[Federal Register Volume 60, Number 17 (Thursday, January 26, 1995)]
[Notices]
[Pages 5185-5204]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-1897]



[[Page 5185]]

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration
[BPD-776-FNC]
RIN 0938-AG27


Medicare Program; Additions To and Deletions From the Current 
List of Covered Surgical Procedures for Ambulatory Surgical Centers

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Final notice with comment period.

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

SUMMARY: This final notice with comment period implements section 
1833(i)(1) of the Social Security Act, which requires, in part, that 
the list of covered ambulatory surgical center (ASC) procedures be 
reviewed and updated at least every 2 years.
    This notice announces the specific additions to and deletions from 
the list of surgical procedures for which facility services are covered 
when the procedures are performed in a Medicare-participating ASC, as 
well as the assigned payment groups for each addition. The notice also 
announces a change in our criteria for deleting procedures from the ASC 
list. This notice also responds to public comments received in response 
to our proposed notice published December 14, 1993 (58 FR 65357). In 
that notice, we requested comments on the proposed additions to and 
deletions from the list of covered surgical procedures for ASCs; the 
proposed quantitative change in our deletion criteria; the development 
of alternatives to the proposed quantitative deletion criteria; and the 
assignment of payment groups for each addition.
    Finally, this notice solicits public comment on certain additions 
to and deletions from the ASC list that had not been suggested in our 
December 1993 proposed notice. It also solicits public comment on the 
assignment of payment groups for certain new procedure codes.

EFFECTIVE DATE: The effective date of this notice is February 27, 1995, 
except as follows. The effective date for the procedures that are being 
deleted from the ASC list, as listed in Addendum A, is April 26, 1995.
    The effective date for the procedures that were deleted from the 
list as a result of deletions from the 1992 Physicians' Current 
Procedural Terminology (CPT), as listed in part 1 of Addendum C, is 
March 31, 1992. The effective date for the procedures that were added 
to the list as a result of additions to the 1992 CPT, as listed in part 
2 of Addendum C, is January 30, 1992.
    The effective date for the procedures that were deleted from the 
list as a result of deletions from the 1993 CPT, as listed in part 3 of 
Addendum C, is July 7, 1993. The effective date for the procedures that 
were added to the list as a result of additions to the 1993 CPT, as 
listed in part 4 of Addendum C, is January 1, 1993.
    The effective date for the procedures that were deleted from the 
list as a result of deletions from the 1994 CPT, as listed in part 5 of 
Addendum C, is April 11, 1994. The effective date for the procedures 
that were added to the list as a result of additions to the 1994 CPT, 
as listed in part 6 of Addendum C, is January 1, 1994.

COMMENT DATES: We are requesting public comment on the addition of, and 
assignment of payment groups for, the following new CPT codes, which 
are listed in Addendum B (since these codes were not suggested in our 
December 1993 proposed notice): CPT codes 29804, 43259, 51040, 52450, 
56309, 56316, 56317, 56351, 56356, and 64421. We are requesting public 
comment on the appropriateness of the deletion of the CPT codes listed 
in Addendum C, part 5, and the deletion of CPT code 36522, listed in 
Addendum A, because these codes were not suggested in our December 1993 
proposed notice. Additionally, we are requesting public comment on the 
appropriateness of the addition of, and assignment of payment groups 
for, the CPT codes listed in part 6 of Addendum C. Comments will be 
considered if we receive them at the appropriate address, as provided 
below, no later than 5 p.m. on March 27 1995.

ADDRESSES: Mail written comments (1 original and 3 copies) to the 
following address: Health Care Financing Administration, Department of 
Health and Human Services, Attention: BPD-776-FNC, P.O. Box 26688, 
Baltimore, MD 21207.
    If you prefer, you may deliver your written comments (1 original 
and 3 copies) to one of the following addresses:

Room 309-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., 
Washington, DC 20201, or
Room 132, East High Rise Building, 6325 Security Boulevard, Baltimore, 
MD 21207.

    Because of staffing and resource limitations, we cannot accept 
comments by facsimile (FAX) transmission. In commenting, please refer 
to file code BPD-776-FNC. Comments received timely will be available 
for public inspection as they are received, generally beginning 
approximately 3 weeks after publication of a document, in Room 309-G of 
the Department's offices at 200 Independence Avenue, SW., Washington, 
DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m. 
(phone: (202) 690-7890).
    Copies: To order copies of the Federal Register containing this 
document, send your request to: New Orders, Superintendent of 
Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date 
of the issue requested and enclose a check or money order payable to 
the Superintendent of Documents, or enclose your Visa or Master Card 
number and expiration date. Credit card orders can also be placed by 
calling the order desk at (202) 512-1800 or by faxing to (202) 512-
2250. The cost for each copy is $8. As an alternative, you can view and 
photocopy the Federal Register document at most libraries designated as 
Federal Depository Libraries and at many other public and academic 
libraries throughout the country that receive the Federal Register.

FOR FURTHER INFORMATION CONTACT: Jackie Sheridan, (410) 966-4635 for 
Additions or Deletions. Joan Sanow, (410) 966-5723 for Payment Groups.

SUPPLEMENTARY INFORMATION:

I. Background

    Section 934 of the Omnibus Reconciliation Act of 1980 (Public Law 
96-499), enacted on December 5, 1980, amended sections 1832(a)(2) and 
1833 of the Social Security Act (the Act) to authorize the Secretary to 
provide benefits for services furnished in an ambulatory surgical 
center (ASC). Section 1833(i)(1) of the Act requires the Secretary to 
specify, in consultation with appropriate medical organizations, 
surgical procedures that, although appropriately performed in an 
inpatient hospital setting, can also be performed safely on an 
ambulatory basis. The report accompanying the legislation explained 
that the Congress intended that procedures currently performed on an 
ambulatory basis in a physician's office, which do not generally 
require the more elaborate facilities of an ASC, should not be included 
in the list of covered procedures (H.R. Rep. No. 1167, 96th Congress, 
2d Session 390 (1980), reprinted in 1980 U.S.C.C.A.N. 5526, 5753).
    On August 5, 1982, we published a final rule in the Federal 
Register (47 FR 34094) to establish Medicare coverage for ASC services 
at 42 CFR part 416. These regulations were amended on November 14, 1986 
(51 FR 41351), June 12, 1987 (52 FR 22454), and April 7, 1988 (53 FR 
11508). We implement the [[Page 5186]] provision requiring the 
Secretary to publish a list of procedures covered in an ASC through 
issuance of periodic notices in the Federal Register.
    Section 9343 of the Omnibus Budget Reconciliation Act of 1986 (OBRA 
'86) (Public Law 99-509), enacted on October 21, 1986, amended section 
1833(i)(1) of the Act to require that the ASC list of procedures be 
reviewed and updated by April 21, 1987, and not less often than every 2 
years thereafter. As a result, we published updates in the Federal 
Register on April 21, 1987 (52 FR 13176), June 1, 1989 (54 FR 23540), 
and December 31, 1991 (56 FR 67666). These updates supplement the 
original list of covered ASC procedures published on August 5, 1982 (47 
FR 34099).
    In line with the Congressional intent, current regulations (42 CFR 
416.65(a)) list the following general requirements regarding the range 
of covered ASC services:
     Procedures on the list are commonly performed on an 
inpatient basis but, consistent with accepted medical practice, also 
may be performed in an ASC.
     The list excludes procedures that are commonly performed, 
or may be safely performed, in a physician's office.
     Procedures are limited to those requiring a dedicated 
operating room and generally do not require an overnight stay.
     The list does not contain procedures excluded from 
Medicare coverage.
    In addition, current regulations (Sec. 416.65(b)) list the 
following specific requirements:
     Covered surgical procedures are limited to those that do 
not generally exceed--

  + A total of 90 minutes operating time; and
  + A total of 4 hours recovery or convalescent time.

     If the covered surgical procedures require anesthesia, the 
anesthesia must be--
  + Local or regional anesthesia; or
  + General anesthesia of 90 minutes or less duration.
     Covered surgical procedures may not be of a type that--

  + Generally result in extensive blood loss;
  + Require major or prolonged invasion of body cavities;
  + Directly involve major blood vessels; or
  + Are generally emergency or life-threatening in nature.

    Currently, ASC covered procedures are classified according to an 
eight group payment classification system, as follows:

  Group 1--$295
  Group 2--$395
  Group 3--$453
  Group 4--$558
  Group 5--$637
  Group 6--$750 ($600+$150)
  Group 7--$883
  Group 8--$880 ($730+$150)

(The $150 payment allowance in Groups 6 and 8 is for intraocular lenses 
(IOLs).) A ninth payment group allotted exclusively to extracorporeal 
shock wave lithotripsy (ESWL) services was established in the notice 
with comment period published December 31, 1991 (56 FR 67666). The 
decision in American Lithotripsy Society v. Sullivan, 785 F. Supp. 1034 
(D.D.C. 1992) prohibits us from paying for these services under the ASC 
benefit at this time. ESWL payment rates are the subject of a separate 
Federal Register proposed notice, which was published October 1, 1993 
(58 FR 51355).
    The ASC facility payment for all procedures in each group is 
established at a single rate adjusted for geographic variation. This 
prospectively determined facility group rate does not include 
physicians' fees and other medical items and services (for example, 
prosthetic devices, except IOLs) for which separate payment is 
authorized under other provisions of the Medicare program. Rather, the 
rate is a standard overhead amount that covers the cost of services 
such as nursing, supplies, equipment, and use of the facility.
    Section 9343 of OBRA '86 amended section 1833(i)(2)(A) of the Act 
to require updating of the ASC payment rates annually beginning no 
later than July 1, 1987. In addition, so that the most current wage 
index values can be used in determining payment amounts for ASC 
facility services, annual ASC payment rate updates are implemented 
concurrently with the annual update of the inpatient hospital 
prospective payment system (PPS) wage index published in the Federal 
Register.
    Section 13531 of the Omnibus Budget Reconciliation Act of 1993 
(OBRA '93) (Public Law 103-66), enacted on August 10, 1993, prohibited 
the Secretary from providing for any inflation update in the ASC 
payment rates for fiscal year 1995. In addition, the legislation 
reduced the allowance for an IOL furnished during or subsequent to 
cataract surgery performed in an ASC from $200 to $150 beginning 
January 1, 1994, and before January 1, 1999. As a result, the payment 
rates and the $150 payment allowance for an IOL in Groups 6 and 8 will 
remain the same in fiscal year 1995.
    In our December 1991 notice, we stated that changes in ASC payment 
rates and the list of ASC covered procedures would be implemented 
concurrently during the years in which both are updated (56 FR 67677). 
The ASC payment rates and the ASC procedure list were updated 
concurrently for the first time effective for ASC services furnished 
beginning December 31, 1991. Because of the OBRA '93 freeze on the ASC 
payment rates for fiscal year 1995, the ASC payment rate update notice 
will not be published this year although we will instruct our carriers 
to adopt the fiscal year 1995 hospital inpatient PPS wage index, 
published in the Federal Register on September 1, 1994 (59 FR 45330), 
to adjust payment rates for regional wage differences.

II. Provisions of the Proposed Notice

    In the proposed notice, which was published December 14, 1993 (58 
FR 65357), we proposed specific procedures for addition to or deletion 
from the ASC list. These proposed changes were the result of our 
consideration of data on site of service from the National Claims 
History File (NCHF) and general correspondence received from the public 
and medical community over the few years preceding publication of the 
proposed notice. (The NCHF is a database maintained by our Bureau of 
Data Management and Strategy. The data in the NCHF are derived from 100 
percent of the Medicare Part A and Part B claims processed.) For each 
proposed addition, we proposed a payment group based on payment rates 
for codes on the existing ASC list, and in the same Physicians' Current 
Procedural Terminology (CPT) grouping, that are similar in surgical 
method and resource consumption. (The CPT is published annually by the 
American Medical Association.)
    With the advice of our medical staff, we proposed to add surgical 
procedures that are performed in ASCs and meet certain standards 
contained in existing regulations. We also proposed to modify our 
criteria for deleting procedures from the ASC list. As the practice of 
medicine has changed over the years, procedures that were at one time 
commonly performed on an inpatient basis gradually have shifted to the 
hospital outpatient department (OPD) as the most common site of 
service, and a few eventually have shifted to the physician's office as 
the primary site of service. Procedures that are not performed on an 
inpatient basis or are primarily performed in a physician's 
[[Page 5187]] office no longer meet the conditions specified in 
regulations. This development results in a corresponding change in 
claims data to lower inpatient and higher physician's office site-of-
service performance percentages, and these procedures no longer meet 
our 20/50 site-of-service criteria. By 20/50 site-of-service criteria, 
we mean that if a procedure is performed on an inpatient basis 20 
percent of the time or less, or in a physician's office 50 percent of 
the time or more, it should not be covered when performed in an ASC. We 
may make exceptions and override the criteria if we believe the data 
are inaccurate or if there are medical reasons to override the data.
    If we had strictly applied the 20/50 criteria to our current ASC 
list without making exceptions, we would have been proposing deletion 
of a number of procedures, such as cataract removal, that we believe 
are appropriate to the ASC setting. We were also concerned with what 
might be termed a ``ping-pong'' situation; that is, adding a procedure 
during one update with 49 percent physician's office performance and 
then deleting it during the next update if it reached 51 percent 
physician's office performance. Consequently, we proposed the following 
criteria for deleting a procedure from ASC coverage: The combined 
inpatient, OPD, and ASC site-of-service percentage is less than 46 
percent of the total volume; and either--
     The procedure is performed 50 percent of the time or more 
in a physician's office; or
     The procedure is performed 10 percent of the time or less 
in an inpatient hospital setting.
    This proposed change would allow the site of service for procedures 
in the physician's office to grow from below 50 percent (when it is 
added) to as high as 54 percent, as long as the percentage of time the 
procedure is performed in a facility with a dedicated operating room 
remains at 46 percent. Similarly, the criteria allow procedures to move 
from an inpatient hospital site of service to an OPD site of service 
and still remain on the ASC list. To determine whether a procedure 
should be added to the ASC list, we indicated that we would continue to 
use the 20/50 site-of-service criteria.
    We incorporate annual revisions of the CPT into our list of 
procedures covered in an ASC. Therefore, we also proposed for public 
comment the procedure codes that were added to or deleted from the ASC 
list through changes to the Medicare Carriers Manual as a result of 
updates of the 1992 and 1993 editions of the CPT.
    In addition, we proposed to remove from the ASC list five CPT codes 
that involve procedures relating to the usage of implantable infusion 
pumps not covered by Medicare.

