table 47–A. procedures. We re-examined the facility
The proposed changes to the criteria resource requirements and clinical
would result in the addition for CY 2008 TABLE 47–A.—PROCEDURES PRO- characteristics of CPT code 21356 and
of many procedures that do not meet the POSED FOR ADDITION TO THE ASC remain convinced that our proposed
current criteria for addition to the list. LIST EFFECTIVE JANUARY 1, 2007 assignment of CPT code 21356 to
As we indicated earlier, we expect the payment group 3 is appropriate.
final rule that will implement the ASC payment Therefore, we are finalizing the
CPT Short descriptor
revised ASC payment system effective group assignment for this procedure in
January 1, 2008 to be published as a payment group 3, as proposed.
separate document in the spring of 13102 Repair wound/le- 1 Comment: A few commenters
2007. sion add-on. supported the proposed addition of CPT
13122 Repair wound/le- 1
codes 22520 (Percutaneous
2. Rationale for Payment Assignment sion add-on.
vertebroplasty, one vertebral body,
13133 Repair wound/le- 1
Currently, procedures on the ASC list sion add-on. unilateral or bilateral injection;
are assigned to one of nine payment 19297 Place breast cath 9 thoracic); 22521 (Percutaneous
groups based on our estimate of the for rad. vertebroplasty, one vertebral body,
costs incurred by the facility to perform 21356 Treat cheek bone 3 unilateral or bilateral injection; lumbar);
the procedure. In the CY 2007 OPPS fracture. and 22522 (Percutaneous vertebroplasty,
proposed rule, we did not propose any 22520 Percutaneous 9 one vertebral body, unilateral or
changes to those nine payment groups; vertebroplasty, bilateral injection; each additional
and we proposed to assign the thor. thoracic or lumbar vertebral body) to the
procedures to be added to the ASC list 22521 Percutaneous 9
vertebroplasty,
ASC list for CY 2007. The commenters
to one of those existing payment groups. lumb. requested that CMS assign CPT code
The payment group to which we assign 22522 Percutaneous 1 22522 to payment group 9 as CMS did
each addition to the ASC list is judged vertebroplasty, CPT codes 22520 and 22521. They
by our medical advisors to be most add’l. stated that, although CPT code 22522
appropriate in terms of facility resource 35476 Repair venous 9 represents an add-on procedure, it
inputs. The list of procedures eligible blockage. nonetheless requires a kit that costs in
for Medicare payment of a facility fee 36818 AV fuse, upper 3 the range of $700 to $1,400. They stated
and the rates for CY 2007 are displayed arm, cephalic. that the facility payment for the
in Addendum AA of this final rule with 37205 Transcath IV stent, 9 procedure is always subject to the
percutaneous.
comment period. The procedures that 37206 Transcath IV stent/ 1
multiple procedure discount because it
are affected by the payment limit perc, add’l. is an add-on procedure, and even the
required by section 5103 of Public Law 43761 Reposition gas- 1 full group 1 payment would not cover
109–171 are identified in that trostomy tube. those costs.
addendum along with their payment 46946 Ligation of hemor- 1 Response: We agree with the
rates. rhoids. commenters’ assertion that when
additional kit(s) are required for
3. Response to Comments to May 4, We received many comments in performing CPT code 22522, those extra
2005 Interim Final Rule for the ASC support of our proposal to add the costs would not be adequately
Update procedures displayed in Table 47–A. In recognized by payment at the group 1
In accordance with section 1833(i)(1) addition, some commenters requested level, especially because the procedure
of the Act, as we proposed in the CY that we add other procedures, that we can only be billed secondarily to
2007 OPPS proposed rule, we are assign specific procedures to higher another procedure, and payment will
updating the list of procedures that are payment groups, and that we not add always be discounted by half due to
covered when furnished in an ASC, several of the proposed procedures to multiple procedure discounting. For
effective January 1, 2007. In the process the list. these reasons, we believe that CPT code
of determining which procedures to add 22522 would be more appropriately
5. Specific Requests for Payment Group assigned to payment group 9 than to
to the list, we focused on requests we
Changes to the Proposed ASC List of group 1 as we proposed. We are
received from the public in their
Additions finalizing the assignment of CPT code
comments on our May 4, 2005 interim
final rule (70 FR 23690). We evaluated Comment: One commenter supported 22522 to ASC payment group 9 for CY
codes for which we received requests the proposal to add CPT code 21356 2007.
from the public. The public comments (Open treatment of depressed zygomatic Comment: Some commenters
include requests for addition and arch fracture (eg, Gillies approach)) but supported the proposal to add CPT code
deletion of specific procedures and for requested that CMS assign the 36818 (Arteriovenous anastomosis,
assignment to higher payment groups procedure to payment group 9 rather open; by upper arm cephalic vein
for specific procedures. than group 3, as proposed. The transposition) to the ASC list for CY
commenter stated that the ASC costs for 2007 and requested that CMS assign the
4. Procedures Proposed for Additions to the procedure are $1,365, and that the procedure to a higher ASC payment
the ASC List group 3 payment of $510 would not group than group 3 as we proposed.
Using the current criteria as described nearly cover those costs. Response: We proposed to assign the
in section XVII.B.1. of this preamble, we Response: We assigned the procedure procedure to group 3 because that is the
identified 14 procedures to propose for to the same payment groups as CPT payment level for CPT code 36819
addition to the ASC list effective code 21355 (Percutaneous treatment of (Arteriovenous anastomosis, open; by
January 1, 2007. The procedures were fracture of malar area, including upper arm basilica vein transposition).
assigned to one of the nine existing ASC zygomatic arch and malar tripod, with The commenter provided no evidence to
support assignment to a higher payment code 35476 (Transluminal balloon patients, physicians may need to
group, and we found nothing in our data angioplasty, percutaneous; venous) to perform both venous and arterial
to suggest that payment for CPT code the ASC list for CY 2007. In general, the angioplasty procedures concurrently. As
36818 should be higher than what we commenters stated that providing access discussed above, we will not be adding
proposed. We believe that assignment to to the procedure in ASCs would be a CPT code 35475 for arterial
the same level as CPT code 36819 is great benefit to dialysis patients who are angioplasties to the ASC list, and we are
appropriate and that payment at the often in need of angioplasty procedures. not finalizing our proposal to add CPT
group 3 level appropriately recognizes One commenter objected to its addition code 35476 for venous angioplasties to
facility costs for the procedure. to the list on the grounds that it was a the ASC list because of safety concerns
Therefore, we are finalizing our significant safety risk because the due to the broad array of vessel
assignment of CPT code 36818 to ASC procedures described by CPT code angioplasties that could be reported
payment group 3 as proposed. 35476 may involve large veins, with the with the two codes. Instead, in order to
Comment: Many commenters potential for serious complications that make those angioplasty procedures for
supported the proposal to add CPT should be handled in the hospital AV fistula maintenance, which could
codes 37205 (Transcatheter placement setting. otherwise be appropriately reported
of an intravascular stent(s), (except Some commenters were disappointed with CPT codes 35475 and 35476,
coronary, carotid, and vertebral vessel), that CMS did not also propose to add available for Medicare payment in
percutaneous; initial vessel) and 37206 CPT code 35475 (Transluminal balloon ASCs, we are implementing two new
(Transcatheter placement of an angioplasty, percutaneous; HCPCS G-codes to specifically describe
intravascular stent(s), (except coronary, brachiocephalic trunk or branches, each the arterial and venous angioplasty
carotid, and vertebral vessel), vessel). They stressed the importance of procedures to maintain hemodialysis
percutaneous; each additional vessel) to our support of the Fistula First ESRD access through arteriovenous fistula or
the ASC list. However, a number of quality initiative and stated that grafts for dialysis patients. These codes
commenters requested that CMS not add including CPT code 35475 would are G0392 (Transluminal balloon
these CPT codes to the ASC list. These provide patients with a more efficient, angioplasty, percutaneous; hemodialysis
commenters stated that the procedures but equally effective, option for access fistula or graft; arterial) and
do not satisfy the criteria for inclusion ensuring the maintenance of their AV G0393 (Transluminal balloon
on the ASC list because they involve fistulas for vascular access. They also angioplasty, percutaneous; hemodialysis
major blood vessels, would exceed the stated that inclusion of both CPT codes access fistula or graft; venous). We are
90-minute limit on operating room time, 35475 and 35476 on the ASC list would adding both HCPCS codes G0392 and
and may be associated with save lives, as well as reduce Medicare G0393 to the ASC list for CY 2007 and
complications that are threatening to expenditures because rates of patient are assigning them to ASC payment
patient safety. complications and hospitalizations group 9.
Response: We found the divergence of would be decreased. Table 47–B displays final decisions
responses among the public comments Response: We are sympathetic to the regarding the procedures we proposed
troubling and reexamined our proposal commenters’ request for the arterial to add to the ASC list for CY 2007.
to add these procedures to the ASC list. code, CPT 35475, to be added to the
Although the procedures are being ASC list. We did not propose to add TABLE 47–B.—FINAL ADDITIONS FROM
performed about half of the time in CPT code 35475 because use of the code THE PROPOSED ADDITIONS TO THE
hospital outpatient departments is not limited to procedures involving
ASC LIST EFFECTIVE JANUARY 1,
(HOPDs), the other half are being arteries in the anatomic sites used for
performed on an inpatient basis and vascular access for hemodialysis or to 2007
they virtually are never done in a procedures normally performed to ASC
physician office. As we have stated in maintain arteriovenous (AV) fistulas. CPT Short descriptor payment
the past, there are many procedures that Procedures involving more proximal group
may be safely performed in a hospital major arteries, and therefore that present
outpatient department that may not be safety concerns for performance in 13102 ........... Repair wound/le- 1
safely provided in an ASC, because only ASCs, are also reported by CPT code sion add-on.
35475, and so the code does not meet 13122 ........... Repair wound/le- 1
the hospital outpatient department has sion add-on.
immediate access to the full spectrum of the clinical criteria for inclusion on the 13133 ........... Repair wound/le- 1
emergency and acute care facilities of ASC list. sion add-on.
the hospital. Additionally, on further review, we 19297 ........... Place breast cath 9
Our medical advisors reconsidered also believe it is most clinically for rad.
our proposal to add CPT codes 37205 appropriate to not finalize our proposal 21356 ........... Treat cheek bone 3
and 37206 to the ASC list and to add CPT code 35476 to the ASC list. fracture.
determined that it would be in the best Although CPT code 35476 is used to 22520 ........... Percutaneous 9
interests of Medicare beneficiaries to report venous rather than arterial vertebroplasty,
procedures, it is appropriately used to thor.
continue to deny payment for them in 22521 ........... Percutaneous 9
ASC facilities. Our medical advisors report many different procedures, some vertebroplasty,
believe that the procedures would of which may involve major veins and lumb.
require more than 4 hours of recovery that are potentially too unsafe for 22522 ........... Percutaneous 9
time and would most often require an performance in ASCs. vertebroplasty,
overnight stay in the facility. However, we are committed to the add’l.
For these reasons, we are not Fistula First end-stage renal disease 36818 ........... AV fuse, upper 3
finalizing our proposal to add CPT quality initiative and want to improve arm, cephalic.
codes 37205 and 37206 to the ASC list access to needed procedural services for 43761 ........... Reposition gas- 1
dialysis patients if at all possible. We trostomy tube.
for CY 2007. 46946 ........... Ligation of hemor- 1
Comment: Many commenters believe that in order to maintain healthy rhoids.
supported the proposed addition of CPT vascular access sites for dialysis
The G-codes and other additions to Response: We agree with the ASC list for CY 2007 and assign it to
the list that are being made in response commenters that the addition of CPT payment group 7. The commenters
to comments on the proposed rule are code 19295 to the list is appropriate for stated that the procedure costs were
displayed in Table 48, Additional CY 2007. We are adding it to the list and very similar to those for CPT code 49568
Procedures for Addition to the ASC List assigning it to ASC payment group 1. (Implantation of mesh or other
for CY 2007. We believe this procedure is important prosthesis for incisional or ventral
to providing high quality health care for hernia repair) and, because that
6. Requests for Additions to the ASC women undergoing evaluation for procedure is assigned to payment group
List from Comments to the August 23, possible breast cancer, often as a result 7, CPT code 57267 should also be
2006 Proposed Rule of the findings from screening assigned to group 7.
a. Requests Accepted for Additions to mammography. Response: We agree with the
the ASC List for CY 2007 Comment: One commenter requested commenters. Our analysis shows that
the addition of CPT code 31620 this procedure may be safely performed
Comment: Many comments requested (Endobronchial ultrasound (EBUS) in the outpatient setting, and that the
that CMS add CPT code 13153 (Repair, during bronchoscopic diagnostic or costs are similar to those for CPT code
complex, eyelids, nose, ears and/or lips; therapeutic intervention(s)) to the ASC 49568. Therefore, we are adding CPT
each additional 5 cm or less) to the ASC list. The commenters explained that it is code 57267 to the ASC list in payment
list for CY 2007. The commenters an add-on procedure that is performed group 7 for CY 2007.
supported our proposal to add CPT in conjunction with bronchoscopies that Comment: One commenter requested
codes 13102 (Repair, complex, trunk; are on the ASC list, and the procedure that CMS add CPT code 61795
1.1 cm to 2.5 cm); 13122 (Repair, meets all of the criteria for inclusion on (Stereotactic computer assisted
complex, trunk; 2.6 cm to 7.5 cm); and the list for CY 2007. volumetric (navigational) procedure,
13133 (Repair, complex, trunk; each Response: We agree with the intracranial, extracranial, or spinal) to
additional 5 cm or less) to the list, but commenter that CPT code 31620 is an the ASC list for CT 2007. The
stated that CMS also should have appropriate procedure for payment in commenter stated that addition of this
proposed to add CPT code 13153, which the ASC and are adding it to the ASC procedure to the ASC list would provide
is the only code in this series of CPT list for CY 2007 in group 1, where CPT improved quality of care by providing a
codes that was not proposed to be code 31622 (Bronchoscopy, rigid or method that would minimize trauma
added. They stated that CPT code 13153 flexible, with or without fluoroscopic and risk for secondary damage to
is comparable to the other codes already guidance; diagnostic, with or without patients during certain procedures.
on the list and should be assigned to cell washing) and other procedures with Response: We agree with the
group 3 with the other codes in its similar resource requirements are commenters that this procedure is
series, CPT codes 13150 (Repair, assigned. appropriate for inclusion on the ASC
complex, eyelids, nose, ears and/or lips; Comment: Several commenters list. It satisfies our clinical criteria so we
1.0 cm or less), 13151 (Repair, complex, requested that CMS add CPT code are adding CPT code 61795 to the list
eyelids, nose, ears and/or lips; 1.1 cm to 43257 (Upper gastrointestinal and assigning it to payment group 1
2.5 cm) and 13152 (Repair, complex, endoscopy including esophagus, with other procedures requiring similar
eyelids, nose, ears and/or lips; 2.6 cm to stomach, and either the duodenum and/ levels of facility resources for CY 2007.
7.5 cm). or jejunum as appropriate; with delivery Comment: Several commenters
of thermal energy to the muscle of lower requested that CPT codes 0176T
Response: We agree with the
esophageal sphincter and/or gastric (Transluminal dilation of aqueous
commenters. We examined the series of
cardia, for treatment of gastroesophageal outflow canal; without retention of
codes and found that CPT code 13153
reflux disease) to the ASC list for CY device or stent) and 0177T
is the only one not proposed to be on
2007. The commenters stated that they (Transluminal dilation of aqueous
the CY 2007 list. The base code to
believed that this treatment for outflow canal; with retention of device
which CPT code 13153 is an add-on
gastroesophageal reflux disease met all or stent) be added to the ASC list for CY
code is 13150 (Repair, complex, eyelids,
the current clinical criteria for inclusion 2007 because they are similar to other
nose, ears and/or lips; 1.0 cm or less)
on the ASC list. surgical procedures on the eye that are
and is assigned to payment group 3. We Response: We agree with the frequently provided in ASCs.
agree that it is appropriate to assign CPT commenters that this procedure satisfies Commenters pointed out that much of
code 13153 to the same payment group our clinical criteria for addition to the the clinical investigation for these
as CPT code 13150 because the list. The utilization data indicate that canaloplasty procedures was performed
procedure can only be billed the procedure is performed 95 percent by surgeons in ASC settings.
secondarily to another procedure, so of the time in the hospital outpatient Response: These CPT codes were
payment will always be discounted by department. Based on the utilization released by the AMA on July 1, 2006 for
half due to multiple procedure data that indicate the safety of implementation on January 1, 2007. We
discounting. Therefore, we are adding performing the procedure in outpatient agree with the commenters that they are
CPT code 13153 to the ASC list in group settings in addition to our medical appropriate for addition to the ASC list
3 for CY 2007. advisors’ clinical judgment that it is an and, based on the expected facility costs
Comment: Several commenters appropriate procedure for performance of the procedures and the associated
requested that CMS add CPT code in the ASC, we are adding CPT code single use devices, appropriately
19295 (Image guided placement, 43257 to the list for CY 2007 and assigned to payment group 9 for CY
metallic localization clip, percutaneous, assigning it to payment group 3. 2007. Therefore, we will add these two
during breast biopsy) to the ASC list. Comment: Several commenters procedures to the ASC list for CY 2007.
The commenters stated that this add-on requested that CMS add CPT code As discussed above, we determined
procedure is performed in conjunction 57267 (Insertion of mesh or other that there are 10 procedures about
with breast biopsies that are on the ASC prosthesis for repair of pelvic floor which we received comments that met
list. They stated that it is appropriate to defect, each site (anterior, posterior the criteria for inclusion on the ASC list
allow payment for this service as well. compartment), vaginal approach) to the for CY 2007 but that we did not propose
to add to the ASC list. We are adding TABLE 49.—PROCEDURES NOT ADDED procedures that are provided
those procedures and assigning them to TO CY 2007 ASC LIST BECAUSE predominantly in the physician office
ASC payment groups as indicated in THEY ARE PREDOMINANTLY PER- setting to the list.
Table 48. FORMED IN THE PHYSICIAN’S OFFICE Procedures that are displayed in Table
49 above include office-based
TABLE 48.—ADDITIONAL PROCEDURES CPT Short descriptor procedures recommended for addition
FOR ADDITION TO THE ASC LIST to the ASC list by commenters to the CY
FOR CY 2007 11603 .. Exc tr-ext mlg+marg 2.1–3 cm. 2007 OPPS proposed rule. Procedures
20610 .. Drain/inject, joint/bursa. that are predominately office-based do
28124 .. Partial removal of toe. not meet our criteria for inclusion on
Payment 40812 .. Excise/repair mouth lesion.
HCPCS Short descriptor the ASC list. Thus, we are finalizing our
group 45300 .. Proctosigmoidoscopy dx.
45303 .. Proctosigmoidoscopy dilate.
proposal to not include on the ASC list
13153 ............ Repair wound/le- 3 45330 .. Diagnostic sigmoidoscopy. any of the services performed
sion add-on. 46221 .. Ligation of hemorrhoid(s). predominantly in physician offices as
19295 ............ Place breast clip, 1 46604 .. Anoscopy and dilation. displayed in Table 49.
percut. 46614 .. Anoscopy, control bleeding. In the CY 2007 OPPS proposed rule,
31620 ............ Endobronchial us 1 46900 .. Destruction, anal lesion(s). we indicated that we were not
add-on. 46910 .. Destruction, anal lesion(s). proposing to add to the ASC list 14
43257 ............ Upper gi scope w/ 3 46916 .. Destruction, anal lesion(s). procedures for which we received
thrml txmnt. 62367 .. Analyze spine infusion pump.
62368 .. Analyze spine infusion pump.
requests for addition because our
57267 ............ Insert mesh/pelvic 7
flr add-on. 64402 .. N block inj, facial. medical advisors believe that those
61795 ............ Brain surgery 1 64405 .. N block inj, occipital. procedures do not meet the clinical
using computer. 64408 .. N block inj, vagus. criteria (§ 416.65) for addition. Our
G0392 ........... AV fistula or graft 9 64412 .. N block inj, spinal accessor. medical advisors believed that the
arterial. 64413 .. N block inj, cervical plexus. procedures listed in Table 43 of the CY
G0393 ........... AV fistula or graft 9 64418 .. N block inj, suprascapular. 2007 OPPS proposed rule (71 FR 49629)
venous. 64425 .. N block inj, ilio-ing/hypogi. are of a type that:
64435 .. N block inj, paracervical.
0176T ........... Aqu canal dilat w/ 9
64445 .. N block inj, sciatic, sng.
• Require an overnight or inpatient
o retent. stay;
64505 .. N block, spenopalatine gangl.
0177T ........... Acq canal dilat w 9 64508 .. N block, carotid sinus s/p. • Require a total of 90 minutes of
retent. 64555 .. Implant neuroelectrodes. operating time or 4 hours or more of
64612 .. Destroy nerve, face muscle. recovery time;
b. Requests Not Accepted for Additions 67028 .. Injection eye drug. • Require major or prolonged
to the ASC List for CY 2007 67105 .. Repair detached retina. invasion of body cavities or involve
67110 .. Repair detached retina. major blood vessels;
There were a number of procedures 67145 .. Treatment of retina. • Are generally emergent or life-
for which we received requests for 67210 .. Treatment of retinal lesion.
67221 .. Ocular photodynamic ther.
threatening; or
addition to the ASC list that we are not • Are of a type that result in extensive
67228 .. Treatment of retinal lesion.
adding to the ASC list because they do blood loss.
not meet the criteria set forth in the Comment: Many commenters These characteristics make
regulations as § 416.65. Those indicated that CMS should remove the procedures ineligible for addition to the
procedures are listed in Tables 50 and criterion that procedures performed list of ASC procedures. The 14
51 below. predominantly in the physician’s office procedures that we proposed to not be
Our data indicate that the procedures are not eligible for inclusion on the ASC added to the list based on clinical
listed in Table 49 are performed list for CY 2007 and, specifically, that criteria, as well as additional procedures
predominantly in physician offices and CMS add CPT code 45330 (Diagnostic for which we received requests in
are therefore, not eligible for inclusion sigmoidoscopy) to the ASC list for CY comments to the August 23, 2006
on the ASC list for CY 2007. Table 49 2007. proposed rule that did not meet the
Response: The current criteria were criteria, are displayed below in Table
includes 13 of the procedures we
used to make decisions regarding 50.
proposed not to add to the ASC list
because they are furnished inclusion on the CY 2007 ASC list. We
did not propose to alter these criteria TABLE 50.—PROCEDURES NOT ADDED
predominantly in the physician office
prior to implementation of the revised TO THE CY 2007 ASC LIST BE-
setting, as well as an additional 22
payment system, as proposed for CY CAUSE THEY DO NOT MEET CUR-
procedures that are performed
2008. Although we proposed to allow RENT CLINICAL CRITERIA FOR ADDI-
predominantly in physician offices that procedures predominantly performed in
commenters to the proposed rule TION TO THE ASC LIST
physician offices to be paid under the
requested we add for CY 2007. One of revised ASC payment system, we will CPT Short descriptor
the procedures on the list in the not make final any proposed changes to
proposed rule, CPT code 31040 the criteria for the revised system until 21390 ...................... Treat eye socket frac-
(Exploration behind jaw) is also not we have considered the public ture.
being added to the list for CY 2007. It comments to that proposal. The 21406 ...................... Treat eye socket frac-
is included in Table 50 rather than in comment period will not close for that ture.
21407 ...................... Treat eye socket frac-
Table 49 below, because it is excluded proposal until after this final rule with ture.
for not meeting our clinical criteria. comment period has been published. 27412 ...................... Autochondrocyte im-
Therefore, for CY 2007, we will plant knee.
continue to adhere to the current criteria 27415 ...................... Osteochondral knee
for inclusion on the list and will not add allograft.
TABLE 50.—PROCEDURES NOT ADDED Comment: Some commenters • 36140–(Establish access to artery)
TO THE CY 2007 ASC LIST BE- addressed many of the codes that we • 6145–(Artery to vein shunt)
CAUSE THEY DO NOT MEET CUR- did not propose to add because we • 6200–(Place catheter in aorta)
believed that they did not meet the • 6215–(Place catheter in artery)
RENT CLINICAL CRITERIA FOR ADDI- • 6216–(Place catheter in artery)
clinical criteria for inclusion on the ASC
TION TO THE ASC LIST—Continued • 36217–(Place catheter in artery)
list for CY 2007. The commenters
disagreed with some of our clinical • 36218–(Place catheter in artery)
CPT Short descriptor
determinations and stated that the • 36245–(Place catheter in artery)
procedures were safe for performance • 36246–(Place catheter in artery)
29866 ...................... Autgrft implnt, knee w/ • 36247–(Place catheter in artery)
scope. on an outpatient basis, satisfy our
• 36248–(Place catheter in artery)
29867 ...................... Allgrft implnt, knee w/ clinical criteria and should be included • 38792–(Identify sentinel node)
scope. on the ASC list. Further, a few
29868 ...................... Meniscal trnspl, knee
• 62290–(Inject spine disk x-ray)
commenters noted that, although we • 62291-(Inject spine disk x-ray)
w/scpe. proposed to exclude those 14
31040 ...................... Exploration behind jaw. • 66990–(Ophthalmic endoscope add-
procedures from the list for CY 2007, we on)
35470 ...................... Repair arterial block-
also proposed to add some of them to • G0289–(Arthro, loose body + chondo)
age.
35471 ...................... Repair arterial block-
the list for payment under the CY 2008 The commenters believed that these
age. revised payment system. They believed procedures were appropriate for
35475 ...................... Repair arterial block- that we should add those procedures addition to the ASC list so that the
age. now rather than wait until CY 2008. facilities could receive separate
35476 ...................... Repair venous block- Response: Our medical advisors payment for them.
age. reviewed all of the procedures requested Response: Many of the requested
35490 ...................... Atherectomy, for addition in the comments. They did
percutaneous.
procedures for addition to the list are
not find reason to change their procedures that are typically performed
35492 ...................... Atherectomy, determinations for any of the
percutaneous. as minor services that are integrally
procedures included in Table 50. At the related to the provision of the primary
35493 ...................... Atherectomy,
least, all of those procedures require surgical procedure. Our policy in the
percutaneous.
35494 ...................... Atherectomy, longer than 4 hours of recovery time and ASC payment system is not necessarily
percutaneous. some of them require overnight stays or to pay separately for each associated
35495 ...................... Atherectomy, involve major blood vessels. component of procedures, even if it is
percutaneous. As noted by several of the described by a separate HCPCS code,
37205 ...................... Transcath IV stent, commenters, we did propose to allow but rather to bundle payment for those
percutaneous. Medicare payment for some of the components together into the payment
37206 ...................... Transcath IV stent/ procedures under the revised ASC
perc, add’l. for the primary surgical procedure.
payment system for CY 2008. Integral to Many of those minor procedures that
42844 ...................... Extensive surgery the proposal for CY 2008 is a revision
throat. commenters requested we add to the
of the criteria used to determine for ASC list are paid as part of the payment
47562 ...................... Laparoscopic cholecys-
tectomy.
which procedures Medicare would for the primary surgical service. For
47563 ...................... Laparo cholecys- provide ASC facility payment. We did instance, Medicare does not make a
tectomy/graph. not propose any revision of the criteria separate facility payment for CPT code
47564 ...................... Laparo cholecys- for CY 2007 and clearly indicated in the 36145, Introduction of needle or
tectomy/explr. proposed rule that all decisions intracatheter; arteriovenous shunt
60210 ...................... Partial thyroid excision. regarding the ASC list for CY 2007 created for dialysis (cannula, fistula, or
63001 ...................... Removal of spinal lam- would be made according to the current graft). The introduction of the needle or
ina. criteria.
63003 ...................... Removal of spinal lam- intracatheter described here is
We are finalizing our proposal not to performed as an integral step that is part
ina. include any of the services that do not
63005 ...................... Removal of spinal lam- of the primary procedure, and it is not
meet current clinical criteria for associated with any particular
ina.
63011 ...................... Removal of spinal lam-
addition to the ASC list that are procedure but may be used in many
ina. displayed in Table 50 above for CY different ones. Presumably, the primary
63020 ...................... Neck spine disk sur- 2007, with modification to also not procedure could not be performed
gery. include procedures recommended by unless the needle or intracatheter were
63030 ...................... Low back disk surgery. commenters to the CY 2007 proposed first placed to provide access to the site
63035 ...................... Spinal disk surgery rule that do meet current clinical for treatment.
add-on. criteria for addition to the ASC list.
63040 ...................... Laminotomy single,
Therefore, we are not adding to the
For these reasons, we are making final ASC list for CY 2007 any procedure that
cervical. our decisions not to add any of the
63042 ...................... Laminotomy, single we have identified as a minor service
procedures included in Table 50 to the that is integrally related to the provision
lumbar.
63047 ...................... Removal of spinal lam-
ASC list for CY 2007. of the primary surgical procedure.
ina. Comment: A number of commenters
63048 ...................... Remove spinal lamina requested that CMS add to the ASC list 7. Requests for Payment Increases for
add-on. certain procedures that have very low Procedures on the Current ASC List
63655 ...................... Implant facility costs and for which payment is Comment: A few commenters
neuroelectrodes. included in that for other procedures. requested that we assign CPT code
64448 ...................... N block inj fem, cont The requested procedures are currently 57288 (Sling operation for stress
inf. assigned the following HCPCS codes: incontinence (eg, fascia or synthetic)) to
64449 ...................... N block inj, lumbar
plexus.
• 36100–(Establish access to artery) a higher ASC payment level. The
• 36120–(Establish access to artery) commenters stated that because
Medicare does not allow separate office costs associated with performing vaginal ovoids for clinical
payment for the synthetic mesh required those procedures in other outpatient brachytherapy) and 58346 (Insertion of
for performing the procedure, payment settings (physician offices and hospital Heyman capsules for clinical
at the current level is inadequate to outpatient departments). These are the brachytherapy) to the highest ASC
cover the cost of the service. They best data available to us because we payment group. The commenters
reported that the costs for the synthetic have no cost data for those procedures believed that payment at a higher level
mesh are between $700 and $850 and in ASCs. We agree with the commenters was necessary in order to cover the costs
that the $717 payment made to the ASC that payment in group 4 may not be of the equipment and supplies used in
does not cover the costs of providing the adequate for either of the procedures, performing the procedures.
service. They stated that if CMS and we believe that the costs for CPT Response: We reviewed the OPPS cost
considers the sling material to be code 58563 are higher than those for data for the procedures as the best
bundled into the ASC facility fee, then CPT code 58353 due to the expensive indicator available to us of facility costs
CPT code 57288 should be assigned to guidance equipment used in the and found that the median costs for CPT
payment group 9. procedure. Therefore, we are assigning codes 57155 and 58346 when furnished
Response: As we explained in our CPT code 58353 to payment group 7 for in the hospital outpatient department
response to comments in the proposed CY 2007 and CPT code 58563 to were $506 and $364, respectively. We
rule related to CPT code 51992 payment group 9 for CY 2007. do not have median cost data for the
(Laparoscopy, surgical; sling operation procedures performed in the ASC but
for stress incontinence (eg, fascia or 8. Other Comments on the May 4, 2005 the ASC payment amount for both
synthetic)) (71 FR 49630), we realize Interim Final Rule services is $446, which is within the
that the synthetic material for the sling In the May 4, 2005 interim final rule range of the procedures’ median costs in
may be costly, but there is no (70 FR 23690), we invited public the generally more costly hospital
identifiable HCPCS code available for comments on the payment assignments outpatient setting. This led us to believe
use in ASCs to report the material, and for specific procedure codes that we that the $446 payment in the ASC is
such material is not eligible for separate added to the ASC list in that rule that quite adequate.
payment from Medicare in the ASC or had not been proposed for addition to We proposed in the CY 2007 OPPS
in any other setting. Further, CPT code the ASC list in the November 26, 2004 proposed rule to retain CPT codes 57155
57288, like CPT code 51992, describes proposed rule (69 FR 69178). We and 58346 in ASC payment group 2.
a procedure that may be performed received comments on 14 of those We received no comments on this
using synthetic material or fascia. As newly-added procedures. A summary of proposal and, therefore, as we proposed,
such, we cannot know whether the more those comments and our treatment of in this final rule with comment period,
costly synthetic material is used in any them for CY 2007 is discussed below. we are not assigning the procedures to
specific procedure and do not believe it Comment: Several commenters higher ASC payment groups.
is appropriate to fully incorporate the requested that we delay adding to the Comment: Several commenters
synthetic supply costs into the payment ASC list CPT codes 33212 (Insertion or requested that CMS remove from the list
for all of the procedures performed. We replacement of pacemaker pulse CPT codes 36475 (Endovenous ablation
continue to believe that ASC payment generator only; single chamber, atrial or therapy of incompetent vein, extremity,
group 5 is an appropriate assignment for ventricular), 33213 (Insertion or inclusive of all imaging guidance and
the procedure, and therefore, as we replacement of pacemaker pulse monitoring, percutaneous,
proposed, we are not changing that generator only; dual chamber), and radiofrequency; first vein); 36476
assignment. 33233 (Removal of permanent (Endovenous ablation therapy of
Comment: One commenter requested pacemaker pulse generator) until we incompetent vein, extremity, inclusive
that CMS assign CPT codes 58353 implement the new ASC payment of all imaging guidance and monitoring,
(Endometrial ablation, thermal; without system. percutaneous, radiofrequency; second
hysteroscopic guidance) and 58563 Response: We added these procedures and subsequent veins in single
(Hysteroscopy, surgical; with to the ASC list in response to a request extremity, each through separate access
endometrial ablation (eg, endometrial from a commenter. Our medical sites); 36478 (Endovenous ablation
resection, electrosurgical ablation, advisors evaluated the request and therapy of incompetent vein, extremity,
thermoablation)) to payment group 9 determined that these were appropriate inclusive of all imaging guidance and
instead of to group 4 to which they are procedures for performance in the ASC monitoring, percutaneous, laser; first
currently assigned. They stated that setting. We continued to believe that the vein); and 36479 (Endovenous ablation
because CMS assigned CPT code 58565 procedures were appropriate for therapy of incompetent vein, extremity,
(Hysteroscopy, surgical; with bilateral performance in the ASC and saw no inclusive of all imaging guidance and
fallopian tube cannulation to induce reason to remove them from the list at monitoring, percutaneous, laser; second
occlusion by placement of permanent this time. and subsequent veins treated in a single
implants) to payment group 9 because We proposed in the CY 2007 OPPS extremity, each through separate access
we believed that it was more resource- proposed rule to retain CPT codes sites). The commenters suggested that if
intensive than other procedures 33212, 33214, and 33233 on the ASC we were unwilling to remove them from
assigned to group 4, that CPT codes list, with their current payment level the list, that we assign the procedures to
58353 and 58563 should also be assignments. a higher payment group. They believed
assigned to group 9. The commenters We received no further comments on that the procedures required
indicated that those two procedures use this proposal and, therefore, as we significantly more facility resources
transcervical, single use devices and proposed, in this final rule with than other procedures with which they
have similar resource intensity to CPT comment period, we are not making any are currently grouped in payment level
code 58565. The commenters did not changes to the ASC assignments for CPT 3. The commenters explained that if the
provide any cost information for either codes 33212, 33213, and 33233. procedures were excluded from the list,
of the procedures. Comment: Two commenters requested more adequate payments would be
Response: We examined cost data that we reassign CPT codes 57155 made to physicians under the MPFS for
available to us regarding the facility or (Insertion of uterine tandems and/or the required resources.
Response: We added these procedures Response: We agreed with the similar clinical indications. After
to the list in response to public commenters and proposed in the CY further review, we were convinced that
comments, because we believe they met 2007 proposed rule to assign the the procedure described by CPT code
all the criteria for addition to the ASC procedure to ASC payment group 7 for 58565 was significantly more resource-
list. We initially assigned the codes to CY 2007. We received no comments on intensive than the other procedures in
ASC payment group 3, consistent with this proposal and, therefore, are ASC payment group 4 and, therefore,
other procedures with similar clinical finalizing our assignment of CPT code proposed to reassign the procedure to
indications. We continued to believe 46947 to ASC payment group 7 for CY ASC payment group 9 for CY 2007.
that these procedures were appropriate 2007. We received no comments to this
for performance in the ASC setting and Comment: One commenter requested proposal and therefore are making final
did not propose to remove them from that we allow separate payment for the our proposal to assign CPT code 58565
the list. However, we agreed with the material used as the sling in the to ASC payment group 9 for CY 2007.
commenters’ point that the procedures procedure described by CPT code 51992 Comment: Several comments
require significantly more facility (Laparoscopy, surgical; sling operation requested that CMS issue instructions to
resources than traditional vein removal for stress incontinence (e.g. fascia or permit separate payment for the
procedures, and proposed to assign synthetic)). The commenter stated that catheters that are inserted during the
them for CY 2007 to payment group 9 without separate payment for the sling procedures described by CPT codes
in the preamble of the CY 2007 OPPS material, the Medicare payment for 19296 (Placement of radiotherapy after
proposed rule. We note that these codes performing the procedure is inadequate loading balloon catheter into the breast
mistakenly were published in to cover the service. The commenter for interstitial radioelement application
Addendum AA of the proposed rule also stated that there is no specific following partial mastectomy, includes
with assignment to payment group 8, HCPCS code to use for billing the imaging guidance; on date separate from
and in the supporting public data files synthetic sling material. partial mastectomy) and 19298
for the CY 2007 proposed rule as Response: We added CPT code 51992 (Placement of radiotherapy after loading
assigned to payment group 8. to the ASC list in the last update in brachytherapy catheters into the breast
Comment: Many commenters also response to comments. We assigned for interstitial radioelement application
CPT code 51992 to ASC payment group following partial mastectomy, includes
expressed their concerns about the lack
5, the same ASC payment group to imaging guidance).
of clarity of the proposed payment
which other procedures to treat stress One commenter supported our
group assignments for CPT codes 36475, inclusion of CPT code 19296 on the
incontinence are assigned. As discussed
36476, 36478, and 36479 for CY 2007. ASC list in payment group 9, but
previously, we realize that the synthetic
Commenters noted the high cost of the asserted that separate payment should
material for the sling may be costly, but
procedures, which were assigned to also be provided for the balloon catheter
there is no identifiable HCPCS code
payment group 3, and stated their belief inserted during the procedure. With
available for use in ASCs to report the
that payment at level three is so low that regard to CPT code 19298, other
material, and such material is not
that ASCs could not afford to provide commenters also stated that the
eligible for separate payment from
the services at that rate. Commenters Medicare in the ASC or in any other payment level is inadequate and that
requested that CMS confirm that these setting. Further, CPT code 51992 separate payment should be allowed for
CPT codes were assigned to payment describes a procedure that may be the catheters inserted during the
group 9, and finalize our proposal for performed using synthetic material or procedure. One of the commenters
their CY 2007 treatment. fascia. As such, we cannot know explained that the catheters used to
Response: We proposed that all four whether the more costly synthetic perform the procedure described by CPT
of these procedures be assigned to material is used in any specific code 19298 are not high cost items
payment group 9 for CY 2007. We procedure and do not believe it is (about $18.50 each) but these
recognize that our data files caused appropriate to fully incorporate the procedures typically use 30 catheters
confusion, and we appreciate the synthetic supply costs into the payment which makes the catheters a significant
commenters bringing the for all of the procedures performed. We cost factor in performing the procedure.
inconsistencies to our attention. We continue to believe that ASC payment Response: In the CY 2007 proposed
continue to believe that these services group 5 is an appropriate assignment for rule, we noted that the catheters used in
should be assigned to payment group 9 the procedure, and therefore, as we these procedures are classified as
for CY 2007. proposed, we are not changing that surgical supplies and, as such, are not
Therefore, we are finalizing our assignment. included on the DMEPOS fee schedule
proposal to retain these procedures on Comment: One commenter requested and are, therefore, not eligible for
the ASC list and assigning them to ASC that we make separate payment for the separate payment in the ASC. Payments
payment group 9 for CY 2007. microinserts that are used in performing for the costs of the catheters are
Comment: Two comments requested CPT code 58565 (Hysteroscopy, packaged into the payments for
that we assign CPT code 46947 surgical; with bilateral fallopian tube performing the procedures. Currently
(Hemorrhoidopexy by stapling) to a cannulation to induce occlusion by CPT code 19298 is assigned to ASC
higher ASC payment group. The placement of permanent implants). The payment group 1. Based on the
commenters stated that due to the cost commenter stated that there is no information provided by the
of the stapler used in the procedure, the specific HCPCS Level II code to describe commenters, we were persuaded that
resources required for this procedure are the microinserts and, thus, separate reassignment to a higher ASC payment
not similar to the other surgical billing for them currently is not group was warranted and proposed to
procedures for the treatment of possible. reassign the CPT code 19298 to ASC
hemorrhoids that are also assigned to Response: We added CPT code 58565 payment group 9 for CY 2007.
ASC payment group 3. The commenters to the ASC list in the last update in We received no comments about this
suggested that it would be more response to public comment. We proposal and, therefore, as we proposed,
appropriate to assign this procedure to assigned the procedure to ASC payment we are reassigning CPT code 19298 to
ASC payment group 7. group 4 with other procedures with ASC payment group 9 and will retain
CPT code 19296 in payment group 9 apply to services furnished before MMA, we have generally followed a
and payment for the balloon catheter January 1, 2008. policy of making as few changes to the
will continue to be included in that rate. In addition, we are making two current ASC payment system as possible
technical changes: revising § 416.120 to prior to implementation of the MMA-
C. Regulatory Changes for CY 2007 replace the incorrect cross-reference to mandated revised payment system, in
As stated earlier, in the CY 2007 ‘‘Part 413’’ with the correct cross- order to minimize the administrative
proposed rule, we proposed a revised reference to ‘‘Part 419’’; and deleting burden on ASCs. However, because
payment system for ASCs to be § 416.150 (Beneficiary appeals) because changes to the system are being made
implemented effective January 1, 2008, it does not conform with the appeals for CY 2007 to comply with the DRA,
including revisions to the ASC list for process provisions of 42 CFR Part 405, we believe that we should also
CY 2008, the ratesetting method, and subparts H and I. implement the requirements of section
the applicable ASC regulations to We received no comments on these 1834(d) of the Act at the same time.
incorporate the requirements and proposed revisions and are finalizing We are confident that implementation
payments for ASC facility services them as proposed without modification. of the coinsurance change required by
under the proposed revised ASC system. D. Implementation of Section 1834(d) of section 1834(d) of the Act, in addition
We expect that a final rule the Act to changes required to comply with the
implementing the revised ASC payment DRA, will not interfere with ASCs’
system will be published separately in Sections 1834(d)(2) and (3) of the Act ability to provide services as usual.
the spring of 2007. The revised ASC require that the computed beneficiary Currently, Medicare provides an ASC
coinsurance amount for screening facility payment for two screening
payment system would not take effect
flexible sigmoidoscopy and screening colonoscopy procedures reported by
until January 1, 2008. However, we need
colonoscopy services provided in HCPCS codes G0105 (Colorectal cancer
to revise our current regulations at part
hospital outpatient departments and screening; colonoscopy on individual at
416, subparts D and E to ensure that the
ASCs be equal to 25 percent of the high risk) and G0121 (Colorectal cancer
rules governing our current system are
payment amount. They also require screening; colonoscopy on individual
clearly distinguishable from those that
Medicare to pay the lesser of the ASC not meeting criteria for high risk), and
will apply to the revised system
or OPPS payment amount for those not for any screening flexible
beginning January 1, 2008. Therefore, as
screening services in each geographic sigmoidoscopies. Those are the only
we proposed, we are revising Subparts
area. procedures that will be affected by the
D and E of Part 416 of the regulations For CY 2007, the OPPS payment
to reflect that these are the rules higher coinsurance amounts in ASCs in
amount will be limited to the lesser ASC CY 2007. Beginning January 1, 2007,
governing the APC payment system payment amount for screening
prior to January 1, 2008, and beneficiaries receiving services
colonoscopies. Medicare payment for described by G0105 or G0121 in ASCs
redesignating the existing Subpart F as screening flexible sigmoidoscopies will
Subpart G under Part 416 to codify the are responsible for a 25-percent
not be affected in CY 2007 because coinsurance rather than the current 20
rules governing the ASC payment those services are not currently paid for
adjustment for NTIOLs. In addition, we percent.
in ASCs. There will be no effect on the Sections 1834(d)(2) and (d)(3) of the
are revising existing— payment amount to ASCs for screening Act also require Medicare to pay the
• § 416.1 (a)(2) and (a)(3) (under Basis colonoscopies. However, beginning in lesser of the ASC or OPPS payment
and scope) and the definition of CY 2007, beneficiaries will be amount for screening flexible
‘‘Facility’’ under § 416.2 to remove the responsible for paying a 25-percent sigmoidoscopies and screening
obsolete reference to ‘‘a hospital coinsurance for screening colonoscopies colonoscopies. Medicare will not make
outpatient department,’’ to add when provided in ASCs. Beneficiaries payment to ASCs for screening
provisions of section 5103 of Public Law have been paying a 25-percent sigmoidoscopies in CY 2007, so there is
109–171, and applicable provisions of coinsurance for such services when no payment comparison to be made for
Public Law 108–173. provided in hospital outpatient those services. This requirement will
• § 416.65 (Covered surgical departments. not impact ASC payments for the above
procedures) to modify the introductory Although the provision is not new, it listed screening colonoscopies in CY
text to clearly denote the section s has not been implemented for ASCs due 2007, because the ASC amount will be
application to covered surgical to ongoing instability in that payment lower than the OPPS payment
procedures furnished before January 1, system and uncertainty regarding plans calculated according to the standard
2008. In addition, we are removing the for a revised payment system. There was OPPS methodology, prior to application
obsolete cross-reference in paragraph uncertainty for several years about of this requirement.
(a)(4) to § 405.310 and replacing it with whether data gathered in a 1994 CMS-
the correct cross-reference to § 411.15. sponsored survey of ASC costs would be E. Implementation of Section 5103 of
• § 416.125 (ASC facility services used to develop new rates for ASCs and, Public Law 109–171 (DRA)
payment rate) to incorporate the if so, how best to configure the payment As noted in section XVII.A.1. of this
limitation on payment imposed by methodology. preamble, section 5103 of Public Law
section 5103 of Public Law 109–171. The MMA requires the 109–171 requires us to substitute the
• § 488.1 (Definitions) to correct a implementation of a revised system no OPPS payment amount for the ASC
longstanding error by adding later than January 1, 2008. However, standard overhead amount for surgical
ambulatory surgical centers to the section 5103 of the Deficit Reduction procedures performed at an ASC on or
definition of a supplier in conformance Act of 2005 (DRA) requires CMS to after January 1, 2007, but prior to the
with section 1861(d) of the Act. make some substantial payment rate revised payment system when the ASC
We also are revising the headings of changes for ASCs in CY 2007. standard overhead amount exceeds the
Subparts D and E and adding new Implementation of section 5103 of the OPPS payment amount for the
§§ 416.76 and 416.121 to Subparts D DRA requires that carriers and ASCs procedure. In Addendum AA of this
and E, respectively, to clearly state that make significant claims processing final rule with comment period, we
the provisions of Subparts D and E system changes. Since passage of the identify the HCPCS codes that we
believe will be subject to section 5103 Section 141(b)(1) of the Social adjustment and to solicit comments on
based on a comparison of the final CY Security Act Amendments of 1994 those requests, or to announce the
2007 OPPS payment rates and the ASC (SSAA 1994), Public Law 103–432, lenses that we have determined meet
standard overhead amounts that are required us to develop and implement the criteria and definition of NTIOLs.
effective in CY 2007. In addition, as we a process under which interested parties We last published a Federal Register
proposed, we are adding paragraph (c) may request a review of the notice pertaining to NTIOLs on April
to § 416.125 to reflect this change. appropriateness of the payment amount 28, 2006 (71 FR 25176).
Comment: A few commenters asked for insertion of an IOL, to ensure that
that CMS not implement the payment a. Current ASC Payment for Insertion of
the facility fee for the procedure
limits because, in some cases, those IOLs
includes payment that is reasonable and
payment decreases would result in related to the cost of acquiring a lens The current ASC payment groups,
payments that would be inadequate to that belongs to a class of NTIOLs. payment rates and procedural HCPCS
cover the costs of the procedures. In the February 8, 1990 Federal codes for cataract extraction with IOL
Response: Implementation of the Register (55 FR 4526), we published a insertion are as follows:
payment limitations required by the final notice entitled ‘‘Revision of Payment Group 6—$826 ($676 + $150
DRA is a statutory requirement. Ambulatory Surgery Center Payment IOL Allowance)
Therefore, we are finalizing the payment Rate Methodology,’’ which • CPT code 66985, Insertion of
limits as required and as presented in implemented Medicare payment for an intraocular lens prosthesis (secondary
our proposed rule without modification. IOL furnished at an ASC as part of the implant), not associated with concurrent
F. Modification of the Current ASC ASC facility fee for insertion of the IOL. cataract removal
In the June 16, 1999 Federal Register
Process for Adjusting Payment for New • CPT code 66986, Exchange of
Technology Intraocular Lenses (NTIOLs) (64 FR 32198), we published a final rule
intraocular lens
entitled ‘‘Adjustment in Payment
1. Background Amounts for New Technology Payment Group 8—$973 ($823 + $150
Intraocular Lenses Furnished by IOL allowance)
At the inception of the ASC benefit on
September 7, 1982, Medicare paid 80 Ambulatory Surgical Centers,’’ to add • CPT code 66982, Extracapsular
percent of the reasonable charge for Subpart F (§§ 416.180 through 416.200) cataract removal with insertion of
IOLs supplied for insertion concurrent to 42 CFR Part 416, which established intraocular lens prosthesis (one stage
with or following cataract surgery a process for adjusting payment procedure), manual or mechanical
performed in an ASC (47 FR 34082, amounts for insertion of a class of technique (for example, irrigation and
August 5, 1982). Section 4063(b) of NTIOLs furnished by ASCs. aspiration or phacoemulsification),
OBRA 1987, Public Law 100–203, Our current regulations at §§ 416.180 complex, requiring devices or
amended the Act to mandate that we through 416.200 define the terms techniques not generally used in routine
include payment for an IOL furnished relevant to the process, establish the cataract surgery (for example, iris
by an ASC for insertion during or payment review process, and establish expansion device, suture support for
following cataract surgery as part of the $50 as the payment adjustment amount intraocular lens, or primary posterior
ASC facility fee for insertion of the IOL, that is added to the ASC facility fee for capsulorrhexis) or performed on
and that the facility fee include payment insertion of a lens that CMS determines patients in the amblyogenic
that is reasonable and related to the cost is an NTIOL. Section 416.200 provides developmental stage
of acquiring the class of lens involved that the payment adjustment applies for • CPT code 66983, Intracapsular
in the procedure. a 5-year period that begins when we cataract extraction with insertion of
Section 4151(c)(3) of the Omnibus recognize the first lens that establishes intraocular lens prosthesis (one stage
Budget Reconciliation Act of 1990 a class of NTIOLs. In accordance with procedure)
(OBRA 1990), Public Law 101–508, § 416.200(b), insertion of a lens that we • CPT code 66984, Extracapsular
froze the IOL payment amount at $200 subsequently recognize as belonging to cataract removal with insertion of
for IOLs furnished by ASCs in an existing NTIOL class would receive intraocular lens prosthesis (one stage
conjunction with surgery performed the payment adjustment for the procedure), manual or mechanical
during the period beginning November remainder of the 5-year period technique (for example, irrigation and
5, 1990, and ending December 31, 1992. established for the class. Section aspiration or phacoemulsification)
We continued paying an IOL allowance 416.185(f)(2) provides that after July 16, b. Classes of NTIOLs Approved for
of $200 from January 1, 1993, through 2002, we have the option of changing Payment Adjustment
December 31, 1993. the $50 adjustment amount through
Section 13533 of the Omnibus Budget proposed and final rulemaking in Since implementation of the process
Reconciliation Act of 1993 (OBRA connection with ASC services. for adjustment of payment amounts for
1993), Public Law 103–66, mandated Since June 16, 1999, we have issued NTIOLs that was established in the June
that payment for an IOL furnished by an a series of Federal Register notices to 16, 1999 Federal Register, we have
ASC be equal to $150 beginning January list lenses for which we received approved three classes of NTIOLs, as
1, 1994, through December 31, 1998. requests for a NTIOL payment shown in Table 51 below:
TABLE 51.—CLASSES OF NTIOLS APPROVED FOR PAYMENT ADJUSTMENT

NTIOL HCPCS $50 Approved for services NTIOL characteristic IOLs eligible for adjustment
category code furnished on or after
1 .......... Q1001 May 18, 2000, through May 18, 2005 .. Multifocal ............................................... Allergan AMO Array Multifocal lens,
model SA40N.
TABLE 51.—CLASSES OF NTIOLS APPROVED FOR PAYMENT ADJUSTMENT—Continued

NTIOL HCPCS $50 Approved for services NTIOL characteristic IOLs eligible for adjustment
category code furnished on or after
2 .......... Q1002 May 18, 2000, through May 18, 2005 .. Reduction in Preexisting Astigmatism .. STAAR Surgical Elastic Ultraviolet-Ab-
sorbing Silicone Posterior Chamber
IOL with Toric Optic, models
AA4203T, AA4203TF, and
AA4203TL.
3 .......... Q1003 February 27, 2006, through February Reduced Spherical Aberration .............. Advanced Medical Optics (AMO)
26, 2011. Tecnis IOL models Z9000, Z9001,
and ZA9003; Alcon Acrysof IQ Model
SN60WF.
2. Proposed and Final Changes as we proposed, to reflect the Basis and • We will announce annually in the
a. Process for Recognizing IOLs as Scope of Subpart G of Part 416. Federal Register document that
Belonging to an Active NTIOL Class The other changes that we are making proposes the update of ASC payment
to Part 416, pertaining to the ASC rates for the following calendar year, a
Currently, we accept and review payment adjustment for NTIOLs, are list of all requests to establish new
applications for inclusion in an active discussed below. NTIOL classes accepted for review
NTIOL class on a continuous basis during the calendar year in which the
throughout the year in accordance with b. Public Notice and Comment proposal is published and the deadline
§§ 416.180 through 416.200 of the Regarding Adjustments of NTIOL for submission of public comments
regulations. As we proposed in the CY Payment Amounts regarding those requests. The deadline
2007 OPPS proposed rule, we are for receipt of public comments will be
As we proposed, we are updating and
continuing this established process and 30 days following publication of the list
streamlining the process for determining
updating and streamlining it, as of requests.
whether an IOL that is to be inserted
discussed below, to specify the request In the Federal Register document that
during or subsequent to cataract
and comment review process, the finalizes the update of ASC payment
extraction qualifies for payment
information that a request must include rates for the following calendar year, we
adjustment as a NTIOL, as set forth in
to be accepted for review, the specific will—
existing § 416.185 of our regulations.
factors to be considered in evaluating + Provide a list of determinations
The basis for the current NTIOL
requests, and the process to provide made as a result of our review of all
payment review process was enacted in
notification of determinations. As stated requests and public comments; and
in section XVII.C. of this preamble, we 1994 and has been implemented
+ Publish the deadline for submitting
are redesignating existing Subpart F of through a series of separate Federal
requests for review in the following
Part 416 as Subpart G, which will Register notices specific to NTIOLs. We
calendar year.
include the regulations pertaining to the are modifying the current process of We note that we did not receive any
ASC payment adjustment for NTIOLs. In using separate Federal Register notices review requests in response to the
addition, we are revising redesignated to notify the public of requests to review specific NTIOL April 28, 2006 notice
Subpart G to include revisions to lenses for membership in new NTIOL (71 FR 25176) soliciting CY 2006
existing § 416.180, § 416.185, § 416.190, classes, to solicit public comment on requests for review of the
§ 416.195, and § 416.200 to reflect the requests, and to notify the public of appropriateness of the payment amount
changes that we are making to this CMS determinations concerning new for particular NTIOLs furnished in
process. classes of NTIOLs for which an ASC ASCs.
One of the regulatory changes that we payment adjustment would be made. Comment: Most commenters
are making is to revise existing We are specifying that these NTIOL– supported in principle our proposal to
§ 416.180 to establish the basis and related notifications will be fully incorporate NTIOL requests and
scope for this ASC payment adjustment. integrated into the annual notice and approvals within the annual ASC notice
This revision eliminates the definitions comment rulemaking for updating the and comment rulemaking cycle to
currently included in that section for ASC payment rates, the specific promote greater coordination and
‘‘Class of new technology intraocular payment system in which NTIOL efficiency. However, several
lenses (IOLs),’’ ‘‘Interested party,’’ ‘‘New payment adjustments are made. Given commenters urged CMS to review
technology IOL,’’ and ‘‘New technology that the NTIOL payment adjustments NTIOLs on a quarterly rather than an
subset.’’ We do not believe that we need are applicable to ASC services and that annual basis. These commenters
to retain these definitions because our proposal for updating the new ASC expressed concern about delays in
additional revisions that we are making payment system to be implemented in beneficiary access to NTIOLs that could
to the regulations at Part 416 will January 2008 anticipates an annual be avoided by quarterly reviews, which,
eliminate the term ‘‘interested party’’ update process in coordination with the commenters noted, would also be
from §§ 416.185(c) and 416.190 and the notice and comment rulemaking on the more consistent with the CMS review
term ‘‘new technology subset’’ from OPPS, aligning the NTIOL process with cycle for OPPS pass-through device
§§ 416.185(g), 416.200(a), (b), and (c) this annual update will promote categories and new technology services.
and further clarify the terms ‘‘new coordination and efficiency, thereby One commenter urged quarterly reviews
technology IOL’’ and ‘‘class of new streamlining and expediting the NTIOL so that lenses that belong to an active
technology intraocular lenses (IOLs).’’ notification, comment, and review NTIOL class would not be competitively
We received no comments on the process. disadvantaged by having to wait for
changes we proposed to § 416.180. Specifically, we are establishing the months or nearly a year to be
Accordingly, we are revising § 416.180 following process: recognized. Another commenter
recommended a 60-day comment period an NTIOL belonging to an active NTIOL + Other comparable clinical
following issuance of the list of requests class when furnished at an ASC. advantages, such as—
for NTIOL status rather than the 30-day We believe that consolidating the ++ Reduced dependence on other
comment period that we proposed. request, review, and approval process eyewear (for example, spectacles,
Response: We appreciate the for new classes of NTIOLs as part of the contact lenses, and reading glasses)
commenters’ support for our proposal to annual ASC payment update cycle and ++ Decreased rate of subsequent
coordinate the public notice and accepting and reviewing requests for diagnostic or therapeutic interventions,
comment process regarding requests to addition to an active NTIOL class on an such as the need for YAG laser
establish new NTIOL classes with the ongoing basis will result in more timely treatment.
update of ASC payment rates. We access to improved health technologies ++ Decreased incidence of
understand and share the commenters’ for Medicare beneficiaries. Accordingly, subsequent IOL exchange.
we are revising § 416.185 to reflect the ++ Decreased blurred vision, glare,
concerns about facilitating beneficiary
changes that we proposed to the current other quantifiable symptom or vision
access to technology with demonstrated
process for publishing separate Federal deficiency.
clinical improvement over existing In order to assess the clinical
technology. However, section 141(b)(3) Register notices specific to NTIOLs.
performance of a candidate IOL to
of the Social Security Act Amendments c. Factors CMS Considers in establish a new NTIOL class, outcomes
of 1994 (SSAA 1994), Public Law 103– Determining Whether an Adjustment of from use of the candidate lens would be
432, requires us both to implement the Payment for Insertion of a New Class of compared with outcomes of use of
payment adjustment for new classes of NTIOL Is Appropriate currently available IOLs. Due to the
NTIOLs through notice and comment rapid evolution of medical technology,
rulemaking in the Federal Register and In determining whether a lens belongs
to a new class of NTIOLs and whether we expect that the baseline of currently
to provide for a 30-day comment period available IOLs for comparison would
on the lenses that are the subjects of the the ASC payment amount for insertion
of that lens in conjunction with cataract change from year to year.
requests contained in the notice. We are Comment: Most commenters
not bound by the same prescriptive surgery is appropriate, we expect that
the insertion of the candidate IOL expressed general agreement with the
statutory requirements with regard to criteria that we proposed as the factors
approval of applications for pass- would result in significantly improved
clinical outcomes compared to currently we would consider in determining
through and new technology status whether an adjustment of payment is
under the OPPS, which is why we are available IOLs. In addition, to establish
a new NTIOL class, the candidate lens appropriate for insertion of a new class
able to implement updates of those of NTIOL. One commenter suggested
provisions as part of the quarterly must be distinguishable from lenses
already approved as members of active amending § 416.195(a)(4) to make it
updates of the OPPS OCE and PRICER. clear that the list of superior outcomes
However, we have issued a guidance or expired classes of NTIOLs that share
a predominant characteristic associated are examples and not an all-inclusive
document entitled ‘‘Revised Process for list.
Recognizing Intraocular Lenses with improved clinical outcomes that
were identified for each class. We Response: We appreciate the
Furnished by Ambulatory Surgery commenter’s concern that we not be
Centers (ASCs) as Belonging to an proposed to base our determinations on
consideration of the following factors: overly prescriptive in what constitutes
Active Subset of New Technology ‘‘superior outcomes.’’ However, we
• The IOL must have been approved
Intraocular Lenses (NTIOLs).’’ This believe that § 416.195(a)(4)(vi), ‘‘Other
by the FDA and claims of specific
guidance document can be accessed on comparable clinical advantages,’’ has
clinical benefits and/or lens
the CMS Web site at: http:// the same effect as the revision suggested
characteristics with established clinical
www.cms.hhs.gov/ASCPayment/ by the commenter. In other words, the
relevance in comparison with currently
05_NTIOLs.asp. superior outcomes cited in
available IOLs must have been approved
The guidance document provides §§ 416.195(a)(4)(i)–(v) are not all-
by the FDA for use in labeling and
details regarding requests for inclusive, and extend to other
advertising.
recognition of IOLs as belonging to an • The IOL is not described by an comparable (but unspecified) clinical
existing, active NTIOL category or active or expired NTIOL class; that is, it advantages. In the preamble of the
subset, the review process, and does not share the predominant, class- proposed rule (71 FR 49633), we suggest
information required for a request to defining characteristic associated with several ‘‘comparable clinical
review. Currently, there is one active improved clinical outcomes with advantages’’ for the purpose of
NTIOL subset whose defining designated members of an active or illustration. These suggestions were
characteristic is the reduction of expired NTIOL class. intended to be examples but not an all-
spherical aberration. CMS accepts • Evidence demonstrates that use of inclusive list.
requests throughout the year to review the IOL results in measurable, clinically Comment: One commenter
the appropriateness of recognizing an meaningful, improved outcomes in recommended removing ‘‘Reduced
IOL as a member of an active subset of comparison with use of currently dependence on other eyewear (for
NTIOLs. That is, review of candidate available IOLs. According to the statute, example, spectacles, contact lenses, and
lenses for an existing, active NTIOL and consistent with previous examples reading glasses)’’ from the list of factors
subset is ongoing and not limited to the provided by CMS, superior outcomes (71 FR 49633) because there should not
annual review process that applies to that would be considered include the be an NTIOL class for which the class-
new NTIOL classes. We ordinarily following: defining clinical advantage falls outside
would complete the review of a request + Reduced risk of intraoperative or the scope of Medicare benefits.
within 90 days of receipt, and upon postoperative complication or trauma; Response: We appreciate the
completion of our review, we would + Accelerated postoperative recovery; comment. To avoid unnecessary
notify the requestor of our + Reduced induced astigmatism; confusion, we will remove ‘‘reduced
determination and post on the CMS + Improved postoperative visual dependence on other eyewear’’ from the
Web site notification of a lens newly acuity; list of illustrative improved clinical
approved for a payment adjustment as + More stable postoperative vision; outcomes.
Comment: The same commenter In the proposed rule, we sought relevant benchmarks. One commenter
recommended that CMS clarify that public comments on the desirability of noted that while foldable spherical
when a requestor seeks to establish a further interpreting the phrase monofocal IOLs represent the current
new NTIOL category for a candidate IOL ‘‘currently available lenses’’ for state-of-the-art against which candidate
that bears the class-defining purposes of comparison and specific NTIOLs ought to be compared at this
characteristic of an existing or expired approaches to providing such time, future advances would create new
NTIOL category but also offers an clarifications. We believe that further standards and require flexibility on the
additional, new technological interpretation could be helpful to part of CMS. Another commenter
characteristic for which a new category requestors seeking to provide the most asserted that, in general, the next IOL
is being sought that is distinguishable relevant, authoritative evidence technological advancement worthy of
from the class-defining characteristic of concerning the clinical benefits of their NTIOL status should build upon the
an active or expired class, the lens lenses in comparison with those state of technology that is current at the
should be eligible for consideration for currently available lenses and to us as time. The same commenter further
NTIOL status as long as the we review the information provided in recommended that CMS, in addition to
characteristic and associated benefit of requests to establish new NTIOL classes. being flexible, consider each request for
the active or expired class is not the However, we also believe that any NTIOL review on an individual, case-
basis of the request for a new class. clarifications should incorporate our by-case basis.
Response: The commenter makes an expectations for technological Response: We appreciate commenters
excellent point. Revised § 416.195(a)(3) progression of the baseline comparison taking the time to formulate and
does not preclude from consideration as lenses over time as we make future communicate their views regarding the
a member of a new class of NTIOL a annual determinations regarding the notion of ‘‘currently available lenses.’’ A
lens that includes as one of its establishment of new NTIOL classes. number of thought-provoking
characteristics a class-defining Therefore, we believe that the public suggestions were advanced. We agree
characteristic associated with members comments regarding practical and with commenters that flexibility is
of an active or expired class. Only if that meaningful approaches to elaborating critical, and that too much specificity
shared characteristic were the on the phrase ‘‘currently available would quickly become outdated by
predominant characteristic of the lens lenses’’ would facilitate both requestors’ advancing technology. The commenters
would it be precluded from approval as submission of complete requests for have presented a number of options for
a new class of NTIOL. However, if the review and appropriate determinations establishing baseline technology that we
lens featured other characteristics, one by CMS regarding new NTIOL classes to will carefully consider and evaluate
or more of which predominated, that receive the ASC payment adjustment. during the course of future review of
were clearly tied with improved clinical NTIOL applications. We look forward to
outcomes, the lens would not be Comment: Several commenters continuing to work with stakeholders to
disqualified from consideration as an presented thoughtful, illuminating ensure that our criteria and the NTIOL
NTIOL just because it also shared a discussions of what might constitute the process generally are reasonable, are
characteristic with members of an active ‘‘currently available lenses’’ with which supportive of ongoing development of
or expired class. a candidate NTIOL would be compared. new IOL technology, and are geared to
Comment: One commenter A couple of commenters suggested improved clinical outcomes for
recommended that if an IOL’s label establishing a threshold of sales in the Medicare beneficiaries.
includes a claim of superiority, that market to delineate currently available In summary, after carefully
CMS take that into account, but not lenses. Other suggestions for considering the comments we received
require having the claim of superiority ascertaining benchmark lenses included regarding the criteria we proposed as
in FDA-approved labeling. The same solicitation of comments from the factors to be considered to determine
commenter disagrees that FDA- ophthalmic medical community and whether an IOL qualifies for a payment
approved labeling must include a IOL industry, and consideration of adjustment as a member of a new class
statement of specific clinical benefits whether the class-defining characteristic of NTIOL when furnished at an ASC, we
that would be the basis of an NTIOL of IOLs in an active or expired NTIOL are adopting as final, without
request. A second commenter took the class has become a medically-accepted modification, our proposed revision of
opposite position and commended CMS baseline technology upon which future § 416.195.
for requiring a copy of the labeling technologies will be added. One
commenter suggested that the best d. Revision of Content of a Request To
claims approved by the FDA for the IOL.
approach to addressing the questions we Review
The second commenter believed that
this requirement (§ 416.195(a)(2)) is at posed in the proposed rule would be To enable us to make a determination
the heart of an NTIOL application and through a Town Hall meeting or other that the criteria for a payment
that the FDA claims are of paramount forum that would bring stakeholders adjustment for a new NTIOL class are
importance in determining whether a and CMS staff together to further met, we proposed to require that a
lens is worthy of NTIOL status. deliberate on the process of how to request include certain specific
Response: We appreciate both determine whether a lens qualifies for information, which is listed below. We
commenters points of view. However, NTIOL status and the appropriateness of made this proposal to revise the content
we are not persuaded by the first a payment adjustment for such lenses. of a request, which is currently set forth
commenter’s arguments that FDA Most commenters who addressed this in § 416.195(a), on the basis of our
approval of claims made in the labeling issue recommended that CMS not experience in evaluating applications
for the IOL is of incidental significance. attempt to define ‘‘currently available for OPPS pass-through status for new
Therefore, we are not modifying lenses’’ with too much specificity. device categories over the past 6 years.
§ 416.195(a)(2) as one of the factors that These commenters stressed that it was We have found that the additional
CMS will use to determine whether an important for CMS to maintain information allows our medical advisors
IOL qualifies for a payment adjustment sufficient flexibility to account for to complete a more comprehensive
as a member of a new class of NTIOL evolving IOL standards and to allow a evaluation, which would ensure that a
when furnished at an ASC. variety of appropriate lenses to serve as payment adjustment is appropriate. We
also have found that such information result from use of the candidate IOL information that is to be characterized
must be updated in a timely manner to compared to use of other currently as confidential.
ensure its relevancy to advancing available IOLs. This discussion must Comment: Several commenters
technologies. Therefore, we also include evidence to demonstrate that objected to our proposal to post on the
proposed to post the information that use of the IOL results in measurable, CMS Web site the information required
we require on the CMS Web site at: clinically significant improvement over in a request for review of a potential
http://www.cms.hhs.gov/center/asc/asp currently available IOLs in one or more new class of NTIOL rather than
to provide quick and easy access for of the following areas: codifying it. Several commenters
updating rather than codifying the items + Reduced risk of intraoperative or expressed concern that lags in Web site
required in the application. postoperative complication or trauma. updates may compromise an NTIOL
In addition, we proposed to require a + Accelerated postoperative recovery. sponsor’s ability to design and
separate request for each NTIOL for + Reduced induced astigmatism. implement requisite studies and
which a payment review as member of + Improved postoperative visual generate data that will adequately
a new class is sought. We also proposed acuity; support timely consideration and
to consider a request that does not + More stable postoperative vision. approval of an application. Another
include all of the following information + Other comparable clinical commenter urged that there be sufficient
as incomplete and we proposed not to advantages, such as— stability in the requirements so that a
accept an incomplete request for review ++ Reduced dependence on other manufacturer does not invest several
until all information is furnished. We eyewear (for example, spectacles, months or years in conducting a
proposed to require the following contact lenses, and reading glasses); comparative clinical study, only to learn
information: ++ Decreased rate of subsequent when it is ready to submit an NTIOL
• Proposed name or description of a diagnostic or therapeutic interventions, request that the criteria have changed.
new class of NTIOLs. such as the need for YAG laser Several commenters suggested that
• Trade/brand name, manufacturer, treatment; requestors have the opportunity to meet
and model number of the IOL for which ++ Decreased incidence of with CMS to discuss the study design
the request to establish a new NTIOL subsequent IOL exchange; and and application processes to ensure that
class is being made. (Applications must ++ Decreased blurred vision, glare or the agency’s demands for
include the name and description of at other quantifiable symptom or vision documentation of an IOL’s benefits are
least one marketed IOL that would be deficiency. fully understood by applicants and are
placed in the proposed new NTIOL • Provide the following information met upon submission of the application.
class.) for the IOL(s) for which a new class is Response: We have received hundreds
• A list of all active or expired NTIOL proposed: of applications for pass-through
classes that describe similar IOLs. For + Dates the candidate IOL was first payment for devices and drugs and
each active or expired class, provide a marketed, reporting inside the United payment for new technology services
detailed explanation as to why that class States and outside the United States under the OPPS using a format and
would not describe the candidate IOL. separately. process similar to that proposed for
• Detailed description of the FDA + Dates of sale of the first unit of the NTIOLs. The format for pass-through
approved clinical indications for the IOL, reporting inside the United States and new technology requests under the
candidate IOL. and outside the United States OPPS as well as the details of the
• Description of the IOL— separately. application process are posted on the
+ What is it? Provide a complete + Number of IOLs that have been sold CMS Web site, but they are not codified.
physical description of the IOL, up to the date of the application. As a matter of policy and practice, we
including its components, for example, + A copy of the FDA’s original are available to meet with anyone with
its composition; coating or covering; approval notification. an interest in developing a request for
haptics; material; and construction. • A copy of the labeling claims consideration of a new class of NTIOLs
+ What does it do? approved by the FDA for the IOL, at any time, to ensure that our
+ How is it used? indicating its clinical advantages and/or requirements are clear and thoroughly
+ What makes it different from other the lens characteristics with clinical understood by the requestor, and also to
currently available IOLs? relevance. give CMS an opportunity to preview a
+ What makes it superior to other • A copy of the FDA’s summary of potential applicant for NTIOL status.
currently available IOLs used for similar the IOL’s safety and effectiveness. The application process is an interactive
indications? • Reports of modifications made after collaboration between CMS and the
+ What are its clinical characteristics, the original FDA approval. requestor that continues until CMS has
for example, is it used for treatment of We stated in the proposed rule that all of the information it needs to be able
specific pathology; what is its life span; we strongly encourage and may give to make a determination.
what are the complications associated greater consideration for the submission We are concerned that commenters
with its use; and for what patient of published, peer-reviewed literature may also be confusing the factors that
populations is it intended? and other materials that demonstrate we are implementing in revised
+ Submit relevant booklets, substantial clinical improvement with § 416.195, which are the criteria that
pamphlets, brochures, product use of the candidate IOL over use of CMS will consider to determine
catalogues, price lists, and/or package currently available IOLs. whether an IOL qualifies for a payment
inserts that further describe and In our proposed § 416.190(d), we adjustment as a member of a new
illuminate the nature of the IOL. provided that, in order for CMS to NTIOL class, with the items of
• If the candidate IOL replaces or invoke the protection allowed under information listed in the proposed rule
improves upon an existing IOL, identify Exemption 4 of the Freedom of in section XVII.E.2.d of the preamble,
the trade/brand name and model of the Information Act (5 U.S.C. 552(b)(4)) and, which comprise a list of the information
existing IOL(s). with respect to trade secrets, the Trade that CMS needs in order to determine
• Full discussion of the clinically Secrets Act (18 U.S.C. 1905), the whether a lens meets the criteria in
meaningful, improved outcomes that requestor must clearly identify all § 416.195.
Finally, we are confused about Response: We agree with the and is associated with improved clinical
commenters’ apprehension regarding commenter’s assertion that there are a outcomes. The date of implementation
the potential for research studies being variety of forms in which credible of a payment adjustment in the case of
undermined in some manner if the evidence can be presented, in addition approval of an IOL as a member of a
information required for a request for to publication in a peer-reviewed new NTIOL class would be set
NTIOL eligibility is not codified. The journal. We encourage the submission of prospectively as of 30 days after
information required for a request for all credible evidence, published or not. publication of the ASC payment update
NTIOL eligibility is mostly descriptive However, we believe that published, final rule, consistent with the statutory
and explanatory; it is not information peer-reviewed literature has particular requirement. The date of
required for a research study. value in that it is the product of a implementation of a payment
Comment: One commenter rigorous process of thorough scrutiny adjustment in the case of approval of a
recommended that any information and standards that are acknowledged lens as a member of an active NTIOL
concerning NTIOLs be made available and recognized throughout the class would be set prospectively as of
for public review and comment. academic and scientific community. the publication date of the ASC
Another commenter contended that the For reasons stated above, as we payment update final rule.
APA requires that the content proposed, we are revising § 416.190 to We received no comments on these
requirements for an NTIOL payment reflect the specified changes to the proposals. Therefore, we are making
request be subject to notice and content of a request for payment review final, without modification, the process
comment rulemaking and subsequently of an IOL, to clarify when a request can and timelines that we proposed.
published in the Code of Federal be submitted and who may submit, and
f. Payment Adjustment
Regulations and also that any future to also clarify the process for
revisions be subject to notice and maintaining confidentiality of The current payment adjustment for a
comment rulemaking. information included in a request. As 5-year period from the implementation
Response: We disagree with the stated earlier, we are not incorporating date of a new NTIOL class is $50. In the
commenters’ contention that the points the list of information required with CY 2007 OPPS proposed rule, we did
of information we proposed to require each request in the regulations, but are not propose to revise this payment
in a request to review a lens must be posting it on the CMS Web site to adjustment for CY 2007.
enumerated in the Code of Federal ensure that such information is updated For CY 2007, we proposed to revise
Regulations. We note that the in a timely manner and relevant to § 416.200(a) through (c) to clarify how
information listed in current advancing IOL technologies. We are the IOL payment adjustment would be
§ 416.195(a)(1) through (5) is included revising § 416.190 to require that the made and how a NTIOL would be paid
in the list of information in section content of each request for an IOL after expiration of the payment
XVII.E.2.d. of the proposed rule (71 FR review must include all information as adjustment. We also proposed minor
49634). The additional points of specified on the CMS Web site for the editorial changes to § 416.200(d).
information that we proposed to require request to be considered complete. Comment: Several commenters
in section XVII.E.2.d. of the preamble expressed concern that the $50 payment
are simply an explicit itemization of e. Notice of CMS Determination adjustment for a new NTIOL class is
‘‘other information that CMS finds In the CY 2007 OPPS proposed rule, inadequate, has not been adjusted for
necessary for identification of the IOL’’ we proposed three possible outcomes inflation since it was initially
(see § 416.195(a)(6) of the current from review of a request for implemented, and is out of step with the
regulations). Instead of requiring determination of a new NTIOL class. As rising costs of innovative research. One
requestors to use a pre-printed, appropriate, for each completed request commenter objected to a flat $50
prescribed application form, we simply for a candidate IOL that is received by adjustment for all NTIOLs on the
list the individual items of information the established deadline, one of the grounds that research, development and
that have to be supplied, which we following determinations would be production costs vary from lens to lens.
accept in whatever format the requestor announced annually in the final rule Several commenters recommended that
finds most convenient. Moreover, the updating the ASC payment rates for the manufacturers be given the opportunity
CY 2007 OPPS proposed rule has next calendar year: to present a request, supported by
provided an opportunity for public • The request for a payment appropriate documentation, for a higher
comment on the information required in adjustment is approved for the IOL for payment adjustment for NTIOLs for
a request for NTIOL consideration. The 5 full years as a member of a new which it is warranted.
few comments that we received are NTIOL class described by a new code. Response: In January 2008, as
addressed below. The criteria for • The request for a payment discussed elsewhere in this final rule
determining whether or not a lens adjustment is approved for the IOL for with comment period, we plan to
qualifies as belonging to a new class of the balance of time remaining as a implement a significantly revised
NTIOL are what require public member of an active NTIOL class. payment system for ASC facility
comment, not the list of information • The request for a payment services, which will affect payment for
needed to apply the criteria. adjustment is not approved. all ASC services, including payment for
Comment: One commenter believed We also proposed to summarize IOLs and their insertion and payment
that the mere fact that scientific briefly in the ASC final rule the for cataract surgery. Only after we have
evidence has been published in a peer- evidence that was reviewed, the public implemented the revised ASC payment
reviewed journal should not impact comments, and the basis for our system in CY 2008 will we be able to
whether CMS determines the evidence determination. When a new NTIOL evaluate whether or not the ASC facility
is credible. The commenter further class is established, we proposed to fee established for cataract surgery with
believed that a study that has been identify the predominant characteristic IOL insertion is appropriate when a lens
accepted or published in a peer- of NTIOLs in that class that sets them determined to be an NTIOL is furnished.
reviewed journal should not be given apart from other IOLs (including those Therefore, we are retaining for now the
greater weight simply because it has previously approved as members of current $50 payment adjustment for a
been published. other expired or active NTIOL classes) new NTIOL class. In addition, we are
adopting as final without modification Regulation (FAR). For Department of health intermediaries (RHHIs) and
our proposal to revise § 416.200(a) Health and Human Services process Medicare claims for home
through (c) to clarify how the IOL acquisitions, the FAR is supplemented health services and hospice services.
payment adjustment will be made and by the Department of Health and Human (Section 1816 of the Act was amended
how a NTIOL will be paid after Services Acquisition Regulation in 1977 to allow the Secretary to
expiration of the payment adjustment; (HHSAR) at 48 CFR chapter 3. Using designate regional or national
and to make minor editorial changes to competitive procedures, CMS will intermediaries, which we refer to as
§ 416.200(d). replace its current claims payment RHHIs, to process claims for home
In summary, after careful contractors (intermediaries and carriers) health services. We have designated
consideration of the public comments with new contract entities, MACs. these RHHIs to serve both the home
we received timely regarding our Section 911(d)(1)(C) of Public Law 108– health agency (HHA) and the hospice
proposed changes, we are adopting as 173 requires that CMS compete and provider communities.) Four Durable
final without modification, with the transition all Medicare claims Medical Equipment Regional Carriers
exception of a few technical edits, the processing workloads to MACs by (DMERCs) process claims for durable
provisions of proposed new Subpart G October 1, 2011. medical equipment, prosthetics, and
under Part 416 to codify the rules In accordance with section 911(e) of orthotics. For a complete listing of the
governing the ASC payment adjustment Public Law 108–173, on or after October current Medicare intermediaries and
for NTIOLs. 1, 2005, any reference to an carriers, refer to the CMS Web site:
‘‘intermediary’’ or ‘‘carrier’’ in a http://www.cms.hhs.gov/contacts/
G. Announcement of CY 2007 Deadline regulation shall be deemed a reference incardir.asp.
for Submitting Requests for CMS Review to a MAC. The process of transition Although health care delivery in the
of Appropriateness of ASC Payment for from intermediaries and carriers to United States has evolved with
Insertion Following Cataract Surgery of MACs is not a single point-in-time advances in modern technology, the
an NTIOL occurrence, but rather necessarily contracting authorities relating to the
In accordance with § 416.185(a) of our happens over a multiyear period due to Medicare FFS administrative structure
regulations, as revised by this final rule the size and nature of the claims did not substantially evolve between the
with comment period, CMS announces workloads involved. Therefore, for the enactment of the Medicare statute in
that, in order to be considered for purposes of clarity, the term 1965 and the enactment of Public Law
payment effective January 1, 2008, ‘‘intermediary’’ is used throughout this 108–173.
requests for a review of an application final rule with comment period to Prior to passage of Public Law 108–
for a new class of new technology IOLs describe a Medicare contractor, 173, intermediary and carrier
must be received at CMS by COB, April pursuant to the authority of section acquisition authorities did not require
1, 2007. Send requests to: ASC/NTIOL, 1816 of the Act, that has not yet full and open competition or unified
Division of Outpatient Care, Mailstop transitioned to a MAC. In addition, for processing of Medicare Part A and Part
C4–05–17, Centers for Medicare and the purpose of clarity, the term ‘‘carrier’’ B claims. Medicare contracting was
Medicaid Services, 7500 Security is used throughout this final rule with significantly hampered by absence of
Boulevard, Baltimore, MD 21244–1850. comment period to describe a Medicare competition and cumbersome
To be considered, requests for NTIOL contractor, pursuant to the authority of termination procedures. In an effort to
reviews must include the information section 1842 of the Act, that has not yet achieve Congress’ goal of a more
posted on the CMS Web site at http:// transitioned to a MAC. efficient and effective Medicare
cms.hhs.gov/ASCPayment/ operation, CMS developed a plan for
B. CMS’ Vision for Medicare Fee-for- most current Medicare Part A and Part
05_NTIOLs.asp#TopOfPage. Service and Medicare Administrative B intermediary and carrier
XVIII. Medicare Contracting Reform Contractors (MAC) responsibilities to be integrated into a
Mandate CMS’ vision for the Medicare fee-for- single contract entity to be administered
service (FFS) program is that of a by a single contractor in each area of the
A. Background
premier health plan that allows for country. These new MACs will handle
Section 911 of the Medicare comprehensive, quality care and world- claims processing and related activities
Prescription Drug, Improvement, and class beneficiary and provider services. traditionally performed by
Modernization Act of 2003 (MMA), Achieving this vision requires intermediaries and carriers.
Public Law 108–173, amended Title substantial improvement of CMS’ Under Medicare contracting reform,
XVIII of the Act to add section 1874A, current FFS administrative structure. the MACs will perform all the core
Contracts with Medicare Administrative Further information on CMS’ plans to claims processing operations for both
Contractors (MACs). Section 1874A of improve Medicare FFS may be obtained Medicare Part A and Part B. CMS will
the Act replaces the prior Medicare through the Medicare Contracting ensure that MACs focus on providing a
intermediary and carrier contracting Reform Web site: http:// high level of customer service to
authorities formerly found in sections www.cms.hhs.gov/medicarereform/ providers and beneficiaries. MACs will
1816 and 1842 of the Act, respectively. contractingreform/. be the providers’ primary contact with
This reform (commonly referred to as As of November 1, 2006, there are 20 Medicare, and CMS will hold the MACs
‘‘Medicare contracting reform’’ for intermediaries and 18 carriers that accountable for overall provider and
Medicare fee-for-service) is intended to process FFS claims. Intermediaries beneficiary satisfaction and correct
improve Medicare’s administrative process claims for Medicare Parts A and claims payment.
services to beneficiaries and health care B relating to services furnished by With respect to financial
providers and to bring standard health care facilities, including management, as was required of
contracting principles to Medicare, such hospitals and SNFs. Carriers process intermediaries and carriers, MACs will
as competition and performance claims for Medicare Part B, in promote the fiscal integrity of the
incentives, which the government has particular, for physician, laboratory, and program and be accountable stewards of
long applied to other Federal programs other nonfacility services. Four the Medicare Trust Fund dollars. The
under the Federal Acquisition intermediaries serve as regional home MACs will be required to pay claims
timely, accurately, and in a reliable providers to select a contractor to of the Act, funds) the power to nominate
manner while promoting cost efficiency perform claims payment and audit their servicing intermediary to
and the delivery of maximum value to functions, has been amended. It now determine and make Medicare payments
the program. contains one sentence mandating the to their members. Under this provision,
We recognize the potential for use of contracts with MACs to an intermediary could be a ‘‘national,
improving the efficiency and administer section 1816 of the Act. state, or other public or private agency
effectiveness of services to Medicare Sections 1816(e), (f), and (g) of the Act, or organization.’’ As previously stated,
beneficiaries and providers through the which authorized the Secretary to under this provision, the American
Medicare contracting reform provisions develop standards, criteria, and Hospital Association nominated the
contained in section 1874A of the Act. procedures for the assignment of national Blue Cross Association to serve
Through our implementation of these providers to intermediaries and to as the prime Medicare intermediary for
provisions, we expect to realize reassign providers periodically, have its membership in 1965, an arrangement
significant performance improvements. been repealed. that will continue to exist until full
The future environment is designed to Section 911(d) of Public Law 108–173 implementation of MACs.
generate substantial savings both from permits the Secretary to transition the Moreover, prior to the enactment of
an administrative and programmatic current intermediary and carrier Public Law 108–173, section 1816(d) of
standpoint and will safeguard CMS’ functions to the MACs. More the Act allowed individual providers
mission. information about CMS’ plans to and groups of providers to—
implement Medicare contracting reform, • Part with their group or association
C. Provider Nomination and the Former
including the Report to the Congress on and nominate another entity to serve as
Medicare Acquisition Authorities
this subject, can be obtained at the CMS their intermediary; and
As originally enacted in 1965 and Web site: http://www.cms.hhs.gov/ • Withdraw its/their nomination from
until the enactment of Public Law 108– medicarereform/contractingreform/. an intermediary, and obtain services
173, section 1816 of the Act afforded MACs will perform all core claims from another intermediary that had an
groups or associations and individual processing operations for both Medicare agreement with the Secretary.
providers of services (as defined at Part A and Part B. The Part A and Part Finally, section 1816(e) of the Act, as
section 1861(a) of the Act) the right to B MACs will operate in distinct, it formerly read, specified the
nominate (appoint) their intermediary. nonoverlapping geographic substantial procedural requirements to
The intermediary agreements were jurisdictions, which will form the basis be followed by the Secretary in the
governed by Medicare laws that diverge of the Medicare claims processing event that the Secretary desired to
from the FAR in a number of important operations. A transitional period runs assign or reassign individual providers
respects. Prior to Public Law 108–173, between October 1, 2005, and October 1, of services to any intermediary other
section 1816 of the Act precluded the 2011. During this period, any existing than the nominated entity. This
Medicare program from competing intermediary and carrier contracts could provision also gave limited authority to
intermediary functions on a full and be maintained until replaced by a MAC the Secretary to designate a regional or
open basis. Rather, institutional contract. The statute requires that all national intermediary for a particular
providers of services, such as hospitals intermediary and carrier contracts are to ‘‘class’’ of providers of services.
and nursing facilities, nominated a be competed and awarded as MAC However, this authority was subject to
particular intermediary to process and contracts by October 1, 2011. substantial procedural requirements.
pay their Medicare Part A claims. Among these procedural requirements
In a significant historical D. Summary of Changes Made to
Section 1816 of the Act were:
development that took place shortly • The Secretary had to promulgate
after Medicare’s enactment in 1965, the Substantial changes to section 1816 of standards, criteria, and procedures for
American Hospital Association and the Act that were required by sections evaluating the performance of
other provider trade associations 911(b) and 911(c) of Public Law 108– intermediaries under section 1816(f) of
nominated the Blue Cross Association 173 took effect on October 1, 2005. The the Act;
(BCA) to serve as the intermediary for changes that we proposed and are • The Secretary had to make a
their membership. The BCA merged finalizing in this final rule with finding, after applying such standards,
with the Blue Shield Association in the comment period to the regulations criteria, and procedures, that the
1970s to form today’s Blue Cross and under 42 CFR Part 421, Subpart B reassignment of the individual provider
Blue Shield Association (BCBSA.) CMS (discussed under section XVIII.E. of this and/or the designation of the regional or
and the BCBSA then entered into a preamble) are intended to conform the national intermediary would result in
prime contract, which continues to regulations to these statutory changes. more efficient and effective
currently exist through the annual Prior to the statutory developments administration of the Medicare program;
renewal process. In turn, the BCBSA directed by Public Law 108–173, section • The Secretary had to provide a full
subcontracted most operational 1816 of the Act provided the foundation explanation of the reasons for
intermediary functions to its member acquisition authority for agreements determining that the intermediary
plans. The BCBSA assigned the majority between CMS, acting for the Secretary, change would result in more efficient
of the nation’s hospitals to its local Blue and intermediaries, for the purpose of and effective administration; and
Cross plans. Some providers of services administering benefits under Medicare • Affected agencies and organizations
nominated commercial insurers to serve Part A and making payments to were given the right to a hearing, and
as their intermediaries. providers of services. any determinations of the Secretary on
Most recently, section 911(b) of Public In particular, section 1816(a) of the nominations and provider assignments
Law 108–173 amended section 1816 of Act formerly gave groups and were subject to judicial review.
the Act to remove the provider associations of providers of services In the former sections 1816(e)(4) and
nomination authority. The section has (which, under section 1861(u) of the 1816(e)(5) of the Act, the Secretary was
been renamed: ‘‘Provisions Relating to Act, includes hospitals, CAHs, SNFs, given authority to establish regional
the Administration of Part A.’’ Section CORFs, HHAs, hospices, and, for the intermediaries with respect to HHAs
1816(a) of the Act, which authorized purposes of sections 1814(g) and 1835(e) and hospice providers, although certain
procedural requirements still had to be intermediaries consistent with sections contracts in effect prior to October 1,
met. 1816(e)(4) and (e)(5) of the Act. 2005, under their terms and conditions
In summary, while, under section In addition to the provisions until October 1, 2011, there was no
1816 of the Act, the Secretary was not discussed above that relate to provider similar extension for existing
required to accept all Medicare nominations, prior to the enactment of nomination arrangements. Section
intermediary nominations, the Secretary Public Law 108–173, section 1816 of the 911(d)(2)(A) of Public Law 108–173
had no independent authority to Act also contained other provisions provides the Secretary with authority to
contract with any entity for Medicare governing agreements with Medicare enter into intermediary agreements
intermediary services outside the intermediaries that were not consistent outside of the provider nomination
nomination process. Moreover, while with the mainstream of Federal process starting with the date of
providers of services were given the acquisition and procurement enactment of Public Law 108–173
opportunity to seek a reassignment to a authorities, as this mainstream is (December 8, 2003). Therefore, while
new intermediary, the Secretary could reflected in the FAR. For instance— Congress specified that the Secretary
not assign or reassign individual • Section 1816(b) of the Act contains should submit a plan for implementing
providers or classes of providers unless provisions that limited payment under section 911 at the start of FY 2005, the
substantial procedural requirements all intermediary agreements to a cost- Secretary was authorized to contract
were followed. reimbursement basis only; outside of the section 1816 nomination
The existing Medicare regulations • Section 1816(f) of the Act required provisions immediately and in advance
under 42 CFR Part 421, particularly the Secretary to publish the of delivery of the report to Congress.
those within Subparts A and B, were performance criteria and standards for This analysis requires that similar,
substantially shaped by this statutory intermediary agreements in the Federal conforming changes be made in our
framework relating to provider Register, and specified requirements regulations as set forth in the proposed
nominations and the assignment or relating to the application of such rule and as finalized in this final rule
reassignment of providers of services to criteria and standards; and with comment period.
intermediaries. In particular, the • Section 1816(g) afforded
E. Provisions of the Proposed and Final
following regulatory provisions have intermediaries the right to terminate
Regulations
their basis in the statutory provisions of their agreements with CMS, but limited
the right of the Secretary to terminate an As discussed under section XVIII.A.
sections 1816(a), (d), and (e) of the Act
agreement; in particular, no provision of this preamble, based on the authority
(all are located within 42 CFR Part 421):
was made for the normal right of the provided in sections 1874A(a) through
• § 421.1(c), which discusses criteria
government to terminate for (d) of the Act, as established by section
to be used in assigning and reassigning
convenience. 911(a)(1) of Public Law 108–173, we are
providers; finalizing our proposed rules to
• § 421.3, which provides exceptions In section 911(b) of Public Law 108–
173, Congress reiterated the requirement establish regulations pertaining to
to definitions to accommodate the MACs in a new Subpart E of 42 CFR
designation of regional intermediaries that CMS begin to move beyond the
legacy nomination-based intermediary Part 421. Moreover, based on the
for HHAs and intermediaries for substantial changes to section 1816 of
hospices; agreements during FY 2006. This was
done by repealing outright or the Act, including the repeal of all of the
• § 421.103, which identifies options section 1816 provisions relating to the
substantially modifying many of the
available to providers for receiving ability of providers to nominate their
provisions of section 1816 of the Act,
Medicare payments; servicing intermediary, as enacted by
effective October 1, 2005. In particular,
• § 421.104, which provides the section 911(b) of Public Law 108–173,
section 911(b) of Public Law 108–173—
procedural framework governing the
• Repealed the prior language of we also are making a number of changes
administration of provider nominations to Subparts A and B of 42 CFR Part 421.
section 1816(a) of the Act, including the
for intermediaries; In addition, we are changing the title of
basic provider nomination provision,
• § 421.105, which obligates CMS to and replaced it with a statement Part 421 from ‘‘Intermediaries and
provide notice as to its action on indicating that Medicare Part A Carriers’’ to ‘‘Medicare Contracting’’ and
nominations; administrative functions would be making conforming revisions to Subpart
• § 421.106, which specifies the contracted through section 1874A of the B of Part 421.
process to be used by a provider Act; As discussed earlier, section 911(b) of
desiring a change of intermediary; • Repealed section 1816(b) of the Act Public Law 108–173 either repealed
• § 421.112, which provides the in full, including its provisions limiting outright or substantially modified
considerations to be taken into account payment to cost reimbursement; sections 1816(a), (b), (c), (d), (e), (f), (g),
by CMS when, among other things, it • Repealed the contract-related (h), (i), and (l) of the Act, and made clear
desires to assign or reassign a provider provisions of section 1816(c) of the Act; that the acquisition authority for Part A
to an intermediary or designate a • Repealed sections 1816(d), (e), (f), claims processing would, after October
regional or national intermediary for a (g), (h), (i), and (l) of the Act; and 1, 2005, be found in section 1874A of
class of providers; • Made conforming changes to the Act. Among all these changes, each
• § 421.114, which governs the sections 1816(c), (j), and (k) of the Act. of the former ‘‘provider nomination’’
assignment or reassignment of With these changes, section 1816 of provisions within section 1816 of the
individual providers; the Act is no longer an acquisition Act was repealed. In addition, section
• § 421.116, which specifies the authority, and there is no vestige of the 911(d)(2)(A) of Public Law 108–173
requirements for designating national or former provider nomination provisions gave the Secretary authority to disregard
regional intermediaries consistent with or the partial exceptions to those the provider nomination provisions in
sections 1816(e)(1) through (e)(3) of the provisions relating to HHAs and hospice this contracting, even prior to October 1,
Act; and providers. 2005. In accordance with these statutory
• § 421.117, which specifies the While section 911(d)(1)(B) of Public changes, we are finalizing our proposal
parameters for assigning HHAs and Law 108–173 allows the Secretary to to substantially modify or delete
hospice providers to regional continue intermediary and carrier §§ 421.1(c), 421.3, 421.103, 421.104,
421.105, 421.106, 421.112, 421.114, 108–173, CMS had considered (and 300 certified beds spread across 3 or
421.116, and 421.117 of the regulations. occasionally approved) requests from more contiguous States.
As discussed earlier, the amendment certain classes of institutional providers • Central Controls—The provider
to title XVIII of the Act (to allow for the covered by these section 1816 chain had to demonstrate that it
new section 1874A: ‘‘Contracts with provisions, primarily, hospitals, SNFs, exercised central controls, assuring
Medicare Administrative Contractors’’) and CAHs, to bill an intermediary other substantial uniformity in operating
requires CMS to contract with eligible than the one servicing providers in the procedures, utilization controls,
entities to perform Medicare functions geographic locale of the provider. The personnel administration, and fiscal
using the FAR. We are adding process and criteria for making these operations among the individual
regulations pertaining to MAC contracts determinations are set forth in detail in providers.
in a new subpart E (Medicare the existing regulations under 42 CFR The administrative efficiencies gained
Administrative Contractors) under Part Part 421, Subpart B (which we are by both the large multi-State chain
421 as follows: § 421.400 (Basis and removing in accordance with the providers and the Medicare program by
scope), § 421.401 (Definitions), and changes effectuated by section 911(b) of allowing single intermediary
§ 421.404 (Assignment of providers and Public Law 108–173). relationships to exist may not be as
suppliers to MACs). In particular, not automatically but on significant as they were formerly. Prior
a fairly frequent basis, CMS approved to the implementation of the
1. Definitions Administration Simplification
requests from large multi-State groups of
As we proposed under proposed provisions of Part C of Title XI of the
such providers under common
§ 421.401, in this final rule with Act, the various intermediaries required
ownership and control, called ‘‘chain
comment period, we are defining a providers to use somewhat divergent
providers,’’ to bill a single intermediary
‘‘Medicare administrative contractor transaction and formatting standards in
on behalf of all the individual providers
(MAC)’’ as an agency, organization, or their electronic claims processing
in the chain through the headquarters
other person with a contract to perform systems. A provider chain with
office, or ‘‘home office,’’ of the chain
any or all of the functions set forth centralized billing processes could make
provider. These chain providers were
under section 1874A of the Act. With a good business case that it should be
granted ‘‘single intermediary’’ status.
respect to the performance of a permitted to bill only one intermediary.
particular function in relation to an The premise behind granting
Moreover, prior to the implementation
individual entitled to benefits under privileges to bill a single intermediary to
of the many prospective payment
Medicare Part A or enrolled under such large multi-State chain providers
systems required by the Balanced
Medicare Part B, or both, or a specific was that this might reduce
Budget Act of 1997 and subsequent
provider of services or supplier (or class administrative billing expenses for the public laws, a greater percentage of
of such providers of services or chain and reduce the administrative Medicare program payments hinged on
suppliers), we are defining an expenses of the Medicare program. In the Medicare cost report audit and
‘‘appropriate MAC’’ as a MAC that has particular, assigning a large multi-State reimbursement process. In such an
a contract to perform a Medicare chain provider to a single intermediary environment, there was potential benefit
administrative function in relation to a facilitated the Medicare cost report to both a chain provider and the
particular individual, provider of audit and reimbursement functions, government to minimize coordination
services, or supplier, or a particular because findings with respect to the cost issues. Finally, the former Medicare
class of providers. report of the chain’s home office could environment involved many
affect the individual provider’s cost intermediaries, so there were naturally
2. Assignment of Providers and report. Otherwise, these audit and more geographic boundaries among
Suppliers to MACs reimbursement issues would need to be contractors that a multi-State chain
As we proposed, in this final rule coordinated among multiple could cross.
with comment period, we are intermediaries. We understand the provisions of
establishing a new § 421.404 to In addition to applying the relevant section 1874A of the Act and, more
incorporate the rules governing the regulatory requirements in 42 CFR Part particularly, the revisions to section
processing of claims submitted by 421, Subpart B in our review of chain 1816 of the Act made by section 911(b)
providers and suppliers that enroll with provider requests for single of Public Law 108–173 to authorize the
and receive Medicare payment and intermediary status, we applied Secretary to assign all providers and
other Medicare services. As a general additional criteria to focus our analysis suppliers, even the members of multi-
rule, Medicare providers and suppliers and to ensure that the exception to our State entities, to the geographically
will be assigned to the MAC that is normal practice of assigning providers based MACs based on their physical
contracted to administer the types of to their ‘‘local’’ intermediary was location. This action is consistent with
services (benefits) billed by the provider warranted. We advised the chain CMS’ vision, as articulated in the
or supplier within the geographic locale provider that it would have to Secretary’s Report to Congress on
in which the provider or supplier is demonstrate that having a single Medicare Contracting, of establishing a
physically located or furnishes health intermediary would be consistent with claims processing environment where
care services, respectively. One efficient and effective administration of most Medicare Part A and Part B claims
significant exception to this general rule the Medicare program, and that the involving a particular beneficiary are
pertains to suppliers of durable medical intermediary would need to have administered by the same contractor.
equipment, prosthetics, orthotics, and sufficient capacity to effectively serve However, as indicated in that Report
supplies. These suppliers will bill the the chain (these elements were (page V–4), we recognize that there may
MAC covering the area where the restatements of the regulatory criteria). still be some legitimate business value
beneficiary resides—a continuation of In addition, we required the chain to to allowing large multi-State chains of
existing policy. meet the following requirements: providers that formerly were able to
In the past, under the provider • Size—The provider chain had to be nominate their intermediary to bill on a
nomination provisions that were comprised of 10 participating facilities consolidated basis to one MAC. While
repealed by section 911 of Public Law or 500 certified beds, or 5 facilities or section 911(d)(1)(C) of Public Law 108–
173 abolished the former provider administrative actions. In other cases, in accordance with Chapter 13 of the
nomination framework, we believe that assignments were made through CMS Program Integrity Manual. As the
allowing the practice of consolidated administrative action. In the case of MACs commence operations in their
billing by large chains is within the smaller chains of otherwise eligible jurisdictions, each MAC will
discretion of the Secretary under section providers, we note that section consolidate all of the LCDs for its
911 of Public Law 108–173. 911(d)(1)(C) of Public Law 108–173 jurisdiction. CMS will continue to issue
Accordingly, in this final rule with abolished the provider nomination national coverage determinations
comment period, we are finalizing our framework and appears to us to (NCDs).
proposal under § 421.404 that— anticipate the use of regional Comment: Several commenters share
• Providers (as defined in 42 CFR contractors. the commitment of CMS to implement
400.202) will generally be assigned to We believe that our establishment of the Medicare contracting reform
the MAC with claims processing MACs that, in most cases, will provisions that are mandated by section
jurisdiction over the geographic locale administer claims from multiple States 911 of the MMA. They requested that
in which the provider is physically will largely resolve the concerns these CMS grant exceptions to the general rule
located. other providers may have. Under our to permit large chain providers to
• Large chain providers comprised of approach, for instance, we believe that choose an appropriate MAC. They
individual providers that were formerly few chain providers will have to bill believed that allowing providers to
permitted by CMS to ‘‘nominate’’ an more than two MACs even if they fail choose their MAC will ensure maximum
intermediary, which we refer to as to meet the tests for being a ‘‘qualified efficiency. Another commenter asked if
‘‘qualified chain providers,’’ will be chain provider.’’ a ‘‘large chain’’ with ‘‘multiple national
permitted to request opportunity to Finally, with respect to suppliers (as offices’’ could request that a specific
consolidate their Medicare billing also defined in 42 CFR 400.202 of our ‘‘chain office’’ be used for consolidation
activities to the MAC with jurisdiction regulations), we are assigning suppliers to one MAC geographic locale.
over the geographic locale in which the (including physicians and nonphysician Response: As specified in proposed
chain’s home office is located. practitioners) to MACs based on the new § 421.404(b)(3), a qualified chain
• Qualified chain providers that were geographic jurisdiction in which they provider approved by CMS to bill a
formerly granted single intermediary operate and furnish services. These single intermediary on behalf of its
status do not need to re-request such requirements mirror the various Part B member providers prior to October 1,
privileges on behalf of the entire chain. claims jurisdiction rules that have been 2005, would be assigned at an
• CMS may grant other exceptions to in place. CMS may grant an exception appropriate time to the MAC contracted
the general rule for assigning providers to this policy only if CMS finds the by CMS to administer claims for the
to MACs, but only based on a finding exception will support the applicable Medicare benefit category for
that such an exception will support the implementation of MACs or will serve the geographic locale in which the chain
implementation of the MACs or if CMS some compelling interest of the provider’s home office is physically
deems the exception to be in the Medicare program. However, we do located. The qualified chain provider
compelling interest of the Medicare incorporate the current special billing would not need to request an exception
program. requirements relating to DMEPOS to § 421.404(b)(1). Accordingly, if the
We are incorporating a definition of suppliers in § 421.210 and § 421.212. commenter’s reference is to one ‘‘large,’’
‘‘qualified chain provider.’’ The criteria We indicated in the proposed rule previously approved, qualified chain
that constitute the definition of a that as we move forward to implement organization, the qualified chain
‘‘qualified chain provider’’ mirror the MAC contracting in keeping with the organization would be assigned to the
elements that were historically applied. statutory mandate of section 911 of MAC serving the geographic area where
We believe these are appropriate criteria Public Law 108–173 and the Secretary’s the qualified chain organization’s home
to employ in reviewing whether a chain Report to Congress, we were inviting office is located. If the commenter’s
provider should even be considered for public comments on these specified reference is to several distinct,
consolidated billing. Less stringent issues, including our proposed previously approved, qualified chain
criteria would clearly cut against the definitions and criteria. (Once the MACs organizations that have recently merged,
statutory mandate to establish MACs are initially implemented, we indicated the several distinct legacy chains would
and end the provider nomination that we may propose more stringent have to request status as a single
process. More stringent criteria might criteria for consolidated billing status, qualified chain organization in
disrupt the operations of many entities in keeping with the overall thrust of accordance with § 421.404(b)(1); and as
that formerly were approved for single section 911 of Public Law 108–173.) part of this process, the newly emerged
intermediary handling under the old Comment: One commenter supported chain organization will be required to
criteria. the approach CMS is taking to establish the location of its home office.
Smaller chains of otherwise eligible consolidate the Medicare Part A and If CMS approves the request, the new
providers (for example, hospitals, SNFs, Part B claims processing functions into qualified chain organization will bill
and CAHs) might also desire one MAC covering several States. The and receive Medicare payment from the
consolidated billing, as well as other commenter was encouraged that this MAC that covers the geographic locale
types of providers (for example, HHAs consolidation will promote greater in which the qualified chain
and hospices). In the latter case, the consistency across geographic regions. organization’s home office is located.
other types of providers (termed The commenter requested that CMS Comment: Several commenters
‘‘ineligible providers’’ in this final rule instruct MACs to review local coverage requested that CMS maintain maximum
with comment period) did not have the determinations (LCDs) and other flexibility for all parties involved in
opportunity to request assignment to policies to ensure consistency in Medicare contracting reform (that is,
(nominate) a particular intermediary coverage between settings of care and to providers and contractors) during the
prior to October 1, 2005. In some cases, align payment policy and incentives transitional phases to the MACs. They
these other types of providers were between physicians and hospitals. suggested that CMS allow large chain
assigned to regional intermediaries Response: As is our current practice, providers the ability to maintain their
based on a nexus of statutory and MACs will be required to develop LCDs existing relationships with
intermediaries until all MAC transitions Response: Up until the date a MAC result in a more efficient and effective
are complete. commences operations in the administration of services.
Response: We cannot allow large jurisdiction where the existing chain Response: We will ensure that
chain providers to maintain their provider’s home office is located, the providers affected by a transition from
existing relationships with existing chain provider will be served a legacy Medicare contractor to a MAC
intermediaries until all MAC transitions by the current intermediary serving the are notified in advance of the transition.
are complete because as intermediary State in which the existing chain This will be a significant activity within
functions are transitioned over time to provider’s home office is located, the implementation plan for each MAC
MACs, those intermediaries will no provided the current intermediary does as the MAC and the provider will need
longer be processing claims. Those not end its contract prior to the time to work together on a number of issues
claims will be processed by the that the new MAC commences (for example, test electronic billing
‘‘replacement’’ MAC. operations. Current intermediaries and arrangements). We have substantial
Comment: One commenter requested carriers will complete their contract experience in overseeing Medicare
that CMS provide a mechanism for a obligations, including serving the claims transitions and have refined
chain provider that has facilities in existing chain provider’s home offices. these processes over many years. The
many Medicare Part A and Part B MAC In the event that the servicing reasons for the transition to MACs were
jurisdictions to consolidate into a intermediary does choose to end its set forth in the preamble to the rule.
smaller number of MACs instead of a contract, CMS will apply § 421.104 in Comment: Several commenters
single MAC in the chain provider’s reassigning the existing chain provider requested that CMS consider the
home office jurisdiction. to another CMS contractor. Our potential impact on providers of
Response: The policy announced in overriding goal is to ensure continuity delayed claims processing during the
proposed § 421.404 allows chain of operations during the period of time implementation of the Medicare
providers that meet the requirements for current contractors are transitioning to contracting reform provisions under
qualified chain organization status to MACs. section 911 of the MMA.
request single MAC billing status on Comment: One commenter asked Response: We note that Medicare
behalf of its member providers. The CMS to allow a qualified chain claims processing timeframes are set
process for submitting the request, organization to select either the MAC elsewhere in statute and CMS’ program
together with the types of that covers the jurisdiction where its requirements will not be affected by the
documentation the qualified chain home office is located, or another MAC transition to MACs. We will review all
organization must submit in support of that covers the jurisdiction where the MAC contract proposals to verify that
its request, will be set forth in detail in chain’s billing office is located (if companies desiring to serve as MACs
a future CMS program manual. A chain different), when deciding to consolidate can meet these requirements, and we
provider may make the business Medicare billing activities. will closely monitor all transitions to
decision to identify a segment of its Response: For the reasons set forth in ensure that strong program performance
organization as a distinct qualified the preamble to the proposed rule, it is is maintained.
chain organization with a regional CMS’ policy that each qualified chain Comment: One commenter
management office that will fall organization may request permission commended CMS for requiring MACs to
appropriately within one MAC from CMS to bill centrally to one MAC. pay claims timely. However, the
jurisdiction. Our current policy does not Further, our requirement is that the commenter strongly requested that CMS
require that all member providers qualified chain organization must bill not allow a MAC to move to a less
within the qualified chain organization the MAC responsible for the geographic frequent payment schedule, believing
bill through the chain provider’s home area where the qualified chain that Medicare claims volumes continue
office MAC. However, the future CMS provider’s home office is located. At this to warrant the most frequent payment
program manual may require that a time, we will not allow the qualified schedule. The commenter also urged
qualified chain organization make clear, chain organization to bill based on the CMS to consider the ability and
in its centralized MAC billing request, location of its billing office (if different). availability of the MAC to meet the
the identity of each member provider, Our policy protects the Medicare needs of the providers assigned to the
and which member providers are program against chain providers that MAC. The commenter believed the
included within the request for might seek less restrictive MACs by MAC should be available during a
centralized billing through the home relocating their billing offices. The provider’s normal business hours,
office MAC. The future CMS program process for submitting the request, regardless of the provider’s location
manual may require each such together with the types of within the MAC jurisdiction.
requesting qualified chain organization, documentation the qualified chain Response: The commenter raised
if approved, to maintain that centralized organization must submit in support of issues that are outside the scope of the
billing configuration until a request for its request, will be set forth in detail in proposed rule. In this final rule with
another change is approved by CMS. a future CMS program manual. As we comment period, we are not responding
Comment: Several commenters asked gain experience with the MAC to those comments. We note that
if an existing chain hospital that is in a environment, we may broaden the Medicare claims processing timeframes
jurisdiction that is transitioning to a centralized billing alternatives to are set elsewhere in statute and will not
MAC, but the existing chain provider’s support options suggested by the be affected by the transition to MACs.
home office is not in that jurisdiction, commenter. We will review the other comments and
will be allowed to continue to bill the Comment: Several commenters consider whether to take other actions,
intermediary it has been using, or must requested that CMS have a clear such as revising or clarifying the MAC
it transition to the contracted MAC in its notification and a transition process for contracts or CMS’ operating instructions
jurisdiction. The commenters also notifying providers of potential or procedures, based on the information
wanted to know whether a chain reassignments deemed necessary by the or recommendations provided in the
organization may convert to a single Agency. They requested that a full comments.
MAC to avoid the need for multiple explanation be given for the reasons for Comment: Several commenters had
transitions. determining that the change would concerns that newly appointed MACs
may not have the expertise or familiarity Response: During the post-award/pre- Comment: Several commenters
needed to process specialized claims commencement period, as an recommended that CMS allow
such as those for end stage renal disease intermediary or carrier transitions to the companies with more than one legal
(ESRD). selected MAC, the selected MAC’s entity, and currently assigned to a single
Response: These commenters raised medical director will consolidate all the intermediary, to continue to bill
issues that are outside the scope of the LCDs for the States in the MAC’s centrally. They also recommended that
proposed rule. In this final rule with jurisdiction by identifying and CMS allow companies with more than
comment period, we are not responding implementing the least restrictive LCD. one legal entity to apply for single MAC
to those comments. We note that we are This process will alleviate a certain status.
requiring MACs that will administer percentage of LCD conflict across States. Response: Existing chain providers,
specialized workloads to demonstrate However, a given MAC will apply only including those with more than one
their capability to do so in their contract the LCDs in force in its own legal entity, assigned to a single
proposals. jurisdiction. MACs will not be required intermediary prior to October 1, 2005,
Comment: Several commenters to apply the LCDs of other MACs. will be assigned to a single MAC at an
requested that CMS allow ESRD The choice to request centralized, appropriate time in accordance with
providers the option of having their home office billing is a business § 421.404(b)(3). If a chain provider with
claims handled by multi-state, regional decision for each qualified chain more than one legal entity, that is
MACs. provider to weigh. We are providing this assigned to a single MAC, subsequently
Response: All of the MACs will serve option under § 421.404(b)(2) of the comes to CMS with a request to change
multi-state areas, for example one will regulations, but are not mandating that the MAC assignment for one of the legal
serve New York and Connecticut. ESRD chains avail themselves of it. We will entities because of a change in the
suppliers will generally be assigned to not routinely provide alternatives (other corporate structure of the overall chain,
MACs based on § 421.404(c)(1). than the general alternative provided by such as spinning off a downstream
However, a group of ESRD suppliers § 421.404(b)(1)) because doing so is not affiliate, then CMS may require the
under common control and common generally in CMS’ administrative entire chain to reapply for single MAC
ownership may obtain a § 421.404(c)(3) interest and could devolve to the former status, applying the then-current CMS
exception if CMS finds the request for ‘‘provider nomination’’ environment. qualified chain organization program
We note that moving from 20 manual.
centralized billing through the home
Comment: One commenter
office MAC will support the intermediaries and 18 carriers to 15
recommended that CMS expand the
implementation of MACs or will serve Medicare Part A and Part B MACs has
field of § 421.404(a) ‘‘eligible providers’’
some other compelling interest of the been widely received as a step in the that are entitled to be counted among
Medicare program, or both. right direction by most segments of the the qualified chain provider’s members.
Comment: One commenter cautioned Medicare provider community and a The commenter argued that allowing
that if a chain were to consolidate to just substantial accomplishment to support otherwise ineligible providers to join in
one MAC, there is the potential for an the contracting reform goal of improving centralized billing status would
excessive workload for a MAC that may the efficiency and effectiveness of facilitate integration of important
have in its jurisdiction many home delivering services to Medicare functions such as coverage rules,
offices for large chain organizations. beneficiaries and providers. provider education, and support for
Response: We believe that the MACs Comment: One commenter requested beneficiaries.
will be fully capable of administering clarification of CMS policy on how Response: The group of ‘‘eligible
their chains’ workload, but we will often qualified chain organization providers’’ under § 421.404(a) was
monitor the concentration of qualified member providers can move in and out established by reference to the provider
chain organization claims across the 15 of centralized billing status. The types that have traditionally been
Medicare Part A and Part B MACs. commenter stated that chains frequently eligible to consolidate their billing. At
Comment: One commenter change in size and scope of operations, this time, we do not intend to extend
recommended that CMS permit all of a such as the establishment of a regional centralized billing beyond these
qualified chain organization’s member central billing office, and determine that provider types. However, we believe
providers within a particular area to bill it is more efficient to change the billing that § 421.404(b)(4) provides CMS the
their local, geographically assigned status for all or some member providers. discretion to make exceptions if
MACs, even if the remainder of the The commenter suggested the status circumstances warrant.
qualified chain organization has change be permitted each fiscal year Comment: Several commenters
requested and been approved for with a minimum required notice of 120 requested that CMS clarify what is
centralized, home office MAC billing. days before the start of the next home meant by the term ‘‘best interest of the
The commenter believed that some local office cost reporting period. program’’.
MACs may be better suited to serve a Response: We appreciate the Response: ‘‘Best interest of the
chain’s providers because LCDs vary industry’s input on workable notice program’’ means that which the
across jurisdictions. Specifically, the requirements. This is a policy detail we responsible CMS personnel (acting in
commenter was concerned about a will address in the future CMS program their official capacity, or capacities)
scenario where the home office MAC’s manual. However, we wish to point out determine on a nonarbitrary and
LCD policy might not cover a that no provider will be allowed to noncapricious basis, using reasonable
hospitalization, even were the local centralize (or decentralize) its billing judgment and information known to
MAC’s policies might allow a physician without CMS approval, and we do not them, to be most advantageous to the
to bill under the same clinical anticipate allowing chains to change Medicare program. In making such a
circumstances. The commenter stated their process frequently. There is a cost determination, CMS personnel may
that the typical chain often operates a to the Medicare Program associated with balance competing factors and options.
variety of providers and suppliers such moving providers from one contractor to The factors considered may change over
as hospitals, freestanding imaging another, and the lead time required will time; for instance, as the Medicare
centers, and physician offices. be more than 120 days in many cases. program’s requirements change,
technology evolves, and the MACs are request was made and provide intermediary responsibilities, to delete
implemented. documentation of CMS authorization for the reference to § 421.117 from this
Comment: One commenter offered centralized billing. Without the proper section, as the statutory provision that
input on the MAC procurement process documentation, a qualified chain made this necessary was repealed by
and asked CMS to consider certain organization must wait for CMS to open Public Law 108–173.
performance-related information in the the period for single-MAC billing status. We did not receive any public
awarding of a future MAC contract. A forthcoming program manual that comments on these proposed technical
Several commenters requested that CMS outlines the process for such requests and conforming changes and, therefore,
include providers in the contractor will provide the appropriate are finalizing them in this final rule
selection and renewal process. They instructions. with comment period without
requested CMS to allow providers to After considering the public modification.
give mid-contract reviews of the MACs’ comments received, we are adopting as c. Options Available to Providers and
performance. One commenter requested final, without modification, the
that CMS ensure that MACs are required CMS (§ 421.103)
proposed provisions of Subpart E of 42
to maintain a significant local presence CFR Part 421 (§§ 421.400, 421.401, and As we proposed, we are finalizing our
inasmuch as each jurisdiction includes 421.404) governing MACs. change of the title of § 421.103 to
several States. ‘‘Payment to Providers’’ and revising the
Response: These commenters raised 3. Other Technical and Conforming contents of § 421.103 to clarify that all
issues that are outside the scope of the Changes providers must receive payments for
provisions of the proposed rule. In this a. Definition of ‘‘Intermediary’’ (§ 421.3) covered services furnished to Medicare
final rule with comment period, we are beneficiaries through an intermediary
not responding to those comments. We did not receive any public (under § 421.404) and eventually
However, we will review the comments comments on our proposal to revise the through a MAC (under § 421.404). We
and consider whether to take other definition of the term ‘‘intermediary’’ are specifying that this function must
actions, such as revising or clarifying under existing § 421.3 to delete remain with the intermediaries. We will
the MAC contracts or the CMS operating reference to ‘‘alternative regional no longer allow providers to receive
instructions or procedures that are intermediaries,’’ and, therefore, are payments directly from CMS, nor will
issued, based on the information or finalizing it in this final rule with we allow providers to receive payments
recommendations provided in the comment period. CMS no longer allows from alternative regional intermediaries.
comments. We note that the Medicare HHAs and hospice care providers to We believe the inclusion of this
contracting reform statute requires us to select an alternative regional function is consistent with the effective
measure providers’ satisfaction with the intermediary. Over the years, as the and efficient administration of the
MACs, and that we will be periodically number of intermediaries in the Medicare program.
surveying providers for this program has decreased, the availability We did not receive any public
information. of alternative intermediaries for HHAs comments on our proposed technical
Comment: One commenter made an and hospices has declined. We have changes.
individual-case-specific request. One of implemented the policy that all HHAs
its ‘‘health care systems’’ supposedly and hospice care facilities are to be d. Nomination for Intermediary
was granted centralized billing assigned to the designated regional (§ 421.104)
privileges by CMS but the transition to intermediary that serves their As we proposed, we are finalizing our
a single intermediary was never geographic jurisdiction. This is required change of the title of § 421.104 to
completed for various reasons. The for the efficient and effective ‘‘Assignment of Providers of Services to
commenter asked CMS to complete the administration of the Medicare program Intermediaries During Transition to
centralized billing transition through as the agency moves forward to Medicare Administrative Contractors
the finalization of this rule. implement the MACs. (MACs)’’ and revising the contents of
Response: Through a series of the section to provide that new
b. Intermediary Functions (§ 421.100)
‘‘Medlearn Matters’’ articles published providers that enter the Medicare
on the CMS Web site at http:// Section 1816(a) of the Act, which program during the transition period
www.cms.hhs.gov/MLNMattersArticles/ allowed providers to nominate an will be assigned to the local designated
2005MMA/List.asp#TopOfPage and intermediary, required that only intermediary that serves the jurisdiction
distributed via Listserves and nominated intermediaries perform the in which the provider is located. We did
communications with CMS components functions of determining payment not receive any public comments on the
and affiliated contractors in September amounts and making payments to proposed technical change. We believe
and October of 2005, CMS notified the providers. Section 1874A of the Act, as this change is necessary as we prepare
Medicare community that no requests added by section 911 of Public Law to transition from intermediary
for provider nomination would be 108–173, eliminates the intermediary agreements and carrier contracts to
accepted beyond October 1, 2005. The nomination process. All activities contracts with the MACs. In the MAC
public comment and response process carried out under intermediary environment, providers will be assigned
connected with a notice of proposed agreements will be transitioned to MAC based on their geographic location to the
rulemaking is not the forum in which contracts by September 30, 2011. MAC that has jurisdiction for their
the Agency treats case-specific requests During the transition period, CMS provider type.
for qualified chain provider or will still require regulations to support
centralized billing status. Chain its intermediary agreements. In the e. Notification of Actions on
organizations that have experienced a proposed rule, we proposed to amend Nominations, Changes to Another
delay in conversion to centralized § 421.100, concerning functions to be Intermediary or to Direct Payment, and
billing in connection with a pre-October included in intermediary agreements, to Requirements for Approval of an
1, 2005 CMS decision to authorize address the dual intermediary Agreement (§ 421.105 and § 421.106)
centralized billing should contact the responsibilities. We also proposed to We did not receive any public
CMS component where the original revise existing § 421.100(i), Dual comments on our proposal to remove
§ 421.105 and § 421.106 from the change to another intermediary or to provisions under which CMS may
regulations; the sections will no longer direct payment. Under Medicare award a fixed price or performance
be applicable with implementation of contracting reform, we require increased incentive contract under the
the new Subpart E of Part 421. flexibility to realign providers to experimental authority contained in 42
Therefore, we are finalizing the removal geographical jurisdictions for effective U.S.C. 1395b–1 for performance of
in this final rule with comment period. implementation of the MACs. We intermediary functions under § 421.100.
reserve the right to reassign providers to The provisions of this section became
f. Considerations Relating to the other jurisdictions if we deem it to be
Effective and Efficient Administration of obsolete with the enactment of section
in the best interest of the program. 911 of Public Law 108–173.
the Medicare Program (§ 421.112) We did not receive any specific public
We are finalizing our proposal to comments on this proposed technical We did not receive any public
revise § 421.112 (a). As stated change. comments on this proposed technical
previously in this final rule with change.
h. Designation of National or Regional
comment period, provider requests to be Intermediaries (§ 421.116) and XIX. Reporting Quality Data for
assigned or reassigned to a particular Designation of Regional and Alternative Improved Quality and Costs Under the
intermediary will no longer be Designated Regional Intermediaries for OPPS
considered. However, we may deem it Home Health Agencies and Hospices
necessary to reassign providers if we (§ 421.117) As noted previously, CMS’ Office of
find it is necessary for the efficient and the Actuary currently projects that
effective administration of the program. We are finalizing our proposal to
delete § 421.116, Designation of national Medicare Part B expenditures will
In addition, there will no longer be a continue to grow at a significant rate, as
or regional intermediaries, and
national intermediary to serve a class of a result of rapid growth in the use of
§ 421.117, Designation of regional and
providers. both physician-related services and
alternative designated regional
We did not receive any specific public intermediaries for HHAs and hospices. hospital outpatient services in the
comments on this technical change. The statutory provisions that made original Medicare fee-for-service
g. Assignment and Reassignment of these regulations necessary were program. Specifically, the actuaries
Providers by CMS (§ 421.114) repealed by Public Law 108–173. project that the expenditures under the
Therefore, we no longer need these OPPS in CY 2007 will be approximately
We are finalizing our proposal to regulations. All providers will receive $32.540 billion. This represents
revise § 421.114 to specify that we may payment for covered services as approximately a 9.2 percent increase
consider it necessary to assign and described in § 421.103. over our estimated expenditure of
reassign providers if the assignment or We did not receive any public $29.809 billion for the OPPS in CY
reassignment is in the best interest of comments on this proposed technical
the program. Before making these 2006, and reflects even more rapid
change. spending growth in recent years. As the
determinations, we will no longer
review provider requests to be i. Awarding of Experimental Contracts following table shows, implementation
reassigned to another intermediary. This (§ 421.118) of the OPPS has not slowed outpatient
is consistent with the proposed policy We are finalizing our proposal to spending growth; in fact, double-digit
to eliminate a provider request to delete § 421.118, which specifies the spending growth has been occurring.
TABLE 52.—GROWTH IN EXPENDITURES UNDER OPPS FROM CY 2001 THROUGH CY 2007 (PROJECTED EXPENDITURES
FOR CY 2006 AND CY 2007) IN BILLIONS
OPPS Growth CY 2001 CY 2002 CY 2003 CY 2004 CY 2005 CY 2006 CY 2007
Incurred Cost ....................................................................... 17.702 19.158 20.8102 23.702 26.518 29.809 32.540
Percent Increase .................................................................. ................ 8.2 8.6 13.9 11.9 12.4 9.2
Source: FY 2007 Mid-Session Review, Budget of the U.S. Government.
As we indicated in the CY 2007 OPPS payment systems that are experiencing general price or enrollment changes.
proposed rule, the current rate of growth rapid spending growth, brisk growth in The table below illustrates the increases
in expenditures for hospital outpatient the intensity and utilization of services in the volume and intensity of
services is of great concern to us. As is the primary reason for the current rate outpatient hospital services over the last
with the other Medicare fee-for-service of growth in the OPPS, rather than several years.
TABLE 53.—PERCENT INCREASE IN VOLUME/INTENSITY OF HOSPITAL OUTPATIENT SERVICES

