[Federal Register Volume 60, Number 236 (Friday, December 8, 1995)]
[Rules and Regulations]
[Pages 63124-63357]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: X95-11208]




[[Page 63123]]

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Part II





Department of Health and Human Services





_______________________________________________________________________



Health Care Financing Administration



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42 CFR Part 400, et al.



Medicare Program; Physician Fee Schedule for Calendar Year 1996; 
Payment Policies and Relative Value Unit Adjustments; Final Rule and 
Notice

Federal Register / Vol. 60, No. 236 / Friday, December 8, 1995 / 
Rules and Regulations

[[Page 63124]]


DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Parts 400, 405, 410, 411, 412, 413, 414, 415, 417, and 489

[BPD-827-FC]
RIN 0938-AG96


Medicare Program; Revisions to Payment Policies and Adjustments 
to the Relative Value Units Under the Physician Fee Schedule for 
Calendar Year 1996

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

ACTION: Final rule with comment period.

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

SUMMARY: This final rule revises various policies affecting payment for 
physician services including Medicare payment for physician services in 
teaching settings, the relative value units (RVUs) for certain existing 
procedure codes, and establishes interim RVUs for new and revised 
procedure codes. The rule also includes the final revised 1996 
geographic practice cost indices.
    The rule redesignates current regulations on teaching hospitals, on 
the services of physicians to providers, on the services of physicians 
in providers, and on the services of interns and residents. This 
redesignation consolidates related rules affecting a specific audience 
in a separate part and, thereby, makes them easier to use.

DATES: Effective Date: This final rule is effective January 1, 1996, 
except part 415 which is effective July 1, 1996.
    Comment Date: We will accept comments on interim RVUs for new or 
revised procedure codes identified in Addendum C. Comments will be 
considered if we receive them at the appropriate addresses, as provided 
below, no later than 5 p.m., February 6, 1996.

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-827-FC, P.O. Box 7519, 
Baltimore, MD 21207-0519.
    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 C5-09-26, 7500 Security Boulevard, Baltimore, MD 21244-1850.

    Because of staffing and resource limitations, we cannot accept 
comments by facsimile (FAX) transmission. In commenting, please refer 
to file code BPD-827-FC. 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).
    For comments that relate to information collection requirements, 
mail a copy of comments to: Allison Herron Eydt, HCFA Desk Officer, 
Office of Information and Regulatory Affairs, Rm. 10235, New Executive 
Office Bldg., Washington, DC 20530.
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ASCII, Lotus 123, and WordPerfect 5.1.

FOR FURTHER INFORMATION CONTACT: Shana Olshan, (410) 786-5714 (for all 
issues except those related to physician services in teaching 
settings). William Morse, (410) 786-4520 (for issues related to 
physician services in teaching settings).

SUPPLEMENTARY INFORMATION: In this final rule, we provide background on 
the statutory authority for and development of the physician fee 
schedule. We also explain in detail the process by which certain 
interim work RVUs are reviewed and, in some cases, revised.
    Section 1848(c)(2)(B) of the Social Security Act (the Act) provides 
that adjustments in RVUs resulting from an annual review of those RVUs 
may not cause total physician fee schedule payments to differ by more 
than $20 million from what they would have been had the adjustments not 
been made. Thus, the statute allows a $20 million tolerance for 
increasing or reducing total expenditures under the physician fee 
schedule. We have determined that net increases because of changes in 
RVUs for codes reviewed as part of a refinement process, the addition 
of new codes to the fee schedule, and the revisions in payment policies 
would have added to projected expenditures in calendar year 1996 by 
approximately $140 million. Therefore, it is necessary to adjust the 
physician fee schedule conversion factors (CFs). We have made the 
adjustments in such a manner as to achieve budget neutrality as we were 
best able to estimate. As a result, the total projected expenditures 
from the revised fee schedule are estimated to be the same as they 
would have been had we not changed the RVUs for any individual codes or 
added new codes to the fee schedule. We have adjusted all CFs by a 
uniform adjustment factor of 0.9964, which results in a uniform 
reduction of 0.36 percent to the CFs for all services.
    The CF is a national value that converts RVUs into payment amounts. 
There are three separate CFs: one for surgical services, one for 
primary care services, and one for nonsurgical services other than 
primary care. The CFs are updated annually.
    Anesthesia services are paid differently from other physicians' 
services under the fee schedule. Payment for anesthesia services is 
based on base unit RVUs that are assigned to each service and on time 
units that can vary by procedure. The base and time units are 
multiplied by an anesthesia-specific CF, not the CFs used for surgical, 
nonsurgical, or primary care services.
    This final rule also contains the second half of the revisions to 
the geographic practice cost indices (GPCIs). Section 1848(e)(1)(c) of 
the Act requires that the GPCIs be reviewed and, if necessary, revised 
at least every 3 years. The first review was required by 1995. The 
first-half of the revision was implemented in 1995. The second half, 

[[Page 63125]]
published in Addendum D, is effective January 1, 1996.
    Addenda to this rule provide the following information:
Addendum A--Explanation and Use of Addenda B through E.
Addendum B--1996 Relative Value Units and Related Information Used in 
Determining Medicare Payments for 1996.
Addendum C--Codes with Interim Relative Value Units.
Addendum D--1996 Geographic Practice Cost Indices by Medicare Carrier 
and Locality.
Addendum E--Procedure Codes Subject to the Site-of-Service 
Differential.

    The RVUs and revisions to payment policies in this final rule apply 
to physicians' services furnished on or after January 1, 1996.
    For those codes identified in Addendum C of this final rule as new 
or revised codes, the RVUs and update indicators are considered to be 
interim as they have not been published before this final rule. 
Therefore, we will accept comments on these interim RVUs and update 
indicators if they are received no later than 5 p.m. February 6, 1996. 
The RVUs for the remaining codes are final.
    To assist readers in referencing sections contained in this final 
rule, we are providing the following table of contents. Some of the 
issues discussed in this final rule affect the payment policies but do 
not require changes to the regulations in the Code of Federal 
Regulations.

Table of Contents

I. Background
    A. Legislative Requirements
    B. Published Changes to the Fee Schedule
    C. Components of the Fee Schedule Payment Amounts
    D. Summary of the Development of the Relative Value Units
    1. Work Relative Value Units
    2. Practice Expense and Malpractice Expense Relative Value Units
II. Specific Proposals for Calendar Year 1996 and Responses to 
Public Comments
    A. Budget-Neutrality Adjustments for Relative Value Units
    B. Bundled Services
    1. Hydration Therapy and Chemotherapy
    2. Evaluation of Psychiatric Records and Reports and Family 
Counseling Services
    3. Fitting of Spectacles
    C. X-Rays and Electrocardiograms Taken in the Emergency Room
    D. Extension of Site-of-Service Payment Differential to Services 
in Ambulatory Surgical Centers
    E. Services of Teaching Physicians
    1. General Background
    2. Payment for Physician Services Furnished in Teaching Settings
    3. Payments for Supervising Physicians in Teaching Settings and 
for Residents in Certain Settings
    4. Public Comments on the Teaching Physician Proposal in the 
Proposed Rule and Our Responses
    F. Unspecified Physical and Occupational Therapy Services (HCFA 
Common Procedure Coding System Codes M0005 Through M0008 and H5300)
    G. Transportation in Connection With Furnishing Diagnostic Tests
    H. Maxillofacial Prosthetic Services
    I. Coverage of Mammography Services
III. Anesthesia Issues
    A. Modifier Units for Anesthesia Services
    B. Issue for Change in Calendar Year 1998--Two Anesthesia 
Providers Involved in One Procedure
IV. Refinement of Relative Value Units for Calendar Year 1996 and 
Responses to Public Comments on Interim Relative Value Units for 
1995
    A. Summary of Issues Discussed Related to the Adjustment of 
Relative Value Units
    B. Process for Establishing Work Relative Value Units for the 
1996 Fee Schedule
    1. Work Relative Value Unit Refinements of Interim and Related 
Relative Value Units
    2. Establishment of Interim Work Relative Value Units for New 
and Revised Codes for 1996
V. Issues for Discussion
    A. Five-Year Refinement of Relative Value Units
    B. Resource-Based Practice Expense Relative Value Units
    C. Case Management in a Fee-for-Service System
VI. Provisions of the Final Rule
VII. Collection of Information Requirements
VIII.Response to Comments
IX. Regulatory Impact Analysis
    A. Regulatory Flexibility Act
    B. Budget-Neutrality Adjustments
    C. Bundled Services
    1. Hydration Therapy and Chemotherapy
    2. Evaluation of Psychiatric Records and Reports and Family 
Counseling Services
    3. Fitting of Spectacles
    D. X-Rays and Electrocardiograms Taken in the Emergency Room
    E. Extension of Site-of-Service Payment Differential to Services 
in Ambulatory Surgical Centers
    F. Services of Teaching Physicians
    G. Unspecified Physical and Occupational Therapy Services (HCFA 
Common Procedure Coding System Codes M0005 Through M0008 and H5300)
    H. Transportation in Connection With Furnishing Diagnostic Tests
    I. Maxillofacial Prosthetic Services
    J. Coverage of Mammography Services
    K. Two Anesthesia Providers Involved in One Procedure
    L. Rural Hospital Impact Statement
    Text of the Final Regulations
    Addenda
Addendum A--Explanation and Use of Addenda B through E
Addendum B--1996 Relative Value Units and Related Information Used 
in Determining Medicare Payments for 1996
Addendum C--Codes with Interim Relative Value Units
Addendum D--1996 Geographic Practice Cost Indices by Medicare 
Carrier and Locality
Addendum E--Procedure Codes Subject to the Site-of-Service 
Differential

    In addition, because of the many organizations and terms to which 
we refer by acronym in this final rule, we are listing these acronyms 
and their corresponding terms in alphabetical order below:

ASC  Ambulatory surgical center
CF  Conversion factor
CFR  Code of Federal Regulations
CPT  [Physicians'] Current Procedural Terminology [4th Edition, 1994, 
copyrighted by the American Medical Association] DEFRA Deficit 
Reduction Act
EKG  Electrocardiogram
GPCI  Geographic Practice Cost Index
GME  Graduate Medical Education
HCFA  Health Care Financing Administration
HCPCS  HCFA Common Procedure Coding System
OBRA  Omnibus Budget Reconciliation Act
ORA  Omnibus Reconciliation Act
RUC  [American Medical Association Specialty Society] Relative [Value] 
Update Committee
RVU  Relative Value Unit
TEFRA  Tax Equity and Fiscal Responsibility Act

I. Background

A. Legislative Requirements

    The Medicare program was established in 1965 by the addition of 
title XVIII to the Social Security Act (the Act). Since January 1, 
1992, Medicare pays for physician services under section 1848 of the 
Act, ``Payment for Physicians' Services.'' This section contains three 
major elements: (1) A fee schedule for the payment of physician 
services; (2) a Medicare volume performance standard for the rates of 
increase in Medicare expenditures for physician services; and (3) 
limits on the amounts that nonparticipating physicians can charge 
beneficiaries. The Act requires that payments under the fee schedule be 
based on national uniform relative value units (RVUs) based on the 
resources used in furnishing a service. Section 1848(c) of the Act 
requires that national RVUs be established for physician work, practice 
expense, and malpractice expense.
    Section 1848(e)(1)(c) of the Act requires us to review and, if 
necessary, adjust the geographic practice cost indices at least every 3 
years. This section of the Act also requires us to phase in the 
adjustment over 2 years and implement only one half of any 

[[Page 63126]]
adjustment if more than 1 year has elapsed since the last geographic 
practice cost index revision. The geographic practice cost indices were 
first implemented in 1992 and were not reviewed until 1994. We 
implemented one half of the adjustment in 1995 and will implement the 
second half of the adjustment in 1996.
    The Act requires that payments vary among fee schedule areas 
according to geographic indices. In general, the fee schedule areas 
that existed under the prior reasonable charge system were retained 
under the fee schedule. A detailed discussion of fee schedule areas can 
be found in the June 5, 1991 proposed rule (56 FR 25832) and in the 
November 25, 1991 final rule (56 FR 59514). We are required by section 
1848(e)(1)(A) of the Act to develop separate indices to measure 
relative cost differences among fee schedule areas compared to the 
national average for each of the three fee schedule components. While 
requiring that the practice expense geographic practice cost indices 
and malpractice geographic practice cost indices reflect the full 
relative cost differences, the Act requires that the work indices 
reflect only one-quarter of the relative cost differences compared to 
the national average.

B. Published Changes to the Fee Schedule

    We published a final rule on November 25, 1991, (56 FR 59502) to 
implement section 1848 of the Act by establishing a fee schedule for 
physician services furnished on or after January 1, 1992. In the 
November 1991 final rule (56 FR 59511), we stated our intention to 
update RVUs for new and revised codes in the American Medical 
Association's Physicians' Current Procedural Terminology (CPT) through 
an ``interim RVU'' process every year. The updates to the RVUs and fee 
schedule policies follow:
     November 25, 1992, as a final notice with comment period 
on new and revised RVUs only (57 FR 55914).
     December 2, 1993, as a final rule with comment period (58 
FR 63626) announcing revised payment policies and RVUs for 1994. (We 
solicited comments on new and revised RVUs only.)
     December 8, 1994, as a final rule with comment period (59 
FR 63410) to revise the geographic adjustment factor values, fee 
schedule payment areas, and payment policies and RVUs for 1995. The 
final rule also discussed the process for periodic review and 
adjustment of RVUs not less frequently than every 5 years as required 
by section 1848(c)(2)(B)(I) of the Act.
Prior Federal Register Documents
    The information in this final rule with comment period updates 
information in the following Federal Register documents:
     June 5, 1991, proposed rule entitled ``Fee Schedule for 
Physicians' Services'' (56 FR 25792).
     November 25, 1991, final rule entitled ``Fee Schedule for 
Physicians' Services'' (56 FR 59502).
     September 15, 1992, correction notice for the 1992 fee 
schedule (57 FR 42491).
     November 25, 1992, final notice with comment period 
entitled ``Fee Schedule for Physicians' Services for CY 1993'' (57 FR 
55914).
     June 7, 1993, correction notice for the 1993 fee schedule 
(58 FR 31964).
     July 14, 1993, proposed rule entitled ``Revisions to 
Payment Policies Under the Physician Fee Schedule'' (58 FR 37994).
     December 2, 1993, final rule with comment period entitled 
``Revisions to Payment Policies and Adjustments to the Relative Value 
Units under the Physician Fee Schedule for Calendar Year 1994'' (58 FR 
63626). (There were two correction notices published for the 1994 
physician fee schedule (July 15, 1994, 59 FR 36069) and (August 4, 
1994, 59 FR 39828).)
     June 24, 1994, proposed rule entitled ``Refinements to 
Geographic Adjustment Factor Values and Other Policies Under the 
Physician Fee Schedule'' (58 FR 32754).
     December 8, 1994, final rule with comment period entitled 
``Refinements to Geographic Adjustment Factor Values, Revisions to 
Payment Policies, Adjustments to the Relative Value Units (RVUs) Under 
the Physician Fee Schedule for Calendar Year 1995, and the 5-Year 
Refinement of RVUs'' (59 FR 63410). (There were two correction notices 
published for the 1995 physician fee schedule (January 3, 1995, 60 FR 
46) and (July 18, 1995, 60 FR 36733).)
     July 26, 1995, proposed rule entitled ``Revisions to 
Payment Policies Under the Physician Fee Schedule for Calendar Year 
1996 (60 FR 38400).
    This final rule would affect the regulations set forth at 42 CFR 
part 400, which consists of an introduction to, and definitions for, 
the Medicare and Medicaid programs; part 405, which encompasses 
regulations on Federal health insurance for the aged and disabled; part 
410, which consists of regulations on supplementary medical insurance 
benefits; part 414, which covers regulations on payment for Part B 
medical and other health services; and new part 415, which contains 
regulations on services of physicians in providers, supervising 
physicians in teaching settings, and residents in certain settings. We 
are making technical and conforming amendments to parts 411, 412, 413, 
417, and 489.

C. Components of the Fee Schedule Payment Amounts

    Under the formula set forth in section 1848(b)(1) of the Act, the 
payment amount for each service paid for under the physician fee 
schedule is the product of three factors: (1) A nationally uniform 
relative value for the service; (2) a geographic adjustment factor for 
each physician fee schedule area; and (3) a nationally uniform 
conversion factor for the service. There are three conversion factors 
(CFs)--one for surgical services, one for nonsurgical services, and one 
for primary care services. The conversion factors convert the relative 
values into payment amounts.
    For each physician fee schedule service, there are three relative 
values: (1) An RVU for physician work; (2) an RVU for practice expense; 
and (3) an RVU for malpractice expense. For each of these components of 
the fee schedule there is a geographic practice cost index for each fee 
schedule area. The geographic practice cost indices reflect the 
relative costs of practice expenses, malpractice insurance, and 
physician work in an area compared to the national average.
    The general formula for calculating the Medicare fee schedule 
amount for a given service in a given fee schedule area can be 
expressed as:

Payment=[(RVUwork  x  GPCIwork) + (RVUpractice expense 
x  GPCIpractice expense) + (RVUmalpractice  x  
GPCImalpractice)]  x  CF

The conversion factors for calendar year 1996 appear in Addendum A. The 
RVUs for calendar year 1996 are in Addendum B. The GPCIs are in 
Addendum D.
    Section 1848(e) of the Act requires the Secretary to develop 
geographic adjustment factors for all physician fee schedule areas. The 
total geographic adjustment factor for a fee schedule area is equal to 
a weighted average of the individual GPCIs for each of the three 
components of the service. Thus, the geographic practice cost indices 
reflect the relative costs of practice expenses, malpractice insurance, 
and physician work in an area compared to the national average. In 
accordance with the law, however, the geographic adjustment factor for 
the physician's 

[[Page 63127]]
work reflects one-quarter of the relative cost of physician's work 
compared to the national average.
    For the first year of the fee schedule, the law required a base-
year CF that was budget-neutral relative to 1991 estimated 
expenditures. The Secretary is required to recommend to the Congress 
updates to the CFs by April 15 of each year as part of the Medicare 
volume performance standards and annual fee schedule update process. 
The Congress may choose to enact the Secretary's recommendation, enact 
another update amount, or not act at all. If the Congress does not act, 
the annual fee schedule update is set according to a ``default'' 
mechanism in the law. Under this mechanism, the update will equal the 
Medicare Economic Index adjusted by the amount actual expenditures for 
the second previous fiscal year (FY) were greater or less than the 
performance standard rate of increase for that FY. (The Medicare 
Economic Index is a physician input price index, in which the annual 
percent changes for the direct-labor price component are adjusted by an 
annual percent change in a 10-year moving average index of labor 
productivity in the nonfarm business sector.) The Medicare volume 
performance standard for FY 1996 and the physician fee schedule update 
for CY 1996 are published elsewhere in this Federal Register issue as a 
final notice (BPD-828-FN).

D. Summary of the Development of the Relative Value Units

1. Work Relative Value Units
    Approximately 7,500 codes represent services included in the 
physician fee schedule. The work RVUs established for the 
implementation of the fee schedule in January 1992 were developed with 
extensive input from the physician community. The original work RVUs 
for most codes were developed by a research team at the Harvard School 
of Public Health in a cooperative agreement with us. In constructing 
the vignettes for the original RVUs, Harvard worked with panels of 
expert physicians and obtained input from physicians from numerous 
specialties.
    The RVUs for radiology services are based on the American College 
of Radiology (ACR) relative value scale, which we integrated into the 
overall physician fee schedule. The RVUs for anesthesia services are 
based on RVUs from a uniform relative value guide. We established a 
separate CF for anesthesia services because we continue to recognize 
time as a factor in determining payment for these services.
    Proposed RVUs for services were published in a proposed rule in the 
Federal Register on June 5, 1991 (56 FR 25792). We responded to the 
comments in the November 1991 final rule. Since many of the RVUs were 
published for the first time in the final rule, we considered the RVUs 
to be interim during the first year of the fee schedule and gave the 
public 120 days to comment on all work RVUs. In response to the final 
rule, we received comments on approximately 1,000 services. We 
responded to those comments and listed the new RVUs in the November 
1992 notice for the 1993 fee schedule for physicians' services. We 
considered these RVUs to be final and did not request comments on them.
    The November 1992 notice (57 FR 55914) also discussed the process 
used to establish work RVUs for codes that were new or revised in 1993. 
The RVUs for these codes, which were listed in Addendum C of the 
November 1992 notice, were considered interim in 1993 and open to 
comment through January 26, 1993.
    We responded to comments received on RVUs listed in Addendum C of 
the November 1992 notice (57 FR 56152) in the December 1993 final rule 
(58 FR 63647) for the 1994 physician fee schedule. The December 1993 
final rule discussed the process used to establish RVUs for codes that 
were new or revised for 1994. The RVUs for these codes, which are 
listed in Addendum C of the December 1993 final rule (58 FR 63842), 
were considered interim in 1994 and open to comment through January 31, 
1994. We proposed RVUs for some non-Medicare and carrier-priced codes 
in our June 1994 proposed rule (59 FR 32760). Codes listed in Table 1 
of the June 1994 proposed rule were open to comment. These comments, in 
addition to comments on RVUs published as interim in the December 1993 
final rule were addressed in the December 1994 final rule (59 FR 
63432). In addition, the December 1994 final rule discussed the process 
used to establish RVUs for codes that were new or revised for 1995. 
Interim RVUs for new or revised procedure codes were open to comment. 
Comments were also accepted on all RVUs considered under the 5-year 
refinement process. The comment period closed on February 6, 1995.
2. Practice Expense and Malpractice Expense Relative Value Units
    Section 1848(c)(2)(C) of the Act requires that the practice expense 
and malpractice expense RVUs equal the product of the base allowed 
charges and the practice expense and malpractice percentages for the 
service. Base allowed charges are defined as the national average 
allowed charges for the service furnished during 1991, as estimated 
using the most recent data available. For most services, we used 1989 
charge data ``aged'' to reflect the 1991 payment rules, since those 
were the most recent data available for the 1992 fee schedule.
    If charge data were unavailable or insufficient, we imputed the 
practice expense and malpractice expense RVUs from the work RVUs. For 
example, if a procedure has work RVUs of 6.00, and the specialty 
practice cost percentages for the specialty furnishing the service is 
60 percent work, 30 percent practice expense, and 10 percent 
malpractice expense, then the total RVUs would be 10.00 (6.00/.60), the 
practice expense RVUs would be 3.00 (10  x  .30), and the malpractice 
expense RVUs would be 1.00 (10  x  .10).

II. Specific Proposals for Calendar Year 1996 and Responses to Public 
Comments

    In response to the publication of the July 26, 1995 proposed rule, 
we received approximately 9,500 comments. We received comments from 
individual physicians and health care workers and professional 
associations and societies. The majority of the comments addressed two 
proposals: (1) Revising Medicare payment for physician services in 
teaching settings; and (2) paying for only one interpretation of an 
electrocardiogram or an x-ray procedure furnished to an emergency room 
patient except in unusual circumstances.
    The proposed rule discussed policies that affect the number of RVUs 
on which payment for certain services would be based. Any changes 
implemented through this final rule are subject to the $20 million 
limitation on annual adjustments as contained in section 1848(c)(2)(B) 
of the Act.
    After reviewing the comments and determining the policies we will 
implement, we have estimated the costs and savings of these policies 
and added those costs and savings to the estimated costs associated 
with any other changes in RVUs for 1996, including RVU changes 
necessitated by the 1995 CPT coding changes. We discuss in detail the 
effects of these changes in the Regulatory Impact Analysis (section 
IX).
    In the July 1995 proposed rule (60 FR 38416), we invited public 
comments on a proposal to calculate the Medicare volume performance 
standard for fiscal year 1996 and all future years based on estimates 
of the average volume and intensity growth specific to each category of 
physician service. We are 

[[Page 63128]]
responding to the comments we received on this issue in the final 
notice entitled ``Physician Fee Schedule Update for Calendar Year 1996 
and Physician Volume Performance Standard Rates of Increase for Federal 
Fiscal Year 1996 (BPD-828-FN) published elsewhere in this Federal 
Register issue.
    For the convenience of the reader, the headings for the policy 
issues in sections II, III, and IV, for the most part, correspond to 
the headings used in the July 1995 proposed rule. More detailed 
background information for each issue can be found in the July 1995 
proposed rule (60 FR 38400).

A. Budget-Neutrality Adjustments for Relative Value Units

    We make annual adjustments to RVUs for the physician fee schedule 
to reflect changes in CPT codes and changes in estimated physician 
work. The statute requires that these revisions may not change 
physician expenditures by more than $20 million compared to estimated 
expenditures that would have occurred if the RVU adjustments had not 
been made. In the past, we have made an adjustment across all RVUs in 
the physician fee schedule to maintain this statutorily-mandated budget 
neutrality.
    We recognize that many other payers, including several Medicaid 
programs, use the Medicare physician fee schedule. To reduce the number 
of system changes required by the annual revisions to the physician fee 
schedule, we proposed to apply these budget-neutrality adjustments to 
the physician fee schedule conversion factors (CFs) rather than across 
all RVUs.
    The impact of this proposal on payment amounts would be minimal 
(slight differences could be caused by rounding). This alternative 
approach would be administratively simpler for Medicare and other 
payers that base payment on the Medicare RVUs, including many State 
Medicaid programs. In addition, this change would provide for 
consistent RVUs from year to year (for those codes with no other 
changes), thus making it easier to analyze payment and policy changes.
    Comment: An overwhelming majority of commenters strongly supported 
our decision to apply the annual budget-neutrality adjustments to the 
physician fee schedule CFs rather than across all RVUs, beginning with 
the publication of this final rule in the Federal Register; however, a 
few commenters suggested that we apply this change retroactively by 
converting all RVUs, which were altered for budget-neutrality reasons, 
back to their original 1992 levels.
    Response: For the sake of administrative simplicity, we will not 
readjust RVUs from periods before the current period. In addition, we 
believe that retroactively adjusting the RVUs would cause unnecessary 
programming costs for those who electronically maintain systems 
containing the RVU data.
    Comment: A few commenters suggested the use of a separate budget-
neutrality factor rather than the adjustment of the physician fee 
schedule CFs to achieve budget neutrality. They stated that private 
payers who use the Medicare fee schedule CFs would then be able to 
decide whether to apply the budget neutrality adjustment. This 
particularly could be an issue for any adjustments needed for the five-
year review of all work RVUs, depending on the magnitude of the 
adjustments.
    Response: We prefer to adjust the existing CFs rather than add an 
additional factor to adjust for budget neutrality. Because we 
explicitly identify the magnitude of the annual budget-neutrality 
adjustment, other payers can decide whether to apply the adjustment to 
their CFs. However, we may reconsider this issue in the future for 
issues such as the 5-year review of RVUs or congressional action.
    Final Decision: Beginning with the publication of this final rule, 
we will apply annual budget-neutrality adjustments to physician fee 
schedule CFs rather than across all RVUs. However, if the Congress 
explicitly sets a conversion factor at a fixed dollar amount for a 
given year, we will consider establishing a separate budget-neutrality 
adjustor.

B. Bundled Services

1. Hydration Therapy and Chemotherapy
    We proposed not paying separately for hydration therapy infusion 
(CPT codes 90780 and 90781) when billed on the same day as chemotherapy 
infusion, CPT codes (96410, 96412, and 96414). Frequently, hydration 
therapy and chemotherapy are performed at the same time. We believe 
paying for both would be duplicative. We would continue to pay 
separately for both the hydration therapy solution and the chemotherapy 
drug. This reflects a policy change that is not explicitly addressed in 
our regulations.
    Comment: Commenters objected to our proposal stating that the 
administration of saline for hydration therapy infusion at the same 
time as chemotherapy infusion requires significant additional work and 
supplies.
    Response: We disagree. The saline and the chemotherapy drug are 
usually administered through the same port or site. In some cases, the 
solutions may even be mixed. We see no significant additional work or 
expense involved in these cases, and we believe that paying separately 
for hydration therapy infusion administered at the same time as 
chemotherapy infusion represents duplicate payment.
    Comment: A commenter agreed with our proposal stating that the same 
access port or site is used for administering the chemotherapy drug and 
the hydration therapy solution. The commenter requested clarification 
as to whether the policy would apply to other drugs, such as 
antiemetics and corticosteroids, which are often administered with 
chemotherapy and, like hydration therapy, billed using CPT codes 90780 
and 90781. The commenter suggested that a logical extension of our 
proposal is to cover the administration of these drugs as well as 
hydration therapy.
    Response: We agree with this comment. CPT codes 90780 and 90781 for 
the administration of saline or drugs such as antiemetics and 
corticosteriods will not be paid separately when furnished at the same 
time as CPT codes 96410, 96412, and 96414 for chemotherapy infusion. 
However, we will pay separately for the drugs.
    Comment: Most commenters agreed that for any given segment of time 
it would be duplicative to pay for both chemotherapy infusion and 
hydration therapy infusion. These commenters noted that the course of 
treatment for many chemotherapy drugs, for example, cisplatin, 
ifosmamide, and methotrexate, require hydration therapy or the infusion 
of an antiemetic on the same day, but either before or after the 
chemotherapy. The commenters believed that in these cases, the work is 
not duplicative, and they should be allowed to bill for the infusion of 
the saline or antiemetic.
    Response: We agree. We are revising our proposal to allow payment 
for hydration therapy or the infusion of an antiemetic or other 
nonchemotherapy drug on the same day as chemotherapy infusion when the 
nonchemotherapy drug is administered sequentially rather than at the 
same time as the chemotherapy infusion.
    Final Decision: We will not pay for the infusion of saline, an 
antiemetic, or any other nonchemotherapy drug under CPT codes 90780 and 
90781 when these drugs are administered at the same time as 
chemotherapy infusion (CPT codes 

[[Page 63129]]
96410, 96412, or 96414). However, we will pay for the infusion of 
saline, antiemetics, or any other nonchemotherapy drug under CPT codes 
90780 and 90781 when these drugs are administered on the same day but 
sequentially to rather than at the same time as chemotherapy infusion, 
under CPT codes 96410, 96412, and 96414. Physicians should use the new 
modifier ``-GB'' to indicate when CPT codes 90780 and 90781 are 
provided sequentially rather than contemporaneously with CPT codes 
96410, 96412, and 96414.
    This policy change is not explicitly addressed in our regulations.
2. Evaluation of Psychiatric Records and Reports and Family Counseling 
Services
    At present, we allow separate payment for CPT codes 90825 and 
90887. However, we believe that the activities described by these codes 
are generally performed as part of the prework and postwork of other 
physician services. The RVUs for psychiatric services (CPT codes 90801 
and 90835 through 90857) include the prework and postwork activities 
described by CPT codes 90825 and 90887. Thus, continuing to allow 
separate payment for these codes, in addition to payment for other 
psychiatric services, results in duplicate payments and is inconsistent 
with our policy for other services.
    Counseling of the family is part of the work of all other 
evaluation and management services. Medicare has a long-standing policy 
of covering these services if they relate to the management of the 
beneficiary's problems and not to the problems of the family member. We 
believe it is appropriate to bundle covered family counseling 
procedures into the other psychiatric codes so that our policy is 
consistent with our policy on services furnished by other physician 
specialties.
    Therefore, we proposed to change the status indicator for CPT codes 
90825 and 90887 to ``B'' to show that payment for these codes is 
bundled into the payment for another service, and separate payment 
would not be allowed. We proposed to implement this change in a budget-
neutral manner by redistributing the RVUs for CPT codes 90825 and 90887 
across the following psychiatric codes: 90801, 90820, 90835, 90842 
through 90847, and 90853 through 90857.
    Comment: Several commenters questioned our claim that the work 
involved in CPT codes 90825 and 90887 is a fundamental element of the 
pre- and postwork of other physician or other psychiatric services, 
stating that medical psychotherapy is a specific procedure, distinct 
from evaluation and management, and that these procedures (CPT codes 
90825 and 90887) are characteristically excluded from psychotherapy. 
Some commenters believed this payment change would be inherently unfair 
to providers who furnish services under CPT codes 90825 and 90887.
    Response: In addressing the concern that CPT codes 90825 and 90887 
are excluded from psychotherapy and represent distinct and different 
services, we note that in the CPT chapter on Psychiatry, General 
Clinical Psychiatric Diagnostic or Evaluative Interview Procedures, CPT 
code 90801 (Psychiatric Interview) refers to both communication with 
family or other sources, as well as the ordering and medical 
interpretation of laboratory or other medical diagnostic studies. 
Further, the definition includes the history and the exchange of 
information with family members and other informants. Additionally, the 
final report by Harvard researchers (``Refinement of the Development of 
a Resource-Based Relative Value Scale for Psychiatrist Services; 
National Institute of Mental Health Contract No. 278-87-0024'') defines 
physician work as encompassing work while with the patient and work 
before and after the service, defined as reviewing records as well as 
communicating with the patient, the patient's family, and other 
professionals. We believe these definitions clearly indicate that the 
evaluation of other records and family counseling fall within the scope 
of medical psychotherapy and, thus, do not represent distinct services. 
Therefore, we believe it is appropriate to bundle payment for these 
services.
    Comment: Several commenters specifically addressed CPT code 90887. 
One commenter agreed that the services encompassed by CPT code 90825 
are usually performed as part of the pre- and postwork for other 
physician services, but expressed concern this was not true for CPT 
code 90887, which is typically the exclusive service being furnished. 
Another commenter questioned the redistribution of the RVUs for CPT 
code 90887. The commenter believed that if, as stated, family 
counseling is part of the postwork of evaluation and management 
services, the RVUs for this service should be distributed across all 
evaluation and management codes, not just the psychiatric codes.
    Response: Family counseling must be related to the patient. The 
fact that this service occurs on different days or times does not 
preclude it from being part of the pre- and postwork. Although we 
recognize that the services described by CPT code 90887 may be provided 
on different dates of service from when the patient received 
psychiatric service, they are still considered part of the postwork 
service associated with that code. We note, also, that the evaluation 
and management services cannot be billed by clinical psychologists and, 
thus, have been included in other service codes.
    If the RVUs for CPT code 90887 were distributed across all 
evaluation and management codes as well as the psychiatric codes for 
this service, the impact would be negligible. That is, the amount to be 
distributed is not of sufficient magnitude to have any noticeable 
effect.
    Comment: One commenter requested that we also consider changing the 
status indicator for CPT code 90862 (Pharmacologic management) to ``B'' 
because, according to the commenter, pharmacological management is part 
of evaluation and management services.
    Response: Separate payment for pharmacological management is not 
permitted on the same day as psychotherapy as this service is already 
included in the codes for psychotherapy. To distinguish services to 
Medicare beneficiaries for the sole purpose of drug management from 
those that include some psychotherapy, HCFA developed HCPCS code M0064. 
This code is defined as a brief office visit for the sole purpose of 
monitoring or changing drug prescriptions used in the treatment of 
mental, psychoneurotic, and personality disorders.
    Comment: According to one commenter, since the original survey of 
psychiatric work conducted by Harvard researchers, managed care has 
increased. With the rise in managed care, there is a decrease in mental 
health benefits. Therefore, the patients that psychiatrists treat, 
especially in the fee-for-service setting, are much more complex. The 
commenter believed this additional work is not currently included in 
the RVUs for psychiatric services. In addition, this commenter has 
found that psychiatrists are spending a greater amount of time 
responding to review requests, developing treatment plans for managed 
care, managing and supervising nonphysician mental health providers, 
and documenting and coding work.
    Response: Section 1848(c)(2)(B) of the Act requires that all RVUs 
be reviewed not less frequently than every 5 years to account for 
changes in medical practice, coding changes, new data, and new 
procedures. Thus, the issues of psychiatric work time, as well as the 

[[Page 63130]]
issue of psychiatric services delivered in a managed care setting, will 
be addressed as part of the 5-year review process.
    Final Decision: We will bundle the payment for CPT codes 90825 and 
90887 into the payment for other psychiatric services. Therefore, 
separate payment for CPT codes 90825 and 90887 is not allowed.
    This policy change is not explicitly addressed in our regulations.
3. Fitting of Spectacles
    We proposed to cease paying separately for the fitting of glasses 
and low vision systems. The payment for the fitting of spectacles is 
included in the payment for the spectacles in the same way that payment 
for other prosthetic fitting services is included in the payment for 
the prosthetic device.
    We proposed to assign a ``B'' status indicator to CPT codes 92352, 
92353, 92354, 92355, 92358, and 92371 to indicate that the services are 
covered under Medicare but that payment for them is bundled into the 
payment for the spectacles. We proposed to implement this in a budget-
neutral manner by redistributing the current RVUs for these services 
across all RVUs.
    This reflects a policy change that is not explicitly addressed in 
our regulations.
    Comment: A commenter believed that these fitting services should 
continue to be paid separately because of the time and expertise 
required to fit glasses for aphakic patients and low vision aids.
    Response: The fitting of spectacles is covered under section 
1861(s)(8) of the Act. Services under this section are not included in 
the definition of physician services as defined in section 1848(j)(3) 
of the Act and are not payable under the physician fee schedule. 
Although we have been allowing payment, the fitting of spectacles is 
included in the payment for the spectacles in the same way that payment 
for other prosthetic fitting services are included in the payment for 
the device. Under the current system, duplicate payment has been made 
for the aforementioned procedure codes.
    Final Decision: We will no longer pay separately for CPT codes 
92352, 92353, 92354, 92355, 92358, and 92371. Beginning January 1, 
1996, these codes will be assigned a ``B'' status indicator to indicate 
that the services are covered under Medicare, but payment for them is 
bundled into the payment for the spectacles.
    This policy change is not explicitly addressed in our regulations.

C. X-Rays and Electrocardiograms Taken in the Emergency Room

    We proposed to pay for the x-ray and/or electrocardiogram (EKG) 
interpretation that contributes to the diagnosis or treatment of the 
patient in the emergency room. We will pay for only one x-ray and/or 
EKG interpretation except under unusual circumstances.
    Comment: The comments from radiologists opposed every aspect of the 
proposal. The primary point raised by virtually all of these commenters 
was that, by training and experience, they were more qualified than 
emergency physicians or other nonradiologists to furnish these 
interpretations. Some radiologists commented that we should require 
board certification as a requirement to bill for the interpretation of 
x-rays.
    Response: In paying for physicians' services under the Act, we are 
charged with determining the following:
     Is the service covered under Medicare?
     Is the service reasonable and necessary for the individual 
beneficiary?
     Is the physician licensed to perform the service in the 
State in which it is furnished?
    In the case of a licensed physician who has furnished a covered 
service (that is not payable through another code) to a Medicare 
beneficiary in an emergency room, it is not readily apparent to us upon 
what basis the claim can be denied. There is no portion of the Act upon 
which to base a decision that only board-certified radiologists can 
furnish x-ray interpretations or board-certified cardiologists can 
furnish EKG interpretations. (Where the Congress has determined that 
there should be special qualifications in order to furnish a service, 
as in the case of mammography, a provision was made in the statute.) 
Our proposed policy for x-ray and EKG interpretation is consistent with 
how we generally treat other physician services.
    Comment: Emergency room physicians supported the direction of the 
proposal but requested clarification of the proposal including its 
effect on payments for second interpretations. Many commended us for 
proposing to change the existing policy but criticized the agency for 
not going far enough. Several emergency physicians commented that it 
was unethical for us to withhold compensation from physicians who make 
life-saving decisions every day based on x-ray and EKG interpretations.
    Response: Our proposal addressed situations in which both the 
emergency physician and the radiologist/cardiologist billed for the 
same interpretation. It is that situation in which a determination 
needs to be made of which interpretation contributed to the diagnosis 
and treatment of the individual patient. If an emergency physician does 
not bill for the interpretation, there would be no change from existing 
policy. We would like to stress that if the only bill received is from 
the radiologist or cardiologist, it is paid on the same basis as 
current claims.
    Comment: We received relatively few comments from physicians and 
other entities specializing in cardiology procedures. Their comments 
focused on the cardiologists' greater qualifications to interpret EKGs 
based on their training and experience.
    Response: The discussion above about the qualifications of the 
interpreting radiologist would also apply here. The situation with EKGs 
is somewhat different than with x-rays because section 13514 of OBRA 
1993, Public Law 103-66, enacted August 10, 1993, requires us to make 
separate payment for EKG interpretations and to exclude the RVUs for 
EKG interpretations from the RVUs for visits and consultations, making 
the EKG portion of the current policy as set forth in section 2020G of 
the Medicare Carriers Manual obsolete.
    Comment: We proposed that the radiologist or cardiologist should be 
paid for the interpretation when it is performed contemporaneously with 
the diagnosis and treatment of the emergency room patient. This 
standard would be met if an interpretation were initially conveyed to 
the treating physician verbally. Nearly all commenters seemed to be 
troubled by the use of the term ``contemporaneous'' and requested 
clarification of the term. Some radiologists indicated that their 
interpretation is furnished contemporaneously if it is provided timely, 
which commenters variously defined as 12-24 hours. Other radiologists 
indicated that there are teleradiology hook-ups to radiologists, homes 
which should satisfy the need for contemporaneous interpretations. 
Several emergency room specialists indicated that the circumstances 
under which a radiologist or cardiologist furnishes a contemporaneous 
interpretation as discussed in the proposal should be clarified. They 
expressed concern that the provision of a verbal interpretation by the 
specialist to the emergency room physician could be used to circumvent 
the stated intention to pay for the interpretation used in the 
diagnosis and treatment of the beneficiary. 

[[Page 63131]]

    Response: When we used the term contemporaneous, we meant that the 
interpretation of the procedure by the radiologist or cardiologist and 
the diagnosis and treatment of the beneficiary by the physician in the 
emergency room occur at the same time, as opposed to an interpretation 
performed hours or days after the beneficiary is sent home. While the 
argument that the carrier should pay for any interpretation furnished 
timely sounds reasonable, it does not reflect the realities of claims 
processing. It would be impossible for a reviewer to make an assessment 
in every individual case as to whether the second interpretation was 
furnished ``timely.'' In situations in which both physicians bill for 
the interpretation, the question to be resolved is whether the 
radiologist or cardiologist performed the interpretation in time to be 
used in the diagnosis and treatment of the patient. As set forth in the 
proposal, we believe that in any case in which the radiologist or 
cardiologist furnishes the interpretation (a written interpretation or 
a verbal interpretation that will be written later), the emergency room 
physician should not bill for the interpretation, and the carrier 
should pay for the claim submitted by the radiologist or cardiologist. 
The comments we received from the emergency room physicians did not 
seem to be requesting payment for interpretations furnished under these 
conditions. We agree that an interpretation furnished via teleradiology 
meets the requirement when the interpretation is used in the diagnosis 
and treatment of the patient.
    Comment: Several commenters indicated that emergency room 
physicians without formal training in interpreting computerized axial 
tomography (CT) scans will miss subtle changes which could lead to 
permanent injuries to patients. They also stated that there were 
problems with the application of the proposal to other diagnostic 
procedures such as mammography, ultrasound, and upper and lower 
gastrointestinal series.
    Response: This proposal applies only to x-ray procedures and EKGs 
furnished in emergency rooms.
    Comment: Many radiologists indicated that the proposal will 
increase the Medicare program costs ``tremendously'' because of the 
potential for self-referral abuse. The commenters believed that 
physicians who see patients in the emergency room will order 
unnecessary tests if they know that they will be able to bill for the 
interpretations of these tests.
    Response: We would be interested in reviewing any evidence the 
radiologists have that emergency room physicians order additional tests 
that are not medically necessary when they are permitted to bill for x-
ray and EKG interpretations. We are also interested in any suggestions 
we might offer to the carriers on how to identify such unnecessary 
testing. We will address any self referral prohibitions within our 
Stark regulations.
    Comment: Several radiologists pointed out that a proper 
interpretation does not really mean a ``check'' or a few words on the 
chart, but requires a full written report.
    Response: We agree completely. The requirement for a written report 
of the interpretation of an x-ray or EKG is an integral part of our 
proposal. We would point out that less extensive ``reviews'' by 
emergency room physicians are not separately billable because payment 
for such reviews is included in the payment for the evaluation and 
management services rendered in an emergency room.
    Comment: Many radiologists commented that, while some emergency 
medicine specialists are very proficient at reading trauma films, they 
lack the necessary training to identify subtle changes. For example, a 
patient is brought into the emergency room with chest trauma. The 
commenter indicated that the emergency physician would identify the 
broken ribs but miss a lung tumor. Several other commenters were 
concerned that a missed early diagnosis could result from an 
interpretation performed by a nonradiologist emergency room physician 
while a radiologist would review the total film rather than just the 
area of clinical concern.
    Response: It seems to us that the major purpose of the emergency 
room x-ray in this instance would be to diagnose the degree of chest 
trauma. However, in this circumstance, if the emergency physician 
billed for the interpretation and a radiologist made an additional 
finding of a lung tumor, it would be appropriate for the carrier to pay 
for both interpretations.
    Comment: One radiologist indicated that all too often the emergency 
room preliminary interpretation is made by a nurse or medical student 
and the films are never reviewed by a staff emergency room physician.
    Response: It is difficult to see how such an observation relates to 
our proposal. A physician could not provide a written interpretation of 
an x-ray unless he or she personally viewed it. A written report of 
interpretation is an integral part of our proposal.
    Comment: Many commenters objected to the hospital playing a role in 
determining which physician should bill for the interpretation of these 
procedures. The following comments were received:
     Hospitals are not capable of making such determinations.
     It would be in the financial interest of the hospital for 
the interpretation to be paid to those physicians who order the most 
tests.
     The medical staff is usually a legally separate and 
independent body from the hospital, and hospitals have no authority to 
become involved in such matters.
     Such decisions should be left to peer review.
     Hospitals should be encouraged to ensure that the billed 
interpretation is the one upon which treatment is based.
     The concept of a hospital making a policy decision as to 
which physician should get paid for interpretations will be a 
regulatory nightmare and the time and money carriers will have to 
expend to monitor the situations will be enormous. However, one 
emergency room physician commented that he hoped the proposal would 
encourage radiologists and cardiologists to furnish these 
interpretations in a more timely fashion.
    Response: In developing our proposal, we considered requiring 
hospitals to notify their local carrier of the identity of the 
physician who would be performing these interpretations for their 
patients. We determined that such a requirement would have had an 
effect as indicated by one of the commenters and that our authority to 
impose such a requirement was questionable. However, under our 
proposal, we suggested that hospitals act to ensure that only one 
interpretation is billed. (Hospitals could do this now; we are not 
mandating an additional duty.) If a carrier receives only one claim, 
there will be no problem. The problem will arise when hospitals do not 
take action and the carrier receives two claims for each interpretation 
and then must make a determination about which claim to pay. It seems 
reasonable to us for hospitals to work with their medical staffs to 
establish guidelines for the billing of x-ray and EKG interpretations 
for emergency room patients.
    Comment: Some commenters expressed concern about the effect of the 
proposal on small, rural hospitals in which there are an insufficient 
number of radiologists to cover the emergency room 24 hours a day. It 
was pointed out that many of these hospitals either go without any 
service at all and ship films to radiologists for interpretation or 

[[Page 63132]]
receive direct radiologist's services on an infrequent basis each week. 
One commenter indicated that consideration should be given to the size 
of the hospital, the definition of what constitutes an emergency room, 
and the availability of radiologic services.
    Response: Since our proposal is limited to emergency room services, 
if a hospital does not have an emergency room and no claims with a 
place of service indicator of emergency room are received, there does 
not appear to be a problem. Likewise, if there is an emergency room in 
a hospital but no emergency room physician bills for an interpretation 
of the test, there is also no problem. We indicated in our proposal 
that if a carrier receives only one claim for a reasonable and 
necessary interpretation of an x-ray or EKG, it would pay the claim, 
generally without further development.
    Comment: One commenter indicated that the proposal was 
inappropriate because emergency room physicians are thankful that 
radiologists will interpret the overnight x-rays the next morning in 
view of the harried circumstances under which services are furnished in 
the emergency room.
    Response: Our proposal does not require emergency room physicians 
to bill for these interpretations. If the emergency room physicians do 
not bill for these interpretations, the radiologist and cardiologist 
may continue to be paid for the interpretations. Our proposal has no 
effect on situations in which the emergency physician does not wish to 
bill for the interpretation.
    Comment: A carrier medical director expressed concern that it will 
be impossible to determine from a claim whether the emergency physician 
has submitted written documentation of the x-ray or EKG interpretation 
for the medical record. The carrier medical director went on to 
indicate that encouraging hospitals to exercise their authority to 
ensure that only one claim for interpretation is received will not work 
and recommended that the current policy should be maintained.
    Response: By submitting a claim for the interpretation of an x-ray 
or EKG, the emergency room physician is stating that he or she has 
prepared a written interpretation of the procedure for inclusion in the 
patient's medical record. We do not agree that the current manual 
policy works well since it became partially obsolete by the physician 
fee schedule.
    Comment: Another carrier medical director indicated that the 
requirement for a written report be strengthened to indicate that 
Medicare is requiring a separately written report which meets the 
hospital's requirement for an official report.
    Response: We agree and will include such a written report 
requirement in the revised manual instructions.
    Comment: Some emergency room physicians commented that they should 
be paid for the x-ray and EKG interpretation in almost every case since 
it is they who furnish the real-time service.
    Response: We believe that our proposal is a better approach. There 
is no question that the cardiologist or radiologist should be paid for 
the interpretation when that physician furnishes the service in time to 
be used in the diagnosis and treatment of the patient. Further, we 
believe that there are physicians who work in emergency rooms who 
prefer to defer to a cardiologist or radiologist for the final 
interpretation and do not wish to prepare written reports or bill for 
interpretations. However, our proposal provides for payment when the 
emergency room physician provides a written interpretation that 
contributed to the diagnosis and treatment of the patient.
    Comment: One commenter indicated that, in their community hospital, 
the radiologist is summoned at the time of the initial diagnosis and 
treatment for the most serious cases, whereas, for less urgent 
examinations, the formal interpretation is made the following morning. 
The commenter went on to say that the issue should be the 
responsiveness of the radiologist when his or her input will affect 
care, and that having x-rays read by nonradiologists is moving in the 
wrong direction.
    Response: As indicated previously, interpretations by radiologists 
used for the diagnosis and treatment of the patient would be payable.
    Comment: A few commenters suggested that the appropriate approach 
is to split the fee for the interpretation between the radiologist and 
the ER physician.
    Response: We do not believe that this would be a workable approach 
since the carrier would not know when or if it would receive the second 
claim.
    Comment: Radiologists made the following additional comments:
     The majority of carrier medical directors do not support 
the proposal.
     The changes do not reflect the findings of the July 1993 
report of the Department of Health and Human Services, Office of 
Inspector General, entitled ``Medicare's Reimbursement for 
Interpretations of Hospital Emergency Room X-Rays.''
    Response: We did present the proposal to a committee of carrier 
medical directors during a monthly conference call on operational 
issues and the views were mixed. The major impression we drew from 
their comments was that they were most concerned with enforcement 
issues. We will continue to seek the guidance of the carrier medical 
directors and other interested parties in developing instructions to 
implement this policy.
    The recommendation of the OIG report was to pay for 
reinterpretations of x-rays only when attending physicians specifically 
request a second physician's interpretation in order to render 
appropriate medical care before the patient is discharged. Any other 
reinterpretation of the attending physician's original interpretation 
should be treated and reimbursed as part of the hospital's quality 
assurance program.
    Using 1990 data, the OIG projected savings of $20.4 million based 
on a cessation on payments for radiologists' interpretations of x-rays 
if its recommendation were implemented. We believe that the OIG 
recommendation would result in no payment for interpretations of these 
services in many cases; therefore, we reject that portion of the 
recommendation. In other words, we believe that one physician should be 
paid for the interpretation of an x-ray.
    Comment: One commenter suggested that the solution to this problem 
be developed through the CPT system. The commenter suggested that we 
propose separate codes for the emergent reading of the test and a 
second, different code for the over-read. This commenter and some 
others indicated that payment for these interpretations be evenly 
divided between the two codes.
    Response: The commenter may want to refer this proposal to the CPT 
Editorial Panel.
    Final Decision: We are adopting the policy as set forth in the 
proposed rule for services furnished on or after January 1, 1996.
    Listed below are the elements of our policy.
     The carrier will pay separately for only one 
interpretation of an EKG or x-ray procedure furnished to an emergency 
room patient. However, there is a provision for payment of second 
interpretation under unusual circumstances such as a questionable 
finding for which the physician performing the initial interpretation 
believes another physician's expertise is needed.
     The professional component of a diagnostic procedure 
furnished to a beneficiary in a hospital includes an interpretation and 
written report for 

[[Page 63133]]
inclusion in the beneficiary's medical record maintained by the 
hospital. We have placed this requirement in the radiology section of 
the regulations on services of physicians in providers at 
Sec. 405.554(a). (Under the recodification, this section becomes 
415.120(a)).
     We distinguish between an ``interpretation and report'' of 
an x-ray or an EKG procedure and a ``review'' of the procedure. An 
interpretation and report of the procedure is separately payable by the 
carrier. A review of the findings of these procedures, without a 
written report, does not meet the conditions for separate payment of 
the service since the review is already included in the emergency room 
visit payment.
     In the case of multiple bills for the same interpretation 
and report, we will instruct the carriers to adopt the following 
procedures:
    + Cease consideration of physician specialty in deciding which 
interpretation and report to pay regardless of when the service is 
performed.
    + Pay for the interpretation and report that directly contributed 
to the diagnosis and treatment of the individual patient.
    + Pay for the interpretation billed by the cardiologist or 
radiologist if the interpretation of the procedure is performed at the 
same time as the diagnosis and treatment of the beneficiary. (This 
interpretation may be a verbal report conveyed to the treating 
physician that will be written in a report at a later time.)
     We will minimize the carrier's need to make decisions 
about which claim to pay when multiple claims for the interpretation 
and report of the same procedure are received by--
    + Encouraging hospitals to work with their medical staffs to ensure 
that only one claim per interpretation is submitted;
    + Advising hospitals that if they allow a physician to perform and 
bill for a medically necessary service (the interpretation and report) 
in an emergency room and permit another physician to perform and bill 
for the same service, the Medicare carrier will not pay two claims;
    + Advising hospitals that the Medicare carrier may determine that 
the hospital's ``official interpretation'' is for quality control and 
liability purposes only and is a service to the hospital rather than to 
an individual beneficiary; and
    + Advising hospitals that Medicare fiscal intermediaries consider 
costs incurred for quality control activities in determining payments 
to hospitals.
     When the Medicare carrier receives only one claim for an 
interpretation and the procedure is reasonable and necessary, the 
carrier will pay the claim. We will presume that the one service billed 
was a service to the individual beneficiary and not a quality control 
measure.
    Manual instructions to the carriers will be issued as soon as 
possible.
    This policy change is not explicitly addressed in our regulations.

D. Extension of Site-of-Service Payment Differential to Services in 
Ambulatory Surgical Centers

    We proposed extending the site-of-service payment differential to 
services on the ambulatory surgical center (ASC) covered list of 
procedures that are predominantly performed in an office setting. We 
see no reason for exempting these procedures from the site-of-service 
payment differential. The practice expense RVUs duplicate many of the 
overhead expenses included in the ASC facility and hospital payment 
rates. As such, when a service is provided in an ASC or a hospital, the 
physician does not bear the same level of practice costs as when the 
same service is furnished in the office. Therefore, in Sec. 414.32 
(``Determining payments for certain physician services furnished in 
facility settings''), we proposed to modify in paragraph (d) 
(``Services excluded from the reduction'') the subordinate paragraph 
(d)(2), which would have the effect of applying the site-of-service 
payment differential to ASC services. The payment differential does not 
apply to procedures performed in an ASC that are not on the ASC list 
because no facility payment is made.
    Comment: Many commenters stated that the Act provides that 
procedures included on the ASC list, by definition, are not office-
based procedures. Commenters indicated that we had concluded in 
previously published regulations on ASCs that certain procedures, such 
as cystoscopies, prostate biopsies, and skin lesion excisions, are not 
office-based procedures.
    Response: Historically, the ASC list included only procedures that 
were performed less than half of the time in an office setting. 
Consequently, the ASC list and the site-of-service payment differential 
lists were mutually exclusive. Over time, many procedures shifted from 
being performed predominately in ASCs to being performed predominately 
in offices. However, in many cases the procedures were retained on the 
ASC list because we were persuaded by arguments that while the 
procedure may usually be done in an office, there were circumstances 
justifying using an ASC. Therefore, the two lists are no longer 
mutually exclusive. Retention of certain procedures on the ASC list 
does not imply that they cannot appropriately be performed in an 
office. In fact, the only procedures proposed for addition to the site-
of-service differential payment list are those that are performed in an 
office setting the majority of the time.
    Comment: Several commenters questioned the accuracy of data or 
indicated that they could not fully evaluate the proposals because we 
did not publish data on which the site-of-service list is based. Some 
stated we should use clinically-based criteria instead of purely 
objective, arithmetic data.
    Many commenters indicated that many of the procedures added to the 
site-of-service differential list were inappropriate and unlikely to be 
office-based procedures because they are extraordinarily complicated 
procedures, require anesthesia or sophisticated equipment, or need to 
be evaluated on a case by case basis. Several commenters believed the 
list to be arbitrary and unfair. Others indicated that physicians 
should not be punished for selecting the medically appropriate site for 
certain procedures on the list. One commenter agreed that we should 
encourage physicians to perform procedures in an office when it is safe 
and effective.
    Another commenter stated that we should pay urologists for supplies 
and a small facility fee to shift procedures to the less costly office 
setting.
    Some commenters stated that because nasal/sinus endoscopy codes 
were added to the ASC list effective January 1, 1994 the site-of-
service data are likely to be skewed toward the physician's office 
setting. Other commenters stated the CPT description for breast biopsy 
(CPT code 19100) was recently changed to include only core needle 
aspiration while fine needle aspiration is now reported using code CPT 
code 88170. One commenter agreed that breast biopsy should be on the 
list. Other commenters argued that the data do not distinguish between 
techniques employed. Many commenters indicated that the policy does not 
account for gender differences. For example, cystoscopies performed on 
males are more difficult and painful and are inappropriate for an 
office setting.
    Response: According to our data, the procedures on the site-of-
service payment differential list are performed in a physician's office 
more than 50 percent of the time. Inclusion of procedures on the list 
is not intended to 

[[Page 63134]]
reflect a judgment regarding the appropriateness of the site where the 
service is performed or to encourage performance of procedures in the 
less costly office setting or to create a financial disincentive for 
the physician to select the most appropriate site. Inclusion on this 
list merely recognizes where the service is being furnished the 
majority of the time. We recognize that although the majority of the 
procedures we proposed to add to the site-of-service list are performed 
in a physician's office, the ASC setting is sometimes appropriate. That 
is the reason they remain on the ASC list. It is not the purpose of 
this policy to dictate where a physician should perform the service. 
The policy reflects the lower practice costs incurred by physicians 
when these services are performed in an ASC or a hospital.
    Comment: One commenter objected to including urodynamic evaluation 
CPT codes 51725, 51726, and 51772 on the site-of-service payment 
differential list. Another commenter provided information demonstrating 
that 21 other proposed procedures should not be on the list because 
more recent data indicate that the procedures are not performed in the 
office more than 50 percent of the time.
    Response: We agree with the comment that urodynamic evaluation 
codes do not belong on the list and have removed CPT codes 51725, 
51726, 51772, and 51785 from the list. We also agree with the comment 
that some of the proposed procedures are not performed in the office 
setting more than 50 percent of the time based on the most current data 
available. Therefore, we have removed the following CPT codes from the 
list: 13150, 14020, 14060, 15740, 21208, 21440, 23066, 26645, 28030, 
28043, 28092, 28261, 40510, 41805, 42408, 46220, 46610, 63600, 64420, 
65270, and 67921.
    Comment: Some commenters stated that the site-of-service payment 
differential should not apply to services furnished in an ASC for which 
no facility payment is made. Another commenter said that many ASCs are 
considered extensions of a physician's office, not a free-standing 
facility, and physicians are responsible for ASC overhead.
    Response: We agree with these comments. Therefore, we have 
clarified the proposal to state that when a service that is not on the 
ASC list is performed in an ASC, the site-of-service payment 
differential does not apply. In this case, we view the ASC as an 
extension of the physician's office and, for purposes of this 
provision, view this as an office service.
    Comment: Some commenters said that there is no difference in 
practice costs between the office setting and the ASC. In some cases, 
costs may be higher in the ASC because of more complicated cases, the 
delivery of anesthesia services, and physician travel costs. Other 
commenters said it is unjustified to conclude that there is no office 
overhead for physicians performing procedures in another setting.
    Some commenters recommended that we make no changes to the site-of-
service payment differential before the implementation of resource-
based practice expense RVUs in 1998. One commenter requested that we 
suspend the site-of-service payment differential altogether. Others 
recommended increasing practice expense payments for procedures 
performed in the office to discourage physicians from using hospital 
ASCs. Other commenters said we should exempt codes that are reduced by 
the interim practice expense reduction of OBRA 1993.
    Response: The site-of-service payment differential is a long 
established policy that aims to avoid duplicate payments for overhead 
while, at the same time, recognizes that some office overhead is 
incurred when physicians perform procedures outside the office setting. 
For this reason, the practice expense RVUs are reduced by only 50 
percent. While we will implement resource-based practice expense RVUs 
in 1998, we see no reason to postpone applying the payment differential 
to ASCs until then. The site-of-service policy currently applies to 
both inpatient and outpatient hospital settings. We see no 
justification for continuing to exempt services provided in ASCs.
    Section 13513 of OBRA 1993 provided for reductions in practice 
expense RVUs for services for which practice expense RVUs exceeded 128 
percent of the work RVUs and that are performed less than 75 percent of 
the time in an office setting. This reduction was based on the 
Congress' determination that practice expense RVUs were too high for 
some procedures. This reduction is independent of the long standing 
site-of-service payment differential.
    Comment: Many commenters stated that the proposal would result in 
reduced quality of care. Other commenters said it did not encourage 
placement of patients in the most appropriate and cost-effective 
setting to address the patient's medical needs. Several commenters 
indicated that since we have determined that the proposed procedures 
are appropriate for ASCs based on medical review and patient safety 
outcome data, it would be inconsistent to apply the site-of-service 
payment differential.
    Some commenters indicated that many of the proposed procedures 
cannot be performed safely in an office. They indicated that offices 
are not certified to meet the same standards of care or health care 
outcomes as ASCs, which are generally safer places to perform 
procedures. They believed the proposal creates a disincentive for 
physicians to use ASCs even when it is in the patient's best interest 
to do so. Other commenters said procedures are performed in an ASC 
because of patient choice or for a patient's safety and comfort. They 
believed that paying less for the most complicated cases will 
discourage doctors from doing such cases, thereby creating serious 
access problems for patients.
    Response: We disagree that application of the site-of-service 
payment differential will penalize a physician who has valid clinical 
reasons for performing a procedure in an ASC. Rather, we believe the 
payment differential will appropriately reflect that the physician 
incurs fewer costs when furnishing service in an ASC. We believe that 
physicians consider the welfare of the beneficiary in selecting the 
appropriate site to perform the service. We do not believe that 
physicians will make inappropriate decisions regarding the health and 
well being of their patients because of a reduction in their payment.
    Comment: Many commenters said that the proposal will encourage 
physicians to buy costly equipment for their offices, such as that 
required for urologic and arthroscopic procedures, which most do not 
have.
    Response: We believe the payment differential is incentive neutral 
with regard to selecting a practice site. That is, we do not believe 
that the payment differential will induce physicians to purchase 
additional equipment to enable them to furnish services in the office.
    Comment: One commenter stated that a large number of procedures 
proposed for addition to the site-of-service list were originally 
exempt from the list because they were performed less than 50 percent 
of the time in a physician's office. Therefore, the practice expense 
values already reflect the costs of furnishing the procedures outside 
the office setting.
    Response: Physicians shift the place of service for procedures from 
the hospital setting to the office setting for various reasons. Two 
reasons are (1) that advances in technology, technique, or other 
factors make it now feasible to do many services in the office setting 
that 

[[Page 63135]]
historically were furnished in a hospital setting; and (2) physicians 
believe that it is cost-effective and efficient to shift the place of 
service. We believe that the direct costs of providing the service 
(staff, supplies, equipment, and space) are reflected in the practice 
expense relative values based on the predominant place of service. 
Therefore, we believe it is appropriate to apply the site-of-service 
reduction to these services when they are performed in a setting where 
we make a payment for the direct costs of providing the service; for 
example, hospitals and ASCs. However, this issue will be further 
examined as part of the development of practice expense RVUs for 1998.
    Comment: Several commenters misunderstood the proposal. Some 
implied that we were proposing a reduction in the ASC facility payment 
rate or reducing payments for office based procedures. One objected to 
applying the site-of-service payment differential to the hospital 
setting. One commenter was not convinced the proposal will save money.
    Several comments concerned issues not covered under this proposal, 
for example, objections to removing certain codes from the ASC approved 
list and requests that particular codes be added or deleted from the 
ASC list. Another commenter suggested that new criteria are needed for 
procedures on the ASC list. Another thought we were proposing removing 
the codes from the ASC list.
    Response: The proposal does not affect ASC facility payment rates 
or physician payments for procedures performed in an office setting. 
The site-of-service payment differential already applies to the 
hospital outpatient setting. The proposal is budget neutral and is not 
intended to reduce Medicare payments. The proposal does not revise 
procedures on the approved ASC list.
    Final Decision: We will extend the site-of-service payment 
differential to office-based services on the ASC list if those services 
are performed in an ASC or in a hospital setting. However, when a 
service that is not on the ASC list is performed in an ASC, the site-
of-service payment differential will not apply. The site-of-service 
list for 1996 appears in Addendum E of this final rule. All additions 
to the list are identified by an asterisk.

E. Services of Teaching Physicians

1. General Background
    Our July 26, 1995 proposed rule (60 FR 38405) discussed Medicare 
payment for those services furnished under graduate medical education 
(GME) programs that are not payable through the mechanisms established 
for direct GME costs by section 1886(h) of the Act. Section 1886(h) 
addresses Medicare payments to hospitals and hospital-based providers 
for the costs of approved GME programs in medicine, osteopathy, 
dentistry, and podiatry. Those costs include residents' salaries and 
fringe benefits, physician compensation costs for GME program 
activities that are not payable on a fee schedule basis, and other GME 
program costs.
    Medicare intermediary expenditures under section 1886(h) of the Act 
for fiscal year 1996 are estimated to be approximately $1.9 billion. In 
addition, under section 1886(d)(5)(B) of the Act, Medicare makes 
additional payments to teaching hospitals under the prospective payment 
system for the higher indirect operating costs hospitals incur by 
having GME programs. (These are costs other than direct GME costs.) 
Medicare indirect GME payments for fiscal year 1996 are estimated to be 
approximately $4.9 billion. Medicare also supports GME programs in 
teaching hospitals through billings for the services of attending 
physicians who involve residents in the care of their patients. The 
amount of Medicare expenditures for these services is not known since 
attending physicians are not required to distinguish between services 
they personally furnish and those they furnish as attending physicians 
in claims submitted to the Part B carriers.
    Our proposal addressed services of teaching physicians that are 
payable on a fee schedule basis, services of residents in settings that 
are not payable under section 1886(h), and services of moonlighting 
residents. In addition, the proposed rule addressed, but did not 
substantially change, existing rules on related issues on Medicare 
payments for the services of residents in approved GME programs 
furnished in certain freestanding skilled nursing facilities and home 
health agencies, and services of residents who are not in approved GME 
programs. We referred to the section 1886(h) mechanisms to distinguish 
between that payment methodology and other payment mechanisms.
    Title XVIII of the Act provides separate coverage and payment bases 
for provider services and physician services. Under Medicare, provider 
services, such as inpatient hospital services and skilled nursing 
facility services, are covered under Hospital Insurance (Part A) and 
are paid from the Part A Trust Fund. Outpatient hospital services are 
covered under Supplementary Medical Insurance (Part B) and are paid 
from the Part B Trust Fund. Provider services are paid on a prospective 
payment, reasonable cost, or other payment mechanism through Medicare 
contractors called ``fiscal intermediaries.'' Physician services and 
other ``medical and other health services,'' as defined in section 
1861(s) of the Act, are generally paid under Part B through Medicare 
contractors called ``carriers.'' To administer the Medicare program, we 
must distinguish clearly between provider services and physician 
services to determine the appropriate payment methodology and the 
appropriate Trust Fund that is liable for payment.
    As discussed in the proposed rule, in part 405 (``Federal Health 
Insurance for the Aged and Disabled''), subpart D (``Principles of 
Reimbursement for Services by Hospital-Based Physicians''), current 
regulations beginning with Sec. 405.480 set forth the basic principles 
regarding payment for services of physicians who practice in providers. 
Additional principles applicable to payment for physician services in 
teaching hospitals appeared in subpart E (``Criteria for Determination 
of Reasonable Charges; Payment for Services of Hospital Interns, 
Residents, and Supervising Physicians'') in Secs. 405.520 and 405.521. 
Principles applicable to services of interns and residents appeared in 
Secs. 405.522 through 405.525. Sections 405.465 and 405.466 addressed 
the payment methodology for teaching hospitals that elect reasonable 
cost payments for physician services. (See sections 
1832(a)(2)(B)(i)(II) and 1861(b)(7) of the Act.) Since the publication 
of those regulations, the Congress enacted a series of legislative 
changes that affected payments for these services, and we proposed to 
revise the regulations to conform to those statutory changes and to 
clarify current policy.
    Section 948 of the Omnibus Reconciliation Act of 1980 (ORA 1980) 
(Pub. L. 96-499), enacted on December 5, 1980, as amended by section 
2307 of the Deficit Reduction Act of 1984 (DEFRA 1984) (Pub. L. 98-
369), enacted on July 18, 1984, addressed payments for physician 
services in teaching settings. (See section 1842(b)(7) of the Act.) 
Another pertinent legislative change, section 108 of the Tax Equity and 
Fiscal Responsibility Act of 1982 (TEFRA 1982) (Pub. L. 97-248), 
enacted on September 3, 1982, added a new section 1887 to the Act. That 
legislation dealt explicitly with distinguishing between the 
professional services physicians furnish to individual patients in a 
provider and services physicians furnish to the provider itself. While 
section 1887 of the Act does not 

[[Page 63136]]
specifically address teaching physicians or GME issues, it is 
consistent with Medicare policy on classifying the activities in which 
physicians in teaching hospitals are engaged.
    We published a final rule with comment period in the Federal 
Register on March 2, 1983 (48 FR 8902), which implemented the 
provisions of section 1887 of the Act. That final rule revised the 
regulations that govern Medicare payment for services of physicians who 
practice in providers such as hospitals, skilled nursing facilities, 
and comprehensive outpatient rehabilitation facilities. As a part of 
that final rule, we revised Secs. 405.480 through 405.482, removed 
Secs. 405.483 through 405.488, and added new Secs. 405.550 through 
405.557. Those regulations--
     Set forth basic criteria for distinguishing those 
physician services furnished in providers that are payable by Part B 
carriers as physician services to individual patients from those 
services that are payable by fiscal intermediaries as physician 
services to the provider itself;
     Set limits on the amounts payable on a reasonable cost 
basis to providers for physician services to the provider; and
     Established more specific criteria for determining the 
basis and amount of payment for physician services in the specialties 
of anesthesiology, radiology, and pathology.
    In the preamble to the March 1983 final rule (48 FR 8906), we 
stated that because of problems related to applying portions of the 
revised regulations to teaching hospitals and to implement sections 
1842(b)(6) and 1861(b)(7) of the Act for physician payment (as amended 
by section 948 of ORA 1980), we planned to publish, in a separate 
document, proposed regulations that would establish special rules 
governing payment for services of physicians in teaching hospitals. 
Those rules would have superseded Secs. 405.520 and 405.521 if they 
became effective. Subsequently, however, the Congress passed DEFRA 
1984, which further amended section 1842(b)(6) of the Act and 
redesignated it as section 1842(b)(7).
    Another statutory change that affected payments to teaching 
hospitals was section 9202 of the Consolidated Omnibus Budget 
Reconciliation Act of 1985 (Pub. L. 99-272), enacted on April 7, 1986, 
as amended by section 9314 of the Omnibus Budget Reconciliation Act of 
1986 (Pub. L. 99-509), enacted on October 21, 1986, which added a new 
section 1886(h) to the Act. Section 1886(h) of the Act revised the 
method of calculating Medicare payment for the direct costs of approved 
GME activities such as residents' salaries and fringe benefits, from 
reasonable cost payment to payments based on hospital-specific per-
resident amounts multiplied by the number of full-time equivalent 
residents working in the hospital during a hospital's cost reporting 
period.
    A major change in the Medicare payment rules for physician services 
in general was enacted as part of the Omnibus Budget Reconciliation Act 
of 1989 (OBRA 1989) (Pub. L. 101-239), enacted on December 19, 1989, 
which added section 1848 to the Act. Section 1848 replaced the 
reasonable charge payment mechanism with a fee schedule for physician 
services. The Omnibus Budget Reconciliation Act of 1990 (OBRA 1990) 
(Pub. L. 101-508), enacted on November 5, 1990, contained several 
modifications and clarifications to the OBRA 1989 provisions that 
established the physician fee schedule.
2. Payment for Physician Services Furnished in Teaching Settings
a. Current Practices
    In our proposed rule (60 FR 38406), we stated that of the nearly 
7,000 hospitals that participate in Medicare, approximately 1,200 have 
GME programs that are approved for residency training by the 
appropriate accrediting organization. (We used the term ``residents'' 
in the preamble of the proposed rule to include residents, interns, and 
fellows who are in formally organized and approved GME programs.)
    For hospital cost reporting periods beginning on or after July 1, 
1985, the costs of residents' compensation (representing payment for 
the residents' services), certain physician compensation costs related 
to GME programs, and other GME program costs are payable based on 
hospital-specific per-resident amounts as described in Sec. 413.86, in 
accordance with section 1886(h) of the Act. Physician compensation 
costs for administrative and supervisory services unrelated to the GME 
program or other approved educational activities are payable as 
operating costs through diagnosis-related group payments under the 
prospective payment system for inpatient services and on a reasonable 
cost basis for inpatient services in hospitals excluded from the 
prospective payment system and for outpatient services.
    In the case of those few teaching hospitals that elect reasonable 
cost payments for physician direct medical and surgical services under 
section 1861(b)(7) of the Act instead of billing for services to 
Medicare beneficiaries on a fee-for-service basis, the election and 
payment mechanisms described in former Secs. 405.465 and 405.466 were 
set forth in the proposed rule in new Sec. 415.160 and in redesignated 
Secs. 415.162 and 415.164.
    Practices vary widely among and within teaching hospitals with 
respect to the degree of physician involvement in the care of patients. 
In some cases, teaching physicians personally direct residents in 
furnishing patient care services. In others, residents assume a greater 
degree of responsibility for the care patients receive, and the 
teaching physicians exercise only general control over the residents' 
activities.
b. Statutory and Other Developments Pertaining to Teaching Physician 
Services
(1) Original Medicare Law and Regulations
    As originally enacted, title XVIII of the Act excluded the services 
of physicians, interns, and residents from the definition of 
``inpatient hospital services,'' except for the services of interns and 
residents in approved training programs. The services of residents in 
an approved program of a hospital with which a skilled nursing facility 
has a transfer agreement are included in the definition of ``extended 
care services'' and in the definition of ``home health services'' in 
the case of a home health agency that is affiliated with or under 
common control of a hospital having the program. These provisions 
established the costs of approved GME programs for provider services 
payable by intermediaries on a reasonable cost basis. The Act did not 
include special rules for payment of physician services in teaching 
hospitals.
    At the time of the publication of the proposed rule, under 
Secs. 405.520 and 405.521 for teaching physician services, and 
Secs. 405.522 through 405.525 for residents' services, a physician in a 
teaching setting was considered the attending physician for a Medicare 
patient, and thereby qualified for Part B payment, only if he or she 
furnished ``personal and identifiable direction'' to the interns and 
residents who provided the actual services to the patient. Before 
January 1, 1992, Part B physician services were paid under the 
reasonable charge payment system. As of January 1, 1992, these 
physician services are paid under the physician fee schedule set forth 
in part 414 (56 FR 59502).
    Although former Sec. 405.521(b) listed examples that illustrated 
the types of responsibilities attending physicians 

[[Page 63137]]
typically carry out, the list was not exhaustive. In individual cases, 
it might be difficult to determine, by referring to Sec. 405.521, 
whether a physician in a teaching setting is the ``attending 
physician'' for a Medicare patient. It might be necessary for the 
carrier to review hospital charts to see if the attending physician 
requirements were met; however, the involvement of the teaching 
physician in individual services was often unclear from a review of the 
charts.
    It became apparent, shortly after the former Secs. 405.520 and 
405.521 were issued, that some Medicare carriers were paying charges 
for physician services in some teaching hospitals, even though interns 
and residents were primarily responsible for the care of the patients. 
The physicians who were billing for these services were often assuming 
only limited responsibility for the medical management of the patients' 
treatment. It also became clear that some physicians were submitting 
charges for services furnished to Medicare patients even though non-
Medicare patients were not billed for similar services, and patients 
generally were not obligated to pay for those physician services.
    In April 1969, those problems led to the issuance of Intermediary 
Letter 372, which set forth specific conditions that physicians in 
teaching settings were required to meet to be considered attending 
physicians and, thus, qualify to charge the carrier for services in 
which they involved residents. It also specified how carriers were 
required to determine the reasonable charges for these services. 
Although Intermediary Letter 372, which was still in effect at the time 
of the publication of the proposed rule, provided guidance to Medicare 
carriers and intermediaries on payment for these services, it was not 
applied uniformly by all Medicare carriers.
(2) 1972 Amendments
    On October 30, 1972, the Congress amended the Act to provide rules 
on payment for physician services (as distinguished from the services 
of interns and residents) furnished in teaching hospitals. Section 227 
of the Social Security Amendments of 1972 (Pub. L. 92-603) amended 
section 1861(b) of the Act to require that Medicare treat those 
services as hospital services and pay for them on a reasonable cost 
basis, except under certain specific circumstances. Section 227 also 
made certain incentives available to hospitals that elected to be paid 
for physician services on a reasonable cost basis.
    In subsequent legislation (section 15 of Pub. L. 93-233, enacted on 
December 31, 1973, and section 7 of the End-Stage Renal Disease Program 
Amendments of 1978 (Pub. L. 95-292), enacted on June 13, 1978), the 
Congress deferred implementation of all provisions of section 227 of 
the 1972 amendments except for the incentives to elect reasonable cost 
payment for physician direct medical and surgical services. The cost 
reimbursement provisions were implemented through former Sec. 405.465, 
as published in a final rule on August 8, 1975 (40 FR 33440). The 
statutory provisions for which the Congress deferred implementation 
were eventually replaced by new provisions passed by the Congress in 
ORA 1980. ORA 1980 reaffirmed, but did not otherwise affect, the 
provisions of section 227 of the 1972 amendments authorizing cost 
reimbursement incentives.
(3) ORA 1980
    Section 948 of ORA 1980 made several important changes in the 
sections of the Medicare statute that address payment for physician 
services in teaching hospitals. Specifically, section 948--
     Repealed the provisions of the 1972 Amendments that 
required Medicare to pay for those services (with certain exceptions) 
on a reasonable cost basis;
     Amended section 1861(b) of the Act to allow hospitals with 
approved teaching programs to elect to be paid on a reasonable cost 
basis for physician direct medical and surgical services furnished to 
their Medicare patients and for the supervision of interns and 
residents in the care of individual patients if all physicians in the 
hospital agree not to bill charges for their services furnished to 
Medicare patients; and
     Added section 1842(b)(6) of the Act (now section 
1842(b)(7)) to specify the conditions that must be met to permit 
payment under Part B for physician services in teaching hospitals that 
do not elect cost reimbursement, and to provide special payment rules 
for determining the customary charges applicable in this situation.
    In the Conference Report accompanying ORA 1980 (H.R. Rep. No. 1479, 
96th Cong., 2d Sess. 145 (1980)), the Conference Committee stated that 
its intention was to permit payment for physician services in a 
teaching hospital on a reasonable charge basis only if the physician is 
the patient's ``attending physician.'' The conferees also endorsed the 
attending physician criteria in Intermediary Letter 372.
    The Conference Report further stated that ``[t]he conferees intend 
(without precluding reasonable changes in the future) that in 
determining the amount payable on a charge basis under Medicare Part B 
for services of physicians in teaching hospitals, the policies 
contained in Intermediary Letter 372 should be generally followed where 
these are not inconsistent with the provisions of the conference 
agreement.'' Ibid. p. 146.
(4) DEFRA 1984
    Subsequently, section 2307(a) of DEFRA 1984 further amended section 
1842(b)(7) of the Act concerning conditions for payment for physician 
services furnished in teaching hospitals that do not elect cost 
reimbursement. Section 2307(a) was later amended by sections 3(b) (5) 
and (6) of the DEFRA Technical Amendments (Public Law 98-617), enacted 
on November 8, 1984. As revised, section 1842(b)(7) of the Act (which 
was redesignated from section 1842(b)(6) of the Act by section 2306 of 
DEFRA '84) provided that--
     The customary charge of a physician qualifying as a 
teaching physician is set no lower than 85 percent of the prevailing 
charge paid for similar services in the same locality; and
     If all the teaching physicians in a teaching hospital 
agree to accept assignment for all the services they furnish to 
Medicare patients in that hospital, the customary charge is set at 90 
percent of the prevailing charge paid for similar services in the same 
locality.
(5) 1989 Proposed Rule
    On February 7, 1989, we published a proposed rule that would have 
implemented the teaching physician payment provisions of both ORA 1980 
and DEFRA 1984 (54 FR 5946). In that document, we proposed the 
following changes relating to teaching physicians:
     Revise the regulations governing the conditions under 
which Medicare payment is made for the services of physicians in 
teaching settings and implement a special methodology for determining 
customary charges for the services of teaching physicians.
     Revise the regulations governing Medicare payment to 
providers for compensation paid to physicians who furnish services that 
are of general benefit to patients in the provider.
    That proposed rule was never published in final because legislation 
enacted in 1989 and 1990 that mandated the implementation of the 
Medicare physician fee schedule had the effect of replacing the payment 
methodology of the proposed rule. 

[[Page 63138]]

3. Payments for Supervising Physicians in Teaching Settings and for 
Residents in Certain Settings
    In our July 26, 1995 proposed rule, we proposed to revise the 
regulations because of the substantial changes that have taken place in 
the way Medicare payments for physician services are determined (that 
is, the replacement of the reasonable charge system with the physician 
fee schedule); the length of time since the publication of the February 
1989 proposed rule; and our decision to propose to replace the 
attending physician criteria of the February 1989 proposed rule. The 
details of the attending physician policy had been set forth earlier in 
Intermediary Letter 372, published in April 1969.
    We proposed to change the attending physician criteria from those 
of Intermediary Letter 372 to make the criteria more flexible in terms 
of the individual teaching physician who may serve as the responsible 
physician for a particular service while ensuring that a teaching 
physician is present during at least some portion of each service 
payable by the carrier. We also proposed rules based on other Medicare 
policies that had been in effect for years but had never been 
explicitly addressed in the regulations.
a. Distinction Between Teaching Hospital and Teaching Setting
    We proposed to distinguish between ``teaching hospital'' and 
``teaching setting,'' because the former is more directly related to 
intermediary payments, and the latter (although defined in terms of 
intermediary payments) is more directly related to carrier payments. We 
proposed to define ``teaching hospital'' as a hospital engaged in an 
approved GME residency program in medicine, osteopathy, dentistry, or 
podiatry. We proposed to define ``teaching setting'' as a provider or 
freestanding setting for which Medicare payment for the services of 
residents is made under the direct GME payment provisions of 
Sec. 413.86 (hospitals, hospital-based providers, and settings, 
including nonprovider settings, meeting the requirements for residents 
in Sec. 413.86(f)(1)(iii)), or on a reasonable cost basis under the 
provisions of Sec. 409.26 or Sec. 409.40(f) for residents' services 
furnished in freestanding skilled nursing facilities or home health 
agencies, respectively.
b. Statutory Requirements for Payment in Teaching Hospitals Not 
Electing Reasonable Costs for Physician Services to Individual Patients
    Section 1842(b)(7) of the Act is generally premised on the use of 
customary charges, that is, the reasonable charge system, as the basis 
for Medicare payments for the services of physicians in teaching 
hospitals. Section 1848 of the Act, however, established the physician 
fee schedule as the payment methodology for physician services 
furnished beginning January 1, 1992 without any exception for physician 
services furnished in teaching settings. Therefore, we based the 
policies in the July 26, 1995 proposed rule on principles established 
in legislation on payment for physician services generally under the 
physician fee schedule, on payment for physician services furnished in 
providers, and on payment to hospitals for GME programs. With regard to 
payment to hospitals for GME programs, the proposal addressed 
activities associated with GME programs that were not payable through 
fiscal intermediary payment mechanisms.
c. Intermediary Letter 372 Attending Physician Criteria
    The Intermediary Letter 372 attending physician criteria and 
related policy were developed by Medicare in 1969 as a means of 
documenting the involvement of teaching physicians in patient care 
services furnished in teaching hospitals and have been controversial 
ever since. It was recognized then and now that residents must furnish 
patient care services to develop their skills as physicians or other 
types of practitioners. The ``attending physician'' policy was 
developed as a mechanism to make Part B fee schedule payments for 
services in which residents were involved. The main requirement of the 
policy was that there would be a single attending physician who 
personally examined the beneficiary within a reasonable time after 
admission, confirmed the diagnosis and course of treatment, and was 
continuously involved in the care of the beneficiary throughout the 
stay. The attending physician policy as set forth in Intermediary 
Letter 372 and related issuances specifically stated that the attending 
physician had to be present when a major surgical procedure or a 
complex or dangerous medical procedure was performed, but was vague, 
perhaps necessarily, on the matter of the presence of the physician 
during other occasions of inpatient service. There was less ambiguity 
with regard to hospital outpatients. Part A Intermediary Letter No. 70-
7/Part B Intermediary Letter No. 70-2 (issued in January 1970), a 
question-and-answer on Intermediary Letter 372, indicated that the 
supervising physician must either personally perform the service or 
function as the attending physician and be present while a service is 
being furnished (question 14).
    Medicare carriers were directed to periodically review the hospital 
charts for verification of the establishment of attending physician 
relationships and their involvement in individual services. If the 
chart did not substantiate a sufficient level of involvement in the 
care furnished, the teaching physician role was seen as supervisory in 
nature, rather than as an attending physician, even though the teaching 
physician may have had legal responsibility for the care furnished to 
the patient. Consequently, the fiscal intermediary for the hospital 
would pay Medicare's share of the salary costs of the teaching 
physician attributable to the supervision of residents, but the 
Medicare carrier would not make payment for the physician services on 
the basis of reasonable charges.
    We believe, after years of working experience with the Intermediary 
Letter 372 attending physician policy, that we should replace it. The 
amount of postpayment review necessary to verify the establishment and 
continuity of the attending physician relationship from patient charts 
had become impractical given reductions in contractor budgets and was 
inconsistent with more recent congressional action. While the Congress 
endorsed the attending physician policy in the Conference Report 
accompanying ORA 1980, the Intermediary Letter 372 policy might be 
viewed as not entirely consistent with the payment mechanism enacted in 
OBRA '86 under section 1886(h) of the Act for payment of direct GME 
costs in teaching hospitals. For example, Intermediary Letter 372 
indicated that, if a physician was not an attending physician but 
supervised a resident who furnished a service, the costs of the 
physician services were payable by the intermediary. Under section 
1886(h) of the Act, if a service was determined not to be an attending 
physician service billable under Part B, the service could not become a 
provider service for purposes of additional payments made under Part A 
since the GME payments were prospectively determined amounts that could 
not be adjusted based on the individual circumstances of the delivery 
of individual services. Further, allocation agreements between 
physicians and hospitals identifying the various activities in which 
the 

[[Page 63139]]
physicians were involved for purposes of determining the appropriate 
payment amounts had no effect on GME payments in an individual hospital 
cost reporting period. The costs that were allocated during the GME 
base period were carried forward regardless of changes in the physician 
activities.
    Moreover, the Intermediary Letter 372 policy left it to individual 
carriers to determine coverage of the services based on customary 
practices in the area or on the competence of individual residents. For 
example, a sentence in Intermediary Letter 372.A. reads as follows:

If the supervising physician was present at surgery, and the surgery 
was performed by a resident acting under his close supervision and 
instruction, he would not be the attending surgeon unless it were 
customary in the community for such services to be performed in a 
similar fashion to private patients who pay for services rendered by 
a private physician.

While this policy might have been appropriate 30 years ago in the early 
days of Medicare, we stated in our proposed rule (60 FR 38409) that we 
believe it is inappropriate to base the determination of whether a 
carrier will pay several thousand dollars or zero dollars for a 
surgical procedure on this standard, which could result in a wide 
disparity of policy from area to area regarding when payment is made.
    Another problem with the Intermediary Letter 372 policy was 
reliance on a single physician to be the attending physician for the 
beneficiary throughout the inpatient stay. The only exception 
permitting an attending physician relationship for only a portion of a 
stay was if the portion was a distinct segment of the patient's course 
of treatment, such as the postoperative period. Another example from 
Intermediary Letter 372 reads as follows:

A group of physicians share the teaching and supervision of the 
house staff on a rotating basis. Each physician sees patients every 
third day as he makes rounds. No physician can be held to be one of 
these patients' attending physician for any portion of the hospital 
care although consultations and other services they personally 
perform for the patient might be covered.

    We stated in our proposed rule (60 FR 38409) that we believe that 
this emphasis on a single teaching physician serving as the attending 
physician through the stay was no longer necessary, and that we should 
provide teaching hospitals and GME programs with flexibility in the 
determination of the responsible teaching physician in an individual 
case. We no longer believe the Intermediary Letter 372 requirement that 
a single physician be recognized by the beneficiary as his or her 
personal physician through a period of hospitalization reflects current 
realities. Further, the existing attending physician regulation might 
operate at cross-purposes with managed care arrangements that often 
employ treatment teams.
    The Intermediary Letter 372 requirements for continuity of care 
might be difficult for carriers to verify from reviews of medical 
records, might be interpreted in different ways by different carriers, 
and might be counterproductive and burdensome in the delivery of 
services to the patient. We believe the proposed policy would address 
potential sources of misunderstanding and abuse that have been 
longstanding Medicare program concerns. For example, Intermediary 
Letter 372 required the attending physician to personally examine the 
patient, review the history and record of test results, etc. From 
discussions with carrier medical directors, it is our understanding 
that some carriers considered the requirements to be met if the 
teaching physician first saw the patient 1 or 2 days after admission. 
In those situations, the carrier might pay for an admission history and 
physical performed by a resident on Saturday while the teaching 
physician did not actually see and examine the patient until Monday. 
Other carriers would maintain that, to pay for the admission history 
and physical as an attending physician, the teaching physician would 
have to see the patient on the day the service was performed.
    We believe that the most important consideration should be the 
presence of the teaching physician during the key portion of the 
service or procedure being furnished by the resident, and that 
requiring both an attending physician relationship and the presence of 
that same physician during every billable service is no longer 
warranted. Thus, under our proposal, carriers would no longer pay for 
services such as admission evaluation and management services unless a 
teaching physician was present during the key portion of the service.
d. Carrier Payment for Services of Teaching Physicians--General
    We proposed to eliminate the Intermediary Letter 372 attending 
physician criteria from the determination of whether payment should be 
made for the services of physicians in teaching settings. We recognize 
that the term ``attending physician'' is used in academic medicine to 
denote the responsible physician, and we believe that hospitals and GME 
programs should be free to designate any physician to be the attending 
physician of the patients in the teaching setting. We proposed to 
require the following conditions for services of teaching physicians 
(physicians who involve residents in the care of their patients) in 
both inpatient and outpatient settings to be payable under the 
physician fee schedule:
     A teaching physician (a physician other than a resident or 
fellow in an approved program) must be present for a key portion of the 
time during the performance of the service for which payment is sought.
     In the case of surgery or a dangerous or complex 
procedure, the teaching physician must be present during all critical 
portions of the procedure and must be immediately available to furnish 
services during the entire service or procedure. We specified that the 
teaching physician presence requirement is not met when the presence of 
a teaching physician is required in two places for concurrent major 
surgeries. The operative notes must indicate when the teaching 
physician presence in individual procedures began and ended. In the 
case of procedures, such as an endoscopy, in which a body area, rather 
than a representation, is viewed, we would not make payment if the 
teaching physician was not present during the viewing. A discussion of 
the findings with a resident would not be sufficient. The situation is 
contrasted with a diagnostic procedure, such as an x-ray, in which the 
physician would not be expected to be present during the performance of 
a test and could bill for an interpretation by reviewing the film with 
the resident (or by performing an independent interpretation).
     In the case of services such as evaluation and management 
services (for example, visits and consultations), for which there are 
several levels of service available for reporting purposes, the 
appropriate payment level must reflect the extent and complexity of the 
service if the service had been fully furnished by the teaching 
physician. In other words, if the medical decision-making in an 
individual service is highly complex to an inexperienced resident, but 
straightforward to the teaching physician, payment is made at the lower 
payment level reflecting the involvement of the teaching physician in 
the service. We intend to promote flexibility and leave the decision to 
the teaching physician as to whether the teaching physician should 
perform hands-on care, in addition to the care furnished by the 
resident in the presence of the teaching physician. 