III. Analysis of and Responses to Public Comments

    In our December 1993 proposed notice, we requested comments on the 
proposed quantitative change in our deletion criteria; the development 
of alternatives to the proposed quantitative deletion criteria; 
proposed additions to and deletions from the ASC list; and the 
assignment of payment groups for each addition. In response, we 
received 558 timely public comments from 191 urologists, 107 ASCs, 52 
anesthesiologists, 50 patients, 30 ophthalmologists, 26 psychiatrists, 
28 plastic surgeons, 14 obstetrician/ gynecologists, 8 
gastroenterologists, 6 dermatologists, 19 professional/medical 
societies, and 27 others (that is, neurologists, attorneys, 
radiologists, a Medicare director, a podiatrist, an accountant, 
otolaryngologists, a supplier, and an oncologist). A summary of these 
comments and our responses to them follows:

Criteria for Determining Procedures for Coverage in an ASC

    In our December 1993 proposed notice, we announced our intention to 
apply alternative utilization threshold criteria for deleting 
procedures from ASC coverage. That is, rather than deleting procedures 
that fall below the current coverage threshold, we proposed alternative 
criteria for deleting procedures that examine the incidence of 
dedicated operating room use (combined ASC, OPD, and inpatient site-of-
service utilization) in determining if a procedure that has dropped 
below the 20 percent inpatient criteria should remain covered in an 
ASC. We specifically solicited comments on the alternative criteria. 
However, we did not receive any comments on this issue.
    In addition, we requested comments on developing alternatives to 
the quantitative criteria we currently use in developing the ASC list. 
We received 64 comments regarding our current site-of-service-based 
criteria. The commenters included 35 ASCs, 16 urologists, 4 
anesthesiologists, and 9 professional societies.
    Comment: Several commenters stated that our criteria are outdated, 
reflecting a period when surgery was rarely performed on an outpatient 
basis. They noted an absence of scientific or medical literature 
supporting the thresholds used. Therefore, they believed the criteria 
are arbitrary.
    Response: The inpatient and physician's office utilization 
thresholds serve as a reasonable interpretation of the statutory 
language ``appropriately performed on an inpatient basis.'' That is, we 
believe that if a procedure is performed at least 20 percent of the 
time on an inpatient basis and no more than 50 percent of the time in a 
physician's office, we can reasonably regard the procedure as 
appropriate to the inpatient setting. Section 1833(i)(1) of the Act 
requires the Secretary to ``specify those surgical procedures which are 
appropriately (when considered in terms of the proper utilization of 
hospital inpatient facilities) performed on an inpatient basis in a 
hospital but which also can be performed safely on an ambulatory 
basis'' in an ASC. Thus, section 1833(i)(1) of the Act is clear that 
procedures included on the ASC list of covered procedures must be those 
that are appropriately performed on an inpatient basis.
    In developing regulations that implemented section 1833(i)(1) of 
the Act, we prepared the criteria set forth at 42 CFR 416.65 (``Covered 
surgical procedures''). Those regulations specify conditions for 
coverage of procedures that are commonly performed on an inpatient 
basis but may be safely performed on an outpatient basis. These 
conditions include requirements such as operating room time not 
exceeding 90 minutes, recovery period not exceeding 4 hours, limited 
blood loss, and limited invasion of body cavities. We believe that 
these criteria reasonably meet the conditions set forth in the 
legislation.
    For several years, we used only the qualitative criteria described 
in the regulations. We added procedures to the list based on 
physicians' review of procedures recommended by medical organizations. 
This system resulted in only a limited number of procedures being added 
to the ASC list.
    Patient variability made it difficult for our physicians to 
accurately determine procedures that should be added to the list, 
especially procedures that are close to the cut-off of the qualitative 
criteria; for example, a surgery time of 2 hours or a recovery time of 
4\1/2\ hours. A given procedure varies with patient condition. That is, 
a procedure that may be accomplished in 90 minutes for one patient may 
take 120 minutes for another.
    In developing the 1987 update of the ASC list, we determined that a 
numerical threshold based on site of service should be used to assist 
us in implementing section 1833(i)(1) of the [[Page 5188]] Act. We 
believed criteria based on site of service, as shown in our current 
claims data, would yield a range of procedures for review by our staff 
of physicians to include on the ASC list. In this way, we would have 
support for the addition of procedures physicians generally perform on 
an inpatient basis. Our physicians then review the complete list of 
procedures that meet the threshold criteria and determine which meet 
the qualitative criteria in our regulations.
    We acknowledge that utilization of outpatient surgical settings has 
increased considerably since we first initiated the threshold criteria 
in 1987. For this reason, we proposed altering the criteria for 
deleting procedures from the ASC covered procedures list. We thus 
recognize some movement to the outpatient setting without eliminating 
coverage. However, once a procedure is performed in a physician's 
office the majority of the time and does not require the setting of an 
ASC, OPD, or inpatient hospital 46 percent of the time, we believe that 
section 1833(i)(1) of the Act requires that we delete ASC coverage of 
the procedure.
    When preparing the December 1993 proposed notice, we considered 
policy alternatives and discussed reverting to physician judgment 
exclusively. However, we believe that this option is too subjective, 
leaving policy decisions solely to the discretion of a few. If we were 
challenged by another physician's opinion, we could be presented with 
the situation of two equally qualified professionals with different 
opinions. Thus, we believe that some objective criteria are essential 
in determining coverage of procedures in an ASC.
    Comment: Some commenters believed that the Common Working File 
(CWF) is inadequate for assessing site of service. (The CWF is a 
Medicare Part A and Part B benefit coordination and prepayment claims 
validation system that uses localized databases maintained by 
designated carriers. The CWF indicates site of service for surgical 
procedures.) The commenters believed that the data produced are skewed, 
especially for periods before the last 2 years when site-of-service 
data had been emphasized. They stated that CPT coding practices vary 
greatly, resulting in the same procedure being coded differently in 
different areas.
    Response: We acknowledge that the early data using site-of-service 
codes contained errors. Those data may have skewed results, 
particularly for low-volume procedures or procedures near the threshold 
levels. Consequently, our criteria allow for exceptions if the data 
appear flawed, or our physicians, after consultation with medical 
societies and local experts, believe a procedure is appropriate to the 
inpatient setting despite the data. Under this exceptions authority, we 
have retained procedures such as cataract extractions, which have not 
met the inpatient criterion for several years. In addition, the public 
has an opportunity to comment, through our rulemaking process, on what 
they believe are errors in the data.
    With regard to the issue of varying CPT coding practices, we 
acknowledge that not all physicians code a particular procedure 
identically. Unfortunately, this variation in coding is often the 
result of an attempt to maximize Medicare payment to the physician for 
the procedure, rather than the result of ambiguous coding guidelines. 
While this upcoding occasionally affects the ASC list, we attempt to 
identify these situations and retain the procedure on the ASC list 
through the exceptions authority if the procedure is appropriate to the 
inpatient setting. We ask physicians to encourage their peers to code 
procedures appropriately to avoid these situations.
    Comment: One commenter believed we should use a 10 percent 
inpatient criterion for adding procedures to the list. The commenter 
also suggested that any procedure generally requiring the prior or 
concurrent administration of general, spinal, or regional anesthesia, 
or of sedation or analgesia sufficient to compromise a patient's 
protective reflexes, be included on the ASC list regardless of 
utilization data.
    Response: The type of anesthesia necessary for a given procedure 
varies among patients. Some patients have very low pain thresholds, 
special psychological needs, or anatomical conditions warranting a 
higher level of anesthesia than others. We encourage every physician to 
use his or her judgment in selecting the appropriate anesthesia. We do 
not encourage the use of anesthesia in settings not appropriately 
equipped for emergency situations.
    The need for an operating room setting for a particular patient is 
not equivalent to a procedure meeting the conditions of section 
1833(i)(1) of the Act for ASC coverage. As discussed above, section 
1833(i)(1) requires that we cover procedures in an ASC only if they are 
appropriately performed on an inpatient basis. Thus, if a patient 
requires a higher degree of anesthesia than is reflected in the 
utilization data, that procedure would be covered in an OPD, or, if 
necessary, in an inpatient hospital setting.
    We had considered revising the criterion for adding procedures on 
the ASC list to 10 percent inpatient utilization. However, we believe 
that the current threshold of 20 percent represents a reasonable 
portion of use necessary to meet the statutory requirement of 
appropriately performed on an inpatient basis.
    Comment: One commenter believed that our physician's office 
threshold should focus on the percentage of physicians performing the 
procedure in the office, rather than the percentage of procedures being 
performed in the office.
    Response: We do not believe that the percentage of physicians 
performing a procedure in their offices, rather than the total site-of-
service utilization data, is preferable for determining ASC coverage. 
Many physicians perform a given procedure only once or twice during the 
year. These physicians are not likely to maintain the specialized 
equipment necessary to perform the procedure in their offices, and, 
therefore, are not likely to perform it in that location. Also, a 
particular physician may not be proficient with the procedure and may 
desire to perform the procedure where there are resources available, 
should a mishap occur.
    We do not believe that a large percentage of physicians performing 
a few procedures should serve as the basis for determining whether a 
procedure meets the conditions of section 1833(i)(1) of the Act. It is 
difficult to ignore the data indicating a procedure is commonly 
performed in a physician's office, if only relatively few physicians 
perform the majority of the procedures, in favor of those physicians 
performing the same procedure on an occasional basis. In addition, 
accurately determining the percentage of physicians performing a 
procedure in their offices would be extremely difficult.
    Comment: One commenter believed that the criteria result in a 
competitive advantage to an OPD over an ASC. The commenter recommended 
that if a procedure can be safely performed in an OPD, it can be safely 
performed in an ASC and should be on the list.
    Response: Section 1833(i)(1) of the Act established criteria for 
coverage in an ASC when the ASC services were added as a Medicare 
benefit in 1980. Section 1833(i)(1) of the Act requires that we develop 
a list of procedures covered in an ASC and base the list on procedures 
that are appropriately performed on an inpatient basis.
    These requirements for ASC coverage are not applicable to an OPD. 
The original Medicare statute provided for coverage of all services 
furnished by an [[Page 5189]] OPD, but it did not provide for any 
limitations on the appropriateness of a procedure for the inpatient 
setting or for the establishment of a list of procedures. Consequently, 
it is reasonable to expect that procedures covered in an OPD will not 
always be the same as procedures covered by section 1833(i)(1) of the 
Act. For example, there is no limitation on an OPD to perform only 
surgical procedures. Thus, adopting the suggestion would result in a 
significant expansion of the ASC benefit beyond that contemplated in 
section 1833(i)(1).
    Comment: One commenter believed that operating and recovery time 
usage are inaccurate indicators of the complexity of procedures, and 
clinical criteria should be used instead. The commenter stated that the 
overriding guideline should be that the patient can return home by the 
close of the business day.
    Response: We recognize the commenter's concern that clinical 
criteria be considered in establishing the ASC list. However, we 
believe that general operating and recovery times are related to 
clinical criteria. That is, we do not look at operating and recovery 
room times on an isolated basis, but rather review the clinical 
information indicating that generally patients require 90 minutes or 
less operating time and 4 hours or less recovery time. We believe that 
these criteria are good indicators of a patient's ability to go home by 
the close of the business day. Procedures requiring longer times than 
those included in the criteria are unlikely to be completed within the 
business day. For example, we would expect that patients arrive at 
least 1 hour before the surgery begins. Thus, our criteria involve 6\1/
2\ hours of an 8 hour work day, allowing 1\1/2\ hours leeway for any 
delays.
    Comment: Some commenters believed that the Medicare program should 
allow for overnight stays in an ASC. The commenters stated that, 
initially, the inclusion of overnight stays could be part of a study 
with a Medicare review at the annual certification survey or a review 
by the Peer Review Organization (PRO).
    Response: Section 1833(i)(i) of the Act provides for coverage of 
surgical procedures that, in addition to other criteria, ``can be 
performed safely on an ambulatory basis.'' We believe section 
1833(i)(1) is clear that coverage of overnight stays under the ASC 
benefit is prohibited. Rather, ambulatory care implies care that is 
furnished with the patient going home by the end of the day. Thus, it 
would require a legislative change to extend Medicare ASC benefits to 
overnight care or recovery care.
    Our Office of Research and Demonstrations has the authority to 
waive certain portions of the statute in order to study alternative 
means of furnishing or paying for services under the Medicare program. 
We solicit research proposals annually through a notice published in 
the Federal Register, and projects are selected on a competitive basis. 
ASCs are welcome to submit their research proposals for consideration 
under the routine solicitation process.
    Comment: One commenter suggested that Medicare develop an 
alternative list of procedures that could be covered in an ASC upon 
precertification from the fiscal intermediary or the PRO. Another 
commenter suggested we establish ``severity levels'' that allow 
physician discretion for procedures and settings. The commenter 
believed that, as certain CPT codes are deleted from the list, the 
codes should continue to justify a facility fee if certain ``severity 
levels'' and health risks apply. The same commenter stated that these 
codes can be billed with a modifier or with the accompanying 
International Classification of Diseases, Ninth Revision, Clinical 
Modification (ICD-9-CM) diagnostic codes explaining the patient's 
condition. Yet a third commenter suggested that an ASC site of service 
could be justified by evaluating certain parameters. The commenter 
believed that an outpatient setting, rather than a physician's office, 
would be appropriate if certain conditions, such as intravenous therapy 
or expensive equipment, are involved.
    Response: For a procedure to be covered in an ASC, the procedure 
must meet the conditions set forth in section 1833(i)(1) of the Act. 
That is, procedures covered in an ASC must be appropriately furnished 
on an inpatient basis but also can be performed safely on an ambulatory 
basis.
    There are some patients who, because of medical conditions, may 
require surgery in an ASC-like setting, that is, a dedicated operating 
room with a recovery area and emergency equipment, etc. Although some 
patients may require this setting because of health status, the 
procedure may still not meet the conditions for ASC coverage set forth 
in section 1833(i)(1) of the Act. That is, a procedure that is 
routinely performed in a physician's office is still not appropriate 
for the inpatient setting, although an occasional patient requires 
hospitalization for the procedure. Precertification of the specific 
needs of the patient does not make the procedure inpatient. Rather, it 
means that a particular physician attests that a patient requires a 
more intensive setting for the procedure.
    Moreover, there are no commonly accepted severity levels that we 
could easily accommodate in the development of the list of covered 
procedures for ASCs. Section 1833(i)(1) of the Act does not provide for 
an evaluation of individual patient conditions, such as severity, in 
the development of the ASC list. The list is required to reflect common 
practices. We would not expect physicians to perform procedures in 
offices not adequately equipped for the procedure. These cases should 
be handled in an OPD if the procedure is not on the ASC list.
    Comment:  One commenter stated that we should be aware that our ASC 
list is used by virtually all Medicaid programs in the U.S., as well as 
private insurers.
    Response: The Medicare ASC list is not intended to be a list of all 
procedures performed in an ASC. Rather, it is a list of procedures that 
meet the requirements of section 1833(i)(1) of the Act. When we develop 
our list, we consider section 1833(i)(1) and the appropriateness of a 
given procedure for the Medicare population. For example, our list 
contains no pediatric procedures. Yet these procedures would be 
appropriate for Medicaid patients.
    The Medicare program cannot be responsible for the actions of third 
party payers. Any programs that have decided to adopt our list should 
do so with appropriate modifications, keeping in mind the limitations 
of section 1833(i)(1) of the Act and the requirements of their 
customers.
    Comment:  Another commenter requested that we consider a list of 
approved procedures and minor surgeries that can be safely performed in 
a physician's office. The commenter believed that this list should 
contain no procedures requiring anesthesia or sedation of any kind.
    Response: We do not believe it is appropriate to develop a list of 
procedures that can safely be performed in physicians' offices. 
Physicians' offices vary significantly in equipment and staffing. We 
have not established standards for physicians' offices, nor do we 
survey them. Because there is broad variability in these offices, the 
development of a list is likely to result in the exclusion of 
procedures that are safely performed in some locations and the unfair 
restriction of physicians' practices. We believe that physicians will 
not perform a procedure in their offices unless they maintain 
appropriate facilities, equipment, and staff to perform the procedure 
safely.
[[Page 5190]]

Additions to the List

    The proposed list of additions in our December 1993 proposed notice 
received no negative comments. The few comments we received were 
positive and were written as an introduction to letters opposing our 
proposed deletions.