CY 2005 CY 2006
CY 2002 CY 2003 CY 2004 (Est.) (Est.)
Percent Increase .......................................................................................................... 3.5 2.4 7.8 7.8 9.7

Source: FY 2007 Mid-Session Review, Budget of the U.S. Government
For outpatient hospital services, the percent, in excess of the long-term growth is projected to be 9.7 percent in
volume and intensity of services for CY trend. This increase follows the 7.8 CY 2006.
2005 are estimated to continue to percent increase in CY 2004, and the As we have stated repeatedly, this
increase significantly at a rate of 7.8 rapid growth in utilization of services in
the OPPS shows that Medicare is paying quality improvement in actual health improved outcomes for Medicare
mainly for more services each year, care delivery. Hospital performance beneficiaries.
regardless of their quality or impact on measures may also provide a foundation Since 2003, we have operated the
beneficiary health. The program should for performance-based rather than Hospital Quality Initiative,3 which is
promote higher quality services, so that volume-based payments, which are used designed to stimulate improvements in
Medicare spending is directed in the in the OPPS today. inpatient hospital care by standardizing
most efficient manner toward higher We have obtained some evidence of hospital performance measures and data
quality services. Medicare payments the potential for improving quality of transmission to ensure that all payers,
should encourage doctors and other care in hospitals by means of the hospitals, and oversight and accrediting
providers in their efforts to achieve collection and submission of entities use the same measures when
better health outcomes for Medicare performance data from the Premier publicly reporting on hospital
beneficiaries at a lower cost. Therefore, Hospital Quality Incentive performance. Section 501(b) of Public
we have been examining the concept of Demonstration.1 This demonstration Law 108–173 authorized us to link the
‘‘value-based purchasing’’ in a number was designed to test whether the quality collection of data for an initial starter set
of payment systems. ‘‘Value-based of inpatient care for Medicare of 10 quality measures to the hospital
purchasing’’ may use a range of beneficiaries can improve when IPPS annual payment update. In order
incentives to achieve identified quality financial incentives are provided. Under to implement this provision, we created
and efficiency goals, as a means of the demonstration, about 270 hospitals the Reporting Hospital Quality Data for
promoting better quality of care and of Premier, Inc., a nationwide alliance of Annual Payment Update (RHQDAPU)
more effective resource use in the not-for-profit hospitals, have been program. For FYs 2005 and 2006,
Medicare payment systems. In voluntarily providing data on 34 quality hospitals that met the RHQDAPU
developing the concept of value-based measures related to five clinical program’s requirements received the full
purchasing, we have been working conditions: heart attack, heart failure, IPPS annual payment update, while
closely with stakeholder partners, pneumonia, coronary artery bypass hospitals that did not comply received
including health professionals and graft, and hip and knee replacements. an update that was reduced by 0.4
providers. Using the quality measures, CMS percentage points. For FY 2005,
In the CY 2007 OPPS proposed rule, identifies hospitals with the highest virtually every hospital in the country
we sought public comment on value- quality performance in each of the five that was eligible to participate
based purchasing as related specifically clinical areas. Hospitals scoring in the submitted data (98.3 percent), and
to hospital outpatient departments. As top 10 percent in each clinical area approximately 96 percent of all
part of our overall goal of promoting receive a two percent bonus payment in participating hospitals met the
value-based purchasing in outpatient addition to the regular Medicare DRG requirements to receive the full update.
payment, we also made one specific payment for the measured condition. The data regarding the starter set of 10
proposal for the CY 2007 OPPS. Hospitals in the second highest 10 quality measures, as well as additional,
Section 1833(t)(2)(E) of the statute
percent receive a one percent bonus voluntarily reported data on other
permits the Secretary to ‘‘establish, in a
payment. In the third year of the quality measures, are available to the
budget neutral manner, * * *
demonstration, if hospitals do not public through the Hospital Compare
adjustments as determined to be
achieve absolute improvements above Web site at: http://
necessary to ensure equitable
the demonstration’s first year composite www.hospitalcompare.hhs.gov.
payments’’ under the OPPS. The
score baseline (the lowest 20 percent) The starter set of 10 quality measures
absence of OPPS measures to promote
for that condition, they will have their that was established for the IPPS
high quality in the provision of services
to Medicare beneficiaries creates an DRG payments reduced by one or two RHQDAPU as of November 1, 2003, are:
issue of payment equity. In general, percent, depending on how far their
Heart Attack (Acute Myocardial
payments to providers in Medicare’s performance is below the baseline.
Infarction/AMI)
payment systems do not vary on the Following the first year of the
demonstration (FY 2004), CMS awarded • Was aspirin given to the patient
basis of quality or efficiency differences
a total of $8.85 million to participating upon arrival to the hospital?
among the providers of services. As a
hospitals in the top two deciles for each • Was aspirin prescribed when the
result, Medicare’s payment systems may
clinical area. In the aggregate, quality of patient was discharged?
direct additional resources to hospitals
care improved in all five clinical areas • Was a beta-blocker given to the
that deliver care that is not of the
that were measured. Preliminary patient upon arrival to the hospital?
highest quality. For that reason, each
Medicare dollar spent does not result in information from the second year of the • Was a beta-blocker prescribed when
the same quality and efficiency of care demonstration indicates that quality is the patient was discharged?
for Medicare beneficiaries. continuing to improve, particularly for • Was an ACE inhibitor given for the
We believe that the collection and the hospitals that were initially poorest patient with heart failure?
submission of performance data and the performing.2 We believe that these Heart Failure (HF)
public reporting of comparative results indicate that reporting of quality
information about hospital performance data may in and of itself lead to • Did the patient get an assessment of
can provide a strong incentive to his or her heart function?
encourage hospital accountability in 1 The Premier Hospital Quality Incentive • Was an ACE inhibitor given to the
general and quality improvement in Demonstration was authorized under section 402 of patient?
Pub. L. 90–248, Social Security Amendments of
particular. Measurement and reporting 1967 (42 U.S.C. 1395b–1). This section authorizes Pneumonia (PNE)
can focus the attention of hospitals and certain types of demonstration projects that waive
• Was an antibiotic given to the
consumers on specific goals and on compliance with the regular payment methods used
in the Medicare program. patient in a timely way?
hospitals’ performance relative to those 2 Additional information on the Premier Hospital
goals. Development and implementation Quality Incentive Demonstration is available on the 3 Additional information on CMS’ Hospital
of performance measurement and CMS Web site at: http://www.cms.hhs.gov/ Quality Initiative is available on the CMS Web site
reporting by hospitals can thus produce HospitalQualityInits/35_HospitalPremier.asp. at: http://www.cms.hhs.gov/HospitalQualityInits/.
• Had the patient received a • ACE inhibitor (ACE–1) or those hospitals that are required to
pneumococcal vaccination? Angiotensin Receptor Blocker (ARBs) report quality data under the IPPS
• Was the patient’s oxygen level for left ventricular systolic dysfunction RHQDAPU program in order to receive
assessed? • Discharge instructions the FY 2007 update, and fail to meet the
For FY 2007 and each subsequent • Adult smoking cessation advice/ requirements for receiving the full FY
year, section 5001(a) of Public Law 109– counseling 2007 IPPS payment update. These
171 amended section 1886(b)(3)(B) of hospitals would receive an update to the
Pneumonia (PNE)
the Act and made changes to the CY 2007 OPPS conversion factor that is
program established under section • Initial antibiotic received within 4 reduced by 2.0 percentage points. Under
501(b) of Public Law 108–173. These hours of hospital arrival proposed § 419.43(h)(2), any reduction
changes require us to expand the • Oxygenation assessment would not affect a hospital’s OPPS
number of measures for which data • Pneumococcal vaccination status update in a subsequent calendar year.
must be submitted, and to change the • Blood culture performed before first Hospitals that meet the IPPS RHQDAPU
percentage point reduction in the antibiotic received in hospital program’s requirements for FY 2007 and
annual payment update from 0.4 • Adult smoking cessation advice/ receive the full IPPS annual payment
percentage points to 2.0 percentage counseling update would also receive the full
• Appropriate initial antibiotic update to the conversion factor used to
points for IPPS hospitals that do not
selection determine payments for CY 2007 under
report the required quality measures in
• Influenza vaccination status the OPPS.
a form and manner, and at a time,
specified by the Secretary. Surgical Care Improvement Project In the proposed rule, we indicated
Effective for payments beginning with (SCIP) that, for this initial phase of
FY 2007, new section implementing an OPPS RHQDAPU
• Prophylactic antibiotic received program in CY 2007, it would be
1886(b)(3)(B)(viii)(IV) of the Act within 1 hour prior to surgical incision
requires the Secretary to begin to adopt necessary to provide an exception for
• Prophylactic antibiotics certain hospital outpatient departments
the expanded set of performance discontinued within 24 hours after
measures set forth in the IOM’s 2005 to the requirement that quality data be
surgery end time submitted under the IPPS RHQDAPU
report entitled, ‘‘Performance In order to receive the full FY 2007
Measurement: Accelerating program in order to receive the full
IPPS update, hospitals are required to OPPS update. The quality data
Improvement.’’ 4 Those measures continue to collect data for all 10 starter
include the HQA measures and the submission requirements of the IPPS
set quality measures (or begin collecting RHQDAPU program apply only to
HCAHPS patient perspective survey. such data, if newly participating in the
Effective for payments beginning with ‘‘subsection (d)’’ hospitals. ‘‘Subsection
program) and are required to provide a (d)’’ hospitals are defined under section
FY 2008, the Secretary must add other written pledge to submit data on the set
measures that reflect consensus among 1886(d)(1)(B) of the Act as hospitals that
of 21 expanded quality measures, in are located in the 50 States or the
affected parties and may replace addition to completing several
existing measures as appropriate. New District of Columbia other than those
administrative tasks regarding quality categories of hospitals or hospital units
section 1886(b)(3)(B)(viii)(VII) of the Act reporting. All of the measures for the
requires the Secretary to post hospital that are specifically excluded from the
IPPS RHQDAPU program are to be IPPS, including psychiatric,
quality data on these measures on the reported on inpatient hospital rehabilitation, long-term care,
CMS Web site. The expanded set of 21 discharges. children’s, and cancer hospitals or
quality measures for the FY 2007 update In the CY 2007 OPPS proposed rule, hospital units. In other words, the
that was included in the FY 2007 IPPS we proposed to employ our equitable provision does not apply to hospitals
final rule (71 FR 48033) is outlined adjustment authority under section and hospital units excluded from the
below: 1833(t)(2)(E) of the Act to adapt the IPPS, or to hospitals located in Puerto
Heart Failure (Acute Myocardial quality improvement mechanism Rico or the U.S. territories. For the
Infarction/AMI) provided by the IPPS RHQDAPU initial stage of implementing the OPPS
program for use in the OPPS. As we RHQDAPU program in CY 2007,
• Aspirin at arrival have discussed above, failure to account hospitals that are paid under the OPPS
• Aspirin prescribed at discharge at all for quality in payment systems but that do not qualify as ‘‘subsection
• ACE inhibitor (ACE-I) or raises a fundamental issue of payment (d)’’ hospitals would continue to receive
Angiotensin Receptor Blocker (ARBs) equity. In the absence of mechanisms the full update to the OPPS conversion
for left ventricular systolic dysfunction that provide incentives for higher factor. However, as we explained in the
• Beta blocker at arrival quality care, Medicare’s payment proposed rule, our intention was to
• Beta blocker prescribed at discharge systems can direct more resources to expand the OPPS RHQDAPU in the
• Thrombolytic agent received within hospitals that do not deliver high future program by requiring all hospitals
30 minutes of hospital arrival quality care to Medicare beneficiaries. that receive payment under the OPPS to
• Percutaneous Coronary Intervention In the proposed rule, we proposed to participate in the program in order to
(PCI) received within 120 minutes of initiate a Reporting Hospital Quality receive a full update, by appropriate
hospital arrival Data for Annual Payment Update under expansion, adaptation, and/or extension
• Adult smoking cessation advice/ the OPPS (OPPS RHQDAPU program), of quality performance measures and
counseling effective for payments beginning quality reporting mechanisms.
Heart Failure (HF) January 1, 2007. We proposed to add a In the proposed rule, we explained
new § 419.43(h) to our regulations to that we believe that it is fair and

• Left ventricular function assessment implement this proposal. Under appropriate, for purposes of the initial
4 Institute of Medicine, ‘‘Performance
proposed new § 419.43(h)(1), we would phase of implementing an OPPS
Measurement: Accelerating Improvement,’’
initially implement an OPPS RHQDAPU RHQDAPU program, to take timely and
December 1, 2005, available at http://www.iom.edu/ program by reducing the OPPS accurate reporting of IPPS RHQDAPU
CMS/3809/19805/31310.aspx. conversion factor update in CY 2007 for program quality measures into account
under our equitable adjustment initially as outpatients, regardless of counseling regarding smoking cessation,
authority. We believe that the 10 their eventual discharge home from the and provision of discharge instructions.
original quality measures and the outpatient department or inpatient Patients with heart failure, a common
expanded set of 21 process measures as admission. Thus, we believe that all chronic medical condition, are seen
reported for inpatient discharges for seven of these measures likely serve as frequently in hospital clinics and
heart attack, heart failure, pneumonia, reasonable proxies for the quality of care emergency departments with
and surgical care reflect the quality of for patients presenting to the hospital exacerbations of their symptoms. Once
care in the outpatient department as outpatient department with chest pain again, their initial treatment is often
well as the inpatient hospital, so they related to a myocardial infarction, who standardized and provided in the
are appropriate for initial use in the commonly receive care along the outpatient setting without consideration
OPPS as specific measures are being continuum from outpatient to inpatient of their eventual discharge from the
developed to reflect the quality of care services in a hospital that provides such outpatient department or inpatient
for hospital outpatients. We believe that care in an integrated system. admission, a decision that ultimately
hospitals generally function as Similarly, there are seven process depends on clinical considerations,
integrated systems that provide health measures related to the care of patients including their response to treatment.
care services to patients in both with pneumonia, who often present Thus, we believe that all four of the
inpatient and outpatient settings for urgently to the hospital’s emergency inpatient quality measures regarding the
many of the same clinical conditions, room with symptoms suggestive of the treatment of patients with heart failure
while recognizing the different typical diagnosis of pneumonia. Because of the are reasonable surrogates for the quality
levels of acuity in the two settings. established clinical evidence regarding of hospital systems of care for
Hospital quality measures for multiple assessment and treatment activities that outpatients with heart failure.
conditions reflect, in part, the systems improve the quality of care for patients Likewise, under the expanded list of
of care established by hospitals in the with pneumonia, most of the quality measures for the FY 2007 IPPS
outpatient setting such as the emergency interventions that are measured, the surgical infection prevention quality
department. Therefore, the well- including oxygenation assessment, measures indicating the provision of a
developed quality measures reported for drawing of blood cultures, assessment of prophylactic antibiotic within 1 hour
the FY 2007 IPPS regarding inpatient the patient’s pneumococcal and prior to surgical incision and
hospital discharges should reasonably influenza vaccine status, and selection prophylactic antibiotics discontinued
represent the quality of care provided to and provision of an initial antibiotic in within 24 hours after surgery end time
hospital outpatients, so we proposed a timely manner, would generally be likely serve as a reasonable
their interim use for the CY 2007 OPPS performed in the outpatient department, representation of the quality of surgical
while quality measures specific to sometimes prior to a clinical decision care for hospital outpatients. Many of
hospital outpatients are being developed about the patient’s ultimate need for the same surgical procedures are
and refined. This use of multiple inpatient admission. In particular, the commonly performed on both hospital
measures for several clinical conditions measures of vaccine status are quality outpatients and inpatients, sometimes
serves as a proxy for the quality of the measures that may be especially in the same operating room suites with
systems of care established by hospitals. appropriate as hospital outpatient attendance by the same clinical staff.
As we expand quality measurement for prevention measures. Their use in the Hospitals often have standardized
hospital setting provides an opportunity protocols for providing antibiotics prior
the hospital outpatient setting, we
for quality improvement in the hospital to surgery and postoperatively based on
intend to move from measures that serve
by encouraging assessment of the types of procedures performed,
as proxies for the quality of care to
immunization status and appropriate rather than on the inpatient or
actual performance measures for the
provision of immunizations, so we see outpatient status of the patient, and a
outpatient setting. The discussion below
no reason why their reporting on decision to admit a patient may not
focuses on the expanded list of 21
hospital inpatients is not also reflective even be made until after the completion
quality of care measures, as the 10
of the quality of hospital outpatient of a procedure. Thus, we have no reason
original measures continue to be
care. While we acknowledge that, in to believe that the preoperative and
included in the quality measurement
general, the clinical picture of patients postoperative antibiotic experiences of a
expansion. who are admitted to the hospital with patient undergoing outpatient surgery
There are seven quality measures pneumonia differs from that of patients would systemically vary from that of a
assessing the processes of care for who are not hospitalized, we expect hospital inpatient.
patients presenting to the hospital with there to be many common elements in In summary, in the CY 2007 OPPS
an acute myocardial infarction, focused their assessment, treatment, and proposed rule we concluded that we
on the care on arrival, the promptness counseling regarding the significance of believe that quality improvement is
of interventions, and discharge care. As smoking as the hospital provides their usually a function of the entire
we noted in the proposed rule, for the initial and subsequent care in the institution as an integrated system that
common urgent condition of a patient outpatient and/or inpatient settings. provides both inpatient and outpatient
presenting to the hospital with chest Therefore, we believe that all seven of services to patients with an overlapping
pain that results in a clinical suspicion the measures related to the treatment of range of medical conditions. Quality
of acute myocardial infarction, in their pneumonia are likely appropriately improvement in a hospital inpatient
effort to provide consistent, high quality reflective of the quality of the care department is likely to correlate with,
care that is founded on evidence-based systems established by hospitals for and indeed to promote, similar quality
guidelines, hospitals often utilize outpatients with a diagnosis of improvement in the hospital’s
clinical care pathways that are pneumonia. outpatient department and other sectors
standardized for such patients There are four quality measures of the institution. Conversely, hospitals
presenting to the emergency room of the related to the treatment of patients with that fail to promote quality
hospital. Such care pathways generally heart failure, including assessment of improvement in key sectors such as
apply to patients with specific medical their cardiac function, use of certain inpatient care are also unlikely to
conditions who present to the hospital medications in their treatment, improve quality in the hospital
outpatient department. We believe that of patients who have been admitted to discussed in comments on this
the FY 2007 IPPS quality measures for the hospital may reasonably reflect proposed rule.
multiple clinical conditions reflect the hospital outpatients’ perspectives on For purposes of computing the update
quality of hospitals’ systems of care that their care experiences as well. to the conversion factor under the OPPS
customarily include key outpatient Finally, with respect to the 30-day in CY 2007, we proposed to reduce the
settings such as the emergency mortality measures, these measures are update to the OPPS conversion factor by
department. Therefore, as an interim linked to the same three medical 2.0 percentage points for any hospital
step while specific quality measures are conditions for which quality process that is eligible to participate in the IPPS
being developed and refined for measures have already been RHQDAPU program, but that has had its
reporting on the quality of care to implemented in the IPPS RHQDAPU IPPS payment update reduced because
hospital outpatients, we proposed that program, in order to expand the quality it failed to comply with that program’s
the initial CY 2007 OPPS RHQDAPU data to more fully reflect the true requirements. Under this proposal,
incorporate all of the quality measures outcomes of care. These mortality hospitals that fail to qualify for the full
that are applicable to the IPPS during measures are risk-adjusted based on CY 2007 OPPS update would receive
FY 2007. historical medical care use, including payments based on a proposed
In the proposed rule, we welcomed inpatient and outpatient hospital care conversion factor of $60.36, reflecting
public comments on the applicability to and physician office visits, and reflect an update of 1.4 percent, in place of the
the OPPS of the various FY 2007 IPPS outcomes of care specifically for proposed conversion factor of $61.551
quality measures as proxies for the Medicare patients. Because we proposed reflecting the full update of 3.4 percent.
quality of care in hospital systems that that the full set of FY 2007 IPPS process We proposed to add a new § 419.43(h)
include outpatient departments, with of care quality measures are acceptable to incorporate our proposal. Under
consideration of both the 10 starter set proxies for the quality of care to hospital proposed § 419.43(h)(1), in order to
measures and the 11 new measures in outpatients as previously discussed, and avoid reduction to the CY 2007 OPPS
the expanded set for FY 2007. we believe that some of the value of update, hospitals that are eligible to
In the proposed rule, we also health care process measures is their participate in the IPPS RHQDAPU
discussed our proposed additional relative ease of measurement and their program must meet the requirements for
quality measures for hospital reporting ultimate relationship to health receiving the full IPPS update for FY
of quality data for the FY 2008 IPPS. outcomes, we believe that the 30-day 2007. Updated procedures and
The proposed areas of expansion for the mortality measures for inpatients may requirements for the IPPS RHQDAPU
FY 2008 IPPS include the HCAHPS also reflect the quality of care to program are included in the FY 2007
survey, which incorporates questions hospital outpatients with the same IPPS final rule. In addition to
measuring patients’ perspectives of their medical conditions. In addition, in view publication in the final rule, all revised
hospital experiences; 3 additional of the common clinical courses of acute procedures will be added to the
measures related to the processes of myocardial infarction, heart failure, and ‘‘Reporting Hospital Quality Data for
surgical care to supplement the 2 initial pneumonia in Medicare beneficiaries, it Annual Payment Update Reference
Surgical Care Improvement Project is highly likely that hospital outpatient Checklist’’ section of the QualityNet
(SCIP) measures to be implemented in services may be provided to previously Exchange Web site (http://
FY 2007; and 3 risk-adjusted hospitalized patients within the www.qnetexchange.org). For purposes of
assessments of mortality within 30 days measures’ timeframe of 30 days after determining which hospitals have not
of hospital admission for acute hospital discharge, thereby contributing qualified to receive the full update
myocardial infarction, heart failure, and to their care and health outcomes. under the OPPS for CY 2007, we
pneumonia. For the same reasons Therefore, in the CY 2007 OPPS indicated in the proposed rule that we
detailed above for the FY 2007 IPPS proposed rule we stated our intention to would follow the determination for FY
SCIP measures, in the proposed rule we adopt the full set of FY 2008 IPPS 2007 full IPPS payment update
explained that we believe that the quality measures as proposed for the CY eligibility under the IPPS RHQDAPU
additional surgical process of care 2008 OPPS RHQDAPU program, while program. Since publication of the CY
measures are a reasonable interim proxy we continue to develop a set of specific 2007 OPPS proposed rule, CMS has
for the quality of surgical care for quality measures for hospital outpatient determined that 171 hospitals are not
hospital outpatients. care. eligible to receive the full FY 2007 IPPS
In addition, the questions on the In the CY 2007 OPPS proposed rule, payment update. As we noted above, we
hospital HCAHPS survey assess aspects we welcomed public comments on the proposed this initiative under the
of the patient’s hospital experience, applicability of the FY 2008 IPPS authority granted by section
including communication with doctors additional quality measures that we 1833(t)(2)(E) of the Act, which
and nurses, responsiveness of the staff, proposed to the care of hospital authorizes the Secretary to ‘‘establish, in
pain management, and discharge outpatients. We also welcomed public a budget neutral manner, * * *
information. These areas of questioning comments on alternative measures of adjustments as determined to be
are all relevant to a hospital’s care for quality of care, including measures of necessary to ensure equitable
its outpatients, who may be treated in the cost or efficiency of care, that are payments’’ under the OPPS. Proposed
the hospital outpatient department for suitable for adoption to reduce the § 419.43(h)(3) provided that the
an extended period of time, particularly incidence of lower-quality and high-cost reduction to the CY 2007 update that we
if they are in observation status or outpatient hospital care for Medicare will implement for hospitals that fail to
recovering from a significant surgical beneficiaries. We indicated that we meet the requirements described above
procedure. As described above, because would formalize our proposal regarding will be implemented in a budget neutral
hospitals generally function as the CY 2008 OPPS RHQDAPU program manner. Therefore, if we determine that
integrated systems, with both inpatients in the CY 2008 OPPS proposed rule, some hospitals would receive a reduced
and outpatients with related medical which may include proposing to adopt update for CY 2007 as a result of failure
conditions passing through the same none, some, or all of the FY 2008 IPPS to meet the requirements established
departments and interacting with RHQDAPU measures, and may also under this initial phase of the OPPS
similar staff, we believe that this survey reflect quality measures that are RHQDAPU program, we would also
make an adjustment to the OPPS measures at the earliest possible date. we welcomed comments on ways in
conversion factor, so that estimated Reporting of a more fully developed, which we could expand the proposed
aggregate payments under the OPPS for outpatient-specific set of quality and OPPS RHQDAPU program to all
CY 2007, taking into account the cost of care measures may be effective hospital outpatient departments that are
reduced update for some hospitals, for purposes of determining the update paid under the OPPS, and on quality
equal the aggregate payments that we as early as CY 2009. However, in and cost of care measures that are
estimate would have been made in CY implementing the system, we explained specifically appropriate for reporting by
2007 if all hospitals received the full that we would allow adequate time for hospital outpatient departments paid
update to the conversion factor. As we development of the appropriate under the OPPS but that do not qualify
noted above, determinations concerning measures; announcement of the quality as ‘‘subsection (d)’’ hospitals.
which hospitals failed to meet the and cost of care measures we have In the proposed rule, we explained
requirements for receiving the full selected; consideration of comments that our ultimate goal is implementation
update to the OPPS conversion factor in from the hospital community, patient of an OPPS RHQDAPU program that
CY 2007 were available in September advocates, and other stakeholders; extends to all hospital outpatient
2006. During the development of the establishment of the requisite departments that are paid under the
proposed rule, we were unable to mechanisms for reporting the measure; OPPS, that is based on a set of quality
determine how many hospitals would and initiation of actual reporting of the and cost of care reporting measures that
receive a reduced update in CY 2007, or measures by hospitals. As we begin to are specific to the hospital outpatient
to determine the budget neutrality develop such a set of hospital setting, and that is appropriately aligned
adjustment factor that would be outpatient-specific quality and cost of with developments in quality reporting
necessary to ensure that estimated care measures, in the proposed rule we and value-based purchasing in other
aggregate payments under the OPPS for welcomed comments on this issue. payment systems such as the IPPS. We
CY 2007 did not change as a result of Specifically, in the CY 2007 OPPS noted that we would take into
implementing the proposed OPPS proposed rule, we invited comments on consideration issues related to the
RHQDAPU program. However, we noted the following (and related) questions: appropriate alignment of quality and
that very few hospitals had previously Which current quality and cost of care cost of care reporting and value-based
failed to qualify for the full annual measures, such as IPPS quality purchasing under the IPPS and OPPS
updates under the IPPS RHQDAPU measures (especially the measure set as during the planning process mandated
program. Therefore, we anticipated that expanded under the DRA), physician by section 5001(b) of the DRA for
any further adjustment to the CY 2007 practice measures, HCAHPS/ACAHPS implementation of inpatient value-based
conversion factor to satisfy the budget etc., are most applicable in the hospital purchasing by FY 2009. We explained
neutrality requirement under section outpatient setting? What would be the that we plan to include all hospital
1833(t)(2)(E) of the Act would be characteristics of an ideal measure set of services, whether inpatient or
negligible. Our projections were correct, quality and cost of care measures for the outpatient, in the report on
as only a few hospitals were not eligible outpatient setting? What quality and implementation of value-based
to receive the full FY 2007 IPPS update. cost of care measures are currently purchasing. We have often heard from
available for the outpatient setting? stakeholders that a more
We explained in the proposed rule What privately-led organizations or comprehensive, systematic approach to
that it was not our intention to maintain alliances are best suited to conduct quality should be our focus. Quality
the specific requirements described needed development and consensus reporting of inpatient and outpatient
above beyond a short initial phase of endorsement of outpatient quality services is consistent with such
implementing an OPPS RHQDAPU measures? comments, and would provide more
program. Rather, our intention is to As we discussed above and we comprehensive information about the
develop this program beyond its initial proposed for the initial stage of quality of services provided by
stage in at least two ways. As we have implementing the OPPS RHQDAPU hospitals. In the proposed rule, we
stated previously, we believe that it is program in CY 2007, hospitals that are requested comments on the alignment of
appropriate and fair during this initial paid under the OPPS but that do not scope and other issues that should be
phase of the OPPS RHQDAPU program qualify as ‘‘subsection (d)’’ hospitals considered during this planning
to take quality data reporting under the would receive the full update to the process, including quality and cost of
IPPS RHQDAPU program into OPPS conversion factor. However, we care reporting measures, data and
consideration for purposes of believe that it is essential to expand the program infrastructure, incentives, and
determining the update for hospitals requirements of the OPPS RHQDAPU public reporting of quality and cost of
under the OPPS. However, it would be program that we proposed to all hospital care measures under value-based
important for a fully developed OPPS outpatient departments paid under the purchasing.
RHQDAPU program to be based on OPPS. Therefore, we indicated that we Finally, in the CY 2007 OPPS
reporting measures that are defined in would also undertake to study, for CYs proposed rule, we requested comments
terms of the quality considerations that 2008 and beyond, approaches to on the most effective use of our
are most appropriate and applicable in adapting and expanding the current authority under section 1833(t)(2)(E) of
the hospital outpatient setting. In quality and cost of care measures under the Act, in light of the concerning
collaboration with health care the IPPS RHQDAPU program for use in evidence of rapid and uneven payment
stakeholders, we indicated in the reporting on the quality of outpatient growth in the OPPS with limited
proposed rule that we intend to begin care in hospitals that are paid under the evidence of patient benefit. In
work on a set of quality and cost of care OPPS but that do not qualify as particular, we indicated that
measures specific to hospital outpatient ‘‘subsection (d)’’ hospitals. We commenters who believe that the
departments for implementation in a explained that we would also begin proposed quality reporting initiative is
later phase of the OPPS RHQDAPU development of mechanisms by which not the most effective use of this
program. We said that we intend to these hospitals could report the authority should consider submitting
implement a hospital outpatient-specific requisite quality data in a timely and comments on alternative, more effective
set of such quality and cost of care effective manner. In the proposed rule, approaches to using this and related
authorities available to CMS under the that the heart attack (Acute Myocardial provide an interim methodology.
Act to promote higher quality, more Infarction/AMI) measures be expanded However, the commenter also stated
equitable care. We stressed that we did to reflect current standards of care, that there should not be a rush to put
not believe that the status quo, with which include provision of both aspirin outpatient measures into place without
rapid and uneven growth in spending and clopidogrel bisulfate to patients prior review of such modifications by
and limited evidence of its value, was with Acute Coronary Syndrome on all stakeholders.
consistent with an efficient hospital discharge. A number of other commenters
outpatient payment program and value- One commenter said that it was not strongly opposed our proposal. Several
driven health care for Medicare clear whether CMS was proposing: (1) commenters objected that the proposal
beneficiaries, and we expect to take That hospitals must report the IPPS was unfair because it would take into
further steps to address this important measures for outpatient services to account reporting that hospitals had
concern. In addition, we sought prevent a 2.0 percent reduction on their already performed before they became
comment on whether section FY 2007 conversion factor update, or (2) aware of the additional payment
1833(t)(2)(F) of the Act also supports the that hospitals that report all of the IPPS reduction proposed under the OPPS for
proposed use of quality reporting to measures will automatically receive the failure to report the measures. Some of
determine a hospital’s update under the full OPPS update. The commenter these commenters expressed the view
OPPS. strongly objected to the application of that, in this respect, the proposal
Comment: Some commenters the IPPS measures to outpatient hospital amounted to retroactive rulemaking,
generally supported the proposal to services and said that CMS should since hospitals could now take no
reduce the update to the OPPS consolidate the various silos of action to avoid a potential reduction to
conversion factor for CY 2007 for those measures into a single set of quality their CY 2007 payments if the proposal
hospitals that are required to report measures that promote patient- is adopted. Other commenters objected
quality data under the IPPS RHQDAPU centeredness, episodes of care, the that the proposal exceeds CMS’
program in order to receive the FY 2007 continuum of care, and disease statutory authority.
update and fail to meet the requirements management. The commenter also Some of these commenters argued
for receiving the full FY 2007 IPPS stated that there needs to be a national that the congressional mandate of
payment update. One commenter measurement framework for quality reporting in the hospital
characterized the proposal as ‘‘an establishing the priorities for outpatient inpatient and home health settings
important and laudable project.’’ measures and that when outpatient precludes CMS from extending
However, this commenter also measures are constructed, there should reporting into the hospital outpatient
expressed concern that the projected be testing prior to public reporting of setting without such specific statutory
expansion of reporting to additional, the findings. However, the commenter authority. These and other commenters
outpatient-specific measures would also expressed support for a policy that also objected that section 1833(t)(2)(E)
require significant increases in hospital CMS ‘‘use the evidence of IPPS of the Act, which allows the Secretary
resources, including additional staff and reporting to influence the OPPS to establish ‘‘other adjustments as
increased vendor workload. Another conversion factor update for CY 2007 determined to be necessary to ensure
commenter agreed with the agency’s * * *.’’ This commenter supported this equitable payments,’’ does not provide
goals of adopting value-based ‘‘extra incentive for hospital quality adequate statutory authority to tie
purchasing and promoting higher reporting,’’ on the grounds that it ‘‘is hospital outpatient payments to quality
quality services. This commenter imperative that all hospitals participate reporting. In addition, some
expressed concern, however, that the in this avenue for accountability and commenters noted that unlike other
adoption of the IPPS standards might quality improvement. Thus, basing a adjustments proposed for the CY 2007
delay development of standards that are portion of OPPS payment on whether OPPS, there appeared to be no provision
appropriate to outpatient care. Another hospitals report their IPPS measures is for the amounts not spent in the full
commenter supported the proposal as warranted.’’ update for hospitals that did not meet
an interim step toward development One commenter noted that some the IPPS quality reporting standards to
and reporting of quality measures that hospitals are still attempting to master be returned to other providers through
are most appropriate to the hospital the original inpatient measures. The increases in payment. They believe that
outpatient department setting. This commenter suggested the most this proposal appeared to be a penalty,
commenter noted that the proposed appropriate time to add outpatient rather than an equitable adjustment.
reduction to a hospital’s outpatient quality indicators would be that when Some commenters also objected to the
payment update would provide an this task has been mastered. The proposed linkage of outpatient payment
additional incentive to spur the commenter also suggested the non- to inpatient measures of quality. Several
submission of the inpatient quality data. inpatient indicators should be added for commenters stated that the IPPS quality
Commenters also recommended that all entities at the same time, noting that measures have no documented validity
CMS evaluate the effectiveness of the CMS proposal under the OPPS does for outpatient care and services. Other
reporting quality data and consider not apply to ambulatory surgical commenters stated that the inpatient
increasing the reduction or shifting the centers. measures are not appropriate proxies for
application of the reduction to reflect Finally, one commenter agreed that hospital outpatient care measures, for a
actual performance rather than mere there is some correlation between variety of reasons. For example, one
reporting. outpatient and inpatient care for the commenter pointed out that there is
Another commenter supported the specific diagnoses included in the evidence that patients diagnosed with
effort to improve the quality of care in current IPPS reporting measures, but AMI, and who have no
hospital outpatient departments. This expressed some concern about the use contraindications for receiving
commenter offered specific suggestions of the IPPS measures as a proxy for the particular medications, have a better
for revising the proposed list of quality quality of hospital outpatient services. outcome if they receive aspirin and beta
measures for use in the hospital The commenter suggested that blockers within a short time of
outpatient department setting. For modification of some current inpatient presenting to the hospital. However,
example, the commenter recommender measures to include outpatients could there is no evidence of better outcomes
for patients who receive aspirin when payments are equitable. As we factor by 2.0 percentage points for those
they present in an emergency explained in the proposed rule, it is hospitals that are required to report
department with chest pain, but are inequitable for hospitals providing quality data under the IPPS RHQDAPU
diagnosed with some condition other poorer quality care that may result in quality reporting program and fail to
than heart attack and are sent home. the provision of more health services to meet the requirements for receiving the
Therefore, these commenters believe Medicare beneficiaries in the hospital full FY 2007 IPPS payment update. We
that CMS should proceed with care in outpatient department to be in a appreciate the perspective of the
taking these measures into account in position to receive higher payments commenters who acknowledged that
the outpatient setting only after a from the OPPS for that episode of care, this initial step was a sensible
thorough, scientific review to establish a result more in keeping with a fee-for- progression and agreed that the proposal
the application of the measures to service payment system that provides would provide an extra incentive for
outpatient care. One commenter payments for services without a focus hospital quality reporting that is an
specifically recommended that CMS on quality. The rapid spending growth effective avenue to hospital
should not proceed with expanding in the OPPS is primarily due to brisk accountability and quality
quality reporting into the hospital growth in the intensity and utilization improvement. We also explained that
outpatient setting in any manner of services, rather than general price or this proposal was only the first phase of
without a thorough scientific review enrollment changes. This growth has implementing a quality reporting
conducted by such organizations as the occurred in an OPPS payment program in the OPPS, which would
National Quality Forum (NQF). The environment that has not yet focused on eventually expand to encompass
commenter noted that the NQF has accounting for high quality care that reporting by all hospitals paid under the
endorsed the 21 hospital-based improves the health of Medicare OPPS and refinement of quality
inpatient quality measures only for beneficiaries. We believe that the OPPS measures to include those specific to
assessing quality of care in the inpatient must look forward, and that future hospital outpatient services.
setting, not for use in the hospital OPPS spending should be directed in In contrast, however, we acknowledge
outpatient setting. Some commenters the most efficient manner possible that many commenters expressed their
were concerned that additional toward higher quality services. A belief that quality performance in the
outpatient hospital-specific measures continued lack of focus on the quality outpatient setting could only be fairly
could result in a greatly increased and value is not desirable for the and accurately assessed through the
administrative burden, due to the program over the upcoming years. reporting of quality measures that are
volume of services in the outpatient Specifically, we believe we have the specific to outpatient hospital care by
setting that is much greater than the statutory authority to provide a all hospitals paid under the OPPS. We
inpatient setting. Other commenters differential update based on quality agree that the current inpatient quality
asked that outpatient quality and cost of reporting in the OPPS as we proposed. measures have some limitations as
care measures conform to standards of While we acknowledge that the IPPS proxies for the quality of outpatient
clinically appropriate care as RHQDAPU program is based in part on hospital care, in particular, their use to
established by peer-reviewed literature a DRA provision, the law does not assess what constitutes effective
or professional consensus, be preclude the Secretary from using his treatment for different patient
sufficiently flexible to allow access to other statutory authorities to ensure that populations. The inpatient measures
new technology and devices, and be other services paid by Medicare, such as have been developed and refined for
reviewed and updated periodically. the outpatient hospital services paid those patients who are admitted as
They thought that when providers met under the OPPS, are of appropriately hospital inpatients, and those patients
a particular measure, it should be high quality. may differ in several ways, including
removed to reduce the reporting burden. CMS’ shift across payment systems to the severity of their illnesses, from
MedPAC agreed that certain of the quality-based payment reform is an hospital outpatients. We agree with
IPPS measures, such as provision of evolutionary process. On the hospital commenters who believe that hospitals
aspirin on arrival to a patient with AMI, inpatient side, we began with linking should be held accountable for the
could conceptually be employed for the IPPS annual payment update to quality of their outpatient hospital
evaluating outpatient quality. However, reporting on 10 quality measures, and services through measures that are
MedPAC also advised that additional we now have expanded the measure set specific to that care. Throughout the
analysis may be necessary in order to for inpatient hospital reporting in FY development of the IPPS quality
ensure that these measures apply in the 2007. In the DRA, Congress mandated measures, we have highly valued
outpatient hospital setting. MedPAC that DHHS develop a plan for stakeholder input in the measure
also expressed a preference that CMS implementation of hospital value-based selection and refinement processes. We
seek the authority to move beyond pay- purchasing beginning with FY 2009. hope they continue to contribute vital
for-reporting toward pay-for- While the plan specifically focuses on input into the OPPS RHQDAPU quality
performance, so that payment updates the inpatient setting, moving toward pay reporting program, as we seek to create
depend on empirical evidence of for reporting in the hospital outpatient a bridge based on quality in the OPPS
outcomes from the quality data, not setting as we proposed is a logical next between the care setting and the
merely on whether the data are step. We believe it is very valuable for payment setting. We do not intend to
submitted. hospitals and CMS to gain as much implement a quality reporting program
Response: We appreciate the many experience as possible with all aspects linked to the OPPS annual update that
thoughtful comments that we received of quality reporting with a focus on is based on quality reporting that does
on our proposal. We continue to believe ultimately enhancing value for not conceptually and practically reflect
that the statute permits us to provide a Medicare. this vital link.

differential payment adjustment under As we discussed in detail in our While the DRA-mandated hospital
the OPPS for quality reporting, proposal, we proposed as an initial step value-based purchasing plan only
consistent with our broad authority in the program’s movement toward requires CMS to design a plan for the
under section 1833(t)(2)(E) of the Act to value-based purchasing to reduce the inpatient hospital setting, as part of that
provide an adjustment to ensure that update to the CY 2007 OPPS conversion work we are also considering issues
related to the implementation of quality development of hospital outpatient approach under the OPPS RHQDAPU
reporting in the hospital outpatient measures, and we plan to accelerate our program.
setting. We see extension of the focus on timetable significantly during CY 2007. We continue to believe that it is not
quality to outpatient hospital services, We appreciate the specific suggestions only appropriate but necessary to
many of which were inpatient services of commenters regarding measure require that hospitals must fully comply
until recently, as a logical progression. development for hospital outpatient with the OPPS RHQDAPU program
Most importantly, we believe that care, and we welcome ongoing public requirements to receive OPPS payment
implementing a payment adjustment input in this area. that reflects the full CY 2009 update to
would serve as an important milestone We have concluded that the most the conversion factor. We believe that
to signal the program’s emerging focus appropriate course at this point is to ensuring that Medicare beneficiaries
on quality services that provide implement the OPPS quality update receive the care they need and that such
significant benefits to the health of reporting program based on measures services are of appropriately high
Medicare beneficiaries. specifically developed to characterize quality are the necessary initial steps to
We agree with the commenters that the quality of hospital outpatient care. incorporating value-based purchasing
assessment of hospital outpatient We believe the process will require 2 into the OPPS. We seek to encourage
performance would ultimately be most years before quality measure data are care that is both efficient and of high
appropriately based on reporting of available. Given our concerns about the quality in the hospital outpatient
hospital outpatient measures developed increasing growth in OPPS spending department. We plan to work quickly
specifically for this purpose. Public without concern for the value of the and collaboratively with the hospital
reporting of specific outpatient hospital services, we do not believe it would be community to develop and implement
quality measures requires not only appropriate to delay focusing on the quality measures for the OPPS that are
having developed, accepted measures, quality of hospital outpatient services fully and specifically reflective of the
but also having in place the beyond the minimum of 2 years quality of hospital outpatient services.
infrastructure for data collection and required for the development and XX. Promoting Effective Use of Health
reporting. To reach the point where an implementation of these measures. Information Technology
outpatient hospital measure is collected
We agree with those commenters who We recognize the potential for health
and reported, based on our experience
pointed out that implementation of the information technology (HIT) to
with developing the IPPS measures,
OPPS RHQDAPU program as proposed facilitate improvements in the quality
multiple steps are involved. For a single
for CY 2007 would mean that hospitals and efficiency of health care services.
measure, these steps include developing
could not have made decisions One recent RAND study found that
the measure, obtaining stakeholder
regarding their participation in the IPPS broad adoption of electronic health
endorsement, vetting the measure with
quality reporting program with full records could save more than $81
appropriate organizations, engaging
knowledge of the effects of their billion annually and, at the same time,
vendors and providing a vehicle for
participation on their OPPS update. improve quality of care.5 The largest
chart reviews to support reporting,
testing of the Web site display, and then While implementation of the OPPS potential savings that the study
beginning data collection. From the start RHQDAPU program in CY 2008 based identified was in the hospital setting
of actual data collection, given the time on hospitals’ participation in the IPPS because of shorter hospital stays
period allowed for submission of data RHQDAPU would be possible because promoted by better coordinated care;
and the time it takes to preview and hospitals would have the opportunity to less nursing time spent on
ultimately generate a usable report, it make decisions knowing the administrative tasks; better use of
would take at least one year before the consequences of their participation, we medications in hospitals; and better
measure could be reported. believe that the quality of hospital utilization of drugs, laboratory services,
CMS has built strong and productive outpatient services would be most and radiology services in hospital
working relationships with many appropriately and fairly rewarded outpatient settings. The study also
organizations, including the Joint through the reporting of quality identified potential quality gains
Commission on Accreditation of measures developed specifically for through enhanced patient safety,
Healthcare Organizations, the NQF, application in the hospital outpatient decision support tools for evidence-
Hospital Quality Alliance, and others setting. Therefore, we are delaying based medicine, and reminder
through our IPPS measure development implementation of the OPPS RHQDAPU mechanisms for screening and
experience. We would hope these program until CY 2009, when we will preventive care. Despite such large
relationships continue in our move to implement a 2.0 point reduction to the potential benefits, the study found that
develop outpatient hospital quality OPPS conversion factor update for those only about 20 to 25 percent of hospitals
measures for reporting. We also would hospitals that do not meet the specific have adopted HIT systems.
seek to minimize the reporting burden requirements of the CY 2009 OPPS It is important to note the caveats to
on hospitals through close collaboration RHQDAPU program. The CY 2009 the RAND study. The projected savings
with the hospital industry to develop program will be based upon CY 2008 are across the health care sector, and
appropriate measures and an efficient hospital reporting of effective measures any Federal savings would be a portion
data collection methodology. Some of the quality of hospital outpatient care of the total savings. In addition, there
commenters recommended that some of that have been carefully developed and are significant assumptions made in the
the current inpatient hospital measures evaluated, and endorsed as appropriate, RAND study. National savings are
could be adapted to provide information with significant input from projected in some cases based on one or
specifically regarding outpatient stakeholders. two small studies. Also, the study
hospital care. However, whether we We have revised proposed § 419.43(h) assumes patient compliance, in the form
adapt existing measures or develop new to reflect this new effective date and we
5 RAND News Release: Rand Study Says
ones, we would need to engage in the are adopting it as revised in this final
Computerizing Medical Records Could Save $81
same development and infrastructure rule with comment period. We also note Billion Annually and Improve the Quality of
activities. We have already begun to that in the CY 2008 OPPS proposed Medical Care, September 14, 2005, available at:
take a more systematic approach to the rule, we may further refine our http://rand.org/news/press.05/09.14.html.
of participation in disease management based purchasing program, beyond the Many commenters provided feedback
programs and following medical advice. intrinsic incentives of the OPPS, to on the proper role of HIT within a
For these reasons, extreme caution provide efficient care, encourage the value-based purchasing system. The
should be used in interpreting these avoidance of unnecessary costs, and majority of commenters noted that
results. increase quality of care. In the proposed adoption of HIT can lead to improved
In his 2004 State of the Union rule, we did not propose adding quality, enhanced patient safety, and
Address, President Bush announced a adoption of HIT to the Medicare increased efficiency. Many commenters
plan to ensure that most Americans hospital conditions of participation. emphasized that HIT can reduce the
have electronic health records within 10 However, we solicited comments on burden associated with quality
years.6 One part of this plan involves promotion of the use of effective HIT reporting. One commenter stated that
developing voluntary standards and through hospital conditions of the foundation of HIT adoption should
promoting the adoption of interoperable participation, perhaps by adding a support the aims outlined within the
HIT systems that use these standards. requirement that hospitals use HIT that IOM’s ‘‘Crossing the Quality Chasm
The 2007 Budget states that ‘‘The is compliant with and certified in its use Report’’: safety, effectiveness, patient-
Administration supports the adoption of of the HIT standards adopted by the centeredness, timeliness, efficiency, and
health information technology (IT) as a Secretary. We anticipate that the equity. Another commenter suggested
normal cost of doing business to ensure American Health Information that CMS could advance its quality
patients receive high quality care.’’ Community will provide advice to the agenda by investing in the development
Over the past several years, CMS has Secretary on these issues. of algorithms for the calculation of
undertaken several activities to promote We received 13 responses to the quality measure scores.
the adoption and effective use of HIT in proposed rule on this section. Below is Most commenters stated that a value-
coordination with other Federal a summary of the comments within each based purchasing system should
agencies and with the Office of the response addressing: (1) CMS’ statutory emphasize process and outcomes
National Coordinator for Health authority and use of our conditions of measures, rather than structural
Information Technology. One of those participation to encourage adoption of measures such as the use of HIT tools
activities is promotion of data standards effective HIT; (2) the role that HIT like computerized physician order
for clinical information, as well as for should play in value-based purchasing; entry. However, two commenters stated
claims and administrative data. In and (3) the importance of that use of HIT should be included as
addition, through our 8th Scope of Work interoperability standards in promoting a structural measure for any value-based
contract with the QIOs, we are offering the adoption of HIT. In addition to these purchasing system.
assistance to hospitals on how to adopt Several commenters addressed the
areas in which we sought comments, we
and redesign care processes to costs associated with HIT
also received several comments on the
effectively use HIT to improve the implementation. Several commenters
challenges of implementing HIT, which
quality of care for Medicare stated that HIT is very costly to
were particularly focused on barriers implement and felt strongly that
beneficiaries, including computerized such as the high cost of implementation.
physician order entry (CPOE) and bar implementation of HIT should be a
Comments: Some commenters shared expense between providers,
coding systems. Finally, our Premier addressed CMS’ statutory authority to
Hospital Quality Incentive purchasers, and payers. Some
encourage adoption of effective HIT. commenters felt that incentives could
Demonstration provides additional One commenter referenced CMS’ aid providers by reducing the cost
financial payments for hospitals that previous use of statutory authority to burden and suggested that direct
achieve improvements in quality, which promulgate exceptions under the Medicare payment for HIT would most
effective HIT systems can facilitate. physician self-referral law as an
We are considering the role of effectively encourage its adoption.
example of the agency’s authority to Several commenters addressed the
interoperable HIT systems in increasing promote the adoption of HIT. Another importance of interoperability standards
the quality of hospital services while commenter stated that CMS does not for HIT. Many commenters noted that
avoiding unnecessary costs. As noted have the statutory authority to promote interoperability standards are a critical
above, the Administration supports the adoption of HIT and, therefore, should component of any HIT system and must
adoption of HIT as a normal cost of concentrate on other mechanisms, such include a standard set of policies,
doing business. While payments under CMS’ demonstrations authority to procedures, and standards for data
the OPPS do not vary depending on the encourage HIT adoption. collection and documentation. The
adoption and use of HIT, hospitals that Several commenters addressed CMS’ commenters also noted the importance
leverage HIT to provide better quality idea of promoting the adoption of HIT of having interoperability standards that
services may more efficiently reap the through CMS conditions of are publicly available and non-
reward of any resulting cost savings. In participation. Some of the commenters proprietary. One commenter suggested
addition, the adoption and use of HIT were in favor of including adoption of that HHS and AHIC should provide
may contribute to improved processes HIT in conditions of participation. One modern terminology to guide the
and outcomes of care, including commenter suggested making adoption of interoperability standards,
shortened hospital stays and the modifications to existing conditions of such as those identified in the
avoidance of adverse drug reactions. participation in lieu of creating new Consolidated Health Informatics (CHI)
In the proposed rule, we sought conditions of participation to and the SNOMED–CT, adopted by CHI
comments on our statutory authority to accommodate adoption of HIT. Many and approved by the National
encourage the adoption and use of HIT. commenters opposed including the Committee on Vital and Health
We also sought comments on the adoption of HIT in the conditions of Statistics. In addition to interoperability
appropriate role of HIT in any value- participation. Commenters opposed to standards, one commenter stated that a
6 Transforming Health Care: The President’s
including HIT implementation within rigorous quality assurance process that
Health Information Technology Plan, available at:
conditions of participation addresses strict adherence to
http://www.whitehouse.gov/infocus/technology/ characterized the proposal as creating interoperability standards should be
economiclpolicy200404/chap3.html. an ‘‘unfunded mandate.’’ required by third party certification.
One commenter strongly supported final rules to allow hospitals and other interoperable HIT as a part of the
the role of both AHIC and the health care providers under some Medicare conditions of participation.
Ambulatory Quality Alliance-Hospital circumstances to donate electronic Rather, we are reserving judgment on
Quality Alliance Steering Committee in prescribing and electronic health the imposition of such a requirement
promoting the adoption of HIT. Another records technology to physicians and and will continue to research the
commenter commended CMS on others without running afoul of the feasibility of doing so. We may revisit
promoting adoption of HIT by Stark (physician self-referral) and anti- this issue in the CY 2008 OPPS
‘‘promulgating regulatory protections kickback statutes. We believe that these proposed rule or in another rulemaking
under the physician self-referral and rules facilitate the adoption of HIT by proceeding.
Anti-Kickback Statutes for donations physicians and other health care
XXI. Health Care Information
related to electronic medical records.’’ providers who might otherwise have
Response: We thank all commenters Transparency Initiative
been unable or unwilling to invest in
for their thoughtful and valuable the technology. The United States (U.S.) faces a
discussion of the issues. In the HIT We also believe that these regulatory dilemma in health care. Although the
section of the preamble to the proposed changes help to stimulate the adoption rate of increase in health care spending
rule, we recognized the potential for of effective HIT, and that, as HIT use slowed last year, costs are still growing
effective HIT to facilitate improvements spreads, the benefits relative to the costs at an unsustainable rate. The U.S.
in the quality and efficiency of health of implementation may increase for all spends $1.9 trillion on health care, or 16
care services. We also pointed out CMS’ stakeholders. percent of the gross domestic product
promotion of the adoption and effective The majority of commenters pointed (GDP). By 2015, projections are that
use of HIT in coordination with other out that the current lack of HIT health care will consume 20 percent of
Federal agencies and the Office of the infrastructure, including lack of GDP. The Medicare program alone
National Coordinator for Health interoperability standards, is a major consumes 3.4 percent of the GDP; by
Information Technology. Here, we will obstacle to adoption and effective use of 2040, it will consume 8.1 percent of the
discuss three initiatives that we are HIT. To address the lack of GDP, and by 2070, 14 percent of the
emphasizing to promote the effective infrastructure, the Secretary has GDP.
use of HIT, in light of the comments we undertaken a national strategy that calls Part of the reason health care costs are
received: (1) Value-based purchasing, for Federal agencies to collaborate with rising so quickly is that most consumers
(2) the recent CMS and OIG final rules private stakeholders in the development of health care—the patients—are
regarding the donation of certain HIT, of architecture, standards, certification frequently not aware of the actual cost
and (3) infrastructure and processes, and methods of governance of their care. Health insurance shields
interoperability standards. to facilitate the adoption of effective them from the full cost of services, and
We continue to explore the HIT. In September 2005, the Secretary they have only limited information
implementation of value-based selected 16 commissioners to serve on about the quality and costs of their care.
purchasing payment system reforms the American Health Information Consequently, consumers do not have
because we believe that, among other Community (AHIC or Community), the incentive or means to carefully shop
advantages, value-based purchasing can which is a federally chartered for providers offering the best value.
encourage hospitals to invest in collaborative forum of private and Thus, providers of care are not subject
activities, such as effective HIT, that public interests charged with advising to the competitive pressures that exist in
have the potential to improve quality the Secretary on how to make health other markets for offering quality
and decrease unnecessary costs. information digital and interoperable. services at the best possible price.
However, linking a portion of Medicare The goals of the Community include Reducing the rate of increase in health
payments to valid measures of quality immediate access to vital medical care prices and avoiding health services
and effective use of resources could give information at the point of care, privacy of little value could help to stem the
hospitals more direct incentives to protection, better data for research, and growth in health care spending, and
implement innovative ideas and overall cost savings. The work of the potentially reduce the number of
approaches that may result in improved Community has been divided among six individuals who are unable to afford
value of care. We agree with the workgroups: (1) The Electronic Health health insurance. Part of the President’s
commenters that noted that the use of Records Workgroup, (2) the Chronic health care agenda is to expand Health
effective HIT could increase quality, Care Workgroup, (3) the Consumer Savings Accounts (HSAs), which would
efficiency, and patient safety. We also Empowerment Workgroup, (4) the provide consumers with greater
agree with the commenters that noted Biosurveillance Workgroup, (5) the financial incentives to compare
that effective use of HIT can be used to Confidentiality, Privacy, and Security providers in terms of price and quality,
decrease the burden of reporting to Workgroup, and (6) the Quality and choose those that offer the best
value-based purchasing programs. Workgroup. The AHIC Workgroups have value.
However, we disagree with the made recommendations, as their initial In order to exercise those choices,
commenters that recommended direct ‘‘breakthroughs,’’ pertaining to: an consumers must have accessible and
government funding of HIT. As stated in electronic medication summary and useful information on the price and
the President’s 2007 Budget, ‘‘the registration history; secure messaging quality of health care items and
Administration supports the adoption of capabilities for individuals with chronic services. Typically, health care
[HIT] as a normal cost of doing business disease; biosurveillance monitoring; providers do not publicly quote or
to ensure patients receive high quality and, through secure means, broadening publish their prices. Moreover, list
care.’’ the availability and access to current prices, or charges, generally differ from
Commenters noted that multiple and historical laboratory results and the actual prices negotiated and paid by
stakeholders in the health care system, interpretations. More information about different health plans. Thus, even if
including purchasers and payers, the Community is available at: http:// consumers were financially motivated
benefit from provider adoption and use www.hhs.gov/healthit/ahic.html. to shop for the best price, it would be
of effective HIT and should share in the In conclusion, we are not at this time very difficult at the current time for
cost. CMS and OIG have recently issued requiring adoption of certified, them to access usable information.
For these reasons, DHHS is launching However, many commenters also noted beneficiaries an unprecedented level of
a major health care information the complexity of such information, detail on the availability of their drugs
transparency initiative in 2006. This particularly price and cost data, and and potential cost liability for plans in
effort builds on steps taken by CMS to identified issues that would need to be their region. We anticipate using our
make quality and price information addressed when determining what experience with these tools and working
available. For example, Medicare has information is most helpful and the with others to develop useful tools for
provided unprecedented information manner in which it should be given to displaying information on outpatient
about drug prices in the Medicare drug consumers. services.
benefit, and is now adding to these In particular, commenters noted that We are grateful for the support for our
efforts in other areas. We recently (1) the price of services varies by patient efforts and will welcome proposals for
posted Medicare payment information needs and services, (2) hospital costs providing consumers and patients
for common elective procedures and also include their public service role, (3) useful information on price and quality.
other common admissions for all physician services are not included in Comment: Several commenters
hospitals by county on our Web site at the hospital bill, and (4) hospital prices suggested that CMS work through the
http://www.cms.hhs.gov/ would vary based on the insurance AQA and Hospital Quality Alliance
HealthCareConInit/ status of the patient. The commenters efforts, along with the joint steering
01_Overview.asp#TopOfPage. We also suggested that price information should committee charged with harmonizing
recently posted geographically-based be easy to understand and use, easy to hospital and physician measurement—
Medicare payment information for access, use common definitions and the Quality Alliance Steering
common elective procedures for language, and explain the factors that Committee—to identify the most useful
ambulatory surgery centers on our Web affect prices. Several commenters also price and quality measures for the
site at http://www.cms.hhs.gov/ described their proposals for making outpatient settings.
HealthCareConInit/03_ASC.asp. We such information more readily available Response: We strongly support the
will post similar information for through state and insurer mandates and AQA and HQA efforts, and believe that
common hospital outpatient and hospital and Federal research efforts to such collaboration is critical to the
physician services this fall. identify the most useful price success of transparency. To the extent
In addition, a number of tools information. Several commenters also these organizations, as well as others,
providing usable health care noted that price and quality information such as the National Quality Forum,
information are already available to should be released together.
reach consensus regarding price or
Medicare beneficiaries. Consumers can Response: We agree that price
quality measures for outpatient settings
access ‘‘Compare’’ Web sites through information is complex and that the
factors that affect price noted by the we would look to their efforts to inform
http://www.medicare.gov where they
commenters should be considered when ours.
can evaluate important aspects of their
determining what information to release Comment: One commenter stated that
health care options for care at a hospital,
and the manner in which it is provided. in addition to making sure the measures
nursing home, home health agency, and
dialysis facility, as well as compare For inpatient services, we released and the process are useful, it is critical
their costs and coverage when choosing Medicare payment information for to make sure the data, particularly
a prescription drug plan. common conditions, and we plan to do claims, are consistent across settings.
CMS is developing a transparency so for outpatient services later this fall. The commenter noted the need to
initiative with the goals of providing This type of information provides update data standards to reflect the
more comprehensive information on beneficiaries and their families with contents of 21st century health records,
quality and costs, including more information on their potential out-of- including moving to ICD–10–CM and
complete measures of health outcomes, pocket costs. Another useful way to using other standards endorsed by the
satisfaction, and volume of services that describe costs may be to provide National Committee on Vital and Health
matter to consumers, and more information on the total costs for a Statistics (NCVHS).
comprehensive measures of costs for course of treatment (beyond just the Response: We agree that it is critically
entire episodes of care, not just inpatient stay) for an episode of care important for the information
payments for particular services and (potentially encompassing all providers underlying these price and quality
admissions. We intend for the project to and over time for a specific condition). measures to be as uniform and accurate
combine public and private health care Consumers may also want information as possible. As directed by the
data to provide cost and quality of care about the quality of care across the President’s Executive Order, we are
information at the physician and episode. Because some services currently engaged in numerous
hospital levels. Quality, cost, pricing, delivered in the outpatient setting are department initiatives to identify and
and patient information will be reported also delivered in ambulatory surgical endorse terminology and messaging
to consumers and purchasers of health centers and physicians’ offices, we also standards and to support a certification
care in a meaningful and transparent may consider comparisons across process for electronic health records.
way. In addition, we anticipate the settings in the future. We also support movement towards the
project will provide a national template We also agree that information on ICD–10–CM coding system. As
for performance measures and a price should be easy to use and access, consumers, patients, and providers
payment structure that aligns payment and that it is important to continue become increasingly engaged in the use
and performance. research on the best way to provide of health care price and quality
The comments we received on our such information to consumers. We information this will become ever more
transparency initiative and our have been posting information on the important.
responses are summarized below. quality of care for several settings, Comment: One commenter noted that
Comment: All commenters supported including hospitals, nursing homes, the length of time used to calculate costs
the concept of providing useful dialysis facilities, Medicare Advantage and quality is critical. The commenter
information for consumers and patients plans, and Part D plans. Regarding the stated that the outcome of a service may
on the price and quality of care Part D information, we have created an take a long time to manifest, sometimes
delivered in the outpatient setting. interactive tool which provides even longer than a year, so that the
length of time used should be provider order entry for prescriptions, affected parties and, to the extent
considered. (2) staffing of intensive care units with feasible and practicable, we must
Response: We recognize that the intensivists, and (3) evidence-based include measures set forth by one or
length of time in which patient hospital referrals. These measures more national consensus building
outcomes manifest may vary. We originate from the Leapfrog Group’s entities.
believe it will be important, particularly original ‘‘three leaps,’’ and are part of Commenters on the FY 2007 IPPS
when assessing the cost and quality of the NQF’s 30 safe practices. proposed rule requested that we notify
broad episodes of care to vary the In 2002, the Secretary of HHS the public as far in advance as possible
episode length depending on the initiated a partnership with several of any proposed expansions of the
patterns of care specific to the collaborators intended to promote measure set and program procedures in
condition. hospital quality improvement and order to encourage broad collaboration
public reporting of hospital quality and to give hospitals time to prepare for
XXII. Additional Quality Measures and information. This collaboration is any anticipated changes. Other
Procedures for Hospital Reporting of known as the Hospital Quality Alliance commenters requested that we adopt
Quality Data for the FY 2008 IPPS (HQA). The collaborators include the additional quality measures and that we
Annual Payment Update American Hospital Association, the do so as soon as feasible. For example,
A. Background Federation of American Hospitals, the several commenters urged that we adopt
Association of American Medical the HCAHPS patient survey as a part of
Section 5001(a) of the Deficit
Colleges, the Joint Commission on the IPPS RHQDAPU program, while
Reduction Act of 2005 (DRA) (Pub. L.
Accreditation of Healthcare others suggested that we adopt more of
109–171) sets out new requirements for
Organizations (JCAHO), the National the IOM measures as well as more
the IPPS Reporting Hospital Quality
Quality Forum (NQF), the American outcome measures, including mortality
Data for Annual Payment Update Medical Association, the Consumer- measures that were not included in the
(RHQDAPU) program. The IPPS Purchaser Disclosure Project, the AARP, 2005 IOM report’s ‘‘baseline’’ quality
RHQDAPU program was established to the American Federation of Labor- measures. In response to these
implement section 501(b) of the Congress of Industrial Organizations comments and as part of our continuing
Medicare Prescription Drug, (AFL–CIO), the Agency for Healthcare efforts to strengthen the IPPS
Improvement and Modernization Act of Research and Quality (AHRQ), as well RHQDAPU program, in the CY 2007
2003 (MMA) (Pub. L. 108–173). It builds as CMS, Quality Improvement OPPS proposed rule, we sought
on our ongoing voluntary Hospital Organizations (QIOs), and other comments on this proposal to expand,
Quality Initiative which is intended to stakeholders who share a common for FY 2008, the measurement set
empower consumers with quality of interest in reporting on hospital quality. beyond those measures we adopted for
care information to make more informed The HQA has been proactive in making purposes of the FY 2007 update. This
decisions about their health care while performance data on hospitals proposed expanded set would further
also encouraging hospitals and accessible to the public, thereby broaden the scope of the IPPS
clinicians to improve the quality of care. improving patient care. RHQDAPU program by including the
Section 5001(a) of Public Law 109– The RHQDAPU program, however, is HCAHPS patients’ perspectives of care
171 revises the mechanism used to distinct from the HQA (formerly known measures as well as surgical care and
update the standardized amount for as the National Voluntary Hospital mortality outcome measures. We
payment for hospital inpatient operating Reporting Initiative). Hospitals received a number of comments in
costs. New sections 1886(b)(3)(B)(viii)(I) participate in the HQA on an entirely response to our proposal. These
and 1886(b)(3)(B)(viii)(II) of the Act voluntary basis. Participation in HQA comments are discussed below.
provide that the payment update for FY has no bearing on payment under Comment: A majority of the
2007 and each subsequent fiscal year Medicare or any other Federal program. commenters appreciated that CMS has
will be reduced by 2.0 percentage points The RHQDAPU program is a CMS proposed measures for FY 2008 that
for any ‘‘subsection (d) hospital’’ that program that ties quality data reporting have already been adopted as part of the
does not submit certain quality data in to payment under the IPPS. In some HQA’s effort to promote public
a form and manner, and at a time, ways, the HQA can be seen as a testing reporting of hospital data. Also,
specified by the Secretary. Under ground for a quality measure before commenters recommended that CMS
sections 1886(b)(3)(B)(viii)(III) and CMS adopts it for purposes of the continue to work with HQA and that
1886(b)(3)(B)(viii) (IV) of the Act, we RHQDAPU program. To date, all of the CMS align its choices of measures and
must expand the ‘‘starter set’’ of quality quality measures CMS has adopted for link payment with the measures chosen
measures that we have used since FY purposes of the RHQDAPU had by HQA to provide a public
2005, and to begin to adopt the baseline previously been for HQA reporting. We accountability for quality. The
set of performance measures as set forth note, however, that HQA adoption is not commenters suggested that this
in a 2005 report issued by the Institute a legal prerequisite for CMS to adopt a alignment will also reinforce the
of Medicine of the National Academy of measure for purposes of the RHQDAPU importance of public transparency on
Sciences (IOM) under section 238(b) of program. quality to help to focus quality
the MMA, effective for payments In the FY 2007 IPPS final rule, we improvement efforts on identified high
beginning with FY 2007. The 2005 IOM began to implement the new IPPS priority care areas.
report’s ‘‘baseline’’ quality measures RHQDAPU program requirements by Response: We strongly value our
include Hospital Quality Alliance adding 11 HQA-approved measures to association with the HQA, which was
(HQA)-approved clinical quality our 10-measure ‘‘starter set’’ of quality established as a public-private
measures, the Hospital Consumer measures, for purposes of the FY 2007 collaboration to promote voluntary
Assessment of Healthcare Providers and update (71 FR 48031 through 48037). hospital public reporting on quality of
Systems (HCAHPS) patient perspective Under section 1886(b)(3)(B)(viii)(V) of care. We plan to continue to work
survey, and three structural measures. the Act, for payments beginning with closely with HQA on the choice of
The structural measures are: (1) FY 2008, we are required to add other measures publicly reported on Hospital
Implementation of computerized measures that reflect consensus among Compare. Additionally, we will
continue to focus efforts on measures place for the transmission and storage of payment. We are using this rulemaking
adopted by the HQA. clinical data in support of our quality in addition to the IPPS rulemaking to
Comment: A majority of the improvement initiatives. Clinical data establish additional measures in order
commenters applauded and expressed are transmitted to the QIO Clinical to give hospitals advance notice and
support for CMS efforts to establish the Warehouse via QualityNet Exchange, a lead time to learn about the collection
measures hospitals will be expected to secure Web site. Access to data stored requirements of the new measures
report under the IPPS RHQDAPU in the QIO Clinical Warehouse is before linking them to payment. We
program early enough for hospitals to limited to authorized parties. We solicit note that the HQA will be collecting and
put the proper data collection processes input from other healthcare reporting these new measures sets
in place. stakeholders to facilitate the design and before hospitals begin reporting these
Response: We appreciate these enhancements to this system. measures for RHQDAPU purposes. For
comments as we recognize the Comment: One commenter stated the example, the HQA began collecting the
importance of communications to current reporting of quality data is SCIP–VTE 1 and SCIP–VTE 2 measures
hospitals. CMS will continue to provide costly, the data definitions change in fourth quarter 2006, when they were
information as early as possible on the quarterly, and it is difficult to use the first published in the HQA
measures hospitals that will be used for validation process. The commenter Specifications Manual for National
the IPPS RHQDAPU program. We also recommended that because payments Hospital Quality Measures. This allows
look forward to commenters’ continued are based on the validation of the hospitals three months to abstract and
support as we expand the set of measures, CMS must absolutely ensure submit these measures before the first
measures for the program. that the CDAC and QIOs interpret the quarter of 2007, when they become IPPS
Comment: One commenter supported data the same way. RHQDAPU measures for purposes of the
the expanded FY 2008 measurement set, Response: The validation and appeal FY 2008 IPPS market basket update.
but urged CMS to also add the structural processes are posted on the QualityNet Collection of SCIP Infection 1 and SCIP
measures that were included in the 2005 Web site under the Hospital/Data Infection 3 as RHQDAPU program
IOM report ‘‘Performance Measurement: Validation tab. The Specifications measures for FY 2008 began third
Accelerating Improvement.’’ Manual for National Hospital Quality quarter of 2006. CMS believes the
Response: At this time we are not Measures is updated routinely to stay addition of SCIP–VTE 1, SCIP–VTE 2,
adopting the three structural measures with current medical practices. and SCIP Infection 2 measures to the
recommended by the Leapfrog Group. Hospitals should continue working with RHQDAPU measures beginning first
As we continue to expand the set of their QIOs in order to keep up with the quarter 2007 provides reasonable
measures under the IPPS RHQDAPU most recent updates. The CDAC utilizes advance notice for hospitals.
program, we will further evaluate and this same manual during validation for
consider these structural measures. the re-abstraction of medical records. B. Additional Quality Measures for FY
Comment: One commenter supported Modifications or clarifications in the 2008
the HQA and its work to implement manual are shared with hospitals, QIOs,
NQF-endorsed measures through a 1. Introduction
and the CDAC concurrently in order to
collaborative, public-private maintain a common abstraction In the CY 2007 OPPS proposed rule,
partnership. However, although the knowledge base. we proposed to add the following
commenter believed that the HQA has We have devoted substantial categories to the FY 2008 IPPS
been instrumental in advancing hospital resources to ensuring that the CDAC RHQDAPU program measure set:
performance reporting via the Hospital process is consistent, reliable and • HCAHPS Survey
Compare Web site, the commenter did accurate. HCAHPS is also known as Hospital
not believe that the HQA adhered to the Comment: Two commenters suggested CAHPS or the CAHPS Hospital
same consensus-building process used that CMS create a private-sector Survey. The HCAHPS survey is
by the NQF. The commenter viewed the mechanism to leverage the reporting composed of the following 27 questions:
roles of these two entities as distinct, benefit the JCAHO is providing through + 18 substantive questions that
though complementary. its vendors, especially with respect to measure critical aspects of the hospital
Response: We agree that the roles of attention to the quality of the data. experience (communication with
the HQA and NQF are distinct. Response: CMS strongly values its doctors; communication with nurses;
However, the NQF is represented on the collaborative relationship with the responsiveness of hospital staff;
HQA and the HQA has in principle and JCAHO and agrees the vendor cleanliness and quietness of hospital
in practice agreed to only employ NQF- community input is important. CMS is environment; pain management;
endorsed measures for public reporting. currently considering whether to form communication about medicines; and
Therefore, all measures advanced by the an advisory work group of vendors to discharge information).
HQA for public reporting have gone work with our staff. + 4 questions that direct patients to
through the NQF consensus building Comment: One commenter did not complete only those survey questions
process. oppose collecting of data on the that apply to them.
Comment: One commenter suggested proposed measures and publishing the + 3 questions to be used to adjust the
that there was a need to develop an measures for the public. However, the mix of patients across hospitals.
infrastructure that would facilitate the commenter opposed tying payment to + 2 questions that support
efficient transmission and storage of the quality of the data during the initial Congressionally-mandated reports, the
data and to designate an oversight entity phases of data collection of new ‘‘National Healthcare Disparities
that is responsible for the infrastructure. measures sets. Also, the commenter Report,’’ and the ‘‘National Healthcare
The commenter recommended that CMS opposed the proposed implementation Quality Report.’’
consult with healthcare stakeholders of the new measure set because it does • Surgical Care Improvement Project
before determining where the quality not give hospitals a transition period to (SCIP)
data are housed. collect data that will affect payments. + SCIP–VTE 1: Venous
Response: We have a centralized Response: We thoroughly evaluate all thromboembolism (VTE) prophylaxis
information technology infrastructure in measures before linking them to ordered for surgery patient
+ SCIP–VTE 2: VTE prophylaxis implementation strategy (February 2003, reporting. For hospitals participating in
within 24 hours pre/post surgery June 2003, and December 2003—68 FR the national implementation of
+ SCIP Infection 2: Prophylactic 5889, 68 FR 38346, 68 FR 68087). In HCAHPS on October 1, 2006, we
antibiotic selection for surgical patients addition to the public comments required participation in a short dry run
• Mortality received, results from a 3-State Pilot period of at least one month. A hospital
+ Acute Myocardial Infarction 30-day Study were used to reduce the pool of could choose to sample and survey
mortality—Medicare patients 66 survey questions to 25 questions. discharges in April, May, and/or June
+ Heart Failure 30-day mortality— In addition to the development and 2006. Data from this ‘‘dry run’’ are not
Medicare patients review processes, we submitted the 25- publicly reported.
+ Pneumonia 30-day mortality— item version of the HCAHPS instrument National implementation began in
Medicare patients to the NQF for its review and October 2006 for this first set of
We discuss these proposed measures endorsement through its consensus hospitals and survey vendors that are
in detail below. development process. The NQF is a participating in the HCAHPS voluntary
2. HCAHPS Survey and the Hospital voluntary consensus standard-setting initiative. The initial data collection
Quality Initiative organization established to standardize covers 9 months of patient discharges
health care quality measurement and (October 2006 through June 2007).
We have partnered with another HHS reporting. NQF endorsement represents Hospital results will be publicly
agency, AHRQ, to develop HCAHPS. the consensus of numerous health care reported on the CMS Hospital Compare
The intent of the HCAHPS initiative is providers, consumer groups, Web site (http://
to provide a standardized survey professional associations, purchasers, www.hospitalcompare.hhs.gov). After
instrument and data collection Federal agencies, and research and the initial implementation, the Web site
methodology for measuring patients’ quality organizations. Following a will contain 12 months of HCAHPS data
perspectives of hospital care. While thorough, multi-stage review process, and will be updated quarterly.
many hospitals currently collect HCAHPS was endorsed by the NQF The HCAHPS survey is currently
information on patients’ satisfaction board in May 2005. In the process, NQF available in English and Spanish.
with care, there is currently no national recommended a few modifications to During the HCAHPS dry run and initial
standard for collecting or publicly the instrument. As a result of the national implementation (discussed
reporting this information that would recommendations of the NQF more fully below), we are soliciting
enable valid comparisons to be made Consensus Development Process, comments from participating hospitals
across hospitals. To make the questions regarding courtesy and and survey vendors regarding additional
appropriate comparisons to support respect were added to the survey. The languages for HCAHPS. This
consumer choice, we believe it is NQF review committee believes that information can be submitted to our
necessary to introduce a standard these questions are important to all HCAHPS mailbox,
measurement approach. HCAHPS can patients, and may be particularly CMSHOSPITALCAHPS@cms.hhs.gov.
be viewed as a core set of questions that meaningful to patients who are From the information we receive, we
can be combined with a broader, members of racial and ethnic minority will establish priorities for HCAHPS
customized set of hospital-specific groups. Upon the recommendation of translation into additional languages.
items. HCAHPS is intended to the NQF, we further examined the costs In order for the remaining hospitals to
complement the data hospitals currently and benefits of the 27-item HCAHPS participate in HCAHPS, future training
collect to support improvements in survey. This cost-benefit analysis of sessions for hospital personnel and
hospitals’ internal customer services HCAHPS was conducted by Abt survey vendors will take place in
and quality related initiatives. Associates, Inc. The report of this January 2007. Hospitals may choose to
Three broad goals have shaped analysis can be found at http:// self-administer HCAHPS, or may choose
HCAHPS. The survey is designed to www.cms.hhs.gov/HospitalQualityInits/ to hire a vendor who has completed the
produce data on the patients’ downloads/ training. A brief dry run of March 2007
perspective of care that allows objective HCAHPSCostsBenefits200512.pdf. discharges will allow newly
and meaningful comparisons among We published a Federal Register participating hospitals and vendors to
hospitals on issues that are important to notice soliciting comments on the draft get ‘‘first-hand’’ experience with all
consumers. In addition, public reporting 27-item HCAHPS Survey in November phases of the data collection and
of the survey results is designed to 2005 (70 FR 67476). The HCAHPS submission process. Details about the
create incentives for hospitals to survey received approval by the Office HCAHPS requirements, and the
improve their quality of care. Also, of Management and Budget (OMB) on additional requirements proposed for
public reporting will serve to enhance December 22, 2005. HCAHPS under the IPPS RHQDAPU
public accountability in health care by Shortly thereafter, we began final program, are included in section XXII.C.
increasing the transparency of the preparations for the voluntary national and XXII.D. of this preamble.
quality of hospital care provided in implementation (as a part of the Comment: Commenters expressed
return for the public investment. With Hospital Quality Initiative) with the appreciation for the iterative process
these goals in mind, the HCAHPS support of the HQA. We also offered that CMS engaged in with the hospital
initiative has taken substantial steps to training sessions for hospitals self- field and other Federal agencies such as
assure that the survey will be credible, administering the survey and survey AHRQ in the development and then
useful, and practical. vendors acting on behalf of hospitals in implementation of HCAHPS.
Throughout the HCAHPS February and April 2006. Since Response: We appreciate the
development process, AHRQ and CMS HCAHPS was a new initiative, we comments and the input we received
have solicited and received a great deal decided that it was critical to hospitals, from stakeholders during the
of public input. AHRQ published a survey vendors, and CMS to acquire development process.
Federal Register notice that called for first-hand experience with data Comment: Because HCAHPS is a new
measures in July 2002 (67 FR 48477) collection, including sampling and data measure set for hospital data collection,
and we solicited input on drafts of the submission to the QualityNet Exchange, one commenter opposed using HCAHPS
HCAHPS instrument and its before we collected data for public as part of the IPPS RHQDAPU program
until at least 12 months of data have challenges, which means that surgeons, to cost effectiveness factors for SCIP
been abstracted, submitted, and anesthesiologists, primary care target areas is accurate. The statement
validated. physicians and internal medicine from the SCIP Education Module
Response: For FY 2008, the IPPS specialists, perioperative nurses, (developed by the Florida QIO) about
annual payment update under the pharmacists, infection control the cost of low-dose unfractionated
program is tied to reporting, not professionals, and hospital executives heparin (LDUH) versus the cost of low-
performance. This gives hospitals the must work together to make surgical molecular weight heparin (LMWH) is
opportunity to use HCAHPS without care improvement a priority. SCIP not meant to be an endorsement of the
tying their scores to performance. partners coordinate their efforts through lower cost thromboprophylaxis. As
HCAHPS has been rigorously tested a steering committee that includes evident in the VTE prophylaxis
and validated in collaboration with a representatives of the American recommendation table located in the
public-private partnership (HQA) on Hospital Association, the American Measure Information Form for SCIP–
hospital quality reporting. In addition, College of Surgeons, the American VTE–1 (found at http://
the National Quality Forum endorsed Society of Anesthesiologists, the www.QualityNet.com, select Hospitals,
HCAHPS in May 2005 (see final report Association of Perioperative Registered then Specifications Manual from the
at http://www.qualityforum.org) and it Nurses, the JCAHO, the Institute of drop-down menu), both forms of
has received final approval from the Healthcare Improvement, the thromboprophylaxis are listed, where
Federal OMB (December 2005). Department of Veterans Affairs (VA), the appropriate.
In order to submit HCAHPS data, each AHRQ, the Centers for Disease Control Comment: One commenter urged
hospital, either self-administering or and Prevention (CDC) and CMS. CMS to take the lead in developing a
through use of a vendor, must SCIP is a comprehensive program, new VTE measure for prophylaxis of
participate in at least a one month dry integrated into the quality improvement medical patients at risk for VTE. The
run. The dry run mirrors all aspects of agenda of the CMS, JCAHO, the CDC, commenter believed that this is
the data collection process: Sampling, the American College of Surgeons, the consistent with NQF-endorsed safe
survey administration, and data VA’s Veterans Health Administration, as practices. The commenter noted that the
submission. The dry run allows well as the other organizations that IPPS RHQDAPU program currently only
participating providers to submit data comprise the SCIP Steering Committee. includes measures for VTE prophylaxis
without having it publicly reported. There are a number of activities in surgery patients and recommended
Hospitals that did not participate in the underway from these and other that CMS expand the measure to
Spring 2006 dry runs will be required to partnering organizations. Hospital include a measure for prophylactic
carry out a dry run in March 2007 participation in the SCIP program is treatment of medical patients at risk for
following training. Approximately 2,500 voluntary. VTE.
hospitals participated in the Spring We received a number of comments Response: Currently, we are
2006 dry run. These hospitals will have on the SCIP measures. supportive of JCAHO’s efforts to create
used HCAHPS for at least one year by Comment: One commenter applauded VTE measures for the medical
July 2007. CMS’ proposal to add SCIP–VTE 1 and community and have provided technical
Unlike the clinical measures, SCIP–VTE 2 to the IPPS RHQDAPU support to that activity in conjunction
hospitals cannot validate survey data. program. The commenter stated that with the alignment of other measures.
Therefore, our oversight focuses on adding these measures for hospitals We will continue to take an active part
ensuring vendors and hospitals are reporting quality data under this in making recommendations for
following the HCAHPS protocols. program will help to improve quality of additional measure development.
During this initial implementation prior care for Medicare beneficiaries, and Comment: One commenter
to July 2007, CMS will begin conducting reduce the risk of post-operative commended CMS for the steps it has
oversight activities to provide feedback complications associated with VTE. taken through the SCIP pilot to increase
to hospitals and survey vendors. We are Response: We appreciate the VTE prophylaxis in acute care hospitals.
also currently providing feedback based comment as we recognize the The commenter believed that the
on the April, May and June 2006 dry importance of these measures in addition of the SCIP–VTE 1 and 2 to the
run submissions and will conduct a improving the quality of care provided Hospital Compare Web site is an
similar process for the March 2007 dry to Medicare beneficiaries. We plan to important step to improving
run. continue to focus efforts on measures prophylaxis and reducing complications
After careful consideration of the that will decrease the risk of surgical in surgical patients. However, the
public comments received, we are complications. We also look forward to commenter believed that there are a
adopting as final the HCAHPS measure the commenter’s continued support as significant number of hospitalized
requirements we proposed. we expand the set of measures for the nonsurgical patients who are at risk for
RHQDAPU program. VTE. The commenter stated VTE is a
3. Surgical Care Improvement Project Comment: One commenter expressed hospital-wide preventable condition;
(SCIP) Quality Measures concern that the CMS Medicare Quality while addressing prophylaxis for
The Surgical Care Improvement Improvement Community (MedQIC) has surgical patients in the hospital setting
Project (SCIP) is a national quality delineated inappropriate cost is a necessary step, alone it is not
partnership of organizations committed effectiveness factors for the SCIP target sufficient to reduce the overall rate of
to improving the safety of surgical care areas. MedQIC’s SCIP target area of VTE across the continuum of care.
through the reduction of post-operative ‘‘Deep vein thrombosis’’ includes a The commenter encouraged CMS to
complications. The primary goal of the discussion of the cost of low-dose go beyond the silos of hospital setting
partnership is to save lives by reducing unfractionated heparin (LDUH) versus and need based on surgery and address
the incidence of surgical complications the cost of low-molecular-weight three critical areas:
by 25 percent by the year 2010. heparin (LMWH). • Continuity of prophylaxis into other
Partners in SCIP believe that a Response: We have reviewed the treatment setting after surgery;
meaningful reduction in complications information currently posted on • Prophylaxis for the medical patients
requires a systems approach to our MedQIC and the information pertaining in the hospital who are high risk of VTE;
• Outcome measures for all other data associated with the measures, these measures were unanimously
hospitalized patients, at 90 days for re- and to provide feedback to CMS on recommended by the NQF Scientific
hospitalization for symptomatic VTE questions related to the calculation of Committee as the sole claims-based 30-
and mortality. the rates. The rates that will be day mortality measures that met the
Response: We believe that the clinical developed for the dry run will be used NQF’s stringent scientific criteria. The
situation for non-surgical patients is for quality improvement purposes and measures were subsequently NQF-
very different. The NQF has endorsed will not be publicly reported to the endorsed through its consensus
surgical VTE prophylaxis measures, but Hospital Compare. More information development process.
has not endorsed any VTE prophylaxis about the dry run will be provided to Comment: One commenter believed
measures for the non-surgical patient. hospitals through the QualityNet that the use of the 30-day risk adjusted
We are working closely with JCAHO in Exchange Web site (http:// mortality for acute myocardial
its work regarding VTE prophylaxis in www.qnetexchange.org). infarction is not congruent with the in-
the non-surgical patient. That work is We proposed to calculate and hospital mortality measures that are part
very time consuming and final measures publicly report 30-day mortality rates of the JCAHO core measures for acute
will take a significant amount of time to for the AMI and HF conditions in the myocardial infarction and an outcome
create and then test. In the interim CMS June 2007 update of the Hospital measure that is being used in the
will move ahead with those measures Compare Web site. Under the proposal, Premier Hospital Quality Incentive
for surgical patients. rates for the 30-day pneumonia Demonstration project.
After careful consideration of the mortality measure would be posted as Response: It is our understanding that
public comments received, we are soon as possible after we receive NQF the once CMS begins publicly reporting
adopting as final the SCIP requirements endorsement. As is currently the case these 30-day mortality measures on
we proposed. for the other measures, hospitals would Hospital Compare, JCAHO will no
be provided a 30-day period in which longer independently report inpatient
4. Mortality Outcome Measures
they would be permitted to preview mortality. The 30-day mortality
CMS recognizes that the current set of their rates before publication. As is measures include both patients who
hospital performance measures should currently the case for the ‘‘starter set’’ expire while in the hospital and patients
be expanded to more fully reflect measures, hospitals that pledged to who expire after discharge. We believe
outcomes of care. The 30-day mortality submit data for full annual payment that the 30-day measure is a better
measures for patients with acute update for FY 2008 would not be measure to assess hospital performance
myocardial infarction (AMI), heart permitted to suppress or withhold because a standardized period of time
failure (HF) and pneumonia are three publication of the rates on the Hospital over which performance is assessed is
separate claims-based, risk-adjusted Compare Web site, except under highly particularly important because (1)
assessments of mortality within 30 days limited circumstances. length of stay varies by hospital due to
of admission for each of the three Comment: Three commenters local custom, efficiency and transfer
conditions. The measures reflect believed that use of the 30-day risk policies, and (2) limiting reporting to in-
outcomes of care for Medicare patients adjusted mortality measures for acute hospital mortality would provide a
only, and rely on Medicare patients’ myocardial infarction and heart failure strong incentive for hospitals to adopt
historical medical care use, including patients did not represent the best strategies to transfer people who are
inpatient and physician office visits and outcome measures that could be dying to other facilities (other acute care
outpatient care 1 year before their selected by Medicare to represent the hospitals or SNFs or home).
hospitalizations, for the risk adjustment quality of care delivered to patients in Comment: One commenter
calculation. hospitals. The commenters recommended that CMS publicly
The 30-day mortality rate measures recommended that CMS identify recognize the limitations associated
for AMI and HF were endorsed by the outcome measures that better reflect the with the use of the mortality measures,
NQF in 2005 (see http:// quality of hospital care. as every risk-adjustment methodology
www.qualityforum.org/news/ Response: We are interested in has limitations based on its underlying
tb3Hospspecsforweb02–10–06.pdf). We identifying other outcome measures that assumptions that the data is available
anticipate that the 30-day mortality rate reflect quality hospital care that are of and used in those calculations.
measure for pneumonia will also be importance to consumers. However, the Additionally, the commenter
endorsed by the NQF since it reflects 30-day risk adjusted mortality measures recommended that CMS to be open to
the same underlying methodology as the for acute myocardial infarction and refining the risk adjustment
other 30-day mortality measures. heart failure complement the other AMI methodology and/or selection of
In contrast to the HCAHPS and SCIP and HF measures already reported on alternate outcome measures based on
quality measures added to the measure Hospital Compare and will provide hospital and health system
set for FY 2008, no additional data additional information to consumers recommendations.
collection from hospitals will be regarding the quality of care for these Response: We will make the mortality
required to calculate the 30-day two important conditions. The evidence measures methodology transparent to
mortality measures. All three measures underlying the process measures for the the public by posting the report on the
can be calculated based on Medicare cardiac conditions is based on outcomes risk adjustment methodology and
inpatient and outpatient claims data of care (usually mortality) measured at measure specifications on the CMS
that are already reported to the a specified time interval (most website at http://www.cms.hhs.gov or
Medicare program for payment frequently 30 days). Also, length of stay http://www.cms.hhs.gov/
purposes. We anticipate that we will varies by hospital due to local custom, HospitalQualityInits/. The limitations of
conduct a national dry run for the AMI efficiency and transfer policies. For the measures will be a part of the report.
and HF measures in late 2006 to test these reasons we believe that 30 day Furthermore, hospitals and health
implementation and educate hospitals risk-adjusted mortality is a better systems will have the opportunity to
on the methodology. During this dry outcome measure to measure the quality examine the methodology, review their
run, hospitals will be given the of care delivered to patients in hospitals own data, and provide feedback to CMS
opportunity to examine their rates and than in-patient mortality. In addition, in a national ‘‘dry run’’ of the measures
prior to public reporting. We also plan requiring that hospitals must follow section 1886(b)(3)(B)(viii)(V) of the Act,
to continue refining and updating the these steps: CMS is also adding ‘‘other measures that
mortality measures in order to ensure • Complete all registration steps; this reflect consensus among affected parties
the scientific soundness of the measure information can be found on ‘‘Reporting and, to the extent feasible and
methodology. Hospital Quality Data for Annual practicable,’’ and include ‘‘measures set
Comment: One commenter supported Payment Update Reference Checklist’’ forth by one or more national consensus
the use of outcome quality measures located on the QualityNet Exchange building entities.’’ Accordingly, CMS
such as the 3 mortality measures. Web site. will add additional SCIP quality
However, the commenter believed that • Continue to collect data for all measures and two 30-day mortality
CMS must make its risk adjustment clinical quality measures that are measures, as discussed in section
method completely transparent to all currently part of the RHQDAPU XXII.E. of this preamble.
stakeholders prior to using these program, and submit the data to the QIO
2. HCAHPS Hospital Pledge and
measures of quality and noted that the Clinical Warehouse either using the Beginning Date for Data Collection
propose rule does not contain a CMS Abstraction & Reporting Tool
transparent explanation of how risk (CART), the JCAHO ORYX Core We proposed that hospitals will need
adjustments will be made. Measures Performance Measurement to submit HCAHPS data to the QIO
Response: We will make the risk System, or another third-party vendor Clinical Warehouse beginning with
adjustment methodologies and measure tool that has met specification discharges that occur in the third
specifications available to the public. requirements for data transmission to calendar quarter of 2007 (July through
Furthermore, prior to publicly reporting QualityNet Exchange. For HCAHPS, the September discharges) in order to be
these mortality measures on Hospital submission needs to be in the required eligible for the full FY 2008 IPPS market
Compare, CMS will conduct a dry run XML formats or through the online data basket update. In order to meet
with all the hospitals in the nation. CMS submission tool. The submission must HCAHPS requirements for the
will not post the hospital mortality rates be done through QualityNet Exchange. RHQDAPU program, we proposed that
on the Hospital Compare Web site Because the information in the QIO all hospitals, including hospitals new to
during the dry run. The dry run is Clinical Warehouse is considered QIO HCAHPS and hospitals that have been
intended to give hospitals an information, it is subject to the stringent collecting data since October 1, 2006,
opportunity to have experience with the QIO confidentiality regulations in 42 must submit a formal pledge to CMS by
measures and the risk adjustment CFR Part 480. July 1, 2007 stating that they will collect
methodology and review their mortality In addition, for purposes of the and submit HCAHPS data to the QIO
rates prior to public reporting. Hospitals annual payment update, we will Clinical Warehouse starting with July
will also have an opportunity to send continue to require hospitals to pass our 2007 discharges. We proposed that to
their feedback to CMS during the dry validation requirements for the clinical meet HCAHPS requirements for the
run. quality measures. We originally set forth RHQDAPU program for FY 2008, all
these requirements in the FY 2006 IPPS hospitals must submit this pledge to
After careful consideration of the
final rule (70 FR 47421), and we will CMS.
public comments received, we are Comment: One commenter wanted
therefore adopting as final the AMI and continue to require that hospitals
achieve an 80-percent reliability. We clarification as to whether all hospitals
heart failure mortality measure need to submit the pledge or just
requirements we proposed. When we will also continue to post information
related to validation requirements on hospitals eligible for the RHQDAPU
proposed adding the pneumonia program.
mortality measure for the FY 2008 IPPS the QualityNet Exchange Web site.
In addition to these general Response: The pledge form referenced
RHQDAPU program, we believed that it in the rule is for participation in the
would soon be endorsed by the NQF. procedures, the specific procedures
below apply to these additional RHQDAPU program, so only hospitals
However, the NQF has not yet endorsed eligible for the RHQDAPU program need
the pneumonia mortality measure. measures.
to submit it.
Therefore, we are not adopting the D. HCAHPS Procedures and Comment: One commenter
pneumonia mortality measure in this Participation Requirements for the FY recommended that CMS include
final rule. We intend to adopt this 2008 IPPS RHQDAPU Program HCAHPS in the annual formal pledge
measure after the NQF endorses it. At form for participation in the RHQDAPU
the time we determine to adopt the 1. Introduction
program.
measure, we would finalize our Under sections 1886(b)(3)(viii)(III) Response: We agree that it will be less
proposal to adopt the pneumonia and 1886(b)(3)(B)(viii)(IV) of the Act, confusing to hospitals to have one
mortality measure in a notice published CMS must begin to adopt the baseline pledge form for both the clinical
in the Federal Register. set of performance measurements as set measures and HCAHPS. We will be
forth in a 2005 report issued by the combining all of the measures,
C. General Procedures and Participation
Institute of Medicine (IOM) of the including HCAHPS, into the RHQDAPU
Requirements for the FY 2008 IPPS
National Academy of Sciences under Notice of Participation form that
RHQDAPU Program
section 238(b) of Public Law 108–173, hospitals fill out and submit to their
All revised procedures for FY 2008 effective for payments beginning with QIO each summer.
also will be added to the ‘‘Reporting FY 2007. CMS is expanding the set of Comment: One commenter requested
Hospital Quality Data for Annual IOM measures that hospitals will be that the RHQDAPU participation form
Payment Update Reference Checklist’’ required to report to receive the full be made available to submit
section of the QualityNet Exchange Web IPPS market basket update for FY 2008. electronically.
site. This checklist also links to all of In accordance with the recommendation Response: The RHQDAPU Notice of
the forms to be completed by hospitals of the 2005 IOM report, CMS is Participation form is available
participating in the program. expanding the ‘‘starter’’ measures by electronically on http://
To participate in the RHQDAPU including the HCAHPS patient www.qualitynet.org. Submitters must
program, as we proposed, we are perspective survey. In accordance with mail or fax their signed forms to the
QIOs. The QIOs then enter the http://www.HCAHPSonline.org/ the end of the month, or continuously
information into the Program Resource techspecs.asp. We received no throughout the month, as long as a
System (PRS). comments on this proposal. simple random sample is generated for
We are finalizing our proposal to the month. The Guidelines include very
require that, in order to be eligible for 6. Additional Steps for HCAHPS
specific information about the four
the full FY 2008 IPPS market basket Participation
allowed modes of survey
update, hospitals must submit a pledge We are finalizing our proposal that, in administration: mail only, telephone
stating that they will collect and submit order to participate in HCAHPS, only, a mixed methodology of mail with
HCAHPS data to the QIO Clinical hospitals that self-administer the survey telephone follow up, and active
Warehouse starting with July 2007 and survey vendors that collect and interactive voice response (IVR). All
discharges. This pledge will be part of submit data on behalf of client hospitals modes of administration require
the RHQDAPU Notice of Participation must follow these steps: following a standardized protocol. The
form for FY 2008 that will include the • Attend Hospital/Survey Vendor Guidelines describe a standardized
clinical measures, HCAHPS, and the Training. Hospitals and survey vendors approach for handling all data,
mortality measures. We will announce that intend to actually administer the including assigning the unique tracking
the deadline for the RHQDAPU Notice survey must attend HCAHPS training. number, the decision rules for capturing
of Participation form at a future date. Hospitals contracting with a survey data, the file specifications, the file
vendor or another hospital to administer layout, the procedure for assigning
3. HCAHPS Dry Run the survey on behalf of the hospital do disposition codes, the definition of a
We are finalizing our proposal to not need to attend training. The next completed survey, and the procedure for
require hospitals that have not had training session will be offered via calculating the total survey response
experience collecting and submitting Webinar in late January 2007. Please see rate. Data preparation and submission
HCAHPS data to the QIO Clinical http://www.HCAHPSonline.org for
guidelines cover registration for data
Warehouse as a result of participating in updated information on training
submission via the QualityNet
the 2006 voluntary initiative must opportunities and registration. At a
Exchange, creation of data files,
participate in a dry run of the survey in minimum, the hospital’s or survey
instructions for data submission via the
March 2007. We proposed to require the vendor’s project manager must attend
QualityNet Exchange, and confirmation
submission of March 2007 dry run data the HCAHPS training for administering
of accuracy of data. Data reporting
to the QIO Clinical Warehouse by July the survey. Hospitals and survey
covers internal and external reports;
13, 2007 from those hospitals not yet vendors that attended training in
among them are the hospital preview
collecting and submitting HCAHPS February or April 2006 and are
reports and the public reports on CMS
data. We received no comments on this participating in the voluntary HCAHPS
data submission beginning October 2006 Hospital Compare. The Quality
proposal. Assurance Guidelines describe the
do not need to participate in the January
4. HCAHPS Data Collection 2007 training sessions. In addition, we exceptions process to review requests
Requirements may hold short refresher training for methodologies that vary from the
sessions for all hospitals self- standard HCAHPS protocols, and the
We also are finalizing our proposal
administering the survey and survey appeals process if an exception is
that, to collect HCAHPS data, a hospital
vendors in the spring of 2007. denied. For the initial implementation
can either contract with an approved
• Review and follow the HCAHPS phase of the HCAHPS survey, no
HCAHPS survey vendor that will
Quality Assurance Guidelines and exceptions to the four approved modes
conduct the survey and submit data on
Updates. HCAHPS Quality Assurance of survey administration will be
the hospital’s behalf to the QIO Clinical
Guidelines have been developed to allowed.
Warehouse, or a hospital can self-
standardize the survey data collection In addition, hospitals/survey vendors
administer the survey without using a
process and to ensure comparability of must follow any updates that are posted
survey vendor provided that the
data reported through HCAHPS. They on http://www.HCAHPSonline.org.
hospital meets Minimum Survey
Requirements as specified at (http:// are located on http:// • Develop Hospital/Survey Vendor
www.HCAHPSonline.org/ www.HCAHPSonline.org and will also HCAHPS Quality Assurance Plan.
programapplication.asp). A current list be presented at the HCAHPS hospital/ Hospitals self-administering the survey
of approved HCAHPS survey vendors survey vendor training. and survey vendors must develop a
can be found at http:// The HCAHPS Quality Assurance Quality Assurance Plan for survey
www.HCAHPSonline.org/ Guidelines (the Guidelines) provide administration in accordance with the
app_vendor.asp. We received no detailed information regarding: Quality Assurance Guidelines presented
comments on this proposal. technical support; sampling protocols; at the HCAHPS hospital/survey vendor
the four allowed modes of survey training and posted on http://
5. HCAHPS Registration Requirements administration; data specifications and www.HCAHPSonline.org/
We are adopting as final our proposal coding; data preparation and programapplication.asp. The HCAHPS
that HCAHPS registration requirements submission; data reporting and the Quality Assurance Plan should include
for the IPPS RHQDAPU program will exceptions process. The Guidelines the following:
include the following: describe technical support that is + Organizational chart
The hospital must be a registered user available to hospitals and survey + Work plan for survey
of QualityNet Exchange. Hospitals that vendors administering HCAHPS by implementation
are self-administering HCAHPS or using a toll-free number or by e-mail. + Description of survey procedures
survey vendors hired by the hospitals The Guidelines provide details and quality controls
must collect and submit HCAHPS regarding the protocol for sampling, + Plans for quality assurance
survey person-level data electronically which is based on drawing a simple oversight of on-site work and of all
to the QIO Clinical Warehouse via random sample each month from the subcontractors’ work
QualityNet Exchange, using prescribed sampling frame of eligible discharges. + Confidentiality/Privacy and
file specifications that can be found at Sampling can be done at one time after Security procedures in accordance with
the Health Insurance Portability and must notify all patients they survey that available as quickly as possible. As
Accountability Act (HIPAA). only the patient himself or herself discussed above, participation in this
The hospital or survey vendor must should complete the survey. Survey initial 9 month reporting period is not
make the HCAHPS Quality Assurance vendors conducting telephone surveys a requirement under the RHQDAPU
Plan available to the HCAHPS project may only speak directly to the patient. program and hospitals do not need to
team upon request. The project team If they reach a family member or participate in this initial reporting
includes CMS, the Health Services someone other than the patient, that period in order to receive the full FY
Advisory Group (HSAG) that is helping person cannot complete the survey. 2008 IPPS market basket update. After
CMS implement HCAHPS, and HSAG’s There are instructions on all mail this initial implementation, reporting of
subcontractors for this project. surveys that only the patient may HCAHPS data will be required under
• Attest to the Accuracy of the complete the survey. the RHQDAPU program. The public
Organization’s Data Collection. Comment: Some commenters reporting period will be 12 months and
Hospitals self-administering the survey expressed concern about having yet hospitals should be targeting to collect
and survey vendors must review and another entity that hospitals and health at least 300 completed HCAHPS surveys
agree that the HCAHPS survey was systems need to be familiar with, over a 12 month period. Smaller
administered in accordance with the especially since they deal primarily hospitals that cannot collect 300
HCAHPS Quality Assurance Guidelines. with the QIO regarding issues around completed HCAHPS surveys during a
• Participate in HCAHPS oversight quality measurement, submission of public reporting period will only be
activities. Hospitals and survey vendors data to the QIO Clinical Warehouse, required to collect as many completed
must participate in a quality oversight annual payment update, and appeals surveys as possible. A small hospital is
process conducted by the HCAHPS related to chart validation. These defined for the purposes of HCAHPS as
project team. Prior to July 2007, the commenters asked whether the QIOs any hospital that cannot achieve 300
purpose of the oversight activities will have any involvement with HCAHPS. completed HCAHPS surveys during a
be to provide feedback to hospitals and Response: The submission of public reporting period because of its
survey vendors on data collection HCAHPS data is similar to the data dearth of eligible hospital discharges
procedures. Starting in July 2007, CMS submission for the clinical measures. during that period. For hospitals that
may ask hospitals/survey vendors to We have contracted with the Iowa cannot collect 300 completed HCAHPS
correct any problems that are found and Foundation of Medical Care (IFMC) for surveys, we plan to note on http://
provide follow-up documentation of the data submission through QualityNet www.hospitalcompare.hhs.gov that the
corrections for review within a defined Exchange and the QIO Clinical results for these hospitals are based on
time period. If we find that the hospital Warehouse, and with the Health less than 100 completed HCAHPS
has not made these corrections, CMS Services Advisory Group, Inc. (HSAG) surveys, or between 100 and 299
may determine that the hospital is not of Arizona for all technical assistance completed HCAHPS surveys.
submitting appropriate HCAHPS data and support for HCAHPS. HSAG is fully
for the RHQDAPU program. available to accommodate assistance 8. HCAHPS Public Reporting
As part of these activities, HCAHPS needs on a national basis for HCAHPS. We are finalizing our proposal to
project staff will review and discuss We believe that this carefully display HCAHPS data on our Web site
with survey vendors and hospitals self- coordinated effort will ensure a high for public viewing in accordance with
administering the survey their specific level of reliability of data collection, section 1886(b)(3)(B)(viii)(VII) of the
Quality Assurance Plans, survey data submission and data oversight Act, which states that the Secretary
management procedures, sampling and since consistency of protocols is must report quality measures that relate
data collection protocols, and data essential to the success of this survey to patients’ perspectives of care on our
preparation and submission. This and to assuring quality data reporting to Web site. Before we display this
review may take place in-person or the public. In addition to these two information, hospitals will be permitted
through other means of communication. QIOs (IFMC and HSAG), we anticipate to review their data to be made public
Comment: One commenter asked how that all QIOs will be involved in the as we have recorded it.
the integrity of HCAHPS survey will be preview process prior to public As discussed above, there are 27
protected if it is sent to a prisoner or reporting. questions included in the HCAHPS
mentally incapacitated patient. The survey. The survey is comprised of
7. HCAHPS Survey Completion substantive questions that directly
commenter also asked how CMS will
Requirements pertain to seven domains of primary
validate that the survey was actually
completed by the patient. We also are finalizing our proposal to importance to the target audience:
Response: Hospitals participating in require hospitals to submit complete doctor communication; nurse
the HCAHPS survey are instructed to HCAHPS data in accordance with the communication; cleanliness and quiet of
exclude certain categories of patients HCAHPS Quality Assurance Guidelines the hospital environment;
from the universe of patients to whom located at http:// responsiveness of hospital staff; pain
the survey may be administered. These www.HCAHPSonline.org and made management; communication about
excluded categories encompass, among available at the hospital/survey vendor medicines; and discharge information.
others, both prisoners and patients training. These requirements specify The survey also includes two overall
admitted to hospital for psychiatric that hospitals are required to survey a questions that measure the patient’s
treatment. In addition, psychiatric random sample of eligible discharges on overall satisfaction with the hospital
hospitals, as defined under section a monthly basis. Hospitals should target and willingness to recommend the
1861(f) of the Act, do not participate in to collect at least 300 completed surveys hospital.
the RHQDAPU program because they over the public reporting period. For the Each of the seven domains is
are excluded from the IPPS. initial HCAHPS national constructed from two or three questions
To ensure that the patient completes implementation, the public reporting from the survey and is reported as a
the survey, hospitals participating in period is 9 months (October 2006 composite score. For public reporting
HCAHPS and the survey vendors that through June 2007) due to broad interest purposes, the seven composite scores or
administer the survey on their behalf in making HCAHPS results publicly items from within these domains and
two overall ratings will be displayed. organizations to have full access to combine their HCAHPS data for all
There will be both national and state provider performance information from campuses of a multi-campus provider.
comparisons for each of the reported the CMS Compare Web site and that the For each reporting period, which is 12
results. We are currently conducting performance information for each months starting in July 2007, hospitals
testing with consumers to ensure that question (rather than just the composite that share a Medicare provider number
the HCAHPS displays on http:// scores) on the HCAHPS survey be need to obtain 300 survey completes
www.hospitalcompare.hhs.gov are available for download. across their multiple campuses. CMS
consumer friendly. Generally, for Response: We are considering will continue to explore ways to collect
CAHPS measures in other settings we different options for the downloadable and report the data by campus in the
display bar graphs with the top response database and will take this request into future.
categories, such as the percent of people consideration as this database is
developed. E. SCIP & Mortality Measure
surveyed that gave the hospital a ‘‘10’’
Requirements for the FY 2008
for a 0 to 10 rating, or the percent that 9. Reporting HCAHPS Results for Multi- RHQDAPU Program
said their doctors ‘‘always’’ Campus Hospitals
communicate well. Users of the site can • We proposed that hospitals be
‘‘drill down’’ to get more detailed Currently, hospitals that share required to complete and return a
information regarding the distribution Medicare provider numbers combine written form on which they agree to
for the response categories underlying their clinical data across campuses for participate in the RHQDAPU program
the survey questions. submission and publication of their for FY 2008.
Comment: A commenter noted that data. We proposed to combine HCAHPS • For the SCIP measures, we
the proposed rule does not contain a data across campuses. However, we are proposed to require hospitals to submit
transparent explanation of how risk considering ways in which data could data starting with discharges that occur
adjustments will be made. potentially be displayed by campus in CY 2007. Hospitals will be required
Response: We will adjust HCAHPS rather than by hospital system in the to submit data on these measures to the
data for mode and patient-mix effects future. As a starting point, we are trying QIO Clinical Warehouse beginning with
prior to public reporting. We will adjust to determine a way to identify those discharges that occur in the first
hospital results to ‘‘level the playing hospitals that share Medicare provider calendar year quarter of 2007 (January
field’’ by adjusting for factors not numbers, which will allow CMS to through March discharges). We
directly related to hospital performance: denote that the measures are made up proposed that the deadline for hospitals
mode of survey administration, patient- of multiple campuses on http:// to submit their data for first calendar
mix, and non-response tendencies. An www.hospitalcompare.hhs.gov. In the quarter of 2007 will be August 15, 2007.
HCAHPS Mode Experiment was future, if feasible, we would like to • For the Mortality measures, we
conducted for several months in 2006, move towards obtaining and reporting proposed to use claims data that is
and the data analyses are now information at the campus level. In the already being collected for index
underway. The adjustment algorithm CY 2007 OPPPS proposed rule, we hospitalizations to calculate the
will be made available prior to the encouraged comments regarding this mortality rates. Therefore, no additional
public reporting of HCAHPS results. issue. data will need to be submitted by
The mode experiment results, including Comment: One commenter hospitals for these measures. Index
the adjustments to be made, will be recommended that all hospital data be hospitalization is the initial
available in late 2006 on http:// treated consistently by reporting both hospitalization for an episode of care.
www.HCAHPSonline.org. Several clinical quality and HCAHPS data by Claims data submitted to CMS for index
questions on the HCAHPS survey, as Medicare provider number or by hospitalizations occurring from July
well as some items from hospital individual hospital. 2005 through June 2006 (3rd quarter CY
administrative data, will be used for Response: We agree that data should 2005 through 2nd quarter CY 2006) will
patient mix adjustment. be reported consistently for both clinical be used to calculate the mortality rates
Comment: A commenter supported quality and HCAHPS data, either by that will be used for FY 2008 annual
publicly reporting HCAHPS survey data Medicare provider number or by payment determination. These rates will
in seven composites and two overall individual hospital. be posted on Hospital Compare in June
ratings displayed on the Hospital Comment: A commenter applauded 2007.
Compare Web site. However, the CMS’ interest in determining a way to • We proposed to display on our Web
commenter suggested that CMS consider identify those hospitals that share a site data collected on the SCIP and
retaining the ability for consumers to Medicare provider number and move Mortality measures for public viewing
drill down so that they may assess the toward displaying performance in accordance with section
hospital’s performance related to a information by campus rather than by 1886(b)(3)(B)(viii)(VII) of the Act. Before
single question. hospital system as it provides we display this information, hospitals
Response: We appreciate this consumers with more information to will be permitted to review their data
sensitivity to consumers’ need to assess assist in decisions about where to obtain that are to be made public as we have
specific information. We are currently services. recorded it.
testing and assessing various data Response: We appreciate the Comment: One commenter stated that,
displays for use on the Hospital comment and will continue to explore for the SCIP–VTE 1, SCIP–VTE 2, and
Compare Web site. We will be testing ways to obtain and report information at SCIP Infection 2 measures, the proposed
drill-downs with consumers and after the campus level. time frame to report these measures do
the testing is completed will determine Currently, hospitals that share not allow for hospitals to have sufficient
the best way to display HCAHPS data. Medicare provider numbers combine staff on board and to make sure they are
We are also testing the seven composites their clinical data across campuses for properly educated and trained to ensure
to ensure that they work well for the submission and publication of their a high degree of accuracy in the data
displays and are consumer friendly. data. For purposes of the FY 2008 abstraction. The commenter
Comment: A commenter asked CMS RHQDAPU program, we are adopting recommends that CMS require hospitals
to continue to allow private sector our proposal to require hospitals to submit data for these measures
beginning with discharges in the third and October releases of the CART and validity, reliability, impact and
quarter 2007 (July through September ORYX tools so there should be no feasibility of the measures; and (2) input
2007). concern regarding the availability of from a wide variety of stakeholders
Response: Collection of SCIP- data collection tools. Hospitals may use including, but not limited to, health care
Infection 1 and SCIP-Infection 3 as these tools immediately. consumers and patients, clinicians and
RHQDAPU measures for FY 2008 As discussed above, after careful providers, purchasers, and researchers.
(which we adopted for purposes of the consideration of the public comments We believe that adopting measures
RHQDAPU program in the FY 2007 received, we are adopting as final the that have been endorsed as a result of
IPPS final rule) began third calendar SCIP requirements we proposed. this process achieves the type of
quarter of 2006. The data submission consensus that Congress envisioned in
F. Conclusion
deadline for third calendar quarter of enacting section 5001(a) of Public Law
2006 is February 15, 2007. For those We believe that our decision to 109–171. The NQF is one consensus
hospitals that are already collecting and include HCAHPS, SCIP and mortality building entity that administers this
submitting data for SCIP-Inf-1 and SCIP- measures as part of the FY 2008 IPPS process and takes these factors into
Inf-3, the addition of SCIP-Inf-2 would RHQDAPU program’s reporting account when endorsing measures. NQF
require collection of only two additional requirements meets the requirements of is a voluntary consensus standard-
data elements (questions). These two section 1886(b)(3)(B)(viii)(III) of the Act. setting organization established to
additional data elements include This provision states that we must standardize health care quality
Antibiotic Allergy and Vancomycin. We expand for FY 2007 and each measurement and reporting, for its
believe the addition of these measures subsequent fiscal year, consistent with review and endorsement through its
to the RHQDAPU measures beginning sections 1886(b)(3)(B)(viii)(IV) through consensus development process. NQF
first quarter 2007 is a reasonable 1886(b)(3)(viii)(VII) of the Act, the set of endorsement, which occurs following a
expectation for hospitals. measures that the Secretary determines thorough, multi-stage review process,
Collection of the SCIP–VTE 1 and to be ‘‘appropriate’’ for the measurement represents the consensus of numerous
SCIP–VTE 2 measures began as a of care furnished by hospitals in health care providers, consumer groups,
voluntary submission in fourth calendar inpatient settings beyond the original professional associations, purchasers,
quarter of 2006 (October through 10-measure starter set of quality Federal agencies, and research and
December discharges) under the measures that applied in FY 2005 and quality organizations. We recognize that
Surgical Care Improvement Project FY 2006. the 30-day Pneumonia mortality is not
(SCIP) discussed in section XXII.B.3. of Section 1886(b)(3)(B)(viii)(IV) of the currently NQF-endorsed. Therefore, as
this final rule with comment period. Act requires us to begin to adopt the discussed above, we have decided not to
These measures were first published in baseline set of performance measures set adopt the 30-day Pneumonia mortality
the Specifications Manual for National forth in the 2005 IOM report effective measure in this final rule with comment
Hospital Quality Measures in the for payment beginning with FY 2007. period.
October 2006 release of the manual, We began to adopt these measures for The HQA is another such consensus
which was available June 9, 2006. This FY 2007 and are now adopting building entity. The HQA is a public-
provided hospitals with an opportunity additional measures, including several private collaboration of numerous
to abstract and submit these measures measures from this report. HCAHPS and stakeholder groups. One goal of HQA is
three months before the first calendar the SCIP Infection 2 measures are to identify a robust set of standardized
quarter of 2007, when they become measures set forth in the 2005 IOM and easy-to-understand hospital quality
RHQDAPU measures for FY2008. report. Thus, we believe our decision to measures that would be used by all
SCIP–VTE–1, SCIP–VTE–2, and SCIP- expand the measure set to include stakeholders in the health care system
Inf-2 measures can be found in the HCAHPS and SCIP Infection 2 measures in order to improve quality of care and
Specifications Manual for National for the FY 2008 IPPS RHQDAPU the ability of consumers to make
Hospital Quality Measures that was program meets this requirement of the informed health care choices. We also
released in June 2006. This version of Act. note that HQA currently relies on the
the manual pertains to fourth calendar Section 1886(b)(3)(B)(viii)(V) of the NQF process as part of its process.
quarter of 2006 and forward (October Act states that effective for payments CMS anticipates that other consensus
through December discharges). beginning with fiscal year 2008, we building entities that take into account
Comment: One commenter noted that, must add ‘‘other measures that reflect the issues of validity, reliability, impact
for the SCIP–VTE 1, SCIP–VTE 2, and consensus among affected parties and, and feasibility of the measures and
SCIP Infection 2 measures, hospitals to the extent feasible and practicable,’’ involves a wide array of stakeholders
and health systems require time to work and include ‘‘measures set forth by one may develop.
with their respective performance or more national consensus building
vendors to make sure that all tools are entities.’’ In addition to adding XXIII. Files Available to the Public Via
available to allow them to do the chart additional measures from the baseline the Internet
abstraction. measures found in the 2005 IOM report, Addenda A and B to this final rule
Response: The above SCIP-Inf-2 has we are adding additional SCIP quality with comment period provide various
been collected since first calendar measures and two 30-day mortality data pertaining to the CY 2007
quarter of 2005 as part of the HQA. The measures. In selecting these measures to payments for services under the OPPS.
Specifications Manual for National adopt consistent with this section for Addendum AA to this final rule with
Hospital Quality Measures for fourth the FY 2008 payment update and comment period include various data
quarter 2006 discharges has been thereafter, CMS is adding standardized pertaining to the ASC list of covered
available to Vendors since June 9, 2006. quality measures that have been procedures and payment rates for
SCIP–VTE 1 and SCIP–VTE 2 have been adopted or endorsed by a national procedures furnished in ASCs in CY
collected since fourth quarter 2006 consensus building entity that utilizes a 2007.
under SCIP. Based on their inclusion in national consensus building process To conserve resources and to make
the SCIP or HQA efforts, these measures that endorses measures based on: (1) Its Addendum B more relevant to the
have been incorporated in the August consideration of issues such as the OPPS, we are including in Addendum
B of this final rule with comment period associated burdens are subject to the Further, we note that there is no
HCPCS codes (including CPT codes) for PRA. additional burden associated with the
services that are assigned a payable incorporation of mortality outcome
Additional Quality Measures for FY
status indicator under the OPPS and measures as this information is
2008: Surgical Care Improvement
HCPCS codes for which we are making currently collected with claims data.
Project (SCIP) We have submitted a copy of this final
a change in status indicator and/or APC
assignment for CY 2007. A list of all Section 5001(a) of the Deficit rule with comment period to the OMB
active HCPCS codes and those codes Reduction Act (DRA) of 2005 (Pub. L. for its review of the aforementioned
discontinued as of December 31, 2006, 109–171) sets out new requirements for information collection requirements.
regardless of their assigned payment the IPPS Reporting Hospital Quality This final rule with comment period
status or comment indicators under the Data for Annual Payment Update also includes associated information
OPPS, is available to the public by (RHQDAPU) program. Under section collections for which CMS has obtained
clicking ‘‘Addendum A and Addendum 1886(b)(3)(B)(viii)(V) of the Act, for the OMB’s approval. The following is a
B Updates’’ on the CMS Web site at: payments beginning with FY 2008, we discussion of these currently OMB
http://www.cms.hhs.gov/ are required to add other measures that approved collections.
HospitalOutpatientPPS/. reflect consensus among affected parties As discussed in section XXII. of this
For the convenience of the public, we and, to the extent feasible and preamble, the IPPS RHQDAPU program
are also including on the CMS Web site practicable, must include measures set expands upon the Hospital Quality
a table that displays the HCPCS data in forth by one or more national consensus Initiative, which is intended to
Addendum B sorted by APC building entities. In this final rule with empower consumers with quality of
comment period, we are setting out the care information to make more informed
assignment, identified as Addendum C.
additional measures that we require for decisions about their health care while
To access Addendum C and other
FY 2008. also encouraging hospitals and
supporting data files related to the CY
clinicians to improve the quality of care.
2007 update of the OPPS, go to http:// The burden associated with this
The information collection associated
www.cms.hhs.gov/ section is the time and effort associated
with the IPPS RHQDAPU is the Hospital
HospitalOutpatientPPS/HORD/ with collecting, copying, and submitting
Quality Alliance (formerly known as the
list.asp#TopOfPage, and select the data. As part of the SCIP, we
National Voluntary Hospital Reporting
regulation number ‘‘CMS–1506–FC’’. At estimate that there will be Initiative) —Hospital Quality Measures.
this same Web site is a link to all of the approximately 3,700 respondents per The OMB approved this information
FY 2007 IPPS wage index related tables year. All of these hospitals already were collection under OMB control number
from the FY 2007 IPPS final notice (71 required to submit SCIP Infection 1 and 0938–0918, with an expiration date of
FR 59886 through 60043), as they would 3 to be eligible to receive the full IPPS December 31, 2008. As a result of the
be used for the CY 2007 OPPS. market basket update for FY 2007. increase from 10 to 21 quality measures,
Similarly, we are including Addendum Additional surgical procedures covering CMS created a revised information
AA on the CMS Web site at: http:// approximately 6,000,000 discharges collection request to include the new
www.cms.hhs.gov/center/asc.asp. annually will be sampled at a 10- quality measures. CMS announced the
For additional assistance, contact percent rate per hospital; therefore, an revised information collection in a 60-
Chuck Braver, (410) 786–6719. additional 600,000 discharges will be day Federal Register notice that
abstracted and submitted by hospitals published on June 9, 2006 (71 FR
XXIV. Collection of Information
for the additional SCIP measures (SCIP 33458). CMS will publish a 30-day
Requirements
Infection 2 and VTE 1, 2). The 10- Federal Register notice prior to the
Under the Paperwork Reduction Act percent sampling rate is a minimum submission of the revised information
(PRA) of 1995, we are required to threshold specified in the most current collection outlined in this final rule
provide 30-day notice in the Federal version of the joint CMS/JCAHO with comment period to OMB.
Register and solicit public comment Hospital Quality Measures Further, as discussed in section XXII.
before a collection of information Specifications Manual. We estimate that of this preamble, for FY 2008, we are
requirement is submitted to the Office of it will take 450,000 hours (3/4 hour per expanding the IPPS RHQDAPU program
Management and Budget (OMB) for sampled discharge) to abstract and to include the HCAHPS Survey, also
review and approval. In order to fairly submit data for these additional known as the Hospital CAHPS or the
evaluate whether an information sampled discharges. CAHPS Hospital Survey. The HCAHPS
collection should be approved by OMB, In addition, hospitals must abstract Survey is composed of 27 questions: 18
section 3506(c)(2)(A) of the PRA and submit additional information substantive questions that encompass
requires that we solicit comment on the needed for the additional SCIP measures critical aspects of the hospital
following issues: covering the surgical procedures already experience (communication with
• The need for the information covered in SCIP Infection 1 and 3. We doctors, communication with nurses,
collection and its usefulness in carrying estimate that about 275,000 discharges responsiveness of hospital staff,
out the proper functions of our agency. will be sampled and abstracted covering cleanliness and quietness of hospital
• The accuracy of our estimate of the these surgical procedures. We estimate environment, pain management,
information collection burden. that it will take an additional 137,500 communication about medicines, and
• The quality, utility, and clarity of hours (1/2 hour per sampled discharge) discharge information); 4 questions to
the information to be collected. for hospitals to abstract and submit this skip patients to appropriate questions; 3
• Recommendations to minimize the additional information. Both estimates questions to adjust for the mix of
information collection burden on the include overhead. patients across hospitals; and 2
affected public, including automated In total, we estimate that an questions to support congressionally
collection techniques. additional 587,500 hours will be used mandated reports. As explained in
The following information collection by hospitals to abstract and submit the section XXII. of this preamble, CMS
requirements are included in this final additional SCIP measures. This estimate published a Federal Register notice
rule with comment period and their includes overhead. soliciting comments on the draft 27-item
HCAHPS Survey in November 2005 (70 (September 1993, Regulatory Planning 2007. A more detailed discussion of the
FR 67476). The OMB approved the and Review), the Regulatory Flexibility effects of this provision is included in
HCAHPS Survey under OMB control Act (RFA) (September 19, 1980, Pub. L. section XXII. of this preamble and
number 0938–0981, with an expiration 96–354), section 1102(b) of the Social section XXVI.E. below.
date of December 31, 2007. Security Act, the Unfunded Mandates However, we estimate the total
Reform Act of 1995 (Pub. L. 104–4), and increase (from changes in this final rule
Revised § 416.190(c)—Request for Executive Order 13132. with comment period as well as
Review of Payment Amount enrollment, utilization, and case-mix
The collection of information 1. Executive Order 12866 changes) in expenditures under the
requirements at 5 CFR 1320 are Executive Order 12866 (as amended OPPS for CY 2007 compared to CY 2006
applicable to requirements affecting 10 by Executive Order 13258, which to be approximately $2.24 billion.
or more entities. Revised § 416.190(c) merely reassigns responsibility of Therefore, this final rule with comment
would require that a request for review duties) directs agencies to assess all period is an economically significant
of the ASC payment amount for costs and benefits of available regulatory rule under Executive Order 12866, and
insertion of an IOL must include all the alternatives and, if regulation is a major rule under 5 U.S.C. 804(2).
information that CMS specifies on its necessary, to select regulatory
approaches that maximize net benefits 2. Regulatory Flexibility Act (RFA)
Web site.
While this section of this final rule (including potential economic, The RFA requires agencies to
with comment period contains environmental, public health and safety determine whether a rule would have a
information collection requirements, we effects, distributive impacts, and significant economic impact on a
estimate that less than 10 ASCs will be equity). A regulatory impact analysis substantial number of small entities. For
affected; therefore, we believe these (RIA) must be prepared for major rules purposes of the RFA, small entities
collection requirements are exempt from with economically significant effects include small businesses, nonprofit
OMB for review and approval, as ($100 million or more in any 1 year). organizations, and small governmental
specified at 5 CFR 1320.3(c)(4). We estimate that the effects of the agencies. Most hospitals and most other
Consequently, this section of the final OPPS provisions that will be providers and suppliers are small
rule with comment period need not be implemented by this final rule with entities, either by nonprofit status or by
reviewed by the OMB under the comment period will result in having revenues of $6 million to $29
authority of the PRA. expenditures exceeding $100 million in million in any 1 year (65 FR 69432).
If you comment on any of these any 1 year. We estimate that adding 19 For purposes of the RFA, we have
information collection and procedures to the ASC list and determined that approximately 37
recordkeeping requirements, please mail implementing section 5103 of Public percent of hospitals and 73 percent of
copies directly to the following: Law 109–171 in CY 2007 will result in ambulatory surgery centers would be
savings to the Medicare program of considered small entities according to
Centers for Medicare & Medicaid
approximately $15 million. A more the Small Business Administration
Services, Office of Strategic
detailed discussion of the effects of the (SBA) size standards. We do not have
Operations and Regulatory Affairs, changes to the ASC list of procedures data available to calculate the
Regulations Development Group, for CY 2007 is provided in section percentages of entities in the
Attn.: Melissa Musotto, CMS–1506– XXVI.C. below. pharmaceutical preparation,
FC, Room C4–26–05, 7500 Security In addition, we estimate that the manufacturing, biological products, or
Boulevard, Baltimore, MD 21244– changes that we are making in section medical instrument industries that
1850; and Office of Information and XVIII. of this preamble to implement would be considered to be small entities
Regulatory Affairs, Office of Medicare contracting reform mandated according to the SBA size standards. For
Management and Budget, Room by section 911 of Public Law 108–173 the pharmaceutical preparation
10235, New Executive Office have no economic effect on current manufacturing industry (NAICS
Building, Washington, DC 20503, Medicare payments in CY 2007. This 325412), the size standard is 750 or
Attn: Carolyn Lovett, CMS Desk aspect of our rule amends our current fewer employees and $67.6 billion in
Officer, (CMS–1506–FC), Medicare contractor regulations to annual sales (1997 business census). For
carolyn_lovett@omb.eop.gov. Fax conform them to the statutory changes biological products (except diagnostic)
(202) 395–6974. mandated by Public Law 108–173 and (NAICS 325414), with $5.7 billion in
XXV. Response to Comments in and of itself does not affect in any annual sales, and medical instruments
way Medicare’s coverage or payment (NAICS 339112), with $18.5 billion in
Because of the large number of public
policies for hospital outpatient services annual sales, the standard is 50 or fewer
comments we normally receive on
or any other covered Medicare services. employees (see the standards Web site
Federal Register documents, we are not
Accordingly, we believe that this at: http://www.sba.gov/regulations/
able to acknowledge or respond to them
provision has no immediate economic siccodes/). Individuals and States are
individually. We will consider all
effect on Medicare payments in CY not included in the definition of a small
comments we receive by the date and
2007. entity.
time specified in the DATES section of Further, we estimate that the changes
this preamble, and, when we proceed Not-for-profit organizations are also
that we are making in section XXII. of considered to be small entities under
with a subsequent document(s), we will this preamble to implement an
respond to those comments in the the RFA. There are 2,167 voluntary
expanded set of quality measures for the hospitals that we consider to be not for-
preamble to that document(s). IPPS Reporting Hospital Quality Data profit organizations to which this final
XXVI. Regulatory Impact Analysis for the Annual Payment Update rule with comment period applies.
(RHQDAPU) program in accordance
A. Overall Impact with sections 1886(b)(3)(B)(viii)(III) and 3. Small Rural Hospitals
We have examined the impacts of this 1886(b)(3)(B)(viii)(IV) of the Act will not In addition, section 1102(b) of the Act
final rule with comment period as have a significant economic effect on requires us to prepare a regulatory
required by Executive Order 12866 Medicare payments to hospitals in CY impact analysis if a rule may have a
significant impact on the operations of or otherwise has Federalism changes to the APC weights, changes to
a substantial number of small rural implications. the wage indices, the continuation of a
hospitals. This analysis must conform to We have examined this final rule with payment adjustment for rural SCHs, and
the provisions of section 604 of the comment period in accordance with the expansion of the rural adjustment to
RFA. With the exception of hospitals Executive Order 13132, Federalism, and EACHs will not increase OPPS
located in certain New England have determined that it will not have an payments because these changes to the
counties, for purposes of section 1102(b) impact on the rights, roles, and OPPS are budget neutral. However,
of the Act, we previously defined a responsibilities of State, local or tribal these updates do change the distribution
small rural hospital as a hospital with governments. As reflected in Table 54, of payments within the budget neutral
fewer than 100 beds that is located we estimate that OPPS payments to system as shown in Table 54 and
outside of a Metropolitan Statistical governmental hospitals (including State, described in more detail in this section.
Area (MSA) (or New England County local, and tribal governmental hospitals)
will increase by 2.7 percent under this 1. Alternatives Considered
Metropolitan Area (NECMA)). However,
under the new labor market definitions final rule with comment period. The Alternatives to the changes we are
that we adopted in the CY 2005 final provisions related to payments to ASCs making and the reasons that we have
rule with comment period (consistent in CY 2007 will not affect payments to chosen these options are discussed
with the FY 2005 IPPS final rule), we no government hospitals. In addition, the throughout this final rule with comment
longer employ NECMAs to define urban provisions related to MACs and period. Some of the major issues
areas in New England. Therefore, we HCAHPS will not affect payments to discussed in this final rule with
now define a small rural hospital as a government hospitals. comment period and the options
hospital with fewer than 100 beds that considered are discussed below.
B. Effects of OPPS Changes in This Final
is located outside of an MSA. Section Rule With Comment Period a. Alternatives Considered for Coding
601(g) of the Social Security and Payment Policy for Visits.
Amendments of 1983 (Pub. L. 98–21) We are making several changes to the
designated hospitals in certain New OPPS that are required by the statute. In section IX. of this preamble, we are
England counties as belonging to the We are required under section creating five new G-codes for emergency
adjacent NECMA. Thus, for purposes of 1833(t)(3)(C)(ii) of the Act to update department visits provided in Type B
the OPPS, we classify these hospitals as annually the conversion factor used to emergency departments and one new G-
urban hospitals. We believe that the determine the APC payment rates. We code for critical care associated with
changes to the OPPS in this final rule are also required under section trauma response. Hospitals will
with comment period will affect both a 1833(t)(9)(A) of the Act to revise, not continue using CPT codes to describe
substantial number of rural hospitals as less often than annually, the wage index clinic visits and emergency department
well as other classes of hospitals and and other adjustments. In addition, we visits provided in Type A emergency
that the effects on some may be must review the clinical integrity of departments. CMS instructed hospitals
significant although the changes to the payment groups and weights at least to report facility resources for clinic and
ASC payment system for CY 2007 will annually. Accordingly, in this final rule emergency department visits using CPT
have no effect on small rural hospitals. with comment period, we are updating E/M codes and to develop internal
Therefore, we conclude that this final the conversion factor and the wage hospital guidelines to determine what
rule with comment period will have a index adjustment for hospital outpatient level of visit to report for each patient.
significant impact on a substantial services furnished beginning January 1, However, since the beginning of the
number of small rural hospitals. 2007, as we discuss in sections II.C. and OPPS, we have acknowledged that the
II.D., respectively, of this preamble. We CPT E/M codes do not adequately
4. Unfunded Mandates also are revising the relative APC describe the facility resources required
Section 202 of the Unfunded payment weights using claims data from to perform the services. One alternative
Mandates Reform Act of 1995 (Pub. L. January 1, 2005, through December 31, considered was to create G-codes to be
104–4) also requires that agencies assess 2005, and updated cost report used by hospitals to report clinic visits,
anticipated costs and benefits before information. In response to a provision Type A and Type B emergency
issuing any rule whose mandates in Public Law 108–173 that we analyze department visits, and critical care
require spending in any 1 year of $100 the cost of outpatient services in rural services, which would describe hospital
million in 1995 dollars, updated hospitals relative to urban hospitals, we resource use. However, many
annually for inflation. That threshold are continuing increased payments to commenters objected to creating G-
level is currently approximately $120 rural SCHs, including EACHs. Section codes before national guidelines were
million. The maximum nationwide cost II.F. of this preamble provides greater implemented. In response to this
to hospitals will be $16.9 million for detail on this rural adjustment. Finally, concern, we are finalizing new G-codes
HCAHPS (Abt Report), $58.7 million in we are not removing any device for visits provided in Type B emergency
noncapital costs for SCIP, and no cost categories from pass-through payment departments because there currently are
for mortality measures. This final rule status in CY 2007. no CPT codes that describe services in
with comment period will not mandate Under this final rule with comment these facilities. In addition, we are
any requirements for State, local, or period, the update change to the creating one new G-code for critical care
tribal government, nor will it affect conversion factor as provided by statute associated with trauma response, in
private sector costs. will increase total OPPS payments by response to commenters’ requests that
3.4 percent in CY 2007. The expiration we pay differentially for critical care
5. Federalism of the one-time wage reclassification provided with and without trauma
Executive Order 13132 establishes under section 508 in April 2007, which response.
certain requirements that an agency is not budget neutral, and an increase in Some hospitals have requested that
must meet when it publishes any rule the fixed-dollar outlier threshold to they be permitted to bill emergency
(proposed or final) that imposes account for the underestimation of department visit codes under the OPPS
substantial direct costs on State and outlier payments in CY 2006, results in for services furnished in a facility that
local governments, preempts State law, a net increase of 3.0 percent. The meets the CPT definition for reporting
emergency department visit E/M codes, and emergency department codes that clinics because they may not be
except that these hospitals are not suggest that five payment levels are available 24 hours per day or may not
available 24 hours a day. For CY 2007, more appropriate than three levels. In require the same high state of readiness
we are establishing a set of codes for addition, providers have indicated that as Type A emergency departments. In
visits provided in dedicated emergency it is administratively burdensome to other respects, their costs may resemble
departments that have an EMTALA code for five levels, but receive payment the costs of visits to Type A emergency
obligation. These codes will be billed by at only three levels, as has been the departments because they both provide
Type B emergency departments, historical policy in the OPPS. If future predominantly unscheduled visits.
specifically those that do not meet the data indicate that three payment levels Therefore, we currently have no
Type A requirements. We are are more appropriate, we may revert accurate methodology for establishing
instructing hospitals to use current back to three payment levels. For payment rates that are appropriate for
emergency department CPT codes to critical care, our claims data indicate visits to Type B emergency departments.
report visits provided in a specific that critical care services associated Therefore, consistent with past payment
subset of dedicated emergency with trauma response are costlier than policies for certain services, such as
departments, called Type A emergency critical care services that are not drug administration, in which we
departments, that are open 24 hours per associated with trauma response. Paying maintained consistent payment policies
day, 7 days per week and that do not for critical care services that are while gathering more detailed cost data,
have an EMTALA obligation solely associated with trauma response at a we are continuing payment to Type B
based on providing at least one-third of higher rate will lead to a more accurate emergency departments at clinic visit
their outpatient visits for the treatment distribution of payments. An alternative rates while we gather hospital claims
of emergency medical conditions on an to this policy is to continue paying at data specific to these visits to review
urgent basis without requiring a three payment levels for both clinic and their costs.
previously scheduled appointment. An emergency department visits and one b. Alternatives Considered for
alternative to this policy is to continue payment level for critical care services. Brachytherapy Source Payments
to uphold past policy and allow only However, for the reasons described
the Type A subset of dedicated above, we are making payment at five Pursuant to sections 1833(t)(2)(H) and
emergency departments to bill levels for clinic and emergency 1833(t)(16)(C) of the Act, we have paid
emergency department visit codes and department visits and two levels for for brachytherapy sources furnished on
require Type B emergency departments or after January 1, 2004, and before
critical care services for CY 2007 to
to bill clinic visit codes. However, this January 1, 2007, on a per source basis
ensure that payments more accurately
would not allow us to determine at an amount equal to the hospital’s
reflect the median costs of the services
whether visits to dedicated emergency charge adjusted to cost by application of
provided.
departments or facilities that incur the hospital-specific overall CCR. For
For CY 2007, we are making payment CY 2007, we are making payment for
EMTALA obligations but do not meet
for emergency visits to Type B brachytherapy sources at a
more prescriptive expectations that are
dedicated emergency departments that prospectively determined rate for each
consistent with the CPT definition of an
emergency department have different are not part of the specific subset source for which we have claims data,
resource costs than visits to either identified as Type A emergency and each source is assigned to its own
clinics or the Type A subset of departments at the same rate as clinic APC. We are converting the median cost
dedicated emergency departments that visits, consistent with current policy. to a relative weight by dividing it by the
meet more prescriptive expectations, This payment policy is similar to our median for APC 0606, scaling the
including 24 hours per day, 7 days per current policy that requires services unscaled weight for budget neutrality,
week availability. furnished in emergency departments and multiplying the scaled weight by
We are creating one new G-code for that have an EMTALA obligation but do the conversion factor to calculate the
critical care associated with trauma not meet the CPT definition of payment rate per source. This is our
response, in response to commenters’ emergency department to be reported standard OPPS methodology for using
requests that we distinguish between using CPT clinic visit E/M codes, median costs to calculate the payment
critical care provided with and without resulting in payments based upon clinic for each APC.
trauma response. An alternative to this visit APCs. While maintaining the same The first alternative we considered
policy is to continue to uphold past payment policy for CY 2007, the was to establish a per day payment for
policy and instruct hospitals to bill one reporting of specific G-codes for brachytherapy sources based on our CY
CPT code for critical care services, emergency department visits provided 2005 claims data. While this alternative
regardless of whether the critical in Type B dedicated emergency would be consistent with the
services were associated with trauma departments will permit us to philosophy of a prospective payment
response. However, if hospitals only specifically collect and analyze the system and would mitigate the effects
billed one code for critical care services hospital resource costs of visits to these on payment of inaccurate coding of the
with and without trauma activation, it facilities in order to determine whether number of sources used, we believe that
would be difficult to pay differentially a future proposal of an alternative a per day payment may not provide
for the two services, as our claims data payment policy may be warranted. An source payment specifically addressed
indicate is appropriate. alternative would be to provide to the hospital resources used under the
We must also establish payment rates payment for services billed by Type B unique clinical circumstances of each
for clinic and emergency department emergency departments at payment individual treatment because of the
visits and critical care services. For CY rates other than the clinic visit rates. variation in the number of sources
2007, we are making payments at five However, we do not know what the required to treat patients under different
payment levels for both clinic and hospital facility costs of these visits clinical conditions. There is
emergency department visits and at two would be because we are unable to considerable clinical variation in the
payment levels for critical care services. identify these services in our historical number of sources used for
We see meaningful differences among claims data. In some respects, their costs brachytherapy services, and we believe
the median costs of five levels of clinic may resemble the costs of visits to a per day payment based on an average
number of sources used may not as provision of nuclear medicine under the HCPCS codes that were new
accurately reflect the resources used for procedures always requires one or more for CY 2006.
an individual Medicare beneficiary’s radiopharmaceuticals, packaging more
2. Limitations of Our Analysis
treatment as the per source payment radiopharmaceuticals effectively would
methodology. Therefore, we are not result in some increases in the The distributional impacts presented
setting payments on a per day basis. associated nuclear medicine procedure here are the projected effects of the
The second alternative we considered APC payment rates. A policy to package policy changes, as well as the statutory
was to continue to make separate additional radiopharmaceuticals would changes that will be effective for CY
payment for sources of brachytherapy be consistent with the OPPS packaging 2007, on various hospital groups. We
under the current methodology of principles and payment policies which estimate the effects of individual policy
hospital charges reduced to costs. generally provide appropriate payment changes by estimating payments per
Although hospitals are familiar with for the ‘‘average’’ service and would service while holding all other payment
this methodology and this alternative is provide greater administrative policies constant. We use the best data
consistent with the requirement that simplicity for hospitals. However, available but do not attempt to predict
sources be paid separately, we believe packaging the costs of all behavioral responses to our policy
that to continue to pay on this basis radiopharmaceuticals into the changes. In addition, we do not make
would be inconsistent with the general procedures in which they are used adjustments for future changes in
methodology of a prospective payment could result in inadequate payment for variables such as service volume,
system and would provide no incentive the highest cost products. service-mix, or number of encounters.
for a hospital to provide services The second alternative that we As we have done in previous rules, we
efficiently and at the lowest cost. considered for CY 2007 would have solicited comments and information
The third alternative we considered established prospective payment rates about the anticipated effect of the
and are accepting for CY 2007 is to for separately payable proposed changes on hospitals and our
make payment for each brachytherapy radiopharmaceuticals using mean costs methodology for estimating them.
source on a per source rate that is derived from the CY 2005 claims data, Comments on the impact of the
calculated using our standard OPPS where the costs are determined using proposed changes for CY 2007 are
methodology. This is consistent with our standard methodology of applying included in the discussion of the
our methodology for setting payment hospital-specific departmental CCRs to applicable topics in the preamble of this
rates for other services and is consistent radiopharmaceutical charges and final rule with comment period. There
with the expiration of the Public Law defaulting to hospital-specific overall were no comments on the methodology
108–173 requirement that payment for CCRs only if appropriate departmental we proposed to use to evaluate the
sources of brachytherapy be made at CCRs are unavailable. This policy impact of the proposed changes other
charges reduced to cost for dates of would have established our packaging than those discussed under applicable
service on and after January 1, 2004, threshold for radiopharmaceuticals at issues.
through December 31, 2006. Moreover, $55, the same as the packaging 3. Estimated Impacts of This Final Rule
for the reasons we discuss in detail in threshold for drugs and biologicals With Comment Period on Hospitals
section VII. of this final rule with under the CY 2007 OPPS. We did not
comment period, we believe that this select this option because commenters The estimated increase in the total
option will provide the most indicated that changes to many payments made under the OPPS is
appropriate payment for brachytherapy radiopharmaceutical HCPCS codes in limited by the increase to the
sources. CY 2006 were made because hospitals conversion factor set under the
were having difficulty with the CY 2005 methodology in the statute. The
c. Alternatives Considered for Payment distributional impacts presented do not
codes, and, therefore, the CY 2005
of Radiopharmaceuticals include assumptions about changes in
hospital claims data were not accurate
In developing the payment policy for and not applicable to the CY 2006 volume and service-mix. The enactment
separately payable codes. of Public Law 108–173 on December 8,
radiopharmaceuticals for this CY 2007 The third alternative that we 2003, provided for the additional
final rule with comment period, we considered and have selected for CY payment outside of the budget
considered three policy options. 2007 is to continue the temporary CY neutrality requirement for wage indices
The first alternative we considered 2006 methodology of paying for for specific hospitals reclassified under
was to package additional separately payable section 508 through CY 2007. Table 54
radiopharmaceuticals, either through radiopharmaceuticals at charges shows the estimated redistribution of
packaging payments for all reduced to cost, where payment would hospital payments among providers as a
radiopharmaceuticals with payments for be determined using each hospital’s result of a new APC structure, wage
the services with which they are billed overall CCR, and establishing our indices, and adjustment for rural SCHs
or setting a packaging threshold radiopharmaceutical packaging (which includes EACHs), which are
established specifically for threshold at $55, as we are doing for budget neutral; the estimated
radiopharmaceuticals that was much other drugs for the CY 2007 OPPS. This distribution of increased payments in
higher than the $55 threshold proposed policy provides stability to the payment CY 2007 resulting from the combined
for other drugs and biologicals. In methodology for radiopharmaceuticals impact of the APC recalibration, wage
contrast to other separately payable from CY 2006 to CY 2007. As we effects, the rural SCH adjustment, and
drugs where the administration of many indicated for CY 2006, this payment the market basket update to the
drugs is reported with only a few drug methodology provides an acceptable conversion factor; and, finally,
administration HCPCS codes, only a proxy for the average acquisition of the estimated payments considering all
small number of specific radiopharmaceutical along with its payments for CY 2007 relative to all
radiopharmaceuticals may be handling cost. We intend this payments for CY 2006, including the
appropriately provided in the methodology to be a temporary measure impact of expiring wage provisions and
performance of each particular nuclear until we have confidence in the coding changes in the outlier threshold.
medicine procedure. Because the and charging practices of hospitals Because updates to the conversion
factor, including the update of the weights, the final CY 2006 weights used a blended wage index consisting of
market basket and the addition of versus the final CY 2007 weights in our 25 percent of the IPPS wage index with
money not dedicated to pass-through baseline model, and calculating the section 508 and 75 percent of the IPPS
payments, are applied uniformly, percent difference in payments. wage index after section 508 expires.
observed redistributions of payments in Column 3 shows the impact of We modeled the independent effect of
the impact table largely depend on the updating the wage index used to all changes in Column 5 using the final
mix of services furnished by a hospital calculate payment by applying the FY weights for CY 2006 and the final
(for example, how the APCs for the 2007 IPPS wage index, combined with weights for CY 2007. The wage indices
hospital’s most frequently furnished the impact of the 7.1 percent rural in each year include wage index
services would change), the impact of adjustment for SCHs and EACHs for increases for hospitals eligible for
the wage index changes on the hospital, services other than drugs, biologicals, reclassification under section 508 of
and the impact of the payment brachytherapy sources, and those Public Law 108–173, and in 2007, these
adjustment for rural SCHs, including receiving pass-through payments. The provisions expire in April 2007. We
EACHs. However, total payments made OPPS wage index used in Column 3 used the final conversion factor for CY
under this system and the extent to does not include changes to the wage 2006 of $59.511 and the final CY 2007
which this final rule with comment index for hospitals reclassified under conversion factor of $61.468. Column 5
period will redistribute money during section 508 of Public Law 108–173. We also contains simulated outlier
implementation also will depend on modeled the independent effect of payments for each year. We used the
changes in volume, practice patterns, updating the wage index and the rural charge inflation factor used in the FY
and the mix of services billed between adjustment by varying only the wage 2007 IPPS rule of 7.57 percent (1.0757)
CY 2006 and CY 2007, which CMS index and the inclusion of EACHs, to increase individual costs on the CY
cannot forecast. Overall, the final OPPS using the CY 2007 scaled weights, and 2005 claims to reflect CY 2006 dollars,
rates for CY 2007 will have a positive a CY 2006 conversion factor that and we used the most recent overall
effect for all hospitals paid under the included a budget neutrality adjustment CCR for each hospital as calculated for
OPPS. Changes will result in a 3.0 for changes in wage effects and the rural the APC median setting process. Using
percent increase in Medicare payments adjustment between CY 2006 and CY the CY 2005 claims and a 7.57 percent
to all hospitals, exclusive of transitional 2007. charge inflation factor, we currently
pass-through payments. Removing Column 4 demonstrates the combined estimate that actual outlier payments for
cancer and children’s hospitals because ‘‘budget neutral’’ impact of proposed CY 2006, using a multiple threshold of
their payments are held harmless to the APC recalibration, the wage index 1.75 and a fixed-dollar threshold of
pre-BBA ratio between payment and update, and the rural adjustment for $1,250 would be 1.25 percent of total
rural SCHs and EACHs on various payments, which is 0.25 percent higher
cost suggests that changes will result in
classes of hospitals, as well as the than the 1.0 percent that we projected
a 3.0 percent increase in Medicare
impact of updating the conversion factor in setting outlier policies for CY 2006,
payments to all other hospitals.
with the market basket update. We due to the differences in the calculation
To illustrate the impact of the final modeled the independent effect of of the overall CCR, as discussed in
CY 2007 changes, our analysis begins budget neutrality adjustments and the section II.A.1.c. of this preamble.
with a baseline simulation model that market basket update by using the Outlier payments of 1.25 percent appear
uses the final CY 2006 weights, the FY weights and wage indices for each year, in the CY 2006 comparison in Column
2006 final post-reclassification IPPS and using a CY 2006 conversion factor 5. We used the same set of claims and
wage indices without additional that included the proposed market a charge inflation factor of 15.15 percent
increases resulting from section 508 basket update and budget neutrality (1.1515) to model the CY 2007 outliers
reclassifications, and the final CY 2006 adjustments for differences in wages at 1.0 percent of total payments using a
conversion factor. Column 2 in Table 54 and the adjustment for rural SCHs and multiple threshold of 1.75 and a fixed-
reflects the independent effects of the EACHs. dollar threshold of $1,825.
APC reclassification and recalibration Finally, Column 5 depicts the full
changes. Column 3 reflects the effects of impact of the final CY 2007 policy on Column 1: Total Number of Hospitals
updated wage indices, including the each hospital group by including the Column 1 in Table 54 shows the total
new occupational mix data described in effect of all the changes for CY 2007 and number of hospital providers (3,992) for
the FY 2007 IPPS final rule, and the comparing them to all estimated which we were able to use CY 2005
adjustment for rural SCHs and EACHs. payments in CY 2006, including those hospital outpatient claims to model CY
The clarification that the rural required by Public Law 108–173. 2006 and CY 2007 payments by classes
adjustment applies to EACHs is not Column 5 shows the combined budget of hospitals. We excluded all hospitals
shown separately because there are so neutral effects of Columns 2 through 4, for which we could not accurately
few EACHs that the overall impact plus the impact of increasing the outlier estimate CY 2006 or CY 2007 payment
cannot be observed when payments are threshold after realigning the overall and entities that are not paid under the
aggregated by type of hospital. These CCR calculation used to model the OPPS. The latter entities include CAHs,
effects are budget neutral, which is outlier threshold with the one used by all-inclusive hospitals, and hospitals
apparent in the overall zero impact in the fiscal intermediaries for payment, located in Guam, the U.S. Virgin
payment for all hospitals in the top row. the impact of changing the percentage of Islands, Northern Marianas, American
Column 2 shows the independent effect total payments dedicated to transitional Samoa, and the State of Maryland. This
of changes resulting from the pass-through payments to 0.21 percent, process is discussed in greater detail in
reclassification of services codes among and the expiration of payment for wage section II.A. of this preamble. At this
APC groups and the recalibration of index increases for hospitals reclassified time, we are unable to calculate a
APC weights based on a complete year under section 508 of Public Law 108– disproportionate share (DSH) variable
of CY 2005 hospital OPPS claims data 173 in April 2007. As noted in section for hospitals not participating in the
and more recent cost report data. We II.D. of this preamble, because section IPPS. Hospitals for which we do not
modeled the independent effect of APC 508 expires in April 2007 and OPPS have a DSH variable are grouped
recalibration by varying only the operates on a calendar year basis, we separately and generally include
psychiatric hospitals, rehabilitation Column 3: New Wage Indices and the Columns 2, and 3, with the exception of
hospitals, and LTCHs. Finally, section Effect of the Rural Adjustment urban hospitals with the lowest volume
1833(t)(7)(D) of the Act permanently Changes introduced by the FY 2007 of services and hospitals not paid under
holds harmless cancer hospitals and IPPS wage indices together with the the IPPS, including psychiatric
children’s hospitals to the proportion of effect of including EACHs in the rural hospitals, rehabilitation hospitals, and
their pre-BBA payment relative to their adjustment would have a modest impact LTCHs (DSH not available). In many
costs. Because this final rule with in CY 2007, with no changes to instances, the redistribution of
comment period will not impact these payments to rural hospitals other than payments created by APC recalibration
hospitals negatively, we removed them offsets those introduced by updating the
SCHs, a decrease of 0.1 percent for large
from our impact analyses. We show the wage indices. However, in a few
urban hospitals, and an increase to other
total number (3,928) of OPPS hospitals, instances, negative APC recalibration
urban hospitals of 0.1 percent. We
excluding the hold-harmless cancer changes compound a reduction in
estimate that rural SCHs will experience
hospitals and children’s hospitals, on payment from updating the wage index.
an increase in payments of 0.1 percent, We estimate that the cumulative
the second line of the table. while all other rural hospitals impact of the budget neutrality
experience no change. With respect to adjustments and the addition of the
Column 2: APC Recalibration
volume, rural hospitals with fewer than market basket update would result in an
The combined effects of the APC 11,000 lines and 21,000–42,999 lines increase in payments for urban hospitals
reclassification and recalibration, in experience increases of 0.1 to 0.9 of 3.5 percent, which is 0.1 percent
Column 2 are typical for APC percent. For both facility size and higher than the market basket update of
recalibration. Overall, these changes volume, no category of rural hospitals 3.4 percent. Large urban hospitals will
increase payments to urban hospitals by experiences an increase greater than 0.9 experience an increase of 3.2 percent
0.1 percent, although some classes of percent. and other urban hospitals will
urban hospitals experience decreases in Overall, urban hospitals experience experience an increase of 3.8 percent.
payments. However, changes to the APC no change in payments as a result of the Urban hospitals with the lowest volume
structure for CY 2007 tend to favor, new wage indices and the rural experience a negative market basket
slightly, urban hospitals. We estimate adjustment. However, large urban update of 1.4 percent. Urban hospitals
that large urban hospitals would see a hospitals experience a decrease of 0.1 with volumes greater than 5,000 lines
0.1 percent decrease, while ‘‘other’’ percent and other urban hospitals have increases from 1.8 percent to 3.5
experience an increase of 0.1 percent. percent.
urban hospitals experience an increase
When categorized by volume, urban We estimate that the cumulative
of 0.2 percent.
hospitals with the largest volume impact of budget neutrality adjustments
Overall, rural hospitals show a experience no change in payment as a and the market basket update will result
modest 0.3 percent decrease as a result result of changes to the wage index and in an overall increase for rural hospitals
of changes to the APC structure. the presence of the rural adjustment, of 3.2 percent, with rural SCHs
Notwithstanding a modest overall and urban hospitals with volumes less experiencing an update of 3.3 percent
increase in payments, there is than 42,999 lines experience decreases and other rural hospitals also
substantial variation among classes of in payment from 0.1 percent to 0.7 experiencing an update of 3.1 percent.
rural hospitals. The lowest volume percent. In general, rural hospitals with more
hospitals experience the largest decrease Looking across other categories of than 5,000 lines of volume experience
of 3.0 percent. Rural hospitals with hospitals, we estimate that updating the increases equal to or greater than 3.1
greater than 5,000 lines of volume wage index and continuing the rural percent. We estimate that low-volume
demonstrate no change or decreases of adjustment will lead major teaching rural hospitals would experience an
no more than 0.4 percent as a result of hospitals to gain 0.1 percent, and increase of 0.9 percent.
APC recalibration. hospitals with minor graduate medical The changes across columns for other
Among other classes of hospitals, the education programs are estimated to classes of hospitals are fairly moderate
largest observed impacts resulting from experience no change. Hospitals serving and most show updates relatively close
APC recalibration include an increase of more than 35 percent low-income to the market basket update with the
0.2 percent for minor teaching hospitals patients are estimated to experience a exception of hospitals not paid under
and a decrease of 0.3 percent for major decrease of 0.1 percent. Hospitals the IPPS, which show negative payment
teaching hospitals. Urban hospitals that serving no low-income patients are updates. Voluntary and proprietary
are treating DSH patients and are also expected to see an increase of 0.2 hospitals also show an increase equal to
teaching hospitals experience an percent, while hospitals for which the or greater than the market basket.
increase of 0.1 percent. We project that percent of low-income patients cannot Governmental hospitals show an
hospitals for which a DSH percentage is be determined are expected to lose 0.4 increase of 3.2 percent.
percent. Voluntary hospitals as classes
not available, including psychiatric Column 5: All Changes for CY 2007
would experience an increase of 0.1
hospitals, rehabilitation hospitals, and Column 5 compares all changes for
percent change in payment due to wage
long-term care hospitals, will CY 2007 to final payment for CY 2006
changes and the effect of the rural
experience decreases in payments of 7.2 and includes any additional dollars
adjustment. Governmental and
percent, and for the urban subset, 7.4 resulting from provisions in Public Law
proprietary hospitals will lose 0.1 and
percent. 108–173 in both years, changes in
0.3 percent, respectively.
Classifying hospitals by type of outlier payment percentages and
Column 4: All Budget Neutrality
ownership suggests that proprietary thresholds, and the difference in pass-