[[Page 63140]]
However, in the case of both hospital inpatient and outpatient 
evaluation and management services, the teaching physician must be 
present during the key portion of the visit.
     The presence of the physician during the service or 
procedure must be documented in the medical records.
    The proposal eliminated the Intermediary Letter 372 requirement 
that the attending physician personally examine the patient and left 
the decision to the teaching physician as to whether he or she should 
perform an examination in addition to the resident's examination based 
on medical and risk management considerations rather than Medicare 
payment rules. For example, a beneficiary might be admitted to the 
hospital on a Saturday and be examined by a resident in the presence of 
a teaching physician on duty at the time. On Monday, another teaching 
physician might be designated to be the attending physician in the 
case. Under the proposal to eliminate the Intermediary Letter 372 
attending physician criteria, the services of both teaching physicians 
in this example would be payable (as long as distinct services are 
furnished).
    Under our proposal, we clarified that services of teaching 
physicians that involve the supervision of residents in the care of 
individual patients are payable under the physician fee schedule only 
if the teaching physician is present during the key portion of the 
service. If a teaching physician is engaged in such activities as 
discussions of the patient's treatment with a resident but is not 
present during any portion of the session with the patient, we believe 
that the supervisory service furnished is a teaching service as 
distinguished from a physician service to an individual patient.
    We believe that this clarification is consistent with existing 
policy. Part A Intermediary Letter No. 70-7/Part B Intermediary Letter 
No. 70-2, issued in January 1970, contained a series of questions and 
answers about the attending physician policy set forth in Intermediary 
Letter No. 372. Question 14 of that issuance addressed services 
furnished in emergency rooms and outpatient departments and states the 
following:
    Q. Intermediary letter No. 372 states, ``An emergency room 
supervising physician may not customarily be considered to be the 
attending physician of patients cared for by the house staff, etc.'' Is 
this also true in the hospital's outpatient department?
    A. Yes, because an attending physician relationship is not normally 
established with anyone other than the treating physician in an 
outpatient department. If the Part B bills are submitted for services 
performed by a physician in either the emergency room or in any part of 
the outpatient department, the hospital records should clearly indicate 
either that: the supervising physician personally performed the 
service; or he functioned as the patient's attending physician and was 
present at the furnishing of the service for which payment is claimed.
    At the same time we were concerned about the integrity of the 
Medicare payment process, we recognized that application of this policy 
to the reimbursement of teaching physicians in family practice 
residency programs raised special concerns about the viability of these 
programs. Family practice residency programs are different from other 
programs because training occurs primarily in an outpatient setting, 
known as a family practice center. In these centers, residents are 
assigned a panel of patients for whom they will provide care throughout 
their 3 years of training. While teaching physicians supervise this 
care and, indeed, are present during the actual furnishing of services 
in some circumstances (most notably with first year residents and for 
more complex patient cases), a general requirement that teaching 
physicians be physically present during all visits to the family 
practice center would undermine the development of this physician/
patient relationship. This requirement also would be incompatible with 
the way family practice centers are organized and staffed and could 
require the hiring of additional teaching physicians when the faculty 
are already in short supply.
    We stated in our July 26, 1995 proposed rule (60 FR 38410) that we 
would be willing to develop a special rule for paying teaching family 
physicians that takes into account the unique nature of these training 
programs while clarifying the appropriate level of involvement of the 
teaching physician in patient care in family practice centers. We 
invited comments on the structure and content of such a rule, or a 
legislative proposal, along with any supportive data. We also invited 
comments on whether and how such a rule might be applied to other 
primary care training programs.
e. Special Treatment--Psychiatric Services
    During the period in which we were developing the February 1989 
proposed rule, we met with representatives of psychiatric GME programs 
who indicated that it was inappropriate for a physician other than the 
treating resident to be viewed by psychiatric patients as their 
physician. In psychiatric programs, the teaching physician may observe 
a resident's treatment of patients only through one-way mirrors or 
video equipment. We accepted this position and proposed that, with 
respect to psychiatric services (including evaluation and management 
services) furnished under an approved psychiatric GME program, the 
teaching physician would be considered to be ``present'' during each 
visit for which payment is sought as long as the teaching physician 
observes the visit through visual devices and meets with the patient 
after the visit.
f. Physician Services Furnished to Renal Dialysis Patients in Teaching 
Hospitals
    Effective for services furnished on or after August 1, 1983, 
Medicare pays for physician services to end-stage renal disease 
patients on the basis of the physician monthly capitation payment 
method described in Sec. 414.314. This payment method generally applies 
to renal-related physician services furnished to outpatient maintenance 
dialysis patients, regardless of where the services are furnished (that 
is, in an independent end-stage renal disease facility, a hospital-
based end-stage renal disease facility, or in the patient's home). 
Physician services furnished to end-stage renal disease patients on or 
after August 7, 1990 may also be paid on the basis of the initial 
method as described in Sec. 414.313. We would continue application of 
these physician payment methods to teaching hospitals with end-stage 
renal disease facilities. We would not impose any special medical 
record documentation requirements solely because the end-stage renal 
disease facility is based in a teaching hospital.
    Physician fee schedule payments for covered physician services 
furnished to inpatients in a hospital by a physician who elects not to 
continue to receive payment on a monthly capitation basis through the 
period of the inpatient stay, or who is paid based on the initial 
method, would be determined according to the rules described in 
proposed Sec. 415.170. Physicians would have to either personally 
furnish the services, or furnish the services as a teaching physician 
as described in proposed Sec. 415.172.
g. Special Criteria for Anesthesia Services and Interpretation of 
Diagnostic Tests
    Special criteria for anesthesia services involving residents appear 
in Sec. 415.178. In the case of diagnostic radiology and other 
diagnostic tests, we make payment 

[[Page 63141]]
for the interpretation if the physician either personally performs the 
interpretation or reviews the resident's interpretation.
h. Services of Residents
    We proposed to incorporate into the regulations longstanding 
Medicare coverage and payment policy regarding the circumstances under 
which the services of residents are payable as physician services. 
These policies are in operating instructions and other issuances.
    Generally, the services of residents in approved GME programs 
furnished in hospitals and hospital-based providers are payable through 
the direct GME payment methodology in Sec. 413.86. For hospital cost 
reporting periods beginning on or after July 1, 1985, a teaching 
hospital is entitled to include residents working in the hospital and 
hospital-based providers in the full-time equivalency count used to 
compute direct GME payments. These payments are based on per-resident 
amounts reflecting GME costs incurred during a base period and updated 
by the Consumer Price Index. Further, effective July 1, 1987, under the 
conditions set forth in Sec. 413.86(f)(1)(iii), a teaching hospital may 
elect to enter into a written agreement with another entity for the 
purpose of including the time spent by residents in furnishing patient 
care services in a setting outside the hospital in the hospital's full-
time equivalency count of residents for GME purposes. The agreement 
must specify that the hospital compensate the resident for the services 
in the nonhospital setting. When an agreement is in effect, the 
teaching setting guidelines of proposed Secs. 415.170 through 415.184 
would apply to services in which physicians involve residents in the 
nonhospital setting. The services of residents in these settings are 
payable as hospital services rather than physician services. We stated 
that proposed Sec. 415.200 would replace current Sec. 405.522.
    Current Sec. 405.523 addressed payment for the services of 
residents who are not in approved programs. The section was applicable 
to the services of a physician employed by a hospital who is authorized 
to practice only in a hospital setting and to residents in an 
unapproved program. We proposed to replace this rule with new 
Sec. 415.202. The proposed rule incorporated the policy currently in 
section 404.1.B of the Provider Reimbursement Manual (HCFA Pub. 15-1), 
which provides that only the costs of the residents' services are 
allowable as Part B costs, and that other costs, such as teaching 
costs, of an unapproved program are not allowable.
    Current Sec. 405.524 (``Interns' and residents' services outside 
the hospital'') provided for reasonable cost payments for the services 
of residents in freestanding skilled nursing facilities and home health 
agencies. We proposed to rename this section to clarify that its scope 
is limited to these types of providers and to include it with only 
minor changes into a new Sec. 415.204.
    We proposed to establish a new Sec. 415.206 to address payment 
issues relating to the services of residents in nonprovider settings, 
such as freestanding clinics that are not part of a hospital. Paragraph 
(a) addresses situations when a teaching hospital and another entity 
have entered into a written agreement under which the time the 
residents spend in patient care activities in these nonhospital 
settings is included in the hospital's full-time equivalency count used 
to compute direct GME payments. If an agreement is in force, the 
carrier would make payments for teaching physician and other physician 
services under the rules in Secs. 415.170 through 415.190.
    If a nonprovider entity, such as a freestanding family practice or 
multispecialty clinic, does not enter into this type of agreement for 
residency training with a teaching hospital, the payment mechanism in 
proposed Sec. 415.206(b) would apply in the case of services furnished 
by certain residents. We modified the policy on Part B billings for 
services furnished by licensed residents in the late 1970's in an 
action designed to enhance the ability of primary care residency 
programs to finance their training activities outside the teaching 
hospital setting. We revised the Medicare Carriers Manual (HCFA Pub. 
14-3) to cover residents' services furnished in a setting that is not 
part of a hospital as physician services if the resident was fully 
licensed to practice by the State in which the service was performed. 
This policy applies whether or not the residents are functioning within 
the scope of their approved GME program. Under these circumstances, the 
resident is functioning in the capacity of a physician, and the 
teaching physician guidelines do not apply.
    Additionally, the services of residents practicing in freestanding 
federally qualified health centers and rural health clinics who meet 
the requirements of proposed Sec. 415.206(b) would be eligible for 
payment under the payment methodology for federally qualified health 
centers. (We would make payments for residents' services in a hospital-
based entity under the provisions of Sec. 413.86 for direct GME 
payments.) We proposed to allow freestanding federally qualified health 
centers and rural health clinics to include the costs of a service 
performed by a resident meeting those requirements as an allowable cost 
on the entity's cost report. We proposed to amend Sec. 405.2468(b)(1), 
which sets forth allowable costs for federally qualified health centers 
and rural health clinic services, to recognize these costs. Further, a 
resident is considered to be a physician as defined in revised 
Sec. 405.2401(b) for the purpose of determining payments to the 
federally qualified health centers and rural health clinics. Consistent 
with the payment method for federally qualified health centers and 
rural health clinics, payments for services furnished by residents in 
federally qualified health centers and rural health clinics would be 
paid under Sec. 405.2462 rather than under the physician fee schedule. 
In other words, services of the resident would be treated in exactly 
the same manner as services of other physicians who are not residents 
in the federally qualified health center or rural health clinic. We 
believe that recognizing the costs of these residents in federally 
qualified health centers and rural health clinic settings would create 
more uniformity in the way these costs are treated by the Medicare 
program.
    We proposed to establish a new Sec. 415.208 to address carrier 
payments for the services of ``moonlighting'' residents. Paragraph (a) 
defines these services as referring to services that licensed residents 
perform that are outside the scope of an approved GME program. 
Paragraph (b) reflects the policy set forth in section 2020.8.C. of the 
Medicare Carriers Manual under which carriers may pay under the 
physician fee schedule for the services of moonlighting residents in 
the outpatient department or emergency department of a hospital in 
which they have their training program if there is a contract between 
the resident and the hospital indicating that the following criteria 
are met:
     The services are identifiable physician services and meet 
the criteria in Sec. 415.102(a) (formerly Sec. 405.550(b)).
     The resident is fully licensed to practice medicine, 
osteopathy, dentistry, or podiatry in the State in which the services 
are performed.
     The services can be separately identified from those 
services that are required as part of the approved GME program.
    Paragraph (c) indicates that the moonlighting services of a 
resident furnished outside the scope of an approved GME program in a 
hospital or other setting that does not participate in 

[[Page 63142]]
the GME program are payable as physician services under the physician 
fee schedule.
i. Redesignation of Regulations on Teaching Hospitals, Teaching 
Physicians, and Physicians Who Practice in Providers
    As a part of this rulemaking process, we proposed to redesignate 
the regulations currently set forth in Secs. 405.465 and 405.466, 
405.480 through 405.482, 405.522 through 405.524, 405.550, 405.551, 
405.554, 405.556, and 405.580 into a new part 415, along with the new 
regulations proposed in this rule. The redesignation is part of our 
continuing effort to improve the overall organization of title 42 of 
the Code of Federal Regulations and, in this case, specifically, the 
organization of the regulations on teaching hospitals, teaching 
physicians, and physicians who practice in providers.
    Except as indicated below, we proposed only technical changes to 
conform cross-references, and no substantive changes were included. We 
proposed to remove Secs. 405.520 and 405.521 because the applicable 
rules for payment of services are obsolete. We also proposed to remove 
the chart for payment to interns and residents in Sec. 405.525 as 
obsolete. In addition, we proposed to remove Sec. 405.552 because the 
applicable payment rules for anesthesia services are set forth in 
Sec. 414.46. The proposed deletion of Sec. 405.552 was an error; we are 
redesignating this section as Sec. 415.110.
    We intended the redesignation to make these regulations easier to 
use. Following is a distribution table that indicates the new section 
numbers that will result from the redesignation or the removal of the 
section:

                           Distribution Table                           
------------------------------------------------------------------------
             Old section                          New section           
------------------------------------------------------------------------
405.465.............................  415.162                           
405.466.............................  415.164                           
 405.480............................  415.55                            
 405.481............................  415.60                            
 405.482............................  415.70                            
 405.520............................  Removed.                          
 405.521............................  Removed.                          
 405.522............................  415.200                           
 405.523............................  415.202                           
 405.524............................  415.204                           
 405.525............................  Removed.                          
 405.550............................  415.100, 415.102                  
 405.551............................  415.105                           
 405.552............................  415.110                           
 405.554............................  415.120                           
 405.556............................  415.130                           
 405.580............................  415.190                           
------------------------------------------------------------------------

    Following is a derivation table that shows the origin of each 
section of the new material:

                            Derivation Table                            
------------------------------------------------------------------------
                        New section                          Old section
------------------------------------------------------------------------
415.1.....................................................              
415.50....................................................              
415.55....................................................       405.480
415.60....................................................       405.481
415.70....................................................       405.482
415.100, 415.102..........................................       405.550
415.105...................................................       405.551
415.110...................................................       405.552
415.120...................................................       405.554
415.130...................................................       405.556
415.150...................................................              
415.152...................................................              
415.160...................................................              
415.162...................................................       405.465
415.164...................................................       405.466
415.170...................................................              
415.172...................................................              
415.174...................................................              
415.176...................................................              
415.178...................................................              
415.180...................................................              
415.184...................................................              
415.190...................................................       405.580
415.200...................................................       405.522
415.202...................................................       405.523
415.204...................................................       405.524
415.206...................................................              
415.208...................................................              
------------------------------------------------------------------------

4. Public Comments on the Teaching Physician Proposal in the Proposed 
Rule and Our Responses
    We received several thousand comments on the teaching physician 
proposal in our July 26, 1995 proposed rule. Almost all of the comments 
came from medical schools, residency programs, and other entities that 
bill for physicians' services in teaching hospitals and GME programs. 
The comments and our responses to them follow.
    Comment: Most commenters argued that the requirement of teaching 
physician presence during individual services was a significant 
departure from the current practice, and that a teaching setting would 
need a great deal of time to implement the requirement. They requested 
a delay in the effective date of any new policy. They believed that 
January 1 would be a particular problem since it falls in the middle of 
the cost reporting period for most teaching hospitals.
    Response: We do not believe that the physical presence requirement 
is a significant departure from current practice. Instead, as we have 
indicated in the proposed rule and in this final rule, the proposed 
rule requiring physical presence clarifies current policy. Under the 
criteria in Intermediary Letter 372, Part B payment should be made only 
when a supervising physician either personally performed the service or 
functioned as the attending physician and was present while the service 
was furnished. It has always been our intent that, at a minimum, a 
teaching physician must be present during a service furnished by an 
intern or resident in order for the teaching physician to receive Part 
B payment.
    We proposed to clarify our policy because it has not been enforced 
consistently across carriers. More specifically, we have learned that 
some teaching physicians are billing Medicare and receiving Part B 
payment for services even when the service is performed by an intern or 
resident outside the presence of the teaching physician and the 
teaching physician has minimal involvement, or no involvement, in the 
service. Under the physician fee schedule, payment amounts are intended 
to reflect the amount of resources required for a particular service, 
and we believe a teaching physician should not receive a resource-based 
fee schedule amount when the physician has expended little or no 
resources with respect to the service. It would be particularly 
inequitable to make a resource-based payment to some teaching 
physicians when other teaching physicians receive no payment because a 
carrier is properly applying the physical presence requirement in 
Intermediary Letter 372.
    Thus, the proposed rule would clarify the physical presence 
requirement reflected in Intermediary Letter 372. At the same time, the 
proposed rule increases flexibility for billing. The criteria in 
Intermediary Letter 372 were premised in part on the notion that the 
same physician served as the attending physician throughout the entire 
inpatient stay; therefore, only that physician could bill Medicare Part 
B. Accordingly, under Intermediary Letter 372, if a patient receives a 
service from the attending physician soon after admission, and receives 
services from other physicians during the course of the inpatient stay, 
the other physicians cannot bill Medicare Part B for services furnished 
by a resident. The proposed rule deletes the requirement of a single 
attending physician, and allows more than one teaching physician to 
receive Medicare Part B payment with respect to a particular inpatient 
stay.
    Although the physical presence requirement merely clarifies current 
policy, we are nevertheless willing to delay the effective date of the 
provisions of this final rule concerning teaching physicians until July 
1, 1996 to give our 

[[Page 63143]]
contractors adequate time to educate all affected parties. This delay 
will apply to all provisions of the regulation concerning teaching 
physicians, including those that state the new policies relating to the 
elimination of the single attending physician requirement and the 
exception for residency programs in certain centers.
    Comment: One commenter stated that section 948 of the Omnibus 
Reconciliation Act of 1980, as amended by section 2307 of the Deficit 
Reduction Act of 1984, requires only that--

The physician renders sufficient personal and identifiable 
physicians' services to the patient and exercises full, personal 
control over the management of the portion of the case for which 
payment is sought.

The commenter believed that these legislative provisions contain no 
physician presence requirement and questioned our authority to change 
25 years of policy without a Congressional mandate to do so.
    Response: We believe that the physical presence requirement is 
entirely consistent with our statutory authority. Under section 1887 of 
the Act, we are authorized to establish criteria to distinguish between 
services furnished for an individual patient, which may be paid for by 
carriers as physician services, and services that are furnished for the 
general benefit to patients in a hospital, which are paid for by 
intermediaries.
    In addition, we do not view the proposed policy as inconsistent 
with the statutory provision cited by the commenter. In the first 
place, we note that section 1842(b)(7) of the Act is largely premised 
on the use of charges as a basis for payment, and the charge-based 
system for physicians' services has been superseded by the enactment of 
the physician fee schedule. Nevertheless, the requirements stated in 
that section are not in conflict with the physical presence 
requirement. Section 1842(b)(7) provides that Part B payment may not be 
made for the services of teaching physicians unless, among other 
things, ``The physician renders sufficient personal and identifiable 
services to the patient and exercises full personal control over the 
management of the portion of the case for which payment is sought.'' 
(Emphasis added.)
    We believe we have ample authority under these provisions, as well 
as section 1848 of the Act, to determine the circumstances under which 
a teaching physician has performed a service for a patient, and thus 
has furnished a ``physician's service'' that warrants Part B payment 
under the physician fee schedule. Currently, despite the criteria in 
Intermediary Letter 372, many teaching physicians are billing Medicare 
and receiving Part B payment in situations when they have minimal, if 
any, involvement in the care of an individual patient. For example, the 
teaching physician may have medical and legal responsibility for the 
care a resident furnishes to a patient but may never actually see the 
patient after admission to the hospital. We believe it is inappropriate 
to make Part B payment in these cases, particularly because the amount 
of payment is resource-based.
    Of course, it is often difficult, and quite time-consuming, to 
determine when a physician is ``sufficiently involved'' in a particular 
patient care service so that Part B payment is warranted. As indicated 
in the proposed rule (60 FR 38409), the amount of postpayment review 
necessary to verify the involvement of teaching physicians in the care 
of individual patients would be enormous, and the use of scarce carrier 
resources in that effort would be impractical. Therefore, consistent 
with our authority to establish standards for determining when a 
service is furnished for a patient, as a general matter we believe the 
most appropriate and feasible manner to determine when Part B payment 
may be made is to require that the teaching physician must be present 
for the service for which payment is sought. The physical presence 
requirement identifies situations when the teaching physician is 
sufficiently involved in the service, and at the same time it provides 
a standard that can be readily documented and verified.
    Comment: One commenter argued that, under the proposed rule, 
teaching physicians would not be reimbursed in any manner under 
Medicare for certain teaching activities that were previously paid for 
under Part B. According to the commenter, Part A payment reflects base 
year costs that include only teaching physician costs related to the 
administration of the teaching program, and ``Teaching physician time 
was not allocable to Part A if attributable to patient care, whether 
the service was personally performed by the physician, or furnished in 
the context of the attending physician relationship.'' The commenter 
argued that teaching activities related to services to individual 
patients could not be included in base year costs and thus would never 
be reimbursed under Part A. The commenter concluded that, under the 
physical presence requirement, teaching activities related to the care 
of individual patients would not be reimbursed under either Part A or 
Part B.
    Response: We believe the policies reflected in this final rule 
fairly reimburse hospitals and physicians for the activities of 
teaching physicians. As we have indicated, currently many teaching 
physicians are billing Medicare and receiving Part B payment even when 
they have little or no involvement in a service furnished by an intern 
or resident. We believe it is not appropriate for teaching physicians 
to receive physician fee schedule payment in these situations as if the 
teaching physician had personally performed the service, particularly 
since fee schedule payments are intended to reflect the amount of 
resources expended by the physician. In order to address this problem, 
and to ensure that Part B payment is made only when the situation 
warrants, this final rule clarifies the physical presence requirement 
reflected in Intermediary Letter 372. We believe the requirement is 
reasonable and necessary because it ensures that Part B payment is made 
only when a teaching physician is sufficiently involved in the service 
and does so in a manner that can be readily documented.
    We recognize that there may be some inherent tension between 
policies for carrier payments under Part B and policies for 
intermediary payments under Part A or Part B. If a service or activity 
is payable under Medicare, and it is not payable under Part B, then 
presumably the service or activity is encompassed in the Part A 
payment. Therefore, any ``change'' in (or clarification of) Part B 
policy may, at least arguably, implicate Part A policy. The commenter 
argued that, despite this relationship between Part A and Part B, under 
the proposed policies, some services might not be reimbursed at all 
under Medicare.
    We believe that the commenter's arguments are misguided. We note 
initially that, as a general matter, payment for the costs of direct 
GME under Part A, like any system that uses base year costs, 
necessarily reflects conditions in the base year, and any number of 
conditions might change after the base year (these changes might 
benefit or hurt the hospital). However, the use of base years for 
purposes of making these Part A payments is required by statute. We do 
not believe we should necessarily perpetuate inappropriate payments 
under Part B simply because payments under Part A cannot be adjusted.
    Moreover, and more significantly, we believe that the policies 
reflected in this final rule taken as a whole reasonably reconcile any 
tension that there might be between Part A payment policies and 

[[Page 63144]]
Part B payment policies. The commenter seemed to suggest that, in 
conducting the Part A base year audits, the agency excluded all costs 
associated with teaching activities that were related to patient care. 
This suggestion, however, is incorrect. Indeed, as the commenter 
acknowledged, time spent supervising residents in patient care was 
allocable to Part A under the audits if there was no attending 
physician relationship. Furthermore, although the commenter also 
asserted that 100 percent of a physician's time was allocable to Part B 
``in the absence of appropriate documentation,'' it follows that time 
spent supervising residents could have been allocated to Part A if the 
hospital or the physician provided appropriate documentation. Thus, 
contrary to the commenter's suggestion, teaching activities related to 
patient care were, or could have been, included in the Part A base year 
costs. We believe we should not perpetuate inappropriate Part B 
policies simply because hospitals and physicians failed to properly 
claim or document Part A costs in the base year.
    The commenter also indicated that, under the proposed rule, certain 
teaching activities would not be reimbursed under Part B even though 
they were reimbursed under Part B previously (incorrectly or 
otherwise). This might relate to activities such as discussions about 
patient charts with a resident when the teaching physician was not 
present during the visit itself. The commenter stated that, in the 
proposed rule, we claimed incorrectly that lost Part B revenues could 
be collected through Part A. Contrary to the commenter's suggestion, we 
did not mean to suggest that services that were previously, but no 
longer, paid for under Part B would be paid for through increased 
payments under Part A. Rather, we meant to indicate that, at times in 
the past, improper payments may have been made.
    We believe that our policies adequately reimburse hospitals and 
teaching physicians for the activities of teaching physicians. First, 
the services of the interns or residents themselves are payable under 
separate mechanisms. Thus, to the extent that services are provided by 
interns and residents who are largely unsupervised, Medicare pays for 
the direct costs of those services through GME payments. Second, 
consistent with the criteria in Intermediary Letter 372, the teaching 
physician may receive Part B payment as long as the physician is 
present for the service. Finally, we are providing further flexibility 
for billing in this final rule, so that services may now be paid for 
under Part B even though the same services could not previously be 
properly billed to Part B; specifically, under this final rule, more 
than one teaching physician may bill Part B with respect to a 
particular hospital inpatient stay, whereas under Intermediary Letter 
372, only a single attending physician could properly bill Part B.
    In short, hospitals and physicians will not, as alleged, be 
systematically underreimbursed under the policies reflected in this 
final rule. The Part A payment encompasses costs of supervising 
residents that were (or could have been) properly allocated and 
substantiated for the base year. Teaching physicians may continue to 
receive Part B payment under the physical presence requirement 
reflected in Intermediary Letter 372. And Part B payment may now be 
made under circumstances in which payment could not properly be made 
under Intermediary Letter 372.
    Comment: Many commenters believed that we developed the teaching 
physician proposal because we had concluded that beneficiaries in 
teaching hospitals receive substandard care when the teaching physician 
is not present during the service or procedure.
    Response: The policy was not intended to specifically address 
quality concerns. Rather, the policy addresses payment issues, in 
particular, identifying when it is appropriate to make Medicare Part B 
payment to teaching physicians who oversee the services of interns and 
residents.
    It is important to distinguish between the services of interns and 
residents and the services of teaching physicians. Medicare fiscal 
intermediaries pay teaching hospitals for the services of interns and 
residents. Those services are described in sections 1861(b) and 1832(a) 
of the Act and are paid under the methodology established by section 
1886(h) of the Act. Thus, the fiscal intermediaries are already paying 
teaching hospitals for services furnished to beneficiaries by 
residents. The graduate medical education costs payable through the 
section 1886(h) methodology also encompass any costs associated with 
the supervisory services of teaching physicians that were appropriately 
allocated during the base period for that methodology (fiscal year 
1984).
    Particularly in light of these other payments, we believe that, if 
we are to pay a fee to another physician who is medically responsible 
for the services the resident is furnishing to the beneficiary, it is 
entirely appropriate to require as a condition of payment that the 
supervising physician furnish a direct, personal physician service to 
the beneficiary. This is the basis for the payment of physician 
services under Medicare. If the resident has personally furnished the 
service to the beneficiary and the intermediary is paying the teaching 
hospital for Medicare's share of the services performed by the 
resident, we believe it is appropriate not to pay a full fee to a 
supervising physician who was not present when the service was 
furnished. Furthermore, the Medicare beneficiary is responsible for a 
20 percent coinsurance amount for that physician's services as well as 
any deductible liability. We believe it is fully consistent with a 
resource-based fee schedule that the physician in whose name the 
service is billed furnishes a service to the beneficiary.
    Comment: Many commenters stated that residency programs cannot 
afford to furnish services to Medicare beneficiaries without Medicare 
payment.
    Response: Medicare fiscal intermediaries pay approximately $7 
billion annually in direct and indirect medical expenses to teaching 
hospitals for the costs associated with approved GME programs.
    Comment: Some commenters expressed concern about the term ``key 
portion'' in determining when the teaching physician should be present. 
They stated that it is often difficult to define the key portion of a 
service or procedure. Many commenters expressed their concern with the 
lack of a clear definition of what constitutes the key portion of every 
service or procedure. Many other commenters contended that the key 
portion of the teaching physician's services takes place during the 
teaching physician's discussions of the case with the resident before 
and after a visit or procedures. This argument was made by physicians 
in both medical and surgical specialties.
    Response: We proposed the concept of the key portion of a service 
or procedure to provide flexibility and to avoid requiring the presence 
of the teaching physician for the duration of every service or 
procedure billed in his or her name. Many of the commenters expressed 
the view that the key portion--and the most meaningful portion--of the 
teaching physician's service to the beneficiary actually takes place in 
the absence of the beneficiary. We do not agree with this 
interpretation of key portion because it blurs the distinction between 
teaching oversight and actually furnishing an identifiable service to 
the beneficiary.
    While we recognize the concern that it may be difficult to 
determine the key portion for a particular service, this concept is 
necessarily general because it 

[[Page 63145]]
is not feasible to define the key portion for each and every billable 
service. In order to provide guidance, we stated some general 
guidelines in the proposed rule. Thus, in the case of surgical, high-
risk, or other complex procedures, the teaching physician must be 
present during all critical portions of the procedure and immediately 
available to furnish services during the entire service or procedure. 
In the case of surgery, the teaching physician's presence is not 
required during opening and closing of the surgical field. In the case 
of procedures performed through an endoscope, the teaching physician 
must be present during the entire viewing.
    In the case of evaluation and management services, the teaching 
physician must be present during the portion of the service that 
determines the level of service billed. The factors to be considered 
are complexity of medical decision-making, extent of history obtained, 
and extent of examination performed. We believe that the teaching 
physician should have considerable discretion in determining the key 
portion of the service, and we do not anticipate that carriers will 
deny claims submitted based on this discretion, as long as the claims 
are documented and in accord with our guidelines. If the teaching 
physician believes that a key portion of an entire evaluation and 
management service cannot be identified, the teaching physician should 
be present for the entire service.
    We plan to address this matter further in carrier manual 
instructions.
    Comment: Some commenters objected to the requirement of the 
proposed rule that the teaching physician be present during the viewing 
portion of a procedure such as an endoscopy. The commenters believed 
that the presence of the physician should be determined by the teaching 
physician based on the competence of the resident.
    Response: In those situations, we believe that the carrier should 
pay for the interpretation of the viewed area by the teaching physician 
rather than by the resident. As indicated earlier, the viewing by the 
resident is not payable as a physician service; this service by the 
resident is paid under direct GME.
    Comment: The majority of the commenters identified themselves as 
representatives of family practice residency programs. The commenters 
made the following points:
     Many appreciated the preamble language of the proposed 
rule indicating our willingness to consider adopting special rules for 
family practice programs.
     Many claimed that hospitals and health care delivery 
systems would cease residency training for family practice programs if 
the proposal went into effect without an exception.
     In a family practice program, the resident is the primary 
care-giver, and the faculty physician sees the patient only in a 
consultative role.
     It is beneficial for family practice residents to see 
patients alone in order to learn medical decision-making and to 
recognize their own limitations.
     A resident cannot be educated in the art and practice of 
medicine without unsupervised patient contact; the proposed policy 
would interfere with the development of a resident's bedside manner.
     One family practice resident objected to the low levels of 
fee payments for his services under Medicare and Medicaid.
      The teaching physician presence requirement intrudes upon 
the relationship between the resident and the patient and, in the view 
of some, would cause Medicare beneficiaries to lose confidence in the 
competence of their resident physician.
     The requirement would necessitate the hiring of more 
teaching physicians and inhibit the ability to finance family practice 
programs through patient care billings.
     In many cases, the presence of the teaching physician is 
superfluous.
     The proposal does not adequately recognize the way 
medicine is practiced in this country.
     The family practice teaching physician is responsible for 
supervising four or more residents and medical students who are seeing 
patients simultaneously. Since the teaching physician must remain with 
the medical students during patient care visits, he or she does not 
have time to be involved in services furnished by the residents.
     The family practice preceptors are responsible for signing 
the medical records after the residents have dictated their entries 
which, in the view of some, guarantees mandatory supervision for each 
and every visit.
     Some residents are experienced physicians who have been in 
private practice for years and are in the residency program only to 
obtain board certification. The proposal does not adequately address 
those residents.
     If the proposed policy is implemented, family practice 
clinics will refuse to treat Medicare beneficiaries. Thus, the 
beneficiaries will be forced to go to medical assistance clinics.
     The proposal would put the resident in the position of 
being a clerk rather than a physician.
     Care furnished in family practice programs is more cost-
effective than care furnished in established practices; therefore, 
total Medicare costs are lower when services are provided by these 
programs.
     The physician presence requirement would inhibit the 
ability of family practice clinics to compete with managed care 
programs in the community.
    In addition, the American Academy of Family Practice proposed a 
specific limited exception to the physician presence requirement that 
we have adopted in large part as set forth below.
    Response: As we have discussed, we believe the physical presence 
requirement is necessary and appropriate as a general rule to ensure 
that Part B payment is not made when a teaching physician does not 
furnish a service for a patient; we also believe that hospitals and 
teaching physicians generally can, as a practical matter, reasonably 
meet the presence requirement and that Part B payment will be made as 
appropriate for the services and activities of teaching physicians. At 
the same time, we believe that, if the nature of a residency program is 
fundamentally incompatible with a physical presence requirement, it may 
be appropriate to make Part B payment if the teaching physicians 
satisfy certain conditions that demonstrate that they are sufficiently 
involved in the care of individual patients to warrant Medicare Part B 
payment. As reflected in the proposed rule, we believe a requirement of 
physical presence would be inherently incompatible with the nature of 
family practice residency programs, and thus unfairly deny 
reimbursement for the activities of teaching physicians in these 
programs and endanger the financial viability of these programs. 
Because of these considerations, we proposed a limited exception for 
family practice residency programs.
    In light of the comments, we have concluded that an exception 
should not be limited to family practice programs, but instead should 
apply to any program that satisfies certain specified criteria. The 
criteria are designed to capture those residency programs with 
requirements that are incompatible with a physical presence 
requirement. Thus, in this final rule, we have decided to establish an 
exception to the physician presence requirement for certain evaluation 
and management services furnished in certain centers within the context 
of certain types of residency 

[[Page 63146]]
training programs. The exception is set forth in a new Sec. 415.174 of 
this final rule.
    Under the exception, carriers may make physician fee schedule 
payment for reasonable and necessary low to mid-level evaluation and 
management services when furnished by a resident without the presence 
of a teaching physician if all of the following conditions are met:
     Services must be furnished in a center located in the 
outpatient department of a hospital or another ambulatory care entity 
in which the time spent by residents in patient care activities is 
included in determining intermediary payments to a hospital under 
Sec. 413.86.
     Any resident furnishing the service without the presence 
of a teaching physician must have completed more than 6 months of an 
approved residency program. The center is responsible for furnishing 
this information to the carrier. The family practice groups recommended 
the 6-month requirement, and we believe it is an appropriate safeguard.
     The teaching physician may not supervise more than four 
residents at any given time and must direct the care from such 
proximity as to constitute immediate availability. The teaching 
physician must--
    + Have no other responsibilities at the time of the service for 
which payment is sought;
    + Assume management responsibility for those beneficiaries seen by 
the residents;
    + Ensure that the services furnished are appropriate;
    + Review with each resident during or immediately after each visit, 
the beneficiary's medical history, physical examination, diagnosis, and 
record of tests and therapies; and
    + Document the extent of his or her own participation in the review 
and direction of the services furnished to each beneficiary.
     The patients seen must be an identifiable group of 
individuals who consider the center to be the continuing source of 
their health care and in which services are furnished by residents 
under the medical direction of teaching physicians. The residents must 
generally follow the same group of patients throughout the course of 
their residency program. We are not requiring that the teaching 
physicians remain the same over any period of time.
     The range of services furnished by residents includes:
    + Acute care for undifferentiated problems or chronic care for 
ongoing conditions.
    + Coordination of care furnished by other physicians and providers.
    + Comprehensive care not limited by organ system, diagnosis, or 
gender.
    We believe that the types of GME programs most likely to qualify 
for this exception include: family practice and some programs in 
general internal medicine, geriatrics, and pediatrics.
     The center must be located in a setting in which the 
resident's time is included in the full-time equivalency count used by 
the intermediary to make direct GME payments to a hospital for services 
of residents in that setting. In a freestanding setting in which 
residents are not counted for the purpose of making these payments, the 
services of licensed residents are already covered as physician 
services.
    This exception to the teaching physician presence applies only to 
specific low- and mid-level evaluation and management codes for office 
or other outpatient visits for both new and established patients. The 
established patient codes to which the exception applies are CPT codes 
99211, 99212, and 99213 (and their successor codes). New patient codes 
to which the exception applies are CPT codes 99201, 99202, and 99203 
(and their successor codes). The teaching physician must be present for 
higher level evaluation and management codes and all invasive 
procedures.
    In paragraph (b) of new Sec. 415.174, we clarify that the exception 
may not be construed as providing a basis for the coverage of otherwise 
noncovered services under Medicare, such as routine physical checkups. 
Further, this special treatment for certain training situations does 
not apply to services involving medical school students. A service 
furnished by a medical school student is a noncovered service under 
Medicare even if the teaching physician is in the room. We will publish 
further instructions on the new policy in the Medicare Carriers Manual.
    Comment: Some commenters who represent physician specialty 
organizations stated that they were opposed to any exception to the 
physician presence requirement if it was limited to a particular 
specialty. They believed that the same rules on physician presence 
should apply to all specialties. Some commenters indicated that special 
treatment for family practice programs ``devalued'' the importance of 
residency training in other programs. Many commenters argued that any 
special treatment given to family practice programs should apply to 
their programs as well. These include psychiatry, physical medicine, 
internal medicine, and obstetrics-gynecology. For example, several 
commenters believed that psychiatric residency programs should be given 
the same special treatment in the final rule as might be afforded to 
family practice programs. Some indicated that the costs of purchasing 
video equipment or one-way mirrors would be too great.
    Response: The exception we are establishing at new Sec. 415.174 is 
not limited to family practice programs; it applies to the indicated 
evaluation and management codes when furnished under the specified 
conditions. We are continuing to provide an additional, special 
exception for psychiatric programs in Sec. 415.184 as originally 
proposed.
    Comment: Some commenters indicated that their family practice 
clinics are not under the sponsorship of a hospital, and that their 
programs do not receive Medicare funds from a hospital for the time the 
resident is in the clinic.
    Response: If the family practice clinic is freestanding (that is, 
not part of a hospital) and the residents are not included in any 
hospital's full-time equivalent count of residents, the services of 
licensed residents are payable under the physician fee schedule on the 
same basis as any other physician's services. This longstanding policy 
applies regardless of whether or not the resident's services are 
furnished within the scope of an approved GME training program.
    Comment: Several commenters expressed concern that the same 
residents for whom we are requiring the presence of a teaching 
physician are not supervised by a teaching physician when they 
``moonlight'' outside of their training programs.
    Response: We recognize moonlighting situations and addressed the 
subject in the proposed rule. When licensed residents moonlight outside 
of their training program, Medicare pays for their services as 
physician services. Medicare does not pay a teaching hospital for these 
services through the direct GME payment mechanism or through the 
indirect medical education payment mechanism. In other words, in 
moonlighting situations, the Medicare program pays for the service only 
once.
    Comment: One organization supported the proposed rule on 
``moonlighting residents'' but sought clarification as to the impact of 
the proposal on inpatient services. Another commenter sought 
clarification of the policy when a licensed resident moonlights in 
another teaching hospital.
    Response: The proposal reflects longstanding policy outlined in 
section 2020.8 of the Medicare Carriers Manual. 

[[Page 63147]]
The policy does not encompass Medicare payment for moonlighting 
services furnished to inpatients in the hospital in which the resident 
has his or her program since we believe these services are virtually 
indistinguishable from the services the resident furnishes within the 
scope of the training program. However, when a licensed resident 
moonlights in another teaching hospital, the carrier must be furnished 
sufficient information to be sure that the moonlighting resident is not 
being included in the residency count (used to determine direct and 
indirect medical education payments) of either hospital for the period 
of time in question. Moreover, in this final rule, we are revising 
proposed Sec. 415.202 (``Services of residents not in approved GME 
programs'') (formerly Sec. 405.523) to clarify that, when an intern or 
resident is in an approved GME program at one hospital and is 
concurrently furnishing moonlighting services in another hospital that 
lacks an approved GME program, the services in the second hospital may 
be reimbursed only pursuant to 42 CFR part 414 or section 2109 of the 
Provider Reimbursement Manual.
    Comment: Some commenters suggested that we should discard the 
current proposal and implement the ``philosophy'' of teaching physician 
immediate availability rather than presence as proposed in the February 
7, 1989 proposed rule.
    Response: The exception that we have added to the policy we are 
adopting is consistent with the philosophy to which the commenters 
referred.
    Comment: Some commenters stated that documentation of a teaching 
physician's presence during a procedure would add costs to an already 
burdensome, bureaucratic process.
    Response: The policy we are adopting cannot be enforced without 
some documentation of the presence of the teaching physician during 
procedures and the personal involvement of the teaching physician in 
evaluation and management services.
    Comment: A few physician specialty organizations supported the 
proposal. In addition, a few physicians stated that the physician 
presence requirements reflected their standard practice. Some 
commenters representing surgeons stated that, while they generally 
supported the physician presence proposal, they objected to the 
requirement that the surgeons have to indicate in their operative notes 
when their presence began and ended since the anesthesiologist and 
nurses already record this information. Many other commenters objected 
to any restriction in the involvement of teaching surgeons in 
concurrent cases. Some commenters believed that third or fourth year 
residents were capable of performing surgical procedures with the 
teaching physician in the operating suite rather than in the operating 
room.
    Response: As we stated in the proposed rule, the notation in the 
nurse's notes is sufficient documentation of the teaching physician's 
presence during surgical procedures. There is no requirement that the 
teaching physician personally record the information if it duplicates 
information available elsewhere. If the teaching physician believes the 
third or fourth year resident is capable of performing surgical 
procedures without supervision, the teaching physician should not bill 
Part B for the surgical services furnished by the resident.
    Comment: One commenter recommended that the teaching physician be 
able to indicate the following general statement on all records:
    I have interviewed and examined the patient, and I agree with the 
history and physical findings as recorded by Dr. (Resident) in his/her 
note of (date).
    The commenter believed that this would clarify that the physician 
participated in the care of the patient, but not require that he or she 
spend valuable time repeating all of the documentation already present 
in the record.
    Response: This statement, by itself, would not be sufficient for 
Part B payment if the physician was not present during the service. If 
the physician was present, it is not necessary for the teaching 
physician to repeat all of the documentation entered into the medical 
records by the resident. The teaching physician may countersign the 
resident's entries and enter additional notes as necessary to indicate 
his or her involvement in the service. We will address these matters in 
more detail in manual instructions.
    Comment: One commenter believed that we should pay teaching 
physicians under case management CPT codes 99361 through 99373 and care 
plan oversight codes (CPT codes 99375 and 99376). These services 
include care team conferences and telephone calls for consultation or 
medical management with other health care professionals. In addition, 
the commenter suggested that we undertake a demonstration project to 
test the feasibility and cost-effectiveness of these payments with the 
goal of implementing a budget-neutral policy for the payments. The same 
commenter also suggested a policy under which the teaching physician 
could bill Medicare for each visit if the physician were present to 
observe every third visit furnished by the resident to the patient.
    Response: Medicare does not allow separate payment for the case 
management codes. We consider case management services to be included 
in the prework and postwork of the evaluation and management codes. The 
suggestion seems to be a way of removing the teaching physician further 
from the actual performance of the service, and we do not support this 
outcome.
    Comment: Under current policy in Sec. 414.46(c)(1)(iii), if a 
teaching anesthesiologist is involved in concurrent cases, the medical 
direction payment rules apply, and a reduced allowance is recognized 
for the physician service in each concurrent case. Commenters argued 
that this standard is inconsistent with the standard for teaching 
surgical services. They indicated their understanding that the teaching 
surgeon can be involved in concurrent procedures and receive a full 
allowance for each surgical procedure.
    Response: We intend to apply the physician presence standard for 
both surgical and anesthesia teaching services and have revised 
Sec. 415.178 (``Anesthesia services'') accordingly. Under the policy we 
are adopting, while we require the teaching surgeon's presence during 
the critical portion of the service, we do not require the surgeon's 
presence during the opening and closing of the patient. However, during 
this period, the teaching surgeon may not be involved in surgical 
services for other patients since this would preclude his or her return 
to the original case. We believe that this policy is analogous to the 
teaching anesthesiologist policy under which, in order to receive an 
unreduced fee, the anesthesiologist must be present during all critical 
portions of the procedure and immediately available to furnish services 
during the entire procedure.
    Comment: A carrier medical director commented that there should be 
a national standard on documentation of what the teaching physician 
actually does. The carrier medical director believed that physicians in 
nonteaching settings have to provide considerably more documentation 
than a counter-signature, and that the teaching physician should make a 
brief notation documenting his or her involvement in support of the 
level of evaluation and management code billed.
    Response: We plan to address this matter in billing instructions to 
implement the new policy.
    Final decision: We are going forward with the policy we proposed 
but have 

[[Page 63148]]
included an exception to the teaching physician presence requirement 
for certain evaluation and management services furnished in certain 
centers within the context of certain types of residency training 
programs. The new exception is found in Sec. 415.174 (``Exception: 
Evaluation and management services furnished in certain centers''). The 
effective date of the regulations concerning teaching physicians will 
be July 1, 1996.

F. Unspecified Physical and Occupational Therapy Services (HCFA Common 
Procedure Coding System Codes M0005 Through M0008 and H5300)

    We proposed to eliminate HCFA Common Procedure Coding System 
(HCPCS) codes M0005 through M0008 and H5300 and to redistribute the 
RVUs to the codes in the physical medicine section of the CPT (CPT 
codes 97010 through 97799). This policy change requires a single way of 
reporting and paying for a service for which there are now two ways to 
report. We proposed no change regarding what services may be covered, 
only as to how covered services would be billed and paid.
    Comment: All the comments we received expressed agreement with our 
proposal to eliminate the HCPCS codes M0005 through M0008 and H5300. 
The commenters stated that these services can be accurately reported 
using the new and revised physical medicine and rehabilitation codes in 
the CPT. They considered the decision to delete these codes to be 
appropriate and long overdue. The commenters cited the opportunity for 
unnecessary duplications of service codes and the misuse or overuse of 
the ``M'' codes in billing by physical therapists to support 
eliminating the HCPCS codes.
    However, some commenters were concerned that carriers might be 
reluctant to follow billing rules under the CPT for occupational and 
physical therapists in the same manner as is accepted for physicians. 
One commenter had encountered problems in the past with carrier 
refusals to accept the range of codes allowed under the scope of 
practice, to allow payment for both physical therapy and occupational 
therapy services required by the same patient, or to reimburse for more 
than one code per visit. Another commenter questioned whether 
occupational therapists in independent practice could report the full 
range of codes or if some codes were appropriate only to physical 
therapists in independent practice. The commenter also observed that 
some procedures can be considered either a physical therapy service or 
an occupational therapy service based solely on the specialty of the 
provider performing the service. Because of the coding flexibility, a 
beneficiary who has met his or her outpatient limit for physical 
therapy can continue to receive some of the same services under the 
occupational therapy outpatient limit if the service is furnished by an 
occupational therapist and vice versa.
    Response: Physical therapy and occupational therapy services 
required by the same patient are permitted, as is payment for more than 
one code per visit, subject to statutory requirements and limitations. 
That is, the provider of a service must be qualified within the State's 
scope of practice to furnish the service. According to Sec. 410.60 
(``Outpatient physical therapy services: Conditions.''), the services 
must be furnished under a written plan of treatment established by the 
physician or therapist caring for the patient. The services also must 
be medically necessary and reasonable for the diagnosis or treatment of 
an illness or injury, as mandated by section 1862(a) of the Act. 
Occupational and physical therapy services furnished to the same 
patient on the same day would necessitate two separate treatment plans, 
two separate physician orders, and both must be medically necessary.
    The current Medicare coding limitations apply when both physical 
therapists and occupational therapists furnish services to the same 
patient. Specifically, we do not allow separate payment for CPT code 
97250 (Myofascial release/soft tissue mobilization, one or more 
regions) for the same patient, on the same date of service as CPT codes 
97265 (Joint mobilization), 97260 (Manipulation (cervical, thoracic, 
lumbosacral, sacroiliac, hand, wrist) (separate procedure)), or 97261 
(each additional area) because these services overlap. Because of the 
duplication of services represented by the codes for manual 
manipulation (CPT codes 97260 and 97261), soft tissue mobilization (CPT 
code 97250), joint mobilization (CPT code 97265), or osteopathic 
manipulation (CPT codes 98925 through 98929), we do not permit separate 
payment if any of these codes are reported for the same patient, on the 
same date of service. Aside from these limitations, there is nothing 
that precludes the payment for both physical therapy and occupational 
therapy services for the same patient on the same date of service.
    The full range of CPT codes 97010 through 97799 may be reported by 
occupational therapists in independent practice as well as by physical 
therapists in independent practice if the service is within the scope 
of practice. We have no national payment policy that prevents 
occupational therapists in independent practice from billing and being 
paid for any CPT code that describes a service they furnish that may be 
covered. We do not allow payment for evaluation and management services 
billed by physical therapists in independent practice and occupational 
therapists in independent practice because the work RVUs for these 
services include work that they are not trained to perform (for 
example, evaluation for and prescription of drug therapy and evaluation 
for and prescription of surgical or other therapy). Otherwise, 
occupational therapists in independent practice may bill using any CPT 
code the carrier determines describes the covered services, not just 
the codes in the physical medicine section of the CPT.
    It follows, therefore, that the same procedure code may be used to 
bill for an occupational therapy service or a physical therapy service. 
The covered outpatient limit applies to both specialties individually.
    Comment: We were requested to clarify whether carriers allow 
payment for therapists' bills submitted under the physician fee 
schedule in the same manner as physicians' bills for similar services.
    Response: Section 1848(j)(3) of the Act defines physicians' 
services to include outpatient physical therapy and occupational 
therapy for physician fee schedule payment and, therefore, bills of 
physical therapists and occupational therapists in independent practice 
are treated in the same manner as bills of a physician for covered 
services.
    Comment: We received one comment asking if RVUs will be established 
for CPT codes 97545 and 97546, which are currently carrier priced.
    Response: We reviewed the RUC recommendations and decided to defer 
assigning RVUs for these codes until there is a better definition of 
the services. It is unclear whether the time specified in the codes 
(CPT 97545, work hardening/conditioning, initial 2 hours and CPT code 
97546, each additional hour) describes the time of the patient or the 
practitioner. It is our belief that it is possible for physical 
therapists in independent practice to do work hardening for four 
patients simultaneously, rotating from patient to patient located 
within the same room. Moreover, we believe that there is more work 
(that is, higher intensity and one-on-one attention) in the first 2 or 
more hours of service, not the initial 2 hours 

[[Page 63149]]
of care in a given day, as these codes are defined. We believe that the 
intensity and amount of work drops off quickly in the process and that 
it would be impossible to value the services correctly under its 
current definition.
    Comment: As noted in the proposed rule, the Health Care 
Professional Advisory Committee will be considering the creation of 
evaluation and management codes for physical therapists in independent 
practice and occupational therapists in independent practice. One 
commenter expressed hope that these codes would be developed by 1997.
    Response: We anticipate these codes will be developed for use in 
1997.
    Final Decision: We will eliminate HCPCS codes M0005 through M0008 
and H5300 and redistribute the RVUs across CPT codes 97010 through 
97799. This policy change is not explicitly addressed in our 
regulations.

G. Transportation in Connection with Furnishing Diagnostic Tests

    The general physician fee schedule policy regarding additional 
payments for travel expenses is that travel is included in the practice 
expense RVUs for a service. However, we have not specifically applied 
that policy to the transportation of equipment used to perform 
diagnostic tests. In the absence of specific instructions from us, 
separate payment for the transportation of diagnostic equipment has 
been at the Medicare carriers' discretion. We proposed to standardize 
payment for transportation of diagnostic equipment by applying the 
general physician fee schedule policy regarding payment for travel 
expenses to transportation services except in some cases of 
transporting portable x-ray and EKG equipment.
    The exceptions are based on longstanding specific instructions. In 
the case of x-ray services furnished by approved suppliers, section 
1861(s)(3) of the Act establishes the coverage of diagnostic x-rays 
furnished in a place of residence used as the patient's home. Although 
the Congress did not explicitly so state, we determined that, because 
there were increased costs associated with transporting the x-ray 
equipment to the beneficiary, the Congress intended for us to pay an 
additional amount for the transportation service. Thus, we established 
codes for use in billing for a transportation component of these 
services. Nothing in our proposal affects the payment of a 
transportation component in connection with the x-ray procedures 
furnished by approved portable x-ray suppliers listed in section 
2070.4.C of the Medicare Carriers Manual.
    We later added the taking of an EKG tracing to the list of services 
approved suppliers of portable x-ray services may furnish (section 
2070.4.F of the Medicare Carriers Manual) and established HCPCS code 
R0076 to pay for the transportation of EKG equipment. Under our 
proposal, we would continue to pay for the transportation of EKG 
equipment by approved suppliers of portable x-ray equipment although we 
did clarify that the policy applied only to standard EKG procedures 
described by CPT code 93005 (or CPT code 93000 if the interpretation is 
billed with the tracing).
    Many Medicare carriers have limited the use of HCPCS code R0076 to 
approved portable x-ray suppliers, but some Medicare carriers permit 
other types of entities, such as independent physiological laboratories 
to use the code. Section 2070.1.G of the Medicare Carriers Manual 
provides for the coverage of an EKG tracing by an independent 
laboratory in the following situations:
     In a home if the beneficiary is a homebound patient.
     In an institution used as a place of residence if the 
patient is confined to the facility and the facility does not have on-
duty personnel qualified to perform the service.
    Under our proposal, we would remove the requirement that the 
beneficiary be confined to his or her home or to an institution for the 
EKG tracing to be a covered service since this requirement does not 
apply to EKG tracings taken by portable x-ray suppliers.
    For all other types of diagnostic tests payable under the physician 
fee schedule, Medicare carriers would pay for the transportation of 
equipment only on a ``by report'' basis under CPT code 99082 if a 
physician submits documentation to justify the ``very unusual'' travel 
set forth in section 15026 of the Medicare Carriers Manual.
    Comment: One commenter, representing a mobile independent 
physiological laboratory, indicated that the laboratory currently 
furnished several types of diagnostic procedures to patients in various 
settings without any separate payment for transportation. The commenter 
appreciated the fact that, under the proposal, the laboratory would now 
receive a transportation payment for CPT code 93005 (a 12-lead EKG) and 
suggested that the exceptions to the transportation payment proposal be 
extended to include CPT code 93225 (holter monitoring) and HCPCS code 
G0005 (patient activated event recording procedures). The commenter 
suggested that HCPCS code R0076 be revised to specifically include the 
transportation of holter monitoring and patient activated event 
recorder equipment to patients upon physician order.
    Response: We were not seeking to expand the list of services 
independent physiological laboratories may furnish for which carriers 
will make separate transportation payments. Since the law does not 
provide for coverage of any diagnostic tests payable under the 
physician fee schedule furnished to beneficiaries in their place of 
residence other than x-ray services furnished under conditions we have 
approved, we will not provide for transportation payments in connection 
with other diagnostic tests furnished by independent physiological 
laboratories.
    Under our proposal, Medicare carriers would make transportation 
payments under HCPCS code R0076 in connection with standard EKG 
procedures (CPT code 93005) furnished by an independent physiological 
laboratory when the coverage conditions of section 2070.5 of the 
Medicare Carriers Manual are met. We made this exception to the general 
policy on transportation of diagnostic equipment because of the 
longstanding nature of the Medicare Carriers Manual policy on 
furnishing EKGs to patients in their residences or in nursing homes by 
``independent'' laboratories. We have some concerns about making this 
exception because it is our understanding that some Medicare carriers 
are not currently making such payments. However, we anticipate that 
this additional cost will be offset, to some degree, nationally by the 
discontinuation of transportation payments to independent physiological 
laboratories for other types of diagnostic tests that Medicare carriers 
may currently allow. In addition, we are modifying our proposal in that 
we are maintaining section 2070.1.G of the Medicare Carriers Manual 
regarding the homebound status of the beneficiary receiving the 
service.
    Comment: A carrier medical director questioned why the proposal did 
not address whether the diagnostic procedure itself was payable when 
furnished by an independent physiological laboratory in settings such 
as a nursing home and whether we were suggesting that such procedures 
should not be done in nursing homes. The commenter noted that it would 
be useful for us to establish a list of ``physiological'' tests that 
can be furnished by an independent physiological laboratory.
    Response: Our proposal does not address the coverage for procedures 


[[Page 63150]]
furnished by independent physiological laboratories. In the absence of 
a national policy on the payment for the services, the coverage for 
independent physiological laboratory services remains within the 
authority of the carrier and must be consistent with any applicable 
State or local laws.
    Comment: A national organization of suppliers of portable x-ray 
services commented that portable x-ray suppliers should be the only 
entities paid under the physician fee schedule who may bill for 
transportation of diagnostic equipment under HCPCS codes R0070, R0075, 
and R0076.
    Response: Under the policy we are adopting, approved suppliers of 
portable x-ray services are the only entities who may bill HCPCS codes 
R0070 and R0075 under the physician fee schedule. Portable x-ray 
suppliers and independent physiological laboratories may bill HCPCS 
code R0076 for the transportation of EKG equipment used to furnish 
standard EKGs (CPT codes 93000 and 93005).
    Comment: A national organization whose membership includes primary 
care physicians opposed the proposal because it would adversely affect 
the availability of portable diagnostic equipment for small hospitals 
and for patients in home care and skilled nursing facilities. The 
commenter noted that it was not in the best interest of patient care to 
force patients to travel to medical facilities outside their 
communities to receive the testing and that Medicare carriers should 
ensure that transportation payments do not exceed transportation costs.
    Response: We believe there is no problem with respect to the 
transportation of diagnostic equipment to small hospitals. The hospital 
must purchase the service ``under arrangements'' if the service is 
provided to its patients. When a hospital purchases services ``under 
arrangement,'' it assumes responsibility for the service furnished, and 
Medicare intermediary payment is made for this service through one of 
several payment mechanisms applicable to payment for hospital services.
    Comment: Several commenters indicated that home and facility bound 
patients would benefit from expanded coverage of portable ultrasound 
services. One commenter indicated that these services offer the patient 
a top quality examination while eliminating the trauma and expense of 
an ambulance ride and emergency room stay. The commenter requested a 
mobile ultrasound transport code and a mobile ultrasound set-up code.
    Response: Our proposal does not affect the furnishing of these 
procedures in homes or facilities; it merely affects any additional 
payment for the transportation of the diagnostic equipment. We can find 
no basis in the statute to support separate payments for the 
transportation of the equipment used to furnish these services.
    Comment: A national physicians' organization recommended we 
establish a list of diagnostic services for which transportation 
payment will be made. It suggested the list include transportation of 
diagnostic equipment used to perform the following:
     Frozen section diagnosis in hospitals and other facilities 
in which surgery is provided.
     Therapeutic apheresis furnished to patients in sites where 
the equipment is not available.
    Response: The frozen section diagnostic equipment should be 
purchased ``under arrangement'' by the hospital and is payable through 
Medicare intermediary payment mechanisms. Therapeutic apheresis 
services are outside the scope of this proposal, which only relates to 
diagnostic tests.
    Comment: We received several comments requesting the following:
     The definition of an independent physiological laboratory 
be extended to include diagnostic and screening mammograms furnished by 
certified facilities.
     Transportation payments be made to mobile facilities 
providing mammography services.
     Diagnostic and screening mammography services be added to 
the list of covered portable x-ray services.
    Response: As indicated in an earlier response, the coverage of 
services furnished by independent physiological laboratories is beyond 
the scope of this proposal. Furthermore, the Congress has placed the 
authority for setting standards for entities furnishing both diagnostic 
and screening mammograms with the Food and Drug Administration. If an 
independent physiological laboratory were to receive certification from 
the Food and Drug Administration, it may furnish these services to 
Medicare beneficiaries.
    Under the policy we are adopting, the only service furnished by an 
independent physiological laboratory for which a separate 
transportation payment may be made is a standard EKG.
    Under our proposal, we were not planning to make any changes in the 
services an approved supplier of portable x-ray services may furnish; 
however, the commenter has made a good point about mammography 
services. Under the changes made to section 1861(s)(3) of the Act by 
section 145(b) of the Social Security Act Amendments of 1994, Public 
Law 103-432, enacted on October 31, 1994, we believe that the Congress 
has added diagnostic mammography as part of the portable x-ray benefit. 
We will issue instructions to Medicare carriers regarding payments 
(including transportation payments) for mammograms furnished by 
approved portable x-ray suppliers.
    Final Decision: We are adopting the proposal to preclude separate 
payment for the transportation of diagnostic equipment except under the 
following circumstances:
     Transportation services billed under HCPCS codes R0070, 
R0075, or R0076 in connection with services furnished by approved 
suppliers of portable x-ray services as set forth in section 2070.4 of 
the Medicare Carriers Manual.
     Transportation services billed by an independent 
physiological laboratory under HCPCS code R0076 in connection with the 
provision of the CPT codes 93000 or 93005 (a 12-lead EKG with 
interpretation and report or a 12-lead EKG, tracing only, without 
interpretation and report, respectively) furnished under the conditions 
set forth in section 2070.1.G. of the Medicare Carriers Manual.
     Transportation services billed on a ``by report'' basis 
under CPT code 99082 (unusual travel) if a physician submits 
documentation to justify ``very unusual'' travel as set forth in 
section 15026 of the Medicare Carriers Manual.
    Payment for expenses associated with the transportation of 
diagnostic equipment under conditions that do not meet any of the above 
criteria is included in the practice expense RVUs assigned to the 
service or procedure and is not separately payable. In addition, we 
plan to develop a proposal related to the transportation of EKG 
equipment furnished by any supplier as part of next year's physician 
fee schedule regulation.

H. Maxillofacial Prosthetic Services

    We proposed to eliminate the carrier-priced status and establish 
RVUs for maxillofacial prosthetic services effective for services 
performed on or after January 1, 1996. We proposed RVUs for CPT codes 
21079 through 21087 and HCPCS codes G0020 and G0021.
    The work RVUs that we proposed were developed by the American 
Academy of Maxillofacial Prosthetics. We believe they appropriately 
represent the work involved in these procedures. 

[[Page 63151]]
Because the CPT codes were introduced in 1991 and the HCPCS codes in 
1995, we have little or no charge data on which to base practice 
expense and malpractice expense RVUs in accordance with section 
1848(c)(2)(C) of the Act. Therefore, we imputed the practice expense 
and malpractice expense RVUs from the work RVUs based on the practice 
cost shares provided by the American Association of Oral and 
Maxillofacial Surgeons. Those shares are 54.7 percent for practice 
expense and 4.4 percent for malpractice expense.
    Comment: We received numerous comments in response to the RVUs 
assigned to maxillofacial prosthetic services. Although there was some 
support for eliminating the carrier-priced status of these services and 
at least one commenter expressed appreciation of the work RVUs, the 
commenters were unanimous in objecting to our use of the American 
Association of Oral and Maxillofacial Surgeons' practice cost shares. 
These commenters stated that the practice and malpractice expenses for 
the sub-specialty of maxillofacial prosthetics differ substantially 
from those of maxillofacial surgery, primarily due to increased 
laboratory, supply, and maxillofacial material costs. The commenters 
believed that the RVUs imputed for practice expense are too low and 
should be between 65 and 70 percent to accurately reflect the practice 
expenses incurred by the prosthodontist. According to the commenters, 
the RVUs we proposed for malpractice expense are too high and should be 
in the range of 1 percent to 3.5 percent of the total RVUs.
    Because maxillofacial prosthodontic practice expenses include 
laboratory charges (including precious metals and impression materials) 
that are rarely seen in oral and maxillofacial surgery and include 
significantly higher practice expenses, the commenters requested that 
we revise the RVUs for maxillofacial prosthetic procedures to account 
for the higher practice cost shares.
    Response: In the absence of charge data, we use the best available 
data to impute practice expense and malpractice expense RVUs. 
Maxillofacial surgery represented the specialty for which we had 
available data that used comparable survey methods. We note, also, that 
we are currently working on a resource-based practice expense study 
and, as part of this effort, hope to have more definitive data in the 
future. At that time, we will reevaluate all maxillofacial practice 
expense RVUs.
    Final Decision: We are recommending no additional modifications to 
the RVUs for maxillofacial codes at this time. The proposed RVUs for 
CPT codes 21079 through 21087 are accepted as final. HCPCS code G0020 
has been replaced by new CPT code 21076, and G0021 has been replaced by 
new CPT code 21077. Because these new CPT codes describe the same 
services as the HCPCS codes, the assigned RVUs will not change. 
Therefore, the proposed relative values for G0020 and G0021 are 
accepted as final but are assigned to CPT codes 21076 and 21077, 
respectively. G0020 and G0021 are deleted effective January 1, 1996. 
All RVUs for oral maxillofacial prosthetic services are published in 
Addendum B.

I. Coverage of Mammography Services

    Based on recommendations from the Food and Drug Administration, the 
National Cancer Institute, and a carrier medical directors' workgroup, 
we proposed to revise the definitions of ``diagnostic'' and 
``screening'' mammography in Sec. 410.34 to make them consistent with 
previous Medicare coverage policy regarding ``diagnostic'' mammography 
and with the way these terms are used in general clinical practice in 
the United States. Specifically, we proposed to expand the definition 
of ``diagnostic'' mammography in Sec. 410.34(a)(1) to include as 
candidates for this service asymptomatic men or women who have a 
personal history of biopsy-proven breast disease. However, we proposed 
to retain the substance of the present definition of ``screening'' 
mammography in Sec. 410.34(a)(2) so that patients with a personal 
history of breast disease can be considered candidates for the 
``screening'' examination, if the woman's attending physician 
determines that this is appropriate.
    Comment: One commenter indicated that, because of the overlap in 
the definitions for ``screening'' and ``diagnostic'' mammograms, the 
proposal would lead to allowing almost every mammogram furnished to a 
Medicare beneficiary to be covered as a diagnostic mammogram, thereby 
increasing Medicare costs for mammograms.
    Response: We do not believe the revised definitions will 
significantly increase the total number of diagnostic mammography 
services furnished. Information from the Medicare carriers indicates 
that most asymptomatic patients with a personal history of biopsy-
proven breast disease are already receiving diagnostic mammograms 
rather than screening mammograms. This final rule is consistent with 
general clinical practice in the United States and falls within the 
parameters of Medicare statutory coverage for diagnostic and screening 
mammograms.
    Comment: Two commenters recommended that we clarify the term ``a 
personal history of biopsy-proven breast disease.'' One commenter 
assumed that both benign (for example, fibroadenomas) and malignant 
neoplasms would fall in that category. The other commenter suggested 
that we make a distinction between ``a personal history of breast 
cancer'' and ``a personal history of biopsy-proven breast disease.''
    Response: We agree that this point needs to be clarified. The 
intent of the proposal was to include both benign and malignant 
neoplasms within the meaning of the term ``a personal history of 
biopsy-proven breast disease.'' Breast diseases, including both benign 
and malignant neoplasms, that require a biopsy and subsequently 
demonstrate a pathologic process, establish a history of biopsy-proven 
breast disease. In the final rule, we are clarifying this by revising 
the term ``a personal history of biopsy-proven breast disease'' to read 
``a personal history of breast cancer or a personal history of biopsy-
proven benign breast disease.''
    Comment: One commenter expressed the opinion that the term 
``fibrocystic disease'' referred to in the preamble of the proposed 
rule should be more appropriately referenced as ``fibrocystic 
changes.''
    Response: The terms ``fibrocystic disease'' and ``fibrocystic 
changes'' are often used synonymously. We agree that, in our discussion 
of this subject in the preamble to the proposed rule, the preferred 
term is ``fibrocystic changes.''
    Comment: One commenter suggested that the proposal should be 
revised to include, as candidates for diagnostic mammography, women who 
have a family history of breast disease (within one generation).
    Response: While there is a growing consensus among clinicians and 
mammography experts that family history is an important etiologic 
factor that places women at high risk of developing breast cancer, and 
thus eligible for screening mammography at frequent intervals, the data 
are not sufficiently definitive at present to consider these women to 
be candidates for diagnostic mammography.
    Comment: One commenter suggested that we discuss whether women who 
have tested positive for any of the recently identified breast cancer 
genes, such as BRCA1, should be considered to have a personal history 
of breast cancer 

[[Page 63152]]
within the meaning of this term in the regulations.
    Response: As we stated in the final rule concerning Medicare 
coverage of screening mammography that was published in the Federal 
Register on September 30, 1994 (59 FR 49826), the term ``a personal 
history of breast cancer'' in Sec. 410.34(b)(4) of the regulations was 
intended to mean that there is documented evidence in the woman's 
medical record that she has tested positive for breast cancer. While 
the development of screening tests in this area is promising, we do not 
believe that the inclusion of these tests as specific criteria for 
coverage of screening mammograms is warranted at this time. However, as 
new information becomes available, we will reconsider this issue.
    Final Decision: We are adopting our proposal to revise the 
definitions of the terms diagnostic and screening mammography in 
Sec. 410.34. As requested by several commenters, we are clarifying the 
final regulations text by revising the term ``a personal history of 
biopsy-proven breast disease'' to read ``a personal history of breast 
cancer or a personal history of biopsy-proven benign breast disease.''

III. Anesthesia Issues

A. Modifier Units for Anesthesia Services

    In the January 26, 1989 proposed rule (54 FR 3794) and the August 
7, 1990 final rule implementing the uniform relative value guide for 
physician anesthesia services, we stated our national policy that 
Medicare carriers cannot recognize payments for anesthesia modifiers. 
Anesthesia modifiers represent additional units charged by physicians 
because of the patient's advanced age, poor physical health status, or 
unusual circumstances including the performance of anesthesia under 
emergency circumstances or anesthesia complicated by the use of 
controlled hypotension.
    For the 3 years preceding the physician fee schedule, Medicare 
carriers had uniformly implemented the policy of not allowing modifier 
units in determining payment for physician anesthesia services.
    The physician fee schedule legislation required us to use the 
uniform relative value guide to the extent feasible and to make any 
necessary adjustments to the anesthesia CF. In the November 1991 final 
rule (56 FR 59509) to implement the physician fee schedule, we stated 
that we were continuing to use the uniform relative value guide to 
determine payment for physician anesthesia services under the physician 
fee schedule. Since it was the established uniform practice for 
Medicare carriers not to recognize modifier units, we believed it was 
sufficient to write the regulations to explain only those elements that 
the Medicare carrier would recognize in calculating anesthesia 
payments, namely anesthesia base and time units. Thus, in the final 
rule to implement the physician fee schedule, we did not include 
specific regulatory language prohibiting anesthesia modifier units.
    Some administrative law judges have interpreted the absence of 
language expressly prohibiting the use of modifier units under the 
physician fee schedule to mean that modifier units can be allowed. This 
is clearly an incorrect interpretation of our regulations, and we have 
chosen to clarify this matter by including a specific reference in the 
regulations stating that modifier units are not allowed. We have 
revised Sec. 414.46 to reflect this policy. Because this clarification 
of the regulations is an interpretive change, the law does not require 
prior notice and comment. However, we will accept comments on this 
change in the regulations.

B. Issue for Change in Calendar Year 1998--Two Anesthesia Providers 
Involved in One Procedure

    As a result of the revised payment methodology for the anesthesia 
care team established by section 13516 of OBRA 1993, we proposed to 
apply the medical direction payment policy to the single procedure 
involving both the physician and the certified registered nurse 
anesthetist. Thus, in Sec. 414.46 we proposed to revise paragraphs (c) 
and (d) to state that, in this situation, the payment allowance for the 
medical direction service of the physician and the medically directed 
service of the certified registered nurse anesthetist or the 
anesthesiologist assistant is based on the specified percentage of the 
payment allowance in Sec. 414.46(d)(3). In addition, we proposed that 
in 1998 and later years, this payment allowance is equal to 50 percent 
of the allowance for personally performed procedures.
    We proposed to implement this policy on January 1, 1998. At that 
time, the change in policy will be done in a budget-neutral manner.
    Comment: Commenters referred to those complicated anesthesia cases 
when it may be medically necessary for two anesthesia care providers to 
be involved. The anesthesia providers could be an anesthesiologist and 
a certified registered nurse anesthetist or two anesthesiologists. They 
asked whether we would permit full payment for each of these providers 
or subject these providers to the new proposal in which case each 
provider would receive only 50 percent of the allowance recognized for 
the anesthesia case personally performed by a single anesthesiologist.
    Response: We are not changing the current policy under which the 
Medicare carriers can, on the basis of medical necessity, recognize 
full payment for the services of each of two anesthesia providers if 
both providers are needed in a single anesthesia case. Thus, the 
Medicare carriers can continue, based on medical necessity, to allow 
full payment for the service furnished by each anesthesia provider in a 
single case.
    Comment: A commenter offered an alternative proposal that would 
achieve budget neutrality but allow implementation beginning in 1996. 
Under the commenter's proposal, which would take effect in 1996, the 
payment allowance for both the certified registered nurse anesthetist 
and the anesthesiologist involved in the single case would be 50 
percent of the allowance recognized for the single anesthesiologist.
    Response: The law recognizes that an anesthesia service is either 
personally performed by a physician (or nonmedically directed certified 
registered nurse anesthetist) or the case is medically directed. We 
have implemented the medical direction policy as applying only to two, 
three, or four concurrent procedures. Therefore, we deemed the case 
involving both the anesthesiologist and the certified registered nurse 
anesthetist to be personally performed by the physician. In the July 
26, 1995 proposed rule, we proposed to modify the definition of medical 
direction to include a single procedure in addition to concurrent 
procedures. The statutory provisions governing medical direction 
provide that, in 1996, the payment allowance for both the certified 
registered nurse anesthetist and the physician are equal to 55 percent 
of the single anesthesiologist payment allowance. Thus, there is no 
direct authority in the law to recognize a payment allowance that is 50 
percent of the single anesthesiologist payment allowance for both the 
certified registered nurse anesthetist and the physician.
    Final Decision: We will apply the medical direction payment policy 
to the single procedure involving both the physician and the certified 
registered nurse anesthetist. We will implement this policy on January 
1, 1998. At that 

[[Page 63153]]
time, the change in policy will be done in a budget-neutral manner.

IV. Refinement of Relative Value Units for Calendar Year 1996 and 
Responses to Public Comments on Interim Relative Value Units for 1995

A. Summary of Issues Discussed Related to the Adjustment of Relative 
Value Units

    Section IV.B. of this final rule describes the methodology used to 
review the comments received on the relative value units (RVUs) for 
physician work and the process used to establish RVUs for new and 
revised CPT codes. (The CPT, which is published annually by the 
American Medical Association, is a listing of descriptive terms and 
identifying codes for reporting medical services and procedures 
performed by physicians.) Changes to codes on the physician fee 
schedule reflected in Addendum B are effective for services furnished 
beginning January 1, 1996.

B. Process for Establishing Work Relative Value Units for the 1996 Fee 
Schedule

    Our December 8, 1994 final rule on the 1995 physician fee schedule 
(59 FR 63410) announced the final RVUs for Medicare payment for 
existing procedure codes under the physician fee schedule and interim 
RVUs for new and revised codes. The RVUs contained in the rule apply to 
physician services furnished beginning January 1, 1995. We announced 
that we would accept comments on interim RVUs for new or revised codes. 
We announced that we considered the RVUs for the remaining codes to be 
subject to public comment under the 5-year refinement process. In this 
section, we summarize the refinements to the interim work RVUs that 
have occurred since publication of the December 1994 final rule and our 
establishment of the work RVUs for new and revised codes for the 1996 
fee schedule.
1. Work Relative Value Unit Refinements of Interim and Related Relative 
Value Units
    a. Methodology (Includes Table 1--Work Relative Value Unit 
Refinements of Interim and Related Relative Value Units).
    Although the RVUs in the December 1994 final rule were used to 
calculate 1995 payment amounts, we considered the RVUs for the new or 
revised codes to be interim. We accepted comments for a period of 60 
days. We received approximately 100 substantive comments from 24 
specialty societies on approximately 83 CPT codes with interim RVUs.
    Only comments received on codes listed in Addendum C of the 
December 1994 final rule were considered this year. We will consider 
comments we received on other codes under the 5-year refinement 
process. We convened a multispecialty panel of physicians to assist us 
in the review of the comments with certain exceptions. The comments 
that we did not submit to panel review are discussed at the end of this 
section. The panel was moderated by our medical staff and consisted of 
the following groups:
     A clinician representing each of the specialties most 
identified with the procedures in question. Each specialist on the 
panel was nominated by the specialty society that submitted the 
comments. Eleven specialty societies, including primary care, were 
represented on the panel.
     Primary care clinicians nominated by the American Academy 
of Family Physicians, the American Society of Internal Medicine, the 
American College of Physicians, and the American Academy of Pediatrics.
     Carrier medical directors.
    After eliminating the codes with final RVUs and certain codes that 
are discussed at the end of this section, we submitted comments on 18 
codes for evaluation by the panel. The panel discussed the work 
involved in each procedure under review in comparison to the work 
associated with other services on the fee schedule. We had assembled a 
set of reference services and asked specialty societies to compare 
clinical aspects of the work of services they believed were incorrectly 
valued to one or more of the reference services. In compiling the set, 
we attempted to include: (1) Services that are commonly performed whose 
work RVUs are not controversial; (2) services that span the entire 
spectrum from the easiest to the most difficult; and (3) at least three 
services performed by each of the major specialties so that each 
specialty would be represented. The set listed approximately 120 
services. Panelists were encouraged to make comparisons to reference 
services.
    The intent of the panel process was to capture each participant's 
independent judgment based on the discussion and his or her clinical 
experience. Following each discussion, each participant rated the work 
for the procedure. Ratings were individual and confidential, and there 
was no attempt to achieve consensus among the panel members.
    We then analyzed the ratings based on a presumption that the final 
rule RVUs were correct. To overcome this presumption, the inaccuracy of 
the interim RVUs had to be apparent to the broad range of physicians 
participating in each panel.
    Ratings of work were analyzed for consistency among the groups 
represented on each panel. In general terms, we used statistical tests 
to determine whether there was enough agreement among the groups of the 
panel and whether the agreed-upon RVUs were significantly different 
from the interim RVUs published in Addendum C of the December 1994 
final rule. We did not modify the RVUs unless there was clear 
indication for a change. If there was agreement across groups for 
change, but the groups did not agree on what the new RVUs should be, we 
eliminated the outlier group and looked for agreement among the two 
remaining groups as the basis for new RVUs. We used the same 
methodology in analyzing the ratings that we used in the refinement 
process for the 1993 fee schedule. The statistical tests were described 
in detail in the November 25, 1992 final notice (57 FR 55938).
    Our decision to convene multispecialty panels of physicians and to 
apply the statistical tests described above was based on our need to 
balance the interests of those who commented on the work RVUs against 
the redistributive effects that would occur in other specialties, 
particularly the potential adverse effect on primary care services. Of 
the 18 codes reviewed by our multispecialty panel, all of the requests 
were for increased values.
    We also received comments on RVUs that were interim for 1995 but 
which we did not submit to the panel for review for a variety of 
reasons. These comments and our decisions on those comments are 
discussed in further detail in section VI.B.1.c. of this final rule. Of 
the 44 interim work RVUs that were reviewed, approximately 41 percent 
were increased, and approximately 59 percent were not changed.

Table 1--Work Relative Value Unit Refinements of Interim Relative Value 
Units

    Table 1 lists the interim and related codes reviewed during the 
1995 refinement process described in this section. This table includes 
the following information:
     CPT code. This is the CPT code for a service.
     Modifier. A ``26'' in this column indicates that the RVUs 
are for the professional component of the code.
     Description. This is an abbreviated version of the 
narrative description of the code. 

[[Page 63154]]

     1995 work RVUs. The work RVUs that appeared in the 
December 1994 rule are shown for each reviewed code.
     Requested work RVUs. This column identifies the work RVUs 
requested by commenters. We received more than one comment on some 
codes, and, in a few of these cases, the commenters requested different 
RVUs. The table lists the highest requested RVUs. For some codes, we 
received recommendations for an increase or decrease but no specific 
RVU recommendations.
     1996 work RVUs. This column contains the final RVUs for 
physician work.
     Basis for decision. This column indicates whether:

--The recommendations of the refinement panel were the basis upon which 
we determined that the interim work RVUs published in the December 1994 
final rule should be retained (indicator 1);
--A new value emerged from our analysis of the refinement panel ratings 
(indicator 2); or
--A new or retained value emerged from some other source (indicator 3). 
Codes with an indicator of 3 are discussed following Table 1, in 
section VI.B.1.c.
--New or retained values emerged through a combination of the panel 
ratings and code descriptor interpretation (indicator 4). Codes with an 
indicator of 4 are discussed following Table 1, in section VI.B.1.b.



                                                                        

[[Page 63154]]
                           Table 1.--Work RVU Refinements of Interim and Related RVUs                           
----------------------------------------------------------------------------------------------------------------
                                                                      1995 work  Requested  1996 work  Basis for
   CPT*       Mod                       Description                      RVU      work RVU     RVU      decision
----------------------------------------------------------------------------------------------------------------
11977....  .........  Removal/reinsert contra cap...................       2.52       3.30       3.30          3
19367....  .........  Breast reconstruction.........................      24.73      26.50      24.73          3
20955....  .........  Microvascular fibula graft....................      37.58      43.00      37.58          3
25337....  .........  Reconstruct ulna/radioulna....................       9.10       9.50       9.50          3
25830....  .........  Fusion radioulnar jnt/ulna....................       9.10       9.50       9.50          3
26580....  .........  Repair hand deformity.........................      15.81      17.71      17.71          3
29445....  .........  Apply rigid leg cast..........................       1.78       0.57       1.78          3
31276....  .........  Sinus surgical endoscopy......................       7.42       8.85       8.85          3
37209....  .........  Exchange arterial catheter....................       1.48       3.66       2.27          2
41822....  .........  Excision of gum lesion........................       2.26       4.20       2.26          1
41823....  .........  Excision of gum lesion........................       3.15       4.60       3.15          1
41828....  .........  Excision of gum lesion........................       1.26       4.44       3.04          2
41830....  .........  Removal of gum tissue.........................       1.12       5.00       3.30          2
43842....  .........  Gastroplasty for obesity......................      13.76      17.47      13.76          3
43843....  .........  Gastroplasty for obesity......................      13.76      17.47      13.76          3
43846....  .........  Gastric bypass for obesity....................      17.84      20.87      17.84          3
43847....  .........  Gastric bypass for obesity....................      19.87      23.24      19.87          3
43848....  .........  Revision gastroplasty.........................      22.10      24.75      22.10          3
52647....  .........  Laser surgery of prostate.....................       7.42      11.51       9.84          2
52648....  .........  Laser surgery of prostate.....................       8.65      11.51      10.69          2
59855....  .........  Abortion......................................       4.75       5.80       5.80          3
64820....  .........  Remove sympathetic nerves.....................       9.10      10.00      10.00          3
76093....         26  Magnetic image, breast........................       1.63       1.94       1.63          1
76094....         26  Magnetic image, both breasts..................       1.63       1.94       1.63          1
76936....         26  Echo guide for artery repair..................       1.31       2.64       1.99          2
90849....  .........  Special family therapy........................       0.59       0.78       0.59          3
90918....  .........  ESRD related services, month..................       9.77      13.27      11.18          4
90919....  .........  ESRD related services, month..................       7.13       9.13       8.54          4
90920....  .........  ESRD related services, month..................       5.86       6.64       7.27          4
90921....  .........  ESRD related services, month..................       3.06       5.06       4.47          4
92587....         26  Evoked auditory test..........................       0.13       1.40       0.13          3
92588....         26  Evoked auditory test..........................       0.36       1.70       0.36          3
93350....         26  Echo exam of heart............................       0.78   Increase       0.78          3
93990....         26  Doppler flow testing..........................       0.25       1.18       0.25          1
95812....         26  Electroencephalogram (EEG)....................       1.08       1.75       1.08          4
95813....         26  Electroencephalogram (EEG)....................       1.73       2.50       1.73          4
96913....  .........  Photochemotherapy, UV-A or B..................       0.00   Increase       0.00          3
97124....  .........  Massage therapy...............................       0.35   Decrease       0.35          3
97265....  .........  Joint mobilization............................       0.45   Decrease       0.45          3
99354....  .........  Prolonged service, office.....................       1.51       2.33       1.51          3
99355....  .........  Prolonged service, office.....................       1.51       1.20       1.51          3
99356....  .........  Prolonged service, inpatient..................       1.44       3.00       1.44          3
99357....  .........  Prolonged service, inpatient..................       1.44       1.50       1.44          3
99375....  .........  Care plan oversight/30-60.....................       1.06       2.65       1.73          2
----------------------------------------------------------------------------------------------------------------


    b. Discussion of codes reviewed by the panel for which 
clarification of the description of the service is required.
    For several of the codes reviewed by the refinement panel, it was 
necessary to reach agreement on the meaning of the codes before 
individual ratings of work could be provided. In the following 
paragraphs, we summarize the 

[[Page 63155]]
panel's understanding of the nature and extent of the services included 
in the codes for which extensive discussion was required.
    End-stage renal disease services, per full month (CPT codes 90918 
through 90921).
    Before rating the work of CPT codes 90918 through 90921, the 
refinement panel discussed the definition of the monthly capitation 
payment and the list of services included in and excluded from the 
monthly capitation payment that was developed by the Renal Physicians 
Association and presented to the RUC and the refinement panel. The 
refinement panel also reviewed HCFA regulations regarding the monthly 
capitation payment and agreed to rate the work of the codes based on 
the following definition and list of services included in and excluded 
from the monthly capitation payment.
    The monthly capitation payment for maintenance dialysis is defined 
as a comprehensive monthly payment that covers all physician services 
associated with the continuing medical management of a maintenance 
dialysis patient.
    The following physician services are included in the monthly 
capitation payment:
     Assessment and determination of the need for outpatient 
chronic dialysis therapy.
     Assessment of the need for a specified diet and the need 
for nutritional supplementation for the control of chronic renal 
failure. Specification of the quantity of total protein, high biologic 
protein, sodium, potassium, and amount of fluids to be allowed during a 
given time period. For diabetic patients with chronic renal failure, 
the prescription usually includes specification of the number of 
calories in the diet.
     Assessment of which mode(s) of chronic dialysis (types of 
hemodialysis or peritoneal dialysis) are suitable for a given patient 
and recommendation of the type(s) of therapy for a given patient.
     Assessment and determination of which type of dialysis 
access is best suited for a given patient and arrangement for creation 
of dialysis access.
     Assessment of whether the patient meets preliminary 
criteria as a renal transplant candidate and presentation of this 
assessment to the patient and family.
     Prescription of the parameters of intradialytic 
management. For chronic hemodialysis therapies, this includes the type 
of dialysis access, the type and amount of anticoagulant to be 
employed, blood flow rates, dialysate flow rate, ultrafiltration rate, 
dialysate temperature, type of dialysate (acetate versus bicarbonate) 
and composition of the electrolytes in the dialysate, size of 
hemodialyzer (surface area) and composition of the dialyzer membrane 
(conventional versus high flux), duration and frequency of treatments, 
the type and frequency of measuring indices of clearance, and 
intradialytic medications to be administered. For chronic peritoneal 
dialysis therapies, this includes the type of peritoneal dialysis, the 
volume of dialysate, concentration of dextrose in the dialysate 
electrolyte composition of the dialysate, duration of each exchange, 
and addition of medication to the dialysate, such as heparin, and the 
type and frequency of measuring indices of clearance. For diabetics, 
the quantity of insulin to be added to each exchange is prescribed.
     Assessment of whether the patient has significant renal 
failure-related anemia, determination of the etiology(ies) for the 
anemia based on diagnostic tests, and prescription of therapy for 
correction of the anemia, such as vitamins, oral or parenteral iron, 
and hormonal therapy such as erythropoietin.
     Assessment of whether the patient has hyperparathyroidism 
and/or renal osteodystrophy secondary to chronic renal failure and 
prescription of appropriate therapy, such as calcium and phosphate 
binders for control of hyperphosphatemia. Based upon assessment of 
parahormone levels, serum calcium levels, and evaluation for the 
presence of metabolic bone disease, the physician determines whether 
oral or parenteral therapy with vitamin D or its analogs is indicated, 
and prescribes the appropriate therapy. Based upon assessment and 
diagnosis of aluminum bone disease, the physician may prescribe 
specific chelation therapy with deferoxamine and the use of 
hemoperfusion for removal of aluminum and the chelator.
     Assessment of whether the patient has dialysis-related 
arthropathy or neuropathy and adjustment of the patient's prescription 
accordingly. Referral of the patient for any additional needed 
specialist evaluation and management of these end-organ problems.
     Assessment of whether the patient has fluid overload 
resulting from renal failure and establishment of an estimated ``ideal 
(dry) weight.'' The physician determines the need for fluid removal 
independent of the dialysis prescription and implements these measures 
when indicated.
     Determination of the need for and prescription of anti-
hypertensive medications and their timing relative to dialysis when the 
patient is hypertensive in spite of correction of fluid overload.
     Periodic review of the dialysis records to ascertain 
whether the patient is receiving the prescribed amount of dialysis and 
ordering of indices of clearance, such as urea kinetics, in order to 
ascertain whether the dialysis prescription is producing adequate 
dialysis. If the indices of clearance suggest that the prescription 
requires alteration, the physician orders changes in the hemodialysis 
prescription, such as blood flow rate, dialyzer surface area, dialysis 
frequency, and/or dialysis duration (length of treatment). For 
peritoneal dialysis patients, the physician may order changes in the 
volume of dialysate, dextrose concentration of the dialysate, and 
duration of the exchanges.
     Periodic visits to the patient during dialysis to 
ascertain whether the dialysis is working well and whether the patient 
is tolerating the procedure well (physiologically and psychologically). 
During these visits, the physician determines whether alteration in any 
aspect of a given patient's prescription is indicated, such as changes 
in the estimate of the patient's dry weight. Review of the treatment 
with the nurse or technician performing the therapy is also included. 
The frequency of these visits will vary depending upon the patient's 
medical status, complicating conditions, and other determinants.
     Performance of periodic physical assessments, based upon 
the patient's clinical stability, in order to determine the necessity 
for alterations in various aspects of the patient's prescription. 
Similarly, the physician reviews the results of periodic laboratory 
testing in order to determine the need for alterations in the patient's 
prescription, such as changes in the amount and timing of phosphate 
binders or dose of erythropoietin.
     Periodic assessment of the adequacy and function of the 
patient's dialysis access.
     Assessment of patients on peritoneal dialysis for evidence 
of peritonitis and the ordering of appropriate tests and antibiotic 
therapy. 

[[Page 63156]]

     Periodic review and update of the patient's short-term and 
long-term care plans with staff.
     Coordination and direction of the care of patients by 
other professional staff, such as dieticians and social workers.
     Certification of the need for items and services such as 
durable medical equipment and home health care services. Care plan 
oversight services described by CPT code 99375 also are included in the 
monthly capitation payment and may not be separately reported.
    The following physician services are excluded from the monthly 
capitation payment:
     Surgical services such as--

--Temporary hemodialysis catheter placement.
--Permanent hemodialysis catheter placement.
--Temporary peritoneal dialysis catheter placement.
--Permanent peritoneal dialysis catheter placement.
--Repair of existing dialysis accesses.
--Placement of catheter(s) for thrombolytic therapy.
--Thrombolytic therapy (systemic, regional, or access catheter only; 
hemodialysis or peritoneal dialysis).
--Thrombectomy of clotted cannula.
--Arthrocentesis.
--Bone marrow aspiration.
--Bone marrow biopsy.

     Interpretation of tests that have a professional component 
such as:

--Electrocardiograms (12 lead, Holter monitor, stress tests, etc.).
--Echocardiograms.
--24-hour blood pressure monitor.
--Nerve conduction velocity and electromyography studies.
--Flow doppler studies.
--Bone densitometry studies.
--Biopsies.
--Spirometry and complete pulmonary function tests.

     Complete evaluation for renal transplantation. While the 
physician assessment of whether the patient meets preliminary criteria 
as a renal transplant candidate is included under the monthly 
capitation payment, the complete evaluation for renal transplantation 
is excluded from the monthly capitation payment.
     Evaluation of potential living transplant donors.
     The training of patients to perform home hemodialysis, 
self hemodialysis, and the various forms of self peritoneal dialysis.
     Non-renal related physician's services. These services may 
be furnished by the physician providing renal care or by another 
physician. They may not be incidental to services furnished during a 
dialysis session or office visit necessitated by the renal condition. 
For example, the medical management of diabetes mellitus that is not 
related to the dialysis or furnished during a dialysis session is 
excluded.
     Covered physician services furnished to hospital 
inpatients, including services related to inpatient dialysis, by a 
physician who elects not to continue to receive the monthly capitation 
payment during the period of inpatient stay. In these cases, the 
physician receives a prorated portion of the monthly capitation payment 
for that month.
     All physician services that antedate the initiation of 
outpatient dialysis.
    While the refinement panel agreed to rate the work of the monthly 
capitation payment codes based on the above definitions, it was unable 
to reach consensus on whether the interpretation of all tests that have 
a professional component should be included in or excluded from the 
monthly capitation payment. Because the American Medical Association 
Specialty Society Relative Value Update Committee (RUC) recommendations 
were based on the Renal Physicians Association's definition, which 
excludes test interpretations from the monthly capitation payment, it 
was decided to rate the physician work based on an assumption that the 
physician work associated with test interpretations was excluded from 
the monthly capitation payment and included in other codes that would 
be reported separately. It was also agreed that the Renal Physicians 
Association and HCFA would examine current utilization data and that 
HCFA would consider bundling the work of test interpretations into the 
monthly capitation payment. This would lead to adding additional RVUs 
to the RVUs that emerged from the panel ratings. The RVUs that emerged 
from the statistical tests of the refinement panel were 4.45.
    Subsequent to the refinement panel, we analyzed utilization data on 
test interpretations provided to end-stage renal disease patients by 
monthly capitation payment physicians. In general, most physicians who 
are paid under the monthly capitation payment method do not separately 
bill for test interpretations. Based on our analysis, we have bundled 
the work RVUs of the test interpretations listed below into the monthly 
capitation payment:
     Bone mineral density studies (CPT codes 76070, 76075, 
78350, and 78351).
     Non-invasive vascular diagnostic studies of hemodialysis 
access (CPT codes 93925, 93926, 93930, 93931, and 93990).
     Nerve conduction studies (CPT codes 95900, 95903, 95904, 
95925, 95926, 95927, 95934, 95935, and 95936).
     Electromyography studies (CPT codes 95860, 95861, 95863, 
95864, 95867, 95868, 95869, and 95872).
    In performing our analysis, we took into account the fact that the 
coding for the four categories of services listed above has changed in 
the past 2 years. Thus, while we used all of the most current 
utilization data, the specific codes listed may be new, revised or 
deleted from CPT 1996. When the physician receiving the monthly 
capitation payment payment performs the services listed above, we will 
not make separate payment. However, these and other medically necessary 
services that are included or bundled into the monthly capitation 
payment are separately payable when furnished by physicians other than 
the monthly capitation payment physician.
    The bundling of these services leads to the addition of 0.02 RVUs 
to the refinement panel rating of 4.45 RVUs to result in the assignment 
of 4.47 RVUs. Medically necessary services that are included or bundled 
into the monthly capitation payment are separately payable when 
furnished by physicians other than the monthly capitation payment 
physician.
    We next increased the RVUs of the pediatric monthly capitation 
payment CPT codes (90918 through 90920) to maintain the relationship of 
adult to pediatric services that we established in last year's final 
rule. This led to the assignment of 11.18 RVUs to CPT code 90918, 8.54 
RVUs to CPT code 90919, and 7.27 RVUs to CPT code 90920.