Additional Suggestions for Coverage

    We received several comments recommending coverage for procedures 
not proposed for addition to the list. Some comments included 
procedures we addressed in the December 1993 proposed notice as having 
been previously considered. The following section, arranged by body 
system, responds to those comments.

Integumentary System

    Comment: Some commenters proposed the addition of the following 
procedures to the list:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
15820.  Blepharoplasty, lower eyelid.                                   
15821.  Blepharoplasty, lower eyelid; with extensive herniated fat pad. 
18522.  Blepharoplasty, upper eyelid.                                   
15823.  Blepharoplasty, upper eyelid; with excessive skin weighting down
         lid.                                                           
------------------------------------------------------------------------

    Response: We proposed to add these procedures to the ASC list in 
1991. Based on our review of the public comments and the advice of our 
medical staff, we decided not to add these procedures to the list 
because they are commonly performed for cosmetic purposes. Section 
1862(a)(10) of the Act prohibits payment for cosmetic surgery or 
expenses incurred in connection with cosmetic surgery. We recognize 
that there are circumstances when surgery on the eyelids is performed 
for noncosmetic reasons; for example, impairment of vision. Often these 
circumstances require a more complex procedure than a simple 
blepharoplasty. For that reason, we include on the ASC list all of the 
blepharoptosis repair codes (CPT codes 67901 through 67908). These 
procedures are performed less commonly for cosmetic purposes than the 
blepharoplasty codes.
    We also reviewed the most recent data regarding site of service and 
noted that the blepharoplasty procedures are performed infrequently on 
an inpatient basis (3 to 5 percent of blepharoplasty procedures are 
performed on an inpatient basis). In light of this and our concern 
about the cosmetic nature of the procedures, we have decided against 
adding CPT codes 15820 through 15823 to the ASC list.
    Comment: Commenters proposed the following procedures for the ASC 
list. All of these procedures involve removal of various size skin 
lesions from different anatomical locations. They are CPT codes 11400 
through 11403, 11420 through 11423, 11440 through 11443 (all of which 
involve excision of benign skin lesions); and CPT codes 11600 through 
11603, 11620 through 11623, and 11640 through 11643 (all of which 
involve excision of malignant skin lesions).
    Response: A review of our billing data indicates that all these 
procedures are performed in the physician's office from 70 percent to 
91 percent of the time, with most of the procedures performed 80 
percent of the time in the physician's office setting. They are 
therefore appropriate to the physician's office and not the ASC.
    Comment: One commenter proposed the following codes for addition to 
the ASC list:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
19200.  Mastectomy, radical, including pectoral muscles, axillary lymph 
         nodes.                                                         
19220.  Mastectomy, radical, including pectoral muscles, axillary and   
         internal mammary lymph nodes (Urban type operation).           
------------------------------------------------------------------------

    Response: These procedures involve axillary node dissection. After 
consultation with physicians in the community, our medical staff 
believe these procedures do not meet the ASC criteria. Surgical time 
frequently exceeds the 90 minutes specified for ASCs in 
Sec. 416.65(b)(1)(i). In addition, since these procedures have 
potential for greater complications, they generally require more 
observation time than the 4 hours specified for inclusion on the ASC 
list in Sec. 416.65(b)(1)(ii). We believe these procedures are 
appropriately performed on an inpatient basis, and our data indicate 
they are both performed 90 percent of the time in the inpatient 
setting. Therefore, we are not adding them to the ASC list.
    Comment: Commenters proposed addition of the following codes:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
19162.  Mastectomy, partial; with axillary lymphadenectomy.             
19240.  Mastectomy, modified radical, including axillary lymph nodes,   
         with or without pectoralis minor muscle, but excluding         
         pectoralis major muscle.                                       
------------------------------------------------------------------------

    Response: Our billing data indicate that CPT code 19162 is 
performed on an inpatient hospital basis 78 percent of the time, and 
CPT code 19240 is performed on an inpatient hospital basis 92 percent 
of the time. In addition, CPT code 19162 requires longer than the 4-
hour recovery time requirement, and CPT code 19240 requires longer than 
the 90-minute operating time requirement for ASC coverage set forth at 
Sec. 416.65(b)(1)(i). Therefore, they fail to meet our criteria for 
coverage in an ASC.

Musculoskeletal System

    Comment: One commenter suggested the addition of the following 
codes to the ASC list:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
22110.  Partial excision of vertebrae (eg, for osteomyelitis); cervical.
22114.  Partial excision of vertebrae (eg, for osteomyelitis); lumbar.  
------------------------------------------------------------------------

    Response: CPT code 22110 is performed 80 percent of the time on an 
inpatient basis; and CPT code 22114, 94 percent. CPT codes 22110 and 
22114 are not appropriate for the ASC setting because the procedures 
require extensive dissection and a recovery time of more than 4 hours.
    Comment: One commenter proposed CPT code 29848 (arthroscopy, wrist 
with release of transverse carpal ligament) for addition to the ASC 
list.
    Response: CPT code 29848 is performed 8 percent of the time on an 
inpatient basis and does not meet our 20 percent inpatient criterion.

Respiratory System

    Comment: One commenter proposed the addition of the following codes 
to the ASC list:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
31231.  Nasal endoscopy, diagnostic, unilateral or bilateral (separate  
         procedure).                                                    
31233.  Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy    
         (via inferior meatus or canine fossa puncture).                
31235.  Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via
         puncture of sphenoidal face or cannulation of osteum).         
------------------------------------------------------------------------

    Response: CPT codes 31233 and 31235 were replacement codes to codes 
previously on the ASC list. They were cross-referred from existing 
codes in the 1994 CPT, and both have been added to the list by our 
manual instructions. (These procedures are listed in Addendum C, part 
6, at the end of this notice.) We are not adding CPT code 31231 to our 
list because it replaced [[Page 5191]] CPT code 31250. This procedure 
was performed 90 percent of the time in the physician's office setting, 
thus failing to meet our criterion for inclusion on the ASC list.

Digestive System

    Comment: Two commenters proposed the following codes for addition 
to the ASC list:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
43030.  Cricopharyngeal myotomy.                                        
43830.  Gastrostomy, temporary (tube, rubber or plastic) (separate      
         procedure).                                                    
------------------------------------------------------------------------

    Response: CPT code 43030 is performed 79 percent of the time on an 
inpatient basis, and CPT 43830 is performed 90 percent of the time on 
an inpatient basis. There is concern about complications with these 
procedures, and both also require a 23-hour observation period before 
discharge. They are therefore not appropriate to the ASC list.
    Comment: Commenters proposed adding the following 19 
gastrointestinal endoscopy codes that were new CPT codes January 1, 
1994: CPT codes 43205, 43216, 43244, 43248, 43250, 43259, 43261, 43458, 
44365, 44376, 44377, 44378, 44394, 44500, 45308, 45309, 45338, 45339, 
and 45384. Some of the codes involved editorial changes of existing CPT 
procedures, and some were new CPT procedures.
    Response: We have added 12 of these 19 gastrointestinal codes to 
the ASC list by our manual instructions. They are CPT codes 43216, 
43248, 43250, 43261, 43458, 43465, 44394, 45308, 45309, 45338, 45339, 
and 45384. These 12 CPT codes with their descriptions are listed in 
Addendum C, part 6, at the end of this notice. We were able to cross-
refer CPT codes deleted from our ASC list (which were identified in 
Appendix B of the 1994 CPT, a summary of additions, deletions, and 
revisions applicable to CPT 1994 codes) to these 12 codes. These codes 
were replacement codes to codes previously on the ASC list. They were 
cross-referred from existing codes in the 1994 CPT and have been added 
to the list by our manual instructions.
    With this notice, we are also adding from Appendix B of the CPT 
another code that meets our criteria, CPT code 43259 (Upper 
gastrointestinal endoscopy including esophagus, stomach, and either the 
duodenum and/or jejunum as appropriate; with endoscopic ultrasound 
examination). We are not, however, adding CPT codes 43205 
(Esophagoscopy, rigid or flexible; with band ligation of esophageal 
varices) and 43244 (Upper gastrointestinal endoscopy including 
esophagus, stomach, and either the duodenum and/or jejunum as 
appropriate; with band ligation of esophageal and/or gastric varices) 
because the treatment of varices risks complications of severe, sudden 
bleeding, which may require an immediate blood transfusion or the 
introduction of a special tube to control the bleeding. These remedies 
would not necessarily be available as quickly in the ASC setting. If 
complications develop, the patient might require air evacuation to the 
hospital setting. Also, the medical community does not fully accept the 
use of band ligation in the treatment of varices because its success 
and comparison to the standard treatment is yet to be completed.
    We are not adding the following CPT codes to the ASC list:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
44376.  Small intestinal endoscopy, enteroscopy beyond second portion of
         duodenum, including ileum; diagnostic, with or without         
         collection of specimen(s) by brushing or washing (separate     
         procedure).                                                    
44378.  Small intestinal endoscopy, enteroscopy beyond second portion of
         duodenum, including ileum; with control of bleeding, any       
         method.                                                        
44500.  Introduction of long gastrointestinal tube (eg, Miller-Abbott)  
         (separate procedure).                                          
------------------------------------------------------------------------

    These procedures require that an endoscopy tube be passed through 
the gastrointestinal system while the patient waits 4 to 6 hours before 
the physician performs the endoscopic study. The patient would need to 
be in the ASC from 6 to 10 hours. We believe that this extended time 
period for the procedure exceeds the spirit, if not the letter, of the 
regulations set forth at Sec. 416.65(b), which establish 5 1/2 hours as 
a maximum procedure/recovery time. In conclusion, our medical 
consultants have determined that CPT codes 43205, 53244, 44376, 44378, 
and 44500 are not appropriate for Medicare patients in the ASC setting.
    Comment: Commenters proposed adding CPT code 45330 (flexible 
sigmoidoscopy) to the ASC list.
    Response: This procedure is performed 73 percent of the time in the 
physician's office and is appropriate to that setting. Therefore, it 
does not meet the criteria for the ASC list and will not be added.

Urinary System

    Comment: One commenter recommended CPT code 51040 (cystostomy tube 
replacement) for addition to the ASC list.
    Response: This procedure meets our criteria and will be added to 
the ASC list (see Addendum B).
    Comment: One commenter proposed CPT code 51715 (injection of 
implant material into the urethra) for addition to the ASC list.
    Response: CPT code 51715 is a new CPT code effective January 1, 
1994. This procedure was previously coded as ``unlisted'' and was not 
covered under any other procedure on the ASC list. Our medical staff 
are knowledgeable of this procedure, and we therefore do not require a 
year of billing data to make a determination. Our medical staff advise 
us that this is a physicians' office procedure, and it is not 
appropriate to add it to the ASC list.
    Comment: One commenter suggested CPT code 51845 (abdomino-vaginal 
vesical neck suspension) for addition to the ASC list.
    Response: CPT code 51845 is performed on an inpatient basis 92 
percent of the time. Generally, there is also a 23-hour observation 
period before discharge. Thus, it exceeds our criterion for the 4-hour 
recovery time in Sec. 416.65(b)(1)(ii). We are, therefore, not adding 
it to the ASC list.
    Comment: Commenters proposed CPT code 52450 (transurethral incision 
of prostate) for addition to the ASC list.
    Response: CPT code 52450 is performed 1 percent of the time in a 
physician's office and 70 percent of the time on an inpatient basis. It 
thus meets our criteria and will be added to the ASC list.
    Comment: Commenters proposed the addition to the ASC list of CPT 
code 52601 (transurethral resection of the prostate (TURP)) when a 
laser is used.
    Response: CPT code 52601 does not specify use of a laser in its 
coding description. Thus, the code represents TURPs done by all 
methods, and it is not possible to identify those performed by laser. 
CPT code 52601 is commonly performed on an inpatient basis with a 94 
percent inpatient hospital site of service. Most cases require over 4 
hours recovery time, and, thus, the procedure does not meet our 
criteria for coverage in an ASC in Sec. 416.65(b)(1)(ii). Should the 
CPT develop a new laser TURP code, we would consider this procedure's 
appropriateness in the ASC.

Male Genital System

    Comment: One commenter suggested the addition of radioactive seed 
implantation to treat prostate cancer.
    Response: There is presently no single surgical procedure code in 
the CPT describing this procedure and [[Page 5192]] consequently no 
billing data to determine site of service. We are uncertain which code 
or codes the commenter is using when performing this procedure, but we 
understand the procedure is often used in conjunction with a radiology 
code. Radiology codes cannot be included in our ASC list because the 
ASC list is restricted to surgical codes in the surgery section of the 
CPT.
    Comment: Commenters proposed the addition of the following codes:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
54400.  Insertion of penile prosthesis; non-inflatable (semi-rigid).    
54401.  Insertion of penile prosthesis; inflatable (self-contained).    
54405.  Insertion of inflatable (multi-component) penile prosthesis,    
         including placement of pump, cylinders, and/or reservoir.      
54407.  Removal, repair, or replacement of inflatable (multi-component) 
         penile prosthesis, including pump and/or reservoir and/or      
         cylinders.                                                     
------------------------------------------------------------------------

    Response: When we previously solicited public comment on penile 
prostheses implant procedures, we received comments unanimously opposed 
to the addition of these codes to the list. Commenters indicated that 
these procedures were inappropriate for the Medicare population in the 
ASC setting. The procedure recovery time exceeds the 4-hour limit, the 
maximum allowed for coverage in an ASC. Surgeons performing these 
procedures reported a recovery time of 24 to 72 hours.
    We have given careful consideration to adding these procedures, 
based on the new comments we received favoring their addition. One 
commenter, who previously had written in strong opposition, stated that 
penile prostheses implants should be added to the list since some 
patients recover in less than 24 hours. Since our regulations indicate 
a 4-hour recovery limit, we have determined that these procedures 
remain inappropriate for the Medicare population in an ASC and should 
not be added to the list.