hospitals would gain 0.2 percent, Changes and Market Basket Update through estimates. Overall, we estimate
governmental hospitals would The addition of the market basket that hospitals will gain 3.0 percent
experience losses of 0.1 percent, and update alleviates any negative impacts under this final rule with comment
voluntary hospitals would experience on payments for CY 2007 created by the period in CY 2007 relative to total
no change. budget neutrality adjustments made in spending in CY 2006. When we
excluded cancer and children’s combined effects of these factors. We hospitals with volumes greater than
hospitals, which are held harmless, the estimate that, overall, urban hospitals 4,999 lines experience increases of at
gain remains 3.0 percent. Hospitals will will gain 3.1 percent. We estimate that least 2.7 percent. We project that low-
receive the 3.4 percent increase due to hospitals in large urban areas will gain volume rural hospitals will experience
the market basket update appearing in 2.9 percent in CY 2007, and hospitals in the greatest decrease in overall payment
Column 4. However, they lose 0.04 other urban areas will gain 3.2 percent. of 0.9 percent.
percent due to the increase in the pass- We estimate that low-volume urban
through estimate between CY 2006 and hospitals will experience a decrease in Among other classes of hospitals, we
CY 2007. Moreover, we estimate that total payments of 1.2 percent between estimate that hospitals not paid under
hospitals also experience a 0.25 percent CY 2006 and CY 2007. the IPPS (DSH Not Available) will
loss due to outlier payments as a result Overall, rural hospitals experience experience decreases in payments
of the increased threshold and the increases that are lower than those between CY 2006 and CY 2007 of 4.0
change to the overall CCR that is used observed for urban hospitals. Overall, percent. We estimate that major
to estimate outlier payments. In we estimate that rural hospitals will teaching hospitals will experience an
addition, there is a loss of 0.17 percent experience an increase in payments of increase of 2.8 percent and that
as a result of the expiration of the 2.7 percent. We also estimate that rural nonteaching hospitals will experience
section 508 wage adjustment. SCHs and other rural hospitals will an increase of 3.0 percent.
In general, urban hospitals appear to experience an increase of 2.6 percent BILLING CODE 4120–01–P
experience the largest gains from the and 2.8 percent, respectively. Rural
ER24NO06.029</GPH>
ER24NO06.030</GPH>
BILLING CODE 4120–01–C liability for copayment for a service to hospitals will experience positive
4. Estimated Effect of This Final Rule the inpatient hospital deductible for the updates in OPPS payments in CY 2007.
With Comment Period on Beneficiaries applicable year. For CY 2007, the Table 54 demonstrates the estimated
inpatient deductible is $992. distributional impact of the OPPS
For services for which the beneficiary
In order to better understand the budget neutrality requirements and an
pays a copayment of 20 percent of the
impact of changes in copayment on additional 3.0 percent increase in
payment rate, the beneficiary share of
beneficiaries, we modeled the percent payments for CY 2007, after considering
payment would increase for services for
change in total copayment liability the market basket increase, the cost of
which OPPS payments will rise and
would decrease for services for which using CY 2005 claims. We estimate, outliers, changes to the pass-through
OPPS payments would fall. For using the claims of the 3,992 hospitals estimate and the elimination of the
example, for an electrocardiogram (APC on which our modeling is based, that section 508 adjustment of Public Law
0099), the minimum unadjusted total beneficiary liability for copayments 108–173. The accompanying discussion,
copayment in CY 2006 was $4.49. In will decline as an overall percentage of in combination with the rest of this final
this final rule with comment period, the total payments from 27.5 percent in CY rule with comment period constitutes a
minimum unadjusted copayment for 2006 (revised from the 29 percent that regulatory impact analysis.
APC 0099 is $4.66 because the OPPS we estimated for CY 2006 in the CY 6. Accounting Statement
payment for the service will increase 2006 OPPS final rule with comment
under this final rule with comment period 70 FR 68727) to 26.6 percent in As required by OMB Circular A–4
period. In another example, for a Level CY 2007. This estimated decline in (available at http://
IV Needle Biopsy (APC 0037), in the CY beneficiary liability is a consequence of www.whitehouse.gov/omb/circulars/
2006 OPPS, the national unadjusted the APC recalibration and a004/a-4.pdf, in Table 55 below, we
copayment was $228.76, and the reconfiguration we are making for CY have prepared an accounting statement
minimum unadjusted copayment was 2007. showing the classification of the
$114.38. In this final rule with comment 5. Conclusion expenditures associated with the CY
period, the national unadjusted 2007 OPPS provisions of this final rule
copayment for APC 0037 is $228.76. The changes in this final rule with with comment period. This table
The minimum unadjusted copayment comment period will affect all classes of provides our best estimate of the
for APC 0037 is $126.20, or 20 percent hospitals. Some hospitals experience increase in Medicare payments under
of the payment for APC 0037. In all significant gains and others less the OPPS as a result of the provisions
ER24NO06.031</GPH>
cases, the statute limits beneficiary significant gains, but almost all presented in this final rule with
comment period for CY 2007. All

expenditures are classified as transfers.
TABLE 55.—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED CY 2007 OPPS EXPENDITURES ASSOCIATED

WITH CY 2007 FINAL RULE PROVISIONS
Category Transfers
Annualized Monetized Transfers .............................................................. $620 Million.

From Whom to Whom .............................................................................. Federal Government to OPPS Medicare Providers.
Annualized Monetized Transfer ................................................................ $150 Million.
From Whom to Whom .............................................................................. Premium Payments from Beneficiaries to Federal Government.
Total ................................................................................................... $470 Million.
C. Effects of Changes to the ASC been for the services provided in CY 2007 to gauge their impact on
Payment System for CY 2007 hospital outpatient departments. individual ASCs, but we received no
We are adding 19 surgical procedures Except for the payment changes comments on the subject.
to the ASC list of Medicare payable required under section 5103 of Public
3. Estimated Effects of This Final Rule
procedures for CY 2007. We are also Law 109–171 and sections 1834(d)(2)
With Comment Period on ASCs
implementing section 5103 of Public and (d)(3) of the Act, we are not making
Law 109–171 and sections 1834(d)(2) any changes in CY 2007 to the ASC CMS estimates that approximately 25
and (d)(3) of the Act. Section 5103 of payment rates that are currently in percent of the cases currently reported
Public Law 109–171 requires the effect. by hospitals for each of the 19 codes we
Secretary to substitute the OPPS CMS estimates that adding the 19 are adding to the ASC list will shift to
payment amount for the ASC standard procedures discussed in section XVII. of the ASC setting in CY 2007. We estimate
overhead amount if the standard this preamble and implementing the that the shift of these procedures to the
overhead amount for facility services for Public Law 109–171 mandate will result less costly ASC setting will result in
surgical procedures performed in an in a savings to the Medicare program of modest savings for the Medicare
ASC, without application of any approximately $15 million in CY 2007. program.
geographic adjustment, exceeds the Savings will also be realized because
1. Alternatives Considered section 5103 of the Public Law 109–171
Medicare OPPS payment amount for the
service for that year, without We are issuing this final rule with will impose a payment limit for 275
application of any geographic comment period to meet a statutory procedures on the CY 2007 ASC list.
adjustment. The OPPS cap on ASC requirement that we update the list of The Office of the Actuary estimates that
payment rates applies to surgical approved ASC procedures at least every adding 19 surgical procedures to the
procedures furnished in ASCs on or 2 years. We implement the biennial ASC list and capping payment for 275
after January 1, 2007, and before the update of the list through notice and procedures on the current ASC list will
effective date of the revised ASC comment in the Federal Register to give result in a combined savings to the
payment system. Except for the payment interested parties an opportunity to Medicare program of approximately $15
changes required under section 5103 of review and comment on proposed million in CY 2007. We have not
Public Law 109–171, we are not making additions to and deletions from the ASC estimated the impact of our changes for
any changes in CY 2007 to the ASC list. The last update of the ASC list CY 2007 on Medicare expenditures in
payment rates that are currently in through notice and comment was subsequent years because we have
effect. effective July 5, 2005. However, the proposed to implement an entirely
Sections 1834(d)(2) and (d)(3) of the statute requires us to update the list at revised payment system in CY 2008.
Act require that the computed least every 2 years, which means we Currently, Medicare pays a facility fee
beneficiary coinsurance amount for must update the list by July 2007. to ASCs only for those procedures that
screening flexible sigmoidoscopy and have been approved for the ASC list.
2. Limitations of Our Analysis The addition of 19 surgical procedures
screening colonoscopy services
provided in hospital outpatient Without datasets related to classes of to the ASC list will be beneficial to
departments and ASCs be equal to 25 ASCs which parallel the data ASCs by making it possible for them to
percent of the payment amount. They maintained in the Medicare provider- offer more surgical procedures to
also require Medicare to pay the lesser specific files for hospitals, we cannot Medicare beneficiaries. We believe that
of the ASC or OPPS rate for those model distributional impacts of the CY approximately 25 percent of the annual
screening services in each geographic 2007 changes in the ASC list and ASC hospital outpatient volume of the 19
area. For CY 2007, the OPPS rate will payments similar to those we prepare procedures added to the ASC list will
be limited to the lesser ASC rate for for our OPPS impact analysis (see Table move to the ASC setting in CY 2007. To
screening colonoscopies. Medicare 54). The actuarial estimate of Medicare the extent that hospital outpatient
payment for screening sigmoidoscopies program costs or savings resulting from utilization decreases and ASC
will not be affected in CY 2007 because the update of the ASC list and utilization increases in CY 2007, the
those services are not currently implementation of section 5103 of Medicare program will realize a savings
provided in ASCs. There will be no Public Law 109–171 and sections because the ASC standard overhead
effect on the fee paid to ASCs for 1834(d)(2) and (d)(3) of the Act in CY amount for all procedures, including the
screening colonoscopies. However, 2007 is based on estimated CY 2007 proposed additions to the ASC list, will
beginning in CY 2007, beneficiaries will utilization. As we have done in previous be equal to or lower than the payment
be responsible for a 25 percent rules, we solicited comments and rate for the same procedures under the
coinsurance for screening colonoscopies information about the anticipated effect OPPS. Because hospitals perform a
when provided in ASCs, as they have of these changes that we proposed for much higher volume of ambulatory
surgeries overall than are performed in Second, beneficiary access to services procedures added to the ASC list, and
ASCs, we do not expect significant will be expanded by the addition of 19 whether or not the ASC provides
hospital revenue losses to result from surgical procedures to the ASC list. services that will be affected by the
migration of procedures that we are Beneficiaries will have an additional payment limits imposed by section 5103
adding to the ASC list to the ASC setting from which to choose were it of Public Law 109–171. Overall, the
setting. necessary for them to undergo one of the Office of the Actuary estimates that the
surgical procedures that we are adding Medicare program will realize a $15
4. Estimated Effects of This Final Rule to the ASC list in CY 2007. million savings as a result of
With Comment Period on Beneficiaries Beneficiary coinsurance for screening implementing the changes for CY 2007.
colonoscopies performed in an ASC will
The changes for CY 2007 will be increase from 20 percent to 25 percent 6. Accounting Statement
positive for beneficiaries in at least two beginning in CY 2007, which is the
respects. First, with the exception of same coinsurance rate applicable to As required by OMB Circular A–4
screening colonoscopies, beneficiary screening colonoscopies under the (available at http://
coinsurance for ASC facility services is OPPS. This coinsurance rate is www.whitehouse.gov/omb/circulars/
set at 20 percent, which is generally legislated. However, we do not believe a004/a-4.pdf), in Table 56 below, we
lower than the OPPS coinsurance rate, that this coinsurance increase will have prepared an accounting statement
which can range from 20 percent to 40 materially affect access to screening showing the classification of the
percent. In addition, in accordance with colonoscopies performed in ASCs. expenditures associated with the CY
section 5103 of Public Law 109–171, no 2007 ASC provisions of this final rule
ASC payment rate in CY 2007 may be 5. Conclusion with comment period. This table
greater than the OPPS rate for a given The impact on ASCs of changes to the provides our best estimate of the
procedure. Thus, due to the limitations ASC payment system for CY 2007 will reduction in Medicare payments under
on the ASC facility rate required by depend on an individual ASC’s mix of the ASC payment system as a result of
Public Law 109–171, beneficiaries will patients and its payers, specifically, the the provisions presented in this final
be assured a lower ASC coinsurance proportion of its patients who are rule with comment period for CY 2007.
amount for more procedures in CY 2007 Medicare beneficiaries, whether or not All expenditures are classified as
than in previous years. the ASC chooses to perform the transfers.
TABLE 56.—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED CY 2007 ASC EXPENDITURES ASSOCIATED WITH
CY 2007 FINAL RULE PROVISIONS
Category Transfers
Annualized Monetized Transfers .............................................................. ¥$15 Million.

From Whom to Whom .............................................................................. Federal Government to ASC Medicare Providers.
Annualized Monetized Transfer ................................................................ ¥$4 Million.
From Whom to Whom .............................................................................. Premium Payments from Beneficiaries to Federal Government.
Total ................................................................................................... ¥$11 Million.
D. Effects of the Medicare Contracting it is administrative in nature and does hospital chooses to employ one)
Reform Mandate not change Medicare’s coverage and beginning in 2007 will participate in
In section XVIII. of this preamble, we reimbursement policies for hospital free HCAHPS training offered via
discuss our revision of the regulations outpatient services or any other covered Webinar in January 2007. All hospitals
under 42 CFR Part 421, Subpart B for Medicare services. that join in 2007 will be required to
Medicare intermediaries and carriers to participate in a month-long dry run in
E. Effects of Additional Quality
conform the regulations to the statutory March 2007. Hospitals that chose not to
Measures and Procedures for Hospital
changes mandated by section 1874A of participate in HCAHPS will not meet
Reporting of Quality Data for IPPS FY
the Act as added by section 911 of the HCAHPS requirements necessary to
2008
Public Law 108–173, which took effect receive the full market basket update for
on October 1, 2005. As discussed in We have tried to minimize the costs FY 2008.
section XVIII. of this preamble, section of HCAHPS, including minimizing the The costs of collecting HCAHPS
1874A of the Act is intended to improve impact on small/rural hospitals. While patient survey data will vary across
Medicare’s administrative services to there are no capital or operational/ hospitals depending on the method
beneficiaries and health care providers maintenance costs associated with the used to collect patient survey data, the
and to bring standard contracting implementation of HCAHPS, there are number of patients surveyed, and
principles to Medicare, such as costs for collecting the data. The whether HCAHPS is incorporated into
competition and performance nationwide costs of conducting the their existing patient satisfaction
incentives, which the government has HCAHPS survey are estimated to be surveys. While hospitals may choose to
long applied to other Federal programs between $3.6 million and $16.9 million administer HCAHPS as a stand-alone
under the FAR. This provision requires per year, assuming approximately 3,700 survey, there are significant cost savings
that CMS replace its current claims hospitals (see Abt Associates, Inc. associated with combining HCAHPS
payment contractors by October 1, 2011, report, http://www.cms.hhs.gov/ with existing surveys.
with new contract entities referred to as HospitalQualityInits/downloads/ We have cited a cost/benefit report
MACs. We believe that this provision HCAHPSCostsBenefits200512.pdf). showing that the costs of conducting
has no immediate economic effect on Hospitals that are self-administering HCAHPS would be as follows. HCAHPS
Medicare payments in CY 2007 because the survey (or their survey vendor, if the collected as a separate survey is
between $11.00 and $15.25 per survey will be credible, useful, and already submitted to CMS for other
complete survey ($3,300 to $4,575 per practical. First, the survey is designed to purposes, such as claims submitted for
hospital), assuming that 80–85 percent produce comparable data on the payment by the hospitals. As no new or
of hospitals collect HCAHPS by mail patient’s perspective of care that allow additional data will be required from
and the remainder by phone or active objective and meaningful comparisons hospitals to calculate the rates for these
IVR. It would be considerably less between hospitals on domains that are measures, we believe that there will be
expensive to combine HCAHPS with important to consumers. Second, public no measurable impact on the hospitals
existing surveys. In a combined survey, reporting of the survey results is as a result of the inclusion of these
it is estimated that it will cost only designed to create incentives for measures in the RHQDAPU set.
$3.26 per complete survey (or $978 per hospitals to improve their quality of
1. Alternatives Considered
hospital) to incorporate the 27-item care. Third, public reporting will serve
HCAHPS instrument into existing to enhance public accountability in The HCAHPS survey and the SCIP
surveys. Depending on the proportion of health care by increasing the and mortality measures are a subset of
hospitals that incorporate HCAHPS into transparency of the quality of hospital CMS’s larger Quality Initiative for both
existing surveys, it is therefore care provided in return for the public the Medicare and Medicaid programs.
estimated that the costs of HCAHPS is investment. For the public at-large, The Hospital Quality Initiative was
between $3.6 million and $16.9 million there is the potential benefit of established nationally in November
per year (Abt Associates, Inc. report, improved health through improvements 2002 for nursing homes, and was
http://www.cms.hhs.gov/ in hospital care. expanded in 2003 to the nation’s home
HospitalQualityInits/downloads/ The intent of HCAHPS is to provide health care agencies and hospitals. The
HCAHPSCostsBenefits200512.pdf). one standardized instrument and Hospital Quality Initiative supports
We have made provisions to reduce accompanying data collection significant improvement in the quality
the burden of the HCAHPS initiative for methodology that is in the public of hospital care that is integral to both
small/rural hospitals. As a cost savings domain for measuring patients’ the Medicare and Medicaid programs.
provisions for all hospitals (but one that perspectives of hospital care. While This initiative aims to improve
is particularly useful for small many hospitals currently collect hospitals’ quality of care by distributing
hospitals), a free on-line tool for data information on patients’ satisfaction objective and easy to understand data
entry is available to hospitals choosing with care, there is no one national on hospital performance. The public
to conduct data entry themselves in lieu standard for collecting or publicly availability of this information will
of contracting with a survey vendor for reporting this information that would encourage consumers and their
this service. The sample size enable valid comparisons to be made physicians to discuss and make better
requirements are reduced for small across all hospitals. In order to make informed decisions on how to get the
hospitals unable to achieve 300 ‘‘apples to apples’’ comparisons to best hospital care, create incentives for
completed surveys. For all hospitals, we support consumer choice, it is necessary hospitals to improve care, and support
are allowing four modes of survey to introduce a standard measurement public accountability. In all, improved
administration (mail, telephone, approach. HCAHPS can be viewed as a care equates to the improvement of
combination of mail and telephone, and core set of questions that can be health for Medicare and Medicaid
active interactive voice recognition), combined with a broader, customized beneficiaries.
and we are allowing for hospitals to set of hospital-specific items. HCAHPS HCAHPS, SCIP and Mortality
either use a vendor or conduct the is meant to complement the data measures parallel the trend in both the
survey on their own. Additionally, we hospitals currently collect to support federal and many state governments to
are allowing hospitals to integrate the improvements in internal customer make hospital performance information
HCAHPS survey with their own patient services and quality related activities. (generally clinical processes or
satisfaction surveys. This option • SCIP outcomes of care) publicly available.
provides significant cost savings to While there are no capital or The goals of HCAHPS are to: (1)
conduct HCAHPS annually: for the mail operational/maintenance costs Produce comparable data on the
mode, it is estimated to cost $603 per associated with the implementation of patient’s perspective of care to allow
hospital; and for the telephone mode, it SCIP, our pilot study concluded that objective and meaningful comparisons
is estimated to be $2,478 per hospital. there will be costs associated with the between hospitals on domains that are
For hospitals collecting 100 completed collection of the data. The data important to consumer decision-making;
surveys, it costs about $326 annually collection costs have been calculated as (2) to have these data publicly reported
per hospital. CMS is providing free follows: SCIP collection as additional to create incentives for hospitals to
HCAHPS training and materials and the measures has been calculated to be improve their quality of care; and (3) to
cost of reporting HCAHPS results to $75.00 and $100.00 per additional hour enhance public accountability by
CMS is minimal. of data abstraction (approximately providers by increasing the
The benefits of public reporting for $16,000 per hospital). Depending on the transparency of the quality of hospital
hospitals are great. There are multiple proportion of hospitals that already care provided in return for the public
reports of hospitals being motivated by collect these measures, it is estimated investment. HCAHPS, SCIP and
these data and using them for that the costs of collecting the Mortality measures fit into a larger
improvement. Not only is there more additional measures is approximately context of performance reporting
consistent evidence regarding hospital $58.7 million per year. For a detailed developed by the Strategic Framework
impact, but there are also several well- discussion of the data collection burden Board of the National Quality Forum.
designed studies that have found at least (burden hours) associated with these This is based on the assumption that
some impact on hospital clinical costs, please refer to the information consumers take value (both cost and
performance (Abt report). collection section of the preamble. quality) into account in any major
HCAHPS provides many benefits to • Mortality purchasing decision. Public reporting of
hospitals and also to society at-large. The 30-day mortality measures for both the clinical measures and HCAHPS
The HCAHPS initiative has taken AMI and HF are each individually is vital to the value-based healthcare
substantial steps to assure that the calculated solely on administrative data purchasing approach. Patient
perspectives of care encompasses an the HCAHPS initiative will require F. Executive Order 12866
important CMS priority, as indicated by some effort and expense on the part of In accordance with the provisions of
the Agency’s support for programs hospitals that volunteer to take part. Executive Order 12866, this final rule
related to the Institute of Medicine’s with comment period was reviewed by
b. Effects on Other Providers
(IOM) call for public reporting, the the OMB.
Hospital Quality Initiative (HQI) and the Physicians will benefit by learning
Hospital Quality Alliance (HQA), a what surveyed consumers/patients List of Subjects
public-private measurement and answered about their quality of care
during their hospital stays, as well as 42 CFR Part 410
reporting collaborative.
The HCAHPS survey has been become informed about surgical care Health facilities, Health professions,
endorsed by the National Quality improvement and mortality rates. Laboratories, Medicare, Rural areas, X-
Forum. Implementing this survey Studies indicate that providers are rays.
fulfills the requirements of sections potentially affected by public reporting.
42 CFR Part 416
1886 (b)(3)(B)(viii)(III) and (IV) of the They may be motivated to improve the
Act that require CMS to expand the quality of care they deliver with the Health facilities, Kidney diseases,
starter set of 10 quality measures used availability of performance information. Medicare, Reporting and recordkeeping
since FY 2005. In expanding these Primary care physicians are also users of requirements.
measures, we must begin to adopt the this information during the referral 42 CFR Part 419
baseline set of performance measures as process of patients to hospitals. Studies
indicate that the public reporting of Hospitals, Medicare, Reporting and
set forth in a 2005 report issued by the
hospital quality indicators may spur recordkeeping requirements.
Institute of Medicine (IOM) of the
National Academy of Sciences under internal hospital quality improvement 42 CFR Part 421
section 238(b) of Public Law 108–173, and lead to changes in physician
behavior within the hospital Administrative practice and
effective for payments beginning with procedure, Health facilities, Health
FY 2007. The IOM measures include the environment.
professions, Medicare, Reporting and
Hospital Quality Alliance (HQA) c. Effects on the Medicare and Medicaid recordkeeping requirements.
measures, the HCAHPS patient Programs
perspective survey, and three structural 42 CFR Part 485
Some potential benefits of publicly
measures. reporting quality information has been Grant program-health, Health
No alternatives were discussed for the described in the literature as pertaining facilities, Medicaid, Medicare,
SCIP and mortality measures. to consumers, providers and purchasers. Reporting and recordkeeping
2. Estimated Effects of This Final Rule Consumers (beneficiaries) could requirements.
With Comment Period incorporate the quality information into 42 CFR Part 488
their decision-making about hospital
a. Effects on Hospitals Administrative practice and
choices, and benefit from better care
Hospitals will benefit from the resulting from the additional measures procedure, Health facilities, Medicare,
information that the HCAHPS survey as well as the questions asked by Reporting and recordkeeping
and the SCIP and Mortality measures HCAHPS, such as questions about requirements.
data collection will provide. Hospitals communication with providers (fewer ■ For reasons stated in the preamble of
are an essential part of the National medical errors due to patient feedback this final rule with comment period, the
Quality Forum’s Strategic Framework about medication effect) and discharge Centers for Medicare & Medicaid
Board. We have made provisions that planning (fewer readmissions due to Services is amending 42 CFR Chapter IV
reduce the burden of the HCAHPS better patient awareness about what to as set forth below:
initiative, especially for small/rural expect when discharged) and the
hospitals. The public reporting of reporting of clinical measures. PART 410—SUPPLEMENTARY
HCAHPS results and additional quality Providers could potentially be MEDICAL INSURANCE (SMI)
measures may stimulate improvements motivated to improve the quality of care BENEFITS
in hospital quality of care in several they provide for results of more effective
■ 1. The authority citation for Part 410
ways. Hospitals can use the publicly and efficient hospital operation.
continues to read as follows:
reported data to benchmark their Providers could also use the information
performance with other institutions. internally to improve communication Authority: Secs. 1102 and 1871 of the
Consumers/patients would potentially and improve performance, use the Social Security Act (42 U.S.C. 1302 and
seek care in hospitals that are publicly 1395hh).
information to justify the need to
reported to perform well. increase staff ratios, use the measures in ■ 2. Section 410.152 is amended by
CMS does not plan to make major choices about practitioner practice revising paragraph (i) and removing
revisions to the HCAHPS survey itself or locales, use the information to improve footnote 1 to read as follows:
to its implementation procedures soon their ratings on patient perspectives and
after HCAHPS national implementation. potentially compete with one another in § 410.152 Amounts of payment.
With the core set of HCAHPS measures, the area of improving accreditation * * * * *
hospitals will have the beginnings of a results, and use the information to (i) Amount of payment: ASC facility
benchmark for trending of their hospital choose hospitals on the basis of quality services. (1) For ASC facility services
results over time. of care for their patients. furnished on or after July 1, 1987 and
To promote its wide and rapid Purchasers could potentially benefit before January 1, 2008, in connection
adoption, HCAHPS has been carefully from this information for supporting with the surgical procedures specified
designed to fit within the framework of shorter lengths of stay, availability of in part 416 of this chapter, Medicare
patient satisfaction surveying that benchmarks, and availability of Part B pays 80 percent of a standard
hospitals currently employ. Still, CMS information to support purchasing overhead amount as specified in
fully understands that participation in decisions. § 416.120(c) of this chapter, except that,
for screening flexible sigmoidoscopies shall be determined prior to application ■ 12. Section 416.125 is amended by
and screening colonoscopies, Part B of any geographic adjustment. adding a new paragraph (c) to read as
coinsurance is 25 percent of the * * * * * follows:
standard overhead amount and ■ 5. Section 416.2 is amended by
Medicare Part B pays 75 percent of the § 416.125 ASC facility services payment
revising the definitions of ‘‘Covered rate.
standard overhead amount. surgical procedures’’ and ‘‘Facility
(2) [Reserved] * * * * *
services’’ to read as follows: (c) For services furnished on or after
* * * * * January 1, 2007, and before the effective
§ 416.2 Definitions.
PART 416—AMBULATORY SURGICAL date of implementation of a revised
* * * * *
SERVICES Covered surgical procedures means payment system, the ASC payment rate
those surgical procedures that meet the for a surgical procedure is the lesser of
■ 3. The authority citation for Part 416 criteria specified in § 416.65 and are the ASC payment rate established under
continues to read as follows: published in the Federal Register. paragraph (a) of this section or the
Facility services means services that prospective payment rate for the
Authority: Secs. 1102 and 1871 of the
are furnished in connection with procedure established under § 419.32 of
Social Security Act (42 U.S.C. 1302 and
1395hh). covered surgical procedures performed this chapter. The lesser payment
in an ASC. amount is determined prior to
■ 4. Section 416.1 is amended by— application of any geographic
■ 6. The heading for Subpart D is
■ a. Revising paragraph (a)(2). adjustment.
revised to read as follows:
■ b. Revising paragraph (a)(3).
§ 416.150 [Removed]
■ c. Adding new paragraphs (a)(4) and Subpart D—Scope of Benefits for
(a)(5). Services Furnished Before January 1, ■ 13. Section 416.150 is removed.
The revisions and additions read as 2008
Subpart F [Redesignated]
follows:
■ 7. Section 416.65 is amended by— ■ 14. Subpart F is redesignated as
§ 416.1 Basis and scope. ■ a. Revising the introductory text. Subpart G.
(a) * * * ■ b. Revising paragraph (a)(4).
(2) Section 1833(i)(1)(A) of the Act The revisions read as follows: New Subpart F [Added and Reserved]
requires the Secretary to specify the § 416.65 Covered surgical procedures.
surgical procedures that can be ■ 15. A new Subpart F is added and
Effective for services furnished before reserved.
performed safely on an ambulatory basis January 1, 2008, covered surgical
in an ambulatory surgical center. ■ 16. Newly designated Subpart G is
procedures are those procedures that
(3) Sections 1833(i)(2)(A) and (D) and revised to read as follows:
meet the standards described in
1833(a)(1)(G) of the Act specify the paragraphs (a) and (b) of this section
amounts to be paid for facility services Subpart G—Adjustment in Payment
and are included in the list published in Amounts for New Technology
furnished in connection with the accordance with paragraph (c) of this
specified surgical procedures when they Intraocular Lenses Furnished by
section. Ambulatory Service Centers
are performed in an ASC. (a) * * *
(4) Section 1833(i)(2)(C) of the Act (4) Are not otherwise excluded under Sec.
provides that if the Secretary has not § 411.15 of this chapter. 416.180 Basis and scope.
updated amounts for ASC facility 416.185 Process for establishing a new class
* * * * *
services furnished during a fiscal year of new technology IOLs.
■ 8. A new § 416.76 is added to Subpart 416.190 Request for review of payment
through 2005 or a calendar year
D to read as follows: amount.
beginning with 2006, the amounts shall
416.195 Determination of membership in
be increased by the percentage increase § 416.76 Applicability. new classes of new technology IOLs.
in the Consumer Price Index for all The provisions of this subpart apply 416.200 Payment adjustment.
urban consumers as estimated by the to facility services furnished before
Secretary for the 12-month period January 1, 2008. § 416.180 Basis and scope.
ending with the midpoint of the year ■ 9. The heading for Subpart E is (a) Basis. This subpart implements
involved, except that, in fiscal year revised to read as follows: section 141 of Public Law 103–432,
2005, the last quarter of calendar year which provides for adjustments to
2005, and each of the calendar years Subpart E—Prospective Payment payment amounts for new technology
2006 through 2009, the increase shall be System for Facility Services Furnished intraocular lenses (IOLs) furnished at
zero percent. Before January 1, 2008 ambulatory surgical centers (ASCs).
(5) Section 1833(i)(2)(E) of the Act (b) Scope. This subpart sets forth—
provides that, with respect to surgical § 416.120 [Amended] (1) The process for interested parties
procedures furnished on or after January ■ 10. In paragraph (a) of § 416.120, the to request that CMS review the
1, 2007, and before the effective date of cross-reference ‘‘Part 413’’ is removed appropriateness of the ASC facility fee
the implementation of a revised and the cross-reference ‘‘Part 419’’ for insertion of an IOL. This process
payment system, the payment amount added in its place. includes a review of whether that
shall be the lesser of the ASC payment ■ 11. A new § 416.121 is added to read payment is reasonable and related to the
rate established under section as follows: cost of acquiring a lens determined by

1833(i)(2)(A) of the Act or the CMS as belonging to a class of new
prospective payment rate for hospital § 416.121 Applicability. technology IOLs;
outpatient department services The provisions of this subpart apply (2) Factors that CMS considers for
established under section 1833(t)(3)(D) to facility services furnished before determination of a new class of new
of the Act. The lesser payment amount January 1, 2008. technology IOLs; and
(3) Application of the payment Freedom of Information Act (5 U.S.C. final rulemaking in connection with
adjustment. 552(b)(4)) and, with respect to trade ASC facility services.
secrets, the Trade Secrets Act (18 U.S.C. (b) CMS adjusts the payment for
§ 416.185 Process for establishing a new 1905), the requestor must clearly insertion of an IOL approved as
class of new technology IOLs.
identify all information that is to be belonging to a class of new technology
(a) Announcement of deadline for characterized as confidential. IOLs for the 5-year period of time
requests for review. CMS announces the established for that class.
deadline for each year’s requests for § 416.195 Determination of membership in (c) Upon expiration of the 5-year
review of a new class of new technology new classes of new technology IOLs. period of the payment adjustment,
IOLs in the final rule updating the ASC (a) Factors to be considered. CMS uses payment reverts to the standard rate for
payment rates for that calendar year. the following criteria to determine IOL insertion procedures performed in
(b) Announcement of new classes of whether an IOL qualifies for a payment ASCs.
new technology IOLs for which review adjustment as a member of a new class (d) ASCs that furnish an IOL
requests have been made and of new technology IOLs when inserted designated by CMS as belonging to a
solicitation of public comments. CMS at an ASC: class of new technology IOLs must
announces the requests for review (1) The IOL is approved by the FDA. submit claims using billing codes
received in a calendar year and the (2) Claims of specific clinical benefits specified by CMS to receive the new
deadline for public comments regarding and/or lens characteristics with technology IOL payment adjustment.
the requests in the proposed rule established clinical relevance in
updating the ASC payment rates for the comparison to currently available IOLs PART 419—PROSPECTIVE PAYMENT
following calendar year. The deadline are approved by the FDA for use in SYSTEM FOR HOSPITAL OUTPATIENT
for submission of public comments is 30 labeling and advertising. DEPARTMENT SERVICES
days following the date of the (3) The IOL is not described by an
publication of the proposed rule. active or expired class of new ■ 17. The authority citation for Part 419
(c) Announcement of determinations technology IOLs; that is, it does not continues to read as follows:
regarding requests for review. CMS share a predominant, class-defining Authority: Secs. 1102, 1833(t), and 1871 of
announces its determinations for a characteristic associated with improved the Social Security Act (42 U.S.C. 1302,
calendar year in the final rule updating clinical outcomes with members of an 1395l(t), and 1395hh).
the ASC payment rates for the following active or expired class. ■ 18. Section 419.21 is amended by
calendar year. CMS publishes the codes (4) Evidence demonstrates that use of revising the introductory text of
and effective dates allowed for those the IOL results in measurable, clinically paragraph (d) to read as follows:
lenses recognized by CMS as belonging meaningful, improved outcomes in
to a class of new technology IOLs. New comparison with use of currently § 419.21 Hospital outpatient services
classes of new technology IOLs are available IOLs. Superior outcomes subject to the outpatient prospective
effective 30 days following the date of include: payment system.
publication of the final rule. (i) Reduced risk of intraoperative or * * * * *
postoperative complication or trauma; (d) The following medical and other
§ 416.190 Request for review of payment (ii) Accelerated postoperative health services furnished by a home
amount.
recovery; health agency (HHA) to patients who are
(a) When requests can be submitted. A (iii) Reduced induced astigmatism; not under an HHA plan or treatment or
request for review of the (iv) Improved postoperative visual by a hospice program furnishing
appropriateness of ASC payment for acuity; services to patients outside the hospice
insertion of an IOL that might qualify (v) More stable postoperative vision; benefit:
for a payment adjustment as belonging (vi) Other comparable clinical * * * * *
to a new class of new technology IOLs advantages. ■ 19. Section 419.43 is amended by—
must be submitted to CMS in (b) CMS determination of eligibility ■ a. Revising paragraph (f).
accordance with the annual published for payment adjustment. CMS reviews ■ b. Revising paragraph (g)(1)(i).
deadline. the information submitted with a ■ c. Adding a new paragraph (h).
(b) Who may submit a request. Any completed request for review, public The revision and addition read as
individual, partnership, corporation, comments submitted timely, and other follows:
association, society, scientific or pertinent information and makes a
academic establishment, or professional determination as follows: § 419.43 Adjustments to national program
or trade organization able to furnish the (1) The IOL is eligible for a payment payment and beneficiary copayment
information required in paragraph (c) of adjustment as a member of a new class amounts.
this section may request that CMS of new technology IOLs. * * * * *
review the appropriateness of the (2) The IOL is a member of an active (f) Excluded services and groups.
payment amount provided under class of new technology IOLs and is Drugs and biologicals that are paid
section 1833(i)(2)(A)(iii) of the Act with eligible for a payment adjustment for the under a separate APC are excluded from
respect to an IOL that meets the criteria remainder of the period established for qualification for outlier payments.
of a new technology IOL under that class. (g) * * *
§ 416.195. (3) The IOL does not meet the criteria (1) * * *
(c) Content of a request. In order to be for designation as a new technology IOL (i) Is a sole community hospital under
accepted by CMS for review, a request and a payment adjustment is not § 412.92 of this chapter or is an essential
for review of the ASC payment amount appropriate. access community hospital under
for insertion of an IOL must include all § 412.109 of this chapter; and
the information as specified by CMS. § 416.200 Payment adjustment. * * * * *
(d) Confidential information. In order (a) CMS establishes the amount of the (h) Applicable adjustments to
for CMS to invoke the protection payment adjustment for classes of new conversion factor for CY 2009 and for
allowed under Exemption 4 of the technology IOLs through proposed and subsequent calendar years—(1) General
rule. For CY 2009 and for subsequent § 419.70 Transitional adjustment to limit payments for Part A or Part B benefits
calendar years, the applicable decline in payments. payable on a cost basis (or under the
adjustment to the conversion factor * * * * * prospective payment system for
specified in § 419.32(b)(1)(iv) is reduced (d) Hold harmless provisions—(1) hospitals) and to perform other related
by 2.0 percentage points for any hospital Temporary treatment for small rural functions. For purposes of applying the
that fails to meet the standards for hospitals before January 1, 2006. For performance criteria in § 421.120 and
reporting of hospital outpatient quality covered hospital outpatient services the performance standards in § 421.122
measures as established by the Secretary furnished in a calendar year before and any adverse action resulting from
for the corresponding calendar year. January 1, 2006, for which the that application, the term
(2) Limitation. Any reduction to a prospective payment system amount is ‘‘intermediary’’ also means a Blue Cross
hospital’s adjustment to its conversion less than the pre-BBA amount, the plan that has entered into a subcontract
factor specified in § 419.32(b)(1)(iv) amount of payment under this part is approved by CMS with the Blue Cross
which occurs as a result of paragraph increased by the amount of that and Blue Shield Association to perform
(h)(1) of this section will apply only to difference if the hospital— intermediary functions.
the calendar year involved and will not (i) Is located in a rural area as defined ■ 25. Section 421.100 is amended by
be taken into account in computing that in § 412.63(b) of this chapter or is revising paragraph (i) to read as follows:
hospital’s applicable adjustment for a treated as being located in a rural area
subsequent calendar year. under section 1886(d)(8)(E) of the Act; § 421.100 Intermediary functions.
(3) Budget neutrality. For CY 2009 and * * * * *
and for each subsequent calendar year, (ii) Has 100 or fewer beds as defined (i) Dual intermediary responsibilities.
CMS makes an adjustment to the in § 412.105(b) of this chapter. Regarding the responsibility for service
conversion factor, so that estimated (2) Temporary treatment for small to provider-based HHAs and provider-
aggregate payments under the OPPS for rural hospitals on or after January 1, based hospices, where the HHA or the
such calendar year are not affected by 2006. For covered hospital outpatient hospice and its parent provider will be
any reductions to hospital adjustments services furnished in a calendar year served by different intermediaries, the
which occur as a result of paragraph from January 1, 2006, through December designated regional intermediary will
(h)(1) of this section, 31, 2008, for which the prospective process bills, make coverage
■ 20. A new § 419.45 is added to payment system amount is less than the determinations, and make payments to
Subpart D to read as follows: pre-BBA amount, the amount of the HHAs and the hospices. The
payment under this paragraph is intermediary serving the parent
§ 419.45 Payment and copayment increased by 95 percent of that provider will perform all fiscal
reduction for devices replaced without cost functions, including audits and
or full credit is received.
difference for services furnished during
2006, 90 percent of that difference for settlement of the Medicare cost reports
(a) General rule. CMS reduces the services furnished during 2007, and 85 and the HHA and hospice supplement
amount of payment for an implanted percent of that difference for services worksheets.
device made under the hospital furnished during 2008 if the hospital— ■ 26. Section 421.103 is revised to read
outpatient prospective payment system (i) Is located in a rural area as defined as follows:
in accordance with § 419.66 for which in § 412.63(b) of this chapter or is
CMS determines that a significant treated as being located in a rural area § 421.103 Payment to providers.
portion of the payment is attributable to under section 1886(d)(8)(E) of the Act; Providers are assigned to
the cost of an implanted device, when (ii) Has 100 or fewer beds as defined intermediaries in accordance with
one of the following situations occur: in § 412.105(b) of this chapter; § 421.104. As the Medicare
(1) The device is replaced without (iii) Is not a sole community hospital Administrative Contractors (MACs) are
cost to the provider or the beneficiary; as defined in § 412.92 of this chapter; implemented, providers are reassigned
or and from intermediaries to MACs in
(2) The provider receives full credit accordance with § 412.404 of this
(iv) Is not an essential access
for the cost of a replaced device. chapter.
(b) Amount of reduction to the APC community hospital under § 412.109 of
this chapter. ■ 27. Section 421.104 is revised to read
payment. The amount of the reduction
* * * * * as follows:
to the APC payment made under
paragraph (a) of this section is § 421.104 Assignment of providers of
calculated in the same manner as the PART 421—MEDICARE CONTRACTING
services to intermediaries during transition
offset amount that would be applied if ■ 22. The heading of Part 421 is revised to Medicare Administrative Contractors
the device implanted in a procedure (MACs).
to read as set out above.
assigned to the APC had transitional ■ 23. The authority citation for Part 421
(a) Beginning October 1, 2005, CMS
pass-through status under § 419.66. continues to read as follows: assigns providers of services and other
(c) Amount of beneficiary copayment. entities that may bill Part A benefits to
The beneficiary copayment is calculated Authority: Secs. 1102 and 1871 of the intermediaries in a manner that will
based on the APC payment after Social Security Act (42 U.S.C. 1302 and
best support the transition to Medicare
1395hh).
application of the reduction under Administrative Contractors (MACs)
paragraph (b) of this section. ■ 24. Section 421.3 is revised to read as under section 1874A of the Act in
■ 21. Section 419.70 is amended by— follows: accordance with Subpart E of this part.
■ a. Revising paragraph (d)(1). (b) These providers of services and
■ b. Redesignating paragraphs (d)(2) and § 421.3 Definitions. other entities must continue to bill the
(d)(3) as paragraphs (d)(3) and (d)(4), As used in this part— intermediary that they were billing prior
respectively. Intermediary means an entity that has to October 1, 2005, until one of the
■ c. Adding a new paragraph (d)(2). a contract with CMS (under statutory following events occurs:
The revisions and addition read as provisions in effect prior to October 1, (1) The intermediary’s agreement with
follows: 2005) to determine and make Medicare CMS ends, and the provider or entity is
directed by CMS to bill another CMS determines that the assignment or Common control exists when an
contractor. reassignment will be in the best individual, a group of individuals, or an
(2) The provider or entity is assigned interests of the Medicare program. organization has the power, directly or
to a MAC that has begun to administer indirectly, to significantly influence or
claims within the geographic locale of § 421.116 [Removed] direct the actions or policies of the
the provider or entity. ■ 32. Section 421.116 is removed. group of suppliers or eligible providers.
(3) CMS directs the provider or entity Common ownership exists when an
to begin billing another CMS contractor § 421.117 [Removed] individual, a group of individuals, or an
in order to support the implementation ■ 33. Section 421.117 is removed. organization possesses significant equity
of MACs under section 1874A of the Act in the group of suppliers or eligible
and Subpart E of this part. § 421.118 [Removed]
providers.
(c) New providers of services and new ■ 34. Section 421.118 is removed. Durable medical equipment,
entities will be assigned to the prosthetics, orthotics, and supplies
intermediary serving their geographic Subpart D [Added and Reserved] (DMEPOS) means the types of services
locale if no MAC has begun to specified in § 421.210(b).
administer Medicare claims in the ■ 35. Subpart D is added to Part 421 and
reserved. Eligible provider means a hospital,
locale. These providers or entities must skilled nursing facility, or critical access
■ 36. A new Subpart E is added to Part
continue to bill the intermediary until hospital that meets the definition of a
one of the events in paragraph (b) of this 421 to read as follows:
provider under § 400.202 of this
section occurs. Subpart E—Medicare Administrative chapter.
(d) Providers or entities will only be Home office means the entity that
Contractors (MACs)
granted exceptions to the provisions of provides centralized management and
paragraphs (b) or (c) of this section if Sec. administrative services to the individual
CMS deems the exception to be in the 421.400 Statutory basis and scope. providers or suppliers under common
compelling interest of the Medicare 421.401 Definitions. ownership and common control, such as
program. 421.404 Assignment of providers and
centralized accounting, purchasing,
(e) CMS will notify the provider or suppliers to MACs.
personnel services, management
entity, the outgoing intermediary, and § 421.400 Statutory basis and scope. direction and control, and other similar
the newly assigned intermediary of services.
assignment or reassignment decisions. (a) Statutory basis. This subpart
implements section 1874A of the Act, Ineligible provider means a provider
§ 421.105 [Removed] which provides for the transition of the under § 400.202 of this chapter that is
claims processing functions and not an eligible provider.
■ 28. Section 421.105 is removed. Medicare benefit category means a
operations for both Medicare Part A and
§ 421.106 [Removed] Part B intermediaries and carriers to category of covered benefits under Part
Medicare Administrative Contractors A or Part B of the Medicare program (for
■ 29. Section 421.106 is removed. example, inpatient hospital services,
■ 30. Section 421.112 is amended by— (MACs). The transition will occur
■ a. Revising paragraph (a). between October 1, 2005, and October 1, post-hospital extended care services,
■ b. Revising paragraph (b). 2011. MACs will be fully operational in and physicians’ services).
The revisions read as follows: distinct, nonoverlapping geographic Provider has the same meaning as
jurisdictions by October 1, 2011. specified under § 400.202 of this
§ 421.112 Considerations relating to the chapter.
effective and efficient administration of the
(b) Scope. This subpart specifies the
requirements under which providers Qualified chain provider means a
program. chain provider comprised of—
(a) In order to accomplish the most and suppliers will be assigned to MACs.
(1) 10 or more eligible providers
effective and efficient administration of § 421.401 Definitions. collectively totaling 500 or more
the Medicare program, the Secretary For purposes of this subpart— certified beds; or
may make determinations with respect Appropriate MAC means a MAC that (2) 5 or more eligible providers
to the termination of an intermediary has a contract under section 1874A of collectively totaling 300 or more
agreement, and CMS may make the Act to perform a particular Medicare certified beds, with eligible providers in
determinations with respect to renewal administrative function in relation to: 3 or more contiguous States.
of an intermediary agreement under (1) A particular individual entitled to Supplier has the same meaning as
§ 421.110. benefits under Part A or enrolled under specified in § 400.202 of this chapter.
(b) When taking the actions specified Part B, or both; (b) Assignment of providers to MACs.
in paragraph (a) of this section, the (2) A specific provider of services or (1) Providers enroll with and receive
Secretary or CMS will consider the supplier; or Medicare payment and other Medicare
performance of the individual (3) A class of providers of services or services from the MAC contracted by
intermediary in its Medicare operations suppliers. CMS to administer claims for the
using the factors contained in the Medicare Administrative Contractor Medicare benefit category applicable to
performance criteria specified in (MAC) means an agency, organization, the provider’s covered services for the
§ 421.120 and the performance or other person with a contract under geographic locale in which the provider
standards specified in § 421.122. section 1874A of the Act. is physically located.
* * * * * (2) Qualified chain providers may
■ 31. Section 421.114 is revised to read
§ 421.404 Assignment of providers and request and receive an exception from
suppliers to MACs. the requirement of paragraph (b)(1) of

as follows:
(a) Definitions. As used in this this section from CMS. Upon CMS’
§ 421.114 Assignment and reassignment section— approval, a qualified chain provider
of providers by CMS. Chain provider means a group of two may enroll with and bill on behalf of the
CMS may assign or reassign any or more providers under common eligible providers under its common
provider to any intermediary if it ownership or control. ownership or common control to the
MAC contracted by CMS to administer (3) CMS may allow a group of ESRD or radio contact, and available on site
claims for the Medicare benefit category suppliers under common ownership within the following timeframes:
applicable to the eligible providers’ and common control to enroll with the * * * * *
covered services for the geographic MAC contracted by CMS to administer (2) A registered nurse with training
locale in which the qualified chain ESRD claims for the geographic locale in and experience in emergency care can
provider’s home office is physically which the group’s home office is located be utilized to conduct specific medical
located. only if—
(3) As MAC contractors become screening examinations only if—
(i) The group of ESRD suppliers
available, qualified chain providers, requests such privileges; and (i) The registered nurse is on site and
granted approval by CMS to enroll with (ii) CMS finds the exception will immediately available at the CAH when
and bill a single intermediary on behalf support the implementation of MACs or a patient requests medical care; and
of their eligible member providers prior will serve some other compelling (ii) The nature of the patient’s request
to October 1, 2005, will be assigned at interest of the Medicare program. for medical care is within the scope of
an appropriate time to the MAC practice of a registered nurse and
contracted by CMS to administer claims PART 485—CONDITIONS OF consistent with applicable State laws
for the applicable Medicare benefit PARTICIPATION: SPECIALIZED and the CAH’s bylaws or rules and
category for the geographic locale in PROVIDERS regulations.
which the chain provider’s home office * * * * *
is physically located. The qualified ■ 37. The authority citation for Part 485
chain provider will not need to request continues to read as follows:
PART 488—SURVEY, CERTIFICATION,
an exception to the requirement of Authority: Secs. 1102 and 1871 of the AND ENFORCEMENT PROCEDURES
paragraph (b)(1) of this section in order Social Security Act (42 U.S.C. 1302 and
for this assignment to take effect. 1395hh). ■ 39. The authority citation for Part 488
(4) CMS may grant an exception to the ■ 38. Section 485.618 is amended by— continues to read as follows:
requirement of paragraph (b)(1) of this ■ a. Revising paragraph (d)(1) Authority: Secs. 1102 and 1871 of the
section to eligible providers that are not introductory text. Social Security Act (42 U.S.C. 1302 and
under the common ownership or ■ b. Redesignating paragraphs (d)(2) and 1395hh).
common control of a qualified chain (d)(3) as paragraphs (d)(3) and (d)(4),
provider, as well as ineligible providers, respectively. ■ 41. In § 488.1, the definition of
only if CMS finds the exception will ■ c. Adding a new paragraph (d)(2). ‘‘supplier’’ is revised to read as follows:
support the implementation of MACs or ■ d. In redesignated paragraph (d)(3)(iv),
will serve some other compelling removing the cross-reference ‘‘paragraph § 488.1 Definitions.
interest of the Medicare program. (d)(2)(iii)’’ and adding the cross- * * * * *
(c) Assignment of suppliers to MACs. reference ‘‘paragraph (d)(3)(iii)’’ in its Supplier means any of the following:
(1) Suppliers, including physicians and place. Independent laboratory; portable X-ray
other practitioners, but excluding ■ e. In redesignated paragraph (d)(4), services; physical therapist in
suppliers of DMEPOS, enroll with and removing the cross-reference ‘‘paragraph independent practice; ESRD facility;
receive Medicare payment and other (d)(2)(iii)’’ and adding the cross- rural health clinic; Federally qualified
Medicare services from the MAC reference ‘‘paragraph (d)(3)(iii)’’ in its health center; chiropractor; or
contracted by CMS to administer claims place. ambulatory surgical center.
for the Medicare benefit category The revisions and additions read as
applicable to the supplier’s covered * * * * *
follows: (Catalog of Federal Domestic Assistance
services for the geographic locale in
§ 485.618 Condition of participation: Program No. 93.773, Medicare—Hospital
which the supplier furnished such Insurance; and Program No. 93.774,
services. Emergency services.
Medicare—Supplementary Medical
(2) Suppliers of DMEPOS receive * * * * * Insurance Program)
Medicare payment and other Medicare (d) Standard: Personnel. (1) Except as
specified in paragraph (d)(3) of this Dated: October 27, 2006.
services from the MAC assigned to
administer claims for DMEPOS for the section, there must be a doctor of Leslie Norwalk,
regional area in which the beneficiary medicine or osteopathy, a physician Acting Administrator, Centers for Medicare
receiving the DMEPOS resides. The assistant, a nurse practitioner, or a & Medicaid Services.
terms of §§ 421.210 and 421.212 clinical nurse specialist, with training or Dated: October 31, 2006.
continue to apply to suppliers of experience in emergency care, on call Michael O. Leavitt,
DMEPOS. and immediately available by telephone Secretary.
ADDENDUM A.—OPPS LIST OF AMBULATORY PAYMENT CLASSIFICATIONS (APCS) WITH STATUS INDICATORS (SI),
RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007
National Minimum
Relative Payment
APC Group title SI Unadjusted Unadjusted
Weight Rate Copayment Copayment
0001 ......... Level I Photochemotherapy .......................................................... S 0.4914 30.21 7.00 6.04

0002 ......... Level I Fine Needle Biopsy/Aspiration ......................................... T 1.0995 67.58 .................... 13.52
0003 ......... Bone Marrow Biopsy/Aspiration ................................................... T 2.4011 147.59 .................... 29.52
0004 ......... Level I Needle Biopsy/Aspiration Except Bone Marrow ............... T 2.0687 127.16 .................... 25.43
0005 ......... Level II Needle Biopsy/Aspiration Except Bone Marrow .............. T 3.9045 240.00 71.59 48.00
0006 ......... Level I Incision & Drainage .......................................................... T 1.4392 88.46 .................... 17.69
0007 ......... Level II Incision & Drainage ......................................................... T 11.1535 685.58 .................... 137.12
0008 ......... Level III Incision and Drainage ..................................................... T 17.5086 1,076.22 .................... 215.24
0009 ......... Nail Procedures ............................................................................ T 0.7744 47.60 .................... 9.52
0010 ......... Level I Destruction of Lesion ........................................................ T 0.4760 29.26 8.02 5.85
0011 ......... Level II Destruction of Lesion ....................................................... T 2.5665 157.76 .................... 31.55
0012 ......... Level I Debridement & Destruction .............................................. T 0.8432 51.83 11.18 10.37
0013 ......... Level II Debridement & Destruction ............................................. T 1.0918 67.11 .................... 13.42
0015 ......... Level III Debridement & Destruction ............................................ T 1.6241 99.83 20.13 19.97
0016 ......... Level IV Debridement & Destruction ............................................ T 2.6749 164.42 .................... 32.88
0017 ......... Level VI Debridement & Destruction ............................................ T 17.4423 1,072.14 227.84 214.43
0018 ......... Biopsy of Skin/Puncture of Lesion ............................................... T 1.0259 63.06 15.44 12.61
0019 ......... Level I Excision/ Biopsy ................................................................ T 4.0919 251.52 71.87 50.30
0020 ......... Level II Excision/ Biopsy ............................................................... T 6.8083 418.49 107.67 83.70
0021 ......... Level III Excision/ Biopsy .............................................................. T 15.1024 928.31 219.48 185.66
0022 ......... Level IV Excision/ Biopsy ............................................................. T 20.0656 1,233.39 354.45 246.68
0023 ......... Exploration Penetrating Wound .................................................... T 4.2212 259.47 .................... 51.89
0024 ......... Level I Skin Repair ....................................................................... T 1.4843 91.24 29.88 18.25
0025 ......... Level II Skin Repair ...................................................................... T 5.2594 323.28 101.85 64.66
0027 ......... Level IV Skin Repair ..................................................................... T 21.4302 1,317.27 329.72 263.45
0028 ......... Level I Breast Surgery .................................................................. T 19.2788 1,185.03 303.74 237.01
0029 ......... Level II Breast Surgery ................................................................. T 28.0166 1,722.12 581.52 344.42
0030 ......... Level III Breast Surgery ................................................................ T 37.8692 2,327.74 747.07 465.55
0031 ......... Smoking Cessation Services ........................................................ X 0.1766 10.86 .................... 2.17
0033 ......... Partial Hospitalization ................................................................... P 3.8188 234.73 .................... 46.95
0035 ......... Arterial/Venous Puncture .............................................................. T 0.1999 12.29 .................... 2.46
0036 ......... Level II Fine Needle Biopsy/Aspiration ........................................ T 2.0738 127.47 .................... 25.49
0037 ......... Level IV Needle Biopsy/Aspiration Except Bone Marrow ............ T 10.2655 631.00 228.76 126.20
0038 ......... Spontaneous MEG ....................................................................... S 53.5161 3,289.53 .................... 657.91
0039 ......... Level I Implantation of Neurostimulator ........................................ S 187.3821 11,518.00 .................... 2,303.60
0040 ......... Percutaneous Implantation of Neurostimulator Electrodes, Ex- S 56.5705 3,477.28 .................... 695.46
cluding Cranial Nerve.
0041 ......... Level I Arthroscopy ....................................................................... T 28.6245 1,759.49 .................... 351.90
0042 ......... Level II Arthroscopy ...................................................................... T 45.5027 2,796.96 804.74 559.39
0043 ......... Closed Treatment Fracture Finger/Toe/Trunk .............................. T 1.6857 103.62 .................... 20.72
0045 ......... Bone/Joint Manipulation Under Anesthesia ................................. T 14.5947 897.11 268.47 179.42
0047 ......... Arthroplasty without Prosthesis .................................................... T 33.4505 2,056.14 537.03 411.23
0048 ......... Level I Arthroplasty with Prosthesis ............................................. T 47.4378 2,915.91 .................... 583.18
0049 ......... Level I Musculoskeletal Procedures Except Hand and Foot ....... T 20.8706 1,282.87 .................... 256.57
0050 ......... Level II Musculoskeletal Procedures Except Hand and Foot ...... T 25.1296 1,544.67 .................... 308.93
0051 ......... Level III Musculoskeletal Procedures Except Hand and Foot ..... T 41.0893 2,525.68 .................... 505.14
0052 ......... Level IV Musculoskeletal Procedures Except Hand and Foot ..... T 66.5800 4,092.54 .................... 818.51
0053 ......... Level I Hand Musculoskeletal Procedures ................................... T 16.1540 992.95 253.49 198.59
0054 ......... Level II Hand Musculoskeletal Procedures .................................. T 25.8758 1,590.53 .................... 318.11
0055 ......... Level I Foot Musculoskeletal Procedures .................................... T 20.4263 1,255.56 355.34 251.11
0056 ......... Level II Foot Musculoskeletal Procedures ................................... T 40.8559 2,511.33 .................... 502.27
0057 ......... Bunion Procedures ....................................................................... T 28.2349 1,735.54 475.91 347.11
0058 ......... Level I Strapping and Cast Application ........................................ S 1.0607 65.20 .................... 13.04
0060 ......... Manipulation Therapy ................................................................... S 0.4657 28.63 .................... 5.73
0061 ......... Laminectomy or Incision for Implantation of Neurostimulator S 84.1967 5,175.40 .................... 1,035.08
Electrodes, Excluding Cranial Nerve.
0062 ......... Level I Treatment Fracture/Dislocation ........................................ T 25.5264 1,569.06 372.87 313.81
0063 ......... Level II Treatment Fracture/Dislocation ....................................... T 37.5382 2,307.40 548.33 461.48
0064 ......... Level III Treatment Fracture/Dislocation ...................................... T 57.2172 3,517.03 835.79 703.41
0065 ......... Level I Stereotactic Radiosurgery ................................................ S 20.3224 1,249.18 .................... 249.84
0066 ......... Level II Stereotactic Radiosurgery ............................................... S 43.0297 2,644.95 .................... 528.99
0067 ......... Level III Stereotactic Radiosurgery .............................................. S 63.3759 3,895.59 .................... 779.12
0068 ......... CPAP Initiation .............................................................................. S 1.5353 94.37 29.48 18.87