Electroencephalogram Codes

    Before rating the work of CPT codes 95812 and 95813 
(electroencephalogram (EEG) extended monitoring), the panel discussed 
extensively the work involved in EEG monitoring compared to other EEG 
and electrodiagnostic services on the fee schedule. Subsequent to the 
panel meeting, the American Academy of Neurology provided us with the 
following written definitions and clinical vignettes to clarify the 
types of services that should be coded using nine 

[[Page 63157]]
common EEG diagnostic codes by comparing and contrasting them. The 
panel members discussed these definitions of the EEG services before 
they rated the work of extended EEG monitoring.
    Extended EEG; up to one hour (CPT code 95812).
    EEG recording is conducted for 45 to 60 minutes. Hyperventilation, 
photic stimulation and/or oral sedation may be used. The physician 
reviews in detail the entire 45-to-60 minute record (270 to 360 pages 
of standard EEG paper).
    The following is a vignette for CPT code 95812: A 35-year-old woman 
experiences episodic loss of consciousness. Differential diagnosis 
includes syncope and several types of seizure disorder. The EEG is 
extended because the EEG technologist detected no epileptic 
abnormalities during the first 20 to 30 minutes of recording, and the 
physician had requested a longer recording if needed to find 
abnormalities. Bursts of epileptic abnormalities are finally detected 
at 55 minutes into the recording. This helps make the diagnosis of a 
seizure disorder. The type of epileptic abnormalities seen on the EEG 
guides the diagnosis and choice of medications.
    Extended EEG; greater than one hour (CPT code 95813).
    EEG recording is conducted continuously for more than 1 hour. 
Hyperventilation, photic stimulation and/or oral sedation may be used. 
The recording is continued until the events sought are obtained, if 
possible. Typical recording time is 2 to 3 hours. The physician reviews 
the entire recording in detail (typically equal to 360 to 1,000-plus 
pages of standard EEG paper). The entire continuous EEG recording is 
also interpreted for additional diagnostic information.
    The following is a vignette for CPT code 95813: A 55-year-old woman 
is comatose in the intensive care unit with multiple medical problems 
and is having repeated episodes of movements possibly representing 
epileptic seizures. Continuous EEG recording is performed for 3 hours, 
including recording during two of her episodes. Four additional 
subclinical ictal events were also detected on the EEG beyond the two 
events noted by the nurses. Events are determined to be epileptic 
seizures, and a treatment plan is developed accordingly.
    Awake EEG (CPT code 95816).
    The test is conducted with the patient awake. The patient often 
becomes drowsy or may briefly fall asleep, but the test is not run 
deliberately to obtain sleep. Hyperventilation and/or photic 
stimulation are usually obtained. The minimum recording time is 20 
minutes. The typical recording time is 20 to 25 minutes. The physician 
reads in detail the entire 20-to-25 minute record (120 to 150 pages of 
standard EEG paper).
    The following is a vignette for CPT code 95816: A 60-year-old man 
complains of memory and other cognitive impairment. Differential 
diagnosis includes dementia and depression. EEG seeks objective 
evidence of organic impairment supporting a diagnosis of a dementia.
    EEG awake and asleep (CPT code 95819).
    Sleep is deliberately sought during the EEG record to identify 
specific epileptic abnormalities. The patient may be sleep-deprived 
before the recording or given sedative medication to induce sleep. The 
recording continues until at least 5 minutes of Stage 2 sleep is 
obtained. During the awake portion of the recording, hyperventilation 
and/or photic stimulation are usually obtained. The minimum recording 
time is 20 minutes. The typical recording time is 30 to 35 minutes. The 
physician reads in detail the entire 30-to-35 minute record (180 to 210 
pages of standard EEG paper).
    The following is a vignette for CPT code 95819: A 25-year-old woman 
experiences recent onset of lapses of consciousness. The differential 
diagnosis includes syncope and several types of seizure disorders. A 
test is conducted to look for evidence of a seizure disorder and to 
help specify which type of seizure disorder.
    EEG; sleep only (CPT code 95822).
    The EEG is conducted with the patient asleep, stuporous, or 
comatose. Little or no awake EEG is recorded. Hyperventilation and 
photic stimulation are generally not performed. Stuporous or comatose 
patients may be stimulated by the technologist to attempt to induce 
state changes. The minimum recording time is 20 minutes. The typical 
recording time is 20 to 30 minutes. The physician reads in detail the 
entire 20 to 30 minute record (120 to 180 pages of standard EEG paper).
    The following is a vignette for CPT code 95822: A 45-year-old man 
is comatose after a head injury. An EEG is performed to assess the 
depth of the coma, assist in assessing prognosis, and evaluate for 
epileptic discharges or focal cerebral abnormality.
    EEG; all night sleep only (CPT code 95827).
    Prolonged EEG recording is performed by leaving equipment at the 
hospital bedside. The recording may or may not be continuous. If not 
continuous, the recording is done periodically as needed. The minimum 
time the EEG is at the bedside is 8 hours. The physician scans the 
hours-long records, reading in detail selected or specific portions. 
The minimum amount of the EEG actually reviewed in detail is 20 minutes 
of recording (120 pages of standard EEG paper). The typical amount 
reviewed in detail is 30 to 40 minutes.
    The following is a vignette for CPT code 95827: A 3-year-old boy is 
comatose from near-drowning. The patient is in a therapeutic 
barbiturate coma. The EEG is used to titrate the amount of barbiturate 
to keep the EEG in burst-suppression. Incidental observations are made 
of any epileptic discharges or focal features. The EEG is kept at the 
intensive care unit bedside for 3 days. Each day, 50 to 90 minutes of 
EEG are printed, of which 20 to 30 minutes (120 to 180 pages of 
standard EEG paper) are reviewed in detail, and other pages are scanned 
for relevant events.
    Electrocorticography (CPT code 95829).
    The EEG is recorded in the operating room from electrodes applied 
directly to the surgically exposed cerebral cortex. Many separate 
recording sites are used. While it is being recorded in the operating 
room, the EEG is interpreted by the EEG physician, who is present in 
the operating room for 60 minutes or more. The EEG physician uses the 
EEG features for determining the extent of surgical resection of the 
cerebral cortex. During this 60 minutes, 30 to 60 minutes of EEG 
recording (minimum 20 minutes) are made from various cortical recording 
sites.
    The following is a vignette for CPT code 95829: A 25-year-old man, 
disabled by medically refractory epileptic seizures, undergoes a 
craniotomy to resect a portion of his temporal lobe. The EEG physician 
interprets the record in the operating room. Electrocorticography is 
used to define the extent of epileptic spiking and slowing, and the 
resection is tailored to include regions of electrically identified 
pathology. Follow-up recording is made to check for any remaining 
epileptic spiking after resection.
    Ambulatory EEG monitoring (CPT code 95950).
    The EEG is recorded onto a long-term storage medium such as 
magnetic disc 

[[Page 63158]]
or tape, using a small portable recorder. The patient is free to take 
this home, returning to the laboratory one or several days later. The 
recording is continuous for 24 hours per day. The patient, family, and 
friends write notes about clinical events. The recorded EEG is scanned 
to find these or other events of clinical interest. Around the time of 
each clinical event of interest, 5 to 10 minutes of the EEG is reviewed 
in detail. The EEG is also surveyed for other EEG findings of clinical 
importance.
    The following is a vignette for CPT code 95950: A 12-year-old boy 
has episodes of staring or daydreaming, possibly representing 
nonconvulsive seizures. Previous routine EEG recording was normal. 
Ambulatory EEG is conducted to search for signs of epileptic 
abnormality. During 2 days of ambulatory monitoring, 6 clinical 
daydreaming events are noted by the family. These demonstrate petit mal 
seizures, as do 10 additional events not noted by the family but found 
on EEG review. A treatment plan is developed accordingly.
    Video EEG long-term monitoring (CPT code 95951).
    This daily procedure is used when video and EEG are continuously 
recorded for several days. Continuous videotaping of the patient's 
behavior is made simultaneously with the EEG. Monitoring is usually 
conducted in a specialized inpatient epilepsy evaluation and monitoring 
unit, with the patient's antiepileptic medications reduced or withdrawn 
to induce epileptic seizures. The physician reviews the EEG and 
videotapes recorded before, during, and after each captured epileptic 
seizure. Typically, several seizures may occur each day. In some 
patients, no seizures may occur for several days, whereas other 
patients may have more than a dozen seizures per day. Randomly selected 
recorded segments are also chosen for review and comparison to look for 
subclinical seizures and isolated epileptic EEG discharges. Monitoring 
generally is continued until at least 5 seizures are captured to 
characterize and to localize the abnormality. The exact number of 
seizures needed varies with the specific clinical circumstances and the 
nature of EEG findings.
    The following is vignette number one for CPT code 95951: A 25-year-
old man has become totally disabled as a result of frequent medically 
refractory epileptic seizures. Long-term video EEG monitoring for 4 
days captures 6 seizures and localizes the ictal onset sufficiently to 
refer the patient for surgical excision of the epileptic area. 
Localization for surgical excision is based primarily on this EEG 
localization. After eventual surgical excision, the patient becomes 
seizure-free, stops medication, and is no longer disabled.
    The following is vignette number two for CPT code 95951: A 9-year-
old boy has frequent seizures not controlled by medication, during some 
of which he abruptly falls to the ground. Because of the falls, he has 
lacerated his scalp on several occasions, requiring trips to the 
emergency room for x-rays, sutures, and antibiotic treatment. His 
physicians are considering corpus callosum section, but some of the 
clinical data suggest that the seizures may be originating from a more 
localized area of one frontal lobe. Forty seizures are recorded in 2 
days, some of which appear to originate from this region. Analysis of 
the recordings indicates, however, that the majority do not, and he 
undergoes callosal section. Following callosal section, he no longer 
has ``falling seizures'' and no longer needs to wear a helmet for 
protection. He does continue to have focal seizures of one arm.
    We have finalized the interim RVUs for the EEG CPT codes; we have 
not changed any of the interim RVUs for these codes. However, we have 
clarified the descriptors for the CPT codes for the services. We have 
assigned 1.08 RVUs to CPT code 95812, 1.73 RVUs to CPT code 95813, 1.08 
RVUs to CPT code 95816, 1.08 RVUs to CPT code 95819, 1.08 RVUs to CPT 
code 95822, 1.08 RVUs to CPT code 95827, 6.21 RVUs to CPT code 95829, 
1.51 RVUs to CPT code 95950, and 3.80 RVUs to CPT code 95951.
    c. Discussion of codes not reviewed by the panel.
    Codes listed in Table 1 with a basis of decision of ``3'' fall into 
several categories. For most of these codes, we received comments that 
were not considered by the multispecialty refinement panel for a 
variety of reasons. Those codes and our rationale for the final work 
RVUs we have established for the codes are discussed below.
    Removal with reinsertion, implantable contraceptive capsules (CPT 
code 11977).
    Comment: A commenter stated that we erred in rejecting the RUC 
recommendation of 3.30 RVUs for CPT code 11977. The commenter 
recommended that ``Removal with reinsertion'' should be assigned the 
full value of both CPT code 11975 (Insertion, implantable contraceptive 
capsules) and CPT code 11976 (Removal, implantable contraceptive 
capsules). Typically, the new capsules are inserted at a different site 
than the one from which the old capsules were removed, thus requiring a 
second incision and closure. In addition, the amount of preservice and 
postservice work associated with reinsertion is similar to the 
preservice and postservice work for the original insertion. The 
physician must ascertain that the patient has not undergone changes in 
health status or experienced side effects that would make her an 
unsuitable candidate for this contraceptive method and must instruct 
her about follow-up care and potential complications.
    Response: We agree with the comment and have assigned 3.30 RVUs to 
CPT code 11977, as recommended.
    Breast reconstruction with a TRAM flap (CPT code 19367).
    Comment: A commenter recommended that the RVUs of CPT code 19367 be 
increased from 24.73 to a minimum 26.50 RVUs. The commenter stated that 
breast reconstruction is similar to facial fracture surgeries and that 
in comparison to CPT code 21159 (Le Forte III), with 40.99 RVUs, a TRAM 
flap reconstruction is a much larger procedure.
    Response: We disagree with this comment that we believe may have 
been based on a misunderstanding of CPT code 21159. This code is used 
to report reconstruction of the midface. It is not used to report the 
repair of facial fractures. When compared to the RVUs of codes for the 
open repair of a facial fracture, for example, CPT code 21432, which is 
assigned 8.05 RVUs, the RVUs of the breast reconstruction code are much 
higher. The 24.73 interim RVUs, which were based on a RUC 
recommendation, will be made final.
    Microvascular fibula graft (CPT code 20955).
    Comment: A commenter recommended 43.00 RVUs for this procedure, 
which was described as a very delicate, labor-intensive procedure 
particularly for mandible reconstruction, multiple osteotomies, and 
plate and wire fixation. The commenter stated that the work and 
postoperative care can be compared to twice that of a breast 
reconstruction with a TRAM flap (CPT code 19367), with 24.73 RVUs. 
Because of the nature of this delicate procedure, the risks for 
malpractice are greater than for any 

[[Page 63159]]
other bone procedure. These risks include complications such as foot 
drop, sensory loss of the lower extremity, complications related to 
skin graft healing, chronic pain, and wound closure.
    Response: We agree this is a complex procedure as confirmed by our 
acceptance of a RUC recommendation of 38.00 RVUs (see Table 4, 
``American Medical Association RUC Recommendations and HCFA's 
Decisions,'' in our December 8, 1994 final rule with comment period (60 
FR 63441)). We do not believe, however, the arguments presented warrant 
an increase to 43.00 RVUs, which would be nearly 3.00 RVUs higher than 
the reference code for repair of a thoracoabdominal aortic aneurysm 
with graft (CPT code 33877) valued at 40.29 RVUs. We have retained 
38.00 RVUs for CPT code 20955 (37.58 RVUs after adjustment for budget 
neutrality).
    Reconstruction for stabilization of unstable distal ulna or distal 
radioulnar joint (CPT code 25337).
    Comment: A commenter disagreed with our decision to value new CPT 
code 25337 at 9.10 RVUs instead of 9.50 RVUs as the RUC recommended. 
The commenter stated that the preservice and postservice work is quite 
similar between the new code and the reference service, CPT code 25312. 
The commenter also stated the intraservice work requires more skill, 
effort, and time because the new code may involve a two-tendon transfer 
with two skin incisions, hence, a larger surgical exposure. The 
potential of injury to the ulnar nerve is high. Confirmation of an 
accurate reduction of the distal ulna requires an intraoperative x-ray, 
and, frequently, internal fixation with K-wires. Tunnels must be 
drilled into bone to allow passage of the tendons.
    Response: We agree with the comment and have assigned 9.50 RVUs to 
CPT code 25337, as recommended.
    Distal radioulnar joint arthrodesis and segmental resection of ulna 
(Sauve-Kapandji procedure) (CPT code 25830).
    Comment: A commenter stated that the work of CPT code 25830 is 
equal to the work of CPT code 25337 (Distal radioulnar tenodesis) and 
recommended that 9.50 RVUs are the most appropriate RVUs for both 
codes. The commenter also stated that the RUC accepted CPT code 25390 
(Osteoplasty, radius or ulna; shortening), with 9.96 RVUs, as a 
reference service for new CPT code 25830. This reference service 
involves excising a carefully measured segment of ulna followed by 
internal fixation using a plate and screws. Preoperative work is 
somewhat greater than the work in new CPT code 25830. New CPT code 
25830 is similar to the reference service in that a small segment of 
ulna is excised and then fused to the adjacent radius using pins or 
screws. Plates are not used and the amount of excised ulna is less 
critical. For these clinical reasons, the commenter recommended 9.50 
RVUs for CPT code 25830.
    Response: We agree with the comment and have assigned 9.50 RVUs to 
CPT code 25830, as recommended.
    Repair of cleft hand (CPT code 26580).
    Comment: A commenter disagreed with our decision to value CPT code 
26580 at 15.99 RVUs (15.81 RVUs rescaled) instead of 17.71 RVUs, as the 
RUC recommended (see Table 4 of our December 8, 1994 final rule with 
comment period (60 FR 63441)). The commenter objected to the use of CPT 
code 28360 (Repair of a cleft foot) as the reference service. The 
commenter argued that the choice of this code as a reference service 
was inappropriate because of its clinical dissimilarity to the revised 
code. The commenter stated that CPT code 26590 (Repair macrodactylia), 
with 17.63 RVUs, is a more appropriate reference service. This code 
deals with a congenital anomaly of the digits of the hand requiring 
exacting microsurgical reconstruction of soft tissue, nerves, and bone 
in an infant. Revised CPT code 26580 requires metacarpal alignment by 
soft tissue dissection or metacarpal osteotomy requiring internal 
fixation, reconstruction of the deep transverse metacarpal ligament, 
and a thumb re-alignment to allow opposition. Mobilization of skin 
flaps may be necessary to achieve skin closure. This is a microsurgical 
procedure performed in infants, with an amount of work similar to the 
work involved in CPT code 26590. For these clinical reasons, the 
commenter recommended that revised CPT code 26580 should have 17.71 
RVUs.
    Response: We agree with the comment and have assigned 17.71 RVUs to 
CPT code 26580, as recommended.
    Application of rigid total contact leg cast (CPT code 29445).
    Comment: A commenter stated that this service is overvalued 
compared to the application of an Unna boot (CPT code 29580), with 0.57 
RVUs.
    Response: We disagree that this service is overvalued. The 
application of a rigid total contact leg cast (CPT code 29445) involves 
more work than the application of an Unna boot because it requires the 
physician to custom make and fabricate the walking surface for each 
cast. The patient is usually diabetic with a grade 1 or 2 foot ulcer. 
The use of casts by these patients is risky because they are at risk of 
developing additional ulcers. Therefore, a great deal of time is spent 
ensuring that the cast will fit properly. Unlike Unna boots or other 
casts, total contact casts are always performed personally by a 
physician who must hold the foot in place while applying the cast.
     Nasal/sinus endoscopy, surgical with frontal sinus exploration, 
with or without removal of tissue from frontal sinus (CPT code 31276).
    Comment: A commenter objected to the assigned 7.42 RVUs and 
requested an increase to 8.85 RVUs. The commenter presented the 
following description of the procedure. This procedure is performed 
around the middle turbinate anterior attachment in the frontal recess 
at 90 degrees to the line of sight. It requires the use of 70 and 30 
degree telescopes, small-angled forceps, curettes, and hooks. It 
requires an exhaustive knowledge of frontal recess anatomy, very 
delicate technique, removal of tiny bone fragments, preservation of 
mucosa, and a dry field. It is very tedious and time-consuming. The 
commenter believed that the overall intensity and time is significantly 
greater for the endoscopic frontal sinustomy than either a total 
ethmoidectomy (CPT code 31255), with 6.96 RVUs, or an external frontal 
sinusotomy (CPT code 31075), with 8.85 RVUs.
    Response: We agree with the comment and have assigned 8.85 RVUs to 
CPT code 31276, as recommended.
    Gastroplasties and gastric bypass for obesity (CPT codes 43842, 
43843, 43846, 43847, and 43848).
    Comment: A commenter requested a re-evaluation of the entire family 
of codes because of a lack of representation of bariatric surgeons in 
the original resource-based relative value scale process. The commenter 
stated that the modest increase in the RVUs we assigned to these 
procedures still left a deficit valuation of approximately 27 percent 
for CPT codes 43842 and 43843, 17 percent for CPT codes 43846 and 
43847, and 12 percent for CPT code 43848.
    Response: We have not revised the interim RVUs because we do not 
believe the commenter made a compelling argument for change. We also 
disagree that the increases in RVUs assigned to 

[[Page 63160]]
these codes were modest. As we discussed in Table 4 of our December 8, 
1994 final rule (59 FR 63444), the increases were as follows: CPT code 
43842 from 11.99 RVUs to 13.91 RVUs; CPT code 43843 from 11.99 RVUs to 
13.91 RVUs; CPT code 43846 from 12.90 RVUs to 18.04 RVUs; CPT code 
43847 from 14.32 RVUs to 20.09 RVUs; and, CPT code 43848 from 15.00 
RVUs to 22.35 RVUs. When the RVUs were adjusted for budget neutrality, 
the RVUs were as follows: CPT code 43842, assigned 13.76 RVUs; CPT code 
43843, assigned 13.76 RVUs; CPT code 43846, assigned 17.84 RVUs; CPT 
code 43847, assigned 19.87 RVUs; and, CPT code 43848 assigned 22.10 
RVUs. We believe that further increases would create rank order 
anomalies with other abdominal surgical procedures on the physician fee 
schedule.
    Induced abortion, by one or more vaginal suppositories (eg. 
prostaglandin) with or without cervical dilation (eg. laminaria), 
including hospital admission and visits (CPT code 59855).
    Comment: A commenter recommended that we assign the RUC-recommended 
5.80 RVUs to CPT code 59855. The commenter believed that our rationale 
for lowering the work RVUs to 4.80 (4.75 rescaled) was ``the physician 
work in placing suppositories is less than the work in an 
amnioinjection, regardless of the number of suppositories needed'' and 
that CPT code 59855 requires less physician work than CPT code 59850 
(Induced abortion by amnioinjection). The commenter stated that while 
it is true that the procedural work associated with placing 
suppositories is less than the procedural work associated with 
amnioinjection, placement of the suppositories or performance of the 
amnioinjection is only one element of the total work of each of these 
services. Use of prostaglandin suppositories typically results in more 
side effects that the physician must manage over a period of time that 
is longer than that associated with the amnioinjection, increasing the 
amount of evaluation and management work for CPT code 59855. Overall, 
CPT code 59855 requires a greater amount of physician work than CPT 
code 59850.
    Response: We agree with the comment and have assigned 5.80 RVUs to 
CPT code 59855, as recommended.
    Sympathectomy, digital arteries (CPT code 64820).
    Comment: A commenter disagreed with our decision to value CPT code 
64820 at 9.20 RVUs (9.10 RVUs rescaled) instead of 10.00 RVUs as the 
RUC recommended. The commenter objected to our determination that the 
work involved in new CPT code 64820 is approximately the same as the 
repair of a blood vessel of the hand or finger (CPT code 35207). The 
commenter stated that the work on the two vessels involved in a digital 
sympathectomy is not similar to the anastomosis of a single vessel and 
offered the following explanation. CPT code 35207 involves the repair 
of a single injured vessel through an existing skin laceration. CPT 
code 35207 has less preservice and intraservice work than new CPT code 
64820. Digital sympathectomy is performed in individuals with 
vasospastic disease of the hand and severe ischemic pain frequently 
with ulceration of the finger tip. Two vessels are always treated 
through an extensile palmar incision on the radial and ulnar side of a 
digit. Using an operating microscope and jeweler's forceps, a tedious 
removal of the adventitia is performed for a distance of 1.5 to 2.0 
centimeters. Extraordinary care must be taken to avoid perforating the 
vessel. Damaging the vessel's media or intima will cause thrombosis and 
possible gangrene of the finger. Considering the clinical circumstances 
regarding the patient indications and actual intraservice work, digital 
sympathectomy represents a greater intensity of work than CPT code 
35207, as measured by increased mental effort and judgment, greater 
technical skill, and considerably more psychological stress. 
Postservice work is similar for both codes, however, with an average of 
four office visits after the procedure. For these clinical reasons, the 
commenter recommended that new CPT code 64820 should have 10.00 RVUs.
    Response: We agree with the comment and have assigned 10.00 RVUs to 
CPT code 64820, as recommended.
    Multiple-family group medical psychotherapy (CPT code 90849).
    Comment: A commenter recommended increases for all psychiatric 
services in response to our request for comments as part of the 5-year 
refinement of RVUs under the physician fee schedule. Included in that 
comment was a recommendation to increase the RVUs for CPT code 90849 
from 0.59 to 0.78 to maintain the relative value with the recommended 
increases for the other psychiatric codes.
    Response: The RVUs assigned to this code were based on a 1994 RUC 
recommendation that we accepted. We have not increased the RVUs this 
year because we believe it is an issue for the 5-year refinement. We 
will consider the recommended RVUs as part of that process. In the 
meantime, we will maintain the assigned 0.59 RVUs.
    Evoked otoacoustic emissions testing (CPT codes 92587 and 92588).
    Comment: A commenter recommended that we provide a ten-fold 
increase in the RVUs for these audiology services to ``properly 
compensate for the training, effort, and time necessary to diagnose 
hearing loss and related disorders.''
    Response: We have not accepted this comment because it did not 
provide enough clinical information about the nature of the work to 
warrant a reconsideration of the interim RVUs.
    Stress echocardiography (CPT code 93350).
    Comment: A commenter expressed concern about the decrease in RVUs 
for this service.
    Response: The decrease in RVUs for stress echocardiography occurred 
as a result of a change in CPT reporting instructions that now direct 
the user to report the appropriate stress testing code from the 93015 
through 93018 series in addition to CPT code 93350. The sum of the RVUs 
for these services is equal to the RVUs that were assigned to CPT code 
93350 in the past when it was the only code used to report stress 
echocardiography.
    Photochemotherapy (Goeckerman and/or PUVA) for severe 
photoresponsive dermatoses requiring at least four to eight hours of 
care under direct supervision of the physician (includes application of 
medication and dressings) (CPT code 96913).
    Comment: A commenter objected to our decision not to assign 
physician work RVUs to this service. The commenter stated that with the 
availability of psoriasis day treatment centers, much Goeckerman 
therapy is now practical in a day treatment program but that it is very 
different from a simple office visit. The commenter argued that there 
is considerable professional judgment involved and there is also an 
extraordinary quantity of nursing time involved since the patient is 
typically in a day treatment center for 6 hours or more a day. The 
treatment requires bathing, scale removal, twice daily application of 
tar over the total body surface, shampoos, scale removal from scalp, 
ultraviolet light, and typically anthralin as well. The treatment is 
extremely time-consuming because the medication must be put on 

[[Page 63161]]
each individual spot while avoiding normal skin.
    Response: We have not revised our decision regarding this code. We 
have not assigned any work RVUs to this service because the commenter 
did not persuade us that photochemotherapy requires any physician work 
beyond that already described by existing evaluation and management 
codes. We have assigned practice expense and malpractice expense RVUs 
based on historic charges for this code so that it will no longer be 
carrier-priced. We have categorized this service as an ``incident to'' 
code, which means that it is covered incident to a physician's service 
when it is furnished by auxiliary personnel employed by the physician 
and working under his or her direct supervision. Payment may not be 
made for this service when it is furnished to hospital inpatients or 
patients in a hospital outpatient department. Physicians may bill for 
evaluation and management services in those settings.
    Joint mobilization and massage (CPT codes 97124 and 97265).
    Comment: One commenter stated that these codes may be overvalued 
relative to osteopathic manipulative treatment (CPT codes 98925 through 
98929) and evaluation and management services.
    Response: The interim RVUs we proposed for these codes were based 
on our acceptance of recommendations we received from the RUC Health 
Care Professionals Advisory Committee Review Board last year. The 
history and functions of this board are described below.
    In 1992 the American Medical Association recommended that a Health 
Care Professionals Advisory Committee be established to expand the CPT 
Editorial Panel and the RUC processes to all groups legally required to 
use the CPT to report their services. Organizations representing 
physician assistants, nurses, occupational and physical therapists, 
optometrists, podiatrists, psychologists, social workers, audiologists 
and speech pathologists were invited to nominate representatives to the 
CPT and RUC Health Care Professionals Advisory Committee. The CPT 
Health Care Professionals Advisory Committee was created to foster 
participation in and solicit comments from these professional 
organizations in coding changes affecting their members, while the RUC 
Health Care Professionals Advisory Committee was formed to allow 
participation in development of RVUs for new and revised codes within 
their scope of practice.
    To further facilitate the decision-making process on issues of 
concern to both medical doctors (MDs) and doctors of osteopathy (DOs) 
and non-MDs and non-DOs, CPT and RUC Health Care Professionals Advisory 
Committee Review Boards were also formed. The review boards bring MDs 
and DOs and non-MDs and non-DOs together to discuss coding issues and 
RVU proposals. The RUC Health Care Professionals Advisory Committee 
Review Board comprises all nine members of the current RUC Health Care 
Professionals Advisory Committee and three RUC members. For codes used 
only or predominantly by non-MDs and non-DOs, the RUC Health Care 
Professionals Advisory Committee Review Board replaces the RUC as the 
body responsible for developing recommendations for HCFA.
    We have decided to maintain the RVUs for joint mobilization (CPT 
code 97265), with 0.45 RVUs, and massage (CPT code 97124), with 0.35 
RVUs, as interim RVUs on the 1996 fee schedule so that we will have 
additional time to re-evaluate them. While we agree that these services 
appropriately are compared to other therapeutic procedures in the 
physical medicine section of CPT, our review of them in light of the 
comment causes us to believe that the interim RVUs we assigned to the 
therapeutic procedures services may have been too high relative to 
other services on the fee schedule, for example, osteopathic 
manipulative treatments and evaluation and management services.
    While we acknowledge that we accepted last year's recommendations 
of the RUC Health Care Professionals Advisory Committee Review Board, 
we now plan to refer these and all other physical medicine and 
rehabilitation codes (CPT codes 97010 through 97770) back to the RUC 
Health Care Professionals Advisory Committee Review Board for its 
reconsideration. We also will notify the RUC of our concerns. In 
addition, we seek public comments on this issue.
    Prolonged physician services (CPT codes 99354 through 99357).
    Comment: A commenter provided extensive arguments for an increase 
in the RVUs of these codes based on the premise that we have 
underestimated the time involved in furnishing these services. Because 
the RVUs for evaluation and management services are related to the time 
specified in the CPT codes, the commenter believed that the selection 
of the appropriate level of service should be based solely on the time 
spent providing the service. For example, a consultation (CPT code 
99253) typically assumes a 55-minute time segment. The commenter stated 
that if less time is spent, the consultation would be coded at a lower 
level as CPT code 99252 or 99251. The commenter believed that the 
correct key references for these prolonged physician services are CPT 
codes 99245 (Office consultation) and 99255 (Hospital inpatient 
consultation) because the times specified in those codes correspond to 
the times specified in the prolonged services codes.
    Response: We have decided not to accept this comment, which we 
believe is based, in part, on a misunderstanding of the relationship of 
the typical times associated with the evaluation and management codes 
and the RVUs assigned to the codes. While it is true that time is a key 
predictor of work, it is not true that physicians are required to 
report their evaluation and management services based solely on the 
amount of time spent furnishing the service. CPT codes 99354 and 99356 
both describe the ``first hour'' of prolonged services. This 
terminology in the code does not require that an entire hour of service 
be furnished in order for the code to be used. In fact, the CPT directs 
the reader to use the code to report 30 to 74 minutes of prolonged 
services. In our discussion of these codes in the December 8, 1994 
Federal Register (59 FR 63437 through 63440), we indicated that we did 
not expect that the typical use of the code would be to report an hour 
of service. We assigned RVUs that are equivalent to 40 minutes of face-
to-face or floor time.
    Finally, for those specialties with very prolonged encounters, we 
have assigned the same RVUS to the ``each additional 30 minutes'' codes 
(CPT codes 99355 and 99357) that we assigned to the ``first hour'' 
codes. This actually represents an increase above the recommended RVUs 
we received from the RUC for CPT codes 99355 and 99357. We believe the 
final RVUs for the prolonged service codes appropriately recognize the 
work associated with very prolonged services.
2. Establishment of Interim Work Relative Value Units for New and 
Revised Codes for 1996
    a. Methodology (Includes Table 2--American Medical Association 
Specialty Society Relative Value Update 

[[Page 63162]]
Committee Recommendations and HCFA's Decisions).
    The major aspect of establishing work RVUs for 1996 was related to 
the assignment of interim RVUs for all new and revised CPT codes. As 
described in our November 1992 notice on the 1993 fee schedule (57 FR 
55938), we established a process, based on recommendations received 
from the RUC, for establishing interim RVUs for new and revised codes.
    The RUC was formed in November 1991 and grew out of a series of 
discussions between the American Medical Association and the major 
national medical specialty societies. The RUC is comprised of 26 
members; 22 are representatives of major specialty societies. The 
remaining members represent the American Medical Association, the 
American Osteopathic Association, and the CPT Editorial Panel. The work 
of the RUC is supported by the RUC Advisory Committee made up of 
representatives of 65 specialty societies in the American Medical 
Association House of Delegates. The RUC used a small group survey 
method to produce work RVUs that were voted on by the RUC, with a two-
thirds vote required for acceptance. The RUC then submitted to us those 
accepted RVUs as recommended values.
    We received work RVU recommendations for approximately 140 new and 
revised codes from the RUC. We also received RUC recommendations for 
base units for two anesthesia codes, CPT codes 00520 (Anesthesia, 
closed chest procedures) and 00540 (Anesthesia, chest procedure) and 
have accepted the recommendations of 6.00 and 13.00 base units, 
respectively. Physician panels consisting of carrier medical directors 
and our staff reviewed the RUC recommendations by comparing them to our 
reference set or to other comparable services on the fee schedule for 
which work RVUs had been established previously, or to both of these 
criteria. The panels also considered the relationships among the new 
and revised codes for which we received the RUC recommendations. We 
agreed with a majority of the relationships reflected in the RUC 
values. In some cases when we agreed with the RUC relationships, we 
revised the RVUs recommended by the RUC in order to achieve work 
neutrality within families of codes. For example, if CPT revised an 
existing code by splitting it into two or more new codes, we took into 
account the RVUs assigned to the existing code and the expected 
utilization of the split codes in such a way that the coding change 
would not lead to an overall increase in RVUs associated with services 
previously described by a single code. For approximately 90 percent of 
the RUC recommendations, proposed RVUs were accepted or increased, and 
for approximately 10 percent, RVUs were decreased.
    We also received two recommendations from specialty societies and 
four recommendations from the Health Care Professionals Advisory 
Committee for new or revised codes for which the RUC did not provide a 
recommendation. The specialty society recommendations were also 
reviewed by the physician panels. All of the proposed RVUs of the 
specialty society recommendations were accepted. All of the proposed 
RVUs of the Health Care Professionals Advisory Committee 
recommendations were decreased.
    Table 2 is a listing of those codes that will be new or revised in 
1996 for which we received recommended work RVUs. This table includes 
the following information:
     A ``#'' identifies a new code for 1996.
     CPT code. This is the CPT code for a service.
     Modifier. A ``26'' in this column indicates that the RVUs 
are for the professional component of the code.
     Description. This is an abbreviated version of the 
narrative description of the code.
     RUC-recommended work RVUs. This column identifies the work 
RVUs recommended by the RUC. If no recommendation was received from the 
RUC, this column shows ``no rec.''
     Health Care Professionals Advisory Committee (HCPAC) 
recommendations.  This column identifies work RVUs recommended by the 
Health Care Professionals Advisory Committee.
     Specialty-recommended RVUs. This column identifies work 
RVUs recommended by a specialty society.
     HCFA decision. This column indicates whether we agreed 
with the RUC recommendation (``agreed''); we established work RVUs that 
are higher than the RUC recommendation (``increased''); or we 
established work RVUs that were less than the RUC recommendation 
(``decreased''). Codes for which we did not accept the RUC 
recommendation are discussed in greater detail following Table 2. A 
discussion follows the table in section VI.B.2.b. An (a) in the column 
indicates that RVUs were not assigned.
     HCFA value. This column contains the 1996 RVUs for 
physician work.
    This table includes only those codes that were reviewed by the full 
RUC or for which we received a recommendation from a specialty society 
or Health Care Professionals Advisory Committee.


                                                                                                                

[[Page 63162]]
                                                 Table 2.--AMA RUC Recommendations and HCFA's Decisions                                                 
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                            RUC             HCPAC          Specialty                                                    
   CPT*       Mod               Description           recommendations  recommendations  recommendations           HCFA  decision          1996 work RVUs
--------------------------------------------------------------------------------------------------------------------------------------------------------
17110....  .........  Destruction of skin lesions...             0.55  ...............  ...............  Agreed.........................            0.55
#20100...  .........  Explore wound, neck...........             9.50  ...............  ...............  Agreed.........................            9.50
#20101...  .........  Explore wound, chest..........             3.00  ...............  ...............  Agreed.........................            3.00
#20102...  .........  Explore wound, abdomen........             3.68  ...............  ...............  Agreed.........................            3.68
#20103...  .........  Explore wound, extremity......             4.95  ...............  ...............  Agreed.........................            4.95
#20930...  .........  Spinal bone allograft.........             0.00  ...............  ...............  Agreed.........................            0.00
#20931...  .........  Spinal bone allograft.........             1.81  ...............  ...............  Agreed.........................            1.81
#20936...  .........  Spinal bone autograft.........             0.00  ...............  ...............  Agreed.........................            0.00
#20937...  .........  Spinal bone autograft.........             2.79  ...............  ...............  Agreed.........................            2.79
#20938...  .........  Spinal bone autograft.........             3.02  ...............  ...............  Agreed.........................            3.02
#21076...  .........  Prepare face/oral prosthesis..  ...............  ...............            12.54   Agreed........................           12.54
#21077...  .........  Prepare face/oral prosthesis..  ...............  ...............            31.54   Agreed........................           31.54
#21141...  .........  Reconstruct midface, lefort...            16.92  ...............  ...............  Agreed.........................           16.92
#21142...  .........  Reconstruct midface, lefort...            17.58  ...............  ...............  Agreed.........................           17.58

[[Page 63163]]
                                                                                                                                                        
#21143...  .........  Reconstruct midface, lefort...            18.30  ...............  ...............  Agreed.........................           18.30
21145....  .........  Reconstruct midface, lefort...            18.92  ...............  ...............  Agreed.........................           18.92
21146....  .........  Reconstruct midface, lefort...            19.58  ...............  ...............  Agreed.........................           19.58
21147....  .........  Reconstruct midface, lefort...            20.30  ...............  ...............  Agreed.........................           20.30
22100....  .........  Remove part of neck vertebra..             9.05  ...............  ...............  Agreed.........................            9.05
22101....  .........  Remove part, thorax vertebra..             9.00  ...............  ...............  Agreed.........................            9.00
22102....  .........  Remove part, lumbar vertebra..             9.00  ...............  ...............  Agreed.........................            9.00
#22103...  .........  Remove extra spine segment....             2.34  ...............  ...............  Agreed.........................            2.34
22110....  .........  Remove part of neck vertebra..            11.59  ...............  ...............  Agreed.........................           11.59
22112....  .........  Remove part, thorax vertebra..            11.59  ...............  ...............  Agreed.........................           11.59
22114....  .........  Remove part, lumbar vertebra..            11.59  ...............  ...............  Agreed.........................           11.59
#22116...  .........  Remove extra spine segment....             2.32  ...............  ...............  Agreed.........................            2.32
22210....  .........  Revision of neck spine........            22.51  ...............  ...............  Agreed.........................           22.51
22212....  .........  Revision of thorax spine......            18.14  ...............  ...............  Agreed.........................           18.14
22214....  .........  Revision of lumbar spine......            18.14  ...............  ...............  Agreed.........................           18.14
#22216...  .........  Revise, extra spine segment...             6.04  ...............  ...............  Agreed.........................            6.04
22220....  .........  Revision of neck spine........            20.15  ...............  ...............  Agreed.........................           20.15
22222....  .........  Revision of thorax spine......            20.15  ...............  ...............  Agreed.........................           20.15
22224....  .........  Revision of lumbar spine......            20.15  ...............  ...............  Agreed.........................           20.15
#22226...  .........  Revise, extra spine segment...             6.04  ...............  ...............  Agreed.........................            6.04
22305....  .........  Treat spine process fracture..             1.86  ...............  ...............  Agreed.........................            1.86
22310....  .........  Treat spine fracture..........             1.86  ...............  ...............  Agreed.........................            1.86
22315....  .........  Treat spine fracture..........             8.36  ...............  ...............  Agreed.........................            8.36
22325....  .........  Repair of spine fracture......            17.19  ...............  ...............  Agreed.........................           17.19
22326....  .........  Repair neck spine fracture....            18.43  ...............  ...............  Agreed.........................           18.43
22327....  .........  Repair thorax spine fracture..            17.56  ...............  ...............  Agreed.........................           17.56
#22328...  .........  Repair each add spine fx......             4.61  ...............  ...............  Agreed.........................            4.61
22548....  .........  Neck spine fusion.............            24.08  ...............  ...............  Agreed.........................           24.08
22554....  .........  Neck spine fusion.............            17.24  ...............  ...............  Agreed.........................           17.24
22556....  .........  Thorax spine fusion...........            22.27  ...............  ...............  Agreed.........................           22.27
22558....  .........  Lumbar spine fusion...........            21.22  ...............  ...............  Agreed.........................           21.22
22585....  .........  Additional spinal fusion......             5.53  ...............  ...............  Agreed.........................            5.53
22590....  .........  Spine & skull spinal fusion...            19.50  ...............  ...............  Agreed.........................           19.50
22595....  .........  Neck spinal fusion............            18.19  ...............  ...............  Agreed.........................           18.19
22600....  .........  Neck spine fusion.............            14.74  ...............  ...............  Agreed.........................           14.74
22610....  .........  Thorax spine fusion...........            14.62  ...............  ...............  Agreed.........................           14.62
22612....  .........  Lumbar spine fusion...........            20.19  ...............  ...............  Agreed.........................           20.19
#22614...  .........  Spine fusion, extra segment...             6.44  ...............  ...............  Agreed.........................            6.44
22630....  .........  Lumbar spine fusion...........            20.03  ...............  ...............  Agreed.........................           20.03
#22632...  .........  Spine fusion, extra segment...             5.23  ...............  ...............  Agreed.........................            5.23
22800....  .........  Fusion of spine...............            16.92  ...............  ...............  Agreed.........................           16.92
22802....  .........  Fusion of spine...............            29.74  ...............  ...............  Agreed.........................           29.74
#22804...  .........  Fusion of spine...............            35.00  ...............  ...............  Agreed.........................           35.00
#22808...  .........  Fusion of spine...............            25.00  ...............  ...............  Agreed.........................           25.00
22810....  .........  Fusion of spine...............            29.00  ...............  ...............  Agreed.........................           29.00
22812....  .........  Fusion of spine...............            31.00  ...............  ...............  Agreed.........................           31.00
22830....  .........  Exploration of spinal fusion..            10.22  ...............  ...............  Agreed.........................           10.22
22840....  .........  Insert spine fixation device..             6.27  ...............  ...............  Agreed.........................            6.27
#22841...  .........  Insert spine fixation device..             0.00  ...............  ...............  Agreed.........................            0.00
#22842...  .........  Insert spine fixation device..             7.19  ...............  ...............  Agreed.........................            7.19
#22843...  .........  Insert spine fixation device..             8.97  ...............  ...............  Agreed.........................            8.97
#22844...  .........  Insert spine fixation device..            10.96  ...............  ...............  Agreed.........................           10.96
22845....  .........  Insert spine fixation device..             5.98  ...............  ...............  Agreed.........................            5.98
#22846...  .........  Insert spine fixation device..             8.28  ...............  ...............  Agreed.........................            8.28
#22847...  .........  Insert spine fixation device..             9.20  ...............  ...............  Agreed.........................            9.20
#22848...  .........  Insert pelvic fixation device.             6.00  ...............  ...............  Agreed.........................            6.00
#22851...  .........  Apply spine prosth device.....             6.71  ...............  ...............  Agreed.........................            6.71
32095....  .........  Biopsy through chest wall.....             7.13  ...............  ...............  Agreed.........................            7.13
#32501...  .........  Repair bronchus (add-on)......             4.69  ...............  ...............  Agreed.........................            4.69
#33253...  .........  Reconstruct atria.............            30.00  ...............  ...............  Agreed.........................           30.00
#33924...  .........  Remove pulmonary shunt........             5.50  ...............  ...............  Agreed.........................            5.50
#38231...  .........  Stem cell collection..........             1.74  ...............  ...............  Decreased......................            1.50
38240....  .........  Bone marrow/stem transplant...             2.24  ...............  ...............  Agreed.........................            2.24
38241....  .........  Bone marrow/stem transplant...             2.24  ...............  ...............  Agreed.........................            2.24
47350....  .........  Repair liver wound............            11.29  ...............  ...............  Agreed.........................           11.29
47360....  .........  Repair liver wound............            15.34  ...............  ...............  Agreed.........................           15.34
#47361...  .........  Repair liver wound............            28.00  ...............  ...............  Agreed.........................           28.00
#47362...  .........  Repair liver wound............            10.00  ...............  ...............  Agreed.........................           10.00

[[Page 63164]]
                                                                                                                                                        
49000....  .........  Exploration of abdomen........             8.99  ...............  ...............  Agreed.........................            8.99
49002....  .........  Reopening of abdomen..........             9.40  ...............  ...............  Agreed.........................            9.40
49010....  .........  Exploration behind abdomen....            11.19  ...............  ...............  Agreed.........................           11.19
55859....  .........  Percut/needle insert, pros....            14.00  ...............  ...............  Decreased......................            8.29
#56343...  .........  Laparoscopic salpingostomy....             6.96  ...............  ...............  Agreed.........................            6.96
#56344...  .........  Laparoscopic fimbrioplasty....             7.16  ...............  ...............  Agreed.........................            7.16
#57284...  .........  Repair paravaginal defect.....            12.10  ...............  ...............  Agreed.........................           12.10
#59610...  .........  Vbac delivery.................            22.63  ...............  ...............  Decreased......................           22.55
#59612...  .........  Vbac delivery only............            15.00  ...............  ...............  Decreased......................           14.84
#59614...  .........  Vbac care after delivery......            16.00  ...............  ...............  Decreased......................           15.96
#59618...  .........  Attempted vbac delivery.......            25.03  ...............  ...............  Increased......................           25.23
#59620...  .........  Attempted vbac delivery only..            16.75  ...............  ...............  Increased......................           16.95
#59622...  .........  Attempted vbac after care.....            17.94  ...............  ...............  Increased......................           18.11
62274....  .........  Inject spinal anesthetic......             1.78  ...............  ...............  Agreed.........................            1.78
62288....  .........  Injection into spinal canal...             1.74  ...............  ...............  Agreed.........................            1.74
#62350...  .........  Implant spinal catheter.......             6.25  ...............  ...............  Agreed.........................            6.25
#62351...  .........  Implant spinal catheter.......             9.25  ...............  ...............  Agreed.........................            9.25
#62355...  .........  Remove spinal canal catheter..             4.80  ...............  ...............  Agreed.........................            4.80
#62360...  .........  Insert spine infusion device..             2.00  ...............  ...............  Agreed.........................            2.00
#62361...  .........  Implant spine infusion pump...             4.80  ...............  ...............  Agreed.........................            4.80
#62362...  .........  Implant spine infusion pump...             6.29  ...............  ...............  Agreed.........................            6.29
#62365...  .........  Remove spine infusion device..             4.77  ...............  ...............  Agreed.........................            4.77
#62367...         26  Analyze spine infusion pump...             0.48  ...............  ...............  Agreed.........................            0.48
#62368...         26  Analyze spine infusion pump...             0.75  ...............  ...............  Agreed.........................            0.75
67107....  .........  Repair detached retina........            13.99  ...............  ...............  Agreed.........................           13.99
67108....  .........  Repair detached retina........            19.90  ...............  ...............  Agreed.........................           19.90
67112....  .........  Re-repair detached retina.....            16.15  ...............  ...............  Agreed.........................           16.15
# 76965..         26   Echo guidance radiotherapy...             1.34  ...............  ...............  Agreed.........................            1.34
# 78459..         26   Heart muscle imaging (PET)...             1.88  ...............  ...............  Agreed.........................            1.88
# 78810..         26   Tumor imaging (PET)..........             1.93  ...............  ...............  Agreed.........................            1.93
# 90922..  .........  ESRD related services, day....             0.44  ...............  ...............  Decreased......................            0.37
# 90923..  .........  Esrd related services, day....             0.30  ...............  ...............  Decreased......................            0.28
# 90924..  .........  Esrd related services, day....             0.22  ...............  ...............  Increased......................            0.24
# 90925..  .........  Esrd related services, day....             0.17  ...............  ...............  Decreased......................            0.15
92506....  .........  Speech & hearing evaluation...             0.86  ...............  ...............  Agreed.........................            0.86
92507....  .........  Speech/hearing therapy........             0.52  ...............  ...............  Agreed.........................            0.52
92508....  .........  Speech/hearing therapy........             0.26  ...............  ...............  Agreed.........................            0.26
# 92510..  .........  Rehab for ear implant.........             1.50  ...............  ...............  Agreed.........................            1.50
92516....  .........  Facial nerve function test....             0.43  ...............  ...............  Agreed.........................            0.43
# 92525..  .........  Oral function evaluation......             1.61  ...............  ...............  Decreased......................            1.13
# 92526..  .........  Oral function therapy.........             0.64  ...............  ...............  Decreased......................            0.52
92546....         26   Sinusoidal rotational test...             0.29  ...............  ...............  Agreed.........................            0.29
# 92579..  .........  Visual audiometry (vra).......  ...............  ...............  ...............  (a)............................  ..............
# 92597..  .........  Oral speech device eval.......             1.50  ...............  ...............  Decreased......................            1.11
# 92598..  .........  Modify oral speech device.....             0.99  ...............  ...............  Decreased......................            0.73
# 92987..  .........  Revision of mitral valve......            20.69  ...............  ...............  Agreed.........................           20.69
95872....         26   Muscle test, one fiber.......             1.50  ...............  ...............  Agreed.........................            1.50
95900....         26   Motor nerve conduction test..             0.42  ...............  ...............  Agreed.........................            0.42
# 95903..         26   Motor nerve conduction test..             0.60  ...............  ...............  Agreed.........................            0.60
95904....         26   Sense nerve conduction test..             0.34  ...............  ...............  Agreed.........................            0.34
95925....         26   Somatosensory testing........             0.81  ...............  ...............  Decreased......................            0.54
# 95926..         26   Somatosensory testing........             0.81  ...............  ...............  Decreased......................            0.54
# 95927..         26   Somatosensory testing........             0.81  ...............  ...............  Decreased......................            0.54
# 95930..         26   Visual evoked potential test.             0.35  ...............  ...............  Agreed.........................            0.35
# 95934..         26   `H' reflex test..............             0.51  ...............  ...............  Agreed.........................            0.51
# 95936..         26   `H' reflex test..............             0.55  ...............  ...............  Agreed.........................            0.55
97116....  .........  Gait training therapy.........             0.40  ...............  ...............  Agreed.........................            0.40
# 97535..  .........  Self care mngment training....  ...............             0.45  ...............  Decreased......................            0.33
# 97537..  .........  Community/work reintegration..  ...............             0.45  ...............  Decreased......................            0.33
# 97542..  .........  Wheelchair mngement training..  ...............             0.45  ...............  Decreased......................            0.25
# 97703..  .........  Prosthetic checkout...........  ...............             0.45  ...............  Decreased......................            0.25
99238....  .........  Hospital discharge day........             1.06  ...............  ...............  Agreed.........................            1.06
# 99239..  .........  Hospital discharge day........             1.75  ...............  ...............  Agreed.........................            1.75
# 99435..  .........  Hospital NB discharge day.....             1.50  ...............  ...............  Agreed.........................            1.50
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[[Page 63165]]

    b. Discussion of codes for which the recommendations were not 
accepted or for which clarification of the code is necessary.
    The following is a summary of our rationale for not accepting 
particular recommendations. It is arranged by type of service in CPT 
code order. We have included in this section a clarification of the 
intended use of one family of codes for which we accepted the RUC 
recommendations. This summary refers only to work RVUs.
    Exploration of penetrating wounds (CPT codes 20100 through 20103).
    We accepted the RUC recommendations for these codes but are 
concerned that they could be inappropriately used to report the repair 
of wounds. Therefore, we are providing a clarification of the codes 
based on the language that will be included in CPT 1996.
    These codes are used to report the treatment of wounds resulting 
from penetrating trauma that require surgical exploration and 
enlargement of the wound, extension of dissection (to determine 
penetration), debridement, removal of foreign body(s), ligation or 
coagulation of minor subcutaneous and/or muscular blood vessel(s), of 
the subcutaneous tissue, muscle fascia, and/or muscle. If a repair is 
done to major blood vessel(s) requiring thoracotomy or laparotomy, 
those specific code(s) would supersede the use of CPT codes 20100 
through 20103. These codes should not be used to report simple, 
intermediate, or complex repair of wound(s) that do not require 
enlargement of the wound, extension of dissection, etc., as stated 
above.
    Blood-derived peripheral stem cell harvesting for transplantation, 
per collection (CPT code 38231).
    The RUC recommended 1.74 RVUs based on its determination that the 
work is equivalent to the work of CPT code 36520 (Therapeutic 
apheresis). We believe that the work associated with this procedure is 
less than that for CPT code 36520 in that the patients are less ill and 
the risk of complications is much less. In addition, patients require 
less physician monitoring, and the procedure is more likely to be 
performed on an outpatient basis. We believe the work is comparable to 
a level-5 evaluation and management service (CPT code 99215), which is 
assigned 1.50 RVUs.
    However, as with therapeutic apheresis, we do not permit payment 
for both harvesting and certain evaluation and management codes on the 
same date. Specifically, we do not allow separate payment for CPT codes 
99211 through 99215 (Established patient office or other outpatient 
visits), 99231 through 99233 (Subsequent hospital care), and 99261 
through 99263 (Follow-up inpatient consultations) on the same date that 
CPT code 38231 (Stem cell harvesting) is furnished because it would 
allow duplicate payment for the evaluation and management service. 
Physicians furnishing stem cell harvesting services may choose to bill 
for the appropriate evaluation and management visit or consultation 
code indicating the level of services furnished rather than billing for 
the stem cell harvesting. This will permit physicians to be paid for 
the level of service furnished.
    Separate payment will be allowed for physician services furnished 
to establish the required vascular access if performed by the physician 
and if the criteria for payment under the appropriate CPT code are 
satisfied. We will also allow separate billing for CPT codes 99221 
through 99223 (Initial hospital visit), CPT codes 99241 through 99245 
and 99251 through 99255 (Initial consultations), and CPT code 99238 
(Hospital discharge service) when billed on the same date as CPT code 
38231 (Stem cell harvesting) because the work associated with these 
evaluation and management services is not included in work RVUs 
assigned to the stem cell harvesting. These policies are consistent 
with the policies for therapeutic apheresis that were established for 
the 1995 fee schedule.
    Transperineal placement of needles or catheters into prostate for 
interstitial radioelement application, with or without cystoscopy (CPT 
code 55859).
    We received a RUC recommendation of 14.00 RVUs based upon the use 
of CPT code 61770 (Stereotactic localization, any method, including 
burr hole(s) with insertion of catheter(s) for brachytherapy) as a 
reference procedure. We believe that these RVUs are too high and 
disagree with the RUC's use of CPT code 61770 as a reference procedure; 
we view that procedure as requiring greater technical skill, mental 
effort, and judgment. The recommended 14.00 RVUs are higher than the 
RVUs assigned to CPT code 55860 (Exposure of prostate, any approach, 
for insertion of radioactive substance), which is assigned 13.33 RVUs. 
This is an open surgical procedure with significantly more 
postprocedure work than CPT code 55859, which can be performed on an 
outpatient basis.
    The placement of needles or catheters into the prostate is 
performed under ultrasonic guidance, and the guidance is separately 
reported by new CPT code 76965 for which we accepted the RUC 
recommendation of 1.34 RVUs. In addition, CPT also directs separate 
reporting of the interstitial radioelement application (CPT codes 77776 
through 77778). CPT code 77778 (Interstitial radioelement application, 
complex) is the code most likely to be reported. We assigned 10.46 RVUs 
to this code. Thus, a physician performing all aspects of this 
procedure would report all three codes with 25.80 total RVUs if we 
accepted the RUC recommendation of 14.00 for code 55859.
    We believe it is possible that urologists responding to the 
surveyed vignette may have misunderstood that this code is used to 
report only the placement of the needles or catheters into the prostate 
and that they inadvertently included in their estimates of work the 
separately reported work of ultrasonic guidance and application of the 
radioelements.
    We believe that a more appropriate reference procedure than a 
neurosurgical procedure would be another prostate procedure that can be 
performed on an outpatient basis. We selected CPT code 55700 (Biopsy, 
prostate; needle or punch, single or multiple, any approach), which is 
assigned 1.57 RVUs. Because of the increased intraoperative time and 
complexity as well as the increased surgical risk associated with CPT 
code 55859, we have increased the RVUs four-fold to 6.28 RVUs. In 
addition we added 2.01 RVUs, the RVUs assigned to CPT code 52000, to 
reflect the added work of the cystoscopy. This addition results is the 
assignment of 8.29 RVUs for CPT code 55859.
    Vaginal birth after cesarean (CPT codes 59610, 59612, 59614, 59618, 
59620, and 59622).
    The CPT has added a new section to the 1996 edition for ``delivery 
after previous cesarean delivery.'' Included in this section are six 
new codes that are used to report the services furnished to patients 
who have had a previous cesarean delivery and who present with the 
expectation of a vaginal delivery. If the patient has a successful 
vaginal delivery after a previous cesarean delivery (VBAC), then either 
CPT code 59610, 59612, or 59614 is reported. If the attempt is 
unsuccessful and another cesarean delivery is carried out, either 

[[Page 63166]]
CPT code 59618, 59620, or 59622 is reported. The RUC-recommended RVUs 
for all six codes that added varying increments of work to the RVUs of 
the six existing codes that are used to report routine vaginal and 
cesarean deliveries. The following table includes the RVUs for the six 
existing codes, the RUC recommendations for the six new VBAC codes and 
the difference in RVUs for each of the six pairs.

----------------------------------------------------------------------------------------------------------------
                                                                              RUC-                              
                                             RVUs of      Corresponding    Recommended                     HCFA 
         Existing delivery code             existing      new VBAC code   RVUs for new   RVU difference    RVUs 
                                          delivery code                     VBAC code                           
----------------------------------------------------------------------------------------------------------------
59400..................................           20.99           59610           22.63            1.64    22.55
59409..................................           13.28           59612           15.00            1.72    14.84
59410..................................           14.44           59614           16.00            1.56    15.96
59510..................................           23.67           59618           25.03            1.36    25.23
59514..................................           15.39           59620           16.75            1.36    16.95
59515..................................           16.55           59622           17.94            1.39    18.11
----------------------------------------------------------------------------------------------------------------

    While we accept the RUC conclusion that VBAC services entail more 
physician work and that the existing delivery codes are appropriate 
reference points, we disagree with the variable and small differences 
in work from one code to the next. We believe the increased stress, 
mental effort, and judgment associated with VBAC is the same regardless 
of the particular delivery service furnished. Therefore, we are adding 
1.56 RVUs (the median RVUs of the above differences) to each of the 
existing delivery codes. This results in the interim RVUs identified in 
the last column of the table as ``HCFA RVUs.''
    End-stage renal disease services, per day (CPT codes 90922 through 
90925).
    CPT 1996 will include four codes for the reporting of end-stage 
renal disease services on a per day rather than per month basis. We did 
not accept the RUC recommendations for these codes that were based on 
the RUC's recommendations for the monthly codes (CPT codes 90918 
through 90921). As discussed in section VI.B.1.b. of this final rule, 
new RVUs emerged from the refinement panel ratings for these codes. We 
calculated work RVUs for the four ``per day'' end-stage renal disease 
codes by dividing the RVUs of the ``per full month'' codes by 30. This 
led to the assignment of 0.37 RVUs to CPT code 90922, 0.28 RVUs to CPT 
code 90923, 0.24 RVUs to CPT code 90924, and 0.15 RVUs to CPT code 
90925.
    Evaluation of swallowing and oral function for feeding (CPT code 
92525).
    The RUC made its recommendation of 1.61 RVUs based on a clinical 
vignette of an inpatient whose evaluation included a barium swallow. 
The RUC lowered the specialty's recommendation to better account for 
the times when the barium swallow might not be done. We believe the 
RVUs recommended, which are between the RVUs of a level-3 inpatient 
consultation (CPT code 99253), with 1.56 RVUs, and a level-4 inpatient 
consultation (CPT code 99254) with 2.27 RVUs, are too high. While we 
believe that the intraservice work determined by the survey for the 
vignette may be reasonable, we do not believe that the surveyed 
vignette represented a typical patient.
    Our data suggest that this procedure, which was formerly reported 
by CPT code 92506, is performed primarily in the physician's office. We 
took into consideration that the procedure is currently reported using 
CPT code 92506, which is assigned 0.86 RVUs. We then took into account 
that the barium swallow is probably included in at least 50 percent of 
the cases and that the evaluation of the barium swallow is an integral 
part of the procedure. Therefore, we added half the value of CPT code 
74230 (Swallowing function, pharynx and/or esophagus, with 
cineradiography and/or video), which is assigned 0.54 RVUs to the 0.86 
RVUs for CPT code 92506 resulting in an assignment of 1.13 RVUs to CPT 
code 92525. These RVUs are slightly higher than the RVUs of CPT code 
99242, which is the code for a level-2 office consultation, the 
components of which include an expanded problem-focused history, an 
expanded problem-focused examination, and straightforward medical 
decision making.
    Treatment of swallowing dysfunction and/or oral function for 
feeding (CPT code 92526).
    The RUC recommended 0.64 RVUs based on a clinical vignette of an 
inpatient similar to the patient described in the vignette used for CPT 
code 92525 described above. Our data suggest that this procedure, which 
is currently reported using CPT code 92507, also is performed primarily 
in physicians' offices. Because we believe the surveyed vignette does 
not describe a typical patient, we reduced the RUC recommendation for 
CPT code 92526 to 0.52 RVUs, which are the same RVUs as those for CPT 
code 92507 (Speech, language or hearing therapy, with continuing 
medical supervision; individual). These RVUs are slightly less than the 
RVUs assigned to a mid-level office visit (CPT code 99213), with 0.55 
RVUs, which typically requires 15 minutes of face-to-face time with a 
physician.
    Visual reinforcement audiometry (VRA) (CPT code 92579).
    The RUC made no recommendation for RVUs for this procedure. As with 
most of the audiologic function tests, we do not believe this service 
requires performance by a physician. Consequently, we have not assigned 
physician work RVUs to this code. However, we have assigned 0.69 
practice expense RVUs and 0.07 malpractice expense RVUs.
    Evaluation for use and/or fitting of voice prosthetic or 
augmentative/alternative communication device to supplement oral speech 
(CPT code 92597).
    The RUC recommended 1.50 RVUs. We believe the recommended RVUs are 
too high because they are comparable to the highest level established 
patient office visit, CPT code 99215, the components of which include a 
comprehensive history, a comprehensive examination, and medical 
decision-making of high complexity. We do not believe the work of these 
two services is comparable. Rather, we believe the work associated with 
CPT code 92597 is slightly less than the work associated with a level-3 
new patient office visit (CPT code 99203) with 1.14 RVUs and a level-2 
inpatient consultation (CPT code 99252) with 1.13 RVUs. Therefore, we 
have assigned 1.11 RVUs to CPT code 92597. 

[[Page 63167]]

    Modification of voice prosthetic or augmentative/alternative 
communication device to supplement oral speech (CPT code 92598).
    The RUC recommended 0.99 RVUs, which are higher than the RVUs 
assigned to a level-4 established patient office visit (CPT code 
99214), with 0.94 RVUs. We believe that the recommendation is too high. 
However, we believe that the relative relationship between this service 
and CPT code 92597, as established by the RUC, should be maintained. 
Thus, we calculated the interim RVUs by multiplying the recommended 
0.99 RVUs by 74 percent (0.99 x 1.11/1.5) representing the percentage 
of the RUC-recommended RVUs, which we accepted for the preceding code. 
This calculation results in 0.73 interim RVUs for CPT code 92598.
    Short-latency somatosensory evoked potential studies, stimulation 
of any/all peripheral nerves or skin sites, recording from the central 
nervous system (CPT codes 95925 through 95927).
    The existing code for the reporting of somatosensory testing is CPT 
code 95925. The descriptor in CPT 1995 is ``Somatosensory testing 
(e.g., cerebral evoked potentials), one or more nerves.'' CPT revised 
existing CPT code 95925 by splitting it into three codes (95925, 95926, 
and 95927), which will be used to report testing of the upper limbs, 
lower limbs, and trunk or head, respectively. Currently, 0.81 RVUs are 
assigned to CPT code 95925. The RUC viewed the coding change as 
editorial and recommended 0.81 RVUs for each of these codes. While we 
agree that the same RVUs should be assigned to the three codes, we have 
not accepted the specific recommendation of 0.81 RVUs because we do not 
view it as an editorial change. We believe that the RUC failed to take 
account of the fact that some patients will require testing of both the 
upper and lower limbs during an encounter and that, under the existing 
code, only one unit of service can be reported regardless of the number 
of nerves tested because the descriptor specifies ``one or more 
nerves.'' We estimate that the cases previously reported with CPT code 
95925 will be reported under the new and revised codes as follows: 
About 50 percent will be reported with revised CPT code 95925; about 50 
percent will be reported as new CPT code 95926; about 1 percent will be 
reported as CPT code 95927; and 50 percent of all testing will involve 
both CPT codes 95925 and 95926 during the same encounter. Using these 
estimates, we adjusted the RVUs for the three codes so that the total 
number of RVUs under the new codes will be the same as the total number 
of RVUs under the old codes. This results in a decrease of the RUC's 
recommendation of 0.81 RVUs for each of the codes to 0.54 RVUs for each 
of the codes.

                            Additional Codes                            
------------------------------------------------------------------------
             CPT code                            Description            
------------------------------------------------------------------------
97535.............................  Self care/home management training  
                                     (eg, activities of daily living    
                                     (ADL) and compensatory training,   
                                     meal preparation, safety           
                                     procedures, and instructions in use
                                     of adaptive equipment) direct one  
                                     on one contact by provider, each 15
                                     minutes.                           
97537.............................  Community/work reintegration,       
                                     training (eg, shopping,            
                                     transportation, money management,  
                                     avocational activities and/or work 
                                     environment/modification analysis, 
                                     work task analysis), direct one on 
                                     one contact by provider, each 15   
                                     minutes.                           
97542.............................  Wheelchair management/propulsion    
                                     training, each 15 minutes.         
97703.............................  Checkout for orthotic/prosthetic    
                                     use, established patient, each 15  
                                     minutes.                           
------------------------------------------------------------------------

    The RUC Health Care Professionals Advisory Committee Review Board 
recommended 0.45 RVUs for each of these services on the basis of their 
comparability to other physical medicine codes, for example, CPT code 
97110 (Therapeutic procedure, one or more areas, each 15 minutes; 
therapeutic exercises to develop strength and endurance, range of 
motion and flexibility). While we agree that these new services 
appropriately are compared to other therapeutic procedures, our review 
of the new services causes us to believe that the interim RVUs we 
assigned to the therapeutic procedures services may have been too high 
relative to other services on the fee schedule, for example, evaluation 
and management services.
    We have decided to maintain the interim RVUs for the physical 
medicine and rehabilitation codes (CPT codes 97010 through 97770) as 
interim RVUs on the 1996 fee schedule so that we will have additional 
time to re-evaluate them. While we acknowledge that we accepted last 
year's recommendations of the Health Care Professionals Advisory 
Committee Review Board to assign 0.45 RVUs to CPT code 97110 and 
several other of the therapeutic procedures, we now plan to refer these 
codes back to the RUC Health Care Professionals Advisory Committee 
Review Board for its reconsideration, and we will notify the RUC of our 
concerns. In addition, we seek public comments on this issue.
    For new CPT codes 97535 and 97537, we believe the recommended 0.45 
RVUs are too high. Since they are currently reported using CPT code 
97540 (Training in activities of daily living (self care skills and/or 
daily life management skills); initial 30 minutes, each visit), which 
has 0.44 RVUs, we divided the RVUs for CPT code 97540 by 2 to arrive at 
RVUs for 15 minutes and added 50 percent to account for the prework and 
postwork inherent in the service. This results in 0.33 RVUs for CPT 
codes 97535 and 97537.
    For new CPT codes 97542 and 97703, we believe the recommended 0.45 
RVUs are too high. We believe these services are comparable to attended 
modality services such as manual electrical stimulation (CPT code 
97032), with 0.25 RVUs. Therefore, we have assigned 0.25 RVUs to both 
CPT codes 97542 and 97703.

------------------------------------------------------------------------
             CPT code                            Description            
------------------------------------------------------------------------
99238.............................  Hospital discharge day management;  
                                     30 minutes or less.                
99239.............................  Hospital discharge day management;  
                                     more than 30 minutes.              
------------------------------------------------------------------------

    We agreed with the RUC recommendation of 1.06 RVUs for CPT code 
99238 and 1.75 RVUs for CPT code 99239. The reporting of CPT code 99239 
must be supported by documentation in the patient's medical record of 
the time spent by the physician furnishing the service as well as 
documentation of the actual services furnished. Time spent by 
individuals other than the physician should not be considered in 
selecting the appropriate hospital discharge day management code.

                                                                        

[[Page 63168]]
------------------------------------------------------------------------
             CPT code                            Description            
------------------------------------------------------------------------
99411.............................  Preventive medicine counseling and/ 
                                     or risk factor reduction           
                                     intervention(s) provided to        
                                     individuals in a group setting     
                                     (separate procedure): approximately
                                     30 minutes.                        
99412.............................  Preventive medicine counseling and/ 
                                     or risk factor reduction           
                                     intervention(s) provided to        
                                     individuals in a group setting     
                                     (separate procedure): approximately
                                     60 minutes.                        
------------------------------------------------------------------------



    We agreed with the RUC recommendations of 0.15 RVUs for CPT code 
99411 and 0.25 RVUs for CPT code 99412. While these services are not 
covered by Medicare, we believe it is important to state the 
assumptions we made in agreeing with the RUC-recommended RVUs. The 
intent of the codes is to represent an interactive service between the 
patient and the physician. We expect that the interaction will be 
documented in each patient's individual medical record. In addition, 
since the RVUs are based on physician work, the codes should not be 
reported unless they are personally performed by a physician; they 
should not be used to report group preventive medicine counseling 
furnished by anyone other than a physician. Nor is the service to be 
reported if it is furnished in a place of service other than the 
physician's office. Finally, the assigned RVUs are based on a group of 
two to five persons for CPT code 99411 and a group of two to six 
persons for CPT code 99412. Preventive medicine furnished to groups 
larger than these should be reported using code 99249 which is for the 
reporting of preventive medicine services not listed in CPT.
    c. Temporary alpha-numeric HCFA Common Procedure Coding System 
codes.
    For the 1996 Medicare fee schedule for physicians services, we have 
established several new alpha-numeric HCFA Common Procedure Coding 
System (HCPCS) codes for the reporting of certain new services that are 
not clearly described by existing CPT codes. In this section, we 
discuss our rationale for establishing the codes as well as the basis 
of the interim RVUs we have assigned to them. We view these codes as 
temporary since we will be referring them to the CPT Editorial Panel 
for possible inclusion in future editions of the CPT.
    Measurement of post-voiding residual urine and/or bladder capacity 
by ultrasound (HCPCS code G0050).
    Measurement of postvoiding residual (PVR) urine and/or bladder 
capacity can be done by simple diagnostic catheterization. It can also 
be done by ultrasound using either traditional sonographic equipment or 
smaller less expensive equipment whose capacity is limited only to 
bladder volume determination. When done by catheterization, CPT code 
53670, with 0.74 RVUs, is reported. When done by ultrasound, CPT code 
76857, pelvic echography, with 1.65 RVUs, is reported whether done 
using traditional equipment or the smaller bladder scan. There is 
presently no separate CPT code for a bladder scan only. Both individual 
carriers and a manufacturer of bladder scanning devices have 
recommended that we establish a separate code to distinguish bladder 
scans from general pelvic scans because they believe that payment for 
CPT code 76857 is too high for only a bladder scan to determine PVR. We 
agree with this recommendation and are issuing the new HCPCS code 
G0050.

----------------------------------------------------------------------------------------------------------------
                                                                  Work                     Malpractice    Total 
                          HCPCS code                              RVUs    Practice RVUs       RVUs         RVUs 
----------------------------------------------------------------------------------------------------------------
G0050.........................................................     0.00            0.81            0.05     0.86
----------------------------------------------------------------------------------------------------------------

    We believe that this bladder scan performs the same function as a 
simple diagnostic catheterization but without the risk of infection. To 
recognize the slightly higher equipment costs, we have established 
interim total RVUs for bladder scan of 0.86, or about 0.12 RVUs higher 
than for catheterization. We have not assigned physician work RVUs for 
a bladder scan. We expect that the scan will be performed after a 
physician has examined the patient and determined the medical necessity 
for a bladder scan. Physician interpretation of the scan is included in 
the associated evaluation and management service.
    Lung volume reduction surgery (reduction pneumoplasty) eg, lung 
shaving, lung contouring, unilateral or bilateral (HCPCS code G0061).
    Lung volume reduction surgery, also termed reduction pneumoplasty, 
lung shaving, or lung contouring is a procedure performed to improve 
pulmonary function in patients with severe emphysema. Medicare has not 
established that the procedure is reasonable and necessary for the 
diagnosis or treatment of illness or injury. Therefore, we have 
excluded this procedure from coverage under the provisions of section 
1862(a)(1)(A) of the Act.
    Although we have assigned a noncoverage indicator of ``N'' to this 
code, we are providing interim RVUs for those who look to the Medicare 
fee schedule for information on the relative value of all physicians 
services including those not covered by Medicare.
    We believe the procedure is most often being reported as wedge 
resection(s) of the lung using CPT code 32500, which has 13.10 work 
RVUs. Based on discussions with carrier medical directors, we believe 
that lung volume reduction surgery is more difficult than wedge 
resection(s). After considering existing CPT codes for other pulmonary 
procedures, we have assigned 17.62 RVUs on an interim basis to HCPCS 
code G0061. These are the same RVUs assigned to total pulmonary 
decortication (CPT code 32220), which we believe is similar to lung 
reduction surgery in terms of physician work.

V. Issues for Discussion

A. Five-Year Refinement of Relative Value Units

    Section 1848(c)(2)(B)(i) of the Act requires that we review all 
RVUs no less often than every 5 years. Since we implemented the 
physician fee schedule effective for services furnished beginning 
January 1, 1992, we have initiated the 5-year refinement of RVUs that 
will be effective for services furnished beginning January 1, 1997.
    All work RVUs included in the December 1994 final rule (59 FR 
63617) were subject to comment. During the comment period, which closed 
on February 6, 1995, we received approximately 500 public comments on 
approximately 1,100 procedure codes. After review by our medical staff, 
we forwarded comments on approximately 700 CPT codes for consideration 
by the 

[[Page 63169]]
American Medical Association/Specialty Society Relative Value Update 
Committee (RUC).
    After a thorough review of the RUC recommendations, we will 
announce any proposed changes to the work RVUs in the Federal Register 
in early 1996 and provide an opportunity for the public to comment 
before we finalize the changes.

B. Resource-Based Practice Expense Relative Value Units

    With the exception of anesthesia services, physician services and 
other diagnostic services paid under the physician fee schedule have 
practice expense and malpractice expense RVUs. Payments for practice 
expense RVUs account for approximately 42 percent of physician fee 
schedule payments.
    The practice expense RVUs are derived from historical allowed 
charge data. The common criticism is that the practice expense RVUs are 
not truly resource-based because they are not based on resource costs.
    Section 121 of the Social Security Act Amendments of 1994, Public 
Law 103-432, enacted on October 31, 1994, requires the Secretary to 
develop a methodology for a resource-based system for determining 
practice expense RVUs for each physician service. In developing the 
methodology, the Secretary must consider the staff, equipment, and 
supplies used in the provision of medical and surgical services in 
various settings. The Secretary must report to the Congress on the 
methodology by June 30, 1996. The new payment methodology is effective 
for services furnished in 1998. There is no transition provision for 
these services.
    We awarded a contract to Abt Associates in March 1995. Abt will 
develop a uniform database that can be used to support a number of 
analytical methods (for example, microcosting or economic cost 
functions) to estimate practice expense per service. Abt will also 
provide us with both direct and indirect practice expense estimates for 
all services paid under the physician fee schedule. We expect that 
these estimates will vary based on the site where the service is 
furnished. For example, the practice expense for a physician service 
furnished in the hospital outpatient department will differ from the 
practice expense for the same service performed in the physician's 
office.
    As we pointed out in our July 26, 1995 proposed rule (60 FR 38400), 
Abt will use information from two separate processes to generate 
practice expense RVUs for physician services (60 FR 38417). Through the 
use of Clinical Practice Expert Panels, Abt will estimate the expenses, 
including the cost of clinical labor, supplies, and medical equipment 
for specific physician services. The Clinical Practice Expert Panels 
will also consider whether additional items, such as the cost of 
administrative services, can be directly assigned to individual 
services. The remaining expenses for physician services will be 
calculated from the information obtained through the practice expense 
survey.

Practice Expense Survey

    Abt will obtain physician practice specific information through a 
practice expense survey. Abt expects to receive responses from 
approximately 3,000 practices.
    The survey instrument was sent to the Office of the Secretary in 
the Department of Health and Human Services on August 7, 1995. Under 
current procedures, the Department has a 60-day period to review this 
survey. After Departmental clearance, the survey is sent to the Office 
of Management and Budget where it will undergo a 60-day clearance 
process. Under the current schedule, the earliest clearance on the 
survey will be in early December.
    We expect that Abt will send the survey to individual practices 
starting in January 1996. Abt estimates that it will take approximately 
7 months for its staff to mail the survey, to compile the completed 
responses, and to assemble the data into a database.
    As we stated in the July 26, 1995 proposed rule, one of the main 
objectives of the practice expense survey will be to collect indirect 
practice expenses so that these expenses can be related to individual 
CPT procedure codes.

Clinical Practice Expert Panels

    We furnished Abt with a list of all the codes in the Medicare 
physician fee schedule database for which practice expense RVUs are to 
be estimated. As a starting point, Abt used a classification system 
that is a hybrid of the Ambulatory Patient Groups system developed by 
3M and the Berenson-Eggers-Holahan (Urban Institute) system to group 
the codes into similar families of codes. The objective was to sort the 
codes into families that are clinically related and have relatively 
comparable direct costs. This system was reviewed by our medical staff, 
clinical consultants, and the Clinical Practice Expert Panel Technical 
Expert Group, the advisory group for the overall design of the project.
    At a HCFA-sponsored public meeting on August 18, 1995, a draft copy 
of this classification system was provided to various specialty groups. 
These groups were given the opportunity to review the families of codes 
and the Clinical Practice Expert Panel to which the family was assigned 
and to suggest one or more reference codes for each family. Abt 
considered these comments in the development of the final 
classification system.
    At this time, Abt has grouped the codes into 199 families. These 
families have been assigned to 15 Clinical Practice Expert Panels. Each 
Clinical Practice Expert Panel is generally assigned between 6 to 25 
families. A goal is to keep the number of service families per Clinical 
Practice Expert Panel manageable.
    Each Clinical Practice Expert Panel will be composed of up to 15 
members. Clinical Practice Expert Panel membership is not restricted to 
practicing physicians. Clinical Practice Expert Panel members can be 
practice managers and nonphysician clinicians who are knowledgeable 
about physician practice expenses. There will be a primary care 
physician and surgeon on every Clinical Practice Expert Panel. The 
remainder of the Clinical Practice Expert Panel members will be 
composed of the primary providers of the services in the Clinical 
Practice Expert Panel families.
    The Clinical Practice Expert Panel is to reach consensus on the 
detailed direct inputs for one reference procedure per family. The 
following four criteria were established to guide the selection process 
of the reference procedure:
     The service should be commonly performed.
     The service should have a mid-range level of resource 
usage relative to the other codes in the family.
     The service should be a code whose definition or coding 
application has not changed in the last several years.
     The variation across physicians in the way the service is 
performed should be minimal.
    A Clinical Practice Expert Panel Technical Expert Group meeting was 
held on September 7 and 8, 1995. The Clinical Practice Expert Panel 
Technical Expert Group devoted its attention to 

[[Page 63170]]
the following topics: service family composition including criteria; 
reference procedures per family; composition of the Clinical Practice 
Expert Panel; and the process for conducting the Clinical Practice 
Expert Panels, in particular, the worksheets to be completed.

Future Scheduled Activities

    A mock Clinical Practice Expert Panel meeting will be held in 
January 1996. The purpose of the mock Clinical Practice Expert Panel 
meeting is to pre-test the Clinical Practice Expert Panel process and 
worksheets.
    The first series of Clinical Practice Expert Panel meetings will be 
conducted beginning in late January 1996. Before the Clinical Practice 
Expert Panel meetings, each Clinical Practice Expert Panel member (and 
if it so chooses, specialty group) will complete the worksheets on the 
resource costs of reference procedures. Abt will compile these data and 
provide summary information to each Clinical Practice Expert Panel 
member. The Clinical Practice Expert Panel members will use a consensus 
approach to estimate the direct inputs for the reference services.
    The second series of Clinical Practice Expert Panel meetings will 
be conducted in the spring of 1996. The Clinical Practice Expert Panel 
members will use an extrapolation process to estimate the direct costs 
of the other nonreference procedures in the same family.
    Data collection on the practice expense survey will be completed by 
June 1996. Abt will deliver data files by August 1, 1996. We expect to 
award multiple contracts to analyze the data. Abt's report on the 
analysis of the data is due by September 1996.
    We expect to publish the proposed rule in the Federal Register in 
the spring of 1997 and the final rule in the fall of 1997. We will 
implement the resource-based practice expense RVUs beginning January 1, 
1998.
    As we also stated in the July 26, 1995 proposed rule, this 
discussion of our efforts to implement the requirement in the statute 
to develop a resource-based relative value scale is for informational 
purposes and is not a formal proposal. We were not soliciting comments 
on the proposal. While we did receive several comments, we are not 
providing a summary of these comments nor responses to them because it 
was not a formal proposal. We will, however, consider the comments.

C. Case Management in a Fee-for-Service System

    In the July 26, 1995 proposed rule, we solicited information, 
recommendations, and suggestions from the public on how we might apply 
case management to the Medicare fee-for-service system. While the 
comments we received addressed the issues we raised in the proposed 
rule, we are now seeking comments on some additional issues.
    We are currently interested in paying physicians for the management 
of patients with specific diagnoses. We believe that physicians often 
provide extensive case management to patients with certain chronic 
conditions and that these management activities may maintain or improve 
health status. We are interested in learning more about which patients 
would benefit from this case management.
    We are also exploring various managed care options within the 
Medicare fee-for-service system. We are interested in receiving public 
comment about the appropriateness and feasibility of creating periodic 
capitated payments for comprehensive management of medical cases.
    Our intent at this time is to solicit information, recommendations, 
and suggestions from the public on how we might create a capitated 
payment for case management. We are particularly interested in the 
following:
     What types of patients would benefit from extensive case 
management? We are considering developing bundled payments for 
physician services furnished to patients with dementia and one or more 
co-morbidities, diabetes, hypertension, or congestive heart failure. We 
are seeking comments on these and other types of patients who would 
benefit from case management. Any information about the types of 
services that should be included in a bundled payment for care of these 
patients and data on the prevalence of a given medical condition or 
combination of conditions in the Medicare population would be 
appreciated.
     What is an appropriate periodicity for a capitated 
payment? There is precedent in the Medicare program for monthly and 
weekly capitated payments. (Medicare pays on a monthly basis for 
physician services associated with the continuing medical management of 
a maintenance dialysis patient and has a weekly radiation therapy 
management payment.) Do other schedules such as quarterly or 
semiannually make more sense for identifiable groups of patients?

VI. Provisions of the Final Rule

    The provisions of this final rule, for the most part, restate the 
provisions of the July 1995 proposed rule. This section includes the 
following changes from the proposed rule:
     Adds a new statutory basis section in Sec. 405.500 for 
subpart E (``Criteria for Determining Reasonable Charges'') in part 405 
and also revises the authority citation for subpart E.
     Redesignates Sec. 405.552 (``Conditions for payment: 
Anesthesiology services'') as Sec. 415.110.
     Adds a statutory basis section in Sec. 405.2400 for 
subpart X (``Health Clinic and Federally Qualified Health Center 
Services'') of part 405 and also revises the authority citation for 
subpart X.
     Revises Sec. 405.2468 (``Allowable costs'') to expand the 
definition of physician services in rural health clinics and Federally 
qualified health centers to include services of residents as defined in 
Sec. 415.152 (``Definitions'') who meet the requirements in 
Sec. 415.206(b) (concerning physician fee schedule payment for services 
of residents in nonprovider settings).
     Revises Sec. 414.30 (``Conversion factor update'') to 
incorporate a change regarding the downward adjustment to the 
conversion factor required by section 13511 of OBRA 1993.
     Revises Sec. 414.32 (``Determining payments for certain 
physicians' services furnished in facility settings'') to state that 
when a service which is not on the ASC list is performed in an ASC, the 
site-of-service payment differential does not apply.
     Removes the urodynamic evaluation CPT codes 51725, 51726, 
51772, 51785 and CPT codes 13150, 14020, 14060, 15740, 21208, 21440, 
23066, 26645, 28030, 28043, 28092, 28261, 40510, 41805, 42408, 46220, 
46610, 63600, 64420, 65270, and 67921 from the site-of-service payment 
differential list as proposed.
     Revises Sec. 414.46 (``Additional rules for payment of 
anesthesia services'') to state that anesthesia CPT modifier units are 
not allowed for Medicare payment.
     Moves the ``Scope'' paragraph (a) in Sec. 415.100 of 
subpart C (``Part B Carrier Payments for Physician Services to 
Beneficiaries in Providers'') of part 415 in the proposed rule into a 
separate Sec. 415.100. Redesignates the remaining paragraphs in 
proposed rule Sec. 415.100 as Sec. 415.102 (``Conditions for fee 

[[Page 63171]]
schedule payment for physician services to beneficiaries in 
providers'').
     Creates a limited exception to the teaching physician 
presence requirement for certain residency programs in new Sec. 415.174 
(``Exception: Evaluation and management services furnished in certain 
centers'').
    In addition, the final rule differs from the proposed rule in that 
we have revised our proposed payment policy related to hydration 
therapy and chemotherapy as a result of public comments. We will allow 
separate payment for hydration therapy or the infusion of antiemetics 
or other nonchemotherapy drug on the same date of service as 
chemotherapy infusion only when the nonchemotherapy drug is 
administered sequentially rather than at the same time as the 
chemotherapy infusion. However, as we proposed, we will not pay for 
hydration therapy when administered at the same time as chemotherapy 
infusion.

VII. Collection of Information Requirements

    Under the Paperwork Reduction Act of 1995, agencies are required to 
provide 60-day notice in the Federal Register and solicit public 
comment before a collection of information requirement is submitted to 
the Office of Management and Budget (OMB) for review and approval. In 
order to fairly evaluate whether an information collection should be 
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act 
of 1995 requires that we solicit comment on the following issues:
     Whether the information collection is necessary and useful 
to carry out the proper functions of the agency;
     The accuracy of the agency's estimate of the information 
collection burden;
     The quality, utility, and clarity of the information to be 
collected; and
     Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
    Therefore, we are soliciting public comment on each of these issues 
for the information collection requirements discussed below.
    The following sections of this document contain information 
collection requirements as described below:
    The information collection requirements in Sec. 415.60 
(``Allocation of physician compensation costs''), in paragraph (f)(1), 
concern determination and payment of allowable physician compensation 
costs. The requirements also concern the amounts of time the physician 
spends in furnishing physician services to the provider, physician 
services to patients, and services that are not paid under either Part 
A or Part B of Medicare; and assurance that the compensation is 
reasonable in terms of the time devoted to these services. The 
information collection requirements in Sec. 415.60(g) concern 
recordkeeping requirements for allocation of physician compensation 
costs. They also concern time records used to allocate physician 
compensation, information on which the physician compensation 
allocation is based, and retention of this information for a 4-year 
period after the end of each cost reporting period to which the 
allocation applies. Respondents that will provide the information are 
7,091 hospitals, 10,630 freestanding skilled nursing facilities, and 
258 freestanding comprehensive outpatient rehabilitation facilities. 
The respondents will provide the information in Exhibits 2 through 4 on 
Form HCFA-339, ``Provider Cost Report Reimbursement Questionnaire.''
    The information collection requirements in Sec. 415.130 
(``Conditions for payment: Physician pathology services''), paragraph 
(b)(3), concern a written narrative report included in the 
beneficiary's medical record for clinical consultation pathology 
services. The services must be requested by the beneficiary's attending 
physician, relate to a test result that lies outside the clinically 
significant normal or expected range in view of the condition of the 
beneficiary, and require the exercise of medical judgment by the 
consultant physicians. Respondents who will provide the information are 
physicians furnishing clinical consultation pathology services.
    The information collection requirements in Sec. 415.162 
(``Determining payment for physician services furnished to 
beneficiaries in teaching hospitals'') concern the apportionment of 
compensation in the case of teaching hospitals electing cost 
reimbursement for direct medical and surgical services furnished by 
physicians to beneficiaries and supervision of interns and residents 
furnishing care to beneficiaries in a teaching hospital. Respondents 
that will provide the information are 40 cost election teaching 
hospitals. The respondents will provide the information on Supplemental 
Worksheet, Part I and Part II, of Form HCFA-2552-92.
    The information collection requirements in Sec. 415.172 
(``Physician fee schedule payment for services of teaching 
physicians''), paragraph (b), concern documentation in the medical 
records that the teaching physician was present at the time the service 
was furnished, and, in the case of evaluation and management services, 
personal documentation by the teaching physician in the medical records 
of his or her participation in the service. The information collection 
requirements also concern, in the case of surgical, high-risk, or other 
complex procedures, the presence of the teaching physician during all 
critical portions of the procedure and immediate availability to 
furnish services during the entire service or procedure. In the case of 
surgery, the teaching physician's presence is not required during 
opening and closing of the surgical field. In the case of procedures 
performed through an endoscope, the teaching physician must be present 
during the entire viewing. In the case of evaluation and management 
services, the teaching physician must be present during the portion of 
the service that determines the level of service billed. Respondents 
who will provide this information are physicians, residents, or nurses; 
however, in the case of evaluation and management services, the 
teaching physician must personally document in the medical records his 
or her participation in the service.
    The information collection requirements in Sec. 415.174 
(``Exception: Evaluation and management services furnished in certain 
centers''), paragraph (a)(3)(v), concern documentation of the extent of 
the teaching physician's participation in the review and direction of 
the services furnished to each beneficiary in an outpatient department 
of a hospital or another ambulatory care entity. The information 
collection requirements concern the conditions under which carriers 
will make physician fee schedule payment for certain evaluation and 
management services of lower and mid-level complexity furnished by a 
resident without the presence of a teaching physician. Respondents who 
will provide this information are teaching physicians.
    The information collection requirements in Sec. 415.178 
(``Anesthesia services''), paragraph (b), concern 

[[Page 63172]]
documentation of the teaching physician's presence or participation in 
the administration of the anesthesia and a preoperative and 
postoperative visit by the teaching physician. The teaching physician 
must be present during all critical portions of the procedure and 
immediately available to furnish services during the entire service or 
procedure. The teaching physician cannot receive an unreduced fee if he 
or she performs services involving other patients during the period the 
anesthesia resident is furnishing services in a single case. 
Respondents who will provide this information are teaching physicians.
    The information collection requirements in Sec. 415.180 (``Teaching 
setting requirements for the interpretation of diagnostic radiology and 
other diagnostic tests''), paragraph (b), concern documentation that 
the teaching physician personally performed the interpretation or 
reviewed the resident's interpretation with the resident. Physician fee 
schedule payment will be made in those situations. Respondents who will 
provide this information are teaching physicians.
    The table below indicates the annual number of responses for each 
regulation section in this final rule containing information collection 
requirements, the average burden per response in minutes or hours, and 
the total annual burden hours.

                               Estimated Annual Reporting and Recordkeeping Burden                              
----------------------------------------------------------------------------------------------------------------
                                        Annual No. of      Annual          Average burden per      Annual burden
             CFR sections                 responses       frequency             response               hours    
----------------------------------------------------------------------------------------------------------------
415.60...............................          17,979               1  11 hours.................         197,769
415.130..............................           9,273               1  3 minutes................             464
415.162..............................              40               1  2 hours..................              80
415.172..............................       3,200,232               1  1 minute.................          53,337
415.174..............................       1,237,516               1  1 minute.................          20,625
415.178..............................         106,819               1  1 minute.................           1,780
415.180..............................       1,000,107               1  1 minute.................          16,668
----------------------------------------------------------------------------------------------------------------

    The information collection requirements were approved by OMB for 
Secs. 415.60 and 415.162 as Secs. 405.481 and 405.465, respectively, 
under OMB control number 0938-0301 and expire August 31, 1998.
    We have submitted a copy of this final rule with comment period to 
OMB for its review of the information collection requirements in 
Secs. 415.130, 415.172, 415.174, 415.178, and 415.180. These 
requirements are not effective until they have been approved by OMB. A 
document will be published in the Federal Register when OMB approval is 
obtained.
    Organizations and individuals desiring to submit comments on the 
information collection and recordkeeping requirements should send them 
to the Health Care Financing Administration, Office of Financial and 
Human Resources, Management Planning and Analysis Staff, 7500 Security 
Boulevard, Baltimore, Maryland, 21244-1850 and to the Office of 
Management and Budget official whose name appears in the ADDRESSES 
section of this preamble.

VIII. Response to Comments

    Because of the large number of items of correspondence we normally 
receive on Federal Register documents published for comment, we are not 
able to acknowledge or respond to them individually. We will consider 
all comments we receive by the date and time specified in the DATES 
section of this preamble, and, if we proceed with a subsequent 
document, we will respond to the comments in the preamble to that 
document.

IX. Regulatory Impact Analysis

A. Regulatory Flexibility Act

    Consistent with the Regulatory Flexibility Act (5 U.S.C. 601 
through 612), we prepare a regulatory flexibility analysis unless the 
Secretary certifies that a rule will not have a significant economic 
impact on a substantial number of small entities. For purposes of the 
Regulatory Flexibility Act, all physicians are considered to be small 
entities.
    This final rule will not have a significant economic impact on a 
substantial number of small entities. Nevertheless, we are preparing a 
regulatory flexibility analysis because the provisions of this rule are 
expected to have varying effects on the distribution of Medicare 
physician payments across specialties and across geographic areas. We 
anticipate that virtually all of the approximately 500,000 physicians 
who furnish covered services to Medicare beneficiaries will be affected 
by one or more provisions of this rule. In addition, physicians who are 
paid by private insurers for non-Medicare services will be affected to 
the extent that they are paid by private insurers that choose to use 
the RVUs. However, with few exceptions, we expect that the impact on 
individual medical practitioners will be limited.
    In accordance with the provisions of Executive Order 12866, this 
final rule was reviewed by the Office of Management and Budget.

B. Budget-Neutrality Adjustment

    Section 1848(c)(2)(B) of the Act requires that adjustments to RVUs 
in a year may not cause the amount of expenditures for the year to 
differ by more than $20 million from the amount of expenditures that 
would have been made if these adjustments had not been made. We refer 
to this as the budget-neutrality adjustment.
    In past years, we have made this adjustment across all RVUs. This 
year, as we proposed, we are making this adjustment on the conversion 
factors instead of the RVUs. This alternative approach is 
administratively simpler, and it facilitates policy and data analysis 
of RVUs. It does not significantly affect the final payments that are 
made to physicians because any changes to payments will be the result 
of rounding and will be minimal.
    The issues discussed in sections IX.C. through IX.K. will have no 
impact on Medicare program expenditures because the effects of these 
changes have been neutralized in the calculation of the conversion 
factors for 1996.
    We have estimated the net increase in program costs in calendar 
year 1996 

[[Page 63173]]
resulting from the adjustments to RVUs and revisions in payment 
policies to be approximately $140 million. This is a net figure in that 
savings from the reductions in RVUs for some services partially offset 
the cost associated with increases in the RVUs for other services. This 
figure requires a reduction of 0.36 percent in the conversion factors 
for all services to comply with the statutory limitation on increases 
in expenditures. Although a $20 million tolerance is permitted under 
the law, this 0.36 percent reduction to all conversion factors is 
designed to approximate budget neutrality as closely as possible, 
without creating any increase or decrease in expenditures as a result 
of RVU adjustments or revisions in payment policies.

C. Bundled Services

1. Hydration Therapy and Chemotherapy
    Bundling of payment for CPT codes 90780 and 90781, (Therapeutic 
infusions except for chemotherapy) into CPT codes 96410, 96412, and 
96414 (Chemotherapy infusion), when nonchemotherapy drugs are infused 
at the same time as chemotherapy drugs means that in some cases, 
physicians will no longer be paid for CPT codes 90780 and 90781. 
However, our policy will allow physicians to continue to be paid for 
CPT codes 90780 and 90781 when done on the same day as CPT codes 96410, 
96412, and 96414 if the nonchemotherapy drugs are infused sequentially 
rather than contemporaneously with the chemotherapy drugs. We are 
unable to determine from our existing data which portion of billings 
for CPT codes 90780 and 90781 that are currently furnished on the same 
day as CPT codes 96410, 96412, and 96414 are for sequential or 
contemporaneous services. Therefore, at this time, we are unable to 
estimate the impact of this policy. We expect that the impact will be 
minor.
2. Evaluation of Psychiatric Records and Reports and Family Counseling 
Services
    Bundling of payment for CPT codes 90825 and 90887 into the payment 
for other psychiatric codes means that physicians who are currently 
billing for, and receiving separate payment for, these services may no 
longer do so. Because we believe that the services described by CPT 
codes 90825 and 90887 are captured in the prework and postwork of other 
psychiatric services, we will implement this change in policy by 
redistributing the RVUs for CPT codes 90825 and 90887 equally into the 
following psychiatric procedure codes: CPT codes 90801, 90820, 90835, 
90842 through 90847, and 90853 through 90857. We estimate that this 
change will increase the RVUs for the latter codes by approximately 0.7 
percent.
3. Fitting of Spectacles
    We will cease making separate payment under the physician fee 
schedule for fitting of spectacles and low vision systems (CPT codes 
92352 through 92358 and 92371) beginning January 1, 1996. Payment for 
these services is already included in the payment for the prosthetic 
device. We will redistribute the payment currently made for these CPT 
codes across all physician services, which is what would have occurred 
had we not included these fees when the fee schedule was created. 
Because the total payment for spectacle fitting services is relatively 
low (approximately $2.5 million in calendar year 1994) compared to the 
total payment for all physician services, we believe the impact on RVUs 
for all physician services is negligible.
    Virtually all of the providers who have been billing for the 
fitting of spectacles as a professional service have been optometrists. 
Under this revised policy, they are no longer able to bill separately 
for this service. The effect on individual optometrists will depend 
upon the amount of their income derived from billing for spectacle 
fitting services.