Laparoscopy/Peritoneoscopy/Hysteroscopy

    Comment: One commenter proposed the following codes for addition to 
the ASC list:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
56308.  Laparoscopy, surgical; with vaginal hysterectomy with or without
         removal of tube(s), with or without removal of ovary(s)        
         (laparoscopic assisted vaginal hysterectomy).                  
56309.  Laparoscopy, surgical; with removal of leiomyomata subserosal   
         (single or multiple).                                          
------------------------------------------------------------------------

    Response: CPT code 56308 is performed on an inpatient basis 91 
percent of the time. This procedures involves cutting a hole in the 
pelvis floor and the severing of major arteries and veins. It also 
requires longer than 4 hours recovery time. We are therefore not adding 
it to the ASC list. CPT code 56309 meets our criteria and will be added 
to the list (see Addendum B).
    Comment: Commenters wrote proposing that the following laparoscopic 
cholecystectomy procedure codes be added to the ASC list (21 commenters 
for CPT code 56340, 18 for CPT code 56341, and 17 for CPT code 56342, 
respectively):

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
56340.  Laparoscopy, surgical; cholecystectomy (any method).            
56341.  Laparoscopy, surgical; cholecystectomy with cholangiography.    
56342.  Laparoscopy, surgical; cholecystectomy with exploration of      
         common duct.                                                   
------------------------------------------------------------------------

    Response: The medical information available indicates laparoscopic 
cholecystectomy usually requires a 23-hour observation period or an 
inpatient stay, and, therefore, exceeds the 4-hour recovery time 
requirement in Sec. 416.65(b)(1)(ii). Therefore, we are not adding it 
to the list.
    Comment: Commenters also proposed the addition of the following 
codes to the ASC list:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
56316.  Laparoscopy, surgical; repair of initial inguinal hernia.       
56317.  Laparoscopy, surgical; repair of recurrent inguinal hernia.     
------------------------------------------------------------------------

    Response: These procedures meet our criteria and will be added to 
the list (see Addendum B).
    Comment: One commenter proposed the following codes for addition to 
the ASC list:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
56351.  Hysteroscopy, surgical; with sampling (biopsy) of endometrium   
         and/or polypectomy, with or without D & C.                     
56356.  Hysteroscopy, surgical; with endometrial ablation (any method). 
------------------------------------------------------------------------

    Response: These procedures meet our criteria and will be added to 
the list (see Addendum B).

Nervous System

    Comment: Commenters proposed that we add to the ASC list the 
following nerve injection codes: CPT codes 62298, 64400, 64402, 64405, 
64408, 64412, 64413, 64418, 64425, 64435, 64440, 64441, 64445, 64450, 
64505, and 64508.
    Response: According to our claims data, most of these procedures 
are performed less than 20 percent of the time on an inpatient basis 
and over 50 percent of the time in a physician's office (most being 
performed over 70 percent of the time in a physician's office). The 
exceptions are CPT codes 62298 and 64425, which meet the physician's 
office criterion but are performed less than 20 percent of the time in 
the inpatient setting, and CPT code 64508, which meets the inpatient 
criterion but is performed over 50 percent of the time in a physician's 
office. Since all these nerve injection codes fail to meet at least one 
of the criteria for addition, we are not adding them to the ASC list.
    Comment: One commenter proposed the addition of CPT code 64421 
(injection of intercostal nerves).
    Response: CPT code 64421 is performed 31 percent of the time in a 
physician's office and 22 percent of the time on an inpatient basis. 
This procedure thus meets our criteria and will be added to the list 
(see Addendum B).
    Comment: Two commenters proposed the addition to the ASC list of 
CPT code 64612, and one commenter proposed CPT code 64613. The 
descriptions of these CPT codes follow:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
64612.  Destruction by neurolytic agent (chemodenervation of muscle     
         endplate); muscles enervated by facial nerve (eg, for          
         blepharospasm, hemifacial spasm).                              
64613.  Destruction by neurolytic agent (chemodenervation of muscle     
         endplate); cervical spinal muscles (eg, for spasmodic          
         torticollis).                                                  
------------------------------------------------------------------------

    Response: CPT code 64612 is performed in the physician's office 84 
percent of the time, and CPT code 64613 [[Page 5193]] is performed in 
the physician's office 74 percent of the time. Thus, the codes fail to 
meet the criteria for our list.

Eye and Ocular Adnexa

    Comment: One commenter proposed the addition of CPT code 65770 
(keratoprosthesis).
    Response: CPT code 65770 is performed 10 percent of the time in a 
physician's office and 62 percent of the time on an inpatient basis. 
This procedure thus meets our criteria and will be added to the list 
(see Addendum B).
    Comment: Several commenters suggested adding CPT code 65772 
(corneal relaxing incision for correction of surgically induced 
astigmatism), and one suggested adding code CPT code 65775 (corneal 
wedge resection for correction of surgically induced astigmatism).
    Response: Neither procedure meets our inpatient criterion. CPT 
codes 65772 is performed 1 percent of the time on an inpatient basis, 
and CPT code 65775 is performed 3 percent of the time on an inpatient 
basis. Therefore, we are not adding them to the ASC list.
    Comment: Commenters proposed the addition of the following CPT 
codes:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
65855.  Trabeculoplasty by laser surgery, one or more sessions (defined 
         treatment series).                                             
66761.  Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (one or
         more sessions).                                                
67145.  Chemodenervation of extraocular muscle.                         
67210.  Destruction of localized lesion of retina (eg, maculopathy,     
         choroidopathy, small tumors), one or more sessions;            
         photocoagulation (laser or xenon arc).                         
67228.  Destruction of extensive or progressive retinopathy (eg,        
         diabetic retinopathy), one or more sessions; photocoagulation  
         (laser or xenon arc).                                          
------------------------------------------------------------------------

    Commenters stated that these codes are already performed from 25 
percent to 40 percent of the time in the OPD, and their failure to meet 
the 20 percent inpatient criterion should not preclude their addition 
to the ASC list.
    Response: A review of our most recent billing data indicates that 
none of these procedures is performed 40 percent of the time in the 
OPD; rather, they are performed from 14 percent to 30 percent of the 
time in the OPD. However, each of these procedures is performed from 58 
percent to 79 percent of the time in a physician's office. Since these 
procedures not only fail to meet the 20 percent inpatient criterion but 
also the 50 percent physician's office criterion, they will not be 
added to the ASC list.
    Comment: One commenter proposed the following CPT codes for 
addition to the list:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
65125.  Modification of ocular implant (eg, drilling receptacle for     
         prosthesis appendage) (separate procedure).                    
65860.  Severing adhesions of anterior segment, laser technique         
         (separate procedure).                                          
66172.  Fistulization of sclera for glaucoma; trabeculectomy ab externo 
         with scarring from previous ocular surgery or trauma (includes 
         injection of antifibrotic agents).                             
66825.  Repositioning of intraocular lens prosthesis, requiring an      
         incision (separate procedure).                                 
------------------------------------------------------------------------

    Response: CPT codes 65125 and 66825 do not meet the inpatient 
criterion. CPT code 65125 is performed 5 percent of the time on an 
inpatient basis, and CPT code 66825 is performed 7 percent of the time 
on an inpatient basis. CPT code 65860 is performed in a physician's 
office 65 percent of the time. CPT code 66172 is a new code added in 
1994 and is not cross-referred to a procedure currently covered in an 
ASC. We generally need a year of billing data before we can make a 
decision as to the appropriate setting for performance. Therefore, none 
of these codes will be added to the ASC list.
    Comment: One commenter proposed the addition of CPT code 66820 
(discission of secondary membraneous cataract, stab incision).
    Response: CPT code 66820 is performed 5 percent of the time on an 
inpatient basis and 53 percent of the time in a physician's office and, 
thus, fails to meet our criteria and will not be added to the list.
    Comment: Commenters proposed the addition of the following codes:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
67345.  Chemodenervation of extraocular muscle.                         
67900.  Repair of brow ptosis (supraciliary, mid-forehead or coronal    
         approach).                                                     
68115.  Excision of lesion, conjunctiva; over 1 cm.                     
------------------------------------------------------------------------

    Response: CPT code 67345 is a physician's office procedure, 
performed 85 percent of the time in that setting. CPT codes 67900 and 
68115 fail to meet our inpatient criterion with only 3 percent each 
inpatient performance. Therefore, these codes will not be added to the 
ASC list.

Auditory System

    Comment: Commenters proposed the addition of CPT code 69433 
(tympanostomy).
    Response: This procedure is performed 91 percent of the time in a 
physician's office. Therefore, it fails to meet the criteria for 
inclusion on the ASC list.

Other Procedures

    Comment: One commenter proposed the use of hyperbaric medical 
treatment in an ASC with payment for an appropriate technical 
component. The commenter stated that the routine care of wounds in 
conjunction with the use of hyperbaric treatments is included under CPT 
code 99183, but this code does not include coverage of technical costs 
in an ASC.
    Response: The Medicare list of surgical procedures covered in an 
ASC includes only surgical procedures listed in the surgical section of 
the CPT. Hyperbaric medical treatment is not surgery and is listed in 
the CPT under miscellaneous, special services. Thus, we cannot add it 
to the ASC list.

Proposed Deletions

Integumentary System

    Comment: We proposed to delete nine skin lesion excision codes: CPT 
codes 11042, 11424, 11604, 13101, 13121, 13132, 13152, 14040, and 
14041. All nine codes received comments opposing their deletion. 
Commenters stated that these procedures may sometimes involve 
complications and compromise safety in the physician's office.
    Response: The physician's office site of performance for these 
procedures ranges from 53 percent to 71 percent. However, each of these 
CPT procedure codes involves a range of lesion sizes and anatomical 
sites. For example, CPT code 11424, representing a 3.1 to 4.0 cm. 
lesion, includes scalp, neck, hands, feet, and genitalia. While a 4 cm. 
foot or hand lesion may be excised in the physician's office, a 4 cm. 
lesion on the genitalia requires a higher surgical setting. Larger size 
lesions, especially if malignant, require the sterile environment of an 
operating room, extensive anesthesia, and the monitoring of patient 
cardiovascular parameters and vital signs. Our medical staff thus 
believe the commenters are correct that our site-of-service data for 
these codes are deceptive.
    As we have stated earlier in this notice and in previous notices, 
we may occasionally make an exception to our general criteria, if, 
based on the advice of our medical staff, we believe that the site-of-
service data are deceptive. We [[Page 5194]] are making an exception to 
the criteria and retaining all the referenced skin lesion codes, based 
on the recommendation of our medical staff and consultants.

Cardiovascular System

    Comment: Commenters opposed the deletion of the following codes:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
36530.  Insertion of implantable intravenous infusion pump.             
36531.  Revision of implantable intravenous infusion pump.              
36532.  Removal of implantable intravenous infusion pump.               
------------------------------------------------------------------------

    Response: We stated in the proposed notice that the Office of 
Health Technology Assessment (OHTA), a component of the Public Health 
Service's Agency for Health Care Policy and Research, would be issuing 
an assessment on the safety and efficacy of infusion pumps for certain 
treatments and we would re-evaluate our policy on these pumps in light 
of that assessment. OHTA issued its assessment, and consequently we 
revised our manual instruction in section 60-14B of the Medicare 
Coverage Issues Manual. According to this revision, the former 
instruction limiting Medicare coverage of infusion pumps to intra-
arterial pumps for certain medical conditions has been revised to 
include intravenous infusion pumps for a greater number of medical 
indications. As a result, we are not deleting CPT codes 36530, 36531, 
and 36532.
    Comment: Several commenters were opposed to our deletion of CPT 
code 63750 (insertion, subarachnoid catheter with reservoir and/or pump 
for intermittent or continuous infusion of drug, including laminectomy) 
and CPT code 63780 (insertion or replacement, subarachnoid or epidural 
catheter, with reservoir and/or pump for drug infusion, without 
laminectomy).
    Response: Our medical advisors state that these procedures can be 
performed safely, effectively, and appropriately in the ASC setting. We 
are therefore retaining these procedures on the list.
Urinary System
    Comment: We received over 300 comments in opposition to the 
deletion of CPT code 52000 (cystourethroscopy (separate procedure)). Of 
these comments, 200 were also against deleting the following CPT codes:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
52281.  Cystourethroscopy, with calibration and/or dilation of urethral 
         stricture or stenosis, with or without meatotomy and injection 
         procedure for cystography, male or female.                     
52285.  Cystourethroscopy for treatment of the female urethral syndrome 
         with any or all of the following: urethral meatotomy, urethral 
         dilation, internal urethrotomy, lysis of urethrovaginal septal 
         fibrosis, lateral incision of the bladder neck, and fulguration
         of polyp(s) of urethra, bladder neck, and/or trigone.          
------------------------------------------------------------------------

    Most commenters opposed to the cystoscopy's deletion were 
urologists. The main themes mentioned by the commenters were the 
following: the differences in male and female cystoscopies, the 
differences in type of cystoscopies, diagnostic versus therapeutic 
cystoscopies, our deceptive data, and physician/patient access 
problems.
    Response: Although the three cystoscopies proposed for deletion 
exceed our physician's office criterion, we are making an exception to 
this standard and retaining these codes on the list, based on the 
advice of our medical staff and consultants. Numerous commenters 
offered significant medical evidence for retention of cystoscopies on 
the ASC list, especially for male patients. Moreover, an exhaustive 
review of our data supports the commenters' belief that female 
cystoscopies skew the data in favor of the physician's office site of 
service and many CPT code 52000 cystoscopies, when performed, are 
upgraded to therapeutic cystoscopies and not reported under CPT code 
52000.
Male Genital System
    Comment: We received 136 comments in opposition to the deletion of 
CPT code 55700 (prostate biopsy). The following were the main themes 
mentioned in the comments: patient health, complications and infection, 
sterilization problems, and the use of the ultrasound machine.
    Response: As with cystoscopies, information indicates many patients 
in need of a prostate biopsy have comorbidities or other complications 
that necessitate close monitoring. Complications of prostate biopsy can 
be serious. Infection and bleeding are not uncommon and, at times, 
warrant hospital admission.
    Although prostate biopsy exceeds our physician's office criterion, 
we are making an exception to our standard and are retaining this 
procedure on the list. We base our determination on the number of 
comments received citing significant medical evidence, and the advice 
of our medical staff and consultants that prostate biopsy is an 
appropriate procedure for the ASC list.
Nervous System
    Comment: Several commenters were opposed to our proposed deletion 
of the following codes:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
64442.  Injection, anesthetic agent; paravertebral facet joint nerve,   
         lumbar, single level.                                          
64510.  Injection, anesthetic agent; stellate ganglion (cervical        
         sympathetic).                                                  
------------------------------------------------------------------------

    They believed these codes should not be deleted because they 
frequently require the standby of a crash cart, should a complication 
occur during injection. CPT code 64442 requires a fluoroscopy, which 
few physicians' offices own; CPT code 64510 may compromise the 
patient's airway with the inadvertent block of a laryngeal nerve with a 
local anesthetic; and both procedures cause patient cardiac arrhythmias 
in 25 percent of patients. Commenters believed our data are erroneous 
since the data exclude anesthesiologists from site-of-service data, and 
anesthesiologists are the primary physicians performing these 
procedures.
    Response: In view of these stated medical concerns and because the 
inclusion of anesthesiologists in a new claims data run resulted in the 
two procedures falling below the 50 percent physician's office 
criterion, both procedures will be retained on the list.

