[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.
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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
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number and expiration date. Credit card orders can also be placed by
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2250. The cost for each copy is $8. As an alternative, you can view and
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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
[[Page 5204]]
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