D. X-Rays and Electrocardiograms Taken in the Emergency Room

    Under policy issued in 1981, the interpretation of an x-ray or EKG 
furnished to an emergency room patient by a radiologist or 
cardiologist, respectively, ``almost always'' constituted a covered 
Part B service payable by the carrier, regardless of whether the test 
results had been previously used in the diagnosis and treatment of the 
patient by a physician in the emergency room and regardless of when the 
specialist furnished the interpretation. A study completed by the 
Office of Inspector General of the Department of Health and Human 
Services, dated July 1993, recommended that we change this policy to 
indicate that the second interpretation is generally a quality control 
service to be taken into account by intermediaries in determining 
hospital reasonable costs. Further, we understand that some carriers 
are currently paying both the emergency room physician and the 
radiologist or cardiologist for the interpretation of the same x-ray or 
EKG.
    We will pay for only one interpretation of an x-ray or EKG 
furnished to an emergency room patient except under unusual 
circumstances. In situations in which both the emergency room physician 
and the radiologist or cardiologist bill for the interpretation, we 
will instruct the carriers to pay for the interpretation used in the 
diagnosis and treatment of the patient. We will consider the second 
interpretation to be a quality control service. Under this policy, we 
will reduce the incidence of carriers' paying twice for an 
interpretation, but we have no estimate of the number of duplicate 
payments that will be eliminated. We believe that the specialists will 
be affected primarily. If hospitals want to ensure that their 
specialists are paid for these interpretations, they can make 
arrangements to preclude the emergency room physician from billing for 
the same service.

E. Extension of Site-of-Service Payment Differential to Services in 
Ambulatory Surgical Centers

    We are extending the site-of-service payment limit to office-based 
services if those services are performed in an ambulatory surgical 
center, effective for services furnished beginning January 1, 1996. We 
are adding 126 procedure codes to the list. Were it not for budget-
neutrality adjustments, we estimate that these additions would result 
in a $24.6 million reduction in 1996 Medicare payments.

F. Services of Teaching Physicians

    This change removes the single attending physician criteria for 
hospital patients. It allows and promotes supervision of the care by 
physician group practices. We believe allowing for more than one 
teaching physician per beneficiary inpatient stay will result in 
negligible additional cost, but the lack of any data prevents us from 
quantifying the effects of this change. In addition, this rule will 
incorporate longstanding Medicare coverage and payment policy regarding 
the circumstances under which the services of residents are payable as 
physician services.
    We will require the physical presence of a teaching physician 
during the key portion of the service in order for the teaching 
physician to receive Part B physician fee schedule payment for the 
service. Details regarding the physical 

[[Page 63174]]
presence of a teaching physician during different types of services and 
procedures are discussed in section II.F. of this preamble. Although we 
lack specific data, we believe that the provisions of this part of the 
final rule have no budgetary effect because we believe that the 
potential costs are offset by the potential savings.

G. Unspecified Physical and Occupational Therapy Services (HCFA Common 
Procedure Coding System Codes M0005 Through M0008 and H5300)

    We are eliminating HCPCS codes M0005 through M0008 and H5300 and 
redistributing the RVUs to codes in the physical medicine and 
rehabilitation section of the CPT (codes 97010 through 97799). The 
codes we are deleting are general codes that do not describe adequately 
the service being furnished. Their use precludes effective review 
necessary to ensure that the services being paid are covered by 
Medicare. In 1995, the American Medical Association revised the CPT 
codes in the Physical Medicine and Rehabilitation section of the CPT to 
better reflect the provision of physical and occupational therapy 
services.
    We believe that each unit of service currently billed under the 
codes we are deleting will be billed under a CPT or HCPCS code and that 
the total amount of Medicare payment for physical medicine services 
will not change significantly as a result of the elimination of these 
codes. Therefore, we believe there will be no additional costs or 
savings as a result of this change in billing. Since the original codes 
were not descriptive, we had no way of comparing payments. However, we 
believe that we are eliminating potential manipulation of payment and 
are improving the data collected by requiring practitioners to use the 
more specific codes when billing for these services.

H. Transportation in Connection With Furnishing Diagnostic Tests

    Under the policy adopted in this final rule, we are restricting the 
discretion of carriers to make separate payments for the transportation 
of diagnostic testing equipment. Effective for services furnished 
beginning January 1, 1996, the general policy is that separate 
transportation payments will be made only in connection with the 
following services:
     X-ray and standard EKG services furnished by an approved 
portable x-ray supplier; and
     Standard EKG services furnished by an independent 
physiological laboratory under special conditions.
    For all other types of diagnostic tests payable under the physician 
fee schedule, travel expenses are considered to be ``bundled'' into the 
payment for the procedure, and Medicare carriers will pay for the 
transportation of equipment only on a ``by report'' basis under CPT 
code 99082 if a physician submits documentation to justify the ``very 
unusual'' travel as set forth in section 15026 of the Medicare 
Carriers' Manual.
    We are unable to assess the impact of this new national policy 
because carriers have had such varying payment policies on this issue. 
We had thought that this might be a significant policy change since we 
had received many inquiries on the subject in recent years; however, we 
received fewer than 10 comments on this policy as set forth in the 
proposed rule, and we now conclude that the national impact of the new 
policy will not be significant. There will likely be an impact on 
payments to independent physiological laboratories in some areas in 
which transportation payments were made before January 1, but it is not 
possible to assess these reductions from the comments received.

I. Maxillofacial Prosthetic Services

    We are establishing national RVUs for these services and, 
therefore, are discontinuing pricing by individual carriers, effective 
January 1, 1996. We estimate that total expenditures for CPT codes 
21079 through 21087 and codes G0020 and G0021 (replaced by CPT codes 
21076 and 20177 in 1996), based on the RVUs will be approximately $2.4 
million in calendar year 1996. The 1994 Medicare expenditures for these 
codes under the carrier pricing methodology were approximately $1.5 
million which, if updated for 1995, would be approximately $1.6 
million. Thus, we estimate an increase of approximately $800,000 for 
these codes. However, total expenditures for physician services will 
not increase because we are implementing this change in a budget-
neutral manner in accordance with section 1848(c)(2)(B)(ii) of the Act.
    These services are furnished most frequently by oral surgeons 
(dentists only) and by maxillofacial surgeons. Because we estimate that 
the total expenditures for these services will increase slightly, we 
expect that, in general, the physicians who perform and bill for these 
procedures will realize an increase in payment. However, in some areas, 
the payment amounts based on national RVUs may be lower than those 
calculated by the local carrier.

J. Coverage of Mammography Services

    We are expanding the definition of ``diagnostic'' mammography to 
include as candidates for this service asymptomatic men or women who 
have a personal history of breast cancer or a personal history of 
biopsy-proven benign breast disease. We do not believe this change will 
result in a significant increase in the total number of mammography 
services because information from carriers indicates that most 
asymptomatic patients in these categories are already receiving 
diagnostic mammography services.

K. Two Anesthesia Providers Involved in One Procedure

    We will apply the medical direction payment policy to the single 
procedure involving both the physician and the CRNA. We will not 
implement this policy until January 1, 1998, at which time the proposal 
will be budget-neutral. In 1998, the allowance for the medically-
directed CRNA service and the medical-direction service of the 
anesthesiologist will be equivalent to 50 percent of the allowance 
recognized for the service personally performed by the anesthesiologist 
alone. Thus, payment for both services will be no different than what 
would be allowed for the anesthesia service personally performed by the 
anesthesiologist.
    Although this proposal is budget-neutral, total payments to 
anesthesiologists will decrease slightly and payments to the CRNAs' 
employers will increase slightly. We cannot quantify the amount of the 
losses to the anesthesiologists or the gains to the CRNAs' employers. 
However, anesthesiologists can lessen their losses by actually 
personally performing as many of these services as possible and 
receiving the same allowance they would have in the absence of this new 
policy.

L. Rural Hospital Impact Statement

    Section 1102(b) of the Act requires the Secretary to prepare a 
regulatory impact analysis if a rule 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 
Regulatory Flexibility Act. For purposes of section 

[[Page 63175]]
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.
    This final rule will have little direct effect on payments to rural 
hospitals since this rule will change only payments made to physicians 
and certain other practitioners under Part B of the Medicare program 
and will not change payments to hospitals under Part A. We do not 
believe the changes will have a major, indirect effect on rural 
hospitals.
    Therefore, we are not preparing an analysis for section 1102(b) of 
the Act since we have determined, and the Secretary certifies, that 
this rule will not have a significant impact on the operations of a 
substantial number of small rural hospitals.

List of Subjects

42 CFR Part 400

    Grant programs--health, Health facilities, Health maintenance 
organizations (HMO), Medicaid, Medicare, Reporting and recordkeeping 
requirements.

42 CFR Part 405

    Administrative practice and procedure, Health facilities, Health 
professions, Kidney diseases, Medicare, Reporting and recordkeeping 
requirements, Rural areas, X-rays.

42 CFR Part 410

    Health facilities, Health professions, Kidney diseases, 
Laboratories, Medicare, Rural areas, X-rays.

42 CFR Part 411

    Kidney diseases, Medicare, Reporting and recordkeeping 
requirements.

42 CFR Part 412

    Administrative practice and procedure, Health facilities, Medicare, 
Puerto Rico, Reporting and recordkeeping requirements.

42 CFR Part 413

    Health facilities, Kidney diseases, Medicare, Puerto Rico, 
Reporting and recordkeeping requirements.

42 CFR Part 414

    Administrative practice and procedure, Health facilities, Health 
professions, Kidney diseases, Medicare, Reporting and recordkeeping 
requirements, Rural areas, X-rays.

42 CFR Part 415

    Health facilities, Health professions, Medicare, Reporting and 
recordkeeping requirements.

42 CFR Part 417

    Administrative practice and procedure, Grant programs--health, 
Health care, Health facilities, Health insurance, Health maintenance 
organizations (HMO), Loan programs--health, Medicare, Reporting and 
recordkeeping requirements.

42 CFR Part 489

    Health facilities, Medicare, Reporting and recordkeeping 
requirements.

    Under the authority of 42 U.S.C. 1302 and 1395hh, 42 CFR chapter IV 
is amended as set forth below:

PART 400--INTRODUCTION; DEFINITIONS

    A. Part 400 is amended as set forth below:
    1. The authority citation for part 400 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh) and 44 U.S.C. Chapter 35.

    2. In Sec. 400.202, the introductory text is republished and the 
definition of GME is added in alphabetical order to read as follows:


Sec. 400.202  Definitions specific to Medicare.

    As used in connection with the Medicare program, unless the context 
indicates otherwise--
* * * * *
    GME stands for graduate medical education.
* * * * *

PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED

    B. Part 405 is amended as set forth below:

Subpart D--[Removed and Reserved]

    1. Subpart D, consisting of Secs. 405.465 through 405.482, is 
removed and reserved.
    2. Subpart E is amended as set forth below:
    a. The authority citation for subpart E is revised to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

    b. The heading for subpart E is revised to read as follows:

Subpart E--Criteria for Determining Reasonable Charges

    c. A new Sec. 405.500 is added to read as follows:


Sec. 405.500  Basis.

    Subpart E is based on the provisions of the following sections of 
the Act: Section 1814(b) provides for Part A payment on the basis of 
the lesser of a provider's reasonable costs or customary charges. 
Section 1832 establishes the scope of benefits provided under the Part 
B supplementary medical insurance program. Section 1833(a) sets forth 
the amounts of payment for supplementary medical insurance services on 
the basis of the lesser of a provider's reasonable costs or customary 
charges. Section 1834(a) specifies how payments are made for the 
purchase or rental of new and used durable medical equipment for 
Medicare beneficiaries. Section 1834(b) provides for payment for 
radiologist services on a fee schedule basis. Section 1834(c) provides 
for payments and standards for screening mammography. Section 1842(b) 
sets forth the provisions for a carrier to enter into a contract with 
the Secretary and to make determinations with respect to Part B claims. 
Section 1842(h) sets forth the requirements for a physician or supplier 
to voluntarily enter into an agreement with the Secretary to become a 
participating physician or supplier. Section 1842(i) sets forth the 
provisions for the payment of Part B claims. Section 1848 establishes a 
fee schedule for payment of physician services. Section 1861(b) sets 
forth the inpatient hospital services covered by the Medicare program. 
Section 1861(s) sets forth medical and other health services covered by 
the Medicare program. Section 1861(v) sets forth the general authority 
under which HCFA may establish limits on provider costs recognized as 
reasonable in determining Medicare program payments. Section 1861(aa) 
sets forth the rural health clinic services and Federally qualified 
health center services covered by the Medicare program. Section 
1861(jj) defines the term ``covered osteoporosis drug.'' Section 
1862(a)(14) lists services that are excluded from coverage. Section 
1866(a) specifies the terms for provider agreements. Section 1881 
authorizes special rules for the coverage of and payment for services 
furnished to patients with end-stage renal disease. Section 1886 sets 
forth the requirements for payment to hospitals for inpatient hospital 
services. Section 1887 sets forth 

[[Page 63176]]
requirements for payment of provider-based physicians and payment under 
certain percentage arrangements. Section 1889 provides for Medicare and 
Medigap information by telephone.


Sec. 405.501  [Amended]

    d. In Sec. 405.501, the following changes are made:
    i. Paragraphs (c) and (d) are removed, and paragraphs (e) and (f) 
are redesignated as paragraphs (c) and (d), respectively.
    ii. In newly redesignated paragraph (c), the phrase ``Secs. 405.480 
through 405.482 and Secs. 405.550 through 405.557'' is removed, and the 
phrase ``Secs. 415.55 through 415.70 and Secs. 415.100 through 415.130 
of this chapter'' is added in its place.
    iii. In newly redesignated paragraph (d), the words ``For services 
furnished on or after January 1, 1989, payment'' are removed, and the 
word ``Payment'' is added in their place.


Secs. 405.520-405.525  [Removed]

    e. Sections 405.520 through 405.525 are removed.

Subpart F--[Removed and Reserved]

    3. Subpart F, consisting of Secs. 405.550 through 405.580, is 
removed and reserved.

Subpart X--Rural Health Clinic and Federally Qualified Health 
Center Services

    4. Subpart X is amended as set forth below:
    a. The authority citation for subpart X is revised to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

    b. A new Sec. 405.2400 is added to read as follows:


Sec. 405.2400  Basis.

    Subpart X is based on the provisions of the following sections of 
the Act: Section 1833 sets forth the amounts of payment for 
supplementary medical insurance services. Section 1861(aa) sets forth 
the rural health clinic services and Federally qualified health center 
services covered by the Medicare program.
    c. In Sec. 405.2401, paragraph (b), the introductory text is 
republished, and the definition for physician is revised to read as 
follows:


Sec. 405.2401  Scope and definitions.

* * * * *
    (b) Definitions. As used in this subpart, unless the context 
indicates otherwise:
* * * * *
    Physician means the following:
    (1) A doctor of medicine or osteopathy legally authorized to 
practice medicine and surgery by the State in which the function is 
performed.
    (2) Within limitations as to the specific services furnished, a 
doctor of dentistry or dental or oral surgery, a doctor of optometry, a 
doctor of podiatry or surgical chiropody or a chiropractor. (See 
section 1861(r) of the Act for specific limitations.)
    (3) A resident (including residents as defined in Sec. 415.152 of 
this chapter who meet the requirements in Sec. 415.206(b) of this 
chapter for payment under the physician fee schedule).
* * * * *
    d. In Sec. 405.2468, the introductory text of paragraph (b) is 
republished, and paragraph (b)(1) is revised to read as follows:


Sec. 405.2468  Allowable costs.

* * * * *
    (b) Typical rural health clinic and Federally qualified health 
center costs. The following types and items of cost are included in 
allowable costs to the extent that they are covered and reasonable:
    (1) Compensation for the services of physicians, (including 
residents as defined in Sec. 415.152 of this chapter who meet the 
requirements in Sec. 415.206(b) of this chapter for payment under the 
physician fee schedule), physician assistants, nurse practitioners, 
nurse midwives, specialized nurse practitioners, visiting nurses, 
qualified clinical psychologists, and clinical social workers employed 
by the clinic or center.
* * * * *

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS

    C. Part 410 is amended as set forth below:
    1. The authority citation for part 410 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

    2. Section 410.34 is amended by republishing the introductory text 
to paragraph (a) and revising paragraphs (a)(1), (a)(2), and (d) to 
read as follows:


Sec. 410.34  Mammography services: Conditions for and limitations on 
coverage.

    (a) Definitions. As used in this section, the following definitions 
apply:
    (1) Diagnostic mammography means a radiologic procedure furnished 
to a man or woman with signs or symptoms of breast disease, or a 
personal history of breast cancer, or a personal history of biopsy-
proven benign breast disease, and includes a physician's interpretation 
of the results of the procedure.
    (2) Screening mammography means a radiologic procedure furnished to 
a woman without signs or symptoms of breast disease, for the purpose of 
early detection of breast cancer, and includes a physician's 
interpretation of the results of the procedure.
* * * * *
    (d) Limitations on coverage of screening mammography services. The 
following limitations apply to coverage of screening mammography 
services as described in paragraph (a)(2) of this section:
    (1) The service must be, at a minimum a two-view exposure (that is, 
a cranio-caudal and a medial lateral oblique view) of each breast.
    (2) Payment may not be made for screening mammography performed on 
a woman under age 35.
    (3) Payment may be made for only 1 screening mammography performed 
on a woman over age 34, but under age 40.
    (4) For a woman over age 39, but under age 50, the following 
limitations apply:
    (i) Payment may be made for a screening mammography performed after 
at least 11 months have passed following the month in which the last 
screening mammography was performed if the woman has--
    (A) A personal history of breast cancer;
    (B) A personal history of biopsy-proven benign breast disease;
    (C) A mother, sister, or daughter who has had breast cancer; or
    (D) Not given birth before age 30.
    (ii) If the woman does not meet the conditions described in 
paragraph (d)(4)(i) of this section, payment may be made for a 
screening mammography performed after at least 23 months have passed 
following the month in which the last screening mammography was 
performed.
    (5) For a woman over age 49, but under age 65, payment may be made 
for a screening mammography performed after at least 11 months have 
passed 

[[Page 63177]]
following the month in which the last screening mammography was 
performed.
    (6) For a woman over age 64, payment may be made for a screening 
mammography performed after at least 23 months have passed following 
the month in which the last screening mammography was performed.

PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES

    D. Part 414 is amended as set forth below:
    1. The authority citation for part 414 continues to read as 
follows:

    Authority: Secs. 1102, 1871, and 1881(b)(1) of the Social 
Security Act (42 U.S.C. 1302, 1395hh, and 1395rr(b)(1)).

    2. In Sec. 414.2, the following definitions are added 
alphabetically:


Sec. 414.2  Definitions.

    AA stands for anesthesiologist assistant.
* * * * *
    CRNA stands for certified registered nurse anesthetist.
* * * * *
    3. In Sec. 414.28, the introductory text is republished, and 
paragraph (b) is revised to read as follows:


Sec. 414.28  Conversion factors.

    HCFA establishes CFs in accordance with section 1848(d) of the Act.
* * * * *
    (b) Subsequent CFs. For calendar years 1993 through 1995, the CF 
for each year is equal to the CF for the previous year, adjusted in 
accordance with Sec. 414.30. Beginning January 1, 1996, the CF for each 
calendar year may be further adjusted so that adjustments to the fee 
schedule in accordance with section 1848(c)(2)(B)(ii) of the Act do not 
cause total expenditures under the fee schedule to differ by more than 
$20 million from the amount that would have been spent if these 
adjustments had not been made.
    4. In Sec. 414.30, the introductory text to the section and the 
introductory text to paragraph (b) are republished, paragraph (b)(2) is 
revised, and paragraph (c) is added to read as follows:


Sec. 414.30  Conversion factor update.

    Unless Congress acts in accordance with section 1848(d)(3) of the 
Act--
* * * * *
    (b) Downward adjustment. The downward adjustment may not exceed the 
following:
* * * * *
    (2) For CY 1994, 2.5 percentage points.
* * * * *
    (c) For CYs 1995 and thereafter, 5 percentage points.
    5. In Sec. 414.32, the introductory text to paragraph (d) is 
republished and paragraph (d)(2) is revised to read as follows:


Sec. 414.32  Determining payments for certain physician services 
furnished in facility settings.

* * * * *
    (d) Services excluded from the reduction. The reduction established 
under this section does not apply to the following:
* * * * *
    (2) Surgical services not on the ambulatory surgical center covered 
list of procedures published under Sec. 416.65(c) of this chapter when 
furnished in an ambulatory surgical center.
* * * * *


Sec. 414.46  [Amended]

    6. In Sec. 414.46, the following changes are made:
    a. The word ``procedure'' in paragraph (g) is removed, and the word 
``service'' is added in its place. The word ``procedures'' in 
paragraphs (a)(1), (e) and (g) is removed, and the word ``services'' is 
added in its place.
    b. Paragraphs (b), (c), and (d) are revised to read as follows:


Sec. 414.46  Additional rules for payment of anesthesia services.

* * * * *
    (b) Determination of payment amount--Basic rule. For anesthesia 
services performed, medically directed, or medically supervised by a 
physician, HCFA pays the lesser of the actual charge or the anesthesia 
fee schedule amount.
    (1) The physician fee schedule amount for an anesthesia service is 
based on the product of the allowable base and time units and an 
anesthesia-specific CF.
    (2) The allowable base units are determined by the uniform relative 
value guide based on the 1988 American Society of Anesthesiologists' 
Relative Value Guide except that the number of base units recognized 
for anesthesia services furnished during cataract or iridectomy surgery 
is four units. The uniform base units are identified in program 
operating instructions.
    (3) Modifier units are not allowed. Modifier units include 
additional units charged by a physician or a CRNA for patient health 
status, risk, age, or unusual circumstances.
    (c) Physician personally performs the anesthesia procedure.
    (1) HCFA considers an anesthesia service to be personally performed 
under any of the following circumstances:
    (i) The physician performs the entire anesthesia service alone.
    (ii) The physician establishes an attending physician relationship 
in one or two concurrent cases involving an intern or resident and the 
service was furnished before January 1, 1994.
    (iii) The physician establishes an attending physician relationship 
in one case involving an intern or resident and the service was 
furnished on or after January 1, 1994 but prior to January 1, 1996. For 
services on or after January 1, 1996, the physician must be the 
teaching physician as defined in Secs. 415.170 through 415.184 of this 
chapter.
    (iv) The physician and the CRNA or AA are involved in a single case 
and the services of each are found to be medically necessary.
    (v) The physician is continuously involved in a single case 
involving a student nurse anesthetist.
    (vi) The physician is continuously involved in a single case 
involving a CRNA or AA and the service was furnished prior to January 
1, 1998.
    (2) HCFA determines the fee schedule amount for an anesthesia 
service personally performed by a physician on the basis of an 
anesthesia-specific fee schedule CF and unreduced base units and 
anesthesia time units. One anesthesia time unit is equivalent to 15 
minutes of anesthesia time, and fractions of a 15-minute period are 
recognized as fractions of an anesthesia time unit.
    (d) Anesthesia services medically directed by a physician. (1) HCFA 
considers an anesthesia service to be medically directed by a physician 
if:
    (i) The physician performs the activities described in Sec. 415.110 
of this chapter.
    (ii) The physician directs qualified individuals involved in two, 
three, or four concurrent cases.
    (iii) Medical direction can occur for a single case furnished on or 
after January 1, 1998 if the physician performs the activities 
described in Sec. 415.110 of this 

[[Page 63178]]
chapter and medically directs a single CRNA or AA.
    (2) The rules for medical direction differ for certain time periods 
depending on the nature of the qualified individual who is directed by 
the physician. If more than two procedures are directed on or after 
January 1, 1994, the qualified individuals could be AAs, CRNAs, 
interns, or residents. The medical direction rules apply to student 
nurse anesthetists only if the physician directs two concurrent cases, 
each of which involves a student nurse anesthetist or the physician 
directs one case involving a student nurse anesthetist and the other 
involving a CRNA, AA, intern, or resident.
    (3) Payment for medical direction is based on a specific percentage 
of the payment allowance recognized for the anesthesia service 
personally performed by a physician alone. The following percentages 
apply for the years specified:
    (i) CY 1994--60 percent of the payment allowance for personally 
performed procedures.
    (ii) CY 1995--57.5 percent of the payment allowance for personally 
performed services.
    (iii) CY 1996--55 percent of the payment allowance for personally 
performed services.
    (iv) CY 1997--52.5 percent of the payment allowance for personally 
performed services.
    (v) CY 1998 and thereafter--50 percent of the payment allowance for 
personally performed services.
* * * * *
    7. Section 414.60 is revised to read as follows:


Sec. 414.60  Payment for the services of CRNAs.

    (a) Basis for payment. Beginning with CY 1994--
    (1) The allowance for an anesthesia service furnished by a 
medically directed CRNA is based on a fixed percentage of the allowance 
recognized for the anesthesia service personally performed by the 
physician alone, as specified in Sec. 414.46(d)(3); and
    (2) The CF for an anesthesia service furnished by a CRNA not 
directed by a physician may not exceed the CF for a service personally 
performed by a physician.
    (b) To whom payment may be made. Payment for an anesthesia service 
furnished by a CRNA may be made to the CRNA or to any individual or 
entity (such as a hospital, rural primary care hospital, physician, 
group practice, or ambulatory surgical center) with which the CRNA has 
an employment or contract relationship that provides for payment to be 
made to the individual or entity.
    (c) Condition for payment. Payment for the services of a CRNA may 
be made only on an assignment related basis, and any assignment 
accepted by a CRNA is binding on any other person presenting a claim or 
request for payment for the service.

Subpart H--[Removed and Reserved]

    8. Subpart H, consisting of Secs. 414.450 through 414.453, is 
removed and reserved.
    E. A new part 415 is added to read as follows:

PART 415--SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS, 
SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN 
CERTAIN SETTINGS

Subpart A--General Provisions

Sec.
415.1  Basis and scope.

Subpart B--Fiscal Intermediary Payments to Providers for Physician 
Services

415.50  Scope.
415.55  General payment rules.
415.60  Allocation of physician compensation costs.
415.70  Limits on compensation for physician services in providers.

Subpart C--Part B Carrier Payments for Physician Services to 
Beneficiaries in Providers

415.100  Scope.
415.102  Conditions for fee schedule payment for physician services 
to beneficiaries in providers.
415.105  Amounts of payment for physician services to beneficiaries 
in providers.
415.110  Conditions for payment: Anesthesiology services.
415.120  Conditions for payment: Radiology services.
415.130  Conditions for payment: Physician pathology services.

Subpart D--Physician Services in Teaching Settings

415.150  Scope.
415.152  Definitions.
415.160  Election of reasonable cost payment for direct medical and 
surgical services of physicians in teaching hospitals: General 
provisions.
415.162  Determining payment for physician services furnished to 
beneficiaries in teaching hospitals.
415.164  Payment to a fund.
415.170  Conditions for payment on a fee schedule basis for 
physician services in a teaching setting.
415.172  Physician fee schedule payment for services of teaching 
physicians.
415.174  Exception: Evaluation and management services furnished in 
certain centers.
415.176  Renal dialysis services.
415.178  Anesthesia services.
415.180  Teaching setting requirements for the interpretation of 
diagnostic radiology and other diagnostic tests.
415.184  Psychiatric services.
415.190  Conditions of payment: Assistants at surgery in teaching 
hospitals.

Subpart E--Services of Residents

415.200  Services of residents in approved GME programs.
415.202  Services of residents not in approved GME programs.
415.204  Services of residents in skilled nursing facilities and 
home health agencies.
415.206  Services of residents in nonprovider settings.
415.208  Services of moonlighting residents.

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

Subpart A--General Provisions


Sec. 415.1  Basis and scope.

    (a) Basis. This part is based on the provisions of the following 
sections of the Act: Section 1848 establishes a fee schedule for 
payment for physician services. Section 1861(q) specifies what is 
included in the term ``physician services'' covered under Medicare. 
Section 1862(a)(14) sets forth the exclusion of nonphysician services 
furnished to hospital patients under Part B of Medicare. Section 
1886(d)(5)(B) provides for a payment adjustment under the prospective 
payment system for the operating costs of inpatient hospital services 
furnished to Medicare beneficiaries in cost reporting periods beginning 
on or after October 1, 1983, to account for the indirect costs of 
medical education. Section 1886(h) establishes the methodology for 
Medicare payment of the cost of direct GME activities.
    (b) Scope. This part sets forth rules for fiscal intermediary 
payments to providers for physician services, Part B carrier payments 
for physician services to beneficiaries in providers, physician 
services in teaching settings, and services of residents.

Subpart B--Fiscal Intermediary Payments to Providers for Physician 
Services


Sec. 415.50  Scope.

    This subpart sets forth rules for payment by fiscal intermediaries 
to providers for services furnished by 

[[Page 63179]]
physicians. Payment for covered services is made either under the 
prospective payment system (PPS) to PPS-participating providers in 
accordance with part 412 of this chapter or under the reasonable cost 
method to non-PPS participating providers in accordance with part 413 
of this chapter.


Sec. 415.55  General payment rules.

    (a) Allowable costs. Except as specified otherwise in Secs. 413.102 
of this chapter (concerning compensation of owners), 415.60 (concerning 
allocation of physician compensation costs), and 415.162 (concerning 
payment for physician services furnished to beneficiaries in teaching 
hospitals), costs a provider incurs for services of physicians are 
allowable only if the following conditions are met:
    (1) The services do not meet the conditions in Sec. 415.102(a) 
regarding fee schedule payment for services of physicians to a 
beneficiary in a provider.
    (2) The services include a surgeon's supervision of services of a 
qualified anesthetist, but do not include physician availability 
services, except for reasonable availability services furnished for 
emergency rooms and the services of standby surgical team physicians.
    (3) The provider has incurred a cost for salary or other 
compensation it furnished the physician for the services.
    (4) The costs incurred by the provider for the services meet the 
requirements in Sec. 413.9 of this chapter regarding costs related to 
patient care.
    (5) The costs do not include supervision of interns and residents 
unless the provider elects reasonable cost payment as specified in 
Sec. 415.160, or any other costs incurred in connection with an 
approved GME program that are payable under Sec. 413.86 of this 
chapter.
    (b) Allocation of allowable costs. The provider must follow the 
rules in Sec. 415.60 regarding allocation of physician compensation 
costs to determine its costs of services.
    (c) Limits on allowable costs. The intermediary must apply the 
limits on compensation set forth in Sec. 415.70 to determine its 
payments to a provider for the costs of services.


Sec. 415.60  Allocation of physician compensation costs.

    (a) Definition. For purposes of this subpart, physician 
compensation costs means monetary payments, fringe benefits, deferred 
compensation, and any other items of value (excluding office space or 
billing and collection services) that a provider or other organization 
furnishes a physician in return for the physician services. Other 
organizations are entities related to the provider within the meaning 
of Sec. 413.17 of this chapter or entities that furnish services for 
the provider under arrangements within the meaning of the Act.
    (b) General rule. Except as provided in paragraph (d) of this 
section, each provider that incurs physician compensation costs must 
allocate those costs, in proportion to the percentage of total time 
that is spent in furnishing each category of services, among--
    (1) Physician services to the provider (as described in 
Sec. 415.55);
    (2) Physician services to patients (as described in Sec. 415.102); 
and
    (3) Activities of the physician, such as funded research, that are 
not paid under either Part A or Part B of Medicare.
    (c) Allowable physician compensation costs. Only costs allocated to 
payable physician services to the provider (as described in 
Sec. 415.55) are allowable costs to the provider under this subpart.
    (d) Allocation of all compensation to services to the provider. 
Generally, the total physician compensation received by a physician is 
allocated among all services furnished by the physician, unless--
    (1) The provider certifies that the compensation is attributable 
solely to the physician services furnished to the provider; and
    (2) The physician bills all patients for the physician services he 
or she furnishes to them and personally receives the payment from or on 
behalf of the patients. If returned directly or indirectly to the 
provider or an organization related to the provider within the meaning 
of Sec. 413.17 of this chapter, these payments are not compensation for 
physician services furnished to the provider.
    (e) Assumed allocation of all compensation to beneficiary services. 
If the provider and physician agree to accept the assumed allocation of 
all the physician services to direct services to beneficiaries as 
described under Sec. 415.102(a), HCFA does not require a written 
allocation agreement between the physician and the provider.
    (f) Determination and payment of allowable physician compensation 
costs. (1) Except as provided under paragraph (e) of this section, the 
intermediary pays the provider for these costs only if--
    (i) The provider submits to the intermediary a written allocation 
agreement between the provider and the physician that specifies the 
respective amounts of time the physician spends in furnishing physician 
services to the provider, physician services to patients, and services 
that are not payable under either Part A or Part B of Medicare; and
    (ii) The compensation is reasonable in terms of the time devoted to 
these services.
    (2) In the absence of a written allocation agreement, the 
intermediary assumes, for purposes of determining reasonable costs of 
the provider, that 100 percent of the physician compensation cost is 
allocated to services to beneficiaries as specified in paragraph (b)(2) 
of this section.
    (g) Recordkeeping requirements. Except for services furnished in 
accordance with the assumed allocation under paragraph (e) of this 
section, each provider that claims payment for services of physicians 
under this subpart must meet all of the following requirements:
    (1) Maintain the time records or other information it used to 
allocate physician compensation in a form that permits the information 
to be validated by the intermediary or the carrier.
    (2) Report the information on which the physician compensation 
allocation is based to the intermediary or the carrier on an annual 
basis and promptly notify the intermediary or carrier of any revisions 
to the compensation allocation.
    (3) Retain each physician compensation allocation, and the 
information on which it is based, for at least 4 years after the end of 
each cost reporting period to which the allocation applies.


Sec. 415.70  Limits on compensation for physician services in 
providers.

    (a) Principle and scope. (1) Except as provided in paragraphs 
(a)(2) and (a)(3) of this section, HCFA establishes reasonable 
compensation equivalency limits on the amount of compensation paid to 
physicians by providers. These limits are applied to a provider's costs 
incurred in compensating physicians for services to the provider, as 
described in Sec. 415.55(a).
    (2) Limits established under this section do not apply to costs of 
physician compensation attributable to furnishing inpatient hospital 
services that are paid for under the prospective 

[[Page 63180]]
payment system implemented under part 412 of this chapter or to costs 
of physician compensation attributable to approved GME programs that 
are payable under Sec. 413.86 of this chapter.
    (3) Compensation that a physician receives for activities that may 
not be paid for under either Part A or Part B of Medicare is not 
considered in applying these limits.
    (b) Methodology for establishing limits. HCFA establishes a 
methodology for determining annual reasonable compensation equivalency 
limits and, to the extent possible, considers average physician incomes 
by specialty and type of location using the best available data.
    (c) Application of limits. If the level of compensation exceeds the 
limits established under paragraph (b) of this section, Medicare 
payment is based on the level established by the limits.
    (d) Adjustment of the limits. The intermediary may adjust limits 
established under paragraph (b) of this section to account for costs 
incurred by the physician or the provider related to malpractice 
insurance, professional memberships, and continuing medical education.
    (1) For the costs of membership in professional societies and 
continuing medical education, the intermediary may adjust the limit by 
the lesser of--
    (i) The actual cost incurred by the provider or the physician for 
these activities; or
    (ii) Five percent of the appropriate limit.
    (2) For the cost of malpractice expenses incurred by either the 
provider or the physician, the intermediary may adjust the reasonable 
compensation equivalency limit by the cost of the malpractice insurance 
expense related to the physician service furnished to patients in 
providers.
    (e) Exception to limits. An intermediary may grant a provider an 
exception to the limits established under paragraph (b) of this section 
only if the provider can demonstrate to the intermediary that it is 
unable to recruit or maintain an adequate number of physicians at a 
compensation level within these limits.
    (f) Notification of changes in methodologies and payment limits. 
(1) Before the start of a cost reporting period to which limits 
established under this section will be applied, HCFA publishes a notice 
in the Federal Register that sets forth the amount of the limits and 
explains how it calculated the limits.
    (2) If HCFA proposes to revise the methodology for establishing 
payment limits under this section, HCFA publishes a notice, with 
opportunity for public comment, in the Federal Register. The notice 
explains the proposed basis and methodology for setting limits, 
specifies the limits that would result, and states the date of 
implementation of the limits.
    (3) If HCFA updates limits by applying the most recent economic 
index data without revising the limit methodology, HCFA publishes the 
revised limits in a notice in the Federal Register without prior 
publication of a proposal or public comment period.

Subpart C--Part B Carrier Payments for Physician Services to 
Beneficiaries in Providers


Sec. 415.100  Scope.

    This subpart implements section 1887(a)(1)(A) of the Act by 
providing general conditions that must be met in order for services 
furnished by physicians to beneficiaries in providers to be paid for on 
the basis of the physician fee schedule under part 414 of this chapter. 
Section 415.102 sets forth the conditions for fee schedule payment for 
physician services to beneficiaries in providers. Section 415.105 sets 
forth general requirements for determining the amounts of payment for 
services that meet the conditions of this section. Sections 415.120 and 
415.130 set forth additional conditions for payment for physician 
services in the specialties of radiology and pathology (laboratory 
services).


Sec. 415.102  Conditions for fee schedule payment for physician 
services to beneficiaries in providers.

    (a) General rule. If the physician furnishes services to 
beneficiaries in providers, the carrier pays on a fee schedule basis 
provided the following requirements are met:
    (1) The services are personally furnished for an individual 
beneficiary by a physician.
    (2) The services contribute directly to the diagnosis or treatment 
of an individual beneficiary.
    (3) The services ordinarily require performance by a physician.
    (4) In the case of radiology or laboratory services, the additional 
requirements in Sec. 415.120 or Sec. 415.130, respectively, are met.
    (b) Exception. If a physician furnishes services in a provider that 
do not meet the requirements in paragraph (a) of this section, but are 
related to beneficiary care furnished by the provider, the intermediary 
pays for those services, if otherwise covered. The intermediary follows 
the rules in Secs. 415.55 and 415.60 for payment on the basis of 
reasonable cost or PPS, as appropriate.
    (c) Effect of billing charges for physician services to a provider.
    (1) If a physician furnishes services that may be paid under the 
reasonable cost rules in Sec. 415.55 or Sec. 415.60, and paid by the 
intermediary, or would be paid under those rules except for the PPS 
rules in part 412 of this chapter, and under the payment rules for GME 
established by Sec. 413.86 of this chapter, neither the provider nor 
the physician may seek payment from the carrier, beneficiary, or 
another insurer.
    (2) If a physician furnishes services to an individual beneficiary 
that do not meet the applicable conditions in Secs. 415.120 (concerning 
conditions for payment for radiology services) and 415.130 (concerning 
conditions for payment for physician pathology services), the carrier 
does not pay on a fee schedule basis.
    (3) If the physician, the provider, or another entity bills the 
carrier or the beneficiary or another insurer for physician services 
furnished to the provider, as described in Sec. 415.55(a), HCFA 
considers the provider to which the services are furnished to have 
violated its provider participation agreement, and may terminate that 
agreement. See part 489 of this chapter for rules governing provider 
agreements.
    (d) Effect of physician assumption of operating costs. If a 
physician or other entity enters into an agreement (such as a lease or 
concession) with a provider, and the physician (or entity) assumes some 
or all of the operating costs of the provider department in which the 
physician furnishes physician services, the following rules apply:
    (1) If the conditions set forth in paragraph (a) of this section 
are met, the carrier pays for the physician services under the 
physician fee schedule in part 414 of this chapter.
    (2) To the extent the provider incurs a cost payable on a 
reasonable cost basis under part 413 of this chapter, the intermediary 
pays the provider on a reasonable cost basis for the costs associated 
with producing these services, including overhead, supplies, equipment 
costs, and services furnished by nonphysician personnel.
    (3) The physician (or other entity) is treated as being related to 
the provider within the meaning of Sec. 413.17 of this 

[[Page 63181]]
chapter (concerning cost to related organizations).
    (4) The physician (or other entity) must make its books and records 
available to the provider and the intermediary as necessary to verify 
the nature and extent of the costs of the services furnished by the 
physician (or other entity).


Sec. 415.105  Amounts of payment for physician services to 
beneficiaries in providers.

    (a) General rule. The carrier determines amounts of payment for 
physician services to beneficiaries in providers in accordance with the 
general rules governing the physician fee schedule payment in part 414 
of this chapter, except as provided in paragraph (b) of this section.
    (b) Application in certain settings--(1) Teaching hospitals. The 
carrier applies the rules in subpart D of this part (concerning 
physician services in teaching settings), in addition to those in this 
section, in determining whether fee schedule payment should be made for 
physician services to individual beneficiaries in a teaching hospital.
    (2) Hospital-based ESRD facilities. The carrier applies 
Secs. 414.310 through 414.314 of this chapter, which set forth 
determination of reasonable charges under the ESRD program, to 
determine the amount of payment for physician services furnished to 
individual beneficiaries in a hospital-based ESRD facility approved 
under part 405 subpart U.


Sec. 415.110  Conditions for payment: Anesthesiology services.

    (a) Services furnished directly or concurrently. The carrier pays a 
physician for anesthesia services furnished to patients in a provider 
on a fee schedule basis only if the services meet the conditions in 
Sec. 415.102(a) and the following additional conditions:
    (1) For each patient, the physician--
    (i) Performs a pre-anesthetic examination and evaluation;
    (ii) Prescribes the anesthesia plan;
    (iii) Personally participates in the most demanding procedures in 
the anesthesia plan, including induction and emergence;
    (iv) Ensures that any procedures in the anesthesia plan that he or 
she does not perform are performed by a qualified individual as defined 
in program operating instructions;
    (v) Monitors the course of anesthesia administration at frequent 
intervals;
    (vi) Remains physically present and available for immediate 
diagnosis and treatment of emergencies; and
    (vii) Provides indicated post-anesthesia care.
    (2) The physician performs the procedure personally or directs no 
more than four anesthesia procedures concurrently and does not perform 
any other services while he or she is directing the concurrent 
procedures.
    (b) Supervision of more than four procedures concurrently. If a 
physician is involved in furnishing more than four procedures 
concurrently, or is performing other services while directing the 
concurrent procedures, the concurrent anesthesia services are physician 
services to the provider in which the procedures are performed. In 
these cases, the physician is not required to meet the criteria of 
paragraphs (a)(1) (iii) and (vii) of this section personally, but must 
ensure that a qualified individual performs any procedure in which the 
physician does not personally participate. In these cases, the 
intermediary pays for the services under the rules in Secs. 415.55 and 
415.60 on reasonable cost payment for physician services to providers 
or under the rules in part 412 of this chapter for payment under the 
prospective payment system.


Sec. 415.120  Conditions for payment: Radiology services.

    (a) Services to beneficiaries. The carrier pays for radiology 
services furnished by a physician to a beneficiary on a fee schedule 
basis only if the services meet the conditions for fee schedule payment 
in Sec. 415.102(a) and are identifiable, direct, and discrete 
diagnostic or therapeutic services furnished to an individual 
beneficiary, such as interpretation of x-ray plates, angiograms, 
myelograms, pyelograms, or ultrasound procedures. The carrier pays for 
interpretations only if there is a written report prepared for 
inclusion in the patient's medical record maintained by the hospital.
    (b) Services to providers. The carrier does not pay on a fee 
schedule basis for physician services to the provider (for example, 
administrative or supervisory services) or for provider services needed 
to produce the x-ray films or other items that are interpreted by the 
radiologist. However, the intermediary pays the provider for these 
services in accordance with Sec. 415.55 for provider costs; 
Sec. 415.102(d)(2) for costs incurred by a physician, such as under a 
lease or concession agreement; or part 412 of this chapter for payment 
under PPS.


Sec. 415.130  Conditions for payment: Physician pathology services.

    (a) Physician pathology services. The carrier pays for pathology 
services furnished by a physician to an individual beneficiary on a fee 
schedule basis only if the services meet the conditions for payment in 
Sec. 415.102(a) and are one of the following services:
    (1) Surgical pathology services.
    (2) Specific cytopathology, hematology, and blood banking services 
that have been identified to require performance by a physician and are 
listed in program operating instructions.
    (3) Clinical consultation services that meet the requirements in 
paragraph (b) of this section.
    (4) Clinical laboratory interpretative services that meet the 
requirements of paragraphs (b)(1), (b)(3), and (b)(4) of this section 
and that are specifically listed in program operating instructions.
    (b) Clinical consultation services. For purposes of this section, 
clinical consultation services must meet the following requirements:
    (1) Be requested by the beneficiary's attending physician.
    (2) Relate to a test result that lies outside the clinically 
significant normal or expected range in view of the condition of the 
beneficiary.
    (3) Result in a written narrative report included in the 
beneficiary's medical record.
    (4) Require the exercise of medical judgment by the consultant 
physician.
    (c) Physician pathology services furnished by an independent 
laboratory. Laboratory services, including the technical component of a 
service, furnished to a hospital inpatient or outpatient by an 
independent laboratory are paid on a fee schedule basis under this 
subpart only if they are physician pathology services as described in 
paragraph (a) of this section.

Subpart D--Physician Services in Teaching Settings


Sec. 415.150  Scope.

    This subpart sets forth the rules governing payment for the 
services of physicians in teaching settings and the criteria for 
determining whether the payments are made as one of the following:
    (a) Services to the hospital under the reasonable cost election in 
Secs. 415.160 through 415.164. 

[[Page 63182]]

    (b) Provider services through the direct GME payment mechanism in 
Sec. 413.86 of this chapter.
    (c) Physician services to beneficiaries under the physician fee 
schedule as set forth in part 414 of this chapter.


Sec. 415.152  Definitions.

    As used in this subpart--
    Approved graduate medical education (GME) program means a residency 
program approved by the Accreditation Council for Graduate Medical 
Education of the American Medical Association, by the Committee on 
Hospitals of the Bureau of Professional Education of the American 
Osteopathic Association, by the Council on Dental Education of the 
American Dental Association, or by the Council on Podiatric Medicine 
Education of the American Podiatric Medical Association.
    Direct medical and surgical services means services to individual 
beneficiaries that are either personally furnished by a physician or 
furnished by a resident under the supervision of a physician in a 
teaching hospital making the cost election described in Secs. 415.160 
through 415.162.
    Nonprovider setting means a setting other than a hospital, skilled 
nursing facility, home health agency, or comprehensive outpatient 
rehabilitation facility in which residents furnish services. These 
include, but are not limited to, family practice or multispecialty 
clinics and physician offices.
    Resident means one of the following:
    (1) An individual who participates in an approved GME program, 
including programs in osteopathy, dentistry, and podiatry.
    (2) A physician who is not in an approved GME program, but who is 
authorized to practice only in a hospital, for example, individuals 
with temporary or restricted licenses, or unlicensed graduates of 
foreign medical schools. For purposes of this subpart, the term 
resident is synonymous with the terms intern and fellow.
    Teaching hospital means a hospital engaged in an approved GME 
residency program in medicine, osteopathy, dentistry, or podiatry.
    Teaching physician means a physician (other than another resident) 
who involves residents in the care of his or her patients.
    Teaching setting means any provider, hospital-based provider, or 
nonprovider settings in which Medicare payment for the services of 
residents is made under the direct GME payment provisions of 
Sec. 413.86, or on a reasonable-cost basis under the provisions of 
Sec. 409.26 or Sec. 409.40(f) for resident services furnished in 
skilled nursing facilities or home health agencies, respectively.


Sec. 415.160  Election of reasonable cost payment for direct medical 
and surgical services of physicians in teaching hospitals: General 
provisions.

    (a) Scope. A teaching hospital may elect to receive payment on a 
reasonable cost basis for the direct medical and surgical services of 
its physicians in lieu of fee schedule payments that might otherwise be 
made for these services.
    (b) Conditions. A teaching hospital may elect to receive these 
payments only if--
    (1) The hospital notifies its intermediary in writing of the 
election and meets the conditions of either paragraph (b)(2) or 
paragraph (b)(3) of this section;
    (2) All physicians who furnish services to Medicare beneficiaries 
in the hospital agree not to bill charges for these services; or
    (3) All physicians who furnish services to Medicare beneficiaries 
in the hospital are employees of the hospital and, as a condition of 
employment, are precluded from billing for these services.
    (c) Effect of election. If a teaching hospital elects to receive 
reasonable cost payment for physician direct medical and surgical 
services furnished to beneficiaries--
    (1) Those services and the supervision of interns and residents 
furnishing care to individual beneficiaries are covered as hospital 
services, and
    (2) The intermediary pays the hospital for those services on a 
reasonable cost basis under the rules in Sec. 415.162. (Payment for 
other physician compensation costs related to approved GME programs is 
made as described in Sec. 413.86 of this chapter.)
    (d) Election declined. If the teaching hospital does not make this 
election, payment is made--
    (1) For physician services furnished to beneficiaries on a fee 
schedule basis as described in part 414 subject to the rules in this 
subpart, and
    (2) For the supervision of interns and residents as described in 
Sec. 413.86.


Sec. 415.162  Determining payment for physician services furnished to 
beneficiaries in teaching hospitals.

    (a) General rule. Payments for direct medical and surgical services 
of physicians furnished to beneficiaries and supervision of interns and 
residents furnishing care to beneficiaries is made by Medicare on the 
basis of reasonable cost if the hospital exercises the election as 
provided for in Sec. 415.160. If this election is made, the following 
occurs:
    (1) Physician services furnished to beneficiaries and supervision 
of interns and residents furnishing care to beneficiaries are paid on a 
reasonable-cost basis, as provided for in paragraph (b) of this 
section.
    (2) Payment for certain medical school costs may be made as 
provided for in paragraph (c) of this section.
    (3) Payments for services donated by volunteer physicians to 
beneficiaries are made to a fund designated by the organized medical 
staff of the teaching hospital or medical school as provided for in 
paragraph (d) of this section.
    (b) Reasonable cost of physician services and supervision of 
interns and residents.
    (1) Physician services furnished to beneficiaries and supervision 
of interns and residents furnishing care to beneficiaries in a teaching 
hospital are payable as provider services on a reasonable-cost basis.
    (2) For purposes of this paragraph, reasonable cost is defined as 
the direct salary paid to these physicians, plus applicable fringe 
benefits.
    (3) The costs must be allocated to the services as provided by 
paragraph (j) of this section and apportioned to program beneficiaries 
as provided by paragraph (g) of this section.
    (4) Other allowable costs incurred by the provider related to the 
services described in this paragraph are payable subject to the 
requirements applicable to all other provider services.
    (c) Reasonable costs for the services furnished by a medical school 
or related organization in a hospital. An amount is payable to the 
hospital by HCFA under the Medicare program provided that the costs 
would be payable if incurred directly by the hospital rather than under 
the arrangement. The amount must not be in excess of the reasonable 
costs (as defined in paragraphs (c)(1) and (c)(2) of this section) 
incurred by a teaching hospital for services furnished by a medical 
school or organization as described in Sec. 413.17 of this chapter for 
certain costs to the medical school (or a related organization) in 
furnishing services in the hospital.
    (1) Reasonable costs of physician services.
    (i) When the medical school and the hospital are related 
organizations. If the 

[[Page 63183]]
medical school (or organization related to the medical school) and the 
hospital are related by common ownership or control as described in 
Sec. 413.17 of this chapter--
    (A) The costs of these services are allowable costs to the hospital 
under the provisions of Sec. 413.17 of this chapter; and
    (B) The reimbursable costs to the hospital are determined under the 
provisions of this section in the same manner as the costs incurred for 
physicians on the hospital staff and without regard to payments made to 
the medical school by the hospital.
    (ii) When the medical school and the hospital are not related 
organizations.
    (A) If the medical school and the hospital are not related 
organizations under the provisions of Sec. 413.17 of this chapter and 
the hospital makes payment to the medical school for the costs of those 
services furnished to all patients, payment is made by Medicare to the 
hospital for the reasonable cost incurred by the hospital for its 
payments to the medical school for services furnished to beneficiaries.
    (B) Costs incurred under an arrangement must be allocated to the 
full range of services furnished to the hospital by the medical school 
physicians on the same basis as provided for under paragraph (j) of 
this section, and costs allocated to direct medical and surgical 
services furnished to hospital patients must be apportioned to 
beneficiaries as provided for under paragraph (g) of this section.
    (C) If the medical school and the hospital are not related 
organizations under the provisions of Sec. 413.17 of this chapter and 
the hospital makes payment to the medical school only for the costs of 
those services furnished to beneficiaries, costs of the medical school 
not to exceed 105 percent of the sum of physician direct salaries, 
applicable fringe benefits, employer's portion of FICA taxes, Federal 
and State unemployment taxes, and workmen's compensation paid by the 
medical school or an organization related to the medical school may be 
recognized as allowable costs of the medical school.
    (D) These allowable medical school costs must be allocated to the 
full range of services furnished by the physicians of the medical 
school or organization related as provided by paragraph (j) of this 
section.
    (E) Costs allocated to direct medical and surgical services 
furnished to hospital patients must be apportioned to beneficiaries as 
provided by paragraph (g) of this section.
    (2) Reasonable costs of other than direct medical and surgical 
services. These costs are determined in accordance with paragraph 
(c)(1) of this section except that--
    (i) If the hospital makes payment to the medical school for other 
than direct medical and surgical services furnished to beneficiaries 
and supervision of interns and residents furnishing care to 
beneficiaries, these payments are subject to the required cost-finding 
and apportionment methods applicable to the cost of other hospital 
services (except for direct medical and surgical services furnished to 
beneficiaries); or
    (ii) If the hospital makes payment to the medical school only for 
these services furnished to beneficiaries, the cost of these services 
is not subject to cost-finding and apportionment as otherwise provided 
by this subpart, and the reasonable cost paid by Medicare must be 
determined on the basis of the health insurance ratio(s) used in the 
apportionment of all other provider costs (excluding physician direct 
medical and surgical services furnished to beneficiaries) applied to 
the allowable medical school costs incurred by the medical school for 
the services furnished to all patients of the hospital.
    (d) ``Salary equivalent'' payments for direct medical and surgical 
services furnished by physicians on the voluntary staff of the 
hospital.
    (1) HCFA makes payments under the Medicare program to a fund as 
defined in Sec. 415.164 for direct medical and surgical services 
furnished to beneficiaries on a regularly scheduled basis by physicians 
on the unpaid voluntary medical staff of the hospital (or medical 
school under arrangement with the hospital).
    (i) These payments represent compensation for contributed medical 
staff time which, if not contributed, would have to be obtained through 
employed staff on a payable basis.
    (ii) Payments for volunteer services are determined by applying to 
the regularly scheduled contributed time an hourly rate not to exceed 
the equivalent of the average direct salary (exclusive of fringe 
benefits) paid to all full-time, salaried physicians (other than 
interns and residents) on the hospital staff or, if the number of full-
time salaried physicians is minimal in absolute terms or in relation to 
the number of physicians on the voluntary staff, to physicians at like 
institutions in the area.
    (iii) This ``salary equivalent'' is a single hourly rate covering 
all physicians regardless of specialty and is applied to the actual 
regularly scheduled time contributed by the physicians in furnishing 
direct medical and surgical services to beneficiaries including 
supervision of interns and residents in that care.
    (iv) A physician who receives any compensation from the hospital or 
a medical school related to the hospital by common ownership or control 
(within the meaning of Sec. 413.17 of this chapter) for direct medical 
and surgical services furnished to any patient in the hospital is not 
considered an unpaid voluntary physician for purposes of this 
paragraph.
    (v) If, however, a physician receives compensation from the 
hospital or related medical school or organization only for services 
that are other than direct medical and surgical services, a salary 
equivalent payment for the physician's regularly scheduled direct 
medical and surgical services to beneficiaries in the hospital may be 
imputed. However, the sum of the imputed value for volunteer services 
and the physician's actual compensation from the hospital and the 
related medical school (or organization) may not exceed the amount that 
would have been imputed if all of the physician's hospital and medical 
school services (compensated and volunteer) had been volunteer 
services, or paid at the rate of $30,000 per year, whichever is less.
    (2) The following examples illustrate how the allowable imputed 
value for volunteer services is determined. In each example, it has 
been assumed that the average salary equivalent hourly rate is equal to 
the hourly rate for the individual physician's compensated services.

    Example No: 1. Dr. Jones received $3,000 a year from Hospital X 
for services other than direct medical services to all patients, for 
example, utilization review and administrative services. Dr. Jones 
also voluntarily furnished direct medical services to beneficiaries. 
The imputed value of the volunteer services amounted to $10,000 for 
the cost reporting period. The full imputed value of Dr. Jones' 
volunteer direct medical services would be allowed since the total 
amount of the imputed value ($10,000) and the compensated services 
($3,000) does not exceed $30,000.
    Example No: 2. Dr. Smith received $25,000 from Hospital X for 
services as a department head in a teaching hospital. Dr. Smith also 
voluntarily furnished direct medical services to beneficiaries. The 
imputed value of the 

[[Page 63184]]
volunteer services amounted to $10,000. Only $5,000 of the imputed 
value of volunteer services would be allowed since the total amount 
of the imputed value ($10,000) and the compensated services 
($25,000) exceeds the $30,000 maximum amount allowable for all of 
Dr. Smith's services.

Computation:

Maximum amount allowable for all services performed by Dr.              
 Smith for purposes of this computation......................    $30,000
Less compensation received from Hospital X for other than               
 direct medical services to individual patients..............    $25,000
Allowable amount of imputed value for the volunteer services            
 furnished by Dr. Smith......................................     $5,000
                                                                        

    Example No. 3. Dr. Brown is not compensated by Hospital X for 
any services furnished in the hospital. Dr. Brown voluntarily 
furnished direct surgical services to beneficiaries for a period of 
6 months, and the imputed value of these services amounted to 
$20,000. The allowable amount of the imputed value for volunteer 
services furnished by Dr. Brown would be limited to $15,000 ($30,000 
x 6/12).

    (3) The amount of the imputed value for volunteer services 
applicable to beneficiaries and payable to a fund is determined in 
accordance with the aggregate per diem method described in paragraph 
(g) of this section.
    (4) Medicare payments to a fund must be used by the fund solely for 
improvement of care of hospital patients or for educational or 
charitable purposes (which may include but are not limited to medical 
and other scientific research).
    (i) No personal financial gain, either direct or indirect, from 
benefits of the fund may inure to any of the hospital staff physicians, 
medical school faculty, or physicians for whom Medicare imputes costs 
for purposes of payment into the fund.
    (ii) Expenses met from contributions made to the hospital from a 
fund are not included as a reimbursable cost when expended by the 
hospital, and depreciation expense is not allowed with respect to 
equipment or facilities donated to the hospital by a fund or purchased 
by the hospital from monies in a fund.
    (e) Requirements for payment--(1) Physicians on the hospital staff. 
The requirements under which the costs of physician direct medical and 
surgical services (including supervision of interns and residents) to 
beneficiaries are the same as those applicable to the cost of all other 
covered provider services except that the costs of these services are 
separately determined as provided by this section and are not subject 
to cost-finding as described in Sec. 413.24 of this chapter.
    (2) Physicians on the medical school faculty. Payment is made to a 
hospital for the costs of services of physicians on the medical school 
faculty, provided that if the medical school is not related to the 
hospital (within the meaning of Sec. 413.17 of this chapter, concerning 
cost to related organizations), the hospital does not make payment to 
the medical school for services furnished to all patients and the 
following requirements are met: If the hospital makes payment to the 
medical school for services furnished to all patients, these 
requirements do not apply. (See paragraph (c)(1)(ii) of this section.)
    (i) There is a written agreement between the hospital and the 
medical school or organization, specifying the types and extent of 
services to be furnished by the medical school and specifying that the 
hospital must pay to the medical school an amount at least equal to the 
reasonable cost (as defined in paragraph (c) of this section) of 
furnishing the services to beneficiaries.
    (ii) The costs are paid to the medical school by the hospital no 
later than the date on which the cost report covering the period in 
which the services were furnished is due to HCFA.
    (iii) Payment for the services furnished under an arrangement would 
have been made to the hospital had the services been furnished directly 
by the hospital.
    (3) Physicians on the voluntary staff of the hospital (or medical 
school under arrangement with the hospital). If the conditions for 
payment to a fund outlined in Sec. 415.164 are met, payments are made 
on a ``salary equivalent'' basis (as defined in paragraph (d) of this 
section) to a fund.
    (f) Requirements for payment for medical school faculty services 
other than physician direct medical and surgical services. If the 
requirements for payment for physician direct medical and surgical 
services furnished to beneficiaries in a teaching hospital described in 
paragraph (e) of this section are met, payment is made to a hospital 
for the costs of medical school faculty services other than physician 
direct medical and surgical services furnished in a teaching hospital.
    (g) Aggregate per diem methods of apportionment--(1) For the costs 
of physician direct medical and surgical services. The cost of 
physician direct medical and surgical services furnished in a teaching 
hospital to beneficiaries is determined on the basis of an average cost 
per diem as defined in paragraph (h)(1) of this section for physician 
direct medical and surgical services to all patients (see Secs. 415.172 
through 415.184) for each of the following categories of physicians:
    (i) Physicians on the hospital staff.
    (ii) Physicians on the medical school faculty.
    (2) For the imputed value of physician volunteer direct medical and 
surgical services. The imputed value of physician direct medical and 
surgical services furnished to beneficiaries in a teaching hospital is 
determined on the basis of an average per diem, as defined in paragraph 
(h)(1) of this section, for physician direct medical and surgical 
services to all patients except that the average per diem is derived 
from the imputed value of the physician volunteer direct medical and 
surgical services furnished to all patients.
    (h) Definitions. (1) Average cost per diem for physician direct 
medical and surgical services (including supervision of interns and 
residents) furnished in a teaching hospital to patients in each 
category of physician services described in paragraph (g)(1) of this 
section means the amount computed by dividing total reasonable costs of 
these services in each category by the sum of--
    (i) Inpatient days (as defined in paragraph (h)(2) of this 
section); and
    (ii) Outpatient visit days (as defined in paragraph (h)(3) of this 
section).
    (2) Inpatient days are determined by counting the day of admission 
as 3.5 days and each day after a patient's day of admission, except the 
day of discharge, as 1 day.
    (3) Outpatient visit days are determined by counting only one visit 
day for each calendar day that a patient visits an outpatient 
department or multiple outpatient departments.
    (i) Application. (1) The following illustrates how apportionment 
based on the aggregate per diem method for costs of physician direct 
medical and surgical services furnished in a teaching hospital to 
patients is determined.

Teaching Hospital Y

Statistical and financial data:

Total inpatient days as defined in paragraph (h)(2) of this             
 section and outpatient visit days as defined in paragraph              
 (h)(3) of this section....................................      75,000 

[[Page 63185]]
                                                                        
Total inpatient Part A days................................       20,000
Total inpatient Part B days where Part A coverage is not                
 available.................................................        1,000
Total outpatient Part B visit days.........................        5,000
Total cost of direct medical and surgical services                      
 furnished to all patients by physicians on the hospital                
 staff as determined in accordance with paragraph (i) of                
 this section..............................................   $1,500,000
Total cost of direct medical and surgical services                      
 furnished to all patients by physicians on the medical                 
 school faculty as determined in accordance with paragraph              
 (i) of this section.......................................   $1,650,000
                                                                        



    Computation of cost applicable to program for physicians on the 
hospital staff:
    Average cost per diem for direct medical and surgical services 
to patients by physicians on the hospital staff: $1,500,000  
75,000 = $20 per diem.

Cost of physician direct medical and surgical services                  
 furnished to inpatient beneficiaries covered under Part A:             
 $20 per diem  x  20,000...................................     $400,000
Cost of physician direct medical and surgical services                  
 furnished to inpatient beneficiaries covered under Part B:             
 $20 per diem  x  1,000....................................      $20,000
Cost of physician direct medical and surgical services                  
 furnished to outpatient beneficiaries covered under Part               
 B: $20 per diem  x  5,000.................................     $100,000
                                                                        

    Computation of cost applicable to program for physicians on the 
medical school faculty:
    Average cost per diem for direct medical and surgical services 
to patients by physicians on the medical school faculty: $1,650,000 
 75,000 = $22 per diem.

Cost of physician direct medical and surgical services                  
 furnished to inpatient beneficiaries covered under Part A:             
 $22 per diem  x  20,000...................................     $440,000
Cost of physician direct medical and surgical services                  
 furnished to inpatient beneficiaries covered under Part B:             
 $20 per diem  x  1,000....................................      $22,000
Cost of physician direct medical and surgical services                  
 furnished to outpatient beneficiaries covered under Part               
 B: $22 per diem  x  5,000.................................     $110,000
                                                                        

    (2) The following illustrates how the imputed value of physician 
volunteer direct medical and surgical services furnished in a 
teaching hospital to beneficiaries is determined.
    Example: The physicians on the medical staff of Teaching 
Hospital Y donated a total of 5,000 hours in furnishing direct 
medical and surgical services to patients of the hospital during a 
cost reporting period and did not receive any compensation from 
either the hospital or the medical school. Also, the imputed value 
for any physician volunteer services did not exceed the rate of 
$30,000 per year per physician.

Statistical and financial data:

Total salaries paid to the full-time salaried physicians by             
 the hospital (excluding interns and residents)............     $800,000
Total physicians who were paid for an average of 40 hours               
 per week or 2,080 (52 weeks x 40 hours per week) hours per             
 year......................................................           20
Average hourly rate equivalent: $800,000  41,600                
 (2,080  x  20)............................................       $19.23
                                                                        

    Computation of total imputed value of physician volunteer 
services applicable to all patients:

(Total donated hours  x  average hourly rate equivalent):               
 5,000  x  $19.23..........................................      $96,150
Total inpatient days (as defined in paragraph (h)(2) of                 
 this section) and outpatient visit days (as defined in                 
 paragraph (h)(3) of this section).........................       75,000
Total inpatient Part A days................................       20,000
Total inpatient Part B days if Part A coverage is not                   
 available.................................................        1,000
Total outpatient Part B visit days.........................        5,000
                                                                        

    Computation of imputed value of physician volunteer direct 
medical and surgical services furnished to Medicare beneficiaries:
    Average per diem for physician direct medical and surgical 
services to all patients: $96,150  75,000 = $1.28 per diem

Imputed value of physician direct medical and surgical                  
 services furnished to inpatient beneficiaries covered                  
 under Part A: $1.28 per diem  x  20,000...................      $25,600
Imputed value of physician direct medical and surgical                  
 services furnished to inpatient beneficiaries covered                  
 under Part B: $1.28 per diem  x  1,000....................       $1,280
Imputed value of physician direct medical and surgical                  
 services furnished to outpatient beneficiaries covered                 
 under Part B: $1.28 per diem  x  5,000....................       $6,400
Total......................................................      $33,280
                                                                        

    (j) Allocation of compensation paid to physicians in a teaching 
hospital. 
    (1) In determining reasonable cost under this section, the 
compensation paid by a teaching hospital, or a medical school or 
related organization under arrangement with the hospital, to physicians 
in a teaching hospital must be allocated to the full range of services 
implicit in the physician compensation arrangements. (However, see 
paragraph (d) of this section for the computation of the ``salary 
equivalent'' payments for volunteer services furnished to patients.)
    (2) This allocation must be made and must be capable of 
substantiation on the basis of the proportion of each physician's time 
spent in furnishing each type of service to the hospital or medical 
school.


Sec. 415.164  Payment to a fund.

    (a) General rules. Payment for certain voluntary services by 
physicians in teaching hospitals (as these services are described in 
Sec. 415.160) is made on a salary equivalent basis (as described in 
Sec. 415.162(d)) subject to the conditions and limitations contained in 
parts 405 and 413 of this chapter and this part 415, to a single fund 
(as defined in paragraph (b) of this section) designated by the 
organized medical staff of the hospital (or, if the services are 
furnished in the hospital by the faculty of a medical school, to a fund 
as may be designated by the faculty), if the following conditions are 
met:
    (1) The hospital (or medical school furnishing the services under 
arrangement with the hospital) incurs no actual cost in furnishing the 
services.
    (2) The hospital has an agreement with HCFA under part 489 of this 
chapter.
    (3) The intermediary, or HCFA as appropriate, has received written 
assurances that--
    (i) The payment is used solely for the improvement of care of 
hospital patients or for educational or charitable purposes; and
    (ii) Neither the individuals who are furnished the services nor any 
other persons are charged for the services (and if charged, provision 
is made for the return of any monies incorrectly collected).

[[Page 63186]]

    (b) Definition of a fund. For purposes of paragraph (a) of this 
section, a fund is an organization that meets either of the following 
requirements:
    (1) The organization has and retains exemption, as a governmental 
entity or under section 501(c)(3) of the Internal Revenue Code 
(nonprofit educational, charitable, and similar organizations), from 
Federal taxation.
    (2) The organization is an organization of physicians who, under 
the terms of their employment by an entity that meets the requirements 
of paragraph (b)(1) of this section, are required to turn over to that 
entity all income that the physician organization derives from the 
physician services.
    (c) Status of a fund. A fund approved for payment under paragraph 
(a) of this section has all the rights and responsibilities of a 
provider under Medicare except that it does not enter into an agreement 
with HCFA under part 489 of this chapter.


Sec. 415.170  Conditions for payment on a fee schedule basis for 
physician services in a teaching setting.

    Services meeting the conditions for payment in Sec. 415.102(a) 
furnished in teaching settings are payable under the physician fee 
schedule if--
    (a) The services are personally furnished by a physician who is not 
a resident; or
    (b) The services are furnished by a resident in the presence of a 
teaching physician except as provided in Sec. 415.172 (concerning 
physician fee schedule payment for services of teaching physicians), 
Sec. 415.174 (concerning an exception for services furnished in 
hospital outpatient and certain other ambulatory settings), 
Sec. 415.176 (concerning renal dialysis services), and Sec. 415.184 
(concerning psychiatric services), as applicable.


Sec. 415.172  Physician fee schedule payment for services of teaching 
physicians.

    (a) General rule. If a resident participates in a service furnished 
in a teaching setting, physician fee schedule payment is made only if a 
teaching physician is present during the key portion of any service or 
procedure for which payment is sought.
    (1) In the case of surgical, high-risk, or other complex 
procedures, the teaching physician must be present during all critical 
portions of the procedure and immediately available to furnish services 
during the entire service or procedure.
    (i) In the case of surgery, the teaching physician's presence is 
not required during opening and closing of the surgical field.
    (ii) In the case of procedures performed through an endoscope, the 
teaching physician must be present during the entire viewing.
    (2) In the case of evaluation and management services, the teaching 
physician must be present during the portion of the service that 
determines the level of service billed. (However, in the case of 
evaluation and management services furnished in hospital outpatient 
departments and certain other ambulatory settings, the requirements of 
Sec. 415.174 apply.)
    (b) Documentation. Except for services furnished as set forth in 
Secs. 415.174 (concerning an exception for services furnished in 
hospital outpatient and certain other ambulatory settings), 415.176 
(concerning renal dialysis services), and 415.184 (concerning 
psychiatric services), the medical records must document the teaching 
physician was present at the time the service is furnished. The 
presence of the teaching physician during procedures may be 
demonstrated by the notes in the medical records made by a physician, 
resident, or nurse. In the case of evaluation and management 
procedures, the teaching physician must personally document his or her 
participation in the service in the medical records.
    (c) Payment level. In the case of services such as evaluation and 
management for which there are several levels of service codes 
available for reporting purposes, the appropriate payment level must 
reflect the extent and complexity of the service when fully furnished 
by the teaching physician.


Sec. 415.174  Exception: Evaluation and management services furnished 
in certain centers.

    (a) In the case of certain evaluation and management codes of lower 
and mid-level complexity (as specified by HCFA in program 
instructions), carriers may make physician fee schedule payment for a 
service furnished by a resident without the presence of a teaching 
physician. For the exception to apply, all of the following conditions 
must be met:
    (1) The services must be furnished in a center that is located in 
an outpatient department of a hospital or another ambulatory care 
entity in which the time spent by residents in patient care activities 
is included in determining intermediary payments to a hospital under 
Sec. 413.86.
    (2) Any resident furnishing the service without the presence of a 
teaching physician must have completed more than 6 months of an 
approved residency program.
    (3) The teaching physician must not direct the care of more than 
four residents at any given time and must direct the care from such 
proximity as to constitute immediate availability. The teaching 
physician must--
    (i) Have no other responsibilities at the time;
    (ii) Assume management responsibility for those beneficiaries seen 
by the residents;
    (iii) Ensure that the services furnished are appropriate;
    (iv) Review with each resident during or immediately after each 
visit, the beneficiary's medical history, physical examination, 
diagnosis, and record of tests and therapies; and
    (v) Document the extent of the teaching physician's participation 
in the review and direction of the services furnished to each 
beneficiary.
    (4) The range of services furnished by residents in the center 
includes all of the following:
    (i) Acute care for undifferentiated problems or chronic care for 
ongoing conditions.
    (ii) Coordination of care furnished by other physicians and 
providers.
    (iii) Comprehensive care not limited by organ system, diagnosis, or 
gender.
    (5) The patients seen must be an identifiable group of individuals 
who consider the center to be the continuing source of their health 
care and in which services are furnished by residents under the medical 
direction of teaching physicians.
    (b) Nothing in paragraph (a) of this section may be construed as 
providing a basis for the coverage of services not determined to be 
covered under Medicare, such as routine physical checkups.


Sec. 415.176  Renal dialysis services.

    In the case of renal dialysis services, physicians who are not paid 
under the physician monthly capitation payment method (as described in 
Sec. 414.314 of this chapter) must meet the requirements of 
Secs. 415.170 and 415.172 (concerning physician fee schedule payment 
for services of teaching physicians).


Sec. 415.178  Anesthesia services.

    (a) General rule. An unreduced physician fee schedule payment may 
be made if a physician is involved in a 

[[Page 63187]]
single anesthesia procedure involving an anesthesia resident. In the 
case of anesthesia services, the teaching physician must be present 
during all critical portions of the procedure and immediately available 
to furnish services during the entire service or procedure. The 
teaching physician cannot receive an unreduced fee if he or she 
performs services involving other patients during the period the 
anesthesia resident is furnishing services in a single case. For 
additional rules for payment of anesthesia services involving 
residents, see Sec. 414.46(c)(1)(iii)).
    (b) Documentation. Documentation must indicate the physician's 
presence or participation in the administration of the anesthesia and a 
preoperative and postoperative visit by the physician.


Sec. 415.180  Teaching setting requirements for the interpretation of 
diagnostic radiology and other diagnostic tests.

    (a) General rule. Physician fee schedule payment is made for the 
interpretation of diagnostic radiology and other diagnostic tests if 
the interpretation is performed or reviewed by a physician other than a 
resident.
    (b) Documentation. Documentation must indicate that the physician 
personally performed the interpretation or reviewed the resident's 
interpretation with the resident.


Sec. 415.184  Psychiatric services.

    To qualify for physician fee schedule payment for psychiatric 
services furnished under an approved GME program, the physician must 
meet the requirements of Secs. 415.170 and 415.172, including 
documentation, except that the requirement for the presence of the 
teaching physician during the service in which a resident is involved 
may be met by observation of the service by use of a one-way mirror, 
video equipment, or similar device.


Sec. 415.190  Conditions of payment: Assistants at surgery in teaching 
hospitals.

    (a) Basis, purpose, and scope. This section describes the 
conditions under which Medicare pays on a fee schedule basis for the 
services of an assistant at surgery in a teaching hospital. This 
section is based on section 1842(b)(7)(D)(I) of the Act and applies 
only to hospitals with an approved GME residency program. Except as 
specified in paragraph (c) of this section, fee schedule payment is not 
available for assistants at surgery in hospitals with--
    (1) A training program relating to the medical specialty required 
for the surgical procedure; and
    (2) A resident in a training program relating to the specialty 
required for the surgery available to serve as an assistant at surgery.
    (b) Definition. Assistant at surgery means a physician who actively 
assists the physician in charge of a case in performing a surgical 
procedure.
    (c) Conditions for payment for assistants at surgery. Payment on a 
fee schedule basis is made for the services of an assistant at surgery 
in a teaching hospital only if the services meet one of the following 
conditions:
    (1) Are required as a result of exceptional medical circumstances.
    (2) Are complex medical procedures performed by a team of 
physicians, each performing a discrete, unique function integral to the 
performance of a complex medical procedure that requires the special 
skills of more than one physician.
    (3) Constitute concurrent medical care relating to a medical 
condition that requires the presence of, and active care by, a 
physician of another specialty during surgery.
    (4) Are medically required and are furnished by a physician who is 
primarily engaged in the field of surgery, and the primary surgeon does 
not use interns and residents in the surgical procedures that the 
surgeon performs (including preoperative and postoperative care).
    (5) Are not related to a surgical procedure for which HCFA 
determines that assistants are used less than 5 percent of the time.

Subpart E--Services of Residents


Sec. 415.200  Services of residents in approved GME programs.

    (a) General rules. Services furnished in hospitals by residents in 
approved GME programs are specifically excluded from being paid as 
``physician services'' defined in Sec. 414.2 of this chapter and are 
payable as hospital services. This exclusion applies whether or not the 
resident is licensed to practice under the laws of the State in which 
he or she performs the service. The payment methodology for services of 
residents in hospitals and hospital-based providers is set forth in 
Sec. 413.86 of this chapter.
    (b) Exception. For low and mid-level evaluation and management 
services furnished under certain conditions in centers located in 
hospital outpatient departments and other ambulatory settings, see 
Sec. 415.174.
    (c) Definitions. See Sec. 415.152 for definitions of terms used in 
this subpart E.


Sec. 415.202  Services of residents not in approved GME programs.

    (a) General rules. For services of a physician employed by a 
hospital who is authorized to practice only in a hospital setting and 
for the services of a resident who is not in any approved GME program, 
payment is made to the hospital on a Part B reasonable cost basis 
regardless of whether the services are furnished to hospital inpatients 
or outpatients.
    (b) Payment. For services described in paragraph (a) of this 
section, payment is made under Part B by reducing the reasonable costs 
of furnishing the services by the beneficiary deductible and paying 80 
percent of the remaining amount. No payment is made for other costs of 
unapproved programs, such as administrative costs related to teaching 
activities of physicians.


Sec. 415.204  Services of residents in skilled nursing facilities and 
home health agencies.

    (a) Medicare Part A payment. Payment is made under Medicare Part A 
for interns' and residents' services furnished in the following 
settings that meet the specified requirements:
    (1) Skilled nursing facility. Payment to a participating skilled 
nursing facility may include the cost of services of an intern or 
resident who is in an approved GME program in a hospital with which the 
skilled nursing facility has a transfer agreement that provides, in 
part, for the transfer of patients and the interchange of medical 
records.
    (2) Home health agency. A participating home health agency may 
receive payment for the cost of the services of an intern or resident 
who is under an approved GME program of a hospital with which the home 
health agency is affiliated or under common control if these services 
are furnished as part of the home health visits for a Medicare 
beneficiary. (Nevertheless, see Sec. 413.86 of this chapter for the 
costs of approved GME programs in hospital-based providers.)
    (b) Medicare Part B payment. Medical services of a resident of a 
hospital that are furnished by a skilled nursing facility or home 
health agency are paid under Medicare Part B if payment is not provided 
under Medicare Part A. Payment is made under Part B for a resident's 
services by reducing the 

[[Page 63188]]
reasonable costs of furnishing the services by the beneficiary 
deductible and paying 80 percent of the remaining amount.


Sec. 415.206  Services of residents in nonprovider settings.

    Patient care activities of residents in approved GME programs that 
are furnished in nonprovider settings are payable in one of the 
following two ways:
    (a) Direct GME payments. If the conditions in 
Sec. 413.86(f)(1)(iii) regarding patient care activities and training 
of residents are met, the time residents spend in nonprovider settings 
such as clinics, nursing facilities, and physician offices in 
connection with approved GME programs is included in determining the 
number of full-time equivalency residents in the calculation of a 
teaching hospital's resident count. The teaching physician rules on 
carrier payments in Secs. 415.170 through 415.184 apply in these 
teaching settings.
    (b) Physician fee schedule. (1) Services furnished by a resident in 
a nonprovider setting are covered as physician services and payable 
under the physician fee schedule if the following requirements are met:
    (i) The resident is fully licensed to practice medicine, 
osteopathy, dentistry, or podiatry in the State in which the service is 
performed.
    (ii) The time spent in patient care activities in the nonprovider 
setting is not included in a teaching hospital's full-time equivalency 
resident count for the purpose of direct GME payments.
    (2) Payment may be made regardless of whether a resident is 
functioning within the scope of his or her GME program in the 
nonprovider setting.
    (3) If fee schedule payment is made for the resident's services in 
a nonprovider setting, payment must not be made for the services of a 
teaching physician.
    (4) The carrier must apply the physician fee schedule payment rules 
set forth in subpart A of part 414 of this chapter to payments for 
services furnished by a resident in a nonprovider setting.


Sec. 415.208  Services of moonlighting residents.

    (a) Definition. For purposes of this section, the term services of 
moonlighting residents refers to services that licensed residents 
perform that are outside the scope of an approved GME program.
    (b) Services in GME program hospitals. (1) The services of 
residents to inpatients of hospitals in which the residents have their 
approved GME program are not covered as physician services and are 
payable under Sec. 413.86 regarding direct GME payments.
    (2) Services of residents that are not related to their approved 
GME programs and are performed in an outpatient department or emergency 
department of a hospital in which they have their training program are 
covered as physician services and payable under the physician fee 
schedule if all of the following criteria are met:
    (i) The services are identifiable physician services and meet the 
conditions for payment of physician services to beneficiaries in 
providers in Sec. 415.102(a).
    (ii) The resident is fully licensed to practice medicine, 
osteopathy, dentistry, or podiatry by the State in which the services 
are performed.
    (iii) The services performed can be separately identified from 
those services that are required as part of the approved GME program.
    (3) If the criteria specified in paragraph (b)(2) of this section 
are met, the services of the moonlighting resident are considered to 
have been furnished by the individual in his or her capacity as a 
physician, rather than in the capacity of a resident. The carrier must 
review the contracts and agreements for these services to ensure 
compliance with the criteria specified in paragraph (b)(2) of this 
section.
    (4) No payment is made for services of a ``teaching physician'' 
associated with moonlighting services, and the time spent furnishing 
these services is not included in the teaching hospital's full-time 
equivalency count for the indirect GME payment (Sec. 412.105 of this 
chapter) and for the direct GME payment (Sec. 413.86 of this chapter).
    (c) Other settings. Moonlighting services of a licensed resident in 
an approved GME program furnished outside the scope of that program in 
a hospital or other setting that does not participate in the approved 
GME program are payable under the physician fee schedule as set forth 
in Sec. 415.206(b)(1).
F. Technical Amendments

PART 400--[AMENDED]

    1. In Sec. 400.310, the following changes are made:
    a. The entries for Secs. 405.481 and 405.552 are removed.
    b. The table is amended by adding the following entries:


Sec. 400.310  Display of currently valid OMB control numbers.

------------------------------------------------------------------------
                                                             Current OMB
 Sections in 42 CFR that contain collections of information    control  
                                                               numbers  
------------------------------------------------------------------------
                                                                        
                  *        *        *        *        *                 
415.60.....................................................    0938-0301
415.162....................................................    0938-0301
                                                                        
                    *        *        *  *          *                   
------------------------------------------------------------------------

PART 405--[AMENDED]


Sec. 405.502  [Amended]

    2. In Sec. 405.502(a)(10), the phrase ``Sec. 405.580(c)(2) or (3)'' 
is removed, and the phrase ``Sec. 415.190(c)(2) or (c)(3) of this 
chapter'' is added in its place.

PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE 
PAYMENT

    3. The authority citation for part 411 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).


Sec. 411.15  [Amended]

    4. In Sec. 411.15(m)(2)(i), ``Sec. 405.550(b)'' is removed, and 
``Sec. 415.102(a)'' is added in its place.

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

    5. The authority citation for part 412 continues to read as 
follows:

    Authority: Secs. 1102, 1815(e), 1820, 1871, and 1886 of the 
Social Security Act (42 U.S.C. 1302, 1395g(e), 1395i-4, 1395hh, and 
1395ww).


Sec. 412.50  [Amended]

    6. In Sec. 412.50, the following changes are made:
    a. In paragraph (a), ``Sec. 405.550(b)'' is removed, and 
``Sec. 415.102(a)'' is added in its place.
    b. In paragraph (b), ``Sec. 405.550(b)'' is removed, and 
``Sec. 415.102(a)'' is added in its place.


Sec. 412.71  [Amended]

    7. In Sec. 412.71(c)(1)(i), ``Sec. 405.550(b)'' is removed, and 
``Sec. 415.102(a)'' is added in its place.


Sec. 412.105  [Amended]

    8. In Sec. 412.105(g)(1)(i)(A), ``Sec. 405.522(a)'' is removed, and 
``Sec. 415.200(a)'' is added in its place. 

[[Page 63189]]


PART 413--[AMENDED]

    9. The authority citation for part 413 continues to read as 
follows:

    Authority: Secs. 1102, 1861(v)(1)(A), and 1871 of the Social 
Security Act (42 U.S.C. 1302, 1395x(v)(1)(A), and 1395hh).


Sec. 413.5  [Amended]

    10. In Sec. 413.5(c)(9), the phrase ``(as described in Sec. 405.465 
of this chapter) where elected as provided for in Sec. 405.521 of this 
chapter.'' is removed, and the phrase ``(as described in Sec. 415.162 
of this chapter) if elected as provided for in Sec. 415.160 of this 
chapter.'' is added in its place.


Sec. 413.13  [Amended]

    11. In Sec. 413.13(g)(1)(i), the phrase ``Secs. 405.480 through 
405.482'' is removed, and the phrase ``Secs. 415.55 through 415.70'' is 
added in its place.


Sec. 413.80  [Amended]

    12. In Sec. 413.80(h), the phrase ``, as described in Sec. 414.450 
of this chapter,'' is removed.


Sec. 413.86  [Amended]

    13. In Sec. 413.86, the following changes are made:
    a. In paragraph (b), in the definition of ``Approved medical 
residency program'' in paragraph (1), ``Sec. 405.522(a)'' is removed, 
and ``Sec. 415.200(a)'' is added in its place.
    b. In paragraph (g)(1)(ii), ``Sec. 405.522(a)'' is removed, and 
``Sec. 415.200(a)'' is added in its place.


Sec. 413.174  [Amended]

    14. In Sec. 413.174(b)(4)(iv), the phrase ``Secs. 405.465 through 
405.482'' is removed, and the phrase ``Secs. 415.55 through 415.70, 
Sec. 415.162, and Sec. 415.164'' is added in its place.

PART 414--[AMENDED]


Sec. 414.58  [Amended]

    15. In Sec. 414.58, the following changes are made:
    a. In paragraph (a), the phrase ``Secs. 405.550 through 405.580'' 
is removed, and the phrase ``Secs. 415.100 through 415.130, and 
Sec. 415.190'' is added in its place.
    b. In paragraph (b), the phrase ``Sec. 405.465 of this chapter if 
the hospital exercises the election described in Sec. 405.521(c)(2) of 
this chapter'' is removed, and the phrase ``Sec. 415.162 of this 
chapter if the hospital exercises the election described in 
Sec. 415.160 of this chapter'' is added in its place.

PART 417--HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL 
PLANS, AND HEALTH CARE PREPAYMENT PLANS

    16. The authority citation for part 417 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh), secs. 1301, 1306, and 1310 of the Public 
Health Service Act (42 U.S.C. 300e, 300e-5, and 300e-9); and 31 
U.S.C. 9701.


Sec. 417.554  [Amended]

    17. In Sec. 417.554, the phrase ``Sec. 405.480, part 412 of this 
chapter, and Secs. 413.55 and 413.24'' is removed, and the phrase 
``part 412, Secs. 413.24, 413.55, and 415.55'' is added in its place.

PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL

    18. The authority citation for part 489 continues to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).


Sec. 489.20  [Amended]

    19. In Sec. 489.20(d)(1), ``Sec. 405.550(b)'' is removed, and 
``Sec. 415.102(a)'' is added in its place.


Sec. 489.21  [Amended]

    20. In Sec. 489.21(f), ``Sec. 405.550(b)'' is removed, and 
``Sec. 415.102(a)'' is added in its place.

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: November 28, 1995.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
    Dated: December 1, 1995.
Donna E. Shalala,
Secretary.

    Note: These addenda will not appear in the Code of Federal 
Regulations.

Addendum A--Explanation and Use of Addenda B Through E

    The addenda on the following pages provide various data 
pertaining to the Medicare fee schedule for physician services 
furnished in 1995. Addendum B contains the RVUs for work, practice 
expense, and malpractice expense, and other information for all 
services included in the physician fee schedule. Addendum C provides 
interim RVUs and related information for codes that are subject to 
comment. Each code listed in Addendum C is also included in Addendum 
B. Further explanations of the information in these addenda are 
provided at the beginning of each addendum.
    To compute a fee schedule amount according to the formula 
provided in the final rule, use the RVUs listed in Addendum B and 
the GPCIs for 1996 listed in Addendum D of this final rule. In 
applying the formula, use the appropriate CF: For services 
designated as surgical, use a CF of $40.7986. For primary care 
services, use a CF of $35.4173. For other nonsurgical services, use 
a CF of $34.6293.
    Addendum D lists the GPCIs for 1996.
    Addendum E lists the procedure codes subject to the site-of-
service differential.

Addendum B--1996 Relative Value Units and Related Information Used in 
Determining Medicare Payments for 1996

    This addendum contains the following information for each CPT 
code and alphanumeric HCPCS code, except for alphanumeric codes 
beginning with B (enteral and parenteral therapy), E (durable 
medical equipment), K (temporary codes for nonphysician services or 
items), or L (orthotics), and codes for anesthesiology.
    1. CPT/HCPCS code. This is the CPT or alphanumeric HCPCS number 
for the service. Alphanumeric HCPCS codes are included at the end of 
this addendum.
    2. Modifier. A modifier is shown if there is a technical 
component (modifier TC) and a professional component (PC) (modifier 
-26) for the service. If there is a PC and a TC for the service, 
Addendum B contains three entries for the code: One for the global 
values (both professional and technical); one for modifier -26 (PC); 
and one for modifier TC. The global service is not designated by a 
modifier, and physicians must bill using the code without a modifier 
if the physician furnishes both the PC and the TC of the service.
    3. Status indicator. This indicator shows whether the CPT/HCPCS 
code is in the physician fee schedule and whether it is separately 
payable if the service is covered.
    A = Active code. These codes are separately payable under the 
fee schedule if covered. There will be RVUs for codes with this 
status. The presence of an ``A'' indicator does not mean that 
Medicare has made a national decision regarding the coverage of the 
service. Carriers remain responsible for coverage decisions in the 
absence of a national Medicare policy.
    B = Bundled code. Payment for covered services is always bundled 
into payment for other services not specified. If RVUs are shown, 
they are not used for Medicare payment. If these services are 
covered, payment for them is subsumed by the payment for the 
services to which they are incident. (An example is a telephone call 
from a hospital nurse regarding care of a patient.)
    C = Carrier-priced code. Carriers will establish RVUs and 
payment amounts for these services, generally on a case-by-case 
basis following review of documentation, such as an operative 
report.
    D = Deleted code. These codes are deleted effective with the 
beginning of the calendar year. 

[[Page 63190]]

    E = Excluded from physician fee schedule by regulation. These 
codes are for items or services that we chose to exclude from the 
physician fee schedule payment by regulation. No RVUs are shown, and 
no payment may be made under the physician fee schedule for these 
codes. Payment for them, if they are covered, continues under 
reasonable charge or other payment procedures.
    G = Code not valid for Medicare purposes. Medicare does not 
recognize codes assigned this status. Medicare uses another code for 
reporting of, and payment for, these services.
    H = Deleted modifier. This code had TC and PC components in 
1995. For 1996, these components are deleted.
    N = Noncovered service. These codes are noncovered services. 
Medicare payment may not be made for these codes. If RVUs are shown, 
they are not used for Medicare payment.
    P = Bundled or excluded code. There are no RVUs for these 
services. No separate payment should be made for them under the 
physician fee schedule.

--If the item or service is covered as incident to a physician 
service and is furnished on the same day as a physician service, 
payment for it is bundled into the payment for the physician service 
to which it is incident (an example is an elastic bandage furnished 
by a physician incident to a physician service).
--If the item or service is covered as other than incident to a 
physician service, it is excluded from the physician fee schedule 
(for example, colostomy supplies) and is paid under the other 
payment provisions of the Act.

    R = Restricted coverage. Special coverage instructions apply. If 
the service is covered and no RVUs are shown, it is carrier-priced.
    T = Injections. There are RVUs for these services, but they are 
only paid if there are no other services payable under the physician 
fee schedule billed on the same date by the same provider. If any 
other services payable under the physician fee schedule are billed 
on the same date by the same provider, these services are bundled 
into the service(s) for which payment is made.
    X = Exclusion by law. These codes represent an item or service 
that is not within the definition of ``physician services'' for 
physician fee schedule payment purposes. No RVUs are shown for these 
codes, and no payment may be made under the physician fee schedule. 
(Examples are ambulance services and clinical diagnostic laboratory 
services.)
    4. Description of code. This is an abbreviated version of the 
narrative description of the code.
    5. Physician work RVUs. These are the RVUs for the physician 
work for this service in 1996. Codes that are not used for Medicare 
payment are identified with a ``#.''
    6. Practice expense RVUs. These are the RVUs for the practice 
expense for the service for 1996. Codes that are subject to the OBRA 
1993 practice expense reduction are identified by an asterisk in 
this column.
    7. Malpractice expense RVUs. These are the RVUs for the 
malpractice expense for the service for 1996.
    8. Total RVUs. This is the sum of the work, practice expense, 
and malpractice expense RVUs for 1996.
    9. Global period. This indicator shows the number of days in the 
global period for the code (0, 10, or 90 days). An explanation of 
the alpha codes follows:
    MMM = The code describes a service furnished in uncomplicated 
maternity cases including antepartum care, delivery, and postpartum 
care. The usual global surgical concept does not apply. See the 1996 
Physicians' Current Procedural Terminology for specific definitions.
    XXX = The global concept does not apply.
    YYY = The global period is to be set by the carrier (for 
example, unlisted surgery codes).
    ZZZ = The code is part of another service and falls within the 
global period for the other service.
    10. Update indicator. This column indicates whether the update 
for surgical procedures, primary care services, or other nonsurgical 
services applies to the CPT/HCPCS code in column 1. A ``0'' appears 
in this field for codes that are deleted in 1996 or are not paid 
under the physician fee schedule. A ``P'' in this column indicates 
that the update and CF for primary care services applies to this 
code. An ``N'' in this column indicates that the update and CF for 
other nonsurgical services applies to this code. An ``S'' in this 
column indicates that the separate update and CF for surgical 
procedures applies.