0069 ......... Thoracoscopy ............................................................................... T 31.9442 1,963.55 591.64 392.71
0070 ......... Thoracentesis/Lavage Procedures ............................................... T 3.6244 222.78 .................... 44.56
0071 ......... Level I Endoscopy Upper Airway ................................................. T 0.7698 47.32 11.20 9.46
0072 ......... Level II Endoscopy Upper Airway ................................................ T 1.4054 86.39 21.27 17.28
0073 ......... Level III Endoscopy Upper Airway ............................................... T 3.8463 236.42 69.15 47.28
0074 ......... Level IV Endoscopy Upper Airway ............................................... T 14.7928 909.28 292.25 181.86
RELATIVE WEIGHTS, AND COPAYMENT AMOUNTS CALENDAR YEAR 2007—Continued
National Minimum
Relative Payment
0075 ......... Level V Endoscopy Upper Airway ................................................ T 21.9512 1,349.30 445.92 269.86
0076 ......... Level I Endoscopy Lower Airway ................................................. T 9.5228 585.35 189.82 117.07
0077 ......... Level I Pulmonary Treatment ....................................................... S 0.3527 21.68 7.74 4.34
0078 ......... Level II Pulmonary Treatment ...................................................... S 1.1206 68.88 14.55 13.78
0079 ......... Ventilation Initiation and Management ......................................... S 2.6116 160.53 .................... 32.11
0080 ......... Diagnostic Cardiac Catheterization .............................................. T 37.0615 2,278.10 838.92 455.62
0081 ......... Non-Coronary Angioplasty or Atherectomy .................................. T 42.9360 2,639.19 .................... 527.84
0082 ......... Coronary Atherectomy .................................................................. T 72.1982 4,437.88 954.62 887.58
0083 ......... Coronary Angioplasty and Percutaneous Valvuloplasty .............. T 58.7904 3,613.73 .................... 722.75
0084 ......... Level I Electrophysiologic Evaluation ........................................... S 9.8924 608.07 .................... 121.61
0085 ......... Level II Electrophysiologic Evaluation .......................................... T 34.2808 2,107.17 426.25 421.43
0086 ......... Ablate Heart Dysrhythm Focus .................................................... T 47.4931 2,919.31 812.36 583.86
0087 ......... Cardiac Electrophysiologic Recording/Mapping ........................... T 32.8988 2,022.22 .................... 404.44
0088 ......... Thrombectomy .............................................................................. T 37.7391 2,319.75 655.22 463.95
0089 ......... Insertion/Replacement of Permanent Pacemaker and Elec- T 123.6693 7,601.70 1,682.28 1,520.34
trodes.
0090 ......... Insertion/Replacement of Pacemaker Pulse Generator ............... T 98.3023 6,042.45 1,612.80 1,208.49
0091 ......... Level II Vascular Ligation ............................................................. T 34.7288 2,134.71 .................... 426.94
0092 ......... Level I Vascular Ligation .............................................................. T 24.8809 1,529.38 309.87 305.88
0093 ......... Vascular Reconstruction/Fistula Repair without Device ............... T 22.8653 1,405.48 .................... 281.10
0094 ......... Level I Resuscitation and Cardioversion ...................................... S 2.4233 148.96 46.29 29.79
0095 ......... Cardiac Rehabilitation ................................................................... S 0.5748 35.33 13.86 7.07
0096 ......... Non-Invasive Vascular Studies ..................................................... S 1.5303 94.06 37.62 18.81
0097 ......... Cardiac and Ambulatory Blood Pressure Monitoring ................... X 1.0225 62.85 23.79 12.57
0098 ......... Injection of Sclerosing Solution .................................................... T 1.0798 66.37 .................... 13.27
0099 ......... Electrocardiograms ....................................................................... S 0.3789 23.29 .................... 4.66
0100 ......... Cardiac Stress Tests .................................................................... X 2.5336 155.74 41.44 31.15
0101 ......... Tilt Table Evaluation ..................................................................... S 4.2769 262.89 100.24 52.58
0103 ......... Miscellaneous Vascular Procedures ............................................ T 16.2375 998.09 223.63 199.62
0104 ......... Transcatheter Placement of Intracoronary Stents ........................ T 87.7183 5,391.87 .................... 1,078.37
0105 ......... Repair/Revision/Removal of Pacemakers, AICDs, or Vascular T 25.6142 1,574.45 370.40 314.89
Devices.
0106 ......... Insertion/Replacement of Pacemaker Leads and/or Electrodes .. T 58.8594 3,617.97 .................... 723.59
0107 ......... Insertion of Cardioverter-Defibrillator ............................................ T 304.4894 18,716.35 .................... 3,743.27
0108 ......... Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads T 379.7339 23,341.48 .................... 4,668.30
0109 ......... Removal of Implanted Devices ..................................................... T 10.9918 675.64 .................... 135.13
0110 ......... Transfusion ................................................................................... S 3.4584 212.58 .................... 42.52
0111 ......... Blood Product Exchange .............................................................. S 11.7134 720.00 198.40 144.00
0112 ......... Apheresis, Photopheresis, and Plasmapheresis .......................... S 30.2231 1,857.75 433.29 371.55
0113 ......... Excision Lymphatic System .......................................................... T 21.2621 1,306.94 .................... 261.39
0114 ......... Thyroid/Lymphadenectomy Procedures ....................................... T 37.7224 2,318.72 467.95 463.74
0115 ......... Cannula/Access Device Procedures ............................................ T 29.2133 1,795.68 374.81 359.14
0121 ......... Level I Tube changes and Repositioning ..................................... T 2.3587 144.98 43.80 29.00
0122 ......... Level II Tube changes and Repositioning .................................... T 7.4800 459.78 .................... 91.96
0123 ......... Bone Marrow Harvesting and Bone Marrow/Stem Cell Trans- S 20.3582 1,251.38 .................... 250.28
plant.
0125 ......... Refilling of Infusion Pump ............................................................. T 2.2041 135.48 .................... 27.10
0126 ......... Level I Urinary and Anal Procedures ........................................... T 1.0887 66.92 16.45 13.38
0127 ......... Level IV Stereotactic Radiosurgery .............................................. S 138.4486 8,510.16 .................... 1,702.03
0130 ......... Level I Laparoscopy ..................................................................... T 32.1241 1,974.60 659.53 394.92
0131 ......... Level II Laparoscopy .................................................................... T 43.5488 2,676.86 1,001.89 535.37
0132 ......... Level III Laparoscopy ................................................................... T 70.5066 4,333.90 1,239.22 866.78
0140 ......... Esophageal Dilation without Endoscopy ...................................... T 5.4566 335.41 91.40 67.08
0141 ......... Level I Upper GI Procedures ........................................................ T 8.3175 511.26 143.38 102.25
0142 ......... Small Intestine Endoscopy ........................................................... T 9.4946 583.61 152.78 116.72
0143 ......... Lower GI Endoscopy .................................................................... T 8.7686 538.99 186.06 107.80
0146 ......... Level I Sigmoidoscopy and Anoscopy ......................................... T 4.8683 299.24 64.40 59.85
0147 ......... Level II Sigmoidoscopy and Anoscopy ........................................ T 8.5477 525.41 .................... 105.08
0148 ......... Level I Anal/Rectal Procedures .................................................... T 5.0770 312.07 .................... 62.41
0149 ......... Level III Anal/Rectal Procedures .................................................. T 22.2682 1,368.78 293.06 273.76
0150 ......... Level IV Anal/Rectal Procedures .................................................. T 29.6189 1,820.61 437.12 364.12
0151 ......... Endoscopic Retrograde Cholangio-Pancreatography (ERCP) ..... T 19.8381 1,219.41 245.46 243.88
0152 ......... Level I Percutaneous Abdominal and Biliary Procedures ............ T 20.2682 1,245.85 .................... 249.17
0153 ......... Peritoneal and Abdominal Procedures ......................................... T 22.0832 1,357.41 397.95 271.48
0154 ......... Hernia/Hydrocele Procedures ....................................................... T 29.2182 1,795.98 464.85 359.20
0155 ......... Level II Anal/Rectal Procedures ................................................... T 12.7389 783.03 .................... 156.61
0156 ......... Level III Urinary and Anal Procedures ......................................... T 3.4079 209.48 .................... 41.90
0157 ......... Colorectal Cancer Screening: Barium Enema ............................. S 2.1149 130.00 .................... 26.00
0158 ......... Colorectal Cancer Screening: Colonoscopy ................................. T 7.8492 446.00 .................... 111.50
National Minimum
Relative Payment
0159 ......... Colorectal Cancer Screening: Flexible Sigmoidoscopy ............... S 3.6592 224.92 .................... 56.23
0160 ......... Level I Cystourethroscopy and other Genitourinary Procedures T 6.4951 399.24 101.58 79.85
0161 ......... Level II Cystourethroscopy and other Genitourinary Procedures T 19.2251 1,181.73 249.36 236.35
0162 ......... Level III Cystourethroscopy and other Genitourinary Procedures T 23.8700 1,467.24 .................... 293.45
0163 ......... Level IV Cystourethroscopy and other Genitourinary Procedures T 34.9261 2,146.84 .................... 429.37
0164 ......... Level II Urinary and Anal Procedures .......................................... T 2.1393 131.50 .................... 26.30
0165 ......... Level IV Urinary and Anal Procedures ......................................... T 18.1679 1,116.74 .................... 223.35
0166 ......... Level I Urethral Procedures .......................................................... T 18.3960 1,130.77 .................... 226.15
0168 ......... Level II Urethral Procedures ......................................................... T 29.0253 1,784.13 388.16 356.83
0169 ......... Lithotripsy ...................................................................................... T 43.5398 2,676.30 1,009.47 535.26
0170 ......... Dialysis .......................................................................................... S 6.6089 406.24 .................... 81.25
0171 ......... Level V Anal/Rectal Procedures ................................................... T 37.8991 2,329.58 716.76 465.92
0180 ......... Circumcision ................................................................................. T 20.5513 1,263.25 304.87 252.65
0181 ......... Penile Procedures ........................................................................ T 32.9873 2,027.66 621.82 405.53
0183 ......... Testes/Epididymis Procedures ..................................................... T 23.5310 1,446.40 .................... 289.28
0184 ......... Prostate Biopsy ............................................................................. T 5.6262 345.83 96.27 69.17
0188 ......... Level II Female Reproductive Proc .............................................. T 1.2900 79.29 .................... 15.86
0189 ......... Level III Female Reproductive Proc ............................................. T 2.8966 178.05 .................... 35.61
0190 ......... Level I Hysteroscopy .................................................................... T 21.3586 1,312.87 424.28 262.57
0191 ......... Level I Female Reproductive Proc ............................................... T 0.1468 9.02 2.55 1.80
0192 ......... Level IV Female Reproductive Proc ............................................. T 6.6592 409.33 .................... 81.87
0193 ......... Level V Female Reproductive Proc .............................................. T 14.8489 912.73 .................... 182.55
0194 ......... Level VIII Female Reproductive Proc ........................................... T 20.5081 1,260.59 397.84 252.12
0195 ......... Level IX Female Reproductive Proc ............................................. T 28.5095 1,752.42 483.80 350.48
0196 ......... Dilation and Curettage .................................................................. T 17.7499 1,091.05 338.23 218.21
0197 ......... Infertility Procedures ..................................................................... T 4.0007 245.92 .................... 49.18
0198 ......... Pregnancy and Neonatal Care Procedures ................................. T 1.4222 87.42 32.19 17.48
0200 ......... Level VII Female Reproductive Proc ............................................ T 16.9328 1,040.83 243.36 208.17
0201 ......... Level VI Female Reproductive Proc ............................................. T 18.5201 1,138.39 329.65 227.68
0202 ......... Level X Female Reproductive Proc .............................................. T 42.9896 2,642.48 981.50 528.50
0203 ......... Level IV Nerve Injections .............................................................. T 12.1702 748.08 240.33 149.62
0204 ......... Level I Nerve Injections ................................................................ T 2.2614 139.00 40.13 27.80
0206 ......... Level II Nerve Injections ............................................................... T 5.7253 351.92 75.55 70.38
0207 ......... Level III Nerve Injections .............................................................. T 6.3603 390.95 86.92 78.19
0208 ......... Laminotomies and Laminectomies ............................................... T 44.1489 2,713.74 .................... 542.75
0209 ......... Level II MEG, Extended EEG Studies and Sleep Studies ........... S 11.2463 691.29 268.73 138.26
0212 ......... Nervous System Injections ........................................................... T 2.9907 183.83 65.96 36.77
0213 ......... Level I MEG, Extended EEG Studies and Sleep Studies ............ S 2.2755 139.87 53.58 27.97
0214 ......... Electroencephalogram .................................................................. S 1.1968 73.56 28.24 14.71
0215 ......... Level I Nerve and Muscle Tests ................................................... S 0.5741 35.29 .................... 7.06
0216 ......... Level III Nerve and Muscle Tests ................................................. S 2.7199 167.19 .................... 33.44
0218 ......... Level II Nerve and Muscle Tests .................................................. S 1.1872 72.97 .................... 14.59
0220 ......... Level I Nerve Procedures ............................................................. T 17.8499 1,097.20 .................... 219.44
0221 ......... Level II Nerve Procedures ............................................................ T 33.1520 2,037.79 463.62 407.56
0222 ......... Implantation of Neurological Device ............................................. T 181.6249 11,164.12 .................... 2,232.82
0223 ......... Implantation or Revision of Pain Management Catheter ............. T 30.8394 1,895.64 .................... 379.13
0224 ......... Implantation of Reservoir/Pump/Shunt ......................................... T 47.0342 2,891.10 .................... 578.22
0225 ......... Implantation of Neurostimulator Electrodes, Cranial Nerve ......... S 221.1512 13,593.72 .................... 2,718.74
0226 ......... Implantation of Drug Infusion Reservoir ....................................... T 112.6322 6,923.28 .................... 1,384.66
0227 ......... Implantation of Drug Infusion Device ........................................... T 174.4056 10,720.36 .................... 2,144.07
0228 ......... Creation of Lumbar Subarachnoid Shunt ..................................... T 39.2633 2,413.44 .................... 482.69
0229 ......... Transcatherter Placement of Intravascular Shunts ...................... T 68.4697 4,208.70 .................... 841.74
0230 ......... Level I Eye Tests & Treatments ................................................... S 0.7898 48.55 14.97 9.71
0231 ......... Level III Eye Tests & Treatments ................................................. S 2.1451 131.86 .................... 26.37
0232 ......... Level I Anterior Segment Eye Procedures ................................... T 6.0673 372.94 93.43 74.59
0233 ......... Level II Anterior Segment Eye Procedures .................................. T 15.2259 935.91 266.33 187.18
0234 ......... Level III Anterior Segment Eye Procedures ................................. T 22.9970 1,413.58 511.31 282.72
0235 ......... Level I Posterior Segment Eye Procedures ................................. T 3.9333 241.77 58.93 48.35
0236 ......... Level II Posterior Segment Eye Procedures ................................ T 16.5239 1,015.69 .................... 203.14
0237 ......... Level III Posterior Segment Eye Procedures ............................... T 27.6020 1,696.64 .................... 339.33
0238 ......... Level I Repair and Plastic Eye Procedures ................................. T 2.8954 177.97 .................... 35.59
0239 ......... Level II Repair and Plastic Eye Procedures ................................ T 7.2819 447.60 .................... 89.52
0240 ......... Level III Repair and Plastic Eye Procedures ............................... T 17.1243 1,052.60 309.52 210.52
0241 ......... Level IV Repair and Plastic Eye Procedures ............................... T 25.2550 1,552.37 384.47 310.47
0242 ......... Level V Repair and Plastic Eye Procedures ................................ T 35.2292 2,165.47 597.36 433.09
0243 ......... Strabismus/Muscle Procedures .................................................... T 21.2801 1,308.05 430.35 261.61
0244 ......... Corneal Transplant ....................................................................... T 38.2707 2,352.42 803.26 470.48
0245 ......... Level I Cataract Procedures without IOL Insert ........................... T 14.8702 914.04 217.05 182.81
0246 ......... Cataract Procedures with IOL Insert ............................................ T 23.6313 1,452.57 495.96 290.51
National Minimum
Relative Payment
0247 ......... Laser Eye Procedures Except Retinal ......................................... T 5.0839 312.50 104.31 62.50
0248 ......... Laser Retinal Procedures ............................................................. T 5.0841 312.51 95.08 62.50
0249 ......... Level II Cataract Procedures without IOL Insert .......................... T 29.2281 1,796.59 524.67 359.32
0250 ......... Nasal Cauterization/Packing ......................................................... T 1.1791 72.48 25.39 14.50
0251 ......... Level I ENT Procedures ............................................................... T 2.4520 150.72 .................... 30.14
0252 ......... Level II ENT Procedures .............................................................. T 7.5511 464.15 109.16 92.83
0253 ......... Level III ENT Procedures ............................................................. T 16.4266 1,009.71 282.29 201.94
0254 ......... Level IV ENT Procedures ............................................................. T 23.3299 1,434.04 321.35 286.81
0256 ......... Level V ENT Procedures .............................................................. T 38.1991 2,348.02 .................... 469.60
0257 ......... Level I Therapeutic Radiologic Procedures ................................. S 1.0974 67.45 .................... 13.49
0258 ......... Tonsil and Adenoid Procedures ................................................... T 22.1165 1,359.46 437.25 271.89
0259 ......... Level VI ENT Procedures ............................................................. T 414.8455 25,499.72 8,698.43 5,099.94
0260 ......... Level I Plain Film Except Teeth ................................................... X 0.7093 43.60 .................... 8.72
0261 ......... Level II Plain Film Except Teeth Including Bone Density Meas- X 1.2224 75.14 .................... 15.03
urement.
0262 ......... Plain Film of Teeth ....................................................................... X 0.6550 40.26 .................... 8.05
0263 ......... Level I Miscellaneous Radiology Procedures .............................. X 1.6956 104.23 23.77 20.85
0264 ......... Level II Miscellaneous Radiology Procedures ............................. X 2.9586 181.86 70.27 36.37
0265 ......... Level I Diagnostic and Screening Ultrasound .............................. S 0.9923 60.99 23.63 12.20
0266 ......... Level II Diagnostic and Screening Ultrasound ............................. S 1.5607 95.93 37.80 19.19
0267 ......... Level III Diagnostic and Screening Ultrasound ............................ S 2.4606 151.25 60.50 30.25
0268 ......... Level I Ultrasound Guidance Procedures .................................... S 1.1882 73.04 .................... 14.61
0269 ......... Level II Echocardiogram Except Transesophageal ...................... S 3.2154 197.64 75.60 39.53
0270 ......... Transesophageal Echocardiogram ............................................... S 6.2505 384.21 141.32 76.84
0272 ......... Fluoroscopy .................................................................................. X 1.2908 79.34 31.64 15.87
0274 ......... Myelography ................................................................................. S 2.5544 157.01 62.80 31.40
0275 ......... Arthrography ................................................................................. S 3.6915 226.91 69.09 45.38
0276 ......... Level I Digestive Radiology .......................................................... S 1.4294 87.86 34.97 17.57
0277 ......... Level II Digestive Radiology ......................................................... S 2.2176 136.31 54.52 27.26
0278 ......... Diagnostic Urography ................................................................... S 2.4159 148.50 59.40 29.70
0279 ......... Level II Angiography and Venography ......................................... S 9.5061 584.32 150.03 116.86
0280 ......... Level III Angiography and Venography ........................................ S 20.8225 1,279.92 353.85 255.98
0282 ......... Miscellaneous Computerized Axial Tomography ......................... S 1.5379 94.53 37.81 18.91
0283 ......... Computed Tomography with Contrast .......................................... S 4.0825 250.94 100.37 50.19
0284 ......... Magnetic Resonance Imaging and Magnetic Resonance S 6.1231 376.37 148.40 75.27
Angiography with Contrast.
0288 ......... Bone Density:Axial Skeleton ........................................................ S 1.1755 72.26 28.90 14.45
0293 ......... Level V Anterior Segment Eye Procedures ................................. T 51.9894 3,195.68 1,128.29 639.14
0296 ......... Level II Therapeutic Radiologic Procedures ................................ S 2.6802 164.75 53.99 32.95
0297 ......... Level III Therapeutic Radiologic Procedures ............................... S 3.6392 223.69 89.47 44.74
0298 ......... Level IV Therapeutic Radiologic Procedures ............................... S 8.3906 515.75 206.30 103.15
0299 ......... Miscellaneous Radiation Treatment ............................................. S 5.8839 361.67 .................... 72.33
0300 ......... Level I Radiation Therapy ............................................................ S 1.4826 91.13 .................... 18.23
0301 ......... Level II Radiation Therapy ........................................................... S 2.2295 137.04 .................... 27.41
0302 ......... Computer Assisted Navigational Procedures ............................... S 4.9138 302.04 105.94 60.41
0303 ......... Treatment Device Construction .................................................... X 2.9430 180.90 66.95 36.18
0304 ......... Level I Therapeutic Radiation Treatment Preparation ................. X 1.5735 96.72 38.68 19.34
0305 ......... Level II Therapeutic Radiation Treatment Preparation ................ X 3.9723 244.17 91.38 48.83
0307 ......... Myocardial Positron Emission Tomography (PET) imaging ......... S 11.8963 731.24 292.49 146.25
0308 ......... Non-Myocardial Positron Emission Tomography (PET) imaging S 13.9166 855.43 .................... 171.09
0309 ......... Level II Ultrasound Guidance Procedures ................................... S 2.1012 129.16 .................... 25.83
0310 ......... Level III Therapeutic Radiation Treatment Preparation ............... X 13.8081 848.76 325.27 169.75
0312 ......... Radioelement Applications ........................................................... S 4.8569 298.54 .................... 59.71
0313 ......... Brachytherapy ............................................................................... S 12.8473 789.70 .................... 157.94
0314 ......... Hyperthermic Therapies ............................................................... S 3.3461 205.68 60.88 41.14
0315 ......... Level II Implantation of Neurostimulator ....................................... T 242.9363 14,932.81 .................... 2,986.56
0320 ......... Electroconvulsive Therapy ............................................................ S 5.5676 342.23 80.06 68.45
0321 ......... Biofeedback and Other Training ................................................... S 1.3384 82.27 21.72 16.45
0322 ......... Brief Individual Psychotherapy ..................................................... S 1.1798 72.52 .................... 14.50
0323 ......... Extended Individual Psychotherapy ............................................. S 1.7066 104.90 .................... 20.98
0324 ......... Family Psychotherapy .................................................................. S 2.1633 132.97 .................... 26.59
0325 ......... Group Psychotherapy ................................................................... S 1.0765 66.17 14.47 13.23

0330 ......... Dental Procedures ........................................................................ S 7.0550 433.66 .................... 86.73
0332 ......... Computed Tomography without Contrast ..................................... S 3.0908 189.99 75.24 38.00
0333 ......... Computed Tomography without Contrast followed by Contrast) S 4.8405 297.54 119.01 59.51
0335 ......... Magnetic Resonance Imaging, Miscellaneous ............................. S 4.5523 279.82 111.92 55.96
Angiography without Contrast.
National Minimum
Relative Payment
Angiography without Contrast followed by Contrast.
0339 ......... Observation ................................................................................... S 7.2039 442.81 .................... 88.56
0340 ......... Minor Ancillary Procedures ........................................................... X 0.6102 37.51 .................... 7.50
0341 ......... Skin Tests ..................................................................................... X 0.0914 5.62 2.24 1.12
0342 ......... Level I Pathology .......................................................................... X 0.0824 5.06 2.02 1.01
0343 ......... Level III Pathology ........................................................................ X 0.5211 32.03 10.84 6.41
0344 ......... Level IV Pathology ........................................................................ X 0.7927 48.73 15.66 9.75
0345 ......... Level I Transfusion Laboratory Procedures ................................. X 0.2178 13.39 2.87 2.68
0346 ......... Level II Transfusion Laboratory Procedures ................................ X 0.3484 21.42 4.39 4.28
0347 ......... Level III Transfusion Laboratory Procedures ............................... X 0.7423 45.63 11.28 9.13
0348 ......... Fertility Laboratory Procedures .................................................... X 0.8321 51.15 .................... 10.23
0350 ......... Administration of flu and PPV vaccine ......................................... S 0.3945 24.25 .................... 0.00
0360 ......... Level I Alimentary Tests ............................................................... X 1.4154 87.00 33.88 17.40
0361 ......... Level II Alimentary Tests .............................................................. X 3.8887 239.03 83.23 47.81
0362 ......... Contact Lens and Spectacle Services ......................................... X 0.5865 36.05 .................... 7.21
0363 ......... Level I Otorhinolaryngologic Function Tests ................................ X 0.8525 52.40 17.44 10.48
0364 ......... Level I Audiometry ........................................................................ X 0.4627 28.44 7.06 5.69
0365 ......... Level II Audiometry ....................................................................... X 1.2419 76.34 18.52 15.27
0366 ......... Level III Audiometry ...................................................................... X 1.8511 113.78 26.14 22.76
0367 ......... Level I Pulmonary Test ................................................................. X 0.6277 38.58 14.68 7.72
0368 ......... Level II Pulmonary Tests .............................................................. X 0.9454 58.11 22.77 11.62
0369 ......... Level III Pulmonary Tests ............................................................. X 2.7669 170.08 44.18 34.02
0370 ......... Allergy Tests ................................................................................. X 1.0270 63.13 .................... 12.63
0372 ......... Therapeutic Phlebotomy ............................................................... X 0.5723 35.18 10.09 7.04
0373 ......... Level I Neuropsychological Testing .............................................. X 1.7682 108.69 .................... 21.74
0374 ......... Monitoring Psychiatric Drugs ........................................................ X 1.1418 70.18 .................... 14.04
0375 ......... Ancillary Outpatient Services When Patient Expires ................... S 58.0781 3,569.94 .................... 713.99
0376 ......... Level II Cardiac Imaging ............................................................... S 4.9832 306.31 119.77 61.26
0377 ......... Level III Cardiac Imaging .............................................................. S 6.5012 399.62 158.84 79.92
0378 ......... Level II Pulmonary Imaging .......................................................... S 5.0975 313.33 125.33 62.67
0379 ......... Injection adenosine 6 MG ............................................................. K .................... 30.49 .................... 6.10
0381 ......... Single Allergy Tests ...................................................................... X 0.2688 16.52 .................... 3.30
0382 ......... Level II Neuropsychological Testing ............................................. X 2.8460 174.94 69.97 34.99
0384 ......... GI Procedures with Stents ............................................................ T 22.9475 1,410.54 295.41 282.11
0385 ......... Level I Prosthetic Urological Procedures ..................................... S 79.2092 4,868.83 .................... 973.77
0386 ......... Level II Prosthetic Urological Procedures .................................... S 137.3897 8,445.07 .................... 1,689.01
0387 ......... Level II Hysteroscopy ................................................................... T 34.0155 2,090.86 655.55 418.17
0388 ......... Discography .................................................................................. S 15.9758 982.00 289.72 196.40
0389 ......... Level I Non-imaging Nuclear Medicine ........................................ S 1.3754 84.54 33.81 16.91
0390 ......... Level I Endocrine Imaging ............................................................ S 2.3432 144.03 57.61 28.81
0391 ......... Level II Endocrine Imaging ........................................................... S 2.7146 166.86 66.18 33.37
0392 ......... Level II Non-imaging Nuclear Medicine ....................................... S 2.0057 123.29 49.31 24.66
0393 ......... Red Cell/Plasma Studies .............................................................. S 3.7562 230.89 82.04 46.18
0394 ......... Hepatobiliary Imaging ................................................................... S 4.3774 269.07 102.61 53.81
0395 ......... GI Tract Imaging ........................................................................... S 3.6526 224.52 89.73 44.90
0396 ......... Bone Imaging ................................................................................ S 3.9174 240.79 95.02 48.16
0397 ......... Vascular Imaging .......................................................................... S 2.4204 148.78 49.58 29.76
0398 ......... Level I Cardiac Imaging ................................................................ S 4.1265 253.65 100.06 50.73
0399 ......... Nuclear Medicine Add-on Imaging ............................................... S 1.5054 92.53 35.80 18.51
0400 ......... Hematopoietic Imaging ................................................................. S 3.9073 240.17 93.22 48.03
0401 ......... Level I Pulmonary Imaging ........................................................... S 3.1802 195.48 78.19 39.10
0402 ......... Brain Imaging ................................................................................ S 4.6418 285.32 114.12 57.06
0403 ......... CSF Imaging ................................................................................. S 3.4923 214.66 83.35 42.93
0404 ......... Renal and Genitourinary Studies Level I ..................................... S 3.4209 210.28 84.11 42.06
0405 ......... Renal and Genitourinary Studies Level II .................................... S 4.0378 248.20 98.77 49.64
0406 ......... Level I Tumor/Infection Imaging ................................................... S 3.9934 245.47 98.18 49.09
0407 ......... Level I Radionuclide Therapy ....................................................... S 3.1779 195.34 78.13 39.07
0408 ......... Level II Tumor/Infection Imaging .................................................. S 5.9245 364.17 .................... 72.83
0409 ......... Red Blood Cell Tests .................................................................... X 0.1227 7.54 2.20 1.51
0411 ......... Respiratory Procedures ................................................................ S 0.3848 23.65 .................... 4.73
0412 ......... IMRT Treatment Delivery ............................................................. S 5.4731 336.42 .................... 67.28
0413 ......... Level II Radionuclide Therapy ...................................................... S 5.2957 325.52 .................... 65.10
0415 ......... Level II Endoscopy Lower Airway ................................................ T 22.0099 1,352.90 459.92 270.58
0416 ......... Level I Intravascular and Intracardiac Ultrasound and Flow Re- S 32.5472 2,000.61 .................... 400.12
serve.
0417 ......... Computerized Reconstruction ...................................................... S 3.2393 199.11 .................... 39.82
0418 ......... Insertion of Left Ventricular Pacing Elect. .................................... T 307.2828 18,888.06 .................... 3,777.61
0421 ......... Prolonged Physiologic Monitoring ................................................ X 1.6270 100.01 .................... 20.00
National Minimum
Relative Payment
0422 ......... Level II Upper GI Procedures ....................................................... T 25.7552 1,583.12 448.81 316.62
0423 ......... Level II Percutaneous Abdominal and Biliary Procedures ........... T 37.3604 2,296.47 .................... 459.29
0425 ......... Level II Arthroplasty with Prosthesis ............................................ T 107.1942 6,589.01 1,378.01 1,317.80
0426 ......... Level II Strapping and Cast Application ....................................... S 2.2777 140.01 .................... 28.00
0427 ......... Level III Tube Changes and Repositioning .................................. T 11.6575 716.56 .................... 143.31
0428 ......... Level III Sigmoidoscopy and Anoscopy ....................................... T 20.6375 1,268.55 .................... 253.71
0429 ......... Level V Cystourethroscopy and other Genitourinary Procedures T 43.1004 2,649.30 .................... 529.86
0432 ......... Health and Behavior Services ...................................................... S 0.6072 37.32 .................... 7.46
0433 ......... Level II Pathology ......................................................................... X 0.2557 15.72 5.93 3.14
0434 ......... Cardiac Defect Repair .................................................................. T 88.0728 5,413.66 .................... 1,082.73
0436 ......... Level I Drug Administration .......................................................... S 0.1809 11.12 .................... 2.22
0437 ......... Level II Drug Administration ......................................................... S 0.3945 24.25 .................... 4.85
0438 ......... Level III Drug Administration ........................................................ S 0.7942 48.82 .................... 9.76
0439 ......... Level IV Drug Administration ........................................................ S 1.5848 97.41 .................... 19.48
0440 ......... Level V Drug Administration ......................................................... S 1.8090 111.20 .................... 22.24
0441 ......... Level VI Drug Administration ........................................................ S 2.4851 152.75 .................... 30.55
0442 ......... Dosimetric Drug Administration .................................................... S 22.3666 1,374.83 .................... 274.97
0443 ......... Overnight Pulse Oximetry ............................................................. X 1.0409 63.98 25.59 12.80
0604 ......... Level 1 Hospital Clinic Visits ........................................................ V 0.8242 50.66 .................... 10.13
0609 ......... Level 1 Emergency Visits ............................................................. V 0.8136 50.01 12.70 10.00
0617 ......... Critical Care .................................................................................. S 6.5894 405.04 111.59 81.01
0618 ......... Trauma Response with Critical Care ........................................... S 8.0455 494.54 197.81 98.91
0621 ......... Level I Vascular Access Procedures ............................................ T 8.7846 539.97 .................... 107.99
0622 ......... Level II Vascular Access Procedures ........................................... T 22.6665 1,393.26 .................... 278.65
0623 ......... Level III Vascular Access Procedures .......................................... T 28.5032 1,752.03 .................... 350.41
0624 ......... Minor Vascular Access Device Procedures ................................. X 0.5145 31.63 12.65 6.33
0625 ......... Level IV Vascular Access Procedures ......................................... T 83.4609 5,130.17 .................... 1,026.03
0648 ......... Level IV Breast Surgery ............................................................... T 51.2269 3,148.82 .................... 629.76
0651 ......... Complex Interstitial Radiation Source Application ....................... S 16.8462 1,035.50 .................... 207.10
0652 ......... Insertion of Intraperitoneal and Pleural Catheters ....................... T 29.5416 1,815.86 .................... 363.17
0653 ......... Vascular Reconstruction/Fistula Repair with Device .................... T 32.3818 1,990.44 .................... 398.09
0654 ......... Insertion/Replacement of a permanent dual chamber pace- T 112.7719 6,931.86 .................... 1,386.37
maker.
0655 ......... Insertion/Replacement/Conversion of a permanent dual cham- T 152.6392 9,382.43 .................... 1,876.49
ber pacemaker.
0656 ......... Transcatheter Placement of Intracoronary Drug-Eluting Stents .. T 108.3003 6,657.00 .................... 1,331.40
0657 ......... Placement of Tissue Clips ............................................................ S 1.7369 106.76 .................... 21.35
0658 ......... Percutaneous Breast Biopsies ..................................................... T 6.4387 395.77 .................... 79.15
0659 ......... Hyperbaric Oxygen ....................................................................... S 1.5906 97.77 .................... 19.55
0660 ......... Level II Otorhinolaryngologic Function Tests ............................... X 1.4461 88.89 28.06 17.78
0661 ......... Level V Pathology ......................................................................... X 2.5255 155.24 62.09 31.05
0662 ......... CT Angiography ............................................................................ S 4.8552 298.44 118.88 59.69
0663 ......... Level I Electronic Analysis of Neurostimulator Pulse Generators S 1.1067 68.03 17.45 13.61
0664 ......... Level I Proton Beam Radiation Therapy ...................................... S 18.8926 1,161.29 .................... 232.26
0665 ......... Bone Density:AppendicularSkeleton ............................................ S 0.5497 33.79 13.51 6.76
0667 ......... Level II Proton Beam Radiation Therapy ..................................... S 22.6031 1,389.37 .................... 277.87
0668 ......... Level I Angiography and Venography .......................................... S 6.2463 383.95 88.26 76.79
0670 ......... Level II Intravascular and Intracardiac Ultrasound and Flow Re- S 32.2854 1,984.52 536.10 396.90
serve.
0672 ......... Level IV Posterior Segment Eye Procedures ............................... T 37.4290 2,300.69 .................... 460.14
0673 ......... Level IV Anterior Segment Eye Procedures ................................ T 37.8967 2,329.43 649.56 465.89
0674 ......... Prostate Cryoablation ................................................................... T 108.7566 6,685.05 .................... 1,337.01
0675 ......... Prostatic Thermotherapy .............................................................. T 41.1375 2,528.64 .................... 505.73
0676 ......... Thrombolysis and Thrombectomy ................................................ T 2.0726 127.40 .................... 25.48
0678 ......... External Counterpulsation ............................................................ T 1.7418 107.06 .................... 21.41

0679 ......... Level II Resuscitation and Cardioversion ..................................... S 5.5233 339.51 95.30 67.90
0680 ......... Insertion of Patient Activated Event Recorders ........................... S 72.6022 4,462.71 .................... 892.54
0681 ......... Knee Arthroplasty ......................................................................... T 205.6815 12,642.83 .................... 2,528.57
0682 ......... Level V Debridement & Destruction ............................................. T 6.8832 423.10 158.65 84.62
0683 ......... Level II Photochemotherapy ......................................................... S 2.6734 164.33 .................... 32.87
0685 ......... Level III Needle Biopsy/Aspiration Except Bone Marrow ............. T 6.1384 377.32 115.47 75.46
National Minimum
Relative Payment
0686 ......... Level III Skin Repair ..................................................................... T 14.0346 862.68 .................... 172.54
0687 ......... Revision/Removal of Neurostimulator Electrodes ........................ T 17.8334 1,096.18 438.47 219.24
0688 ......... Revision/Removal of Neurostimulator Pulse Generator Receiver T 35.5702 2,186.43 874.57 437.29
0689 ......... Electronic Analysis of Cardioverter-defibrillators .......................... S 0.6003 36.90 .................... 7.38
0690 ......... Electronic Analysis of Pacemakers and other Cardiac Devices .. S 0.3613 22.21 8.67 4.44
0691 ......... Electronic Analysis of Programmable Shunts/Pumps .................. S 2.8942 177.90 60.61 35.58
0692 ......... Level II Electronic Analysis of Neurostimulator Pulse Generators S 1.9323 118.77 30.16 23.75
0693 ......... Breast Reconstruction .................................................................. T 36.9988 2,274.24 721.30 454.85
0694 ......... Mohs Surgery ............................................................................... T 3.7292 229.23 91.69 45.85
0695 ......... Level VII Debridement & Destruction ........................................... T 20.4276 1,255.64 266.59 251.13
0697 ......... Level I Echocardiogram Except Transesophageal ....................... S 1.5973 98.18 35.99 19.64
0698 ......... Level II Eye Tests & Treatments .................................................. S 1.1607 71.35 .................... 14.27
0699 ......... Level IV Eye Tests & Treatments ................................................ T 14.3845 884.19 .................... 176.84
0700 ......... Antepartum Manipulation .............................................................. T 2.3864 146.69 .................... 29.34
0701 ......... Sr89 strontium .............................................................................. H .................... .................... .................... ....................
0702 ......... Sm 153 lexidronm ......................................................................... H .................... .................... .................... ....................
0704 ......... In111 satumomab ......................................................................... H .................... .................... .................... ....................
0705 ......... Tc99m tetrofosmin ........................................................................ H .................... .................... .................... ....................
0722 ......... Tc99m pentetate ........................................................................... H .................... .................... .................... ....................
0723 ......... Co57/58 ........................................................................................ H .................... .................... .................... ....................
0724 ......... Co57 cyano ................................................................................... H .................... .................... .................... ....................
0726 ......... Dexrazoxane HCl injection ........................................................... K .................... 180.13 .................... 36.03
0728 ......... Filgrastim 300 mcg injection ......................................................... K .................... 188.07 .................... 37.61
0730 ......... Pamidronate disodium /30 MG ..................................................... K .................... 34.80 .................... 6.96
0731 ......... Sargramostim injection ................................................................. K .................... 25.55 .................... 5.11
0732 ......... Mesna injection ............................................................................. K .................... 10.10 .................... 2.02
0735 ......... Ampho b cholesteryl sulfate ......................................................... K .................... 12.00 .................... 2.40
0736 ......... Amphotericin b liposome inj ......................................................... K .................... 21.25 .................... 4.25
0737 ......... Nitrogen N-13 ammonia ............................................................... H .................... .................... .................... ....................
0738 ......... Rasburicase .................................................................................. K .................... 121.26 .................... 24.25
0739 ......... Tc99m depreotide ......................................................................... H .................... .................... .................... ....................
0740 ......... Tc99m gluceptate ......................................................................... H .................... .................... .................... ....................
0741 ......... Cr51 chromate .............................................................................. H .................... .................... .................... ....................
0742 ......... Tc99m labeled rbc ........................................................................ H .................... .................... .................... ....................
0743 ......... Tc99m mertiatide .......................................................................... H .................... .................... .................... ....................
0744 ......... Plague vaccine, im ....................................................................... K .................... 150.00 .................... 30.00
0746 ......... Dacarbazine 100 mg inj ................................................................ K .................... 4.90 .................... 0.98
0747 ......... Chlorothiazide sodium inj ............................................................. K .................... 123.84 .................... 24.77
0748 ......... Bleomycin sulfate injection ........................................................... K .................... 37.62 .................... 7.52
0750 ......... Dolasetron mesylate ..................................................................... K .................... 6.89 .................... 1.38
0751 ......... Mechlorethamine hcl inj ................................................................ K .................... 141.61 .................... 28.32
0752 ......... Dactinomycin actinomycin d ......................................................... K .................... 493.43 .................... 98.69
0753 ......... Spectinomycn di-hcl inj ................................................................. K .................... 30.08 .................... 6.02
0759 ......... Naltrexone, depot form ................................................................. K .................... 1.94 .................... 0.39
0760 ......... Anadulafungin injection ................................................................. G .................... 1.91 .................... 0.38
0763 ......... Dolasetron mesylate oral .............................................................. K .................... 48.91 .................... 9.78
0764 ......... Granisetron HCl injection .............................................................. K .................... 7.21 .................... 1.44
0765 ......... Granisetron HCl 1 mg oral ........................................................... K .................... 41.18 .................... 8.24
0766 ......... Apomorphine hydrochloride .......................................................... K .................... 2.92 .................... 0.58
0767 ......... Enfuvirtide injection ....................................................................... K .................... 21.82 .................... 4.36
0768 ......... Ondansetron hcl injection ............................................................. K .................... 3.72 .................... 0.74
0769 ......... Ondansetron HCl 8mg oral ........................................................... K .................... 36.06 .................... 7.21
0800 ......... Leuprolide acetate /3.75 MG ........................................................ K .................... 437.58 .................... 87.52
0802 ......... Etoposide oral 50 MG ................................................................... K .................... 32.01 .................... 6.40
0804 ......... Immune globulin subcutaneous .................................................... K .................... 7.08 .................... 1.42
0805 ......... Mecasermin injection .................................................................... K .................... 11.93 .................... 2.39
0806 ......... Hyaluronidase recombinant .......................................................... G .................... 0.40 .................... 0.08
0807 ......... Aldesleukin/single use vial ............................................................ K .................... 726.69 .................... 145.34
0808 ......... Nabilone oral ................................................................................. K .................... 16.96 .................... 3.39
0809 ......... Bcg live intravesical vac ............................................................... K .................... 113.44 .................... 22.69
0810 ......... Goserelin acetate implant ............................................................. K .................... 199.12 .................... 39.82
0811 ......... Carboplatin injection ..................................................................... K .................... 10.12 .................... 2.02
0812 ......... Carmus bischl nitro inj .................................................................. K .................... 139.84 .................... 27.97
0814 ......... Asparaginase injection .................................................................. K .................... 54.46 .................... 10.89
0820 ......... Daunorubicin ................................................................................. K .................... 24.56 .................... 4.91
0821 ......... Daunorubicin citrate liposom ........................................................ K 56.21 .................... 11.24
0823 ......... Docetaxel ...................................................................................... K .................... 302.68 .................... 60.54
0825 ......... Nelarabine injection ...................................................................... K .................... 83.10 .................... 16.62
0827 ......... Floxuridine injection ...................................................................... K .................... 64.17 .................... 12.83
National Minimum
Relative Payment
0828 ......... Gemcitabine HCl ........................................................................... K .................... 121.30 .................... 24.26

0829 ......... Technetium TC-99m aerosol ........................................................ H .................... .................... .................... ....................
0830 ......... Irinotecan injection ........................................................................ K .................... 126.88 .................... 25.38
0831 ......... Ifosfomide injection ....................................................................... K .................... 52.39 .................... 10.48
0832 ......... Idarubicin hcl injection .................................................................. K .................... 308.97 .................... 61.79
0834 ......... Interferon alfa-2a inj ...................................................................... K .................... 37.56 .................... 7.51
0835 ......... Inj cosyntropin per 0.25 MG ......................................................... K .................... 62.91 .................... 12.58
0836 ......... Interferon alfa-2b inj ...................................................................... K .................... 13.75 .................... 2.75
0838 ......... Interferon gamma 1-b inj .............................................................. K .................... 289.87 .................... 57.97
0840 ......... Inj melphalan hydrochl 50 MG ..................................................... K .................... 1,194.15 .................... 238.83
0842 ......... Fludarabine phosphate inj ............................................................ K .................... 243.82 .................... 48.76
0843 ......... Pegaspargase/singl dose vial ....................................................... K .................... 1,687.04 .................... 337.41
0844 ......... Pentostatin injection ...................................................................... K .................... 2,034.63 .................... 406.93
0849 ......... Rituximab cancer treatment .......................................................... K .................... 481.69 .................... 96.34
0850 ......... Streptozocin injection .................................................................... K .................... 152.92 .................... 30.58
0851 ......... Thiotepa injection .......................................................................... K .................... 44.58 .................... 8.92
0852 ......... Topotecan ..................................................................................... K .................... 813.08 .................... 162.62
0855 ......... Vinorelbine tartrate/10 mg ............................................................ K .................... 22.82 .................... 4.56
0856 ......... Porfimer sodium ............................................................................ K .................... 2,505.40 .................... 501.08
0858 ......... Inj cladribine per 1 MG ................................................................. K .................... 37.87 .................... 7.57
0860 ......... Plicamycin (mithramycin) inj ......................................................... K .................... 61.36 .................... 12.27
0861 ......... Leuprolide acetate injeciton .......................................................... K .................... 11.10 .................... 2.22
0862 ......... Mitomycin 5 MG inj ....................................................................... K .................... 18.31 .................... 3.66
0863 ......... Paclitaxel injection ........................................................................ K .................... 14.35 .................... 2.87
0864 ......... Mitoxantrone hydrochl / 5 MG ...................................................... K .................... 223.27 .................... 44.65
0865 ......... Interferon alfa-n3 inj ...................................................................... K .................... 39.48 .................... 7.90
0868 ......... Oral aprepitant .............................................................................. G .................... 4.85 .................... 0.97
0876 ......... Caffeine citrate injection ............................................................... K .................... 3.54 .................... 0.71
0884 ......... Rho d immune globulin inj ............................................................ K .................... 80.52 .................... 16.10
0887 ......... Azathioprine parenteral ................................................................. K .................... 49.17 .................... 9.83
0888 ......... Cyclosporine oral 100 mg ............................................................. K .................... 3.66 .................... 0.73
0890 ......... Lymphocyte immune globulin ....................................................... K .................... 315.76 .................... 63.15
0891 ......... Tacrolimus oral per 1 MG ............................................................. K .................... 3.55 .................... 0.71
0892 ......... Edetate calcium disodium inj ........................................................ K .................... 40.19 .................... 8.04
0895 ......... Deferoxamine mesylate inj ........................................................... K .................... 14.84 .................... 2.97
0896 ......... Sodium Hyaluronate Injection ....................................................... K .................... 124.68 .................... 24.94
0900 ......... Alglucerase injection ..................................................................... K .................... 39.22 .................... 7.84
0901 ......... Alpha 1 proteinase inhibitor .......................................................... K .................... 3.31 .................... 0.66
0902 ......... Botulinum toxin a per unit ............................................................. K .................... 5.04 .................... 1.01
0903 ......... Cytomegalovirus imm IV /vial ....................................................... K .................... 853.18 .................... 170.64
0906 ......... RSV-ivig ........................................................................................ K .................... 16.18 .................... 3.24
0910 ......... Interferon beta-1b / .25 MG .......................................................... K .................... 90.00 .................... 18.00
0911 ......... Inj streptokinase /250000 IU ......................................................... K .................... 79.50 .................... 15.90
0912 ......... Interferon alfacon-1 ....................................................................... K .................... 4.65 .................... 0.93
0913 ......... Ganciclovir long act implant ......................................................... K .................... 4,766.14 .................... 953.23
0916 ......... Injection imiglucerase /unit ........................................................... K .................... 3.91 .................... 0.78
0917 ......... Adenosine injection ....................................................................... K .................... 30.49 .................... 6.10
0925 ......... Factor viii ...................................................................................... K .................... 0.69 .................... 0.14
0926 ......... Factor VIII (porcine) ...................................................................... K .................... 1.33 .................... 0.27
0927 ......... Factor viii recombinant ................................................................. K .................... 1.06 .................... 0.21
0928 ......... Factor ix complex ......................................................................... K .................... 0.72 .................... 0.14
0929 ......... Anti-inhibitor .................................................................................. K .................... 1.36 .................... 0.27
0930 ......... Antithrombin iii injection ................................................................ K .................... 1.62 .................... 0.32
0931 ......... Factor IX non-recombinant ........................................................... K .................... 0.90 .................... 0.18
0932 ......... Factor IX recombinant .................................................................. K .................... 0.99 .................... 0.20
0935 ......... Clonidine hydrochloride ................................................................ K .................... 66.04 .................... 13.21
0949 ......... Frozen plasma, pooled, sd ........................................................... K 0.9346 57.45 .................... 11.49
0950 ......... Whole blood for transfusion .......................................................... K 2.1472 131.98 .................... 26.40
0952 ......... Cryoprecipitate each unit .............................................................. K 0.7905 48.59 .................... 9.72
0954 ......... RBC leukocytes reduced .............................................................. K 2.8590 175.74 .................... 35.15
0955 ......... Plasma, frz between 8-24hour ..................................................... K 1.2489 76.77 .................... 15.35
0956 ......... Plasma protein fract,5%,50ml ....................................................... K 0.8339 51.26 .................... 10.25
0957 ......... Platelets, each unit ....................................................................... K 0.9590 58.95 .................... 11.79
0958 ......... Plaelet rich plasma unit ................................................................ K 3.4048 209.29 .................... 41.86
0959 ......... Red blood cells unit ...................................................................... K 2.1073 129.53 .................... 25.91
0960 ......... Washed red blood cells unit ......................................................... K 3.4331 211.03 .................... 42.21
0961 ......... Albumin (human), 5%, 50ml ......................................................... K .................... 29.68 .................... 5.94
0963 ......... Albumin (human), 5%, 250 ml ...................................................... K .................... 76.81 .................... 15.36
0964 ......... Albumin (human), 25%, 20 ml ...................................................... K .................... 28.80 .................... 5.76
National Minimum
Relative Payment
0965 ......... Albumin (human), 25%, 50ml ....................................................... K .................... 65.26 .................... 13.05
0966 ......... Plasmaprotein fract, 5%,250ml ..................................................... K 3.8746 238.16 .................... 47.63
0967 ......... Blood split unit .............................................................................. K 2.2323 137.22 .................... 27.44
0968 ......... Platelets leukoreduced irrad ......................................................... K 2.0390 125.33 .................... 25.07
0969 ......... RBC leukoreduced irradiated ....................................................... K 3.5394 217.56 .................... 43.51
1009 ......... Cryoprecipitatereducedplasma ..................................................... K 1.3404 82.39 .................... 16.48
1010 ......... Blood, l/r, cmv-neg ........................................................................ K 2.5493 156.70 .................... 31.34
1011 ......... Platelets, hla-m, l/r, unit ................................................................ K 10.9263 671.62 .................... 134.32
1013 ......... Platelets leukocytes reduced ........................................................ K 1.5469 95.08 .................... 19.02
1016 ......... Blood, l/r, froz/degly/wash ............................................................ K 3.4335 211.05 .................... 42.21
1017 ......... Plt, aph/pher, l/r, cmv-neg ............................................................ K 6.4556 396.81 .................... 79.36
1018 ......... Blood, l/r, irradiated ...................................................................... K 2.3472 144.28 .................... 28.86
1019 ......... Plate pheres leukoredu irrad ........................................................ K 10.0443 617.40 .................... 123.48
1020 ......... Plt, pher, l/r cmv-neg, irr ............................................................... K 11.4755 705.38 .................... 141.08
1021 ......... RBC, frz/deg/wsh, l/r, irrad ........................................................... K 8.0727 496.21 .................... 99.24
1022 ......... RBC, l/r, cmv-neg, irrad ................................................................ K 4.2653 262.18 .................... 52.44
1032 ......... Aud osseo dev, int/ext comp ........................................................ H .................... .................... .................... ....................
1045 ......... I131 iodobenguate, dx .................................................................. H .................... .................... .................... ....................
1052 ......... Injection, voriconazole .................................................................. K .................... 4.66 .................... 0.93
1064 ......... I131 iodide cap, rx ........................................................................ H .................... .................... .................... ....................
1083 ......... Adalimumab injection .................................................................... K .................... 308.33 .................... 61.67
1084 ......... Denileukin diftitox, 300 mcg ......................................................... K .................... 1,403.23 .................... 280.65
1086 ......... Temozolomide .............................................................................. K .................... 7.30 .................... 1.46
1088 ......... Iodine I-131 iodide cap, dx ........................................................... H .................... .................... .................... ....................
1096 ......... Tc99m exametazime .................................................................... H .................... .................... .................... ....................
1150 ......... I131 iodide sol, rx ......................................................................... H .................... .................... .................... ....................
1166 ......... Cytarabine liposome ..................................................................... K .................... 396.66 .................... 79.33
1167 ......... Inj, epirubicin hcl, 2 mg ................................................................ K .................... 24.67 .................... 4.93
1178 ......... Busulfan injection .......................................................................... K .................... 8.89 .................... 1.78
1203 ......... Verteporfin injection ...................................................................... K .................... 8.91 .................... 1.78
1207 ......... Octreotide injection, depot ............................................................ K .................... 93.35 .................... 18.67
1280 ......... Corticotropin injection ................................................................... K .................... 116.60 .................... 23.32
1330 ......... Ergonovine maleate injection ....................................................... K .................... 33.11 .................... 6.62
1436 ......... Etidronate disodium inj ................................................................. K .................... 71.41 .................... 14.28
1491 ......... New Technology—Level IA ($0–$10) ........................................... S .................... 5.00 .................... 1.00
1492 ......... New Technology—Level IB ($10–$20) ......................................... S .................... 15.00 .................... 3.00
1493 ......... New Technology—Level IC ($20–$30) ........................................ S .................... 25.00 .................... 5.00
1494 ......... New Technology—Level ID ($30–$40) ........................................ S .................... 35.00 .................... 7.00
1495 ......... New Technology—Level IE ($40–$50) ......................................... S .................... 45.00 .................... 9.00
1496 ......... New Technology—Level IA ($0–$10) ........................................... T .................... 5.00 .................... 1.00
1497 ......... New Technology—Level IB($10–$20) .......................................... T .................... 15.00 .................... 3.00
1498 ......... New Technology—Level IC ($20–$30) ........................................ T .................... 25.00 .................... 5.00
1499 ......... New Technology—Level ID($30–$40) .......................................... T .................... 35.00 .................... 7.00
1500 ......... New Technology—Level IE ($40–$50) ......................................... T .................... 45.00 .................... 9.00
1502 ......... New Technology—Level II ($50–$100) ........................................ S .................... 75.00 .................... 15.00
1503 ......... New Technology—Level III ($100–$200) ..................................... S .................... 150.00 .................... 30.00
1504 ......... New Technology—Level IV ($200–$300) ..................................... S .................... 250.00 .................... 50.00
1505 ......... New Technology—Level V ($300–$400) ...................................... S .................... 350.00 .................... 70.00
1506 ......... New Technology—Level VI ($400–$500) ..................................... S .................... 450.00 .................... 90.00
1507 ......... New Technology—Level VII ($500–$600) .................................... S .................... 550.00 .................... 110.00
1508 ......... New Technology—Level VIII ($600–$700) ................................... S .................... 650.00 .................... 130.00
1509 ......... New Technology—Level IX ($700–$800) ..................................... S .................... 750.00 .................... 150.00
1510 ......... New Technology—Level X ($800–$900) ...................................... S .................... 850.00 .................... 170.00
1511 ......... New Technology—Level XI ($900–$1000) ................................... S .................... 950.00 .................... 190.00
1512 ......... New Technology—Level XII ($1000–$1100) ................................ S .................... 1,050.00 .................... 210.00
1513 ......... New Technology—Level XIII ($1100–$1200) ............................... S .................... 1,150.00 .................... 230.00
1514 ......... New Technology—Level XIV ($1200–$1300) .............................. S .................... 1,250.00 .................... 250.00
1515 ......... New Technology—Level XV ($1300–$1400) ............................... S .................... 1,350.00 .................... 270.00
1516 ......... New Technology—Level XVI ($1400–$1500) .............................. S .................... 1,450.00 .................... 290.00
1517 ......... New Technology—Level XVII ($1500–$1600) ............................. S .................... 1,550.00 .................... 310.00
1518 ......... New Technology—Level XVIII ($1600–$1700) ............................ S .................... 1,650.00 .................... 330.00
1519 ......... New Technology—Level IXX ($1700–$1800) .............................. S .................... 1,750.00 .................... 350.00
1520 ......... New Technology—Level XX ($1800–$1900) ............................... S .................... 1,850.00 .................... 370.00
1521 ......... New Technology—Level XXI ($1900–$2000) .............................. S .................... 1,950.00 .................... 390.00
1522 ......... New Technology—Level XXII ($2000–$2500) ............................. S .................... 2,250.00 .................... 450.00
1523 ......... New Technology—Level XXIII ($2500–$3000) ............................ S .................... 2,750.00 .................... 550.00
1524 ......... New Technology—Level XXIV ($3000–$3500) ............................ S .................... 3,250.00 .................... 650.00
1525 ......... New Technology—Level XXV ($3500–$4000) ............................. S .................... 3,750.00 .................... 750.00
1526 ......... New Technology—Level XXVI ($4000–$4500) ............................ S .................... 4,250.00 .................... 850.00
National Minimum
Relative Payment
1527 ......... New Technology—Level XXVII ($4500–$5000) ........................... S .................... 4,750.00 .................... 950.00
1528 ......... New Technology—Level XXVIII ($5000–$5500) .......................... S .................... 5,250.00 .................... 1,050.00
1529 ......... New Technology—Level XXIX ($5500–$6000) ............................ S .................... 5,750.00 .................... 1,150.00
1530 ......... New Technology—Level XXX ($6000–$6500) ............................. S .................... 6,250.00 .................... 1,250.00
1531 ......... New Technology—Level XXXI ($6500–$7000) ............................ S .................... 6,750.00 .................... 1,350.00
1532 ......... New Technology—Level XXXII ($7000–$7500) ........................... S .................... 7,250.00 .................... 1,450.00
1533 ......... New Technology—Level XXXIII ($7500–$8000) .......................... S .................... 7,750.00 .................... 1,550.00
1534 ......... New Technology—Level XXXIV ($8000–$8500) ......................... S .................... 8,250.00 .................... 1,650.00
1535 ......... New Technology—Level XXXV ($8500–$9000) .......................... S .................... 8,750.00 .................... 1,750.00
1536 ......... New Technology—Level XXXVI ($9000–$9500) ......................... S .................... 9,250.00 .................... 1,850.00
1537 ......... New Technology—Level XXXVII ($9500–$10000) ...................... S .................... 9,750.00 .................... 1,950.00
1539 ......... New Technology—Level II ($50–$100) ........................................ T .................... 75.00 .................... 15.00
1540 ......... New Technology—Level III ($100–$200) ..................................... T .................... 150.00 .................... 30.00
1541 ......... New Technology—Level IV ($200–$300) ..................................... T .................... 250.00 .................... 50.00
1542 ......... New Technology—Level V ($300–$400) ...................................... T .................... 350.00 .................... 70.00
1543 ......... New Technology—Level VI ($400–$500) ..................................... T .................... 450.00 .................... 90.00
1544 ......... New Technology—Level VII ($500–$600) .................................... T .................... 550.00 .................... 110.00
1545 ......... New Technology—Level VIII ($600–$700) ................................... T .................... 650.00 .................... 130.00
1546 ......... New Technology—Level IX ($700–$800) ..................................... T .................... 750.00 .................... 150.00
1547 ......... New Technology—Level X ($800–$900) ...................................... T .................... 850.00 .................... 170.00
1548 ......... New Technology—Level XI ($900–$1000) ................................... T .................... 950.00 .................... 190.00
1549 ......... New Technology—Level XII ($1000–$1100) ................................ T .................... 1,050.00 .................... 210.00
1550 ......... New Technology—Level XIII ($1100–$1200) ............................... T .................... 1,150.00 .................... 230.00
1551 ......... New Technology—Level XIV ($1200–$1300) .............................. T .................... 1,250.00 .................... 250.00
1552 ......... New Technology—Level XV ($1300–$1400) ............................... T .................... 1,350.00 .................... 270.00
1553 ......... New Technology—Level XVI ($1400–$1500) .............................. T .................... 1,450.00 .................... 290.00
1554 ......... New Technology—Level XVII ($1500–$1600) ............................. T .................... 1,550.00 .................... 310.00
1555 ......... New Technology—Level XVIII ($1600–$1700) ............................ T .................... 1,650.00 .................... 330.00
1556 ......... New Technology—Level XIX ($1700–$1800) .............................. T .................... 1,750.00 .................... 350.00
1557 ......... New Technology—Level XX ($1800–$1900) ............................... T .................... 1,850.00 .................... 370.00
1558 ......... New Technology—Level XXI ($1900–$2000) .............................. T .................... 1,950.00 .................... 390.00
1559 ......... New Technology—Level XXII ($2000–$2500) ............................. T .................... 2,250.00 .................... 450.00
1560 ......... New Technology—Level XXIII ($2500–$3000) ............................ T .................... 2,750.00 .................... 550.00
1561 ......... New Technology—Level XXIV ($3000–$3500) ............................ T .................... 3,250.00 .................... 650.00
1562 ......... New Technology—Level XXV ($3500–$4000) ............................. T .................... 3,750.00 .................... 750.00
1563 ......... New Technology—Level XXVI ($4000–$4500) ............................ T .................... 4,250.00 .................... 850.00
1564 ......... New Technology—Level XXVII ($4500–$5000) ........................... T .................... 4,750.00 .................... 950.00
1565 ......... New Technology—Level XXVIII ($5000–$5500) .......................... T .................... 5,250.00 .................... 1,050.00
1566 ......... New Technology—Level XXIX ($5500–$6000) ............................ T .................... 5,750.00 .................... 1,150.00
1567 ......... New Technology—Level XXX ($6000–$6500) ............................. T .................... 6,250.00 .................... 1,250.00
1568 ......... New Technology—Level XXXI ($6500–$7000) ............................ T .................... 6,750.00 .................... 1,350.00
1569 ......... New Technology—Level XXXII ($7000–$7500) ........................... T .................... 7,250.00 .................... 1,450.00
1570 ......... New Technology—Level XXXIII ($7500–$8000) .......................... T .................... 7,750.00 .................... 1,550.00
1571 ......... New Technology—Level XXXIV ($8000–$8500) ......................... T .................... 8,250.00 .................... 1,650.00
1572 ......... New Technology—Level XXXV ($8500–$9000) .......................... T .................... 8,750.00 .................... 1,750.00
1573 ......... New Technology—Level XXXVI ($9000–$9500) ......................... T .................... 9,250.00 .................... 1,850.00
1574 ......... New Technology—Level XXXVII ($9500–$10000) ...................... T .................... 9,750.00 .................... 1,950.00
1600 ......... Tc99m sestamibi ........................................................................... H .................... .................... .................... ....................
1603 ......... TL201 thallium .............................................................................. H .................... .................... .................... ....................
1604 ......... In111 capromab ............................................................................ H .................... .................... .................... ....................
1605 ......... Abciximab injection ....................................................................... K .................... 416.27 .................... 83.25
1606 ......... Injection anistreplase 30 u ............................................................ K .................... 2,268.46 .................... 453.69
1607 ......... Eptifibatide injection ...................................................................... K .................... 15.37 .................... 3.07
1608 ......... Etanercept injection ...................................................................... K .................... 160.39 .................... 32.08
1609 ......... Rho(D) immune globulin h, sd ...................................................... K .................... 14.30 .................... 2.86
1612 ......... Daclizumab, parenteral ................................................................. K .................... 328.83 .................... 65.77
1613 ......... Trastuzumab ................................................................................. K .................... 56.17 .................... 11.23
1629 ......... Nonmetabolic act d/e tissue ......................................................... K .................... 18.49 .................... 3.70
1630 ......... Hep b ig, im .................................................................................. K .................... 119.06 .................... 23.81
1631 ......... Baclofen intrathecal trial ............................................................... K .................... 69.63 .................... 13.93
1632 ......... Metabolic active D/E tissue .......................................................... K .................... 27.89 .................... 5.58
1633 ......... Alefacept ....................................................................................... K .................... 26.31 .................... 5.26
1642 ......... In111 ibritumomab, dx .................................................................. H .................... .................... .................... ....................

1643 ......... Y90 ibritumomab, rx ..................................................................... H .................... .................... .................... ....................
1644 ......... I131 tositumomab, dx ................................................................... H .................... .................... .................... ....................
1645 ......... 1131 tositumomab, rx ................................................................... H .................... .................... .................... ....................
1646 ......... In111 oxyquinoline ........................................................................ H .................... .................... .................... ....................
1647 ......... In111 pentetate ............................................................................. H .................... .................... .................... ....................
1648 ......... Technetium tc99m arcitumomab .................................................. H .................... .................... .................... ....................
National Minimum
Relative Payment
1650 ......... Tc99m succimer ........................................................................... H .................... .................... .................... ....................

1651 ......... F18 fdg .......................................................................................... H .................... .................... .................... ....................
1654 ......... Rb82 rubidium .............................................................................. H .................... .................... .................... ....................
1655 ......... Tinzaparin sodium injection .......................................................... K .................... 2.48 .................... 0.50
1670 ......... Tetanus immune globulin inj ......................................................... K .................... 87.77 .................... 17.55
1671 ......... Ga67 gallium ................................................................................. H .................... .................... .................... ....................
1672 ......... Tc99m bicisate .............................................................................. H .................... .................... .................... ....................
1675 ......... P32 Na phosphate ........................................................................ H .................... .................... .................... ....................
1676 ......... P32 chromic phosphate ................................................................ H .................... .................... .................... ....................
1677 ......... In111 pentetreotide ....................................................................... H .................... .................... .................... ....................
1678 ......... Tc99m fanolesomab ..................................................................... H .................... .................... .................... ....................
1680 ......... Acetylcysteine injection ................................................................. K .................... 1.94 .................... 0.39
1682 ......... Aprotonin, 10,000 kiu .................................................................... K .................... 2.52 .................... 0.50
1683 ......... Basiliximab .................................................................................... K .................... 1,385.86 .................... 277.17
1684 ......... Corticorelin ovine triflutal .............................................................. K .................... 4.17 .................... 0.83
1685 ......... Darbepoetin alfa, non-esrd ........................................................... K .................... 2.99 .................... 0.60
1686 ......... Epoetin alfa, non-esrd .................................................................. K .................... 9.36 .................... 1.87
1687 ......... Digoxin immune fab (ovine) .......................................................... K .................... 533.72 .................... 106.74
1688 ......... Ethanolamine oleate 100 mg ........................................................ K .................... 69.60 .................... 13.92
1689 ......... Fomepizole, 15 mg ....................................................................... K .................... 12.33 .................... 2.47
1690 ......... Hemin, 1 mg ................................................................................. K .................... 6.80 .................... 1.36
1691 ......... Iron dextran 165 injection ............................................................. K .................... 11.78 .................... 2.36
1692 ......... Iron dextran 267 injection ............................................................. K .................... 10.38 .................... 2.08
1693 ......... Lepirudin ....................................................................................... K .................... 153.54 .................... 30.71
1694 ......... Ziconotide injection ....................................................................... G .................... 6.34 .................... 1.27
1695 ......... Nesiritide injection ......................................................................... K .................... 30.13 .................... 6.03
1696 ......... Palifermin injection ........................................................................ K .................... 11.43 .................... 2.29
1697 ......... Pegaptanib sodium injection ......................................................... G .................... 1,107.54 .................... 221.51
1700 ......... Inj secretin synthetic human ......................................................... K .................... 20.31 .................... 4.06
1701 ......... Treprostinil injection ...................................................................... K .................... 54.02 .................... 10.80
1703 ......... Ovine, 1000 USP units ................................................................. K .................... 137.43 .................... 27.49
1704 ......... Inj Vonwillebrand factor IU ........................................................... K .................... 0.88 .................... 0.18
1705 ......... Factor viia ..................................................................................... K .................... 1.10 .................... 0.22
1707 ......... Non-human, metabolic tissue ....................................................... K .................... 1.78 .................... 0.36
1709 ......... Azacitidine injection ...................................................................... K .................... 4.22 .................... 0.84
1710 ......... Clofarabine injection ..................................................................... G .................... 116.62 .................... 23.32
1711 ......... Histrelin implant ............................................................................ K .................... 1,741.71 .................... 348.34
1712 ......... Paclitaxel protein bound ............................................................... G .................... 8.73 .................... 1.75
1713 ......... Inj Fe-based MR contrast,1ml ...................................................... K .................... 30.41 .................... 6.08
1716 ......... Brachytx source, Gold 198 ........................................................... K 0.5991 36.83 .................... 7.37
1717 ......... Brachytx source, HDR Ir-192 ....................................................... K 2.3195 142.58 .................... 28.52
1718 ......... Brachytx source, Iodine 125 ......................................................... K 0.5910 36.33 .................... 7.27
1719 ......... Brachytx sour,Non-HDR Ir-192 ..................................................... K 0.3765 23.14 .................... 4.63
1720 ......... Brachytx sour, Palladium 103 ....................................................... K 0.7942 48.82 .................... 9.76
1738 ......... Oxaliplatin ..................................................................................... K .................... 8.77 .................... 1.75
1739 ......... Pegademase bovine, 25 iu ........................................................... K .................... 177.83 .................... 35.57
1740 ......... Diazoxide injection ........................................................................ K .................... 111.89 .................... 22.38
1741 ......... Urofollitropin, 75 iu ........................................................................ K .................... 49.35 .................... 9.87
1820 ......... Generator neuro rechg bat sys .................................................... H .................... .................... .................... ....................
1821 ......... Interspinous implant ...................................................................... H .................... .................... .................... ....................
2210 ......... Methyldopate hcl injection ............................................................ K .................... 10.01 .................... 2.00
2616 ......... Brachytx source, Yttrium-90 ......................................................... K 172.2337 10,586.86 .................... 2,117.37
2632 ......... Iodine I-125 sodium iodide ........................................................... K 0.3321 20.41 .................... 4.08
2633 ......... Brachytx source, Cesium-131 ...................................................... K 1.4779 90.84 .................... 18.17
2634 ......... Brachytx source, HA, I-125 .......................................................... K 0.5316 32.68 .................... 6.54
2635 ......... Brachytx source, HA, P-103 ......................................................... K 0.8878 54.57 .................... 10.91
2636 ......... Brachytx linear source,P-103 ....................................................... K 0.6427 39.51 .................... 7.90
2731 ......... Immune globulin, powder ............................................................. K .................... 25.27 .................... 5.05
2732 ......... Immune globulin, liquid ................................................................. K .................... 30.33 .................... 6.07
2770 ......... Quinupristin/dalfopristin ................................................................ K .................... 114.49 .................... 22.90
2940 ......... Somatrem injection ....................................................................... K .................... 35.60 .................... 7.12
3030 ......... Sumatriptan succinate / 6 MG ...................................................... K .................... 57.40 .................... 11.48
3032 ......... Dtp/hib vaccine, im ....................................................................... K .................... 45.01 .................... 9.00