Eye and Ocular Adnexa

    Comment: We received comments in opposition to our proposed 
deletion of the following ophthalmologic procedures codes:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
66762.  Iridoplasty by photocoagulation (one or more sessions) (eg, for 
         improvement of vision, for widening of anterior chamber angle).
67101.  Repair of retinal detachment, one or more sessions; cryotherapy 
         or diathermy, with or without drainage of subretinal fluid.    
67105.  Repair of retinal detachment, photocoagulation (laser or xenon  
         arc, one or more sessions), with or without drainage of        
         subretinal fluid.                                              
[[Page 5195]]                                                           
                                                                        
67208.  Destruction of localized lesion of retina (eg, maculopathy,     
         choroidopathy, small tumors), one or more sessions;            
         cryotherapy, diathermy.                                        
67921.  Entropion repair; suture.                                       
------------------------------------------------------------------------

    Commenters were concerned that these procedures could not be 
performed in a physician's office without the purchase of costly 
equipment and they would now have to be performed in the more expensive 
OPD setting.
    Response: The billing data on site-of-service performance for four 
of these five procedures (excluding CPT code 67921) range from 53 
percent to 63 percent physicians' office performance. When considering 
the combined ASC, OPD, and inpatient hospital performances, these four 
procedures do not meet the new 46 percent threshold criterion; rather 
their combined percentages range from 37 percent to 40 percent. In view 
of these combined percentages, we believe we are justified in adhering 
to our proposed intention to delete from the ASC list CPT codes 66762, 
67101, 67105, and 67208.
    The fifth code, CPT code 67921, has a 45 percent combined 
percentage performance in the three settings. Yet, our medical staff 
advise us that this procedure, which involves the inversion of the 
border of the eyelid against the eyeball, is medically appropriate for 
performance in the ASC. This code is also one of a series of 
ophthalmological codes involving blepharoplasties mentioned both in 
this notice and in the previous ASC final notice published in the 
Federal Register on December 31, 1991 (56 FR 67666) as making 
unnecessary our coverage of integumentary system blepharoplasties, 
which are sometimes cosmetic. In view of these factors, we are making 
an exception to our criteria and are retaining CPT code 67921.
    Comment: Commenters believed that four of the ophthalmic procedures 
proposed for removal from the list are subject to the interim practice 
cost reductions. They are the following CPT codes:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
66762.  Iridoplasty by photocoagulation (one or more sessions) (eg, for 
         improvement of vision, for widening of anterior chamber angle).
67101.  Repair of retinal detachment, one or more sessions; cryotherapy 
         or diathermy, with or without drainage of subretinal fluid.    
67105.  Repair of retinal detachment, photocoagulation (laser or xenon  
         arc, one or more sessions), with or without drainage of        
         subretinal fluid.                                              
67208.  Destruction of localized lesion of retina (eg, maculopathy,     
         choroidopathy, small tumors), one ore more sessions;           
         cryotherapy, diathermy.                                        
------------------------------------------------------------------------

    The commenters stated that we should not remove any procedures 
subject to the interim practice cost reductions from the ASC list until 
the fee schedule for physicians' services accurately reflects practice 
costs.
    Response: The commenters are correct that four of the five 
ophthalmic procedures (CPT codes 66762, 67101, 67105, and 67208) 
proposed for deletion from the ASC list are subject to the practice 
expense reduction. (CPT code 67921 (repair of entropion) is not subject 
to the practice expense reduction.)
    OBRA '93 provides for an adjustment to practice expense relative 
value units (RVUs) for services for which practice expense RVUs exceed 
128 percent of the work RVUs and that are performed less than 75 
percent of the time in a physician's office setting. The 1994 practice 
expense RVUs are reduced by 25 percent of the amount by which the 
practice expense RVUs exceed the 1994 work RVUs. In 1995 and 1996, the 
excess, as determined for 1994, will be reduced an additional 25 
percent each year. Practice expense RVUs will not be reduced to an 
amount less than 128 percent of the 1994 work RVUs for a service. 
Services performed more than 75 percent of the time in a physician's 
office setting are not subject to the reduction.
    Services that are primarily performed in a physician's office 
setting are subject to a payment limit, called the site-of-service 
limitation, if they are performed in an inpatient hospital or OPD 
setting. For these procedures, the practice expense RVUs are reduced by 
50 percent. The limitation on the practice expense RVUs reflects lower 
practice costs incurred in the OPD. Procedures on the approved ASC list 
are automatically excluded from this site-of-service limitation.
    We disagree that it is inappropriate to apply the site-of-service 
limitation to procedures subject to the practice expense reduction. 
These are two separate limitations established for different purposes. 
The practice expense reduction is designed to reduce the basic practice 
expense that has been determined by the Congress to be excessive; 
whereas the site-of-service limitation applies to procedures primarily 
performed in an office setting, when the procedures are performed in an 
inpatient hospital or OPD setting.

Procedures Intended for Deletion

    In Addendum E of our December 1993 proposed notice, we published a 
list of procedures that we intended for deletion that were either 
recent additions to the list or had low-volume ASC performance or both. 
The following procedure codes in that addendum received comments.
    Comment: Two commenters were opposed to the deletion of CPT code 
64420, and one commenter opposed the deletion of CPT codes 65270 and 
65272. The descriptions of these CPT codes follow:

------------------------------------------------------------------------
  CPT                                                                   
 Code                              Description                          
------------------------------------------------------------------------
64420.  Injection, anesthetic agent; intercostal nerve single.          
65270.  Repair of laceration; conjunctiva, with or without              
         nonperforating laceration sclera, direct closure.              
65272.  Repair of laceration; conjunctiva, by mobilization and          
         rearrangement, without hospitalization.                        
------------------------------------------------------------------------

    Response: We are retaining these procedures on our list, but we 
restate our intention to delete them in our next biennial update should 
they continue to fail to meet our criteria.

Assignment of Payment Groups

    Comment: Three commenters disagreed with the proposed payment group 
assignment of CPT code 66180 (aqueous shunt to extraocular reservoir, 
(eg, Molteno, Schocket, Denver-Krupin)) to payment group 4. Two 
commenters, both physicians, recommended that the procedure be placed 
in payment group 7 because of the time required to perform the 
procedure and other factors related to postoperative recovery. One 
commenter, a professional society, compared the procedure in terms of 
complexity to a scleral buckling procedure for retinal detachment (CPT 
code 67107) or the placement of a radioactive implant for an ophthalmic 
malignancy (CPT 67218), both of which are assigned to payment group 5.
    Response: After consultation with our medical advisor, we concur 
with the professional society that CPT code 66180 more closely 
resembles procedures currently in payment group 5 in terms of time and 
resource consumption than it does those in payment group 4 or in 
payment group 7. We have therefore assigned this procedure to payment 
group 5. Payment for the aqueous shunt itself (HCFA 
[[Page 5196]] Common Procedure Coding System (HCPCS) code L8612) is not 
a part of the facility fee, but rather is made separately under 
Medicare Part B.
    Comment: A dozen commenters disagreed with the assignment of CPT 
code 58990 (hysteroscopy, diagnostic) to payment group 1, recommending 
that it be placed in payment group 3.
    Response: CPT code 58990 was added as a payment group 1 procedure 
to the list of Medicare-covered ASC procedures, effective for services 
furnished beginning on January 30, 1992. CPT code 58990 was replaced by 
CPT code 56350 (hysteroscopy, diagnostic (separate procedure)) in the 
1993 CPT, and CPT code 58990 was deleted from both the CPT and the ASC 
list. Because this change constituted essentially an editorial rather 
than a substantive revision, we retained CPT code 56350 in payment 
group 1, the same payment group to which its predecessor, CPT code 
58990, had been assigned. CPT code 56350 is on the list of procedures 
for which we are collecting resource cost data in Part II of the 
Medicare ASC survey, and its payment group assignment, along with that 
of all other procedures on the list of Medicare-covered ASC procedures, 
will be reevaluated within the context of the survey data. In the 
interim, CPT code 56350 will remain in payment group 1.

Additional Information

    We received several dozen comments on payment issues that were not 
raised in our December 1993 proposed notice. Primarily, commenters 
recommended placing CPT codes that are currently on the ASC list in a 
higher payment group. A few commenters expressed disappointment over 
the lack of a payment rate update for inflation as a result of the 2-
year freeze enacted by the Congress in OBRA '93.
    As indicated in our December 1993 proposed notice, we are deferring 
changes of payment group assignments for individual procedures on the 
current ASC list pending completion of Part II of the Medicare ASC 
payment rate survey (Form HCFA 452B). On March 15, 1994, we mailed the 
Medicare ASC survey, Part II, to 320 facilities that constitute a 
randomly selected, representative sample of Medicare-participating 
ASCs. The survey collects data on facility overhead and procedure-
specific costs. The payment group assignment and payment group amounts 
for all CPT codes on the list of Medicare-covered ASC procedures will 
be reviewed collectively, within the context of the survey data. 
Therefore, while we are not making any changes in existing payment 
group assignments in this notice, we will publish in the Federal 
Register in accordance with notice and comment procedures any changes 
that we propose to make on the basis of updated cost data collected in 
the ASC survey.

IV. Provisions of the Final Notice

    We are adopting the following new quantitative criteria, suggested 
in our December 1993 proposed notice, for deleting a procedure from ASC 
coverage: The combined inpatient, OPD, and ASC site-of-service 
percentage is less than 46 percent of the total volume; and either--
     The procedure is performed 50 percent of the time or more 
in a physician's office; or
     The procedure is performed 10 percent of the time or less 
in an inpatient hospital setting.
    This change allows the site of service for procedures in the 
physician's office to grow from below 50 percent (when it is added) to 
as high as 54 percent, as long as the proportion of time the procedure 
is performed in the operating room remains at 46 percent. Similarly, 
the criteria allow procedures to move from an inpatient hospital site 
of service to an OPD site of service without being deleted from the ASC 
list.
    We are deleting 4 of the 25 procedure codes we had proposed for 
deletion from the ASC list in our December 1993 proposed notice. For 
the reasons discussed in the analysis of the public comments in section 
III. of this notice, we are retaining the remaining 21 codes on the ASC 
list. Addendum A lists the 4 CPT codes that we are deleting (with the 
body system and description of each procedure, according to appropriate 
CPT terminology). Addendum A also lists a fifth deletion, CPT code 
36522 (photopheresis, extracorporeal), which was not suggested in our 
December 1993 proposed notice. We are deleting this code based on 
information from a provider that this procedure cannot be safely 
performed in an ASC. Our review of the billing data indicates that, 
although this procedure has been on the ASC list, it is performed 0 
percent of the time in an ASC. It is performed 73 percent of the time 
on an inpatient basis and 23 percent of the time in the OPD. We are 
requesting public comment on the appropriateness of this deletion.
    We are adding a total of 30 new procedure codes to the ASC list. 
These codes are listed in Addendum B with the body system and 
description of each procedure and the corresponding payment group. We 
are adding the 20 procedure codes that we had proposed for addition to 
the ASC list in our December 1993 proposed notice. For the reasons 
discussed in the analysis of the public comments in section III. of 
this notice, we are also adding 10 other procedure codes: CPT codes 
29804, 43259, 51040, 52450, 56309, 56316, 56317, 56351, 56356, and 
64421. We are requesting public comment on the appropriateness of the 
addition of these 10 new CPT codes and the assignment of payment groups 
for them since these codes were not suggested in our December 1993 
proposed notice.
    Further, the CPT is updated annually and some deletions and 
additions affect the ASC list. Parts 1 and 3 of Addendum C list CPT 
codes (with the body system and description of each procedure) that 
were deleted by changes to the Medicare Carriers Manual as a result of 
the update of the 1992 and 1993 editions of the CPT, respectively. We 
had proposed these deletions in our December 1993 proposed notice and 
received no comments on them. This notice makes these deletions final. 
Parts 2 and 4 of Addendum C list CPT codes (with the body system and 
description of each procedure and corresponding payment group) that 
were added by changes to the Medicare Carriers Manual as a result of 
the update of the 1992 and 1993 editions of the CPT. We had proposed 
these additions in our December 1993 proposed notice and received no 
comments on them. This notice makes these additions final. Part 5 of 
Addendum C lists CPT codes (with the body system and description of 
each procedure) that were deleted by changes to the Medicare Carriers 
Manual as a result of the update of the 1994 edition of the CPT. 
Because these codes were not suggested for deletion in our December 
1993 proposed notice, we are now requesting public comment on the 
appropriateness of these deletions. This list of deletions differs from 
the Medicare Carriers Manual instruction that was effective April 11, 
1994, in that we are retaining four of the nasal and sinus endoscopy 
codes: CPT codes 31254 through 31256 and 31267. We are retaining these 
codes since we anticipate that they will be reinstated by the CPT 
Editorial Panel effective January 1995. Part 6 of Addendum C lists CPT 
codes (with the body system and description of each procedure and 
corresponding payment group) that were added by changes to the Medicare 
Carriers Manual as a result of the update of the 1994 edition of the 
CPT. Because these codes were not suggested for addition in our 
December 1993 proposed notice, we are now requesting public comment on 
the appropriateness [[Page 5197]] of, and assignment of payment groups 
for, the additions.

V. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1980 (44 U.S.C. 3501 et seq.).

VI. Regulatory Impact Statement

A. Introduction

    This final notice permits facility fees to be paid when the 30 
surgical procedure codes being added by this notice are performed in an 
ASC. We are also deleting 5 codes from the ASC list. We believe the net 
effect of the addition and deletion of these codes will be negligible 
because of the low number of changes we are making at this time and 
because of the relatively low cost and volume of these codes.
    Payments to ASCs are generally lower than payments to hospitals for 
surgery performed in a hospital, whether on an inpatient or OPD basis. 
Although we do not anticipate that many services will shift from the 
hospital inpatient setting to ASCs, we anticipate some program savings 
because payments to ASCs for a given surgical procedure are generally 
lower than payments to hospitals for the same procedure. Additional 
savings will be realized as a result of lower payments to a hospital 
when newly listed procedures continue to be performed on an OPD basis, 
because the OPD rate (less deductible and coinsurance) would be the 
lower of (1) the hospital's reasonable costs or charges, or (2) a blend 
of the hospital's reasonable costs or customary charges and the amount 
that would be paid to a free-standing ASC in the same area for the same 
procedure. The blend is comprised of 42 percent hospital cost and 58 
percent ASC payment rate. We believe payments based on the ASC blended 
rate are approximately 10 percent lower than payments based solely on 
reasonable cost. A factor that could offset some savings would be a 
shift of services from the physician's office to the ASC setting as a 
result of the expansion of the list of covered ASC services. Since a 
facility fee is not paid when surgery is performed in a physician's 
office, this shifting will result in slightly increased program costs.
    The deletions to the ASC list could also result in some changes in 
program costs and savings depending upon whether the deleted services 
are shifted to the lower cost physician's office site or to the higher 
cost OPD setting. We do not anticipate mass shifting of the site of 
service associated with the procedure codes we are adding or deleting.
    We believe this notice will result in no economic impact.