        \4\ * Indicates reduction of Practice 
Expense RVUs as a result of OBRA 1993.

                                            Addendum B.--Relative Value Units (RVUs) and Related Information                                            
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                Physician  Practice                                                     
CPT \1\/          MOD               Status                 Description          work RVUs   expense  Malpractice    Total    Global         Update      
  HCPCS                                                                            \3\     RVUs \4\      RVUs                period                     
---\2\--------------------------------------------------------------------------------------------------------------------------------------------------
10040...  ..................  A                   Acne surgery of skin abscess       1.34      0.32        0.03       1.69       010  S                 
10060...  ..................  A                   Drainage of skin abscess....       1.12      0.44        0.04       1.60       010  S                 
10061...  ..................  A                   Drainage of skin abscess....       2.48      0.64        0.06       3.18       010  S                 
10080...  ..................  A                   Drainage of pilonidal cyst..       1.62      0.50        0.05       2.17       010  N                 
10081...  ..................  A                   Drainage of pilonidal cyst..       2.40      1.11        0.16       3.67       010  S                 
10120...  ..................  A                   Remove foreign body.........       1.19      0.46        0.05       1.70       010  S                 
10121...  ..................  A                   Remove foreign body.........       2.64      1.00        0.12       3.76       010  S                 
10140...  ..................  A                   Drainage of hematoma/fluid..       1.48      0.48        0.05       2.01       010  S                 
10160...  ..................  A                   Puncture drainage of lesion.       1.15      0.38        0.05       1.58       010  S                 
10180...  ..................  A                   Complex drainage, wound.....       2.20      1.05        0.18       3.43       010  S                 
11000...  ..................  A                   Surgical cleansing of skin..       0.91      0.40        0.04       1.35       000  S                 
11001...  ..................  A                   Additional cleansing of skin       0.45      0.26        0.02       0.73       ZZZ  S                 
11040...  ..................  A                   Surgical cleansing, abrasion       0.50      0.40        0.04       0.94       000  S                 
11041...  ..................  A                   Surgical cleansing of skin..       0.82      0.56        0.06       1.44       000  S                 
11042...  ..................  A                   Cleansing of skin/tissue....       1.12      0.65        0.08       1.85       000  S                 
11043...  ..................  A                   Cleansing of tissue/muscle..       1.83      1.81        0.34       3.98       010  S                 
11044...  ..................  A                   Cleansing tissue/muscle/bone       2.28      2.82        0.49       5.59       010  S                 
11050...  ..................  A                   Trim skin lesion............       0.43      0.37        0.03       0.83       000  S                 
11051...  ..................  A                   Trim 2 to 4 skin lesions....       0.66      0.50        0.05       1.21       000  S                 
11052...  ..................  A                   Trim over 4 skin lesions....       0.86      0.41        0.04       1.31       000  S                 
11100...  ..................  A                   Biopsy of skin lesion.......       0.81      0.51        0.04       1.36       000  S                 
11101...  ..................  A                   Biopsy, each added lesion...       0.41      0.29        0.02       0.72       ZZZ  S                 
11200...  ..................  A                   Removal of skin tags........       0.69      0.43        0.04       1.16       010  S                 
11201...  ..................  A                   Removal of added skin tags..       0.26      0.17        0.02       0.45       ZZZ  S                 
11300...  ..................  A                   Shave skin lesion...........       0.51      0.53        0.05       1.09       000  S                 
11301...  ..................  A                   Shave skin lesion...........       0.85      0.67        0.06       1.58       000  S                 

[[Page 63191]]
                                                                                                                                                        
11302...  ..................  A                   Shave skin lesion...........       1.05      0.89        0.09       2.03       000  S                 
11303...  ..................  A                   Shave skin lesion...........       1.24      1.36        0.17       2.77       000  S                 
11305...  ..................  A                   Shave skin lesion...........       0.67      0.52        0.05       1.24       000  S                 
11306...  ..................  A                   Shave skin lesion...........       0.99      0.71        0.07       1.77       000  S                 
11307...  ..................  A                   Shave skin lesion...........       1.14      0.94        0.10       2.18       000  S                 
11308...  ..................  A                   Shave skin lesion...........       1.41      1.40        0.17       2.98       000  S                 
11310...  ..................  A                   Shave skin lesion...........       0.73      0.69        0.06       1.48       000  S                 
11311...  ..................  A                   Shave skin lesion...........       1.05      0.85        0.08       1.98       000  S                 
11312...  ..................  A                   Shave skin lesion...........       1.20      1.12        0.11       2.43       000  S                 
11313...  ..................  A                   Shave skin lesion...........       1.62      1.49        0.15       3.26       000  S                 
11400...  ..................  A                   Removal of skin lesion......       0.86      0.53        0.05       1.44       010  S                 
11401...  ..................  A                   Removal of skin lesion......       1.27      0.67        0.06       2.00       010  S                 
11402...  ..................  A                   Removal of skin lesion......       1.56      0.89        0.09       2.54       010  S                 
11403...  ..................  A                   Removal of skin lesion......       1.87      1.17        0.13       3.17       010  S                 
11404...  ..................  A                   Removal of skin lesion......       2.15      1.38        0.17       3.70       010  S                 
11406...  ..................  A                   Removal of skin lesion......       2.71      1.88        0.33       4.92       010  S                 
11420...  ..................  A                   Removal of skin lesion......       1.01      0.52        0.05       1.58       010  S                 
11421...  ..................  A                   Removal of skin lesion......       1.48      0.71        0.07       2.26       010  S                 
11422...  ..................  A                   Removal of skin lesion......       1.71      0.94        0.10       2.75       010  S                 
11423...  ..................  A                   Removal of skin lesion......       2.12      1.31        0.15       3.58       010  S                 
11424...  ..................  A                   Removal of skin lesion......       2.57      1.39        0.16       4.12       010  S                 
11426...  ..................  A                   Removal of skin lesion......       3.73      1.83        0.29       5.85       010  S                 
11440...  ..................  A                   Removal of skin lesion......       1.10      0.69        0.06       1.85       010  S                 
11441...  ..................  A                   Removal of skin lesion......       1.56      0.85        0.08       2.49       010  S                 
11442...  ..................  A                   Removal of skin lesion......       1.82      1.12        0.11       3.05       010  S                 
11443...  ..................  A                   Removal of skin lesion......       2.44      1.45        0.15       4.04       010  S                 
11444...  ..................  A                   Removal of skin lesion......       3.37      1.47        0.14       4.98       010  S                 
11446...  ..................  A                   Removal of skin lesion......       4.44      1.78        0.18       6.40       010  S                 
11450...  ..................  A                   Removal, sweat gland lesion.       2.58      2.68        0.44       5.70       090  S                 
11451...  ..................  A                   Removal, sweat gland lesion.       3.80      2.90        0.46       7.16       090  S                 
11462...  ..................  A                   Removal, sweat gland lesion.       2.36      2.41        0.36       5.13       090  S                 
11463...  ..................  A                   Removal, sweat gland lesion.       3.80      2.00        0.34       6.14       090  S                 
11470...  ..................  A                   Removal, sweat gland lesion.       3.10      2.78        0.45       6.33       090  S                 
11471...  ..................  A                   Removal, sweat gland lesion.       4.26      2.46        0.48       7.20       090  S                 
11600...  ..................  A                   Removal of skin lesion......       1.36      1.13        0.10       2.59       010  S                 
11601...  ..................  A                   Removal of skin lesion......       1.88      1.39        0.12       3.39       010  S                 
11602...  ..................  A                   Removal of skin lesion......       2.04      1.82        0.16       4.02       010  S                 
11603...  ..................  A                   Removal of skin lesion......       2.30      2.25        0.21       4.76       010  S                 
11604...  ..................  A                   Removal of skin lesion......       2.53      2.59        0.26       5.38       010  S                 
11606...  ..................  A                   Removal of skin lesion......       3.38      3.11        0.49       6.98       010  S                 
11620...  ..................  A                   Removal of skin lesion......       1.29      1.34        0.12       2.75       010  S                 
11621...  ..................  A                   Removal of skin lesion......       1.92      1.75        0.16       3.83       010  S                 
11622...  ..................  A                   Removal of skin lesion......       2.29      2.20        0.19       4.68       010  S                 
11623...  ..................  A                   Removal of skin lesion......       2.88      2.58        0.25       5.71       010  S                 
11624...  ..................  A                   Removal of skin lesion......       3.38      3.21        0.32       6.91       010  S                 
11626...  ..................  A                   Removal of skin lesion......       4.20      3.41        0.51       8.12       010  S                 
11640...  ..................  A                   Removal of skin lesion......       1.48      1.65        0.15       3.28       010  S                 
11641...  ..................  A                   Removal of skin lesion......       2.39      2.09        0.18       4.66       010  S                 
11642...  ..................  A                   Removal of skin lesion......       2.88      2.57        0.23       5.68       010  S                 
11643...  ..................  A                   Removal of skin lesion......       3.45      3.01        0.28       6.74       010  S                 
11644...  ..................  A                   Removal of skin lesion......       4.50      3.51        0.33       8.34       010  S                 
11646...  ..................  A                   Removal of skin lesion......       5.85      4.32        0.60      10.77       010  S                 
11700...  ..................  A                   Scraping of 1-5 nails.......       0.32      0.32        0.03       0.67       000  S                 
11701...  ..................  A                   Scraping of additional nails       0.23      0.23        0.02       0.48       ZZZ  S                 
11710...  ..................  A                   Scraping of 1-5 nails.......       0.32      0.32        0.03       0.67       000  S                 
11711...  ..................  A                   Scraping of additional nails       0.20      0.19        0.02       0.41       ZZZ  S                 
11730...  ..................  A                   Removal of nail plate.......       1.13      0.45        0.04       1.62       000  S                 
11731...  ..................  A                   Removal of second nail plate       0.55      0.51        0.05       1.11       ZZZ  S                 
11732...  ..................  A                   Remove additional nail plate       0.38      0.25        0.02       0.65       ZZZ  S                 
11740...  ..................  A                   Drain blood from under nail.       0.37      0.39        0.04       0.80       000  S                 
11750...  ..................  A                   Removal of nail bed.........       1.66      2.10        0.19       3.95       010  S                 
11752...  ..................  A                   Remove nail bed/finger tip..       2.37      2.82        0.36       5.55       010  S                 
11755...  ..................  A                   Biopsy, nail unit...........       1.31      0.99        0.12       2.42       000  S                 
11760...  ..................  A                   Reconstruction of nail bed..       1.53      0.93        0.09       2.55       010  S                 
11762...  ..................  A                   Reconstruction of nail bed..       2.84      2.57        0.24       5.65       010  S                 
11765...  ..................  A                   Excision of nail fold, toe..       0.64      0.51        0.05       1.20       010  S                 

[[Page 63192]]
                                                                                                                                                        
11770...  ..................  A                   Removal of pilonidal lesion.       2.56      2.67        0.44       5.67       010  S                 
11771...  ..................  A                   Removal of pilonidal lesion.       5.15      4.52        0.92      10.59       090  S                 
11772...  ..................  A                   Removal of pilonidal lesion.       6.36      4.82        1.01      12.19       090  S                 
11900...  ..................  A                   Injection into skin lesions.       0.52      0.25        0.02       0.79       000  S                 
11901...  ..................  A                   Added skin lesions injection       0.80      0.41        0.03       1.24       000  S                 
11920...  ..................  R                   Correct skin color defects..       1.61      1.18        0.23       3.02       000  S                 
11921...  ..................  R                   Correct skin color defects..       1.93      1.40        0.28       3.61       000  S                 
11922...  ..................  R                   Correct skin color defects..       0.49      0.36        0.07       0.92       ZZZ  S                 
11950...  ..................  R                   Therapy for contour defects.       0.84      1.19        0.11       2.14       000  S                 
11951...  ..................  R                   Therapy for contour defects.       1.19      1.19        0.11       2.49       000  S                 
11952...  ..................  R                   Therapy for contour defects.       1.69      1.19        0.11       2.99       000  S                 
11954...  ..................  R                   Therapy for contour defects.       1.85      1.19        0.11       3.15       000  S                 
11960...  ..................  A                   Insert tissue expander(s)...       6.04     *7.73        1.48      15.25       090  S                 
11970...  ..................  A                   Replace tissue expander.....       6.65     *8.51        1.61      16.77       090  S                 
11971...  ..................  A                   Remove tissue expander(s)...       1.51     *2.30        0.82       4.63       090  S                 
11975...  ..................  N                   Insert contraceptive cap....      #1.48      1.06        0.25       2.79       XXX  0                 
11976...  ..................  R                   Removal of contraceptive cap       1.78      1.28        0.30       3.36       XXX  N                 
11977...  ..................  N                   Removal/reinsert contra cap.      #3.30      2.36        0.55       6.21       XXX  0                 
12001...  ..................  A                   Repair superficial wound(s).       1.65      0.57        0.05       2.27       010  N                 
12002...  ..................  A                   Repair superficial wound(s).       1.81      0.79        0.07       2.67       010  N                 
12004...  ..................  A                   Repair superficial wound(s).       2.19      1.14        0.10       3.43       010  N                 
12005...  ..................  A                   Repair superficial wound(s).       2.81      1.47        0.14       4.42       010  N                 
12006...  ..................  A                   Repair superficial wound(s).       3.62      1.78        0.19       5.59       010  N                 
12007...  ..................  A                   Repair superficial wound(s).       4.07      1.80        0.19       6.06       010  S                 
12011...  ..................  A                   Repair superficial wound(s).       1.71      0.74        0.06       2.51       010  N                 
12013...  ..................  A                   Repair superficial wound(s).       1.94      1.03        0.08       3.05       010  N                 
12014...  ..................  A                   Repair superficial wound(s).       2.41      1.19        0.10       3.70       010  N                 
12015...  ..................  A                   Repair superficial wound(s).       3.14      1.62        0.14       4.90       010  N                 
12016...  ..................  A                   Repair superficial wound(s).       3.88      2.26        0.19       6.33       010  N                 
12017...  ..................  A                   Repair superficial wound(s).       4.66      3.36        0.31       8.33       010  N                 
12018...  ..................  A                   Repair superficial wound(s).       5.48      5.15        0.48      11.11       010  S                 
12020...  ..................  A                   Closure of split wound......       2.57      1.19        0.18       3.94       010  S                 
12021...  ..................  A                   Closure of split wound......       1.79      0.62        0.11       2.52       010  S                 
12031...  ..................  A                   Layer closure of wound(s)...       2.10      0.72        0.07       2.89       010  S                 
12032...  ..................  A                   Layer closure of wound(s)...       2.42      1.05        0.10       3.57       010  S                 
12034...  ..................  A                   Layer closure of wound(s)...       2.87      1.47        0.15       4.49       010  S                 
12035...  ..................  A                   Layer closure of wound(s)...       3.38      1.92        0.23       5.53       010  S                 
12036...  ..................  A                   Layer closure of wound(s)...       4.00      2.32        0.37       6.69       010  S                 
12037...  ..................  A                   Layer closure of wound(s)...       4.62      3.09        0.48       8.19       010  S                 
12041...  ..................  A                   Layer closure of wound(s)...       2.32      0.84        0.08       3.24       010  N                 
12042...  ..................  A                   Layer closure of wound(s)...       2.69      1.17        0.12       3.98       010  N                 
12044...  ..................  A                   Layer closure of wound(s)...       3.09      1.62        0.17       4.88       010  N                 
12045...  ..................  A                   Layer closure of wound(s)...       3.59      2.13        0.23       5.95       010  N                 
12046...  ..................  A                   Layer closure of wound(s)...       4.20      2.82        0.37       7.39       010  S                 
12047...  ..................  A                   Layer closure of wound(s)...       4.60      4.02        0.56       9.18       010  N                 
12051...  ..................  A                   Layer closure of wound(s)...       2.42      1.01        0.10       3.53       010  S                 
12052...  ..................  A                   Layer closure of wound(s)...       2.72      1.47        0.14       4.33       010  S                 
12053...  ..................  A                   Layer closure of wound(s)...       3.07      1.76        0.17       5.00       010  S                 
12054...  ..................  A                   Layer closure of wound(s)...       3.41      2.60        0.25       6.26       010  S                 
12055...  ..................  A                   Layer closure of wound(s)...       4.38      3.24        0.37       7.99       010  S                 
12056...  ..................  A                   Layer closure of wound(s)...       5.19      4.74        0.52      10.45       010  S                 
12057...  ..................  A                   Layer closure of wound(s)...       5.91      5.57        0.48      11.96       010  S                 
13100...  ..................  A                   Repair of wound or lesion...       3.07      1.14        0.13       4.34       010  S                 
13101...  ..................  A                   Repair of wound or lesion...       3.87      2.08        0.21       6.16       010  S                 
13120...  ..................  A                   Repair of wound or lesion...       3.25      1.35        0.17       4.77       010  S                 
13121...  ..................  A                   Repair of wound or lesion...       4.28      2.65        0.33       7.26       010  S                 
13131...  ..................  A                   Repair of wound or lesion...       3.74      1.98        0.23       5.95       010  S                 
13132...  ..................  A                   Repair of wound or lesion...       4.21      4.57        0.44       9.22       010  S                 
13150...  ..................  A                   Repair of wound or lesion...       3.76      1.76        0.23       5.75       010  S                 
13151...  ..................  A                   Repair of wound or lesion...       4.40      2.45        0.35       7.20       010  S                 
13152...  ..................  A                   Repair of wound or lesion...       6.28      5.13        0.68      12.09       010  S                 
13160...  ..................  A                   Late closure of wound.......       9.53      3.33        0.58      13.44       090  S                 
13300...  ..................  A                   Repair of wound or lesion...       5.11      5.71        0.86      11.68       010  S                 
14000...  ..................  A                   Skin tissue rearrangement...       5.43      3.41        0.38       9.22       090  S                 
14001...  ..................  A                   Skin tissue rearrangement...       7.78      4.75        0.76      13.29       090  S                 
14020...  ..................  A                   Skin tissue rearrangement...       6.08      4.90        0.49      11.47       090  S                 

[[Page 63193]]
                                                                                                                                                        
14021...  ..................  A                   Skin tissue rearrangement...       9.37      6.21        0.94      16.52       090  S                 
14040...  ..................  A                   Skin tissue rearrangement...       7.18      6.77        0.65      14.60       090  S                 
14041...  ..................  A                   Skin tissue rearrangement...      10.74      7.88        1.02      19.64       090  S                 
14060...  ..................  A                   Skin tissue rearrangement...       8.05      7.75        1.04      16.84       090  S                 
14061...  ..................  A                   Skin tissue rearrangement...      11.42     10.49        1.27      23.18       090  S                 
14300...  ..................  A                   Skin tissue rearrangement...      10.76     11.31        1.84      23.91       090  S                 
14350...  ..................  A                   Skin tissue rearrangement...       9.05      6.07        1.05      16.17       090  S                 
15000...  ..................  A                   Skin graft procedure........       1.95     *2.49        0.53       4.97       ZZZ  S                 
15050...  ..................  A                   Skin pinch graft procedure..       3.90      1.79        0.30       5.99       090  S                 
15100...  ..................  A                   Skin split graft procedure..       8.05      4.54        0.89      13.48       090  S                 
15101...  ..................  A                   Skin split graft procedure..       1.72      1.59        0.33       3.64       ZZZ  S                 
15120...  ..................  A                   Skin split graft procedure..       9.14      6.05        0.94      16.13       090  S                 
15121...  ..................  A                   Skin split graft procedure..       2.67      2.91        0.53       6.11       ZZZ  S                 
15200...  ..................  A                   Skin full graft procedure...       7.46      4.13        0.69      12.28       090  S                 
15201...  ..................  A                   Skin full graft procedure...       1.32     *1.68        0.50       3.50       ZZZ  S                 
15220...  ..................  A                   Skin full graft procedure...       7.42      4.84        0.85      13.11       090  S                 
15221...  ..................  A                   Skin full graft procedure...       1.19     *1.59        0.50       3.28       ZZZ  S                 
15240...  ..................  A                   Skin full graft procedure...       8.30      6.10        1.03      15.43       090  S                 
15241...  ..................  A                   Skin full graft procedure...       1.86     *2.38        0.58       4.82       ZZZ  S                 
15260...  ..................  A                   Skin full graft procedure...       9.56      7.46        0.99      18.01       090  S                 
15261...  ..................  A                   Skin full graft procedure...       2.23     *2.85        0.60       5.68       ZZZ  S                 
15350...  ..................  A                   Skin homograft procedure....       3.89      2.15        0.42       6.46       090  S                 
15400...  ..................  A                   Skin heterograft procedure..       4.91      1.06        0.17       6.14       090  S                 
15570...  ..................  A                   Form skin pedicle flap......       3.75     *5.50        2.08      11.33       090  S                 
15572...  ..................  A                   Form skin pedicle flap......       3.80     *5.38        1.86      11.04       090  S                 
15574...  ..................  A                   Form skin pedicle flap......       3.85     *5.40        1.66      10.91       090  S                 
15576...  ..................  A                   Form skin pedicle flap......       4.27      3.12        0.60       7.99       090  S                 
15580...  ..................  A                   Attach skin pedicle graft...       3.30     *4.31        1.30       8.91       090  S                 
15600...  ..................  A                   Skin graft procedure........       1.70     *2.51        0.88       5.09       090  S                 
15610...  ..................  A                   Skin graft procedure........       2.21     *2.82        0.80       5.83       090  S                 
15620...  ..................  A                   Skin graft procedure........       2.69     *3.44        0.86       6.99       090  S                 
15625...  ..................  A                   Skin graft procedure........       1.81     *2.41        0.78       5.00       090  S                 
15630...  ..................  A                   Skin graft procedure........       3.02     *3.86        0.90       7.78       090  S                 
15650...  ..................  A                   Transfer skin pedicle flap..       3.61     *4.62        0.93       9.16       090  S                 
15732...  ..................  A                   Muscle-skin graft, head/neck      12.10    *15.48        3.46      31.04       090  S                 
15734...  ..................  A                   Muscle-skin graft, trunk....      16.52     19.01        3.24      38.77       090  S                 
15736...  ..................  A                   Muscle-skin graft, arm......      15.26     16.21        3.02      34.49       090  S                 
15738...  ..................  A                   Muscle-skin graft, leg......      10.07    *12.89        3.29      26.25       090  S                 
15740...  ..................  A                   Island pedicle flap graft...       9.45     10.39        1.62      21.46       090  S                 
15750...  ..................  A                   Neurovascular pedicle graft.      10.61     11.96        2.03      24.60       090  S                 
15755...  ..................  A                   Microvascular flap graft....      28.33     30.09        5.33      63.75       090  S                 
15760...  ..................  A                   Composite skin graft........       8.28      7.29        1.11      16.68       090  S                 
15770...  ..................  A                   Derma-fat-fascia graft......       6.85      7.46        0.95      15.26       090  S                 
15775...  ..................  R                   Hair transplant punch grafts       3.96      2.88        0.56       7.40       000  S                 
15776...  ..................  R                   Hair transplant punch grafts       5.54      4.03        0.79      10.36       000  S                 
15780...  ..................  A                   Abrasion treatment of skin..       6.73      1.53        0.13       8.39       090  S                 
15781...  ..................  A                   Abrasion treatment of skin..       4.67      3.77        0.39       8.83       090  S                 
15782...  ..................  A                   Abrasion treatment of skin..       4.19      1.19        0.13       5.51       090  S                 
15783...  ..................  A                   Abrasion treatment of skin..       4.16      1.85        0.19       6.20       090  S                 
15786...  ..................  A                   Abrasion treatment of lesion       1.98      0.62        0.06       2.66       010  S                 
15787...  ..................  A                   Abrasion, added skin lesions       0.33      0.23        0.03       0.59       ZZZ  S                 
15788...  ..................  R                   Chemical peel, face, epiderm       1.96      1.48        0.12       3.56       090  S                 
15789...  ..................  R                   Chemical peel, face, dermal.       4.69      1.48        0.12       6.29       090  S                 
15792...  ..................  R                   Chemical peel, nonfacial....       1.73      0.50        0.05       2.28       090  S                 
15793...  ..................  A                   Chemical peel, nonfacial....       3.51      0.50        0.05       4.06       090  S                 
15810...  ..................  A                   Salabrasion.................       4.49      3.80        0.29       8.58       090  S                 
15811...  ..................  A                   Salabrasion.................       5.14      3.74        0.73       9.61       090  S                 
15819...  ..................  A                   Plastic surgery, neck.......       8.87      8.01        0.87      17.75       090  S                 
15820...  ..................  A                   Revision of lower eyelid....       4.80     *6.14        0.64      11.58       090  S                 
15821...  ..................  A                   Revision of lower eyelid....       5.37     *6.87        0.68      12.92       090  S                 
15822...  ..................  A                   Revision of upper eyelid....       4.27     *5.47        0.56      10.30       090  S                 
15823...  ..................  A                   Revision of upper eyelid....       6.65      7.71        0.61      14.97       090  S                 
15824...  ..................  R                   Removal of forehead wrinkles       0.00      0.00        0.00       0.00       XXX  S                 
15825...  ..................  R                   Removal of neck wrinkles....       0.00      0.00        0.00       0.00       XXX  S                 
15826...  ..................  R                   Removal of brow wrinkles....       0.00      0.00        0.00       0.00       XXX  S                 
15828...  ..................  R                   Removal of face wrinkles....       0.00      0.00        0.00       0.00       XXX  S                 

[[Page 63194]]
                                                                                                                                                        
15829...  ..................  R                   Removal of skin wrinkles....       0.00      0.00        0.00       0.00       XXX  S                 
15831...  ..................  A                   Excise excessive skin tissue      11.66      9.84        2.01      23.51       090  S                 
15832...  ..................  A                   Excise excessive skin tissue      10.97      8.29        1.33      20.59       090  S                 
15833...  ..................  A                   Excise excessive skin tissue      10.02      6.22        1.12      17.36       090  S                 
15834...  ..................  A                   Excise excessive skin tissue      10.16      7.18        1.22      18.56       090  S                 
15835...  ..................  A                   Excise excessive skin tissue      10.98      7.00        1.22      19.20       090  S                 
15836...  ..................  A                   Excise excessive skin tissue       8.83      5.80        1.10      15.73       090  S                 
15837...  ..................  A                   Excise excessive skin tissue       8.08      5.97        0.85      14.90       090  S                 
15838...  ..................  A                   Excise excessive skin tissue       6.78      5.88        0.73      13.39       090  S                 
15839...  ..................  A                   Excise excessive skin tissue       8.92      2.44        0.46      11.82       090  S                 
15840...  ..................  A                   Graft for face nerve palsy..      12.26     15.54        2.28      30.08       090  S                 
15841...  ..................  A                   Graft for face nerve palsy..      21.53     16.87        2.76      41.16       090  S                 
15842...  ..................  A                   Graft for face nerve palsy..      35.98     29.00        2.68      67.66       090  S                 
15845...  ..................  A                   Skin and muscle repair, face      11.80    *15.10        2.54      29.44       090  S                 
15850...  ..................  B                   Removal of sutures..........      #0.78      0.36        0.04       1.18       XXX  0                 
15851...  ..................  A                   Removal of sutures..........       0.86      0.30        0.03       1.19       000  N                 
15852...  ..................  A                   Dressing change, not for           0.86      0.44        0.07       1.37       000  N                 
                                                   burn.                                                                                                
15860...  ..................  A                   Test for blood flow in graft       1.95      1.35        0.25       3.55       000  S                 
15876...  ..................  R                   Suction assisted lipectomy..       0.00      0.00        0.00       0.00       XXX  S                 
15877...  ..................  R                   Suction assisted lipectomy..       0.00      0.00        0.00       0.00       XXX  S                 
15878...  ..................  R                   Suction assisted lipectomy..       0.00      0.00        0.00       0.00       XXX  S                 
15879...  ..................  R                   Suction assisted lipectomy..       0.00      0.00        0.00       0.00       XXX  S                 
15920...  ..................  A                   Removal of tail bone ulcer..       7.37      2.95        0.63      10.95       090  S                 
15922...  ..................  A                   Removal of tail bone ulcer..       9.17      5.98        1.19      16.34       090  S                 
15931...  ..................  A                   Remove sacrum pressure sore.       8.13      2.93        0.55      11.61       090  S                 
15933...  ..................  A                   Remove sacrum pressure sore.       9.64      6.92        1.43      17.99       090  S                 
15934...  ..................  A                   Remove sacrum pressure sore.      11.40      7.46        1.50      20.36       090  S                 
15935...  ..................  A                   Remove sacrum pressure sore.      13.05     11.24        2.27      26.56       090  S                 
15936...  ..................  A                   Remove sacrum pressure sore.      11.31     10.27        2.05      23.63       090  S                 
15937...  ..................  A                   Remove sacrum pressure sore.      12.98     13.47        2.67      29.12       090  S                 
15940...  ..................  A                   Removal of pressure sore....       8.19      3.55        0.73      12.47       090  S                 
15941...  ..................  A                   Removal of pressure sore....      10.15      7.05        1.39      18.59       090  S                 
15944...  ..................  A                   Removal of pressure sore....      10.18      9.26        1.82      21.26       090  S                 
15945...  ..................  A                   Removal of pressure sore....      11.32     11.14        2.09      24.55       090  S                 
15946...  ..................  A                   Removal of pressure sore....      19.81     16.61        3.24      39.66       090  S                 
15950...  ..................  A                   Remove thigh pressure sore..       6.79      3.01        0.58      10.38       090  S                 
15951...  ..................  A                   Remove thigh pressure sore..       9.57      7.65        1.58      18.80       090  S                 
15952...  ..................  A                   Remove thigh pressure sore..      10.18      7.13        1.37      18.68       090  S                 
15953...  ..................  A                   Remove thigh pressure sore..      11.39      9.08        1.87      22.34       090  S                 
15956...  ..................  A                   Remove thigh pressure sore..      13.93     17.17        3.39      34.49       090  S                 
15958...  ..................  A                   Remove thigh pressure sore..      13.89    *17.77        3.76      35.42       090  S                 
15999...  ..................  C                   Removal of pressure sore....       0.00      0.00        0.00       0.00       YYY  S                 
16000...  ..................  A                   Initial treatment of burn(s)       0.89      0.35        0.03       1.27       000  N                 
16010...  ..................  A                   Treatment of burn(s)........       0.87      0.32        0.03       1.22       000  N                 
16015...  ..................  A                   Treatment of burn(s)........       2.35      2.04        0.38       4.77       000  S                 
16020...  ..................  A                   Treatment of burn(s)........       0.80      0.34        0.03       1.17       000  N                 
16025...  ..................  A                   Treatment of burn(s)........       1.85      0.45        0.05       2.35       000  S                 
16030...  ..................  A                   Treatment of burn(s)........       2.08      0.52        0.08       2.68       000  S                 
16035...  ..................  A                   Incision of burn scab.......       4.53      1.88        0.34       6.75       090  S                 
16040...  ..................  A                   Burn wound excision.........       1.02     *1.56        0.53       3.11       000  S                 
16041...  ..................  A                   Burn wound excision.........       2.70      3.16        0.53       6.39       000  S                 
16042...  ..................  A                   Burn wound excision.........       2.35     *3.02        0.53       5.90       000  S                 
17000...  ..................  A                   Destroy benign/premal lesion       0.64      0.42        0.03       1.09       010  S                 
17001...  ..................  A                   Destruction of add'l lesions       0.19      0.19        0.02       0.40       ZZZ  S                 
17002...  ..................  A                   Destruction of add'l lesions       0.19      0.10        0.01       0.30       ZZZ  S                 
17010...  ..................  A                   Destruction skin lesion(s)..       1.01      0.48        0.04       1.53       010  S                 
17100...  ..................  A                   Destruction of skin lesion..       0.53      0.37        0.03       0.93       010  S                 
17101...  ..................  A                   Destruction of 2nd lesion...       0.11      0.18        0.02       0.31       ZZZ  S                 
17102...  ..................  A                   Destruction of add'l lesions       0.11      0.08        0.01       0.20       ZZZ  S                 
17104...  ..................  A                   Destruction of skin lesions.       2.01      0.07        0.01       2.09       010  S                 
17105...  ..................  A                   Destruction of skin lesions.       0.76      0.31        0.03       1.10       010  S                 
17106...  ..................  A                   Destruction of skin lesions.       4.54      1.93        0.18       6.65       090  S                 
17107...  ..................  A                   Destruction of skin lesions.       9.06      3.70        0.39      13.15       090  S                 
17108...  ..................  A                   Destruction of skin lesions.      13.10      9.32        0.69      23.11       090  S                 
17110...  ..................  A                   Destruction of skin lesions.       0.55      0.40        0.03       0.98       010  S                 
17200...  ..................  A                   Electrocautery of skin tags.       0.59      0.41        0.04       1.04       010  S                 

[[Page 63195]]
                                                                                                                                                        
17201...  ..................  A                   Electrocautery added lesions       0.38      0.15        0.01       0.54       ZZZ  S                 
17250...  ..................  A                   Chemical cautery, tissue....       0.50      0.34        0.04       0.88       000  S                 
17260...  ..................  A                   Destruction of skin lesions.       0.86      1.13        0.10       2.09       010  S                 
17261...  ..................  A                   Destruction of skin lesions.       1.12      1.39        0.12       2.63       010  S                 
17262...  ..................  A                   Destruction of skin lesions.       1.53      1.82        0.16       3.51       010  S                 
17263...  ..................  A                   Destruction of skin lesions.       1.74      2.25        0.21       4.20       010  S                 
17264...  ..................  A                   Destruction of skin lesions.       1.89      2.59        0.26       4.74       010  S                 
17266...  ..................  A                   Destruction of skin lesions.       2.29      3.11        0.49       5.89       010  S                 
17270...  ..................  A                   Destruction of skin lesions.       1.27      1.34        0.12       2.73       010  S                 
17271...  ..................  A                   Destruction of skin lesions.       1.44      1.75        0.16       3.35       010  S                 
17272...  ..................  A                   Destruction of skin lesions.       1.72      2.20        0.19       4.11       010  S                 
17273...  ..................  A                   Destruction of skin lesions.       2.00      2.58        0.25       4.83       010  S                 
17274...  ..................  A                   Destruction of skin lesions.       2.54      3.21        0.32       6.07       010  S                 
17276...  ..................  A                   Destruction of skin lesions.       3.15      3.41        0.51       7.07       010  S                 
17280...  ..................  A                   Destruction of skin lesions.       1.12      1.65        0.15       2.92       010  S                 
17281...  ..................  A                   Destruction of skin lesions.       1.67      2.09        0.18       3.94       010  S                 
17282...  ..................  A                   Destruction of skin lesions.       1.99      2.57        0.23       4.79       010  S                 
17283...  ..................  A                   Destruction of skin lesions.       2.59      3.01        0.28       5.88       010  S                 
17284...  ..................  A                   Destruction of skin lesions.       3.16      3.51        0.33       7.00       010  S                 
17286...  ..................  A                   Destruction of skin lesions.       4.39      4.32        0.60       9.31       010  S                 
17304...  ..................  A                   Chemosurgery of skin lesion.       7.60      4.02        0.31      11.93       000  S                 
17305...  ..................  A                   2nd stage chemosurgery......       2.85      2.26        0.17       5.28       000  S                 
17306...  ..................  A                   3rd stage chemosurgery......       2.85      1.40        0.11       4.36       000  S                 
17307...  ..................  A                   Followup skin lesion therapy       2.85      1.47        0.12       4.44       000  S                 
17310...  ..................  A                   Extensive skin chemosurgery.       0.95      0.13        0.01       1.09       000  S                 
17340...  ..................  A                   Cryotherapy of skin.........       0.73      0.28        0.02       1.03       010  S                 
17360...  ..................  A                   Skin peel therapy...........       1.40      0.27        0.02       1.69       010  S                 
17380...  ..................  R                   Hair removal by electrolysis       0.00      0.00        0.00       0.00       XXX  S                 
17999...  ..................  C                   Skin tissue procedure.......       0.00      0.00        0.00       0.00       YYY  S                 
19000...  ..................  A                   Drainage of breast lesion...       0.84      0.38        0.07       1.29       000  S                 
19001...  ..................  A                   Drain added breast lesion...       0.42      0.24        0.05       0.71       ZZZ  S                 
19020...  ..................  A                   Incision of breast lesion...       3.37      1.40        0.28       5.05       090  S                 
19030...  ..................  A                   Injection for breast x-ray..       1.53      0.49        0.04       2.06       000  N                 
19100...  ..................  A                   Biopsy of breast............       1.27      0.64        0.13       2.04       000  S                 
19101...  ..................  A                   Biopsy of breast............       3.13      2.34        0.45       5.92       010  S                 
19110...  ..................  A                   Nipple exploration..........       4.15      2.46        0.51       7.12       090  S                 
19112...  ..................  A                   Excise breast duct fistula..       3.52      2.34        0.35       6.21       090  S                 
19120...  ..................  A                   Removal of breast lesion....       4.84      2.90        0.60       8.34       090  S                 
19125...  ..................  A                   Excision, breast lesion.....       5.85      2.90        0.60       9.35       090  S                 
19126...  ..................  A                   Excision, add'l breast             2.93      1.45        0.31       4.69       ZZZ  S                 
                                                   lesion.                                                                                              
19140...  ..................  A                   Removal of breast tissue....       4.90      4.29        0.91      10.10       090  S                 
19160...  ..................  A                   Removal of breast tissue....       6.65      4.13        0.88      11.66       090  S                 
19162...  ..................  A                   Remove breast tissue, nodes.      12.81      9.38        1.96      24.15       090  S                 
19180...  ..................  A                   Removal of breast...........       8.15      5.61        1.17      14.93       090  S                 
19182...  ..................  A                   Removal of breast...........       7.28      6.07        1.27      14.62       090  S                 
19200...  ..................  A                   Removal of breast...........      14.23     10.22        2.15      26.60       090  S                 
19220...  ..................  A                   Removal of breast...........      14.23     10.73        2.38      27.34       090  S                 
19240...  ..................  A                   Removal of breast...........      14.71      9.44        1.99      26.14       090  S                 
19260...  ..................  A                   Removal of chest wall lesion      13.91      5.05        1.04      20.00       090  S                 
19271...  ..................  A                   Revision of chest wall......      17.07     13.95        2.77      33.79       090  S                 
19272...  ..................  A                   Extensive chest wall surgery      19.47     12.60        2.56      34.63       090  S                 
19290...  ..................  A                   Place needle wire, breast...       1.27      0.44        0.07       1.78       000  S                 
19291...  ..................  A                   Place needle wire, breast...       0.63      0.25        0.04       0.92       ZZZ  S                 
19316...  ..................  A                   Suspension of breast........      10.07     12.84        2.43      25.34       090  S                 
19318...  ..................  A                   Reduction of large breast...      11.08    *14.18        3.23      28.49       090  S                 
19324...  ..................  A                   Enlarge breast..............       5.55      3.29        0.67       9.51       090  S                 
19325...  ..................  A                   Enlarge breast with implant.       8.05      5.87        1.13      15.05       090  S                 
19328...  ..................  A                   Removal of breast implant...       5.32      3.76        0.73       9.81       090  S                 
19330...  ..................  A                   Removal of implant material.       7.18      3.88        0.75      11.81       090  S                 
19340...  ..................  A                   Immediate breast prosthesis.       6.33     *8.10        2.06      16.49       ZZZ  S                 
19342...  ..................  A                   Delayed breast prosthesis...      10.64     10.81        2.03      23.48       090  S                 
19350...  ..................  A                   Breast reconstruction.......       8.21      7.08        1.38      16.67       090  S                 
19355...  ..................  A                   Correct inverted nipple(s)..       7.27      4.93        1.00      13.20       090  S                 
19357...  ..................  A                   Breast reconstruction.......      16.72     12.15        2.37      31.24       090  S                 
19361...  ..................  A                   Breast reconstruction.......      17.82     20.13        3.88      41.83       090  S                 
19364...  ..................  A                   Breast reconstruction.......      27.60     16.68        3.58      47.86       090  S                 

[[Page 63196]]
                                                                                                                                                        
19366...  ..................  A                   Breast reconstruction.......      19.84     16.40        3.18      39.42       090  S                 
19367...  ..................  A                   Breast reconstruction.......      24.73     20.13        3.88      48.74       090  S                 
19368...  ..................  A                   Breast reconstruction.......      31.15     20.13        3.88      55.16       090  S                 
19369...  ..................  A                   Breast reconstruction.......      28.68     20.13        3.88      52.69       090  S                 
19370...  ..................  A                   Surgery of breast capsule...       7.59      6.17        1.19      14.95       090  S                 
19371...  ..................  A                   Removal of breast capsule...       8.84      7.91        1.54      18.29       090  S                 
19380...  ..................  A                   Revise breast reconstruction       8.63      8.11        1.57      18.31       090  S                 
19396...  ..................  A                   Design custom breast implant       2.17      1.57        0.31       4.05       000  S                 
19499...  ..................  C                   Breast surgery procedure....       0.00      0.00        0.00       0.00       YYY  S                 
20000...  ..................  A                   Incision of abscess.........       1.85      0.85        0.08       2.78       010  S                 
20005...  ..................  A                   Incision of deep abscess....       3.02      1.83        0.28       5.13       010  S                 
20100...  ..................  A                   Explore wound, neck.........       9.50      4.97        1.16      15.63       010  S                 
20101...  ..................  A                   Explore wound, chest........       3.00      1.57        0.37       4.94       010  S                 
20102...  ..................  A                   Explore wound, abdomen......       3.68      1.92        0.45       6.05       010  S                 
20103...  ..................  A                   Explore wound, extremity....       4.95      2.59        0.60       8.14       010  S                 
20200...  ..................  A                   Muscle biopsy...............       1.46      1.12        0.18       2.76       000  S                 
20205...  ..................  A                   Deep muscle biopsy..........       2.35      1.88        0.33       4.56       000  S                 
20206...  ..................  A                   Needle biopsy, muscle.......       0.99      0.96        0.14       2.09       000  S                 
20220...  ..................  A                   Bone biopsy, trocar/needle..       1.27      1.31        0.09       2.67       000  N                 
20225...  ..................  A                   Bone biopsy, trocar/needle..       1.87     *2.39        0.28       4.54       000  N                 
20240...  ..................  A                   Bone biopsy, excisional.....       3.07      1.88        0.18       5.13       010  S                 
20245...  ..................  A                   Bone biopsy, excisional.....       3.68      3.58        0.44       7.70       010  S                 
20250...  ..................  A                   Open bone biopsy............       4.63      5.07        0.76      10.46       010  S                 
20251...  ..................  A                   Open bone biopsy............       5.16      5.84        0.92      11.92       010  S                 
20500...  ..................  A                   Injection of sinus tract....       1.18      0.36        0.04       1.58       010  N                 
20501...  ..................  A                   Inject sinus tract for x-ray       0.76      0.30        0.02       1.08       000  N                 
20520...  ..................  A                   Removal of foreign body.....       1.80      0.71        0.08       2.59       010  S                 
20525...  ..................  A                   Removal of foreign body.....       3.23      2.23        0.33       5.79       010  S                 
20550...  ..................  A                   Inj tendon/ligament/cyst....       0.86      0.38        0.04       1.28       000  N                 
20600...  ..................  A                   Drain/inject joint/bursa....       0.66      0.47        0.05       1.18       000  S                 
20605...  ..................  A                   Drain/inject joint/bursa....       0.68      0.45        0.05       1.18       000  S                 
20610...  ..................  A                   Drain/inject joint/bursa....       0.79      0.45        0.05       1.29       000  N                 
20615...  ..................  A                   Treatment of bone cyst......       2.23      0.49        0.06       2.78       010  N                 
20650...  ..................  A                   Insert and remove bone pin..       2.07      1.08        0.14       3.29       010  S                 
20660...  ..................  A                   Apply, remove fixation             2.51      1.56        0.21       4.28       000  S                 
                                                   device.                                                                                              
20661...  ..................  A                   Application of head brace...       4.27      3.82        0.65       8.74       090  S                 
20662...  ..................  A                   Application of pelvis brace.       5.52      6.54        1.03      13.09       090  S                 
20663...  ..................  A                   Application of thigh brace..       4.88      4.64        0.76      10.28       090  S                 
20665...  ..................  A                   Removal of fixation device..       1.26      0.50        0.07       1.83       010  S                 
20670...  ..................  A                   Removal of support implant..       1.69      0.74        0.11       2.54       010  S                 
20680...  ..................  A                   Removal of support implant..       3.25      3.33        0.51       7.09       090  S                 
20690...  ..................  A                   Apply bone fixation device..       3.52      3.66        0.58       7.76       ZZZ  S                 
20692...  ..................  A                   Apply bone fixation device..       6.41      5.51        0.89      12.81       ZZZ  S                 
20693...  ..................  A                   Adjust bone fixation device.       5.42      2.49        0.42       8.33       090  S                 
20694...  ..................  A                   Remove bone fixation device.       3.81      2.60        0.41       6.82       090  S                 
20802...  ..................  A                   Replantation, arm, complete.      39.56     37.72        6.17      83.45       090  S                 
20804...  ..................  D                   Replantation, arm, partial..       0.00      0.00        0.00       0.00       090  S                 
20805...  ..................  A                   Replant forearm, complete...      48.41     46.17        7.56     102.14       090  S                 
20806...  ..................  D                   Replantation, forearm,             0.00      0.00        0.00       0.00       090  S                 
                                                   partial.                                                                                             
20808...  ..................  A                   Replantation, hand, complete      60.19     57.40        9.40     126.99       090  S                 
20812...  ..................  D                   Replantation, hand, partial.       0.00      0.00        0.00       0.00       090  S                 
20816...  ..................  A                   Replantation digit, complete      29.67     28.30        4.63      62.60       090  S                 
20820...  ..................  D                   Replantation, digit, partial       0.00      0.00        0.00       0.00       090  S                 
20822...  ..................  A                   Replantation digit, complete      24.53     23.39        3.83      51.75       090  S                 
20823...  ..................  D                   Replantation, digit, partial       0.00      0.00        0.00       0.00       090  S                 
20824...  ..................  A                   Replantation thumb, complete      29.67     28.30        4.63      62.60       090  S                 
20826...  ..................  D                   Replantation, thumb, partial       0.00      0.00        0.00       0.00       090  S                 
20827...  ..................  A                   Replantation thumb, complete      25.22     24.05        3.94      53.21       090  S                 
20828...  ..................  D                   Replantation, thumb, partial       0.00      0.00        0.00       0.00       090  S                 
20832...  ..................  D                   Replantation, leg, complete.       0.00      0.00        0.00       0.00       090  S                 
20834...  ..................  D                   Replantation, leg, partial..       0.00      0.00        0.00       0.00       090  S                 
20838...  ..................  A                   Replantation, foot, complete      39.56     37.72        6.17      83.45       090  S                 
20840...  ..................  D                   Replantation, foot, partial.       0.00      0.00        0.00       0.00       090  S                 
20900...  ..................  A                   Removal of bone for graft...       5.03      2.80        0.45       8.28       090  S                 
20902...  ..................  A                   Removal of bone for graft...       6.74      4.95        0.80      12.49       090  S                 
20910...  ..................  A                   Remove cartilage for graft..       5.03      0.79        0.09       5.91       090  S                 

[[Page 63197]]
                                                                                                                                                        
20912...  ..................  A                   Remove cartilage for graft..       6.04      4.62        0.64      11.30       090  S                 
20920...  ..................  A                   Removal of fascia for graft.       4.87      3.93        0.50       9.30       090  S                 
20922...  ..................  A                   Removal of fascia for graft.       6.04      4.39        0.71      11.14       090  S                 
20924...  ..................  A                   Removal of tendon for graft.       6.04      5.45        0.85      12.34       090  S                 
20926...  ..................  A                   Removal of tissue for graft.       5.03      2.59        0.39       8.01       090  S                 
20930...  ..................  B                   Spinal bone allograft.......       0.00      0.00        0.00       0.00       XXX  0                 
20931...  ..................  A                   Spinal bone allograft.......       1.81      1.73        0.28       3.82       ZZZ  S                 
20936...  ..................  B                   Spinal bone autograft.......       0.00      0.00        0.00       0.00       XXX  0                 
20937...  ..................  A                   Spinal bone autograft.......       2.79      2.66        0.44       5.89       ZZZ  S                 
20938...  ..................  A                   Spinal bone autograft.......       3.02      2.88        0.47       6.37       ZZZ  S                 
20950...  ..................  A                   Record fluid pressure,             1.26      1.09        0.17       2.52       000  S                 
                                                   muscle.                                                                                              
20955...  ..................  A                   Microvascular fibula graft..      37.58     35.84        5.87      79.29       090  S                 
20960...  ..................  C                   Microvascular rib graft.....       0.00      0.00        0.00       0.00       090  S                 
20962...  ..................  C                   Microvascular bone graft....       0.00      0.00        0.00       0.00       090  S                 
20969...  ..................  A                   Bone-skin graft.............      42.08     40.13        6.57      88.78       090  S                 
20970...  ..................  A                   Bone-skin graft, pelvis.....      41.22     39.31        6.44      86.97       090  S                 
20971...  ..................  C                   Bone-skin graft, rib........       0.00      0.00        0.00       0.00       090  S                 
20972...  ..................  A                   Bone-skin graft, metatarsal.      41.54     39.61        6.49      87.64       090  S                 
20973...  ..................  A                   Bone-skin graft, great toe..      44.31     42.25        6.91      93.47       090  S                 
20974...  ..................  A                   Electrical bone stimulation.       0.62      3.42        0.53       4.57       ZZZ  S                 
20975...  ..................  A                   Electrical bone stimulation.       2.60     *3.33        0.56       6.49       ZZZ  S                 
20999...  ..................  C                   Musculoskeletal surgery.....       0.00      0.00        0.00       0.00       YYY  S                 
21010...  ..................  A                   Incision of jaw joint.......       9.06     10.24        0.93      20.23       090  S                 
21015...  ..................  A                   Resection of facial tumor...       4.94     *6.32        1.13      12.39       090  S                 
21025...  ..................  A                   Excision of bone, lower jaw.       5.03      4.14        0.38       9.55       090  S                 
21026...  ..................  A                   Excision of facial bone(s)..       4.53      3.14        0.28       7.95       090  S                 
21029...  ..................  A                   Contour of face bone lesion.       7.21     *9.23        0.78      17.22       090  S                 
21030...  ..................  A                   Removal of face bone lesion.       7.05      3.35        0.29      10.69       090  S                 
21031...  ..................  A                   Remove exostosis, mandible..       2.01      3.68        0.32       6.01       090  S                 
21032...  ..................  A                   Remove exostosis, maxilla...       4.27      3.88        0.35       8.50       090  S                 
21034...  ..................  A                   Removal of face bone lesion.      15.11      6.98        0.89      22.98       090  S                 
21040...  ..................  A                   Removal of jaw bone lesion..       2.01      2.76        0.24       5.01       090  S                 
21041...  ..................  A                   Removal of jaw bone lesion..       5.03      5.76        0.50      11.29       090  S                 
21044...  ..................  A                   Removal of jaw bone lesion..      11.08      9.55        1.11      21.74       090  S                 
21045...  ..................  A                   Extensive jaw surgery.......      15.11     13.83        1.58      30.52       090  S                 
21050...  ..................  A                   Removal of jaw joint........      10.07     12.33        1.08      23.48       090  S                 
21060...  ..................  A                   Remove jaw joint cartilage..       9.56     11.59        1.04      22.19       090  S                 
21070...  ..................  A                   Remove coronoid process.....       7.66      6.81        0.82      15.29       090  S                 
21076...  ..................  A                   Prepare face/oral prosthesis      12.54     16.77        1.35      30.66       010  S                 
21077...  ..................  A                   Prepare face/oral prosthesis      31.54     42.18        3.39      77.11       090  S                 
21079...  ..................  A                   Prepare face/oral prosthesis      20.88     27.93        2.25      51.06       090  S                 
21080...  ..................  A                   Prepare face/oral prosthesis      23.46     31.38        2.52      57.36       090  S                 
21081...  ..................  A                   Prepare face/oral prosthesis      21.38     28.59        2.30      52.27       090  S                 
21082...  ..................  A                   Prepare face/oral prosthesis      19.50     26.08        2.10      47.68       090  S                 
21083...  ..................  A                   Prepare face/oral prosthesis      18.04     24.13        1.94      44.11       090  S                 
21084...  ..................  A                   Prepare face/oral prosthesis      21.04     28.14        2.28      51.46       090  S                 
21085...  ..................  A                   Prepare face/oral prosthesis       8.41     11.25        0.90      20.56       010  S                 
21086...  ..................  A                   Prepare face/oral prosthesis      23.29     31.15        2.51      56.95       090  S                 
21087...  ..................  A                   Prepare face/oral prosthesis      23.29     31.15        2.51      56.95       090  S                 
21088...  ..................  C                   Prepare face/oral prosthesis       0.00      0.00        0.00       0.00       090  S                 
21089...  ..................  C                   Prepare face/oral prosthesis       0.00      0.00        0.00       0.00       090  S                 
21100...  ..................  A                   Maxillofacial fixation......       4.04      1.06        0.11       5.21       090  S                 
21110...  ..................  A                   Interdental fixation........       5.03      5.53        0.46      11.02       090  S                 
21116...  ..................  A                   Injection, jaw joint x-ray..       0.81      0.73        0.06       1.60       000  S                 
21120...  ..................  A                   Reconstruction of chin......       4.75      3.59        0.42       8.76       090  S                 
21121...  ..................  A                   Reconstruction of chin......       7.46      5.65        0.66      13.77       090  S                 
21122...  ..................  A                   Reconstruction of chin......       8.21      6.23        0.73      15.17       090  S                 
21123...  ..................  A                   Reconstruction of chin......      10.74      8.14        0.95      19.83       090  S                 
21125...  ..................  A                   Augmentation lower jaw bone.       6.22      4.72        0.54      11.48       090  S                 
21127...  ..................  A                   Augmentation lower jaw bone.      10.43      7.91        0.92      19.26       090  S                 
21137...  ..................  A                   Reduction of forehead.......       9.40      7.11        0.83      17.34       090  S                 
21138...  ..................  A                   Reduction of forehead.......      11.72      8.86        1.04      21.62       090  S                 
21139...  ..................  A                   Reduction of forehead.......      14.06     10.64        1.25      25.95       090  S                 
21141...  ..................  A                   Reconstruct midface, lefort.      16.92     14.34        1.68      32.94       090  S                 
21142...  ..................  A                   Reconstruct midface, lefort.      17.58     14.84        1.74      34.16       090  S                 
21143...  ..................  A                   Reconstruct midface, lefort.      18.30     15.40        1.81      35.51       090  S                 

[[Page 63198]]
                                                                                                                                                        
21144...  ..................  D                   Reconstruct midface, lefort.       0.00      0.00        0.00       0.00       090  S                 
21145...  ..................  A                   Reconstruct midface, lefort.      18.92     14.34        1.68      34.94       090  S                 
21146...  ..................  A                   Reconstruct midface, lefort.      19.58     14.84        1.74      36.16       090  S                 
21147...  ..................  A                   Reconstruct midface, lefort.      20.30     15.40        1.81      37.51       090  S                 
21150...  ..................  A                   Reconstruct midface, lefort.      24.41     18.46        2.17      45.04       090  S                 
21151...  ..................  A                   Reconstruct midface, lefort.      27.34     20.68        2.42      50.44       090  S                 
21154...  ..................  A                   Reconstruct midface, lefort.      29.28     22.15        2.59      54.02       090  S                 
21155...  ..................  A                   Reconstruct midface, lefort.      33.19     25.11        2.94      61.24       090  S                 
21159...  ..................  A                   Reconstruct midface, lefort.      40.99     31.02        3.63      75.64       090  S                 
21160...  ..................  A                   Reconstruct midface, lefort.      44.90     33.96        3.98      82.84       090  S                 
21172...  ..................  A                   Reconstruct orbit/forehead..      26.84     20.30        2.37      49.51       090  S                 
21175...  ..................  A                   Reconstruct orbit/forehead..      32.21     24.37        2.85      59.43       090  S                 
21179...  ..................  A                   Reconstruct entire forehead.      21.47     16.24        1.90      39.61       090  S                 
21180...  ..................  A                   Reconstruct entire forehead.      24.41     18.46        2.17      45.04       090  S                 
21181...  ..................  A                   Contour cranial bone lesion.       9.40      7.11        0.83      17.34       090  S                 
21182...  ..................  A                   Reconstruct cranial bone....      31.23     23.63        2.77      57.63       090  S                 
21183...  ..................  A                   Reconstruct cranial bone....      34.17     25.85        3.03      63.05       090  S                 
21184...  ..................  A                   Reconstruct cranial bone....      37.10     28.06        3.28      68.44       090  S                 
21188...  ..................  A                   Reconstruction of midface...      21.47     16.24        1.90      39.61       090  S                 
21193...  ..................  A                   Reconstruct lower jaw bone..      16.23     12.31        1.44      29.98       090  S                 
21194...  ..................  A                   Reconstruct lower jaw bone..      18.81     14.26        1.67      34.74       090  S                 
21195...  ..................  A                   Reconstruct lower jaw bone..      16.27     12.34        1.44      30.05       090  S                 
21196...  ..................  A                   Reconstruct lower jaw bone..      17.94     13.61        1.58      33.13       090  S                 
21198...  ..................  A                   Reconstruct lower jaw bone..      13.36     14.82        1.74      29.92       090  S                 
21206...  ..................  A                   Reconstruct upper jaw bone..      13.36     10.14        1.19      24.69       090  S                 
21208...  ..................  A                   Augmentation of facial bones       9.56     11.26        1.07      21.89       090  S                 
21209...  ..................  A                   Reduction of facial bones...       6.28      4.59        0.76      11.63       090  S                 
21210...  ..................  A                   Face bone graft.............       9.56    *12.24        1.29      23.09       090  S                 
21215...  ..................  A                   Lower jaw bone graft........      10.07    *12.89        1.42      24.38       090  S                 
21230...  ..................  A                   Rib cartilage graft.........      10.07     10.37        1.69      22.13       090  S                 
21235...  ..................  A                   Ear cartilage graft.........       6.28     *8.04        1.09      15.41       090  S                 
21240...  ..................  A                   Reconstruction of jaw joint.      13.10    *16.77        2.09      31.96       090  S                 
21242...  ..................  A                   Reconstruction of jaw joint.      12.10    *15.55        2.25      29.90       090  S                 
21243...  ..................  A                   Reconstruction of jaw joint.      18.98     14.40        1.68      35.06       090  S                 
21244...  ..................  A                   Reconstruction of lower jaw.      11.08    *14.18        1.93      27.19       090  S                 
21245...  ..................  A                   Reconstruction of jaw.......      11.08     11.47        1.31      23.86       090  S                 
21246...  ..................  A                   Reconstruction of jaw.......      11.65      8.83        1.04      21.52       090  S                 
21247...  ..................  A                   Reconstruct lower jaw bone..      21.15    *27.08        2.27      50.50       090  S                 
21248...  ..................  A                   Reconstruction of jaw.......      11.08    *14.18        1.75      27.01       090  S                 
21249...  ..................  A                   Reconstruction of jaw.......      17.12    *23.10        3.29      43.51       090  S                 
21255...  ..................  A                   Reconstruct lower jaw bone..      15.63    *20.00        1.68      37.31       090  S                 
21256...  ..................  A                   Reconstruction of orbit.....      15.13    *19.36        1.63      36.12       090  S                 
21260...  ..................  A                   Revise eye sockets..........      15.44    *19.76        1.66      36.86       090  S                 
21261...  ..................  A                   Revise eye sockets..........      29.43     17.78        1.65      48.86       090  S                 
21263...  ..................  A                   Revise eye sockets..........      26.56    *34.00        2.86      63.42       090  S                 
21267...  ..................  A                   Revise eye sockets..........      17.66     14.61        2.13      34.40       090  S                 
21268...  ..................  A                   Revise eye sockets..........      22.88     15.35        3.13      41.36       090  S                 
21270...  ..................  A                   Augmentation cheek bone.....      12.10      9.60        1.41      23.11       090  S                 
21275...  ..................  A                   Revision orbitofacial bones.      10.50      8.95        1.26      20.71       090  S                 
21280...  ..................  A                   Revision of eyelid..........       5.64      7.19        0.61      13.44       090  S                 
21282...  ..................  A                   Revision of eyelid..........       3.26     *4.52        0.79       8.57       090  S                 
21295...  ..................  A                   Revision of jaw muscle/bone.       1.43      0.96        0.13       2.52       090  S                 
21296...  ..................  A                   Revision of jaw muscle/bone.       3.97      3.62        0.22       7.81       090  S                 
21299...  ..................  C                   Cranio/maxillofacial surgery       0.00      0.00        0.00       0.00       YYY  S                 
21300...  ..................  A                   Treatment of skull fracture.       0.72     *0.92        0.11       1.75       000  S                 
21310...  ..................  A                   Treatment of nose fracture..       0.58     *0.75        0.09       1.42       000  N                 
21315...  ..................  A                   Treatment of nose fracture..       1.41      1.81        0.21       3.43       010  S                 
21320...  ..................  A                   Treatment of nose fracture..       1.82     *2.33        0.34       4.49       010  S                 
21325...  ..................  A                   Repair of nose fracture.....       3.52      4.09        0.52       8.13       090  S                 
21330...  ..................  A                   Repair of nose fracture.....       5.03     *6.45        0.86      12.34       090  S                 
21335...  ..................  A                   Repair of nose fracture.....       8.05    *10.31        1.56      19.92       090  S                 
21336...  ..................  A                   Repair nasal septal fracture       5.35      4.09        0.52       9.96       090  S                 
21337...  ..................  A                   Repair nasal septal fracture       2.52      2.82        0.38       5.72       090  S                 
21338...  ..................  A                   Repair nasoethmoid fracture.       6.04      5.01        0.66      11.71       090  S                 
21339...  ..................  A                   Repair nasoethmoid fracture.       7.56      7.09        0.70      15.35       090  S                 
21340...  ..................  A                   Repair of nose fracture.....      10.07      8.91        1.04      20.02       090  S                 

[[Page 63199]]
                                                                                                                                                        
21343...  ..................  A                   Repair of sinus fracture....      12.10      9.17        1.08      22.35       090  S                 
21344...  ..................  A                   Repair of sinus fracture....      18.43      9.17        1.08      28.68       090  S                 
21345...  ..................  A                   Repair of nose/jaw fracture.       7.63      7.90        0.81      16.34       090  S                 
21346...  ..................  A                   Repair of nose/jaw fracture.       9.92      9.40        1.04      20.36       090  S                 
21347...  ..................  A                   Repair of nose/jaw fracture.      11.86     10.36        1.36      23.58       090  S                 
21348...  ..................  A                   Repair of nose/jaw fracture.      15.60     11.34        2.22      29.16       090  S                 
21355...  ..................  A                   Repair cheek bone fracture..       3.52      1.56        0.17       5.25       010  S                 
21356...  ..................  A                   Repair cheek bone fracture..       3.88     *4.96        0.89       9.73       010  S                 
21360...  ..................  A                   Repair cheek bone fracture..       6.04      7.28        0.89      14.21       090  S                 
21365...  ..................  A                   Repair cheek bone fracture..      13.97     12.35        1.63      27.95       090  S                 
21366...  ..................  A                   Repair cheek bone fracture..      16.61     12.08        2.36      31.05       090  S                 
21385...  ..................  A                   Repair eye socket fracture..       8.56      9.59        1.13      19.28       090  S                 
21386...  ..................  A                   Repair eye socket fracture..       8.56      9.07        1.25      18.88       090  S                 
21387...  ..................  A                   Repair eye socket fracture..       9.07      7.45        0.96      17.48       090  S                 
21390...  ..................  A                   Repair eye socket fracture..       9.47     11.89        1.37      22.73       090  S                 
21395...  ..................  A                   Repair eye socket fracture..      11.85      9.63        1.37      22.85       090  S                 
21400...  ..................  A                   Treat eye socket fracture...       1.31     *1.67        0.17       3.15       090  N                 
21401...  ..................  A                   Repair eye socket fracture..       3.05      2.58        0.32       5.95       090  S                 
21406...  ..................  A                   Repair eye socket fracture..       6.55      5.21        0.74      12.50       090  S                 
21407...  ..................  A                   Repair eye socket fracture..       8.05      7.09        0.78      15.92       090  S                 
21408...  ..................  A                   Repair eye socket fracture..      11.57      8.49        0.99      21.05       090  S                 
21421...  ..................  A                   Treat mouth roof fracture...       4.80     *6.14        0.62      11.56       090  S                 
21422...  ..................  A                   Repair mouth roof fracture..       7.78      9.80        1.19      18.77       090  S                 
21423...  ..................  A                   Repair mouth roof fracture..       9.72      9.80        1.19      20.71       090  S                 
21431...  ..................  A                   Treat craniofacial fracture.       6.59      6.02        0.71      13.32       090  S                 
21432...  ..................  A                   Repair craniofacial fracture       8.05      6.76        0.84      15.65       090  S                 
21433...  ..................  A                   Repair craniofacial fracture      23.69     17.96        2.10      43.75       090  S                 
21435...  ..................  A                   Repair craniofacial fracture      16.12     13.25        1.88      31.25       090  S                 
21436...  ..................  A                   Repair craniofacial fracture      26.21     14.65        2.08      42.94       090  S                 
21440...  ..................  A                   Repair dental ridge fracture       2.52      3.07        0.28       5.87       090  S                 
21445...  ..................  A                   Repair dental ridge fracture       5.03      6.11        0.56      11.70       090  S                 
21450...  ..................  A                   Treat lower jaw fracture....       2.78      2.84        0.26       5.88       090  S                 
21451...  ..................  A                   Treat lower jaw fracture....       4.55     *5.83        0.74      11.12       090  S                 
21452...  ..................  A                   Treat lower jaw fracture....       1.85      1.39        0.17       3.41       090  S                 
21453...  ..................  A                   Treat lower jaw fracture....       5.18     *6.64        0.55      12.37       090  S                 
21454...  ..................  A                   Treat lower jaw fracture....       6.04     *8.19        1.42      15.65       090  S                 
21461...  ..................  A                   Repair lower jaw fracture...       7.56     *9.67        1.30      18.53       090  S                 
21462...  ..................  A                   Repair lower jaw fracture...       9.15    *11.71        1.34      22.20       090  S                 
21465...  ..................  A                   Repair lower jaw fracture...      11.13      8.44        0.99      20.56       090  S                 
21470...  ..................  A                   Repair lower jaw fracture...      14.19     17.13        1.74      33.06       090  S                 
21480...  ..................  A                   Reset dislocated jaw........       0.61     *0.78        0.09       1.48       000  S                 
21485...  ..................  A                   Reset dislocated jaw........       3.73      2.19        0.20       6.12       090  S                 
21490...  ..................  A                   Repair dislocated jaw.......      11.08      6.31        0.52      17.91       090  S                 
21493...  ..................  A                   Treat hyoid bone fracture...       1.19     *1.52        0.13       2.84       090  S                 
21494...  ..................  A                   Repair hyoid bone fracture..       5.87     *7.52        0.63      14.02       090  S                 
21495...  ..................  A                   Repair hyoid bone fracture..       5.32      4.82        0.51      10.65       090  S                 
21497...  ..................  A                   Interdental wiring..........       3.61      3.97        0.38       7.96       090  S                 
21499...  ..................  C                   Head surgery procedure......       0.00      0.00        0.00       0.00       YYY  S                 
21501...  ..................  A                   Drain neck/chest lesion.....       3.52      1.82        0.26       5.60       090  S                 
21502...  ..................  A                   Drain chest lesion..........       6.44      4.22        0.75      11.41       090  S                 
21510...  ..................  A                   Drainage of bone lesion.....       5.03      3.82        0.50       9.35       090  S                 
21550...  ..................  A                   Biopsy of neck/chest........       2.01      0.85        0.12       2.98       010  S                 
21555...  ..................  A                   Remove lesion neck/chest....       4.09      1.60        0.25       5.94       090  S                 
21556...  ..................  A                   Remove lesion neck/chest....       5.28      3.80        0.64       9.72       090  S                 
21557...  ..................  A                   Remove tumor, neck or chest.       8.56      8.50        1.41      18.47       090  S                 
21600...  ..................  A                   Partial removal of rib......       6.27      4.50        0.88      11.65       090  S                 
21610...  ..................  A                   Partial removal of rib......       8.54      5.17        0.76      14.47       090  S                 
21615...  ..................  A                   Removal of rib..............       9.03     10.13        1.96      21.12       090  S                 
21616...  ..................  A                   Removal of rib and nerves...      11.11      7.26        1.50      19.87       090  S                 
21620...  ..................  A                   Partial removal of sternum..       6.04      6.85        1.23      14.12       090  S                 
21627...  ..................  A                   Sternal debridement.........       6.06      5.03        0.90      11.99       090  S                 
21630...  ..................  A                   Extensive sternum surgery...      15.77     12.89        2.40      31.06       090  S                 
21632...  ..................  A                   Extensive sternum surgery...      16.62     11.54        2.22      30.38       090  S                 
21700...  ..................  A                   Revision of neck muscle.....       5.84      4.16        0.50      10.50       090  S                 
21705...  ..................  A                   Revision of neck muscle/rib.       9.03      4.85        0.96      14.84       090  S                 
21720...  ..................  A                   Revision of neck muscle.....       5.44      3.84        0.52       9.80       090  S                 

[[Page 63200]]
                                                                                                                                                        
21725...  ..................  A                   Revision of neck muscle.....       6.55      4.84        0.74      12.13       090  S                 
21740...  ..................  A                   Reconstruction of sternum...      15.42      8.99        1.64      26.05       090  S                 
21750...  ..................  A                   Repair of sternum separation      10.07      7.33        1.43      18.83       090  S                 
21800...  ..................  A                   Treatment of rib fracture...       0.91      0.77        0.07       1.75       090  N                 
21805...  ..................  A                   Treatment of rib fracture...       2.62      1.35        0.17       4.14       090  S                 
21810...  ..................  A                   Treatment of rib fracture(s)       6.68      7.33        0.61      14.62       090  N                 
21820...  ..................  A                   Treat sternum fracture......       1.20      1.36        0.17       2.73       090  S                 
21825...  ..................  A                   Repair sternum fracture.....       6.82      6.90        1.12      14.84       090  S                 
21899...  ..................  C                   Neck/chest surgery procedure       0.00      0.00        0.00       0.00       YYY  S                 
21920...  ..................  A                   Biopsy soft tissue of back..       2.01      0.79        0.11       2.91       010  S                 
21925...  ..................  A                   Biopsy soft tissue of back..       4.23      1.95        0.32       6.50       090  S                 
21930...  ..................  A                   Remove lesion, back or flank       6.55      2.72        0.49       9.76       090  S                 
21935...  ..................  A                   Remove tumor of back........      17.12      6.59        1.30      25.01       090  S                 
22100...  ..................  A                   Remove part of neck vertebra       9.05      7.64        1.09      17.78       090  S                 
22101...  ..................  A                   Remove part, thorax vertebra       9.00      8.01        1.38      18.39       090  S                 
22102...  ..................  A                   Remove part, lumbar vertebra       9.00      4.50        0.67      14.17       090  S                 
22103...  ..................  A                   Remove extra spine segment..       2.34      2.23        0.37       4.94       ZZZ  S                 
22105...  ..................  D                   Remove part of neck vertebra       0.00      0.00        0.00       0.00       090  S                 
22106...  ..................  D                   Remove part, thorax vertebra       0.00      0.00        0.00       0.00       090  S                 
22107...  ..................  D                   Remove part, lumbar vertebra       0.00      0.00        0.00       0.00       090  S                 
22110...  ..................  A                   Remove part of neck vertebra      11.59      9.72        1.64      22.95       090  S                 
22112...  ..................  A                   Remove part, thorax vertebra      11.59      9.90        1.63      23.12       090  S                 
22114...  ..................  A                   Remove part, lumbar vertebra      11.59      7.25        1.17      20.01       090  S                 
22116...  ..................  A                   Remove extra spine segment..       2.32      2.21        0.36       4.89       ZZZ  S                 
22140...  ..................  D                   Reconstruct neck spine......       0.00      0.00        0.00       0.00       090  S                 
22141...  ..................  D                   Reconstruct thorax spine....       0.00      0.00        0.00       0.00       090  S                 
22142...  ..................  D                   Reconstruct lumbar spine....       0.00      0.00        0.00       0.00       090  S                 
22145...  ..................  D                   Reconstruct vertebra(e).....       0.00      0.00        0.00       0.00       ZZZ  S                 
22148...  ..................  D                   Harvesting bone graft.......       0.00      0.00        0.00       0.00       ZZZ  S                 
22150...  ..................  D                   Reconstruct neck spine......       0.00      0.00        0.00       0.00       090  S                 
22151...  ..................  D                   Reconstruct thorax spine....       0.00      0.00        0.00       0.00       090  S                 
22152...  ..................  D                   Reconstruct lumbar spine....       0.00      0.00        0.00       0.00       090  S                 
22210...  ..................  A                   Revision of neck spine......      22.51     13.83        2.43      38.77       090  S                 
22212...  ..................  A                   Revision of thorax spine....      18.14     17.29        2.83      38.26       090  S                 
22214...  ..................  A                   Revision of lumbar spine....      18.14     15.11        2.68      35.93       090  S                 
22216...  ..................  A                   Revise, extra spine segment.       6.04      5.07        0.89      12.00       ZZZ  S                 
22220...  ..................  A                   Revision of neck spine......      20.15     16.64        2.63      39.42       090  S                 
22222...  ..................  A                   Revision of thorax spine....      20.15     13.61        1.58      35.34       090  S                 
22224...  ..................  A                   Revision of lumbar spine....      20.15     14.68        2.66      37.49       090  S                 
22226...  ..................  A                   Revise, extra spine segment.       6.04      5.07        0.89      12.00       ZZZ  S                 
22230...  ..................  D                   Additional revision of spine       0.00      0.00        0.00       0.00       ZZZ  S                 
22305...  ..................  A                   Treat spine process fracture       1.86     *2.38        0.37       4.61       090  S                 
22310...  ..................  A                   Treat spine fracture........       1.86     *2.52        0.69       5.07       090  S                 
22315...  ..................  A                   Treat spine fracture........       8.36      5.51        0.86      14.73       090  S                 
22325...  ..................  A                   Repair of spine fracture....      17.19      8.32        1.34      26.85       090  S                 
22326...  ..................  A                   Repair neck spine fracture..      18.43     15.93        2.74      37.10       090  S                 
22327...  ..................  A                   Repair thorax spine fracture      17.56     15.95        2.35      35.86       090  S                 
22328...  ..................  A                   Repair each add spine fx....       4.61      4.40        0.72       9.73       ZZZ  S                 
22505...  ..................  A                   Manipulation of spine.......       1.77      1.31        0.17       3.25       010  N                 
22548...  ..................  A                   Neck spine fusion...........      24.08     22.74        3.82      50.64       090  S                 
22554...  ..................  A                   Neck spine fusion...........      17.24     19.81        3.52      40.57       090  S                 
22556...  ..................  A                   Thorax spine fusion.........      22.27     21.68        3.58      47.53       090  S                 
22558...  ..................  A                   Lumbar spine fusion.........      21.22     20.17        3.38      44.77       090  S                 
22585...  ..................  A                   Additional spinal fusion....       5.53      5.40        0.93      11.86       ZZZ  S                 
22590...  ..................  A                   Spine & skull spinal fusion.      19.50     21.57        3.44      44.51       090  S                 
22595...  ..................  A                   Neck spinal fusion..........      18.19     22.46        3.87      44.52       090  S                 
22600...  ..................  A                   Neck spine fusion...........      14.74     19.36        3.32      37.42       090  S                 
22610...  ..................  A                   Thorax spine fusion.........      14.62     17.87        2.75      35.24       090  S                 
22612...  ..................  A                   Lumbar spine fusion.........      20.19     20.60        3.33      44.12       090  S                 
22614...  ..................  A                   Spine fusion, extra segment.       6.44      5.65        0.92      13.01       ZZZ  S                 
22625...  ..................  D                   Lumbar spine fusion.........       0.00      0.00        0.00       0.00       090  S                 
22630...  ..................  A                   Lumbar spine fusion.........      20.03     18.44        3.15      41.62       090  S                 
22632...  ..................  A                   Spine fusion, extra segment.       5.23      4.99        0.82      11.04       ZZZ  S                 
22650...  ..................  D                   Additional spinal fusion....       0.00      0.00        0.00       0.00       ZZZ  S                 
22800...  ..................  A                   Fusion of spine.............      16.92    *21.66        3.58      42.16       090  S                 
22802...  ..................  A                   Fusion of spine.............      29.74     28.32        4.61      62.67       090  S                 

[[Page 63201]]
                                                                                                                                                        
22804...  ..................  A                   Fusion of spine.............      35.00     28.32        4.61      67.93       090  S                 
22808...  ..................  A                   Fusion of spine.............      25.00     18.41        3.15      46.56       090  S                 
22810...  ..................  A                   Fusion of spine.............      29.00     18.41        3.15      50.56       090  S                 
22812...  ..................  A                   Fusion of spine.............      31.00     25.93        4.24      61.17       090  S                 
22820...  ..................  D                   Harvesting of bone..........       0.00      0.00        0.00       0.00       ZZZ  S                 
22830...  ..................  A                   Exploration of spinal fusion      10.22    *13.07        2.18      25.47       090  S                 
22840...  ..................  A                   Insert spine fixation device       6.27      5.98        0.98      13.23       ZZZ  S                 
22841...  ..................  B                   Insert spine fixation device       0.00      0.00        0.00       0.00       XXX  0                 
22842...  ..................  A                   Insert spine fixation device       7.19      6.86        1.12      15.17       ZZZ  S                 
22843...  ..................  A                   Insert spine fixation device       8.97      8.55        1.40      18.92       ZZZ  S                 
22844...  ..................  A                   Insert spine fixation device      10.96     10.45        1.71      23.12       ZZZ  S                 
22845...  ..................  A                   Insert spine fixation device       5.98      5.70        0.93      12.61       ZZZ  S                 
22846...  ..................  A                   Insert spine fixation device       8.28      7.90        1.29      17.47       ZZZ  S                 
22847...  ..................  A                   Insert spine fixation device       9.20      8.77        1.44      19.41       ZZZ  S                 
22848...  ..................  A                   Insert pelvic fixation             6.00      5.72        0.94      12.66       ZZZ  S                 
                                                   device.                                                                                              
22849...  ..................  A                   Reinsert spinal fixation....      12.86     11.76        1.97      26.59       090  S                 
22850...  ..................  A                   Remove spine fixation device       8.98      9.17        1.50      19.65       090  S                 
22851...  ..................  A                   Apply spine prosth device...       6.71      6.40        1.05      14.16       ZZZ  S                 
22852...  ..................  A                   Remove spine fixation device       8.40      9.80        1.57      19.77       090  S                 
22855...  ..................  A                   Remove spine fixation device       9.10      7.46        1.25      17.81       090  S                 
22899...  ..................  C                   Spine surgery procedure.....       0.00      0.00        0.00       0.00       YYY  S                 
22900...  ..................  A                   Remove abdominal wall lesion       6.56      3.03        0.60      10.19       090  S                 
22999...  ..................  C                   Abdomen surgery procedure...       0.00      0.00        0.00       0.00       YYY  S                 
23000...  ..................  A                   Removal of calcium deposits.       4.12      3.24        0.47       7.83       090  S                 
23020...  ..................  A                   Release shoulder joint......       8.25      7.27        1.09      16.61       090  S                 
23030...  ..................  A                   Drain shoulder lesion.......       3.16      2.16        0.35       5.67       010  S                 
23031...  ..................  A                   Drain shoulder bursa........       2.69      0.50        0.05       3.24       010  S                 
23035...  ..................  A                   Drain shoulder bone lesion..       7.80      6.22        1.04      15.06       090  S                 
23040...  ..................  A                   Exploratory shoulder surgery       8.39      9.27        1.47      19.13       090  S                 
23044...  ..................  A                   Exploratory shoulder surgery       6.40      6.91        1.18      14.49       090  S                 
23065...  ..................  A                   Biopsy shoulder tissues.....       2.24      0.66        0.09       2.99       010  S                 
23066...  ..................  A                   Biopsy shoulder tissues.....       4.01      1.18        0.10       5.29       090  S                 
23075...  ..................  A                   Removal of shoulder lesion..       2.34      1.68        0.29       4.31       010  S                 
23076...  ..................  A                   Removal of shoulder lesion..       7.12      3.54        0.65      11.31       090  S                 
23077...  ..................  A                   Remove tumor of shoulder....      14.65      7.38        1.38      23.41       090  S                 
23100...  ..................  A                   Biopsy of shoulder joint....       5.63     *7.20        1.24      14.07       090  S                 
23101...  ..................  A                   Shoulder joint surgery......       5.21     *6.68        1.21      13.10       090  S                 
23105...  ..................  A                   Remove shoulder joint lining       7.74     *9.91        1.73      19.38       090  S                 
23106...  ..................  A                   Incision of collarbone joint       5.56      4.75        0.80      11.11       090  S                 
23107...  ..................  A                   Explore, treat shoulder            8.13      9.59        1.60      19.32       090  S                 
                                                   joint.                                                                                               
23120...  ..................  A                   Partial removal, collar bone       6.65      4.61        0.74      12.00       090  S                 
23125...  ..................  A                   Removal of collarbone.......       8.90      8.49        1.27      18.66       090  S                 
23130...  ..................  A                   Partial removal, shoulder          7.10      7.05        1.14      15.29       090  S                 
                                                   bone.                                                                                                
23140...  ..................  A                   Removal of bone lesion......       6.43      4.16        0.73      11.32       090  S                 
23145...  ..................  A                   Removal of bone lesion......       8.54      8.13        1.33      18.00       090  S                 
23146...  ..................  A                   Removal of bone lesion......       7.34      5.23        1.01      13.58       090  S                 
23150...  ..................  A                   Removal of humerus lesion...       7.80      6.64        1.01      15.45       090  S                 
23155...  ..................  A                   Removal of humerus lesion...       9.58      8.80        1.37      19.75       090  S                 
23156...  ..................  A                   Removal of humerus lesion...       8.00      7.64        1.25      16.89       090  S                 
23170...  ..................  A                   Remove collarbone lesion....       6.27      4.81        0.78      11.86       090  S                 
23172...  ..................  A                   Remove shoulder blade lesion       6.24      5.16        0.73      12.13       090  S                 
23174...  ..................  A                   Remove humerus lesion.......       8.71      8.55        1.21      18.47       090  S                 
23180...  ..................  A                   Remove collar bone lesion...       7.82      4.30        0.67      12.79       090  S                 
23182...  ..................  A                   Remove shoulder blade lesion       7.44      6.57        1.13      15.14       090  S                 
23184...  ..................  A                   Remove humerus lesion.......       8.61      8.83        1.48      18.92       090  S                 
23190...  ..................  A                   Partial removal of scapula..       6.78      6.07        0.98      13.83       090  S                 
23195...  ..................  A                   Removal of head of humerus..       9.00      8.91        1.45      19.36       090  S                 
23200...  ..................  A                   Removal of collar bone......      11.05      9.17        1.26      21.48       090  S                 
23210...  ..................  A                   Removal of shoulderblade....      11.39      9.01        1.41      21.81       090  S                 
23220...  ..................  A                   Partial removal of humerus..      13.31     12.05        2.03      27.39       090  S                 
23221...  ..................  A                   Partial removal of humerus..      16.62     18.13        1.19      35.94       090  S                 
23222...  ..................  A                   Partial removal of humerus..      16.64     15.02        2.30      33.96       090  S                 
23330...  ..................  A                   Remove shoulder foreign body       1.80      0.55        0.07       2.42       010  S                 
23331...  ..................  A                   Remove shoulder foreign body       6.89      2.26        0.38       9.53       090  S                 
23332...  ..................  A                   Remove shoulder foreign body      10.59      9.72        1.57      21.88       090  S                 
23350...  ..................  A                   Injection for shoulder x-ray       1.00      0.52        0.05       1.57       000  N                 

[[Page 63202]]
                                                                                                                                                        
23395...  ..................  A                   Muscle transfer, shoulder/        12.42     11.13        1.84      25.39       090  S                 
                                                   arm.                                                                                                 
23397...  ..................  A                   Muscle transfers............      15.23     13.97        2.34      31.54       090  S                 
23400...  ..................  A                   Fixation of shoulder blade..      12.96      9.84        1.68      24.48       090  S                 
23405...  ..................  A                   Incision of tendon & muscle.       7.97      7.49        0.99      16.45       090  S                 
23406...  ..................  A                   Incise tendon(s) & muscle(s)      10.33      9.41        1.58      21.32       090  S                 
23410...  ..................  A                   Repair of tendon(s).........      11.90     10.94        1.75      24.59       090  S                 
23412...  ..................  A                   Repair of tendon(s).........      12.69     13.37        2.16      28.22       090  S                 
23415...  ..................  A                   Release of shoulder ligament       9.51      5.18        0.83      15.52       090  S                 
23420...  ..................  A                   Repair of shoulder..........      12.60     14.68        2.34      29.62       090  S                 
23430...  ..................  A                   Repair biceps tendon........       9.56      7.34        1.19      18.09       090  S                 
23440...  ..................  A                   Removal/transplant tendon...      10.08      7.17        1.17      18.42       090  S                 
23450...  ..................  A                   Repair shoulder capsule.....      12.85     12.75        2.04      27.64       090  S                 
23455...  ..................  A                   Repair shoulder capsule.....      13.82     15.56        2.50      31.88       090  S                 
23460...  ..................  A                   Repair shoulder capsule.....      14.66     14.07        2.24      30.97       090  S                 
23462...  ..................  A                   Repair shoulder capsule.....      14.62     15.13        2.48      32.23       090  S                 
23465...  ..................  A                   Repair shoulder capsule.....      15.14     14.15        2.27      31.56       090  S                 
23466...  ..................  A                   Repair shoulder capsule.....      13.65     16.53        2.67      32.85       090  S                 
23470...  ..................  A                   Reconstruct shoulder joint..      16.12     16.76        2.65      35.53       090  S                 
23472...  ..................  A                   Reconstruct shoulder joint..      16.09    *20.60        4.89      41.58       090  S                 
23480...  ..................  A                   Revision of collarbone......      10.56      6.59        1.02      18.17       090  S                 
23485...  ..................  A                   Revision of collarbone......      12.68     11.35        1.87      25.90       090  S                 
23490...  ..................  A                   Reinforce clavicle..........      11.31      9.98        0.80      22.09       090  S                 
23491...  ..................  A                   Reinforce shoulder bones....      13.63     12.70        2.11      28.44       090  S                 
23500...  ..................  A                   Treat clavicle fracture.....       1.95      1.65        0.21       3.81       090  S                 
23505...  ..................  A                   Treat clavicle fracture.....       3.54      2.57        0.38       6.49       090  S                 
23515...  ..................  A                   Repair clavicle fracture....       7.01      6.93        1.12      15.06       090  S                 
23520...  ..................  A                   Treat clavicle dislocation..       2.03      1.38        0.19       3.60       090  S                 
23525...  ..................  A                   Treat clavicle dislocation..       3.40      1.98        0.27       5.65       090  S                 
23530...  ..................  A                   Repair clavicle dislocation.       7.02      6.58        0.91      14.51       090  S                 
23532...  ..................  A                   Repair clavicle dislocation.       7.59      7.23        1.19      16.01       090  S                 
23540...  ..................  A                   Treat clavicle dislocation..       2.10      1.55        0.19       3.84       090  S                 
23545...  ..................  A                   Treat clavicle dislocation..       3.07      1.98        0.29       5.34       090  S                 
23550...  ..................  A                   Repair clavicle dislocation.       6.65     *8.51        1.46      16.62       090  S                 
23552...  ..................  A                   Repair clavicle dislocation.       7.83      7.29        1.17      16.29       090  S                 
23570...  ..................  A                   Treat shoulderblade fracture       2.10      1.70        0.25       4.05       090  S                 
23575...  ..................  A                   Treat shoulderblade fracture       3.88      2.75        0.43       7.06       090  S                 
23585...  ..................  A                   Repair scapula fracture.....       8.41      7.70        1.29      17.40       090  S                 
23600...  ..................  A                   Treat humerus fracture......       2.75      2.90        0.43       6.08       090  S                 
23605...  ..................  A                   Treat humerus fracture......       4.56      4.76        0.76      10.08       090  S                 
23615...  ..................  A                   Repair humerus fracture.....       8.38    *10.72        1.78      20.88       090  S                 
23616...  ..................  A                   Repair humerus fracture.....      19.88     22.32        3.54      45.74       090  S                 
23620...  ..................  A                   Treat humerus fracture......       2.25     *2.88        0.46       5.59       090  S                 
23625...  ..................  A                   Treat humerus fracture......       3.64      3.82        0.60       8.06       090  S                 
23630...  ..................  A                   Repair humerus fracture.....       6.89      8.82        1.40      17.11       090  S                 
23650...  ..................  A                   Treat shoulder dislocation..       3.24      2.10        0.24       5.58       090  S                 
23655...  ..................  A                   Treat shoulder dislocation..       4.26      2.93        0.44       7.63       090  S                 
23660...  ..................  A                   Repair shoulder dislocation.       7.09      9.07        1.40      17.56       090  S                 
23665...  ..................  A                   Treat dislocation/fracture..       4.16      3.35        0.51       8.02       090  S                 
23670...  ..................  A                   Repair dislocation/fracture.       7.44     *9.52        1.85      18.81       090  S                 
23675...  ..................  A                   Treat dislocation/fracture..       5.60      3.93        0.61      10.14       090  S                 
23680...  ..................  A                   Repair dislocation/fracture.       9.44    *12.09        2.13      23.66       090  S                 
23700...  ..................  A                   Fixation of shoulder........       2.47      2.09        0.34       4.90       010  S                 
23800...  ..................  A                   Fusion of shoulder joint....      13.32     16.35        2.63      32.30       090  S                 
23802...  ..................  A                   Fusion of shoulder joint....      14.67     14.07        2.24      30.98       090  S                 
23900...  ..................  A                   Amputation of arm & girdle..      18.40     12.57        2.40      33.37       090  S                 
23920...  ..................  A                   Amputation at shoulder joint      13.60     13.85        2.54      29.99       090  S                 
23921...  ..................  A                   Amputation follow-up surgery       5.03      4.27        0.74      10.04       090  S                 
23929...  ..................  C                   Shoulder surgery procedure..       0.00      0.00        0.00       0.00       YYY  S                 
23930...  ..................  A                   Drainage of arm lesion......       2.78      1.61        0.24       4.63       010  S                 
23931...  ..................  A                   Drainage of arm bursa.......       1.63      0.75        0.11       2.49       010  S                 
23935...  ..................  A                   Drain arm/elbow bone lesion.       5.56      4.69        0.78      11.03       090  S                 
24000...  ..................  A                   Exploratory elbow surgery...       5.32     *6.81        1.44      13.57       090  S                 
24006...  ..................  A                   Release elbow joint.........       8.70      7.14        1.17      17.01       090  S                 
24065...  ..................  A                   Biopsy arm/elbow soft tissue       2.03      0.79        0.10       2.92       010  S                 
24066...  ..................  A                   Biopsy arm/elbow soft tissue       4.95      2.71        0.41       8.07       090  S                 
24075...  ..................  A                   Remove arm/elbow lesion.....       3.79      1.98        0.35       6.12       090  S                 

[[Page 63203]]
                                                                                                                                                        
24076...  ..................  A                   Remove arm/elbow lesion.....       6.01      3.68        0.67      10.36       090  S                 
24077...  ..................  A                   Remove tumor of arm/elbow...      11.18      9.79        1.87      22.84       090  S                 
24100...  ..................  A                   Biopsy elbow joint lining...       4.67      4.23        0.69       9.59       090  S                 
24101...  ..................  A                   Explore/treat elbow joint...       5.84     *7.47        1.41      14.72       090  S                 
24102...  ..................  A                   Remove elbow joint lining...       7.57     *9.68        1.81      19.06       090  S                 
24105...  ..................  A                   Removal of elbow bursa......       3.43      3.77        0.63       7.83       090  S                 
24110...  ..................  A                   Remove humerus lesion.......       7.08      7.69        1.22      15.99       090  S                 
24115...  ..................  A                   Remove/graft bone lesion....       8.88      7.68        1.33      17.89       090  S                 
24116...  ..................  A                   Remove/graft bone lesion....      11.13      9.72        1.47      22.32       090  S                 
24120...  ..................  A                   Remove elbow lesion.........       6.36      6.02        0.98      13.36       090  S                 
24125...  ..................  A                   Remove/graft bone lesion....       7.40      5.79        0.61      13.80       090  S                 
24126...  ..................  A                   Remove/graft bone lesion....       7.76      7.40        1.21      16.37       090  S                 
24130...  ..................  A                   Removal of head of radius...       5.96      6.72        1.08      13.76       090  S                 
24134...  ..................  A                   Removal of arm bone lesion..       8.98      8.69        1.24      18.91       090  S                 
24136...  ..................  A                   Remove radius bone lesion...       7.33      8.78        0.92      17.03       090  S                 
24138...  ..................  A                   Remove elbow bone lesion....       7.36      6.39        1.06      14.81       090  S                 
24140...  ..................  A                   Partial removal of arm bone.       8.56      8.77        1.45      18.78       090  S                 
24145...  ..................  A                   Partial removal of radius...       7.12      6.38        1.03      14.53       090  S                 
24147...  ..................  A                   Partial removal of elbow....       7.00      6.61        1.08      14.69       090  S                 
24150...  ..................  A                   Extensive humerus surgery...      12.43     14.08        2.24      28.75       090  S                 
24151...  ..................  A                   Extensive humerus surgery...      14.65     13.83        2.11      30.59       090  S                 
24152...  ..................  A                   Extensive radius surgery....       9.51      6.80        1.16      17.47       090  S                 
24153...  ..................  A                   Extensive radius surgery....      10.96     10.44        1.71      23.11       090  S                 
24155...  ..................  A                   Removal of elbow joint......      11.11     10.75        1.72      23.58       090  S                 
24160...  ..................  A                   Remove elbow joint implant..       7.43      4.84        0.80      13.07       090  S                 
24164...  ..................  A                   Remove radius head implant..       5.79      5.53        0.90      12.22       090  S                 
24200...  ..................  A                   Removal of arm foreign body.       1.71      0.56        0.06       2.33       010  N                 
24201...  ..................  A                   Removal of arm foreign body.       4.30      3.06        0.49       7.85       090  S                 
24220...  ..................  A                   Injection for elbow x-ray...       1.31      0.51        0.05       1.87       000  N                 
24301...  ..................  A                   Muscle/tendon transfer......       9.78      7.90        1.23      18.91       090  S                 
24305...  ..................  A                   Arm tendon lengthening......       7.16      3.08        0.29      10.53       090  S                 
24310...  ..................  A                   Revision of arm tendon......       5.72      2.95        0.48       9.15       090  S                 
24320...  ..................  A                   Repair of arm tendon........      10.01      9.20        1.29      20.50       090  S                 
24330...  ..................  A                   Revision of arm muscles.....       9.18      8.74        1.43      19.35       090  S                 
24331...  ..................  A                   Revision of arm muscles.....      10.10      9.62        1.57      21.29       090  S                 
24340...  ..................  A                   Repair of biceps tendon.....       7.58      7.00        1.13      15.71       090  S                 
24342...  ..................  A                   Repair of ruptured tendon...      10.13     10.38        1.76      22.27       090  S                 
24350...  ..................  A                   Repair of tennis elbow......       5.05      4.23        0.69       9.97       090  S                 
24351...  ..................  A                   Repair of tennis elbow......       5.73      4.57        0.73      11.03       090  S                 
24352...  ..................  A                   Repair of tennis elbow......       6.14      5.69        0.93      12.76       090  S                 
24354...  ..................  A                   Repair of tennis elbow......       6.19      5.61        0.94      12.74       090  S                 
24356...  ..................  A                   Revision of tennis elbow....       6.39      7.28        1.18      14.85       090  S                 
24360...  ..................  A                   Reconstruct elbow joint.....      11.76    *15.05        2.47      29.28       090  S                 
24361...  ..................  A                   Reconstruct elbow joint.....      13.50     13.13        2.00      28.63       090  S                 
24362...  ..................  A                   Reconstruct elbow joint.....      14.41     13.14        0.80      28.35       090  S                 
24363...  ..................  A                   Replace elbow joint.........      17.66    *22.61        4.13      44.40       090  S                 
24365...  ..................  A                   Reconstruct head of radius..       7.93      7.52        1.19      16.64       090  S                 
24366...  ..................  A                   Reconstruct head of radius..       8.67     11.05        1.80      21.52       090  S                 
24400...  ..................  A                   Revision of humerus.........      10.55      8.43        1.37      20.35       090  S                 
24410...  ..................  A                   Revision of humerus.........      14.28     14.04        2.06      30.38       090  S                 
24420...  ..................  A                   Revision of humerus.........      12.90     12.30        2.01      27.21       090  S                 
24430...  ..................  A                   Repair of humerus...........      12.26     14.66        2.34      29.26       090  S                 
24435...  ..................  A                   Repair humerus with graft...      12.19    *15.61        2.84      30.64       090  S                 
24470...  ..................  A                   Revision of elbow joint.....       8.32      7.92        1.30      17.54       090  S                 
24495...  ..................  A                   Decompression of forearm....       7.59      5.75        1.10      14.44       090  S                 
24498...  ..................  A                   Reinforce humerus...........      11.30     10.37        1.62      23.29       090  S                 
24500...  ..................  A                   Treat humerus fracture......       3.01      2.54        0.36       5.91       090  S                 
24505...  ..................  A                   Treat humerus fracture......       4.83      4.50        0.71      10.04       090  S                 
24515...  ..................  A                   Repair humerus fracture.....      10.92      9.65        1.54      22.11       090  S                 
24516...  ..................  A                   Repair humerus fracture.....      10.92      9.65        1.54      22.11       090  S                 
24530...  ..................  A                   Treat humerus fracture......       3.30      2.73        0.42       6.45       090  S                 
24535...  ..................  A                   Treat humerus fracture......       6.51      4.85        0.78      12.14       090  S                 
24538...  ..................  A                   Treat humerus fracture......       8.85      7.98        1.26      18.09       090  S                 
24545...  ..................  A                   Repair humerus fracture.....       9.65      9.97        1.59      21.21       090  S                 
24546...  ..................  A                   Repair humerus fracture.....      14.66      9.97        1.59      26.22       090  S                 
24560...  ..................  A                   Treat humerus fracture......       2.62      2.16        0.30       5.08       090  S                 