3038 ......... Inj biperiden lactate/5 mg ............................................................. K .................... 88.15 .................... 17.63
3039 ......... Inj metaraminol bitartrate .............................................................. K .................... 2.62 .................... 0.52
3041 ......... Bivalirudin ..................................................................................... K .................... 1.75 .................... 0.35
3042 ......... Foscarnet sodium injection ........................................................... K .................... 10.49 .................... 2.10
3043 ......... Gamma globulin 1 CC inj ............................................................. K .................... 10.34 .................... 2.07
3045 ......... Meropenem ................................................................................... K .................... 3.68 .................... 0.74
National Minimum
Relative Payment
3048 ......... Doxorubic hcl 10 MG vl chemo .................................................... K .................... 6.00 .................... 1.20
3049 ......... Cyclophosphamide lyophilized ..................................................... K .................... 5.72 .................... 1.14
3050 ......... Sermorelin acetate injection ......................................................... K .................... 1.75 .................... 0.35
7000 ......... Amifostine ..................................................................................... K .................... 463.27 .................... 92.65
7005 ......... Gonadorelin hydroch/ 100 mcg .................................................... K .................... 189.84 .................... 37.97
7011 ......... Oprelvekin injection ...................................................................... K .................... 245.98 .................... 49.20
7015 ......... Oral busulfan ................................................................................ K .................... 2.14 .................... 0.43
7028 ......... Fosphenytoin, 50 mg .................................................................... K .................... 5.59 .................... 1.12
7034 ......... Somatropin injection ..................................................................... K .................... 46.80 .................... 9.36
7035 ......... Teniposide, 50 mg ........................................................................ K .................... 264.88 .................... 52.98
7036 ......... Urokinase 250,000 IU inj .............................................................. K .................... 457.73 .................... 91.55
7038 ......... Monoclonal antibodies .................................................................. K .................... 856.05 .................... 171.21
7041 ......... Tirofiban HCl ................................................................................. K .................... 8.74 .................... 1.75
7042 ......... Capecitabine, oral, 150 mg .......................................................... K .................... 3.83 .................... 0.77
7043 ......... Infliximab injection ........................................................................ K .................... 53.74 .................... 10.75
7045 ......... Inj trimetrexate glucoronate .......................................................... K .................... 145.17 .................... 29.03
7046 ......... Doxorubicin hcl liposome inj ......................................................... K .................... 379.21 .................... 75.84
7048 ......... Alteplase recombinant .................................................................. K .................... 32.07 .................... 6.41
7049 ......... Filgrastim 480 mcg injection ......................................................... K .................... 298.70 .................... 59.74
7051 ......... Leuprolide acetate implant ........................................................... K .................... 2,208.90 .................... 441.78
7308 ......... Aminolevulinic acid hcl top ........................................................... K .................... 107.72 .................... 21.54
9001 ......... Linezolid injection ......................................................................... K .................... 24.16 .................... 4.83
9002 ......... Tenecteplase injection .................................................................. K .................... 2,036.66 .................... 407.33
9003 ......... Palivizumab, per 50 mg ................................................................ K .................... 609.62 .................... 121.92
9004 ......... Gemtuzumab ozogamicin ............................................................. K .................... 2,317.16 .................... 463.43
9005 ......... Reteplase injection ....................................................................... K .................... 902.72 .................... 180.54
9006 ......... Tacrolimus injection ...................................................................... K .................... 140.72 .................... 28.14
9012 ......... Arsenic trioxide ............................................................................. K .................... 33.36 .................... 6.67
9015 ......... Mycophenolate mofetil oral ........................................................... K .................... 2.50 .................... 0.50
9018 ......... Botulinum toxin type B .................................................................. K .................... 8.16 .................... 1.63
9019 ......... Caspofungin acetate ..................................................................... K .................... 32.25 .................... 6.45
9020 ......... Sirolimus, oral ............................................................................... K .................... 7.25 .................... 1.45
9022 ......... IM inj interferon beta 1-a .............................................................. K .................... 108.04 .................... 21.61
9023 ......... Rho d immune globulin 50 mcg ................................................... K .................... 27.70 .................... 5.54
9024 ......... Amphotericin b lipid complex ........................................................ K .................... 11.11 .................... 2.22
9031 ......... Arbutamine HCl injection .............................................................. K .................... 160.00 .................... 32.00
9032 ......... Baclofen 10 MG injection ............................................................. K .................... 198.54 .................... 39.71
9033 ......... Cidofovir injection ......................................................................... K .................... 763.15 .................... 152.63
9038 ......... Inj estrogen conjugate 25 MG ...................................................... K .................... 58.05 .................... 11.61
9040 ......... Intraocular Fomivirsen na ............................................................. K .................... 212.00 .................... 42.40
9042 ......... Glucagon hydrochloride/1 MG ...................................................... K .................... 70.23 .................... 14.05
9044 ......... Ibutilide fumarate injection ............................................................ K .................... 265.75 .................... 53.15
9046 ......... Iron sucrose injection .................................................................... K .................... 0.36 .................... 0.07
9047 ......... Itraconazole injection .................................................................... K .................... 36.45 .................... 7.29
9051 ......... Urea injection ................................................................................ K .................... 37.81 .................... 7.56
9054 ......... Metabolically active tissue ............................................................ K .................... 13.87 .................... 2.77
9100 ......... I131 serum albumin, dx ................................................................ H .................... .................... .................... ....................
9104 ......... Antithymocyte globuln rabbit ........................................................ K .................... 329.62 .................... 65.92
9108 ......... Thyrotropin injection ..................................................................... K .................... 765.76 .................... 153.15
9110 ......... Alemtuzumab injection .................................................................. K .................... 531.24 .................... 106.25
9112 ......... Inj perflutren lip micros,ml ............................................................ K .................... 61.64 .................... 12.33
9115 ......... Zoledronic acid ............................................................................. K .................... 204.03 .................... 40.81
9119 ......... Injection, pegfilgrastim 6mg .......................................................... K .................... 2,163.61 .................... 432.72
9120 ......... Injection, Fulvestrant ..................................................................... K .................... 80.66 .................... 16.13
9121 ......... Injection, argatroban ..................................................................... K .................... 17.48 .................... 3.50
9122 ......... Triptorelin pamoate ....................................................................... K .................... 218.53 .................... 43.71
9124 ......... Daptomycin injection ..................................................................... K .................... 0.33 .................... 0.07
9125 ......... Risperidone, long acting ............................................................... K .................... 4.80 .................... 0.96
9126 ......... Natalizumab injection .................................................................... G .................... 7.72 .................... 1.54
9133 ......... Rabies ig, im/sc ............................................................................ K .................... 64.53 .................... 12.91
9134 ......... Rabies ig, heat treated ................................................................. K .................... 68.24 .................... 13.65
9135 ......... Varicella-zoster ig, im ................................................................... K .................... 140.92 .................... 28.18
9137 ......... Bcg vaccine, percut ...................................................................... K .................... 117.39 .................... 23.48
9139 ......... Rabies vaccine, im ....................................................................... K .................... 157.74 .................... 31.55
9140 ......... Rabies vaccine, id ........................................................................ K .................... 166.16 .................... 33.23
9141 ......... Measles-rubella vaccine, sc ......................................................... K .................... 60.82 .................... 12.16
9143 ......... Meningococcal vaccine, sc ........................................................... K .................... 84.46 .................... 16.89
9144 ......... Encephalitis vaccine, sc ............................................................... K .................... 96.22 .................... 19.24
9145 ......... Meningococcal vaccine, im ........................................................... K .................... 53.71 .................... 10.74
National Minimum
Relative Payment
9148 ......... I123 iodide cap, dx ....................................................................... H .................... .................... .................... ....................
9156 ......... Nonmetabolic active tissue ........................................................... K .................... 45.02 .................... 9.00
9157 ......... LOCM <=149 mg/ml iodine, 1ml .................................................. K .................... 0.29 .................... 0.06
9158 ......... LOCM 150–199mg/ml iodine,1ml ................................................. K .................... 1.96 .................... 0.39
9163 ......... LOCM >= 400 mg/ml iodine,1ml .................................................. K .................... 0.30 .................... 0.06
9164 ......... Inj Gad-base MR contrast,1ml ...................................................... K .................... 2.87 .................... 0.57
9165 ......... Oral MR contrast, 100 ml ............................................................. K .................... 8.90 .................... 1.78
9167 ......... Valrubicin, 200 mg ........................................................................ K .................... 369.60 .................... 73.92
9202 ......... Inj octafluoropropane mic,ml ........................................................ K .................... 49.61 .................... 9.92
9203 ......... Inj perflexane lip micros,ml ........................................................... K .................... 7.05 .................... 1.41
9207 ......... Bortezomib injection ..................................................................... K .................... 31.87 .................... 6.37
9208 ......... Agalsidase beta injection .............................................................. K .................... 127.20 .................... 25.44
9209 ......... Laronidase injection ...................................................................... K .................... 23.87 .................... 4.77
9210 ......... Palonosetron HCl .......................................................................... K .................... 18.08 .................... 3.62
9213 ......... Pemetrexed injection .................................................................... K .................... 42.49 .................... 8.50
9214 ......... Bevacizumab injection .................................................................. K .................... 56.88 .................... 11.38
9215 ......... Cetuximab injection ...................................................................... K .................... 49.86 .................... 9.97
9216 ......... Abarelix injection ........................................................................... K .................... 71.18 .................... 14.24
9217 ......... Leuprolide acetate suspnsion ....................................................... K .................... 227.63 .................... 45.53
9219 ......... Mycophenolic acid ........................................................................ K .................... 2.15 .................... 0.43
9222 ......... Injectable human tissue ................................................................ K .................... 743.96 .................... 148.79
9224 ......... Galsulfase injection ....................................................................... K .................... 1,516.12 .................... 303.22
9225 ......... Fluocinolone acetonide implt ........................................................ G .................... 18,250.00 .................... 3,650.00
9227 ......... Micafungin sodium injection ......................................................... G .................... 1.87 .................... 0.37
9228 ......... Tigecycline injection ...................................................................... G .................... 0.91 .................... 0.18
9229 ......... Ibandronate sodium injection ........................................................ G .................... 139.12 .................... 27.82
9230 ......... Abatacept injection ....................................................................... G .................... 18.70 .................... 3.74
9231 ......... Decitabine injection ....................................................................... G .................... 26.50 .................... 5.30
9232 ......... Injection, idursulfase ..................................................................... G .................... 464.32 .................... 92.86
9233 ......... Injection, ranibizumab ................................................................... G .................... 2,067.00 .................... 413.40
9234 ......... Inj, alglucosidase alfa ................................................................... K .................... 127.20 .................... 25.44
9235 ......... Injection, panitumumab ................................................................. K .................... 84.80 .................... 16.96
9300 ......... Omalizumab injection ................................................................... K .................... 16.61 .................... 3.32
9350 ......... Porous collagen tube per cm ....................................................... G .................... 494.53 .................... 98.91
9351 ......... Acellular derm tissue percm2 ....................................................... G .................... 44.01 .................... 8.80
9500 ......... Platelets, irradiated ....................................................................... K 2.1079 129.57 .................... 25.91
9501 ......... Platelet pheres leukoreduced ....................................................... K 7.9511 488.74 .................... 97.75
9502 ......... Platelet pheresis irradiated ........................................................... K 6.8088 418.52 .................... 83.70
9503 ......... Fr frz plasma donor retested ........................................................ K 1.2119 74.49 .................... 14.90
9504 ......... RBC deglycerolized ...................................................................... K 5.8292 358.31 .................... 71.66
9505 ......... RBC irradiated .............................................................................. K 3.2049 197.00 .................... 39.40
9506 ......... Granulocytes, pheresis unit .......................................................... K 12.2073 750.36 .................... 150.07
9507 ......... Platelets, pheresis ........................................................................ K 7.3686 452.93 .................... 90.59
9508 ......... Plasma 1 donor frz w/in 8 hr ........................................................ K 1.1422 70.21 .................... 14.04
ADDENDUM AA.—LIST OF MEDICARE APPROVED ASC PROCEDURES FOR CY 2007 WITH ADDITIONS AND PAYMENT
RATES, INCLUDING RATES THAT RESULT FROM IMPLEMENTATION OF SECTION 5103 OF THE DEFICIT REDUCTION ACT
OF 2005
A*=new to
list; 2007 OPPS ASC ASC
ASC
CPT payment payment copayment
HCPCS Short descriptor payment DRA cap
Changes: rate rate amount
group
A=Add ($) ($) ($)
D=Delete
10121 ....... Remove foreign body .................................... .................. 928.31 2 446.00 .................. 89.20
10180 ....... Complex drainage, wound ............................. .................. 1,076.22 2 446.00 .................. 89.20
11010 ....... Debride skin, fx .............................................. .................. 251.52 2 251.52 Y .............. 50.30
11011 ....... Debride skin/muscle, fx ................................. .................. 251.52 2 251.52 Y .............. 50.30
11012 ....... Debride skin/muscle/bone, fx ........................ .................. 251.52 2 251.52 Y .............. 50.30
11042 ....... Debride skin/tissue ........................................ .................. 164.42 2 164.42 Y .............. 32.88
11043 ....... Debride tissue/muscle ................................... .................. 164.42 2 164.42 Y .............. 32.88
11044 ....... Debride tissue/muscle/bone .......................... .................. 423.10 2 423.10 Y .............. 84.62
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
11404 ....... Exc tr-ext b9+marg 3.1–4 cm ........................ .................. 928.31 1 333.00 .................. 66.60
11406 ....... Exc tr-ext b9+marg > 4.0 cm ......................... .................. 928.31 2 446.00 .................. 89.20
11424 ....... Exc h-f-nk-sp b9+marg 3.1–4 ........................ .................. 928.31 2 446.00 .................. 89.20
11426 ....... Exc h-f-nk-sp b9+marg > 4 cm ...................... .................. 1,233.39 2 446.00 .................. 89.20
11444 ....... Exc face-mm b9+marg 3.1–4 cm .................. .................. 418.49 1 333.00 .................. 66.60
11446 ....... Exc face-mm b9+marg > 4 cm ...................... .................. 1,233.39 2 446.00 .................. 89.20
11450 ....... Removal, sweat gland lesion ......................... .................. 1,233.39 2 446.00 .................. 89.20
11604 ....... Exc tr-ext mlg+marg 3.1–4 cm ...................... .................. 418.49 2 418.49 Y .............. 83.70
11606 ....... Exc tr-ext mlg+marg > 4 cm .......................... .................. 928.31 2 446.00 .................. 89.20
11624 ....... Exc h-f-nk-sp mlg+marg 3.1–4 ...................... .................. 928.31 2 446.00 .................. 89.20
11626 ....... Exc h-f-nk-sp mlg+mar > 4 cm ...................... .................. 1,233.39 2 446.00 .................. 89.20
11644 ....... Exc face-mm malig+marg 3.1–4 ................... .................. 928.31 2 446.00 .................. 89.20
11646 ....... Exc face-mm mlg+marg > 4 cm .................... .................. 1,233.39 2 446.00 .................. 89.20
11770 ....... Removal of pilonidal lesion ............................ .................. 1,233.39 3 510.00 .................. 102.00
11960 ....... Insert tissue expander(s) ............................... .................. 1,317.27 2 446.00 .................. 89.20
11970 ....... Replace tissue expander ............................... .................. 2,525.68 3 510.00 .................. 102.00
11971 ....... Remove tissue expander(s) ........................... .................. 1,233.39 1 333.00 .................. 66.60
12005 ....... Repair superficial wound(s) ........................... .................. 91.24 2 91.24 Y .............. 18.25
12020 ....... Closure of split wound ................................... .................. 91.24 1 91.24 Y .............. 18.25
12021 ....... Closure of split wound ................................... .................. 91.24 1 91.24 Y .............. 18.25
12034 ....... Layer closure of wound(s) ............................. .................. 91.24 2 91.24 Y .............. 18.25
13100 ....... Repair of wound or lesion ............................. .................. 323.28 2 323.28 Y .............. 64.66
13102 ....... Repair wound/lesion add-on .......................... A* ............. 91.24 1 91.24 Y .............. 18.25
13160 ....... Late closure of wound ................................... .................. 1,317.27 2 446.00 .................. 89.20
14000 ....... Skin tissue rearrangement ............................. .................. 862.68 2 446.00 .................. 89.20
14001 ....... Skin tissue rearrangement ............................. .................. 1,317.27 3 510.00 .................. 102.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
15000 ....... Wound prep, 1st 100 sq cm .......................... D .............. .................... 2 446.00 .................. ....................
15001 ....... Wound prep, addl 100 sq cm ........................ D .............. .................... 1 333.00 .................. ....................
15002 ....... Wnd prep, ch/inf, trk/arm/lg ........................... A .............. 323.28 2 323.28 Y .............. 64.66
15003 ....... Wnd prep, ch/inf addl 100 cm ....................... A .............. 323.28 1 323.28 Y .............. 64.66
15004 ....... Wnd prep ch/inf, f/n/hf/g ................................ A .............. 323.28 2 323.28 Y .............. 64.66
15005 ....... Wnd prep, f/n/hf/g, addl cm ........................... A .............. 323.28 1 323.28 Y .............. 64.66
15040 ....... Harvest cultured skin graft ............................. .................. 91.24 2 91.24 Y .............. 18.25
15050 ....... Skin pinch graft .............................................. .................. 323.28 2 323.28 Y .............. 64.66
15100 ....... Skin splt grft, trnk/arm/leg .............................. .................. 1,317.27 2 446.00 .................. 89.20
15101 ....... Skin splt grft t/a/l, add-on .............................. .................. 1,317.27 3 510.00 .................. 102.00
15110 ....... Epidrm autogrft trnk/arm/leg .......................... .................. 1,317.27 2 446.00 .................. 89.20
15111 ....... Epidrm autogrft t/a/l add-on ........................... .................. 1,317.27 1 333.00 .................. 66.60
15115 ....... Epidrm a-grft face/nck/hf/g ............................ .................. 1,317.27 2 446.00 .................. 89.20
15116 ....... Epidrm a-grft f/n/hf/g addl .............................. .................. 1,317.27 1 333.00 .................. 66.60
15120 ....... Skn splt a-grft fac/nck/hf/g ............................. .................. 1,317.27 2 446.00 .................. 89.20
15121 ....... Skn splt a-grft f/n/hf/g add ............................. .................. 1,317.27 3 510.00 .................. 102.00
15130 ....... Derm autograft, trnk/arm/leg .......................... .................. 1,317.27 2 446.00 .................. 89.20
15131 ....... Derm autograft t/a/l add-on ........................... .................. 1,317.27 1 333.00 .................. 66.60
15135 ....... Derm autograft face/nck/hf/g ......................... .................. 1,317.27 2 446.00 .................. 89.20
15136 ....... Derm autograft, f/n/hf/g add .......................... .................. 1,317.27 1 333.00 .................. 66.60
15150 ....... Cult epiderm grft t/arm/leg ............................. .................. 1,317.27 2 446.00 .................. 89.20
15151 ....... Cult epiderm grft t/a/l addl ............................. .................. 1,317.27 1 333.00 .................. 66.60
15152 ....... Cult epiderm graft t/a/l +% ............................ .................. 1,317.27 1 333.00 .................. 66.60
15155 ....... Cult epiderm graft, f/n/hf/g ............................. .................. 1,317.27 2 446.00 .................. 89.20
15156 ....... Cult epidrm grft f/n/hfg add ............................ .................. 1,317.27 1 333.00 .................. 66.60
15157 ....... Cult epiderm grft f/n/hfg +% .......................... .................. 1,317.27 1 333.00 .................. 66.60
15200 ....... Skin full graft, trunk ........................................ .................. 862.68 3 510.00 .................. 102.00
15201 ....... Skin full graft trunk add-on ............................ .................. 323.28 2 323.28 Y .............. 64.66
15220 ....... Skin full graft sclp/arm/leg ............................. .................. 862.68 2 446.00 .................. 89.20
15221 ....... Skin full graft add-on ..................................... .................. 323.28 2 323.28 Y .............. 64.66
15240 ....... Skin full grft face/genit/hf ............................... .................. 862.68 3 510.00 .................. 102.00
15260 ....... Skin full graft een & lips ................................ .................. 862.68 2 446.00 .................. 89.20
15300 ....... Apply skinallogrft, t/arm/lg ............................. .................. 323.28 2 323.28 Y .............. 64.66
15301 ....... Apply sknallogrft t/a/l addl ............................. .................. 323.28 1 323.28 Y .............. 64.66
15320 ....... Apply skin allogrft f/n/hf/g .............................. .................. 323.28 2 323.28 Y .............. 64.66
15321 ....... Aply sknallogrft f/n/hfg add ............................ .................. 323.28 1 323.28 Y .............. 64.66
15330 ....... Aply acell alogrft t/arm/leg ............................. .................. 323.28 2 323.28 Y .............. 64.66
15331 ....... Aply acell grft t/a/l add-on .............................. .................. 323.28 1 323.28 Y .............. 64.66
15335 ....... Apply acell graft, f/n/hf/g ................................ .................. 323.28 2 323.28 Y .............. 64.66
15336 ....... Aply acell grft f/n/hf/g add .............................. .................. 323.28 1 323.28 Y .............. 64.66
15400 ....... Apply skin xenograft, t/a/l .............................. .................. 323.28 2 323.28 Y .............. 64.66
15401 ....... Apply skn xenogrft t/a/l add ........................... .................. 323.28 2 323.28 Y .............. 64.66
15420 ....... Apply skin xgraft, f/n/hf/g ............................... .................. 323.28 2 323.28 Y .............. 64.66
15421 ....... Apply skn xgrft f/n/hf/g add ............................ .................. 323.28 1 323.28 Y .............. 64.66
15430 ....... Apply acellular xenograft ............................... .................. 323.28 2 323.28 Y .............. 64.66
15431 ....... Apply acellular xgraft add .............................. .................. 323.28 1 323.28 Y .............. 64.66
15570 ....... Form skin pedicle flap ................................... .................. 1,317.27 3 510.00 .................. 102.00
15576 ....... Form skin pedicle flap ................................... .................. 862.68 3 510.00 .................. 102.00
15600 ....... Skin graft ........................................................ .................. 1,317.27 3 510.00 .................. 102.00
15610 ....... Skin graft ........................................................ .................. 1,317.27 3 510.00 .................. 102.00
15620 ....... Skin graft ........................................................ .................. 1,317.27 4 630.00 .................. 126.00
15630 ....... Skin graft ........................................................ .................. 1,317.27 3 510.00 .................. 102.00
15650 ....... Transfer skin pedicle flap .............................. .................. 1,317.27 5 717.00 .................. 143.40
15731 ....... Forehead flap w/vasc pedicle ........................ A .............. 862.68 3 510.00 .................. 102.00
15732 ....... Muscle-skin graft, head/neck ......................... .................. 1,317.27 3 510.00 .................. 102.00
15734 ....... Muscle-skin graft, trunk ................................. .................. 1,317.27 3 510.00 .................. 102.00
15736 ....... Muscle-skin graft, arm ................................... .................. 1,317.27 3 510.00 .................. 102.00
15738 ....... Muscle-skin graft, leg ..................................... .................. 1,317.27 3 510.00 .................. 102.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
15740 ....... Island pedicle flap graft ................................. .................. 862.68 2 446.00 .................. 89.20
15750 ....... Neurovascular pedicle graft ........................... .................. 1,317.27 2 446.00 .................. 89.20
15760 ....... Composite skin graft ...................................... .................. 1,317.27 2 446.00 .................. 89.20
15770 ....... Derma-fat-fascia graft .................................... .................. 1,317.27 3 510.00 .................. 102.00
15775 ....... Hair transplant punch grafts .......................... .................. 323.28 3 323.28 Y .............. 64.66
15776 ....... Hair transplant punch grafts .......................... .................. 323.28 3 323.28 Y .............. 64.66
15820 ....... Revision of lower eyelid ................................. .................. 1,317.27 3 510.00 .................. 102.00
15821 ....... Revision of lower eyelid ................................. .................. 1,317.27 3 510.00 .................. 102.00
15822 ....... Revision of upper eyelid ................................ .................. 1,317.27 3 510.00 .................. 102.00
15823 ....... Revision of upper eyelid ................................ .................. 862.68 5 717.00 .................. 143.40
15824 ....... Removal of forehead wrinkles ....................... .................. 1,317.27 3 510.00 .................. 102.00
15825 ....... Removal of neck wrinkles .............................. .................. 1,317.27 3 510.00 .................. 102.00
15826 ....... Removal of brow wrinkles ............................. .................. 1,317.27 3 510.00 .................. 102.00
15828 ....... Removal of face wrinkles .............................. .................. 1,317.27 3 510.00 .................. 102.00
15829 ....... Removal of skin wrinkles ............................... .................. 1,317.27 5 717.00 .................. 143.40
15830 ....... Exc skin abd .................................................. A .............. 1,233.39 3 510.00 .................. 102.00
15831 ....... Excise excessive skin tissue ......................... D .............. .................... 3 510.00 .................. ....................
15832 ....... Excise excessive skin tissue ......................... .................. 1,233.39 3 510.00 .................. 102.00
15835 ....... Excise excessive skin tissue ......................... .................. 323.28 3 323.28 Y .............. 64.66
15836 ....... Excise excessive skin tissue ......................... .................. 928.31 3 510.00 .................. 102.00
15839 ....... Excise excessive skin tissue ......................... .................. 928.31 3 510.00 .................. 102.00
15840 ....... Graft for face nerve palsy .............................. .................. 1,317.27 4 630.00 .................. 126.00
15841 ....... Graft for face nerve palsy .............................. .................. 1,317.27 4 630.00 .................. 126.00
15845 ....... Skin and muscle repair, face ......................... .................. 1,317.27 4 630.00 .................. 126.00
15847 ....... Exc skin abd add-on ...................................... A .............. 1,233.39 3 510.00 .................. 102.00
15876 ....... Suction assisted lipectomy ............................ .................. 1,317.27 3 510.00 .................. 102.00
15878 ....... Suction assisted lipectomy ............................ .................. 862.68 3 510.00 .................. 102.00
15920 ....... Removal of tail bone ulcer ............................. .................. 251.52 3 251.52 Y .............. 50.30
15922 ....... Removal of tail bone ulcer ............................. .................. 1,317.27 4 630.00 .................. 126.00
15931 ....... Remove sacrum pressure sore ..................... .................. 1,233.39 3 510.00 .................. 102.00
15940 ....... Remove hip pressure sore ............................ .................. 1,233.39 3 510.00 .................. 102.00
15950 ....... Remove thigh pressure sore ......................... .................. 1,233.39 3 510.00 .................. 102.00
16025 ....... Dress/debrid p-thick burn, m ......................... .................. 67.11 2 67.11 Y .............. 13.42
16030 ....... Dress/debrid p-thick burn, l ........................... .................. 99.83 2 99.83 Y .............. 19.97
19020 ....... Incision of breast lesion ................................. .................. 1,076.22 2 446.00 .................. 89.20
19100 ....... Bx breast percut w/o image ........................... .................. 240.00 1 240.00 Y .............. 48.00
19101 ....... Biopsy of breast, open ................................... .................. 1,185.03 2 446.00 .................. 89.20
19102 ....... Bx breast percut w/image .............................. .................. 240.00 2 240.00 Y .............. 48.00
19103 ....... Bx breast percut w/device ............................. .................. 395.77 2 395.77 Y .............. 79.15
19110 ....... Nipple exploration .......................................... .................. 1,185.03 2 446.00 .................. 89.20
19112 ....... Excise breast duct fistula ............................... .................. 1,185.03 3 510.00 .................. 102.00
19120 ....... Removal of breast lesion ............................... .................. 1,185.03 3 510.00 .................. 102.00
19125 ....... Excision, breast lesion ................................... .................. 1,185.03 3 510.00 .................. 102.00
19126 ....... Excision, addl breast lesion ........................... .................. 1,185.03 3 510.00 .................. 102.00
19140 ....... Removal of breast tissue ............................... D .............. .................... 4 630.00 .................. ....................
19160 ....... Partial mastectomy ........................................ D .............. .................... 3 510.00 .................. ....................
19162 ....... P-mastectomy w/ln removal .......................... D .............. .................... 7 995.00 .................. ....................
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
19180 ....... Removal of breast ......................................... D .............. .................... 4 630.00 .................. ....................
19182 ....... Removal of breast ......................................... D .............. .................... 4 630.00 .................. ....................
19290 ....... Place needle wire, breast .............................. .................. .................... 1 333.00 .................. 66.60
19291 ....... Place needle wire, breast .............................. .................. .................... 1 333.00 .................. 66.60
19295 ....... Place breast clip, percut ................................ A* ............. 106.76 1 106.76 Y .............. 21.35
19296 ....... Place po breast cath for rad .......................... .................. 3,148.82 9 1,339.00 .................. 267.80
19297 ....... Place breast cath for rad ............................... A* ............. 3,148.82 9 1,339.00 .................. 267.80
19298 ....... Place breast rad tube/caths ........................... .................. 3,250.00 9 1,339.00 .................. 267.80
19300 ....... Removal of breast tissue ............................... A .............. 1,185.03 4 630.00 .................. 126.00
19301 ....... Partical mastectomy ...................................... A .............. 1,185.03 3 510.00 .................. 102.00
19302 ....... P-mastectomy w/ln removal .......................... A .............. 2,274.24 7 995.00 .................. 199.00
19303 ....... Mast, simple, complete .................................. A .............. 1,722.12 4 630.00 .................. 126.00
19304 ....... Mast, subq ..................................................... A .............. 1,722.12 4 630.00 .................. 126.00
19316 ....... Suspension of breast ..................................... .................. 1,722.12 4 630.00 .................. 126.00
19318 ....... Reduction of large breast .............................. .................. 2,274.24 4 630.00 .................. 126.00
19324 ....... Enlarge breast ............................................... .................. 2,274.24 4 630.00 .................. 126.00
19325 ....... Enlarge breast with implant ........................... .................. 3,148.82 9 1,339.00 .................. 267.80
19328 ....... Removal of breast implant ............................. .................. 1,722.12 1 333.00 .................. 66.60
19330 ....... Removal of implant material .......................... .................. 1,722.12 1 333.00 .................. 66.60
19340 ....... Immediate breast prosthesis ......................... .................. 2,327.74 2 446.00 .................. 89.20
19342 ....... Delayed breast prosthesis ............................. .................. 3,148.82 3 510.00 .................. 102.00
19350 ....... Breast reconstruction ..................................... .................. 1,185.03 4 630.00 .................. 126.00
19355 ....... Correct inverted nipple(s) .............................. .................. 1,722.12 4 630.00 .................. 126.00
19370 ....... Surgery of breast capsule ............................. .................. 1,722.12 4 630.00 .................. 126.00
19371 ....... Removal of breast capsule ............................ .................. 1,722.12 4 630.00 .................. 126.00
19380 ....... Revise breast reconstruction ......................... .................. 2,327.74 5 717.00 .................. 143.40
20005 ....... Incision of deep abscess ............................... .................. 1,282.87 2 446.00 .................. 89.20
20200 ....... Muscle biopsy ................................................ .................. 928.31 2 446.00 .................. 89.20
20205 ....... Deep muscle biopsy ...................................... .................. 928.31 3 510.00 .................. 102.00
20206 ....... Needle biopsy, muscle .................................. .................. 240.00 1 240.00 Y .............. 48.00
20220 ....... Bone biopsy, trocar/needle ............................ .................. 251.52 1 251.52 Y .............. 50.30
20225 ....... Bone biopsy, trocar/needle ............................ .................. 418.49 2 418.49 Y .............. 83.70
20240 ....... Bone biopsy, excisional ................................. .................. 1,233.39 2 446.00 .................. 89.20
20245 ....... Bone biopsy, excisional ................................. .................. 1,233.39 3 510.00 .................. 102.00
20250 ....... Open bone biopsy ......................................... .................. 1,282.87 3 510.00 .................. 102.00
20251 ....... Open bone biopsy ......................................... .................. 1,282.87 3 510.00 .................. 102.00
20525 ....... Removal of foreign body ............................... .................. 1,233.39 3 510.00 .................. 102.00
20650 ....... Insert and remove bone pin .......................... .................. 1,282.87 3 510.00 .................. 102.00
20670 ....... Removal of support implant ........................... .................. 928.31 1 333.00 .................. 66.60
20680 ....... Removal of support implant ........................... .................. 1,233.39 3 510.00 .................. 102.00
20690 ....... Apply bone fixation device ............................. .................. 1,544.67 2 446.00 .................. 89.20
20692 ....... Apply bone fixation device ............................. .................. 1,544.67 3 510.00 .................. 102.00
20693 ....... Adjust bone fixation device ............................ .................. 1,282.87 3 510.00 .................. 102.00
20694 ....... Remove bone fixation device ........................ .................. 1,282.87 1 333.00 .................. 66.60
20900 ....... Removal of bone for graft .............................. .................. 1,544.67 3 510.00 .................. 102.00
20902 ....... Removal of bone for graft .............................. .................. 1,544.67 4 630.00 .................. 126.00
20910 ....... Remove cartilage for graft ............................. .................. 1,317.27 3 510.00 .................. 102.00
20912 ....... Remove cartilage for graft ............................. .................. 1,317.27 3 510.00 .................. 102.00
20920 ....... Removal of fascia for graft ............................ .................. 862.68 4 630.00 .................. 126.00
20922 ....... Removal of fascia for graft ............................ .................. 1,317.27 3 510.00 .................. 102.00
20924 ....... Removal of tendon for graft ........................... .................. 1,544.67 4 630.00 .................. 126.00
20926 ....... Removal of tissue for graft ............................ .................. 862.68 4 630.00 .................. 126.00
20975 ....... Electrical bone stimulation ............................. .................. 37.51 2 37.51 Y .............. 7.50
21010 ....... Incision of jaw joint ........................................ .................. 1,434.04 2 446.00 .................. 89.20
21015 ....... Resection of facial tumor ............................... .................. 1,009.71 3 510.00 .................. 102.00
21025 ....... Excision of bone, lower jaw ........................... .................. 2,348.02 2 446.00 .................. 89.20
21026 ....... Excision of facial bone(s) .............................. .................. 2,348.02 2 446.00 .................. 89.20
21029 ....... Contour of face bone lesion .......................... .................. 2,348.02 2 446.00 .................. 89.20
21034 ....... Excise max/zygoma mlg tumor ..................... .................. 2,348.02 3 510.00 .................. 102.00
21040 ....... Excise mandible lesion .................................. .................. 1,434.04 2 446.00 .................. 89.20
21044 ....... Removal of jaw bone lesion .......................... .................. 2,348.02 2 446.00 .................. 89.20
21046 ....... Remove mandible cyst complex .................... .................. 2,348.02 2 446.00 .................. 89.20
21047 ....... Excise lwr jaw cyst w/repair .......................... .................. 2,348.02 2 446.00 .................. 89.20
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
21050 ....... Removal of jaw joint ...................................... .................. 2,348.02 3 510.00 .................. 102.00
21060 ....... Remove jaw joint cartilage ............................ .................. 2,348.02 2 446.00 .................. 89.20
21070 ....... Remove coronoid process ............................. .................. 2,348.02 3 510.00 .................. 102.00
21100 ....... Maxillofacial fixation ....................................... .................. 2,348.02 2 446.00 .................. 89.20
21120 ....... Reconstruction of chin ................................... .................. 1,434.04 7 995.00 .................. 199.00
21125 ....... Augmentation, lower jaw bone ...................... .................. 1,434.04 7 995.00 .................. 199.00
21127 ....... Augmentation, lower jaw bone ...................... .................. 2,348.02 9 1,339.00 .................. 267.80
21181 ....... Contour cranial bone lesion ........................... .................. 1,434.04 7 995.00 .................. 199.00
21206 ....... Reconstruct upper jaw bone .......................... .................. 2,348.02 5 717.00 .................. 143.40
21208 ....... Augmentation of facial bones ........................ .................. 2,348.02 7 995.00 .................. 199.00
21209 ....... Reduction of facial bones .............................. .................. 2,348.02 5 717.00 .................. 143.40
21210 ....... Face bone graft ............................................. .................. 2,348.02 7 995.00 .................. 199.00
21215 ....... Lower jaw bone graft ..................................... .................. 2,348.02 7 995.00 .................. 199.00
21230 ....... Rib cartilage graft .......................................... .................. 2,348.02 7 995.00 .................. 199.00
21235 ....... Ear cartilage graft .......................................... .................. 1,434.04 7 995.00 .................. 199.00
21240 ....... Reconstruction of jaw joint ............................ .................. 2,348.02 4 630.00 .................. 126.00
21244 ....... Reconstruction of lower jaw .......................... .................. 2,348.02 7 995.00 .................. 199.00
21245 ....... Reconstruction of jaw .................................... .................. 2,348.02 7 995.00 .................. 199.00
21267 ....... Revise eye sockets ........................................ .................. 2,348.02 7 995.00 .................. 199.00
21270 ....... Augmentation, cheek bone ............................ .................. 2,348.02 5 717.00 .................. 143.40
21275 ....... Revision, orbitofacial bones ........................... .................. 2,348.02 7 995.00 .................. 199.00
21280 ....... Revision of eyelid .......................................... .................. 2,348.02 5 717.00 .................. 143.40
21295 ....... Revision of jaw muscle/bone ......................... .................. 464.15 1 333.00 .................. 66.60
21296 ....... Revision of jaw muscle/bone ......................... .................. 1,434.04 1 333.00 .................. 66.60
21300 ....... Treatment of skull fracture ............................. D .............. .................... 2 446.00 .................. ....................
21310 ....... Treatment of nose fracture ............................ .................. 150.72 2 150.72 Y .............. 30.14
21315 ....... Treatment of nose fracture ............................ .................. 150.72 2 150.72 Y .............. 30.14
21320 ....... Treatment of nose fracture ............................ .................. 464.15 2 446.00 .................. 89.20
21325 ....... Treatment of nose fracture ............................ .................. 1,434.04 4 630.00 .................. 126.00
21336 ....... Treat nasal septal fracture ............................. .................. 2,307.40 4 630.00 .................. 126.00
21337 ....... Treat nasal septal fracture ............................. .................. 1,009.71 2 446.00 .................. 89.20
21338 ....... Treat nasoethmoid fracture ........................... .................. 1,434.04 4 630.00 .................. 126.00
21339 ....... Treat nasoethmoid fracture ........................... .................. 1,434.04 5 717.00 .................. 143.40
21345 ....... Treat nose/jaw fracture .................................. .................. 1,434.04 7 995.00 .................. 199.00
21355 ....... Treat cheek bone fracture ............................. .................. 2,348.02 3 510.00 .................. 102.00
21356 ....... Treat cheek bone fracture ............................. A* ............. 1,434.04 3 510.00 .................. 102.00
21400 ....... Treat eye socket fracture ............................... .................. 464.15 2 446.00 .................. 89.20
21401 ....... Treat eye socket fracture ............................... .................. 1,009.71 3 510.00 .................. 102.00
21421 ....... Treat mouth roof fracture ............................... .................. 1,434.04 4 630.00 .................. 126.00
21445 ....... Treat dental ridge fracture ............................. .................. 1,434.04 4 630.00 .................. 126.00
21450 ....... Treat lower jaw fracture ................................. .................. 150.72 3 150.72 Y .............. 30.14
21451 ....... Treat lower jaw fracture ................................. .................. 464.15 4 464.15 Y .............. 92.83
21452 ....... Treat lower jaw fracture ................................. .................. 1,009.71 2 446.00 .................. 89.20
21480 ....... Reset dislocated jaw ...................................... .................. 150.72 1 150.72 Y .............. 30.14
21485 ....... Reset dislocated jaw ...................................... .................. 1,009.71 2 446.00 .................. 89.20
21490 ....... Repair dislocated jaw .................................... .................. 2,348.02 3 510.00 .................. 102.00
21497 ....... Interdental wiring ........................................... .................. 1,009.71 2 446.00 .................. 89.20
21501 ....... Drain neck/chest lesion ................................. .................. 1,076.22 2 446.00 .................. 89.20
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
21502 ....... Drain chest lesion .......................................... .................. 1,282.87 2 446.00 .................. 89.20
21555 ....... Remove lesion, neck/chest ............................ .................. 1,233.39 2 446.00 .................. 89.20
21556 ....... Remove lesion, neck/chest ............................ .................. 1,233.39 2 446.00 .................. 89.20
21600 ....... Partial removal of rib ..................................... .................. 1,544.67 2 446.00 .................. 89.20
21610 ....... Partial removal of rib ..................................... .................. 1,544.67 2 446.00 .................. 89.20
21700 ....... Revision of neck muscle ................................ .................. 1,282.87 2 446.00 .................. 89.20
21720 ....... Revision of neck muscle ................................ .................. 1,282.87 3 510.00 .................. 102.00
21725 ....... Revision of neck muscle ................................ .................. 88.46 3 88.46 Y .............. 17.69
21800 ....... Treatment of rib fracture ................................ .................. 103.62 1 103.62 Y .............. 20.72
21805 ....... Treatment of rib fracture ................................ .................. 1,569.06 2 446.00 .................. 89.20
21820 ....... Treat sternum fracture ................................... .................. 103.62 1 103.62 Y .............. 20.72
21925 ....... Biopsy soft tissue of back .............................. .................. 1,233.39 2 446.00 .................. 89.20
21930 ....... Remove lesion, back or flank ........................ .................. 1,233.39 2 446.00 .................. 89.20
21935 ....... Remove tumor, back ..................................... .................. 1,233.39 3 510.00 .................. 102.00
22305 ....... Treat spine process fracture .......................... .................. 103.62 1 103.62 Y .............. 20.72
22310 ....... Treat spine fracture ....................................... .................. 103.62 1 103.62 Y .............. 20.72
22315 ....... Treat spine fracture ....................................... .................. 103.62 2 103.62 Y .............. 20.72
22505 ....... Manipulation of spine ..................................... .................. 897.11 2 446.00 .................. 89.20
22520 ....... Percut vertebroplasty thor ............................. A* ............. 1,544.67 9 1,339.00 .................. 267.80
22521 ....... Percut vertebroplasty lumb ............................ A* ............. 1,544.67 9 1,339.00 .................. 267.80
22522 ....... Percut vertebroplasty add" .......................... A* ............. 1,544.67 9 1,339.00 .................. 267.80
22900 ....... Remove abdominal wall lesion ...................... .................. 1,233.39 4 630.00 .................. 126.00
23000 ....... Removal of calcium deposits ......................... .................. 928.31 2 446.00 .................. 89.20
23020 ....... Release shoulder joint ................................... .................. 2,525.68 2 446.00 .................. 89.20
23030 ....... Drain shoulder lesion ..................................... .................. 1,076.22 1 333.00 .................. 66.60
23031 ....... Drain shoulder bursa ..................................... .................. 1,076.22 3 510.00 .................. 102.00
23035 ....... Drain shoulder bone lesion ............................ .................. 1,282.87 3 510.00 .................. 102.00
23040 ....... Exploratory shoulder surgery ......................... .................. 1,544.67 3 510.00 .................. 102.00
23044 ....... Exploratory shoulder surgery ......................... .................. 1,544.67 4 630.00 .................. 126.00
23066 ....... Biopsy shoulder tissues ................................. .................. 1,233.39 2 446.00 .................. 89.20
23075 ....... Removal of shoulder lesion ........................... .................. 928.31 2 446.00 .................. 89.20
23076 ....... Removal of shoulder lesion ........................... .................. 1,233.39 2 446.00 .................. 89.20
23077 ....... Remove tumor of shoulder ............................ .................. 1,233.39 3 510.00 .................. 102.00
23100 ....... Biopsy of shoulder joint ................................. .................. 1,282.87 2 446.00 .................. 89.20
23101 ....... Shoulder joint surgery .................................... .................. 1,544.67 7 995.00 .................. 199.00
23105 ....... Remove shoulder joint lining ......................... .................. 1,544.67 4 630.00 .................. 126.00
23106 ....... Incision of collarbone joint ............................. .................. 1,544.67 4 630.00 .................. 126.00
23107 ....... Explore treat shoulder joint ............................ .................. 1,544.67 4 630.00 .................. 126.00
23120 ....... Partial removal, collar bone ........................... .................. 2,525.68 5 717.00 .................. 143.40
23125 ....... Removal of collar bone .................................. .................. 2,525.68 5 717.00 .................. 143.40
23130 ....... Remove shoulder bone, part ......................... .................. 2,525.68 5 717.00 .................. 143.40
23140 ....... Removal of bone lesion ................................. .................. 1,282.87 4 630.00 .................. 126.00
23150 ....... Removal of humerus lesion ........................... .................. 1,544.67 4 630.00 .................. 126.00
23170 ....... Remove collar bone lesion ............................ .................. 1,544.67 2 446.00 .................. 89.20
23172 ....... Remove shoulder blade lesion ...................... .................. 1,544.67 2 446.00 .................. 89.20
23174 ....... Remove humerus lesion ................................ .................. 1,544.67 2 446.00 .................. 89.20
23180 ....... Remove collar bone lesion ............................ .................. 1,544.67 4 630.00 .................. 126.00
23182 ....... Remove shoulder blade lesion ...................... .................. 1,544.67 4 630.00 .................. 126.00
23190 ....... Partial removal of scapula ............................. .................. 1,544.67 4 630.00 .................. 126.00
23195 ....... Removal of head of humerus ........................ .................. 1,544.67 5 717.00 .................. 143.40
23330 ....... Remove shoulder foreign body ..................... .................. 418.49 1 333.00 .................. 66.60
23331 ....... Remove shoulder foreign body ..................... .................. 1,233.39 1 333.00 .................. 66.60
23395 ....... Muscle transfer,shoulder/arm ........................ .................. 2,525.68 5 717.00 .................. 143.40
23397 ....... Muscle transfers ............................................ .................. 4,092.54 7 995.00 .................. 199.00
23400 ....... Fixation of shoulder blade ............................. .................. 1,544.67 7 995.00 .................. 199.00
23405 ....... Incision of tendon & muscle .......................... .................. 1,544.67 2 446.00 .................. 89.20
23406 ....... Incise tendon(s) & muscle(s) ......................... .................. 1,544.67 2 446.00 .................. 89.20
23410 ....... Repair rotator cuff, acute ............................... .................. 2,525.68 5 717.00 .................. 143.40
23412 ....... Repair rotator cuff, chronic ............................ .................. 2,525.68 7 995.00 .................. 199.00
23415 ....... Release of shoulder ligament ........................ .................. 2,525.68 5 717.00 .................. 143.40
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
23420 ....... Repair of shoulder ......................................... .................. 2,525.68 7 995.00 .................. 199.00
23430 ....... Repair biceps tendon ..................................... .................. 2,525.68 4 630.00 .................. 126.00
23440 ....... Remove/transplant tendon ............................. .................. 2,525.68 4 630.00 .................. 126.00
23450 ....... Repair shoulder capsule ................................ .................. 4,092.54 5 717.00 .................. 143.40
23480 ....... Revision of collar bone .................................. .................. 2,525.68 4 630.00 .................. 126.00
23485 ....... Revision of collar bone .................................. .................. 4,092.54 7 995.00 .................. 199.00
23490 ....... Reinforce clavicle ........................................... .................. 2,525.68 3 510.00 .................. 102.00
23491 ....... Reinforce shoulder bones .............................. .................. 4,092.54 3 510.00 .................. 102.00
23500 ....... Treat clavicle fracture .................................... .................. 103.62 1 103.62 Y .............. 20.72
23505 ....... Treat clavicle fracture .................................... .................. 103.62 1 103.62 Y .............. 20.72
23515 ....... Treat clavicle fracture .................................... .................. 3,517.03 3 510.00 .................. 102.00
23520 ....... Treat clavicle dislocation ............................... .................. 103.62 1 103.62 Y .............. 20.72
23530 ....... Treat clavicle dislocation ............................... .................. 2,307.40 3 510.00 .................. 102.00
23570 ....... Treat shoulder blade fx .................................. .................. 103.62 1 103.62 Y .............. 20.72
23575 ....... Treat shoulder blade fx .................................. .................. 103.62 1 103.62 Y .............. 20.72
23585 ....... Treat scapula fracture .................................... .................. 3,517.03 3 510.00 .................. 102.00
23605 ....... Treat humerus fracture .................................. .................. 103.62 2 103.62 Y .............. 20.72
23615 ....... Treat humerus fracture .................................. .................. 3,517.03 4 630.00 .................. 126.00
23650 ....... Treat shoulder dislocation ............................. .................. 103.62 1 103.62 Y .............. 20.72
23655 ....... Treat shoulder dislocation ............................. .................. 897.11 1 333.00 .................. 66.60
23660 ....... Treat shoulder dislocation ............................. .................. 2,307.40 3 510.00 .................. 102.00
23665 ....... Treat dislocation/fracture ............................... .................. 103.62 2 103.62 Y .............. 20.72
23670 ....... Treat dislocation/fracture ............................... .................. 3,517.03 3 510.00 .................. 102.00
23675 ....... Treat dislocation/fracture ............................... .................. 103.62 2 103.62 Y .............. 20.72
23680 ....... Treat dislocation/fracture ............................... .................. 2,307.40 3 510.00 .................. 102.00
23700 ....... Fixation of shoulder ....................................... .................. 897.11 1 333.00 .................. 66.60
23800 ....... Fusion of shoulder joint ................................. .................. 4,092.54 4 630.00 .................. 126.00
23802 ....... Fusion of shoulder joint ................................. .................. 2,525.68 7 995.00 .................. 199.00
23921 ....... Amputation follow-up surgery ........................ .................. 323.28 3 323.28 Y .............. 64.66
23930 ....... Drainage of arm lesion .................................. .................. 1,076.22 1 333.00 .................. 66.60
23931 ....... Drainage of arm bursa ................................... .................. 1,076.22 2 446.00 .................. 89.20
23935 ....... Drain arm/elbow bone lesion ......................... .................. 1,282.87 2 446.00 .................. 89.20
24000 ....... Exploratory elbow surgery ............................. .................. 1,544.67 4 630.00 .................. 126.00
24006 ....... Release elbow joint ....................................... .................. 1,544.67 4 630.00 .................. 126.00
24066 ....... Biopsy arm/elbow soft tissue ......................... .................. 928.31 2 446.00 .................. 89.20
24075 ....... Remove arm/elbow lesion ............................. .................. 928.31 2 446.00 .................. 89.20
24076 ....... Remove arm/elbow lesion ............................. .................. 1,233.39 2 446.00 .................. 89.20
24077 ....... Remove tumor of arm/elbow ......................... .................. 1,233.39 3 510.00 .................. 102.00
24100 ....... Biopsy elbow joint lining ................................ .................. 1,282.87 1 333.00 .................. 66.60
24101 ....... Explore/treat elbow joint ................................ .................. 1,544.67 4 630.00 .................. 126.00
24102 ....... Remove elbow joint lining .............................. .................. 1,544.67 4 630.00 .................. 126.00
24105 ....... Removal of elbow bursa ................................ .................. 1,282.87 3 510.00 .................. 102.00
24115 ....... Remove/graft bone lesion .............................. .................. 1,544.67 3 510.00 .................. 102.00
24120 ....... Remove elbow lesion .................................... .................. 1,282.87 3 510.00 .................. 102.00
24130 ....... Removal of head of radius ............................ .................. 1,544.67 3 510.00 .................. 102.00
24134 ....... Removal of arm bone lesion ......................... .................. 1,544.67 2 446.00 .................. 89.20
24136 ....... Remove radius bone lesion ........................... .................. 1,544.67 2 446.00 .................. 89.20
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
24138 ....... Remove elbow bone lesion ........................... .................. 1,544.67 2 446.00 .................. 89.20
24140 ....... Partial removal of arm bone .......................... .................. 1,544.67 3 510.00 .................. 102.00
24145 ....... Partial removal of radius ................................ .................. 1,544.67 3 510.00 .................. 102.00
24147 ....... Partial removal of elbow ................................ .................. 1,544.67 2 446.00 .................. 89.20
24155 ....... Removal of elbow joint .................................. .................. 2,525.68 3 510.00 .................. 102.00
24160 ....... Remove elbow joint implant .......................... .................. 1,544.67 2 446.00 .................. 89.20
24164 ....... Remove radius head implant ......................... .................. 1,544.67 3 510.00 .................. 102.00
24201 ....... Removal of arm foreign body ........................ .................. 928.31 2 446.00 .................. 89.20
24301 ....... Muscle/tendon transfer .................................. .................. 1,544.67 4 630.00 .................. 126.00
24305 ....... Arm tendon lengthening ................................ .................. 1,544.67 4 630.00 .................. 126.00
24310 ....... Revision of arm tendon ................................. .................. 1,282.87 3 510.00 .................. 102.00
24320 ....... Repair of arm tendon ..................................... .................. 2,525.68 3 510.00 .................. 102.00
24330 ....... Revision of arm muscles ............................... .................. 4,092.54 3 510.00 .................. 102.00
24331 ....... Revision of arm muscles ............................... .................. 2,525.68 3 510.00 .................. 102.00
24340 ....... Repair of biceps tendon ................................ .................. 2,525.68 3 510.00 .................. 102.00
24341 ....... Repair arm tendon/muscle ............................ .................. 2,525.68 3 510.00 .................. 102.00
24342 ....... Repair of ruptured tendon ............................. .................. 2,525.68 3 510.00 .................. 102.00
24345 ....... Repr elbw med ligmnt w/tissu ....................... .................. 1,544.67 2 446.00 .................. 89.20
24350 ....... Repair of tennis elbow ................................... .................. 1,544.67 3 510.00 .................. 102.00
24356 ....... Revision of tennis elbow ................................ .................. 1,544.67 3 510.00 .................. 102.00
24360 ....... Reconstruct elbow joint ................................. .................. 2,056.14 5 717.00 .................. 143.40
24363 ....... Replace elbow joint ....................................... .................. 6,589.01 7 995.00 .................. 199.00
24365 ....... Reconstruct head of radius ........................... .................. 2,056.14 5 717.00 .................. 143.40
24366 ....... Reconstruct head of radius ........................... .................. 6,589.01 5 717.00 .................. 143.40
24400 ....... Revision of humerus ...................................... .................. 1,544.67 4 630.00 .................. 126.00
24430 ....... Repair of humerus ......................................... .................. 4,092.54 3 510.00 .................. 102.00
24435 ....... Repair humerus with graft ............................. .................. 4,092.54 4 630.00 .................. 126.00
24470 ....... Revision of elbow joint ................................... .................. 2,525.68 3 510.00 .................. 102.00
24495 ....... Decompression of forearm ............................ .................. 1,544.67 2 446.00 .................. 89.20
24498 ....... Reinforce humerus ........................................ .................. 4,092.54 3 510.00 .................. 102.00
24586 ....... Treat elbow fracture ....................................... .................. 3,517.03 4 630.00 .................. 126.00
24600 ....... Treat elbow dislocation .................................. .................. 103.62 1 103.62 Y .............. 20.72
24605 ....... Treat elbow dislocation .................................. .................. 897.11 2 446.00 .................. 89.20
24615 ....... Treat elbow dislocation .................................. .................. 3,517.03 3 510.00 .................. 102.00
24620 ....... Treat elbow fracture ....................................... .................. 103.62 2 103.62 Y .............. 20.72
24655 ....... Treat radius fracture ...................................... .................. 103.62 1 103.62 Y .............. 20.72
24665 ....... Treat radius fracture ...................................... .................. 2,307.40 4 630.00 .................. 126.00
24666 ....... Treat radius fracture ...................................... .................. 3,517.03 4 630.00 .................. 126.00
24670 ....... Treat ulnar fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
24675 ....... Treat ulnar fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72
24685 ....... Treat ulnar fracture ........................................ .................. 2,307.40 3 510.00 .................. 102.00
24800 ....... Fusion of elbow joint ...................................... .................. 2,525.68 4 630.00 .................. 126.00
24802 ....... Fusion/graft of elbow joint ............................. .................. 2,525.68 5 717.00 .................. 143.40
24925 ....... Amputation follow-up surgery ........................ .................. 1,282.87 3 510.00 .................. 102.00
25000 ....... Incision of tendon sheath .............................. .................. 1,282.87 3 510.00 .................. 102.00
25020 ....... Decompress forearm 1 space ....................... .................. 1,282.87 3 510.00 .................. 102.00
25023 ....... Decompress forearm 1 space ....................... .................. 1,544.67 3 510.00 .................. 102.00
25024 ....... Decompress forearm 2 spaces ..................... .................. 1,544.67 3 510.00 .................. 102.00
25025 ....... Decompress forearm 2 spaces ..................... .................. 1,544.67 3 510.00 .................. 102.00
25028 ....... Drainage of forearm lesion ............................ .................. 1,282.87 1 333.00 .................. 66.60
25031 ....... Drainage of forearm bursa ............................ .................. 1,282.87 2 446.00 .................. 89.20
25035 ....... Treat forearm bone lesion ............................. .................. 1,282.87 2 446.00 .................. 89.20
25040 ....... Explore/treat wrist joint .................................. .................. 1,544.67 5 717.00 .................. 143.40
25066 ....... Biopsy forearm soft tissues ........................... .................. 1,233.39 2 446.00 .................. 89.20
25075 ....... Removal forearm lesion subcu ...................... .................. 928.31 2 446.00 .................. 89.20
25076 ....... Removal forearm lesion deep ....................... .................. 1,233.39 3 510.00 .................. 102.00
25077 ....... Remove tumor, forearm/wrist ........................ .................. 1,233.39 3 510.00 .................. 102.00
25085 ....... Incision of wrist capsule ................................ .................. 1,282.87 3 510.00 .................. 102.00
25100 ....... Biopsy of wrist joint ........................................ .................. 1,282.87 2 446.00 .................. 89.20
25101 ....... Explore/treat wrist joint .................................. .................. 1,544.67 3 510.00 .................. 102.00
25105 ....... Remove wrist joint lining ................................ .................. 1,544.67 4 630.00 .................. 126.00
25107 ....... Remove wrist joint cartilage .......................... .................. 1,544.67 3 510.00 .................. 102.00
25110 ....... Remove wrist tendon lesion .......................... .................. 1,282.87 3 510.00 .................. 102.00
25111 ....... Remove wrist tendon lesion .......................... .................. 992.95 3 510.00 .................. 102.00
25112 ....... Remove wrist tendon lesion .......................... .................. 992.95 4 630.00 .................. 126.00
25115 ....... Remove wrist/forearm lesion ......................... .................. 1,282.87 4 630.00 .................. 126.00
25116 ....... Remove wrist/forearm lesion ......................... .................. 1,282.87 4 630.00 .................. 126.00
25118 ....... Excise wrist tendon sheath ............................ .................. 1,544.67 2 446.00 .................. 89.20
25119 ....... Partial removal of ulna ................................... .................. 1,544.67 3 510.00 .................. 102.00
25120 ....... Removal of forearm lesion ............................ .................. 1,544.67 3 510.00 .................. 102.00
25125 ....... Remove/graft forearm lesion ......................... .................. 1,544.67 3 510.00 .................. 102.00
25126 ....... Remove/graft forearm lesion ......................... .................. 1,544.67 3 510.00 .................. 102.00
25130 ....... Removal of wrist lesion ................................. .................. 1,544.67 3 510.00 .................. 102.00
25135 ....... Remove & graft wrist lesion .......................... .................. 1,544.67 3 510.00 .................. 102.00
25136 ....... Remove & graft wrist lesion .......................... .................. 1,544.67 3 510.00 .................. 102.00
25145 ....... Remove forearm bone lesion ........................ .................. 1,544.67 2 446.00 .................. 89.20
25210 ....... Removal of wrist bone ................................... .................. 1,590.53 3 510.00 .................. 102.00
25215 ....... Removal of wrist bones ................................. .................. 1,590.53 4 630.00 .................. 126.00
25248 ....... Remove forearm foreign body ....................... .................. 1,282.87 2 446.00 .................. 89.20
25250 ....... Removal of wrist prosthesis .......................... .................. 1,544.67 1 333.00 .................. 66.60
25251 ....... Removal of wrist prosthesis .......................... .................. 1,544.67 1 333.00 .................. 66.60
25260 ....... Repair forearm tendon/muscle ...................... .................. 1,544.67 4 630.00 .................. 126.00
25275 ....... Repair forearm tendon sheath ....................... .................. 1,544.67 4 630.00 .................. 126.00
25280 ....... Revise wrist/forearm tendon .......................... .................. 1,544.67 4 630.00 .................. 126.00
25290 ....... Incise wrist/forearm tendon ........................... .................. 1,544.67 3 510.00 .................. 102.00
25295 ....... Release wrist/forearm tendon ........................ .................. 1,282.87 3 510.00 .................. 102.00
25300 ....... Fusion of tendons at wrist ............................. .................. 1,544.67 3 510.00 .................. 102.00
25301 ....... Fusion of tendons at wrist ............................. .................. 1,544.67 3 510.00 .................. 102.00
25310 ....... Transplant forearm tendon ............................ .................. 2,525.68 3 510.00 .................. 102.00
25312 ....... Transplant forearm tendon ............................ .................. 2,525.68 4 630.00 .................. 126.00
25315 ....... Revise palsy hand tendon(s) ......................... .................. 2,525.68 3 510.00 .................. 102.00
25316 ....... Revise palsy hand tendon(s) ......................... .................. 4,092.54 3 510.00 .................. 102.00
25320 ....... Repair/revise wrist joint ................................. .................. 2,525.68 3 510.00 .................. 102.00
25332 ....... Revise wrist joint ............................................ .................. 2,056.14 5 717.00 .................. 143.40
25335 ....... Realignment of hand ..................................... .................. 2,525.68 3 510.00 .................. 102.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
25337 ....... Reconstruct ulna/radioulnar ........................... .................. 2,525.68 5 717.00 .................. 143.40
25350 ....... Revision of radius .......................................... .................. 4,092.54 3 510.00 .................. 102.00
25355 ....... Revision of radius .......................................... .................. 2,525.68 3 510.00 .................. 102.00
25360 ....... Revision of ulna ............................................. .................. 1,544.67 3 510.00 .................. 102.00
25365 ....... Revise radius & ulna ..................................... .................. 1,544.67 3 510.00 .................. 102.00
25370 ....... Revise radius or ulna ..................................... .................. 2,525.68 3 510.00 .................. 102.00
25375 ....... Revise radius & ulna ..................................... .................. 2,525.68 4 630.00 .................. 126.00
25390 ....... Shorten radius or ulna ................................... .................. 1,544.67 3 510.00 .................. 102.00
25391 ....... Lengthen radius or ulna ................................. .................. 2,525.68 4 630.00 .................. 126.00
25392 ....... Shorten radius & ulna .................................... .................. 1,544.67 3 510.00 .................. 102.00
25393 ....... Lengthen radius & ulna ................................. .................. 2,525.68 4 630.00 .................. 126.00
25400 ....... Repair radius or ulna ..................................... .................. 1,544.67 3 510.00 .................. 102.00
25405 ....... Repair/graft radius or ulna ............................. .................. 1,544.67 4 630.00 .................. 126.00
25415 ....... Repair radius & ulna ...................................... .................. 1,544.67 3 510.00 .................. 102.00
25420 ....... Repair/graft radius & ulna .............................. .................. 4,092.54 4 630.00 .................. 126.00
25425 ....... Repair/graft radius or ulna ............................. .................. 2,525.68 3 510.00 .................. 102.00
25426 ....... Repair/graft radius & ulna .............................. .................. 2,525.68 4 630.00 .................. 126.00
25440 ....... Repair/graft wrist bone .................................. .................. 4,092.54 4 630.00 .................. 126.00
25441 ....... Reconstruct wrist joint ................................... .................. 6,589.01 5 717.00 .................. 143.40
25446 ....... Wrist replacement .......................................... .................. 6,589.01 7 995.00 .................. 199.00
25447 ....... Repair wrist joint(s) ........................................ .................. 2,056.14 5 717.00 .................. 143.40
25449 ....... Remove wrist joint implant ............................ .................. 2,056.14 5 717.00 .................. 143.40
25450 ....... Revision of wrist joint ..................................... .................. 2,525.68 3 510.00 .................. 102.00
25455 ....... Revision of wrist joint ..................................... .................. 2,525.68 3 510.00 .................. 102.00
25490 ....... Reinforce radius ............................................. .................. 2,525.68 3 510.00 .................. 102.00
25491 ....... Reinforce ulna ................................................ .................. 2,525.68 3 510.00 .................. 102.00
25492 ....... Reinforce radius and ulna ............................. .................. 2,525.68 3 510.00 .................. 102.00
25505 ....... Treat fracture of radius .................................. .................. 103.62 1 103.62 Y .............. 20.72
25515 ....... Treat fracture of radius .................................. .................. 2,307.40 3 510.00 .................. 102.00
25520 ....... Treat fracture of radius .................................. .................. 103.62 1 103.62 Y .............. 20.72
25535 ....... Treat fracture of ulna ..................................... .................. 103.62 1 103.62 Y .............. 20.72
25545 ....... Treat fracture of ulna ..................................... .................. 2,307.40 3 510.00 .................. 102.00
25565 ....... Treat fracture radius & ulna ........................... .................. 103.62 2 103.62 Y .............. 20.72
25574 ....... Treat fracture radius & ulna ........................... .................. 3,517.03 3 510.00 .................. 102.00
25575 ....... Treat fracture radius/ulna .............................. .................. 3,517.03 3 510.00 .................. 102.00
25605 ....... Treat fracture radius/ulna .............................. .................. 103.62 3 103.62 Y .............. 20.72
25606 ....... Treat fx distal radial ....................................... A .............. 1,569.06 3 510.00 .................. 102.00
25607 ....... Treat fx rad extra-articul ................................ A .............. 3,517.03 5 717.00 .................. 143.40
25608 ....... Treat fx rad intra-articul ................................. A .............. 3,517.03 5 717.00 .................. 143.40
25609 ....... Treat fx radial 3+ frag .................................... A .............. 3,517.03 5 717.00 .................. 143.40
25611 ....... Treat fracture radius/ulna .............................. D .............. .................... 3 510.00 .................. ....................
25620 ....... Treat fracture radius/ulna .............................. D .............. .................... 5 717.00 .................. ....................
25624 ....... Treat wrist bone fracture ............................... .................. 103.62 2 103.62 Y .............. 20.72
25628 ....... Treat wrist bone fracture ............................... .................. 2,307.40 3 510.00 .................. 102.00
25635 ....... Treat wrist bone fracture ............................... .................. 103.62 1 103.62 Y .............. 20.72
25645 ....... Treat wrist bone fracture ............................... .................. 2,307.40 3 510.00 .................. 102.00
25660 ....... Treat wrist dislocation .................................... .................. 103.62 1 103.62 Y .............. 20.72
25670 ....... Treat wrist dislocation .................................... .................. 1,569.06 3 510.00 .................. 102.00
25671 ....... Pin radioulnar dislocation .............................. .................. 1,569.06 1 333.00 .................. 66.60
25680 ....... Treat wrist fracture ......................................... .................. 103.62 2 103.62 Y .............. 20.72
25685 ....... Treat wrist fracture ......................................... .................. 1,569.06 3 510.00 .................. 102.00
25800 ....... Fusion of wrist joint ........................................ .................. 4,092.54 4 630.00 .................. 126.00
25805 ....... Fusion/graft of wrist joint ............................... .................. 2,525.68 5 717.00 .................. 143.40
25810 ....... Fusion/graft of wrist joint ............................... .................. 4,092.54 5 717.00 .................. 143.40
25820 ....... Fusion of hand bones .................................... .................. 992.95 4 630.00 .................. 126.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
25825 ....... Fuse hand bones with graft ........................... .................. 1,590.53 5 717.00 .................. 143.40
25830 ....... Fusion, radioulnar jnt/ulna ............................. .................. 4,092.54 5 717.00 .................. 143.40
25922 ....... Amputate hand at wrist .................................. .................. 1,282.87 3 510.00 .................. 102.00
25929 ....... Amputation follow-up surgery ........................ .................. 862.68 3 510.00 .................. 102.00
26011 ....... Drainage of finger abscess ............................ .................. 685.58 1 333.00 .................. 66.60
26020 ....... Drain hand tendon sheath ............................. .................. 992.95 2 446.00 .................. 89.20
26025 ....... Drainage of palm bursa ................................. .................. 992.95 1 333.00 .................. 66.60
26030 ....... Drainage of palm bursa(s) ............................. .................. 992.95 2 446.00 .................. 89.20
26034 ....... Treat hand bone lesion .................................. .................. 992.95 2 446.00 .................. 89.20
26040 ....... Release palm contracture .............................. .................. 1,590.53 4 630.00 .................. 126.00
26055 ....... Incise finger tendon sheath ........................... .................. 992.95 2 446.00 .................. 89.20
26060 ....... Incision of finger tendon ................................ .................. 992.95 2 446.00 .................. 89.20
26070 ....... Explore/treat hand joint .................................. .................. 992.95 2 446.00 .................. 89.20
26075 ....... Explore/treat finger joint ................................. .................. 992.95 4 630.00 .................. 126.00
26080 ....... Explore/treat finger joint ................................. .................. 992.95 4 630.00 .................. 126.00
26100 ....... Biopsy hand joint lining .................................. .................. 992.95 2 446.00 .................. 89.20
26105 ....... Biopsy finger joint lining ................................. .................. 992.95 1 333.00 .................. 66.60
26110 ....... Biopsy finger joint lining ................................. .................. 992.95 1 333.00 .................. 66.60
26115 ....... Removal hand lesion subcut ......................... .................. 1,233.39 2 446.00 .................. 89.20
26116 ....... Removal hand lesion, deep ........................... .................. 1,233.39 2 446.00 .................. 89.20
26117 ....... Remove tumor, hand/finger ........................... .................. 1,233.39 3 510.00 .................. 102.00
26125 ....... Release palm contracture .............................. .................. 992.95 4 630.00 .................. 126.00
26130 ....... Remove wrist joint lining ................................ .................. 992.95 3 510.00 .................. 102.00
26135 ....... Revise finger joint, each ................................ .................. 1,590.53 4 630.00 .................. 126.00
26140 ....... Revise finger joint, each ................................ .................. 992.95 2 446.00 .................. 89.20
26145 ....... Tendon excision, palm/finger ......................... .................. 992.95 3 510.00 .................. 102.00
26160 ....... Remove tendon sheath lesion ....................... .................. 992.95 3 510.00 .................. 102.00
26170 ....... Removal of palm tendon, each ..................... .................. 992.95 3 510.00 .................. 102.00
26180 ....... Removal of finger tendon .............................. .................. 992.95 3 510.00 .................. 102.00
26185 ....... Remove finger bone ...................................... .................. 992.95 4 630.00 .................. 126.00
26200 ....... Remove hand bone lesion ............................. .................. 992.95 2 446.00 .................. 89.20
26210 ....... Removal of finger lesion ................................ .................. 992.95 2 446.00 .................. 89.20
26215 ....... Remove/graft finger lesion ............................. .................. 992.95 3 510.00 .................. 102.00
26230 ....... Partial removal of hand bone ........................ .................. 992.95 7 992.95 Y .............. 198.59
26235 ....... Partial removal, finger bone .......................... .................. 992.95 3 510.00 .................. 102.00
26236 ....... Partial removal, finger bone .......................... .................. 992.95 3 510.00 .................. 102.00
26250 ....... Extensive hand surgery ................................. .................. 992.95 3 510.00 .................. 102.00
26255 ....... Extensive hand surgery ................................. .................. 1,590.53 3 510.00 .................. 102.00
26260 ....... Extensive finger surgery ................................ .................. 992.95 3 510.00 .................. 102.00
26261 ....... Extensive finger surgery ................................ .................. 992.95 3 510.00 .................. 102.00
26262 ....... Partial removal of finger ................................ .................. 992.95 2 446.00 .................. 89.20
26320 ....... Removal of implant from hand ...................... .................. 928.31 2 446.00 .................. 89.20
26350 ....... Repair finger/hand tendon ............................. .................. 1,590.53 1 333.00 .................. 66.60
26352 ....... Repair/graft hand tendon ............................... .................. 1,590.53 4 630.00 .................. 126.00
26390 ....... Revise hand/finger tendon ............................. .................. 1,590.53 4 630.00 .................. 126.00
26410 ....... Repair hand tendon ....................................... .................. 992.95 3 510.00 .................. 102.00
26415 ....... Excision, hand/finger tendon ......................... .................. 1,590.53 4 630.00 .................. 126.00
26416 ....... Graft hand or finger tendon ........................... .................. 1,590.53 3 510.00 .................. 102.00
26418 ....... Repair finger tendon ...................................... .................. 992.95 4 630.00 .................. 126.00
26420 ....... Repair/graft finger tendon .............................. .................. 1,590.53 4 630.00 .................. 126.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
26437 ....... Realignment of tendons ................................. .................. 992.95 3 510.00 .................. 102.00
26440 ....... Release palm/finger tendon ........................... .................. 992.95 3 510.00 .................. 102.00
26442 ....... Release palm & finger tendon ....................... .................. 1,590.53 3 510.00 .................. 102.00
26445 ....... Release hand/finger tendon .......................... .................. 992.95 3 510.00 .................. 102.00
26449 ....... Release forearm/hand tendon ....................... .................. 1,590.53 3 510.00 .................. 102.00
26450 ....... Incision of palm tendon ................................. .................. 992.95 3 510.00 .................. 102.00
26455 ....... Incision of finger tendon ................................ .................. 992.95 3 510.00 .................. 102.00
26460 ....... Incise hand/finger tendon .............................. .................. 992.95 3 510.00 .................. 102.00
26471 ....... Fusion of finger tendons ................................ .................. 992.95 2 446.00 .................. 89.20
26474 ....... Fusion of finger tendons ................................ .................. 992.95 2 446.00 .................. 89.20
26476 ....... Tendon lengthening ....................................... .................. 992.95 1 333.00 .................. 66.60
26477 ....... Tendon shortening ......................................... .................. 992.95 1 333.00 .................. 66.60
26478 ....... Lengthening of hand tendon .......................... .................. 992.95 1 333.00 .................. 66.60
26479 ....... Shortening of hand tendon ............................ .................. 992.95 1 333.00 .................. 66.60
26480 ....... Transplant hand tendon ................................. .................. 1,590.53 3 510.00 .................. 102.00
26483 ....... Transplant/graft hand tendon ........................ .................. 1,590.53 3 510.00 .................. 102.00
26485 ....... Transplant palm tendon ................................. .................. 1,590.53 2 446.00 .................. 89.20
26489 ....... Transplant/graft palm tendon ......................... .................. 1,590.53 3 510.00 .................. 102.00
26490 ....... Revise thumb tendon ..................................... .................. 1,590.53 3 510.00 .................. 102.00
26492 ....... Tendon transfer with graft ............................. .................. 1,590.53 3 510.00 .................. 102.00
26494 ....... Hand tendon/muscle transfer ........................ .................. 1,590.53 3 510.00 .................. 102.00
26496 ....... Revise thumb tendon ..................................... .................. 1,590.53 3 510.00 .................. 102.00
26497 ....... Finger tendon transfer ................................... .................. 1,590.53 3 510.00 .................. 102.00
26498 ....... Finger tendon transfer ................................... .................. 1,590.53 4 630.00 .................. 126.00
26499 ....... Revision of finger ........................................... .................. 1,590.53 3 510.00 .................. 102.00
26500 ....... Hand tendon reconstruction .......................... .................. 992.95 4 630.00 .................. 126.00
26502 ....... Hand tendon reconstruction .......................... .................. 1,590.53 4 630.00 .................. 126.00
26504 ....... Hand tendon reconstruction .......................... D .............. .................... 4 630.00 .................. ....................
26508 ....... Release thumb contracture ........................... .................. 992.95 3 510.00 .................. 102.00
26510 ....... Thumb tendon transfer .................................. .................. 1,590.53 3 510.00 .................. 102.00
26516 ....... Fusion of knuckle joint ................................... .................. 1,590.53 1 333.00 .................. 66.60
26517 ....... Fusion of knuckle joints ................................. .................. 1,590.53 3 510.00 .................. 102.00
26518 ....... Fusion of knuckle joints ................................. .................. 1,590.53 3 510.00 .................. 102.00
26520 ....... Release knuckle contracture ......................... .................. 992.95 3 510.00 .................. 102.00
26525 ....... Release finger contracture ............................ .................. 992.95 3 510.00 .................. 102.00
26530 ....... Revise knuckle joint ....................................... .................. 2,056.14 3 510.00 .................. 102.00
26531 ....... Revise knuckle with implant .......................... .................. 2,915.91 7 995.00 .................. 199.00
26535 ....... Revise finger joint .......................................... .................. 2,056.14 5 717.00 .................. 143.40
26536 ....... Revise/implant finger joint ............................. .................. 2,915.91 5 717.00 .................. 143.40
26540 ....... Repair hand joint ........................................... .................. 992.95 4 630.00 .................. 126.00
26541 ....... Repair hand joint with graft ........................... .................. 1,590.53 7 995.00 .................. 199.00
26542 ....... Repair hand joint with graft ........................... .................. 992.95 4 630.00 .................. 126.00
26545 ....... Reconstruct finger joint .................................. .................. 1,590.53 4 630.00 .................. 126.00
26546 ....... Repair nonunion hand ................................... .................. 1,590.53 4 630.00 .................. 126.00
26548 ....... Reconstruct finger joint .................................. .................. 1,590.53 4 630.00 .................. 126.00
26550 ....... Construct thumb replacement ....................... .................. 1,590.53 2 446.00 .................. 89.20
26555 ....... Positional change of finger ............................ .................. 1,590.53 3 510.00 .................. 102.00
26560 ....... Repair of web finger ...................................... .................. 992.95 2 446.00 .................. 89.20
26561 ....... Repair of web finger ...................................... .................. 1,590.53 3 510.00 .................. 102.00
26562 ....... Repair of web finger ...................................... .................. 1,590.53 4 630.00 .................. 126.00
26565 ....... Correct metacarpal flaw ................................. .................. 1,590.53 5 717.00 .................. 143.40
26567 ....... Correct finger deformity ................................. .................. 1,590.53 5 717.00 .................. 143.40
26568 ....... Lengthen metacarpal/finger ........................... .................. 1,590.53 3 510.00 .................. 102.00
26580 ....... Repair hand deformity ................................... .................. 992.95 5 717.00 .................. 143.40
26587 ....... Reconstruct extra finger ................................ .................. 992.95 5 717.00 .................. 143.40
26590 ....... Repair finger deformity .................................. .................. 992.95 5 717.00 .................. 143.40
26591 ....... Repair muscles of hand ................................. .................. 1,590.53 3 510.00 .................. 102.00
26593 ....... Release muscles of hand .............................. .................. 992.95 3 510.00 .................. 102.00
26596 ....... Excision constricting tissue ............................ .................. 992.95 2 446.00 .................. 89.20
26605 ....... Treat metacarpal fracture .............................. .................. 103.62 2 103.62 Y .............. 20.72
26607 ....... Treat metacarpal fracture .............................. .................. 103.62 2 103.62 Y .............. 20.72
26608 ....... Treat metacarpal fracture .............................. .................. 1,569.06 4 630.00 .................. 126.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
26615 ....... Treat metacarpal fracture .............................. .................. 2,307.40 4 630.00 .................. 126.00
26645 ....... Treat thumb fracture ...................................... .................. 103.62 1 103.62 Y .............. 20.72
26650 ....... Treat thumb fracture ...................................... .................. 1,569.06 2 446.00 .................. 89.20
26665 ....... Treat thumb fracture ...................................... .................. 2,307.40 4 630.00 .................. 126.00
26675 ....... Treat hand dislocation ................................... .................. 103.62 2 103.62 Y .............. 20.72
26676 ....... Pin hand dislocation ...................................... .................. 1,569.06 2 446.00 .................. 89.20
26685 ....... Treat hand dislocation ................................... .................. 2,307.40 3 510.00 .................. 102.00
26686 ....... Treat hand dislocation ................................... .................. 3,517.03 3 510.00 .................. 102.00
26705 ....... Treat knuckle dislocation ............................... .................. 103.62 2 103.62 Y .............. 20.72
26706 ....... Pin knuckle dislocation .................................. .................. 103.62 2 103.62 Y .............. 20.72
26715 ....... Treat knuckle dislocation ............................... .................. 2,307.40 4 630.00 .................. 126.00
26727 ....... Treat finger fracture, each ............................. .................. 1,569.06 7 995.00 .................. 199.00
26742 ....... Treat finger fracture, each ............................. .................. 103.62 2 103.62 Y .............. 20.72
26756 ....... Pin finger fracture, each ................................ .................. 1,569.06 2 446.00 .................. 89.20
26776 ....... Pin finger dislocation ..................................... .................. 1,569.06 2 446.00 .................. 89.20
26785 ....... Treat finger dislocation .................................. .................. 1,569.06 2 446.00 .................. 89.20
26820 ....... Thumb fusion with graft ................................. .................. 1,590.53 5 717.00 .................. 143.40
26841 ....... Fusion of thumb ............................................. .................. 1,590.53 4 630.00 .................. 126.00
26842 ....... Thumb fusion with graft ................................. .................. 1,590.53 4 630.00 .................. 126.00
26843 ....... Fusion of hand joint ....................................... .................. 1,590.53 3 510.00 .................. 102.00
26844 ....... Fusion/graft of hand joint ............................... .................. 1,590.53 3 510.00 .................. 102.00
26850 ....... Fusion of knuckle ........................................... .................. 1,590.53 4 630.00 .................. 126.00
26852 ....... Fusion of knuckle with graft ........................... .................. 1,590.53 4 630.00 .................. 126.00
26860 ....... Fusion of finger joint ...................................... .................. 1,590.53 3 510.00 .................. 102.00
26861 ....... Fusion of finger jnt, add-on ........................... .................. 1,590.53 2 446.00 .................. 89.20
26862 ....... Fusion/graft of finger joint .............................. .................. 1,590.53 4 630.00 .................. 126.00
26863 ....... Fuse/graft added joint .................................... .................. 1,590.53 3 510.00 .................. 102.00
26910 ....... Amputate metacarpal bone ........................... .................. 1,590.53 3 510.00 .................. 102.00
26951 ....... Amputation of finger/thumb ........................... .................. 992.95 2 446.00 .................. 89.20
26952 ....... Amputation of finger/thumb ........................... .................. 992.95 4 630.00 .................. 126.00
26990 ....... Drainage of pelvis lesion ............................... .................. 1,282.87 1 333.00 .................. 66.60
26991 ....... Drainage of pelvis bursa ................................ .................. 1,282.87 1 333.00 .................. 66.60
27000 ....... Incision of hip tendon .................................... .................. 1,282.87 2 446.00 .................. 89.20
27033 ....... Exploration of hip joint ................................... .................. 2,525.68 3 510.00 .................. 102.00
27035 ....... Denervation of hip joint .................................. .................. 2,525.68 4 630.00 .................. 126.00
27040 ....... Biopsy of soft tissues ..................................... .................. 418.49 1 333.00 .................. 66.60
27041 ....... Biopsy of soft tissues ..................................... .................. 418.49 2 418.49 Y .............. 83.70
27047 ....... Remove hip/pelvis lesion ............................... .................. 1,233.39 2 446.00 .................. 89.20
27048 ....... Remove hip/pelvis lesion ............................... .................. 1,233.39 3 510.00 .................. 102.00
27049 ....... Remove tumor, hip/pelvis .............................. .................. 1,233.39 3 510.00 .................. 102.00
27050 ....... Biopsy of sacroiliac joint ................................ .................. 1,282.87 3 510.00 .................. 102.00
27052 ....... Biopsy of hip joint .......................................... .................. 1,282.87 3 510.00 .................. 102.00
27060 ....... Removal of ischial bursa ............................... .................. 1,282.87 5 717.00 .................. 143.40
27062 ....... Remove femur lesion/bursa ........................... .................. 1,282.87 5 717.00 .................. 143.40
27065 ....... Removal of hip bone lesion ........................... .................. 1,282.87 5 717.00 .................. 143.40
27066 ....... Removal of hip bone lesion ........................... .................. 1,544.67 5 717.00 .................. 143.40
27067 ....... Remove/graft hip bone lesion ........................ .................. 1,544.67 5 717.00 .................. 143.40
27080 ....... Removal of tail bone ...................................... .................. 1,544.67 2 446.00 .................. 89.20
27086 ....... Remove hip foreign body .............................. .................. 418.49 1 333.00 .................. 66.60
27087 ....... Remove hip foreign body .............................. .................. 1,282.87 3 510.00 .................. 102.00
27097 ....... Revision of hip tendon ................................... .................. 1,544.67 3 510.00 .................. 102.00
27098 ....... Transfer tendon to pelvis ............................... .................. 1,544.67 3 510.00 .................. 102.00
27100 ....... Transfer of abdominal muscle ....................... .................. 2,525.68 4 630.00 .................. 126.00
27105 ....... Transfer of spinal muscle .............................. .................. 2,525.68 4 630.00 .................. 126.00
27110 ....... Transfer of iliopsoas muscle .......................... .................. 2,525.68 4 630.00 .................. 126.00
27111 ....... Transfer of iliopsoas muscle .......................... .................. 2,525.68 4 630.00 .................. 126.00
27193 ....... Treat pelvic ring fracture ................................ .................. 103.62 1 103.62 Y .............. 20.72
27194 ....... Treat pelvic ring fracture ................................ .................. 897.11 2 446.00 .................. 89.20
27202 ....... Treat tail bone fracture .................................. .................. 2,307.40 2 446.00 .................. 89.20
27230 ....... Treat thigh fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
27250 ....... Treat hip dislocation ...................................... .................. 103.62 1 103.62 Y .............. 20.72
27252 ....... Treat hip dislocation ...................................... .................. 897.11 2 446.00 .................. 89.20
27265 ....... Treat hip dislocation ...................................... .................. 103.62 1 103.62 Y .............. 20.72
27275 ....... Manipulation of hip joint ................................. .................. 897.11 2 446.00 .................. 89.20
27301 ....... Drain thigh/knee lesion .................................. .................. 1,076.22 3 510.00 .................. 102.00
27305 ....... Incise thigh tendon & fascia .......................... .................. 1,282.87 2 446.00 .................. 89.20
27306 ....... Incision of thigh tendon ................................. .................. 1,282.87 3 510.00 .................. 102.00
27307 ....... Incision of thigh tendons ................................ .................. 1,282.87 3 510.00 .................. 102.00
27310 ....... Exploration of knee joint ................................ .................. 1,544.67 4 630.00 .................. 126.00
27315 ....... Partial removal, thigh nerve ........................... D .............. .................... 2 446.00 .................. ....................
27320 ....... Partial removal, thigh nerve ........................... D .............. .................... 2 446.00 .................. ....................
27323 ....... Biopsy, thigh soft tissues ............................... .................. 418.49 1 333.00 .................. 66.60
27324 ....... Biopsy, thigh soft tissues ............................... .................. 1,233.39 1 333.00 .................. 66.60
27325 ....... Neurectomy, hamstring .................................. A .............. 1,097.20 2 446.00 .................. 89.20
27326 ....... Neurectomy, popliteal .................................... A .............. 1,097.20 2 446.00 .................. 89.20
27327 ....... Removal of thigh lesion ................................. .................. 1,233.39 2 446.00 .................. 89.20
27328 ....... Removal of thigh lesion ................................. .................. 1,233.39 3 510.00 .................. 102.00
27329 ....... Remove tumor, thigh/knee ............................ .................. 1,233.39 4 630.00 .................. 126.00
27330 ....... Biopsy, knee joint lining ................................. .................. 1,544.67 4 630.00 .................. 126.00
27331 ....... Explore/treat knee joint .................................. .................. 1,544.67 4 630.00 .................. 126.00
27332 ....... Removal of knee cartilage ............................. .................. 1,544.67 4 630.00 .................. 126.00
27333 ....... Removal of knee cartilage ............................. .................. 1,544.67 4 630.00 .................. 126.00
27334 ....... Remove knee joint lining ............................... .................. 1,544.67 4 630.00 .................. 126.00
27335 ....... Remove knee joint lining ............................... .................. 1,544.67 4 630.00 .................. 126.00
27340 ....... Removal of kneecap bursa ............................ .................. 1,282.87 3 510.00 .................. 102.00
27345 ....... Removal of knee cyst .................................... .................. 1,282.87 4 630.00 .................. 126.00
27347 ....... Remove knee cyst ......................................... .................. 1,282.87 4 630.00 .................. 126.00
27350 ....... Removal of kneecap ...................................... .................. 1,544.67 4 630.00 .................. 126.00
27355 ....... Remove femur lesion ..................................... .................. 1,544.67 3 510.00 .................. 102.00
27356 ....... Remove femur lesion/graft ............................ .................. 1,544.67 4 630.00 .................. 126.00
27357 ....... Remove femur lesion/graft ............................ .................. 1,544.67 5 717.00 .................. 143.40
27358 ....... Remove femur lesion/fixation ........................ .................. 1,544.67 5 717.00 .................. 143.40
27360 ....... Partial removal, leg bone(s) .......................... .................. 1,544.67 5 717.00 .................. 143.40
27372 ....... Removal of foreign body ............................... .................. 1,233.39 7 995.00 .................. 199.00
27380 ....... Repair of kneecap tendon ............................. .................. 1,282.87 1 333.00 .................. 66.60
27381 ....... Repair/graft kneecap tendon ......................... .................. 1,282.87 3 510.00 .................. 102.00
27385 ....... Repair of thigh muscle ................................... .................. 1,282.87 3 510.00 .................. 102.00
27386 ....... Repair/graft of thigh muscle .......................... .................. 1,282.87 3 510.00 .................. 102.00
27390 ....... Incision of thigh tendon ................................. .................. 1,282.87 1 333.00 .................. 66.60
27393 ....... Lengthening of thigh tendon .......................... .................. 1,544.67 2 446.00 .................. 89.20
27394 ....... Lengthening of thigh tendons ........................ .................. 1,544.67 3 510.00 .................. 102.00
27395 ....... Lengthening of thigh tendons ........................ .................. 2,525.68 3 510.00 .................. 102.00
27396 ....... Transplant of thigh tendon ............................. .................. 1,544.67 3 510.00 .................. 102.00
27397 ....... Transplants of thigh tendons ......................... .................. 2,525.68 3 510.00 .................. 102.00
27400 ....... Revise thigh muscles/tendons ....................... .................. 2,525.68 3 510.00 .................. 102.00
27403 ....... Repair of knee cartilage ................................ .................. 1,544.67 4 630.00 .................. 126.00
27405 ....... Repair of knee ligament ................................ .................. 2,525.68 4 630.00 .................. 126.00
27407 ....... Repair of knee ligament ................................ .................. 4,092.54 4 630.00 .................. 126.00
27409 ....... Repair of knee ligaments ............................... .................. 2,525.68 4 630.00 .................. 126.00
27418 ....... Repair degenerated kneecap ........................ .................. 2,525.68 3 510.00 .................. 102.00
27420 ....... Revision of unstable kneecap ....................... .................. 2,525.68 3 510.00 .................. 102.00
27422 ....... Revision of unstable kneecap ....................... .................. 2,525.68 7 995.00 .................. 199.00
27424 ....... Revision/removal of kneecap ........................ .................. 2,525.68 3 510.00 .................. 102.00
27425 ....... Lat retinacular release open .......................... .................. 1,544.67 7 995.00 .................. 199.00
27427 ....... Reconstruction, knee ..................................... .................. 2,525.68 3 510.00 .................. 102.00
27430 ....... Revision of thigh muscles .............................. .................. 2,525.68 4 630.00 .................. 126.00
27435 ....... Incision of knee joint ...................................... .................. 2,525.68 4 630.00 .................. 126.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
27437 ....... Revise kneecap ............................................. .................. 2,056.14 4 630.00 .................. 126.00
27438 ....... Revise kneecap with implant ......................... .................. 2,915.91 5 717.00 .................. 143.40
27441 ....... Revision of knee joint .................................... .................. 2,056.14 5 717.00 .................. 143.40
27496 ....... Decompression of thigh/knee ........................ .................. 1,282.87 5 717.00 .................. 143.40
27500 ....... Treatment of thigh fracture ............................ .................. 103.62 1 103.62 Y .............. 20.72
27509 ....... Treatment of thigh fracture ............................ .................. 1,569.06 3 510.00 .................. 102.00
27516 ....... Treat thigh fx growth plate ............................. .................. 103.62 1 103.62 Y .............. 20.72
27517 ....... Treat thigh fx growth plate ............................. .................. 103.62 1 103.62 Y .............. 20.72
27520 ....... Treat kneecap fracture .................................. .................. 103.62 1 103.62 Y .............. 20.72
27530 ....... Treat knee fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72
27532 ....... Treat knee fracture ........................................ .................. 103.62 1 103.62 Y .............. 20.72
27538 ....... Treat knee fracture(s) .................................... .................. 103.62 1 103.62 Y .............. 20.72
27550 ....... Treat knee dislocation ................................... .................. 103.62 1 103.62 Y .............. 20.72
27552 ....... Treat knee dislocation ................................... .................. 897.11 1 333.00 .................. 66.60
27560 ....... Treat kneecap dislocation .............................. .................. 103.62 1 103.62 Y .............. 20.72
27562 ....... Treat kneecap dislocation .............................. .................. 897.11 1 333.00 .................. 66.60
27566 ....... Treat kneecap dislocation .............................. .................. 2,307.40 2 446.00 .................. 89.20
27570 ....... Fixation of knee joint ..................................... .................. 897.11 1 333.00 .................. 66.60
27600 ....... Decompression of lower leg .......................... .................. 1,282.87 3 510.00 .................. 102.00
27603 ....... Drain lower leg lesion .................................... .................. 1,076.22 2 446.00 .................. 89.20
27604 ....... Drain lower leg bursa .................................... .................. 1,282.87 2 446.00 .................. 89.20
27605 ....... Incision of achilles tendon ............................. .................. 1,255.56 1 333.00 .................. 66.60
27606 ....... Incision of achilles tendon ............................. .................. 1,282.87 1 333.00 .................. 66.60
27607 ....... Treat lower leg bone lesion ........................... .................. 1,282.87 2 446.00 .................. 89.20
27610 ....... Explore/treat ankle joint ................................. .................. 1,544.67 2 446.00 .................. 89.20
27612 ....... Exploration of ankle joint ............................... .................. 1,544.67 3 510.00 .................. 102.00
27614 ....... Biopsy lower leg soft tissue ........................... .................. 1,233.39 2 446.00 .................. 89.20
27615 ....... Remove tumor, lower leg .............................. .................. 1,544.67 3 510.00 .................. 102.00
27618 ....... Remove lower leg lesion ............................... .................. 928.31 2 446.00 .................. 89.20
27619 ....... Remove lower leg lesion ............................... .................. 1,233.39 3 510.00 .................. 102.00
27620 ....... Explore/treat ankle joint ................................. .................. 1,544.67 4 630.00 .................. 126.00
27625 ....... Remove ankle joint lining .............................. .................. 1,544.67 4 630.00 .................. 126.00
27626 ....... Remove ankle joint lining .............................. .................. 1,544.67 4 630.00 .................. 126.00
27630 ....... Removal of tendon lesion .............................. .................. 1,282.87 3 510.00 .................. 102.00
27635 ....... Remove lower leg bone lesion ...................... .................. 1,544.67 3 510.00 .................. 102.00
27637 ....... Remove/graft leg bone lesion ........................ .................. 1,544.67 3 510.00 .................. 102.00
27638 ....... Remove/graft leg bone lesion ........................ .................. 1,544.67 3 510.00 .................. 102.00
27640 ....... Partial removal of tibia ................................... .................. 2,525.68 2 446.00 .................. 89.20
27641 ....... Partial removal of fibula ................................. .................. 1,544.67 2 446.00 .................. 89.20
27647 ....... Extensive ankle/heel surgery ......................... .................. 2,525.68 3 510.00 .................. 102.00
27650 ....... Repair achilles tendon ................................... .................. 2,525.68 3 510.00 .................. 102.00
27652 ....... Repair/graft achilles tendon ........................... .................. 4,092.54 3 510.00 .................. 102.00
27654 ....... Repair of achilles tendon ............................... .................. 2,525.68 3 510.00 .................. 102.00
27656 ....... Repair leg fascia defect ................................. .................. 1,282.87 2 446.00 .................. 89.20
27658 ....... Repair of leg tendon, each ............................ .................. 1,282.87 1 333.00 .................. 66.60
27675 ....... Repair lower leg tendons ............................... .................. 1,282.87 2 446.00 .................. 89.20
27676 ....... Repair lower leg tendons ............................... .................. 1,544.67 3 510.00 .................. 102.00
27680 ....... Release of lower leg tendon .......................... .................. 1,544.67 3 510.00 .................. 102.00
27681 ....... Release of lower leg tendons ........................ .................. 1,544.67 2 446.00 .................. 89.20
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
27685 ....... Revision of lower leg tendon ......................... .................. 1,544.67 3 510.00 .................. 102.00
27686 ....... Revise lower leg tendons .............................. .................. 1,544.67 3 510.00 .................. 102.00
27687 ....... Revision of calf tendon .................................. .................. 1,544.67 3 510.00 .................. 102.00
27690 ....... Revise lower leg tendon ................................ .................. 2,525.68 4 630.00 .................. 126.00
27691 ....... Revise lower leg tendon ................................ .................. 2,525.68 4 630.00 .................. 126.00
27692 ....... Revise additional leg tendon ......................... .................. 2,525.68 3 510.00 .................. 102.00
27695 ....... Repair of ankle ligament ................................ .................. 1,544.67 2 446.00 .................. 89.20
27696 ....... Repair of ankle ligaments .............................. .................. 1,544.67 2 446.00 .................. 89.20
27698 ....... Repair of ankle ligament ................................ .................. 1,544.67 2 446.00 .................. 89.20
27700 ....... Revision of ankle joint ................................... .................. 2,056.14 5 717.00 .................. 143.40
27704 ....... Removal of ankle implant .............................. .................. 1,282.87 2 446.00 .................. 89.20
27705 ....... Incision of tibia ............................................... .................. 2,525.68 2 446.00 .................. 89.20
27707 ....... Incision of fibula ............................................. .................. 1,282.87 2 446.00 .................. 89.20
27709 ....... Incision of tibia & fibula ................................. .................. 1,544.67 2 446.00 .................. 89.20
27730 ....... Repair of tibia epiphysis ................................ .................. 1,544.67 2 446.00 .................. 89.20
27732 ....... Repair of fibula epiphysis .............................. .................. 1,544.67 2 446.00 .................. 89.20
27734 ....... Repair lower leg epiphyses ........................... .................. 1,544.67 2 446.00 .................. 89.20
27740 ....... Repair of leg epiphyses ................................. .................. 1,544.67 2 446.00 .................. 89.20
27742 ....... Repair of leg epiphyses ................................. .................. 2,525.68 2 446.00 .................. 89.20
27745 ....... Reinforce tibia ................................................ .................. 4,092.54 3 510.00 .................. 102.00
27750 ....... Treatment of tibia fracture ............................. .................. 103.62 1 103.62 Y .............. 20.72
27752 ....... Treatment of tibia fracture ............................. .................. 103.62 1 103.62 Y .............. 20.72
27756 ....... Treatment of tibia fracture ............................. .................. 1,569.06 3 510.00 .................. 102.00
27760 ....... Treatment of ankle fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72
27766 ....... Treatment of ankle fracture ........................... .................. 2,307.40 3 510.00 .................. 102.00
27780 ....... Treatment of fibula fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72
27781 ....... Treatment of fibula fracture ........................... .................. 103.62 1 103.62 Y .............. 20.72
27784 ....... Treatment of fibula fracture ........................... .................. 2,307.40 3 510.00 .................. 102.00
27824 ....... Treat lower leg fracture ................................. .................. 103.62 1 103.62 Y .............. 20.72
27825 ....... Treat lower leg fracture ................................. .................. 103.62 2 103.62 Y .............. 20.72
27826 ....... Treat lower leg fracture ................................. .................. 2,307.40 3 510.00 .................. 102.00
27829 ....... Treat lower leg joint ....................................... .................. 2,307.40 2 446.00 .................. 89.20
27830 ....... Treat lower leg dislocation ............................. .................. 103.62 1 103.62 Y .............. 20.72
27831 ....... Treat lower leg dislocation ............................. .................. 103.62 1 103.62 Y .............. 20.72
27832 ....... Treat lower leg dislocation ............................. .................. 2,307.40 2 446.00 .................. 89.20
27840 ....... Treat ankle dislocation ................................... .................. 103.62 1 103.62 Y .............. 20.72
27842 ....... Treat ankle dislocation ................................... .................. 897.11 1 333.00 .................. 66.60
27846 ....... Treat ankle dislocation ................................... .................. 2,307.40 3 510.00 .................. 102.00
27848 ....... Treat ankle dislocation ................................... .................. 2,307.40 3 510.00 .................. 102.00
27860 ....... Fixation of ankle joint ..................................... .................. 897.11 1 333.00 .................. 66.60
27870 ....... Fusion of ankle joint, open ............................ .................. 4,092.54 4 630.00 .................. 126.00
27871 ....... Fusion of tibiofibular joint ............................... .................. 4,092.54 4 630.00 .................. 126.00
27889 ....... Amputation of foot at ankle ........................... .................. 1,544.67 3 510.00 .................. 102.00
27892 ....... Decompression of leg .................................... .................. 1,282.87 3 510.00 .................. 102.00
28002 ....... Treatment of foot infection ............................. .................. 1,282.87 3 510.00 .................. 102.00
28003 ....... Treatment of foot infection ............................. .................. 1,282.87 3 510.00 .................. 102.00
28005 ....... Treat foot bone lesion .................................... .................. 1,255.56 3 510.00 .................. 102.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
28008 ....... Incision of foot fascia ..................................... .................. 1,255.56 3 510.00 .................. 102.00
28011 ....... Incision of toe tendons .................................. .................. 1,255.56 3 510.00 .................. 102.00
28020 ....... Exploration of foot joint .................................. .................. 1,255.56 2 446.00 .................. 89.20
28022 ....... Exploration of foot joint .................................. .................. 1,255.56 2 446.00 .................. 89.20
28024 ....... Exploration of toe joint ................................... .................. 1,255.56 2 446.00 .................. 89.20
28030 ....... Removal of foot nerve ................................... D .............. .................... 4 630.00 .................. ....................
28035 ....... Decompression of tibia nerve ........................ .................. 1,097.20 4 630.00 .................. 126.00
28043 ....... Excision of foot lesion .................................... .................. 1,233.39 2 446.00 .................. 89.20
28045 ....... Excision of foot lesion .................................... .................. 1,255.56 3 510.00 .................. 102.00
28046 ....... Resection of tumor, foot ................................ .................. 1,255.56 3 510.00 .................. 102.00
28050 ....... Biopsy of foot joint lining ............................... .................. 1,255.56 2 446.00 .................. 89.20
28052 ....... Biopsy of foot joint lining ............................... .................. 1,255.56 2 446.00 .................. 89.20
28054 ....... Biopsy of toe joint lining ................................ .................. 1,255.56 2 446.00 .................. 89.20
28055 ....... Neurectomy, foot ........................................... A .............. 1,097.20 4 630.00 .................. 126.00
28060 ....... Partial removal, foot fascia ............................ .................. 1,255.56 2 446.00 .................. 89.20
28062 ....... Removal of foot fascia ................................... .................. 1,255.56 3 510.00 .................. 102.00
28070 ....... Removal of foot joint lining ............................ .................. 1,255.56 3 510.00 .................. 102.00
28072 ....... Removal of foot joint lining ............................ .................. 1,255.56 3 510.00 .................. 102.00
28080 ....... Removal of foot lesion ................................... .................. 1,255.56 3 510.00 .................. 102.00
28086 ....... Excise foot tendon sheath ............................. .................. 1,255.56 2 446.00 .................. 89.20
28088 ....... Excise foot tendon sheath ............................. .................. 1,255.56 2 446.00 .................. 89.20
28092 ....... Removal of toe lesions .................................. .................. 1,255.56 3 510.00 .................. 102.00
28100 ....... Removal of ankle/heel lesion ........................ .................. 1,255.56 2 446.00 .................. 89.20
28102 ....... Remove/graft foot lesion ................................ .................. 2,511.33 3 510.00 .................. 102.00
28108 ....... Removal of toe lesions .................................. .................. 1,255.56 2 446.00 .................. 89.20
28110 ....... Part removal of metatarsal ............................ .................. 1,255.56 3 510.00 .................. 102.00
28114 ....... Removal of metatarsal heads ........................ .................. 1,255.56 3 510.00 .................. 102.00
28116 ....... Revision of foot .............................................. .................. 1,255.56 3 510.00 .................. 102.00
28118 ....... Removal of heel bone ................................... .................. 1,255.56 4 630.00 .................. 126.00
28119 ....... Removal of heel spur .................................... .................. 1,255.56 4 630.00 .................. 126.00
28120 ....... Part removal of ankle/heel ............................. .................. 1,255.56 7 995.00 .................. 199.00
28122 ....... Partial removal of foot bone .......................... .................. 1,255.56 3 510.00 .................. 102.00
28126 ....... Partial removal of toe .................................... .................. 1,255.56 3 510.00 .................. 102.00
28130 ....... Removal of ankle bone .................................. .................. 1,255.56 3 510.00 .................. 102.00
28140 ....... Removal of metatarsal ................................... .................. 1,255.56 3 510.00 .................. 102.00
28150 ....... Removal of toe .............................................. .................. 1,255.56 3 510.00 .................. 102.00
28171 ....... Extensive foot surgery ................................... .................. 1,255.56 3 510.00 .................. 102.00
28192 ....... Removal of foot foreign body ........................ .................. 928.31 2 446.00 .................. 89.20
28193 ....... Removal of foot foreign body ........................ .................. 418.49 4 418.49 Y .............. 83.70
28200 ....... Repair of foot tendon ..................................... .................. 1,255.56 3 510.00 .................. 102.00
28202 ....... Repair/graft of foot tendon ............................. .................. 1,255.56 3 510.00 .................. 102.00
28208 ....... Repair of foot tendon ..................................... .................. 1,255.56 3 510.00 .................. 102.00
28210 ....... Repair/graft of foot tendon ............................. .................. 2,511.33 3 510.00 .................. 102.00
28222 ....... Release of foot tendons ................................ .................. 1,255.56 1 333.00 .................. 66.60
28225 ....... Release of foot tendon .................................. .................. 1,255.56 1 333.00 .................. 66.60
28226 ....... Release of foot tendons ................................ .................. 1,255.56 1 333.00 .................. 66.60
28234 ....... Incision of foot tendon ................................... .................. 1,255.56 2 446.00 .................. 89.20
28238 ....... Revision of foot tendon .................................. .................. 2,511.33 3 510.00 .................. 102.00
28240 ....... Release of big toe ......................................... .................. 1,255.56 2 446.00 .................. 89.20
28250 ....... Revision of foot fascia ................................... .................. 1,255.56 3 510.00 .................. 102.00
28260 ....... Release of midfoot joint ................................. .................. 1,255.56 3 510.00 .................. 102.00
28261 ....... Revision of foot tendon .................................. .................. 1,255.56 3 510.00 .................. 102.00
28262 ....... Revision of foot and ankle ............................. .................. 1,255.56 4 630.00 .................. 126.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
28264 ....... Release of midfoot joint ................................. .................. 2,511.33 1 333.00 .................. 66.60
28270 ....... Release of foot contracture ........................... .................. 1,255.56 3 510.00 .................. 102.00
28280 ....... Fusion of toes ................................................ .................. 1,255.56 2 446.00 .................. 89.20
28285 ....... Repair of hammertoe ..................................... .................. 1,255.56 3 510.00 .................. 102.00
28286 ....... Repair of hammertoe ..................................... .................. 1,255.56 4 630.00 .................. 126.00
28288 ....... Partial removal of foot bone .......................... .................. 1,255.56 3 510.00 .................. 102.00
28289 ....... Repair hallux rigidus ...................................... .................. 1,255.56 3 510.00 .................. 102.00
28290 ....... Correction of bunion ...................................... .................. 1,735.54 2 446.00 .................. 89.20
28300 ....... Incision of heel bone ..................................... .................. 2,511.33 2 446.00 .................. 89.20
28302 ....... Incision of ankle bone .................................... .................. 1,255.56 2 446.00 .................. 89.20
28304 ....... Incision of midfoot bones ............................... .................. 2,511.33 2 446.00 .................. 89.20
28305 ....... Incise/graft midfoot bones ............................. .................. 2,511.33 3 510.00 .................. 102.00
28306 ....... Incision of metatarsal ..................................... .................. 1,255.56 4 630.00 .................. 126.00
28309 ....... Incision of metatarsals ................................... .................. 2,511.33 4 630.00 .................. 126.00
28310 ....... Revision of big toe ......................................... .................. 1,255.56 3 510.00 .................. 102.00
28312 ....... Revision of toe ............................................... .................. 1,255.56 3 510.00 .................. 102.00
28313 ....... Repair deformity of toe .................................. .................. 1,255.56 2 446.00 .................. 89.20
28315 ....... Removal of sesamoid bone ........................... .................. 1,255.56 4 630.00 .................. 126.00
28320 ....... Repair of foot bones ...................................... .................. 2,511.33 4 630.00 .................. 126.00
28322 ....... Repair of metatarsals .................................... .................. 2,511.33 4 630.00 .................. 126.00
28340 ....... Resect enlarged toe tissue ............................ .................. 1,255.56 4 630.00 .................. 126.00
28341 ....... Resect enlarged toe ...................................... .................. 1,255.56 4 630.00 .................. 126.00
28344 ....... Repair extra toe(s) ......................................... .................. 1,255.56 4 630.00 .................. 126.00
28345 ....... Repair webbed toe(s) .................................... .................. 1,255.56 4 630.00 .................. 126.00
28400 ....... Treatment of heel fracture ............................. .................. 103.62 1 103.62 Y .............. 20.72
28405 ....... Treatment of heel fracture ............................. .................. 103.62 2 103.62 Y .............. 20.72
28406 ....... Treatment of heel fracture ............................. .................. 1,569.06 2 446.00 .................. 89.20
28415 ....... Treat heel fracture ......................................... .................. 2,307.40 3 510.00 .................. 102.00
28420 ....... Treat/graft heel fracture ................................. .................. 2,307.40 4 630.00 .................. 126.00
28445 ....... Treat ankle fracture ....................................... .................. 2,307.40 3 510.00 .................. 102.00
28456 ....... Treat midfoot fracture .................................... .................. 1,569.06 2 446.00 .................. 89.20
28465 ....... Treat midfoot fracture, each .......................... .................. 2,307.40 3 510.00 .................. 102.00
28476 ....... Treat metatarsal fracture ............................... .................. 1,569.06 2 446.00 .................. 89.20
28485 ....... Treat metatarsal fracture ............................... .................. 2,307.40 4 630.00 .................. 126.00
28496 ....... Treat big toe fracture ..................................... .................. 1,569.06 2 446.00 .................. 89.20
28505 ....... Treat big toe fracture ..................................... .................. 2,307.40 3 510.00 .................. 102.00
28525 ....... Treat toe fracture ........................................... .................. 2,307.40 3 510.00 .................. 102.00
28531 ....... Treat sesamoid bone fracture ....................... .................. 2,307.40 3 510.00 .................. 102.00
28545 ....... Treat foot dislocation ..................................... .................. 1,569.06 1 333.00 .................. 66.60
28555 ....... Repair foot dislocation ................................... .................. 2,307.40 2 446.00 .................. 89.20
28575 ....... Treat foot dislocation ..................................... .................. 103.62 1 103.62 Y .............. 20.72
28605 ....... Treat foot dislocation ..................................... .................. 103.62 1 103.62 Y .............. 20.72
28635 ....... Treat toe dislocation ...................................... .................. 897.11 1 333.00 .................. 66.60
28636 ....... Treat toe dislocation ...................................... .................. 1,569.06 3 510.00 .................. 102.00
28645 ....... Repair toe dislocation .................................... .................. 2,307.40 3 510.00 .................. 102.00
28665 ....... Treat toe dislocation ...................................... .................. 897.11 1 333.00 .................. 66.60
28666 ....... Treat toe dislocation ...................................... .................. 1,569.06 3 510.00 .................. 102.00
28675 ....... Repair of toe dislocation ................................ .................. 2,307.40 3 510.00 .................. 102.00
28705 ....... Fusion of foot bones ...................................... .................. 2,511.33 4 630.00 .................. 126.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
28737 ....... Revision of foot bones ................................... .................. 2,511.33 5 717.00 .................. 143.40
28750 ....... Fusion of big toe joint .................................... .................. 2,511.33 4 630.00 .................. 126.00
28810 ....... Amputation toe & metatarsal ......................... .................. 1,255.56 2 446.00 .................. 89.20
28820 ....... Amputation of toe .......................................... .................. 1,255.56 2 446.00 .................. 89.20
28825 ....... Partial amputation of toe ............................... .................. 1,255.56 2 446.00 .................. 89.20
29800 ....... Jaw arthroscopy/surgery ................................ .................. 1,759.49 3 510.00 .................. 102.00
29804 ....... Jaw arthroscopy/surgery ................................ .................. 1,759.49 3 510.00 .................. 102.00
29805 ....... Shoulder arthroscopy, dx ............................... .................. 1,759.49 3 510.00 .................. 102.00
29806 ....... Shoulder arthroscopy/surgery ........................ .................. 2,796.96 3 510.00 .................. 102.00
29827 ....... Arthroscop rotator cuff repr ........................... .................. 2,796.96 5 717.00 .................. 143.40
29830 ....... Elbow arthroscopy ......................................... .................. 1,759.49 3 510.00 .................. 102.00
29834 ....... Elbow arthroscopy/surgery ............................ .................. 1,759.49 3 510.00 .................. 102.00
29840 ....... Wrist arthroscopy ........................................... .................. 1,759.49 3 510.00 .................. 102.00
29843 ....... Wrist arthroscopy/surgery .............................. .................. 1,759.49 3 510.00 .................. 102.00
29848 ....... Wrist endoscopy/surgery ............................... .................. 1,759.49 9 1,339.00 .................. 267.80
29850 ....... Knee arthroscopy/surgery .............................. .................. 1,759.49 4 630.00 .................. 126.00
29855 ....... Tibial arthroscopy/surgery ............................. .................. 2,796.96 4 630.00 .................. 126.00
29856 ....... Tibial arthroscopy/surgery ............................. .................. 1,759.49 4 630.00 .................. 126.00
29860 ....... Hip arthroscopy, dx ........................................ .................. 1,759.49 4 630.00 .................. 126.00
29861 ....... Hip arthroscopy/surgery ................................. .................. 1,759.49 4 630.00 .................. 126.00
29862 ....... Hip arthroscopy/surgery ................................. .................. 2,796.96 9 1,339.00 .................. 267.80
29863 ....... Hip arthroscopy/surgery ................................. .................. 2,796.96 4 630.00 .................. 126.00
29870 ....... Knee arthroscopy, dx ..................................... .................. 1,759.49 3 510.00 .................. 102.00
29871 ....... Knee arthroscopy/drainage ............................ .................. 1,759.49 3 510.00 .................. 102.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
29891 ....... Ankle arthroscopy/surgery ............................. .................. 1,759.49 3 510.00 .................. 102.00
29893 ....... Scope, plantar fasciotomy ............................. .................. 1,255.56 9 1,255.56 Y .............. 251.11
29900 ....... Mcp joint arthroscopy, dx .............................. .................. 992.95 3 510.00 .................. 102.00
29901 ....... Mcp joint arthroscopy, surg ........................... .................. 992.95 3 510.00 .................. 102.00
29902 ....... Mcp joint arthroscopy, surg ........................... .................. 992.95 3 510.00 .................. 102.00
30115 ....... Removal of nose polyp(s) .............................. .................. 1,009.71 2 446.00 .................. 89.20
30117 ....... Removal of intranasal lesion ......................... .................. 1,009.71 3 510.00 .................. 102.00
30118 ....... Removal of intranasal lesion ......................... .................. 1,434.04 3 510.00 .................. 102.00
30120 ....... Revision of nose ............................................ .................. 1,009.71 1 333.00 .................. 66.60
30125 ....... Removal of nose lesion ................................. .................. 2,348.02 2 446.00 .................. 89.20
30130 ....... Excise inferior turbinate ................................. .................. 1,009.71 3 510.00 .................. 102.00
30140 ....... Resect inferior turbinate ................................ .................. 1,434.04 2 446.00 .................. 89.20
30150 ....... Partial removal of nose .................................. .................. 2,348.02 3 510.00 .................. 102.00
30160 ....... Removal of nose ............................................ .................. 2,348.02 4 630.00 .................. 126.00
30220 ....... Insert nasal septal button .............................. .................. 464.15 3 464.15 Y .............. 92.83
30310 ....... Remove nasal foreign body ........................... .................. 1,009.71 1 333.00 .................. 66.60
30320 ....... Remove nasal foreign body ........................... .................. 1,009.71 2 446.00 .................. 89.20
30400 ....... Reconstruction of nose .................................. .................. 2,348.02 4 630.00 .................. 126.00
30430 ....... Revision of nose ............................................ .................. 1,434.04 3 510.00 .................. 102.00
30435 ....... Revision of nose ............................................ .................. 2,348.02 5 717.00 .................. 143.40
30450 ....... Revision of nose ............................................ .................. 2,348.02 7 995.00 .................. 199.00
30460 ....... Revision of nose ............................................ .................. 2,348.02 7 995.00 .................. 199.00
30462 ....... Revision of nose ............................................ .................. 2,348.02 9 1,339.00 .................. 267.80
30465 ....... Repair nasal stenosis .................................... .................. 2,348.02 9 1,339.00 .................. 267.80
30520 ....... Repair of nasal septum ................................. .................. 1,434.04 4 630.00 .................. 126.00
30540 ....... Repair nasal defect ........................................ .................. 2,348.02 5 717.00 .................. 143.40
30545 ....... Repair nasal defect ........................................ .................. 2,348.02 5 717.00 .................. 143.40
30560 ....... Release of nasal adhesions .......................... .................. 150.72 2 150.72 Y .............. 30.14
30580 ....... Repair upper jaw fistula ................................. .................. 2,348.02 4 630.00 .................. 126.00
30600 ....... Repair mouth/nose fistula .............................. .................. 2,348.02 4 630.00 .................. 126.00
30620 ....... Intranasal reconstruction ............................... .................. 2,348.02 7 995.00 .................. 199.00
30630 ....... Repair nasal septum defect ........................... .................. 1,434.04 7 995.00 .................. 199.00
30801 ....... Ablate inf turbinate, superf ............................ .................. 464.15 1 333.00 .................. 66.60
30802 ....... Cauterization, inner nose ............................... .................. 464.15 1 333.00 .................. 66.60
30903 ....... Control of nosebleed ..................................... .................. 72.48 1 72.48 Y .............. 14.50
30905 ....... Control of nosebleed ..................................... .................. 72.48 1 72.48 Y .............. 14.50
30906 ....... Repeat control of nosebleed ......................... .................. 72.48 1 72.48 Y .............. 14.50
30915 ....... Ligation, nasal sinus artery ............................ .................. 1,529.38 2 446.00 .................. 89.20
30920 ....... Ligation, upper jaw artery .............................. .................. 1,529.38 3 510.00 .................. 102.00
30930 ....... Ther fx, nasal inf turbinate ............................. .................. 1,009.71 4 630.00 .................. 126.00
31020 ....... Exploration, maxillary sinus ........................... .................. 1,434.04 2 446.00 .................. 89.20
31030 ....... Exploration, maxillary sinus ........................... .................. 2,348.02 3 510.00 .................. 102.00
31032 ....... Explore sinus, remove polyps ....................... .................. 2,348.02 4 630.00 .................. 126.00
31050 ....... Exploration, sphenoid sinus ........................... .................. 2,348.02 2 446.00 .................. 89.20
31051 ....... Sphenoid sinus surgery ................................. .................. 2,348.02 4 630.00 .................. 126.00
31070 ....... Exploration of frontal sinus ............................ .................. 1,434.04 2 446.00 .................. 89.20
31075 ....... Exploration of frontal sinus ............................ .................. 2,348.02 4 630.00 .................. 126.00
31080 ....... Removal of frontal sinus ................................ .................. 2,348.02 4 630.00 .................. 126.00
31090 ....... Exploration of sinuses ................................... .................. 2,348.02 5 717.00 .................. 143.40
31200 ....... Removal of ethmoid sinus ............................. .................. 2,348.02 2 446.00 .................. 89.20
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
31233 ....... Nasal/sinus endoscopy, dx ............................ .................. 86.39 2 86.39 Y .............. 17.28
31235 ....... Nasal/sinus endoscopy, dx ............................ .................. 909.28 1 333.00 .................. 66.60
31237 ....... Nasal/sinus endoscopy, surg ......................... .................. 909.28 2 446.00 .................. 89.20
31239 ....... Nasal/sinus endoscopy, surg ......................... .................. 1,349.30 4 630.00 .................. 126.00
31254 ....... Revision of ethmoid sinus ............................. .................. 1,349.30 3 510.00 .................. 102.00
31256 ....... Exploration maxillary sinus ............................ .................. 1,349.30 3 510.00 .................. 102.00
31267 ....... Endoscopy, maxillary sinus ........................... .................. 1,349.30 3 510.00 .................. 102.00
31276 ....... Sinus endoscopy, surgical ............................. .................. 1,349.30 3 510.00 .................. 102.00
31300 ....... Removal of larynx lesion ............................... .................. 1,434.04 5 717.00 .................. 143.40
31320 ....... Diagnostic incision, larynx ............................. .................. 2,348.02 2 446.00 .................. 89.20
31400 ....... Revision of larynx .......................................... .................. 2,348.02 2 446.00 .................. 89.20
31420 ....... Removal of epiglottis ..................................... .................. 2,348.02 2 446.00 .................. 89.20
31510 ....... Laryngoscopy with biopsy ............................. .................. 909.28 2 446.00 .................. 89.20
31511 ....... Remove foreign body, larynx ......................... .................. 86.39 2 86.39 Y .............. 17.28
31512 ....... Removal of larynx lesion ............................... .................. 909.28 2 446.00 .................. 89.20
31513 ....... Injection into vocal cord ................................. .................. 86.39 2 86.39 Y .............. 17.28
31515 ....... Laryngoscopy for aspiration .......................... .................. 909.28 1 333.00 .................. 66.60
31525 ....... Dx laryngoscopy excl nb ............................... .................. 909.28 1 333.00 .................. 66.60
31526 ....... Dx laryngoscopy w/oper scope ..................... .................. 1,349.30 2 446.00 .................. 89.20
31527 ....... Laryngoscopy for treatment ........................... .................. 1,349.30 1 333.00 .................. 66.60
31528 ....... Laryngoscopy and dilation ............................. .................. 909.28 2 446.00 .................. 89.20
31529 ....... Laryngoscopy and dilation ............................. .................. 909.28 2 446.00 .................. 89.20
31530 ....... Laryngoscopy w/fb removal ........................... .................. 1,349.30 2 446.00 .................. 89.20
31531 ....... Laryngoscopy w/fb & op scope ..................... .................. 1,349.30 3 510.00 .................. 102.00
31535 ....... Laryngoscopy w/biopsy ................................. .................. 1,349.30 2 446.00 .................. 89.20
31536 ....... Laryngoscopy w/bx & op scope .................... .................. 1,349.30 3 510.00 .................. 102.00
31540 ....... Laryngoscopy w/exc of tumor ........................ .................. 1,349.30 3 510.00 .................. 102.00
31541 ....... Larynscop w/tumr exc + scope ..................... .................. 1,349.30 4 630.00 .................. 126.00
31545 ....... Remove vc lesion w/scope ............................ .................. 1,349.30 4 630.00 .................. 126.00
31546 ....... Remove vc lesion scope/graft ....................... .................. 1,349.30 4 630.00 .................. 126.00
31560 ....... Laryngoscop w/arytenoidectom ..................... .................. 1,349.30 5 717.00 .................. 143.40
31561 ....... Larynscop, remve cart + scop ....................... .................. 1,349.30 5 717.00 .................. 143.40
31570 ....... Laryngoscope w/vc inj ................................... .................. 909.28 2 446.00 .................. 89.20
31571 ....... Laryngoscop w/vc inj + scope ....................... .................. 1,349.30 2 446.00 .................. 89.20
31576 ....... Laryngoscopy with biopsy ............................. .................. 1,349.30 2 446.00 .................. 89.20
31577 ....... Remove foreign body, larynx ......................... .................. 236.42 2 236.42 Y .............. 47.28
31578 ....... Removal of larynx lesion ............................... .................. 1,349.30 2 446.00 .................. 89.20
31590 ....... Reinnervate larynx ......................................... .................. 2,348.02 5 717.00 .................. 143.40
31595 ....... Larynx nerve surgery ..................................... .................. 2,348.02 2 446.00 .................. 89.20
31603 ....... Incision of windpipe ....................................... .................. 464.15 1 333.00 .................. 66.60
31611 ....... Surgery/speech prosthesis ............................ .................. 1,434.04 3 510.00 .................. 102.00
31612 ....... Puncture/clear windpipe ................................ .................. 1,434.04 1 333.00 .................. 66.60
31613 ....... Repair windpipe opening ............................... .................. 1,434.04 2 446.00 .................. 89.20
31614 ....... Repair windpipe opening ............................... .................. 2,348.02 2 446.00 .................. 89.20
31615 ....... Visualization of windpipe ............................... .................. 585.35 1 333.00 .................. 66.60
31620 ....... Endobronchial us add-on ............................... A* ............. 1,984.52 1 333.00 .................. 66.60
31622 ....... Dx bronchoscope/wash ................................. .................. 585.35 1 333.00 .................. 66.60
31623 ....... Dx bronchoscope/brush ................................. .................. 585.35 2 446.00 .................. 89.20
31624 ....... Dx bronchoscope/lavage ............................... .................. 585.35 2 446.00 .................. 89.20
31625 ....... Bronchoscopy w/biopsy(s) ............................. .................. 585.35 2 446.00 .................. 89.20
31628 ....... Bronchoscopy/lung bx, each ......................... .................. 585.35 2 446.00 .................. 89.20
31629 ....... Bronchoscopy/needle bx, each ..................... .................. 585.35 2 446.00 .................. 89.20
31630 ....... Bronchoscopy dilate/fx repr ........................... .................. 1,352.90 2 446.00 .................. 89.20
31631 ....... Bronchoscopy, dilate w/stent ......................... .................. 1,352.90 2 446.00 .................. 89.20
31635 ....... Bronchoscopy w/fb removal .......................... .................. 585.35 2 446.00 .................. 89.20
31636 ....... Bronchoscopy, bronch stents ........................ .................. 1,352.90 2 446.00 .................. 89.20
31637 ....... Bronchoscopy, stent add-on .......................... .................. 585.35 1 333.00 .................. 66.60
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
31638 ....... Bronchoscopy, revise stent ........................... .................. 1,352.90 2 446.00 .................. 89.20
31640 ....... Bronchoscopy w/tumor excise ....................... .................. 1,352.90 2 446.00 .................. 89.20
31641 ....... Bronchoscopy, treat blockage ....................... .................. 1,352.90 2 446.00 .................. 89.20
31643 ....... Diag bronchoscope/catheter .......................... .................. 585.35 2 446.00 .................. 89.20
31645 ....... Bronchoscopy, clear airways ......................... .................. 585.35 1 333.00 .................. 66.60
31646 ....... Bronchoscopy, reclear airway ....................... .................. 585.35 1 333.00 .................. 66.60
31656 ....... Bronchoscopy, inj for x-ray ............................ .................. 585.35 1 333.00 .................. 66.60
31700 ....... Insertion of airway catheter ........................... D .............. .................... 1 333.00 .................. ....................
31717 ....... Bronchial brush biopsy .................................. .................. 236.42 1 236.42 Y .............. 47.28
31720 ....... Clearance of airways ..................................... .................. 47.32 1 47.32 Y .............. 9.46
31730 ....... Intro, windpipe wire/tube ................................ .................. 236.42 1 236.42 Y .............. 47.28
31750 ....... Repair of windpipe ......................................... .................. 2,348.02 5 717.00 .................. 143.40
31755 ....... Repair of windpipe ......................................... .................. 2,348.02 2 446.00 .................. 89.20
31820 ....... Closure of windpipe lesion ............................ .................. 1,009.71 1 333.00 .................. 66.60
31825 ....... Repair of windpipe defect .............................. .................. 1,434.04 2 446.00 .................. 89.20
31830 ....... Revise windpipe scar ..................................... .................. 1,434.04 2 446.00 .................. 89.20
32000 ....... Drainage of chest .......................................... .................. 222.78 1 222.78 Y .............. 44.56
32400 ....... Needle biopsy chest lining ............................. .................. 377.32 1 333.00 .................. 66.60
32405 ....... Biopsy, lung or mediastinum ......................... .................. 377.32 1 333.00 .................. 66.60
32420 ....... Puncture/clear lung ........................................ .................. 222.78 1 222.78 Y .............. 44.56
33010 ....... Drainage of heart sac .................................... .................. 222.78 2 222.78 Y .............. 44.56
33011 ....... Repeat drainage of heart sac ........................ .................. 222.78 2 222.78 Y .............. 44.56
33212 ....... Insertion of pulse generator ........................... .................. 6,042.45 3 510.00 .................. 102.00
33213 ....... Insertion of pulse generator ........................... .................. 6,931.86 3 510.00 .................. 102.00
33222 ....... Revise pocket, pacemaker ............................ .................. 1,317.27 2 446.00 .................. 89.20
33223 ....... Revise pocket, pacing-defib .......................... .................. 1,317.27 2 446.00 .................. 89.20
33233 ....... Removal of pacemaker system ..................... .................. 1,574.45 2 446.00 .................. 89.20
35188 ....... Repair blood vessel lesion ............................ .................. 2,319.75 4 630.00 .................. 126.00
35207 ....... Repair blood vessel lesion ............................ .................. 2,319.75 4 630.00 .................. 126.00
35875 ....... Removal of clot in graft ................................. .................. 2,319.75 9 1,339.00 .................. 267.80
35876 ....... Removal of clot in graft ................................. .................. 2,319.75 9 1,339.00 .................. 267.80
36260 ....... Insertion of infusion pump ............................. .................. 1,752.03 3 510.00 .................. 102.00
36261 ....... Revision of infusion pump ............................. .................. 1,752.03 2 446.00 .................. 89.20
36262 ....... Removal of infusion pump ............................. .................. 1,393.26 1 333.00 .................. 66.60
36475 ....... Endovenous rf, 1st vein ................................. .................. 2,134.71 9 1,339.00 .................. 267.80
36476 ....... Endovenous rf, vein add-on .......................... .................. 2,134.71 9 1,339.00 .................. 267.80
36478 ....... Endovenous laser, 1st vein ........................... .................. 1,529.38 9 1,339.00 .................. 267.80
36479 ....... Endovenous laser vein addon ....................... .................. 1,529.38 9 1,339.00 .................. 267.80
36555 ....... Insert non-tunnel cv cath ............................... .................. 539.97 1 333.00 .................. 66.60
36556 ....... Insert non-tunnel cv cath ............................... .................. 539.97 1 333.00 .................. 66.60
36557 ....... Insert tunneled cv cath .................................. .................. 1,393.26 2 446.00 .................. 89.20
36568 ....... Insert picc cath .............................................. .................. 539.97 1 333.00 .................. 66.60
36569 ....... Insert picc cath .............................................. .................. 539.97 1 333.00 .................. 66.60
36570 ....... Insert picvad cath .......................................... .................. 1,393.26 3 510.00 .................. 102.00
36571 ....... Insert picvad cath .......................................... .................. 1,393.26 3 510.00 .................. 102.00
36575 ....... Repair tunneled cv cath ................................. .................. 539.97 2 446.00 .................. 89.20
36576 ....... Repair tunneled cv cath ................................. .................. 539.97 2 446.00 .................. 89.20
36578 ....... Replace tunneled cv cath .............................. .................. 1,393.26 2 446.00 .................. 89.20
36580 ....... Replace cvad cath ......................................... .................. 539.97 1 333.00 .................. 66.60
36584 ....... Replace picc cath .......................................... .................. 539.97 1 333.00 .................. 66.60
36585 ....... Replace picvad cath ...................................... .................. 1,393.26 3 510.00 .................. 102.00
36589 ....... Removal tunneled cv cath ............................. .................. 539.97 1 333.00 .................. 66.60
36590 ....... Removal tunneled cv cath ............................. .................. 539.97 1 333.00 .................. 66.60
36640 ....... Insertion catheter, artery ................................ .................. 1,752.03 1 333.00 .................. 66.60
36800 ....... Insertion of cannula ....................................... .................. 1,795.68 3 510.00 .................. 102.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
36818 ....... Av fuse, uppr arm, cephalic ........................... A* ............. 2,319.75 3 510.00 .................. 102.00
36819 ....... Av fuse, uppr arm, basilic .............................. .................. 2,319.75 3 510.00 .................. 102.00
36820 ....... Av fusion/forearm vein ................................... .................. 2,319.75 3 510.00 .................. 102.00
36821 ....... Av fusion direct any site ................................ .................. 2,319.75 3 510.00 .................. 102.00
36825 ....... Artery-vein autograft ...................................... .................. 2,319.75 4 630.00 .................. 126.00
36830 ....... Artery-vein nonautograft ................................ .................. 2,319.75 4 630.00 .................. 126.00
36831 ....... Open thrombect av fistula ............................. .................. 2,319.75 9 1,339.00 .................. 267.80
36832 ....... Av fistula revision, open ................................ .................. 2,319.75 4 630.00 .................. 126.00
36833 ....... Av fistula revision ........................................... .................. 2,319.75 4 630.00 .................. 126.00
36834 ....... Repair A-V aneurysm .................................... .................. 2,319.75 3 510.00 .................. 102.00
36835 ....... Artery to vein shunt ....................................... .................. 1,795.68 4 630.00 .................. 126.00
36860 ....... External cannula declotting ........................... .................. 127.40 2 127.40 Y .............. 25.48
36861 ....... Cannula declotting ......................................... .................. 1,795.68 3 510.00 .................. 102.00
36870 ....... Percut thrombect av fistula ............................ .................. 1,990.44 9 1,339.00 .................. 267.80
37500 ....... Endoscopy ligate perf veins .......................... .................. 2,134.71 3 510.00 .................. 102.00
37607 ....... Ligation of a-v fistula ..................................... .................. 1,529.38 3 510.00 .................. 102.00
37609 ....... Temporal artery procedure ............................ .................. 928.31 2 446.00 .................. 89.20
37650 ....... Revision of major vein ................................... .................. 1,529.38 2 446.00 .................. 89.20
37700 ....... Revise leg vein .............................................. .................. 2,134.71 2 446.00 .................. 89.20
37718 ....... Ligate/strip short leg vein .............................. .................. 2,134.71 3 510.00 .................. 102.00
37722 ....... Ligate/strip long leg vein ................................ .................. 2,134.71 3 510.00 .................. 102.00
37735 ....... Removal of leg veins/lesion ........................... .................. 2,134.71 3 510.00 .................. 102.00
37760 ....... Ligation, leg veins, open ................................ .................. 1,529.38 3 510.00 .................. 102.00
37780 ....... Revision of leg vein ....................................... .................. 1,529.38 3 510.00 .................. 102.00
37785 ....... Ligate/divide/excise vein ................................ .................. 1,529.38 3 510.00 .................. 102.00
37790 ....... Penile venous occlusion ................................ .................. 2,027.66 3 510.00 .................. 102.00
38300 ....... Drainage, lymph node lesion ......................... .................. 685.58 1 333.00 .................. 66.60
38305 ....... Drainage, lymph node lesion ......................... .................. 1,076.22 2 446.00 .................. 89.20
38308 ....... Incision of lymph channels ............................ .................. 1,306.94 2 446.00 .................. 89.20
38500 ....... Biopsy/removal, lymph nodes ........................ .................. 1,306.94 2 446.00 .................. 89.20
38505 ....... Needle biopsy, lymph nodes ......................... .................. 240.00 1 240.00 Y .............. 48.00
38542 ....... Explore deep node(s), neck .......................... .................. 2,318.72 2 446.00 .................. 89.20
38550 ....... Removal, neck/armpit lesion ......................... .................. 1,306.94 3 510.00 .................. 102.00
38555 ....... Removal, neck/armpit lesion ......................... .................. 1,306.94 4 630.00 .................. 126.00
38570 ....... Laparoscopy, lymph node biop ..................... .................. 2,676.86 9 1,339.00 .................. 267.80
38571 ....... Laparoscopy, lymphadenectomy ................... .................. 4,333.90 9 1,339.00 .................. 267.80
38572 ....... Laparoscopy, lymphadenectomy ................... .................. 2,676.86 9 1,339.00 .................. 267.80
38740 ....... Remove armpit lymph nodes ......................... .................. 2,318.72 2 446.00 .................. 89.20
38745 ....... Remove armpit lymph nodes ......................... .................. 2,318.72 4 630.00 .................. 126.00
38760 ....... Remove groin lymph nodes ........................... .................. 1,306.94 2 446.00 .................. 89.20
40500 ....... Partial excision of lip ...................................... .................. 1,009.71 2 446.00 .................. 89.20
40525 ....... Reconstruct lip with flap ................................ .................. 1,434.04 2 446.00 .................. 89.20
40527 ....... Reconstruct lip with flap ................................ .................. 1,434.04 2 446.00 .................. 89.20
40530 ....... Partial removal of lip ...................................... .................. 1,434.04 2 446.00 .................. 89.20
40650 ....... Repair lip ........................................................ .................. 464.15 3 464.15 Y .............. 92.83
40652 ....... Repair lip ........................................................ .................. 464.15 3 464.15 Y .............. 92.83
40654 ....... Repair lip ........................................................ .................. 464.15 3 464.15 Y .............. 92.83
40700 ....... Repair cleft lip/nasal ...................................... .................. 2,348.02 7 995.00 .................. 199.00
40801 ....... Drainage of mouth lesion .............................. .................. 464.15 2 446.00 .................. 89.20
40814 ....... Excise/repair mouth lesion ............................ .................. 1,009.71 2 446.00 .................. 89.20
40816 ....... Excision of mouth lesion ................................ .................. 1,434.04 2 446.00 .................. 89.20
40818 ....... Excise oral mucosa for graft .......................... .................. 150.72 1 150.72 Y .............. 30.14
40819 ....... Excise lip or cheek fold ................................. .................. 464.15 1 333.00 .................. 66.60
40831 ....... Repair mouth laceration ................................ .................. 464.15 1 333.00 .................. 66.60
40840 ....... Reconstruction of mouth ................................ .................. 1,434.04 2 446.00 .................. 89.20
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
41005 ....... Drainage of mouth lesion .............................. .................. 150.72 1 150.72 Y .............. 30.14
41006 ....... Drainage of mouth lesion .............................. .................. 1,434.04 1 333.00 .................. 66.60
41010 ....... Incision of tongue fold ................................... .................. 464.15 1 333.00 .................. 66.60
41112 ....... Excision of tongue lesion ............................... .................. 1,009.71 2 446.00 .................. 89.20
41116 ....... Excision of mouth lesion ................................ .................. 1,009.71 1 333.00 .................. 66.60
41120 ....... Partial removal of tongue .............................. .................. 1,434.04 5 717.00 .................. 143.40
41250 ....... Repair tongue laceration ............................... .................. 150.72 2 150.72 Y .............. 30.14
41251 ....... Repair tongue laceration ............................... .................. 150.72 2 150.72 Y .............. 30.14
41252 ....... Repair tongue laceration ............................... .................. 464.15 2 446.00 .................. 89.20
41500 ....... Fixation of tongue .......................................... .................. 1,434.04 1 333.00 .................. 66.60
41510 ....... Tongue to lip surgery ..................................... .................. 1,009.71 1 333.00 .................. 66.60
41520 ....... Reconstruction, tongue fold ........................... .................. 464.15 2 446.00 .................. 89.20
41800 ....... Drainage of gum lesion ................................. .................. 88.46 1 88.46 Y .............. 17.69
41827 ....... Excision of gum lesion ................................... .................. 1,434.04 2 446.00 .................. 89.20
42000 ....... Drainage mouth roof lesion ........................... .................. 150.72 2 150.72 Y .............. 30.14
42107 ....... Excision lesion, mouth roof ........................... .................. 1,434.04 2 446.00 .................. 89.20
42120 ....... Remove palate/lesion .................................... .................. 2,348.02 4 630.00 .................. 126.00
42140 ....... Excision of uvula ............................................ .................. 464.15 2 446.00 .................. 89.20
42145 ....... Repair palate, pharynx/uvula ......................... .................. 1,434.04 5 717.00 .................. 143.40
42180 ....... Repair palate ................................................. .................. 150.72 1 150.72 Y .............. 30.14
42182 ....... Repair palate ................................................. .................. 2,348.02 2 446.00 .................. 89.20
42200 ....... Reconstruct cleft palate ................................. .................. 2,348.02 5 717.00 .................. 143.40
42226 ....... Lengthening of palate .................................... .................. 2,348.02 5 717.00 .................. 143.40
42235 ....... Repair palate ................................................. .................. 1,009.71 5 717.00 .................. 143.40
42260 ....... Repair nose to lip fistula ................................ .................. 1,434.04 4 630.00 .................. 126.00
42300 ....... Drainage of salivary gland ............................. .................. 1,009.71 1 333.00 .................. 66.60
42305 ....... Drainage of salivary gland ............................. .................. 1,009.71 2 446.00 .................. 89.20
42310 ....... Drainage of salivary gland ............................. .................. 150.72 1 150.72 Y .............. 30.14
42320 ....... Drainage of salivary gland ............................. .................. 150.72 1 150.72 Y .............. 30.14
42340 ....... Removal of salivary stone ............................. .................. 1,009.71 2 446.00 .................. 89.20
42405 ....... Biopsy of salivary gland ................................. .................. 1,009.71 2 446.00 .................. 89.20
42408 ....... Excision of salivary cyst ................................ .................. 1,009.71 3 510.00 .................. 102.00
42409 ....... Drainage of salivary cyst ............................... .................. 1,009.71 3 510.00 .................. 102.00
42410 ....... Excise parotid gland/lesion ............................ .................. 2,348.02 3 510.00 .................. 102.00
42440 ....... Excise submaxillary gland ............................. .................. 2,348.02 3 510.00 .................. 102.00
42450 ....... Excise sublingual gland ................................. .................. 1,434.04 2 446.00 .................. 89.20
42500 ....... Repair salivary duct ....................................... .................. 1,434.04 3 510.00 .................. 102.00
42505 ....... Repair salivary duct ....................................... .................. 2,348.02 4 630.00 .................. 126.00
42507 ....... Parotid duct diversion .................................... .................. 2,348.02 3 510.00 .................. 102.00
42600 ....... Closure of salivary fistula .............................. .................. 1,009.71 1 333.00 .................. 66.60
42665 ....... Ligation of salivary duct ................................. .................. 1,434.04 7 995.00 .................. 199.00
42700 ....... Drainage of tonsil abscess ............................ .................. 150.72 1 150.72 Y .............. 30.14
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
42720 ....... Drainage of throat abscess ........................... .................. 1,009.71 1 333.00 .................. 66.60
42725 ....... Drainage of throat abscess ........................... .................. 2,348.02 2 446.00 .................. 89.20
42802 ....... Biopsy of throat .............................................. .................. 1,009.71 1 333.00 .................. 66.60
42804 ....... Biopsy of upper nose/throat .......................... .................. 1,009.71 1 333.00 .................. 66.60
42806 ....... Biopsy of upper nose/throat .......................... .................. 1,434.04 2 446.00 .................. 89.20
42808 ....... Excise pharynx lesion .................................... .................. 1,009.71 2 446.00 .................. 89.20
42810 ....... Excision of neck cyst ..................................... .................. 1,434.04 3 510.00 .................. 102.00
42815 ....... Excision of neck cyst ..................................... .................. 2,348.02 5 717.00 .................. 143.40
42820 ....... Remove tonsils and adenoids ....................... .................. 1,359.46 3 510.00 .................. 102.00
42821 ....... Remove tonsils and adenoids ....................... .................. 1,359.46 5 717.00 .................. 143.40
42825 ....... Removal of tonsils ......................................... .................. 1,359.46 4 630.00 .................. 126.00
42826 ....... Removal of tonsils ......................................... .................. 1,359.46 4 630.00 .................. 126.00
42830 ....... Removal of adenoids ..................................... .................. 1,359.46 4 630.00 .................. 126.00
42860 ....... Excision of tonsil tags .................................... .................. 1,359.46 3 510.00 .................. 102.00
42870 ....... Excision of lingual tonsil ................................ .................. 1,359.46 3 510.00 .................. 102.00
42890 ....... Partial removal of pharynx ............................. .................. 2,348.02 7 995.00 .................. 199.00
42892 ....... Revision of pharyngeal walls ......................... .................. 2,348.02 7 995.00 .................. 199.00
42900 ....... Repair throat wound ...................................... .................. 464.15 1 333.00 .................. 66.60
42950 ....... Reconstruction of throat ................................ .................. 1,434.04 2 446.00 .................. 89.20
42955 ....... Surgical opening of throat ............................. .................. 1,434.04 2 446.00 .................. 89.20
42960 ....... Control throat bleeding .................................. .................. 72.48 1 72.48 Y .............. 14.50
42962 ....... Control throat bleeding .................................. .................. 2,348.02 2 446.00 .................. 89.20
42972 ....... Control nose/throat bleeding ......................... .................. 1,009.71 3 510.00 .................. 102.00
43200 ....... Esophagus endoscopy .................................. .................. 511.26 1 333.00 .................. 66.60
43201 ....... Esoph scope w/submucous inj ...................... .................. 511.26 1 333.00 .................. 66.60
43202 ....... Esophagus endoscopy, biopsy ...................... .................. 511.26 1 333.00 .................. 66.60
43204 ....... Esoph scope w/sclerosis inj .......................... .................. 511.26 1 333.00 .................. 66.60
43205 ....... Esophagus endoscopy/ligation ...................... .................. 511.26 1 333.00 .................. 66.60
43216 ....... Esophagus endoscopy/lesion ........................ .................. 511.26 1 333.00 .................. 66.60
43219 ....... Esophagus endoscopy .................................. .................. 1,410.54 1 333.00 .................. 66.60
43220 ....... Esoph endoscopy, dilation ............................. .................. 511.26 1 333.00 .................. 66.60
43227 ....... Esoph endoscopy, repair ............................... .................. 511.26 2 446.00 .................. 89.20
43228 ....... Esoph endoscopy, ablation ........................... .................. 1,583.12 2 446.00 .................. 89.20
43231 ....... Esoph endoscopy w/us exam ........................ .................. 511.26 2 446.00 .................. 89.20
43232 ....... Esoph endoscopy w/us fn bx ........................ .................. 511.26 2 446.00 .................. 89.20
43234 ....... Upper GI endoscopy, exam ........................... .................. 511.26 1 333.00 .................. 66.60
43235 ....... Uppr gi endoscopy, diagnosis ....................... .................. 511.26 1 333.00 .................. 66.60
43236 ....... Uppr gi scope w/submuc inj .......................... .................. 511.26 2 446.00 .................. 89.20
43237 ....... Endoscopic us exam, esoph ......................... .................. 511.26 2 446.00 .................. 89.20
43238 ....... Uppr gi endoscopy w/us fn bx ....................... .................. 511.26 2 446.00 .................. 89.20
43239 ....... Upper GI endoscopy, biopsy ......................... .................. 511.26 2 446.00 .................. 89.20
43240 ....... Esoph endoscope w/drain cyst ...................... .................. 511.26 2 446.00 .................. 89.20
43241 ....... Upper GI endoscopy with tube ...................... .................. 511.26 2 446.00 .................. 89.20
43242 ....... Uppr gi endoscopy w/us fn bx ....................... .................. 511.26 2 446.00 .................. 89.20
43243 ....... Upper gi endoscopy & inject ......................... .................. 511.26 2 446.00 .................. 89.20
43244 ....... Upper GI endoscopy/ligation ......................... .................. 511.26 2 446.00 .................. 89.20
43245 ....... Uppr gi scope dilate strictr ............................. .................. 511.26 2 446.00 .................. 89.20
43246 ....... Place gastrostomy tube ................................. .................. 511.26 2 446.00 .................. 89.20
43247 ....... Operative upper GI endoscopy ..................... .................. 511.26 2 446.00 .................. 89.20
43248 ....... Uppr gi endoscopy/guide wire ....................... .................. 511.26 2 446.00 .................. 89.20
43250 ....... Upper GI endoscopy/tumor ........................... .................. 511.26 2 446.00 .................. 89.20
43256 ....... Uppr gi endoscopy w/stent ............................ .................. 1,410.54 3 510.00 .................. 102.00
43257 ....... Uppr gi scope w/thrml txmnt .......................... A* ............. 1,583.12 3 510.00 .................. 102.00
43259 ....... Endoscopic ultrasound exam ........................ .................. 511.26 3 510.00 .................. 102.00
43260 ....... Endo cholangiopancreatograph ..................... .................. 1,219.41 2 446.00 .................. 89.20
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
43450 ....... Dilate esophagus ........................................... .................. 335.41 1 333.00 .................. 66.60
43453 ....... Dilate esophagus ........................................... .................. 335.41 1 333.00 .................. 66.60
43456 ....... Dilate esophagus ........................................... .................. 335.41 2 335.41 Y .............. 67.08
43458 ....... Dilate esophagus ........................................... .................. 335.41 2 335.41 Y .............. 67.08
43600 ....... Biopsy of stomach ......................................... .................. 511.26 1 333.00 .................. 66.60
43653 ....... Laparoscopy, gastrostomy ............................. .................. 2,676.86 9 1,339.00 .................. 267.80
43750 ....... Place gastrostomy tube ................................. .................. 511.26 2 446.00 .................. 89.20
43760 ....... Change gastrostomy tube ............................. .................. 144.98 1 144.98 Y .............. 29.00
43761 ....... Reposition gastrostomy tube ......................... A* ............. 459.78 1 333.00 .................. 66.60
43870 ....... Repair stomach opening ................................ .................. 511.26 1 333.00 .................. 66.60
44100 ....... Biopsy of bowel ............................................. .................. 511.26 1 333.00 .................. 66.60
44312 ....... Revision of ileostomy ..................................... .................. 1,317.27 1 333.00 .................. 66.60
44340 ....... Revision of colostomy .................................... .................. 1,317.27 3 510.00 .................. 102.00
44360 ....... Small bowel endoscopy ................................. .................. 583.61 2 446.00 .................. 89.20
44361 ....... Small bowel endoscopy/biopsy ..................... .................. 583.61 2 446.00 .................. 89.20
44370 ....... Small bowel endoscopy/stent ........................ .................. 1,410.54 9 1,339.00 .................. 267.80
44377 ....... Small bowel endoscopy/biopsy ..................... .................. 583.61 2 446.00 .................. 89.20
44379 ....... Sbowel endoscope w/stent ............................ .................. 1,410.54 9 1,339.00 .................. 267.80
44383 ....... Ileoscopy w/stent ........................................... .................. 1,410.54 9 1,339.00 .................. 267.80
44385 ....... Endoscopy of bowel pouch ........................... .................. 538.99 1 333.00 .................. 66.60
44386 ....... Endoscopy, bowel pouch/biop ....................... .................. 538.99 1 333.00 .................. 66.60
44388 ....... Colonoscopy .................................................. .................. 538.99 1 333.00 .................. 66.60
44389 ....... Colonoscopy with biopsy ............................... .................. 538.99 1 333.00 .................. 66.60
44390 ....... Colonoscopy for foreign body ........................ .................. 538.99 1 333.00 .................. 66.60
44391 ....... Colonoscopy for bleeding .............................. .................. 538.99 1 333.00 .................. 66.60
44392 ....... Colonoscopy & polypectomy ......................... .................. 538.99 1 333.00 .................. 66.60
44393 ....... Colonoscopy, lesion removal ......................... .................. 538.99 1 333.00 .................. 66.60
44394 ....... Colonoscopy w/snare .................................... .................. 538.99 1 333.00 .................. 66.60
44397 ....... Colonoscopy w/stent ...................................... .................. 1,410.54 1 333.00 .................. 66.60
45000 ....... Drainage of pelvic abscess ........................... .................. 312.07 1 312.07 Y .............. 62.41
45005 ....... Drainage of rectal abscess ............................ .................. 783.03 2 446.00 .................. 89.20
45020 ....... Drainage of rectal abscess ............................ .................. 783.03 2 446.00 .................. 89.20
45100 ....... Biopsy of rectum ............................................ .................. 1,368.78 1 333.00 .................. 66.60
45108 ....... Removal of anorectal lesion .......................... .................. 1,368.78 2 446.00 .................. 89.20
45150 ....... Excision of rectal stricture ............................. .................. 1,368.78 2 446.00 .................. 89.20
45160 ....... Excision of rectal lesion ................................. .................. 1,368.78 2 446.00 .................. 89.20
45170 ....... Excision of rectal lesion ................................. .................. 1,368.78 2 446.00 .................. 89.20
45190 ....... Destruction, rectal tumor ............................... .................. 1,368.78 9 1,339.00 .................. 267.80
45305 ....... Proctosigmoidoscopy w/bx ............................ .................. 525.41 1 333.00 .................. 66.60
45307 ....... Proctosigmoidoscopy fb ................................. .................. 1,268.55 1 333.00 .................. 66.60
45308 ....... Proctosigmoidoscopy removal ....................... .................. 525.41 1 333.00 .................. 66.60
45317 ....... Proctosigmoidoscopy bleed ........................... .................. 525.41 1 333.00 .................. 66.60
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
45320 ....... Proctosigmoidoscopy ablate .......................... .................. 1,268.55 1 333.00 .................. 66.60
45321 ....... Proctosigmoidoscopy volvul .......................... .................. 1,268.55 1 333.00 .................. 66.60
45327 ....... Proctosigmoidoscopy w/stent ........................ .................. 1,410.54 1 333.00 .................. 66.60
45331 ....... Sigmoidoscopy and biopsy ............................ .................. 299.24 1 299.24 Y .............. 59.85
45332 ....... Sigmoidoscopy w/fb removal ......................... .................. 299.24 1 299.24 Y .............. 59.85
45333 ....... Sigmoidoscopy & polypectomy ...................... .................. 525.41 1 333.00 .................. 66.60
45334 ....... Sigmoidoscopy for bleeding .......................... .................. 525.41 1 333.00 .................. 66.60
45335 ....... Sigmoidoscopy w/submuc inj ........................ .................. 299.24 1 299.24 Y .............. 59.85
45337 ....... Sigmoidoscopy & decompress ...................... .................. 299.24 1 299.24 Y .............. 59.85
45338 ....... Sigmoidoscopy w/tumr remove ..................... .................. 525.41 1 333.00 .................. 66.60
45339 ....... Sigmoidoscopy w/ablate tumr ........................ .................. 525.41 1 333.00 .................. 66.60
45340 ....... Sig w/balloon dilation ..................................... .................. 525.41 1 333.00 .................. 66.60
45341 ....... Sigmoidoscopy w/ultrasound ......................... .................. 525.41 1 333.00 .................. 66.60
45342 ....... Sigmoidoscopy w/us guide bx ....................... .................. 525.41 1 333.00 .................. 66.60
45345 ....... Sigmoidoscopy w/stent .................................. .................. 1,410.54 1 333.00 .................. 66.60
45355 ....... Surgical colonoscopy ..................................... .................. 538.99 1 333.00 .................. 66.60
45378 ....... Diagnostic colonoscopy ................................. .................. 538.99 2 446.00 .................. 89.20
45379 ....... Colonoscopy w/fb removal ............................ .................. 538.99 2 446.00 .................. 89.20
45380 ....... Colonoscopy and biopsy ............................... .................. 538.99 2 446.00 .................. 89.20
45381 ....... Colonoscopy, submucous inj ......................... .................. 538.99 2 446.00 .................. 89.20
45382 ....... Colonoscopy/control bleeding ........................ .................. 538.99 2 446.00 .................. 89.20
45383 ....... Lesion removal colonoscopy ......................... .................. 538.99 2 446.00 .................. 89.20
45384 ....... Lesion remove colonoscopy .......................... .................. 538.99 2 446.00 .................. 89.20
45385 ....... Lesion removal colonoscopy ......................... .................. 538.99 2 446.00 .................. 89.20
45386 ....... Colonoscopy dilate stricture .......................... .................. 538.99 2 446.00 .................. 89.20
45387 ....... Colonoscopy w/stent ...................................... .................. 1,410.54 1 333.00 .................. 66.60
45391 ....... Colonoscopy w/endoscope us ....................... .................. 538.99 2 446.00 .................. 89.20
45392 ....... Colonoscopy w/endoscopic fnb ..................... .................. 538.99 2 446.00 .................. 89.20
45500 ....... Repair of rectum ............................................ .................. 1,368.78 2 446.00 .................. 89.20
45505 ....... Repair of rectum ............................................ .................. 1,820.61 2 446.00 .................. 89.20
45560 ....... Repair of rectocele ........................................ .................. 1,820.61 2 446.00 .................. 89.20
45900 ....... Reduction of rectal prolapse .......................... .................. 312.07 1 312.07 Y .............. 62.41
45905 ....... Dilation of anal sphincter ............................... .................. 1,368.78 1 333.00 .................. 66.60
45910 ....... Dilation of rectal narrowing ............................ .................. 1,368.78 1 333.00 .................. 66.60
45915 ....... Remove rectal obstruction ............................. .................. 312.07 1 312.07 Y .............. 62.41
45990 ....... Surg dx exam, anorectal ............................... .................. 312.07 2 312.07 Y .............. 62.41
46020 ....... Placement of seton ........................................ .................. 1,368.78 3 510.00 .................. 102.00
46030 ....... Removal of rectal marker .............................. .................. 312.07 1 312.07 Y .............. 62.41
46040 ....... Incision of rectal abscess .............................. .................. 1,368.78 3 510.00 .................. 102.00
46050 ....... Incision of anal abscess ................................ .................. 312.07 1 312.07 Y .............. 62.41
46080 ....... Incision of anal sphincter ............................... .................. 1,368.78 3 510.00 .................. 102.00
46200 ....... Removal of anal fissure ................................. .................. 1,368.78 2 446.00 .................. 89.20
46210 ....... Removal of anal crypt .................................... .................. 1,368.78 2 446.00 .................. 89.20
46211 ....... Removal of anal crypts .................................. .................. 1,368.78 2 446.00 .................. 89.20
46220 ....... Removal of anal tag ...................................... .................. 1,368.78 1 333.00 .................. 66.60
46230 ....... Removal of anal tags ..................................... .................. 1,368.78 1 333.00 .................. 66.60
46250 ....... Hemorrhoidectomy ......................................... .................. 1,368.78 3 510.00 .................. 102.00
46257 ....... Remove hemorrhoids & fissure ..................... .................. 1,368.78 3 510.00 .................. 102.00
46258 ....... Remove hemorrhoids & fistula ...................... .................. 1,368.78 3 510.00 .................. 102.00
46261 ....... Remove hemorrhoids & fissure ..................... .................. 1,368.78 4 630.00 .................. 126.00
46262 ....... Remove hemorrhoids & fistula ...................... .................. 1,368.78 4 630.00 .................. 126.00
46270 ....... Removal of anal fistula .................................. .................. 1,368.78 3 510.00 .................. 102.00
46288 ....... Repair anal fistula .......................................... .................. 1,368.78 4 630.00 .................. 126.00
46608 ....... Anoscopy, remove for body ........................... .................. 525.41 1 333.00 .................. 66.60
46610 ....... Anoscopy, remove lesion .............................. .................. 1,268.55 1 333.00 .................. 66.60
46611 ....... Anoscopy ....................................................... .................. 525.41 1 333.00 .................. 66.60
46612 ....... Anoscopy, remove lesions ............................. .................. 1,268.55 1 333.00 .................. 66.60
46615 ....... Anoscopy ....................................................... .................. 1,268.55 2 446.00 .................. 89.20
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
46700 ....... Repair of anal stricture .................................. .................. 1,368.78 3 510.00 .................. 102.00
46706 ....... Repr of anal fistula w/glue ............................. .................. 1,820.61 1 333.00 .................. 66.60
46750 ....... Repair of anal sphincter ................................ .................. 2,329.58 3 510.00 .................. 102.00
46753 ....... Reconstruction of anus .................................. .................. 1,368.78 3 510.00 .................. 102.00
46754 ....... Removal of suture from anus ........................ .................. 1,368.78 2 446.00 .................. 89.20
46762 ....... Implant artificial sphincter .............................. .................. 2,329.58 7 995.00 .................. 199.00
46917 ....... Laser surgery, anal lesions ........................... .................. 1,255.64 1 333.00 .................. 66.60
46922 ....... Excision of anal lesion(s) ............................... .................. 1,255.64 1 333.00 .................. 66.60
46924 ....... Destruction, anal lesion(s) ............................. .................. 1,255.64 1 333.00 .................. 66.60
46937 ....... Cryotherapy of rectal lesion ........................... .................. 1,368.78 2 446.00 .................. 89.20
46938 ....... Cryotherapy of rectal lesion ........................... .................. 1,820.61 2 446.00 .................. 89.20
46946 ....... Ligation of hemorrhoids ................................. A* ............. 783.03 1 333.00 .................. 66.60
46947 ....... Hemorrhoidopexy by stapling ........................ .................. 1,820.61 7 995.00 .................. 199.00
47000 ....... Needle biopsy of liver .................................... .................. 377.32 1 333.00 .................. 66.60
47510 ....... Insert catheter, bile duct ................................ .................. 1,245.85 2 446.00 .................. 89.20
47511 ....... Insert bile duct drain ...................................... .................. 1,245.85 9 1,245.85 Y .............. 249.17
47525 ....... Change bile duct catheter ............................. .................. 716.56 1 333.00 .................. 66.60
47530 ....... Revise/reinsert bile tube ................................ .................. 716.56 1 333.00 .................. 66.60
47552 ....... Biliary endoscopy thru skin ............................ .................. 1,245.85 2 446.00 .................. 89.20
47556 ....... Biliary endoscopy thru skin ............................ .................. 1,245.85 9 1,245.85 Y .............. 249.17
47560 ....... Laparoscopy w/cholangio .............................. .................. 1,974.60 3 510.00 .................. 102.00
47561 ....... Laparo w/cholangio/biopsy ............................ .................. 1,974.60 3 510.00 .................. 102.00
47630 ....... Remove bile duct stone ................................. .................. 1,245.85 3 510.00 .................. 102.00
48102 ....... Needle biopsy, pancreas ............................... .................. 377.32 1 333.00 .................. 66.60
49080 ....... Puncture, peritoneal cavity ............................ .................. 222.78 2 222.78 Y .............. 44.56
49081 ....... Removal of abdominal fluid ........................... .................. 222.78 2 222.78 Y .............. 44.56
49085 ....... Remove abdomen foreign body .................... D .............. .................... 2 446.00 .................. ....................
49180 ....... Biopsy, abdominal mass ................................ .................. 377.32 1 333.00 .................. 66.60
49250 ....... Excision of umbilicus ..................................... .................. 1,357.41 4 630.00 .................. 126.00
49320 ....... Diag laparo separate proc ............................. .................. 1,974.60 3 510.00 .................. 102.00
49321 ....... Laparoscopy, biopsy ...................................... .................. 1,974.60 4 630.00 .................. 126.00
49322 ....... Laparoscopy, aspiration ................................. .................. 1,974.60 4 630.00 .................. 126.00
49402 ....... Remove foreign body, adbomen ................... A .............. 1,357.41 2 446.00 .................. 89.20
49419 ....... Insrt abdom cath for chemotx ........................ .................. 1,795.68 1 333.00 .................. 66.60
49420 ....... Insert abdom drain, temp .............................. .................. 1,815.86 1 333.00 .................. 66.60
49421 ....... Insert abdom drain, perm .............................. .................. 1,815.86 1 333.00 .................. 66.60
49422 ....... Remove perm cannula/catheter .................... .................. 1,574.45 1 333.00 .................. 66.60
49426 ....... Revise abdomen-venous shunt ..................... .................. 1,357.41 2 446.00 .................. 89.20
49495 ....... Rpr ing hernia baby, reduc ............................ .................. 1,795.98 4 630.00 .................. 126.00
49496 ....... Rpr ing hernia baby, blocked ........................ .................. 1,795.98 4 630.00 .................. 126.00
49500 ....... Rpr ing hernia, init, reduce ............................ .................. 1,795.98 4 630.00 .................. 126.00
49501 ....... Rpr ing hernia, init blocked ............................ .................. 1,795.98 9 1,339.00 .................. 267.80
49505 ....... Prp i/hern init reduc >5 yr .............................. .................. 1,795.98 4 630.00 .................. 126.00
49507 ....... Prp i/hern init block >5 yr .............................. .................. 1,795.98 9 1,339.00 .................. 267.80
49520 ....... Rerepair ing hernia, reduce ........................... .................. 1,795.98 7 995.00 .................. 199.00
49521 ....... Rerepair ing hernia, blocked ......................... .................. 1,795.98 9 1,339.00 .................. 267.80
49525 ....... Repair ing hernia, sliding ............................... .................. 1,795.98 4 630.00 .................. 126.00
49540 ....... Repair lumbar hernia ..................................... .................. 1,795.98 2 446.00 .................. 89.20
49550 ....... Rpr rem hernia, init, reduce ........................... .................. 1,795.98 5 717.00 .................. 143.40
49553 ....... Rpr fem hernia, init blocked .......................... .................. 1,795.98 9 1,339.00 .................. 267.80
49555 ....... Rerepair fem hernia, reduce .......................... .................. 1,795.98 5 717.00 .................. 143.40
49557 ....... Rerepair fem hernia, blocked ........................ .................. 1,795.98 9 1,339.00 .................. 267.80
49560 ....... Rpr ventral hern init, reduc ............................ .................. 1,795.98 4 630.00 .................. 126.00
49561 ....... Rpr ventral hern init, block ............................ .................. 1,795.98 9 1,339.00 .................. 267.80
49565 ....... Rerepair ventrl hern, reduce .......................... .................. 1,795.98 4 630.00 .................. 126.00
49566 ....... Rerepair ventrl hern, block ............................ .................. 1,795.98 9 1,339.00 .................. 267.80
49568 ....... Hernia repair w/mesh .................................... .................. 1,795.98 7 995.00 .................. 199.00
49570 ....... Rpr epigastric hern, reduce ........................... .................. 1,795.98 4 630.00 .................. 126.00
49572 ....... Rpr epigastric hern, blocked .......................... .................. 1,795.98 9 1,339.00 .................. 267.80
49580 ....... Rpr umbil hern, reduc < 5 yr ......................... .................. 1,795.98 4 630.00 .................. 126.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
49582 ....... Rpr umbil hern, block < 5 yr .......................... .................. 1,795.98 9 1,339.00 .................. 267.80
49585 ....... Rpr umbil hern, reduc > 5 yr ......................... .................. 1,795.98 4 630.00 .................. 126.00
49587 ....... Rpr umbil hern, block > 5 yr .......................... .................. 1,795.98 9 1,339.00 .................. 267.80
49590 ....... Repair spigelian hernia .................................. .................. 1,795.98 3 510.00 .................. 102.00
49600 ....... Repair umbilical lesion ................................... .................. 1,795.98 4 630.00 .................. 126.00
49650 ....... Laparo hernia repair initial ............................. .................. 2,676.86 4 630.00 .................. 126.00
49651 ....... Laparo hernia repair recur ............................. .................. 2,676.86 7 995.00 .................. 199.00
50200 ....... Biopsy of kidney ............................................ .................. 377.32 1 333.00 .................. 66.60
50390 ....... Drainage of kidney lesion .............................. .................. 377.32 1 333.00 .................. 66.60
50392 ....... Insert kidney drain ......................................... .................. 1,181.73 1 333.00 .................. 66.60
50393 ....... Insert ureteral tube ........................................ .................. 1,181.73 1 333.00 .................. 66.60
50395 ....... Create passage to kidney .............................. .................. 1,181.73 1 333.00 .................. 66.60
50396 ....... Measure kidney pressure .............................. .................. 131.50 1 131.50 Y .............. 26.30
50398 ....... Change kidney tube ....................................... .................. 459.78 1 333.00 .................. 66.60
50551 ....... Kidney endoscopy ......................................... .................. 399.24 1 333.00 .................. 66.60
50553 ....... Kidney endoscopy ......................................... .................. 1,181.73 1 333.00 .................. 66.60
50555 ....... Kidney endoscopy & biopsy .......................... .................. 399.24 1 333.00 .................. 66.60
50557 ....... Kidney endoscopy & treatment ..................... .................. 1,467.24 1 333.00 .................. 66.60
50561 ....... Kidney endoscopy & treatment ..................... .................. 1,181.73 1 333.00 .................. 66.60
50688 ....... Change of ureter tube/stent ........................... .................. 459.78 1 333.00 .................. 66.60
50947 ....... Laparo new ureter/bladder ............................ .................. 2,676.86 9 1,339.00 .................. 267.80
50948 ....... Laparo new ureter/bladder ............................ .................. 2,676.86 9 1,339.00 .................. 267.80
50951 ....... Endoscopy of ureter ...................................... .................. 399.24 1 333.00 .................. 66.60
50953 ....... Endoscopy of ureter ...................................... .................. 399.24 1 333.00 .................. 66.60
50955 ....... Ureter endoscopy & biopsy ........................... .................. 1,181.73 1 333.00 .................. 66.60
50957 ....... Ureter endoscopy & treatment ...................... .................. 1,181.73 1 333.00 .................. 66.60
50970 ....... Ureter endoscopy .......................................... .................. 399.24 1 333.00 .................. 66.60
50972 ....... Ureter endoscopy & catheter ......................... .................. 399.24 1 333.00 .................. 66.60
50974 ....... Ureter endoscopy & biopsy ........................... .................. 1,181.73 1 333.00 .................. 66.60
51010 ....... Drainage of bladder ....................................... .................. 1,116.74 1 333.00 .................. 66.60
51020 ....... Incise & treat bladder .................................... .................. 1,467.24 4 630.00 .................. 126.00
51030 ....... Incise & treat bladder .................................... .................. 1,467.24 4 630.00 .................. 126.00
51040 ....... Incise & drain bladder .................................... .................. 1,467.24 4 630.00 .................. 126.00
51045 ....... Incise bladder/drain ureter ............................. .................. 399.24 4 399.24 Y .............. 79.85
51050 ....... Removal of bladder stone ............................. .................. 1,467.24 4 630.00 .................. 126.00
51065 ....... Remove ureter calculus ................................. .................. 1,467.24 4 630.00 .................. 126.00
51080 ....... Drainage of bladder abscess ......................... .................. 1,076.22 1 333.00 .................. 66.60
51500 ....... Removal of bladder cyst ................................ .................. 1,795.98 4 630.00 .................. 126.00
51520 ....... Removal of bladder lesion ............................. .................. 1,467.24 4 630.00 .................. 126.00
51710 ....... Change of bladder tube ................................. .................. 459.78 1 333.00 .................. 66.60
51715 ....... Endoscopic injection/implant ......................... .................. 1,784.13 3 510.00 .................. 102.00
51726 ....... Complex cystometrogram .............................. .................. 209.48 1 209.48 Y .............. 41.90
51772 ....... Urethra pressure profile ................................. .................. 131.50 1 131.50 Y .............. 26.30
51785 ....... Anal/urinary muscle study ............................. .................. 66.92 1 66.92 Y .............. 13.38
51880 ....... Repair of bladder opening ............................. .................. 1,467.24 1 333.00 .................. 66.60
51992 ....... Laparo sling operation ................................... .................. 2,676.86 5 717.00 .................. 143.40
52000 ....... Cystoscopy .................................................... .................. 399.24 1 333.00 .................. 66.60
52001 ....... Cystoscopy, removal of clots ......................... .................. 399.24 2 399.24 Y .............. 79.85
52005 ....... Cystoscopy & ureter catheter ........................ .................. 1,181.73 2 446.00 .................. 89.20
52007 ....... Cystoscopy and biopsy .................................. .................. 1,181.73 2 446.00 .................. 89.20
52010 ....... Cystoscopy & duct catheter ........................... .................. 399.24 2 399.24 Y .............. 79.85
52204 ....... Cystoscopy w/biopsy(s) ................................. .................. 1,181.73 2 446.00 .................. 89.20
52214 ....... Cystoscopy and treatment ............................. .................. 1,467.24 2 446.00 .................. 89.20
52250 ....... Cystoscopy and radiotracer ........................... .................. 1,467.24 4 630.00 .................. 126.00
52270 ....... Cystoscopy & revise urethra ......................... .................. 1,181.73 2 446.00 .................. 89.20
52275 ....... Cystoscopy & revise urethra ......................... .................. 1,181.73 2 446.00 .................. 89.20
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
52282 ....... Cystoscopy, implant stent .............................. .................. 2,146.84 9 1,339.00 .................. 267.80
52310 ....... Cystoscopy and treatment ............................. .................. 399.24 2 399.24 Y .............. 79.85
52317 ....... Remove bladder stone .................................. .................. 1,467.24 1 333.00 .................. 66.60
52318 ....... Remove bladder stone .................................. .................. 1,467.24 2 446.00 .................. 89.20
52325 ....... Cystoscopy, stone removal ........................... .................. 1,467.24 4 630.00 .................. 126.00
52327 ....... Cystoscopy, inject material ............................ .................. 1,467.24 2 446.00 .................. 89.20
52334 ....... Create passage to kidney .............................. .................. 1,467.24 3 510.00 .................. 102.00
52341 ....... Cysto w/ureter stricture tx .............................. .................. 1,467.24 3 510.00 .................. 102.00
52342 ....... Cysto w/up stricture tx ................................... .................. 1,467.24 3 510.00 .................. 102.00
52343 ....... Cysto w/renal stricture tx ............................... .................. 1,467.24 3 510.00 .................. 102.00
52344 ....... Cysto/uretero, stricture tx .............................. .................. 1,467.24 3 510.00 .................. 102.00
52345 ....... Cysto/uretero w/up stricture ........................... .................. 1,467.24 3 510.00 .................. 102.00
52346 ....... Cystouretero w/renal strict ............................. .................. 1,467.24 3 510.00 .................. 102.00
52351 ....... Cystouretero & or pyeloscope ....................... .................. 1,181.73 3 510.00 .................. 102.00
52352 ....... Cystouretero w/stone remove ........................ .................. 1,467.24 4 630.00 .................. 126.00
52353 ....... Cystouretero w/lithotripsy .............................. .................. 2,146.84 4 630.00 .................. 126.00
52354 ....... Cystouretero w/biopsy ................................... .................. 1,467.24 4 630.00 .................. 126.00
52355 ....... Cystouretero w/excise tumor ......................... .................. 1,467.24 4 630.00 .................. 126.00
52400 ....... Cystouretero w/congen repr .......................... .................. 1,467.24 3 510.00 .................. 102.00
52402 ....... Cystourethro cut ejacul duct .......................... .................. 1,467.24 3 510.00 .................. 102.00
52450 ....... Incision of prostate ........................................ .................. 1,467.24 3 510.00 .................. 102.00
52500 ....... Revision of bladder neck ............................... .................. 1,467.24 3 510.00 .................. 102.00
52510 ....... Dilation prostatic urethra ................................ .................. 1,181.73 3 510.00 .................. 102.00
52601 ....... Prostatectomy (TURP) ................................... .................. 2,146.84 4 630.00 .................. 126.00
52606 ....... Control postop bleeding ................................. .................. 1,467.24 1 333.00 .................. 66.60
52612 ....... Prostatectomy, first stage .............................. .................. 2,146.84 2 446.00 .................. 89.20
52614 ....... Prostatectomy, second stage ........................ .................. 2,146.84 1 333.00 .................. 66.60
52620 ....... Remove residual prostate .............................. .................. 2,146.84 1 333.00 .................. 66.60
52630 ....... Remove prostate regrowth ............................ .................. 2,146.84 2 446.00 .................. 89.20
52640 ....... Relieve bladder contracture ........................... .................. 1,467.24 2 446.00 .................. 89.20
52647 ....... Laser surgery of prostate .............................. .................. 2,649.30 9 1,339.00 .................. 267.80
52648 ....... Laser surgery of prostate .............................. .................. 2,649.30 9 1,339.00 .................. 267.80
52700 ....... Drainage of prostate abscess ........................ .................. 1,467.24 2 446.00 .................. 89.20
53000 ....... Incision of urethra .......................................... .................. 1,130.77 1 333.00 .................. 66.60
53040 ....... Drainage of urethra abscess ......................... .................. 1,130.77 2 446.00 .................. 89.20
53080 ....... Drainage of urinary leakage .......................... .................. 1,130.77 3 510.00 .................. 102.00
53200 ....... Biopsy of urethra ........................................... .................. 1,130.77 1 333.00 .................. 66.60
53210 ....... Removal of urethra ........................................ .................. 1,784.13 5 717.00 .................. 143.40
53215 ....... Removal of urethra ........................................ .................. 1,130.77 5 717.00 .................. 143.40
53220 ....... Treatment of urethra lesion ........................... .................. 1,784.13 2 446.00 .................. 89.20
53230 ....... Removal of urethra lesion ............................. .................. 1,784.13 2 446.00 .................. 89.20
53235 ....... Removal of urethra lesion ............................. .................. 1,130.77 3 510.00 .................. 102.00
53240 ....... Surgery for urethra pouch ............................. .................. 1,784.13 2 446.00 .................. 89.20
53250 ....... Removal of urethra gland .............................. .................. 1,130.77 2 446.00 .................. 89.20
53270 ....... Removal of urethra gland .............................. .................. 1,130.77 2 446.00 .................. 89.20
53275 ....... Repair of urethra defect ................................. .................. 1,130.77 2 446.00 .................. 89.20
53400 ....... Revise urethra, stage 1 ................................. .................. 1,784.13 3 510.00 .................. 102.00
53405 ....... Revise urethra, stage 2 ................................. .................. 1,784.13 2 446.00 .................. 89.20
53410 ....... Reconstruction of urethra .............................. .................. 1,784.13 2 446.00 .................. 89.20
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
53420 ....... Reconstruct urethra, stage 1 ......................... .................. 1,784.13 3 510.00 .................. 102.00
53425 ....... Reconstruct urethra, stage 2 ......................... .................. 1,784.13 2 446.00 .................. 89.20
53431 ....... Reconstruct urethra/bladder .......................... .................. 1,784.13 2 446.00 .................. 89.20
53440 ....... Male sling procedure ..................................... .................. 4,868.83 2 446.00 .................. 89.20
53442 ....... Remove/revise male sling ............................. .................. 1,784.13 1 333.00 .................. 66.60
53444 ....... Insert tandem cuff .......................................... .................. 4,868.83 2 446.00 .................. 89.20
53445 ....... Insert uro/ves nck sphincter .......................... .................. 8,445.07 1 333.00 .................. 66.60
53446 ....... Remove uro sphincter ................................... .................. 1,784.13 1 333.00 .................. 66.60
53447 ....... Remove/replace ur sphincter ......................... .................. 8,445.07 1 333.00 .................. 66.60
53449 ....... Repair uro sphincter ...................................... .................. 1,784.13 1 333.00 .................. 66.60
53450 ....... Revision of urethra ........................................ .................. 1,784.13 1 333.00 .................. 66.60
53502 ....... Repair of urethra injury .................................. .................. 1,130.77 2 446.00 .................. 89.20
53520 ....... Repair of urethra defect ................................. .................. 1,784.13 2 446.00 .................. 89.20
53605 ....... Dilate urethra stricture ................................... .................. 1,181.73 2 446.00 .................. 89.20
53665 ....... Dilation of urethra .......................................... .................. 1,130.77 1 333.00 .................. 66.60
54000 ....... Slitting of prepuce .......................................... .................. 1,130.77 2 446.00 .................. 89.20
54001 ....... Slitting of prepuce .......................................... .................. 1,130.77 2 446.00 .................. 89.20
54015 ....... Drain penis lesion .......................................... .................. 1,076.22 4 630.00 .................. 126.00
54057 ....... Laser surg, penis lesion(s) ............................ .................. 1,072.14 1 333.00 .................. 66.60
54060 ....... Excision of penis lesion(s) ............................. .................. 1,072.14 1 333.00 .................. 66.60
54065 ....... Destruction, penis lesion(s) ........................... .................. 1,255.64 1 333.00 .................. 66.60
54100 ....... Biopsy of penis .............................................. .................. 928.31 1 333.00 .................. 66.60
54105 ....... Biopsy of penis .............................................. .................. 1,233.39 1 333.00 .................. 66.60
54110 ....... Treatment of penis lesion .............................. .................. 2,027.66 2 446.00 .................. 89.20
54111 ....... Treat penis lesion, graft ................................. .................. 2,027.66 2 446.00 .................. 89.20
54112 ....... Treat penis lesion, graft ................................. .................. 2,027.66 2 446.00 .................. 89.20
54120 ....... Partial removal of penis ................................. .................. 2,027.66 2 446.00 .................. 89.20
54150 ....... Circumcision w/regionl block ......................... .................. 1,263.25 1 333.00 .................. 66.60
54152 ....... Circumcision .................................................. .................. 1,263.25 1 333.00 .................. 66.60
54160 ....... Circumcision, neonate ................................... .................. 1,263.25 2 446.00 .................. 89.20
54161 ....... Circum 28 days or older ................................ .................. 1,263.25 2 446.00 .................. 89.20
54162 ....... Lysis penil circumic lesion ............................. .................. 1,263.25 2 446.00 .................. 89.20
54163 ....... Repair of circumcision ................................... .................. 1,263.25 2 446.00 .................. 89.20
54164 ....... Frenulotomy of penis ..................................... .................. 1,263.25 2 446.00 .................. 89.20
54220 ....... Treatment of penis lesion .............................. .................. 131.50 1 131.50 Y .............. 26.30
54300 ....... Revision of penis ........................................... .................. 2,027.66 3 510.00 .................. 102.00
54328 ....... Revise penis/urethra ...................................... .................. 2,027.66 3 510.00 .................. 102.00
54340 ....... Secondary urethral surgery ........................... .................. 2,027.66 3 510.00 .................. 102.00
54352 ....... Reconstruct urethra/penis .............................. .................. 2,027.66 3 510.00 .................. 102.00
54360 ....... Penis plastic surgery ..................................... .................. 2,027.66 3 510.00 .................. 102.00
54380 ....... Repair penis ................................................... .................. 2,027.66 3 510.00 .................. 102.00
54385 ....... Repair penis ................................................... .................. 2,027.66 3 510.00 .................. 102.00
54400 ....... Insert semi-rigid prosthesis ............................ .................. 4,868.83 3 510.00 .................. 102.00
54401 ....... Insert self-contd prosthesis ............................ .................. 8,445.07 3 510.00 .................. 102.00
54405 ....... Insert multi-comp penis pros ......................... .................. 8,445.07 3 510.00 .................. 102.00
54406 ....... Remove muti-comp penis pros ...................... .................. 2,027.66 3 510.00 .................. 102.00
54408 ....... Repair multi-comp penis pros ........................ .................. 2,027.66 3 510.00 .................. 102.00
54410 ....... Remove/replace penis prosth ........................ .................. 8,445.07 3 510.00 .................. 102.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
54415 ....... Remove self-contd penis pros ....................... .................. 2,027.66 3 510.00 .................. 102.00
54416 ....... Remv/repl penis contain pros ........................ .................. 8,445.07 3 510.00 .................. 102.00
54440 ....... Repair of penis .............................................. .................. 2,027.66 4 630.00 .................. 126.00
54450 ....... Preputial stretching ........................................ .................. 209.48 1 209.48 Y .............. 41.90
54500 ....... Biopsy of testis .............................................. .................. 631.00 1 333.00 .................. 66.60
54505 ....... Biopsy of testis .............................................. .................. 1,446.40 1 333.00 .................. 66.60
54512 ....... Excise lesion testis ........................................ .................. 1,446.40 2 446.00 .................. 89.20
54520 ....... Removal of testis ........................................... .................. 1,446.40 3 510.00 .................. 102.00
54522 ....... Orchiectomy, partial ....................................... .................. 1,446.40 3 510.00 .................. 102.00
54530 ....... Removal of testis ........................................... .................. 1,795.98 4 630.00 .................. 126.00
54550 ....... Exploration for testis ...................................... .................. 1,795.98 4 630.00 .................. 126.00
54600 ....... Reduce testis torsion ..................................... .................. 1,446.40 4 630.00 .................. 126.00
54620 ....... Suspension of testis ...................................... .................. 1,446.40 3 510.00 .................. 102.00
54640 ....... Suspension of testis ...................................... .................. 1,795.98 4 630.00 .................. 126.00
54660 ....... Revision of testis ........................................... .................. 1,446.40 2 446.00 .................. 89.20
54670 ....... Repair testis injury ......................................... .................. 1,446.40 3 510.00 .................. 102.00
54680 ....... Relocation of testis(es) .................................. .................. 1,446.40 3 510.00 .................. 102.00
54690 ....... Laparoscopy, orchiectomy ............................. .................. 2,676.86 9 1,339.00 .................. 267.80
54700 ....... Drainage of scrotum ...................................... .................. 1,446.40 2 446.00 .................. 89.20
54800 ....... Biopsy of epididymis ...................................... .................. 127.16 1 127.16 Y .............. 25.43
54820 ....... Exploration of epididymis ............................... D .............. .................... 1 333.00 .................. ....................
54830 ....... Remove epididymis lesion ............................. .................. 1,446.40 3 510.00 .................. 102.00
54840 ....... Remove epididymis lesion ............................. .................. 1,446.40 4 630.00 .................. 126.00
54860 ....... Removal of epididymis .................................. .................. 1,446.40 3 510.00 .................. 102.00
54861 ....... Removal of epididymis .................................. .................. 1,446.40 4 630.00 .................. 126.00
54865 ....... Explore epididymis ......................................... A .............. 1,446.40 1 333.00 .................. 66.60
54900 ....... Fusion of spermatic ducts ............................. .................. 1,446.40 4 630.00 .................. 126.00
54901 ....... Fusion of spermatic ducts ............................. .................. 1,446.40 4 630.00 .................. 126.00
55040 ....... Removal of hydrocele .................................... .................. 1,795.98 3 510.00 .................. 102.00
55041 ....... Removal of hydroceles .................................. .................. 1,795.98 5 717.00 .................. 143.40
55060 ....... Repair of hydrocele ....................................... .................. 1,446.40 4 630.00 .................. 126.00
55100 ....... Drainage of scrotum abscess ........................ .................. 685.58 1 333.00 .................. 66.60
55110 ....... Explore scrotum ............................................. .................. 1,446.40 2 446.00 .................. 89.20
55120 ....... Removal of scrotum lesion ............................ .................. 1,446.40 2 446.00 .................. 89.20
55150 ....... Removal of scrotum ....................................... .................. 1,446.40 1 333.00 .................. 66.60
55175 ....... Revision of scrotum ....................................... .................. 1,446.40 1 333.00 .................. 66.60
55180 ....... Revision of scrotum ....................................... .................. 1,446.40 2 446.00 .................. 89.20
55200 ....... Incision of sperm duct ................................... .................. 1,446.40 2 446.00 .................. 89.20
55250 ....... Removal of sperm duct(s) ............................. .................. 1,446.40 2 446.00 .................. 89.20
55400 ....... Repair of sperm duct ..................................... .................. 1,446.40 1 333.00 .................. 66.60
55500 ....... Removal of hydrocele .................................... .................. 1,446.40 3 510.00 .................. 102.00
55520 ....... Removal of sperm cord lesion ....................... .................. 1,446.40 4 630.00 .................. 126.00
55530 ....... Revise spermatic cord veins ......................... .................. 1,446.40 4 630.00 .................. 126.00
55535 ....... Revise spermatic cord veins ......................... .................. 1,795.98 4 630.00 .................. 126.00
55540 ....... Revise hernia & sperm veins ........................ .................. 1,795.98 5 717.00 .................. 143.40
55550 ....... Laparo ligate spermatic vein ......................... .................. 2,676.86 9 1,339.00 .................. 267.80
55680 ....... Remove sperm pouch lesion ......................... .................. 1,446.40 1 333.00 .................. 66.60
55700 ....... Biopsy of prostate .......................................... .................. 345.83 2 345.83 Y .............. 69.17
55705 ....... Biopsy of prostate .......................................... .................. 345.83 2 345.83 Y .............. 69.17
55859 ....... Percut/needle insert, pros .............................. D .............. .................... 9 1,339.00 .................. ....................
55873 ....... Cryoablate prostate ....................................... .................. 6,685.05 9 1,339.00 .................. 267.80
55875 ....... Transperi needle place, pros ......................... A .............. 2,146.84 9 1,339.00 .................. 267.80
56440 ....... Surgery for vulva lesion ................................. .................. 1,260.59 2 446.00 .................. 89.20
56441 ....... Lysis of labial lesion(s) .................................. .................. 912.73 1 333.00 .................. 66.60
56442 ....... Hymenotomy .................................................. A .............. 912.73 1 333.00 .................. 66.60