B. Regulatory Flexibility Act

    We generally prepare a regulatory flexibility analysis that is 
consistent with the Regulatory Flexibility Act (RFA) (5 U.S.C. 601 
through 612) unless the Secretary certifies that a notice will not have 
a significant economic impact on a substantial number of small 
entities. For purposes of the RFA, all physicians, ASCs, and hospitals 
are considered to be small entities.
    In addition, section 1102(b) of the Act requires the Secretary to 
prepare a regulatory impact analysis if a notice may have a significant 
impact on the operations of a substantial number of small rural 
hospitals. This analysis must conform to the provisions of section 604 
of the RFA. For purposes of section 1102(b) of the Act, we define a 
small rural hospital as a hospital that is located outside of a 
Metropolitan Statistical Area and has fewer than 50 beds.
    We will delete a procedure from the ASC list only if the combined 
hospital inpatient, OPD, and ASC site-of-service percentage is less 
than 46 percent of the total volume; and either the procedure is 
performed 50 percent of the time or more in a physician's office, or 
the procedure is performed 10 percent of the time or less in an 
inpatient hospital setting. Because procedures will not be added or 
deleted as a result of slight shifts of the site of service, we believe 
we are adding stability to the list that should assist all small 
entities to plan for the future.
    Therefore, for the reasons cited above, we are not preparing 
analyses for either the RFA or section 1102(b) of the Act since we have 
determined, and the Secretary certifies, that this notice will not 
result in a significant economic impact on a substantial number of 
small entities and will not have a significant impact on the operations 
of a substantial number of small rural hospitals.
    In accordance with the provisions of Executive Order 12866, this 
notice was not reviewed by the Office of Management and Budget.

(Section 1833(i)(1) of the Social Security Act (42 U.S.C. 
1395l(i)(1))

(Catalog of Federal Domestic Assistance Program No. 93.774, 
Medicare--Supplementary Medical Insurance Program)

    Dated: October 28, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.

    Dated: December 10, 1994.
Donna E. Shalala,
Secretary.

Addendum A

Deletions From the List of Covered Procedures for Ambulatory 
Surgical Centers

    The following addendum is the final list of deletions from the ASC 
list. These deletions are effective April 26, 1995. In the first column 
is the CPT code for the procedure; and in the second column, the body 
system and description of the procedure. In this addendum, ``combined'' 
percentage refers to the total of inpatient hospital, hospital 
outpatient department, and ASC site-of-service percentages.
    We are requesting public comments only on CPT code 36522 in 
Addendum A because we had not proposed this code for deletion in our 
December 1993 proposed notice.

------------------------------------------------------------------------
  CPT                                                                   
 Code                      Body system and description                  
------------------------------------------------------------------------
                          CARDIOVASCULAR SYSTEM                         
                                                                        
36522.  Photopheresis, extracorporeal (73 percent inpatient, 2 percent  
         office, 96 percent combined)                                   
                                                                        
                          EYE AND OCULAR ADNEXA                         
                                                                        
66762.  Iridoplasty by photocoagulation (one or more sessions) (eg, for 
         improvement of vision, for widening of anterior chamber angle) 
         (2 percent inpatient, 59 percent office, 37 percent combined)  
67101.  Repair of retinal detachment, one or more sessions; cryotherapy 
         or diathermy, with or without drainage of subretinal fluid (8  
         percent inpatient, 62 percent office, 37 percent combined)     
67105.  Repair of retinal detachment, one or more sessions;             
         photocoagulation (laser or xenon arc, one or more sessions),   
         with or without drainage of subretinal fluid (6 percent        
         inpatient, 63 percent office, 36 percent combined)             
67208.  Destruction of localized lesion of retina (eg, maculopathy,     
         choroidopathy, small tumors), one or more sessions;            
         cryotherapy, diathermy (5 percent inpatient, 57 percent office,
         40 percent combined)                                           
------------------------------------------------------------------------

Addendum B

Additions to the List of Covered Procedures for Ambulatory Surgical 
Centers

    The following addendum is the final list of additions to the ASC 
list and the [[Page 5198]] corresponding payment groups. These 
additions are effective February 27, 1995. In the first column is the 
CPT code for the procedure; in the second column, the payment group for 
the procedure; and in the third column, the body system and description 
of the procedure.
    We are requesting public comments on the appropriateness of the 
addition of, and assignment of payment groups for, only the following 
CPT codes in Addendum B because we had not suggested them for addition 
in our December 1993 proposed notice: CPT codes 29804, 43259, 51040, 
52450, 56309, 56316, 56317, 56351, 56356, and 64421.

------------------------------------------------------------------------
  CPT    Payment                                                        
 Code     group                 Body system and description             
------------------------------------------------------------------------
                         MUSCULOSKELETAL SYSTEM                         
                                                                        
20694.        1   Removal, under anesthesia, of external fixation system
20910.        3   Cartilage graft; costochondral                        
26416.        3   Removal of tube or rod and insertion of extensor      
                   tendon graft (includes obtaining graft), hand or     
                   finger                                               
26587.        5   Reconstruction of supernumerary digit, soft tissue and
                   bone                                                 
28307.        4   Osteotomy, metatarsal, base or shaft, single, with or 
                   without lengthening, for shortening or angular       
                   correction; first metatarsal with autograft          
28340.        4   Reconstruction, toe, macrodactyly; soft tissue        
                   resection                                            
28341.        4   Reconstruction, toe, macrodactyly; requiring bone     
                   resection                                            
28344.        4   Reconstruction, toe(s); polydactyly                   
28345.        4   Reconstruction, toe(s); syndactyly, with or without   
                   skin graft(s), each web                              
28456.        2   Percutaneous skeletal fixation of tarsal bone fracture
                   (except talus and calcaneus); with manipulation, each
29804.        3   Arthroscopy, temporomandibular joint, surgical        
                                                                        
                           RESPIRATORY SYSTEM                           
                                                                        
31084.        4   Sinusotomy frontal; obliterative, with osteoplastic   
                   flap, brow incision                                  
                                                                        
                            DIGESTIVE SYSTEM                            
                                                                        
43259.        3   Upper gastrointestinal endoscopy including esophagus, 
                   stomach, and either the duodenum and/or jejunum as   
                   appropriate; with endoscopic ultrasound examination  
49250.        4   Umbilectomy, omphalectomy, excision of umbilicus      
                   (separate procedure)                                 
                                                                        
                             URINARY SYSTEM                             
                                                                        
51040.        4   Cystostomy, cystostomy with drainage                  
52450.        3   Transurethral incision of prostate                    
                                                                        
                           MALE GENITAL SYSTEM                          
                                                                        
54015.        4   Incision and drainage of penis, deep                  
54205.        4   Injection procedure for Peyronie disease; with        
                   surgical exposure of plaque                          
                                                                        
                 LAPAROSCOPY/PERITONEOSCOPY/HYSTEROSCOPY                
                                                                        
56309.        5   Laparoscopy, surgical; with removal of leiomyomata,   
                   subserosal (single or multiple)                      
56316.        4   Laparoscopy, surgical; repair of initial inguinal     
                   hernia                                               
56317.        7   Laparoscopy, surgical; repair of recurrent inguinal   
                   hernia                                               
56351.        3   Hysteroscopy, surgical, with sampling (biopsy) of     
                   endometrium and/or polypectomy, with or without D & C
56356.        4   Hysteroscopy, surgical; with endometrial ablation (any
                   method)                                              
                                                                        
                          FEMALE GENITAL SYSTEM                         
                                                                        
56441.        1   Lysis of labial adhesions                             
                                                                        
                             NERVOUS SYSTEM                             
                                                                        
62275.        1   Injection of anesthetic substance (including          
                   narcotics), diagnostic or therapeutic; epidural,     
                   cervical or thoracic, single                         
64421.        1   Injection, anesthetic agent; intercostal nerves,      
                   multiple, regional block                             
                                                                        
                          EYE AND OCULAR ADNEXA                         
                                                                        
65770.        7   Keratoprosthesis                                      
66180.        5   Aqueous shunt to extraocular reservoir, (eg, Molteno, 
                   Schocket, Denver-Krupin)                             
66185.        2   Revision of aqueous shunt to extraocular reservoir    
67340.        4   Strabismus surgery involving exploration and/or repair
                   of detached extraocular muscle(s)                    
------------------------------------------------------------------------

Addendum C

1. Deletions From the List of Covered Procedures for Ambulatory 
Surgical Centers, Deleted From the 1992 CPT
    The CPT is updated annually, and some additions and deletions 
affect the ASC list. The following part 1 of this addendum is the list 
of procedures that were deleted from the ASC list because they were 
deleted from the 1992 CPT. These deletions were effective March 31, 
1992. In the first column is the CPT code for the procedure; and in the 
second column, the body system and description of the procedure.

------------------------------------------------------------------------
  CPT                                                                   
 code                      Body system and description                  
------------------------------------------------------------------------
                          INTEGUMENTARY SYSTEM                          
                                                                        
15410.  Free transplantation of skin flap by microsurgical technique,   
         including microvascular anastomosis; 100 sq cm or less         
15412.  Free transplantation of skin flap by microsurgical technique,   
         including microvascular anastomosis, between 101 and 160 sq cm 
15414.  Free transplantation of skin flap by microsurgical technique,   
         including microvascular anastomosis; between 161 and 230 sq cm 
15416.  Free transplantation of skin flap by microsurgical technique,   
         including microvascular anastomosis; over 230 sq cm            
15500.  Formation of tube pedicle without transfer or major ``delay'' of
         large flap without transfer; on trunk                          
15505.  Formation of tube pedicle without transfer or major ``delay'' of
         large flap without transfer; on scalp, arms, or legs           
15510.  Formation of tube pedicle without transfer, or major ``delay''  
         of large flap without transfer; on forehead, cheeks, chin,     
         mouth, neck, axillae, genitalia, hands, or feet                
15515.  Formation of tube pedicle without transfer, or major ``delay''  
         of large flap without transfer; on eyelids, nose, ears, or lips
15540.  Primary attachment of open or tubed pedicle flap to recipient   
         site requiring minimal preparation; to trunk                   
15545.  Primary attachment of open or tubed pedicle flap to recipient   
         site requiring minimal preparation; to scalp, arms, or legs    
15550.  Primary attachment of open or tubed pedicle flap to recipient   
         site requiring minimal preparation; to forehead, cheeks, chin, 
         mouth, neck, axillae, genitalia, or hands, feet                
15555.  Primary attachment of open or tubed pedicle flap to recipient   
         site requiring minimal preparation; to eyelids, nose, ears, or 
         lips                                                           
15700.  Excision of lesion and/or excisional preparation of recipient   
         site and attachment of direct or tubed pedicle flap; trunk     
[[Page 5199]]                                                           
                                                                        
15710.  Excision of lesion and/or excisional preparation of recipient   
         site and attachment of direct or tubed pedicle flap; scalp,    
         arms, or legs                                                  
15720.  Excision of lesion and/or excisional preparation of recipient   
         site and attachment of direct or tubed pedicle flap; forehead, 
         cheeks, chin, mouth, neck, axillae, genitalia, hands or feet   
15730.  Excision of lesion and/or excisional preparation of recipient   
         site and attachment of direct or tubed pedicle flap; eyelids,  
         nose, ears, or lips                                            
15954.  Excision, trochanteric pressure ulcer, with bipedicle flap      
         closure                                                        
15955.  Excision, trochanteric pressure ulcer, with bipedicle flap      
         closure; with ostectomy                                        
15960.  Excision, heel pressure ulcer, with primary suture              
15961.  Excision, heel pressure ulcer, with primary suture; with        
         ostectomy                                                      
15964.  Excision, heel pressure ulcer, with local skin flap closure     
15965.  Excision, heel pressure ulcer, with local skin flap closure;    
         with ostectomy                                                 
15966.  Excision, heel pressure ulcer, with other flap closure          
15967.  Excision, heel pressure ulcer, with other flap closure; with    
         ostectomy                                                      
15970.  Excision, leg pressure ulcer, with primary suture               
15971.  Excision, leg pressure ulcer, with primary suture; with         
         ostectomy                                                      
15972.  Excision, leg pressure ulcer, with local skin flap(s)           
15973.  Excision, leg pressure ulcer, with local skin flap(s); with     
         ostectomy                                                      
15974.  Excision, leg pressure ulcer, with muscle or myocutaneous flap  
         closure                                                        
15975.  Excision, leg pressure ulcer, with muscle or myocutaneous flap  
         closure; with ostectomy                                        
15980.  Excision, knee pressure ulcer, with local skin flap closure     
15981.  Excision, knee pressure ulcer, with local skin flap closure;    
         with ostectomy                                                 
15982.  Excision, knee pressure ulcer, with other flap closure          
15983.  Excision, knee pressure ulcer, with other flap closure; with    
         ostectomy                                                      
19360.  Breast Reconstruction with muscle or myocutaneous flap          
                                                                        
                           RESPIRATORY SYSTEM                           
                                                                        
30820.  Cryosurgery of turbinates, unilateral or bilateral              
                                                                        
                          CARDIOVASCULAR SYSTEM                         
                                                                        
36495.  Insertion of implantable intravenous infusion pump or venous    
         access port                                                    
36496.  Revision of implantable intravenous infusion pump or venous     
         access port                                                    
36497.  Removal of implantable intravenous infusion pump or venous      
         access port                                                    
                                                                        
                          EYE AND OCULAR ADNEXA                         
                                                                        
66702.  Ciliary body destruction, any method (eg, diathermy,            
         cryotherapy, laser, dialysis)                                  
67907.  Repair of blepharoptosis; superior rectus tendon transplant     
------------------------------------------------------------------------

2. Additions to the List of Covered Procedures for Ambulatory Surgical 
Centers, Added to the 1992 CPT (Added to the Medicare Carriers Manual 
January 30, 1992)
    The CPT is updated annually, and some additions and deletions 
affect the ASC list. The following part 2 of this addendum is the list 
of procedures that were added to the ASC list because of additions to 
the 1992 CPT. These procedures were added to the ASC list by the 
Medicare Carriers Manual and were effective January 30, 1992. In the 
first column is the CPT code for the procedure; in the second column, 
the payment group for the procedure; and in the third column, the body 
system and description of the procedure.

------------------------------------------------------------------------
  CPT    Payment                                                        
 code     group                 Body system and description             
------------------------------------------------------------------------
                          INTEGUMENTARY SYSTEM                          
                                                                        
15570.        3   Formation of direct or tubed pedicle, with or without 
                   transfer; trunk                                      
15572.        3   Formation of direct or tubed pedicle, with or without 
                   transfer; scalp, arms, or legs                       
15574.        3   Formation of direct or tubed pedicle, with or without 
                   transfer; forehead, cheeks, chin, mouth, neck,       
                   axillae, genitalia, hands, or feet                   
15576.        3   Formation of direct or tubed pedicle, with or without 
                   transfer; eyelids, nose, ears, lips or intraoral     
19357.        5   Breast reconstruction, immediate or delayed, with     
                   tissue expander, including subsequent expansion      
                                                                        
                           RESPIRATORY SYSTEM                           
                                                                        
30801.        1   Cauterization and/or ablation, mucosa of turbinates,  
                   unilateral or bilateral, any method (separate        
                   procedure); superficial                              
30802.        1   Cauterization and/or ablation, mucosa of turbinates,  
                   unilateral or bilateral, any method (separate        
                   procedure); intramural                               
                                                                        
                          CARDIOVASCULAR SYSTEM                         
36533.        3   Insertion of implantable venous access port, with or  
                   without subcutaneous reservoir                       
36534.        2   Revision of implantable venous access port and/or     
                   subcutaneous reservoir                               
36535.        1   Removal of implantable venous access port and/or      
                   subcutaneous reservoir                               
                                                                        
                          EYE AND OCULAR ADNEXA                         
                                                                        
66700.        2   Ciliary body destruction; diathermy                   
66710.        2   Ciliary body destruction; cyclophotocoagulation       
66720.        2   Ciliary body destruction; cryotherapy                 
66740.        2   Ciliary body destruction; cyclodialysis               
66986.        6   Exchange of intraocular lens                          
------------------------------------------------------------------------

3. Deletions from the List of Covered Procedures for Ambulatory 
Surgical Centers, Deleted From the 1993 CPT
    The CPT is updated annually, and some additions and deletions 
affect the ASC list. The following part 3 of this addendum is the list 
of procedures that were deleted from the ASC list because they were 
deleted from the 1993 CPT. These deletions were effective July 7, 1993. 
In the first column is the CPT code for the procedure; and in the 
second column, the body system and description of the procedure.