[[Page 63204]]
                                                                                                                                                        
24565...  ..................  A                   Treat humerus fracture......       5.22      3.45        0.54       9.21       090  S                 
24566...  ..................  A                   Treat humerus fracture......       7.17      6.06        0.96      14.19       090  S                 
24575...  ..................  A                   Repair humerus fracture.....       9.91      7.79        1.24      18.94       090  S                 
24576...  ..................  A                   Treat humerus fracture......       2.66      2.16        0.33       5.15       090  S                 
24577...  ..................  A                   Treat humerus fracture......       5.45      4.00        0.61      10.06       090  S                 
24579...  ..................  A                   Repair humerus fracture.....      10.85      8.37        1.35      20.57       090  S                 
24582...  ..................  A                   Treat humerus fracture......       7.83      6.62        1.06      15.51       090  S                 
24586...  ..................  A                   Repair elbow fracture.......      14.37     14.72        2.36      31.45       090  S                 
24587...  ..................  A                   Repair elbow fracture.......      14.26     13.72        2.17      30.15       090  S                 
24600...  ..................  A                   Treat elbow dislocation.....       4.08      1.95        0.26       6.29       090  S                 
24605...  ..................  A                   Treat elbow dislocation.....       5.08      2.29        0.37       7.74       090  S                 
24615...  ..................  A                   Repair elbow dislocation....       8.76      9.29        1.48      19.53       090  S                 
24620...  ..................  A                   Treat elbow fracture........       6.62      3.78        0.57      10.97       090  S                 
24635...  ..................  A                   Repair elbow fracture.......      12.42     11.06        1.78      25.26       090  S                 
24640...  ..................  A                   Treat elbow dislocation.....       1.15      1.01        0.08       2.24       010  N                 
24650...  ..................  A                   Treat radius fracture.......       2.01      2.25        0.33       4.59       090  S                 
24655...  ..................  A                   Treat radius fracture.......       4.17      3.01        0.45       7.63       090  S                 
24665...  ..................  A                   Repair radius fracture......       7.69      7.13        1.14      15.96       090  S                 
24666...  ..................  A                   Repair radius fracture......       8.87     10.27        1.60      20.74       090  S                 
24670...  ..................  A                   Treatment of ulna fracture..       2.39      1.95        0.27       4.61       090  S                 
24675...  ..................  A                   Treatment of ulna fracture..       4.52      3.51        0.54       8.57       090  S                 
24685...  ..................  A                   Repair ulna fracture........       8.34      8.40        1.34      18.08       090  S                 
24800...  ..................  A                   Fusion of elbow joint.......      10.75     10.59        1.55      22.89       090  S                 
24802...  ..................  A                   Fusion/graft of elbow joint.      12.79     12.18        1.99      26.96       090  S                 
24900...  ..................  A                   Amputation of upper arm.....       8.76      7.68        1.39      17.83       090  S                 
24920...  ..................  A                   Amputation of upper arm.....       8.69      6.78        1.19      16.66       090  S                 
24925...  ..................  A                   Amputation follow-up surgery       6.61      6.27        0.75      13.63       090  S                 
24930...  ..................  A                   Amputation follow-up surgery       9.40      8.16        1.17      18.73       090  S                 
24931...  ..................  A                   Amputate upper arm & implant      11.71     11.17        1.84      24.72       090  S                 
24935...  ..................  A                   Revision of amputation......      14.37     13.70        2.24      30.31       090  S                 
24940...  ..................  C                   Revision of upper arm.......       0.00      0.00        0.00       0.00       090  S                 
24999...  ..................  C                   Upper arm/elbow surgery.....       0.00      0.00        0.00       0.00       YYY  S                 
25000...  ..................  A                   Incision of tendon sheath...       3.20      3.94        0.62       7.76       090  S                 
25020...  ..................  A                   Decompression of forearm....       5.55      4.35        0.77      10.67       090  S                 
25023...  ..................  A                   Decompression of forearm....      11.80      5.44        0.94      18.18       090  S                 
25028...  ..................  A                   Drainage of forearm lesion..       4.88      2.06        0.36       7.30       090  S                 
25031...  ..................  A                   Drainage of forearm bursa...       3.90      0.66        0.09       4.65       090  S                 
25035...  ..................  A                   Treat forearm bone lesion...       6.83      6.30        1.01      14.14       090  S                 
25040...  ..................  A                   Explore/treat wrist joint...       6.61      5.69        0.90      13.20       090  S                 
25065...  ..................  A                   Biopsy forearm soft tissues.       2.39      0.75        0.09       3.23       010  S                 
25066...  ..................  A                   Biopsy forearm soft tissues.       3.87      1.54        0.22       5.63       090  S                 
25075...  ..................  A                   Removal of forearm lesion...       3.61      2.19        0.37       6.17       090  S                 
25076...  ..................  A                   Removal of forearm lesion...       4.77      3.77        0.67       9.21       090  S                 
25077...  ..................  A                   Remove tumor, forearm/wrist.       9.25      8.48        1.67      19.40       090  S                 
25085...  ..................  A                   Incision of wrist capsule...       5.13      4.62        0.71      10.46       090  S                 
25100...  ..................  A                   Biopsy of wrist joint.......       3.66     *4.69        0.79       9.14       090  S                 
25101...  ..................  A                   Explore/treat wrist joint...       4.43      5.61        0.98      11.02       090  S                 
25105...  ..................  A                   Remove wrist joint lining...       5.56     *7.11        1.19      13.86       090  S                 
25107...  ..................  A                   Remove wrist joint cartilage       5.89      5.28        0.89      12.06       090  S                 
25110...  ..................  A                   Remove wrist tendon lesion..       3.79      2.80        0.46       7.05       090  S                 
25111...  ..................  A                   Remove wrist tendon lesion..       3.24      3.22        0.55       7.01       090  S                 
25112...  ..................  A                   Reremove wrist tendon lesion       4.38      3.72        0.66       8.76       090  S                 
25115...  ..................  A                   Remove wrist/forearm lesion.       6.26      7.14        1.23      14.63       090  S                 
25116...  ..................  A                   Remove wrist/forearm lesion.       6.44      8.17        1.38      15.99       090  S                 
25118...  ..................  A                   Excise wrist tendon sheath..       4.11     *5.26        1.02      10.39       090  S                 
25119...  ..................  A                   Partial removal of ulna.....       5.64     *7.22        1.32      14.18       090  S                 
25120...  ..................  A                   Removal of forearm lesion...       5.70      6.53        1.14      13.37       090  S                 
25125...  ..................  A                   Remove/graft forearm lesion.       7.06      6.84        1.04      14.94       090  S                 
25126...  ..................  A                   Remove/graft forearm lesion.       7.13      6.80        1.12      15.05       090  S                 
25130...  ..................  A                   Removal of wrist lesion.....       5.08      4.21        0.67       9.96       090  S                 
25135...  ..................  A                   Remove & graft wrist lesion.       6.58      5.46        0.97      13.01       090  S                 
25136...  ..................  A                   Remove & graft wrist lesion.       5.68      4.74        0.85      11.27       090  S                 
25145...  ..................  A                   Remove forearm bone lesion..       5.97      5.95        0.75      12.67       090  S                 
25150...  ..................  A                   Partial removal of ulna.....       6.56      6.67        1.12      14.35       090  S                 
25151...  ..................  A                   Partial removal of radius...       6.86      5.75        1.02      13.63       090  S                 
25170...  ..................  A                   Extensive forearm surgery...      10.45      9.79        1.51      21.75       090  S                 

[[Page 63205]]
                                                                                                                                                        
25210...  ..................  A                   Removal of wrist bone.......       5.55      4.88        0.80      11.23       090  S                 
25215...  ..................  A                   Removal of wrist bones......       7.40      8.68        1.42      17.50       090  S                 
25230...  ..................  A                   Partial removal of radius...       4.86      5.57        0.85      11.28       090  S                 
25240...  ..................  A                   Partial removal of ulna.....       4.91      5.30        0.86      11.07       090  S                 
25246...  ..................  A                   Injection for wrist x-ray...       1.45      0.50        0.05       2.00       000  N                 
25248...  ..................  A                   Remove forearm foreign body.       4.96      2.18        0.37       7.51       090  S                 
25250...  ..................  A                   Removal of wrist prosthesis.       6.31      5.63        0.91      12.85       090  S                 
25251...  ..................  A                   Removal of wrist prosthesis.       9.08      8.25        1.39      18.72       090  S                 
25260...  ..................  A                   Repair forearm tendon/muscle       7.33      4.61        0.78      12.72       090  S                 
25263...  ..................  A                   Repair forearm tendon/muscle       7.37      5.77        1.03      14.17       090  S                 
25265...  ..................  A                   Repair forearm tendon/muscle       9.54      7.93        1.41      18.88       090  S                 
25270...  ..................  A                   Repair forearm tendon/muscle       5.71      3.36        0.55       9.62       090  S                 
25272...  ..................  A                   Repair forearm tendon/muscle       6.75      3.44        0.54      10.73       090  S                 
25274...  ..................  A                   Repair forearm tendon/muscle       8.44      6.62        1.13      16.19       090  S                 
25280...  ..................  A                   Revise wrist/forearm tendon.       6.82      4.22        0.69      11.73       090  S                 
25290...  ..................  A                   Incise wrist/forearm tendon.       5.03      2.47        0.41       7.91       090  S                 
25295...  ..................  A                   Release wrist/forearm tendon       6.26      3.05        0.52       9.83       090  S                 
25300...  ..................  A                   Fusion of tendons at wrist..       8.46      7.36        1.19      17.01       090  S                 
25301...  ..................  A                   Fusion of tendons at wrist..       8.09      6.77        1.18      16.04       090  S                 
25310...  ..................  A                   Transplant forearm tendon...       7.68      7.14        1.17      15.99       090  S                 
25312...  ..................  A                   Transplant forearm tendon...       9.08      7.63        1.31      18.02       090  S                 
25315...  ..................  A                   Revise palsy hand tendon(s).       9.45      8.06        1.34      18.85       090  S                 
25316...  ..................  A                   Revise palsy hand tendon(s).      11.49     10.58        1.78      23.85       090  S                 
25320...  ..................  A                   Repair/revise wrist joint...       9.89      8.60        1.45      19.94       090  S                 
25330...  ..................  A                   Revise wrist joint..........      10.85      9.23        1.50      21.58       090  S                 
25331...  ..................  A                   Revise wrist joint..........      12.60     14.66        2.40      29.66       090  S                 
25332...  ..................  A                   Revise wrist joint..........      10.83      9.98        1.61      22.42       090  S                 
25335...  ..................  A                   Realignment of hand.........      12.11     11.41        1.56      25.08       090  S                 
25337...  ..................  A                   Reconstruct ulna/radioulnar.       9.50      8.60        1.45      19.55       090  S                 
25350...  ..................  A                   Revision of radius..........       8.23      7.61        1.26      17.10       090  S                 
25355...  ..................  A                   Revision of radius..........       9.55      9.12        1.49      20.16       090  S                 
25360...  ..................  A                   Revision of ulna............       7.88      6.41        0.99      15.28       090  S                 
25365...  ..................  A                   Revise radius & ulna........      11.63     10.31        1.57      23.51       090  S                 
25370...  ..................  A                   Revise radius or ulna.......      12.34     11.76        1.92      26.02       090  S                 
25375...  ..................  A                   Revise radius & ulna........      12.27     13.38        0.87      26.52       090  S                 
25390...  ..................  A                   Shorten radius/ulna.........       9.85      8.82        1.50      20.17       090  S                 
25391...  ..................  A                   Lengthen radius/ulna........      12.75     11.25        1.93      25.93       090  S                 
25392...  ..................  A                   Shorten radius & ulna.......      13.05     12.44        2.04      27.53       090  S                 
25393...  ..................  A                   Lengthen radius & ulna......      14.90     14.21        2.32      31.43       090  S                 
25400...  ..................  A                   Repair radius or ulna.......      10.30     10.78        1.75      22.83       090  S                 
25405...  ..................  A                   Repair/graft radius or ulna.      13.48     12.42        2.02      27.92       090  S                 
25415...  ..................  A                   Repair radius & ulna........      12.64     11.42        1.92      25.98       090  S                 
25420...  ..................  A                   Repair/graft radius & ulna..      15.34     14.70        2.28      32.32       090  S                 
25425...  ..................  A                   Repair/graft radius or ulna.      12.44     12.02        1.87      26.33       090  S                 
25426...  ..................  A                   Repair/graft radius & ulna..      14.92     11.72        2.13      28.77       090  S                 
25440...  ..................  A                   Repair/graft wrist bone.....       9.95      9.05        1.50      20.50       090  S                 
25441...  ..................  A                   Reconstruct wrist joint.....      12.26     11.36        1.89      25.51       090  S                 
25442...  ..................  A                   Reconstruct wrist joint.....      10.34      7.06        1.22      18.62       090  S                 
25443...  ..................  A                   Reconstruct wrist joint.....       9.88      9.38        1.52      20.78       090  S                 
25444...  ..................  A                   Reconstruct wrist joint.....      10.64     10.14        1.66      22.44       090  S                 
25445...  ..................  A                   Reconstruct wrist joint.....       9.27     10.36        1.72      21.35       090  S                 
25446...  ..................  A                   Wrist replacement...........      15.52    *19.86        3.49      38.87       090  S                 
25447...  ..................  A                   Repair wrist joint(s).......       9.86      9.65        1.56      21.07       090  S                 
25449...  ..................  A                   Remove wrist joint implant..      13.78      7.84        1.16      22.78       090  S                 
25450...  ..................  A                   Revision of wrist joint.....       7.67      7.31        1.19      16.17       090  S                 
25455...  ..................  A                   Revision of wrist joint.....       9.15      8.71        1.42      19.28       090  S                 
25490...  ..................  A                   Reinforce radius............       9.12      8.69        1.42      19.23       090  S                 
25491...  ..................  A                   Reinforce ulna..............       9.54      9.10        1.49      20.13       090  S                 
25492...  ..................  A                   Reinforce radius and ulna...      11.75     11.20        1.84      24.79       090  S                 
25500...  ..................  A                   Treat fracture of radius....       2.30      2.33        0.29       4.92       090  S                 
25505...  ..................  A                   Treat fracture of radius....       4.96      3.57        0.51       9.04       090  S                 
25515...  ..................  A                   Repair fracture of radius...       8.63      7.63        1.22      17.48       090  S                 
25520...  ..................  A                   Repair fracture of radius...       6.01      5.74        0.94      12.69       090  S                 
25525...  ..................  A                   Repair fracture of radius...      11.69     11.15        1.83      24.67       090  S                 
25526...  ..................  A                   Repair fracture of radius...      12.43     11.85        1.94      26.22       090  S                 
25530...  ..................  A                   Treat fracture of ulna......       1.94      2.44        0.35       4.73       090  S                 

[[Page 63206]]
                                                                                                                                                        
25535...  ..................  A                   Treat fracture of ulna......       4.91      3.57        0.54       9.02       090  S                 
25545...  ..................  A                   Repair fracture of ulna.....       8.35      7.58        1.20      17.13       090  S                 
25560...  ..................  A                   Treat fracture radius & ulna       2.29      2.27        0.27       4.83       090  S                 
25565...  ..................  A                   Treat fracture radius & ulna       5.29      4.66        0.70      10.65       090  S                 
25574...  ..................  A                   Treat fracture radius & ulna       6.03     *7.72        1.73      15.48       090  S                 
25575...  ..................  A                   Repair fracture radius/ulna.       9.47     10.70        1.73      21.90       090  S                 
25600...  ..................  A                   Treat fracture radius/ulna..       2.48      2.84        0.42       5.74       090  S                 
25605...  ..................  A                   Treat fracture radius/ulna..       5.36      3.95        0.61       9.92       090  S                 
25611...  ..................  A                   Repair fracture radius/ulna.       7.11      6.01        0.97      14.09       090  S                 
25620...  ..................  A                   Repair fracture radius/ulna.       8.15      7.13        1.14      16.42       090  S                 
25622...  ..................  A                   Treat wrist bone fracture...       2.43      2.28        0.33       5.04       090  S                 
25624...  ..................  A                   Treat wrist bone fracture...       4.28      3.67        0.57       8.52       090  S                 
25628...  ..................  A                   Repair wrist bone fracture..       7.81      7.13        1.16      16.10       090  S                 
25630...  ..................  A                   Treat wrist bone fracture...       2.73      2.19        0.30       5.22       090  S                 
25635...  ..................  A                   Treat wrist bone fracture...       4.16      3.36        0.50       8.02       090  S                 
25645...  ..................  A                   Repair wrist bone fracture..       6.85      6.68        0.95      14.48       090  S                 
25650...  ..................  A                   Repair wrist bone fracture..       2.87      2.66        0.36       5.89       090  S                 
25660...  ..................  A                   Treat wrist dislocation.....       4.53      1.82        0.26       6.61       090  S                 
25670...  ..................  A                   Repair wrist dislocation....       7.52      7.08        1.12      15.72       090  S                 
25675...  ..................  A                   Treat wrist dislocation.....       4.44      2.28        0.34       7.06       090  S                 
25676...  ..................  A                   Repair wrist dislocation....       7.55      7.32        1.11      15.98       090  S                 
25680...  ..................  A                   Treat wrist fracture........       5.63      2.44        0.36       8.43       090  S                 
25685...  ..................  A                   Repair wrist fracture.......       9.23      8.79        1.44      19.46       090  S                 
25690...  ..................  A                   Treat wrist dislocation.....       5.16      4.89        0.73      10.78       090  S                 
25695...  ..................  A                   Repair wrist dislocation....       7.94      7.04        1.17      16.15       090  S                 
25800...  ..................  A                   Fusion of wrist joint.......       9.21     10.94        1.80      21.95       090  S                 
25805...  ..................  A                   Fusion/graft of wrist joint.      10.57     12.85        2.09      25.51       090  S                 
25810...  ..................  A                   Fusion/graft of wrist joint.       9.79    *12.53        2.06      24.38       090  S                 
25820...  ..................  A                   Fusion of hand bones........       7.14      8.91        1.48      17.53       090  S                 
25825...  ..................  A                   Fusion hand bones with graft       8.60    *11.02        1.99      21.61       090  S                 
25830...  ..................  A                   Fusion radioulnar jnt/ulna..       9.50      8.60        1.45      19.55       090  S                 
25900...  ..................  A                   Amputation of forearm.......       8.15      7.08        1.31      16.54       090  S                 
25905...  ..................  A                   Amputation of forearm.......       8.40      7.11        1.15      16.66       090  S                 
25907...  ..................  A                   Amputation follow-up surgery       7.27      5.74        1.00      14.01       090  S                 
25909...  ..................  A                   Amputation follow-up surgery       8.37      5.55        1.06      14.98       090  S                 
25915...  ..................  A                   Amputation of forearm.......      16.61     15.83        2.59      35.03       090  S                 
25920...  ..................  A                   Amputate hand at wrist......       8.09      7.00        1.20      16.29       090  S                 
25922...  ..................  A                   Amputate hand at wrist......       6.96      5.55        1.02      13.53       090  S                 
25924...  ..................  A                   Amputation follow-up surgery       7.87      7.50        1.22      16.59       090  S                 
25927...  ..................  A                   Amputation of hand..........       8.27      6.29        1.22      15.78       090  S                 
25929...  ..................  A                   Amputation follow-up surgery       7.13      4.74        0.96      12.83       090  S                 
25931...  ..................  A                   Amputation follow-up surgery       7.35      4.54        0.90      12.79       090  S                 
25999...  ..................  C                   Forearm or wrist surgery....       0.00      0.00        0.00       0.00       YYY  S                 
26010...  ..................  A                   Drainage of finger abscess..       1.49      0.48        0.05       2.02       010  N                 
26011...  ..................  A                   Drainage of finger abscess..       2.14      1.54        0.24       3.92       010  S                 
26020...  ..................  A                   Drain hand tendon sheath....       4.01      3.72        0.63       8.36       090  S                 
26025...  ..................  A                   Drainage of palm bursa......       4.32      4.51        0.76       9.59       090  S                 
26030...  ..................  A                   Drainage of palm bursa(s)...       5.36      5.73        0.98      12.07       090  S                 
26034...  ..................  A                   Treat hand bone lesion......       5.59      4.23        0.71      10.53       090  S                 
26035...  ..................  A                   Decompress fingers/hand.....       8.38      5.17        0.86      14.41       090  S                 
26037...  ..................  A                   Decompress fingers/hand.....       6.68      6.37        1.05      14.10       090  S                 
26040...  ..................  A                   Release palm contracture....       3.09      2.86        0.49       6.44       090  S                 
26045...  ..................  A                   Release palm contracture....       5.27      4.83        0.81      10.91       090  S                 
26055...  ..................  A                   Incise finger tendon sheath.       2.56     *3.28        0.56       6.40       090  S                 
26060...  ..................  A                   Incision of finger tendon...       2.71      1.13        0.17       4.01       090  S                 
26070...  ..................  A                   Explore/treat hand joint....       3.34      2.76        0.42       6.52       090  S                 
26075...  ..................  A                   Explore/treat finger joint..       3.44      3.78        0.62       7.84       090  S                 
26080...  ..................  A                   Explore/treat finger joint..       3.78      3.14        0.51       7.43       090  S                 
26100...  ..................  A                   Biopsy hand joint lining....       3.54      2.99        0.45       6.98       090  S                 
26105...  ..................  A                   Biopsy finger joint lining..       3.58      4.17        0.67       8.42       090  S                 
26110...  ..................  A                   Biopsy finger joint lining..       3.40      2.93        0.50       6.83       090  S                 
26115...  ..................  A                   Removal of hand lesion......       3.68      2.01        0.34       6.03       090  S                 
26116...  ..................  A                   Removal of hand lesion......       5.19      3.71        0.62       9.52       090  S                 
26117...  ..................  A                   Remove tumor, hand/finger...       8.24      5.07        0.91      14.22       090  S                 
26121...  ..................  A                   Release palm contracture....       7.34     *9.40        1.61      18.35       090  S                 
26123...  ..................  A                   Release palm contracture....       8.64      9.10        1.53      19.27       090  S                 

[[Page 63207]]
                                                                                                                                                        
26125...  ..................  A                   Release palm contracture....       4.61      2.62        0.45       7.68       ZZZ  S                 
26130...  ..................  A                   Remove wrist joint lining...       5.13      5.01        0.86      11.00       090  S                 
26135...  ..................  A                   Revise finger joint, each...       6.67      4.86        0.82      12.35       090  S                 
26140...  ..................  A                   Revise finger joint, each...       5.88      4.40        0.75      11.03       090  S                 
26145...  ..................  A                   Tendon excision, palm/finger       6.03      4.71        0.80      11.54       090  S                 
26160...  ..................  A                   Remove tendon sheath lesion.       3.00      2.32        0.40       5.72       090  S                 
26170...  ..................  A                   Removal of palm tendon, each       4.62      2.83        0.45       7.90       090  S                 
26180...  ..................  A                   Removal of finger tendon....       5.00      4.01        0.71       9.72       090  S                 
26200...  ..................  A                   Remove hand bone lesion.....       5.25      4.48        0.72      10.45       090  S                 
26205...  ..................  A                   Remove/graft bone lesion....       7.24      6.40        1.03      14.67       090  S                 
26210...  ..................  A                   Removal of finger lesion....       4.97      3.90        0.64       9.51       090  S                 
26215...  ..................  A                   Remove/graft finger lesion..       6.81      5.55        0.94      13.30       090  S                 
26230...  ..................  A                   Partial removal of hand bone       5.96      4.26        0.69      10.91       090  S                 
26235...  ..................  A                   Partial removal, finger bone       5.82      4.17        0.71      10.70       090  S                 
26236...  ..................  A                   Partial removal, finger bone       4.95      3.86        0.66       9.47       090  S                 
26250...  ..................  A                   Extensive hand surgery......       7.26      6.00        1.07      14.33       090  S                 
26255...  ..................  A                   Extensive hand surgery......      11.66      8.94        1.54      22.14       090  S                 
26260...  ..................  A                   Extensive finger surgery....       6.74      5.73        0.97      13.44       090  S                 
26261...  ..................  A                   Extensive finger surgery....       8.54      7.70        1.31      17.55       090  S                 
26262...  ..................  A                   Partial removal of finger...       5.41      4.75        0.76      10.92       090  S                 
26320...  ..................  A                   Removal of implant from hand       3.74      3.54        0.57       7.85       090  S                 
26350...  ..................  A                   Repair finger/hand tendon...       5.76      5.74        0.99      12.49       090  S                 
26352...  ..................  A                   Repair/graft hand tendon....       7.26      6.60        1.10      14.96       090  S                 
26356...  ..................  A                   Repair finger/hand tendon...       7.05      7.21        1.24      15.50       090  S                 
26357...  ..................  A                   Repair finger/hand tendon...       8.16      6.58        1.19      15.93       090  S                 
26358...  ..................  A                   Repair/graft hand tendon....       8.69      7.40        1.27      17.36       090  S                 
26370...  ..................  A                   Repair finger/hand tendon...       6.71      6.71        1.13      14.55       090  S                 
26372...  ..................  A                   Repair/graft hand tendon....       8.27      6.39        1.15      15.81       090  S                 
26373...  ..................  A                   Repair finger/hand tendon...       7.67      6.85        1.11      15.63       090  S                 
26390...  ..................  A                   Revise hand/finger tendon...       8.73      7.95        1.23      17.91       090  S                 
26392...  ..................  A                   Repair/graft hand tendon....       9.77      8.61        1.26      19.64       090  S                 
26410...  ..................  A                   Repair hand tendon..........       4.37      3.29        0.51       8.17       090  S                 
26412...  ..................  A                   Repair/graft hand tendon....       5.91      6.01        0.97      12.89       090  S                 
26415...  ..................  A                   Excision, hand/finger tendon       8.05      6.75        0.90      15.70       090  S                 
26416...  ..................  A                   Graft hand or finger tendon.       9.06      8.64        1.41      19.11       090  S                 
26418...  ..................  A                   Repair finger tendon........       4.02      3.58        0.59       8.19       090  S                 
26420...  ..................  A                   Repair/graft finger tendon..       6.37      5.68        0.96      13.01       090  S                 
26426...  ..................  A                   Repair finger/hand tendon...       5.86      6.31        1.07      13.24       090  S                 
26428...  ..................  A                   Repair/graft finger tendon..       6.90      5.50        1.00      13.40       090  S                 
26432...  ..................  A                   Repair finger tendon........       3.87      3.15        0.51       7.53       090  S                 
26433...  ..................  A                   Repair finger tendon........       4.41      3.94        0.66       9.01       090  S                 
26434...  ..................  A                   Repair/graft finger tendon..       5.80      4.95        0.84      11.59       090  S                 
26437...  ..................  A                   Realignment of tendons......       5.53      4.05        0.68      10.26       090  S                 
26440...  ..................  A                   Release palm/finger tendon..       4.76      3.57        0.59       8.92       090  S                 
26442...  ..................  A                   Release palm & finger tendon       6.10      3.37        0.59      10.06       090  S                 
26445...  ..................  A                   Release hand/finger tendon..       4.16      3.25        0.54       7.95       090  S                 
26449...  ..................  A                   Release forearm/hand tendon.       6.39      5.57        0.96      12.92       090  S                 
26450...  ..................  A                   Incision of palm tendon.....       3.54      2.28        0.36       6.18       090  S                 
26455...  ..................  A                   Incision of finger tendon...       3.51      1.89        0.33       5.73       090  S                 
26460...  ..................  A                   Incise hand/finger tendon...       3.33      1.72        0.30       5.35       090  S                 
26471...  ..................  A                   Fusion of finger tendons....       5.55      4.15        0.67      10.37       090  S                 
26474...  ..................  A                   Fusion of finger tendons....       5.14      4.61        0.75      10.50       090  S                 
26476...  ..................  A                   Tendon lengthening..........       5.00      2.89        0.27       8.16       090  S                 
26477...  ..................  A                   Tendon shortening...........       4.97      3.99        0.73       9.69       090  S                 
26478...  ..................  A                   Lengthening of hand tendon..       5.62      4.30        0.72      10.64       090  S                 
26479...  ..................  A                   Shortening of hand tendon...       5.56      5.29        0.86      11.71       090  S                 
26480...  ..................  A                   Transplant hand tendon......       6.49      6.53        1.11      14.13       090  S                 
26483...  ..................  A                   Transplant/graft hand tendon       7.87      8.50        1.40      17.77       090  S                 
26485...  ..................  A                   Transplant palm tendon......       7.28      6.50        1.08      14.86       090  S                 
26489...  ..................  A                   Transplant/graft palm tendon       9.00      3.40        0.51      12.91       090  S                 
26490...  ..................  A                   Revise thumb tendon.........       7.99      7.80        1.28      17.07       090  S                 
26492...  ..................  A                   Tendon transfer with graft..       9.17      8.75        1.21      19.13       090  S                 
26494...  ..................  A                   Hand tendon/muscle transfer.       8.05      7.28        1.23      16.56       090  S                 
26496...  ..................  A                   Revise thumb tendon.........       9.17      8.73        1.53      19.43       090  S                 
26497...  ..................  A                   Finger tendon transfer......       9.15      8.02        1.38      18.55       090  S                 
26498...  ..................  A                   Finger tendon transfer......      13.55     11.78        2.04      27.37       090  S                 

[[Page 63208]]
                                                                                                                                                        
26499...  ..................  A                   Revision of finger..........       8.56      7.75        1.25      17.56       090  S                 
26500...  ..................  A                   Hand tendon reconstruction..       5.67      3.49        0.60       9.76       090  S                 
26502...  ..................  A                   Hand tendon reconstruction..       6.74      5.27        0.95      12.96       090  S                 
26504...  ..................  A                   Hand tendon reconstruction..       7.05      6.72        1.11      14.88       090  S                 
26508...  ..................  A                   Release thumb contracture...       5.61      4.15        0.72      10.48       090  S                 
26510...  ..................  A                   Thumb tendon transfer.......       5.03      4.15        0.68       9.86       090  S                 
26516...  ..................  A                   Fusion of knuckle joint.....       6.75      4.16        0.67      11.58       090  S                 
26517...  ..................  A                   Fusion of knuckle joints....       8.34      7.07        1.23      16.64       090  S                 
26518...  ..................  A                   Fusion of knuckle joints....       8.53      6.51        1.22      16.26       090  S                 
26520...  ..................  A                   Release knuckle contracture.       5.01      4.48        0.71      10.20       090  S                 
26525...  ..................  A                   Release finger contracture..       5.04      3.64        0.62       9.30       090  S                 
26530...  ..................  A                   Revise knuckle joint........       6.38      5.16        0.85      12.39       090  S                 
26531...  ..................  A                   Revise knuckle with implant.       7.57      6.65        1.11      15.33       090  S                 
26535...  ..................  A                   Revise finger joint.........       4.95      4.84        0.58      10.37       090  S                 
26536...  ..................  A                   Revise/implant finger joint.       6.06      7.21        1.19      14.46       090  S                 
26540...  ..................  A                   Repair hand joint...........       6.03      6.64        1.12      13.79       090  S                 
26541...  ..................  A                   Repair hand joint with graft       8.20      8.94        1.47      18.61       090  S                 
26542...  ..................  A                   Repair hand joint with graft       6.38      5.67        0.97      13.02       090  S                 
26545...  ..................  A                   Reconstruct finger joint....       6.50      5.27        0.94      12.71       090  S                 
26548...  ..................  A                   Reconstruct finger joint....       7.61      5.79        1.00      14.40       090  S                 
26550...  ..................  A                   Construct thumb replacement.      20.77     19.81        3.24      43.82       090  S                 
26552...  ..................  C                   Construct thumb replacement.       0.00      0.00        0.00       0.00       090  S                 
26555...  ..................  A                   Positional change of finger.      16.16     15.41        2.52      34.09       090  S                 
26557...  ..................  C                   Construct finger replacement       0.00      0.00        0.00       0.00       090  S                 
26558...  ..................  C                   Added finger surgery........       0.00      0.00        0.00       0.00       090  S                 
26559...  ..................  C                   Added finger surgery........       0.00      0.00        0.00       0.00       090  S                 
26560...  ..................  A                   Repair of web finger........       5.23      4.65        0.66      10.54       090  S                 
26561...  ..................  A                   Repair of web finger........      10.50      8.89        1.56      20.95       090  S                 
26562...  ..................  A                   Repair of web finger........       9.23     10.97        0.82      21.02       090  S                 
26565...  ..................  A                   Correct metacarpal flaw.....       6.45      5.82        0.85      13.12       090  S                 
26567...  ..................  A                   Correct finger deformity....       6.53      4.28        0.67      11.48       090  S                 
26568...  ..................  A                   Lengthen metacarpal/finger..       8.66      8.45        1.06      18.17       090  S                 
26580...  ..................  A                   Repair hand deformity.......      17.71     16.89        2.76      37.36       090  S                 
26585...  ..................  A                   Repair finger deformity.....      13.58     12.95        2.12      28.65       090  S                 
26587...  ..................  C                   Reconstruct extra finger....       0.00      0.00        0.00       0.00       090  S                 
26590...  ..................  A                   Repair finger deformity.....      17.44     16.63        2.72      36.79       090  S                 
26591...  ..................  A                   Repair muscles of hand......       2.90      2.29        0.39       5.58       090  S                 
26593...  ..................  A                   Release muscles of hand.....       4.89      4.12        0.70       9.71       090  S                 
26596...  ..................  A                   Excision constricting tissue       8.64      8.24        1.35      18.23       090  S                 
26597...  ..................  A                   Release of scar contracture.       9.37      8.02        1.37      18.76       090  S                 
26600...  ..................  A                   Treat metacarpal fracture...       1.81      1.54        0.22       3.57       090  S                 
26605...  ..................  A                   Treat metacarpal fracture...       2.67      2.29        0.36       5.32       090  S                 
26607...  ..................  A                   Treat metacarpal fracture...       5.12      3.55        0.57       9.24       090  S                 
26608...  ..................  A                   Treat metacarpal fracture...       5.12      3.55        0.57       9.24       090  S                 
26615...  ..................  A                   Repair metacarpal fracture..       5.18      4.87        0.80      10.85       090  S                 
26641...  ..................  A                   Treat thumb dislocation.....       3.74      1.11        0.14       4.99       090  S                 
26645...  ..................  A                   Treat thumb fracture........       4.23      2.20        0.33       6.76       090  S                 
26650...  ..................  A                   Repair thumb fracture.......       5.49      4.01        0.64      10.14       090  S                 
26665...  ..................  A                   Repair thumb fracture.......       7.14      6.39        1.09      14.62       090  S                 
26670...  ..................  A                   Treat hand dislocation......       3.54      0.96        0.10       4.60       090  S                 
26675...  ..................  A                   Treat hand dislocation......       4.44      4.34        0.60       9.38       090  S                 
26676...  ..................  A                   Pin hand dislocation........       5.29      4.86        0.67      10.82       090  S                 
26685...  ..................  A                   Repair hand dislocation.....       6.54      5.76        0.91      13.21       090  S                 
26686...  ..................  A                   Repair hand dislocation.....       7.48      6.31        1.04      14.83       090  S                 
26700...  ..................  A                   Treat knuckle dislocation...       3.54      0.88        0.10       4.52       090  S                 
26705...  ..................  A                   Treat knuckle dislocation...       3.99      1.78        0.27       6.04       090  S                 
26706...  ..................  A                   Pin knuckle dislocation.....       4.92      4.68        0.75      10.35       090  S                 
26715...  ..................  A                   Repair knuckle dislocation..       5.48      4.13        0.66      10.27       090  S                 
26720...  ..................  A                   Treat finger fracture, each.       1.56      1.10        0.15       2.81       090  S                 
26725...  ..................  A                   Treat finger fracture, each.       3.18      1.54        0.23       4.95       090  S                 
26727...  ..................  A                   Treat finger fracture, each.       4.92      2.45        0.38       7.75       090  S                 
26735...  ..................  A                   Repair finger fracture, each       5.72      3.73        0.61      10.06       090  S                 
26740...  ..................  A                   Treat finger fracture, each.       1.81      1.16        0.16       3.13       090  S                 
26742...  ..................  A                   Treat finger fracture, each.       3.70      1.98        0.32       6.00       090  S                 
26746...  ..................  A                   Repair finger fracture, each       5.55      4.75        0.80      11.10       090  S                 
26750...  ..................  A                   Treat finger fracture, each.       1.60      0.83        0.10       2.53       090  S                 

[[Page 63209]]
                                                                                                                                                        
26755...  ..................  A                   Treat finger fracture, each.       2.97      1.08        0.15       4.20       090  S                 
26756...  ..................  A                   Pin finger fracture, each...       4.19      1.90        0.33       6.42       090  S                 
26765...  ..................  A                   Repair finger fracture, each       4.04      2.66        0.45       7.15       090  S                 
26770...  ..................  A                   Treat finger dislocation....       2.89      0.76        0.08       3.73       090  S                 
26775...  ..................  A                   Treat finger dislocation....       3.51      1.13        0.17       4.81       090  S                 
26776...  ..................  A                   Pin finger dislocation......       4.60      2.08        0.35       7.03       090  S                 
26785...  ..................  A                   Repair finger dislocation...       4.08      2.97        0.48       7.53       090  S                 
26820...  ..................  A                   Thumb fusion with graft.....       7.84      6.65        1.05      15.54       090  S                 
26841...  ..................  A                   Fusion of thumb.............       6.79      6.17        1.00      13.96       090  S                 
26842...  ..................  A                   Thumb fusion with graft.....       7.75      8.58        1.37      17.70       090  S                 
26843...  ..................  A                   Fusion of hand joint........       7.21      6.37        1.10      14.68       090  S                 
26844...  ..................  A                   Fusion/graft of hand joint..       8.24      7.35        1.19      16.78       090  S                 
26850...  ..................  A                   Fusion of knuckle...........       6.57      4.63        0.76      11.96       090  S                 
26852...  ..................  A                   Fusion of knuckle with graft       7.97      5.72        1.00      14.69       090  S                 
26860...  ..................  A                   Fusion of finger joint......       4.49      4.30        0.68       9.47       090  S                 
26861...  ..................  A                   Fusion of finger joint,            1.74     *2.23        0.43       4.40       ZZZ  S                 
                                                   added.                                                                                               
26862...  ..................  A                   Fusion/graft of finger joint       7.06      5.16        0.85      13.07       090  S                 
26863...  ..................  A                   Fuse/graft added joint......       3.90      3.37        0.57       7.84       ZZZ  S                 
26910...  ..................  A                   Amputate metacarpal bone....       7.18      5.16        0.93      13.27       090  S                 
26951...  ..................  A                   Amputation of finger/thumb..       4.41      2.87        0.49       7.77       090  S                 
26952...  ..................  A                   Amputation of finger/thumb..       6.02      4.00        0.69      10.71       090  S                 
26989...  ..................  C                   Hand/finger surgery.........       0.00      0.00        0.00       0.00       YYY  S                 
26990...  ..................  A                   Drainage of pelvis lesion...       6.76      3.10        0.51      10.37       090  S                 
26991...  ..................  A                   Drainage of pelvis bursa....       6.05      1.81        0.29       8.15       090  S                 
26992...  ..................  A                   Drainage of bone lesion.....      13.97      6.38        1.05      21.40       090  S                 
27000...  ..................  A                   Incision of hip tendon......       5.27      1.85        0.24       7.36       090  S                 
27001...  ..................  A                   Incision of hip tendon......       7.70      2.34        0.38      10.42       090  S                 
27003...  ..................  A                   Incision of hip tendon......       6.53      6.77        1.08      14.38       090  S                 
27005...  ..................  A                   Incision of hip tendon......       9.00      3.37        0.54      12.91       090  S                 
27006...  ..................  A                   Incision of hip tendons.....       9.50      4.64        0.77      14.91       090  S                 
27025...  ..................  A                   Incision of hip/thigh fascia      10.16      6.12        1.02      17.30       090  S                 
27030...  ..................  A                   Drainage of hip joint.......      12.09     11.42        1.86      25.37       090  S                 
27033...  ..................  A                   Exploration of hip joint....      12.38     11.52        1.85      25.75       090  S                 
27035...  ..................  A                   Denervation of hip joint....      15.72     11.86        2.21      29.79       090  S                 
27040...  ..................  A                   Biopsy of soft tissues......       3.26      0.72        0.11       4.09       010  N                 
27041...  ..................  A                   Biopsy of soft tissues......       9.36      2.67        0.44      12.47       090  S                 
27047...  ..................  A                   Remove hip/pelvis lesion....       7.16      1.89        0.32       9.37       090  S                 
27048...  ..................  A                   Remove hip/pelvis lesion....       5.70      4.33        0.82      10.85       090  S                 
27049...  ..................  A                   Remove tumor, hip/pelvis....      12.52     10.14        1.87      24.53       090  S                 
27050...  ..................  A                   Biopsy of sacroiliac joint..       3.73     *4.78        0.90       9.41       090  S                 
27052...  ..................  A                   Biopsy of hip joint.........       5.45     *6.97        1.59      14.01       090  S                 
27054...  ..................  A                   Removal of hip joint lining.       7.60     *9.72        2.26      19.58       090  S                 
27060...  ..................  A                   Removal of ischial bursa....       4.73      3.93        0.68       9.34       090  S                 
27062...  ..................  A                   Remove femur lesion/bursa...       4.74      4.23        0.70       9.67       090  S                 
27065...  ..................  A                   Removal of hip bone lesion..       4.98      5.59        0.90      11.47       090  S                 
27066...  ..................  A                   Removal of hip bone lesion..       9.17      7.90        1.30      18.37       090  S                 
27067...  ..................  A                   Remove/graft hip bone lesion      12.64     11.63        1.93      26.20       090  S                 
27070...  ..................  A                   Partial removal of hip bone.       9.58      7.41        1.21      18.20       090  S                 
27071...  ..................  A                   Partial removal of hip bone.      10.23      8.50        1.45      20.18       090  S                 
27075...  ..................  A                   Extensive hip surgery.......      15.85     13.54        2.32      31.71       090  S                 
27076...  ..................  A                   Extensive hip surgery.......      17.93     16.37        2.61      36.91       090  S                 
27077...  ..................  A                   Extensive hip surgery.......      21.29     18.98        3.24      43.51       090  S                 
27078...  ..................  A                   Extensive hip surgery.......      11.86      9.20        1.67      22.73       090  S                 
27079...  ..................  A                   Extensive hip surgery.......      12.11      8.64        1.66      22.41       090  S                 
27080...  ..................  A                   Removal of tail bone........       5.63      4.78        0.87      11.28       090  S                 
27086...  ..................  A                   Remove hip foreign body.....       1.82      0.58        0.07       2.47       010  S                 
27087...  ..................  A                   Remove hip foreign body.....       8.01      3.62        0.60      12.23       090  S                 
27090...  ..................  A                   Removal of hip prosthesis...      12.00      9.09        1.46      22.55       090  S                 
27091...  ..................  A                   Removal of hip prosthesis...      20.48     19.81        3.16      43.45       090  S                 
27093...  ..................  A                   Injection for hip x-ray.....       1.30      0.82        0.11       2.23       000  S                 
27095...  ..................  A                   Injection for hip x-ray.....       1.50      0.93        0.13       2.56       000  N                 
27097...  ..................  A                   Revision of hip tendon......       8.08      7.71        1.26      17.05       090  S                 
27098...  ..................  A                   Transfer tendon to pelvis...       8.08      7.71        1.26      17.05       090  S                 
27100...  ..................  A                   Transfer of abdominal muscle      10.57      7.68        1.42      19.67       090  S                 
27105...  ..................  A                   Transfer of spinal muscle...      11.26      5.89        1.36      18.51       090  S                 
27110...  ..................  A                   Transfer of iliopsoas muscle      12.49     10.61        1.86      24.96       090  S                 

[[Page 63210]]
                                                                                                                                                        
27111...  ..................  A                   Transfer of iliopsoas muscle      11.44     11.63        1.65      24.72       090  S                 
27120...  ..................  A                   Reconstruction of hip socket      16.43     18.10        2.95      37.48       090  S                 
27122...  ..................  A                   Reconstruction of hip socket      13.56    *17.36        2.94      33.86       090  S                 
27125...  ..................  A                   Partial hip replacement.....      13.21    *16.91        3.01      33.13       090  S                 
27130...  ..................  A                   Total hip replacement.......      18.68    *23.91        4.58      47.17       090  S                 
27132...  ..................  A                   Total hip replacement.......      21.44    *27.44        5.09      53.97       090  S                 
27134...  ..................  A                   Revise hip joint replacement      24.54    *31.41        5.96      61.91       090  S                 
27137...  ..................  A                   Revise hip joint replacement      18.67    *23.90        4.82      47.39       090  S                 
27138...  ..................  A                   Revise hip joint replacement      18.93    *24.23        4.58      47.74       090  S                 
27140...  ..................  A                   Transplant of femur ridge...      11.43     11.05        1.71      24.19       090  S                 
27146...  ..................  A                   Incision of hip bone........      13.72     10.88        1.35      25.95       090  S                 
27147...  ..................  A                   Revision of hip bone........      17.58     16.97        2.76      37.31       090  S                 
27151...  ..................  A                   Incision of hip bones.......      18.58     17.71        2.90      39.19       090  S                 
27156...  ..................  A                   Revision of hip bones.......      20.16     18.32        3.08      41.56       090  S                 
27158...  ..................  A                   Revision of pelvis..........      18.10     14.42        2.64      35.16       090  S                 
27161...  ..................  A                   Incision of neck of femur...      15.20     14.31        2.31      31.82       090  S                 
27165...  ..................  A                   Incision/fixation of femur..      16.20     16.76        2.63      35.59       090  S                 
27170...  ..................  A                   Repair/graft femur head/neck      14.90     16.41        2.65      33.96       090  S                 
27175...  ..................  A                   Treat slipped epiphysis.....       7.24      1.18        0.18       8.60       090  S                 
27176...  ..................  A                   Treat slipped epiphysis.....      10.89     10.39        1.70      22.98       090  S                 
27177...  ..................  A                   Repair slipped epiphysis....      13.76     12.39        2.05      28.20       090  S                 
27178...  ..................  A                   Repair slipped epiphysis....      10.76     10.46        1.55      22.77       090  S                 
27179...  ..................  A                   Revise head/neck of femur...      11.69     11.15        1.83      24.67       090  S                 
27181...  ..................  A                   Repair slipped epiphysis....      13.80     13.14        2.16      29.10       090  S                 
27185...  ..................  A                   Revision of femur epiphysis.       8.30      2.77        0.87      11.94       090  S                 
27187...  ..................  A                   Reinforce hip bones.........      12.57    *16.09        2.76      31.42       090  S                 
27193...  ..................  A                   Treat pelvic ring fracture..       4.64      2.41        0.39       7.44       090  S                 
27194...  ..................  A                   Treat pelvic ring fracture..       8.73      3.90        0.50      13.13       090  S                 
27200...  ..................  A                   Treat tail bone fracture....       1.76      1.49        0.17       3.42       090  S                 
27202...  ..................  A                   Repair tail bone fracture...       6.52      6.15        0.89      13.56       090  S                 
27215...  ..................  A                   Pelvic fracture(s) treatment       9.39    *12.02        2.33      23.74       090  S                 
27216...  ..................  A                   Treat pelvic ring fracture..      14.20      4.30        0.66      19.16       090  S                 
27217...  ..................  A                   Treat pelvic ring fracture..      13.19     14.55        2.33      30.07       090  S                 
27218...  ..................  A                   Treat pelvic ring fracture..      18.83     14.55        2.33      35.71       090  S                 
27220...  ..................  A                   Treat hip socket fracture...       5.26      4.26        0.64      10.16       090  S                 
27222...  ..................  A                   Treat hip socket fracture...      10.95      6.37        1.03      18.35       090  S                 
27226...  ..................  A                   Treat hip wall fracture.....      13.93     15.78        2.52      32.23       090  S                 
27227...  ..................  A                   Treat hip fracture(s).......      15.39    *19.70        3.20      38.29       090  S                 
27228...  ..................  A                   Treat hip fracture(s).......      17.90     19.95        3.20      41.05       090  S                 
27230...  ..................  A                   Treat fracture of thigh.....       4.95      3.30        0.41       8.66       090  S                 
27232...  ..................  A                   Treat fracture of thigh.....       9.32      8.98        1.46      19.76       090  S                 
27235...  ..................  A                   Repair of thigh fracture....      11.02    *14.10        2.60      27.72       090  S                 
27236...  ..................  A                   Repair of thigh fracture....      14.14     16.91        2.71      33.76       090  S                 
27238...  ..................  A                   Treatment of thigh fracture.       5.06      4.91        0.71      10.68       090  S                 
27240...  ..................  A                   Treatment of thigh fracture.      10.86      9.70        1.53      22.09       090  S                 
27244...  ..................  A                   Repair of thigh fracture....      14.35     16.30        2.62      33.27       090  S                 
27245...  ..................  A                   Repair of thigh fracture....      18.72     16.30        2.62      37.64       090  S                 
27246...  ..................  A                   Treatment of thigh fracture.       4.36      3.87        0.60       8.83       090  S                 
27248...  ..................  A                   Repair of thigh fracture....       9.73    *12.46        2.11      24.30       090  S                 
27250...  ..................  A                   Treat hip dislocation.......       6.31      3.19        0.45       9.95       090  S                 
27252...  ..................  A                   Treat hip dislocation.......       9.47      4.34        0.68      14.49       090  S                 
27253...  ..................  A                   Repair of hip dislocation...      11.98     13.14        2.11      27.23       090  S                 
27254...  ..................  A                   Repair of hip dislocation...      17.29     13.47        2.27      33.03       090  S                 
27256...  ..................  A                   Treatment of hip dislocation       3.72      1.88        0.31       5.91       010  S                 
27257...  ..................  A                   Treatment of hip dislocation       4.82      4.62        0.73      10.17       010  S                 
27258...  ..................  A                   Repair of hip dislocation...      14.40     13.73        2.25      30.38       090  S                 
27259...  ..................  A                   Repair of hip dislocation...      18.03     17.20        2.82      38.05       090  S                 
27265...  ..................  A                   Treatment of hip dislocation       5.58      3.46        0.54       9.58       090  S                 
27266...  ..................  A                   Treatment of hip dislocation       7.73      4.45        0.71      12.89       090  S                 
27275...  ..................  A                   Manipulation of hip joint...       2.00      1.88        0.30       4.18       010  S                 
27280...  ..................  A                   Fusion of sacroiliac joint..      11.81     10.06        1.77      23.64       090  S                 
27282...  ..................  A                   Fusion of pubic bones.......      10.57      9.01        1.69      21.27       090  S                 
27284...  ..................  A                   Fusion of hip joint.........      15.62     14.50        2.40      32.52       090  S                 
27286...  ..................  A                   Fusion of hip joint.........      15.65     15.20        2.26      33.11       090  S                 
27290...  ..................  A                   Amputation of leg at hip....      21.68     25.40        4.70      51.78       090  S                 
27295...  ..................  A                   Amputation of leg at hip....      17.32     16.54        2.95      36.81       090  S                 

[[Page 63211]]
                                                                                                                                                        
27299...  ..................  C                   Pelvis/hip joint surgery....       0.00      0.00        0.00       0.00       YYY  S                 
27301...  ..................  A                   Drain thigh/knee lesion.....       5.96      2.46        0.40       8.82       090  S                 
27303...  ..................  A                   Drainage of bone lesion.....       7.69      5.86        0.96      14.51       090  S                 
27305...  ..................  A                   Incise thigh tendon & fascia       5.42      3.80        0.68       9.90       090  S                 
27306...  ..................  A                   Incision of thigh tendon....       4.27      1.99        0.32       6.58       090  S                 
27307...  ..................  A                   Incision of thigh tendons...       5.30      3.01        0.48       8.79       090  S                 
27310...  ..................  A                   Exploration of knee joint...       8.26      9.60        1.51      19.37       090  S                 
27315...  ..................  A                   Partial removal, thigh nerve       6.51      5.38        0.96      12.85       090  S                 
27320...  ..................  A                   Partial removal, thigh nerve       5.90      5.18        0.73      11.81       090  S                 
27323...  ..................  A                   Biopsy thigh soft tissues...       2.67      0.91        0.13       3.71       010  S                 
27324...  ..................  A                   Biopsy thigh soft tissues...       4.53      2.63        0.45       7.61       090  S                 
27327...  ..................  A                   Removal of thigh lesion.....       4.32      2.29        0.40       7.01       090  S                 
27328...  ..................  A                   Removal of thigh lesion.....       5.31      4.07        0.73      10.11       090  S                 
27329...  ..................  A                   Remove tumor, thigh/knee....      11.74     11.69        2.14      25.57       090  S                 
27330...  ..................  A                   Biopsy knee joint lining....       4.71     *6.02        1.19      11.92       090  S                 
27331...  ..................  A                   Explore/treat knee joint....       5.51     *7.05        1.49      14.05       090  S                 
27332...  ..................  A                   Removal of knee cartilage...       7.85    *10.05        1.73      19.63       090  S                 
27333...  ..................  A                   Removal of knee cartilage...       6.81     *9.01        2.52      18.34       090  S                 
27334...  ..................  A                   Remove knee joint lining....       7.95    *10.18        1.77      19.90       090  S                 
27335...  ..................  A                   Remove knee joint lining....       9.19    *11.76        2.05      23.00       090  S                 
27340...  ..................  A                   Removal of kneecap bursa....       3.92      3.85        0.62       8.39       090  S                 
27345...  ..................  A                   Removal of knee cyst........       5.63      5.63        0.95      12.21       090  S                 
27350...  ..................  A                   Removal of kneecap..........       7.42     *9.49        1.54      18.45       090  S                 
27355...  ..................  A                   Remove femur lesion.........       7.06      7.58        1.23      15.87       090  S                 
27356...  ..................  A                   Remove femur lesion/graft...       8.60      8.20        1.34      18.14       090  S                 
27357...  ..................  A                   Remove femur lesion/graft...       9.63      8.80        1.43      19.86       090  S                 
27358...  ..................  A                   Remove femur lesion/fixation       4.74      4.55        0.72      10.01       ZZZ  S                 
27360...  ..................  A                   Partial removal leg bone(s).       9.23      8.56        1.40      19.19       090  S                 
27365...  ..................  A                   Extensive leg surgery.......      13.84     13.94        2.43      30.21       090  S                 
27370...  ..................  A                   Injection for knee x-ray....       0.96      0.60        0.05       1.61       000  N                 
27372...  ..................  A                   Removal of foreign body.....       4.81      3.42        0.54       8.77       090  S                 
27380...  ..................  A                   Repair of kneecap tendon....       6.63      7.94        1.29      15.86       090  S                 
27381...  ..................  A                   Repair/graft kneecap tendon.       9.66     11.27        1.82      22.75       090  S                 
27385...  ..................  A                   Repair of thigh muscle......       7.17      8.84        1.42      17.43       090  S                 
27386...  ..................  A                   Repair/graft of thigh muscle       9.72    *12.44        2.02      24.18       090  S                 
27390...  ..................  A                   Incision of thigh tendon....       4.89      4.36        0.71       9.96       090  S                 
27391...  ..................  A                   Incision of thigh tendons...       6.67      5.42        0.90      12.99       090  S                 
27392...  ..................  A                   Incision of thigh tendons...       8.52      7.67        1.28      17.47       090  S                 
27393...  ..................  A                   Lengthening of thigh tendon.       5.95      5.67        0.93      12.55       090  S                 
27394...  ..................  A                   Lengthening of thigh tendons       7.97      5.73        0.94      14.64       090  S                 
27395...  ..................  A                   Lengthening of thigh tendons      10.96     10.48        1.65      23.09       090  S                 
27396...  ..................  A                   Transplant of thigh tendon..       7.33      7.06        1.11      15.50       090  S                 
27397...  ..................  A                   Transplants of thigh tendons       9.33      8.88        1.45      19.66       090  S                 
27400...  ..................  A                   Revise thigh muscles/tendons       8.47      7.89        1.24      17.60       090  S                 
27403...  ..................  A                   Repair of knee cartilage....       7.80      8.79        1.44      18.03       090  S                 
27405...  ..................  A                   Repair of knee ligament.....       7.97     10.17        1.67      19.81       090  S                 
27407...  ..................  A                   Repair of knee ligament.....       9.44      8.87        1.42      19.73       090  S                 
27409...  ..................  A                   Repair of knee ligaments....      11.80    *15.10        2.48      29.38       090  S                 
27418...  ..................  A                   Repair degenerated kneecap..       9.82     12.23        1.85      23.90       090  S                 
27420...  ..................  A                   Revision of unstable kneecap       9.15     10.99        1.74      21.88       090  S                 
27422...  ..................  A                   Revision of unstable kneecap       9.10     11.45        1.83      22.38       090  S                 
27424...  ..................  A                   Revision/removal of kneecap.       9.13    *11.68        1.89      22.70       090  S                 
27425...  ..................  A                   Lateral retinacular release.       5.04     *6.46        1.08      12.58       090  S                 
27427...  ..................  A                   Reconstruction, knee........       8.68    *11.12        2.25      22.05       090  S                 
27428...  ..................  A                   Reconstruction, knee........      10.68    *13.67        2.71      27.06       090  S                 
27429...  ..................  A                   Reconstruction, knee........      11.86     11.27        1.83      24.96       090  S                 
27430...  ..................  A                   Revision of thigh muscles...       8.92      9.36        1.50      19.78       090  S                 
27435...  ..................  A                   Incision of knee joint......       8.74      7.03        1.13      16.90       090  S                 
27437...  ..................  A                   Revise kneecap..............       7.74     *9.91        1.55      19.20       090  S                 
27438...  ..................  A                   Revise kneecap with implant.      10.29     13.13        2.14      25.56       090  S                 
27440...  ..................  A                   Revision of knee joint......       9.49     11.83        2.10      23.42       090  S                 
27441...  ..................  A                   Revision of knee joint......       9.81      9.14        1.51      20.46       090  S                 
27442...  ..................  A                   Revision of knee joint......      11.14    *14.25        3.05      28.44       090  S                 
27443...  ..................  A                   Revision of knee joint......      10.18    *13.03        3.34      26.55       090  S                 
27445...  ..................  A                   Revision of knee joint......      16.39    *20.98        4.21      41.58       090  S                 
27446...  ..................  A                   Revision of knee joint......      15.03    *19.25        3.87      38.15       090  S                 

[[Page 63212]]
                                                                                                                                                        
27447...  ..................  A                   Total knee replacement......      19.69    *25.20        4.95      49.84       090  S                 
27448...  ..................  A                   Incision of thigh...........      10.25     12.87        2.09      25.21       090  S                 
27450...  ..................  A                   Incision of thigh...........      13.08     14.84        2.36      30.28       090  S                 
27454...  ..................  A                   Realignment of thigh bone...      12.26    *15.70        2.82      30.78       090  S                 
27455...  ..................  A                   Realignment of knee.........      12.01     12.01        1.95      25.97       090  S                 
27457...  ..................  A                   Realignment of knee.........      12.60     13.30        2.14      28.04       090  S                 
27465...  ..................  A                   Shortening of thigh bone....      12.84     12.24        2.00      27.08       090  S                 
27466...  ..................  A                   Lengthening of thigh bone...      15.08     13.43        2.27      30.78       090  S                 
27468...  ..................  A                   Shorten/lengthen thighs.....      17.65     16.84        2.75      37.24       090  S                 
27470...  ..................  A                   Repair of thigh.............      14.82     16.67        2.60      34.09       090  S                 
27472...  ..................  A                   Repair/graft of thigh.......      16.40     19.87        3.16      39.43       090  S                 
27475...  ..................  A                   Surgery to stop leg growth..       8.11      7.74        1.27      17.12       090  S                 
27477...  ..................  A                   Surgery to stop leg growth..       9.32    *11.93        2.57      23.82       090  S                 
27479...  ..................  A                   Surgery to stop leg growth..      12.18     11.63        1.89      25.70       090  S                 
27485...  ..................  A                   Surgery to stop leg growth..       8.31      7.91        1.30      17.52       090  S                 
27486...  ..................  A                   Revise knee joint replace...      16.63    *21.28        4.26      42.17       090  S                 
27487...  ..................  A                   Revise knee joint replace...      21.69    *27.76        5.97      55.42       090  S                 
27488...  ..................  A                   Removal of knee prosthesis..      14.48     16.16        2.58      33.22       090  S                 
27495...  ..................  A                   Reinforce thigh.............      14.26     17.63        2.82      34.71       090  S                 
27496...  ..................  A                   Decompression of thigh/knee.       4.75      4.53        0.74      10.02       090  S                 
27497...  ..................  A                   Decompression of thigh/knee.       5.81      5.55        0.91      12.27       090  S                 
27498...  ..................  A                   Decompression of thigh/knee.       6.63      6.32        1.04      13.99       090  S                 
27499...  ..................  A                   Decompression of thigh/knee.       7.64      7.28        1.19      16.11       090  S                 
27500...  ..................  A                   Treatment of thigh fracture.       5.29      5.41        0.82      11.52       090  S                 
27501...  ..................  A                   Treatment of thigh fracture.       5.29      5.41        0.82      11.52       090  S                 
27502...  ..................  A                   Treatment of thigh fracture.       9.51      7.67        1.21      18.39       090  S                 
27503...  ..................  A                   Treatment of thigh fracture.       9.51      7.67        1.21      18.39       090  S                 
27506...  ..................  A                   Repair of thigh fracture....      15.93     16.02        2.56      34.51       090  S                 
27507...  ..................  A                   Treatment of thigh fracture.      12.85     16.02        2.56      31.43       090  S                 
27508...  ..................  A                   Treatment of thigh fracture.       5.21      4.22        0.65      10.08       090  S                 
27509...  ..................  A                   Treatment of thigh fracture.       6.77      4.22        0.65      11.64       090  S                 
27510...  ..................  A                   Treatment of thigh fracture.       8.19      6.82        1.09      16.10       090  S                 
27511...  ..................  A                   Treatment of thigh fracture.      12.50    *16.00        2.56      31.06       090  S                 
27513...  ..................  A                   Treatment of thigh fracture.      16.78     16.02        2.56      35.36       090  S                 
27514...  ..................  A                   Repair of thigh fracture....      15.98     15.76        2.53      34.27       090  S                 
27516...  ..................  A                   Repair of thigh growth plate       4.92      4.82        0.71      10.45       090  S                 
27517...  ..................  A                   Repair of thigh growth plate       8.20      7.82        1.28      17.30       090  S                 
27519...  ..................  A                   Repair of thigh growth plate      13.82     12.68        2.05      28.55       090  S                 
27520...  ..................  A                   Treat kneecap fracture......       2.68      3.04        0.45       6.17       090  S                 
27524...  ..................  A                   Repair of kneecap fracture..       9.38     10.34        1.65      21.37       090  S                 
27530...  ..................  A                   Treatment of knee fracture..       3.23      3.40        0.51       7.14       090  S                 
27532...  ..................  A                   Treatment of knee fracture..       6.81      5.68        0.91      13.40       090  S                 
27535...  ..................  A                   Treatment of knee fracture..      10.36     11.69        1.88      23.93       090  S                 
27536...  ..................  A                   Repair of knee fracture.....      14.51     11.69        1.88      28.08       090  S                 
27538...  ..................  A                   Treat knee fracture(s)......       4.64      3.37        0.51       8.52       090  S                 
27540...  ..................  A                   Repair of knee fracture.....      12.38     10.95        1.74      25.07       090  S                 
27550...  ..................  A                   Treat knee dislocation......       5.53      2.57        0.36       8.46       090  S                 
27552...  ..................  A                   Treat knee dislocation......       7.39      3.43        0.53      11.35       090  S                 
27556...  ..................  A                   Repair of knee dislocation..      13.47     12.48        1.95      27.90       090  S                 
27557...  ..................  A                   Repair of knee dislocation..      15.80     14.60        2.43      32.83       090  S                 
27558...  ..................  A                   Repair of knee dislocation..      16.75     14.60        2.43      33.78       090  S                 
27560...  ..................  A                   Treat kneecap dislocation...       3.64      1.43        0.16       5.23       090  S                 
27562...  ..................  A                   Treat kneecap dislocation...       5.48      5.18        0.76      11.42       090  S                 
27566...  ..................  A                   Repair kneecap dislocation..      11.48     10.58        1.67      23.73       090  S                 
27570...  ..................  A                   Fixation of knee joint......       1.69      1.72        0.28       3.69       010  S                 
27580...  ..................  A                   Fusion of knee..............      12.26    *15.70        2.56      30.52       090  S                 
27590...  ..................  A                   Amputate leg at thigh.......      10.24      9.11        1.80      21.15       090  S                 
27591...  ..................  A                   Amputate leg at thigh.......      11.09     11.77        2.11      24.97       090  S                 
27592...  ..................  A                   Amputate leg at thigh.......       8.75      8.11        1.61      18.47       090  S                 
27594...  ..................  A                   Amputation follow-up surgery       6.30      3.65        0.68      10.63       090  S                 
27596...  ..................  A                   Amputation follow-up surgery       9.63      7.37        1.42      18.42       090  S                 
27598...  ..................  A                   Amputate lower leg at knee..       9.56     10.04        1.78      21.38       090  S                 
27599...  ..................  C                   Leg surgery procedure.......       0.00      0.00        0.00       0.00       YYY  S                 
27600...  ..................  A                   Decompression of lower leg..       5.02      3.39        0.64       9.05       090  S                 
27601...  ..................  A                   Decompression of lower leg..       4.98      3.38        0.67       9.03       090  S                 
27602...  ..................  A                   Decompression of lower leg..       6.63      4.05        0.77      11.45       090  S                 

[[Page 63213]]
                                                                                                                                                        
27603...  ..................  A                   Drain lower leg lesion......       4.41      2.38        0.41       7.20       090  S                 
27604...  ..................  A                   Drain lower leg bursa.......       4.23      1.02        0.14       5.39       090  S                 
27605...  ..................  A                   Incision of achilles tendon.       2.82      1.18        0.14       4.14       010  S                 
27606...  ..................  A                   Incision of achilles tendon.       3.87      2.12        0.35       6.34       010  S                 
27607...  ..................  A                   Treat lower leg bone lesion.       7.05      6.01        0.98      14.04       090  S                 
27610...  ..................  A                   Explore/treat ankle joint...       7.27      7.43        1.13      15.83       090  S                 
27612...  ..................  A                   Exploration of ankle joint..       6.23     *7.97        1.30      15.50       090  S                 
27613...  ..................  A                   Biopsy lower leg soft tissue       2.12      0.67        0.10       2.89       010  S                 
27614...  ..................  A                   Biopsy lower leg soft tissue       5.29      2.26        0.38       7.93       090  S                 
27615...  ..................  A                   Remove tumor, lower leg.....      11.79      8.23        1.42      21.44       090  S                 
27618...  ..................  A                   Remove lower leg lesion.....       4.94      2.10        0.32       7.36       090  S                 
27619...  ..................  A                   Remove lower leg lesion.....       7.98      4.13        0.67      12.78       090  S                 
27620...  ..................  A                   Explore, treat ankle joint..       5.69      6.03        0.96      12.68       090  S                 
27625...  ..................  A                   Remove ankle joint lining...       7.88      8.71        1.27      17.86       090  S                 
27626...  ..................  A                   Remove ankle joint lining...       8.49    *10.86        1.25      20.60       090  S                 
27630...  ..................  A                   Removal of tendon lesion....       4.65      3.10        0.46       8.21       090  S                 
27635...  ..................  A                   Remove lower leg bone lesion       7.29      8.04        1.27      16.60       090  S                 
27637...  ..................  A                   Remove/graft leg bone lesion       9.14      8.47        1.40      19.01       090  S                 
27638...  ..................  A                   Remove/graft leg bone lesion       9.89      9.15        1.52      20.56       090  S                 
27640...  ..................  A                   Partial removal of tibia....      10.21      9.81        1.57      21.59       090  S                 
27641...  ..................  A                   Partial removal of fibula...       8.36      7.13        1.18      16.67       090  S                 
27645...  ..................  A                   Extensive lower leg surgery.      13.14     11.64        1.98      26.76       090  S                 
27646...  ..................  A                   Extensive lower leg surgery.      11.69     10.75        1.71      24.15       090  S                 
27647...  ..................  A                   Extensive ankle/heel surgery      11.21      9.95        1.35      22.51       090  S                 
27648...  ..................  A                   Injection for ankle x-ray...       0.96      0.52        0.05       1.53       000  N                 
27650...  ..................  A                   Repair achilles tendon......       9.07      8.98        1.41      19.46       090  S                 
27652...  ..................  A                   Repair/graft achilles tendon       9.62     10.41        1.56      21.59       090  S                 
27654...  ..................  A                   Repair of achilles tendon...       9.34     10.93        1.65      21.92       090  S                 
27656...  ..................  A                   Repair leg fascia defect....       4.31      3.18        0.54       8.03       090  S                 
27658...  ..................  A                   Repair of leg tendon, each..       4.61      4.02        0.60       9.23       090  S                 
27659...  ..................  A                   Repair of leg tendon, each..       6.28      5.87        0.86      13.01       090  S                 
27664...  ..................  A                   Repair of leg tendon, each..       4.33      3.41        0.52       8.26       090  S                 
27665...  ..................  A                   Repair of leg tendon, each..       5.11      4.95        0.76      10.82       090  S                 
27675...  ..................  A                   Repair lower leg tendons....       6.78      6.40        0.94      14.12       090  S                 
27676...  ..................  A                   Repair lower leg tendons....       7.87      7.56        1.14      16.57       090  S                 
27680...  ..................  A                   Release of lower leg tendon.       5.37      4.12        0.61      10.10       090  S                 
27681...  ..................  A                   Release of lower leg tendons       6.36      5.97        0.86      13.19       090  S                 
27685...  ..................  A                   Revision of lower leg tendon       6.08      3.83        0.41      10.32       090  S                 
27686...  ..................  A                   Revise lower leg tendons....       6.93      6.56        0.90      14.39       090  S                 
27687...  ..................  A                   Revision of calf tendon.....       5.84      5.45        0.76      12.05       090  S                 
27690...  ..................  A                   Revise lower leg tendon.....       8.09      6.74        0.88      15.71       090  S                 
27691...  ..................  A                   Revise lower leg tendon.....       9.25      7.89        1.23      18.37       090  S                 
27692...  ..................  A                   Revise additional leg tendon       1.87      2.03        0.29       4.19       ZZZ  S                 
27695...  ..................  A                   Repair of ankle ligament....       6.09     *7.79        1.32      15.20       090  S                 
27696...  ..................  A                   Repair of ankle ligaments...       7.72      7.06        1.16      15.94       090  S                 
27698...  ..................  A                   Repair of ankle ligament....       8.87    *11.35        1.86      22.08       090  S                 
27700...  ..................  A                   Revision of ankle joint.....       8.67    *11.11        1.51      21.29       090  S                 
27702...  ..................  A                   Reconstruct ankle joint.....      12.64    *16.18        3.99      32.81       090  S                 
27703...  ..................  A                   Reconstruction, ankle joint.      14.49     13.82        2.25      30.56       090  S                 
27704...  ..................  A                   Removal of ankle implant....       7.20      5.84        0.98      14.02       090  S                 
27705...  ..................  A                   Incision of tibia...........       9.63     10.74        1.76      22.13       090  S                 
27707...  ..................  A                   Incision of fibula..........       3.71     *4.75        0.79       9.25       090  S                 
27709...  ..................  A                   Incision of tibia & fibula..       9.14    *11.70        2.14      22.98       090  S                 
27712...  ..................  A                   Realignment of lower leg....      11.81     10.99        1.63      24.43       090  S                 
27715...  ..................  A                   Revision of lower leg.......      12.97     12.61        1.88      27.46       090  S                 
27720...  ..................  A                   Repair of tibia.............      10.95     13.97        2.25      27.17       090  S                 
27722...  ..................  A                   Repair/graft of tibia.......      10.92     10.50        1.64      23.06       090  S                 
27724...  ..................  A                   Repair/graft of tibia.......      12.11    *15.50        2.87      30.48       090  S                 
27725...  ..................  A                   Repair of lower leg.........      11.04     10.43        1.53      23.00       090  S                 
27727...  ..................  A                   Repair of lower leg.........      12.89      9.38        1.84      24.11       090  S                 
27730...  ..................  A                   Repair of tibia epiphysis...       6.88      3.59        0.84      11.31       090  S                 
27732...  ..................  A                   Repair of fibula epiphysis..       5.06      4.84        0.79      10.69       090  S                 
27734...  ..................  A                   Repair lower leg epiphyses..       7.89      7.54        1.23      16.66       090  S                 
27740...  ..................  A                   Repair of leg epiphyses.....       8.75      8.36        1.36      18.47       090  S                 
27742...  ..................  A                   Repair of leg epiphyses.....       9.72      9.29        1.52      20.53       090  S                 
27745...  ..................  A                   Reinforce tibia.............       9.39      8.97        1.39      19.75       090  S                 

[[Page 63214]]
                                                                                                                                                        
27750...  ..................  A                   Treatment of tibia fracture.       2.90      3.45        0.50       6.85       090  S                 
27752...  ..................  A                   Treatment of tibia fracture.       5.16      5.09        0.81      11.06       090  S                 
27756...  ..................  A                   Repair of tibia fracture....       5.84     *7.48        1.70      15.02       090  S                 
27758...  ..................  A                   Repair of tibia fracture....      10.51    *13.46        2.22      26.19       090  S                 
27759...  ..................  A                   Repair of tibia fracture....      12.60     13.74        2.22      28.56       090  S                 
27760...  ..................  A                   Treatment of ankle fracture.       2.81      2.58        0.37       5.76       090  S                 
27762...  ..................  A                   Treatment of ankle fracture.       4.80      3.36        0.50       8.66       090  S                 
27766...  ..................  A                   Repair of ankle fracture....       7.61      7.87        1.26      16.74       090  S                 
27780...  ..................  A                   Treatment of fibula fracture       2.47      1.97        0.26       4.70       090  S                 
27781...  ..................  A                   Treatment of fibula fracture       4.20      3.29        0.49       7.98       090  S                 
27784...  ..................  A                   Repair of fibula fracture...       6.45      5.59        0.87      12.91       090  S                 
27786...  ..................  A                   Treatment of ankle fracture.       2.66      2.52        0.38       5.56       090  S                 
27788...  ..................  A                   Treatment of ankle fracture.       4.25      3.27        0.50       8.02       090  S                 
27792...  ..................  A                   Repair of ankle fracture....       7.04      7.38        1.17      15.59       090  S                 
27808...  ..................  A                   Treatment of ankle fracture.       2.63      2.79        0.39       5.81       090  S                 
27810...  ..................  A                   Treatment of ankle fracture.       4.82      5.05        0.80      10.67       090  S                 
27814...  ..................  A                   Repair of ankle fracture....       9.87     10.00        1.60      21.47       090  S                 
27816...  ..................  A                   Treatment of ankle fracture.       2.71     *3.47        0.55       6.73       090  S                 
27818...  ..................  A                   Treatment of ankle fracture.       5.08     *6.51        1.06      12.65       090  S                 
27822...  ..................  A                   Repair of ankle fracture....       8.39    *10.73        1.88      21.00       090  S                 
27823...  ..................  A                   Repair of ankle fracture....      10.90     12.79        2.05      25.74       090  S                 
27824...  ..................  A                   Treat lower leg fracture....       2.71     *3.47        0.55       6.73       090  S                 
27825...  ..................  A                   Treat lower leg fracture....       5.08     *6.51        1.06      12.65       090  S                 
27826...  ..................  A                   Treat lower leg fracture....       7.43     *9.50        1.88      18.81       090  S                 
27827...  ..................  A                   Treat lower leg fracture....       9.90     11.71        1.88      23.49       090  S                 
27828...  ..................  A                   Treat lower leg fracture....      12.33     12.79        2.05      27.17       090  S                 
27829...  ..................  A                   Treat lower leg joint.......       4.87     *6.23        1.37      12.47       090  S                 
27830...  ..................  A                   Treat lower leg dislocation.       3.50      3.25        0.46       7.21       090  S                 
27831...  ..................  A                   Treat lower leg dislocation.       4.27      3.98        0.59       8.84       090  S                 
27832...  ..................  A                   Repair lower leg dislocation       5.96      5.70        0.89      12.55       090  S                 
27840...  ..................  A                   Treat ankle dislocation.....       4.27      1.87        0.21       6.35       090  S                 
27842...  ..................  A                   Treat ankle dislocation.....       5.72      2.22        0.34       8.28       090  S                 
27846...  ..................  A                   Repair ankle dislocation....       9.04      8.59        1.37      19.00       090  S                 
27848...  ..................  A                   Repair ankle dislocation....      10.45      8.36        1.32      20.13       090  S                 
27860...  ..................  A                   Fixation of ankle joint.....       2.29      1.39        0.23       3.91       010  S                 
27870...  ..................  A                   Fusion of ankle joint.......      10.42    *13.34        2.22      25.98       090  S                 
27871...  ..................  A                   Fusion of tibiofibular joint       8.55      7.79        1.21      17.55       090  S                 
27880...  ..................  A                   Amputation of lower leg.....      10.69      8.36        1.60      20.65       090  S                 
27881...  ..................  A                   Amputation of lower leg.....      10.89     10.82        1.87      23.58       090  S                 
27882...  ..................  A                   Amputation of lower leg.....       7.80      7.36        1.42      16.58       090  S                 
27884...  ..................  A                   Amputation follow-up surgery       7.40      3.37        0.61      11.38       090  S                 
27886...  ..................  A                   Amputation follow-up surgery       8.35      7.17        1.34      16.86       090  S                 
27888...  ..................  A                   Amputation of foot at ankle.       8.70      9.49        1.65      19.84       090  S                 
27889...  ..................  A                   Amputation of foot at ankle.       8.82      8.43        1.55      18.80       090  S                 
27892...  ..................  A                   Decompression of leg........       6.03      3.39        0.64      10.06       090  S                 
27893...  ..................  A                   Decompression of leg........       5.99      3.38        0.67      10.04       090  S                 
27894...  ..................  A                   Decompression of leg........       7.64      4.05        0.77      12.46       090  S                 
27899...  ..................  C                   Leg/ankle surgery procedure.       0.00      0.00        0.00       0.00       YYY  S                 
28001...  ..................  A                   Drainage of bursa of foot...       2.68      0.52        0.05       3.25       010  S                 
28002...  ..................  A                   Treatment of foot infection.       3.76      2.25        0.33       6.34       010  S                 
28003...  ..................  A                   Treatment of foot infection.       7.49      3.50        0.59      11.58       090  S                 
28005...  ..................  A                   Treat foot bone lesion......       7.65      4.08        0.61      12.34       090  S                 
28008...  ..................  A                   Incision of foot fascia.....       4.19      2.68        0.29       7.16       090  S                 
28010...  ..................  A                   Incision of toe tendon......       2.97      3.62        0.33       6.92       090  S                 
28011...  ..................  A                   Incision of toe tendons.....       3.99      1.77        0.19       5.95       090  S                 
28020...  ..................  A                   Exploration of a foot joint.       4.75      4.40        0.56       9.71       090  S                 
28022...  ..................  A                   Exploration of a foot joint.       4.41      2.74        0.31       7.46       090  S                 
28024...  ..................  A                   Exploration of a toe joint..       4.12      2.39        0.24       6.75       090  S                 
28030...  ..................  A                   Removal of foot nerve.......       5.78      3.93        0.42      10.13       090  S                 
28035...  ..................  A                   Decompression of tibia nerve       4.83     *6.18        0.90      11.91       090  S                 
28043...  ..................  A                   Excision of foot lesion.....       3.41      1.73        0.20       5.34       090  S                 
28045...  ..................  A                   Excision of foot lesion.....       4.46      3.99        0.46       8.91       090  S                 
28046...  ..................  A                   Resection of tumor, foot....       9.41      5.35        0.79      15.55       090  S                 
28050...  ..................  A                   Biopsy of foot joint lining.       3.99      3.84        0.53       8.36       090  S                 
28052...  ..................  A                   Biopsy of foot joint lining.       3.70      3.82        0.43       7.95       090  S                 
28054...  ..................  A                   Biopsy of toe joint lining..       3.21      2.24        0.28       5.73       090  S                 

[[Page 63215]]
                                                                                                                                                        
28060...  ..................  A                   Partial removal foot fascia.       5.05      4.22        0.53       9.80       090  S                 
28062...  ..................  A                   Removal of foot fascia......       6.23      7.06        0.86      14.15       090  S                 
28070...  ..................  A                   Removal of foot joint lining       4.73      4.48        0.48       9.69       090  S                 
28072...  ..................  A                   Removal of foot joint lining       4.32      3.21        0.42       7.95       090  S                 
28080...  ..................  A                   Removal of foot lesion......       3.18     *4.07        0.45       7.70       090  S                 
28086...  ..................  A                   Excise foot tendon sheath...       4.52      3.12        0.46       8.10       090  S                 
28088...  ..................  A                   Excise foot tendon sheath...       3.62      3.62        0.40       7.64       090  S                 
28090...  ..................  A                   Removal of foot lesion......       4.26      3.02        0.29       7.57       090  S                 
28092...  ..................  A                   Removal of toe lesions......       3.49      2.03        0.25       5.77       090  S                 
28100...  ..................  A                   Removal of ankle/heel lesion       5.37      4.58        0.56      10.51       090  S                 
28102...  ..................  A                   Remove/graft foot lesion....       7.31      6.84        0.85      15.00       090  S                 
28103...  ..................  A                   Remove/graft foot lesion....       6.10      5.61        0.69      12.40       090  S                 
28104...  ..................  A                   Removal of foot lesion......       4.86      4.33        0.49       9.68       090  S                 
28106...  ..................  A                   Remove/graft foot lesion....       6.74      6.42        0.79      13.95       090  S                 
28107...  ..................  A                   Remove/graft foot lesion....       5.16      4.86        0.48      10.50       090  S                 
28108...  ..................  A                   Removal of toe lesions......       4.01      4.20        0.38       8.59       090  S                 
28110...  ..................  A                   Part removal of metatarsal..       3.82      3.48        0.39       7.69       090  S                 
28111...  ..................  A                   Part removal of metatarsal..       4.64      5.04        0.65      10.33       090  S                 
28112...  ..................  A                   Part removal of metatarsal..       4.23      3.96        0.45       8.64       090  S                 
28113...  ..................  A                   Part removal of metatarsal..       4.09      4.44        0.48       9.01       090  S                 
28114...  ..................  A                   Removal of metatarsal heads.       7.16     *9.17        1.42      17.75       090  S                 
28116...  ..................  A                   Revision of foot............       6.17      5.48        0.57      12.22       090  S                 
28118...  ..................  A                   Removal of heel bone........       5.56      5.71        0.66      11.93       090  S                 
28119...  ..................  A                   Removal of heel spur........       5.10      5.44        0.57      11.11       090  S                 
28120...  ..................  A                   Part removal of ankle/heel..       4.81      5.04        0.67      10.52       090  S                 
28122...  ..................  A                   Partial removal of foot bone       6.62      4.48        0.54      11.64       090  S                 
28124...  ..................  A                   Partial removal of toe......       4.39      4.11        0.37       8.87       090  S                 
28126...  ..................  A                   Partial removal of toe......       3.39      3.98        0.36       7.73       090  S                 
28130...  ..................  A                   Removal of ankle bone.......       7.33      7.03        0.88      15.24       090  S                 
28140...  ..................  A                   Removal of metatarsal.......       6.45      4.93        0.62      12.00       090  S                 
28150...  ..................  A                   Removal of toe..............       3.83      3.29        0.38       7.50       090  S                 
28153...  ..................  A                   Partial removal of toe......       3.40      3.99        0.36       7.75       090  S                 
28160...  ..................  A                   Partial removal of toe......       3.59      4.12        0.38       8.09       090  S                 
28171...  ..................  A                   Extensive foot surgery......       8.98      7.99        0.88      17.85       090  S                 
28173...  ..................  A                   Extensive foot surgery......       8.18      5.74        0.74      14.66       090  S                 
28175...  ..................  A                   Extensive foot surgery......       5.59      5.38        0.58      11.55       090  S                 
28190...  ..................  A                   Removal of foot foreign body       1.91      0.52        0.05       2.48       010  S                 
28192...  ..................  A                   Removal of foot foreign body       4.49      1.95        0.24       6.68       090  S                 
28193...  ..................  A                   Removal of foot foreign body       5.44      2.38        0.30       8.12       090  S                 
28200...  ..................  A                   Repair of foot tendon.......       4.45      5.06        0.50      10.01       090  S                 
28202...  ..................  A                   Repair/graft of foot tendon.       6.38      5.82        0.77      12.97       090  S                 
28208...  ..................  A                   Repair of foot tendon.......       4.11      2.81        0.28       7.20       090  S                 
28210...  ..................  A                   Repair/graft of foot tendon.       5.95      5.60        0.60      12.15       090  S                 
28220...  ..................  A                   Release of foot tendon......       4.27      3.87        0.43       8.57       090  S                 
28222...  ..................  A                   Release of foot tendons.....       5.36      6.40        0.63      12.39       090  S                 
28225...  ..................  A                   Release of foot tendon......       3.42      2.37        0.25       6.04       090  S                 
28226...  ..................  A                   Release of foot tendons.....       4.27      3.38        0.40       8.05       090  S                 
28230...  ..................  A                   Incision of foot tendon(s)..       4.00      2.43        0.22       6.65       090  S                 
28232...  ..................  A                   Incision of toe tendon......       3.26      1.60        0.15       5.01       090  S                 
28234...  ..................  A                   Incision of foot tendon.....       3.19      1.53        0.14       4.86       090  S                 
28236...  ..................  D                   Transfer of foot tendon.....       0.00      0.00        0.00       0.00       090  S                 
28238...  ..................  A                   Revision of foot tendon.....       7.27      7.23        0.85      15.35       090  S                 
28240...  ..................  A                   Release of big toe..........       4.12      2.13        0.23       6.48       090  S                 
28250...  ..................  A                   Revision of foot fascia.....       5.66      4.46        0.50      10.62       090  S                 
28260...  ..................  A                   Release of midfoot joint....       7.50      4.43        0.48      12.41       090  S                 
28261...  ..................  A                   Revision of foot tendon.....       8.92      5.91        0.58      15.41       090  S                 
28262...  ..................  A                   Revision of foot and ankle..      12.19     11.91        1.44      25.54       090  S                 
28264...  ..................  A                   Release of midfoot joint....       9.80      9.56        1.17      20.53       090  S                 
28270...  ..................  A                   Release of foot contracture.       4.58      2.63        0.23       7.44       090  S                 
28272...  ..................  A                   Release of toe joint, each..       3.67      2.04        0.18       5.89       090  S                 
28280...  ..................  A                   Fusion of toes..............       4.93      2.22        0.30       7.45       090  S                 
28285...  ..................  A                   Repair of hammertoe.........       4.41      4.37        0.39       9.17       090  S                 
28286...  ..................  A                   Repair of hammertoe.........       4.41      3.58        0.38       8.37       090  S                 
28288...  ..................  A                   Partial removal of foot bone       3.73      3.75        0.43       7.91       090  S                 
28290...  ..................  A                   Correction of bunion........       5.37      5.36        0.63      11.36       090  S                 
28292...  ..................  A                   Correction of bunion........       6.24      7.05        0.74      14.03       090  S                 

[[Page 63216]]
                                                                                                                                                        
28293...  ..................  A                   Correction of bunion........       8.25      9.55        0.98      18.78       090  S                 
28294...  ..................  A                   Correction of bunion........       8.14      9.16        0.86      18.16       090  S                 
28296...  ..................  A                   Correction of bunion........       8.69      8.81        0.98      18.48       090  S                 
28297...  ..................  A                   Correction of bunion........       8.69      9.02        1.05      18.76       090  S                 
28298...  ..................  A                   Correction of bunion........       7.52      8.89        0.79      17.20       090  S                 
28299...  ..................  A                   Correction of bunion........       8.46     10.14        1.08      19.68       090  S                 
28300...  ..................  A                   Incision of heel bone.......       9.12      6.52        0.79      16.43       090  S                 
28302...  ..................  A                   Incision of ankle bone......       9.13      8.89        1.12      19.14       090  S                 
28304...  ..................  A                   Incision of midfoot bones...       8.67      6.44        0.70      15.81       090  S                 
28305...  ..................  A                   Incise/graft midfoot bones..       9.99      9.85        1.03      20.87       090  S                 
28306...  ..................  A                   Incision of metatarsal......       5.71      4.57        0.47      10.75       090  S                 
28307...  ..................  A                   Incision of metatarsal......       6.04      5.87        0.76      12.67       090  S                 
28308...  ..................  A                   Incision of metatarsal......       5.09      5.71        0.50      11.30       090  S                 
28309...  ..................  A                   Incision of metatarsals.....       8.83      6.87        1.00      16.70       090  S                 
28310...  ..................  A                   Revision of big toe.........       5.06      4.17        0.42       9.65       090  S                 
28312...  ..................  A                   Revision of toe.............       4.29      4.56        0.45       9.30       090  S                 
28313...  ..................  A                   Repair deformity of toe.....       4.75      2.57        0.31       7.63       090  S                 
28315...  ..................  A                   Removal of sesamoid bone....       4.60      4.24        0.41       9.25       090  S                 
28320...  ..................  A                   Repair of foot bones........       8.76      8.69        1.03      18.48       090  S                 
28322...  ..................  A                   Repair of metatarsals.......       8.03      4.67        0.52      13.22       090  S                 
28340...  ..................  A                   Resect enlarged toe tissue..       6.58      6.34        0.91      13.83       090  S                 
28341...  ..................  A                   Resect enlarged toe.........       7.86      7.66        0.96      16.48       090  S                 
28344...  ..................  A                   Repair extra toe(s).........       3.89      3.70        0.60       8.19       090  S                 
28345...  ..................  A                   Repair webbed toe(s)........       5.52      5.34        0.73      11.59       090  S                 
28360...  ..................  A                   Reconstruct cleft foot......      12.49     11.91        1.95      26.35       090  S                 
28400...  ..................  A                   Treatment of heel fracture..       2.01     *2.57        0.40       4.98       090  S                 
28405...  ..................  A                   Treatment of heel fracture..       4.28      3.90        0.58       8.76       090  S                 
28406...  ..................  A                   Treatment of heel fracture..       5.82      6.09        0.93      12.84       090  S                 
28415...  ..................  A                   Repair of heel fracture.....      13.28      9.02        1.39      23.69       090  S                 
28420...  ..................  A                   Repair/graft heel fracture..      15.80     10.89        1.63      28.32       090  S                 
28430...  ..................  A                   Treatment of ankle fracture.       1.96      2.45        0.35       4.76       090  S                 
28435...  ..................  A                   Treatment of ankle fracture.       3.25      3.36        0.50       7.11       090  S                 
28436...  ..................  A                   Treatment of ankle fracture.       4.40      4.19        0.68       9.27       090  S                 
28445...  ..................  A                   Repair of ankle fracture....       8.78      8.80        1.40      18.98       090  S                 
28450...  ..................  A                   Treat midfoot fracture, each       1.77      1.87        0.25       3.89       090  S                 
28455...  ..................  A                   Treat midfoot fracture, each       2.94      2.54        0.34       5.82       090  S                 
28456...  ..................  A                   Repair midfoot fracture.....       2.39      2.27        0.38       5.04       090  S                 
28465...  ..................  A                   Repair midfoot fracture,           6.55      5.54        0.81      12.90       090  S                 
                                                   each.                                                                                                
28470...  ..................  A                   Treat metatarsal fracture...       1.76      1.80        0.23       3.79       090  S                 
28475...  ..................  A                   Treat metatarsal fracture...       2.74      2.34        0.30       5.38       090  S                 
28476...  ..................  A                   Repair metatarsal fracture..       3.15      3.37        0.45       6.97       090  S                 
28485...  ..................  A                   Repair metatarsal fracture..       5.31      4.68        0.60      10.59       090  S                 
28490...  ..................  A                   Treat big toe fracture......       1.01      0.90        0.10       2.01       090  S                 
28495...  ..................  A                   Treat big toe fracture......       1.48      1.12        0.13       2.73       090  S                 
28496...  ..................  A                   Repair big toe fracture.....       2.18      2.07        0.31       4.56       090  S                 
28505...  ..................  A                   Repair big toe fracture.....       3.55      2.99        0.43       6.97       090  S                 
28510...  ..................  A                   Treatment of toe fracture...       1.01      0.89        0.09       1.99       090  S                 
28515...  ..................  A                   Treatment of toe fracture...       1.36      1.12        0.11       2.59       090  S                 
28525...  ..................  A                   Repair of toe fracture......       3.08      2.06        0.29       5.43       090  S                 
28530...  ..................  A                   Treat sesamoid bone fracture       1.01      1.00        0.10       2.11       090  S                 
28531...  ..................  A                   Treat sesamoid bone fracture       2.01      1.91        0.32       4.24       090  S                 
28540...  ..................  A                   Treat foot dislocation......       1.89      0.60        0.06       2.55       090  S                 
28545...  ..................  A                   Treat foot dislocation......       2.19      1.31        0.14       3.64       090  S                 
28546...  ..................  A                   Treat foot dislocation......       2.89      2.74        0.45       6.08       090  S                 
28555...  ..................  A                   Repair foot dislocation.....       5.84      5.58        0.73      12.15       090  S                 
28570...  ..................  A                   Treat foot dislocation......       1.56      1.59        0.17       3.32       090  S                 
28575...  ..................  A                   Treat foot dislocation......       2.91      2.77        0.42       6.10       090  S                 
28576...  ..................  A                   Treat foot dislocation......       3.75      2.77        0.42       6.94       090  S                 
28585...  ..................  A                   Repair foot dislocation.....       7.46      4.96        0.55      12.97       090  S                 
28600...  ..................  A                   Treat foot dislocation......       1.76      0.68        0.08       2.52       090  S                 
28605...  ..................  A                   Treat foot dislocation......       2.42      2.26        0.34       5.02       090  S                 
28606...  ..................  A                   Treat foot dislocation......       4.48      3.49        0.55       8.52       090  S                 
28615...  ..................  A                   Repair foot dislocation.....       5.12      4.96        0.78      10.86       090  S                 
28630...  ..................  A                   Treat toe dislocation.......       1.65      1.03        0.11       2.79       010  S                 
28635...  ..................  A                   Treat toe dislocation.......       1.86      1.45        0.18       3.49       010  S                 
28636...  ..................  A                   Treat toe dislocation.......       2.67      2.56        0.42       5.65       010  S                 