56515 ....... Destroy vulva lesion/s compl ......................... .................. 1,255.64 3 510.00 .................. 102.00
56620 ....... Partial removal of vulva ................................. .................. 1,752.42 5 717.00 .................. 143.40
56625 ....... Complete removal of vulva ............................ .................. 1,752.42 7 995.00 .................. 199.00
56700 ....... Partial removal of hymen ............................... .................. 1,260.59 1 333.00 .................. 66.60
56720 ....... Incision of hymen ........................................... D .............. .................... 1 333.00 .................. ....................
56740 ....... Remove vagina gland lesion ......................... .................. 1,260.59 3 510.00 .................. 102.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
56800 ....... Repair of vagina ............................................ .................. 1,260.59 3 510.00 .................. 102.00
56810 ....... Repair of perineum ........................................ .................. 1,260.59 5 717.00 .................. 143.40
57000 ....... Exploration of vagina ..................................... .................. 912.73 1 333.00 .................. 66.60
57010 ....... Drainage of pelvic abscess ........................... .................. 912.73 2 446.00 .................. 89.20
57020 ....... Drainage of pelvic fluid .................................. .................. 409.33 2 409.33 Y .............. 81.87
57023 ....... I & d vag hematoma, non-ob ......................... .................. 1,076.22 1 333.00 .................. 66.60
57065 ....... Destroy vag lesions, complex ........................ .................. 1,260.59 1 333.00 .................. 66.60
57105 ....... Biopsy of vagina ............................................ .................. 1,260.59 2 446.00 .................. 89.20
57130 ....... Remove vagina lesion ................................... .................. 1,260.59 2 446.00 .................. 89.20
57135 ....... Remove vagina lesion ................................... .................. 1,260.59 2 446.00 .................. 89.20
57155 ....... Insert uteri tandems/ovoids ........................... .................. 409.33 2 409.33 Y .............. 81.87
57180 ....... Treat vaginal bleeding ................................... .................. 178.05 1 178.05 Y .............. 35.61
57200 ....... Repair of vagina ............................................ .................. 1,260.59 1 333.00 .................. 66.60
57210 ....... Repair vagina/perineum ................................. .................. 1,260.59 2 446.00 .................. 89.20
57230 ....... Repair of urethral lesion ................................ .................. 1,752.42 3 510.00 .................. 102.00
57240 ....... Repair bladder & vagina ................................ .................. 1,752.42 5 717.00 .................. 143.40
57250 ....... Repair rectum & vagina ................................. .................. 1,752.42 5 717.00 .................. 143.40
57260 ....... Repair of vagina ............................................ .................. 1,752.42 5 717.00 .................. 143.40
57265 ....... Extensive repair of vagina ............................. .................. 2,642.48 7 995.00 .................. 199.00
57267 ....... Insert mesh/pelvic flr addon .......................... A* ............. 1,752.42 7 995.00 .................. 199.00
57268 ....... Repair of bowel bulge .................................... .................. 1,752.42 3 510.00 .................. 102.00
57288 ....... Repair bladder defect .................................... .................. 2,642.48 5 717.00 .................. 143.40
57289 ....... Repair bladder & vagina ................................ .................. 1,752.42 5 717.00 .................. 143.40
57291 ....... Construction of vagina ................................... .................. 1,752.42 5 717.00 .................. 143.40
57300 ....... Repair rectum-vagina fistula .......................... .................. 1,752.42 3 510.00 .................. 102.00
57400 ....... Dilation of vagina ........................................... .................. 1,260.59 2 446.00 .................. 89.20
57410 ....... Pelvic examination ......................................... .................. 912.73 2 446.00 .................. 89.20
57415 ....... Remove vaginal foreign body ........................ .................. 1,260.59 2 446.00 .................. 89.20
57513 ....... Laser surgery of cervix .................................. .................. 912.73 2 446.00 .................. 89.20
57520 ....... Conization of cervix ....................................... .................. 1,260.59 2 446.00 .................. 89.20
57522 ....... Conization of cervix ....................................... .................. 1,752.42 2 446.00 .................. 89.20
57530 ....... Removal of cervix .......................................... .................. 1,752.42 3 510.00 .................. 102.00
57550 ....... Removal of residual cervix ............................ .................. 1,752.42 3 510.00 .................. 102.00
57556 ....... Remove cervix, repair bowel ......................... .................. 2,642.48 5 717.00 .................. 143.40
57558 ....... D&c of cervical stump .................................... A .............. 1,091.05 3 510.00 .................. 102.00
57700 ....... Revision of cervix .......................................... .................. 1,260.59 1 333.00 .................. 66.60
57820 ....... D & c of residual cervix ................................. D .............. .................... 3 510.00 .................. ....................
58120 ....... Dilation and curettage .................................... .................. 1,091.05 2 446.00 .................. 89.20
58145 ....... Myomectomy vag method ............................. .................. 1,752.42 5 717.00 .................. 143.40
58346 ....... Insert heyman uteri capsule .......................... .................. 912.73 2 446.00 .................. 89.20
58350 ....... Reopen fallopian tube .................................... .................. 1,752.42 3 510.00 .................. 102.00
58353 ....... Endometr ablate, thermal .............................. .................. 1,752.42 7 995.00 .................. 199.00
58545 ....... Laparoscopic myomectomy ........................... .................. 1,974.60 9 1,339.00 .................. 267.80
58546 ....... Laparo-myomectomy, complex ...................... .................. 2,676.86 9 1,339.00 .................. 267.80
58550 ....... Laparo-asst vag hysterectomy ...................... .................. 4,333.90 9 1,339.00 .................. 267.80
58555 ....... Hysteroscopy, dx, sep proc ........................... .................. 1,312.87 1 333.00 .................. 66.60
58558 ....... Hysteroscopy, biopsy ..................................... .................. 1,312.87 3 510.00 .................. 102.00
58559 ....... Hysteroscopy, lysis ........................................ .................. 1,312.87 2 446.00 .................. 89.20
58560 ....... Hysteroscopy, resect septum ........................ .................. 2,090.86 3 510.00 .................. 102.00
58561 ....... Hysteroscopy, remove myoma ...................... .................. 2,090.86 3 510.00 .................. 102.00
58562 ....... Hysteroscopy, remove fb ............................... .................. 1,312.87 3 510.00 .................. 102.00
58563 ....... Hysteroscopy, ablation .................................. .................. 2,090.86 9 1,339.00 .................. 267.80
58565 ....... Hysteroscopy, sterilization ............................. .................. 2,642.48 9 1,339.00 .................. 267.80
58660 ....... Laparoscopy, lysis ......................................... .................. 2,676.86 5 717.00 .................. 143.40
58661 ....... Laparoscopy, remove adnexa ....................... .................. 2,676.86 5 717.00 .................. 143.40
58662 ....... Laparoscopy, excise lesions .......................... .................. 2,676.86 5 717.00 .................. 143.40
58670 ....... Laparoscopy, tubal cautery ........................... .................. 2,676.86 3 510.00 .................. 102.00
58671 ....... Laparoscopy, tubal block ............................... .................. 2,676.86 3 510.00 .................. 102.00
58672 ....... Laparoscopy, fimbrioplasty ............................ .................. 2,676.86 5 717.00 .................. 143.40
58673 ....... Laparoscopy, salpingostomy ......................... .................. 2,676.86 5 717.00 .................. 143.40
58800 ....... Drainage of ovarian cyst(s) ........................... .................. 912.73 3 510.00 .................. 102.00
58820 ....... Drain ovary abscess, open ............................ .................. 1,752.42 3 510.00 .................. 102.00
58900 ....... Biopsy of ovary(s) .......................................... .................. 912.73 3 510.00 .................. 102.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
58970 ....... Retrieval of oocyte ......................................... .................. 245.92 1 245.92 Y .............. 49.18
58974 ....... Transfer of embryo ........................................ .................. 245.92 1 245.92 Y .............. 49.18
58976 ....... Transfer of embryo ........................................ .................. 245.92 1 245.92 Y .............. 49.18
59160 ....... D& c after delivery ......................................... .................. 1,091.05 3 510.00 .................. 102.00
59812 ....... Treatment of miscarriage ............................... .................. 1,138.39 5 717.00 .................. 143.40
59820 ....... Care of miscarriage ....................................... .................. 1,138.39 5 717.00 .................. 143.40
59821 ....... Treatment of miscarriage ............................... .................. 1,138.39 5 717.00 .................. 143.40
59840 ....... Abortion .......................................................... .................. 1,040.83 5 717.00 .................. 143.40
59841 ....... Abortion .......................................................... .................. 1,040.83 5 717.00 .................. 143.40
59870 ....... Evacuate mole of uterus ................................ .................. 1,138.39 5 717.00 .................. 143.40
59871 ....... Remove cerclage suture ................................ .................. 1,260.59 5 717.00 .................. 143.40
60000 ....... Drain thyroid/tongue cyst ............................... .................. 464.15 1 333.00 .................. 66.60
60200 ....... Remove thyroid lesion ................................... .................. 2,318.72 2 446.00 .................. 89.20
60280 ....... Remove thyroid duct lesion ........................... .................. 2,318.72 4 630.00 .................. 126.00
60281 ....... Remove thyroid duct lesion ........................... .................. 2,318.72 4 630.00 .................. 126.00
61020 ....... Remove brain cavity fluid .............................. .................. 183.83 1 183.83 Y .............. 36.77
61026 ....... Injection into brain canal ................................ .................. 183.83 1 183.83 Y .............. 36.77
61050 ....... Remove brain canal fluid ............................... .................. 183.83 1 183.83 Y .............. 36.77
61055 ....... Injection into brain canal ................................ .................. 183.83 1 183.83 Y .............. 36.77
61070 ....... Brain canal shunt procedure ......................... .................. 183.83 1 183.83 Y .............. 36.77
61215 ....... Insert brain-fluid device ................................. .................. 2,891.10 3 510.00 .................. 102.00
61790 ....... Treat trigeminal nerve .................................... .................. 1,097.20 3 510.00 .................. 102.00
61791 ....... Treat trigeminal tract ...................................... .................. 351.92 3 351.92 Y .............. 70.38
61795 ....... Brain surgery using computer ....................... A* ............. 302.04 1 302.04 Y .............. 60.41
61885 ....... Insrt/redo neurostim 1 array .......................... .................. 11,518.00 2 446.00 .................. 89.20
61886 ....... Implant neurostim arrays ............................... .................. 14,932.81 3 510.00 .................. 102.00
61888 ....... Revise/remove neuroreceiver ........................ .................. 2,186.43 1 333.00 .................. 66.60
62194 ....... Replace/irrigate catheter ................................ .................. 716.56 1 333.00 .................. 66.60
62225 ....... Replace/irrigate catheter ................................ .................. 716.56 1 333.00 .................. 66.60
62230 ....... Replace/revise brain shunt ............................ .................. 2,891.10 2 446.00 .................. 89.20
62263 ....... Epidural lysis mult sessions .......................... .................. 748.08 1 333.00 .................. 66.60
62264 ....... Epidural lysis on single day ........................... .................. 748.08 1 333.00 .................. 66.60
62268 ....... Drain spinal cord cyst .................................... .................. 183.83 1 183.83 Y .............. 36.77
62269 ....... Needle biopsy, spinal cord ............................ .................. 377.32 1 333.00 .................. 66.60
62270 ....... Spinal fluid tap, diagnostic ............................. .................. 139.00 1 139.00 Y .............. 27.80
62272 ....... Drain cerebro spinal fluid ............................... .................. 139.00 1 139.00 Y .............. 27.80
62273 ....... Inject epidural patch ...................................... .................. 351.92 1 333.00 .................. 66.60
62280 ....... Treat spinal cord lesion ................................. .................. 390.95 1 333.00 .................. 66.60
62281 ....... Treat spinal cord lesion ................................. .................. 390.95 1 333.00 .................. 66.60
62282 ....... Treat spinal canal lesion ................................ .................. 390.95 1 333.00 .................. 66.60
62287 ....... Percutaneous diskectomy .............................. .................. 2,037.79 9 1,339.00 .................. 267.80
62294 ....... Injection into spinal artery .............................. .................. 183.83 3 183.83 Y .............. 36.77
62310 ....... Inject spine c/t ................................................ .................. 390.95 1 333.00 .................. 66.60
62311 ....... Inject spine l/s (cd) ........................................ .................. 390.95 1 333.00 .................. 66.60
62318 ....... Inject spine w/cath, c/t ................................... .................. 390.95 1 333.00 .................. 66.60
62319 ....... Inject spine w/cath l/s (cd) ............................. .................. 390.95 1 333.00 .................. 66.60
62350 ....... Implant spinal canal cath ............................... .................. 1,895.64 2 446.00 .................. 89.20
62355 ....... Remove spinal canal catheter ....................... .................. 748.08 2 446.00 .................. 89.20
62360 ....... Insert spine infusion device ........................... .................. 6,923.28 2 446.00 .................. 89.20
62361 ....... Implant spine infusion pump .......................... .................. 10,720.36 2 446.00 .................. 89.20
62362 ....... Implant spine infusion pump .......................... .................. 10,720.36 2 446.00 .................. 89.20
62365 ....... Remove spine infusion device ....................... .................. 2,037.79 2 446.00 .................. 89.20
63600 ....... Remove spinal cord lesion ............................ .................. 1,097.20 2 446.00 .................. 89.20
63610 ....... Stimulation of spinal cord .............................. .................. 1,097.20 1 333.00 .................. 66.60
63650 ....... Implant neuroelectrodes ................................ .................. 3,477.28 2 446.00 .................. 89.20
63660 ....... Revise/remove neuroelectrode ...................... .................. 1,096.18 1 333.00 .................. 66.60
63685 ....... Insrt/redo spine n generator .......................... .................. 11,164.12 2 446.00 .................. 89.20
63688 ....... Revise/remove neuroreceiver ........................ .................. 2,186.43 1 333.00 .................. 66.60
63744 ....... Revision of spinal shunt ................................ .................. 2,413.44 3 510.00 .................. 102.00
63746 ....... Removal of spinal shunt ................................ .................. 675.64 2 446.00 .................. 89.20
64410 ....... Nblock inj, phrenic ......................................... .................. 351.92 1 333.00 .................. 66.60
64415 ....... Nblock inj, brachial plexus ............................. .................. 139.00 1 139.00 Y .............. 27.80
64417 ....... Nblock inj, axillary .......................................... .................. 139.00 1 139.00 Y .............. 27.80
64420 ....... Nblock inj, intercost, sng ............................... .................. 139.00 1 139.00 Y .............. 27.80
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
64421 ....... Nblock inj, intercost, mlt ................................ .................. 351.92 1 333.00 .................. 66.60
64430 ....... Nblock inj, pudendal ...................................... .................. 139.00 1 139.00 Y .............. 27.80
64470 ....... Inj paravertebral c/t ........................................ .................. 390.95 1 333.00 .................. 66.60
64472 ....... Inj paravertebral c/t add-on ........................... .................. 351.92 1 333.00 .................. 66.60
64475 ....... Inj paravertebral l/s ........................................ .................. 390.95 1 333.00 .................. 66.60
64476 ....... Inj paravertebral l/s add-on ............................ .................. 351.92 1 333.00 .................. 66.60
64479 ....... Inj foramen epidural c/t .................................. .................. 390.95 1 333.00 .................. 66.60
64480 ....... Inj foramen epidural add-on .......................... .................. 390.95 1 333.00 .................. 66.60
64483 ....... Inj foramen epidural l/s .................................. .................. 390.95 1 333.00 .................. 66.60
64484 ....... Inj foramen epidural add-on .......................... .................. 390.95 1 333.00 .................. 66.60
64510 ....... Nblock, stellate ganglion ................................ .................. 390.95 1 333.00 .................. 66.60
64517 ....... Nblock inj, hypogas plxs ................................ .................. 139.00 2 139.00 Y .............. 27.80
64520 ....... Nblock, lumbar/thoracic ................................. .................. 390.95 1 333.00 .................. 66.60
64530 ....... Nblock inj, celiac pelus .................................. .................. 390.95 1 333.00 .................. 66.60
64585 ....... Revise/remove neuroelectrode ...................... .................. 1,096.18 1 333.00 .................. 66.60
64590 ....... Insrt/redo pn/gastr stimul ............................... .................. 11,164.12 2 446.00 .................. 89.20
64595 ....... Revise/rmv pn/gastr stimul ............................ .................. 2,186.43 1 333.00 .................. 66.60
64600 ....... Injection treatment of nerve ........................... .................. 748.08 1 333.00 .................. 66.60
64622 ....... Destr paravertebrl nerve l/s ........................... .................. 748.08 1 333.00 .................. 66.60
64623 ....... Destr paravertebral n add-on ........................ .................. 390.95 1 333.00 .................. 66.60
64626 ....... Destr paravertebrl nerve c/t ........................... .................. 748.08 1 333.00 .................. 66.60
64627 ....... Destr paravertebral n add-on ........................ .................. 390.95 1 333.00 .................. 66.60
64630 ....... Injection treatment of nerve ........................... .................. 351.92 2 351.92 Y .............. 70.38
64680 ....... Injection treatment of nerve ........................... .................. 390.95 2 390.95 Y .............. 78.19
64702 ....... Revise finger/toe nerve .................................. .................. 1,097.20 1 333.00 .................. 66.60
64704 ....... Revise hand/foot nerve .................................. .................. 1,097.20 1 333.00 .................. 66.60
64708 ....... Revise arm/leg nerve ..................................... .................. 1,097.20 2 446.00 .................. 89.20
64712 ....... Revision of sciatic nerve ................................ .................. 1,097.20 2 446.00 .................. 89.20
64713 ....... Revision of arm nerve(s) ............................... .................. 1,097.20 2 446.00 .................. 89.20
64714 ....... Revise low back nerve(s) .............................. .................. 1,097.20 2 446.00 .................. 89.20
64716 ....... Revision of cranial nerve ............................... .................. 1,097.20 3 510.00 .................. 102.00
64718 ....... Revise ulnar nerve at elbow .......................... .................. 1,097.20 2 446.00 .................. 89.20
64719 ....... Revise ulnar nerve at wrist ............................ .................. 1,097.20 2 446.00 .................. 89.20
64721 ....... Carpal tunnel surgery .................................... .................. 1,097.20 2 446.00 .................. 89.20
64722 ....... Relieve pressure on nerve(s) ........................ .................. 1,097.20 1 333.00 .................. 66.60
64726 ....... Release foot/toe nerve .................................. .................. 1,097.20 1 333.00 .................. 66.60
64727 ....... Internal nerve revision ................................... .................. 1,097.20 1 333.00 .................. 66.60
64732 ....... Incision of brow nerve ................................... .................. 1,097.20 2 446.00 .................. 89.20
64734 ....... Incision of cheek nerve .................................. .................. 1,097.20 2 446.00 .................. 89.20
64736 ....... Incision of chin nerve ..................................... .................. 1,097.20 2 446.00 .................. 89.20
64738 ....... Incision of jaw nerve ...................................... .................. 1,097.20 2 446.00 .................. 89.20
64740 ....... Incision of tongue nerve ................................ .................. 1,097.20 2 446.00 .................. 89.20
64742 ....... Incision of facial nerve ................................... .................. 1,097.20 2 446.00 .................. 89.20
64744 ....... Incise nerve, back of head ............................ .................. 1,097.20 2 446.00 .................. 89.20
64746 ....... Incise diaphragm nerve ................................. .................. 1,097.20 2 446.00 .................. 89.20
64771 ....... Sever cranial nerve ........................................ .................. 1,097.20 2 446.00 .................. 89.20
64772 ....... Incision of spinal nerve .................................. .................. 1,097.20 2 446.00 .................. 89.20
64774 ....... Remove skin nerve lesion ............................. .................. 1,097.20 2 446.00 .................. 89.20
64776 ....... Remove digit nerve lesion ............................. .................. 1,097.20 3 510.00 .................. 102.00
64778 ....... Digit nerve surgery add-on ............................ .................. 1,097.20 2 446.00 .................. 89.20
64782 ....... Remove limb nerve lesion ............................. .................. 1,097.20 3 510.00 .................. 102.00
64783 ....... Limb nerve surgery add-on ........................... .................. 1,097.20 2 446.00 .................. 89.20
64784 ....... Remove nerve lesion ..................................... .................. 1,097.20 3 510.00 .................. 102.00
64786 ....... Remove sciatic nerve lesion .......................... .................. 2,037.79 3 510.00 .................. 102.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
64787 ....... Implant nerve end .......................................... .................. 1,097.20 2 446.00 .................. 89.20
64788 ....... Remove skin nerve lesion ............................. .................. 1,097.20 3 510.00 .................. 102.00
64790 ....... Removal of nerve lesion ................................ .................. 1,097.20 3 510.00 .................. 102.00
64792 ....... Removal of nerve lesion ................................ .................. 2,037.79 3 510.00 .................. 102.00
64795 ....... Biopsy of nerve .............................................. .................. 1,097.20 2 446.00 .................. 89.20
64802 ....... Remove sympathetic nerves ......................... .................. 1,097.20 2 446.00 .................. 89.20
64821 ....... Remove sympathetic nerves ......................... .................. 1,590.53 4 630.00 .................. 126.00
64831 ....... Repair of digit nerve ...................................... .................. 2,037.79 4 630.00 .................. 126.00
64832 ....... Repair nerve add-on ...................................... .................. 2,037.79 1 333.00 .................. 66.60
64834 ....... Repair of hand or foot nerve ......................... .................. 2,037.79 2 446.00 .................. 89.20
64837 ....... Repair nerve add-on ...................................... .................. 2,037.79 1 333.00 .................. 66.60
64840 ....... Repair of leg nerve ........................................ .................. 2,037.79 2 446.00 .................. 89.20
64856 ....... Repair/transpose nerve ................................. .................. 2,037.79 2 446.00 .................. 89.20
64857 ....... Repair arm/leg nerve ..................................... .................. 2,037.79 2 446.00 .................. 89.20
64858 ....... Repair sciatic nerve ....................................... .................. 2,037.79 2 446.00 .................. 89.20
64859 ....... Nerve surgery ................................................ .................. 2,037.79 1 333.00 .................. 66.60
64861 ....... Repair of arm nerves ..................................... .................. 2,037.79 3 510.00 .................. 102.00
64862 ....... Repair of low back nerves ............................. .................. 2,037.79 3 510.00 .................. 102.00
64864 ....... Repair of facial nerve .................................... .................. 2,037.79 3 510.00 .................. 102.00
64865 ....... Repair of facial nerve .................................... .................. 2,037.79 4 630.00 .................. 126.00
64870 ....... Fusion of facial/other nerve ........................... .................. 2,037.79 4 630.00 .................. 126.00
64872 ....... Subsequent repair of nerve ........................... .................. 2,037.79 2 446.00 .................. 89.20
64874 ....... Repair & revise nerve add-on ....................... .................. 2,037.79 3 510.00 .................. 102.00
64876 ....... Repair nerve/shorten bone ............................ .................. 2,037.79 3 510.00 .................. 102.00
64885 ....... Nerve graft, head or neck .............................. .................. 2,037.79 2 446.00 .................. 89.20
64886 ....... Nerve graft, head or neck .............................. .................. 2,037.79 2 446.00 .................. 89.20
64890 ....... Nerve graft, hand or foot ............................... .................. 2,037.79 2 446.00 .................. 89.20
64892 ....... Nerve graft, arm or leg .................................. .................. 2,037.79 2 446.00 .................. 89.20
64901 ....... Nerve graft add-on ......................................... .................. 2,037.79 2 446.00 .................. 89.20
64902 ....... Nerve graft add-on ......................................... .................. 2,037.79 2 446.00 .................. 89.20
64905 ....... Nerve pedicle transfer ................................... .................. 2,037.79 2 446.00 .................. 89.20
64907 ....... Nerve pedicle transfer ................................... .................. 2,037.79 1 333.00 .................. 66.60
65091 ....... Revise eye ..................................................... .................. 2,165.47 3 510.00 .................. 102.00
65093 ....... Revise eye with implant ................................. .................. 2,165.47 3 510.00 .................. 102.00
65101 ....... Removal of eye .............................................. .................. 2,165.47 3 510.00 .................. 102.00
65103 ....... Remove eye/insert implant ............................ .................. 2,165.47 3 510.00 .................. 102.00
65105 ....... Remove eye/attach implant ........................... .................. 2,165.47 4 630.00 .................. 126.00
65110 ....... Removal of eye .............................................. .................. 2,165.47 5 717.00 .................. 143.40
65112 ....... Remove eye/revise socket ............................ .................. 2,165.47 7 995.00 .................. 199.00
65114 ....... Remove eye/revise socket ............................ .................. 2,165.47 7 995.00 .................. 199.00
65130 ....... Insert ocular implant ...................................... .................. 1,552.37 3 510.00 .................. 102.00
65135 ....... Insert ocular implant ...................................... .................. 1,552.37 2 446.00 .................. 89.20
65140 ....... Attach ocular implant ..................................... .................. 2,165.47 3 510.00 .................. 102.00
65150 ....... Revise ocular implant .................................... .................. 1,552.37 2 446.00 .................. 89.20
65155 ....... Reinsert ocular implant .................................. .................. 2,165.47 3 510.00 .................. 102.00
65175 ....... Removal of ocular implant ............................. .................. 1,052.60 1 333.00 .................. 66.60
65235 ....... Remove foreign body from eye ..................... .................. 935.91 2 446.00 .................. 89.20
65260 ....... Remove foreign body from eye ..................... .................. 1,015.69 3 510.00 .................. 102.00
65265 ....... Remove foreign body from eye ..................... .................. 1,696.64 4 630.00 .................. 126.00
65270 ....... Repair of eye wound ..................................... .................. 1,052.60 2 446.00 .................. 89.20
65290 ....... Repair of eye socket wound .......................... .................. 1,308.05 3 510.00 .................. 102.00
65400 ....... Removal of eye lesion ................................... .................. 935.91 1 333.00 .................. 66.60
65410 ....... Biopsy of cornea ............................................ .................. 935.91 2 446.00 .................. 89.20
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
65420 ....... Removal of eye lesion ................................... .................. 935.91 2 446.00 .................. 89.20
65426 ....... Removal of eye lesion ................................... .................. 1,413.58 5 717.00 .................. 143.40
65710 ....... Corneal transplant ......................................... .................. 2,352.42 7 995.00 .................. 199.00
65770 ....... Revise cornea with implant ........................... .................. 3,195.68 7 995.00 .................. 199.00
65772 ....... Correction of astigmatism .............................. .................. 935.91 4 630.00 .................. 126.00
65775 ....... Correction of astigmatism .............................. .................. 935.91 4 630.00 .................. 126.00
65780 ....... Ocular reconst, transplant ............................. .................. 2,352.42 5 717.00 .................. 143.40
65800 ....... Drainage of eye ............................................. .................. 935.91 1 333.00 .................. 66.60
65805 ....... Drainage of eye ............................................. .................. 935.91 1 333.00 .................. 66.60
65810 ....... Drainage of eye ............................................. .................. 1,413.58 3 510.00 .................. 102.00
65815 ....... Drainage of eye ............................................. .................. 1,413.58 2 446.00 .................. 89.20
65820 ....... Relieve inner eye pressure ............................ .................. 372.94 1 333.00 .................. 66.60
65850 ....... Incision of eye ................................................ .................. 1,413.58 4 630.00 .................. 126.00
65865 ....... Incise inner eye adhesions ............................ .................. 935.91 1 333.00 .................. 66.60
65870 ....... Incise inner eye adhesions ............................ .................. 1,413.58 4 630.00 .................. 126.00
65875 ....... Incise inner eye adhesions ............................ .................. 1,413.58 4 630.00 .................. 126.00
65880 ....... Incise inner eye adhesions ............................ .................. 935.91 4 630.00 .................. 126.00
65900 ....... Remove eye lesion ........................................ .................. 935.91 5 717.00 .................. 143.40
65920 ....... Remove implant of eye .................................. .................. 1,413.58 7 995.00 .................. 199.00
65930 ....... Remove blood clot from eye ......................... .................. 1,413.58 5 717.00 .................. 143.40
66020 ....... Injection treatment of eye .............................. .................. 935.91 1 333.00 .................. 66.60
66030 ....... Injection treatment of eye .............................. .................. 372.94 1 333.00 .................. 66.60
66130 ....... Remove eye lesion ........................................ .................. 1,413.58 7 995.00 .................. 199.00
66150 ....... Glaucoma surgery ......................................... .................. 1,413.58 4 630.00 .................. 126.00
66172 ....... Incision of eye ................................................ .................. 1,413.58 4 630.00 .................. 126.00
66180 ....... Implant eye shunt .......................................... .................. 2,329.43 5 717.00 .................. 143.40
66185 ....... Revise eye shunt ........................................... .................. 2,329.43 2 446.00 .................. 89.20
66220 ....... Repair eye lesion ........................................... .................. 2,300.69 3 510.00 .................. 102.00
66225 ....... Repair/graft eye lesion ................................... .................. 2,329.43 4 630.00 .................. 126.00
66250 ....... Follow-up surgery of eye ............................... .................. 935.91 2 446.00 .................. 89.20
66500 ....... Incision of iris ................................................. .................. 372.94 1 333.00 .................. 66.60
66505 ....... Incision of iris ................................................. .................. 372.94 1 333.00 .................. 66.60
66600 ....... Remove iris and lesion .................................. .................. 1,413.58 3 510.00 .................. 102.00
66605 ....... Removal of iris ............................................... .................. 1,413.58 3 510.00 .................. 102.00
66625 ....... Removal of iris ............................................... .................. 372.94 3 372.94 Y .............. 74.59
66630 ....... Removal of iris ............................................... .................. 1,413.58 3 510.00 .................. 102.00
66635 ....... Removal of iris ............................................... .................. 1,413.58 3 510.00 .................. 102.00
66680 ....... Repair iris & ciliary body ................................ .................. 1,413.58 3 510.00 .................. 102.00
66682 ....... Repair iris & ciliary body ................................ .................. 1,413.58 2 446.00 .................. 89.20
66700 ....... Destruction, ciliary body ................................ .................. 935.91 2 446.00 .................. 89.20
66710 ....... Ciliary transsleral therapy .............................. .................. 935.91 2 446.00 .................. 89.20
66711 ....... Ciliary endoscopic ablation ............................ .................. 935.91 2 446.00 .................. 89.20
66720 ....... Destruction, ciliary body ................................ .................. 935.91 2 446.00 .................. 89.20
66740 ....... Destruction, ciliary body ................................ .................. 1,413.58 2 446.00 .................. 89.20
66821 ....... After cataract laser surgery ........................... .................. 312.50 2 312.50 Y .............. 62.50
66825 ....... Reposition intraocular lens ............................ .................. 1,413.58 4 630.00 .................. 126.00
66830 ....... Removal of lens lesion .................................. .................. 372.94 4 372.94 Y .............. 74.59
66840 ....... Removal of lens material ............................... .................. 914.04 4 630.00 .................. 126.00
66850 ....... Removal of lens material ............................... .................. 1,796.59 7 995.00 .................. 199.00
66852 ....... Removal of lens material ............................... .................. 1,796.59 4 630.00 .................. 126.00
66920 ....... Extraction of lens ........................................... .................. 1,796.59 4 630.00 .................. 126.00
66930 ....... Extraction of lens ........................................... .................. 1,796.59 5 717.00 .................. 143.40
66940 ....... Extraction of lens ........................................... .................. 914.04 5 717.00 .................. 143.40
66982 ....... Cataract surgery, complex ............................. .................. 1,452.57 8 973.00 .................. 194.60
66983 ....... Cataract surg w/iol, 1 stage ........................... .................. 1,452.57 8 973.00 .................. 194.60
66984 ....... Cataract surg w/iol, 1 stage ........................... .................. 1,452.57 8 973.00 .................. 194.60
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
66985 ....... Insert lens prosthesis ..................................... .................. 1,452.57 6 826.00 .................. 165.20
66986 ....... Exchange lens prosthesis .............................. .................. 1,452.57 6 826.00 .................. 165.20
67005 ....... Partial removal of eye fluid ............................ .................. 1,696.64 4 630.00 .................. 126.00
67010 ....... Partial removal of eye fluid ............................ .................. 1,696.64 4 630.00 .................. 126.00
67015 ....... Release of eye fluid ....................................... .................. 1,696.64 1 333.00 .................. 66.60
67025 ....... Replace eye fluid ........................................... .................. 1,696.64 1 333.00 .................. 66.60
67027 ....... Implant eye drug system ............................... .................. 2,300.69 4 630.00 .................. 126.00
67030 ....... Incise inner eye strands ................................ .................. 1,015.69 1 333.00 .................. 66.60
67031 ....... Laser surgery, eye strands ............................ .................. 312.50 2 312.50 Y .............. 62.50
67036 ....... Removal of inner eye fluid ............................. .................. 2,300.69 4 630.00 .................. 126.00
67038 ....... Strip retinal membrane .................................. .................. 2,300.69 5 717.00 .................. 143.40
67039 ....... Laser treatment of retina ............................... .................. 2,300.69 7 995.00 .................. 199.00
67040 ....... Laser treatment of retina ............................... .................. 2,300.69 7 995.00 .................. 199.00
67107 ....... Repair detached retina .................................. .................. 2,300.69 5 717.00 .................. 143.40
67108 ....... Repair detached retina .................................. .................. 2,300.69 7 995.00 .................. 199.00
67112 ....... Rerepair detached retina ............................... .................. 2,300.69 7 995.00 .................. 199.00
67115 ....... Release encircling material ........................... .................. 1,015.69 2 446.00 .................. 89.20
67120 ....... Remove eye implant material ........................ .................. 1,015.69 2 446.00 .................. 89.20
67121 ....... Remove eye implant material ........................ .................. 1,696.64 2 446.00 .................. 89.20
67141 ....... Treatment of retina ........................................ .................. 241.77 2 241.77 Y .............. 48.35
67218 ....... Treatment of retinal lesion ............................. .................. 1,015.69 5 717.00 .................. 143.40
67227 ....... Treatment of retinal lesion ............................. .................. 1,696.64 1 333.00 .................. 66.60
67250 ....... Reinforce eye wall ......................................... .................. 1,052.60 3 510.00 .................. 102.00
67255 ....... Reinforce/graft eye wall ................................. .................. 1,696.64 3 510.00 .................. 102.00
67311 ....... Revise eye muscle ........................................ .................. 1,308.05 3 510.00 .................. 102.00
67312 ....... Revise two eye muscles ................................ .................. 1,308.05 4 630.00 .................. 126.00
67314 ....... Revise eye muscle ........................................ .................. 1,308.05 4 630.00 .................. 126.00
67316 ....... Revise two eye muscles ................................ .................. 1,308.05 4 630.00 .................. 126.00
67318 ....... Revise eye muscle(s) .................................... .................. 1,308.05 4 630.00 .................. 126.00
67320 ....... Revise eye muscle(s) add-on ........................ .................. 1,308.05 4 630.00 .................. 126.00
67331 ....... Eye surgery follow-up add-on ........................ .................. 1,308.05 4 630.00 .................. 126.00
67332 ....... Rerevise eye muscles add-on ....................... .................. 1,308.05 4 630.00 .................. 126.00
67334 ....... Revise eye muscle w/suture .......................... .................. 1,308.05 4 630.00 .................. 126.00
67335 ....... Eye suture during surgery ............................. .................. 1,308.05 4 630.00 .................. 126.00
67340 ....... Revise eye muscle add-on ............................ .................. 1,308.05 4 630.00 .................. 126.00
67343 ....... Release eye tissue ........................................ .................. 1,308.05 7 995.00 .................. 199.00
67346 ....... Biopsy, eye muscle ........................................ A .............. 884.19 1 333.00 .................. 66.60
67350 ....... Biopsy eye muscle ......................................... D .............. .................... 1 333.00 .................. ....................
67400 ....... Explore/biopsy eye socket ............................. .................. 1,552.37 3 510.00 .................. 102.00
67405 ....... Explore/drain eye socket ............................... .................. 1,552.37 4 630.00 .................. 126.00
67412 ....... Explore/treat eye socket ................................ .................. 1,552.37 5 717.00 .................. 143.40
67415 ....... Aspiration, orbital contents ............................ .................. 1,052.60 1 333.00 .................. 66.60
67440 ....... Explore/drain eye socket ............................... .................. 2,165.47 5 717.00 .................. 143.40
67445 ....... Explr/decompress eye socket ........................ .................. 2,165.47 5 717.00 .................. 143.40
67450 ....... Explore/biopsy eye socket ............................. .................. 2,165.47 5 717.00 .................. 143.40
67550 ....... Insert eye socket implant ............................... .................. 2,165.47 4 630.00 .................. 126.00
67560 ....... Revise eye socket implant ............................. .................. 1,552.37 2 446.00 .................. 89.20
67570 ....... Decompress optic nerve ................................ .................. 2,165.47 4 630.00 .................. 126.00
67715 ....... Incision of eyelid fold ..................................... .................. 1,052.60 1 333.00 .................. 66.60
67808 ....... Remove eyelid lesion(s) ................................ .................. 1,052.60 2 446.00 .................. 89.20
67830 ....... Revise eyelashes ........................................... .................. 447.60 2 446.00 .................. 89.20
67835 ....... Revise eyelashes ........................................... .................. 1,052.60 2 446.00 .................. 89.20
67880 ....... Revision of eyelid .......................................... .................. 935.91 3 510.00 .................. 102.00
67900 ....... Repair brow defect ........................................ .................. 1,052.60 4 630.00 .................. 126.00
67901 ....... Repair eyelid defect ....................................... .................. 1,052.60 5 717.00 .................. 143.40
67909 ....... Revise eyelid defect ...................................... .................. 1,052.60 4 630.00 .................. 126.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
67911 ....... Revise eyelid defect ...................................... .................. 1,052.60 3 510.00 .................. 102.00
67912 ....... Correction eyelid w/implant ........................... .................. 1,052.60 3 510.00 .................. 102.00
67935 ....... Repair eyelid wound ...................................... .................. 1,052.60 2 446.00 .................. 89.20
67971 ....... Reconstruction of eyelid ................................ .................. 1,552.37 3 510.00 .................. 102.00
68115 ....... Remove eyelid lining lesion ........................... .................. 1,052.60 2 446.00 .................. 89.20
68130 ....... Remove eyelid lining lesion ........................... .................. 935.91 2 446.00 .................. 89.20
68320 ....... Revise/graft eyelid lining ................................ .................. 1,052.60 4 630.00 .................. 126.00
68330 ....... Revise eyelid lining ........................................ .................. 1,413.58 4 630.00 .................. 126.00
68340 ....... Separate eyelid adhesions ............................ .................. 1,052.60 4 630.00 .................. 126.00
68371 ....... Harvest eye tissue, alograft ........................... .................. 935.91 2 446.00 .................. 89.20
68500 ....... Removal of tear gland ................................... .................. 1,552.37 3 510.00 .................. 102.00
68505 ....... Partial removal, tear gland ............................ .................. 1,552.37 3 510.00 .................. 102.00
68510 ....... Biopsy of tear gland ....................................... .................. 1,052.60 1 333.00 .................. 66.60
68520 ....... Removal of tear sac ...................................... .................. 1,552.37 3 510.00 .................. 102.00
68525 ....... Biopsy of tear sac .......................................... .................. 1,052.60 1 333.00 .................. 66.60
68540 ....... Remove tear gland lesion .............................. .................. 1,552.37 3 510.00 .................. 102.00
68550 ....... Remove tear gland lesion .............................. .................. 1,552.37 3 510.00 .................. 102.00
68700 ....... Repair tear ducts ........................................... .................. 1,552.37 2 446.00 .................. 89.20
68720 ....... Create tear sac drain ..................................... .................. 1,552.37 4 630.00 .................. 126.00
68745 ....... Create tear duct drain .................................... .................. 1,552.37 4 630.00 .................. 126.00
68750 ....... Create tear duct drain .................................... .................. 1,552.37 4 630.00 .................. 126.00
68770 ....... Close tear system fistula ............................... .................. 1,052.60 4 630.00 .................. 126.00
68810 ....... Probe nasolacrimal duct ................................ .................. 131.86 1 131.86 Y .............. 26.37
68811 ....... Probe nasolacrimal duct ................................ .................. 1,052.60 2 446.00 .................. 89.20
68815 ....... Probe nasolacrimal duct ................................ .................. 1,052.60 2 446.00 .................. 89.20
69110 ....... Remove external ear, partial ......................... .................. 928.31 1 333.00 .................. 66.60
69120 ....... Removal of external ear ................................ .................. 1,434.04 2 446.00 .................. 89.20
69140 ....... Remove ear canal lesion(s) ........................... .................. 1,434.04 2 446.00 .................. 89.20
69145 ....... Remove ear canal lesion(s) ........................... .................. 928.31 2 446.00 .................. 89.20
69150 ....... Extensive ear canal surgery .......................... .................. 464.15 3 464.15 Y .............. 92.83
69205 ....... Clear outer ear canal ..................................... .................. 1,233.39 1 333.00 .................. 66.60
69300 ....... Revise external ear ........................................ .................. 1,434.04 3 510.00 .................. 102.00
69310 ....... Rebuild outer ear canal ................................. .................. 2,348.02 3 510.00 .................. 102.00
69320 ....... Rebuild outer ear canal ................................. .................. 2,348.02 7 995.00 .................. 199.00
69421 ....... Incision of eardrum ........................................ .................. 1,009.71 3 510.00 .................. 102.00
69436 ....... Create eardrum opening ................................ .................. 1,009.71 3 510.00 .................. 102.00
69440 ....... Exploration of middle ear ............................... .................. 1,434.04 3 510.00 .................. 102.00
69450 ....... Eardrum revision ............................................ .................. 2,348.02 1 333.00 .................. 66.60
69501 ....... Mastoidectomy ............................................... .................. 2,348.02 7 995.00 .................. 199.00
69502 ....... Mastoidectomy ............................................... .................. 1,434.04 7 995.00 .................. 199.00
69505 ....... Remove mastoid structures ........................... .................. 2,348.02 7 995.00 .................. 199.00
69511 ....... Extensive mastoid surgery ............................ .................. 2,348.02 7 995.00 .................. 199.00
69530 ....... Extensive mastoid surgery ............................ .................. 2,348.02 7 995.00 .................. 199.00
69550 ....... Remove ear lesion ......................................... .................. 2,348.02 5 717.00 .................. 143.40
69552 ....... Remove ear lesion ......................................... .................. 2,348.02 7 995.00 .................. 199.00
69601 ....... Mastoid surgery revision ................................ .................. 2,348.02 7 995.00 .................. 199.00
OF 2005—Continued
A*=new to
ASC
group
A=Add ($) ($) ($)
D=Delete
69620 ....... Repair of eardrum .......................................... .................. 1,434.04 2 446.00 .................. 89.20
69631 ....... Repair eardrum structures ............................. .................. 2,348.02 5 717.00 .................. 143.40
69632 ....... Rebuild eardrum structures ........................... .................. 2,348.02 5 717.00 .................. 143.40
69635 ....... Repair eardrum structures ............................. .................. 2,348.02 7 995.00 .................. 199.00
69641 ....... Revise middle ear & mastoid ........................ .................. 2,348.02 7 995.00 .................. 199.00
69650 ....... Release middle ear bone .............................. .................. 1,434.04 7 995.00 .................. 199.00
69660 ....... Revise middle ear bone ................................. .................. 2,348.02 5 717.00 .................. 143.40
69666 ....... Repair middle ear structures ......................... .................. 2,348.02 4 630.00 .................. 126.00
69667 ....... Repair middle ear structures ......................... .................. 2,348.02 4 630.00 .................. 126.00
69670 ....... Remove mastoid air cells .............................. .................. 2,348.02 3 510.00 .................. 102.00
69676 ....... Remove middle ear nerve ............................. .................. 2,348.02 3 510.00 .................. 102.00
69700 ....... Close mastoid fistula ..................................... .................. 2,348.02 3 510.00 .................. 102.00
69711 ....... Remove/repair hearing aid ............................ .................. 2,348.02 1 333.00 .................. 66.60
69714 ....... Implant temple bone w/stimul ........................ .................. 2,348.02 9 1,339.00 .................. 267.80
69715 ....... Temple bne implnt w/stimulat ........................ .................. 2,348.02 9 1,339.00 .................. 267.80
69717 ....... Temple bone implant revision ....................... .................. 2,348.02 9 1,339.00 .................. 267.80
69718 ....... Revise temple bone implant .......................... .................. 2,348.02 9 1,339.00 .................. 267.80
69720 ....... Release facial nerve ...................................... .................. 2,348.02 5 717.00 .................. 143.40
69740 ....... Repair facial nerve ......................................... .................. 2,348.02 5 717.00 .................. 143.40
69745 ....... Repair facial nerve ......................................... .................. 2,348.02 5 717.00 .................. 143.40
69801 ....... Incise inner ear .............................................. .................. 2,348.02 5 717.00 .................. 143.40
69802 ....... Incise inner ear .............................................. .................. 2,348.02 7 995.00 .................. 199.00
69805 ....... Explore inner ear ........................................... .................. 2,348.02 7 995.00 .................. 199.00
69806 ....... Explore inner ear ........................................... .................. 2,348.02 7 995.00 .................. 199.00
69820 ....... Establish inner ear window ............................ .................. 2,348.02 5 717.00 .................. 143.40
69840 ....... Revise inner ear window ............................... .................. 2,348.02 5 717.00 .................. 143.40
69905 ....... Remove inner ear .......................................... .................. 2,348.02 7 995.00 .................. 199.00
69910 ....... Remove inner ear & mastoid ......................... .................. 2,348.02 7 995.00 .................. 199.00
69915 ....... Incise inner ear nerve .................................... .................. 2,348.02 7 995.00 .................. 199.00
69930 ....... Implant cochlear device ................................. .................. 25,499.72 7 995.00 .................. 199.00
0176T ....... Aqu canal dilat w/o retent .............................. A .............. 2,329.43 9 1,339.00 .................. 267.80
0177T ....... Aqu canal dilat w retent ................................. A .............. 2,329.43 9 1,339.00 .................. 267.80
G0105 ...... Colorectal scrn; hi risk ind ............................. .................. 446.00 2 446.00 .................. 111.50
G0121 ...... Colon ca scrn not hi rsk ind .......................... .................. 446.00 2 446.00 .................. 111.50
G0260 ...... Inj for sacroiliac jt anesth ............................... .................. 351.92 1 333.00 .................. 66.60
G0392 ...... AV fistula or graft arterial ............................... A .............. 2,624.19 9 1,339.00 .................. 334.75
G0393 ...... AV fistula or graft venous .............................. A .............. 2,624.19 9 1,339.00 .................. 334.75
ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007
National Minimum
CPT/ Relative Payment
Description CI SI APC unadjusted unadjusted
HCPCS weight rate copayment copayment
00100 ....... Anesth, salivary gland ....................................... ......... N .................. .................. .................. .................. ..................
00102 ....... Anesth, repair of cleft lip .................................... ......... N .................. .................. .................. .................. ..................
00103 ....... Anesth, blepharoplasty ...................................... ......... N .................. .................. .................. .................. ..................
00104 ....... Anesth, electroshock ......................................... ......... N .................. .................. .................. .................. ..................
00120 ....... Anesth, ear surgery ........................................... ......... N .................. .................. .................. .................. ..................
00124 ....... Anesth, ear exam .............................................. ......... N .................. .................. .................. .................. ..................
00126 ....... Anesth, tympanotomy ........................................ ......... N .................. .................. .................. .................. ..................
ADDENDUM B.—PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION CALENDAR YEAR 2007—Continued
National Minimum
00140 ....... Anesth, procedures on eye ............................... ......... N .................. .................. .................. .................. ..................
00142 ....... Anesth, lens surgery .......................................... ......... N .................. .................. .................. .................. ..................
00144 ....... Anesth, corneal transplant ................................. ......... N .................. .................. .................. .................. ..................
00145 ....... Anesth, vitreoretinal surg ................................... ......... N .................. .................. .................. .................. ..................
00147 ....... Anesth, iridectomy ............................................. ......... N .................. .................. .................. .................. ..................
00148 ....... Anesth, eye exam .............................................. ......... N .................. .................. .................. .................. ..................
00160 ....... Anesth, nose/sinus surgery ............................... ......... N .................. .................. .................. .................. ..................
00162 ....... Anesth, nose/sinus surgery ............................... ......... N .................. .................. .................. .................. ..................
00164 ....... Anesth, biopsy of nose ...................................... ......... N .................. .................. .................. .................. ..................
00170 ....... Anesth, procedure on mouth ............................. ......... N .................. .................. .................. .................. ..................
00172 ....... Anesth, cleft palate repair .................................. ......... N .................. .................. .................. .................. ..................
00174 ....... Anesth, pharyngeal surgery ............................... ......... N .................. .................. .................. .................. ..................
00190 ....... Anesth, face/skull bone surg ............................. ......... N .................. .................. .................. .................. ..................
00210 ....... Anesth, open head surgery ............................... ......... N .................. .................. .................. .................. ..................
00212 ....... Anesth, skull drainage ....................................... ......... N .................. .................. .................. .................. ..................
00216 ....... Anesth, head vessel surgery ............................. ......... N .................. .................. .................. .................. ..................
00218 ....... Anesth, special head surgery ............................ ......... N .................. .................. .................. .................. ..................
00220 ....... Anesth, intrcrn nerve ......................................... ......... N .................. .................. .................. .................. ..................
00222 ....... Anesth, head nerve surgery .............................. ......... N .................. .................. .................. .................. ..................
00300 ....... Anesth, head/neck/ptrunk .................................. ......... N .................. .................. .................. .................. ..................
00320 ....... Anesth, neck organ, 1 & over ............................ ......... N .................. .................. .................. .................. ..................
00322 ....... Anesth, biopsy of thyroid ................................... ......... N .................. .................. .................. .................. ..................
00326 ....... Anesth, larynx/trach, < 1 yr ............................... ......... N .................. .................. .................. .................. ..................
00350 ....... Anesth, neck vessel surgery ............................. ......... N .................. .................. .................. .................. ..................
00352 ....... Anesth, neck vessel surgery ............................. ......... N .................. .................. .................. .................. ..................
00400 ....... Anesth, skin, ext/per/atrunk ............................... ......... N .................. .................. .................. .................. ..................
00402 ....... Anesth, surgery of breast .................................. ......... N .................. .................. .................. .................. ..................
00404 ....... Anesth, surgery of breast .................................. CH .. N .................. .................. .................. .................. ..................
00406 ....... Anesth, surgery of breast .................................. CH .. N .................. .................. .................. .................. ..................
00410 ....... Anesth, correct heart rhythm ............................. ......... N .................. .................. .................. .................. ..................
00450 ....... Anesth, surgery of shoulder .............................. ......... N .................. .................. .................. .................. ..................
00454 ....... Anesth, collar bone biopsy ................................ ......... N .................. .................. .................. .................. ..................
00470 ....... Anesth, removal of rib ....................................... ......... N .................. .................. .................. .................. ..................
00472 ....... Anesth, chest wall repair ................................... ......... N .................. .................. .................. .................. ..................
00500 ....... Anesth, esophageal surgery .............................. ......... N .................. .................. .................. .................. ..................
00520 ....... Anesth, chest procedure .................................... ......... N .................. .................. .................. .................. ..................
00522 ....... Anesth, chest lining biopsy ................................ ......... N .................. .................. .................. .................. ..................
00528 ....... Anesth, chest partition view ............................... ......... N .................. .................. .................. .................. ..................
00529 ....... Anesth, chest partition view ............................... ......... N .................. .................. .................. .................. ..................
00530 ....... Anesth, pacemaker insertion ............................. ......... N .................. .................. .................. .................. ..................
00532 ....... Anesth, vascular access .................................... ......... N .................. .................. .................. .................. ..................
00534 ....... Anesth, cardioverter/defib .................................. ......... N .................. .................. .................. .................. ..................
00537 ....... Anesth, cardiac electrophys .............................. ......... N .................. .................. .................. .................. ..................
00539 ....... Anesth, trach-bronch reconst ............................ ......... N .................. .................. .................. .................. ..................
00541 ....... Anesth, one lung ventilation .............................. ......... N .................. .................. .................. .................. ..................
00548 ....... Anesth, trachea,bronchi surg ............................. ......... N .................. .................. .................. .................. ..................
00550 ....... Anesth, sternal debridement .............................. ......... N .................. .................. .................. .................. ..................
00563 ....... Anesth, heart surg w/arrest ............................... ......... N .................. .................. .................. .................. ..................
00566 ....... Anesth, cabg w/o pump ..................................... ......... N .................. .................. .................. .................. ..................
00600 ....... Anesth, spine, cord surgery ............................... ......... N .................. .................. .................. .................. ..................
00625 ....... Anes spine tranthor w/o vent ............................. NI .... N .................. .................. .................. .................. ..................
00626 ....... Anes, spine transthor w/vent ............................. NI .... N .................. .................. .................. .................. ..................
00634 ....... Anesth for chemonucleolysis ............................. ......... N .................. .................. .................. .................. ..................
00635 ....... Anesth, lumbar puncture ................................... ......... N .................. .................. .................. .................. ..................
00640 ....... Anesth, spine manipulation ............................... ......... N .................. .................. .................. .................. ..................
00700 ....... Anesth, abdominal wall surg ............................. ......... N .................. .................. .................. .................. ..................
00702 ....... Anesth, for liver biopsy ...................................... ......... N .................. .................. .................. .................. ..................
00740 ....... Anesth, upper gi visualize ................................. ......... N .................. .................. .................. .................. ..................
00750 ....... Anesth, repair of hernia ..................................... ......... N .................. .................. .................. .................. ..................
00770 ....... Anesth, blood vessel repair ............................... ......... N .................. .................. .................. .................. ..................
00790 ....... Anesth, surg upper abdomen ............................ ......... N .................. .................. .................. .................. ..................
00797 ....... Anesth, surgery for obesity ................................ ......... N .................. .................. .................. .................. ..................
00810 ....... Anesth, low intestine scope ............................... ......... N .................. .................. .................. .................. ..................
National Minimum
00834 ....... Anesth, hernia repair< 1 yr ................................ ......... N .................. .................. .................. .................. ..................
00836 ....... Anesth hernia repair preemie ............................ ......... N .................. .................. .................. .................. ..................
00840 ....... Anesth, surg lower abdomen ............................. ......... N .................. .................. .................. .................. ..................
00842 ....... Anesth, amniocentesis ....................................... ......... N .................. .................. .................. .................. ..................
00851 ....... Anesth, tubal ligation ......................................... ......... N .................. .................. .................. .................. ..................
00860 ....... Anesth, surgery of abdomen ............................. ......... N .................. .................. .................. .................. ..................
00862 ....... Anesth, kidney/ureter surg ................................. ......... N .................. .................. .................. .................. ..................
00870 ....... Anesth, bladder stone surg ............................... ......... N .................. .................. .................. .................. ..................
00872 ....... Anesth kidney stone destruct ............................ ......... N .................. .................. .................. .................. ..................
00873 ....... Anesth kidney stone destruct ............................ ......... N .................. .................. .................. .................. ..................
00880 ....... Anesth, abdomen vessel surg ........................... ......... N .................. .................. .................. .................. ..................
00902 ....... Anesth, anorectal surgery .................................. ......... N .................. .................. .................. .................. ..................
00906 ....... Anesth, removal of vulva ................................... ......... N .................. .................. .................. .................. ..................
00910 ....... Anesth, bladder surgery .................................... ......... N .................. .................. .................. .................. ..................
00912 ....... Anesth, bladder tumor surg ............................... ......... N .................. .................. .................. .................. ..................
00914 ....... Anesth, removal of prostate .............................. ......... N .................. .................. .................. .................. ..................
00916 ....... Anesth, bleeding control .................................... ......... N .................. .................. .................. .................. ..................
00918 ....... Anesth, stone removal ....................................... ......... N .................. .................. .................. .................. ..................
00920 ....... Anesth, genitalia surgery ................................... ......... N .................. .................. .................. .................. ..................
00921 ....... Anesth, vasectomy ............................................ ......... N .................. .................. .................. .................. ..................
00922 ....... Anesth, sperm duct surgery .............................. ......... N .................. .................. .................. .................. ..................
00924 ....... Anesth, testis exploration .................................. ......... N .................. .................. .................. .................. ..................
00926 ....... Anesth, removal of testis ................................... ......... N .................. .................. .................. .................. ..................
00928 ....... Anesth, removal of testis ................................... ......... N .................. .................. .................. .................. ..................
00930 ....... Anesth, testis suspension .................................. ......... N .................. .................. .................. .................. ..................
00938 ....... Anesth, insert penis device ............................... ......... N .................. .................. .................. .................. ..................
00940 ....... Anesth, vaginal procedures ............................... ......... N .................. .................. .................. .................. ..................
00942 ....... Anesth, surg on vag/urethral ............................. ......... N .................. .................. .................. .................. ..................
00948 ....... Anesth, repair of cervix ...................................... ......... N .................. .................. .................. .................. ..................
00950 ....... Anesth, vaginal endoscopy ................................ ......... N .................. .................. .................. .................. ..................
00952 ....... Anesth, hysteroscope/graph .............................. ......... N .................. .................. .................. .................. ..................
01112 ....... Anesth, bone aspirate/bx ................................... ......... N .................. .................. .................. .................. ..................
01120 ....... Anesth, pelvis surgery ....................................... ......... N .................. .................. .................. .................. ..................
01130 ....... Anesth, body cast procedure ............................. ......... N .................. .................. .................. .................. ..................
01160 ....... Anesth, pelvis procedure ................................... ......... N .................. .................. .................. .................. ..................
01170 ....... Anesth, pelvis surgery ....................................... ......... N .................. .................. .................. .................. ..................
01173 ....... Anesth, fx repair, pelvis ..................................... ......... N .................. .................. .................. .................. ..................
01180 ....... Anesth, pelvis nerve removal ............................ ......... N .................. .................. .................. .................. ..................
01190 ....... Anesth, pelvis nerve removal ............................ ......... N .................. .................. .................. .................. ..................
01200 ....... Anesth, hip joint procedure ................................ ......... N .................. .................. .................. .................. ..................
01202 ....... Anesth, arthroscopy of hip ................................. ......... N .................. .................. .................. .................. ..................
01210 ....... Anesth, hip joint surgery .................................... ......... N .................. .................. .................. .................. ..................
01215 ....... Anesth, revise hip repair .................................... ......... N .................. .................. .................. .................. ..................
01220 ....... Anesth, procedure on femur .............................. ......... N .................. .................. .................. .................. ..................
01230 ....... Anesth, surgery of femur ................................... ......... N .................. .................. .................. .................. ..................
01250 ....... Anesth, upper leg surgery ................................. ......... N .................. .................. .................. .................. ..................
01260 ....... Anesth, upper leg veins surg ............................. ......... N .................. .................. .................. .................. ..................
01270 ....... Anesth, thigh arteries surg ................................ ......... N .................. .................. .................. .................. ..................
01320 ....... Anesth, knee area surgery ................................ ......... N .................. .................. .................. .................. ..................
01340 ....... Anesth, knee area procedure ............................ ......... N .................. .................. .................. .................. ..................
01380 ....... Anesth, knee joint procedure ............................. ......... N .................. .................. .................. .................. ..................
01382 ....... Anesth, dx knee arthroscopy ............................. ......... N .................. .................. .................. .................. ..................
01390 ....... Anesth, knee area procedure ............................ ......... N .................. .................. .................. .................. ..................
01400 ....... Anesth, knee joint surgery ................................. ......... N .................. .................. .................. .................. ..................
01420 ....... Anesth, knee joint casting ................................. ......... N .................. .................. .................. .................. ..................
01430 ....... Anesth, knee veins surgery ............................... ......... N .................. .................. .................. .................. ..................
01432 ....... Anesth, knee vessel surg .................................. ......... N .................. .................. .................. .................. ..................
01440 ....... Anesth, knee arteries surg ................................ ......... N .................. .................. .................. .................. ..................
01462 ....... Anesth, lower leg procedure .............................. ......... N .................. .................. .................. .................. ..................
01464 ....... Anesth, ankle/ft arthroscopy .............................. ......... N .................. .................. .................. .................. ..................
01470 ....... Anesth, lower leg surgery .................................. ......... N .................. .................. .................. .................. ..................
01472 ....... Anesth, achilles tendon surg ............................. ......... N .................. .................. .................. .................. ..................
01474 ....... Anesth, lower leg surgery .................................. ......... N .................. .................. .................. .................. ..................
01480 ....... Anesth, lower leg bone surg .............................. ......... N .................. .................. .................. .................. ..................
01482 ....... Anesth, radical leg surgery ................................ ......... N .................. .................. .................. .................. ..................
National Minimum
01484 ....... Anesth, lower leg revision ................................. ......... N .................. .................. .................. .................. ..................
01490 ....... Anesth, lower leg casting .................................. ......... N .................. .................. .................. .................. ..................
01500 ....... Anesth, leg arteries surg ................................... ......... N .................. .................. .................. .................. ..................
01520 ....... Anesth, lower leg vein surg ............................... ......... N .................. .................. .................. .................. ..................
01522 ....... Anesth, lower leg vein surg ............................... ......... N .................. .................. .................. .................. ..................
01620 ....... Anesth, shoulder procedure .............................. ......... N .................. .................. .................. .................. ..................
01622 ....... Anes dx shoulder arthroscopy ........................... ......... N .................. .................. .................. .................. ..................
01650 ....... Anesth, shoulder artery surg ............................. ......... N .................. .................. .................. .................. ..................
01670 ....... Anesth, shoulder vein surg ................................ ......... N .................. .................. .................. .................. ..................
01680 ....... Anesth, shoulder casting ................................... ......... N .................. .................. .................. .................. ..................
01682 ....... Anesth, airplane cast ......................................... ......... N .................. .................. .................. .................. ..................
01710 ....... Anesth, elbow area surgery ............................... ......... N .................. .................. .................. .................. ..................
01712 ....... Anesth, uppr arm tendon surg ........................... ......... N .................. .................. .................. .................. ..................
01714 ....... Anesth, uppr arm tendon surg ........................... ......... N .................. .................. .................. .................. ..................
01716 ....... Anesth, biceps tendon repair ............................. ......... N .................. .................. .................. .................. ..................
01730 ....... Anesth, uppr arm procedure .............................. ......... N .................. .................. .................. .................. ..................
01732 ....... Anesth, dx elbow arthroscopy ........................... ......... N .................. .................. .................. .................. ..................
01740 ....... Anesth, upper arm surgery ................................ ......... N .................. .................. .................. .................. ..................
01742 ....... Anesth, humerus surgery .................................. ......... N .................. .................. .................. .................. ..................
01744 ....... Anesth, humerus repair ..................................... ......... N .................. .................. .................. .................. ..................
01758 ....... Anesth, humeral lesion surg .............................. ......... N .................. .................. .................. .................. ..................
01760 ....... Anesth, elbow replacement ............................... ......... N .................. .................. .................. .................. ..................
01770 ....... Anesth, uppr arm artery surg ............................ ......... N .................. .................. .................. .................. ..................
01772 ....... Anesth, uppr arm embolectomy ........................ ......... N .................. .................. .................. .................. ..................
01780 ....... Anesth, upper arm vein surg ............................. ......... N .................. .................. .................. .................. ..................
01782 ....... Anesth, uppr arm vein repair ............................. ......... N .................. .................. .................. .................. ..................
01810 ....... Anesth, lower arm surgery ................................ ......... N .................. .................. .................. .................. ..................
01820 ....... Anesth, lower arm procedure ............................ ......... N .................. .................. .................. .................. ..................
01829 ....... Anesth, dx wrist arthroscopy ............................. ......... N .................. .................. .................. .................. ..................
01830 ....... Anesth, lower arm surgery ................................ ......... N .................. .................. .................. .................. ..................
01832 ....... Anesth, wrist replacement ................................. ......... N .................. .................. .................. .................. ..................
01840 ....... Anesth, lwr arm artery surg ............................... ......... N .................. .................. .................. .................. ..................
01842 ....... Anesth, lwr arm embolectomy ........................... ......... N .................. .................. .................. .................. ..................
01844 ....... Anesth, vascular shunt surg .............................. ......... N .................. .................. .................. .................. ..................
01850 ....... Anesth, lower arm vein surg .............................. ......... N .................. .................. .................. .................. ..................
01852 ....... Anesth, lwr arm vein repair ............................... ......... N .................. .................. .................. .................. ..................
01860 ....... Anesth, lower arm casting ................................. ......... N .................. .................. .................. .................. ..................
01905 ....... Anes, spine inject, x-ray/re ................................ ......... N .................. .................. .................. .................. ..................
01916 ....... Anesth, dx arteriography ................................... ......... N .................. .................. .................. .................. ..................
01920 ....... Anesth, catheterize heart ................................... ......... N .................. .................. .................. .................. ..................
01922 ....... Anesth, cat or MRI scan .................................... ......... N .................. .................. .................. .................. ..................
01924 ....... Anes, ther interven rad, art ................................ ......... N .................. .................. .................. .................. ..................
01925 ....... Anes, ther interven rad, car ............................... ......... N .................. .................. .................. .................. ..................
01926 ....... Anes, tx interv rad hrt/cran ................................ ......... N .................. .................. .................. .................. ..................
01930 ....... Anes, ther interven rad, vei ............................... ......... N .................. .................. .................. .................. ..................
01931 ....... Anes, ther interven rad, tip ................................ ......... N .................. .................. .................. .................. ..................
01932 ....... Anes, tx interv rad, th vein ................................ ......... N .................. .................. .................. .................. ..................
01933 ....... Anes, tx interv rad, cran v ................................. ......... N .................. .................. .................. .................. ..................
01951 ....... Anesth, burn, less 4 percent ............................. ......... N .................. .................. .................. .................. ..................
01952 ....... Anesth, burn, 4–9 percent ................................. ......... N .................. .................. .................. .................. ..................
01953 ....... Anesth, burn, each 9 percent ............................ ......... N .................. .................. .................. .................. ..................
01958 ....... Anesth, antepartum manipul .............................. ......... N .................. .................. .................. .................. ..................
01960 ....... Anesth, vaginal delivery ..................................... ......... N .................. .................. .................. .................. ..................
01961 ....... Anesth, cs delivery ............................................ ......... N .................. .................. .................. .................. ..................
01962 ....... Anesth, emer hysterectomy ............................... ......... N .................. .................. .................. .................. ..................
01963 ....... Anesth, cs hysterectomy ................................... ......... N .................. .................. .................. .................. ..................
01965 ....... Anesth, inc/missed ab proc ............................... ......... N .................. .................. .................. .................. ..................
01966 ....... Anesth, induced ab procedure .......................... ......... N .................. .................. .................. .................. ..................
01967 ....... Anesth/analg, vag delivery ................................ ......... N .................. .................. .................. .................. ..................
01968 ....... Anes/analg cs deliver add-on ............................ ......... N .................. .................. .................. .................. ..................
01969 ....... Anesth/analg cs hyst add-on ............................. ......... N .................. .................. .................. .................. ..................
01991 ....... Anesth, nerve block/inj ...................................... ......... N .................. .................. .................. .................. ..................
01992 ....... Anesth, n block/inj, prone .................................. ......... N .................. .................. .................. .................. ..................
01995 ....... Regional anesthesia limb .................................. CH .. D .................. .................. .................. .................. ..................
01996 ....... Hosp manage cont drug admin ......................... ......... N .................. .................. .................. .................. ..................
01999 ....... Unlisted anesth procedure ................................. ......... N .................. .................. .................. .................. ..................
10021 ....... Fna w/o image ................................................... ......... T 0002 1.0995 67.58 .................. 13.52
10022 ....... Fna w/image ...................................................... ......... T 0036 2.0738 127.47 .................. 25.49
National Minimum
10040 ....... Acne surgery ...................................................... ......... T 0010 0.476 29.26 8.02 5.85
10060 ....... Drainage of skin abscess .................................. ......... T 0006 1.4392 88.46 .................. 17.69
10061 ....... Drainage of skin abscess .................................. ......... T 0006 1.4392 88.46 .................. 17.69
10080 ....... Drainage of pilonidal cyst .................................. ......... T 0006 1.4392 88.46 .................. 17.69
10081 ....... Drainage of pilonidal cyst .................................. ......... T 0007 11.1535 685.58 .................. 137.12
10120 ....... Remove foreign body ........................................ ......... T 0006 1.4392 88.46 .................. 17.69
10121 ....... Remove foreign body ........................................ ......... T 0021 15.1024 928.31 219.48 185.66
10140 ....... Drainage of hematoma/fluid .............................. ......... T 0007 11.1535 685.58 .................. 137.12
10160 ....... Puncture drainage of lesion ............................... ......... T 0018 1.0259 63.06 15.44 12.61
10180 ....... Complex drainage, wound ................................. ......... T 0008 17.5086 1,076.22 .................. 215.24
11000 ....... Debride infected skin ......................................... ......... T 0013 1.0918 67.11 .................. 13.42
11001 ....... Debride infected skin add-on ............................. ......... T 0012 0.8432 51.83 11.18 10.37
11010 ....... Debride skin, fx .................................................. ......... T 0019 4.0919 251.52 71.87 50.30
11011 ....... Debride skin/muscle, fx ..................................... ......... T 0019 4.0919 251.52 71.87 50.30
11012 ....... Debride skin/muscle/bone, fx ............................ ......... T 0019 4.0919 251.52 71.87 50.30
11040 ....... Debride skin, partial ........................................... ......... T 0015 1.6241 99.83 20.13 19.97
11041 ....... Debride skin, full ................................................ ......... T 0015 1.6241 99.83 20.13 19.97
11042 ....... Debride skin/tissue ............................................ ......... T 0016 2.6749 164.42 .................. 32.88
11043 ....... Debride tissue/muscle ....................................... ......... T 0016 2.6749 164.42 .................. 32.88
11044 ....... Debride tissue/muscle/bone .............................. ......... T 0682 6.8832 423.10 158.65 84.62
11055 ....... Trim skin lesion .................................................. ......... T 0012 0.8432 51.83 11.18 10.37
11056 ....... Trim skin lesions, 2 to 4 .................................... ......... T 0012 0.8432 51.83 11.18 10.37
11057 ....... Trim skin lesions, over 4 ................................... ......... T 0013 1.0918 67.11 .................. 13.42
11100 ....... Biopsy, skin lesion ............................................. ......... T 0018 1.0259 63.06 15.44 12.61
11101 ....... Biopsy, skin add-on ........................................... ......... T 0018 1.0259 63.06 15.44 12.61
11200 ....... Removal of skin tags ......................................... ......... T 0013 1.0918 67.11 .................. 13.42
11201 ....... Remove skin tags add-on .................................. ......... T 0015 1.6241 99.83 20.13 19.97
11300 ....... Shave skin lesion ............................................... ......... T 0012 0.8432 51.83 11.18 10.37
11302 ....... Shave skin lesion ............................................... ......... T 0013 1.0918 67.11 .................. 13.42
11400 ....... Exc tr-ext b9+marg 0.5 < cm ............................. ......... T 0019 4.0919 251.52 71.87 50.30
11401 ....... Exc tr-ext b9+marg 0.6–1 cm ............................ ......... T 0019 4.0919 251.52 71.87 50.30
11406 ....... Exc tr-ext b9+marg > 4.0 cm ............................. ......... T 0021 15.1024 928.31 219.48 185.66
11420 ....... Exc h-f-nk-sp b9+marg 0.5 < ............................. ......... T 0020 6.8083 418.49 107.67 83.70
11421 ....... Exc h-f-nk-sp b9+marg 0.6–1 ............................ ......... T 0020 6.8083 418.49 107.67 83.70
11426 ....... Exc h-f-nk-sp b9+marg > 4 cm .......................... ......... T 0022 20.0656 1,233.39 354.45 246.68
11440 ....... Exc face-mm b9+marg 0.5 < cm ....................... ......... T 0019 4.0919 251.52 71.87 50.30
11441 ....... Exc face-mm b9+marg 0.6–1 cm ...................... ......... T 0019 4.0919 251.52 71.87 50.30
11446 ....... Exc face-mm b9+marg > 4 cm .......................... ......... T 0022 20.0656 1,233.39 354.45 246.68
11450 ....... Removal, sweat gland lesion ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68
11600 ....... Exc tr-ext mlg+marg 0.5 < cm ........................... ......... T 0019 4.0919 251.52 71.87 50.30
11601 ....... Exc tr-ext mlg+marg 0.6–1 cm .......................... ......... T 0019 4.0919 251.52 71.87 50.30
11606 ....... Exc tr-ext mlg+marg > 4 cm .............................. ......... T 0021 15.1024 928.31 219.48 185.66
11620 ....... Exc h-f-nk-sp mlg+marg 0.5 < ........................... ......... T 0020 6.8083 418.49 107.67 83.70
National Minimum
11621 ....... Exc h-f-nk-sp mlg+marg 0.6–1 .......................... ......... T 0019 4.0919 251.52 71.87 50.30
11626 ....... Exc h-f-nk-sp mlg+mar > 4 cm .......................... ......... T 0022 20.0656 1,233.39 354.45 246.68
11640 ....... Exc face-mm malig+marg 0.5 < ........................ ......... T 0020 6.8083 418.49 107.67 83.70
11641 ....... Exc face-mm malig+marg 0.6–1 ....................... ......... T 0020 6.8083 418.49 107.67 83.70
11646 ....... Exc face-mm mlg+marg > 4 cm ........................ ......... T 0022 20.0656 1,233.39 354.45 246.68
11719 ....... Trim nail(s) ......................................................... ......... T 0009 0.7744 47.60 .................. 9.52
11720 ....... Debride nail, 1–5 ............................................... ......... T 0009 0.7744 47.60 .................. 9.52
11721 ....... Debride nail, 6 or more ...................................... ......... T 0009 0.7744 47.60 .................. 9.52
11730 ....... Removal of nail plate ......................................... ......... T 0013 1.0918 67.11 .................. 13.42
11732 ....... Remove nail plate, add-on ................................ ......... T 0012 0.8432 51.83 11.18 10.37
11740 ....... Drain blood from under nail ............................... ......... T 0009 0.7744 47.60 .................. 9.52
11750 ....... Removal of nail bed ........................................... ......... T 0019 4.0919 251.52 71.87 50.30
11752 ....... Remove nail bed/finger tip ................................. ......... T 0022 20.0656 1,233.39 354.45 246.68
11755 ....... Biopsy, nail unit ................................................. ......... T 0019 4.0919 251.52 71.87 50.30
11760 ....... Repair of nail bed .............................................. ......... T 0024 1.4843 91.24 29.88 18.25
11762 ....... Reconstruction of nail bed ................................. ......... T 0024 1.4843 91.24 29.88 18.25
11765 ....... Excision of nail fold, toe .................................... ......... T 0015 1.6241 99.83 20.13 19.97
11770 ....... Removal of pilonidal lesion ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68
11900 ....... Injection into skin lesions ................................... ......... T 0012 0.8432 51.83 11.18 10.37
11901 ....... Added skin lesions injection .............................. ......... T 0012 0.8432 51.83 11.18 10.37
11920 ....... Correct skin color defects .................................. ......... T 0024 1.4843 91.24 29.88 18.25
11950 ....... Therapy for contour defects .............................. ......... T 0024 1.4843 91.24 29.88 18.25
11960 ....... Insert tissue expander(s) ................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
11970 ....... Replace tissue expander ................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14
11971 ....... Remove tissue expander(s) ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68
11976 ....... Removal of contraceptive cap ........................... ......... T 0019 4.0919 251.52 71.87 50.30
11980 ....... Implant hormone pellet(s) .................................. ......... X 0340 0.6102 37.51 .................. 7.50
11981 ....... Insert drug implant device ................................. ......... X 0340 0.6102 37.51 .................. 7.50
11982 ....... Remove drug implant device ............................. ......... X 0340 0.6102 37.51 .................. 7.50
11983 ....... Remove/insert drug implant ............................... ......... X 0340 0.6102 37.51 .................. 7.50
12001 ....... Repair superficial wound(s) ............................... ......... T 0024 1.4843 91.24 29.88 18.25
12020 ....... Closure of split wound ....................................... ......... T 0024 1.4843 91.24 29.88 18.25
12021 ....... Closure of split wound ....................................... ......... T 0024 1.4843 91.24 29.88 18.25
12031 ....... Layer closure of wound(s) ................................. ......... T 0024 1.4843 91.24 29.88 18.25
National Minimum
13100 ....... Repair of wound or lesion ................................. ......... T 0025 5.2594 323.28 101.85 64.66
13102 ....... Repair wound/lesion add-on .............................. ......... T 0024 1.4843 91.24 29.88 18.25
13151 ....... Repair of wound or lesion ................................. CH .. T 0025 5.2594 323.28 101.85 64.66
13160 ....... Late closure of wound ....................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
14000 ....... Skin tissue rearrangement ................................. ......... T 0686 14.0346 862.68 .................. 172.54
14001 ....... Skin tissue rearrangement ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
14021 ....... Skin tissue rearrangement ................................. CH .. T 0686 14.0346 862.68 .................. 172.54
15000 ....... Wound prep, 1st 100 sq cm .............................. CH .. D .................. .................. .................. .................. ..................
15001 ....... Wound prep, addl 100 sq cm ............................ CH .. D .................. .................. .................. .................. ..................
15002 ....... Wnd prep, ch/inf, trk/arm/lg ............................... NI .... T 0025 5.2594 323.28 101.85 64.66
15003 ....... Wnd prep, ch/inf addl 100 cm ........................... NI .... T 0025 5.2594 323.28 101.85 64.66
15004 ....... Wnd prep ch/inf, f/n/hf/g .................................... NI .... T 0025 5.2594 323.28 101.85 64.66
15005 ....... Wnd prep, f/n/hf/g, addl cm ............................... NI .... T 0025 5.2594 323.28 101.85 64.66
15040 ....... Harvest cultured skin graft ................................. ......... T 0024 1.4843 91.24 29.88 18.25
15050 ....... Skin pinch graft .................................................. ......... T 0025 5.2594 323.28 101.85 64.66
15100 ....... Skin splt grft, trnk/arm/leg .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15101 ....... Skin splt grft t/a/l, add-on .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15110 ....... Epidrm autogrft trnk/arm/leg .............................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15111 ....... Epidrm autogrft t/a/l add-on ............................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15115 ....... Epidrm a-grft face/nck/hf/g ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
15116 ....... Epidrm a-grft f/n/hf/g addl .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15120 ....... Skn splt a-grft fac/nck/hf/g ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15121 ....... Skn splt a-grft f/n/hf/g add ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15130 ....... Derm autograft, trnk/arm/leg .............................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15131 ....... Derm autograft t/a/l add-on ............................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15135 ....... Derm autograft face/nck/hf/g ............................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15136 ....... Derm autograft, f/n/hf/g add .............................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15150 ....... Cult epiderm grft t/arm/leg ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15151 ....... Cult epiderm grft t/a/l addl ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15152 ....... Cult epiderm graft t/a/l +% ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
15155 ....... Cult epiderm graft, f/n/hf/g ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15156 ....... Cult epidrm grft f/n/hfg add ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
15157 ....... Cult epiderm grft f/n/hfg +% .............................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15170 ....... Acell graft trunk/arms/legs ................................. CH .. T 0025 5.2594 323.28 101.85 64.66
15171 ....... Acell graft t/arm/leg add-on ............................... CH .. T 0025 5.2594 323.28 101.85 64.66
15175 ....... Acellular graft, f/n/hf/g ........................................ CH .. T 0025 5.2594 323.28 101.85 64.66
15176 ....... Acell graft, f/n/hf/g add-on ................................. CH .. T 0025 5.2594 323.28 101.85 64.66
15200 ....... Skin full graft, trunk ............................................ CH .. T 0686 14.0346 862.68 .................. 172.54
15201 ....... Skin full graft trunk add-on ................................ ......... T 0025 5.2594 323.28 101.85 64.66
15220 ....... Skin full graft sclp/arm/leg ................................. CH .. T 0686 14.0346 862.68 .................. 172.54
15221 ....... Skin full graft add-on ......................................... ......... T 0025 5.2594 323.28 101.85 64.66
15240 ....... Skin full grft face/genit/hf ................................... ......... T 0686 14.0346 862.68 .................. 172.54
15260 ....... Skin full graft een & lips .................................... ......... T 0686 14.0346 862.68 .................. 172.54
15300 ....... Apply skinallogrft, t/arm/lg ................................. CH .. T 0025 5.2594 323.28 101.85 64.66
National Minimum
15301 ....... Apply sknallogrft t/a/l addl ................................. ......... T 0025 5.2594 323.28 101.85 64.66
15320 ....... Apply skin allogrft f/n/hf/g .................................. ......... T 0025 5.2594 323.28 101.85 64.66
15321 ....... Aply sknallogrft f/n/hfg add ................................ ......... T 0025 5.2594 323.28 101.85 64.66
15330 ....... Aply acell alogrft t/arm/leg ................................. ......... T 0025 5.2594 323.28 101.85 64.66
15331 ....... Aply acell grft t/a/l add-on .................................. ......... T 0025 5.2594 323.28 101.85 64.66
15335 ....... Apply acell graft, f/n/hf/g .................................... ......... T 0025 5.2594 323.28 101.85 64.66
15336 ....... Aply acell grft f/n/hf/g add .................................. ......... T 0025 5.2594 323.28 101.85 64.66
15340 ....... Apply cult skin substitute ................................... CH .. T 0025 5.2594 323.28 101.85 64.66
15341 ....... Apply cult skin sub add-on ................................ CH .. T 0025 5.2594 323.28 101.85 64.66
15360 ....... Apply cult derm sub, t/a/l ................................... CH .. T 0025 5.2594 323.28 101.85 64.66
15361 ....... Aply cult derm sub t/a/l add ............................... CH .. T 0025 5.2594 323.28 101.85 64.66
15365 ....... Apply cult derm sub f/n/hf/g ............................... CH .. T 0025 5.2594 323.28 101.85 64.66
15366 ....... Apply cult derm f/hf/g add ................................. CH .. T 0025 5.2594 323.28 101.85 64.66
15400 ....... Apply skin xenograft, t/a/l .................................. ......... T 0025 5.2594 323.28 101.85 64.66
15401 ....... Apply skn xenogrft t/a/l add ............................... ......... T 0025 5.2594 323.28 101.85 64.66
15420 ....... Apply skin xgraft, f/n/hf/g ................................... ......... T 0025 5.2594 323.28 101.85 64.66
15421 ....... Apply skn xgrft f/n/hf/g add ................................ ......... T 0025 5.2594 323.28 101.85 64.66
15430 ....... Apply acellular xenograft ................................... ......... T 0025 5.2594 323.28 101.85 64.66
15431 ....... Apply acellular xgraft add .................................. ......... T 0025 5.2594 323.28 101.85 64.66
15570 ....... Form skin pedicle flap ....................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15576 ....... Form skin pedicle flap ....................................... ......... T 0686 14.0346 862.68 .................. 172.54
15600 ....... Skin graft ............................................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
15610 ....... Skin graft ............................................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
15620 ....... Skin graft ............................................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
15630 ....... Skin graft ............................................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
15650 ....... Transfer skin pedicle flap .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15731 ....... Forehead flap w/vasc pedicle ............................ NI .... T 0686 14.0346 862.68 .................. 172.54
15732 ....... Muscle-skin graft, head/neck ............................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15734 ....... Muscle-skin graft, trunk ..................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15736 ....... Muscle-skin graft, arm ....................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15738 ....... Muscle-skin graft, leg ......................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15740 ....... Island pedicle flap graft ..................................... ......... T 0686 14.0346 862.68 .................. 172.54
15750 ....... Neurovascular pedicle graft ............................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15760 ....... Composite skin graft .......................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15770 ....... Derma-fat-fascia graft ........................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
15775 ....... Hair transplant punch grafts .............................. ......... T 0025 5.2594 323.28 101.85 64.66
15776 ....... Hair transplant punch grafts .............................. ......... T 0025 5.2594 323.28 101.85 64.66
15780 ....... Abrasion treatment of skin ................................. ......... T 0022 20.0656 1,233.39 354.45 246.68
15781 ....... Abrasion treatment of skin ................................. ......... T 0019 4.0919 251.52 71.87 50.30
15782 ....... Abrasion treatment of skin ................................. ......... T 0019 4.0919 251.52 71.87 50.30
15783 ....... Abrasion treatment of skin ................................. ......... T 0016 2.6749 164.42 .................. 32.88
15786 ....... Abrasion, lesion, single ...................................... ......... T 0013 1.0918 67.11 .................. 13.42
15787 ....... Abrasion, lesions, add-on .................................. ......... T 0013 1.0918 67.11 .................. 13.42
15788 ....... Chemical peel, face, epiderm ............................ ......... T 0012 0.8432 51.83 11.18 10.37
15789 ....... Chemical peel, face, dermal .............................. ......... T 0015 1.6241 99.83 20.13 19.97
15792 ....... Chemical peel, nonfacial ................................... ......... T 0013 1.0918 67.11 .................. 13.42
15793 ....... Chemical peel, nonfacial ................................... ......... T 0012 0.8432 51.83 11.18 10.37
15819 ....... Plastic surgery, neck ......................................... ......... T 0025 5.2594 323.28 101.85 64.66
15820 ....... Revision of lower eyelid ..................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15821 ....... Revision of lower eyelid ..................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15822 ....... Revision of upper eyelid .................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15823 ....... Revision of upper eyelid .................................... CH .. T 0686 14.0346 862.68 .................. 172.54
15824 ....... Removal of forehead wrinkles ........................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15825 ....... Removal of neck wrinkles .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15826 ....... Removal of brow wrinkles ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15828 ....... Removal of face wrinkles .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15829 ....... Removal of skin wrinkles ................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
15830 ....... Exc skin abd ...................................................... NI .... T 0022 20.0656 1,233.39 354.45 246.68
15831 ....... Excise excessive skin tissue ............................. CH .. D .................. .................. .................. .................. ..................
15832 ....... Excise excessive skin tissue ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68
15835 ....... Excise excessive skin tissue ............................. ......... T 0025 5.2594 323.28 101.85 64.66
15840 ....... Graft for face nerve palsy .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
National Minimum
15841 ....... Graft for face nerve palsy .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15842 ....... Flap for face nerve palsy ................................... ......... T 0686 14.0346 862.68 .................. 172.54
15845 ....... Skin and muscle repair, face ............................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15847 ....... Exc skin abd add-on .......................................... NI .... T 0022 20.0656 1,233.39 354.45 246.68
15850 ....... Removal of sutures ............................................ ......... T 0016 2.6749 164.42 .................. 32.88
15851 ....... Removal of sutures ............................................ ......... T 0016 2.6749 164.42 .................. 32.88
15852 ....... Dressing change not for burn ............................ ......... X 0340 0.6102 37.51 .................. 7.50
15860 ....... Test for blood flow in graft ................................. CH .. X 0340 0.6102 37.51 .................. 7.50
15876 ....... Suction assisted lipectomy ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
15878 ....... Suction assisted lipectomy ................................ ......... T 0686 14.0346 862.68 .................. 172.54
15920 ....... Removal of tail bone ulcer ................................. ......... T 0019 4.0919 251.52 71.87 50.30
15922 ....... Removal of tail bone ulcer ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
15931 ....... Remove sacrum pressure sore ......................... ......... T 0022 20.0656 1,233.39 354.45 246.68
15940 ....... Remove hip pressure sore ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68
15950 ....... Remove thigh pressure sore ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68
15999 ....... Removal of pressure sore ................................. ......... T 0019 4.0919 251.52 71.87 50.30
16000 ....... Initial treatment of burn(s) ................................. ......... T 0012 0.8432 51.83 11.18 10.37
16020 ....... Dress/debrid p-thick burn, s .............................. ......... T 0013 1.0918 67.11 .................. 13.42
16025 ....... Dress/debrid p-thick burn, m ............................. ......... T 0013 1.0918 67.11 .................. 13.42
16030 ....... Dress/debrid p-thick burn, l ............................... ......... T 0015 1.6241 99.83 20.13 19.97
16035 ....... Incision of burn scab, initi .................................. CH .. T 0016 2.6749 164.42 .................. 32.88
17000 ....... Destruct premalg lesion ..................................... ......... T 0010 0.476 29.26 8.02 5.85
17003 ....... Destruct premalg les, 2–14 ............................... ......... T 0010 0.476 29.26 8.02 5.85
17004 ....... Destroy premlg lesions 15+ ............................... ......... T 0011 2.5665 157.76 .................. 31.55
17106 ....... Destruction of skin lesions ................................. ......... T 0011 2.5665 157.76 .................. 31.55
17110 ....... Destruct b9 lesion, 1–14 .................................... CH .. T 0012 0.8432 51.83 11.18 10.37
17111 ....... Destruct lesion, 15 or more ............................... ......... T 0013 1.0918 67.11 .................. 13.42
17250 ....... Chemical cautery, tissue ................................... ......... T 0013 1.0918 67.11 .................. 13.42
17260 ....... Destruction of skin lesions ................................. ......... T 0015 1.6241 99.83 20.13 19.97
17304 ....... 1 stage mohs, up to 5 spec ............................... CH .. D .................. .................. .................. .................. ..................
17307 ....... Mohs addl stage up to 5 spec ........................... CH .. D .................. .................. .................. .................. ..................
17310 ....... Mohs any stage > 5 spec each ......................... CH .. D .................. .................. .................. .................. ..................
17311 ....... Mohs, 1 stage, h/n/hf/g ...................................... NI .... T 0694 3.7292 229.23 91.69 45.85
National Minimum
17312 ....... Mohs addl stage ................................................ NI .... T 0694 3.7292 229.23 91.69 45.85
17313 ....... Mohs, 1 stage, t/a/l ............................................ NI .... T 0694 3.7292 229.23 91.69 45.85
17314 ....... Mohs, addl stage, t/a/l ....................................... NI .... T 0694 3.7292 229.23 91.69 45.85
17315 ....... Mohs surg, addl block ....................................... NI .... T 0694 3.7292 229.23 91.69 45.85
17340 ....... Cryotherapy of skin ............................................ CH .. T 0016 2.6749 164.42 .................. 32.88
17360 ....... Skin peel therapy ............................................... ......... T 0013 1.0918 67.11 .................. 13.42
17380 ....... Hair removal by electrolysis .............................. ......... T 0013 1.0918 67.11 .................. 13.42
17999 ....... Skin tissue procedure ........................................ CH .. T 0012 0.8432 51.83 11.18 10.37
19000 ....... Drainage of breast lesion .................................. ......... T 0004 2.0687 127.16 .................. 25.43
19001 ....... Drain breast lesion add-on ................................ CH .. T 0002 1.0995 67.58 .................. 13.52
19020 ....... Incision of breast lesion ..................................... ......... T 0008 17.5086 1,076.22 .................. 215.24
19030 ....... Injection for breast x-ray .................................... ......... N .................. .................. .................. .................. ..................
19100 ....... Bx breast percut w/o image ............................... ......... T 0005 3.9045 240.00 71.59 48.00
19101 ....... Biopsy of breast, open ....................................... ......... T 0028 19.2788 1,185.03 303.74 237.01
19102 ....... Bx breast percut w/image .................................. ......... T 0005 3.9045 240.00 71.59 48.00
19103 ....... Bx breast percut w/device ................................. ......... T 0658 6.4387 395.77 .................. 79.15
19105 ....... Cryosurg ablate fa, each ................................... NI .... T 0029 28.0166 1,722.12 581.52 344.42
19110 ....... Nipple exploration .............................................. ......... T 0028 19.2788 1,185.03 303.74 237.01
19112 ....... Excise breast duct fistula ................................... ......... T 0028 19.2788 1,185.03 303.74 237.01
19120 ....... Removal of breast lesion ................................... ......... T 0028 19.2788 1,185.03 303.74 237.01
19125 ....... Excision, breast lesion ....................................... ......... T 0028 19.2788 1,185.03 303.74 237.01
19126 ....... Excision, addl breast lesion ............................... ......... T 0028 19.2788 1,185.03 303.74 237.01
19140 ....... Removal of breast tissue ................................... CH .. D .................. .................. .................. .................. ..................
19160 ....... Partial mastectomy ............................................ CH .. D .................. .................. .................. .................. ..................
19162 ....... P-mastectomy w/ln removal .............................. CH .. D .................. .................. .................. .................. ..................
19180 ....... Removal of breast ............................................. CH .. D .................. .................. .................. .................. ..................
19260 ....... Removal of chest wall lesion ............................. ......... T 0021 15.1024 928.31 219.48 185.66
19290 ....... Place needle wire, breast .................................. ......... N .................. .................. .................. .................. ..................
19291 ....... Place needle wire, breast .................................. ......... N .................. .................. .................. .................. ..................
19295 ....... Place breast clip, percut .................................... ......... S 0657 1.7369 106.76 .................. 21.35
19296 ....... Place po breast cath for rad .............................. CH .. T 0648 51.2269 3,148.82 .................. 629.76
19297 ....... Place breast cath for rad ................................... CH .. T 0648 51.2269 3,148.82 .................. 629.76
19298 ....... Place breast rad tube/caths ............................... ......... S 1524 .................. 3,250.00 .................. 650.00
19300 ....... Removal of breast tissue ................................... NI .... T 0028 19.2788 1,185.03 303.74 237.01
19301 ....... Partical mastectomy .......................................... NI .... T 0028 19.2788 1,185.03 303.74 237.01
19302 ....... P-mastectomy w/ln removal .............................. NI .... T 0693 36.9988 2,274.24 721.30 454.85
19303 ....... Mast, simple, complete ...................................... NI .... T 0029 28.0166 1,722.12 581.52 344.42
19304 ....... Mast, subq ......................................................... NI .... T 0029 28.0166 1,722.12 581.52 344.42
19305 ....... Mast, radical ...................................................... NI .... C .................. .................. .................. .................. ..................
19306 ....... Mast, rad, urban type ........................................ NI .... C .................. .................. .................. .................. ..................
19307 ....... Mast, mod rad .................................................... NI .... T 0030 37.8692 2,327.74 747.07 465.55
19316 ....... Suspension of breast ......................................... ......... T 0029 28.0166 1,722.12 581.52 344.42
19318 ....... Reduction of large breast .................................. ......... T 0693 36.9988 2,274.24 721.30 454.85
19324 ....... Enlarge breast ................................................... ......... T 0693 36.9988 2,274.24 721.30 454.85
19325 ....... Enlarge breast with implant ............................... ......... T 0648 51.2269 3,148.82 .................. 629.76
19328 ....... Removal of breast implant ................................. ......... T 0029 28.0166 1,722.12 581.52 344.42
19330 ....... Removal of implant material .............................. ......... T 0029 28.0166 1,722.12 581.52 344.42
19340 ....... Immediate breast prosthesis ............................. ......... T 0030 37.8692 2,327.74 747.07 465.55
19342 ....... Delayed breast prosthesis ................................. ......... T 0648 51.2269 3,148.82 .................. 629.76
19350 ....... Breast reconstruction ......................................... ......... T 0028 19.2788 1,185.03 303.74 237.01
19355 ....... Correct inverted nipple(s) .................................. ......... T 0029 28.0166 1,722.12 581.52 344.42
19357 ....... Breast reconstruction ......................................... ......... T 0648 51.2269 3,148.82 .................. 629.76
19366 ....... Breast reconstruction ......................................... ......... T 0029 28.0166 1,722.12 581.52 344.42
19370 ....... Surgery of breast capsule ................................. ......... T 0029 28.0166 1,722.12 581.52 344.42
19371 ....... Removal of breast capsule ................................ ......... T 0029 28.0166 1,722.12 581.52 344.42
19380 ....... Revise breast reconstruction ............................. ......... T 0030 37.8692 2,327.74 747.07 465.55
19396 ....... Design custom breast implant ........................... ......... T 0029 28.0166 1,722.12 581.52 344.42
19499 ....... Breast surgery procedure .................................. ......... T 0028 19.2788 1,185.03 303.74 237.01
20000 ....... Incision of abscess ............................................ ......... T 0006 1.4392 88.46 .................. 17.69
20005 ....... Incision of deep abscess ................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
20100 ....... Explore wound, neck ......................................... ......... T 0023 4.2212 259.47 .................. 51.89
20101 ....... Explore wound, chest ........................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
20102 ....... Explore wound, abdomen .................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
20103 ....... Explore wound, extremity .................................. ......... T 0023 4.2212 259.47 .................. 51.89
20150 ....... Excise epiphyseal bar ........................................ ......... T 0051 41.0893 2,525.68 .................. 505.14
20200 ....... Muscle biopsy .................................................... ......... T 0021 15.1024 928.31 219.48 185.66
National Minimum
20205 ....... Deep muscle biopsy .......................................... ......... T 0021 15.1024 928.31 219.48 185.66
20206 ....... Needle biopsy, muscle ...................................... ......... T 0005 3.9045 240.00 71.59 48.00
20220 ....... Bone biopsy, trocar/needle ................................ ......... T 0019 4.0919 251.52 71.87 50.30
20225 ....... Bone biopsy, trocar/needle ................................ ......... T 0020 6.8083 418.49 107.67 83.70
20240 ....... Bone biopsy, excisional ..................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
20245 ....... Bone biopsy, excisional ..................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
20250 ....... Open bone biopsy ............................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
20251 ....... Open bone biopsy ............................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
20500 ....... Injection of sinus tract ........................................ ......... T 0251 2.452 150.72 .................. 30.14
20501 ....... Inject sinus tract for x-ray .................................. ......... N .................. .................. .................. .................. ..................
20520 ....... Removal of foreign body ................................... ......... T 0019 4.0919 251.52 71.87 50.30
20525 ....... Removal of foreign body ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
20526 ....... Ther injection, carp tunnel ................................. ......... T 0204 2.2614 139.00 40.13 27.80
20550 ....... Inj tendon sheath/ligament ................................ ......... T 0204 2.2614 139.00 40.13 27.80
20551 ....... Inj tendon origin/insertion .................................. ......... T 0204 2.2614 139.00 40.13 27.80
20552 ....... Inj trigger point, 1/2 muscl ................................. ......... T 0204 2.2614 139.00 40.13 27.80
20553 ....... Inject trigger points, ´ 3 .................................... ......... T 0204 2.2614 139.00 40.13 27.80
20600 ....... Drain/inject, joint/bursa ...................................... ......... T 0204 2.2614 139.00 40.13 27.80
20612 ....... Aspirate/inj ganglion cyst ................................... ......... T 0204 2.2614 139.00 40.13 27.80
20615 ....... Treatment of bone cyst ...................................... ......... T 0004 2.0687 127.16 .................. 25.43
20650 ....... Insert and remove bone pin .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57
20662 ....... Application of pelvis brace ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
20663 ....... Application of thigh brace .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
20665 ....... Removal of fixation device ................................ ......... X 0340 0.6102 37.51 .................. 7.50
20670 ....... Removal of support implant ............................... ......... T 0021 15.1024 928.31 219.48 185.66
20680 ....... Removal of support implant ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68
20690 ....... Apply bone fixation device ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
20692 ....... Apply bone fixation device ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
20693 ....... Adjust bone fixation device ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
20694 ....... Remove bone fixation device ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57
20822 ....... Replantation digit, complete .............................. ......... T 0054 25.8758 1,590.53 .................. 318.11
20900 ....... Removal of bone for graft .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
20902 ....... Removal of bone for graft .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
20910 ....... Remove cartilage for graft ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
20912 ....... Remove cartilage for graft ................................. ......... T 0027 21.4302 1,317.27 329.72 263.45
20920 ....... Removal of fascia for graft ................................ ......... T 0686 14.0346 862.68 .................. 172.54
20922 ....... Removal of fascia for graft ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
20924 ....... Removal of tendon for graft ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93
20926 ....... Removal of tissue for graft ................................ ......... T 0686 14.0346 862.68 .................. 172.54
20950 ....... Fluid pressure, muscle ...................................... ......... T 0006 1.4392 88.46 .................. 17.69
20972 ....... Bone/skin graft, metatarsal ................................ ......... T 0056 40.8559 2,511.33 .................. 502.27
20973 ....... Bone/skin graft, great toe .................................. ......... T 0056 40.8559 2,511.33 .................. 502.27
20975 ....... Electrical bone stimulation ................................. ......... X 0340 0.6102 37.51 .................. 7.50
20979 ....... Us bone stimulation ........................................... ......... X 0340 0.6102 37.51 .................. 7.50
20982 ....... Ablate, bone tumor(s) perq ................................ CH .. T 0051 41.0893 2,525.68 .................. 505.14
20999 ....... Musculoskeletal surgery .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
21010 ....... Incision of jaw joint ............................................ ......... T 0254 23.3299 1,434.04 321.35 286.81
21015 ....... Resection of facial tumor ................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
21025 ....... Excision of bone, lower jaw ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21026 ....... Excision of facial bone(s) .................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21029 ....... Contour of face bone lesion .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21030 ....... Excise max/zygoma b9 tumor ........................... ......... T 0254 23.3299 1,434.04 321.35 286.81
21031 ....... Remove exostosis, mandible ............................. ......... T 0254 23.3299 1,434.04 321.35 286.81
21032 ....... Remove exostosis, maxilla ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81
21034 ....... Excise max/zygoma mlg tumor ......................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21040 ....... Excise mandible lesion ...................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
21044 ....... Removal of jaw bone lesion .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21046 ....... Remove mandible cyst complex ........................ ......... T 0256 38.1991 2,348.02 .................. 469.60
21047 ....... Excise lwr jaw cyst w/repair .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21048 ....... Remove maxilla cyst complex ........................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21049 ....... Excis uppr jaw cyst w/repair .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21050 ....... Removal of jaw joint .......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21060 ....... Remove jaw joint cartilage ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
21070 ....... Remove coronoid process ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21076 ....... Prepare face/oral prosthesis .............................. ......... T 0254 23.3299 1,434.04 321.35 286.81
21077 ....... Prepare face/oral prosthesis .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60
National Minimum
21085 ....... Prepare face/oral prosthesis .............................. ......... T 0253 16.4266 1,009.71 282.29 201.94
21089 ....... Prepare face/oral prosthesis .............................. ......... T 0251 2.452 150.72 .................. 30.14
21100 ....... Maxillofacial fixation ........................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21110 ....... Interdental fixation ............................................. ......... T 0252 7.5511 464.15 109.16 92.83
21116 ....... Injection, jaw joint x-ray ..................................... ......... N .................. .................. .................. .................. ..................
21120 ....... Reconstruction of chin ....................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
21125 ....... Augmentation, lower jaw bone .......................... ......... T 0254 23.3299 1,434.04 321.35 286.81
21127 ....... Augmentation, lower jaw bone .......................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21137 ....... Reduction of forehead ....................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
21138 ....... Reduction of forehead ....................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21139 ....... Reduction of forehead ....................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21150 ....... Reconstruct midface, lefort ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
21175 ....... Reconstruct orbit/forehead ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
21181 ....... Contour cranial bone lesion ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81
21195 ....... Reconst lwr jaw w/o fixation .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21198 ....... Reconstr lwr jaw segment ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21199 ....... Reconstr lwr jaw w/advance .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21206 ....... Reconstruct upper jaw bone .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21208 ....... Augmentation of facial bones ............................ ......... T 0256 38.1991 2,348.02 .................. 469.60
21209 ....... Reduction of facial bones .................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21210 ....... Face bone graft ................................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21215 ....... Lower jaw bone graft ......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21230 ....... Rib cartilage graft .............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21235 ....... Ear cartilage graft .............................................. ......... T 0254 23.3299 1,434.04 321.35 286.81
21240 ....... Reconstruction of jaw joint ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
21244 ....... Reconstruction of lower jaw .............................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21245 ....... Reconstruction of jaw ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
21260 ....... Revise eye sockets ............................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
21270 ....... Augmentation, cheek bone ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
21275 ....... Revision, orbitofacial bones ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21280 ....... Revision of eyelid .............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21282 ....... Revision of eyelid .............................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
21295 ....... Revision of jaw muscle/bone ............................. ......... T 0252 7.5511 464.15 109.16 92.83
21296 ....... Revision of jaw muscle/bone ............................. ......... T 0254 23.3299 1,434.04 321.35 286.81
21299 ....... Cranio/maxillofacial surgery ............................... ......... T 0251 2.452 150.72 .................. 30.14
21300 ....... Treatment of skull fracture ................................. CH .. D .................. .................. .................. .................. ..................
21310 ....... Treatment of nose fracture ................................ ......... T 0251 2.452 150.72 .................. 30.14
21315 ....... Treatment of nose fracture ................................ ......... T 0251 2.452 150.72 .................. 30.14
21320 ....... Treatment of nose fracture ................................ ......... T 0252 7.5511 464.15 109.16 92.83
21325 ....... Treatment of nose fracture ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81
21336 ....... Treat nasal septal fracture ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48
21337 ....... Treat nasal septal fracture ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
21338 ....... Treat nasoethmoid fracture ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81
21339 ....... Treat nasoethmoid fracture ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81
21340 ....... Treatment of nose fracture ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
21345 ....... Treat nose/jaw fracture ...................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
21355 ....... Treat cheek bone fracture ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
21356 ....... Treat cheek bone fracture ................................. ......... T 0254 23.3299 1,434.04 321.35 286.81
21390 ....... Treat eye socket fracture ................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21400 ....... Treat eye socket fracture ................................... ......... T 0252 7.5511 464.15 109.16 92.83
National Minimum
21401 ....... Treat eye socket fracture ................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
21421 ....... Treat mouth roof fracture ................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
21440 ....... Treat dental ridge fracture ................................. ......... T 0254 23.3299 1,434.04 321.35 286.81
21445 ....... Treat dental ridge fracture ................................. ......... T 0254 23.3299 1,434.04 321.35 286.81
21450 ....... Treat lower jaw fracture ..................................... ......... T 0251 2.452 150.72 .................. 30.14
21451 ....... Treat lower jaw fracture ..................................... ......... T 0252 7.5511 464.15 109.16 92.83
21452 ....... Treat lower jaw fracture ..................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
21453 ....... Treat lower jaw fracture ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
21454 ....... Treat lower jaw fracture ..................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
21480 ....... Reset dislocated jaw .......................................... ......... T 0251 2.452 150.72 .................. 30.14
21485 ....... Reset dislocated jaw .......................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
21490 ....... Repair dislocated jaw ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
21495 ....... Treat hyoid bone fracture .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
21497 ....... Interdental wiring ............................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
21499 ....... Head surgery procedure .................................... ......... T 0251 2.452 150.72 .................. 30.14
21501 ....... Drain neck/chest lesion ..................................... ......... T 0008 17.5086 1,076.22 .................. 215.24
21502 ....... Drain chest lesion .............................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
21550 ....... Biopsy of neck/chest .......................................... CH .. T 0020 6.8083 418.49 107.67 83.70
21555 ....... Remove lesion, neck/chest ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68
21556 ....... Remove lesion, neck/chest ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68
21557 ....... Remove tumor, neck/chest ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68
21600 ....... Partial removal of rib ......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
21610 ....... Partial removal of rib ......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
21685 ....... Hyoid myotomy & suspension ........................... ......... T 0252 7.5511 464.15 109.16 92.83
21700 ....... Revision of neck muscle .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
21720 ....... Revision of neck muscle .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
21725 ....... Revision of neck muscle .................................... ......... T 0006 1.4392 88.46 .................. 17.69
21742 ....... Repair stern/nuss w/o scope ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14
21743 ....... Repair sternum/nuss w/scope ........................... ......... T 0051 41.0893 2,525.68 .................. 505.14
21800 ....... Treatment of rib fracture .................................... ......... T 0043 1.6857 103.62 .................. 20.72
21805 ....... Treatment of rib fracture .................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
21820 ....... Treat sternum fracture ....................................... ......... T 0043 1.6857 103.62 .................. 20.72
21899 ....... Neck/chest surgery procedure ........................... ......... T 0251 2.452 150.72 .................. 30.14
21920 ....... Biopsy soft tissue of back .................................. ......... T 0020 6.8083 418.49 107.67 83.70
21925 ....... Biopsy soft tissue of back .................................. ......... T 0022 20.0656 1,233.39 354.45 246.68
21930 ....... Remove lesion, back or flank ............................ ......... T 0022 20.0656 1,233.39 354.45 246.68
21935 ....... Remove tumor, back ......................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
22100 ....... Remove part of neck vertebra ........................... ......... T 0208 44.1489 2,713.74 .................. 542.75
22101 ....... Remove part, thorax vertebra ............................ ......... T 0208 44.1489 2,713.74 .................. 542.75
22102 ....... Remove part, lumbar vertebra ........................... ......... T 0208 44.1489 2,713.74 .................. 542.75
22103 ....... Remove extra spine segment ............................ ......... T 0208 44.1489 2,713.74 .................. 542.75
22222 ....... Revision of thorax spine .................................... ......... T 0208 44.1489 2,713.74 .................. 542.75
22305 ....... Treat spine process fracture .............................. ......... T 0043 1.6857 103.62 .................. 20.72
22310 ....... Treat spine fracture ........................................... ......... T 0043 1.6857 103.62 .................. 20.72
22315 ....... Treat spine fracture ........................................... ......... T 0043 1.6857 103.62 .................. 20.72
22505 ....... Manipulation of spine ......................................... ......... T 0045 14.5947 897.11 268.47 179.42
22520 ....... Percut vertebroplasty thor ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
22521 ....... Percut vertebroplasty lumb ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
22522 ....... Percut vertebroplasty add"l ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
22523 ....... Percut kyphoplasty, thor .................................... ......... T 0052 66.58 4,092.54 .................. 818.51
22524 ....... Percut kyphoplasty, lumbar ............................... ......... T 0052 66.58 4,092.54 .................. 818.51
22525 ....... Percut kyphoplasty, add-on ............................... ......... T 0052 66.58 4,092.54 .................. 818.51
22526 ....... Idet, single level ................................................. NI .... T 0050 25.1296 1,544.67 .................. 308.93
22527 ....... Idet, 1 or more levels ......................................... NI .... T 0050 25.1296 1,544.67 .................. 308.93
22612 ....... Lumbar spine fusion .......................................... ......... T 0208 44.1489 2,713.74 .................. 542.75
22614 ....... Spine fusion, extra segment .............................. ......... T 0208 44.1489 2,713.74 .................. 542.75
22851 ....... Apply spine prosth device ................................. CH .. T 0049 20.8706 1,282.87 .................. 256.57
22857 ....... Lumbar artif diskectomy .................................... NI .... C .................. .................. .................. .................. ..................
22862 ....... Revise lumbar artif disc ..................................... NI .... C .................. .................. .................. .................. ..................
22865 ....... Remove lumb artif disc ...................................... NI .... C .................. .................. .................. .................. ..................
22899 ....... Spine surgery procedure ................................... CH .. T 0049 20.8706 1,282.87 .................. 256.57
22900 ....... Remove abdominal wall lesion .......................... ......... T 0022 20.0656 1,233.39 354.45 246.68
22999 ....... Abdomen surgery procedure ............................. CH .. T 0049 20.8706 1,282.87 .................. 256.57
National Minimum
23000 ....... Removal of calcium deposits ............................. ......... T 0021 15.1024 928.31 219.48 185.66
23020 ....... Release shoulder joint ....................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
23030 ....... Drain shoulder lesion ......................................... ......... T 0008 17.5086 1,076.22 .................. 215.24
23031 ....... Drain shoulder bursa ......................................... ......... T 0008 17.5086 1,076.22 .................. 215.24
23035 ....... Drain shoulder bone lesion ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
23040 ....... Exploratory shoulder surgery ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
23044 ....... Exploratory shoulder surgery ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
23065 ....... Biopsy shoulder tissues ..................................... CH .. T 0020 6.8083 418.49 107.67 83.70
23066 ....... Biopsy shoulder tissues ..................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
23075 ....... Removal of shoulder lesion ............................... ......... T 0021 15.1024 928.31 219.48 185.66
23076 ....... Removal of shoulder lesion ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68
23077 ....... Remove tumor of shoulder ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68
23100 ....... Biopsy of shoulder joint ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
23101 ....... Shoulder joint surgery ........................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
23105 ....... Remove shoulder joint lining ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
23106 ....... Incision of collarbone joint ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
23107 ....... Explore treat shoulder joint ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
23120 ....... Partial removal, collar bone ............................... ......... T 0051 41.0893 2,525.68 .................. 505.14
23125 ....... Removal of collar bone ...................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
23130 ....... Remove shoulder bone, part ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14
23140 ....... Removal of bone lesion ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
23150 ....... Removal of humerus lesion ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93
23170 ....... Remove collar bone lesion ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
23172 ....... Remove shoulder blade lesion .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93
23174 ....... Remove humerus lesion .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
23180 ....... Remove collar bone lesion ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
23182 ....... Remove shoulder blade lesion .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93
23190 ....... Partial removal of scapula ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
23195 ....... Removal of head of humerus ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93
23330 ....... Remove shoulder foreign body ......................... ......... T 0020 6.8083 418.49 107.67 83.70
23331 ....... Remove shoulder foreign body ......................... ......... T 0022 20.0656 1,233.39 354.45 246.68
23350 ....... Injection for shoulder x-ray ................................ ......... N .................. .................. .................. .................. ..................
23395 ....... Muscle transfer,shoulder/arm ............................ ......... T 0051 41.0893 2,525.68 .................. 505.14
23397 ....... Muscle transfers ................................................ ......... T 0052 66.58 4,092.54 .................. 818.51
23400 ....... Fixation of shoulder blade ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
23405 ....... Incision of tendon & muscle .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
23406 ....... Incise tendon(s) & muscle(s) ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
23410 ....... Repair rotator cuff, acute ................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14
23412 ....... Repair rotator cuff, chronic ................................ CH .. T 0051 41.0893 2,525.68 .................. 505.14
23415 ....... Release of shoulder ligament ............................ ......... T 0051 41.0893 2,525.68 .................. 505.14
23420 ....... Repair of shoulder ............................................. CH .. T 0051 41.0893 2,525.68 .................. 505.14
23430 ....... Repair biceps tendon ......................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14
23440 ....... Remove/transplant tendon ................................. CH .. T 0051 41.0893 2,525.68 .................. 505.14
23450 ....... Repair shoulder capsule .................................... ......... T 0052 66.58 4,092.54 .................. 818.51
23462 ....... Repair shoulder capsule .................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14
23466 ....... Repair shoulder capsule .................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14
23470 ....... Reconstruct shoulder joint ................................. ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80
23480 ....... Revision of collar bone ...................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
23485 ....... Revision of collar bone ...................................... CH .. T 0052 66.58 4,092.54 .................. 818.51
23490 ....... Reinforce clavicle ............................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
23491 ....... Reinforce shoulder bones .................................. CH .. T 0052 66.58 4,092.54 .................. 818.51
23500 ....... Treat clavicle fracture ........................................ ......... T 0043 1.6857 103.62 .................. 20.72
23505 ....... Treat clavicle fracture ........................................ ......... T 0043 1.6857 103.62 .................. 20.72
23515 ....... Treat clavicle fracture ........................................ CH .. T 0064 57.2172 3,517.03 835.79 703.41
23520 ....... Treat clavicle dislocation ................................... ......... T 0043 1.6857 103.62 .................. 20.72
23530 ....... Treat clavicle dislocation ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
National Minimum
23570 ....... Treat shoulder blade fx ...................................... ......... T 0043 1.6857 103.62 .................. 20.72
23575 ....... Treat shoulder blade fx ...................................... ......... T 0043 1.6857 103.62 .................. 20.72
23585 ....... Treat scapula fracture ........................................ CH .. T 0064 57.2172 3,517.03 835.79 703.41
23600 ....... Treat humerus fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72
23615 ....... Treat humerus fracture ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41
23650 ....... Treat shoulder dislocation ................................. ......... T 0043 1.6857 103.62 .................. 20.72
23655 ....... Treat shoulder dislocation ................................. ......... T 0045 14.5947 897.11 268.47 179.42
23660 ....... Treat shoulder dislocation ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48
23665 ....... Treat dislocation/fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72
23670 ....... Treat dislocation/fracture ................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41
23675 ....... Treat dislocation/fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72
23680 ....... Treat dislocation/fracture ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
23700 ....... Fixation of shoulder ........................................... ......... T 0045 14.5947 897.11 268.47 179.42
23800 ....... Fusion of shoulder joint ..................................... CH .. T 0052 66.58 4,092.54 .................. 818.51
23802 ....... Fusion of shoulder joint ..................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
23921 ....... Amputation follow-up surgery ............................ ......... T 0025 5.2594 323.28 101.85 64.66
23929 ....... Shoulder surgery procedure .............................. ......... T 0043 1.6857 103.62 .................. 20.72
23930 ....... Drainage of arm lesion ...................................... ......... T 0008 17.5086 1,076.22 .................. 215.24
23931 ....... Drainage of arm bursa ....................................... ......... T 0008 17.5086 1,076.22 .................. 215.24
23935 ....... Drain arm/elbow bone lesion ............................. ......... T 0049 20.8706 1,282.87 .................. 256.57
24000 ....... Exploratory elbow surgery ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
24006 ....... Release elbow joint ........................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24065 ....... Biopsy arm/elbow soft tissue ............................. ......... T 0021 15.1024 928.31 219.48 185.66
24066 ....... Biopsy arm/elbow soft tissue ............................. ......... T 0021 15.1024 928.31 219.48 185.66
24075 ....... Remove arm/elbow lesion ................................. ......... T 0021 15.1024 928.31 219.48 185.66
24076 ....... Remove arm/elbow lesion ................................. ......... T 0022 20.0656 1,233.39 354.45 246.68
24077 ....... Remove tumor of arm/elbow ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68
24100 ....... Biopsy elbow joint lining .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
24101 ....... Explore/treat elbow joint .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24102 ....... Remove elbow joint lining .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
24105 ....... Removal of elbow bursa .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
24115 ....... Remove/graft bone lesion .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
24120 ....... Remove elbow lesion ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
24130 ....... Removal of head of radius ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
24134 ....... Removal of arm bone lesion ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
24136 ....... Remove radius bone lesion ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24138 ....... Remove elbow bone lesion ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24140 ....... Partial removal of arm bone .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
24145 ....... Partial removal of radius .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24147 ....... Partial removal of elbow .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24149 ....... Radical resection of elbow ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
24150 ....... Extensive humerus surgery ............................... CH .. T 0051 41.0893 2,525.68 .................. 505.14
24151 ....... Extensive humerus surgery ............................... ......... T 0052 66.58 4,092.54 .................. 818.51
24152 ....... Extensive radius surgery ................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14
24153 ....... Extensive radius surgery ................................... ......... T 0052 66.58 4,092.54 .................. 818.51
24155 ....... Removal of elbow joint ...................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
24160 ....... Remove elbow joint implant .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
24164 ....... Remove radius head implant ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
24200 ....... Removal of arm foreign body ............................ ......... T 0019 4.0919 251.52 71.87 50.30
24201 ....... Removal of arm foreign body ............................ ......... T 0021 15.1024 928.31 219.48 185.66
24220 ....... Injection for elbow x-ray .................................... ......... N .................. .................. .................. .................. ..................
24300 ....... Manipulate elbow w/anesth ............................... ......... T 0045 14.5947 897.11 268.47 179.42
24301 ....... Muscle/tendon transfer ...................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24305 ....... Arm tendon lengthening .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24310 ....... Revision of arm tendon ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
24320 ....... Repair of arm tendon ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
24330 ....... Revision of arm muscles ................................... CH .. T 0052 66.58 4,092.54 .................. 818.51
24331 ....... Revision of arm muscles ................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
24332 ....... Tenolysis, triceps ............................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
24340 ....... Repair of biceps tendon .................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
24341 ....... Repair arm tendon/muscle ................................ ......... T 0051 41.0893 2,525.68 .................. 505.14
National Minimum
24342 ....... Repair of ruptured tendon ................................. ......... T 0051 41.0893 2,525.68 .................. 505.14
24343 ....... Repr elbow lat ligmnt w/tiss ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24344 ....... Reconstruct elbow lat ligmnt ............................. CH .. T 0052 66.58 4,092.54 .................. 818.51
24345 ....... Repr elbw med ligmnt w/tissu ........................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24346 ....... Reconstruct elbow med ligmnt .......................... ......... T 0051 41.0893 2,525.68 .................. 505.14
24350 ....... Repair of tennis elbow ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24356 ....... Revision of tennis elbow .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24360 ....... Reconstruct elbow joint ..................................... ......... T 0047 33.4505 2,056.14 537.03 411.23
24361 ....... Reconstruct elbow joint ..................................... ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80
24362 ....... Reconstruct elbow joint ..................................... ......... T 0048 47.4378 2,915.91 .................. 583.18
24363 ....... Replace elbow joint ........................................... ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80
24365 ....... Reconstruct head of radius ............................... ......... T 0047 33.4505 2,056.14 537.03 411.23
24366 ....... Reconstruct head of radius ............................... ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80
24400 ....... Revision of humerus .......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
24430 ....... Repair of humerus ............................................. CH .. T 0052 66.58 4,092.54 .................. 818.51
24435 ....... Repair humerus with graft ................................. CH .. T 0052 66.58 4,092.54 .................. 818.51
24470 ....... Revision of elbow joint ....................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
24495 ....... Decompression of forearm ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
24498 ....... Reinforce humerus ............................................ CH .. T 0052 66.58 4,092.54 .................. 818.51
24586 ....... Treat elbow fracture ........................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41
24600 ....... Treat elbow dislocation ...................................... ......... T 0043 1.6857 103.62 .................. 20.72
24605 ....... Treat elbow dislocation ...................................... ......... T 0045 14.5947 897.11 268.47 179.42
24615 ....... Treat elbow dislocation ...................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41
24620 ....... Treat elbow fracture ........................................... ......... T 0043 1.6857 103.62 .................. 20.72
24640 ....... Treat elbow dislocation ...................................... ......... T 0043 1.6857 103.62 .................. 20.72
24650 ....... Treat radius fracture .......................................... ......... T 0043 1.6857 103.62 .................. 20.72
24655 ....... Treat radius fracture .......................................... ......... T 0043 1.6857 103.62 .................. 20.72
24665 ....... Treat radius fracture .......................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
24666 ....... Treat radius fracture .......................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41
24670 ....... Treat ulnar fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72
24675 ....... Treat ulnar fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72
24685 ....... Treat ulnar fracture ............................................ CH .. T 0063 37.5382 2,307.40 548.33 461.48
24800 ....... Fusion of elbow joint .......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
24802 ....... Fusion/graft of elbow joint ................................. ......... T 0051 41.0893 2,525.68 .................. 505.14
24925 ....... Amputation follow-up surgery ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57
24935 ....... Revision of amputation ...................................... ......... T 0052 66.58 4,092.54 .................. 818.51
24999 ....... Upper arm/elbow surgery .................................. ......... T 0043 1.6857 103.62 .................. 20.72
25000 ....... Incision of tendon sheath .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
25001 ....... Incise flexor carpi radialis .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
25020 ....... Decompress forearm 1 space ........................... ......... T 0049 20.8706 1,282.87 .................. 256.57
25023 ....... Decompress forearm 1 space ........................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25024 ....... Decompress forearm 2 spaces ......................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25025 ....... Decompress forearm 2 spaces ......................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25028 ....... Drainage of forearm lesion ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
25031 ....... Drainage of forearm bursa ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
25035 ....... Treat forearm bone lesion ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
National Minimum
25040 ....... Explore/treat wrist joint ...................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25065 ....... Biopsy forearm soft tissues ............................... CH .. T 0020 6.8083 418.49 107.67 83.70
25066 ....... Biopsy forearm soft tissues ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68
25075 ....... Removal forearm lesion subcu .......................... ......... T 0021 15.1024 928.31 219.48 185.66
25076 ....... Removal forearm lesion deep ........................... ......... T 0022 20.0656 1,233.39 354.45 246.68
25077 ....... Remove tumor, forearm/wrist ............................ ......... T 0022 20.0656 1,233.39 354.45 246.68
25085 ....... Incision of wrist capsule .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
25100 ....... Biopsy of wrist joint ............................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
25101 ....... Explore/treat wrist joint ...................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25105 ....... Remove wrist joint lining .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25107 ....... Remove wrist joint cartilage .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25109 ....... Excise tendon forearm/wrist .............................. NI .... T 0049 20.8706 1,282.87 .................. 256.57
25110 ....... Remove wrist tendon lesion .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57
25111 ....... Remove wrist tendon lesion .............................. ......... T 0053 16.154 992.95 253.49 198.59
25112 ....... Reremove wrist tendon lesion ........................... ......... T 0053 16.154 992.95 253.49 198.59
25115 ....... Remove wrist/forearm lesion ............................. ......... T 0049 20.8706 1,282.87 .................. 256.57
25116 ....... Remove wrist/forearm lesion ............................. ......... T 0049 20.8706 1,282.87 .................. 256.57
25118 ....... Excise wrist tendon sheath ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
25119 ....... Partial removal of ulna ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25120 ....... Removal of forearm lesion ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
25125 ....... Remove/graft forearm lesion ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25126 ....... Remove/graft forearm lesion ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25130 ....... Removal of wrist lesion ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25135 ....... Remove & graft wrist lesion .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25136 ....... Remove & graft wrist lesion .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25145 ....... Remove forearm bone lesion ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93
25170 ....... Extensive forearm surgery ................................. CH .. T 0051 41.0893 2,525.68 .................. 505.14
25210 ....... Removal of wrist bone ....................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
25215 ....... Removal of wrist bones ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
25246 ....... Injection for wrist x-ray ...................................... ......... N .................. .................. .................. .................. ..................
25248 ....... Remove forearm foreign body ........................... ......... T 0049 20.8706 1,282.87 .................. 256.57
25250 ....... Removal of wrist prosthesis .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25251 ....... Removal of wrist prosthesis .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25259 ....... Manipulate wrist w/anesthes ............................. ......... T 0043 1.6857 103.62 .................. 20.72
25260 ....... Repair forearm tendon/muscle .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25275 ....... Repair forearm tendon sheath ........................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25280 ....... Revise wrist/forearm tendon .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25290 ....... Incise wrist/forearm tendon ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25295 ....... Release wrist/forearm tendon ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57
25300 ....... Fusion of tendons at wrist ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25301 ....... Fusion of tendons at wrist ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25310 ....... Transplant forearm tendon ................................ ......... T 0051 41.0893 2,525.68 .................. 505.14
25312 ....... Transplant forearm tendon ................................ ......... T 0051 41.0893 2,525.68 .................. 505.14
25315 ....... Revise palsy hand tendon(s) ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14
25316 ....... Revise palsy hand tendon(s) ............................. CH .. T 0052 66.58 4,092.54 .................. 818.51
25320 ....... Repair/revise wrist joint ..................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
25332 ....... Revise wrist joint ................................................ ......... T 0047 33.4505 2,056.14 537.03 411.23
25335 ....... Realignment of hand ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
25337 ....... Reconstruct ulna/radioulnar ............................... ......... T 0051 41.0893 2,525.68 .................. 505.14
25350 ....... Revision of radius .............................................. CH .. T 0052 66.58 4,092.54 .................. 818.51
25355 ....... Revision of radius .............................................. ......... T 0051 41.0893 2,525.68 .................. 505.14
25360 ....... Revision of ulna ................................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25365 ....... Revise radius & ulna ......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25370 ....... Revise radius or ulna ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
25375 ....... Revise radius & ulna ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
25390 ....... Shorten radius or ulna ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25391 ....... Lengthen radius or ulna ..................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
25392 ....... Shorten radius & ulna ........................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
25393 ....... Lengthen radius & ulna ..................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
25394 ....... Repair carpal bone, shorten .............................. ......... T 0053 16.154 992.95 253.49 198.59
25400 ....... Repair radius or ulna ......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
National Minimum
25405 ....... Repair/graft radius or ulna ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
25415 ....... Repair radius & ulna .......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
25420 ....... Repair/graft radius & ulna .................................. CH .. T 0052 66.58 4,092.54 .................. 818.51
25425 ....... Repair/graft radius or ulna ................................. ......... T 0051 41.0893 2,525.68 .................. 505.14
25426 ....... Repair/graft radius & ulna .................................. ......... T 0051 41.0893 2,525.68 .................. 505.14
25430 ....... Vasc graft into carpal bone ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11
25431 ....... Repair nonunion carpal bone ............................ ......... T 0054 25.8758 1,590.53 .................. 318.11
25440 ....... Repair/graft wrist bone ...................................... CH .. T 0052 66.58 4,092.54 .................. 818.51
25441 ....... Reconstruct wrist joint ....................................... ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80
25442 ....... Reconstruct wrist joint ....................................... ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80
25443 ....... Reconstruct wrist joint ....................................... ......... T 0048 47.4378 2,915.91 .................. 583.18
25446 ....... Wrist replacement .............................................. ......... T 0425 107.1942 6,589.01 1,378.01 1,317.80
25447 ....... Repair wrist joint(s) ............................................ ......... T 0047 33.4505 2,056.14 537.03 411.23
25449 ....... Remove wrist joint implant ................................ ......... T 0047 33.4505 2,056.14 537.03 411.23
25450 ....... Revision of wrist joint ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
25455 ....... Revision of wrist joint ......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
25490 ....... Reinforce radius ................................................. ......... T 0051 41.0893 2,525.68 .................. 505.14
25491 ....... Reinforce ulna .................................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
25492 ....... Reinforce radius and ulna ................................. ......... T 0051 41.0893 2,525.68 .................. 505.14
25500 ....... Treat fracture of radius ...................................... ......... T 0043 1.6857 103.62 .................. 20.72
25515 ....... Treat fracture of radius ...................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
25530 ....... Treat fracture of ulna ......................................... ......... T 0043 1.6857 103.62 .................. 20.72
25535 ....... Treat fracture of ulna ......................................... ......... T 0043 1.6857 103.62 .................. 20.72
25545 ....... Treat fracture of ulna ......................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
25560 ....... Treat fracture radius & ulna ............................... ......... T 0043 1.6857 103.62 .................. 20.72
25565 ....... Treat fracture radius & ulna ............................... ......... T 0043 1.6857 103.62 .................. 20.72
25574 ....... Treat fracture radius & ulna ............................... CH .. T 0064 57.2172 3,517.03 835.79 703.41
25575 ....... Treat fracture radius/ulna .................................. CH .. T 0064 57.2172 3,517.03 835.79 703.41
25600 ....... Treat fracture radius/ulna .................................. ......... T 0043 1.6857 103.62 .................. 20.72
25605 ....... Treat fracture radius/ulna .................................. ......... T 0043 1.6857 103.62 .................. 20.72
25606 ....... Treat fx distal radial ........................................... NI .... T 0062 25.5264 1,569.06 372.87 313.81
25607 ....... Treat fx rad extra-articul .................................... NI .... T 0064 57.2172 3,517.03 835.79 703.41
25608 ....... Treat fx rad intra-articul ..................................... NI .... T 0064 57.2172 3,517.03 835.79 703.41
25609 ....... Treat fx radial 3+ frag ........................................ NI .... T 0064 57.2172 3,517.03 835.79 703.41
25611 ....... Treat fracture radius/ulna .................................. CH .. D .................. .................. .................. .................. ..................
25620 ....... Treat fracture radius/ulna .................................. CH .. D .................. .................. .................. .................. ..................
25622 ....... Treat wrist bone fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72
25628 ....... Treat wrist bone fracture ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
25645 ....... Treat wrist bone fracture ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
25651 ....... Pin ulnar styloid fracture .................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
25652 ....... Treat fracture ulnar styloid ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48
25660 ....... Treat wrist dislocation ........................................ ......... T 0043 1.6857 103.62 .................. 20.72
25670 ....... Treat wrist dislocation ........................................ CH .. T 0062 25.5264 1,569.06 372.87 313.81
25671 ....... Pin radioulnar dislocation .................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81
25680 ....... Treat wrist fracture ............................................. ......... T 0043 1.6857 103.62 .................. 20.72
25685 ....... Treat wrist fracture ............................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81
25800 ....... Fusion of wrist joint ............................................ CH .. T 0052 66.58 4,092.54 .................. 818.51
25805 ....... Fusion/graft of wrist joint ................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
25810 ....... Fusion/graft of wrist joint ................................... CH .. T 0052 66.58 4,092.54 .................. 818.51
25820 ....... Fusion of hand bones ........................................ ......... T 0053 16.154 992.95 253.49 198.59
25825 ....... Fuse hand bones with graft ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11
25830 ....... Fusion, radioulnar jnt/ulna ................................. CH .. T 0052 66.58 4,092.54 .................. 818.51
25922 ....... Amputate hand at wrist ...................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
25929 ....... Amputation follow-up surgery ............................ ......... T 0686 14.0346 862.68 .................. 172.54
25999 ....... Forearm or wrist surgery ................................... ......... T 0043 1.6857 103.62 .................. 20.72
National Minimum
26010 ....... Drainage of finger abscess ................................ ......... T 0006 1.4392 88.46 .................. 17.69
26011 ....... Drainage of finger abscess ................................ ......... T 0007 11.1535 685.58 .................. 137.12
26020 ....... Drain hand tendon sheath ................................. ......... T 0053 16.154 992.95 253.49 198.59
26025 ....... Drainage of palm bursa ..................................... ......... T 0053 16.154 992.95 253.49 198.59
26030 ....... Drainage of palm bursa(s) ................................. ......... T 0053 16.154 992.95 253.49 198.59
26034 ....... Treat hand bone lesion ...................................... ......... T 0053 16.154 992.95 253.49 198.59
26035 ....... Decompress fingers/hand .................................. ......... T 0053 16.154 992.95 253.49 198.59
26037 ....... Decompress fingers/hand .................................. ......... T 0053 16.154 992.95 253.49 198.59
26040 ....... Release palm contracture .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11
26055 ....... Incise finger tendon sheath ............................... ......... T 0053 16.154 992.95 253.49 198.59
26060 ....... Incision of finger tendon .................................... ......... T 0053 16.154 992.95 253.49 198.59
26070 ....... Explore/treat hand joint ...................................... ......... T 0053 16.154 992.95 253.49 198.59
26075 ....... Explore/treat finger joint ..................................... ......... T 0053 16.154 992.95 253.49 198.59
26080 ....... Explore/treat finger joint ..................................... ......... T 0053 16.154 992.95 253.49 198.59
26100 ....... Biopsy hand joint lining ...................................... ......... T 0053 16.154 992.95 253.49 198.59
26105 ....... Biopsy finger joint lining ..................................... ......... T 0053 16.154 992.95 253.49 198.59
26110 ....... Biopsy finger joint lining ..................................... ......... T 0053 16.154 992.95 253.49 198.59
26115 ....... Removal hand lesion subcut ............................. ......... T 0022 20.0656 1,233.39 354.45 246.68
26116 ....... Removal hand lesion, deep ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68
26117 ....... Remove tumor, hand/finger ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68
26125 ....... Release palm contracture .................................. ......... T 0053 16.154 992.95 253.49 198.59
26130 ....... Remove wrist joint lining .................................... ......... T 0053 16.154 992.95 253.49 198.59
26135 ....... Revise finger joint, each .................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26140 ....... Revise finger joint, each .................................... ......... T 0053 16.154 992.95 253.49 198.59
26145 ....... Tendon excision, palm/finger ............................. ......... T 0053 16.154 992.95 253.49 198.59
26160 ....... Remove tendon sheath lesion ........................... ......... T 0053 16.154 992.95 253.49 198.59
26170 ....... Removal of palm tendon, each ......................... ......... T 0053 16.154 992.95 253.49 198.59
26180 ....... Removal of finger tendon .................................. ......... T 0053 16.154 992.95 253.49 198.59
26185 ....... Remove finger bone .......................................... ......... T 0053 16.154 992.95 253.49 198.59
26200 ....... Remove hand bone lesion ................................. ......... T 0053 16.154 992.95 253.49 198.59
26210 ....... Removal of finger lesion .................................... ......... T 0053 16.154 992.95 253.49 198.59
26215 ....... Remove/graft finger lesion ................................. ......... T 0053 16.154 992.95 253.49 198.59
26230 ....... Partial removal of hand bone ............................ ......... T 0053 16.154 992.95 253.49 198.59
26235 ....... Partial removal, finger bone .............................. ......... T 0053 16.154 992.95 253.49 198.59
26236 ....... Partial removal, finger bone .............................. ......... T 0053 16.154 992.95 253.49 198.59
26250 ....... Extensive hand surgery ..................................... ......... T 0053 16.154 992.95 253.49 198.59
26255 ....... Extensive hand surgery ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26260 ....... Extensive finger surgery .................................... ......... T 0053 16.154 992.95 253.49 198.59
26261 ....... Extensive finger surgery .................................... ......... T 0053 16.154 992.95 253.49 198.59
26262 ....... Partial removal of finger .................................... ......... T 0053 16.154 992.95 253.49 198.59
26320 ....... Removal of implant from hand .......................... ......... T 0021 15.1024 928.31 219.48 185.66
26340 ....... Manipulate finger w/anesth ................................ ......... T 0043 1.6857 103.62 .................. 20.72
26350 ....... Repair finger/hand tendon ................................. ......... T 0054 25.8758 1,590.53 .................. 318.11
26352 ....... Repair/graft hand tendon ................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26390 ....... Revise hand/finger tendon ................................. ......... T 0054 25.8758 1,590.53 .................. 318.11
26410 ....... Repair hand tendon ........................................... ......... T 0053 16.154 992.95 253.49 198.59
26415 ....... Excision, hand/finger tendon ............................. ......... T 0054 25.8758 1,590.53 .................. 318.11
26416 ....... Graft hand or finger tendon ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26418 ....... Repair finger tendon .......................................... ......... T 0053 16.154 992.95 253.49 198.59
26420 ....... Repair/graft finger tendon .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11
26437 ....... Realignment of tendons ..................................... ......... T 0053 16.154 992.95 253.49 198.59
26440 ....... Release palm/finger tendon ............................... ......... T 0053 16.154 992.95 253.49 198.59
26442 ....... Release palm & finger tendon ........................... ......... T 0054 25.8758 1,590.53 .................. 318.11
National Minimum
26445 ....... Release hand/finger tendon .............................. ......... T 0053 16.154 992.95 253.49 198.59
26449 ....... Release forearm/hand tendon ........................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26450 ....... Incision of palm tendon ..................................... ......... T 0053 16.154 992.95 253.49 198.59
26455 ....... Incision of finger tendon .................................... ......... T 0053 16.154 992.95 253.49 198.59
26460 ....... Incise hand/finger tendon .................................. ......... T 0053 16.154 992.95 253.49 198.59
26471 ....... Fusion of finger tendons .................................... ......... T 0053 16.154 992.95 253.49 198.59
26474 ....... Fusion of finger tendons .................................... ......... T 0053 16.154 992.95 253.49 198.59
26476 ....... Tendon lengthening ........................................... ......... T 0053 16.154 992.95 253.49 198.59
26477 ....... Tendon shortening ............................................. ......... T 0053 16.154 992.95 253.49 198.59
26478 ....... Lengthening of hand tendon .............................. ......... T 0053 16.154 992.95 253.49 198.59
26479 ....... Shortening of hand tendon ................................ ......... T 0053 16.154 992.95 253.49 198.59
26480 ....... Transplant hand tendon ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26483 ....... Transplant/graft hand tendon ............................ ......... T 0054 25.8758 1,590.53 .................. 318.11
26485 ....... Transplant palm tendon ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26489 ....... Transplant/graft palm tendon ............................. ......... T 0054 25.8758 1,590.53 .................. 318.11
26490 ....... Revise thumb tendon ......................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26492 ....... Tendon transfer with graft ................................. ......... T 0054 25.8758 1,590.53 .................. 318.11
26494 ....... Hand tendon/muscle transfer ............................ ......... T 0054 25.8758 1,590.53 .................. 318.11
26496 ....... Revise thumb tendon ......................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26497 ....... Finger tendon transfer ....................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26498 ....... Finger tendon transfer ....................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26499 ....... Revision of finger ............................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26500 ....... Hand tendon reconstruction .............................. ......... T 0053 16.154 992.95 253.49 198.59
26502 ....... Hand tendon reconstruction .............................. ......... T 0054 25.8758 1,590.53 .................. 318.11
26504 ....... Hand tendon reconstruction .............................. CH .. D .................. .................. .................. .................. ..................
26508 ....... Release thumb contracture ............................... ......... T 0053 16.154 992.95 253.49 198.59
26510 ....... Thumb tendon transfer ...................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26516 ....... Fusion of knuckle joint ....................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26517 ....... Fusion of knuckle joints ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26518 ....... Fusion of knuckle joints ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26520 ....... Release knuckle contracture ............................. ......... T 0053 16.154 992.95 253.49 198.59
26525 ....... Release finger contracture ................................ ......... T 0053 16.154 992.95 253.49 198.59
26530 ....... Revise knuckle joint ........................................... ......... T 0047 33.4505 2,056.14 537.03 411.23
26531 ....... Revise knuckle with implant .............................. ......... T 0048 47.4378 2,915.91 .................. 583.18
26535 ....... Revise finger joint .............................................. ......... T 0047 33.4505 2,056.14 537.03 411.23
26536 ....... Revise/implant finger joint ................................. ......... T 0048 47.4378 2,915.91 .................. 583.18
26540 ....... Repair hand joint ............................................... ......... T 0053 16.154 992.95 253.49 198.59
26541 ....... Repair hand joint with graft ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26542 ....... Repair hand joint with graft ............................... ......... T 0053 16.154 992.95 253.49 198.59
26545 ....... Reconstruct finger joint ...................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26546 ....... Repair nonunion hand ....................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26548 ....... Reconstruct finger joint ...................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26550 ....... Construct thumb replacement ........................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26555 ....... Positional change of finger ................................ ......... T 0054 25.8758 1,590.53 .................. 318.11
26560 ....... Repair of web finger .......................................... ......... T 0053 16.154 992.95 253.49 198.59
26561 ....... Repair of web finger .......................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26562 ....... Repair of web finger .......................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26565 ....... Correct metacarpal flaw ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26567 ....... Correct finger deformity ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26568 ....... Lengthen metacarpal/finger ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26580 ....... Repair hand deformity ....................................... ......... T 0053 16.154 992.95 253.49 198.59
26587 ....... Reconstruct extra finger .................................... ......... T 0053 16.154 992.95 253.49 198.59
26590 ....... Repair finger deformity ...................................... ......... T 0053 16.154 992.95 253.49 198.59
26591 ....... Repair muscles of hand ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26593 ....... Release muscles of hand .................................. ......... T 0053 16.154 992.95 253.49 198.59
26596 ....... Excision constricting tissue ................................ ......... T 0053 16.154 992.95 253.49 198.59
26600 ....... Treat metacarpal fracture .................................. ......... T 0043 1.6857 103.62 .................. 20.72
26608 ....... Treat metacarpal fracture .................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81
26615 ....... Treat metacarpal fracture .................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48
26641 ....... Treat thumb dislocation ..................................... ......... T 0043 1.6857 103.62 .................. 20.72
26645 ....... Treat thumb fracture .......................................... ......... T 0043 1.6857 103.62 .................. 20.72
26650 ....... Treat thumb fracture .......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
26665 ....... Treat thumb fracture .......................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
26670 ....... Treat hand dislocation ....................................... ......... T 0043 1.6857 103.62 .................. 20.72
26675 ....... Treat hand dislocation ....................................... ......... T 0043 1.6857 103.62 .................. 20.72
26676 ....... Pin hand dislocation .......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
26685 ....... Treat hand dislocation ....................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
26686 ....... Treat hand dislocation ....................................... CH .. T 0064 57.2172 3,517.03 835.79 703.41
National Minimum
26700 ....... Treat knuckle dislocation ................................... ......... T 0043 1.6857 103.62 .................. 20.72
26705 ....... Treat knuckle dislocation ................................... ......... T 0043 1.6857 103.62 .................. 20.72
26706 ....... Pin knuckle dislocation ...................................... ......... T 0043 1.6857 103.62 .................. 20.72
26715 ....... Treat knuckle dislocation ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
26720 ....... Treat finger fracture, each ................................. ......... T 0043 1.6857 103.62 .................. 20.72
26727 ....... Treat finger fracture, each ................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81
26756 ....... Pin finger fracture, each .................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
26770 ....... Treat finger dislocation ...................................... ......... T 0043 1.6857 103.62 .................. 20.72
26775 ....... Treat finger dislocation ...................................... ......... T 0045 14.5947 897.11 268.47 179.42
26776 ....... Pin finger dislocation ......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
26785 ....... Treat finger dislocation ...................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
26820 ....... Thumb fusion with graft ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26841 ....... Fusion of thumb ................................................. ......... T 0054 25.8758 1,590.53 .................. 318.11
26842 ....... Thumb fusion with graft ..................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26843 ....... Fusion of hand joint ........................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26844 ....... Fusion/graft of hand joint ................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26850 ....... Fusion of knuckle ............................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26852 ....... Fusion of knuckle with graft ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26860 ....... Fusion of finger joint .......................................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26861 ....... Fusion of finger jnt, add-on ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26862 ....... Fusion/graft of finger joint .................................. ......... T 0054 25.8758 1,590.53 .................. 318.11
26863 ....... Fuse/graft added joint ........................................ ......... T 0054 25.8758 1,590.53 .................. 318.11
26910 ....... Amputate metacarpal bone ............................... ......... T 0054 25.8758 1,590.53 .................. 318.11
26951 ....... Amputation of finger/thumb ............................... ......... T 0053 16.154 992.95 253.49 198.59
26952 ....... Amputation of finger/thumb ............................... ......... T 0053 16.154 992.95 253.49 198.59
26989 ....... Hand/finger surgery ........................................... ......... T 0043 1.6857 103.62 .................. 20.72
26990 ....... Drainage of pelvis lesion ................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
26991 ....... Drainage of pelvis bursa .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27000 ....... Incision of hip tendon ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
27033 ....... Exploration of hip joint ....................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27035 ....... Denervation of hip joint ...................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14
27040 ....... Biopsy of soft tissues ......................................... ......... T 0020 6.8083 418.49 107.67 83.70
27041 ....... Biopsy of soft tissues ......................................... ......... T 0020 6.8083 418.49 107.67 83.70
27047 ....... Remove hip/pelvis lesion ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
27048 ....... Remove hip/pelvis lesion ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
27049 ....... Remove tumor, hip/pelvis .................................. ......... T 0022 20.0656 1,233.39 354.45 246.68
27050 ....... Biopsy of sacroiliac joint .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27052 ....... Biopsy of hip joint .............................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27060 ....... Removal of ischial bursa ................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27062 ....... Remove femur lesion/bursa ............................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27065 ....... Removal of hip bone lesion ............................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27066 ....... Removal of hip bone lesion ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27067 ....... Remove/graft hip bone lesion ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93
27080 ....... Removal of tail bone .......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27086 ....... Remove hip foreign body .................................. ......... T 0020 6.8083 418.49 107.67 83.70
27087 ....... Remove hip foreign body .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27093 ....... Injection for hip x-ray ......................................... ......... N .................. .................. .................. .................. ..................
27095 ....... Injection for hip x-ray ......................................... ......... N .................. .................. .................. .................. ..................
27097 ....... Revision of hip tendon ....................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27098 ....... Transfer tendon to pelvis ................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27100 ....... Transfer of abdominal muscle ........................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27105 ....... Transfer of spinal muscle .................................. ......... T 0051 41.0893 2,525.68 .................. 505.14
27110 ....... Transfer of iliopsoas muscle .............................. ......... T 0051 41.0893 2,525.68 .................. 505.14
27111 ....... Transfer of iliopsoas muscle .............................. ......... T 0051 41.0893 2,525.68 .................. 505.14
27193 ....... Treat pelvic ring fracture .................................... ......... T 0043 1.6857 103.62 .................. 20.72
27194 ....... Treat pelvic ring fracture .................................... ......... T 0045 14.5947 897.11 268.47 179.42
27200 ....... Treat tail bone fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72
27202 ....... Treat tail bone fracture ...................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
27216 ....... Treat pelvic ring fracture .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27220 ....... Treat hip socket fracture .................................... ......... T 0043 1.6857 103.62 .................. 20.72
National Minimum
27230 ....... Treat thigh fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72
27235 ....... Treat thigh fracture ............................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
27250 ....... Treat hip dislocation .......................................... ......... T 0043 1.6857 103.62 .................. 20.72
27252 ....... Treat hip dislocation .......................................... ......... T 0045 14.5947 897.11 268.47 179.42
27275 ....... Manipulation of hip joint ..................................... ......... T 0045 14.5947 897.11 268.47 179.42
27299 ....... Pelvis/hip joint surgery ....................................... ......... T 0043 1.6857 103.62 .................. 20.72
27301 ....... Drain thigh/knee lesion ...................................... ......... T 0008 17.5086 1,076.22 .................. 215.24
27305 ....... Incise thigh tendon & fascia .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27306 ....... Incision of thigh tendon ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27307 ....... Incision of thigh tendons .................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27310 ....... Exploration of knee joint .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27315 ....... Partial removal, thigh nerve ............................... CH .. D .................. .................. .................. .................. ..................
27320 ....... Partial removal, thigh nerve ............................... CH .. D .................. .................. .................. .................. ..................
27323 ....... Biopsy, thigh soft tissues ................................... CH .. T 0020 6.8083 418.49 107.67 83.70
27324 ....... Biopsy, thigh soft tissues ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
27325 ....... Neurectomy, hamstring ...................................... NI .... T 0220 17.8499 1,097.20 .................. 219.44
27326 ....... Neurectomy, popliteal ........................................ NI .... T 0220 17.8499 1,097.20 .................. 219.44
27327 ....... Removal of thigh lesion ..................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
27328 ....... Removal of thigh lesion ..................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
27329 ....... Remove tumor, thigh/knee ................................ ......... T 0022 20.0656 1,233.39 354.45 246.68
27330 ....... Biopsy, knee joint lining ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27331 ....... Explore/treat knee joint ...................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27332 ....... Removal of knee cartilage ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27333 ....... Removal of knee cartilage ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27334 ....... Remove knee joint lining ................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27335 ....... Remove knee joint lining ................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27340 ....... Removal of kneecap bursa ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
27345 ....... Removal of knee cyst ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
27347 ....... Remove knee cyst ............................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27350 ....... Removal of kneecap .......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27355 ....... Remove femur lesion ......................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27356 ....... Remove femur lesion/graft ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
27357 ....... Remove femur lesion/graft ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
27358 ....... Remove femur lesion/fixation ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93
27360 ....... Partial removal, leg bone(s) .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27370 ....... Injection for knee x-ray ...................................... ......... N .................. .................. .................. .................. ..................
27372 ....... Removal of foreign body ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