------------------------------------------------------------------------
  CPT                                                                   
 Code                      Body system and description                  
------------------------------------------------------------------------
                          INTEGUMENTARY SYSTEM                          
                                                                        
10141.  Incision and drainage of hematoma; complicated                  
                                                                        
                         MUSCULOSKELETAL SYSTEM                         
                                                                        
21455.  Closed manipulative treatment by interdental fixation of closed 
         or open mandibular fracture                                    
23510.  Treatment of open clavicular fracture, with uncomplicated soft  
         tissue closure                                                 
23580.  Treatment of open scapular fracture with uncomplicated soft     
         tissue closure                                                 
23610.  Treatment of open humeral (surgical or anatomical neck)         
         fracture, with uncomplicated soft tissue closure               
23658.  Treatment of open shoulder dislocation, with uncomplicated soft 
         tissue closure                                                 
24506.  Treatment of closed humeral shaft fracture; percutaneous        
         insertion of pin or rod                                        
24510.  Treatment of open humeral shaft fracture, with uncomplicated    
         soft tissue closure                                            
[[Page 5200]]                                                           
                                                                        
24531.  Treatment of closed humeral supracondylar or transcondylar      
         fracture, without manipulation; with traction (pin or skin)    
24536.  Treatment of closed humeral supracondylar or transcondylar      
         fracture, with manipulation; with traction (pin or skin)       
24540.  Treatment of open humeral supracondylar or transcondylar        
         fracture, with uncomplicated soft tissue closure               
24542.  Treatment of open humeral supracondylar or transcondylar        
         fracture, with uncomplicated soft tissue closure, with traction
         (pin or skin)                                                  
24570.  Treatment of open humeral epicondylar fracture, medial or       
         lateral, with uncomplicated soft tissue closure                
24578.  Treatment of open humeral condylar fracture, medial or lateral, 
         with uncomplicated soft tissue closure                         
24580.  Treatment of closed comminuted elbow fracture (fracture distal  
         humerus and/or proximal ulna and/or proximal radius), treatment
         with traction (pin or skin), without manipulation              
24581.  Treatment of closed comminuted elbow fracture (fracture distal  
         humerus and/or proximal ulna and/or proximal radius), treatment
         with traction (pin or skin); with manipulation                 
24583.  Treatment of open comminuted elbow fracture (fracture distal    
         humerus and/or proximal ulna and/or proximal radius), with     
         uncomplicated soft tissue closure                              
24585.  Open treatment of closed or open comminuted elbow fracture      
         (fracture distal humerus and/or proximal radius), with or      
         without internal or external skeletal fixation                 
24588.  Open treatment of closed or open comminuted elbow fracture      
         (fracture distal humerus and/or proximal radius), with implants
         and fascia lata ligament reconstruction                        
24610.  Treatment of open elbow dislocation, with uncomplicated soft    
         tissue closure                                                 
24625.  Treatment of open Monteggia type of fracture dislocation at     
         elbow (fracture proximal end of ulna with dislocation of radial
         head), with uncomplicated soft tissue closure                  
24660.  Treatment of open radial head or neck fracture, with            
         uncomplicated soft tissue closure                              
24680.  Treatment of open ulnar fracture, proximal end (olecranon       
         process), with uncomplicated soft tissue closure               
25510.  Treatment of open radial shaft fracture, with uncomplicated soft
         tissue closure                                                 
25540.  Treatment of open ulnar shaft fracture, with uncomplicated soft 
         tissue closure                                                 
25570.  Treatment of open radial and ulnar shaft fractures, with        
         uncomplicated soft tissue closure                              
25610.  Treatment of closed, complex, distal radial fracture (eg, Colles
         or Smith type) or epiphyseal separation, with or without       
         fracture of ulnar styloid, requiring manipulation; without     
         external skeletal fixation or percutaneous pinning             
25615.  Treatment of open distal radial fracture (eg, Colles or Smith   
         type) or epiphyseal separation, with or without fracture of    
         ulnar styloid, with uncomplicated soft tissue closure          
25626.  Treatment of open carpal scaphoid (navicular) fracture, with    
         uncomplicated soft tissue closure                              
25640.  Treatment of closed carpal bone fracture (excluding carpal      
         scaphoid (navicular), with uncomplicated soft tissue closure,  
         each bone                                                      
25665.  Treatment of open radiocarpal or intercarpal dislocation, one or
         more bones, with uncomplicated soft tissue closure             
26610.  Treatment of open metacarpal fracture, single, with             
         uncomplicated soft tissue closure, each bone                   
26655.  Treatment of open carpometacarpal fracture dislocation, thumb   
         (Bennett fracture), with or without internal or external       
         skeletal fixation                                              
26660.  Treatment of open carpometacarpal fracture dislocation, thumb   
         (Bennett fracture), with skeletal fixation                     
26680.  Treatment of open carpometacarpal dislocation, other than       
         Bennett fracture, single, with uncomplicated soft tissue       
         closure                                                        
26710.  Treatment of open metacarpophalangeal dislocation, single, with 
         uncomplicated soft tissue closure                              
26730.  Treatment of open phalangeal shaft fracture, proximal or middle 
         phalanx, finger or thumb, with uncomplicated soft tissue       
         closure, each                                                  
26744.  Treatment of open articular fracture, involving                 
         metacarpophalangeal or proximal interphalangeal joint, with    
         uncomplicated soft tissue closure, each                        
26780.  Treatment of open interphalangeal joint dislocation, single,    
         with uncomplicated soft tissue closure                         
27190.  Treatment of closed sacral fracture                             
27192.  Open treatment of closed or open sacral fracture                
27195.  Treatment of sacroiliac and/or symphysis pubis dislocation,     
         without manipulation                                           
27196.  Treatment of sacroiliac and/or symphysis pubis dislocation, with
         anesthesia and with manipulation                               
27201.  Treatment of open coccygeal fracture                            
27210.  Treatment of closed iliac, pubic or ischial fracture            
27504.  Treatment of open femoral shaft fracture (including             
         supracondylar), with uncomplicated soft tissue closure         
27512.  Treatment of open femoral fracture, distal end, medial or       
         lateral condyle, with uncomplicated soft tissue closure        
27522.  Treatment of open patellar fracture, with uncomplicated soft    
         tissue closure                                                 
27534.  Treatment of open tibial fracture, proximal (plateau), with     
         uncomplicated soft tissue closure                              
27564.  Treatment of open patellar dislocation, with uncomplicated soft 
         tissue closure                                                 
27754.  Treatment of open tibial shaft fracture, with uncomplicated soft
         tissue closure                                                 
27764.  Treatment of open distal tibial fracture (medial malleolus),    
         with uncomplicated soft tissue closure                         
27782.  Treatment of open proximal fibula or shaft fracture, with       
         uncomplicated soft tissue closure                              
27790.  Treatment of open distal fibular fracture (lateral malleolus),  
         with uncomplicated soft tissue closure                         
27800.  Treatment of closed tibia and fibula fractures, shafts; without 
         manipulation                                                   
27802.  Treatment of closed tibia and fibula fractures, shafts; with    
         manipulation                                                   
27804.  Treatment of open tibia and fibula fractures, shafts, with      
         uncomplicated soft tissue closure (eg ``pins above and below'')
27812.  Treatment of open bimalleolar ankle fracture, with uncomplicated
         soft tissue closure                                            
27820.  Treatment of open trimalleolar ankle fracture, with             
         uncomplicated soft tissue closure                              
27844.  Treatment of open ankle dislocation, with uncomplicated soft    
         tissue closure                                                 
28410.  Treatment of open calcaneal fracture, with uncomplicated soft   
         tissue closure                                                 
28440.  Treatment of open talus fracture, with uncomplicated soft tissue
         closure                                                        
28460.  Treatment of open tarsal bone fracture (except talus and        
         calcaneous), with uncomplicated soft tissue closure, each      
28480.  Treatment of open metatarsal fracture, with uncomplicated soft  
         tissue closure, each                                           
28500.  Treatment of open fracture great toe, phalanx or phalanges, with
         uncomplicated soft tissue closure                              
28520.  Treatment of open fracture, phalanx or phalanges, other than    
         great toe, with uncomplicated soft tissue closure, each        
28640.  Treatment of open metatarsophalangeal joint dislocation, with   
         uncomplicated soft tissue closure                              
28670.  Treatment of open interphalangeal joint dislocation, with       
         uncomplicated soft tissue closure                              
                                                                        
[[Page 5201]]                                                           
                                                                        
                           RESPIRATORY SYSTEM                           
                                                                        
31719.  Transtracheal (percutaneous) introduction of indwelling tube for
         therapy (eg, tickle tube, catheter for oxygen administration)  
                                                                        
                          FEMALE GENITAL SYSTEM                         
                                                                        
56000.  Incision and drainage of perineal abscess (nonobstetrical)      
56100.  Biopsy of perineum (separate procedure)                         
56200.  Perineoplasty, repair of perineum, nonobstetrical (separate     
         procedure)                                                     
57451.  Culdoscopy, diagnostic; with biopsy and/or lysis of adhesions or
         tubal sterilization                                            
58980.  Laparoscopy, diagnostic (separate procedure)                    
58984.  Laparoscopy, surgical; with fulguration or excision of lesions  
         of the ovary, pelvic viscera, or peritoneal surface by any     
         method                                                         
58985.  Laparoscopy, surgical; with lysis of adhesions                  
58986.  Laparoscopy, surgical; with biopsy (single or multiple)         
58987.  Laparoscopy, surgical; with aspiration (single or multiple)     
58988.  Laparoscopy, surgical; with removal of adnexal structures       
         (partial or total oophorectomy and/or salpingectomy)           
58990.  Hysteroscopy; diagnostic                                        
58992.  Hysteroscopy; with lysis of intrauterine adhesions or resection 
         of intrauterine septum (any method)                            
58994.  Hysteroscopy; with removal of submucous leiomyomata (any method)
------------------------------------------------------------------------

4. Additions to the List of Covered Procedures for Ambulatory Surgical 
Centers, Added to the 1993 CPT (Added to the Medicare Carriers Manual 
January 1, 1993)
    The CPT is updated annually, and some additions and deletions 
affect the ASC list. The following part 4 of this addendum is the list 
of procedures that were added to the ASC list because of additions to 
the 1993 CPT. These procedures were added to the ASC list by the 
Medicare Carriers Manual and were effective January 1, 1993. In the 
first column is the CPT code for the procedure; in the second column, 
the payment group for the procedure; and in the third column, the body 
system and description of the procedure.

------------------------------------------------------------------------
  CPT    Payment                                                        
 Code     Group                 Body system and description             
------------------------------------------------------------------------
                         MUSCOLOSKELETAL SYSTEM                         
                                                                        
23616.        4   Open treatment of proximal humeral (surgical or       
                   anatomical neck) fracture, with or without internal  
                   or external fixation, with or without repair of      
                   tuberosity(-ies); with proximal humeral prosthetic   
                   replacement                                          
24516.        4   Open treatment of humeral shaft fracture, with        
                   insertion of intramedullary implant, with or without 
                   cerclage and/or locking screws                       
24546.        5   Open treatment of humeral supracondylar or            
                   transcondylar fracture, with or without internal or  
                   external fixation; with intercondylar extension      
25520.        1   Closed treatment of radial shaft fracture, with       
                   dislocation of distal radioulnar joint (Galeazzi     
                   fracture/dislocation)                                
25525.        4   Open treatment of radial shaft fracture, with internal
                   and/or external fixation and closed treatment of     
                   dislocation of distal radioulnar joint (Galeazzi     
                   fracture/dislocation), with or without percutaneous  
                   skeletal fixation                                    
25526.        5   Open treatment of radial shaft fracture, with internal
                   and/or external fixation and open treatment, with or 
                   without internal or external fixation of distal      
                   radioulnar (Galeazzi fracture/ dislocation), includes
                   repair of triangular cartilage                       
25574.        3   Open treatment of radial and ulnar shaft fractures,   
                   with internal or external fixation; of radius or ulna
27193.        1   Closed treatment of pelvic ring fracture, dislocation,
                   diastasis or subluxation; without manipulation       
27194.        2   Closed treatment of pelvic ring fracture, dislocation,
                   diastasis or subluxation; with manipulation,         
                   requiring more than local anesthesia                 
27501.        2   Closed treatment of supracondylar or transcondylar    
                   femoral fracture with or without intercondylar       
                   extension, without manipulation                      
27503.        3   Closed treatment of supracondylar or transcondylar    
                   femoral fracture with or without intercondylar       
                   extension; with manipulation, with or without skin or
                   skeletal traction                                    
27507.        4   Open treatment of femoral shaft fracture with plate/  
                   screws, with or without cerclage                     
27509.        3   Percutaneous skeletal fixation of supracondylar or    
                   transcondylar femoral fracture, with or without      
                   intercondylar extension                              
27511.        4   Open treatment of femoral supracondylar fracture      
                   without intercondylar extension, with or without     
                   internal or external fixation                        
27513.        5   Open treatment of femoral supracondylar or            
                   transcondylar fracture with intercondylar extension, 
                   with or without internal or external fixation        
27535.        3   Open treatment of tibial fracture, proximal (plateau);
                   unicondylar, with or without internal or external    
                   fixation                                             
27759.        4   Open treatment of tibial shaft fracture (with or      
                   without fibular fracture) by intermedullary implant, 
                   with or without interlocking screws and/or cerclage  
27824.        1   Closed treatment of fracture of weight bearing        
                   articular portion of distal tibia (eg, pilon or      
                   tibial plafond), with or without anesthesia; without 
                   manipulation                                         
27825.        2   Closed treatment of fracture of weight bearing        
                   articular portion of distal tibia (eg, pilon or      
                   tibial plafond), with or without anesthesia; with    
                   skeletal traction and/or requiring manipulation      
27826.        3   Open treatment of fracture of weight bearing articular
                   surface/portion of distal tibia (eg, pilon or tibial 
                   plafond), with internal or external fixation; of     
                   fibula only                                          
27827.        3   Open treatment of fracture of weight bearing articular
                   surface/portion of distal tibia (eg, pilon or tibial 
                   plafond), with internal or external fixation; of     
                   tibia only                                           
[[Page 5202]]                                                           
                                                                        