[[Page 63217]]
                                                                                                                                                        
28645...  ..................  A                   Repair toe dislocation......       3.96      3.24        0.38       7.58       090  S                 
28660...  ..................  A                   Treat toe dislocation.......       1.18      0.63        0.06       1.87       010  S                 
28665...  ..................  A                   Treat toe dislocation.......       1.87      0.98        0.11       2.96       010  S                 
28666...  ..................  A                   Treat toe dislocation.......       2.56      2.44        0.40       5.40       010  S                 
28675...  ..................  A                   Repair of toe dislocation...       2.68      3.00        0.41       6.09       090  S                 
28705...  ..................  A                   Fusion of foot bones........      14.23     15.11        2.35      31.69       090  S                 
28715...  ..................  A                   Fusion of foot bones........      12.18     12.33        1.89      26.40       090  S                 
28725...  ..................  A                   Fusion of foot bones........      10.86      9.44        1.44      21.74       090  S                 
28730...  ..................  A                   Fusion of foot bones........       9.91      9.00        1.33      20.24       090  S                 
28735...  ..................  A                   Fusion of foot bones........      10.07      9.76        1.37      21.20       090  S                 
28737...  ..................  A                   Revision of foot bones......       8.89      8.87        1.13      18.89       090  S                 
28740...  ..................  A                   Fusion of foot bones........       6.20      5.14        0.72      12.06       090  S                 
28750...  ..................  A                   Fusion of big toe joint.....       4.77      5.32        0.82      10.91       090  S                 
28755...  ..................  A                   Fusion of big toe joint.....       4.48      3.69        0.45       8.62       090  S                 
28760...  ..................  A                   Fusion of big toe joint.....       5.47      5.40        0.65      11.52       090  S                 
28800...  ..................  A                   Amputation of midfoot.......       7.37      6.65        1.19      15.21       090  S                 
28805...  ..................  A                   Amputation thru metatarsal..       7.55      6.32        1.21      15.08       090  S                 
28810...  ..................  A                   Amputation toe & metatarsal.       5.53      3.91        0.75      10.19       090  S                 
28820...  ..................  A                   Amputation of toe...........       3.56      2.58        0.46       6.60       090  S                 
28825...  ..................  A                   Partial amputation of toe...       3.13      2.40        0.41       5.94       090  S                 
28899...  ..................  C                   Foot/toes surgery procedure.       0.00      0.00        0.00       0.00       YYY  S                 
29000...  ..................  A                   Application of body cast....       2.25      1.85        0.21       4.31       000  S                 
29010...  ..................  A                   Application of body cast....       2.06      2.33        0.34       4.73       000  S                 
29015...  ..................  A                   Application of body cast....       2.41      2.33        0.33       5.07       000  S                 
29020...  ..................  A                   Application of body cast....       2.11      1.82        0.23       4.16       000  S                 
29025...  ..................  A                   Application of body cast....       2.40      0.75        0.14       3.29       000  S                 
29035...  ..................  A                   Application of body cast....       1.77      1.95        0.32       4.04       000  S                 
29040...  ..................  A                   Application of body cast....       2.22      2.02        0.30       4.54       000  S                 
29044...  ..................  A                   Application of body cast....       2.12      2.09        0.34       4.55       000  S                 
29046...  ..................  A                   Application of body cast....       2.41      2.23        0.36       5.00       000  S                 
29049...  ..................  A                   Application of shoulder cast       0.89      0.42        0.06       1.37       000  S                 
29055...  ..................  A                   Application of shoulder cast       1.78      1.20        0.17       3.15       000  S                 
29058...  ..................  A                   Application of shoulder cast       1.31      0.65        0.09       2.05       000  S                 
29065...  ..................  A                   Application of long arm cast       0.87      0.80        0.13       1.80       000  S                 
29075...  ..................  A                   Application of forearm cast.       0.77      0.61        0.10       1.48       000  S                 
29085...  ..................  A                   Apply hand/wrist cast.......       0.87      0.50        0.08       1.45       000  S                 
29105...  ..................  A                   Apply long arm splint.......       0.87      0.50        0.08       1.45       000  S                 
29125...  ..................  A                   Apply forearm splint........       0.59      0.37        0.05       1.01       000  S                 
29126...  ..................  A                   Apply forearm splint........       0.77      0.40        0.06       1.23       000  S                 
29130...  ..................  A                   Application of finger splint       0.50      0.17        0.02       0.69       000  S                 
29131...  ..................  A                   Application of finger splint       0.55      0.39        0.06       1.00       000  S                 
29200...  ..................  A                   Strapping of chest..........       0.65      0.27        0.03       0.95       000  N                 
29220...  ..................  A                   Strapping of low back.......       0.64      0.38        0.05       1.07       000  S                 
29240...  ..................  A                   Strapping of shoulder.......       0.71      0.27        0.03       1.01       000  S                 
29260...  ..................  A                   Strapping of elbow or wrist.       0.55      0.23        0.03       0.81       000  S                 
29280...  ..................  A                   Strapping of hand or finger.       0.51      0.21        0.02       0.74       000  S                 
29305...  ..................  A                   Application of hip cast.....       2.03      1.88        0.31       4.22       000  S                 
29325...  ..................  A                   Application of hip casts....       2.32      1.94        0.28       4.54       000  S                 
29345...  ..................  A                   Application of long leg cast       1.40      1.02        0.16       2.58       000  S                 
29355...  ..................  A                   Application of long leg cast       1.53      1.10        0.17       2.80       000  S                 
29358...  ..................  A                   Apply long leg cast brace...       1.43     *1.84        0.33       3.60       000  S                 
29365...  ..................  A                   Application of long leg cast       1.18      0.86        0.14       2.18       000  S                 
29405...  ..................  A                   Apply short leg cast........       0.86      0.79        0.12       1.77       000  S                 
29425...  ..................  A                   Apply short leg cast........       1.01      0.97        0.14       2.12       000  S                 
29435...  ..................  A                   Apply short leg cast........       1.18      1.18        0.18       2.54       000  S                 
29440...  ..................  A                   Addition of walker to cast..       0.57      0.23        0.03       0.83       000  S                 
29445...  ..................  A                   Apply rigid leg cast........       1.78      1.70        0.28       3.76       000  S                 
29450...  ..................  A                   Application of leg cast.....       1.02      0.39        0.04       1.45       000  S                 
29505...  ..................  A                   Application long leg splint.       0.69      0.57        0.07       1.33       000  S                 
29515...  ..................  A                   Application lower leg splint       0.73      0.47        0.06       1.26       000  S                 
29520...  ..................  A                   Strapping of hip............       0.54      0.36        0.03       0.93       000  S                 
29530...  ..................  A                   Strapping of knee...........       0.57      0.35        0.05       0.97       000  S                 
29540...  ..................  A                   Strapping of ankle..........       0.51      0.30        0.03       0.84       000  S                 
29550...  ..................  A                   Strapping of toes...........       0.47      0.28        0.03       0.78       000  S                 
29580...  ..................  A                   Application of paste boot...       0.57      0.79        0.04       1.40       000  S                 
29590...  ..................  A                   Application of foot splint..       0.76      0.28        0.03       1.07       000  S                 

[[Page 63218]]
                                                                                                                                                        
29700...  ..................  A                   Removal/revision of cast....       0.88      0.32        0.05       1.25       000  S                 
29705...  ..................  A                   Removal/revision of cast....       1.12      0.35        0.05       1.52       000  S                 
29710...  ..................  A                   Removal/revision of cast....       1.34      0.45        0.07       1.86       000  S                 
29715...  ..................  A                   Removal/revision of cast....       0.94      0.86        0.12       1.92       000  S                 
29720...  ..................  A                   Repair of body cast.........       0.68      0.23        0.04       0.95       000  S                 
29730...  ..................  A                   Windowing of cast...........       0.75      0.26        0.04       1.05       000  S                 
29740...  ..................  A                   Wedging of cast.............       1.12      0.38        0.06       1.56       000  S                 
29750...  ..................  A                   Wedging of clubfoot cast....       1.26      0.50        0.07       1.83       000  S                 
29799...  ..................  C                   Casting/strapping procedure.       0.00      0.00        0.00       0.00       YYY  S                 
29800...  ..................  A                   Jaw arthroscopy/surgery.....       5.28      4.01        0.46       9.75       090  S                 
29804...  ..................  A                   Jaw arthroscopy/surgery.....       7.99    *10.23        1.46      19.68       090  S                 
29815...  ..................  A                   Shoulder arthroscopy........       5.74      4.84        0.76      11.34       090  S                 
29819...  ..................  A                   Shoulder arthroscopy/surgery       7.33     *9.38        1.73      18.44       090  S                 
29820...  ..................  A                   Shoulder arthroscopy/surgery       6.81     *8.72        1.73      17.26       090  S                 
29821...  ..................  A                   Shoulder arthroscopy/surgery       7.43     *9.50        2.13      19.06       090  S                 
29822...  ..................  A                   Shoulder arthroscopy/surgery       7.14     *9.14        1.74      18.02       090  S                 
29823...  ..................  A                   Shoulder arthroscopy/surgery       7.86    *10.07        2.32      20.25       090  S                 
29825...  ..................  A                   Shoulder arthroscopy/surgery       7.33     *9.38        2.05      18.76       090  S                 
29826...  ..................  A                   Shoulder arthroscopy/surgery       8.70    *11.14        2.31      22.15       090  S                 
29830...  ..................  A                   Elbow arthroscopy...........       5.63      5.32        0.83      11.78       090  S                 
29834...  ..................  A                   Elbow arthroscopy/surgery...       6.13      5.84        0.96      12.93       090  S                 
29835...  ..................  A                   Elbow arthroscopy/surgery...       6.33      6.03        0.99      13.35       090  S                 
29836...  ..................  A                   Elbow arthroscopy/surgery...       7.37      7.03        1.15      15.55       090  S                 
29837...  ..................  A                   Elbow arthroscopy/surgery...       6.72      6.40        1.06      14.18       090  S                 
29838...  ..................  A                   Elbow arthroscopy/surgery...       7.42      7.05        1.14      15.61       090  S                 
29840...  ..................  A                   Wrist arthroscopy...........       5.39      3.29        0.54       9.22       090  S                 
29843...  ..................  A                   Wrist arthroscopy/surgery...       5.86      5.60        0.91      12.37       090  S                 
29844...  ..................  A                   Wrist arthroscopy/surgery...       6.22      5.59        0.95      12.76       090  S                 
29845...  ..................  A                   Wrist arthroscopy/surgery...       7.34      7.00        1.15      15.49       090  S                 
29846...  ..................  A                   Wrist arthroscopy/surgery...       6.60     *8.45        2.20      17.25       090  S                 
29847...  ..................  A                   Wrist arthroscopy/surgery...       6.93      6.78        0.97      14.68       090  S                 
29848...  ..................  A                   Wrist arthroscopy/surgery...       4.04      3.85        0.62       8.51       090  S                 
29850...  ..................  A                   Knee arthroscopy/surgery....       7.96    *10.19        1.74      19.89       090  S                 
29851...  ..................  A                   Knee arthroscopy/surgery....      12.38     10.95        1.74      25.07       090  S                 
29855...  ..................  A                   Tibial arthroscopy/surgery..       9.48     11.69        1.88      23.05       090  S                 
29856...  ..................  A                   Tibial arthroscopy/surgery..      13.28     11.69        1.88      26.85       090  S                 
29870...  ..................  A                   Knee arthroscopy, diagnostic       4.94      4.02        0.64       9.60       090  S                 
29871...  ..................  A                   Knee arthroscopy/drainage...       6.29      6.77        0.96      14.02       090  S                 
29874...  ..................  A                   Knee arthroscopy/surgery....       6.79     *8.69        1.52      17.00       090  S                 
29875...  ..................  A                   Knee arthroscopy/surgery....       6.16     *7.88        1.61      15.65       090  S                 
29876...  ..................  A                   Knee arthroscopy/surgery....       7.51     *9.61        1.95      19.07       090  S                 
29877...  ..................  A                   Knee arthroscopy/surgery....       7.05     *9.03        1.81      17.89       090  S                 
29879...  ..................  A                   Knee arthroscopy/surgery....       7.63     *9.76        2.19      19.58       090  S                 
29880...  ..................  A                   Knee arthroscopy/surgery....       8.09    *10.35        2.22      20.66       090  S                 
29881...  ..................  A                   Knee arthroscopy/surgery....       7.46     *9.54        1.82      18.82       090  S                 
29882...  ..................  A                   Knee arthroscopy/surgery....       8.24    *10.54        1.90      20.68       090  S                 
29883...  ..................  A                   Knee arthroscopy/surgery....       9.00    *11.52        2.80      23.32       090  S                 
29884...  ..................  A                   Knee arthroscopy/surgery....       6.92     *8.86        1.56      17.34       090  S                 
29885...  ..................  A                   Knee arthroscopy/surgery....       8.63      8.23        1.35      18.21       090  S                 
29886...  ..................  A                   Knee arthroscopy/surgery....       7.13      6.80        1.12      15.05       090  S                 
29887...  ..................  A                   Knee arthroscopy/surgery....       8.58     10.52        1.71      20.81       090  S                 
29888...  ..................  A                   Knee arthroscopy/surgery....      13.28    *17.00        3.18      33.46       090  S                 
29889...  ..................  A                   Knee arthroscopy/surgery....      10.76     10.26        1.68      22.70       090  S                 
29894...  ..................  A                   Ankle arthroscopy/surgery...       6.95     *8.90        1.47      17.32       090  S                 
29895...  ..................  A                   Ankle arthroscopy/surgery...       6.73     *8.60        1.51      16.84       090  S                 
29897...  ..................  A                   Ankle arthroscopy/surgery...       6.92     *8.86        1.77      17.55       090  S                 
29898...  ..................  A                   Ankle arthroscopy/surgery...       8.03    *10.28        1.91      20.22       090  S                 
29909...  ..................  C                   Arthroscopy of joint........       0.00      0.00        0.00       0.00       YYY  S                 
30000...  ..................  A                   Drainage of nose lesion.....       1.38      0.58        0.05       2.01       010  S                 
30020...  ..................  A                   Drainage of nose lesion.....       1.38      0.60        0.06       2.04       010  S                 
30100...  ..................  A                   Intranasal biopsy...........       0.94      0.69        0.08       1.71       000  S                 
30110...  ..................  A                   Removal of nose polyp(s)....       1.58      1.29        0.14       3.01       010  S                 
30115...  ..................  A                   Removal of nose polyp(s)....       4.25      2.81        0.30       7.36       090  S                 
30117...  ..................  A                   Removal of intranasal lesion       3.06      2.84        0.31       6.21       090  S                 
30118...  ..................  A                   Removal of intranasal lesion       9.23      8.01        0.92      18.16       090  S                 
30120...  ..................  A                   Revision of nose............       5.14     *6.59        1.00      12.73       090  S                 

[[Page 63219]]
                                                                                                                                                        
30124...  ..................  A                   Removal of nose lesion......       3.00      1.34        0.16       4.50       090  S                 
30125...  ..................  A                   Removal of nose lesion......       6.79      5.55        0.73      13.07       090  S                 
30130...  ..................  A                   Removal of turbinate bones..       3.17      1.67        0.17       5.01       090  S                 
30140...  ..................  A                   Removal of turbinate bones..       3.28      3.04        0.34       6.66       090  S                 
30150...  ..................  A                   Partial removal of nose.....       8.48      7.92        1.07      17.47       090  S                 
30160...  ..................  A                   Removal of nose.............       8.92    *11.42        1.73      22.07       090  S                 
30200...  ..................  A                   Injection treatment of nose.       0.78      0.37        0.04       1.19       000  S                 
30210...  ..................  A                   Nasal sinus therapy.........       1.03      0.26        0.03       1.32       010  S                 
30220...  ..................  A                   Insert nasal septal button..       1.49      1.51        0.16       3.16       010  S                 
30300...  ..................  A                   Remove nasal foreign body...       0.99      0.46        0.05       1.50       010  S                 
30310...  ..................  A                   Remove nasal foreign body...       1.91      1.62        0.18       3.71       010  S                 
30320...  ..................  A                   Remove nasal foreign body...       4.39      4.29        0.43       9.11       090  S                 
30400...  ..................  R                   Reconstruction of nose......       9.24      9.97        1.36      20.57       090  S                 
30410...  ..................  R                   Reconstruction of nose......      12.39     14.54        2.01      28.94       090  S                 
30420...  ..................  R                   Reconstruction of nose......      15.40     17.78        2.22      35.40       090  S                 
30430...  ..................  R                   Revision of nose............       6.73      6.09        0.66      13.48       090  S                 
30435...  ..................  R                   Revision of nose............      11.23     10.17        1.10      22.50       090  S                 
30450...  ..................  R                   Revision of nose............      18.06     11.24        0.91      30.21       090  S                 
30460...  ..................  A                   Revision of nose............       9.48      8.58        0.93      18.99       090  S                 
30462...  ..................  A                   Revision of nose............      18.98     17.16        1.87      38.01       090  S                 
30520...  ..................  A                   Repair of nasal septum......       5.55     *7.10        0.96      13.61       090  S                 
30540...  ..................  A                   Repair nasal defect.........       7.46      6.63        0.70      14.79       090  S                 
30545...  ..................  A                   Repair nasal defect.........      10.89     10.83        0.93      22.65       090  S                 
30560...  ..................  A                   Release of nasal adhesions..       1.21      0.55        0.06       1.82       010  S                 
30580...  ..................  A                   Repair upper jaw fistula....       6.49      6.24        0.57      13.30       090  S                 
30600...  ..................  A                   Repair mouth/nose fistula...       5.87      3.77        0.36      10.00       090  S                 
30620...  ..................  A                   Intranasal reconstruction...       5.55     *7.10        1.10      13.75       090  S                 
30630...  ..................  A                   Repair nasal septum defect..       6.83      6.24        0.71      13.78       090  S                 
30801...  ..................  A                   Cauterization inner nose....       1.02      0.47        0.05       1.54       010  S                 
30802...  ..................  A                   Cauterization inner nose....       1.98      0.94        0.11       3.03       010  S                 
30901...  ..................  A                   Control of nosebleed........       1.21      0.56        0.06       1.83       000  S                 
30903...  ..................  A                   Control of nosebleed........       1.54      0.85        0.08       2.47       000  S                 
30905...  ..................  A                   Control of nosebleed........       1.97      1.79        0.17       3.93       000  S                 
30906...  ..................  A                   Repeat control of nosebleed.       2.45      1.08        0.11       3.64       000  S                 
30915...  ..................  A                   Ligation nasal sinus artery.       6.72      4.95        0.52      12.19       090  S                 
30920...  ..................  A                   Ligation upper jaw artery...       7.46     *9.54        1.32      18.32       090  S                 
30930...  ..................  A                   Therapy fracture of nose....       1.21      0.71        0.08       2.00       010  S                 
30999...  ..................  C                   Nasal surgery procedure.....       0.00      0.00        0.00       0.00       YYY  N                 
31000...  ..................  A                   Irrigation maxillary sinus..       1.10      0.43        0.05       1.58       010  S                 
31002...  ..................  A                   Irrigation sphenoid sinus...       1.86      0.46        0.05       2.37       010  S                 
31020...  ..................  A                   Exploration maxillary sinus.       2.81      2.66        0.29       5.76       090  S                 
31030...  ..................  A                   Exploration maxillary sinus.       5.60     *7.16        0.86      13.62       090  S                 
31032...  ..................  A                   Explore sinus, remove polyps       6.22     *7.96        0.99      15.17       090  S                 
31040...  ..................  A                   Exploration behind upper jaw       8.83      7.98        0.86      17.67       090  S                 
31050...  ..................  A                   Exploration sphenoid sinus..       5.07      5.96        0.64      11.67       090  S                 
31051...  ..................  A                   Sphenoid sinus surgery......       6.85      8.12        0.85      15.82       090  S                 
31070...  ..................  A                   Exploration of frontal sinus       4.04      4.69        0.50       9.23       090  S                 
31075...  ..................  A                   Exploration of frontal sinus       8.57     10.51        1.10      20.18       090  S                 
31080...  ..................  A                   Removal of frontal sinus....      10.73      9.21        1.12      21.06       090  S                 
31081...  ..................  A                   Removal of frontal sinus....      11.93     10.32        1.30      23.55       090  S                 
31084...  ..................  A                   Removal of frontal sinus....      12.69     14.79        1.62      29.10       090  S                 
31085...  ..................  A                   Removal of frontal sinus....      13.38     15.65        1.76      30.79       090  S                 
31086...  ..................  A                   Removal of frontal sinus....      11.98     10.87        1.15      24.00       090  S                 
31087...  ..................  A                   Removal of frontal sinus....      12.14     10.39        1.33      23.86       090  S                 
31090...  ..................  A                   Exploration of sinuses......       8.65    *11.32        2.12      22.09       090  S                 
31200...  ..................  A                   Removal of ethmoid sinus....       4.68      4.62        0.48       9.78       090  S                 
31201...  ..................  A                   Removal of ethmoid sinus....       7.91      7.01        0.75      15.67       090  S                 
31205...  ..................  A                   Removal of ethmoid sinus....       9.65      8.03        0.81      18.49       090  S                 
31225...  ..................  A                   Removal of upper jaw........      15.19    *19.44        2.37      37.00       090  S                 
31230...  ..................  A                   Removal of upper jaw........      21.06     21.74        2.48      45.28       090  S                 
31231...  ..................  A                   Nasal endoscopy, dx.........       1.10      1.37        0.15       2.62       000  S                 
31233...  ..................  A                   Nasal/sinus endoscopy, dx...       2.18     *2.79        0.31       5.28       000  S                 
31235...  ..................  A                   Nasal/sinus endoscopy, dx...       2.64      2.39        0.26       5.29       000  S                 
31237...  ..................  A                   Nasal/sinus endoscopy, surg.       2.98      3.37        0.37       6.72       000  S                 
31238...  ..................  A                   Nasal/sinus endoscopy, surg.       3.26     *4.17        0.45       7.88       000  S                 
31239...  ..................  A                   Nasal/sinus endoscopy, surg.       8.50    *10.88        1.18      20.56       010  S                 

[[Page 63220]]
                                                                                                                                                        
31240...  ..................  A                   Nasal/sinus endoscopy, surg.       2.61     *3.34        0.37       6.32       000  S                 
31254...  ..................  A                   Revision of ethmoid sinus...       4.65     *5.95        0.69      11.29       000  S                 
31255...  ..................  A                   Removal of ethmoid sinus....       6.96     *8.91        1.14      17.01       000  S                 
31256...  ..................  A                   Exploration maxillary sinus.       3.29      3.77        0.41       7.47       000  S                 
31267...  ..................  A                   Endoscopy, maxillary sinus..       5.46      5.23        0.81      11.50       000  S                 
31276...  ..................  A                   Sinus surgical endoscopy....       8.85      6.72        0.73      16.30       000  S                 
31287...  ..................  A                   Nasal/sinus endoscopy, surg.       3.92     *5.01        0.65       9.58       000  S                 
31288...  ..................  A                   Nasal/sinus endoscopy, surg.       4.58     *5.86        0.78      11.22       000  S                 
31290...  ..................  A                   Nasal/sinus endoscopy, surg.      12.87    *16.47        1.80      31.14       010  S                 
31291...  ..................  A                   Nasal/sinus endoscopy, surg.      13.52    *17.31        1.88      32.71       010  S                 
31292...  ..................  A                   Nasal/sinus endoscopy, surg.      10.45    *13.38        1.45      25.28       010  S                 
31293...  ..................  A                   Nasal/sinus endoscopy, surg.      11.43    *14.64        1.59      27.66       010  S                 
31294...  ..................  A                   Nasal/sinus endoscopy, surg.      13.06    *16.72        1.83      31.61       010  S                 
31299...  ..................  C                   Sinus surgery procedure.....       0.00      0.00        0.00       0.00       YYY  S                 
31300...  ..................  A                   Removal of larynx lesion....      13.28     11.58        1.28      26.14       090  S                 
31320...  ..................  A                   Diagnostic incision larynx..       4.54      3.87        0.48       8.89       090  S                 
31360...  ..................  A                   Removal of larynx...........      15.19     19.36        2.19      36.74       090  S                 
31365...  ..................  A                   Removal of larynx...........      21.83     27.14        3.10      52.07       090  S                 
31367...  ..................  A                   Partial removal of larynx...      18.98     17.22        1.88      38.08       090  S                 
31368...  ..................  A                   Partial removal of larynx...      23.72     26.76        3.06      53.54       090  S                 
31370...  ..................  A                   Partial removal of larynx...      18.50     17.18        1.88      37.56       090  S                 
31375...  ..................  A                   Partial removal of larynx...      18.50     14.84        1.56      34.90       090  S                 
31380...  ..................  A                   Partial removal of larynx...      18.50     17.27        1.88      37.65       090  S                 
31382...  ..................  A                   Partial removal of larynx...      18.50     16.06        1.78      36.34       090  S                 
31390...  ..................  A                   Removal of larynx & pharynx.      21.15    *27.08        4.05      52.28       090  S                 
31395...  ..................  A                   Reconstruct larynx & pharynx      26.19    *33.52        4.42      64.13       090  S                 
31400...  ..................  A                   Revision of larynx..........       9.06      7.81        0.91      17.78       090  S                 
31420...  ..................  A                   Removal of epiglottis.......       9.06      8.08        0.84      17.98       090  S                 
31500...  ..................  A                   Insert emergency airway.....       2.33      1.14        0.14       3.61       000  N                 
31502...  ..................  A                   Change of windpipe airway...       0.65      0.58        0.07       1.30       000  S                 
31505...  ..................  A                   Diagnostic laryngoscopy.....       0.61      0.43        0.05       1.09       000  S                 
31510...  ..................  A                   Laryngoscopy with biopsy....       1.92      0.55        0.07       2.54       000  S                 
31511...  ..................  A                   Remove foreign body, larynx.       2.16      0.96        0.10       3.22       000  S                 
31512...  ..................  A                   Removal of larynx lesion....       2.07      1.79        0.20       4.06       000  S                 
31513...  ..................  A                   Injection into vocal cord...       2.10     *2.68        0.38       5.16       000  S                 
31515...  ..................  A                   Laryngoscopy for aspiration.       1.80      1.13        0.14       3.07       000  S                 
31520...  ..................  A                   Diagnostic laryngoscopy.....       2.56      1.64        0.18       4.38       000  S                 
31525...  ..................  A                   Diagnostic laryngoscopy.....       2.63      2.20        0.23       5.06       000  S                 
31526...  ..................  A                   Diagnostic laryngoscopy.....       2.57     *3.29        0.38       6.24       000  S                 
31527...  ..................  A                   Laryngoscopy for treatment..       3.27      2.99        0.30       6.56       000  S                 
31528...  ..................  A                   Laryngoscopy and dilatation.       2.37      2.66        0.30       5.33       000  S                 
31529...  ..................  A                   Laryngoscopy and dilatation.       2.68      2.46        0.25       5.39       000  S                 
31530...  ..................  A                   Operative laryngoscopy......       3.39      3.63        0.39       7.41       000  S                 
31531...  ..................  A                   Operative laryngoscopy......       3.73     *4.78        0.60       9.11       000  S                 
31535...  ..................  A                   Operative laryngoscopy......       3.16      4.01        0.45       7.62       000  S                 
31536...  ..................  A                   Operative laryngoscopy......       3.17     *4.06        0.59       7.82       000  S                 
31540...  ..................  A                   Operative laryngoscopy......       4.13     *5.29        0.61      10.03       000  S                 
31541...  ..................  A                   Operative laryngoscopy......       3.56     *4.56        0.75       8.87       000  S                 
31560...  ..................  A                   Operative laryngoscopy......       5.46      4.99        0.51      10.96       000  S                 
31561...  ..................  A                   Operative laryngoscopy......       4.90     *6.27        1.08      12.25       000  S                 
31570...  ..................  A                   Laryngoscopy with injection.       3.87     *4.95        0.60       9.42       000  S                 
31571...  ..................  A                   Laryngoscopy with injection.       3.52     *4.51        0.69       8.72       000  S                 
31575...  ..................  A                   Diagnostic laryngoscopy.....       1.10      1.56        0.17       2.83       000  S                 
31576...  ..................  A                   Laryngoscopy with biopsy....       1.97     *2.52        0.33       4.82       000  S                 
31577...  ..................  A                   Remove foreign body, larynx.       2.47     *3.16        0.37       6.00       000  S                 
31578...  ..................  A                   Removal of larynx lesion....       2.84     *3.63        0.48       6.95       000  S                 
31579...  ..................  A                   Diagnostic laryngoscopy.....       2.26      2.33        0.26       4.85       000  S                 
31580...  ..................  A                   Revision of larynx..........      11.01    *14.09        1.63      26.73       090  S                 
31582...  ..................  A                   Revision of larynx..........      19.73     17.87        1.94      39.54       090  S                 
31584...  ..................  A                   Repair of larynx fracture...      18.50     12.72        1.34      32.56       090  S                 
31585...  ..................  A                   Repair of larynx fracture...       4.40      3.77        0.40       8.57       090  S                 
31586...  ..................  A                   Repair of larynx fracture...       7.24      6.55        0.71      14.50       090  S                 
31587...  ..................  A                   Revision of larynx..........       7.98      7.21        0.79      15.98       090  S                 
31588...  ..................  A                   Revision of larynx..........      11.82     10.70        1.16      23.68       090  S                 
31590...  ..................  A                   Reinnervate larynx..........       6.36      5.76        0.62      12.74       090  S                 
31595...  ..................  A                   Larynx nerve surgery........       7.58      6.84        0.74      15.16       090  S                 

[[Page 63221]]
                                                                                                                                                        
31599...  ..................  C                   Larynx surgery procedure....       0.00      0.00        0.00       0.00       YYY  S                 
31600...  ..................  A                   Incision of windpipe........       3.62      4.04        0.65       8.31       000  S                 
31601...  ..................  A                   Incision of windpipe........       4.45      5.03        0.66      10.14       000  S                 
31603...  ..................  A                   Incision of windpipe........       4.15      4.23        0.66       9.04       000  S                 
31605...  ..................  A                   Incision of windpipe........       3.58      4.19        0.50       8.27       000  S                 
31610...  ..................  A                   Incision of windpipe........       7.87      6.67        0.92      15.46       090  S                 
31611...  ..................  A                   Surgery/speech prosthesis...       5.03     *6.45        1.04      12.52       090  S                 
31612...  ..................  A                   Puncture/clear windpipe.....       0.91      1.17        0.12       2.20       000  S                 
31613...  ..................  A                   Repair windpipe opening.....       4.24      2.21        0.28       6.73       090  S                 
31614...  ..................  A                   Repair windpipe opening.....       6.11      6.74        0.73      13.58       090  S                 
31615...  ..................  A                   Visualization of windpipe...       2.09      1.95        0.22       4.26       000  S                 
31622...  ..................  A                   Diagnostic bronchoscopy.....       2.80      3.57        0.34       6.71       000  N                 
31625...  ..................  A                   Bronchoscopy with biopsy....       3.37      3.83        0.35       7.55       000  N                 
31628...  ..................  A                   Bronchoscopy with biopsy....       3.81     *4.88        0.38       9.07       000  N                 
31629...  ..................  A                   Bronchoscopy with biopsy....       3.37     *4.31        0.34       8.02       000  N                 
31630...  ..................  A                   Bronchoscopy with repair....       3.82      3.72        0.50       8.04       000  S                 
31631...  ..................  A                   Bronchoscopy with dilation..       4.37      3.94        0.48       8.79       000  N                 
31635...  ..................  A                   Remove foreign body, airway.       3.68      4.53        0.53       8.74       000  S                 
31640...  ..................  A                   Bronchoscopy & remove lesion       4.94      5.02        0.67      10.63       000  S                 
31641...  ..................  A                   Bronchoscopy, treat blockage       5.03     *6.45        0.85      12.33       000  N                 
31645...  ..................  A                   Bronchoscopy, clear airways.       3.16      3.62        0.30       7.08       000  N                 
31646...  ..................  A                   Bronchoscopy, reclear              2.72      3.06        0.27       6.05       000  N                 
                                                   airways.                                                                                             
31656...  ..................  A                   Bronchoscopy, inject for x-        2.17     *2.77        0.31       5.25       000  N                 
                                                   ray.                                                                                                 
31700...  ..................  A                   Insertion of airway catheter       1.34      1.38        0.17       2.89       000  N                 
31708...  ..................  A                   Instill airway contrast dye.       1.41      0.77        0.09       2.27       000  N                 
31710...  ..................  A                   Insertion of airway catheter       1.30      0.90        0.12       2.32       000  N                 
31715...  ..................  A                   Injection for bronchus x-ray       1.11      0.48        0.04       1.63       000  N                 
31717...  ..................  A                   Bronchial brush biopsy......       2.12      0.73        0.06       2.91       000  N                 
31720...  ..................  A                   Clearance of airways........       1.06      0.74        0.09       1.89       000  N                 
31725...  ..................  A                   Clearance of airways........       1.96      1.41        0.15       3.52       000  N                 
31730...  ..................  A                   Intro windpipe wire/tube....       2.85      2.47        0.23       5.55       000  N                 
31750...  ..................  A                   Repair of windpipe..........       9.05      8.88        1.09      19.02       090  S                 
31755...  ..................  A                   Repair of windpipe..........      14.69     13.30        1.44      29.43       090  S                 
31760...  ..................  A                   Repair of windpipe..........      20.89     10.92        2.55      34.36       090  S                 
31766...  ..................  A                   Reconstruction of windpipe..      28.82     18.40        1.12      48.34       090  S                 
31770...  ..................  A                   Repair/graft of bronchus....      21.15     15.07        2.08      38.30       090  S                 
31775...  ..................  A                   Reconstruct bronchus........      22.15     16.37        1.92      40.44       090  S                 
31780...  ..................  A                   Reconstruct windpipe........      16.14     17.33        2.08      35.55       090  S                 
31781...  ..................  A                   Reconstruct windpipe........      22.22     16.86        1.96      41.04       090  S                 
31785...  ..................  A                   Remove windpipe lesion......      16.14      8.92        1.17      26.23       090  S                 
31786...  ..................  A                   Remove windpipe lesion......      22.54     13.30        2.24      38.08       090  S                 
31800...  ..................  A                   Repair of windpipe injury...       6.77      4.90        0.76      12.43       090  S                 
31805...  ..................  A                   Repair of windpipe injury...      12.59      9.82        1.41      23.82       090  S                 
31820...  ..................  A                   Closure of windpipe lesion..       4.10      3.58        0.46       8.14       090  S                 
31825...  ..................  A                   Repair of windpipe defect...       6.31      5.00        0.58      11.89       090  S                 
31830...  ..................  A                   Revise windpipe scar........       4.26      3.66        0.42       8.34       090  S                 
31899...  ..................  C                   Airways surgical procedure..       0.00      0.00        0.00       0.00       YYY  S                 
32000...  ..................  A                   Drainage of chest...........       1.54      0.90        0.08       2.52       000  N                 
32002...  ..................  A                   Treatment of collapsed lung.       2.19      1.34        0.22       3.75       000  N                 
32005...  ..................  A                   Treat lung lining chemically       2.19      1.09        0.15       3.43       000  S                 
32020...  ..................  A                   Insertion of chest tube.....       3.98      2.63        0.43       7.04       000  S                 
32035...  ..................  A                   Exploration of chest........       6.55      6.76        1.25      14.56       090  S                 
32036...  ..................  A                   Exploration of chest........       7.56      7.13        1.32      16.01       090  S                 
32095...  ..................  A                   Biopsy through chest wall...       7.13      8.25        1.45      16.83       090  S                 
32100...  ..................  A                   Exploration/biopsy of chest.      10.07     11.24        2.10      23.41       090  S                 
32110...  ..................  A                   Explore/repair chest........      11.76     11.51        2.01      25.28       090  S                 
32120...  ..................  A                   Re-exploration of chest.....       9.62      9.45        1.72      20.79       090  S                 
32124...  ..................  A                   Explore chest, free               10.93     10.94        2.21      24.08       090  S                 
                                                   adhesions.                                                                                           
32140...  ..................  A                   Removal of lung lesion(s)...      12.14     12.37        2.42      26.93       090  S                 
32141...  ..................  A                   Remove/treat lung lesions...      12.14     13.42        2.53      28.09       090  S                 
32150...  ..................  A                   Removal of lung lesion(s)...      12.42     10.34        2.01      24.77       090  S                 
32151...  ..................  A                   Remove lung foreign body....      12.42      9.15        1.37      22.94       090  S                 
32160...  ..................  A                   Open chest heart massage....       7.13     *9.13        1.52      17.78       090  S                 
32200...  ..................  A                   Drainage of lung lesion.....      13.10      6.89        0.93      20.92       090  S                 
32215...  ..................  A                   Treat chest lining..........      10.07      7.62        1.28      18.97       090  S                 
32220...  ..................  A                   Release of lung.............      17.62     15.81        3.01      36.44       090  S                 

[[Page 63222]]
                                                                                                                                                        
32225...  ..................  A                   Partial release of lung.....      12.10     11.84        2.28      26.22       090  S                 
32310...  ..................  A                   Removal of chest lining.....      12.05     11.64        2.10      25.79       090  S                 
32320...  ..................  A                   Free/remove chest lining....      19.15     18.10        3.40      40.65       090  S                 
32400...  ..................  A                   Needle biopsy chest lining..       1.76      1.48        0.12       3.36       000  N                 
32402...  ..................  A                   Open biopsy chest lining....       6.55      7.58        1.34      15.47       090  S                 
32405...  ..................  A                   Biopsy, lung or mediastinum.       1.93      2.12        0.18       4.23       000  N                 
32420...  ..................  A                   Puncture/clear lung.........       2.18      1.50        0.13       3.81       000  N                 
32440...  ..................  A                   Removal of lung.............      19.15     18.56        3.55      41.26       090  S                 
32442...  ..................  A                   Sleeve pneumonectomy........      24.68     17.94        3.50      46.12       090  S                 
32445...  ..................  A                   Removal of lung.............      23.37     20.46        3.88      47.71       090  S                 
32480...  ..................  A                   Partial removal of lung.....      16.84     17.15        3.23      37.22       090  S                 
32482...  ..................  A                   Bilobectomy.................      18.54     17.15        3.23      38.92       090  S                 
32484...  ..................  A                   Segmentectomy...............      19.52     17.15        3.23      39.90       090  S                 
32485...  ..................  D                   Partial removal of lung.....       0.00      0.00        0.00       0.00       090  S                 
32486...  ..................  A                   Sleeve lobectomy............      22.75     16.54        3.23      42.52       090  S                 
32488...  ..................  A                   Completion pneumonectomy....      24.41     17.74        3.46      45.61       090  S                 
32500...  ..................  A                   Partial removal of lung.....      13.10     13.47        2.56      29.13       090  S                 
32501...  ..................  A                   Repair bronchus (add-on)....       4.69      4.31        0.70       9.70       ZZZ  S                 
32520...  ..................  A                   Remove lung & revise chest..      19.42     20.67        3.93      44.02       090  S                 
32522...  ..................  A                   Remove lung & revise chest..      21.94     21.90        4.19      48.03       090  S                 
32525...  ..................  A                   Remove lung & revise chest..      24.33     23.50        4.61      52.44       090  S                 
32540...  ..................  A                   Removal of lung lesion......      13.31     11.67        2.05      27.03       090  S                 
32601...  ..................  A                   Thoracoscopy, diagnostic....       5.46      3.47        0.57       9.50       000  S                 
32602...  ..................  A                   Thoracoscopy, diagnostic....       5.96      3.87        0.64      10.47       000  S                 
32603...  ..................  A                   Thoracoscopy, diagnostic....       7.81      3.47        0.57      11.85       000  S                 
32604...  ..................  A                   Thoracoscopy, diagnostic....       8.78      3.87        0.64      13.29       000  S                 
32605...  ..................  A                   Thoracoscopy, diagnostic....       6.93      3.47        0.57      10.97       000  S                 
32606...  ..................  A                   Thoracoscopy, diagnostic....       8.40      3.87        0.64      12.91       000  S                 
32650...  ..................  A                   Thoracoscopy, surgical......      10.07      7.62        1.28      18.97       090  S                 
32651...  ..................  A                   Thoracoscopy, surgical......      12.10     11.84        2.28      26.22       090  S                 
32652...  ..................  A                   Thoracoscopy, surgical......      17.62     15.81        3.01      36.44       090  S                 
32653...  ..................  A                   Thoracoscopy, surgical......      12.42     10.34        2.01      24.77       090  S                 
32654...  ..................  A                   Thoracoscopy, surgical......      11.76     11.51        2.01      25.28       090  S                 
32655...  ..................  A                   Thoracoscopy, surgical......      12.42     13.42        2.53      28.37       090  S                 
32656...  ..................  A                   Thoracoscopy, surgical......      12.10     13.36        2.36      27.82       090  S                 
32657...  ..................  A                   Thoracoscopy, surgical......      13.10     13.47        2.56      29.13       090  S                 
32658...  ..................  A                   Thoracoscopy, surgical......      11.08     13.26        2.52      26.86       090  S                 
32659...  ..................  A                   Thoracoscopy, surgical......      10.91    *13.96        2.61      27.48       090  S                 
32660...  ..................  A                   Thoracoscopy, surgical......      16.62     19.93        3.56      40.11       090  S                 
32661...  ..................  A                   Thoracoscopy, surgical......      12.70      9.25        1.47      23.42       090  S                 
32662...  ..................  A                   Thoracoscopy, surgical......      15.76     14.55        2.74      33.05       090  S                 
32663...  ..................  A                   Thoracoscopy, surgical......      17.43     17.15        3.23      37.81       090  S                 
32664...  ..................  A                   Thoracoscopy, surgical......      13.65     10.55        2.04      26.24       090  S                 
32665...  ..................  A                   Thoracoscopy, surgical......      14.73     14.33        2.64      31.70       090  S                 
32800...  ..................  A                   Repair lung hernia..........      12.10      8.28        1.58      21.96       090  S                 
32810...  ..................  A                   Close chest after drainage..      11.59      6.50        1.19      19.28       090  S                 
32815...  ..................  A                   Close bronchial fistula.....      21.36     15.22        2.62      39.20       090  S                 
32820...  ..................  A                   Reconstruct injured chest...      19.78     19.01        3.24      42.03       090  S                 
32850...  ..................  X                   Donor pneumonectomy.........       0.00      0.00        0.00       0.00       XXX  0                 
32851...  ..................  A                   Lung transplant, single.....      35.14     25.55        4.99      65.68       090  S                 
32852...  ..................  A                   Lung transplant w/bypass....      38.11     27.71        5.41      71.23       090  S                 
32853...  ..................  A                   Lung transplant, double.....      43.93     31.94        6.24      82.11       090  S                 
32854...  ..................  A                   Lung transplant w/bypass....      46.90     34.10        6.67      87.67       090  S                 
32900...  ..................  A                   Removal of rib(s)...........      18.14      8.47        1.63      28.24       090  S                 
32905...  ..................  A                   Revise & repair chest wall..      19.15     12.74        2.60      34.49       090  S                 
32906...  ..................  A                   Revise & repair chest wall..      25.17     15.42        2.92      43.51       090  S                 
32940...  ..................  A                   Revision of lung............      18.14     11.37        1.75      31.26       090  S                 
32960...  ..................  A                   Therapeutic pneumothorax....       1.84      0.93        0.13       2.90       000  N                 
32999...  ..................  C                   Chest surgery procedure.....       0.00      0.00        0.00       0.00       YYY  S                 
33010...  ..................  A                   Drainage of heart sac.......       2.24      1.54        0.14       3.92       000  N                 
33011...  ..................  A                   Repeat drainage of heart sac       2.24      1.11        0.12       3.47       000  N                 
33015...  ..................  A                   Incision of heart sac.......       5.64      4.26        0.62      10.52       090  S                 
33020...  ..................  A                   Incision of heart sac.......      11.08     13.26        2.52      26.86       090  S                 
33025...  ..................  A                   Incision of heart sac.......      10.91    *13.96        2.61      27.48       090  S                 
33030...  ..................  A                   Partial removal of heart sac      16.62     21.02        3.92      41.56       090  S                 
33031...  ..................  A                   Partial removal of heart sac      19.64     13.25        2.50      35.39       090  S                 

[[Page 63223]]
                                                                                                                                                        
33050...  ..................  A                   Removal of heart sac lesion.      12.70      9.25        1.47      23.42       090  S                 
33120...  ..................  A                   Removal of heart lesion.....      22.57    *28.89        5.17      56.63       090  S                 
33130...  ..................  A                   Removal of heart lesion.....      19.53     13.50        2.22      35.25       090  S                 
33200...  ..................  A                   Insertion of heart pacemaker      11.08     12.27        1.90      25.25       090  S                 
33201...  ..................  A                   Insertion of heart pacemaker       8.93     11.19        1.67      21.79       090  S                 
33206...  ..................  A                   Insertion of heart pacemaker       6.04     *7.73        1.34      15.11       090  S                 
33207...  ..................  A                   Insertion of heart pacemaker       7.28      9.01        1.33      17.62       090  S                 
33208...  ..................  A                   Insertion of heart pacemaker       7.28     *9.50        1.54      18.32       090  N                 
33210...  ..................  A                   Insertion of heart electrode       3.30      3.30        0.27       6.87       000  N                 
33211...  ..................  A                   Insertion of heart electrode       3.40      3.30        0.27       6.97       000  N                 
33212...  ..................  A                   Insertion of pulse generator       5.21      5.38        0.88      11.47       090  S                 
33213...  ..................  A                   Insertion of pulse generator       6.15      5.38        0.88      12.41       090  N                 
33214...  ..................  A                   Upgrade of pacemaker system.       7.43      5.40        1.06      13.89       090  N                 
33216...  ..................  A                   Revision implanted electrode       5.07      5.02        0.55      10.64       090  N                 
33217...  ..................  A                   Insert/revise electrode.....       5.43      5.02        0.55      11.00       090  N                 
33218...  ..................  A                   Repair pacemaker electrodes.       5.02      4.59        0.62      10.23       090  S                 
33220...  ..................  A                   Repair pacemaker electrode..       5.10      4.59        0.62      10.31       090  N                 
33222...  ..................  A                   Pacemaker aicd pocket.......       4.59      5.70        1.01      11.30       090  S                 
33223...  ..................  A                   Pacemaker aicd pocket.......       6.14      5.70        1.01      12.85       090  S                 
33233...  ..................  A                   Removal of pacemaker system.       2.97      2.64        0.05       5.66       090  N                 
33234...  ..................  A                   Removal of pacemaker system.       8.69      4.74        0.38      13.81       090  S                 
33235...  ..................  A                   Removal pacemaker electrode.       9.93      5.21        0.55      15.69       090  N                 
33236...  ..................  A                   Remove electrode/thoracotomy      11.71      3.98        0.62      16.31       090  S                 
33237...  ..................  A                   Remove electrode/thoracotomy      12.69      9.60        1.13      23.42       090  S                 
33238...  ..................  A                   Remove electrode/thoracotomy      14.15     10.29        2.01      26.45       090  S                 
33240...  ..................  A                   Insert/replace pulse gener..       7.20      5.38        0.88      13.46       090  S                 
33241...  ..................  A                   Remove pulse generator only.       2.97      2.16        0.43       5.56       090  S                 
33242...  ..................  A                   Repair pulse generator/leads       5.85     *7.50        1.54      14.89       090  S                 
33243...  ..................  A                   Remove generator/thoracotomy      21.47      9.02        1.54      32.03       090  S                 
33244...  ..................  A                   Remove generator............       8.34      9.02        1.54      18.90       090  S                 
33245...  ..................  A                   Implant heart defibrillator.      12.57    *16.09        2.36      31.02       090  S                 
33246...  ..................  A                   Implant heart defibrillator.      19.28     20.79        3.19      43.26       090  S                 
33247...  ..................  A                   Insert/replace leads........       9.76    *12.49        2.36      24.61       090  N                 
33249...  ..................  A                   Insert/replace leads/gener..      12.83    *16.42        3.19      32.44       090  S                 
33250...  ..................  A                   Ablate heart dysrhythm focus      19.54     11.56        0.86      31.96       090  S                 
33251...  ..................  A                   Ablate heart dysrhythm focus      22.57     16.41        3.21      42.19       090  S                 
33253...  ..................  A                   Reconstruct atria...........      30.00     21.81        4.26      56.07       090  S                 
33260...  ..................  D                   Ablate heart dysrhythm focus       0.00      0.00        0.00       0.00       090  S                 
33261...  ..................  A                   Ablate heart dysrhythm focus      22.57     13.96        2.73      39.26       090  S                 
33300...  ..................  A                   Repair of heart wound.......      16.19     14.36        2.60      33.15       090  S                 
33305...  ..................  A                   Repair of heart wound.......      19.22     17.40        3.07      39.69       090  S                 
33310...  ..................  A                   Exploratory heart surgery...      17.12     11.28        1.93      30.33       090  S                 
33315...  ..................  A                   Exploratory heart surgery...      20.15     14.48        2.57      37.20       090  S                 
33320...  ..................  A                   Repair major blood vessel(s)      15.39     14.14        2.51      32.04       090  S                 
33321...  ..................  A                   Repair major vessel.........      18.74     21.75        3.61      44.10       090  S                 
33322...  ..................  A                   Repair major blood vessel(s)      18.40     21.75        3.61      43.76       090  S                 
33330...  ..................  A                   Insert major vessel graft...      19.15     12.67        1.93      33.75       090  S                 
33332...  ..................  A                   Insert major vessel graft...      22.50     15.07        2.39      39.96       090  S                 
33335...  ..................  A                   Insert major vessel graft...      27.66     15.07        2.39      45.12       090  S                 
33350...  ..................  D                   Repair major blood vessel(s)       0.00      0.00        0.00       0.00       090  S                 
33400...  ..................  A                   Repair of aortic valve......      23.16     26.21        2.83      52.20       090  S                 
33401...  ..................  A                   Valvuloplasty, open.........      22.45     26.21        2.83      51.49       090  S                 
33403...  ..................  A                   Valvuloplasty, w/cp bypass..      23.43     26.21        2.83      52.47       090  S                 
33404...  ..................  A                   Prepare heart-aorta conduit.      26.62     31.25        5.59      63.46       090  S                 
33405...  ..................  A                   Replacement of aortic valve.      28.47     30.48        5.33      64.28       090  S                 
33406...  ..................  A                   Replacement, aortic valve...      31.23     38.65        7.45      77.33       090  S                 
33411...  ..................  A                   Replacement of aortic valve.      30.37     38.65        7.45      76.47       090  S                 
33412...  ..................  A                   Replacement of aortic valve.      32.26     38.65        7.45      78.36       090  S                 
33413...  ..................  A                   Replacement, aortic valve...      34.17     41.09        7.23      82.49       090  S                 
33414...  ..................  A                   Repair, aortic valve........      29.28     38.65        7.45      75.38       090  S                 
33415...  ..................  A                   Revision, subvalvular tissue      25.02     30.48        5.33      60.83       090  S                 
33416...  ..................  A                   Revise ventricle muscle.....      28.20     28.14        4.99      61.33       090  S                 
33417...  ..................  A                   Repair of aortic valve......      27.34     34.71        6.18      68.23       090  S                 
33420...  ..................  A                   Revision of mitral valve....      20.69     19.82        2.45      42.96       090  S                 
33422...  ..................  A                   Revision of mitral valve....      23.72    *30.35        6.45      60.52       090  S                 
33425...  ..................  A                   Repair of mitral valve......      25.57     31.27        5.42      62.26       090  S                 

[[Page 63224]]
                                                                                                                                                        
33426...  ..................  A                   Repair of mitral valve......      26.07     31.96        5.80      63.83       090  S                 
33427...  ..................  A                   Repair of mitral valve......      32.07     34.71        6.30      73.08       090  S                 
33430...  ..................  A                   Replacement of mitral valve.      29.42     34.85        6.11      70.38       090  S                 
33460...  ..................  A                   Revision of tricuspid valve.      21.60     26.07        4.73      52.40       090  S                 
33463...  ..................  A                   Valvuloplasty, tricuspid....      24.16     32.67        5.95      62.78       090  S                 
33464...  ..................  A                   Valvuloplasty, tricuspid....      25.87     32.67        5.95      64.49       090  S                 
33465...  ..................  A                   Replace tricuspid valve.....      26.57     32.67        5.95      65.19       090  S                 
33468...  ..................  A                   Revision of tricuspid valve.      28.20     34.71        6.30      69.21       090  S                 
33470...  ..................  A                   Revision of pulmonary valve.      19.52     19.82        2.45      41.79       090  S                 
33471...  ..................  A                   Valvotomy, pulmonary valve..      21.13     26.21        2.83      50.17       090  S                 
33472...  ..................  A                   Revision of pulmonary valve.      20.91    *28.70        2.83      52.44       090  S                 
33474...  ..................  A                   Revision of pulmonary valve.      20.91    *28.70        2.83      52.44       090  S                 
33475...  ..................  A                   Replacement, pulmonary valve      27.34     34.85        6.11      68.30       090  S                 
33476...  ..................  A                   Revision of heart chamber...      24.41     28.14        4.99      57.54       090  S                 
33478...  ..................  A                   Revision of heart chamber...      25.38     31.27        5.42      62.07       090  S                 
33500...  ..................  A                   Repair heart vessel fistula.      23.91     29.55        5.20      58.66       090  S                 
33501...  ..................  A                   Repair heart vessel fistula.      16.14     14.14        2.51      32.79       090  S                 
33502...  ..................  A                   Coronary artery correction..      19.80     14.14        2.51      36.45       090  S                 
33503...  ..................  A                   Coronary artery graft.......      20.15     29.55        5.20      54.90       090  S                 
33504...  ..................  A                   Coronary artery graft.......      23.16     29.55        5.20      57.91       090  S                 
33505...  ..................  A                   Repair artery w/tunnel......      25.38     34.24        6.03      65.65       090  S                 
33506...  ..................  A                   Repair artery, translocation      25.38     34.24        6.03      65.65       090  S                 
33510...  ..................  A                   CABG, vein, single..........      23.29     29.55        5.20      58.04       090  S                 
33511...  ..................  A                   CABG, vein, two.............      25.57     32.44        5.71      63.72       090  S                 
33512...  ..................  A                   CABG, vein, three...........      27.84     35.33        6.22      69.39       090  S                 
33513...  ..................  A                   CABG, vein, four............      30.12     38.21        6.73      75.06       090  S                 
33514...  ..................  A                   CABG, vein, five............      32.39     41.09        7.23      80.71       090  S                 
33516...  ..................  A                   CABG, vein, six+............      34.66     43.97        7.74      86.37       090  S                 
33517...  ..................  A                   CABG, artery-vein, single...       2.27      2.89        0.50       5.66       090  S                 
33518...  ..................  A                   CABG, artery-vein, two......       4.55      5.77        1.02      11.34       090  S                 
33519...  ..................  A                   CABG, artery-vein, three....       6.82      8.65        1.52      16.99       090  S                 
33521...  ..................  A                   CABG, artery-vein, four.....       9.10     11.54        2.03      22.67       090  S                 
33522...  ..................  A                   CABG, artery-vein, five.....      11.37     14.43        2.54      28.34       090  S                 
33523...  ..................  A                   CABG, artery-vein, six+.....      13.65     17.32        3.05      34.02       090  S                 
33530...  ..................  A                   Coronary artery, bypass/reop       5.86     *7.51        2.18      15.55       ZZZ  S                 
33533...  ..................  A                   CABG, arterial, single......      24.00     30.45        5.36      59.81       090  S                 
33534...  ..................  A                   CABG, arterial, two.........      26.99     34.24        6.03      67.26       090  S                 
33535...  ..................  A                   CABG, arterial, three.......      29.98     38.03        6.70      74.71       090  S                 
33536...  ..................  A                   CABG, arterial, four+.......      32.96     41.82        7.37      82.15       090  S                 
33542...  ..................  A                   Removal of heart lesion.....      26.57     30.73        5.53      62.83       090  S                 
33545...  ..................  A                   Repair of heart damage......      33.96     34.92        6.28      75.16       090  S                 
33572...  ..................  A                   Open coronary endarterectomy       4.45      3.23        0.63       8.31       ZZZ  S                 
33600...  ..................  A                   Closure of valve............      28.31     34.85        6.11      69.27       090  S                 
33602...  ..................  A                   Closure of valve............      27.34     30.48        5.33      63.15       090  S                 
33606...  ..................  A                   Anastomosis/artery-aorta....      29.28     38.65        7.45      75.38       090  S                 
33608...  ..................  A                   Repair anomaly w/conduit....      30.02     38.65        7.45      76.12       090  S                 
33610...  ..................  A                   Repair by enlargement.......      29.28     38.65        7.45      75.38       090  S                 
33611...  ..................  A                   Repair double ventricle.....      31.23     38.65        7.45      77.33       090  S                 
33612...  ..................  A                   Repair double ventricle.....      32.06     38.65        7.45      78.16       090  S                 
33615...  ..................  A                   Repair (simple fontan)......      30.50     38.65        7.45      76.60       090  S                 
33617...  ..................  A                   Repair by modified fontan...      32.21     38.65        7.45      78.31       090  S                 
33619...  ..................  A                   Repair single ventricle.....      35.39     44.30        8.04      87.73       090  S                 
33641...  ..................  A                   Repair heart septum defect..      19.93    *25.51        4.87      50.31       090  S                 
33645...  ..................  A                   Revision of heart veins.....      22.78     27.61        4.87      55.26       090  S                 
33647...  ..................  A                   Repair heart septum defects.      27.44     34.92        6.28      68.64       090  S                 
33660...  ..................  A                   Repair of heart defects.....      24.41     31.27        5.42      61.10       090  S                 
33665...  ..................  A                   Repair of heart defects.....      27.34     31.27        5.42      64.03       090  S                 
33670...  ..................  A                   Repair of heart chambers....      31.23     38.65        7.45      77.33       090  S                 
33681...  ..................  A                   Repair heart septum defect..      26.36     34.92        6.28      67.56       090  S                 
33684...  ..................  A                   Repair heart septum defect..      28.31     34.92        6.28      69.51       090  S                 
33688...  ..................  A                   Repair heart septum defect..      29.28     34.92        6.28      70.48       090  S                 
33690...  ..................  A                   Reinforce pulmonary artery..      18.31     22.10        4.29      44.70       090  S                 
33692...  ..................  A                   Repair of heart defects.....      29.28     38.65        7.45      75.38       090  S                 
33694...  ..................  A                   Repair of heart defects.....      30.26     38.65        7.45      76.36       090  S                 
33696...  ..................  D                   Repair of heart defects.....       0.00      0.00        0.00       0.00       090  S                 
33697...  ..................  A                   Repair of heart defects.....      32.21     38.65        7.45      78.31       090  S                 

[[Page 63225]]
                                                                                                                                                        
33698...  ..................  D                   Repair of heart defects.....       0.00      0.00        0.00       0.00       090  S                 
33702...  ..................  A                   Repair of heart defects.....      25.38     30.48        5.33      61.19       090  S                 
33710...  ..................  A                   Repair of heart defects.....      28.35     34.92        6.28      69.55       090  S                 
33720...  ..................  A                   Repair of heart defect......      25.38     30.48        5.33      61.19       090  S                 
33722...  ..................  A                   Repair of heart defect......      27.34     30.48        5.33      63.15       090  S                 
33730...  ..................  A                   Repair heart-vein defect(s).      29.89     38.65        7.45      75.99       090  S                 
33732...  ..................  A                   Repair heart-vein defect....      27.09     31.27        5.42      63.78       090  S                 
33735...  ..................  A                   Revision of heart chamber...      19.97     25.69        4.87      50.53       090  S                 
33736...  ..................  A                   Revision of heart chamber...      22.45     25.69        4.87      53.01       090  S                 
33737...  ..................  A                   Revision of heart chamber...      20.50     25.69        4.87      51.06       090  S                 
33750...  ..................  A                   Major vessel shunt..........      20.15     22.10        4.29      46.54       090  S                 
33755...  ..................  A                   Major vessel shunt..........      20.50     22.10        4.29      46.89       090  S                 
33762...  ..................  A                   Major vessel shunt..........      20.50     22.10        4.29      46.89       090  S                 
33764...  ..................  A                   Major vessel shunt & graft..      20.50     22.10        4.29      46.89       090  S                 
33766...  ..................  A                   Major vessel shunt..........      21.47     22.10        4.29      47.86       090  S                 
33767...  ..................  A                   Atrial septectomy/septostomy      23.43     25.69        4.87      53.99       090  S                 
33770...  ..................  A                   Repair great vessels defect.      31.96     38.65        7.45      78.06       090  S                 
33771...  ..................  A                   Repair great vessels defect.      33.19     38.65        7.45      79.29       090  S                 
33774...  ..................  A                   Repair great vessels defect.      29.28     31.27        5.42      65.97       090  S                 
33775...  ..................  A                   Repair great vessels defect.      30.50     31.27        5.42      67.19       090  S                 
33776...  ..................  A                   Repair great vessels defect.      32.21     34.92        6.28      73.41       090  S                 
33777...  ..................  A                   Repair great vessels defect.      31.73     31.27        5.42      68.42       090  S                 
33778...  ..................  A                   Repair great vessels defect.      34.17     41.82        7.37      83.36       090  S                 
33779...  ..................  A                   Repair great vessels defect.      34.41     41.82        7.37      83.60       090  S                 
33780...  ..................  A                   Repair great vessels defect.      35.14     41.82        7.37      84.33       090  S                 
33781...  ..................  A                   Repair great vessels defect.      34.65     41.82        7.37      83.84       090  S                 
33786...  ..................  A                   Repair arterial trunk.......      33.19     38.65        7.45      79.29       090  S                 
33788...  ..................  A                   Revision of pulmonary artery      25.38     29.55        5.20      60.13       090  S                 
33800...  ..................  A                   Aortic suspension...........      15.18     14.14        2.51      31.83       090  S                 
33802...  ..................  A                   Repair vessel defect........      16.60     22.10        4.29      42.99       090  S                 
33803...  ..................  A                   Repair vessel defect........      18.54     22.10        4.29      44.93       090  S                 
33813...  ..................  A                   Repair septal defect........      19.52     22.10        4.29      45.91       090  S                 
33814...  ..................  A                   Repair septal defect........      24.41     30.48        5.33      60.22       090  S                 
33820...  ..................  A                   Revise major vessel.........      15.62     22.10        4.29      42.01       090  S                 
33822...  ..................  A                   Revise major vessel.........      16.60     22.10        4.29      42.99       090  S                 
33824...  ..................  A                   Revise major vessel.........      18.54     22.10        4.29      44.93       090  S                 
33840...  ..................  A                   Remove aorta constriction...      19.52     31.25        5.59      56.36       090  S                 
33845...  ..................  A                   Remove aorta constriction...      20.99     31.25        5.59      57.83       090  S                 
33851...  ..................  A                   Remove aorta constriction...      20.01     31.25        5.59      56.85       090  S                 
33852...  ..................  A                   Repair septal defect........      22.45     31.25        5.59      59.29       090  S                 
33853...  ..................  A                   Repair septal defect........      30.26     38.65        7.45      76.36       090  S                 
33860...  ..................  A                   Ascending aorta graft.......      31.23     34.71        6.18      72.12       090  S                 
33861...  ..................  A                   Ascending aorta graft.......      33.19     34.71        6.18      74.08       090  S                 
33863...  ..................  A                   Ascending aorta graft.......      35.14     34.71        6.18      76.03       090  S                 
33870...  ..................  A                   Transverse aortic arch graft      37.74     44.30        8.04      90.08       090  S                 
33875...  ..................  A                   Thoracic aorta graft........      26.94     31.25        5.59      63.78       090  S                 
33877...  ..................  A                   Thoracoabdominal graft......      40.29     44.11        8.38      92.78       090  S                 
33910...  ..................  A                   Remove lung artery emboli...      21.86     14.65        2.77      39.28       090  S                 
33915...  ..................  A                   Remove lung artery emboli...      18.84     12.02        2.22      33.08       090  S                 
33916...  ..................  A                   Surgery of great vessel.....      24.17     17.57        3.43      45.17       090  S                 
33917...  ..................  A                   Repair pulmonary artery.....      23.43     34.71        6.30      64.44       090  S                 
33918...  ..................  A                   Repair pulmonary atresia....      25.38     29.55        5.20      60.13       090  S                 
33919...  ..................  A                   Repair pulmonary atresia....      31.11     38.65        7.45      77.21       090  S                 
33920...  ..................  A                   Repair pulmonary atresia....      30.75     38.65        7.45      76.85       090  S                 
33922...  ..................  A                   Transect pulmonary artery...      22.45     26.21        2.83      51.49       090  S                 
33924...  ..................  A                   Remove pulmonary shunt......       5.50      4.00        0.78      10.28       ZZZ  S                 
33930...  ..................  X                   Removal of donor heart/lung.       0.00      0.00        0.00       0.00       XXX  0                 
33935...  ..................  R                   Transplantation, heart/lung.      56.87     77.57       13.54     147.98       090  S                 
33940...  ..................  X                   Removal of donor heart......       0.00      0.00        0.00       0.00       XXX  0                 
33945...  ..................  R                   Transplantation of heart....      39.56     64.80       11.05     115.41       090  S                 
33960...  ..................  A                   External circulation assist.      19.36      7.01        0.94      27.31       XXX  S                 
33961...  ..................  A                   External circulation assist.      10.93      7.01        0.94      18.88       XXX  S                 
33970...  ..................  A                   Aortic circulation assist...       8.05      7.54        1.00      16.59       000  S                 
33971...  ..................  A                   Aortic circulation assist...       4.04     *5.16        0.91      10.11       090  S                 
33973...  ..................  A                   Insert balloon device.......       9.76      7.54        1.00      18.30       000  S                 
33974...  ..................  A                   Remove intra-aortic balloon.      12.69      5.56        0.91      19.16       090  S                 

[[Page 63226]]
                                                                                                                                                        
33975...  ..................  A                   Implant ventricular device..      19.52     14.19        2.77      36.48       090  S                 
33976...  ..................  A                   Implant ventricular device..      26.60     19.33        3.78      49.71       090  S                 
33977...  ..................  A                   Remove ventricular device...      17.08     12.41        2.43      31.92       090  S                 
33978...  ..................  A                   Remove ventricular device...      19.52     14.19        2.77      36.48       090  S                 
33999...  ..................  C                   Cardiac surgery procedure...       0.00      0.00        0.00       0.00       YYY  S                 
34001...  ..................  A                   Removal of artery clot......      11.69      9.58        1.87      23.14       090  S                 
34051...  ..................  A                   Removal of artery clot......      13.62      8.81        1.59      24.02       090  S                 
34101...  ..................  A                   Removal of artery clot......       8.73      8.34        1.71      18.78       090  S                 
34111...  ..................  A                   Removal of arm artery clot..       7.18      7.59        1.59      16.36       090  S                 
34151...  ..................  A                   Removal of artery clot......      15.23     11.96        2.39      29.58       090  S                 
34201...  ..................  A                   Removal of artery clot......       8.04      8.90        1.78      18.72       090  S                 
34203...  ..................  A                   Removal of leg artery clot..      11.06      8.63        1.72      21.41       090  S                 
34401...  ..................  A                   Removal of vein clot........      11.64      8.07        1.39      21.10       090  S                 
34421...  ..................  A                   Removal of vein clot........       8.89      7.45        1.51      17.85       090  S                 
34451...  ..................  A                   Removal of vein clot........      13.13     10.69        2.14      25.96       090  S                 
34471...  ..................  A                   Removal of vein clot........       9.12      3.51        0.55      13.18       090  S                 
34490...  ..................  A                   Removal of vein clot........       6.51      7.27        1.54      15.32       090  S                 
34501...  ..................  A                   Repair valve, femoral vein..       9.71      7.35        0.86      17.92       090  S                 
34502...  ..................  A                   Reconstruct, vena cava......      25.65     18.65        3.64      47.94       090  S                 
34510...  ..................  A                   Transposition of vein valve.      11.75      8.89        1.04      21.68       090  S                 
34520...  ..................  A                   Cross-over vein graft.......      12.33      9.33        1.09      22.75       090  S                 
34530...  ..................  A                   Leg vein fusion.............      16.33     12.35        1.44      30.12       090  S                 
35001...  ..................  A                   Repair defect of artery.....      18.14     15.90        3.18      37.22       090  S                 
35002...  ..................  A                   Repair artery rupture, neck.      19.43     12.64        2.41      34.48       090  S                 
35005...  ..................  A                   Repair defect of artery.....      16.62     10.28        2.19      29.09       090  S                 
35011...  ..................  A                   Repair defect of artery.....      10.43    *13.35        2.76      26.54       090  S                 
35013...  ..................  A                   Repair artery rupture, arm..      15.96     14.70        3.03      33.69       090  S                 
35021...  ..................  A                   Repair defect of artery.....      17.62     18.13        3.06      38.81       090  S                 
35022...  ..................  A                   Repair artery rupture, chest      21.15     14.78        2.80      38.73       090  S                 
35045...  ..................  A                   Repair defect of arm artery.       9.98     12.35        2.50      24.83       090  S                 
35081...  ..................  A                   Repair defect of artery.....      22.15     21.45        4.18      47.78       090  S                 
35082...  ..................  A                   Repair artery rupture, aorta      28.82     22.91        4.59      56.32       090  S                 
35091...  ..................  A                   Repair defect of artery.....      28.10     22.67        4.25      55.02       090  S                 
35092...  ..................  A                   Repair artery rupture, aorta      36.06     26.27        5.21      67.54       090  S                 
35102...  ..................  A                   Repair defect of artery.....      23.44     22.15        4.32      49.91       090  S                 
35103...  ..................  A                   Repair artery rupture, groin      31.31     26.16        5.21      62.68       090  S                 
35111...  ..................  A                   Repair defect of artery.....      15.12     17.60        3.70      36.42       090  S                 
35112...  ..................  A                   Repair artery rupture,spleen      17.38     10.45        2.22      30.05       090  S                 
35121...  ..................  A                   Repair defect of artery.....      24.68     19.12        3.66      47.46       090  S                 
35122...  ..................  A                   Repair artery rupture, belly      32.08     17.92        3.96      53.96       090  S                 
35131...  ..................  A                   Repair defect of artery.....      17.00     15.88        3.15      36.03       090  S                 
35132...  ..................  A                   Repair artery rupture, groin      20.40     18.68        3.58      42.66       090  S                 
35141...  ..................  A                   Repair defect of artery.....      13.28     14.70        2.88      30.86       090  S                 
35142...  ..................  A                   Repair artery rupture, thigh      14.62     16.10        3.24      33.96       090  S                 
35151...  ..................  A                   Repair defect of artery.....      15.76     15.36        2.94      34.06       090  S                 
35152...  ..................  A                   Repair artery rupture, knee.      15.46      9.27        1.95      26.68       090  S                 
35161...  ..................  A                   Repair defect of artery.....      17.45     15.88        3.15      36.48       090  S                 
35162...  ..................  A                   Repair artery rupture.......      18.45     18.68        3.58      40.71       090  S                 
35180...  ..................  A                   Repair blood vessel lesion..      12.16      7.37        1.48      21.01       090  S                 
35182...  ..................  A                   Repair blood vessel lesion..      16.12     10.65        1.61      28.38       090  S                 
35184...  ..................  A                   Repair blood vessel lesion..      10.79      9.73        1.96      22.48       090  S                 
35188...  ..................  A                   Repair blood vessel lesion..      13.10      8.11        1.59      22.80       090  S                 
35189...  ..................  A                   Repair blood vessel lesion..      17.12     11.33        2.21      30.66       090  S                 
35190...  ..................  A                   Repair blood vessel lesion..      11.79     10.34        2.14      24.27       090  S                 
35201...  ..................  A                   Repair blood vessel lesion..       8.90     10.07        1.94      20.91       090  S                 
35206...  ..................  A                   Repair blood vessel lesion..       8.49     10.15        2.03      20.67       090  S                 
35207...  ..................  A                   Repair blood vessel lesion..       9.06     10.80        1.93      21.79       090  S                 
35211...  ..................  A                   Repair blood vessel lesion..      20.15     13.38        2.59      36.12       090  S                 
35216...  ..................  A                   Repair blood vessel lesion..      17.12     10.68        2.08      29.88       090  S                 
35221...  ..................  A                   Repair blood vessel lesion..      15.11     11.09        2.20      28.40       090  S                 
35226...  ..................  A                   Repair blood vessel lesion..       8.17     10.28        1.95      20.40       090  S                 
35231...  ..................  A                   Repair blood vessel lesion..      10.76    *13.78        2.91      27.45       090  S                 
35236...  ..................  A                   Repair blood vessel lesion..       9.39    *12.02        2.56      23.97       090  S                 
35241...  ..................  A                   Repair blood vessel lesion..      21.15     13.49        2.60      37.24       090  S                 
35246...  ..................  A                   Repair blood vessel lesion..      18.14     16.95        2.15      37.24       090  S                 
35251...  ..................  A                   Repair blood vessel lesion..      16.12      9.59        1.88      27.59       090  S                 

[[Page 63227]]
                                                                                                                                                        
35256...  ..................  A                   Repair blood vessel lesion..      10.14     12.40        2.39      24.93       090  S                 
35261...  ..................  A                   Repair blood vessel lesion..      10.39     13.16        2.66      26.21       090  S                 
35266...  ..................  A                   Repair blood vessel lesion..       9.06    *11.59        2.41      23.06       090  S                 
35271...  ..................  A                   Repair blood vessel lesion..      20.15     12.53        2.56      35.24       090  S                 
35276...  ..................  A                   Repair blood vessel lesion..      17.12     10.85        2.26      30.23       090  S                 
35281...  ..................  A                   Repair blood vessel lesion..      15.11     17.28        3.37      35.76       090  S                 
35286...  ..................  A                   Repair blood vessel lesion..      10.78     11.71        2.33      24.82       090  S                 
35301...  ..................  A                   Rechanneling of artery......      15.95     14.46        2.81      33.22       090  S                 
35311...  ..................  A                   Rechanneling of artery......      22.61     22.06        4.61      49.28       090  S                 
35321...  ..................  A                   Rechanneling of artery......      11.08     12.96        2.69      26.73       090  S                 
35331...  ..................  A                   Rechanneling of artery......      22.15     13.34        2.66      38.15       090  S                 
35341...  ..................  A                   Rechanneling of artery......      23.67     17.37        3.53      44.57       090  S                 
35351...  ..................  A                   Rechanneling of artery......      19.15     14.95        2.97      37.07       090  S                 
35355...  ..................  A                   Rechanneling of artery......      15.11     15.42        2.99      33.52       090  S                 
35361...  ..................  A                   Rechanneling of artery......      22.15     19.37        3.88      45.40       090  S                 
35363...  ..................  A                   Rechanneling of artery......      23.16     22.77        4.40      50.33       090  S                 
35371...  ..................  A                   Rechanneling of artery......      10.49     12.51        2.50      25.50       090  S                 
35372...  ..................  A                   Rechanneling of artery......      12.28     11.20        2.28      25.76       090  S                 
35381...  ..................  A                   Rechanneling of artery......      14.50     13.67        2.71      30.88       090  S                 
35390...  ..................  A                   Reoperation, carotid........       3.19      1.67        0.39       5.25       ZZZ  S                 
35450...  ..................  A                   Repair arterial blockage....      10.07    *12.89        1.38      24.34       000  N                 
35452...  ..................  A                   Repair arterial blockage....       6.91      4.35        0.61      11.87       000  S                 
35454...  ..................  A                   Repair arterial blockage....       6.04     *7.73        1.53      15.30       000  S                 
35456...  ..................  A                   Repair arterial blockage....       7.35     *9.41        1.69      18.45       000  S                 
35458...  ..................  A                   Repair arterial blockage....       9.49     10.13        1.83      21.45       000  S                 
35459...  ..................  A                   Repair arterial blockage....       8.63     10.39        1.69      20.71       000  S                 
35460...  ..................  A                   Repair venous blockage......       6.04      3.16        0.74       9.94       000  S                 
35470...  ..................  A                   Repair arterial blockage....       8.63     10.39        1.69      20.71       000  N                 
35471...  ..................  A                   Repair arterial blockage....      10.07    *12.89        1.38      24.34       000  N                 
35472...  ..................  A                   Repair arterial blockage....       6.91      3.61        0.85      11.37       000  N                 
35473...  ..................  A                   Repair arterial blockage....       6.04     *7.73        1.53      15.30       000  N                 
35474...  ..................  A                   Repair arterial blockage....       7.36     *9.42        1.69      18.47       000  N                 
35475...  ..................  R                   Repair arterial blockage....       9.49     10.13        1.83      21.45       000  N                 
35476...  ..................  A                   Repair venous blockage......       6.04      3.16        0.74       9.94       000  N                 
35480...  ..................  A                   Atherectomy, open...........      11.08     13.43        1.38      25.89       000  S                 
35481...  ..................  A                   Atherectomy, open...........       7.61      4.35        0.61      12.57       000  S                 
35482...  ..................  A                   Atherectomy, open...........       6.65     *8.51        1.53      16.69       000  S                 
35483...  ..................  A                   Atherectomy, open...........       8.10    *10.36        1.69      20.15       000  S                 
35484...  ..................  A                   Atherectomy, open...........      10.44     10.13        1.83      22.40       000  S                 
35485...  ..................  A                   Atherectomy, open...........       9.49      4.52        1.06      15.07       000  S                 
35490...  ..................  A                   Atherectomy, percutaneous...      11.08     13.43        1.38      25.89       000  N                 
35491...  ..................  A                   Atherectomy, percutaneous...       7.61      4.35        0.61      12.57       000  N                 
35492...  ..................  A                   Atherectomy, percutaneous...       6.65     *8.51        1.53      16.69       000  N                 
35493...  ..................  A                   Atherectomy, percutaneous...       8.10    *10.36        1.69      20.15       000  N                 
35494...  ..................  A                   Atherectomy, percutaneous...      10.44     10.13        1.83      22.40       000  N                 
35495...  ..................  A                   Atherectomy, percutaneous...       9.49      4.52        1.06      15.07       000  N                 
35501...  ..................  A                   Artery bypass graft.........      18.23     19.35        3.49      41.07       090  S                 
35506...  ..................  A                   Artery bypass graft.........      18.23     19.17        3.64      41.04       090  S                 
35507...  ..................  A                   Artery bypass graft.........      18.23     17.92        3.61      39.76       090  S                 
35508...  ..................  A                   Artery bypass graft.........      17.21     18.11        3.43      38.75       090  S                 
35509...  ..................  A                   Artery bypass graft.........      16.70     18.90        3.92      39.52       090  S                 
35511...  ..................  A                   Artery bypass graft.........      15.39     10.40        1.92      27.71       090  S                 
35515...  ..................  A                   Artery bypass graft.........      17.21     11.25        2.01      30.47       090  S                 
35516...  ..................  A                   Artery bypass graft.........      14.88     17.37        3.54      35.79       090  S                 
35518...  ..................  A                   Artery bypass graft.........      14.05     17.47        3.38      34.90       090  S                 
35521...  ..................  A                   Artery bypass graft.........      14.80     17.53        3.34      35.67       090  S                 
35526...  ..................  A                   Artery bypass graft.........      18.63     12.95        2.44      34.02       090  S                 
35531...  ..................  A                   Artery bypass graft.........      24.17     20.25        3.90      48.32       090  S                 
35533...  ..................  A                   Artery bypass graft.........      19.15     21.04        4.43      44.62       090  S                 
35536...  ..................  A                   Artery bypass graft.........      21.65     21.37        4.17      47.19       090  S                 
35541...  ..................  A                   Artery bypass graft.........      24.17     19.55        3.65      47.37       090  S                 
35546...  ..................  A                   Artery bypass graft.........      24.17     21.39        4.26      49.82       090  S                 
35548...  ..................  A                   Artery bypass graft.........      20.13     19.55        3.65      43.33       090  S                 
35549...  ..................  A                   Artery bypass graft.........      21.91     21.39        4.26      47.56       090  S                 
35551...  ..................  A                   Artery bypass graft.........      25.17     19.25        3.87      48.29       090  S                 
35556...  ..................  A                   Artery bypass graft.........      15.47     18.71        3.71      37.89       090  S                 

[[Page 63228]]
                                                                                                                                                        
35558...  ..................  A                   Artery bypass graft.........      12.82    *16.41        3.23      32.46       090  S                 
35560...  ..................  A                   Artery bypass graft.........      22.12     20.22        3.93      46.27       090  S                 
35563...  ..................  A                   Artery bypass graft.........      13.83      8.32        1.70      23.85       090  S                 
35565...  ..................  A                   Artery bypass graft.........      13.83    *17.69        3.51      35.03       090  S                 
35566...  ..................  A                   Artery bypass graft.........      20.21     20.62        4.08      44.91       090  S                 
35571...  ..................  A                   Artery bypass graft.........      16.66     19.36        3.87      39.89       090  S                 
35582...  ..................  A                   Vein bypass graft...........      25.69     23.74        4.89      54.32       090  S                 
35583...  ..................  A                   Vein bypass graft...........      15.97    *20.44        4.13      40.54       090  S                 
35585...  ..................  A                   Vein bypass graft...........      19.05     22.95        4.63      46.63       090  S                 
35587...  ..................  A                   Vein bypass graft...........      17.07     21.51        4.13      42.71       090  S                 
35601...  ..................  A                   Artery bypass graft.........      16.19     18.83        3.33      38.35       090  S                 
35606...  ..................  A                   Artery bypass graft.........      17.40     17.55        3.51      38.46       090  S                 
35612...  ..................  A                   Artery bypass graft.........      14.39     16.75        3.30      34.44       090  S                 
35616...  ..................  A                   Artery bypass graft.........      14.39     16.79        3.42      34.60       090  S                 
35621...  ..................  A                   Artery bypass graft.........      13.23    *16.94        3.80      33.97       090  S                 
35623...  ..................  A                   Bypass graft, not vein......      15.42      8.06        1.88      25.36       090  S                 
35626...  ..................  A                   Artery bypass graft.........      22.26     20.51        4.08      46.85       090  S                 
35631...  ..................  A                   Artery bypass graft.........      23.16     17.87        3.57      44.60       090  S                 
35636...  ..................  A                   Artery bypass graft.........      21.15     13.50        2.45      37.10       090  S                 
35641...  ..................  A                   Artery bypass graft.........      22.67     20.56        4.08      47.31       090  S                 
35642...  ..................  A                   Artery bypass graft.........      16.70     10.33        2.20      29.23       090  S                 
35645...  ..................  A                   Artery bypass graft.........      16.19     11.15        2.05      29.39       090  S                 
35646...  ..................  A                   Artery bypass graft.........      24.00     23.78        4.73      52.51       090  S                 
35650...  ..................  A                   Artery bypass graft.........      13.05    *16.71        3.56      33.32       090  S                 
35651...  ..................  A                   Artery bypass graft.........      23.67     24.09        4.69      52.45       090  S                 
35654...  ..................  A                   Artery bypass graft.........      17.62     22.10        4.42      44.14       090  S                 
35656...  ..................  A                   Artery bypass graft.........      13.86    *17.73        3.60      35.19       090  S                 
35661...  ..................  A                   Artery bypass graft.........      11.81    *15.11        3.30      30.22       090  S                 
35663...  ..................  A                   Artery bypass graft.........      12.82    *16.41        3.80      33.03       090  S                 
35665...  ..................  A                   Artery bypass graft.........      14.05     17.79        3.57      35.41       090  S                 
35666...  ..................  A                   Artery bypass graft.........      15.97     20.06        4.00      40.03       090  S                 
35671...  ..................  A                   Artery bypass graft.........      12.18    *15.60        4.08      31.86       090  S                 
35681...  ..................  A                   Artery bypass graft.........       8.05    *10.42        3.52      21.99       ZZZ  S                 
35691...  ..................  A                   Arterial transposition......      16.70     19.62        3.81      40.13       090  S                 
35693...  ..................  A                   Arterial transposition......      14.01      9.40        1.91      25.32       090  S                 
35694...  ..................  A                   Arterial transposition......      17.81      9.33        2.17      29.31       090  S                 
35695...  ..................  A                   Arterial transposition......      17.81      9.33        2.17      29.31       090  S                 
35700...  ..................  A                   Reoperation, bypass graft...       3.08      1.61        0.38       5.07       ZZZ  S                 
35701...  ..................  A                   Exploration, carotid artery.       4.54     *5.82        1.25      11.61       090  S                 
35721...  ..................  A                   Exploration, femoral artery.       4.54      5.56        1.11      11.21       090  S                 
35741...  ..................  A                   Exploration popliteal artery       4.54      5.73        1.15      11.42       090  S                 
35761...  ..................  A                   Exploration of artery/vein..       4.54      5.81        1.14      11.49       090  S                 
35800...  ..................  A                   Explore neck vessels........       6.04      5.28        0.97      12.29       090  S                 
35820...  ..................  A                   Explore chest vessels.......      11.64      7.92        1.43      20.99       090  S                 
35840...  ..................  A                   Explore abdominal vessels...       8.63      7.23        1.44      17.30       090  S                 
35860...  ..................  A                   Explore limb vessels........       4.54      5.81        1.15      11.50       090  S                 
35870...  ..................  A                   Repair vessel graft defect..      20.35     10.64        2.47      33.46       090  S                 
35875...  ..................  A                   Removal of clot in graft....       9.07      8.21        1.65      18.93       090  S                 
35876...  ..................  A                   Removal of clot in graft....      12.91      8.21        1.65      22.77       090  S                 
35901...  ..................  A                   Excision, graft, neck.......       7.25      7.18        1.46      15.89       090  S                 
35903...  ..................  A                   Excision, graft, extremity..       8.63      7.18        1.46      17.27       090  S                 
35905...  ..................  A                   Excision, graft, thorax.....      16.89      7.18        1.46      25.53       090  S                 
35907...  ..................  A                   Excision, graft, abdomen....      17.68      7.18        1.46      26.32       090  S                 
36000...  ..................  A                   Place needle in vein........       0.18     *0.24        0.04       0.46       XXX  N                 
36005...  ..................  A                   Injection, venography.......       0.95      0.47        0.04       1.46       000  N                 
36010...  ..................  A                   Place catheter in vein......       2.43      2.11        0.31       4.85       XXX  N                 
36011...  ..................  A                   Place catheter in vein......       3.14      1.90        0.22       5.26       XXX  N                 
36012...  ..................  A                   Place catheter in vein......       3.52      2.67        0.32       6.51       XXX  N                 
36013...  ..................  A                   Place catheter in artery....       2.52      2.11        0.31       4.94       XXX  N                 
36014...  ..................  A                   Place catheter in artery....       3.02      2.28        0.27       5.57       XXX  N                 
36015...  ..................  A                   Place catheter in artery....       3.52      2.67        0.32       6.51       XXX  N                 
36100...  ..................  A                   Establish access to artery..       3.02      2.59        0.32       5.93       XXX  N                 
36120...  ..................  A                   Establish access to artery..       2.01      2.32        0.30       4.63       XXX  N                 
36140...  ..................  A                   Establish access to artery..       2.01      1.41        0.24       3.66       XXX  N                 
36145...  ..................  A                   Artery to vein shunt........       2.01     *2.57        0.49       5.07       XXX  N                 
36160...  ..................  A                   Establish access to aorta...       2.52      2.32        0.35       5.19       XXX  S                 

[[Page 63229]]
                                                                                                                                                        
36200...  ..................  A                   Place catheter in aorta.....       3.02      2.73        0.28       6.03       XXX  N                 
36215...  ..................  A                   Place catheter in artery....       4.47      2.78        0.23       7.48       XXX  N                 
36216...  ..................  A                   Place catheter in artery....       5.28      3.29        0.27       8.84       XXX  N                 
36217...  ..................  A                   Place catheter in artery....       6.30      3.92        0.32      10.54       XXX  N                 
36218...  ..................  A                   Place catheter in artery....       1.01      0.62        0.05       1.68       XXX  N                 
36245...  ..................  A                   Place catheter in artery....       5.07      3.15        0.26       8.48       XXX  N                 
36246...  ..................  A                   Place catheter in artery....       5.28      3.29        0.27       8.84       XXX  N                 
36247...  ..................  A                   Place catheter in artery....       6.30      3.92        0.32      10.54       XXX  N                 
36248...  ..................  A                   Place catheter in artery....       1.01      0.62        0.05       1.68       XXX  N                 
36260...  ..................  A                   Insertion of infusion pump..       9.27      6.74        1.41      17.42       090  S                 
36261...  ..................  A                   Revision of infusion pump...       5.04      2.23        0.42       7.69       090  S                 
36262...  ..................  A                   Removal of infusion pump....       3.70      1.93        0.40       6.03       090  S                 
36299...  ..................  C                   Vessel injection procedure..       0.00      0.00        0.00       0.00       YYY  N                 
36400...  ..................  A                   Drawing blood...............       0.18      0.09        0.01       0.28       XXX  N                 
36405...  ..................  A                   Drawing blood...............       0.18      0.45        0.03       0.66       XXX  N                 
36406...  ..................  A                   Drawing blood...............       0.18      0.16        0.01       0.35       XXX  S                 
36410...  ..................  A                   Drawing blood...............       0.18      0.22        0.02       0.42       XXX  N                 
36415...  ..................  G                   Drawing blood...............       0.00      0.00        0.00       0.00       XXX  0                 
36420...  ..................  A                   Establish access to vein....       1.01      0.51        0.05       1.57       XXX  N                 
36425...  ..................  A                   Establish access to vein....       0.76      0.08        0.01       0.85       XXX  N                 
36430...  ..................  A                   Blood transfusion service...       0.00      0.96        0.07       1.03       XXX  N                 
36440...  ..................  A                   Blood transfusion service...       1.03      0.94        0.07       2.04       XXX  S                 
36450...  ..................  A                   Exchange transfusion service       2.23      1.88        0.18       4.29       XXX  N                 
36455...  ..................  A                   Exchange transfusion service       2.43      2.27        0.22       4.92       XXX  N                 
36460...  ..................  A                   Transfusion service, fetal..       6.59      4.71        1.09      12.39       XXX  N                 
36468...  ..................  R                   Injection(s); spider veins..       0.00      0.00        0.00       0.00       XXX  S                 
36469...  ..................  R                   Injection(s); spider veins..       0.00      0.00        0.00       0.00       XXX  S                 
36470...  ..................  A                   Injection therapy of vein...       1.02      0.27        0.04       1.33       010  S                 
36471...  ..................  A                   Injection therapy of veins..       1.49      0.39        0.05       1.93       010  S                 
36481...  ..................  A                   Insertion of catheter, vein.       6.99      5.30        0.61      12.90       000  S                 
36488...  ..................  A                   Insertion of catheter, vein.       1.35      0.97        0.14       2.46       000  N                 
36489...  ..................  A                   Insertion of catheter, vein.       1.22      1.12        0.17       2.51       000  N                 
36490...  ..................  A                   Insertion of catheter, vein.       1.67      1.38        0.20       3.25       000  N                 
36491...  ..................  A                   Insertion of catheter, vein.       1.43      1.71        0.32       3.46       000  N                 
36493...  ..................  A                   Repositioning of cvc........       1.21      0.63        0.16       2.00       000  N                 
36500...  ..................  A                   Insertion of catheter, vein.       3.52      0.08        0.01       3.61       000  N                 
36510...  ..................  A                   Insertion of catheter, vein.       1.09      0.34        0.02       1.45       000  N                 
36520...  ..................  A                   Plasma and/or cell exchange.       1.74      1.92        0.12       3.78       000  N                 
36522...  ..................  A                   Photopheresis...............       1.67     *2.48        0.37       4.52       000  S                 
36530...  ..................  R                   Insertion of infusion pump..       4.83      4.82        1.02      10.67       010  S                 
36531...  ..................  R                   Revision of infusion pump...       4.80      4.37        0.27       9.44       010  S                 
36532...  ..................  R                   Removal of infusion pump....       3.23      1.77        0.37       5.37       010  S                 
36533...  ..................  A                   Insertion of access port....       3.82      4.29        0.85       8.96       010  S                 
36534...  ..................  A                   Revision of access port.....       3.79      3.46        0.21       7.46       010  S                 
36535...  ..................  A                   Removal of access port......       2.22      1.81        0.38       4.41       010  S                 
36600...  ..................  A                   Withdrawal of arterial blood       0.32      0.28        0.02       0.62       XXX  N                 
36620...  ..................  A                   Insertion catheter, artery..       1.15      0.66        0.14       1.95       000  N                 
36625...  ..................  A                   Insertion catheter, artery..       2.11      0.86        0.18       3.15       000  N                 
36640...  ..................  A                   Insertion catheter, artery..       2.10      2.32        0.40       4.82       000  N                 
36660...  ..................  A                   Insertion catheter, artery..       1.40      0.49        0.04       1.93       000  N                 
36680...  ..................  A                   Insert needle, bone cavity..       1.20      1.24        0.10       2.54       000  N                 
36800...  ..................  A                   Insertion of cannula........       2.43      2.22        0.28       4.93       000  N                 
36810...  ..................  A                   Insertion of cannula........       3.97      4.85        0.74       9.56       000  S                 
36815...  ..................  A                   Insertion of cannula........       2.62     *3.35        0.70       6.67       000  S                 
36821...  ..................  A                   Artery-vein fusion..........       8.39      7.24        1.46      17.09       090  S                 
36822...  ..................  A                   Insertion of cannula(s).....       5.03      5.60        0.77      11.40       090  S                 
36825...  ..................  A                   Artery-vein graft...........       9.36     11.20        2.21      22.77       090  S                 
36830...  ..................  A                   Artery-vein graft...........       7.78     *9.96        2.36      20.10       090  S                 
36832...  ..................  A                   Revise artery-vein fistula..       5.84     *7.48        2.38      15.70       090  S                 
36834...  ..................  A                   Repair A-V aneurysm.........       9.32      7.80        1.66      18.78       090  S                 
36835...  ..................  A                   Artery to vein shunt........       6.54      3.42        0.79      10.75       090  S                 
36860...  ..................  A                   Cannula declotting..........       2.01      2.57        0.43       5.01       000  N                 
36861...  ..................  A                   Cannula declotting..........       2.52     *3.22        1.01       6.75       000  S                 
37140...  ..................  A                   Revision of circulation.....      22.15     16.29        3.34      41.78       090  S                 
37145...  ..................  A                   Revision of circulation.....      23.16     17.13        1.72      42.01       090  S                 
37160...  ..................  A                   Revision of circulation.....      20.15     17.74        3.79      41.68       090  S                 