27380 ....... Repair of kneecap tendon ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27381 ....... Repair/graft kneecap tendon ............................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27385 ....... Repair of thigh muscle ....................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27386 ....... Repair/graft of thigh muscle .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27390 ....... Incision of thigh tendon ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27393 ....... Lengthening of thigh tendon .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27394 ....... Lengthening of thigh tendons ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93
27395 ....... Lengthening of thigh tendons ............................ ......... T 0051 41.0893 2,525.68 .................. 505.14
27396 ....... Transplant of thigh tendon ................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27397 ....... Transplants of thigh tendons ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14
27400 ....... Revise thigh muscles/tendons ........................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27403 ....... Repair of knee cartilage .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27405 ....... Repair of knee ligament .................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27407 ....... Repair of knee ligament .................................... CH .. T 0052 66.58 4,092.54 .................. 818.51
27409 ....... Repair of knee ligaments ................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27412 ....... Autochondrocyte implant knee .......................... ......... T 0042 45.5027 2,796.96 804.74 559.39
27415 ....... Osteochondral knee allograft ............................. ......... T 0042 45.5027 2,796.96 804.74 559.39
27418 ....... Repair degenerated kneecap ............................ ......... T 0051 41.0893 2,525.68 .................. 505.14
27420 ....... Revision of unstable kneecap ........................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27422 ....... Revision of unstable kneecap ........................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27424 ....... Revision/removal of kneecap ............................ ......... T 0051 41.0893 2,525.68 .................. 505.14
27425 ....... Lat retinacular release open .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27427 ....... Reconstruction, knee ......................................... CH .. T 0051 41.0893 2,525.68 .................. 505.14
27428 ....... Reconstruction, knee ......................................... ......... T 0052 66.58 4,092.54 .................. 818.51
27429 ....... Reconstruction, knee ......................................... ......... T 0052 66.58 4,092.54 .................. 818.51
National Minimum
27430 ....... Revision of thigh muscles .................................. ......... T 0051 41.0893 2,525.68 .................. 505.14
27435 ....... Incision of knee joint .......................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27437 ....... Revise kneecap ................................................. ......... T 0047 33.4505 2,056.14 537.03 411.23
27438 ....... Revise kneecap with implant ............................. ......... T 0048 47.4378 2,915.91 .................. 583.18
27440 ....... Revision of knee joint ........................................ ......... T 0047 33.4505 2,056.14 537.03 411.23
27446 ....... Revision of knee joint ........................................ ......... T 0681 205.6815 12,642.83 .................. 2,528.57
27475 ....... Surgery to stop leg growth ................................ ......... T 0050 25.1296 1,544.67 .................. 308.93
27496 ....... Decompression of thigh/knee ............................ ......... T 0049 20.8706 1,282.87 .................. 256.57
27500 ....... Treatment of thigh fracture ................................ ......... T 0043 1.6857 103.62 .................. 20.72
27509 ....... Treatment of thigh fracture ................................ CH .. T 0062 25.5264 1,569.06 372.87 313.81
27516 ....... Treat thigh fx growth plate ................................. ......... T 0043 1.6857 103.62 .................. 20.72
27517 ....... Treat thigh fx growth plate ................................. ......... T 0043 1.6857 103.62 .................. 20.72
27520 ....... Treat kneecap fracture ...................................... ......... T 0043 1.6857 103.62 .................. 20.72
27524 ....... Treat kneecap fracture ...................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
27530 ....... Treat knee fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72
27532 ....... Treat knee fracture ............................................ ......... T 0043 1.6857 103.62 .................. 20.72
27538 ....... Treat knee fracture(s) ........................................ ......... T 0043 1.6857 103.62 .................. 20.72
27550 ....... Treat knee dislocation ....................................... ......... T 0043 1.6857 103.62 .................. 20.72
27552 ....... Treat knee dislocation ....................................... ......... T 0045 14.5947 897.11 268.47 179.42
27560 ....... Treat kneecap dislocation .................................. ......... T 0043 1.6857 103.62 .................. 20.72
27562 ....... Treat kneecap dislocation .................................. ......... T 0045 14.5947 897.11 268.47 179.42
27566 ....... Treat kneecap dislocation .................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48
27570 ....... Fixation of knee joint ......................................... ......... T 0045 14.5947 897.11 268.47 179.42
27599 ....... Leg surgery procedure ...................................... ......... T 0043 1.6857 103.62 .................. 20.72
27600 ....... Decompression of lower leg .............................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27603 ....... Drain lower leg lesion ........................................ ......... T 0008 17.5086 1,076.22 .................. 215.24
27604 ....... Drain lower leg bursa ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
27605 ....... Incision of achilles tendon ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
27606 ....... Incision of achilles tendon ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27607 ....... Treat lower leg bone lesion ............................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27610 ....... Explore/treat ankle joint ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27612 ....... Exploration of ankle joint ................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27613 ....... Biopsy lower leg soft tissue ............................... ......... T 0020 6.8083 418.49 107.67 83.70
27614 ....... Biopsy lower leg soft tissue ............................... ......... T 0022 20.0656 1,233.39 354.45 246.68
27615 ....... Remove tumor, lower leg .................................. CH .. T 0050 25.1296 1,544.67 .................. 308.93
27618 ....... Remove lower leg lesion ................................... ......... T 0021 15.1024 928.31 219.48 185.66
27619 ....... Remove lower leg lesion ................................... ......... T 0022 20.0656 1,233.39 354.45 246.68
27620 ....... Explore/treat ankle joint ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27625 ....... Remove ankle joint lining .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27626 ....... Remove ankle joint lining .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27630 ....... Removal of tendon lesion .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27635 ....... Remove lower leg bone lesion .......................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27637 ....... Remove/graft leg bone lesion ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93
27638 ....... Remove/graft leg bone lesion ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93
27640 ....... Partial removal of tibia ....................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27641 ....... Partial removal of fibula ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27647 ....... Extensive ankle/heel surgery ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14
27648 ....... Injection for ankle x-ray ..................................... ......... N .................. .................. .................. .................. ..................
27650 ....... Repair achilles tendon ....................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27652 ....... Repair/graft achilles tendon ............................... CH .. T 0052 66.58 4,092.54 .................. 818.51
27654 ....... Repair of achilles tendon ................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27656 ....... Repair leg fascia defect ..................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27658 ....... Repair of leg tendon, each ................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
National Minimum
27675 ....... Repair lower leg tendons ................................... ......... T 0049 20.8706 1,282.87 .................. 256.57
27676 ....... Repair lower leg tendons ................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27680 ....... Release of lower leg tendon .............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27681 ....... Release of lower leg tendons ............................ ......... T 0050 25.1296 1,544.67 .................. 308.93
27685 ....... Revision of lower leg tendon ............................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27686 ....... Revise lower leg tendons .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27687 ....... Revision of calf tendon ...................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27690 ....... Revise lower leg tendon .................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27691 ....... Revise lower leg tendon .................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27692 ....... Revise additional leg tendon ............................. ......... T 0051 41.0893 2,525.68 .................. 505.14
27695 ....... Repair of ankle ligament .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27696 ....... Repair of ankle ligaments .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27698 ....... Repair of ankle ligament .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27700 ....... Revision of ankle joint ....................................... ......... T 0047 33.4505 2,056.14 537.03 411.23
27704 ....... Removal of ankle implant .................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27705 ....... Incision of tibia ................................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27707 ....... Incision of fibula ................................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
27709 ....... Incision of tibia & fibula ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27730 ....... Repair of tibia epiphysis .................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27732 ....... Repair of fibula epiphysis .................................. ......... T 0050 25.1296 1,544.67 .................. 308.93
27734 ....... Repair lower leg epiphyses ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27740 ....... Repair of leg epiphyses ..................................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27742 ....... Repair of leg epiphyses ..................................... ......... T 0051 41.0893 2,525.68 .................. 505.14
27745 ....... Reinforce tibia .................................................... CH .. T 0052 66.58 4,092.54 .................. 818.51
27750 ....... Treatment of tibia fracture ................................. ......... T 0043 1.6857 103.62 .................. 20.72
27752 ....... Treatment of tibia fracture ................................. ......... T 0043 1.6857 103.62 .................. 20.72
27756 ....... Treatment of tibia fracture ................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81
27760 ....... Treatment of ankle fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72
27766 ....... Treatment of ankle fracture ............................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
27780 ....... Treatment of fibula fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72
27781 ....... Treatment of fibula fracture ............................... ......... T 0043 1.6857 103.62 .................. 20.72
27784 ....... Treatment of fibula fracture ............................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
27824 ....... Treat lower leg fracture ..................................... ......... T 0043 1.6857 103.62 .................. 20.72
27825 ....... Treat lower leg fracture ..................................... ......... T 0043 1.6857 103.62 .................. 20.72
27826 ....... Treat lower leg fracture ..................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
27829 ....... Treat lower leg joint ........................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
27830 ....... Treat lower leg dislocation ................................. ......... T 0043 1.6857 103.62 .................. 20.72
27831 ....... Treat lower leg dislocation ................................. ......... T 0043 1.6857 103.62 .................. 20.72
27832 ....... Treat lower leg dislocation ................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48
27840 ....... Treat ankle dislocation ....................................... ......... T 0043 1.6857 103.62 .................. 20.72
27842 ....... Treat ankle dislocation ....................................... ......... T 0045 14.5947 897.11 268.47 179.42
27846 ....... Treat ankle dislocation ....................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
27848 ....... Treat ankle dislocation ....................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
27860 ....... Fixation of ankle joint ......................................... ......... T 0045 14.5947 897.11 268.47 179.42
27870 ....... Fusion of ankle joint, open ................................ CH .. T 0052 66.58 4,092.54 .................. 818.51
27871 ....... Fusion of tibiofibular joint ................................... CH .. T 0052 66.58 4,092.54 .................. 818.51
27889 ....... Amputation of foot at ankle ............................... ......... T 0050 25.1296 1,544.67 .................. 308.93
27892 ....... Decompression of leg ........................................ ......... T 0049 20.8706 1,282.87 .................. 256.57
27899 ....... Leg/ankle surgery procedure ............................. ......... T 0043 1.6857 103.62 .................. 20.72
28001 ....... Drainage of bursa of foot ................................... ......... T 0007 11.1535 685.58 .................. 137.12
28002 ....... Treatment of foot infection ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
28003 ....... Treatment of foot infection ................................. ......... T 0049 20.8706 1,282.87 .................. 256.57
National Minimum
28005 ....... Treat foot bone lesion ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28008 ....... Incision of foot fascia ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28010 ....... Incision of toe tendon ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28011 ....... Incision of toe tendons ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28020 ....... Exploration of foot joint ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28022 ....... Exploration of foot joint ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28024 ....... Exploration of toe joint ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28030 ....... Removal of foot nerve ....................................... CH .. D .................. .................. .................. .................. ..................
28035 ....... Decompression of tibia nerve ............................ ......... T 0220 17.8499 1,097.20 .................. 219.44
28043 ....... Excision of foot lesion ........................................ CH .. T 0022 20.0656 1,233.39 354.45 246.68
28045 ....... Excision of foot lesion ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28046 ....... Resection of tumor, foot .................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28050 ....... Biopsy of foot joint lining ................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28052 ....... Biopsy of foot joint lining ................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28054 ....... Biopsy of toe joint lining .................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28055 ....... Neurectomy, foot ............................................... NI .... T 0220 17.8499 1,097.20 .................. 219.44
28060 ....... Partial removal, foot fascia ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28062 ....... Removal of foot fascia ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28070 ....... Removal of foot joint lining ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28072 ....... Removal of foot joint lining ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28080 ....... Removal of foot lesion ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28086 ....... Excise foot tendon sheath ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28088 ....... Excise foot tendon sheath ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28092 ....... Removal of toe lesions ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28100 ....... Removal of ankle/heel lesion ............................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28102 ....... Remove/graft foot lesion .................................... ......... T 0056 40.8559 2,511.33 .................. 502.27
28108 ....... Removal of toe lesions ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28110 ....... Part removal of metatarsal ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28114 ....... Removal of metatarsal heads ............................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28116 ....... Revision of foot .................................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28118 ....... Removal of heel bone ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28119 ....... Removal of heel spur ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28120 ....... Part removal of ankle/heel ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28122 ....... Partial removal of foot bone .............................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28124 ....... Partial removal of toe ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28130 ....... Removal of ankle bone ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28140 ....... Removal of metatarsal ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28150 ....... Removal of toe .................................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28171 ....... Extensive foot surgery ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28190 ....... Removal of foot foreign body ............................ ......... T 0019 4.0919 251.52 71.87 50.30
28200 ....... Repair of foot tendon ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28202 ....... Repair/graft of foot tendon ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28208 ....... Repair of foot tendon ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28210 ....... Repair/graft of foot tendon ................................. ......... T 0056 40.8559 2,511.33 .................. 502.27
28220 ....... Release of foot tendon ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28222 ....... Release of foot tendons .................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28225 ....... Release of foot tendon ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28226 ....... Release of foot tendons .................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28230 ....... Incision of foot tendon(s) ................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28232 ....... Incision of toe tendon ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28234 ....... Incision of foot tendon ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28238 ....... Revision of foot tendon ...................................... ......... T 0056 40.8559 2,511.33 .................. 502.27
28240 ....... Release of big toe ............................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28250 ....... Revision of foot fascia ....................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28260 ....... Release of midfoot joint ..................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
National Minimum
28261 ....... Revision of foot tendon ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28262 ....... Revision of foot and ankle ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28264 ....... Release of midfoot joint ..................................... ......... T 0056 40.8559 2,511.33 .................. 502.27
28270 ....... Release of foot contracture ............................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28272 ....... Release of toe joint, each .................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28280 ....... Fusion of toes .................................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28285 ....... Repair of hammertoe ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28286 ....... Repair of hammertoe ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28288 ....... Partial removal of foot bone .............................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28289 ....... Repair hallux rigidus .......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28290 ....... Correction of bunion .......................................... ......... T 0057 28.2349 1,735.54 475.91 347.11
28300 ....... Incision of heel bone ......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27
28302 ....... Incision of ankle bone ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28304 ....... Incision of midfoot bones ................................... ......... T 0056 40.8559 2,511.33 .................. 502.27
28305 ....... Incise/graft midfoot bones ................................. ......... T 0056 40.8559 2,511.33 .................. 502.27
28306 ....... Incision of metatarsal ......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28309 ....... Incision of metatarsals ....................................... ......... T 0056 40.8559 2,511.33 .................. 502.27
28310 ....... Revision of big toe ............................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28312 ....... Revision of toe ................................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28313 ....... Repair deformity of toe ...................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28315 ....... Removal of sesamoid bone ............................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28320 ....... Repair of foot bones .......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27
28322 ....... Repair of metatarsals ........................................ ......... T 0056 40.8559 2,511.33 .................. 502.27
28340 ....... Resect enlarged toe tissue ................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28341 ....... Resect enlarged toe .......................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28344 ....... Repair extra toe(s) ............................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28345 ....... Repair webbed toe(s) ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28360 ....... Reconstruct cleft foot ......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27
28400 ....... Treatment of heel fracture ................................. ......... T 0043 1.6857 103.62 .................. 20.72
28405 ....... Treatment of heel fracture ................................. ......... T 0043 1.6857 103.62 .................. 20.72
28406 ....... Treatment of heel fracture ................................. CH .. T 0062 25.5264 1,569.06 372.87 313.81
28415 ....... Treat heel fracture ............................................. CH .. T 0063 37.5382 2,307.40 548.33 461.48
28420 ....... Treat/graft heel fracture ..................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
28445 ....... Treat ankle fracture ........................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
28450 ....... Treat midfoot fracture, each .............................. ......... T 0043 1.6857 103.62 .................. 20.72
28455 ....... Treat midfoot fracture, each .............................. ......... T 0043 1.6857 103.62 .................. 20.72
28456 ....... Treat midfoot fracture ........................................ CH .. T 0062 25.5264 1,569.06 372.87 313.81
28465 ....... Treat midfoot fracture, each .............................. CH .. T 0063 37.5382 2,307.40 548.33 461.48
28470 ....... Treat metatarsal fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72
28475 ....... Treat metatarsal fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72
28476 ....... Treat metatarsal fracture ................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
28485 ....... Treat metatarsal fracture ................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
28490 ....... Treat big toe fracture ......................................... ......... T 0043 1.6857 103.62 .................. 20.72
28495 ....... Treat big toe fracture ......................................... ......... T 0043 1.6857 103.62 .................. 20.72
28496 ....... Treat big toe fracture ......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
28505 ....... Treat big toe fracture ......................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
28510 ....... Treatment of toe fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72
28515 ....... Treatment of toe fracture ................................... ......... T 0043 1.6857 103.62 .................. 20.72
28525 ....... Treat toe fracture ............................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
28530 ....... Treat sesamoid bone fracture ........................... ......... T 0043 1.6857 103.62 .................. 20.72
28531 ....... Treat sesamoid bone fracture ........................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
28540 ....... Treat foot dislocation ......................................... ......... T 0043 1.6857 103.62 .................. 20.72
28545 ....... Treat foot dislocation ......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
28555 ....... Repair foot dislocation ....................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
National Minimum
28630 ....... Treat toe dislocation .......................................... ......... T 0043 1.6857 103.62 .................. 20.72
28635 ....... Treat toe dislocation .......................................... ......... T 0045 14.5947 897.11 268.47 179.42
28636 ....... Treat toe dislocation .......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
28645 ....... Repair toe dislocation ........................................ CH .. T 0063 37.5382 2,307.40 548.33 461.48
28660 ....... Treat toe dislocation .......................................... ......... T 0043 1.6857 103.62 .................. 20.72
28665 ....... Treat toe dislocation .......................................... ......... T 0045 14.5947 897.11 268.47 179.42
28666 ....... Treat toe dislocation .......................................... CH .. T 0062 25.5264 1,569.06 372.87 313.81
28675 ....... Repair of toe dislocation .................................... CH .. T 0063 37.5382 2,307.40 548.33 461.48
28705 ....... Fusion of foot bones .......................................... ......... T 0056 40.8559 2,511.33 .................. 502.27
28737 ....... Revision of foot bones ....................................... ......... T 0056 40.8559 2,511.33 .................. 502.27
28750 ....... Fusion of big toe joint ........................................ ......... T 0056 40.8559 2,511.33 .................. 502.27
28755 ....... Fusion of big toe joint ........................................ ......... T 0055 20.4263 1,255.56 355.34 251.11
28760 ....... Fusion of big toe joint ........................................ ......... T 0056 40.8559 2,511.33 .................. 502.27
28810 ....... Amputation toe & metatarsal ............................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28820 ....... Amputation of toe .............................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
28825 ....... Partial amputation of toe ................................... ......... T 0055 20.4263 1,255.56 355.34 251.11
28890 ....... High energy eswt, plantar f ............................... CH .. T 0050 25.1296 1,544.67 .................. 308.93
28899 ....... Foot/toes surgery procedure ............................. ......... T 0043 1.6857 103.62 .................. 20.72
29000 ....... Application of body cast .................................... ......... S 0058 1.0607 65.20 .................. 13.04
29049 ....... Application of figure eight .................................. ......... S 0058 1.0607 65.20 .................. 13.04
29055 ....... Application of shoulder cast .............................. ......... S 0426 2.2777 140.01 .................. 28.00
29058 ....... Application of shoulder cast .............................. ......... S 0058 1.0607 65.20 .................. 13.04
29065 ....... Application of long arm cast .............................. ......... S 0426 2.2777 140.01 .................. 28.00
29075 ....... Application of forearm cast ................................ ......... S 0426 2.2777 140.01 .................. 28.00
29085 ....... Apply hand/wrist cast ......................................... ......... S 0058 1.0607 65.20 .................. 13.04
29086 ....... Apply finger cast ................................................ ......... S 0058 1.0607 65.20 .................. 13.04
29105 ....... Apply long arm splint ......................................... ......... S 0058 1.0607 65.20 .................. 13.04
29125 ....... Apply forearm splint ........................................... ......... S 0058 1.0607 65.20 .................. 13.04
29126 ....... Apply forearm splint ........................................... ......... S 0058 1.0607 65.20 .................. 13.04
29130 ....... Application of finger splint ................................. ......... S 0058 1.0607 65.20 .................. 13.04
29131 ....... Application of finger splint ................................. ......... S 0058 1.0607 65.20 .................. 13.04
29200 ....... Strapping of chest .............................................. ......... S 0058 1.0607 65.20 .................. 13.04
29220 ....... Strapping of low back ........................................ ......... S 0058 1.0607 65.20 .................. 13.04
29240 ....... Strapping of shoulder ........................................ ......... S 0058 1.0607 65.20 .................. 13.04
29260 ....... Strapping of elbow or wrist ................................ ......... S 0058 1.0607 65.20 .................. 13.04
29280 ....... Strapping of hand or finger ................................ ......... S 0058 1.0607 65.20 .................. 13.04
29305 ....... Application of hip cast ....................................... ......... S 0426 2.2777 140.01 .................. 28.00
29325 ....... Application of hip casts ...................................... ......... S 0426 2.2777 140.01 .................. 28.00
29345 ....... Application of long leg cast ............................... ......... S 0426 2.2777 140.01 .................. 28.00
29358 ....... Apply long leg cast brace .................................. ......... S 0426 2.2777 140.01 .................. 28.00
29405 ....... Apply short leg cast ........................................... ......... S 0426 2.2777 140.01 .................. 28.00
29440 ....... Addition of walker to cast .................................. ......... S 0058 1.0607 65.20 .................. 13.04
29445 ....... Apply rigid leg cast ............................................ ......... S 0426 2.2777 140.01 .................. 28.00
29450 ....... Application of leg cast ....................................... ......... S 0058 1.0607 65.20 .................. 13.04
29505 ....... Application, long leg splint ................................. ......... S 0058 1.0607 65.20 .................. 13.04
29515 ....... Application lower leg splint ................................ ......... S 0058 1.0607 65.20 .................. 13.04
29520 ....... Strapping of hip ................................................. ......... S 0058 1.0607 65.20 .................. 13.04
29530 ....... Strapping of knee .............................................. ......... S 0058 1.0607 65.20 .................. 13.04
National Minimum
29540 ....... Strapping of ankle and/or ft ............................... ......... S 0058 1.0607 65.20 .................. 13.04
29550 ....... Strapping of toes ............................................... ......... S 0058 1.0607 65.20 .................. 13.04
29580 ....... Application of paste boot ................................... ......... S 0058 1.0607 65.20 .................. 13.04
29590 ....... Application of foot splint .................................... ......... S 0058 1.0607 65.20 .................. 13.04
29700 ....... Removal/revision of cast ................................... ......... S 0058 1.0607 65.20 .................. 13.04
29720 ....... Repair of body cast ........................................... ......... S 0058 1.0607 65.20 .................. 13.04
29730 ....... Windowing of cast ............................................. ......... S 0058 1.0607 65.20 .................. 13.04
29740 ....... Wedging of cast ................................................. ......... S 0058 1.0607 65.20 .................. 13.04
29750 ....... Wedging of clubfoot cast ................................... ......... S 0058 1.0607 65.20 .................. 13.04
29799 ....... Casting/strapping procedure .............................. ......... S 0058 1.0607 65.20 .................. 13.04
29800 ....... Jaw arthroscopy/surgery .................................... ......... T 0041 28.6245 1,759.49 .................. 351.90
29804 ....... Jaw arthroscopy/surgery .................................... ......... T 0041 28.6245 1,759.49 .................. 351.90
29805 ....... Shoulder arthroscopy, dx ................................... ......... T 0041 28.6245 1,759.49 .................. 351.90
29806 ....... Shoulder arthroscopy/surgery ............................ ......... T 0042 45.5027 2,796.96 804.74 559.39
29819 ....... Shoulder arthroscopy/surgery ............................ ......... T 0041 28.6245 1,759.49 .................. 351.90
29827 ....... Arthroscop rotator cuff repr ............................... ......... T 0042 45.5027 2,796.96 804.74 559.39
29830 ....... Elbow arthroscopy ............................................. ......... T 0041 28.6245 1,759.49 .................. 351.90
29834 ....... Elbow arthroscopy/surgery ................................ ......... T 0041 28.6245 1,759.49 .................. 351.90
29840 ....... Wrist arthroscopy ............................................... ......... T 0041 28.6245 1,759.49 .................. 351.90
29843 ....... Wrist arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90
29848 ....... Wrist endoscopy/surgery ................................... ......... T 0041 28.6245 1,759.49 .................. 351.90
29850 ....... Knee arthroscopy/surgery .................................. ......... T 0041 28.6245 1,759.49 .................. 351.90
29851 ....... Knee arthroscopy/surgery .................................. ......... T 0042 45.5027 2,796.96 804.74 559.39
29855 ....... Tibial arthroscopy/surgery ................................. ......... T 0042 45.5027 2,796.96 804.74 559.39
29856 ....... Tibial arthroscopy/surgery ................................. ......... T 0041 28.6245 1,759.49 .................. 351.90
29860 ....... Hip arthroscopy, dx ............................................ ......... T 0041 28.6245 1,759.49 .................. 351.90
29861 ....... Hip arthroscopy/surgery ..................................... ......... T 0041 28.6245 1,759.49 .................. 351.90
29862 ....... Hip arthroscopy/surgery ..................................... ......... T 0042 45.5027 2,796.96 804.74 559.39
29863 ....... Hip arthroscopy/surgery ..................................... ......... T 0042 45.5027 2,796.96 804.74 559.39
29866 ....... Autgrft implnt, knee w/scope ............................. ......... T 0042 45.5027 2,796.96 804.74 559.39
29867 ....... Allgrft implnt, knee w/scope ............................... ......... T 0042 45.5027 2,796.96 804.74 559.39
29868 ....... Meniscal trnspl, knee w/scpe ............................ ......... T 0042 45.5027 2,796.96 804.74 559.39
29870 ....... Knee arthroscopy, dx ......................................... ......... T 0041 28.6245 1,759.49 .................. 351.90
29871 ....... Knee arthroscopy/drainage ................................ ......... T 0041 28.6245 1,759.49 .................. 351.90
29891 ....... Ankle arthroscopy/surgery ................................. ......... T 0041 28.6245 1,759.49 .................. 351.90
National Minimum
29893 ....... Scope, plantar fasciotomy ................................. ......... T 0055 20.4263 1,255.56 355.34 251.11
29899 ....... Ankle arthroscopy/surgery ................................. ......... T 0042 45.5027 2,796.96 804.74 559.39
29900 ....... Mcp joint arthroscopy, dx .................................. ......... T 0053 16.154 992.95 253.49 198.59
29901 ....... Mcp joint arthroscopy, surg ............................... ......... T 0053 16.154 992.95 253.49 198.59
29902 ....... Mcp joint arthroscopy, surg ............................... ......... T 0053 16.154 992.95 253.49 198.59
29999 ....... Arthroscopy of joint ............................................ ......... T 0041 28.6245 1,759.49 .................. 351.90
30000 ....... Drainage of nose lesion ..................................... ......... T 0251 2.452 150.72 .................. 30.14
30020 ....... Drainage of nose lesion ..................................... ......... T 0251 2.452 150.72 .................. 30.14
30100 ....... Intranasal biopsy ................................................ ......... T 0252 7.5511 464.15 109.16 92.83
30110 ....... Removal of nose polyp(s) .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
30115 ....... Removal of nose polyp(s) .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
30117 ....... Removal of intranasal lesion ............................. ......... T 0253 16.4266 1,009.71 282.29 201.94
30118 ....... Removal of intranasal lesion ............................. ......... T 0254 23.3299 1,434.04 321.35 286.81
30120 ....... Revision of nose ................................................ ......... T 0253 16.4266 1,009.71 282.29 201.94
30124 ....... Removal of nose lesion ..................................... ......... T 0252 7.5511 464.15 109.16 92.83
30125 ....... Removal of nose lesion ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
30130 ....... Excise inferior turbinate ..................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
30140 ....... Resect inferior turbinate .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
30150 ....... Partial removal of nose ...................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
30160 ....... Removal of nose ................................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
30200 ....... Injection treatment of nose ................................ ......... T 0252 7.5511 464.15 109.16 92.83
30210 ....... Nasal sinus therapy ........................................... ......... T 0252 7.5511 464.15 109.16 92.83
30220 ....... Insert nasal septal button .................................. ......... T 0252 7.5511 464.15 109.16 92.83
30300 ....... Remove nasal foreign body ............................... ......... X 0340 0.6102 37.51 .................. 7.50
30310 ....... Remove nasal foreign body ............................... ......... T 0253 16.4266 1,009.71 282.29 201.94
30320 ....... Remove nasal foreign body ............................... ......... T 0253 16.4266 1,009.71 282.29 201.94
30400 ....... Reconstruction of nose ...................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
30430 ....... Revision of nose ................................................ ......... T 0254 23.3299 1,434.04 321.35 286.81
30435 ....... Revision of nose ................................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
30465 ....... Repair nasal stenosis ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
30520 ....... Repair of nasal septum ..................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
30540 ....... Repair nasal defect ............................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
30545 ....... Repair nasal defect ............................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
30560 ....... Release of nasal adhesions .............................. ......... T 0251 2.452 150.72 .................. 30.14
30580 ....... Repair upper jaw fistula ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
30600 ....... Repair mouth/nose fistula .................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
30620 ....... Intranasal reconstruction ................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
30630 ....... Repair nasal septum defect ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81
30801 ....... Ablate inf turbinate, superf ................................ ......... T 0252 7.5511 464.15 109.16 92.83
30802 ....... Cauterization, inner nose ................................... ......... T 0252 7.5511 464.15 109.16 92.83
30901 ....... Control of nosebleed ......................................... ......... T 0250 1.1791 72.48 25.39 14.50
30906 ....... Repeat control of nosebleed ............................. ......... T 0250 1.1791 72.48 25.39 14.50
30915 ....... Ligation, nasal sinus artery ................................ CH .. T 0092 24.8809 1,529.38 309.87 305.88
30920 ....... Ligation, upper jaw artery .................................. ......... T 0092 24.8809 1,529.38 309.87 305.88
30930 ....... Ther fx, nasal inf turbinate ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
30999 ....... Nasal surgery procedure ................................... ......... T 0251 2.452 150.72 .................. 30.14
31000 ....... Irrigation, maxillary sinus ................................... ......... T 0251 2.452 150.72 .................. 30.14
31002 ....... Irrigation, sphenoid sinus ................................... ......... T 0252 7.5511 464.15 109.16 92.83
31020 ....... Exploration, maxillary sinus ............................... ......... T 0254 23.3299 1,434.04 321.35 286.81
31030 ....... Exploration, maxillary sinus ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60
31032 ....... Explore sinus, remove polyps ........................... ......... T 0256 38.1991 2,348.02 .................. 469.60
31040 ....... Exploration behind upper jaw ............................ ......... T 0254 23.3299 1,434.04 321.35 286.81
31050 ....... Exploration, sphenoid sinus ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60
31051 ....... Sphenoid sinus surgery ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
31070 ....... Exploration of frontal sinus ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81
31075 ....... Exploration of frontal sinus ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
31080 ....... Removal of frontal sinus .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
National Minimum
31090 ....... Exploration of sinuses ....................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
31200 ....... Removal of ethmoid sinus ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
31231 ....... Nasal endoscopy, dx ......................................... ......... T 0072 1.4054 86.39 21.27 17.28
31233 ....... Nasal/sinus endoscopy, dx ................................ ......... T 0072 1.4054 86.39 21.27 17.28
31235 ....... Nasal/sinus endoscopy, dx ................................ ......... T 0074 14.7928 909.28 292.25 181.86
31237 ....... Nasal/sinus endoscopy, surg ............................. CH .. T 0074 14.7928 909.28 292.25 181.86
31238 ....... Nasal/sinus endoscopy, surg ............................. ......... T 0074 14.7928 909.28 292.25 181.86
31239 ....... Nasal/sinus endoscopy, surg ............................. ......... T 0075 21.9512 1,349.30 445.92 269.86
31240 ....... Nasal/sinus endoscopy, surg ............................. ......... T 0074 14.7928 909.28 292.25 181.86
31254 ....... Revision of ethmoid sinus ................................. ......... T 0075 21.9512 1,349.30 445.92 269.86
31255 ....... Removal of ethmoid sinus ................................. ......... T 0075 21.9512 1,349.30 445.92 269.86
31256 ....... Exploration maxillary sinus ................................ ......... T 0075 21.9512 1,349.30 445.92 269.86
31267 ....... Endoscopy, maxillary sinus ............................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31276 ....... Sinus endoscopy, surgical ................................. ......... T 0075 21.9512 1,349.30 445.92 269.86
31299 ....... Sinus surgery procedure ................................... ......... T 0251 2.452 150.72 .................. 30.14
31300 ....... Removal of larynx lesion ................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
31320 ....... Diagnostic incision, larynx ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
31400 ....... Revision of larynx .............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
31420 ....... Removal of epiglottis ......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
31500 ....... Insert emergency airway ................................... ......... S 0094 2.4233 148.96 46.29 29.79
31502 ....... Change of windpipe airway ............................... ......... T 0121 2.3587 144.98 43.80 29.00
31505 ....... Diagnostic laryngoscopy .................................... ......... T 0071 0.7698 47.32 11.20 9.46
31510 ....... Laryngoscopy with biopsy ................................. ......... T 0074 14.7928 909.28 292.25 181.86
31511 ....... Remove foreign body, larynx ............................. ......... T 0072 1.4054 86.39 21.27 17.28
31512 ....... Removal of larynx lesion ................................... ......... T 0074 14.7928 909.28 292.25 181.86
31513 ....... Injection into vocal cord ..................................... ......... T 0072 1.4054 86.39 21.27 17.28
31515 ....... Laryngoscopy for aspiration .............................. ......... T 0074 14.7928 909.28 292.25 181.86
31520 ....... Dx laryngoscopy, newborn ................................ ......... T 0072 1.4054 86.39 21.27 17.28
31525 ....... Dx laryngoscopy excl nb ................................... ......... T 0074 14.7928 909.28 292.25 181.86
31526 ....... Dx laryngoscopy w/oper scope ......................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31527 ....... Laryngoscopy for treatment ............................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31528 ....... Laryngoscopy and dilation ................................. ......... T 0074 14.7928 909.28 292.25 181.86
31529 ....... Laryngoscopy and dilation ................................. ......... T 0074 14.7928 909.28 292.25 181.86
31530 ....... Laryngoscopy w/fb removal ............................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31531 ....... Laryngoscopy w/fb & op scope ......................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31535 ....... Laryngoscopy w/biopsy ..................................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31536 ....... Laryngoscopy w/bx & op scope ........................ ......... T 0075 21.9512 1,349.30 445.92 269.86
31540 ....... Laryngoscopy w/exc of tumor ............................ ......... T 0075 21.9512 1,349.30 445.92 269.86
31541 ....... Larynscop w/tumr exc + scope ......................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31545 ....... Remove vc lesion w/scope ................................ ......... T 0075 21.9512 1,349.30 445.92 269.86
31546 ....... Remove vc lesion scope/graft ........................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31560 ....... Laryngoscop w/arytenoidectom ......................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31561 ....... Larynscop, remve cart + scop ........................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31570 ....... Laryngoscope w/vc inj ....................................... ......... T 0074 14.7928 909.28 292.25 181.86
31571 ....... Laryngoscop w/vc inj + scope ........................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31576 ....... Laryngoscopy with biopsy ................................. ......... T 0075 21.9512 1,349.30 445.92 269.86
31577 ....... Remove foreign body, larynx ............................. ......... T 0073 3.8463 236.42 69.15 47.28
31578 ....... Removal of larynx lesion ................................... ......... T 0075 21.9512 1,349.30 445.92 269.86
31590 ....... Reinnervate larynx ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
31595 ....... Larynx nerve surgery ......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
31599 ....... Larynx surgery procedure .................................. ......... T 0251 2.452 150.72 .................. 30.14
31600 ....... Incision of windpipe ........................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
31603 ....... Incision of windpipe ........................................... ......... T 0252 7.5511 464.15 109.16 92.83
National Minimum
31605 ....... Incision of windpipe ........................................... ......... T 0252 7.5511 464.15 109.16 92.83
31611 ....... Surgery/speech prosthesis ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81
31612 ....... Puncture/clear windpipe .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
31613 ....... Repair windpipe opening ................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
31614 ....... Repair windpipe opening ................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
31615 ....... Visualization of windpipe ................................... ......... T 0076 9.5228 585.35 189.82 117.07
31620 ....... Endobronchial us add-on ................................... ......... S 0670 32.2854 1,984.52 536.10 396.90
31622 ....... Dx bronchoscope/wash ..................................... ......... T 0076 9.5228 585.35 189.82 117.07
31623 ....... Dx bronchoscope/brush ..................................... ......... T 0076 9.5228 585.35 189.82 117.07
31624 ....... Dx bronchoscope/lavage ................................... ......... T 0076 9.5228 585.35 189.82 117.07
31625 ....... Bronchoscopy w/biopsy(s) ................................. ......... T 0076 9.5228 585.35 189.82 117.07
31628 ....... Bronchoscopy/lung bx, each ............................. ......... T 0076 9.5228 585.35 189.82 117.07
31629 ....... Bronchoscopy/needle bx, each ......................... ......... T 0076 9.5228 585.35 189.82 117.07
31630 ....... Bronchoscopy dilate/fx repr ............................... ......... T 0415 22.0099 1,352.90 459.92 270.58
31631 ....... Bronchoscopy, dilate w/stent ............................. ......... T 0415 22.0099 1,352.90 459.92 270.58
31632 ....... Bronchoscopy/lung bx, add’l .............................. ......... T 0076 9.5228 585.35 189.82 117.07
31633 ....... Bronchoscopy/needle bx add’l ........................... ......... T 0076 9.5228 585.35 189.82 117.07
31635 ....... Bronchoscopy w/fb removal .............................. ......... T 0076 9.5228 585.35 189.82 117.07
31636 ....... Bronchoscopy, bronch stents ............................ ......... T 0415 22.0099 1,352.90 459.92 270.58
31637 ....... Bronchoscopy, stent add-on .............................. ......... T 0076 9.5228 585.35 189.82 117.07
31638 ....... Bronchoscopy, revise stent ............................... ......... T 0415 22.0099 1,352.90 459.92 270.58
31640 ....... Bronchoscopy w/tumor excise ........................... ......... T 0415 22.0099 1,352.90 459.92 270.58
31641 ....... Bronchoscopy, treat blockage ........................... ......... T 0415 22.0099 1,352.90 459.92 270.58
31643 ....... Diag bronchoscope/catheter .............................. ......... T 0076 9.5228 585.35 189.82 117.07
31645 ....... Bronchoscopy, clear airways ............................. ......... T 0076 9.5228 585.35 189.82 117.07
31646 ....... Bronchoscopy, reclear airway ........................... ......... T 0076 9.5228 585.35 189.82 117.07
31656 ....... Bronchoscopy, inj for x-ray ................................ ......... T 0076 9.5228 585.35 189.82 117.07
31700 ....... Insertion of airway catheter ............................... CH .. D .................. .................. .................. .................. ..................
31708 ....... Instill airway contrast dye .................................. CH .. D .................. .................. .................. .................. ..................
31710 ....... Insertion of airway catheter ............................... CH .. D .................. .................. .................. .................. ..................
31715 ....... Injection for bronchus x-ray ............................... ......... N .................. .................. .................. .................. ..................
31717 ....... Bronchial brush biopsy ...................................... ......... T 0073 3.8463 236.42 69.15 47.28
31720 ....... Clearance of airways ......................................... ......... T 0071 0.7698 47.32 11.20 9.46
31730 ....... Intro, windpipe wire/tube .................................... ......... T 0073 3.8463 236.42 69.15 47.28
31750 ....... Repair of windpipe ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
31755 ....... Repair of windpipe ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
31785 ....... Remove windpipe lesion .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
31820 ....... Closure of windpipe lesion ................................ ......... T 0253 16.4266 1,009.71 282.29 201.94
31825 ....... Repair of windpipe defect .................................. ......... T 0254 23.3299 1,434.04 321.35 286.81
31830 ....... Revise windpipe scar ......................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
31899 ....... Airways surgical procedure ............................... ......... T 0076 9.5228 585.35 189.82 117.07
32000 ....... Drainage of chest .............................................. ......... T 0070 3.6244 222.78 .................. 44.56
32002 ....... Treatment of collapsed lung .............................. ......... T 0070 3.6244 222.78 .................. 44.56
32005 ....... Treat lung lining chemically ............................... ......... T 0070 3.6244 222.78 .................. 44.56
32019 ....... Insert pleural catheter ........................................ CH .. T 0652 29.5416 1,815.86 .................. 363.17
32020 ....... Insertion of chest tube ....................................... ......... T 0070 3.6244 222.78 .................. 44.56
32201 ....... Drain, percut, lung lesion ................................... ......... T 0070 3.6244 222.78 .................. 44.56
32400 ....... Needle biopsy chest lining ................................. ......... T 0685 6.1384 377.32 115.47 75.46
32405 ....... Biopsy, lung or mediastinum ............................. ......... T 0685 6.1384 377.32 115.47 75.46
32420 ....... Puncture/clear lung ............................................ ......... T 0070 3.6244 222.78 .................. 44.56
32601 ....... Thoracoscopy, diagnostic .................................. ......... T 0069 31.9442 1,963.55 591.64 392.71
32960 ....... Therapeutic pneumothorax ................................ ......... T 0070 3.6244 222.78 .................. 44.56
32998 ....... Perq rf ablate tx, pul tumor ................................ NI .... T 0423 37.3604 2,296.47 .................. 459.29
32999 ....... Chest surgery procedure ................................... ......... T 0070 3.6244 222.78 .................. 44.56
33010 ....... Drainage of heart sac ........................................ ......... T 0070 3.6244 222.78 .................. 44.56
33011 ....... Repeat drainage of heart sac ............................ ......... T 0070 3.6244 222.78 .................. 44.56
33200 ....... Insertion of heart pacemaker ............................. CH .. D .................. .................. .................. .................. ..................
33201 ....... Insertion of heart pacemaker ............................. CH .. D .................. .................. .................. .................. ..................
33202 ....... Insert epicard eltrd, open ................................... NI .... C .................. .................. .................. .................. ..................
33203 ....... Insert epicard eltrd, endo ................................... NI .... C .................. .................. .................. .................. ..................
33206 ....... Insertion of heart pacemaker ............................. ......... T 0089 123.6693 7,601.70 1,682.28 1,520.34
33207 ....... Insertion of heart pacemaker ............................. ......... T 0089 123.6693 7,601.70 1,682.28 1,520.34
33208 ....... Insertion of heart pacemaker ............................. ......... T 0655 152.6392 9,382.43 .................. 1,876.49
33210 ....... Insertion of heart electrode ................................ ......... T 0106 58.8594 3,617.97 .................. 723.59
National Minimum
33211 ....... Insertion of heart electrode ................................ ......... T 0106 58.8594 3,617.97 .................. 723.59
33212 ....... Insertion of pulse generator ............................... ......... T 0090 98.3023 6,042.45 1,612.80 1,208.49
33213 ....... Insertion of pulse generator ............................... ......... T 0654 112.7719 6,931.86 .................. 1,386.37
33214 ....... Upgrade of pacemaker system ......................... ......... T 0655 152.6392 9,382.43 .................. 1,876.49
33215 ....... Reposition pacing-defib lead ............................. ......... T 0105 25.6142 1,574.45 370.40 314.89
33216 ....... Insert lead pace-defib, one ................................ ......... T 0106 58.8594 3,617.97 .................. 723.59
33217 ....... Insert lead pace-defib, dual ............................... ......... T 0106 58.8594 3,617.97 .................. 723.59
33218 ....... Repair lead pace-defib, one .............................. CH .. T 0105 25.6142 1,574.45 370.40 314.89
33220 ....... Repair lead pace-defib, dual ............................. CH .. T 0105 25.6142 1,574.45 370.40 314.89
33222 ....... Revise pocket, pacemaker ................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
33223 ....... Revise pocket, pacing-defib .............................. ......... T 0027 21.4302 1,317.27 329.72 263.45
33224 ....... Insert pacing lead & connect ............................. ......... T 0418 307.2828 18,888.06 .................. 3,777.61
33225 ....... Lventric pacing lead add-on .............................. ......... T 0418 307.2828 18,888.06 .................. 3,777.61
33226 ....... Reposition l ventric lead .................................... ......... T 0105 25.6142 1,574.45 370.40 314.89
33233 ....... Removal of pacemaker system ......................... ......... T 0105 25.6142 1,574.45 370.40 314.89
33234 ....... Removal of pacemaker system ......................... ......... T 0105 25.6142 1,574.45 370.40 314.89
33235 ....... Removal pacemaker electrode .......................... ......... T 0105 25.6142 1,574.45 370.40 314.89
33241 ....... Remove pulse generator ................................... ......... T 0105 25.6142 1,574.45 370.40 314.89
33244 ....... Remove eltrd, transven ..................................... ......... T 0105 25.6142 1,574.45 370.40 314.89
33245 ....... Insert epic eltrd pace-defib ................................ CH .. D .................. .................. .................. .................. ..................
33246 ....... Insert epic eltrd/generator .................................. CH .. D .................. .................. .................. .................. ..................
33253 ....... Reconstruct atria ................................................ CH .. D .................. .................. .................. .................. ..................
33254 ....... Ablate atria, lmtd ................................................ NI .... C .................. .................. .................. .................. ..................
33255 ....... Ablate atria w/o bypass, ext .............................. NI .... C .................. .................. .................. .................. ..................
33256 ....... Ablate atria w/bypass, exten ............................. NI .... C .................. .................. .................. .................. ..................
33265 ....... Ablate atria w/bypass, endo .............................. NI .... C .................. .................. .................. .................. ..................
33266 ....... Ablate atria w/o bypass endo ............................ NI .... C .................. .................. .................. .................. ..................
33282 ....... Implant pat-active ht record ............................... ......... S 0680 72.6022 4,462.71 .................. 892.54
33284 ....... Remove pat-active ht record ............................. ......... T 0109 10.9918 675.64 .................. 135.13
33508 ....... Endoscopic vein harvest .................................... ......... N .................. .................. .................. .................. ..................
33675 ....... Close mult vsd ................................................... NI .... C .................. .................. .................. .................. ..................
33676 ....... Close mult vsd w/resection ................................ NI .... C .................. .................. .................. .................. ..................
33677 ....... Cl mult vsd w/rem pul band ............................... NI .... C .................. .................. .................. .................. ..................
33724 ....... Repair venous anomaly ..................................... NI .... C .................. .................. .................. .................. ..................
33726 ....... Repair pul venous stenosis ............................... NI .... C .................. .................. .................. .................. ..................
33999 ....... Cardiac surgery procedure ................................ ......... T 0070 3.6244 222.78 .................. 44.56
34101 ....... Removal of artery clot ....................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
34111 ....... Removal of arm artery clot ................................ ......... T 0088 37.7391 2,319.75 655.22 463.95
34201 ....... Removal of artery clot ....................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
34203 ....... Removal of leg artery clot ................................. ......... T 0088 37.7391 2,319.75 655.22 463.95
34421 ....... Removal of vein clot .......................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
34501 ....... Repair valve, femoral vein ................................. ......... T 0088 37.7391 2,319.75 655.22 463.95
34510 ....... Transposition of vein valve ................................ ......... T 0088 37.7391 2,319.75 655.22 463.95
34520 ....... Cross-over vein graft ......................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
34530 ....... Leg vein fusion .................................................. ......... T 0088 37.7391 2,319.75 655.22 463.95
35011 ....... Repair defect of artery ....................................... ......... T 0653 32.3818 1,990.44 .................. 398.09
35180 ....... Repair blood vessel lesion ................................ ......... T 0093 22.8653 1,405.48 .................. 281.10
35188 ....... Repair blood vessel lesion ................................ ......... T 0088 37.7391 2,319.75 655.22 463.95
35207 ....... Repair blood vessel lesion ................................ ......... T 0088 37.7391 2,319.75 655.22 463.95
35302 ....... Rechanneling of artery ...................................... NI .... C .................. .................. .................. .................. ..................
35321 ....... Rechanneling of artery ...................................... ......... T 0093 22.8653 1,405.48 .................. 281.10
35381 ....... Rechanneling of artery ...................................... CH .. D .................. .................. .................. .................. ..................
35458 ....... Repair arterial blockage ..................................... ......... T 0081 42.936 2,639.19 .................. 527.84
National Minimum
35460 ....... Repair venous blockage .................................... ......... T 0081 42.936 2,639.19 .................. 527.84
35476 ....... Repair venous blockage .................................... ......... T 0081 42.936 2,639.19 .................. 527.84
35484 ....... Atherectomy, open ............................................. ......... T 0081 42.936 2,639.19 .................. 527.84
35485 ....... Atherectomy, open ............................................. ......... T 0081 42.936 2,639.19 .................. 527.84
35490 ....... Atherectomy, percutaneous ............................... ......... T 0081 42.936 2,639.19 .................. 527.84
35500 ....... Harvest vein for bypass ..................................... ......... T 0081 42.936 2,639.19 .................. 527.84
35507 ....... Artery bypass graft ............................................ CH .. D .................. .................. .................. .................. ..................
35537 ....... Artery bypass graft ............................................ NI .... C .................. .................. .................. .................. ..................
35572 ....... Harvest femoropopliteal vein ............................. ......... N .................. .................. .................. .................. ..................
35685 ....... Bypass graft patency/patch ............................... ......... T 0093 22.8653 1,405.48 .................. 281.10
35686 ....... Bypass graft/av fist patency .............................. ......... T 0093 22.8653 1,405.48 .................. 281.10
35761 ....... Exploration of artery/vein ................................... ......... T 0115 29.2133 1,795.68 374.81 359.14
35860 ....... Explore limb vessels .......................................... ......... T 0093 22.8653 1,405.48 .................. 281.10
35875 ....... Removal of clot in graft ..................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
35876 ....... Removal of clot in graft ..................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
35879 ....... Revise graft w/vein ............................................ ......... T 0088 37.7391 2,319.75 655.22 463.95
35881 ....... Revise graft w/vein ............................................ ......... T 0088 37.7391 2,319.75 655.22 463.95
35883 ....... Revise graft w/nonauto graft ............................. NI .... T 0088 37.7391 2,319.75 655.22 463.95
35884 ....... Revise graft w/vein ............................................ NI .... T 0088 37.7391 2,319.75 655.22 463.95
35903 ....... Excision, graft, extremity ................................... ......... T 0115 29.2133 1,795.68 374.81 359.14
36000 ....... Place needle in vein .......................................... ......... N .................. .................. .................. .................. ..................
36002 ....... Pseudoaneurysm injection trt ............................ ......... S 0267 2.4606 151.25 60.50 30.25
36005 ....... Injection ext venography .................................... ......... N .................. .................. .................. .................. ..................
36010 ....... Place catheter in vein ........................................ ......... N .................. .................. .................. .................. ..................
36013 ....... Place catheter in artery ..................................... ......... N .................. .................. .................. .................. ..................
36100 ....... Establish access to artery ................................. ......... N .................. .................. .................. .................. ..................
36145 ....... Artery to vein shunt ........................................... ......... N .................. .................. .................. .................. ..................
36160 ....... Establish access to aorta .................................. ......... N .................. .................. .................. .................. ..................
36200 ....... Place catheter in aorta ...................................... ......... N .................. .................. .................. .................. ..................
36260 ....... Insertion of infusion pump ................................. ......... T 0623 28.5032 1,752.03 .................. 350.41
36261 ....... Revision of infusion pump ................................. ......... T 0623 28.5032 1,752.03 .................. 350.41
36262 ....... Removal of infusion pump ................................. ......... T 0622 22.6665 1,393.26 .................. 278.65
36299 ....... Vessel injection procedure ................................ ......... N .................. .................. .................. .................. ..................
36400 ....... Bl draw < 3 yrs fem/jugular ............................... ......... N .................. .................. .................. .................. ..................
36405 ....... Bl draw < 3 yrs scalp vein ................................. ......... N .................. .................. .................. .................. ..................
36406 ....... Bl draw < 3 yrs other vein ................................. ......... N .................. .................. .................. .................. ..................
National Minimum
36410 ....... Non-routine bl draw > 3 yrs ............................... ......... N .................. .................. .................. .................. ..................
36416 ....... Capillary blood draw .......................................... ......... N .................. .................. .................. .................. ..................
36420 ....... Vein access cutdown < 1 yr .............................. ......... T 0035 0.1999 12.29 .................. 2.46
36425 ....... Vein access cutdown > 1 yr .............................. ......... T 0035 0.1999 12.29 .................. 2.46
36430 ....... Blood transfusion service .................................. ......... S 0110 3.4584 212.58 .................. 42.52
36440 ....... Bl push transfuse, 2 yr or < ............................... ......... S 0110 3.4584 212.58 .................. 42.52
36450 ....... Bl exchange/transfuse, nb ................................. ......... S 0110 3.4584 212.58 .................. 42.52
36455 ....... Bl exchange/transfuse non-nb ........................... ......... S 0110 3.4584 212.58 .................. 42.52
36460 ....... Transfusion service, fetal ................................... ......... S 0110 3.4584 212.58 .................. 42.52
36468 ....... Injection(s), spider veins .................................... ......... T 0098 1.0798 66.37 .................. 13.27
36469 ....... Injection(s), spider veins .................................... ......... T 0098 1.0798 66.37 .................. 13.27
36470 ....... Injection therapy of vein .................................... ......... T 0098 1.0798 66.37 .................. 13.27
36471 ....... Injection therapy of veins ................................... ......... T 0098 1.0798 66.37 .................. 13.27
36475 ....... Endovenous rf, 1st vein ..................................... ......... T 0091 34.7288 2,134.71 .................. 426.94
36476 ....... Endovenous rf, vein add-on .............................. ......... T 0091 34.7288 2,134.71 .................. 426.94
36478 ....... Endovenous laser, 1st vein ............................... CH .. T 0092 24.8809 1,529.38 309.87 305.88
36479 ....... Endovenous laser vein addon ........................... CH .. T 0092 24.8809 1,529.38 309.87 305.88
36481 ....... Insertion of catheter, vein .................................. ......... N .................. .................. .................. .................. ..................
36511 ....... Apheresis wbc ................................................... ......... S 0111 11.7134 720.00 198.40 144.00
36512 ....... Apheresis rbc ..................................................... ......... S 0111 11.7134 720.00 198.40 144.00
36513 ....... Apheresis platelets ............................................ ......... S 0111 11.7134 720.00 198.40 144.00
36514 ....... Apheresis plasma .............................................. ......... S 0111 11.7134 720.00 198.40 144.00
36515 ....... Apheresis, adsorp/reinfuse ................................ ......... S 0112 30.2231 1,857.75 433.29 371.55
36516 ....... Apheresis, selective ........................................... ......... S 0112 30.2231 1,857.75 433.29 371.55
36522 ....... Photopheresis .................................................... ......... S 0112 30.2231 1,857.75 433.29 371.55
36540 ....... Collect blood venous device .............................. CH .. Q 0624 0.5145 31.63 12.65 6.33
36550 ....... Declot vascular device ....................................... ......... T 0676 2.0726 127.40 .................. 25.48
36555 ....... Insert non-tunnel cv cath ................................... ......... T 0621 8.7846 539.97 .................. 107.99
36556 ....... Insert non-tunnel cv cath ................................... ......... T 0621 8.7846 539.97 .................. 107.99
36557 ....... Insert tunneled cv cath ...................................... ......... T 0622 22.6665 1,393.26 .................. 278.65
36566 ....... Insert tunneled cv cath ...................................... CH .. T 0625 83.4609 5,130.17 .................. 1,026.03
36568 ....... Insert picc cath .................................................. ......... T 0621 8.7846 539.97 .................. 107.99
36569 ....... Insert picc cath .................................................. ......... T 0621 8.7846 539.97 .................. 107.99
36570 ....... Insert picvad cath .............................................. ......... T 0622 22.6665 1,393.26 .................. 278.65
36571 ....... Insert picvad cath .............................................. ......... T 0622 22.6665 1,393.26 .................. 278.65
36575 ....... Repair tunneled cv cath ..................................... ......... T 0621 8.7846 539.97 .................. 107.99
36576 ....... Repair tunneled cv cath ..................................... ......... T 0621 8.7846 539.97 .................. 107.99
36578 ....... Replace tunneled cv cath .................................. ......... T 0622 22.6665 1,393.26 .................. 278.65
36580 ....... Replace cvad cath ............................................. ......... T 0621 8.7846 539.97 .................. 107.99
36584 ....... Replace picc cath .............................................. ......... T 0621 8.7846 539.97 .................. 107.99
36585 ....... Replace picvad cath .......................................... ......... T 0622 22.6665 1,393.26 .................. 278.65
36589 ....... Removal tunneled cv cath ................................. ......... T 0621 8.7846 539.97 .................. 107.99
36590 ....... Removal tunneled cv cath ................................. ......... T 0621 8.7846 539.97 .................. 107.99
36595 ....... Mech remov tunneled cv cath ........................... ......... T 0622 22.6665 1,393.26 .................. 278.65
36596 ....... Mech remov tunneled cv cath ........................... ......... T 0621 8.7846 539.97 .................. 107.99
36597 ....... Reposition venous catheter ............................... ......... T 0621 8.7846 539.97 .................. 107.99
36598 ....... Inj w/fluor, eval cv device .................................. ......... X 0340 0.6102 37.51 .................. 7.50
36600 ....... Withdrawal of arterial blood ............................... CH .. Q 0035 0.1999 12.29 .................. 2.46
36620 ....... Insertion catheter, artery .................................... ......... N .................. .................. .................. .................. ..................
36625 ....... Insertion catheter, artery .................................... ......... N .................. .................. .................. .................. ..................
36640 ....... Insertion catheter, artery .................................... ......... T 0623 28.5032 1,752.03 .................. 350.41
36680 ....... Insert needle, bone cavity ................................. ......... T 0002 1.0995 67.58 .................. 13.52
36800 ....... Insertion of cannula ........................................... ......... T 0115 29.2133 1,795.68 374.81 359.14
36818 ....... Av fuse, uppr arm, cephalic ............................... ......... T 0088 37.7391 2,319.75 655.22 463.95
36819 ....... Av fuse, uppr arm, basilic .................................. ......... T 0088 37.7391 2,319.75 655.22 463.95
36820 ....... Av fusion/forearm vein ....................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
36821 ....... Av fusion direct any site .................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
36825 ....... Artery-vein autograft .......................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
National Minimum
36830 ....... Artery-vein nonautograft .................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
36831 ....... Open thrombect av fistula ................................. ......... T 0088 37.7391 2,319.75 655.22 463.95
36832 ....... Av fistula revision, open .................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
36833 ....... Av fistula revision ............................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
36834 ....... Repair A–V aneurysm ....................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
36835 ....... Artery to vein shunt ........................................... ......... T 0115 29.2133 1,795.68 374.81 359.14
36838 ....... Dist revas ligation, hemo ................................... ......... T 0088 37.7391 2,319.75 655.22 463.95
36860 ....... External cannula declotting ............................... ......... T 0676 2.0726 127.40 .................. 25.48
36861 ....... Cannula declotting ............................................. ......... T 0115 29.2133 1,795.68 374.81 359.14
36870 ....... Percut thrombect av fistula ................................ ......... T 0653 32.3818 1,990.44 .................. 398.09
37183 ....... Remove hepatic shunt (tips) .............................. ......... T 0229 68.4697 4,208.70 .................. 841.74
37184 ....... Prim art mech thrombectomy ............................ CH .. T 0088 37.7391 2,319.75 655.22 463.95
37185 ....... Prim art m-thrombect add-on ............................ CH .. T 0088 37.7391 2,319.75 655.22 463.95
37186 ....... Sec art m-thrombect add-on .............................. CH .. T 0088 37.7391 2,319.75 655.22 463.95
37187 ....... Venous mech thrombectomy ............................. CH .. T 0088 37.7391 2,319.75 655.22 463.95
37188 ....... Venous m-thrombectomy add-on ...................... CH .. T 0088 37.7391 2,319.75 655.22 463.95
37195 ....... Thrombolytic therapy, stroke ............................. ......... T 0676 2.0726 127.40 .................. 25.48
37200 ....... Transcatheter biopsy ......................................... ......... T 0685 6.1384 377.32 115.47 75.46
37201 ....... Transcatheter therapy infuse ............................. ......... T 0676 2.0726 127.40 .................. 25.48
37202 ....... Transcatheter therapy infuse ............................. ......... T 0676 2.0726 127.40 .................. 25.48
37203 ....... Transcatheter retrieval ....................................... ......... T 0103 16.2375 998.09 223.63 199.62
37204 ....... Transcatheter occlusion ..................................... ......... T 0115 29.2133 1,795.68 374.81 359.14
37205 ....... Transcath iv stent, percut .................................. ......... T 0229 68.4697 4,208.70 .................. 841.74
37206 ....... Transcath iv stent/perc addl .............................. ......... T 0229 68.4697 4,208.70 .................. 841.74
37207 ....... Transcath iv stent, open .................................... ......... T 0229 68.4697 4,208.70 .................. 841.74
37208 ....... Transcath iv stent/open addl ............................. ......... T 0229 68.4697 4,208.70 .................. 841.74
37209 ....... Change iv cath at thromb tx .............................. ......... T 0103 16.2375 998.09 223.63 199.62
37210 ....... Embolization uterine fibroid ............................... NI .... T 0202 42.9896 2,642.48 981.50 528.50
37250 ....... Iv us first vessel add-on .................................... ......... S 0416 32.5472 2,000.61 .................. 400.12
37251 ....... Iv us each add vessel add-on ........................... ......... S 0416 32.5472 2,000.61 .................. 400.12
37500 ....... Endoscopy ligate perf veins .............................. CH .. T 0091 34.7288 2,134.71 .................. 426.94
37501 ....... Vascular endoscopy procedure ......................... ......... T 0092 24.8809 1,529.38 309.87 305.88
37565 ....... Ligation of neck vein .......................................... ......... T 0093 22.8653 1,405.48 .................. 281.10
37600 ....... Ligation of neck artery ....................................... ......... T 0093 22.8653 1,405.48 .................. 281.10
37605 ....... Ligation of neck artery ....................................... ......... T 0091 34.7288 2,134.71 .................. 426.94
37606 ....... Ligation of neck artery ....................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88
37607 ....... Ligation of a-v fistula ......................................... ......... T 0092 24.8809 1,529.38 309.87 305.88
37609 ....... Temporal artery procedure ................................ ......... T 0021 15.1024 928.31 219.48 185.66
37615 ....... Ligation of neck artery ....................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88
37620 ....... Revision of major vein ....................................... ......... T 0091 34.7288 2,134.71 .................. 426.94
37650 ....... Revision of major vein ....................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88
37700 ....... Revise leg vein .................................................. ......... T 0091 34.7288 2,134.71 .................. 426.94
37718 ....... Ligate/strip short leg vein .................................. CH .. T 0091 34.7288 2,134.71 .................. 426.94
37722 ....... Ligate/strip long leg vein .................................... CH .. T 0091 34.7288 2,134.71 .................. 426.94
37735 ....... Removal of leg veins/lesion ............................... CH .. T 0091 34.7288 2,134.71 .................. 426.94
37760 ....... Ligation, leg veins, open .................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88
37765 ....... Phleb veins—extrem—to 20 .............................. CH .. T 0092 24.8809 1,529.38 309.87 305.88
37766 ....... Phleb veins—extrem 20+ .................................. CH .. T 0092 24.8809 1,529.38 309.87 305.88
37780 ....... Revision of leg vein ........................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88
37785 ....... Ligate/divide/excise vein .................................... CH .. T 0092 24.8809 1,529.38 309.87 305.88
37790 ....... Penile venous occlusion .................................... ......... T 0181 32.9873 2,027.66 621.82 405.53
37799 ....... Vascular surgery procedure .............................. ......... T 0103 16.2375 998.09 223.63 199.62
38120 ....... Laparoscopy, splenectomy ................................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37
38129 ....... Laparoscope proc, spleen ................................. ......... T 0130 32.1241 1,974.60 659.53 394.92
38200 ....... Injection for spleen x-ray ................................... ......... N .................. .................. .................. .................. ..................
38204 ....... Bl donor search management ........................... ......... N .................. .................. .................. .................. ..................
38205 ....... Harvest allogenic stem cells .............................. ......... S 0111 11.7134 720.00 198.40 144.00
38206 ....... Harvest auto stem cells ..................................... ......... S 0111 11.7134 720.00 198.40 144.00
38220 ....... Bone marrow aspiration ..................................... ......... T 0003 2.4011 147.59 .................. 29.52
38221 ....... Bone marrow biopsy .......................................... ......... T 0003 2.4011 147.59 .................. 29.52
38230 ....... Bone marrow collection ..................................... ......... S 0123 20.3582 1,251.38 .................. 250.28
38240 ....... Bone marrow/stem transplant ............................ ......... S 0123 20.3582 1,251.38 .................. 250.28
38241 ....... Bone marrow/stem transplant ............................ ......... S 0123 20.3582 1,251.38 .................. 250.28
38242 ....... Lymphocyte infuse transplant ............................ ......... S 0111 11.7134 720.00 198.40 144.00
38300 ....... Drainage, lymph node lesion ............................. ......... T 0007 11.1535 685.58 .................. 137.12
38305 ....... Drainage, lymph node lesion ............................. ......... T 0008 17.5086 1,076.22 .................. 215.24
38308 ....... Incision of lymph channels ................................ ......... T 0113 21.2621 1,306.94 .................. 261.39
38500 ....... Biopsy/removal, lymph nodes ............................ ......... T 0113 21.2621 1,306.94 .................. 261.39
38505 ....... Needle biopsy, lymph nodes ............................. ......... T 0005 3.9045 240.00 71.59 48.00
National Minimum
38542 ....... Explore deep node(s), neck .............................. ......... T 0114 37.7224 2,318.72 467.95 463.74
38550 ....... Removal, neck/armpit lesion ............................. ......... T 0113 21.2621 1,306.94 .................. 261.39
38555 ....... Removal, neck/armpit lesion ............................. ......... T 0113 21.2621 1,306.94 .................. 261.39
38570 ....... Laparoscopy, lymph node biop ......................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
38571 ....... Laparoscopy, lymphadenectomy ....................... ......... T 0132 70.5066 4,333.90 1,239.22 866.78
38572 ....... Laparoscopy, lymphadenectomy ....................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
38589 ....... Laparoscope proc, lymphatic ............................. ......... T 0130 32.1241 1,974.60 659.53 394.92
38700 ....... Removal of lymph nodes, neck ......................... ......... T 0113 21.2621 1,306.94 .................. 261.39
38720 ....... Removal of lymph nodes, neck ......................... ......... T 0113 21.2621 1,306.94 .................. 261.39
38740 ....... Remove armpit lymph nodes ............................. ......... T 0114 37.7224 2,318.72 467.95 463.74
38745 ....... Remove armpit lymph nodes ............................. ......... T 0114 37.7224 2,318.72 467.95 463.74
38760 ....... Remove groin lymph nodes ............................... ......... T 0113 21.2621 1,306.94 .................. 261.39
38790 ....... Inject for lymphatic x-ray ................................... ......... N .................. .................. .................. .................. ..................
38792 ....... Identify sentinel node ......................................... CH .. Q 0389 1.3754 84.54 33.81 16.91
38794 ....... Access thoracic lymph duct ............................... ......... N .................. .................. .................. .................. ..................
38999 ....... Blood/lymph system procedure ......................... ......... S 0110 3.4584 212.58 .................. 42.52
39400 ....... Visualization of chest ......................................... ......... T 0069 31.9442 1,963.55 591.64 392.71
40490 ....... Biopsy of lip ....................................................... ......... T 0251 2.452 150.72 .................. 30.14
40500 ....... Partial excision of lip .......................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
40525 ....... Reconstruct lip with flap .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
40527 ....... Reconstruct lip with flap .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
40530 ....... Partial removal of lip .......................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
40650 ....... Repair lip ............................................................ ......... T 0252 7.5511 464.15 109.16 92.83
40652 ....... Repair lip ............................................................ ......... T 0252 7.5511 464.15 109.16 92.83
40654 ....... Repair lip ............................................................ ......... T 0252 7.5511 464.15 109.16 92.83
40700 ....... Repair cleft lip/nasal .......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
40799 ....... Lip surgery procedure ........................................ ......... T 0251 2.452 150.72 .................. 30.14
40800 ....... Drainage of mouth lesion .................................. CH .. T 0006 1.4392 88.46 .................. 17.69
40801 ....... Drainage of mouth lesion .................................. ......... T 0252 7.5511 464.15 109.16 92.83
40804 ....... Removal, foreign body, mouth .......................... ......... X 0340 0.6102 37.51 .................. 7.50
40805 ....... Removal, foreign body, mouth .......................... ......... T 0252 7.5511 464.15 109.16 92.83
40806 ....... Incision of lip fold ............................................... ......... T 0251 2.452 150.72 .................. 30.14
40808 ....... Biopsy of mouth lesion ...................................... ......... T 0251 2.452 150.72 .................. 30.14
40810 ....... Excision of mouth lesion .................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
40812 ....... Excise/repair mouth lesion ................................ ......... T 0253 16.4266 1,009.71 282.29 201.94
40814 ....... Excise/repair mouth lesion ................................ ......... T 0253 16.4266 1,009.71 282.29 201.94
40818 ....... Excise oral mucosa for graft .............................. ......... T 0251 2.452 150.72 .................. 30.14
40819 ....... Excise lip or cheek fold ..................................... ......... T 0252 7.5511 464.15 109.16 92.83
40820 ....... Treatment of mouth lesion ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
40830 ....... Repair mouth laceration .................................... ......... T 0251 2.452 150.72 .................. 30.14
40831 ....... Repair mouth laceration .................................... ......... T 0252 7.5511 464.15 109.16 92.83
40840 ....... Reconstruction of mouth .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
40844 ....... Reconstruction of mouth .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
40845 ....... Reconstruction of mouth .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
40899 ....... Mouth surgery procedure .................................. ......... T 0251 2.452 150.72 .................. 30.14
41000 ....... Drainage of mouth lesion .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
41005 ....... Drainage of mouth lesion .................................. ......... T 0251 2.452 150.72 .................. 30.14
41010 ....... Incision of tongue fold ....................................... ......... T 0252 7.5511 464.15 109.16 92.83
41100 ....... Biopsy of tongue ................................................ ......... T 0252 7.5511 464.15 109.16 92.83
41105 ....... Biopsy of tongue ................................................ ......... T 0253 16.4266 1,009.71 282.29 201.94
National Minimum
41108 ....... Biopsy of floor of mouth .................................... ......... T 0252 7.5511 464.15 109.16 92.83
41110 ....... Excision of tongue lesion ................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
41115 ....... Excision of tongue fold ...................................... ......... T 0252 7.5511 464.15 109.16 92.83
41120 ....... Partial removal of tongue .................................. ......... T 0254 23.3299 1,434.04 321.35 286.81
41250 ....... Repair tongue laceration ................................... ......... T 0251 2.452 150.72 .................. 30.14
41251 ....... Repair tongue laceration ................................... ......... T 0251 2.452 150.72 .................. 30.14
41252 ....... Repair tongue laceration ................................... ......... T 0252 7.5511 464.15 109.16 92.83
41500 ....... Fixation of tongue .............................................. ......... T 0254 23.3299 1,434.04 321.35 286.81
41510 ....... Tongue to lip surgery ......................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
41520 ....... Reconstruction, tongue fold ............................... ......... T 0252 7.5511 464.15 109.16 92.83
41599 ....... Tongue and mouth surgery ............................... ......... T 0251 2.452 150.72 .................. 30.14
41800 ....... Drainage of gum lesion ..................................... CH .. T 0006 1.4392 88.46 .................. 17.69
41805 ....... Removal foreign body, gum .............................. ......... T 0254 23.3299 1,434.04 321.35 286.81
41806 ....... Removal foreign body,jawbone ......................... ......... T 0253 16.4266 1,009.71 282.29 201.94
41820 ....... Excision, gum, each quadrant ........................... ......... T 0252 7.5511 464.15 109.16 92.83
41821 ....... Excision of gum flap .......................................... ......... T 0252 7.5511 464.15 109.16 92.83
41822 ....... Excision of gum lesion ....................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
41830 ....... Removal of gum tissue ...................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
41850 ....... Treatment of gum lesion .................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
41870 ....... Gum graft ........................................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
41872 ....... Repair gum ........................................................ ......... T 0253 16.4266 1,009.71 282.29 201.94
41874 ....... Repair tooth socket ............................................ ......... T 0254 23.3299 1,434.04 321.35 286.81
41899 ....... Dental surgery procedure .................................. ......... T 0251 2.452 150.72 .................. 30.14
42000 ....... Drainage mouth roof lesion ............................... ......... T 0251 2.452 150.72 .................. 30.14
42100 ....... Biopsy roof of mouth ......................................... ......... T 0252 7.5511 464.15 109.16 92.83
42104 ....... Excision lesion, mouth roof ............................... ......... T 0253 16.4266 1,009.71 282.29 201.94
42120 ....... Remove palate/lesion ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
42140 ....... Excision of uvula ................................................ ......... T 0252 7.5511 464.15 109.16 92.83
42145 ....... Repair palate, pharynx/uvula ............................. ......... T 0254 23.3299 1,434.04 321.35 286.81
42160 ....... Treatment mouth roof lesion ............................. ......... T 0253 16.4266 1,009.71 282.29 201.94
42180 ....... Repair palate ..................................................... ......... T 0251 2.452 150.72 .................. 30.14
42182 ....... Repair palate ..................................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
42200 ....... Reconstruct cleft palate ..................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
42226 ....... Lengthening of palate ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
42227 ....... Lengthening of palate ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
42235 ....... Repair palate ..................................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
42260 ....... Repair nose to lip fistula .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
42280 ....... Preparation, palate mold ................................... ......... T 0251 2.452 150.72 .................. 30.14
42281 ....... Insertion, palate prosthesis ................................ ......... T 0253 16.4266 1,009.71 282.29 201.94
42299 ....... Palate/uvula surgery .......................................... ......... T 0251 2.452 150.72 .................. 30.14
42300 ....... Drainage of salivary gland ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
42305 ....... Drainage of salivary gland ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
42310 ....... Drainage of salivary gland ................................. ......... T 0251 2.452 150.72 .................. 30.14
42320 ....... Drainage of salivary gland ................................. ......... T 0251 2.452 150.72 .................. 30.14
42330 ....... Removal of salivary stone ................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
42400 ....... Biopsy of salivary gland ..................................... ......... T 0005 3.9045 240.00 71.59 48.00
42405 ....... Biopsy of salivary gland ..................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
42408 ....... Excision of salivary cyst .................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
42409 ....... Drainage of salivary cyst ................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
42410 ....... Excise parotid gland/lesion ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
National Minimum
42440 ....... Excise submaxillary gland ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
42450 ....... Excise sublingual gland ..................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
42500 ....... Repair salivary duct ........................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
42505 ....... Repair salivary duct ........................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
42507 ....... Parotid duct diversion ........................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
42550 ....... Injection for salivary x-ray .................................. ......... N .................. .................. .................. .................. ..................
42600 ....... Closure of salivary fistula .................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
42650 ....... Dilation of salivary duct ..................................... ......... T 0252 7.5511 464.15 109.16 92.83
42660 ....... Dilation of salivary duct ..................................... ......... T 0251 2.452 150.72 .................. 30.14
42665 ....... Ligation of salivary duct ..................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
42699 ....... Salivary surgery procedure ................................ ......... T 0251 2.452 150.72 .................. 30.14
42700 ....... Drainage of tonsil abscess ................................ ......... T 0251 2.452 150.72 .................. 30.14
42720 ....... Drainage of throat abscess ............................... ......... T 0253 16.4266 1,009.71 282.29 201.94
42725 ....... Drainage of throat abscess ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60
42800 ....... Biopsy of throat .................................................. CH .. T 0252 7.5511 464.15 109.16 92.83
42802 ....... Biopsy of throat .................................................. ......... T 0253 16.4266 1,009.71 282.29 201.94
42804 ....... Biopsy of upper nose/throat .............................. ......... T 0253 16.4266 1,009.71 282.29 201.94
42806 ....... Biopsy of upper nose/throat .............................. ......... T 0254 23.3299 1,434.04 321.35 286.81
42808 ....... Excise pharynx lesion ........................................ ......... T 0253 16.4266 1,009.71 282.29 201.94
42809 ....... Remove pharynx foreign body .......................... ......... X 0340 0.6102 37.51 .................. 7.50
42810 ....... Excision of neck cyst ......................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
42815 ....... Excision of neck cyst ......................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
42820 ....... Remove tonsils and adenoids ........................... ......... T 0258 22.1165 1,359.46 437.25 271.89
42821 ....... Remove tonsils and adenoids ........................... ......... T 0258 22.1165 1,359.46 437.25 271.89
42825 ....... Removal of tonsils ............................................. ......... T 0258 22.1165 1,359.46 437.25 271.89
42826 ....... Removal of tonsils ............................................. ......... T 0258 22.1165 1,359.46 437.25 271.89
42830 ....... Removal of adenoids ......................................... ......... T 0258 22.1165 1,359.46 437.25 271.89
42842 ....... Extensive surgery of throat ................................ ......... T 0254 23.3299 1,434.04 321.35 286.81
42844 ....... Extensive surgery of throat ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
42860 ....... Excision of tonsil tags ........................................ ......... T 0258 22.1165 1,359.46 437.25 271.89
42870 ....... Excision of lingual tonsil .................................... ......... T 0258 22.1165 1,359.46 437.25 271.89
42890 ....... Partial removal of pharynx ................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
42892 ....... Revision of pharyngeal walls ............................. ......... T 0256 38.1991 2,348.02 .................. 469.60
42900 ....... Repair throat wound .......................................... ......... T 0252 7.5511 464.15 109.16 92.83
42950 ....... Reconstruction of throat .................................... ......... T 0254 23.3299 1,434.04 321.35 286.81
42955 ....... Surgical opening of throat ................................. ......... T 0254 23.3299 1,434.04 321.35 286.81
42960 ....... Control throat bleeding ...................................... ......... T 0250 1.1791 72.48 25.39 14.50
42962 ....... Control throat bleeding ...................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
42970 ....... Control nose/throat bleeding ............................. ......... T 0250 1.1791 72.48 25.39 14.50
42972 ....... Control nose/throat bleeding ............................. ......... T 0253 16.4266 1,009.71 282.29 201.94
42999 ....... Throat surgery procedure .................................. ......... T 0251 2.452 150.72 .................. 30.14
43020 ....... Incision of esophagus ........................................ ......... T 0252 7.5511 464.15 109.16 92.83
43030 ....... Throat muscle surgery ....................................... ......... T 0253 16.4266 1,009.71 282.29 201.94
43130 ....... Removal of esophagus pouch ........................... CH .. T 0256 38.1991 2,348.02 .................. 469.60
43200 ....... Esophagus endoscopy ...................................... ......... T 0141 8.3175 511.26 143.38 102.25
43201 ....... Esoph scope w/submucous inj .......................... ......... T 0141 8.3175 511.26 143.38 102.25
43202 ....... Esophagus endoscopy, biopsy .......................... ......... T 0141 8.3175 511.26 143.38 102.25
43204 ....... Esoph scope w/sclerosis inj .............................. ......... T 0141 8.3175 511.26 143.38 102.25
43205 ....... Esophagus endoscopy/ligation .......................... ......... T 0141 8.3175 511.26 143.38 102.25
43216 ....... Esophagus endoscopy/lesion ............................ ......... T 0141 8.3175 511.26 143.38 102.25
43219 ....... Esophagus endoscopy ...................................... ......... T 0384 22.9475 1,410.54 295.41 282.11
43220 ....... Esoph endoscopy, dilation ................................. ......... T 0141 8.3175 511.26 143.38 102.25
43227 ....... Esoph endoscopy, repair ................................... ......... T 0141 8.3175 511.26 143.38 102.25
43228 ....... Esoph endoscopy, ablation ............................... ......... T 0422 25.7552 1,583.12 448.81 316.62
43231 ....... Esoph endoscopy w/us exam ............................ ......... T 0141 8.3175 511.26 143.38 102.25
43232 ....... Esoph endoscopy w/us fn bx ............................ ......... T 0141 8.3175 511.26 143.38 102.25
43234 ....... Upper GI endoscopy, exam ............................... ......... T 0141 8.3175 511.26 143.38 102.25
43235 ....... Uppr gi endoscopy, diagnosis ........................... ......... T 0141 8.3175 511.26 143.38 102.25
43236 ....... Uppr gi scope w/submuc inj .............................. ......... T 0141 8.3175 511.26 143.38 102.25
43237 ....... Endoscopic us exam, esoph ............................. ......... T 0141 8.3175 511.26 143.38 102.25
National Minimum
43238 ....... Uppr gi endoscopy w/us fn bx ........................... ......... T 0141 8.3175 511.26 143.38 102.25
43239 ....... Upper GI endoscopy, biopsy ............................. ......... T 0141 8.3175 511.26 143.38 102.25
43240 ....... Esoph endoscope w/drain cyst .......................... ......... T 0141 8.3175 511.26 143.38 102.25
43241 ....... Upper GI endoscopy with tube .......................... ......... T 0141 8.3175 511.26 143.38 102.25
43242 ....... Uppr gi endoscopy w/us fn bx ........................... ......... T 0141 8.3175 511.26 143.38 102.25
43243 ....... Upper gi endoscopy & inject ............................. ......... T 0141 8.3175 511.26 143.38 102.25
43244 ....... Upper GI endoscopy/ligation ............................. ......... T 0141 8.3175 511.26 143.38 102.25
43245 ....... Uppr gi scope dilate strictr ................................. ......... T 0141 8.3175 511.26 143.38 102.25
43246 ....... Place gastrostomy tube ..................................... ......... T 0141 8.3175 511.26 143.38 102.25
43247 ....... Operative upper GI endoscopy ......................... ......... T 0141 8.3175 511.26 143.38 102.25
43248 ....... Uppr gi endoscopy/guide wire ........................... ......... T 0141 8.3175 511.26 143.38 102.25
43250 ....... Upper GI endoscopy/tumor ............................... ......... T 0141 8.3175 511.26 143.38 102.25
43256 ....... Uppr gi endoscopy w/stent ................................ ......... T 0384 22.9475 1,410.54 295.41 282.11
43257 ....... Uppr gi scope w/thrml txmnt .............................. ......... T 0422 25.7552 1,583.12 448.81 316.62
43259 ....... Endoscopic ultrasound exam ............................ ......... T 0141 8.3175 511.26 143.38 102.25
43260 ....... Endo cholangiopancreatograph ......................... ......... T 0151 19.8381 1,219.41 245.46 243.88
43280 ....... Laparoscopy, fundoplasty .................................. ......... T 0132 70.5066 4,333.90 1,239.22 866.78
43289 ....... Laparoscope proc, esoph .................................. ......... T 0130 32.1241 1,974.60 659.53 394.92
43450 ....... Dilate esophagus ............................................... ......... T 0140 5.4566 335.41 91.40 67.08
43499 ....... Esophagus surgery procedure .......................... ......... T 0141 8.3175 511.26 143.38 102.25
43510 ....... Surgical opening of stomach ............................. ......... T 0141 8.3175 511.26 143.38 102.25
43600 ....... Biopsy of stomach ............................................. ......... T 0141 8.3175 511.26 143.38 102.25
43647 ....... Lap impl electrode, antrum ................................ NI .... T 0130 32.1241 1,974.60 659.53 394.92
43648 ....... Lap revise/remv eltrd antrum ............................. NI .... T 0130 32.1241 1,974.60 659.53 394.92
43651 ....... Laparoscopy, vagus nerve ................................ ......... T 0132 70.5066 4,333.90 1,239.22 866.78
43652 ....... Laparoscopy, vagus nerve ................................ ......... T 0132 70.5066 4,333.90 1,239.22 866.78
43653 ....... Laparoscopy, gastrostomy ................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
43659 ....... Laparoscope proc, stom .................................... ......... T 0130 32.1241 1,974.60 659.53 394.92
43752 ....... Nasal/orogastric w/stent .................................... ......... X 0272 1.2908 79.34 31.64 15.87
43760 ....... Change gastrostomy tube ................................. ......... T 0121 2.3587 144.98 43.80 29.00
43761 ....... Reposition gastrostomy tube ............................. ......... T 0122 7.48 459.78 .................. 91.96
43830 ....... Place gastrostomy tube ..................................... ......... T 0422 25.7552 1,583.12 448.81 316.62
43870 ....... Repair stomach opening .................................... ......... T 0141 8.3175 511.26 143.38 102.25
43881 ....... Impl/redo electrd, antrum ................................... NI .... C .................. .................. .................. .................. ..................
43882 ....... Revise/remove electrd antrum ........................... NI .... C .................. .................. .................. .................. ..................
43886 ....... Revise gastric port, open ................................... ......... T 0025 5.2594 323.28 101.85 64.66
43887 ....... Remove gastric port, open ................................ ......... T 0025 5.2594 323.28 101.85 64.66
43888 ....... Change gastric port, open ................................. ......... T 0686 14.0346 862.68 .................. 172.54
43999 ....... Stomach surgery procedure .............................. ......... T 0141 8.3175 511.26 143.38 102.25
44100 ....... Biopsy of bowel ................................................. ......... T 0141 8.3175 511.26 143.38 102.25
44152 ....... Removal of colon/ileostomy ............................... CH .. D .................. .................. .................. .................. ..................
44153 ....... Removal of colon/ileostomy ............................... CH .. D .................. .................. .................. .................. ..................
44157 ....... Colectomy w/ileoanal anast ............................... NI .... C .................. .................. .................. .................. ..................
44158 ....... Colectomy w/neo-rectum pouch ........................ NI .... C .................. .................. .................. .................. ..................
44180 ....... Lap, enterolysis .................................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
44186 ....... Lap, jejunostomy ................................................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37
44206 ....... Lap part colectomy w/stoma .............................. ......... T 0132 70.5066 4,333.90 1,239.22 866.78
44207 ....... Lcolectomy/coloproctostomy .............................. ......... T 0132 70.5066 4,333.90 1,239.22 866.78
44208 ....... Lcolectomy/coloproctostomy .............................. ......... T 0132 70.5066 4,333.90 1,239.22 866.78
44213 ....... Lap, mobil splenic fl add-on .............................. ......... T 0130 32.1241 1,974.60 659.53 394.92
44238 ....... Laparoscope proc, intestine .............................. ......... T 0130 32.1241 1,974.60 659.53 394.92
National Minimum
44312 ....... Revision of ileostomy ......................................... ......... T 0027 21.4302 1,317.27 329.72 263.45
44340 ....... Revision of colostomy ........................................ ......... T 0027 21.4302 1,317.27 329.72 263.45
44360 ....... Small bowel endoscopy ..................................... ......... T 0142 9.4946 583.61 152.78 116.72
44361 ....... Small bowel endoscopy/biopsy ......................... ......... T 0142 9.4946 583.61 152.78 116.72
44370 ....... Small bowel endoscopy/stent ............................ ......... T 0384 22.9475 1,410.54 295.41 282.11
44377 ....... Small bowel endoscopy/biopsy ......................... ......... T 0142 9.4946 583.61 152.78 116.72
44379 ....... Sbowel endoscope w/stent ................................ ......... T 0384 22.9475 1,410.54 295.41 282.11
44383 ....... Ileoscopy w/stent ............................................... ......... T 0384 22.9475 1,410.54 295.41 282.11
44385 ....... Endoscopy of bowel pouch ............................... ......... T 0143 8.7686 538.99 186.06 107.80
44386 ....... Endoscopy, bowel pouch/biop ........................... ......... T 0143 8.7686 538.99 186.06 107.80
44388 ....... Colonoscopy ...................................................... ......... T 0143 8.7686 538.99 186.06 107.80
44389 ....... Colonoscopy with biopsy ................................... ......... T 0143 8.7686 538.99 186.06 107.80
44390 ....... Colonoscopy for foreign body ............................ ......... T 0143 8.7686 538.99 186.06 107.80
44391 ....... Colonoscopy for bleeding .................................. ......... T 0143 8.7686 538.99 186.06 107.80
44392 ....... Colonoscopy & polypectomy ............................. ......... T 0143 8.7686 538.99 186.06 107.80
44393 ....... Colonoscopy, lesion removal ............................. ......... T 0143 8.7686 538.99 186.06 107.80
44394 ....... Colonoscopy w/snare ........................................ ......... T 0143 8.7686 538.99 186.06 107.80
44397 ....... Colonoscopy w/stent .......................................... ......... T 0384 22.9475 1,410.54 295.41 282.11
44500 ....... Intro, gastrointestinal tube ................................. ......... T 0121 2.3587 144.98 43.80 29.00
44701 ....... Intraop colon lavage add-on .............................. ......... N .................. .................. .................. .................. ..................
44799 ....... Unlisted procedure intestine .............................. CH .. T 0153 22.0832 1,357.41 397.95 271.48
44901 ....... Drain app abscess, percut ................................. ......... T 0037 10.2655 631.00 228.76 126.20
44970 ....... Laparoscopy, appendectomy ............................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
44979 ....... Laparoscope proc, app ...................................... ......... T 0130 32.1241 1,974.60 659.53 394.92
45000 ....... Drainage of pelvic abscess ............................... ......... T 0148 5.077 312.07 .................. 62.41
45005 ....... Drainage of rectal abscess ................................ ......... T 0155 12.7389 783.03 .................. 156.61
45020 ....... Drainage of rectal abscess ................................ ......... T 0155 12.7389 783.03 .................. 156.61
45100 ....... Biopsy of rectum ................................................ ......... T 0149 22.2682 1,368.78 293.06 273.76
45108 ....... Removal of anorectal lesion .............................. CH .. T 0149 22.2682 1,368.78 293.06 273.76
45150 ....... Excision of rectal stricture ................................. ......... T 0149 22.2682 1,368.78 293.06 273.76
45160 ....... Excision of rectal lesion ..................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
45170 ....... Excision of rectal lesion ..................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
45190 ....... Destruction, rectal tumor ................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
45300 ....... Proctosigmoidoscopy dx .................................... ......... T 0146 4.8683 299.24 64.40 59.85
45303 ....... Proctosigmoidoscopy dilate ............................... ......... T 0147 8.5477 525.41 .................. 105.08
45305 ....... Proctosigmoidoscopy w/bx ................................ ......... T 0147 8.5477 525.41 .................. 105.08
45307 ....... Proctosigmoidoscopy fb ..................................... ......... T 0428 20.6375 1,268.55 .................. 253.71
45308 ....... Proctosigmoidoscopy removal ........................... ......... T 0147 8.5477 525.41 .................. 105.08
45317 ....... Proctosigmoidoscopy bleed ............................... ......... T 0147 8.5477 525.41 .................. 105.08
45320 ....... Proctosigmoidoscopy ablate .............................. ......... T 0428 20.6375 1,268.55 .................. 253.71
45321 ....... Proctosigmoidoscopy volvul .............................. ......... T 0428 20.6375 1,268.55 .................. 253.71
45327 ....... Proctosigmoidoscopy w/stent ............................ ......... T 0384 22.9475 1,410.54 295.41 282.11
45330 ....... Diagnostic sigmoidoscopy ................................. ......... T 0146 4.8683 299.24 64.40 59.85
45331 ....... Sigmoidoscopy and biopsy ................................ ......... T 0146 4.8683 299.24 64.40 59.85
45332 ....... Sigmoidoscopy w/fb removal ............................. ......... T 0146 4.8683 299.24 64.40 59.85
45333 ....... Sigmoidoscopy & polypectomy .......................... ......... T 0147 8.5477 525.41 .................. 105.08
45334 ....... Sigmoidoscopy for bleeding .............................. ......... T 0147 8.5477 525.41 .................. 105.08
45335 ....... Sigmoidoscopy w/submuc inj ............................ ......... T 0146 4.8683 299.24 64.40 59.85
45337 ....... Sigmoidoscopy & decompress .......................... ......... T 0146 4.8683 299.24 64.40 59.85
45338 ....... Sigmoidoscopy w/tumr remove ......................... ......... T 0147 8.5477 525.41 .................. 105.08
45339 ....... Sigmoidoscopy w/ablate tumr ............................ ......... T 0147 8.5477 525.41 .................. 105.08
45340 ....... Sig w/balloon dilation ......................................... ......... T 0147 8.5477 525.41 .................. 105.08
45341 ....... Sigmoidoscopy w/ultrasound ............................. ......... T 0147 8.5477 525.41 .................. 105.08
45342 ....... Sigmoidoscopy w/us guide bx ........................... ......... T 0147 8.5477 525.41 .................. 105.08
45345 ....... Sigmoidoscopy w/stent ...................................... ......... T 0384 22.9475 1,410.54 295.41 282.11
45355 ....... Surgical colonoscopy ......................................... ......... T 0143 8.7686 538.99 186.06 107.80
45378 ....... Diagnostic colonoscopy ..................................... ......... T 0143 8.7686 538.99 186.06 107.80
National Minimum
45379 ....... Colonoscopy w/fb removal ................................ ......... T 0143 8.7686 538.99 186.06 107.80
45380 ....... Colonoscopy and biopsy ................................... ......... T 0143 8.7686 538.99 186.06 107.80
45381 ....... Colonoscopy, submucous inj ............................. ......... T 0143 8.7686 538.99 186.06 107.80
45382 ....... Colonoscopy/control bleeding ............................ ......... T 0143 8.7686 538.99 186.06 107.80
45383 ....... Lesion removal colonoscopy ............................. ......... T 0143 8.7686 538.99 186.06 107.80
45384 ....... Lesion remove colonoscopy .............................. ......... T 0143 8.7686 538.99 186.06 107.80
45385 ....... Lesion removal colonoscopy ............................. ......... T 0143 8.7686 538.99 186.06 107.80
45386 ....... Colonoscopy dilate stricture .............................. ......... T 0143 8.7686 538.99 186.06 107.80
45387 ....... Colonoscopy w/stent .......................................... ......... T 0384 22.9475 1,410.54 295.41 282.11
45391 ....... Colonoscopy w/endoscope us ........................... ......... T 0143 8.7686 538.99 186.06 107.80
45392 ....... Colonoscopy w/endoscopic fnb ......................... ......... T 0143 8.7686 538.99 186.06 107.80
45499 ....... Laparoscope proc, rectum ................................. ......... T 0130 32.1241 1,974.60 659.53 394.92
45500 ....... Repair of rectum ................................................ ......... T 0149 22.2682 1,368.78 293.06 273.76
45505 ....... Repair of rectum ................................................ ......... T 0150 29.6189 1,820.61 437.12 364.12
45520 ....... Treatment of rectal prolapse ............................. ......... T 0098 1.0798 66.37 .................. 13.27
45541 ....... Correct rectal prolapse ...................................... ......... T 0150 29.6189 1,820.61 437.12 364.12
45560 ....... Repair of rectocele ............................................ ......... T 0150 29.6189 1,820.61 437.12 364.12
45900 ....... Reduction of rectal prolapse .............................. ......... T 0148 5.077 312.07 .................. 62.41
45905 ....... Dilation of anal sphincter ................................... ......... T 0149 22.2682 1,368.78 293.06 273.76
45910 ....... Dilation of rectal narrowing ................................ ......... T 0149 22.2682 1,368.78 293.06 273.76
45915 ....... Remove rectal obstruction ................................. ......... T 0148 5.077 312.07 .................. 62.41
45990 ....... Surg dx exam, anorectal ................................... ......... T 0148 5.077 312.07 .................. 62.41
45999 ....... Rectum surgery procedure ................................ ......... T 0148 5.077 312.07 .................. 62.41
46020 ....... Placement of seton ............................................ CH .. T 0149 22.2682 1,368.78 293.06 273.76
46030 ....... Removal of rectal marker .................................. ......... T 0148 5.077 312.07 .................. 62.41
46040 ....... Incision of rectal abscess .................................. ......... T 0149 22.2682 1,368.78 293.06 273.76
46045 ....... Incision of rectal abscess .................................. CH .. T 0149 22.2682 1,368.78 293.06 273.76
46050 ....... Incision of anal abscess .................................... ......... T 0148 5.077 312.07 .................. 62.41
46060 ....... Incision of rectal abscess .................................. CH .. T 0149 22.2682 1,368.78 293.06 273.76
46070 ....... Incision of anal septum ...................................... ......... T 0155 12.7389 783.03 .................. 156.61
46080 ....... Incision of anal sphincter ................................... ......... T 0149 22.2682 1,368.78 293.06 273.76
46083 ....... Incise external hemorrhoid ................................ CH .. T 0164 2.1393 131.50 .................. 26.30
46200 ....... Removal of anal fissure ..................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
46210 ....... Removal of anal crypt ........................................ ......... T 0149 22.2682 1,368.78 293.06 273.76
46211 ....... Removal of anal crypts ...................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
46220 ....... Removal of anal tag .......................................... ......... T 0149 22.2682 1,368.78 293.06 273.76
46221 ....... Ligation of hemorrhoid(s) ................................... ......... T 0148 5.077 312.07 .................. 62.41
46230 ....... Removal of anal tags ......................................... ......... T 0149 22.2682 1,368.78 293.06 273.76
46250 ....... Hemorrhoidectomy ............................................. CH .. T 0149 22.2682 1,368.78 293.06 273.76
46257 ....... Remove hemorrhoids & fissure ......................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
46258 ....... Remove hemorrhoids & fistula .......................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
46261 ....... Remove hemorrhoids & fissure ......................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
46262 ....... Remove hemorrhoids & fistula .......................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
46270 ....... Removal of anal fistula ...................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
46288 ....... Repair anal fistula .............................................. CH .. T 0149 22.2682 1,368.78 293.06 273.76
46320 ....... Removal of hemorrhoid clot .............................. CH .. T 0155 12.7389 783.03 .................. 156.61
46500 ....... Injection into hemorrhoid(s) ............................... ......... T 0155 12.7389 783.03 .................. 156.61
46505 ....... Chemodenervation anal musc ........................... ......... T 0148 5.077 312.07 .................. 62.41
46600 ....... Diagnostic anoscopy .......................................... ......... X 0340 0.6102 37.51 .................. 7.50
46604 ....... Anoscopy and dilation ....................................... ......... T 0147 8.5477 525.41 .................. 105.08
46606 ....... Anoscopy and biopsy ........................................ ......... T 0146 4.8683 299.24 64.40 59.85
46608 ....... Anoscopy, remove for body ............................... ......... T 0147 8.5477 525.41 .................. 105.08
46610 ....... Anoscopy, remove lesion .................................. ......... T 0428 20.6375 1,268.55 .................. 253.71
46611 ....... Anoscopy ........................................................... ......... T 0147 8.5477 525.41 .................. 105.08
46612 ....... Anoscopy, remove lesions ................................. ......... T 0428 20.6375 1,268.55 .................. 253.71
46614 ....... Anoscopy, control bleeding ............................... ......... T 0146 4.8683 299.24 64.40 59.85
46615 ....... Anoscopy ........................................................... ......... T 0428 20.6375 1,268.55 .................. 253.71
46700 ....... Repair of anal stricture ...................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
46706 ....... Repr of anal fistula w/glue ................................. ......... T 0150 29.6189 1,820.61 437.12 364.12
46750 ....... Repair of anal sphincter .................................... CH .. T 0171 37.8991 2,329.58 716.76 465.92
46753 ....... Reconstruction of anus ...................................... CH .. T 0149 22.2682 1,368.78 293.06 273.76
46754 ....... Removal of suture from anus ............................ ......... T 0149 22.2682 1,368.78 293.06 273.76
46762 ....... Implant artificial sphincter .................................. CH .. T 0171 37.8991 2,329.58 716.76 465.92
National Minimum
46900 ....... Destruction, anal lesion(s) ................................. ......... T 0016 2.6749 164.42 .................. 32.88
46910 ....... Destruction, anal lesion(s) ................................. ......... T 0017 17.4423 1,072.14 227.84 214.43
46916 ....... Cryosurgery, anal lesion(s) ................................ ......... T 0013 1.0918 67.11 .................. 13.42
46917 ....... Laser surgery, anal lesions ............................... ......... T 0695 20.4276 1,255.64 266.59 251.13
46922 ....... Excision of anal lesion(s) ................................... ......... T 0695 20.4276 1,255.64 266.59 251.13
46924 ....... Destruction, anal lesion(s) ................................. ......... T 0695 20.4276 1,255.64 266.59 251.13
46934 ....... Destruction of hemorrhoids ............................... ......... T 0155 12.7389 783.03 .................. 156.61
46935 ....... Destruction of hemorrhoids ............................... ......... T 0155 12.7389 783.03 .................. 156.61
46936 ....... Destruction of hemorrhoids ............................... ......... T 0149 22.2682 1,368.78 293.06 273.76
46937 ....... Cryotherapy of rectal lesion ............................... ......... T 0149 22.2682 1,368.78 293.06 273.76
46938 ....... Cryotherapy of rectal lesion ............................... ......... T 0150 29.6189 1,820.61 437.12 364.12
46940 ....... Treatment of anal fissure ................................... ......... T 0149 22.2682 1,368.78 293.06 273.76
46942 ....... Treatment of anal fissure ................................... ......... T 0148 5.077 312.07 .................. 62.41
46945 ....... Ligation of hemorrhoids ..................................... ......... T 0155 12.7389 783.03 .................. 156.61
46946 ....... Ligation of hemorrhoids ..................................... ......... T 0155 12.7389 783.03 .................. 156.61
46947 ....... Hemorrhoidopexy by stapling ............................ ......... T 0150 29.6189 1,820.61 437.12 364.12
46999 ....... Anus surgery procedure .................................... ......... T 0148 5.077 312.07 .................. 62.41
47000 ....... Needle biopsy of liver ........................................ ......... T 0685 6.1384 377.32 115.47 75.46
47001 ....... Needle biopsy, liver add-on ............................... ......... N .................. .................. .................. .................. ..................
47011 ....... Percut drain, liver lesion .................................... ......... T 0037 10.2655 631.00 228.76 126.20
47370 ....... Laparo ablate liver tumor rf ............................... ......... T 0132 70.5066 4,333.90 1,239.22 866.78
47371 ....... Laparo ablate liver cryosurg .............................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
47379 ....... Laparoscope procedure, liver ............................ ......... T 0130 32.1241 1,974.60 659.53 394.92
47382 ....... Percut ablate liver rf .......................................... ......... T 0423 37.3604 2,296.47 .................. 459.29
47399 ....... Liver surgery procedure ..................................... CH .. T 0004 2.0687 127.16 .................. 25.43
47490 ....... Incision of gallbladder ........................................ ......... T 0152 20.2682 1,245.85 .................. 249.17
47500 ....... Injection for liver x-rays ..................................... ......... N .................. .................. .................. .................. ..................
47505 ....... Injection for liver x-rays ..................................... ......... N .................. .................. .................. .................. ..................
47510 ....... Insert catheter, bile duct .................................... ......... T 0152 20.2682 1,245.85 .................. 249.17
47511 ....... Insert bile duct drain .......................................... ......... T 0152 20.2682 1,245.85 .................. 249.17
47525 ....... Change bile duct catheter ................................. ......... T 0427 11.6575 716.56 .................. 143.31
47530 ....... Revise/reinsert bile tube .................................... ......... T 0427 11.6575 716.56 .................. 143.31
47552 ....... Biliary endoscopy thru skin ................................ ......... T 0152 20.2682 1,245.85 .................. 249.17
47560 ....... Laparoscopy w/cholangio .................................. ......... T 0130 32.1241 1,974.60 659.53 394.92
47561 ....... Laparo w/cholangio/biopsy ................................ ......... T 0130 32.1241 1,974.60 659.53 394.92
47562 ....... Laparoscopic cholecystectomy .......................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
47563 ....... Laparo cholecystectomy/graph .......................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
47564 ....... Laparo cholecystectomy/explr ........................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
47579 ....... Laparoscope proc, biliary .................................. ......... T 0130 32.1241 1,974.60 659.53 394.92
47630 ....... Remove bile duct stone ..................................... ......... T 0152 20.2682 1,245.85 .................. 249.17
47716 ....... Fusion of bile duct cyst ...................................... CH .. D .................. .................. .................. .................. ..................
47719 ....... Fusion of bile duct cyst ...................................... NI .... C .................. .................. .................. .................. ..................
47999 ....... Bile tract surgery procedure .............................. ......... T 0152 20.2682 1,245.85 .................. 249.17
48005 ....... Resect/debride pancreas ................................... CH .. D .................. .................. .................. .................. ..................
48102 ....... Needle biopsy, pancreas ................................... ......... T 0685 6.1384 377.32 115.47 75.46
48105 ....... Resect/debride pancreas ................................... NI .... C .................. .................. .................. .................. ..................
48180 ....... Fuse pancreas and bowel ................................. CH .. D .................. .................. .................. .................. ..................
48511 ....... Drain pancreatic pseudocyst ............................. ......... T 0037 10.2655 631.00 228.76 126.20
48548 ....... Fuse pancreas and bowel ................................. NI .... C .................. .................. .................. .................. ..................
48999 ....... Pancreas surgery procedure ............................. ......... T 0004 2.0687 127.16 .................. 25.43
49021 ....... Drain abdominal abscess .................................. ......... T 0037 10.2655 631.00 228.76 126.20
49041 ....... Drain, percut, abdom abscess ........................... ......... T 0037 10.2655 631.00 228.76 126.20
49061 ....... Drain, percut, retroper absc ............................... ......... T 0037 10.2655 631.00 228.76 126.20
49080 ....... Puncture, peritoneal cavity ................................ ......... T 0070 3.6244 222.78 .................. 44.56
49081 ....... Removal of abdominal fluid ............................... ......... T 0070 3.6244 222.78 .................. 44.56
49085 ....... Remove abdomen foreign body ........................ CH .. D .................. .................. .................. .................. ..................
49180 ....... Biopsy, abdominal mass .................................... ......... T 0685 6.1384 377.32 115.47 75.46
49200 ....... Removal of abdominal lesion ............................ ......... T 0130 32.1241 1,974.60 659.53 394.92
49250 ....... Excision of umbilicus ......................................... ......... T 0153 22.0832 1,357.41 397.95 271.48
49320 ....... Diag laparo separate proc ................................. ......... T 0130 32.1241 1,974.60 659.53 394.92
49321 ....... Laparoscopy, biopsy .......................................... ......... T 0130 32.1241 1,974.60 659.53 394.92
49322 ....... Laparoscopy, aspiration ..................................... ......... T 0130 32.1241 1,974.60 659.53 394.92
49323 ....... Laparo drain lymphocele ................................... ......... T 0130 32.1241 1,974.60 659.53 394.92
49324 ....... Lap insertion perm ip cath ................................. NI .... T 0130 32.1241 1,974.60 659.53 394.92
49325 ....... Lap revision perm ip cath .................................. NI .... T 0130 32.1241 1,974.60 659.53 394.92
49326 ....... Lap w/omentopexy add-on ................................ NI .... T 0130 32.1241 1,974.60 659.53 394.92
National Minimum
49329 ....... Laparo proc, abdm/per/oment ........................... ......... T 0130 32.1241 1,974.60 659.53 394.92
49400 ....... Air injection into abdomen ................................. ......... N .................. .................. .................. .................. ..................
49402 ....... Remove foreign body, adbomen ....................... NI .... T 0153 22.0832 1,357.41 397.95 271.48
49419 ....... Insrt abdom cath for chemotx ............................ ......... T 0115 29.2133 1,795.68 374.81 359.14
49420 ....... Insert abdom drain, temp .................................. ......... T 0652 29.5416 1,815.86 .................. 363.17
49421 ....... Insert abdom drain, perm .................................. ......... T 0652 29.5416 1,815.86 .................. 363.17
49422 ....... Remove perm cannula/catheter ........................ ......... T 0105 25.6142 1,574.45 370.40 314.89
49423 ....... Exchange drainage catheter .............................. ......... T 0427 11.6575 716.56 .................. 143.31
49424 ....... Assess cyst, contrast inject ............................... ......... N .................. .................. .................. .................. ..................
49426 ....... Revise abdomen-venous shunt ......................... ......... T 0153 22.0832 1,357.41 397.95 271.48
49427 ....... Injection, abdominal shunt ................................. ......... N .................. .................. .................. .................. ..................
49429 ....... Removal of shunt ............................................... ......... T 0105 25.6142 1,574.45 370.40 314.89
49435 ....... Insert subq exten to ip cath ............................... NI .... T 0427 11.6575 716.56 .................. 143.31
49436 ....... Embedded ip cath exit-site ................................ NI .... T 0427 11.6575 716.56 .................. 143.31
49491 ....... Rpr hern preemie reduc .................................... ......... T 0154 29.2182 1,795.98 464.85 359.20
49492 ....... Rpr ing hern premie, blocked ............................ ......... T 0154 29.2182 1,795.98 464.85 359.20
49495 ....... Rpr ing hernia baby, reduc ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20
49496 ....... Rpr ing hernia baby, blocked ............................ ......... T 0154 29.2182 1,795.98 464.85 359.20
49500 ....... Rpr ing hernia, init, reduce ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20
49501 ....... Rpr ing hernia, init blocked ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20
49505 ....... Prp i/hern init reduc >5 yr .................................. ......... T 0154 29.2182 1,795.98 464.85 359.20
49507 ....... Prp i/hern init block >5 yr .................................. ......... T 0154 29.2182 1,795.98 464.85 359.20
49520 ....... Rerepair ing hernia, reduce ............................... ......... T 0154 29.2182 1,795.98 464.85 359.20
49521 ....... Rerepair ing hernia, blocked ............................. ......... T 0154 29.2182 1,795.98 464.85 359.20
49525 ....... Repair ing hernia, sliding ................................... ......... T 0154 29.2182 1,795.98 464.85 359.20
49540 ....... Repair lumbar hernia ......................................... ......... T 0154 29.2182 1,795.98 464.85 359.20
49550 ....... Rpr rem hernia, init, reduce ............................... ......... T 0154 29.2182 1,795.98 464.85 359.20
49553 ....... Rpr fem hernia, init blocked .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20
49555 ....... Rerepair fem hernia, reduce .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20
49557 ....... Rerepair fem hernia, blocked ............................ ......... T 0154 29.2182 1,795.98 464.85 359.20
49560 ....... Rpr ventral hern init, reduc ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20
49561 ....... Rpr ventral hern init, block ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20
49565 ....... Rerepair ventrl hern, reduce .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20
49566 ....... Rerepair ventrl hern, block ................................ ......... T 0154 29.2182 1,795.98 464.85 359.20
49568 ....... Hernia repair w/mesh ........................................ ......... T 0154 29.2182 1,795.98 464.85 359.20
49570 ....... Rpr epigastric hern, reduce ............................... ......... T 0154 29.2182 1,795.98 464.85 359.20
49572 ....... Rpr epigastric hern, blocked .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20
49580 ....... Rpr umbil hern, reduc < 5 yr ............................. ......... T 0154 29.2182 1,795.98 464.85 359.20
49582 ....... Rpr umbil hern, block < 5 yr .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20
49585 ....... Rpr umbil hern, reduc > 5 yr ............................. ......... T 0154 29.2182 1,795.98 464.85 359.20
49587 ....... Rpr umbil hern, block > 5 yr .............................. ......... T 0154 29.2182 1,795.98 464.85 359.20
49590 ....... Repair spigelian hernia ...................................... ......... T 0154 29.2182 1,795.98 464.85 359.20
49600 ....... Repair umbilical lesion ....................................... ......... T 0154 29.2182 1,795.98 464.85 359.20
49650 ....... Laparo hernia repair initial ................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
49651 ....... Laparo hernia repair recur ................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
49659 ....... Laparo proc, hernia repair ................................. ......... T 0130 32.1241 1,974.60 659.53 394.92
49999 ....... Abdomen surgery procedure ............................. ......... T 0153 22.0832 1,357.41 397.95 271.48
50020 ....... Renal abscess, open drain ................................ ......... T 0162 23.87 1,467.24 .................. 293.45
50021 ....... Renal abscess, percut drain .............................. ......... T 0037 10.2655 631.00 228.76 126.20
50080 ....... Removal of kidney stone ................................... ......... T 0429 43.1004 2,649.30 .................. 529.86
50081 ....... Removal of kidney stone ................................... ......... T 0429 43.1004 2,649.30 .................. 529.86
50200 ....... Biopsy of kidney ................................................ ......... T 0685 6.1384 377.32 115.47 75.46
50382 ....... Change ureter stent, percut ............................... ......... T 0161 19.2251 1,181.73 249.36 236.35
50384 ....... Remove ureter stent, percut .............................. ......... T 0161 19.2251 1,181.73 249.36 236.35
50387 ....... Change ext/int ureter stent ................................ ......... T 0122 7.48 459.78 .................. 91.96
50389 ....... Remove renal tube w/fluoro .............................. ......... T 0156 3.4079 209.48 .................. 41.90
50390 ....... Drainage of kidney lesion .................................. ......... T 0685 6.1384 377.32 115.47 75.46
50391 ....... Instll rx agnt into rnal tub ................................... CH .. T 0126 1.0887 66.92 16.45 13.38
50392 ....... Insert kidney drain ............................................. ......... T 0161 19.2251 1,181.73 249.36 236.35
50393 ....... Insert ureteral tube ............................................ ......... T 0161 19.2251 1,181.73 249.36 236.35
50394 ....... Injection for kidney x-ray ................................... ......... N .................. .................. .................. .................. ..................
50395 ....... Create passage to kidney .................................. ......... T 0161 19.2251 1,181.73 249.36 236.35
50396 ....... Measure kidney pressure .................................. ......... T 0164 2.1393 131.50 .................. 26.30
50398 ....... Change kidney tube ........................................... ......... T 0122 7.48 459.78 .................. 91.96
50541 ....... Laparo ablate renal cyst .................................... ......... T 0130 32.1241 1,974.60 659.53 394.92
50542 ....... Laparo ablate renal mass .................................. ......... T 0132 70.5066 4,333.90 1,239.22 866.78
50543 ....... Laparo partial nephrectomy ............................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
50544 ....... Laparoscopy, pyeloplasty .................................. ......... T 0130 32.1241 1,974.60 659.53 394.92
50549 ....... Laparoscope proc, renal .................................... ......... T 0130 32.1241 1,974.60 659.53 394.92
50551 ....... Kidney endoscopy ............................................. ......... T 0160 6.4951 399.24 101.58 79.85
National Minimum
50553 ....... Kidney endoscopy ............................................. ......... T 0161 19.2251 1,181.73 249.36 236.35
50555 ....... Kidney endoscopy & biopsy .............................. ......... T 0160 6.4951 399.24 101.58 79.85
50557 ....... Kidney endoscopy & treatment ......................... ......... T 0162 23.87 1,467.24 .................. 293.45
50561 ....... Kidney endoscopy & treatment ......................... ......... T 0161 19.2251 1,181.73 249.36 236.35
50562 ....... Renal scope w/tumor resect .............................. ......... T 0160 6.4951 399.24 101.58 79.85
50574 ....... Kidney endoscopy & biopsy .............................. ......... T 0160 6.4951 399.24 101.58 79.85
50575 ....... Kidney endoscopy ............................................. ......... T 0163 34.9261 2,146.84 .................. 429.37
50576 ....... Kidney endoscopy & treatment ......................... ......... T 0161 19.2251 1,181.73 249.36 236.35
50590 ....... Fragmenting of kidney stone ............................. ......... T 0169 43.5398 2,676.30 1,009.47 535.26
50592 ....... Perc rf ablate renal tumor .................................. ......... T 0423 37.3604 2,296.47 .................. 459.29
50684 ....... Injection for ureter x-ray .................................... ......... N .................. .................. .................. .................. ..................
50686 ....... Measure ureter pressure ................................... CH .. T 0126 1.0887 66.92 16.45 13.38
50688 ....... Change of ureter tube/stent ............................... ......... T 0122 7.48 459.78 .................. 91.96
50690 ....... Injection for ureter x-ray .................................... ......... N .................. .................. .................. .................. ..................
50945 ....... Laparoscopy ureterolithotomy ........................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
50947 ....... Laparo new ureter/bladder ................................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37
50948 ....... Laparo new ureter/bladder ................................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37
50949 ....... Laparoscope proc, ureter .................................. ......... T 0130 32.1241 1,974.60 659.53 394.92
50951 ....... Endoscopy of ureter .......................................... ......... T 0160 6.4951 399.24 101.58 79.85
50953 ....... Endoscopy of ureter .......................................... ......... T 0160 6.4951 399.24 101.58 79.85
50955 ....... Ureter endoscopy & biopsy ............................... ......... T 0161 19.2251 1,181.73 249.36 236.35
50957 ....... Ureter endoscopy & treatment .......................... ......... T 0161 19.2251 1,181.73 249.36 236.35
50970 ....... Ureter endoscopy .............................................. ......... T 0160 6.4951 399.24 101.58 79.85
50972 ....... Ureter endoscopy & catheter ............................. ......... T 0160 6.4951 399.24 101.58 79.85
50974 ....... Ureter endoscopy & biopsy ............................... ......... T 0161 19.2251 1,181.73 249.36 236.35
51000 ....... Drainage of bladder ........................................... ......... T 0164 2.1393 131.50 .................. 26.30
51005 ....... Drainage of bladder ........................................... CH .. T 0126 1.0887 66.92 16.45 13.38
51010 ....... Drainage of bladder ........................................... ......... T 0165 18.1679 1,116.74 .................. 223.35
51020 ....... Incise & treat bladder ........................................ ......... T 0162 23.87 1,467.24 .................. 293.45
51030 ....... Incise & treat bladder ........................................ ......... T 0162 23.87 1,467.24 .................. 293.45
51040 ....... Incise & drain bladder ........................................ ......... T 0162 23.87 1,467.24 .................. 293.45
51045 ....... Incise bladder/drain ureter ................................. ......... T 0160 6.4951 399.24 101.58 79.85
51050 ....... Removal of bladder stone ................................. ......... T 0162 23.87 1,467.24 .................. 293.45
51065 ....... Remove ureter calculus ..................................... ......... T 0162 23.87 1,467.24 .................. 293.45
51080 ....... Drainage of bladder abscess ............................. ......... T 0008 17.5086 1,076.22 .................. 215.24
51500 ....... Removal of bladder cyst .................................... ......... T 0154 29.2182 1,795.98 464.85 359.20
51520 ....... Removal of bladder lesion ................................. ......... T 0162 23.87 1,467.24 .................. 293.45
51600 ....... Injection for bladder x-ray .................................. ......... N .................. .................. .................. .................. ..................
51605 ....... Preparation for bladder xray .............................. ......... N .................. .................. .................. .................. ..................
51610 ....... Injection for bladder x-ray .................................. ......... N .................. .................. .................. .................. ..................
51700 ....... Irrigation of bladder ............................................ ......... T 0164 2.1393 131.50 .................. 26.30
51701 ....... Insert bladder catheter ....................................... ......... X 0340 0.6102 37.51 .................. 7.50
51702 ....... Insert temp bladder cath .................................... ......... X 0340 0.6102 37.51 .................. 7.50
51703 ....... Insert bladder cath, complex ............................. CH .. T 0126 1.0887 66.92 16.45 13.38
51705 ....... Change of bladder tube ..................................... ......... T 0121 2.3587 144.98 43.80 29.00
51710 ....... Change of bladder tube ..................................... ......... T 0122 7.48 459.78 .................. 91.96
51715 ....... Endoscopic injection/implant ............................. ......... T 0168 29.0253 1,784.13 388.16 356.83
51720 ....... Treatment of bladder lesion ............................... CH .. T 0164 2.1393 131.50 .................. 26.30
51725 ....... Simple cystometrogram ..................................... CH .. T 0164 2.1393 131.50 .................. 26.30
51726 ....... Complex cystometrogram .................................. ......... T 0156 3.4079 209.48 .................. 41.90
51736 ....... Urine flow measurement .................................... CH .. T 0126 1.0887 66.92 16.45 13.38
51741 ....... Electro-uroflowmetry, first .................................. CH .. T 0126 1.0887 66.92 16.45 13.38
51772 ....... Urethra pressure profile ..................................... CH .. T 0164 2.1393 131.50 .................. 26.30
51784 ....... Anal/urinary muscle study ................................. CH .. T 0126 1.0887 66.92 16.45 13.38
51785 ....... Anal/urinary muscle study ................................. CH .. T 0126 1.0887 66.92 16.45 13.38
51792 ....... Urinary reflex study ............................................ CH .. T 0126 1.0887 66.92 16.45 13.38
51795 ....... Urine voiding pressure study ............................. ......... T 0164 2.1393 131.50 .................. 26.30
51797 ....... Intraabdominal pressure test ............................. ......... T 0164 2.1393 131.50 .................. 26.30
51798 ....... Us urine capacity measure ................................ ......... X 0340 0.6102 37.51 .................. 7.50
51880 ....... Repair of bladder opening ................................. ......... T 0162 23.87 1,467.24 .................. 293.45
51990 ....... Laparo urethral suspension ............................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
51992 ....... Laparo sling operation ....................................... CH .. T 0131 43.5488 2,676.86 1,001.89 535.37
51999 ....... Laparoscope proc, bladder ................................ ......... T 0130 32.1241 1,974.60 659.53 394.92
52000 ....... Cystoscopy ........................................................ ......... T 0160 6.4951 399.24 101.58 79.85
52001 ....... Cystoscopy, removal of clots ............................. ......... T 0160 6.4951 399.24 101.58 79.85
National Minimum
52005 ....... Cystoscopy & ureter catheter ............................ ......... T 0161 19.2251 1,181.73 249.36 236.35
52007 ....... Cystoscopy and biopsy ...................................... ......... T 0161 19.2251 1,181.73 249.36 236.35
52010 ....... Cystoscopy & duct catheter ............................... ......... T 0160 6.4951 399.24 101.58 79.85
52204 ....... Cystoscopy w/biopsy(s) ..................................... ......... T 0161 19.2251 1,181.73 249.36 236.35
52214 ....... Cystoscopy and treatment ................................. ......... T 0162 23.87 1,467.24 .................. 293.45
52250 ....... Cystoscopy and radiotracer ............................... ......... T 0162 23.87 1,467.24 .................. 293.45
52260 ....... Cystoscopy and treatment ................................. ......... T 0161 19.2251 1,181.73 249.36 236.35
52265 ....... Cystoscopy and treatment ................................. ......... T 0160 6.4951 399.24 101.58 79.85
52270 ....... Cystoscopy & revise urethra ............................. ......... T 0161 19.2251 1,181.73 249.36 236.35
52275 ....... Cystoscopy & revise urethra ............................. ......... T 0161 19.2251 1,181.73 249.36 236.35
52282 ....... Cystoscopy, implant stent .................................. ......... T 0163 34.9261 2,146.84 .................. 429.37
52310 ....... Cystoscopy and treatment ................................. ......... T 0160 6.4951 399.24 101.58 79.85
52317 ....... Remove bladder stone ...................................... ......... T 0162 23.87 1,467.24 .................. 293.45
52318 ....... Remove bladder stone ...................................... ......... T 0162 23.87 1,467.24 .................. 293.45
52325 ....... Cystoscopy, stone removal ............................... ......... T 0162 23.87 1,467.24 .................. 293.45
52327 ....... Cystoscopy, inject material ................................ ......... T 0162 23.87 1,467.24 .................. 293.45
52334 ....... Create passage to kidney .................................. ......... T 0162 23.87 1,467.24 .................. 293.45
52341 ....... Cysto w/ureter stricture tx .................................. ......... T 0162 23.87 1,467.24 .................. 293.45
52342 ....... Cysto w/up stricture tx ....................................... ......... T 0162 23.87 1,467.24 .................. 293.45
52343 ....... Cysto w/renal stricture tx ................................... ......... T 0162 23.87 1,467.24 .................. 293.45
52344 ....... Cysto/uretero, stricture tx .................................. ......... T 0162 23.87 1,467.24 .................. 293.45
52345 ....... Cysto/uretero w/up stricture ............................... ......... T 0162 23.87 1,467.24 .................. 293.45
52346 ....... Cystouretero w/renal strict ................................. ......... T 0162 23.87 1,467.24 .................. 293.45
52351 ....... Cystouretero & or pyeloscope ........................... ......... T 0161 19.2251 1,181.73 249.36 236.35
52352 ....... Cystouretero w/stone remove ............................ ......... T 0162 23.87 1,467.24 .................. 293.45
52353 ....... Cystouretero w/lithotripsy .................................. ......... T 0163 34.9261 2,146.84 .................. 429.37
52354 ....... Cystouretero w/biopsy ....................................... ......... T 0162 23.87 1,467.24 .................. 293.45
52355 ....... Cystouretero w/excise tumor ............................. ......... T 0162 23.87 1,467.24 .................. 293.45
52400 ....... Cystouretero w/congen repr .............................. ......... T 0162 23.87 1,467.24 .................. 293.45
52402 ....... Cystourethro cut ejacul duct .............................. ......... T 0162 23.87 1,467.24 .................. 293.45
52450 ....... Incision of prostate ............................................ ......... T 0162 23.87 1,467.24 .................. 293.45
52500 ....... Revision of bladder neck ................................... ......... T 0162 23.87 1,467.24 .................. 293.45
52510 ....... Dilation prostatic urethra .................................... ......... T 0161 19.2251 1,181.73 249.36 236.35
52601 ....... Prostatectomy (TURP) ....................................... ......... T 0163 34.9261 2,146.84 .................. 429.37
52606 ....... Control postop bleeding ..................................... ......... T 0162 23.87 1,467.24 .................. 293.45
52612 ....... Prostatectomy, first stage .................................. ......... T 0163 34.9261 2,146.84 .................. 429.37
52614 ....... Prostatectomy, second stage ............................ ......... T 0163 34.9261 2,146.84 .................. 429.37
52620 ....... Remove residual prostate .................................. ......... T 0163 34.9261 2,146.84 .................. 429.37
52630 ....... Remove prostate regrowth ................................ ......... T 0163 34.9261 2,146.84 .................. 429.37
52640 ....... Relieve bladder contracture ............................... ......... T 0162 23.87 1,467.24 .................. 293.45
52647 ....... Laser surgery of prostate .................................. ......... T 0429 43.1004 2,649.30 .................. 529.86
52648 ....... Laser surgery of prostate .................................. ......... T 0429 43.1004 2,649.30 .................. 529.86
52700 ....... Drainage of prostate abscess ............................ ......... T 0162 23.87 1,467.24 .................. 293.45
53000 ....... Incision of urethra .............................................. ......... T 0166 18.396 1,130.77 .................. 226.15
53040 ....... Drainage of urethra abscess ............................. ......... T 0166 18.396 1,130.77 .................. 226.15
53060 ....... Drainage of urethra abscess ............................. ......... T 0166 18.396 1,130.77 .................. 226.15
53080 ....... Drainage of urinary leakage .............................. ......... T 0166 18.396 1,130.77 .................. 226.15
53085 ....... Drainage of urinary leakage .............................. ......... T 0166 18.396 1,130.77 .................. 226.15
53200 ....... Biopsy of urethra ............................................... ......... T 0166 18.396 1,130.77 .................. 226.15
53210 ....... Removal of urethra ............................................ ......... T 0168 29.0253 1,784.13 388.16 356.83
National Minimum
53215 ....... Removal of urethra ............................................ ......... T 0166 18.396 1,130.77 .................. 226.15
53220 ....... Treatment of urethra lesion ............................... ......... T 0168 29.0253 1,784.13 388.16 356.83
53230 ....... Removal of urethra lesion ................................. ......... T 0168 29.0253 1,784.13 388.16 356.83
53235 ....... Removal of urethra lesion ................................. ......... T 0166 18.396 1,130.77 .................. 226.15
53240 ....... Surgery for urethra pouch ................................. ......... T 0168 29.0253 1,784.13 388.16 356.83
53250 ....... Removal of urethra gland .................................. ......... T 0166 18.396 1,130.77 .................. 226.15
53260 ....... Treatment of urethra lesion ............................... ......... T 0166 18.396 1,130.77 .................. 226.15
53265 ....... Treatment of urethra lesion ............................... ......... T 0166 18.396 1,130.77 .................. 226.15
53270 ....... Removal of urethra gland .................................. ......... T 0166 18.396 1,130.77 .................. 226.15
53275 ....... Repair of urethra defect ..................................... ......... T 0166 18.396 1,130.77 .................. 226.15
53400 ....... Revise urethra, stage 1 ..................................... ......... T 0168 29.0253 1,784.13 388.16 356.83
53405 ....... Revise urethra, stage 2 ..................................... ......... T 0168 29.0253 1,784.13 388.16 356.83
53410 ....... Reconstruction of urethra .................................. ......... T 0168 29.0253 1,784.13 388.16 356.83
53420 ....... Reconstruct urethra, stage 1 ............................. ......... T 0168 29.0253 1,784.13 388.16 356.83
53425 ....... Reconstruct urethra, stage 2 ............................. ......... T 0168 29.0253 1,784.13 388.16 356.83
53431 ....... Reconstruct urethra/bladder .............................. ......... T 0168 29.0253 1,784.13 388.16 356.83
53440 ....... Male sling procedure ......................................... ......... S 0385 79.2092 4,868.83 .................. 973.77
53442 ....... Remove/revise male sling ................................. ......... T 0168 29.0253 1,784.13 388.16 356.83
53444 ....... Insert tandem cuff .............................................. ......... S 0385 79.2092 4,868.83 .................. 973.77
53445 ....... Insert uro/ves nck sphincter .............................. ......... S 0386 137.3897 8,445.07 .................. 1,689.01
53446 ....... Remove uro sphincter ....................................... ......... T 0168 29.0253 1,784.13 388.16 356.83
53447 ....... Remove/replace ur sphincter ............................. ......... S 0386 137.3897 8,445.07 .................. 1,689.01
53449 ....... Repair uro sphincter .......................................... ......... T 0168 29.0253 1,784.13 388.16 356.83
53450 ....... Revision of urethra ............................................ ......... T 0168 29.0253 1,784.13 388.16 356.83
53460 ....... Revision of urethra ............................................ ......... T 0166 18.396 1,130.77 .................. 226.15
53500 ....... Urethrlys, transvag w/ scope ............................. ......... T 0168 29.0253 1,784.13 388.16 356.83
53502 ....... Repair of urethra injury ...................................... ......... T 0166 18.396 1,130.77 .................. 226.15
53505 ....... Repair of urethra injury ...................................... ......... T 0168 29.0253 1,784.13 388.16 356.83
53510 ....... Repair of urethra injury ...................................... ......... T 0166 18.396 1,130.77 .................. 226.15
53515 ....... Repair of urethra injury ...................................... ......... T 0168 29.0253 1,784.13 388.16 356.83
53520 ....... Repair of urethra defect ..................................... ......... T 0168 29.0253 1,784.13 388.16 356.83
53600 ....... Dilate urethra stricture ....................................... ......... T 0156 3.4079 209.48 .................. 41.90
53601 ....... Dilate urethra stricture ....................................... CH .. T 0126 1.0887 66.92 16.45 13.38
53605 ....... Dilate urethra stricture ....................................... ......... T 0161 19.2251 1,181.73 249.36 236.35
53620 ....... Dilate urethra stricture ....................................... ......... T 0165 18.1679 1,116.74 .................. 223.35
53621 ....... Dilate urethra stricture ....................................... ......... T 0164 2.1393 131.50 .................. 26.30
53660 ....... Dilation of urethra .............................................. CH .. T 0126 1.0887 66.92 16.45 13.38
53661 ....... Dilation of urethra .............................................. CH .. T 0126 1.0887 66.92 16.45 13.38
53665 ....... Dilation of urethra .............................................. ......... T 0166 18.396 1,130.77 .................. 226.15
53850 ....... Prostatic microwave thermotx ........................... ......... T 0675 41.1375 2,528.64 .................. 505.73
53852 ....... Prostatic rf thermotx .......................................... ......... T 0675 41.1375 2,528.64 .................. 505.73
53853 ....... Prostatic water thermother ................................ ......... T 0162 23.87 1,467.24 .................. 293.45
53899 ....... Urology surgery procedure ................................ CH .. T 0126 1.0887 66.92 16.45 13.38
54000 ....... Slitting of prepuce .............................................. ......... T 0166 18.396 1,130.77 .................. 226.15
54001 ....... Slitting of prepuce .............................................. ......... T 0166 18.396 1,130.77 .................. 226.15
54015 ....... Drain penis lesion .............................................. ......... T 0008 17.5086 1,076.22 .................. 215.24
54050 ....... Destruction, penis lesion(s) ............................... ......... T 0013 1.0918 67.11 .................. 13.42
54055 ....... Destruction, penis lesion(s) ............................... ......... T 0017 17.4423 1,072.14 227.84 214.43
54056 ....... Cryosurgery, penis lesion(s) .............................. ......... T 0012 0.8432 51.83 11.18 10.37
54057 ....... Laser surg, penis lesion(s) ................................ ......... T 0017 17.4423 1,072.14 227.84 214.43
54060 ....... Excision of penis lesion(s) ................................. ......... T 0017 17.4423 1,072.14 227.84 214.43
54065 ....... Destruction, penis lesion(s) ............................... ......... T 0695 20.4276 1,255.64 266.59 251.13
54100 ....... Biopsy of penis .................................................. ......... T 0021 15.1024 928.31 219.48 185.66
54105 ....... Biopsy of penis .................................................. ......... T 0022 20.0656 1,233.39 354.45 246.68
54110 ....... Treatment of penis lesion .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53
54111 ....... Treat penis lesion, graft ..................................... ......... T 0181 32.9873 2,027.66 621.82 405.53
54112 ....... Treat penis lesion, graft ..................................... ......... T 0181 32.9873 2,027.66 621.82 405.53
54115 ....... Treatment of penis lesion .................................. ......... T 0008 17.5086 1,076.22 .................. 215.24
54120 ....... Partial removal of penis ..................................... ......... T 0181 32.9873 2,027.66 621.82 405.53
54150 ....... Circumcision w/regionl block ............................. ......... T 0180 20.5513 1,263.25 304.87 252.65
54152 ....... Circumcision ...................................................... ......... T 0180 20.5513 1,263.25 304.87 252.65
54160 ....... Circumcision, neonate ....................................... ......... T 0180 20.5513 1,263.25 304.87 252.65
54161 ....... Circum 28 days or older .................................... ......... T 0180 20.5513 1,263.25 304.87 252.65
54162 ....... Lysis penil circumic lesion ................................. ......... T 0180 20.5513 1,263.25 304.87 252.65
54163 ....... Repair of circumcision ....................................... ......... T 0180 20.5513 1,263.25 304.87 252.65
54164 ....... Frenulotomy of penis ......................................... ......... T 0180 20.5513 1,263.25 304.87 252.65
54200 ....... Treatment of penis lesion .................................. CH .. T 0164 2.1393 131.50 .................. 26.30
54205 ....... Treatment of penis lesion .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53
54220 ....... Treatment of penis lesion .................................. CH .. T 0164 2.1393 131.50 .................. 26.30
National Minimum
54230 ....... Prepare penis study ........................................... ......... N .................. .................. .................. .................. ..................
54231 ....... Dynamic cavernosometry .................................. ......... T 0165 18.1679 1,116.74 .................. 223.35
54235 ....... Penile injection ................................................... ......... T 0164 2.1393 131.50 .................. 26.30
54240 ....... Penis study ........................................................ CH .. T 0126 1.0887 66.92 16.45 13.38
54250 ....... Penis study ........................................................ ......... T 0164 2.1393 131.50 .................. 26.30
54300 ....... Revision of penis ............................................... ......... T 0181 32.9873 2,027.66 621.82 405.53
54328 ....... Revise penis/urethra .......................................... ......... T 0181 32.9873 2,027.66 621.82 405.53
54340 ....... Secondary urethral surgery ............................... ......... T 0181 32.9873 2,027.66 621.82 405.53
54352 ....... Reconstruct urethra/penis .................................. ......... T 0181 32.9873 2,027.66 621.82 405.53
54360 ....... Penis plastic surgery ......................................... ......... T 0181 32.9873 2,027.66 621.82 405.53
54380 ....... Repair penis ....................................................... ......... T 0181 32.9873 2,027.66 621.82 405.53
54385 ....... Repair penis ....................................................... ......... T 0181 32.9873 2,027.66 621.82 405.53
54400 ....... Insert semi-rigid prosthesis ................................ ......... S 0385 79.2092 4,868.83 .................. 973.77
54401 ....... Insert self-contd prosthesis ................................ ......... S 0386 137.3897 8,445.07 .................. 1,689.01
54405 ....... Insert multi-comp penis pros ............................. ......... S 0386 137.3897 8,445.07 .................. 1,689.01
54406 ....... Remove muti-comp penis pros .......................... ......... T 0181 32.9873 2,027.66 621.82 405.53
54408 ....... Repair multi-comp penis pros ............................ ......... T 0181 32.9873 2,027.66 621.82 405.53
54410 ....... Remove/replace penis prosth ............................ ......... S 0386 137.3897 8,445.07 .................. 1,689.01
54415 ....... Remove self-contd penis pros ........................... ......... T 0181 32.9873 2,027.66 621.82 405.53
54416 ....... Remv/repl penis contain pros ............................ ......... S 0386 137.3897 8,445.07 .................. 1,689.01
54440 ....... Repair of penis .................................................. ......... T 0181 32.9873 2,027.66 621.82 405.53
54450 ....... Preputial stretching ............................................ ......... T 0156 3.4079 209.48 .................. 41.90
54500 ....... Biopsy of testis .................................................. ......... T 0037 10.2655 631.00 228.76 126.20
54505 ....... Biopsy of testis .................................................. ......... T 0183 23.531 1,446.40 .................. 289.28
54512 ....... Excise lesion testis ............................................ ......... T 0183 23.531 1,446.40 .................. 289.28
54520 ....... Removal of testis ............................................... ......... T 0183 23.531 1,446.40 .................. 289.28
54522 ....... Orchiectomy, partial ........................................... ......... T 0183 23.531 1,446.40 .................. 289.28
54530 ....... Removal of testis ............................................... ......... T 0154 29.2182 1,795.98 464.85 359.20
54550 ....... Exploration for testis .......................................... ......... T 0154 29.2182 1,795.98 464.85 359.20
54560 ....... Exploration for testis .......................................... ......... T 0183 23.531 1,446.40 .................. 289.28
54600 ....... Reduce testis torsion ......................................... ......... T 0183 23.531 1,446.40 .................. 289.28
54620 ....... Suspension of testis .......................................... ......... T 0183 23.531 1,446.40 .................. 289.28
54640 ....... Suspension of testis .......................................... ......... T 0154 29.2182 1,795.98 464.85 359.20
54660 ....... Revision of testis ............................................... ......... T 0183 23.531 1,446.40 .................. 289.28
54670 ....... Repair testis injury ............................................. ......... T 0183 23.531 1,446.40 .................. 289.28
54680 ....... Relocation of testis(es) ...................................... ......... T 0183 23.531 1,446.40 .................. 289.28
54690 ....... Laparoscopy, orchiectomy ................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
54692 ....... Laparoscopy, orchiopexy ................................... ......... T 0132 70.5066 4,333.90 1,239.22 866.78
54699 ....... Laparoscope proc, testis ................................... ......... T 0130 32.1241 1,974.60 659.53 394.92
54700 ....... Drainage of scrotum .......................................... ......... T 0183 23.531 1,446.40 .................. 289.28
54800 ....... Biopsy of epididymis .......................................... ......... T 0004 2.0687 127.16 .................. 25.43
54820 ....... Exploration of epididymis ................................... CH .. D .................. .................. .................. .................. ..................
54830 ....... Remove epididymis lesion ................................. ......... T 0183 23.531 1,446.40 .................. 289.28
54840 ....... Remove epididymis lesion ................................. ......... T 0183 23.531 1,446.40 .................. 289.28
54860 ....... Removal of epididymis ...................................... ......... T 0183 23.531 1,446.40 .................. 289.28
54861 ....... Removal of epididymis ...................................... ......... T 0183 23.531 1,446.40 .................. 289.28
54865 ....... Explore epididymis ............................................. NI .... T 0183 23.531 1,446.40 .................. 289.28
54900 ....... Fusion of spermatic ducts ................................. ......... T 0183 23.531 1,446.40 .................. 289.28
54901 ....... Fusion of spermatic ducts ................................. ......... T 0183 23.531 1,446.40 .................. 289.28
55000 ....... Drainage of hydrocele ....................................... ......... T 0004 2.0687 127.16 .................. 25.43
55040 ....... Removal of hydrocele ........................................ ......... T 0154 29.2182 1,795.98 464.85 359.20
55041 ....... Removal of hydroceles ...................................... ......... T 0154 29.2182 1,795.98 464.85 359.20
55060 ....... Repair of hydrocele ........................................... ......... T 0183 23.531 1,446.40 .................. 289.28
55100 ....... Drainage of scrotum abscess ............................ CH .. T 0007 11.1535 685.58 .................. 137.12
55110 ....... Explore scrotum ................................................. ......... T 0183 23.531 1,446.40 .................. 289.28
55120 ....... Removal of scrotum lesion ................................ ......... T 0183 23.531 1,446.40 .................. 289.28
55150 ....... Removal of scrotum ........................................... ......... T 0183 23.531 1,446.40 .................. 289.28
55175 ....... Revision of scrotum ........................................... ......... T 0183 23.531 1,446.40 .................. 289.28
National Minimum
55180 ....... Revision of scrotum ........................................... ......... T 0183 23.531 1,446.40 .................. 289.28
55200 ....... Incision of sperm duct ....................................... ......... T 0183 23.531 1,446.40 .................. 289.28
55250 ....... Removal of sperm duct(s) ................................. ......... T 0183 23.531 1,446.40 .................. 289.28
55300 ....... Prepare, sperm duct x-ray ................................. ......... N .................. .................. .................. .................. ..................
55400 ....... Repair of sperm duct ......................................... ......... T 0183 23.531 1,446.40 .................. 289.28
55450 ....... Ligation of sperm duct ....................................... ......... T 0183 23.531 1,446.40 .................. 289.28
55500 ....... Removal of hydrocele ........................................ ......... T 0183 23.531 1,446.40 .................. 289.28
55520 ....... Removal of sperm cord lesion ........................... ......... T 0183 23.531 1,446.40 .................. 289.28
55530 ....... Revise spermatic cord veins ............................. ......... T 0183 23.531 1,446.40 .................. 289.28
55535 ....... Revise spermatic cord veins ............................. ......... T 0154 29.2182 1,795.98 464.85 359.20
55540 ....... Revise hernia & sperm veins ............................ ......... T 0154 29.2182 1,795.98 464.85 359.20
55550 ....... Laparo ligate spermatic vein ............................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
55559 ....... Laparo proc, spermatic cord .............................. ......... T 0130 32.1241 1,974.60 659.53 394.92
55600 ....... Incise sperm duct pouch ................................... ......... T 0183 23.531 1,446.40 .................. 289.28
55680 ....... Remove sperm pouch lesion ............................. ......... T 0183 23.531 1,446.40 .................. 289.28
55700 ....... Biopsy of prostate .............................................. ......... T 0184 5.6262 345.83 96.27 69.17
55705 ....... Biopsy of prostate .............................................. ......... T 0184 5.6262 345.83 96.27 69.17
55859 ....... Percut/needle insert, pros .................................. CH .. D .................. .................. .................. .................. ..................
55860 ....... Surgical exposure, prostate ............................... ......... T 0165 18.1679 1,116.74 .................. 223.35
55870 ....... Electroejaculation ............................................... ......... T 0197 4.0007 245.92 .................. 49.18
55873 ....... Cryoablate prostate ........................................... ......... T 0674 108.7566 6,685.05 .................. 1,337.01
55875 ....... Transperi needle place, pros ............................. NI .... T 0163 34.9261 2,146.84 .................. 429.37
55876 ....... Place rt device/marker, pros .............................. NI .... T 0156 3.4079 209.48 .................. 41.90
55899 ....... Genital surgery procedure ................................. CH .. T 0126 1.0887 66.92 16.45 13.38
56405 ....... I & D of vulva/perineum ..................................... ......... T 0189 2.8966 178.05 .................. 35.61
56420 ....... Drainage of gland abscess ................................ CH .. T 0188 1.29 79.29 .................. 15.86
56440 ....... Surgery for vulva lesion ..................................... ......... T 0194 20.5081 1,260.59 397.84 252.12
56441 ....... Lysis of labial lesion(s) ...................................... ......... T 0193 14.8489 912.73 .................. 182.55
56442 ....... Hymenotomy ...................................................... NI .... T 0193 14.8489 912.73 .................. 182.55
56501 ....... Destroy, vulva lesions, sim ................................ ......... T 0017 17.4423 1,072.14 227.84 214.43
56515 ....... Destroy vulva lesion/s compl ............................. ......... T 0695 20.4276 1,255.64 266.59 251.13
56605 ....... Biopsy of vulva/perineum .................................. ......... T 0019 4.0919 251.52 71.87 50.30
56606 ....... Biopsy of vulva/perineum .................................. ......... T 0019 4.0919 251.52 71.87 50.30
56620 ....... Partial removal of vulva ..................................... ......... T 0195 28.5095 1,752.42 483.80 350.48
56625 ....... Complete removal of vulva ................................ ......... T 0195 28.5095 1,752.42 483.80 350.48
56700 ....... Partial removal of hymen ................................... ......... T 0194 20.5081 1,260.59 397.84 252.12
56720 ....... Incision of hymen ............................................... CH .. D .................. .................. .................. .................. ..................
56740 ....... Remove vagina gland lesion ............................. ......... T 0194 20.5081 1,260.59 397.84 252.12
56800 ....... Repair of vagina ................................................ ......... T 0194 20.5081 1,260.59 397.84 252.12
56805 ....... Repair clitoris ..................................................... ......... T 0193 14.8489 912.73 .................. 182.55
56810 ....... Repair of perineum ............................................ ......... T 0194 20.5081 1,260.59 397.84 252.12
56820 ....... Exam of vulva w/scope ...................................... ......... T 0188 1.29 79.29 .................. 15.86
56821 ....... Exam/biopsy of vulva w/scope .......................... ......... T 0189 2.8966 178.05 .................. 35.61
57000 ....... Exploration of vagina ......................................... ......... T 0193 14.8489 912.73 .................. 182.55
57010 ....... Drainage of pelvic abscess ............................... ......... T 0193 14.8489 912.73 .................. 182.55
57020 ....... Drainage of pelvic fluid ...................................... ......... T 0192 6.6592 409.33 .................. 81.87
57022 ....... I & d vaginal hematoma, pp .............................. ......... T 0007 11.1535 685.58 .................. 137.12
57023 ....... I & d vag hematoma, non-ob ............................. ......... T 0008 17.5086 1,076.22 .................. 215.24
57061 ....... Destroy vag lesions, simple ............................... ......... T 0194 20.5081 1,260.59 397.84 252.12
57065 ....... Destroy vag lesions, complex ............................ ......... T 0194 20.5081 1,260.59 397.84 252.12
57100 ....... Biopsy of vagina ................................................ ......... T 0192 6.6592 409.33 .................. 81.87
57105 ....... Biopsy of vagina ................................................ ......... T 0194 20.5081 1,260.59 397.84 252.12
57106 ....... Remove vagina wall, partial .............................. ......... T 0194 20.5081 1,260.59 397.84 252.12
57107 ....... Remove vagina tissue, part ............................... ......... T 0195 28.5095 1,752.42 483.80 350.48
57109 ....... Vaginectomy partial w/nodes ............................. ......... T 0195 28.5095 1,752.42 483.80 350.48
57120 ....... Closure of vagina ............................................... ......... T 0195 28.5095 1,752.42 483.80 350.48
57130 ....... Remove vagina lesion ....................................... ......... T 0194 20.5081 1,260.59 397.84 252.12
57135 ....... Remove vagina lesion ....................................... ......... T 0194 20.5081 1,260.59 397.84 252.12
57150 ....... Treat vagina infection ........................................ ......... T 0191 0.1468 9.02 2.55 1.80
57155 ....... Insert uteri tandems/ovoids ............................... ......... T 0192 6.6592 409.33 .................. 81.87
57160 ....... Insert pessary/other device ............................... ......... T 0188 1.29 79.29 .................. 15.86
57170 ....... Fitting of diaphragm/cap .................................... ......... T 0191 0.1468 9.02 2.55 1.80
57180 ....... Treat vaginal bleeding ....................................... ......... T 0189 2.8966 178.05 .................. 35.61
57210 ....... Repair vagina/perineum ..................................... ......... T 0194 20.5081 1,260.59 397.84 252.12
57220 ....... Revision of urethra ............................................ ......... T 0202 42.9896 2,642.48 981.50 528.50
57230 ....... Repair of urethral lesion .................................... ......... T 0195 28.5095 1,752.42 483.80 350.48
57240 ....... Repair bladder & vagina .................................... ......... T 0195 28.5095 1,752.42 483.80 350.48
National Minimum
57250 ....... Repair rectum & vagina ..................................... ......... T 0195 28.5095 1,752.42 483.80 350.48
57265 ....... Extensive repair of vagina ................................. ......... T 0202 42.9896 2,642.48 981.50 528.50
57267 ....... Insert mesh/pelvic flr addon .............................. CH .. T 0195 28.5095 1,752.42 483.80 350.48
57268 ....... Repair of bowel bulge ........................................ ......... T 0195 28.5095 1,752.42 483.80 350.48
57282 ....... Colpopexy, extraperitoneal ................................ CH .. T 0202 42.9896 2,642.48 981.50 528.50
57283 ....... Colpopexy, intraperitoneal ................................. CH .. T 0202 42.9896 2,642.48 981.50 528.50
57284 ....... Repair paravaginal defect .................................. ......... T 0202 42.9896 2,642.48 981.50 528.50
57287 ....... Revise/remove sling repair ................................ CH .. T 0195 28.5095 1,752.42 483.80 350.48
57288 ....... Repair bladder defect ........................................ ......... T 0202 42.9896 2,642.48 981.50 528.50
57289 ....... Repair bladder & vagina .................................... ......... T 0195 28.5095 1,752.42 483.80 350.48
57291 ....... Construction of vagina ....................................... ......... T 0195 28.5095 1,752.42 483.80 350.48
57292 ....... Construct vagina with graft ................................ CH .. T 0195 28.5095 1,752.42 483.80 350.48
57295 ....... Change vaginal graft ......................................... ......... T 0194 20.5081 1,260.59 397.84 252.12
57296 ....... Revise vag graft, open abd ............................... NI .... C .................. .................. .................. .................. ..................
57300 ....... Repair rectum-vagina fistula .............................. ......... T 0195 28.5095 1,752.42 483.80 350.48
57310 ....... Repair urethrovaginal lesion .............................. ......... T 0202 42.9896 2,642.48 981.50 528.50
57320 ....... Repair bladder-vagina lesion ............................. ......... T 0195 28.5095 1,752.42 483.80 350.48
57330 ....... Repair bladder-vagina lesion ............................. ......... T 0195 28.5095 1,752.42 483.80 350.48
57335 ....... Repair vagina ..................................................... CH .. T 0195 28.5095 1,752.42 483.80 350.48
57400 ....... Dilation of vagina ............................................... ......... T 0194 20.5081 1,260.59 397.84 252.12
57410 ....... Pelvic examination ............................................. ......... T 0193 14.8489 912.73 .................. 182.55
57415 ....... Remove vaginal foreign body ............................ ......... T 0194 20.5081 1,260.59 397.84 252.12
57420 ....... Exam of vagina w/scope ................................... ......... T 0189 2.8966 178.05 .................. 35.61
57421 ....... Exam/biopsy of vag w/scope ............................. ......... T 0189 2.8966 178.05 .................. 35.61
57425 ....... Laparoscopy, surg, colpopexy ........................... ......... T 0130 32.1241 1,974.60 659.53 394.92
57452 ....... Exam of cervix w/scope ..................................... CH .. T 0188 1.29 79.29 .................. 15.86
57454 ....... Bx/curett of cervix w/scope ................................ ......... T 0189 2.8966 178.05 .................. 35.61
57455 ....... Biopsy of cervix w/scope ................................... ......... T 0189 2.8966 178.05 .................. 35.61
57456 ....... Endocerv curettage w/scope ............................. ......... T 0189 2.8966 178.05 .................. 35.61
57460 ....... Bx of cervix w/scope, leep ................................. ......... T 0193 14.8489 912.73 .................. 182.55
57461 ....... Conz of cervix w/scope, leep ............................ ......... T 0194 20.5081 1,260.59 397.84 252.12
57500 ....... Biopsy of cervix ................................................. CH .. T 0189 2.8966 178.05 .................. 35.61
57505 ....... Endocervical curettage ...................................... ......... T 0189 2.8966 178.05 .................. 35.61
57510 ....... Cauterization of cervix ....................................... ......... T 0193 14.8489 912.73 .................. 182.55
57511 ....... Cryocautery of cervix ......................................... CH .. T 0188 1.29 79.29 .................. 15.86
57513 ....... Laser surgery of cervix ...................................... ......... T 0193 14.8489 912.73 .................. 182.55
57520 ....... Conization of cervix ........................................... ......... T 0194 20.5081 1,260.59 397.84 252.12
57522 ....... Conization of cervix ........................................... ......... T 0195 28.5095 1,752.42 483.80 350.48
57530 ....... Removal of cervix .............................................. ......... T 0195 28.5095 1,752.42 483.80 350.48
57550 ....... Removal of residual cervix ................................ ......... T 0195 28.5095 1,752.42 483.80 350.48
57555 ....... Remove cervix/repair vagina ............................. ......... T 0195 28.5095 1,752.42 483.80 350.48
57556 ....... Remove cervix, repair bowel ............................. ......... T 0202 42.9896 2,642.48 981.50 528.50
57558 ....... D&c of cervical stump ........................................ NI .... T 0196 17.7499 1,091.05 338.23 218.21
57700 ....... Revision of cervix .............................................. ......... T 0194 20.5081 1,260.59 397.84 252.12
57800 ....... Dilation of cervical canal .................................... ......... T 0193 14.8489 912.73 .................. 182.55
57820 ....... D & c of residual cervix ..................................... CH .. D .................. .................. .................. .................. ..................
58100 ....... Biopsy of uterus lining ....................................... ......... T 0188 1.29 79.29 .................. 15.86
58110 ....... Bx done w/colposcopy add-on .......................... ......... T 0188 1.29 79.29 .................. 15.86
58120 ....... Dilation and curettage ........................................ ......... T 0196 17.7499 1,091.05 338.23 218.21
58145 ....... Myomectomy vag method ................................. ......... T 0195 28.5095 1,752.42 483.80 350.48
58260 ....... Vaginal hysterectomy ........................................ CH .. T 0195 28.5095 1,752.42 483.80 350.48
58262 ....... Vag hyst including t/o ........................................ CH .. T 0195 28.5095 1,752.42 483.80 350.48
58263 ....... Vag hyst w/t/o & vag repair ............................... CH .. T 0195 28.5095 1,752.42 483.80 350.48
58270 ....... Vag hyst w/enterocele repair ............................. CH .. T 0195 28.5095 1,752.42 483.80 350.48
58290 ....... Vag hyst complex .............................................. CH .. T 0202 42.9896 2,642.48 981.50 528.50
58291 ....... Vag hyst incl t/o, complex ................................. CH .. T 0202 42.9896 2,642.48 981.50 528.50
58292 ....... Vag hyst t/o & repair, compl .............................. CH .. T 0202 42.9896 2,642.48 981.50 528.50
58294 ....... Vag hyst w/enterocele, compl ........................... CH .. T 0202 42.9896 2,642.48 981.50 528.50
58301 ....... Remove intrauterine device ............................... CH .. T 0188 1.29 79.29 .................. 15.86
58321 ....... Artificial insemination ......................................... ......... T 0197 4.0007 245.92 .................. 49.18
58322 ....... Artificial insemination ......................................... ......... T 0197 4.0007 245.92 .................. 49.18
58323 ....... Sperm washing .................................................. ......... T 0197 4.0007 245.92 .................. 49.18
58340 ....... Catheter for hysterography ................................ ......... N .................. .................. .................. .................. ..................
58345 ....... Reopen fallopian tube ........................................ ......... T 0193 14.8489 912.73 .................. 182.55
58346 ....... Insert heyman uteri capsule .............................. ......... T 0193 14.8489 912.73 .................. 182.55
58350 ....... Reopen fallopian tube ........................................ ......... T 0195 28.5095 1,752.42 483.80 350.48
58353 ....... Endometr ablate, thermal .................................. ......... T 0195 28.5095 1,752.42 483.80 350.48
58356 ....... Endometrial cryoablation ................................... ......... T 0202 42.9896 2,642.48 981.50 528.50
National Minimum
58541 ....... Lsh, uterus 250 g or less ................................... NI .... T 0131 43.5488 2,676.86 1,001.89 535.37
58542 ....... Lsh w/t/o ut 250 g or less .................................. NI .... T 0131 43.5488 2,676.86 1,001.89 535.37
58543 ....... Lsh uterus above 250 g ..................................... NI .... T 0131 43.5488 2,676.86 1,001.89 535.37
58544 ....... Lsh w/t/o uterus above 250 g ............................ NI .... T 0131 43.5488 2,676.86 1,001.89 535.37
58545 ....... Laparoscopic myomectomy ............................... ......... T 0130 32.1241 1,974.60 659.53 394.92
58546 ....... Laparo-myomectomy, complex .......................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
58548 ....... Lap radical hyst ................................................. NI .... C .................. .................. .................. .................. ..................
58550 ....... Laparo-asst vag hysterectomy .......................... ......... T 0132 70.5066 4,333.90 1,239.22 866.78
58552 ....... Laparo-vag hyst incl t/o ..................................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
58553 ....... Laparo-vag hyst, complex ................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
58554 ....... Laparo-vag hyst w/t/o, compl ............................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37
58555 ....... Hysteroscopy, dx, sep proc ............................... ......... T 0190 21.3586 1,312.87 424.28 262.57
58558 ....... Hysteroscopy, biopsy ......................................... ......... T 0190 21.3586 1,312.87 424.28 262.57
58559 ....... Hysteroscopy, lysis ............................................ ......... T 0190 21.3586 1,312.87 424.28 262.57
58560 ....... Hysteroscopy, resect septum ............................ ......... T 0387 34.0155 2,090.86 655.55 418.17
58561 ....... Hysteroscopy, remove myoma .......................... ......... T 0387 34.0155 2,090.86 655.55 418.17
58562 ....... Hysteroscopy, remove fb ................................... ......... T 0190 21.3586 1,312.87 424.28 262.57
58563 ....... Hysteroscopy, ablation ...................................... ......... T 0387 34.0155 2,090.86 655.55 418.17
58565 ....... Hysteroscopy, sterilization ................................. ......... T 0202 42.9896 2,642.48 981.50 528.50
58578 ....... Laparo proc, uterus ........................................... ......... T 0130 32.1241 1,974.60 659.53 394.92
58579 ....... Hysteroscope procedure .................................... ......... T 0190 21.3586 1,312.87 424.28 262.57
58600 ....... Division of fallopian tube ................................... ......... T 0195 28.5095 1,752.42 483.80 350.48
58615 ....... Occlude fallopian tube(s) ................................... ......... T 0194 20.5081 1,260.59 397.84 252.12
58660 ....... Laparoscopy, lysis ............................................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
58661 ....... Laparoscopy, remove adnexa ........................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
58662 ....... Laparoscopy, excise lesions .............................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
58670 ....... Laparoscopy, tubal cautery ............................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
58671 ....... Laparoscopy, tubal block ................................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
58672 ....... Laparoscopy, fimbrioplasty ................................ ......... T 0131 43.5488 2,676.86 1,001.89 535.37
58673 ....... Laparoscopy, salpingostomy ............................. ......... T 0131 43.5488 2,676.86 1,001.89 535.37
58679 ....... Laparo proc, oviduct-ovary ................................ ......... T 0130 32.1241 1,974.60 659.53 394.92
58770 ....... Create new tubal opening ................................. ......... T 0195 28.5095 1,752.42 483.80 350.48
58800 ....... Drainage of ovarian cyst(s) ............................... ......... T 0193 14.8489 912.73 .................. 182.55
58820 ....... Drain ovary abscess, open ................................ ......... T 0195 28.5095 1,752.42 483.80 350.48
58823 ....... Drain pelvic abscess, percut ............................. ......... T 0193 14.8489 912.73 .................. 182.55
58900 ....... Biopsy of ovary(s) .............................................. ......... T 0193 14.8489 912.73 .................. 182.55
58920 ....... Partial removal of ovary(s) ................................ ......... T 0195 28.5095 1,752.42 483.80 350.48
58925 ....... Removal of ovarian cyst(s) ................................ ......... T 0195 28.5095 1,752.42 483.80 350.48
58957 ....... Resect recurrent gyn mal .................................. NI .... C .................. .................. .................. .................. ..................
58958 ....... Resect recur gyn mal w/lym .............................. NI .... C .................. .................. .................. .................. ..................
58970 ....... Retrieval of oocyte ............................................. ......... T 0197 4.0007 245.92 .................. 49.18
58974 ....... Transfer of embryo ............................................ ......... T 0197 4.0007 245.92 .................. 49.18
58976 ....... Transfer of embryo ............................................ ......... T 0197 4.0007 245.92 .................. 49.18
58999 ....... Genital surgery procedure ................................. ......... T 0191 0.1468 9.02 2.55 1.80
59000 ....... Amniocentesis, diagnostic ................................. ......... T 0198 1.4222 87.42 32.19 17.48
59001 ....... Amniocentesis, therapeutic ................................ ......... T 0192 6.6592 409.33 .................. 81.87
59012 ....... Fetal cord puncture,prenatal .............................. ......... T 0198 1.4222 87.42 32.19 17.48
59015 ....... Chorion biopsy ................................................... ......... T 0198 1.4222 87.42 32.19 17.48
59020 ....... Fetal contract stress test ................................... CH .. T 0189 2.8966 178.05 .................. 35.61
59025 ....... Fetal non-stress test .......................................... ......... T 0198 1.4222 87.42 32.19 17.48
59030 ....... Fetal scalp blood sample ................................... ......... T 0198 1.4222 87.42 32.19 17.48
59070 ....... Transabdom amnioinfus w/us ............................ ......... T 0198 1.4222 87.42 32.19 17.48
59072 ....... Umbilical cord occlud w/us ................................ ......... T 0198 1.4222 87.42 32.19 17.48
59074 ....... Fetal fluid drainage w/us ................................... ......... T 0198 1.4222 87.42 32.19 17.48
59076 ....... Fetal shunt placement, w/us .............................. ......... T 0198 1.4222 87.42 32.19 17.48
59100 ....... Remove uterus lesion ........................................ ......... T 0195 28.5095 1,752.42 483.80 350.48
59150 ....... Treat ectopic pregnancy .................................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
59151 ....... Treat ectopic pregnancy .................................... ......... T 0131 43.5488 2,676.86 1,001.89 535.37
59160 ....... D& c after delivery ............................................. ......... T 0196 17.7499 1,091.05 338.23 218.21
59200 ....... Insert cervical dilator .......................................... ......... T 0189 2.8966 178.05 .................. 35.61
59300 ....... Episiotomy or vaginal repair .............................. ......... T 0193 14.8489 912.73 .................. 182.55
59409 ....... Obstetrical care .................................................. ......... T 0194 20.5081 1,260.59 397.84 252.12
59412 ....... Antepartum manipulation ................................... ......... T 0700 2.3864 146.69 .................. 29.34
59414 ....... Deliver placenta ................................................. ......... T 0193 14.8489 912.73 .................. 182.55
59612 ....... Vbac delivery only ............................................. ......... T 0194 20.5081 1,260.59 397.84 252.12
59812 ....... Treatment of miscarriage ................................... ......... T 0201 18.5201 1,138.39 329.65 227.68
59820 ....... Care of miscarriage ........................................... ......... T 0201 18.5201 1,138.39 329.65 227.68
59821 ....... Treatment of miscarriage ................................... ......... T 0201 18.5201 1,138.39 329.65 227.68
59840 ....... Abortion .............................................................. ......... T 0200 16.9328 1,040.83 243.36 208.17
National Minimum
59841 ....... Abortion .............................................................. ......... T 0200 16.9328 1,040.83 243.36 208.17
59866 ....... Abortion (mpr) .................................................... ......... T 0198 1.4222 87.42 32.19 17.48
59870 ....... Evacuate mole of uterus .................................... ......... T 0201 18.5201 1,138.39 329.65 227.68
59871 ....... Remove cerclage suture .................................... ......... T 0194 20.5081 1,260.59 397.84 252.12
59897 ....... Fetal invas px w/us ............................................ ......... T 0198 1.4222 87.42 32.19 17.48
59898 ....... Laparo proc, ob care/deliver .............................. ......... T 0130 32.1241 1,974.60 659.53 394.92
59899 ....... Maternity care procedure ................................... ......... T 0198 1.4222 87.42 32.19 17.48
60000 ....... Drain thyroid/tongue cyst ................................... ......... T 0252 7.5511 464.15 109.16 92.83
60001 ....... Aspirate/inject thyriod cyst ................................. ......... T 0004 2.0687 127.16 .................. 25.43
60100 ....... Biopsy of thyroid ................................................ ......... T 0004 2.0687 127.16 .................. 25.43
60200 ....... Remove thyroid lesion ....................................... ......... T 0114 37.7224 2,318.72 467.95 463.74
60210 ....... Partial thyroid excision ....................................... ......... T 0114 37.7224 2,318.72 467.95 463.74
60212 ....... Partial thyroid excision ....................................... ......... T 0114 37.7224 2,318.72 467.95 463.74
60220 ....... Partial removal of thyroid ................................... ......... T 0114 37.7224 2,318.72 467.95 463.74
60225 ....... Partial removal of thyroid ................................... ......... T 0114 37.7224 2,318.72 467.95 463.74
60240 ....... Removal of thyroid ............................................. ......... T 0114 37.7224 2,318.72 467.95 463.74
60252 ....... Removal of thyroid ............................................. ......... T 0256 38.1991 2,348.02 .................. 469.60
60260 ....... Repeat thyroid surgery ...................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
60280 ....... Remove thyroid duct lesion ............................... ......... T 0114 37.7224 2,318.72 467.95 463.74
60281 ....... Remove thyroid duct lesion ............................... ......... T 0114 37.7224 2,318.72 467.95 463.74
60500 ....... Explore parathyroid glands ................................ ......... T 0256 38.1991 2,348.02 .................. 469.60
60502 ....... Re-explore parathyroids .................................... CH .. T 0256 38.1991 2,348.02 .................. 469.60
60512 ....... Autotransplant parathyroid ................................. ......... T 0022 20.0656 1,233.39 354.45 246.68
60520 ....... Removal of thymus gland .................................. CH .. T 0256 38.1991 2,348.02 .................. 469.60
60659 ....... Laparo proc, endocrine ...................................... ......... T 0130 32.1241 1,974.60 659.53 394.92
60699 ....... Endocrine surgery procedure ............................ ......... T 0114 37.7224 2,318.72 467.95 463.74
61000 ....... Remove cranial cavity fluid ................................ ......... T 0212 2.9907 183.83 65.96 36.77
61001 ....... Remove cranial cavity fluid ................................ ......... T 0212 2.9907 183.83 65.96 36.77
61020 ....... Remove brain cavity fluid .................................. ......... T 0212 2.9907 183.83 65.96 36.77
61026 ....... Injection into brain canal .................................... ......... T 0212 2.9907 183.83 65.96 36.77
61050 ....... Remove brain canal fluid ................................... ......... T 0212 2.9907 183.83 65.96 36.77
61055 ....... Injection into brain canal .................................... ......... T 0212 2.9907 183.83 65.96 36.77
61070 ....... Brain canal shunt procedure ............................. ......... T 0212 2.9907 183.83 65.96 36.77
61215 ....... Insert brain-fluid device ..................................... ......... T 0224 47.0342 2,891.10 .................. 578.22
61330 ....... Decompress eye socket .................................... ......... T 0256 38.1991 2,348.02 .................. 469.60
61334 ....... Explore orbit/remove object ............................... ......... T 0256 38.1991 2,348.02 .................. 469.60
61623 ....... Endovasc tempory vessel occl .......................... ......... T 0081 42.936 2,639.19 .................. 527.84
61626 ....... Transcath occlusion, non-cns ............................ ......... T 0081 42.936 2,639.19 .................. 527.84
61720 ....... Incise skull/brain surgery ................................... CH .. T 0221 33.152 2,037.79 463.62 407.56
61790 ....... Treat trigeminal nerve ........................................ ......... T 0220 17.8499 1,097.20 .................. 219.44
61791 ....... Treat trigeminal tract .......................................... ......... T 0206 5.7253 351.92 75.55 70.38
61795 ....... Brain surgery using computer ........................... ......... S 0302 4.9138 302.04 105.94 60.41
61880 ....... Revise/remove neuroelectrode .......................... ......... T 0687 17.8334 1,096.18 438.47 219.24