27828.        4   Open treatment of fracture of weight bearing articular
                   surface/portion of distal tibia (eg, pilon or tibial 
                   plafond), with internal or external fixation; of both
                   tibia and fibula                                     
27829.        2   Open treatment of distal tibiofibular joint           
                   (syndesmosis) disruption, with or without internal or
                   external fixation                                    
28576.        3   Percutaneous skeletal fixation of talotarsal joint    
                   dislocation, with manipulation                       
28636.        3   Percutaneous skeletal fixation of metatarsophalangeal 
                   joint dislocation, with manipulation                 
28666.        3   Percutaneous skeletal fixation of interphalangeal     
                   joint dislocation, with manipulation                 
29850.        4   Arthroscopically aided treatment of intercondylar     
                   spine(s) and/or tuberosity fracture(s) of the knee,  
                   with or without manipulation; without internal or    
                   external fixation (includes arthroscopy)             
29851.        4   Arthroscopically aided treatment of intercondylar     
                   spine(s) and/or tuberosity fracture(s) of the knee,  
                   with or without manipulation; with internal or       
                   external fixation (includes arthroscopy)             
29855.        4   Arthroscopically aided treatment of tibial fracture,  
                   proximal (plateau); unicondylar, with or without     
                   internal or external fixation (includes arthroscopy) 
29856.        4   Arthroscopically aided treatment of tibial fracture,  
                   proximal (plateau); bicondylar, with or without      
                   internal or external fixation (includes arthroscopy) 
                                                                        
                           RESPIRATORY SYSTEM                           
                                                                        
31730.        1   Transtracheal (percutaneous) introduction of needle   
                   wire dilator/stent or indwelling tube for oxygen     
                   therapy                                              
                                                                        
                          FEMALE GENITAL SYSTEM                         
                                                                        
56300.        3   Laparoscopy, diagnostic (separate procedure)          
56303.        5   Laparoscopy, surgical; with fulguration or excision of
                   lesions of the ovary, pelvic viscera, or peritoneal  
                   surface by any method                                
56304.        5   Laparoscopy, surgical; with lysis of adhesions        
56305.        4   Laparoscopy, surgical; with biopsy (single or         
                   multiple)                                            
56306.        4   Laparoscopy, surgical; with aspiration (single or     
                   multiple)                                            
56307.        5   Laparoscopy, surgical; with removal of adnexal        
                   structures (partial or total oophorectomy and/or     
                   salpingectomy)                                       
56350.        1   Hysteroscopy, diagnostic (separate procedure)         
56352.        2   Hysteroscopy, surgical; with lysis of intrauterine    
                   adhesions (any method)                               
56354.        3   Hysteroscopy, surgical; with removal of leiomyomata   
56405.        2   Incision and drainage of vulva or perineal abscess    
56605.        1   Biopsy of vulva or perineum (separate procedure); one 
                   lesion                                               
56810.        5   Perineoplasty, repair of perineum, non-obstetrical    
                   (separate procedure)                                 
------------------------------------------------------------------------

5. Deletions From the List of Covered Procedures for Ambulatory 
Surgical Centers, Deleted from the 1994 CPT
    The CPT is updated annually, and some additions and deletions 
affect the ASC list. The following part 5 of this addendum is the list 
of procedures that were deleted from the ASC list because they were 
deleted from the 1994 CPT. These deletions were effective April 11, 
1994. This list of deletions differs from the Medicare Carriers Manual 
instruction that was effective April 11, 1994, in that we have since 
decided to retain four of the nasal and sinus endoscopy codes: CPT 
codes 31254 through 31256 and 31267. We are retaining these codes since 
we anticipate that they will be reinstated by the CPT Editorial Panel 
effective January 1995.
    In the first column is the CPT code for the procedure; and in the 
second column, the body system and description of the procedure.
    We are requesting public comments on the appropriateness of the 
deletion of the CPT codes in Addendum C, part 5, because we had not 
suggested them for deletion in our December 1993 proposed notice.

------------------------------------------------------------------------
  CPT                                                                   
 Code                      Body system and description                  
------------------------------------------------------------------------
                           RESPIRATORY SYSTEM                           
                                                                        
31252.  Nasal endoscopy, surgical; with nasal polypectomy               
31258.  Nasal endoscopy, surgical; with removal of foreign body(s)      
31260.  Maxillary sinus endoscopy, diagnostic, with or without biopsy   
         (separate procedure)                                           
31263.  Maxillary sinus endoscopy, surgical; with removal of foreign    
         body(s)                                                        
31265.  Maxillary sinus endoscopy, surgical; with removal of cyst       
31268.  Maxillary sinus endoscopy, surgical; with removal of fungus ball
31270.  Sphenoid endoscopy, diagnostic, with or without biopsy (separate
         procedure)                                                     
31275.  Sphenoid endoscopy, surgical                                    
31277.  Sphenoid endoscopy, surgical; with removal of mucous membrane   
                                                                        
                          CARDIOVASCULAR SYSTEM                         
                                                                        
36820.  Insertion of cannula for hemodialysis, other purpose;           
         arteriovenous, internal (Climino type)                         
                                                                        
                            DIGESTIVE SYSTEM                            
                                                                        
43451.  Dilation of esophagus, by unguided sound or bougie, single or   
         multiple passes; subsequent session                            
43455.  Dilation of esophagus, by balloon or dilator; under fluoroscopic
         guidance                                                       
45310.  Proctosigmoidoscopy; with removal of polyp or papilloma         
45336.  Sigmoidoscopy, flexible fiberoptic; with ablation of tumor or   
         mucosal lesion (eg, electrocoagulation, laser photocoagulation,
         hot biopsy/fluguration)                                        
46000.  Fistulotomy, subcutaneous                                       
49300.  Peritoneoscopy; without biopsy                                  
49301.  Peritoneoscopy; with biopsy                                     
49302.  Peritoneoscopy with guided transhepatic cholangiography; without
         biopsy                                                         
49303.  Peritoneoscopy with guided transhepatic cholangiography; with   
         biopsy                                                         
49401.  Pneumoperitoneum (separate procedure); subsequent               
49510.  Repair inguinal hernia, age 5 or over; with orchiectomy, with or
         without implantation of prosthesis                             
49515.  Repair inguinal hernia, age 5 or over; with orchiectomy, with   
         excision of hydrocele or spermatocele                          
49552.  Repair femoral hernia, Henry approach                           
49575.  Repair epigastric hernia, properitoneal fat (separate           
         procedure); complex                                            
49581.  Repair umbilical hernia; age 5 or over                          
------------------------------------------------------------------------

6. Additions to the List of Covered Procedures for Ambulatory Surgical 
Centers, Added to the 1994 CPT (Added to the Medicare Carriers Manual 
January 1, 1994)
    The CPT is updated annually, and some additions and deletions 
affect the ASC list. The following part 6 of this addendum is the list 
of procedures that were added to the ASC list because of additions to 
the 1994 CPT. These procedures were added to the ASC list by the 
Medicare Carriers Manual and were effective January 1, 1994. In the 
[[Page 5203]] first column is the CPT code for the procedure; in the 
second column, the payment group for the procedure; and in the third 
column, the body system and description of the procedure.
    We are requesting public comments on the appropriateness of the 
addition of, and assignment of payment groups for, the CPT codes in 
Addendum C, part 6, because we had not suggested them for addition in 
our December 1993 proposed notice.

------------------------------------------------------------------------
  CPT    Payment                                                        
 code     group                 Body system and description             
------------------------------------------------------------------------
                          INTEGUMENTARY SYSTEM                          
                                                                        
19125.        3   Excision of breast lesion identified by pre-operative 
                   placement of radiological marker; single lesion      
19126.        3   Excision of breast lesion identified by pre-operative 
                   placement of radiological marker; each additional    
                   lesion separately identified by a radiological marker
                                                                        
                         MUSCULOSKELETAL SYSTEM                         
                                                                        
24566.        2   Percutaneous skeletal fixation of humeral epicondylar 
                   fracture, medial or lateral, with manipulation       
24582.        2   Percutaneous skeletal fixation of humeral condylar    
                   fracture, medial or lateral, with manipulation       
                                                                        
                           RESPIRATORY SYSTEM                           
                                                                        
31233.        2   Nasal/sinus endoscopy, diagnostic with maxillary      
                   sinusoscopy (via inferior meatus or canine fossa     
                   puncture)                                            
31235.        1   Nasal/sinus endoscopy, diagnostic with sphenoid       
                   sinusoscopy (via puncture of sphenoidal face or      
                   cannulation of osteum)                               
31237.        2   Nasal/sinus endoscopy, surgical; with biopsy,         
                   polypectomy or debridement (separate procedure)      
31238.        1   Nasal/sinus endoscopy, surgical; with control of      
                   epistaxis                                            
31239.        4   Nasal/sinus endoscopy, surgical; with                 
                   dacryocystorhinostomy                                
31240.        2   Nasal/sinus endoscopy, surgical; with concha bullosa  
                   resection                                            
31245.        3   Nasal/sinus endoscopy, surgical, with osteomeatal     
                   complex (OMC) resection and/or anterior              
                   ethmoidectomy, with or without removal of polyp(s)   
31246.        3   Nasal/sinus endoscopy, surgical, with osteomeatal     
                   complex (OMC) resection and/or anterior              
                   ethmoidectomy, with or without removal of polyp(s);  
                   with antrostomy                                      
31247.        3   Nasal/sinus endoscopy, surgical, with osteomeatal     
                   complex (OMC) resection and/or anterior              
                   ethmoidectomy, with or without removal of polyp(s);  
                   with antrostomy and removal of antral mucosal disease
31248.        3   Nasal/sinus endoscopy, surgical, with osteomeatal     
                   complex (OMC) resection and/or anterior              
                   ethmoidectomy, with or without removal of polyp(s);  
                   with frontal sinus exploration                       
31249.        3   Nasal/sinus endoscopy, surgical, with osteomeatal     
                   complex (OMC) resection and/or anterior              
                   ethmoidectomy, with or without removal of polyp(s);  
                   with frontal sinus exploration and antrostomy        
31251.        3   Nasal/sinus endoscopy, surgical, with osteomeatal     
                   complex (OMC) resection and/or anterior              
                   ethmoidectomy, with or without removal of polyp(s);  
                   with frontal sinus exploration, antrostomy, and      
                   removal of antral mucosal disease                    
31261.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy (APE), with or without       
                   removal of polyp(s)                                  
31262.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy (APE), with or without       
                   removal of polyp(s); with antrostomy                 
31264.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy (APE), with or without       
                   removal of polyp(s); with antrostomy and removal of  
                   antral mucosal disease                               
31266.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy (APE), with or without       
                   removal of polyp(s); with frontal sinus exploration  
31269.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy (APE), with or without       
                   removal of polyp(s); with frontal sinus exploration  
                   and antrostomy                                       
31271.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy (APE), with or without       
                   removal of polyp(s); with frontal sinus exploration, 
                   antrostomy, and removal of antral mucosal disease    
31280.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy and sphenoidotomy (APS), with
                   or without removal of polyp(s)                       
31281.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy and sphenoidotomy (APS), with
                   or without removal of polyp(s); with antrostomy      
31282.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy and sphenoidotomy (APS), with
                   or without removal of polyp(s); with antrostomy and  
                   removal of antral mucosal disease                    
31283.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy and sphenoidotomy (APS), with
                   or without removal of polyp(s); with frontal sinus   
                   exploration                                          
31284.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy and sphenoidotomy (APS), with
                   or without removal of polyp(s); with frontal sinus   
                   exploration and antrostomy                           
31286.        5   Nasal/sinus endoscopy, surgical, with anterior and    
                   posterior ethmoidectomy and sphenoidotomy (APS), with
                   or without removal of polyp(s); with frontal sinus   
                   exploration, antrostomy and removal of antral mucosal
                   disease                                              
31287.        3   Nasal/sinus endoscopy, surgical, with sphenoidotomy   
31288.        3   Nasal/sinus endoscopy, surgical, with sphenoidotomy;  
                   with removal of tissue from the sphenoid sinus       
                                                                        
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                            DIGESTIVE SYSTEM                            
                                                                        
43216.        1   Esophagoscopy, rigid or flexible; with removal of     
                   tumor(s), polyp(s), or other lesion(s) by hot biopsy 
                   forceps or bipolar cautery                           
43248.        2   Upper gastrointestinal endoscopy including esophagus, 
                   stomach, and either the duodenum and/or jejunum as   
                   appropriate; with insertion of guide wire followed by
                   dilation of esophagus over guide wire                
43250.        2   Upper gastrointestinal endoscopy including esophagus, 
                   stomach, and either the duodenum and/or jejunum as   
                   appropriate; with removal of tumor(s), polyp(s), or  
                   other lesion(s) by hot biopsy forceps or bipolar     
                   cautery                                              
43261.        2   Endoscopic retrograde cholangiopancreatography (ERCP);
                   with biopsy, single or multiple                      
43458.        2   Dilation of esophagus with balloon (30 mm diameter or 
                   larger) for achalasia                                
44365.        2   Small intestinal endoscopy, enteroscopy beyond second 
                   portion of duodenum, not including ileum; with       
                   removal of tumor(s), polyp(s), or other lesion(s) by 
                   hot biopsy forceps or bipolar cautery                
44394.        1   Colonoscopy through stoma; with removal of tumor(s),  
                   polyp(s), or other lesion(s) by snare technique      
45308.        1   Proctosigmoidosopy, rigid; with removal of single     
                   tumor, polyp, or other lesion by hot biopsy forceps  
                   or bipolar cautery                                   
45309.        1   Proctosigmoidoscopy, rigid; with removal of single    
                   tumor, polyp, or other lesion by snare technique     
45338.        1   Sigmoidoscopy, flexible; with removal of tumor(s),    
                   polyp(s), or other lesion(s) by snare technique      
45339.        1   Sigmoidoscopy, flexible; with ablation of tumor(s),   
                   polyp(s), other lesion(s) not amenable to removal by 
                   hot biopsy forceps, bipolar cautery or snare         
                   technique                                            
45384.        2   Colonoscopy, flexible, proximal to splenic flexure;   
                   with removal of tumor(s), polyp(s), or other         
                   lesion(s) by hot biopsy forceps or bipolar cautery   
46611.        1   Anoscopy; with removal of single tumor, polyp, or     
                   other lesion by snare technique                      
49585.        4   Repair umbilical hernia, age 5 or over; reducible     
                                                                        
                 LAPAROSCOPY/PERITONEOSCOPY/HYSTEROSCOPY                
                                                                        
56360.        2   Peritoneoscopy; without biopsy                        
56361.        3   Peritoneoscopy; with biopsy                           
56362.        3   Peritoneoscopy; with guided transhepatic              
                   cholangiography; with biopsy                         
56363.        3   Peritoneoscopy with guided transhepatic               
                   cholangiography; with biopsy                         
                                                                        
                          EYE AND OCULAR ADNEXA                         
                                                                        
66172.        4   Fistulization of sclera for glaucoma; trabeculectomy  
                   ab externo with scarring from previous ocular surgery
                   or trauma (includes injection of antifibrotic agents)
------------------------------------------------------------------------

[FR Doc. 95-1897 Filed 1-25-95; 8:45 am]
BILLING CODE 4120-01-P