Rule: Medicare: Hospital Outpatient Prospective Payment System and 2007 CY Payment Rates

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Friday,

November 24, 2006

42 CFR Parts 410, 416 et al.

access hospitals (CAHs). prefer Microsoft Word.) payment issues.

3. Colorectal Cancer Screening 1. Hold Harmless Transitional Payment Oncology Procedures

A. ASC Background b. Intermediary Functions b. Alternatives Considered for

Regulations 4. Unfunded Mandates delivery of care, the Congress mandated

meetings per year; has a Designated recommendation. For discussions of

TABLE 2.—CY 2007 PACKAGED SERVICES BY REVENUE CODE

250 .................................................. PHARMACY.

TABLE 2.—CY 2007 PACKAGED SERVICES BY REVENUE CODE—Continued

251 .................................................. GENERIC.

TABLE 5.—NEW HCPCS CODES IMPLEMENTED IN APRIL OR JULY 2006

(See the discussion immediately below commenters expected to be

TABLE 6.—CATEGORY III CPT CODES IMPLEMENTED IN JULY 2006

TABLE 7.—APC EXCEPTIONS TO THE 2 TIMES RULE FOR CY 2007

0007 ................... Level II Incision & Drainage.

TABLE 9.—CY 2007 APC ASSIGNMENT FOR MEG

0144T ............................................... CT heart wo dye; qual calc ....................................................................... 0398 $261.66

TABLE 12.—CY 2007 APC ASSIGNMENT FOR MYOCARDIAL PET

Ancillary Codes Packaged ....................................................................... 6,748 $890.56 $10,224.17 $3,240.13 $3,026.62

BILLING CODE 4120–01–C

TABLE 17.—RECONFIGURATION OF APC 0046

21336 ........................................................... Treat nasal septal fracture ................................................................................................ 0063

24579 ........................................................... Treat humerus fracture ...................................................................................................... 0064

TABLE 17.—RECONFIGURATION OF APC 0046—Continued

24666 ........................................................... Treat radius fracture .......................................................................................................... 0064

28476 ........................................................... Treat metatarsal fracture ................................................................................................... 0062

TABLE 17.—RECONFIGURATION OF APC 0046—Continued

28546 ........................................................... Treat foot dislocation ......................................................................................................... 0062

circumstances in which hospitals billed

0039 ................... S Level I Implantation of Neurostimulator .......................................................................................................... 78.85

J7319 .............................................................. C9220 0896 Sodium hyaluronate injection

TABLE 23.—LIST OF DRUGS AND BIOLOGICALS WITH PASS-THROUGH STATUS IN CY 2007

C9232 ............................................................................................... ** 9232 Injection, idursulfase.

J0580 .................................................... Penicillin g benzathine inj ..................................................... K N

do not include packaged drugs and McrPartBDrugAvgSalesPrice/ We received many comments in

C9234 .. Inj, alglucosidase alfa ............................................................................................................................ K 9234

A. Background service, adjusted to cost. The period of

Iodine-125 .................................................................................... $31.33 $36.35 $25.37 $32.63 $36.12

* Based on median from CY 2001 claims.

TABLE 30.—SEPARATELY PAYABLE BRACHYTHERAPY SOURCES FOR CY 2007

TABLE 30.—SEPARATELY PAYABLE BRACHYTHERAPY SOURCES FOR CY 2007—Continued

administration services provided in hospital outpatient departments on or

TABLE 32.—CY 2007 NEWLY RECOGNIZED DRUG ADMINISTRATION CPT CODES*

BILLING CODE 4120–01–C

HCPCS Short descriptor Long descriptor

APC Title APC Median Levels of CPT Codes Assigned to APC

Emergency Department Visits

Critical Care Services

Critical Care .............................................. $478.04 Critical care, first hour.

the acuity level of the patient. In with other low-level clinic

BILLING CODE 4120–01–C

BILLING CODE 4120–01–C

57282 .............................................. Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus).

16035 ............................................... Escharotomy; initial incision ...................................................................... 0016 T

CY 2007 PROPOSED PAYMENT STATUS INDICATORS (CORRECTED)

2. Payment Status Indicators To

Indicator Item/code/service OPPS payment status

3. Payment Status Indicators To

Indicator Item/code/service OPPS payment status

4. Payment Status Indicators To

Indicator Item/code/service OPPS payment status