[[Page 63230]]
                                                                                                                                                        
37180...  ..................  A                   Revision of circulation.....      23.16     14.19        2.76      40.11       090  S                 
37181...  ..................  A                   Splice spleen/kidney veins..      25.17     16.41        3.52      45.10       090  S                 
37200...  ..................  A                   Transcatheter biopsy........       4.56      1.59        0.13       6.28       000  N                 
37201...  ..................  A                   Transcatheter therapy infuse       7.25      5.50        0.64      13.39       000  N                 
37202...  ..................  A                   Transcatheter therapy infuse       5.68      4.30        0.50      10.48       000  N                 
37203...  ..................  A                   Transcatheter retrieval.....       5.03      3.82        0.45       9.30       000  N                 
37204...  ..................  A                   Transcatheter occlusion.....      18.14     13.76        1.60      33.50       000  N                 
37205...  ..................  A                   Transcatheter stent.........       8.28      5.16        0.42      13.86       000  S                 
37206...  ..................  A                   Transcatheter stent.........       4.13      2.58        0.21       6.92       ZZZ  S                 
37207...  ..................  A                   Transcatheter stent.........       8.28      5.16        0.42      13.86       000  S                 
37208...  ..................  A                   Transcatheter stent.........       4.13      2.58        0.21       6.92       ZZZ  S                 
37209...  ..................  A                   Exchange arterial catheter..       2.27      1.41        0.11       3.79       000  N                 
37565...  ..................  A                   Ligation of neck vein.......       3.90      3.79        0.74       8.43       090  S                 
37600...  ..................  A                   Ligation of neck artery.....       3.90     *4.98        0.80       9.68       090  S                 
37605...  ..................  A                   Ligation of neck artery.....       4.63      5.56        1.04      11.23       090  S                 
37606...  ..................  A                   Ligation of neck artery.....       4.63     *5.92        0.72      11.27       090  S                 
37607...  ..................  A                   Ligation of fistula.........       5.84      3.06        0.71       9.61       090  S                 
37609...  ..................  A                   Temporal artery procedure...       2.27      2.22        0.38       4.87       010  S                 
37615...  ..................  A                   Ligation of neck artery.....       4.39     *5.62        1.11      11.12       090  S                 
37616...  ..................  A                   Ligation of chest artery....      14.69      4.21        0.83      19.73       090  S                 
37617...  ..................  A                   Ligation of abdomen artery..      14.19      8.00        1.54      23.73       090  S                 
37618...  ..................  A                   Ligation of extremity artery       3.90     *4.98        1.06       9.94       090  S                 
37620...  ..................  A                   Revision of major vein......       9.24      8.81        1.48      19.53       090  S                 
37650...  ..................  A                   Revision of major vein......       4.39      4.02        0.52       8.93       090  S                 
37660...  ..................  A                   Revision of major vein......       9.65      5.75        1.07      16.47       090  S                 
37700...  ..................  A                   Revise leg vein.............       3.52      3.64        0.73       7.89       090  S                 
37720...  ..................  A                   Removal of leg vein.........       5.22      5.11        1.04      11.37       090  S                 
37730...  ..................  A                   Removal of leg veins........       6.63      6.95        1.40      14.98       090  S                 
37735...  ..................  A                   Removal of leg veins/lesion.       9.90      8.34        1.68      19.92       090  S                 
37760...  ..................  A                   Revision of leg veins.......       9.90      7.48        1.52      18.90       090  S                 
37780...  ..................  A                   Revision of leg vein........       3.52      1.89        0.35       5.76       090  S                 
37785...  ..................  A                   Revise secondary varicosity.       3.56      0.98        0.18       4.72       090  S                 
37788...  ..................  A                   Revascularization, penis....      21.33     15.14        1.48      37.95       090  S                 
37790...  ..................  A                   Penile venous occlusion.....       8.02      5.70        0.55      14.27       090  S                 
37799...  ..................  C                   Vascular surgery procedure..       0.00      0.00        0.00       0.00       YYY  S                 
38100...  ..................  A                   Removal of spleen, total....      11.99      8.55        1.81      22.35       090  S                 
38101...  ..................  A                   Removal of spleen, partial..      12.59      6.99        1.51      21.09       090  S                 
38102...  ..................  A                   Removal of spleen, total....       4.80      2.51        0.58       7.89       ZZZ  S                 
38115...  ..................  A                   Repair of ruptured spleen...      12.59      7.64        1.49      21.72       090  S                 
38200...  ..................  A                   Injection for spleen x-ray..       2.64      1.71        0.15       4.50       000  S                 
38230...  ..................  A                   Bone marrow collection......       3.16      2.78        0.21       6.15       010  N                 
38231...  ..................  A                   Stem cell collection........       1.50      1.37        0.08       2.95       000  N                 
38240...  ..................  A                   Bone marrow/stem transplant.       2.24      2.08        0.14       4.46       XXX  N                 
38241...  ..................  A                   Bone marrow/stem transplant.       2.24      2.04        0.13       4.41       XXX  N                 
38300...  ..................  A                   Drainage lymph node lesion..       1.48      0.58        0.10       2.16       010  S                 
38305...  ..................  A                   Drainage lymph node lesion..       4.24      1.96        0.36       6.56       090  S                 
38308...  ..................  A                   Incision of lymph channels..       4.55      3.37        0.45       8.37       090  S                 
38380...  ..................  A                   Thoracic duct procedure.....       6.53      4.44        0.76      11.73       090  S                 
38381...  ..................  A                   Thoracic duct procedure.....      12.10      7.56        1.50      21.16       090  S                 
38382...  ..................  A                   Thoracic duct procedure.....       9.24      4.84        1.13      15.21       090  S                 
38500...  ..................  A                   Biopsy/removal, lymph              2.83      1.59        0.31       4.73       010  S                 
                                                   node(s).                                                                                             
38505...  ..................  A                   Needle biopsy, lymph node(s)       1.14      1.12        0.17       2.43       000  S                 
38510...  ..................  A                   Biopsy/removal, lymph              3.90      2.54        0.45       6.89       090  S                 
                                                   node(s).                                                                                             
38520...  ..................  A                   Biopsy/removal, lymph              4.86      2.99        0.56       8.41       090  S                 
                                                   node(s).                                                                                             
38525...  ..................  A                   Biopsy/removal, lymph              4.37      2.59        0.53       7.49       090  S                 
                                                   node(s).                                                                                             
38530...  ..................  A                   Biopsy/removal, lymph              5.82      3.17        0.65       9.64       090  S                 
                                                   node(s).                                                                                             
38542...  ..................  A                   Explore deep node(s), neck..       5.41      4.26        0.59      10.26       090  S                 
38550...  ..................  A                   Removal neck/armpit lesion..       6.42      3.23        0.63      10.28       090  S                 
38555...  ..................  A                   Removal neck/armpit lesion..      13.05      7.27        1.38      21.70       090  S                 
38562...  ..................  A                   Removal, pelvic lymph nodes.       9.65      6.88        1.20      17.73       090  S                 
38564...  ..................  A                   Removal, abdomen lymph nodes      10.00      7.39        1.51      18.90       090  S                 
38700...  ..................  A                   Removal of lymph nodes, neck       7.56      9.64        1.31      18.51       090  S                 
38720...  ..................  A                   Removal of lymph nodes, neck      12.29    *15.73        2.04      30.06       090  S                 
38724...  ..................  A                   Removal of lymph nodes, neck      13.22     14.36        2.00      29.58       090  S                 
38740...  ..................  A                   Remove armpit lymph nodes...       6.28      4.72        1.00      12.00       090  S                 
38745...  ..................  A                   Remove armpits lymph nodes..       8.08      8.28        1.76      18.12       090  S                 

[[Page 63231]]
                                                                                                                                                        
38746...  ..................  A                   Remove thoracic lymph nodes.       4.39      2.29        0.53       7.21       ZZZ  S                 
38747...  ..................  A                   Remove abdominal lymph nodes       4.89      2.56        0.59       8.04       ZZZ  S                 
38760...  ..................  A                   Remove groin lymph nodes....       8.19      6.63        1.35      16.17       090  S                 
38765...  ..................  A                   Remove groin lymph nodes....      14.98     12.67        2.42      30.07       090  S                 
38770...  ..................  A                   Remove pelvis lymph nodes...      12.10     15.40        1.73      29.23       090  S                 
38780...  ..................  A                   Remove abdomen lymph nodes..      15.17     16.06        3.13      34.36       090  S                 
38790...  ..................  A                   Injection for lymphatic xray       1.29     *1.64        0.19       3.12       000  N                 
38794...  ..................  A                   Access thoracic lymph duct..       4.05      2.84        0.38       7.27       090  S                 
38999...  ..................  C                   Blood/lymph system procedure       0.00      0.00        0.00       0.00       YYY  S                 
39000...  ..................  A                   Exploration of chest........       5.03      6.05        1.08      12.16       090  S                 
39010...  ..................  A                   Exploration of chest........      10.78     11.46        2.08      24.32       090  S                 
39200...  ..................  A                   Removal chest lesion........      12.40     11.58        2.14      26.12       090  S                 
39220...  ..................  A                   Removal chest lesion........      16.16     14.94        2.83      33.93       090  S                 
39400...  ..................  A                   Visualization of chest......       5.11      5.12        0.95      11.18       010  S                 
39499...  ..................  C                   Chest procedure.............       0.00      0.00        0.00       0.00       YYY  S                 
39501...  ..................  A                   Repair diaphragm laceration.      12.10     10.66        2.10      24.86       090  S                 
39502...  ..................  A                   Repair paraesophageal hernia      15.18     11.93        2.45      29.56       090  S                 
39503...  ..................  A                   Repair of diaphragm hernia..      33.22     25.18        2.94      61.34       090  S                 
39520...  ..................  A                   Repair of diaphragm hernia..      15.18     12.53        2.46      30.17       090  S                 
39530...  ..................  A                   Repair of diaphragm hernia..      14.22     14.06        2.71      30.99       090  S                 
39531...  ..................  A                   Repair of diaphragm hernia..      15.23     10.00        1.80      27.03       090  S                 
39540...  ..................  A                   Repair of diaphragm hernia..      12.10     11.98        2.51      26.59       090  S                 
39541...  ..................  A                   Repair of diaphragm hernia..      13.10     12.16        2.37      27.63       090  S                 
39545...  ..................  A                   Revision of diaphragm.......      12.10      7.90        1.31      21.31       090  S                 
39599...  ..................  C                   Diaphragm surgery procedure.       0.00      0.00        0.00       0.00       YYY  S                 
40490...  ..................  A                   Biopsy of lip...............       1.22      0.74        0.07       2.03       000  S                 
40500...  ..................  A                   Partial excision of lip.....       4.08     *5.23        0.94      10.25       090  S                 
40510...  ..................  A                   Partial excision of lip.....       4.57     *5.84        0.83      11.24       090  S                 
40520...  ..................  A                   Partial excision of lip.....       4.54      4.50        0.68       9.72       090  S                 
40525...  ..................  A                   Reconstruct lip with flap...       7.26     *9.30        1.43      17.99       090  S                 
40527...  ..................  A                   Reconstruct lip with flap...       8.71    *11.16        1.65      21.52       090  S                 
40530...  ..................  A                   Partial removal of lip......       5.14      5.10        0.74      10.98       090  S                 
40650...  ..................  A                   Repair lip..................       3.49     *4.47        0.65       8.61       090  S                 
40652...  ..................  A                   Repair lip..................       4.08     *5.23        0.79      10.10       090  S                 
40654...  ..................  A                   Repair lip..................       5.13     *6.57        1.00      12.70       090  S                 
40700...  ..................  A                   Repair cleft lip/nasal......      12.04      8.46        1.28      21.78       090  S                 
40701...  ..................  A                   Repair cleft lip/nasal......      15.10    *19.33        1.62      36.05       090  S                 
40702...  ..................  A                   Repair cleft lip/nasal......      12.34      9.37        1.10      22.81       090  S                 
40720...  ..................  A                   Repair cleft lip/nasal......      12.91      9.59        1.79      24.29       090  S                 
40761...  ..................  A                   Repair cleft lip/nasal......      14.00     10.84        1.74      26.58       090  S                 
40799...  ..................  C                   Lip surgery procedure.......       0.00      0.00        0.00       0.00       YYY  S                 
40800...  ..................  A                   Drainage of mouth lesion....       1.12      0.74        0.07       1.93       010  S                 
40801...  ..................  A                   Drainage of mouth lesion....       2.48      1.70        0.16       4.34       010  S                 
40804...  ..................  A                   Removal foreign body, mouth.       1.19      0.58        0.06       1.83       010  S                 
40805...  ..................  A                   Removal foreign body, mouth.       2.64      2.50        0.30       5.44       010  S                 
40806...  ..................  A                   Incision of lip fold........       0.31      0.36        0.03       0.70       000  S                 
40808...  ..................  A                   Biopsy of mouth lesion......       0.91      0.76        0.08       1.75       010  S                 
40810...  ..................  A                   Excision of mouth lesion....       1.26      1.18        0.11       2.55       010  S                 
40812...  ..................  A                   Excise/repair mouth lesion..       2.26      1.50        0.14       3.90       010  S                 
40814...  ..................  A                   Excise/repair mouth lesion..       3.27      3.23        0.32       6.82       090  S                 
40816...  ..................  A                   Excision of mouth lesion....       3.52      3.22        0.33       7.07       090  S                 
40818...  ..................  A                   Excise oral mucosa for graft       2.26      2.25        0.20       4.71       090  S                 
40819...  ..................  A                   Excise lip or cheek fold....       2.26      1.23        0.14       3.63       090  S                 
40820...  ..................  A                   Treatment of mouth lesion...       1.23      0.53        0.06       1.82       010  S                 
40830...  ..................  A                   Repair mouth laceration.....       1.71      0.67        0.07       2.45       010  S                 
40831...  ..................  A                   Repair mouth laceration.....       2.41      1.94        0.21       4.56       010  S                 
40840...  ..................  R                   Reconstruction of mouth.....       8.31      6.28        0.73      15.32       090  S                 
40842...  ..................  R                   Reconstruction of mouth.....       8.31      6.28        0.73      15.32       090  S                 
40843...  ..................  R                   Reconstruction of mouth.....      11.63      8.80        1.03      21.46       090  S                 
40844...  ..................  R                   Reconstruction of mouth.....      15.37     11.63        1.36      28.36       090  S                 
40845...  ..................  R                   Reconstruction of mouth.....      17.94     23.99        1.93      43.86       090  S                 
40899...  ..................  C                   Mouth surgery procedure.....       0.00      0.00        0.00       0.00       YYY  S                 
41000...  ..................  A                   Drainage of mouth lesion....       1.25      0.76        0.08       2.09       010  S                 
41005...  ..................  A                   Drainage of mouth lesion....       1.21      0.62        0.07       1.90       010  S                 
41006...  ..................  A                   Drainage of mouth lesion....       3.03      1.01        0.11       4.15       090  S                 
41007...  ..................  A                   Drainage of mouth lesion....       2.89      2.90        0.30       6.09       090  S                 

[[Page 63232]]
                                                                                                                                                        
41008...  ..................  A                   Drainage of mouth lesion....       3.16      1.06        0.11       4.33       090  S                 
41009...  ..................  A                   Drainage of mouth lesion....       3.35      3.31        0.34       7.00       090  S                 
41010...  ..................  A                   Incision of tongue fold.....       1.19      0.37        0.04       1.60       010  S                 
41015...  ..................  A                   Drainage of mouth lesion....       3.72      0.87        0.10       4.69       090  S                 
41016...  ..................  A                   Drainage of mouth lesion....       3.72      3.69        0.38       7.79       090  S                 
41017...  ..................  A                   Drainage of mouth lesion....       3.72      1.40        0.14       5.26       090  S                 
41018...  ..................  A                   Drainage of mouth lesion....       4.75      3.93        0.38       9.06       090  S                 
41100...  ..................  A                   Biopsy of tongue............       1.58      0.80        0.08       2.46       010  S                 
41105...  ..................  A                   Biopsy of tongue............       1.37      1.03        0.12       2.52       010  S                 
41108...  ..................  A                   Biopsy of floor of mouth....       1.00      0.85        0.09       1.94       010  S                 
41110...  ..................  A                   Excision of tongue lesion...       1.46      1.30        0.15       2.91       010  S                 
41112...  ..................  A                   Excision of tongue lesion...       2.63      2.39        0.23       5.25       090  S                 
41113...  ..................  A                   Excision of tongue lesion...       3.09      3.41        0.37       6.87       090  S                 
41114...  ..................  A                   Excision of tongue lesion...       7.88      6.39        0.73      15.00       090  S                 
41115...  ..................  A                   Excision of tongue fold.....       1.69      1.78        0.17       3.64       010  S                 
41116...  ..................  A                   Excision of mouth lesion....       2.36      2.49        0.27       5.12       090  S                 
41120...  ..................  A                   Partial removal of tongue...       8.83      7.28        0.88      16.99       090  S                 
41130...  ..................  A                   Partial removal of tongue...      10.27      9.06        1.14      20.47       090  S                 
41135...  ..................  A                   Tongue and neck surgery.....      14.29    *18.30        2.64      35.23       090  S                 
41140...  ..................  A                   Removal of tongue...........      23.46     18.89        2.45      44.80       090  S                 
41145...  ..................  A                   Tongue removal; neck surgery      27.58     22.79        2.95      53.32       090  S                 
41150...  ..................  A                   Tongue, mouth, jaw surgery..      19.36     18.96        2.46      40.78       090  S                 
41153...  ..................  A                   Tongue, mouth, neck surgery.      21.18     25.00        3.03      49.21       090  S                 
41155...  ..................  A                   Tongue, jaw, & neck surgery.      23.40    *29.95        3.75      57.10       090  S                 
41250...  ..................  A                   Repair tongue laceration....       1.86      1.07        0.11       3.04       010  S                 
41251...  ..................  A                   Repair tongue laceration....       2.22      2.07        0.21       4.50       010  S                 
41252...  ..................  A                   Repair tongue laceration....       2.92      2.35        0.26       5.53       010  S                 
41500...  ..................  A                   Fixation of tongue..........       3.50      3.29        0.26       7.05       090  S                 
41510...  ..................  A                   Tongue to lip surgery.......       3.32      2.53        0.45       6.30       090  S                 
41520...  ..................  A                   Reconstruction, tongue fold.       2.63      2.88        0.28       5.79       090  S                 
41599...  ..................  C                   Tongue and mouth surgery....       0.00      0.00        0.00       0.00       YYY  S                 
41800...  ..................  A                   Drainage of gum lesion......       1.12      0.69        0.07       1.88       010  S                 
41805...  ..................  A                   Removal foreign body, gum...       1.19      0.84        0.08       2.11       010  S                 
41806...  ..................  A                   Removal foreign body,              2.64      1.64        0.15       4.43       010  S                 
                                                   jawbone.                                                                                             
41820...  ..................  R                   Excision, gum, each quadrant       0.00      0.00        0.00       0.00       XXX  S                 
41821...  ..................  R                   Excision of gum flap........       0.00      0.00        0.00       0.00       XXX  S                 
41822...  ..................  R                   Excision of gum lesion......       2.26      3.03        0.25       5.54       010  S                 
41823...  ..................  R                   Excision of gum lesion......       3.15      4.20        0.34       7.69       090  S                 
41825...  ..................  A                   Excision of gum lesion......       1.26      1.49        0.14       2.89       010  S                 
41826...  ..................  A                   Excision of gum lesion......       2.26      2.07        0.18       4.51       010  S                 
41827...  ..................  A                   Excision of gum lesion......       3.27      3.78        0.38       7.43       090  S                 
41828...  ..................  R                   Excision of gum lesion......       3.04      4.07        0.33       7.44       010  S                 
41830...  ..................  R                   Removal of gum tissue.......       3.30      4.41        0.36       8.07       010  S                 
41850...  ..................  R                   Treatment of gum lesion.....       0.00      0.00        0.00       0.00       XXX  S                 
41870...  ..................  R                   Gum graft...................       0.00      0.00        0.00       0.00       XXX  S                 
41872...  ..................  R                   Repair gum..................       2.44      3.26        0.27       5.97       090  S                 
41874...  ..................  R                   Repair tooth socket.........       2.94      3.93        0.32       7.19       090  S                 
41899...  ..................  C                   Dental surgery procedure....       0.00      0.00        0.00       0.00       YYY  S                 
42000...  ..................  A                   Drainage mouth roof lesion..       1.18      0.62        0.06       1.86       010  S                 
42100...  ..................  A                   Biopsy roof of mouth........       1.26      0.79        0.08       2.13       010  S                 
42104...  ..................  A                   Excision lesion, mouth roof.       1.59      1.62        0.17       3.38       010  S                 
42106...  ..................  A                   Excision lesion, mouth roof.       2.63      2.22        0.21       5.06       010  S                 
42107...  ..................  A                   Excision lesion, mouth roof.       4.20      4.91        0.50       9.61       090  S                 
42120...  ..................  A                   Remove palate/lesion........       5.39     *6.90        1.01      13.30       090  S                 
42140...  ..................  A                   Excision of uvula...........       1.54      1.35        0.15       3.04       090  S                 
42145...  ..................  A                   Repair, palate, pharynx/           7.04     *9.01        1.45      17.50       090  S                 
                                                   uvula.                                                                                               
42160...  ..................  A                   Treatment mouth roof lesion.       1.75      1.53        0.16       3.44       010  S                 
42180...  ..................  A                   Repair palate...............       2.45      2.24        0.26       4.95       010  S                 
42182...  ..................  A                   Repair palate...............       3.78      3.47        0.38       7.63       010  S                 
42200...  ..................  A                   Reconstruct cleft palate....       9.48      7.19        0.85      17.52       090  S                 
42205...  ..................  A                   Reconstruct cleft palate....       8.96     10.82        0.79      20.57       090  S                 
42210...  ..................  A                   Reconstruct cleft palate....      10.02     12.51        0.95      23.48       090  S                 
42215...  ..................  A                   Reconstruct cleft palate....       8.42      7.68        0.86      16.96       090  S                 
42220...  ..................  A                   Reconstruct cleft palate....       6.65      5.40        0.81      12.86       090  S                 
42225...  ..................  A                   Reconstruct cleft palate....       9.08      6.90        1.08      17.06       090  S                 
42226...  ..................  A                   Lengthening of palate.......       9.42      7.89        0.86      18.17       090  S                 

[[Page 63233]]
                                                                                                                                                        
42227...  ..................  A                   Lengthening of palate.......       8.89      7.41        0.38      16.68       090  S                 
42235...  ..................  A                   Repair palate...............       7.50      5.55        0.49      13.54       090  S                 
42260...  ..................  A                   Repair nose to lip fistula..       4.17      3.98        0.44       8.59       090  S                 
42280...  ..................  A                   Preparation, palate mold....       1.49      1.99        0.17       3.65       010  S                 
42281...  ..................  A                   Insertion, palate prosthesis       1.77      1.47        0.15       3.39       010  S                 
42299...  ..................  C                   Palate/uvula surgery........       0.00      0.00        0.00       0.00       YYY  S                 
42300...  ..................  A                   Drainage of salivary gland..       1.88      0.96        0.12       2.96       010  S                 
42305...  ..................  A                   Drainage of salivary gland..       5.59      2.18        0.27       8.04       090  S                 
42310...  ..................  A                   Drainage of salivary gland..       1.51      1.03        0.12       2.66       010  S                 
42320...  ..................  A                   Drainage of salivary gland..       2.30      1.83        0.22       4.35       010  S                 
42325...  ..................  A                   Create salivary cyst drain..       2.65      2.12        0.20       4.97       090  S                 
42326...  ..................  A                   Create salivary cyst drain..       3.65      4.34        0.33       8.32       090  S                 
42330...  ..................  A                   Removal of salivary stone...       2.16      1.10        0.12       3.38       010  S                 
42335...  ..................  A                   Removal of salivary stone...       3.21      2.47        0.27       5.95       090  S                 
42340...  ..................  A                   Removal of salivary stone...       4.47      4.25        0.45       9.17       090  S                 
42400...  ..................  A                   Biopsy of salivary gland....       0.78      0.79        0.10       1.67       000  S                 
42405...  ..................  A                   Biopsy of salivary gland....       3.24      1.54        0.19       4.97       010  S                 
42408...  ..................  A                   Excision of salivary cyst...       4.41      3.24        0.38       8.03       090  S                 
42409...  ..................  A                   Drainage of salivary cyst...       2.71      2.81        0.30       5.82       090  S                 
42410...  ..................  A                   Excise parotid gland/lesion.       8.88      5.94        0.92      15.74       090  S                 
42415...  ..................  A                   Excise parotid gland/lesion.      16.12     12.68        1.68      30.48       090  S                 
42420...  ..................  A                   Excise parotid gland/lesion.      18.63     14.82        1.87      35.32       090  S                 
42425...  ..................  A                   Excise parotid gland/lesion.      12.36     11.10        1.43      24.89       090  S                 
42426...  ..................  A                   Excise parotid gland/lesion.      19.88     24.12        3.21      47.21       090  S                 
42440...  ..................  A                   Excision submaxillary gland.       6.61      7.98        0.99      15.58       090  S                 
42450...  ..................  A                   Excision sublingual gland...       4.38      3.42        0.35       8.15       090  S                 
42500...  ..................  A                   Repair salivary duct........       4.06      4.61        0.50       9.17       090  S                 
42505...  ..................  A                   Repair salivary duct........       5.92      7.34        0.86      14.12       090  S                 
42507...  ..................  A                   Parotid duct diversion......       5.96      4.65        0.67      11.28       090  S                 
42508...  ..................  A                   Parotid duct diversion......       8.64      7.61        0.94      17.19       090  S                 
42509...  ..................  A                   Parotid duct diversion......      11.08      7.31        1.23      19.62       090  S                 
42510...  ..................  A                   Parotid duct diversion......       7.71      7.65        0.84      16.20       090  S                 
42550...  ..................  A                   Injection for salivary x-ray       1.25      0.44        0.04       1.73       000  N                 
42600...  ..................  A                   Closure of salivary fistula.       4.58      3.89        0.46       8.93       090  S                 
42650...  ..................  A                   Dilation of salivary duct...       0.77      0.39        0.04       1.20       000  S                 
42660...  ..................  A                   Dilation of salivary duct...       1.13      0.50        0.06       1.69       000  S                 
42665...  ..................  A                   Ligation of salivary duct...       2.43      2.04        0.25       4.72       090  S                 
42699...  ..................  C                   Salivary surgery procedure..       0.00      0.00        0.00       0.00       YYY  S                 
42700...  ..................  A                   Drainage of tonsil abscess..       1.57      0.85        0.10       2.52       010  S                 
42720...  ..................  A                   Drainage of throat abscess..       2.61      1.89        0.22       4.72       010  S                 
42725...  ..................  A                   Drainage of throat abscess..       7.60      4.45        0.53      12.58       090  S                 
42800...  ..................  A                   Biopsy of throat............       1.34      0.74        0.08       2.16       010  S                 
42802...  ..................  A                   Biopsy of throat............       1.49      1.02        0.12       2.63       010  S                 
42804...  ..................  A                   Biopsy of upper nose/throat.       1.19      1.09        0.13       2.41       010  S                 
42806...  ..................  A                   Biopsy of upper nose/throat.       1.53      1.40        0.16       3.09       010  S                 
42808...  ..................  A                   Excise pharynx lesion.......       2.25      2.52        0.29       5.06       010  S                 
42809...  ..................  A                   Remove pharynx foreign body.       1.76      0.82        0.08       2.66       010  S                 
42810...  ..................  A                   Excision of neck cyst.......       3.20      3.14        0.47       6.81       090  S                 
42815...  ..................  A                   Excision of neck cyst.......       6.75      8.47        1.12      16.34       090  S                 
42820...  ..................  A                   Remove tonsils and adenoids.       3.59      3.15        0.32       7.06       090  S                 
42821...  ..................  A                   Remove tonsils and adenoids.       4.10      3.93        0.46       8.49       090  S                 
42825...  ..................  A                   Removal of tonsils..........       3.21      2.64        0.33       6.18       090  S                 
42826...  ..................  A                   Removal of tonsils..........       3.19      3.86        0.43       7.48       090  S                 
42830...  ..................  A                   Removal of adenoids.........       2.49      1.86        0.27       4.62       090  S                 
42831...  ..................  A                   Removal of adenoids.........       2.61      2.36        0.25       5.22       090  S                 
42835...  ..................  A                   Removal of adenoids.........       2.22      1.86        0.10       4.18       090  S                 
42836...  ..................  A                   Removal of adenoids.........       3.10      2.79        0.31       6.20       090  S                 
42842...  ..................  A                   Extensive surgery of throat.       8.13      6.69        0.73      15.55       090  S                 
42844...  ..................  A                   Extensive surgery of throat.      12.73     10.85        1.27      24.85       090  S                 
42845...  ..................  A                   Extensive surgery of throat.      21.88     18.62        2.22      42.72       090  S                 
42860...  ..................  A                   Excision of tonsil tags.....       2.14      1.89        0.21       4.24       090  S                 
42870...  ..................  A                   Excision of lingual tonsil..       5.16      2.32        0.26       7.74       090  S                 
42880...  ..................  A                   Excise nose/throat lesion...       6.01      4.62        0.52      11.15       090  S                 
42890...  ..................  A                   Partial removal of pharynx..      11.67      8.99        1.03      21.69       090  S                 
42892...  ..................  A                   Revision of pharyngeal walls      13.94     10.92        1.27      26.13       090  S                 
42894...  ..................  A                   Revision of pharyngeal walls      20.68     16.06        1.83      38.57       090  S                 

[[Page 63234]]
                                                                                                                                                        
42900...  ..................  A                   Repair throat wound.........       4.98      4.26        0.48       9.72       010  S                 
42950...  ..................  A                   Reconstruction of throat....       7.70      9.86        1.10      18.66       090  S                 
42953...  ..................  A                   Repair throat, esophagus....       8.21      6.34        0.93      15.48       090  S                 
42955...  ..................  A                   Surgical opening of throat..       6.50      3.32        0.43      10.25       090  S                 
42960...  ..................  A                   Control throat bleeding.....       2.28      1.08        0.12       3.48       010  S                 
42961...  ..................  A                   Control throat bleeding.....       5.18      1.75        0.19       7.12       090  S                 
42962...  ..................  A                   Control throat bleeding.....       6.64      5.98        0.68      13.30       090  S                 
42970...  ..................  A                   Control nose/throat bleeding       4.78      1.03        0.10       5.91       090  N                 
42971...  ..................  A                   Control nose/throat bleeding       5.56      2.90        0.34       8.80       090  S                 
42972...  ..................  A                   Control nose/throat bleeding       6.55      4.55        0.73      11.83       090  S                 
42999...  ..................  C                   Throat surgery procedure....       0.00      0.00        0.00       0.00       YYY  S                 
43020...  ..................  A                   Incision of esophagus.......       7.72      6.58        0.71      15.01       090  S                 
43030...  ..................  A                   Throat muscle surgery.......       7.15     *9.15        1.21      17.51       090  S                 
43045...  ..................  A                   Incision of esophagus.......      18.83     12.45        2.36      33.64       090  S                 
43100...  ..................  A                   Excision of esophagus lesion       8.47      6.19        0.95      15.61       090  S                 
43101...  ..................  A                   Excision of esophagus lesion      15.11      9.48        1.88      26.47       090  S                 
43107...  ..................  A                   Removal of esophagus........      27.20     22.50        4.42      54.12       090  S                 
43108...  ..................  A                   Removal of esophagus........      32.64     25.27        4.77      62.68       090  S                 
43112...  ..................  A                   Removal of esophagus........      29.67     21.65        4.22      55.54       090  S                 
43113...  ..................  A                   Removal of esophagus........      33.63     25.27        4.77      63.67       090  S                 
43116...  ..................  A                   Partial removal of esophagus      29.67     25.27        4.77      59.71       090  S                 
43117...  ..................  A                   Partial removal of esophagus      28.47     25.27        4.77      58.51       090  S                 
43118...  ..................  A                   Partial removal of esophagus      31.65     25.27        4.77      61.69       090  S                 
43121...  ..................  A                   Partial removal of esophagus      27.69     21.36        4.19      53.24       090  S                 
43122...  ..................  A                   Parital removal of esophagus      27.69     21.36        4.19      53.24       090  S                 
43123...  ..................  A                   Partial removal of esophagus      31.65     25.27        4.77      61.69       090  S                 
43124...  ..................  A                   Removal of esophagus........      24.73     22.50        4.42      51.65       090  S                 
43130...  ..................  A                   Removal of esophagus pouch..      10.68     10.51        1.60      22.79       090  S                 
43135...  ..................  A                   Removal of esophagus pouch..      15.11     11.72        2.17      29.00       090  S                 
43200...  ..................  A                   Esophagus endoscopy.........       1.59     *2.04        0.26       3.89       000  S                 
43202...  ..................  A                   Esophagus endoscopy, biopsy.       1.89     *2.41        0.31       4.61       000  N                 
43204...  ..................  A                   Esophagus endoscopy & inject       3.77     *4.83        0.36       8.96       000  N                 
43205...  ..................  A                   Esophagus endoscopy/ligation       3.79      2.70        0.18       6.67       000  N                 
43215...  ..................  A                   Esophagus endoscopy.........       2.60     *3.33        0.46       6.39       000  N                 
43216...  ..................  A                   Esophagus endoscopy/lesion..       2.40     *3.58        0.37       6.35       000  N                 
43217...  ..................  A                   Esophagus endoscopy.........       2.90     *3.58        0.37       6.85       000  N                 
43219...  ..................  A                   Esophagus endoscopy.........       2.80     *3.58        0.34       6.72       000  N                 
43220...  ..................  A                   Esophagus endoscopy,               2.10     *2.68        0.27       5.05       000  N                 
                                                   dilation.                                                                                            
43226...  ..................  A                   Esophagus endoscopy,               2.34     *3.00        0.26       5.60       000  N                 
                                                   dilation.                                                                                            
43227...  ..................  A                   Esophagus endoscopy, repair.       3.60     *4.61        0.34       8.55       000  N                 
43228...  ..................  A                   Esophagus endoscopy,               3.77      4.79        0.38       8.94       000  N                 
                                                   ablation.                                                                                            
43234...  ..................  A                   Upper GI endoscopy, exam....       2.01     *2.57        0.30       4.88       000  N                 
43235...  ..................  A                   Upper GI endoscopy,                2.39     *3.07        0.29       5.75       000  N                 
                                                   diagnosis.                                                                                           
43239...  ..................  A                   Upper GI endoscopy, biopsy..       2.69     *3.44        0.33       6.46       000  N                 
43241...  ..................  A                   Upper GI endoscopy with tube       2.59     *3.31        0.38       6.28       000  N                 
43243...  ..................  A                   Upper GI endoscopy & inject.       4.57      5.63        0.39      10.59       000  N                 
43244...  ..................  A                   Upper GI endoscopy/ligation.       4.59      3.47        0.41       8.47       000  N                 
43245...  ..................  A                   Operative upper GI endoscopy       3.39     *4.34        0.40       8.13       000  N                 
43246...  ..................  A                   Place gastrostomy tube......       4.33     *5.55        0.51      10.39       000  N                 
43247...  ..................  A                   Operative upper GI endoscopy       3.39     *4.34        0.38       8.11       000  N                 
43248...  ..................  A                   Upper GI endoscopy/guidewire       3.15     *4.03        0.35       7.53       000  N                 
43249...  ..................  A                   Esophagus endoscopy,               2.90      3.73        0.30       6.93       000  N                 
                                                   dilation.                                                                                            
43250...  ..................  A                   Upper GI endoscopy/tumor....       3.20     *4.60        0.43       8.23       000  N                 
43251...  ..................  A                   Operative upper GI endoscopy       3.70     *4.60        0.43       8.73       000  N                 
43255...  ..................  A                   Operative upper GI endoscopy       4.40      5.63        0.38      10.41       000  N                 
43258...  ..................  A                   Operative upper GI endoscopy       4.55      5.41        0.38      10.34       000  N                 
43259...  ..................  A                   Endoscopic ultrasound exam..       4.89      4.02        0.35       9.26       000  N                 
43260...  ..................  A                   Endoscopy,bile duct/pancreas       5.96      5.98        0.39      12.33       000  N                 
43261...  ..................  A                   Endoscopy,bile duct/pancreas       6.27      5.98        0.39      12.64       000  N                 
43262...  ..................  A                   Endoscopy,bile duct/pancreas       7.39      9.00        0.58      16.97       000  N                 
43263...  ..................  A                   Endoscopy,bile duct/pancreas       6.19      5.83        0.38      12.40       000  N                 
43264...  ..................  A                   Endoscopy,bile duct/pancreas       8.90      8.92        0.61      18.43       000  N                 
43265...  ..................  A                   Endoscopy,bile duct/pancreas       8.90      6.82        0.49      16.21       000  N                 
43267...  ..................  A                   Endoscopy,bile duct/pancreas       7.39      7.41        0.48      15.28       000  N                 
43268...  ..................  A                   Endoscopy,bile duct/pancreas       7.39      8.72        0.56      16.67       000  N                 
43269...  ..................  A                   Endoscopy,bile duct/pancreas       6.04      7.35        0.51      13.90       000  N                 

[[Page 63235]]
                                                                                                                                                        
43271...  ..................  A                   Endoscopy,bile duct/pancreas       7.39      7.63        0.50      15.52       000  N                 
43272...  ..................  A                   Endoscopy,bile duct/pancreas       7.39      5.60        0.42      13.41       000  N                 
43300...  ..................  A                   Repair of esophagus.........       8.72    *11.17        1.70      21.59       090  S                 
43305...  ..................  A                   Repair esophagus and fistula      16.14     13.71        1.78      31.63       090  S                 
43310...  ..................  A                   Repair of esophagus.........      24.20     16.99        3.23      44.42       090  S                 
43312...  ..................  A                   Repair esophagus and fistula      27.26     13.72        2.30      43.28       090  S                 
43320...  ..................  A                   Fuse esophagus & stomach....      14.49     11.68        2.05      28.22       090  S                 
43324...  ..................  A                   Revise esophagus & stomach..      15.18     11.88        2.53      29.59       090  S                 
43325...  ..................  A                   Revise esophagus & stomach..      14.63     11.61        2.29      28.53       090  S                 
43326...  ..................  A                   Revise esophagus & stomach..      14.37      7.52        1.75      23.64       090  S                 
43330...  ..................  A                   Repair of esophagus.........      14.27     11.36        2.39      28.02       090  S                 
43331...  ..................  A                   Repair of esophagus.........      14.73     14.33        2.64      31.70       090  S                 
43340...  ..................  A                   Fuse esophagus & intestine..      14.16     12.44        2.52      29.12       090  S                 
43341...  ..................  A                   Fuse esophagus & intestine..      15.26      9.90        1.56      26.72       090  S                 
43350...  ..................  A                   Surgical opening, esophagus.      11.25      7.88        1.15      20.28       090  S                 
43351...  ..................  A                   Surgical opening, esophagus.      13.42      8.77        1.53      23.72       090  S                 
43352...  ..................  A                   Surgical opening, esophagus.      10.92      8.86        1.47      21.25       090  S                 
43360...  ..................  A                   Gastrointestinal repair.....      26.06     21.36        4.19      51.61       090  S                 
43361...  ..................  A                   Gastrointestinal repair.....      29.67     25.27        4.77      59.71       090  S                 
43400...  ..................  A                   Ligate esophagus veins......      15.55     10.82        1.63      28.00       090  S                 
43401...  ..................  A                   Esophagus surgery for veins.      16.26      9.59        1.93      27.78       090  S                 
43405...  ..................  A                   Ligate/staple esophagus.....      14.84     14.33        2.64      31.81       090  S                 
43410...  ..................  A                   Repair esophagus wound......       9.61      8.90        1.54      20.05       090  S                 
43415...  ..................  A                   Repair esophagus wound......      15.86     12.74        2.52      31.12       090  S                 
43420...  ..................  A                   Repair esophagus opening....      10.19      5.88        0.78      16.85       090  S                 
43425...  ..................  A                   Repair esophagus opening....      15.58      9.94        1.71      27.23       090  S                 
43450...  ..................  A                   Dilate esophagus............       1.38      0.68        0.05       2.11       000  N                 
43453...  ..................  A                   Dilate esophagus............       1.51      1.51        0.11       3.13       000  N                 
43456...  ..................  A                   Dilate esophagus............       3.52      2.47        0.24       6.23       000  N                 
43458...  ..................  A                   Dilation of esophagus.......       3.06     *1.52        0.27       4.85       000  N                 
43460...  ..................  A                   Pressure treatment esophagus       3.80      1.67        0.15       5.62       000  N                 
43499...  ..................  C                   Esophagus surgery procedure.       0.00      0.00        0.00       0.00       YYY  N                 
43500...  ..................  A                   Surgical opening of stomach.       7.60      6.13        1.20      14.93       090  S                 
43501...  ..................  A                   Surgical repair of stomach..      13.85      8.58        1.83      24.26       090  S                 
43502...  ..................  A                   Surgical repair of stomach..      15.82      8.58        1.83      26.23       090  S                 
43510...  ..................  A                   Surgical opening of stomach.       9.27      8.29        0.94      18.50       090  N                 
43520...  ..................  A                   Incision of pyloric muscle..       7.00      4.48        0.87      12.35       090  S                 
43600...  ..................  A                   Biopsy of stomach...........       1.91      0.50        0.05       2.46       000  N                 
43605...  ..................  A                   Biopsy of stomach...........       8.23      5.91        1.29      15.43       090  S                 
43610...  ..................  A                   Excision of stomach lesion..      10.11      8.17        1.71      19.99       090  S                 
43611...  ..................  A                   Excision of stomach lesion..      12.43      8.17        1.71      22.31       090  S                 
43620...  ..................  A                   Removal of stomach..........      21.03     15.38        3.19      39.60       090  S                 
43621...  ..................  A                   Removal of stomach..........      21.47     15.38        3.19      40.04       090  S                 
43622...  ..................  A                   Removal of stomach..........      22.82     15.38        3.19      41.39       090  S                 
43631...  ..................  A                   Removal of stomach, partial.      18.10     12.42        2.66      33.18       090  S                 
43632...  ..................  A                   Removal stomach, partial....      18.10     12.42        2.66      33.18       090  S                 
43633...  ..................  A                   Removal stomach, partial....      18.54     12.42        2.66      33.62       090  S                 
43634...  ..................  A                   Removal stomach, partial....      19.89     20.83        4.57      45.29       090  S                 
43635...  ..................  A                   Partial removal of stomach..       2.06      1.08        0.26       3.40       ZZZ  S                 
43638...  ..................  A                   Partial removal of stomach..      20.15     12.75        2.73      35.63       090  S                 
43639...  ..................  A                   Removal stomach, partial....      20.64     12.75        2.73      36.12       090  S                 
43640...  ..................  A                   Vagotomy & pylorus repair...      13.28     10.34        2.19      25.81       090  S                 
43641...  ..................  A                   Vagotomy & pylorus repair...      13.28     10.34        2.18      25.80       090  S                 
43750...  ..................  A                   Place gastrostomy tube......       5.71      4.35        0.56      10.62       010  N                 
43760...  ..................  A                   Change gastrostomy tube.....       1.10      0.69        0.09       1.88       000  N                 
43761...  ..................  A                   Reposition gastrostomy tube.       2.01      1.06        0.25       3.32       000  N                 
43800...  ..................  A                   Reconstruction of pylorus...       9.41      6.85        1.47      17.73       090  S                 
43810...  ..................  A                   Fusion of stomach and bowel.      10.08      7.64        1.53      19.25       090  S                 
43820...  ..................  A                   Fusion of stomach and bowel.      10.43      8.29        1.75      20.47       090  S                 
43825...  ..................  A                   Fusion of stomach and bowel.      13.28     11.08        2.30      26.66       090  S                 
43830...  ..................  A                   Place gastrostomy tube......       4.84     *6.19        1.19      12.22       090  S                 
43831...  ..................  A                   Place gastrostomy tube......       6.41      5.20        0.93      12.54       090  S                 
43832...  ..................  A                   Place gastrostomy tube......      10.68      7.95        1.36      19.99       090  S                 
43840...  ..................  A                   Repair of stomach lesion....      10.45      7.84        1.66      19.95       090  S                 
43842...  ..................  A                   Gastroplasty for obesity....      13.76     13.72        2.93      30.41       090  S                 
43843...  ..................  A                   Gastroplasty for obesity....      13.76     13.72        2.93      30.41       090  S                 

[[Page 63236]]
                                                                                                                                                        
43846...  ..................  A                   Gastric bypass for obesity..      17.84     14.80        3.30      35.94       090  S                 
43847...  ..................  A                   Gastric bypass for obesity..      19.87     14.80        3.30      37.97       090  S                 
43848...  ..................  A                   Revision gastroplasty.......      22.10     14.80        3.30      40.20       090  S                 
43850...  ..................  A                   Revise stomach-bowel fusion.      18.14     11.64        2.25      32.03       090  S                 
43855...  ..................  A                   Revise stomach-bowel fusion.      19.15     10.44        2.28      31.87       090  S                 
43860...  ..................  A                   Revise stomach-bowel fusion.      18.14     11.46        2.51      32.11       090  S                 
43865...  ..................  A                   Revise stomach-bowel fusion.      19.15     13.39        2.98      35.52       090  S                 
43870...  ..................  A                   Repair stomach opening......       6.56      5.77        1.14      13.47       090  S                 
43880...  ..................  A                   Repair stomach-bowel fistula      18.14      8.25        1.76      28.15       090  S                 
43999...  ..................  C                   Stomach surgery procedure...       0.00      0.00        0.00       0.00       YYY  N                 
44005...  ..................  A                   Freeing of bowel adhesion...      12.52      8.28        1.75      22.55       090  S                 
44010...  ..................  A                   Incision of small bowel.....       9.24      6.91        1.42      17.57       090  S                 
44015...  ..................  A                   Insert needle catheter,            2.62      3.22        0.45       6.29       ZZZ  S                 
                                                   bowel.                                                                                               
44020...  ..................  A                   Exploration of small bowel..      10.69      7.81        1.65      20.15       090  S                 
44021...  ..................  A                   Decompress small bowel......      10.83      7.00        1.48      19.31       090  S                 
44025...  ..................  A                   Incision of large bowel.....      11.07      7.74        1.61      20.42       090  S                 
44050...  ..................  A                   Reduce bowel obstruction....      10.05      7.77        1.64      19.46       090  S                 
44055...  ..................  A                   Correct malrotation of bowel      11.92      7.66        1.60      21.18       090  S                 
44100...  ..................  A                   Biopsy of bowel.............       2.01      1.38        0.13       3.52       000  N                 
44110...  ..................  A                   Excision of bowel lesion(s).       9.01      7.67        1.58      18.26       090  S                 
44111...  ..................  A                   Excision of bowel lesion(s).      11.05      9.67        2.14      22.86       090  S                 
44120...  ..................  A                   Removal of small intestine..      13.15      9.46        2.02      24.63       090  S                 
44121...  ..................  A                   Removal of small intestine..       4.45      2.32        0.54       7.31       ZZZ  S                 
44125...  ..................  A                   Removal of small intestine..      13.15     10.75        2.28      26.18       090  S                 
44130...  ..................  A                   Bowel to bowel fusion.......      11.09      8.67        1.86      21.62       090  S                 
44139...  ..................  A                   Mobilization of colon.......       2.23      1.17        0.27       3.67       ZZZ  S                 
44140...  ..................  A                   Partial removal of colon....      16.97     11.37        2.40      30.74       090  S                 
44141...  ..................  A                   Partial removal of colon....      17.36     11.86        2.55      31.77       090  S                 
44143...  ..................  A                   Partial removal of colon....      15.00     12.26        2.62      29.88       090  S                 
44144...  ..................  A                   Partial removal of colon....      15.00     12.06        2.53      29.59       090  S                 
44145...  ..................  A                   Partial removal of colon....      21.29     13.25        2.78      37.32       090  S                 
44146...  ..................  A                   Partial removal of colon....      22.22     14.98        3.14      40.34       090  S                 
44147...  ..................  A                   Partial removal of colon....      16.23     15.34        3.30      34.87       090  S                 
44150...  ..................  A                   Removal of colon............      19.04     14.84        3.17      37.05       090  S                 
44151...  ..................  A                   Removal of colon/ileostomy..      17.95     10.21        2.22      30.38       090  S                 
44152...  ..................  A                   Removal of colon/ileostomy..      22.98     15.44        3.36      41.78       090  S                 
44153...  ..................  A                   Removal of colon/ileostomy..      24.69     19.35        3.63      47.67       090  S                 
44155...  ..................  A                   Removal of colon............      22.09     16.65        3.50      42.24       090  S                 
44156...  ..................  A                   Removal of colon/ileostomy..      20.48     11.40        2.52      34.40       090  S                 
44160...  ..................  A                   Removal of colon............      14.09     12.44        2.68      29.21       090  S                 
44300...  ..................  A                   Open bowel to skin..........       7.77      6.03        1.29      15.09       090  S                 
44310...  ..................  A                   Ileostomy/jejunostomy.......      10.07      7.88        1.66      19.61       090  S                 
44312...  ..................  A                   Revision of ileostomy.......       5.34      3.08        0.45       8.87       090  S                 
44314...  ..................  A                   Revision of ileostomy.......       9.77      6.68        1.21      17.66       090  S                 
44316...  ..................  A                   Devise bowel pouch..........      13.59      9.64        1.43      24.66       090  S                 
44320...  ..................  A                   Colostomy...................      11.39      7.46        1.57      20.42       090  S                 
44322...  ..................  A                   Colostomy with biopsies.....      10.31      9.07        1.88      21.26       090  S                 
44340...  ..................  A                   Revision of colostomy.......       4.92      1.68        0.35       6.95       090  S                 
44345...  ..................  A                   Revision of colostomy.......      10.05      4.84        1.03      15.92       090  S                 
44346...  ..................  A                   Revision of colostomy.......      11.13      6.65        1.38      19.16       090  S                 
44360...  ..................  A                   Small bowel endoscopy.......       2.92     *3.74        0.32       6.98       000  N                 
44361...  ..................  A                   Small bowel endoscopy,             3.23     *4.14        0.34       7.71       000  N                 
                                                   biopsy.                                                                                              
44363...  ..................  A                   Small bowel endoscopy.......       3.94      2.99        0.36       7.29       000  N                 
44364...  ..................  A                   Small bowel endoscopy.......       4.22      4.73        0.72       9.67       000  N                 
44365...  ..................  A                   Small bowel endoscopy.......       3.73      4.73        0.72       9.18       000  N                 
44366...  ..................  A                   Small bowel endoscopy.......       4.97      5.86        0.45      11.28       000  N                 
44369...  ..................  A                   Small bowel endoscopy.......       5.09     *6.52        0.50      12.11       000  N                 
44372...  ..................  A                   Small bowel endoscopy.......       4.97      5.83        0.67      11.47       000  N                 
44373...  ..................  A                   Small bowel endoscopy.......       3.94     *5.03        0.50       9.47       000  N                 
44376...  ..................  A                   Small bowel endoscopy.......       5.69      4.05        0.26      10.00       000  N                 
44377...  ..................  A                   Small bowel endoscopy.......       5.98      4.26        0.28      10.52       000  N                 
44378...  ..................  A                   Small bowel endoscopy.......       7.71      5.27        0.35      13.33       000  N                 
44380...  ..................  A                   Small bowel endoscopy.......       1.51     *1.94        0.22       3.67       000  N                 
44382...  ..................  A                   Small bowel endoscopy.......       1.82     *2.33        0.29       4.44       000  N                 
44385...  ..................  A                   Endoscopy of bowel pouch....       1.82     *2.33        0.34       4.49       000  S                 
44386...  ..................  A                   Endoscopy, bowel pouch,            2.12      1.54        0.15       3.81       000  N                 
                                                   biopsy.                                                                                              

[[Page 63237]]
                                                                                                                                                        
44388...  ..................  A                   Colon endoscopy.............       2.82     *3.61        0.50       6.93       000  S                 
44389...  ..................  A                   Colonoscopy with biopsy.....       3.13     *4.00        0.45       7.58       000  N                 
44390...  ..................  A                   Colonoscopy for foreign body       3.83      2.63        0.28       6.74       000  N                 
44391...  ..................  A                   Colonoscopy for bleeding....       4.32      5.26        0.53      10.11       000  N                 
44392...  ..................  A                   Colonoscopy & polypectomy...       3.82     *5.16        0.70       9.68       000  N                 
44393...  ..................  A                   Colonoscopy, lesion removal.       4.84      5.41        0.70      10.95       000  N                 
44394...  ..................  A                   Colonoscopy w/snare.........       4.43     *5.16        0.70      10.29       000  N                 
44500...  ..................  A                   Intro, gastrointestinal tube       0.49      0.36        0.02       0.87       000  N                 
44602...  ..................  A                   Suture, small intestine.....       9.72      7.65        1.62      18.99       090  S                 
44603...  ..................  A                   Suture, small intestine.....      12.94      9.09        1.96      23.99       090  S                 
44604...  ..................  A                   Suture, large intestine.....      12.94      7.87        1.67      22.48       090  S                 
44605...  ..................  A                   Repair of bowel lesion......      13.91      9.37        2.02      25.30       090  S                 
44615...  ..................  A                   Intestinal stricturoplasty..      12.89      6.74        1.57      21.20       090  S                 
44620...  ..................  A                   Repair bowel opening........       9.65      5.97        1.26      16.88       090  S                 
44625...  ..................  A                   Repair bowel opening........      12.10      9.58        2.03      23.71       090  S                 
44640...  ..................  A                   Repair bowel-skin fistula...      13.34      6.54        1.35      21.23       090  S                 
44650...  ..................  A                   Repair bowel fistula........      13.76      7.33        1.46      22.55       090  S                 
44660...  ..................  A                   Repair bowel-bladder fistula      13.14      8.34        1.21      22.69       090  S                 
44661...  ..................  A                   Repair bowel-bladder fistula      15.44     13.94        2.52      31.90       090  S                 
44680...  ..................  A                   Surgical revision, intestine      12.41      9.71        2.14      24.26       090  S                 
44799...  ..................  C                   Intestine surgery procedure.       0.00      0.00        0.00       0.00       YYY  S                 
44800...  ..................  A                   Excision of bowel pouch.....      10.12      5.24        1.08      16.44       090  S                 
44820...  ..................  A                   Excision of mesentery lesion       9.31      5.80        1.21      16.32       090  S                 
44850...  ..................  A                   Repair of mesentery.........       8.64      5.60        1.18      15.42       090  S                 
44899...  ..................  C                   Bowel surgery procedure.....       0.00      0.00        0.00       0.00       YYY  S                 
44900...  ..................  A                   Drainage of appendix abscess       7.86      4.28        0.88      13.02       090  S                 
44950...  ..................  A                   Appendectomy................       6.06      4.89        1.01      11.96       090  S                 
44955...  ..................  A                   Appendectomy................       1.53     *1.96        0.60       4.09       ZZZ  S                 
44960...  ..................  A                   Appendectomy................       9.78      5.89        1.24      16.91       090  S                 
45000...  ..................  A                   Drainage of pelvic abscess..       4.28      1.59        0.24       6.11       090  S                 
45005...  ..................  A                   Drainage of rectal abscess..       1.96      1.29        0.21       3.46       010  S                 
45020...  ..................  A                   Drainage of rectal abscess..       4.40      2.61        0.51       7.52       090  S                 
45100...  ..................  A                   Biopsy of rectum............       3.38      1.88        0.35       5.61       090  S                 
45108...  ..................  A                   Removal of anorectal lesion.       4.28      2.66        0.53       7.47       090  S                 
45110...  ..................  A                   Removal of rectum...........      21.68     16.32        3.43      41.43       090  S                 
45111...  ..................  A                   Partial removal of rectum...      14.97     11.77        2.49      29.23       090  S                 
45112...  ..................  A                   Removal of rectum...........      24.02     16.06        3.36      43.44       090  S                 
45113...  ..................  A                   Partial proctectomy.........      24.69     16.06        3.36      44.11       090  S                 
45114...  ..................  A                   Partial removal of rectum...      21.20     15.39        3.24      39.83       090  S                 
45116...  ..................  A                   Partial removal of rectum...      19.09     10.77        2.34      32.20       090  S                 
45120...  ..................  A                   Removal of rectum...........      22.78     16.39        3.54      42.71       090  S                 
45121...  ..................  A                   Removal of rectum and colon.      24.96     10.79        2.01      37.76       090  S                 
45123...  ..................  A                   Partial proctectomy.........      13.27     11.77        2.49      27.53       090  S                 
45130...  ..................  A                   Excision of rectal prolapse.      13.03      8.92        1.79      23.74       090  S                 
45135...  ..................  A                   Excision of rectal prolapse.      15.36     15.95        3.50      34.81       090  S                 
45150...  ..................  A                   Excision of rectal stricture       5.26      3.38        0.63       9.27       090  S                 
45160...  ..................  A                   Excision of rectal lesion...      12.34      7.46        1.56      21.36       090  S                 
45170...  ..................  A                   Excision of rectal lesion...       9.40      4.62        0.96      14.98       090  S                 
45190...  ..................  A                   Destruction, rectal tumor...       7.91      5.09        1.06      14.06       090  S                 
45300...  ..................  A                   Proctosigmoidoscopy.........       0.70      0.55        0.07       1.32       000  S                 
45303...  ..................  A                   Proctosigmoidoscopy.........       0.50     *0.64        0.12       1.26       000  S                 
45305...  ..................  A                   Proctosigmoidoscopy; biopsy.       1.01      0.84        0.14       1.99       000  S                 
45307...  ..................  A                   Proctosigmoidoscopy.........       1.71      1.27        0.18       3.16       000  S                 
45308...  ..................  A                   Proctosigmoidoscopy.........       1.51      1.13        0.20       2.84       000  S                 
45309...  ..................  A                   Proctosigmoidoscopy.........       2.01      1.13        0.20       3.34       000  S                 
45315...  ..................  A                   Proctosigmoidoscopy.........       2.54      1.19        0.18       3.91       000  S                 
45317...  ..................  A                   Proctosigmoidoscopy.........       2.73      1.26        0.19       4.18       000  S                 
45320...  ..................  A                   Proctosigmoidoscopy.........       2.88      1.87        0.34       5.09       000  S                 
45321...  ..................  A                   Proctosigmoidoscopy.........       2.12      1.47        0.27       3.86       000  S                 
45330...  ..................  A                   Sigmoidoscopy, diagnostic...       0.96     *1.23        0.12       2.31       000  N                 
45331...  ..................  A                   Sigmoidoscopy and biopsy....       1.26     *1.61        0.15       3.02       000  N                 
45332...  ..................  A                   Sigmoidoscopy...............       1.96      1.76        0.16       3.88       000  N                 
45333...  ..................  A                   Sigmoidoscopy & polypectomy.       1.96      2.24        0.26       4.46       000  N                 
45334...  ..................  A                   Sigmoidoscopy for bleeding..       2.99      2.71        0.23       5.93       000  N                 
45337...  ..................  A                   Sigmoidoscopy, decompression       2.36     *3.03        0.38       5.77       000  N                 
45338...  ..................  A                   Sigmoidoscopy...............       2.57      2.24        0.26       5.07       000  N                 

[[Page 63238]]
                                                                                                                                                        
45339...  ..................  A                   Sigmoidoscopy...............       3.14      3.24        0.31       6.69       000  N                 
45355...  ..................  A                   Surgical colonoscopy........       3.52      1.17        0.10       4.79       000  N                 
45378...  ..................  A                   Diagnostic colonoscopy......       3.70      4.13        0.39       8.22       000  N                 
45379...  ..................  A                   Colonoscopy.................       4.72      5.33        0.45      10.50       000  N                 
45380...  ..................  A                   Colonoscopy and biopsy......       4.01      4.79        0.40       9.20       000  N                 
45382...  ..................  A                   Colonoscopy, control               5.73      5.87        0.41      12.01       000  N                 
                                                   bleeding.                                                                                            
45383...  ..................  A                   Colonoscopy, lesion removal.       5.87      5.92        0.50      12.29       000  N                 
45384...  ..................  A                   Colonoscopy.................       4.70     *6.65        0.58      11.93       000  N                 
45385...  ..................  A                   Colonoscopy, lesion removal.       5.31     *6.65        0.58      12.54       000  N                 
45500...  ..................  A                   Repair of rectum............       6.59      5.95        1.21      13.75       090  S                 
45505...  ..................  A                   Repair of rectum............       5.54      6.29        1.23      13.06       090  S                 
45520...  ..................  A                   Treatment of rectal prolapse       0.55      0.61        0.10       1.26       000  N                 
45540...  ..................  A                   Correct rectal prolapse.....      11.98      9.89        2.10      23.97       090  S                 
45541...  ..................  A                   Correct rectal prolapse.....       9.79     10.17        2.04      22.00       090  S                 
45550...  ..................  A                   Repair rectum; remove             13.38     11.49        2.38      27.25       090  S                 
                                                   sigmoid.                                                                                             
45560...  ..................  A                   Repair of rectocele.........       7.48      4.79        0.98      13.25       090  S                 
45562...  ..................  A                   Exploration/repair of rectum      11.13      8.09        1.58      20.80       090  S                 
45563...  ..................  A                   Exploration/repair of rectum      17.55     12.77        2.49      32.81       090  S                 
45800...  ..................  A                   Repair rectumbladder fistula      12.75      9.82        1.45      24.02       090  S                 
45805...  ..................  A                   Repair fistula; colostomy...      15.08     12.32        2.39      29.79       090  S                 
45820...  ..................  A                   Repair rectourethral fistula      13.31      8.98        1.23      23.52       090  S                 
45825...  ..................  A                   Repair fistula; colostomy...      15.45      9.87        1.66      26.98       090  S                 
45900...  ..................  A                   Reduction of rectal prolapse       1.68      0.58        0.11       2.37       010  S                 
45905...  ..................  A                   Dilation of anal sphincter..       1.51      0.71        0.12       2.34       010  S                 
45910...  ..................  A                   Dilation of rectal narrowing       1.86      0.87        0.13       2.86       010  S                 
45915...  ..................  A                   Remove rectal obstruction...       2.09      0.78        0.09       2.96       010  N                 
45999...  ..................  C                   Rectum surgery procedure....       0.00      0.00        0.00       0.00       YYY  N                 
46030...  ..................  A                   Removal of rectal marker....       1.20      0.40        0.07       1.67       010  S                 
46040...  ..................  A                   Incision of rectal abscess..       4.90      1.69        0.34       6.93       090  S                 
46045...  ..................  A                   Incision of rectal abscess..       3.91      1.85        0.38       6.14       090  S                 
46050...  ..................  A                   Incision of anal abscess....       1.14      0.60        0.11       1.85       010  S                 
46060...  ..................  A                   Incision of rectal abscess..       5.03      5.35        1.12      11.50       090  S                 
46070...  ..................  A                   Incision of anal septum.....       2.63      1.37        0.33       4.33       090  S                 
46080...  ..................  A                   Incision of anal sphincter..       2.35      2.13        0.43       4.91       010  S                 
46083...  ..................  A                   Incise external hemorrhoid..       1.35      0.63        0.08       2.06       010  N                 
46200...  ..................  A                   Removal of anal fissure.....       3.02      3.29        0.66       6.97       090  S                 
46210...  ..................  A                   Removal of anal crypt.......       2.52      0.77        0.14       3.43       090  S                 
46211...  ..................  A                   Removal of anal crypts......       4.07      1.90        0.38       6.35       090  S                 
46220...  ..................  A                   Removal of anal tab.........       1.51      0.63        0.12       2.26       010  S                 
46221...  ..................  A                   Ligation of hemorrhoid(s)...       1.38      0.66        0.14       2.18       010  S                 
46230...  ..................  A                   Removal of anal tabs........       2.52      0.83        0.12       3.47       010  S                 
46250...  ..................  A                   Hemorrhoidectomy............       4.29      2.84        0.52       7.65       090  S                 
46255...  ..................  A                   Hemorrhoidectomy............       4.95      4.72        0.85      10.52       090  S                 
46257...  ..................  A                   Remove hemorrhoids & fissure       5.87      5.23        1.08      12.18       090  S                 
46258...  ..................  A                   Remove hemorrhoids & fistula       6.26      5.87        1.22      13.35       090  S                 
46260...  ..................  A                   Hemorrhoidectomy............       6.70      6.07        1.25      14.02       090  S                 
46261...  ..................  A                   Remove hemorrhoids & fissure       6.54      6.62        1.34      14.50       090  S                 
46262...  ..................  A                   Remove hemorrhoids & fistula       6.77      6.72        1.39      14.88       090  S                 
46270...  ..................  A                   Removal of anal fistula.....       3.51      1.87        0.37       5.75       090  S                 
46275...  ..................  A                   Removal of anal fistula.....       4.35      5.50        1.13      10.98       090  S                 
46280...  ..................  A                   Removal of anal fistula.....       5.63      6.08        1.24      12.95       090  S                 
46285...  ..................  A                   Removal of anal fistula.....       3.88      2.28        0.43       6.59       090  S                 
46288...  ..................  A                   Repair anal fistula.........       6.83      3.57        0.83      11.23       090  S                 
46320...  ..................  A                   Removal of hemorrhoid clot..       1.58      0.70        0.11       2.39       010  S                 
46500...  ..................  A                   Injection into hemorrhoids..       1.53      0.32        0.06       1.91       010  S                 
46600...  ..................  A                   Diagnostic anoscopy.........       0.50      0.28        0.03       0.81       000  N                 
46604...  ..................  A                   Anoscopy and dilation.......       1.31      0.38        0.06       1.75       000  S                 
46606...  ..................  A                   Anoscopy and biopsy.........       0.81      0.36        0.06       1.23       000  S                 
46608...  ..................  A                   Anoscopy; remove foreign           1.51      1.07        0.12       2.70       000  N                 
                                                   body.                                                                                                
46610...  ..................  A                   Anoscopy; remove lesion.....       1.32      0.85        0.15       2.32       000  S                 
46611...  ..................  A                   Anoscopy....................       1.81      0.85        0.15       2.81       000  S                 
46612...  ..................  A                   Anoscopy; remove lesions....       2.34      1.39        0.20       3.93       000  S                 
46614...  ..................  A                   Anoscopy; control bleeding..       2.01      1.55        0.25       3.81       000  S                 
46615...  ..................  A                   Anoscopy....................       2.68      1.55        0.25       4.48       000  S                 
46700...  ..................  A                   Repair of anal stricture....       6.40      6.14        1.24      13.78       090  S                 
46705...  ..................  A                   Repair of anal stricture....       6.38      3.60        0.77      10.75       090  S                 

[[Page 63239]]
                                                                                                                                                        
46715...  ..................  A                   Repair of anovaginal fistula       6.73      3.51        0.82      11.06       090  S                 
46716...  ..................  A                   Repair of anovaginal fistula      11.58      6.05        1.40      19.03       090  S                 
46730...  ..................  A                   Construction of absent anus.      20.54     10.74        2.50      33.78       090  S                 
46735...  ..................  A                   Construction of absent anus.      24.91     13.04        3.04      40.99       090  S                 
46740...  ..................  A                   Construction of absent anus.      22.08     11.55        2.68      36.31       090  S                 
46742...  ..................  A                   Repair, imperforated anus...      27.82     19.75        1.93      49.50       090  S                 
46744...  ..................  A                   Repair, cloacal anomaly.....      31.23     22.17        2.17      55.57       090  S                 
46746...  ..................  A                   Repair, cloacal anomaly.....      34.17     24.26        2.37      60.80       090  S                 
46748...  ..................  A                   Repair, cloacal anomaly.....      38.07     27.03        2.64      67.74       090  S                 
46750...  ..................  A                   Repair of anal sphincter....       7.35      6.00        1.22      14.57       090  S                 
46751...  ..................  A                   Repair of anal sphincter....       7.78      4.07        0.95      12.80       090  S                 
46753...  ..................  A                   Reconstruction of anus......       6.04      4.89        1.02      11.95       090  S                 
46754...  ..................  A                   Removal of suture from anus.       1.51      1.48        0.30       3.29       010  S                 
46760...  ..................  A                   Repair of anal sphincter....      10.61      6.80        1.41      18.82       090  S                 
46761...  ..................  A                   Repair of anal sphincter....      10.16      6.83        1.35      18.34       090  S                 
46762...  ..................  A                   Implant artificial sphincter       9.26      5.72        1.21      16.19       090  S                 
46900...  ..................  A                   Destruction, anal lesion(s).       1.81      0.39        0.06       2.26       010  S                 
46910...  ..................  A                   Destruction, anal lesion(s).       1.81      0.64        0.08       2.53       010  S                 
46916...  ..................  A                   Cryosurgery, anal lesion(s).       1.81      0.67        0.06       2.54       010  S                 
46917...  ..................  A                   Laser surgery, anal                1.81      1.94        0.31       4.06       010  S                 
                                                   lesion(s).                                                                                           
46922...  ..................  A                   Excision of anal lesion(s)..       1.81      1.28        0.23       3.32       010  S                 
46924...  ..................  A                   Destruction, anal lesion(s).       2.71      2.56        0.46       5.73       010  S                 
46934...  ..................  A                   Destruction of hemorrhoids..       3.84      1.19        0.17       5.20       090  N                 
46935...  ..................  A                   Destruction of hemorrhoids..       2.40      1.62        0.22       4.24       010  N                 
46936...  ..................  A                   Destruction of hemorrhoids..       4.17      2.29        0.24       6.70       090  N                 
46937...  ..................  A                   Cryotherapy of rectal lesion       2.66      2.35        0.45       5.46       010  S                 
46938...  ..................  A                   Cryotherapy of rectal lesion       4.42      2.50        0.52       7.44       090  S                 
46940...  ..................  A                   Treatment of anal fissure...       2.29      0.51        0.09       2.89       010  S                 
46942...  ..................  A                   Treatment of anal fissure...       2.01      0.46        0.08       2.55       010  S                 
46945...  ..................  A                   Ligation of hemorrhoids.....       3.06      0.63        0.12       3.81       090  S                 
46946...  ..................  A                   Ligation of hemorrhoids.....       4.04      0.94        0.17       5.15       090  S                 
46999...  ..................  C                   Anus surgery procedure......       0.00      0.00        0.00       0.00       YYY  S                 
47000...  ..................  A                   Needle biopsy of liver......       1.90      1.40        0.13       3.43       000  N                 
47001...  ..................  A                   Needle biopsy, liver........       1.90      1.40        0.13       3.43       ZZZ  S                 
47010...  ..................  A                   Drainage of liver lesion....       8.75      6.75        1.13      16.63       090  S                 
47015...  ..................  A                   Inject/aspirate liver cyst..       8.78      6.75        1.13      16.66       090  S                 
47100...  ..................  A                   Wedge biopsy of liver.......       6.75      3.29        0.67      10.71       090  S                 
47120...  ..................  A                   Partial removal of liver....      19.99     12.00        2.48      34.47       090  S                 
47122...  ..................  A                   Extensive removal of liver..      32.54     17.58        3.59      53.71       090  S                 
47125...  ..................  A                   Partial removal of liver....      28.68     17.43        3.61      49.72       090  S                 
47130...  ..................  A                   Partial removal of liver....      31.56     19.19        3.89      54.64       090  S                 
47133...  ..................  X                   Removal of donor liver......       0.00      0.00        0.00       0.00       XXX  0                 
47134...  ..................  R                   Partial removal, donor liver      39.15     20.48        4.77      64.40       XXX  S                 
47135...  ..................  R                   Transplantation of liver....      77.61     54.48        8.49     140.58       090  S                 
47136...  ..................  R                   Transplantation of liver....      64.04     33.50        7.79     105.33       090  S                 
47300...  ..................  A                   Surgery for liver lesion....       8.75      7.67        1.59      18.01       090  S                 
47350...  ..................  A                   Repair liver wound..........      11.29      7.46        1.49      20.24       090  S                 
47355...  ..................  D                   Repair liver wound..........       0.00      0.00        0.00       0.00       090  S                 
47360...  ..................  A                   Repair liver wound..........      15.34     10.93        2.18      28.45       090  S                 
47361...  ..................  A                   Repair liver wound..........      28.00     14.64        3.41      46.05       090  S                 
47362...  ..................  A                   Repair liver wound..........      10.00      5.23        1.22      16.45       090  S                 
47399...  ..................  C                   Liver surgery procedure.....       0.00      0.00        0.00       0.00       YYY  S                 
47400...  ..................  A                   Incision of liver duct......      18.90      8.53        1.36      28.79       090  S                 
47420...  ..................  A                   Incision of bile duct.......      15.31      9.48        1.99      26.78       090  S                 
47425...  ..................  A                   Incision of bile duct.......      14.79     11.71        2.45      28.95       090  S                 
47460...  ..................  A                   Incise bile duct sphincter..      14.41     15.54        1.82      31.77       090  N                 
47480...  ..................  A                   Incision of gallbladder.....       8.05      7.60        1.59      17.24       090  S                 
47490...  ..................  A                   Incision of gallbladder.....       6.04      3.57        0.38       9.99       090  N                 
47500...  ..................  A                   Injection for liver x-rays..       1.96      1.51        0.14       3.61       000  N                 
47505...  ..................  A                   Injection for liver x-rays..       0.76     *0.98        0.14       1.88       000  N                 
47510...  ..................  A                   Insert catheter, bile duct..       7.39      2.87        0.25      10.51       090  N                 
47511...  ..................  A                   Insert bile duct drain......       9.91      2.87        0.25      13.03       090  N                 
47525...  ..................  A                   Change bile duct catheter...       5.41      1.59        0.16       7.16       010  N                 
47530...  ..................  A                   Revise, reinsert bile tube..       5.41      1.51        0.19       7.11       090  N                 
47550...  ..................  A                   Bile duct endoscopy.........       3.02      1.56        0.35       4.93       000  S                 
47552...  ..................  A                   Biliary endoscopy, thru skin       6.04      1.36        0.21       7.61       000  S                 

[[Page 63240]]
                                                                                                                                                        
47553...  ..................  A                   Biliary endoscopy, thru skin       6.35      3.80        0.62      10.77       000  N                 
47554...  ..................  A                   Biliary endoscopy, thru skin       9.06      3.93        0.67      13.66       000  S                 
47555...  ..................  A                   Biliary endoscopy, thru skin       7.56      2.63        0.30      10.49       000  N                 
47556...  ..................  A                   Biliary endoscopy, thru skin       8.56      2.63        0.30      11.49       000  N                 
47600...  ..................  A                   Removal of gallbladder......      10.68      7.53        1.58      19.79       090  S                 
47605...  ..................  A                   Removal of gallbladder......      11.53      8.14        1.75      21.42       090  S                 
47610...  ..................  A                   Removal of gallbladder......      13.86      9.37        2.00      25.23       090  S                 
47612...  ..................  A                   Removal of gallbladder......      14.75     14.23        3.05      32.03       090  S                 
47620...  ..................  A                   Removal of gallbladder......      15.79     11.23        2.36      29.38       090  S                 
47630...  ..................  A                   Remove bile duct stone......       8.31      3.75        0.40      12.46       090  N                 
47700...  ..................  A                   Exploration of bile ducts...      13.75      7.63        1.58      22.96       090  S                 
47701...  ..................  A                   Bile duct revision..........      26.57      8.21        1.90      36.68       090  S                 
47711...  ..................  A                   Excision of bile duct tumor.      18.16     12.06        2.46      32.68       090  S                 
47712...  ..................  A                   Excision of bile duct tumor.      23.74     12.06        2.46      38.26       090  S                 
47715...  ..................  A                   Excision of bile duct cyst..      14.50      8.22        1.71      24.43       090  S                 
47716...  ..................  A                   Fusion of bile duct cyst....      12.53      6.56        1.53      20.62       090  S                 
47720...  ..................  A                   Fuse gallbladder & bowel....      11.90      9.16        1.93      22.99       090  S                 
47721...  ..................  A                   Fuse upper gi structures....      14.41     11.42        2.47      28.30       090  S                 
47740...  ..................  A                   Fuse gallbladder & bowel....      13.93     10.21        2.14      26.28       090  S                 
47741...  ..................  A                   Fuse gallbladder & bowel....      16.23     14.35        3.02      33.60       090  S                 
47760...  ..................  A                   Fuse bile ducts and bowel...      19.93     11.61        2.53      34.07       090  S                 
47765...  ..................  A                   Fuse liver ducts & bowel....      19.04     14.61        2.97      36.62       090  S                 
47780...  ..................  A                   Fuse bile ducts and bowel...      20.40     13.07        2.73      36.20       090  S                 
47785...  ..................  A                   Fuse bile ducts and bowel...      24.41     13.07        2.73      40.21       090  S                 
47800...  ..................  A                   Reconstruction of bile ducts      17.71     13.22        2.43      33.36       090  S                 
47801...  ..................  A                   Placement, bile duct support      11.28      5.48        0.81      17.57       090  S                 
47802...  ..................  A                   Fuse liver duct & intestine.      16.01     10.27        1.75      28.03       090  S                 
47900...  ..................  A                   Suture bile duct injury.....      15.63     13.22        2.43      31.28       090  S                 
47999...  ..................  C                   Bile tract surgery procedure       0.00      0.00        0.00       0.00       YYY  S                 
48000...  ..................  A                   Drainage of abdomen.........      13.10      7.05        1.40      21.55       090  S                 
48001...  ..................  A                   Placement of drain, pancreas      15.54      8.13        1.89      25.56       090  S                 
48005...  ..................  A                   Resect/debride pancreas.....      17.57      9.19        2.14      28.90       090  S                 
48020...  ..................  A                   Removal of pancreatic stone.      12.98      6.78        1.57      21.33       090  S                 
48100...  ..................  A                   Biopsy of pancreas..........      10.19      4.21        0.79      15.19       090  S                 
48102...  ..................  A                   Needle biopsy, pancreas.....       4.43      2.41        0.25       7.09       010  N                 
48120...  ..................  A                   Removal of pancreas lesion..      12.79      9.72        2.07      24.58       090  S                 
48140...  ..................  A                   Partial removal of pancreas.      18.27     13.29        2.83      34.39       090  S                 
48145...  ..................  A                   Partial removal of pancreas.      19.09     15.71        3.16      37.96       090  S                 
48146...  ..................  A                   Pancreatectomy..............      21.73     16.49        1.92      40.14       090  S                 
48148...  ..................  A                   Removal of pancreatic duct..      14.41      8.23        1.68      24.32       090  S                 
48150...  ..................  A                   Partial removal of pancreas.      40.25     22.54        4.75      67.54       090  S                 
48152...  ..................  A                   Pancreatectomy..............      36.50     22.54        4.75      63.79       090  S                 
48153...  ..................  A                   Pancreatectomy..............      40.25     22.54        4.75      67.54       090  S                 
48154...  ..................  A                   Pancreatectomy..............      36.50     22.54        4.75      63.79       090  S                 
48155...  ..................  A                   Removal of pancreas.........      19.43     20.40        4.26      44.09       090  S                 
48160...  ..................  N                   Pancreas removal, transplant       0.00      0.00        0.00       0.00       XXX  0                 
48180...  ..................  A                   Fuse pancreas and bowel.....      20.88     12.60        2.63      36.11       090  S                 
48400...  ..................  A                   Injection, intraoperative...       1.95      1.03        0.24       3.22       ZZZ  N                 
48500...  ..................  A                   Surgery of pancreas cyst....      12.04      8.53        1.66      22.23       090  S                 
48510...  ..................  A                   Drain pancreatic pseudocyst.      11.22      7.54        1.44      20.20       090  S                 
48520...  ..................  A                   Fuse pancreas cyst and bowel      12.97     11.30        2.43      26.70       090  S                 
48540...  ..................  A                   Fuse pancreas cyst and bowel      15.77     12.66        2.65      31.08       090  S                 
48545...  ..................  A                   Pancreatorrhaphy............      14.65      7.66        1.79      24.10       090  S                 
48547...  ..................  A                   Duodenal exclusion..........      21.18     11.08        2.58      34.84       090  S                 
48550...  ..................  N                   Donor pancreatectomy........       0.00      0.00        0.00       0.00       XXX  0                 
48554...  ..................  N                   Transplantallograft pancreas     #34.17     17.87        4.16      56.20       XXX  0                 
48556...  ..................  A                   Removal, allograft pancreas.      13.89      7.26        1.69      22.84       090  S                 
48999...  ..................  C                   Pancreas surgery procedure..       0.00      0.00        0.00       0.00       YYY  S                 
49000...  ..................  A                   Exploration of abdomen......       8.99      6.79        1.40      17.18       090  S                 
49002...  ..................  A                   Reopening of abdomen........       9.40      6.05        1.21      16.66       090  S                 
49010...  ..................  A                   Exploration behind abdomen..      11.19      6.95        1.31      19.45       090  S                 
49020...  ..................  A                   Drain abdominal abscess.....       9.06      4.82        0.91      14.79       090  S                 
49040...  ..................  A                   Drain abdominal abscess.....       8.74      6.54        1.27      16.55       090  S                 
49060...  ..................  A                   Drain abdominal abscess.....      10.55      5.54        1.01      17.10       090  S                 
49080...  ..................  A                   Puncture, peritoneal cavity.       1.35      0.87        0.08       2.30       000  N                 
49081...  ..................  A                   Removal of abdominal fluid..       1.26      0.75        0.07       2.08       000  N                 

[[Page 63241]]
                                                                                                                                                        
49085...  ..................  A                   Remove abdomen foreign body.       7.91      3.46        0.67      12.04       090  S                 
49180...  ..................  A                   Biopsy, abdominal mass......       1.49      1.82        0.20       3.51       000  N                 
49200...  ..................  A                   Removal of abdominal lesion.       9.19      8.38        1.70      19.27       090  S                 
49201...  ..................  A                   Removal of abdominal lesion.      13.60     12.10        2.50      28.20       090  S                 
49215...  ..................  A                   Excise sacral spine tumor...      21.05      8.50        1.59      31.14       090  S                 
49220...  ..................  A                   Multiple surgery, abdomen...      13.66     12.30        2.53      28.49       090  S                 
49250...  ..................  A                   Excision of umbilicus.......       7.42      4.52        0.96      12.90       090  S                 
49255...  ..................  A                   Removal of omentum..........       4.04     *5.16        1.15      10.35       090  S                 
49400...  ..................  A                   Air injection into abdomen..       1.88      1.12        0.17       3.17       000  S                 
49420...  ..................  A                   Insert abdominal drain......       2.22      1.58        0.20       4.00       000  S                 
49421...  ..................  A                   Insert abdominal drain......       4.89      4.14        0.81       9.84       090  S                 
49422...  ..................  A                   Remove perm cannula/catheter       5.85      4.14        0.81      10.80       010  S                 
49425...  ..................  A                   Insert abdomen-venous drain.      10.22      8.48        1.78      20.48       090  S                 
49426...  ..................  A                   Revise abdomen-venous shunt.       8.57      5.39        1.07      15.03       090  S                 
49427...  ..................  A                   Injection, abdominal shunt..       0.89      0.49        0.03       1.41       000  N                 
49428...  ..................  A                   Ligation of shunt...........       1.98      1.04        0.24       3.26       010  S                 
49429...  ..................  A                   Removal of shunt............       6.35      3.32        0.77      10.44       010  S                 
49495...  ..................  A                   Repair inguinal hernia, init       5.79      4.98        0.95      11.72       090  S                 
49496...  ..................  A                   Repair inguinal hernia, init       8.37      5.04        1.08      14.49       090  S                 
49500...  ..................  A                   Repair inguinal hernia......       4.41      4.98        0.95      10.34       090  S                 
49501...  ..................  A                   Repair inguinal hernia, init       7.26      5.04        1.08      13.38       090  S                 
49505...  ..................  A                   Repair inguinal hernia......       6.17      4.51        0.94      11.62       090  S                 
49507...  ..................  A                   Repair, inguinal hernia.....       7.40      5.04        1.08      13.52       090  S                 
49520...  ..................  A                   Rerepair inguinal hernia....       7.87      5.22        1.11      14.20       090  S                 
49521...  ..................  A                   Repair inguinal hernia, rec.       9.43      5.04        1.08      15.55       090  S                 
49525...  ..................  A                   Repair inguinal hernia......       6.97      5.55        1.16      13.68       090  S                 
49540...  ..................  A                   Repair lumbar hernia........       7.91      5.20        1.12      14.23       090  S                 
49550...  ..................  A                   Repair femoral hernia.......       6.97      4.61        0.97      12.55       090  S                 
49553...  ..................  A                   Repair femoral hernia, init.       7.40      4.61        0.97      12.98       090  S                 
49555...  ..................  A                   Repair femoral hernia.......       7.29      6.07        1.26      14.62       090  S                 
49557...  ..................  A                   Repair femoral hernia, recur       8.73      6.07        1.26      16.06       090  S                 
49560...  ..................  A                   Repair abdominal hernia.....       9.48      5.65        1.19      16.32       090  S                 
49561...  ..................  A                   Repair incisional hernia....      11.38      5.65        1.19      18.22       090  S                 
49565...  ..................  A                   Rerepair abdominal hernia...       9.48      6.41        1.35      17.24       090  S                 
49566...  ..................  A                   Repair incisional hernia....      11.38      6.41        1.35      19.14       090  S                 
49568...  ..................  A                   Hernia repair w/mesh........       4.89      2.56        0.59       8.04       ZZZ  S                 
49570...  ..................  A                   Repair epigastric hernia....       4.46      4.38        0.91       9.75       090  S                 
49572...  ..................  A                   Repair, epigastric hernia...       5.35      5.60        1.18      12.13       090  S                 
49580...  ..................  A                   Repair umbilical hernia.....       3.24     *4.15        0.94       8.33       090  S                 
49582...  ..................  A                   Repair umbilical hernia.....       5.13      4.61        0.94      10.68       090  S                 
49585...  ..................  A                   Repair umbilical hernia.....       4.95      4.41        0.91      10.27       090  S                 
49587...  ..................  A                   Repair umbilical hernia.....       5.93      4.41        0.91      11.25       090  S                 
49590...  ..................  A                   Repair abdominal hernia.....       6.55      5.63        1.22      13.40       090  S                 
49600...  ..................  A                   Repair umbilical lesion.....       9.48      5.26        0.77      15.51       090  S                 
49605...  ..................  A                   Repair umbilical lesion.....      21.92      8.57        1.77      32.26       090  S                 
49606...  ..................  A                   Repair umbilical lesion.....      17.93      8.31        0.96      27.20       090  S                 
49610...  ..................  A                   Repair umbilical lesion.....       9.83      5.48        1.27      16.58       090  S                 
49611...  ..................  A                   Repair umbilical lesion.....       8.25      9.00        0.58      17.83       090  S                 
49900...  ..................  A                   Repair of abdominal wall....       4.54      3.66        0.75       8.95       090  S                 
49905...  ..................  A                   Omental flap................       6.55      3.42        0.80      10.77       ZZZ  S                 
49999...  ..................  C                   Abdomen surgery procedure...       0.00      0.00        0.00       0.00       YYY  S                 
50010...  ..................  A                   Exploration of kidney.......      10.07      9.55        1.13      20.75       090  S                 
50020...  ..................  A                   Drainage of kidney abscess..      12.41      6.80        0.85      20.06       090  S                 
50040...  ..................  A                   Drainage of kidney..........      13.80      7.18        0.62      21.60       090  N                 
50045...  ..................  A                   Exploration of kidney.......      14.48      9.81        0.89      25.18       090  S                 
50060...  ..................  A                   Removal of kidney stone.....      18.00     12.25        1.21      31.46       090  S                 
50065...  ..................  A                   Incision of kidney..........      19.62     13.93        1.35      34.90       090  S                 
50070...  ..................  A                   Incision of kidney..........      19.15     12.87        1.35      33.37       090  S                 
50075...  ..................  A                   Removal of kidney stone.....      24.05     16.87        1.62      42.54       090  S                 
50080...  ..................  A                   Removal of kidney stone.....      13.98     12.20        1.15      27.33       090  S                 
50081...  ..................  A                   Removal of kidney stone.....      20.58     14.96        1.44      36.98       090  S                 
50100...  ..................  A                   Revise kidney blood vessels.      15.11     10.34        1.35      26.80       090  S                 
50120...  ..................  A                   Exploration of kidney.......      15.00     10.91        1.24      27.15       090  S                 
50125...  ..................  A                   Explore and drain kidney....      15.61     10.95        1.06      27.62       090  S                 
50130...  ..................  A                   Removal of kidney stone.....      16.12     12.80        1.26      30.18       090  S                 
50135...  ..................  A                   Exploration of kidney.......      18.14     17.05        1.63      36.82       090  S                 

[[Page 63242]]
                                                                                                                                                        
50200...  ..................  A                   Biopsy of kidney............       2.63      2.61        0.22       5.46       000  N                 
50205...  ..................  A                   Biopsy of kidney............      12.69      5.64        0.69      19.02       090  S                 
50220...  ..................  A                   Removal of kidney...........      15.98     13.31        1.43      30.72       090  S                 
50225...  ..................  A                   Removal of kidney...........      18.93     16.52        1.70      37.15       090  S                 
50230...  ..................  A                   Removal of kidney...........      20.56     18.40        1.84      40.80       090  S                 
50234...  ..................  A                   Removal of kidney & ureter..      21.11     16.65        1.65      39.41       090  S                 
50236...  ..................  A                   Removal of kidney & ureter..      23.33     17.74        1.74      42.81       090  S                 
50240...  ..................  A                   Partial removal of kidney...      20.24     16.00        1.70      37.94       090  S                 
50280...  ..................  A                   Removal of kidney lesion....      14.63     10.86        1.16      26.65       090  S                 
50290...  ..................  A                   Removal of kidney lesion....      13.69      8.87        1.19      23.75       090  S                 
50300...  ..................  X                   Removal of donor kidney.....       0.00      0.00        0.00       0.00       XXX  0                 
50320...  ..................  A                   Removal of donor kidney.....      21.22     16.49        2.40      40.11       090  S                 
50340...  ..................  A                   Removal of kidney...........      10.73     12.49        2.24      25.46       090  S                 
50360...  ..................  A                   Transplantation of kidney...      27.05     24.45        4.24      55.74       090  S                 
50365...  ..................  A                   Transplantation of kidney...      32.54     30.71        3.89      67.14       090  S                 
50370...  ..................  A                   Remove transplanted kidney..      11.11     11.08        1.92      24.11       090  S                 
50380...  ..................  A                   Reimplantation of kidney....      16.49     10.12        1.71      28.32       090  S                 
50390...  ..................  A                   Drainage of kidney lesion...       3.24      1.69        0.15       5.08       000  N                 
50392...  ..................  A                   Insert kidney drain.........       5.59      2.36        0.20       8.15       000  N                 
50393...  ..................  A                   Insert ureteral tube........       6.88      3.01        0.26      10.15       000  N                 
50394...  ..................  A                   Injection for kidney x-ray..       0.76      0.55        0.05       1.36       000  N                 
50395...  ..................  A                   Create passage to kidney....       5.15      3.33        0.29       8.77       000  N                 
50396...  ..................  A                   Measure kidney pressure.....       2.09      0.50        0.05       2.64       000  N                 
50398...  ..................  A                   Change kidney tube..........       1.46      0.53        0.05       2.04       000  S                 
50400...  ..................  A                   Revision of kidney/ureter...      18.07     13.66        1.36      33.09       090  S                 
50405...  ..................  A                   Revision of kidney/ureter...      22.45     17.29        1.74      41.48       090  S                 
50500...  ..................  A                   Repair of kidney wound......      18.27     12.46        1.64      32.37       090  S                 
50520...  ..................  A                   Close kidney-skin fistula...      15.93     10.34        1.50      27.77       090  S                 
50525...  ..................  A                   Repair renal-abdomen fistula      20.59     12.61        1.99      35.19       090  S                 
50526...  ..................  A                   Repair renal-abdomen fistula      22.15      7.39        2.32      31.86       090  S                 
50540...  ..................  A                   Revision of horseshoe kidney      19.15     13.41        1.54      34.10       090  S                 
50551...  ..................  A                   Kidney endoscopy............       5.60      2.19        0.21       8.00       000  S                 
50553...  ..................  A                   Kidney endoscopy............       5.99      1.66        0.17       7.82       000  S                 
50555...  ..................  A                   Kidney endoscopy & biopsy...       6.53      4.70        0.45      11.68       000  S                 
50557...  ..................  A                   Kidney endoscopy & treatment       6.62      4.71        0.49      11.82       000  S                 
50559...  ..................  A                   Renal endoscopy; radiotracer       6.78      1.34        0.14       8.26       000  S                 
50561...  ..................  A                   Kidney endoscopy & treatment       7.59      5.12        0.49      13.20       000  S                 
50570...  ..................  A                   Kidney endoscopy............       9.54      1.45        0.14      11.13       000  S                 
50572...  ..................  A                   Kidney endoscopy............      10.35      7.25        0.75      18.35       000  S                 
50574...  ..................  A                   Kidney endoscopy & biopsy...      11.02      7.08        0.64      18.74       000  S                 
50575...  ..................  A                   Kidney endoscopy............      13.98      9.93        0.97      24.88       000  S                 
50576...  ..................  A                   Kidney endoscopy & treatment      10.99      8.69        0.77      20.45       000  S                 
50578...  ..................  A                   Renal endoscopy; radiotracer      11.35      3.79        1.19      16.33       000  S                 
50580...  ..................  A                   Kidney endoscopy & treatment      11.86      3.58        0.35      15.79       000  S                 
50590...  ..................  A                   Fragmenting of kidney stone.       9.62     10.11        0.97      20.70       090  S                 
50600...  ..................  A                   Exploration of ureter.......      14.78      9.69        1.01      25.48       090  S                 
50605...  ..................  A                   Insert ureteral support.....      14.40      6.11        0.60      21.11       090  S                 
50610...  ..................  A                   Removal of ureter stone.....      14.86     11.77        1.17      27.80       090  S                 
50620...  ..................  A                   Removal of ureter stone.....      14.17     11.49        1.16      26.82       090  S                 
50630...  ..................  A                   Removal of ureter stone.....      13.95     12.71        1.25      27.91       090  S                 
50650...  ..................  A                   Removal of ureter...........      16.37     12.07        1.21      29.65       090  S                 
50660...  ..................  A                   Removal of ureter...........      18.44     12.49        1.53      32.46       090  S                 
50684...  ..................  A                   Injection for ureter x-ray..       0.76      0.49        0.05       1.30       000  S                 
50686...  ..................  A                   Measure ureter pressure.....       1.51      0.37        0.04       1.92       000  S                 
50688...  ..................  A                   Change of ureter tube.......       1.14      0.39        0.04       1.57       010  S                 
50690...  ..................  A                   Injection for ureter x-ray..       1.16      0.32        0.03       1.51       000  S                 
50700...  ..................  A                   Revision of ureter..........      14.10     12.57        1.29      27.96       090  S                 
50715...  ..................  A                   Release of ureter...........      17.60     11.24        1.49      30.33       090  S                 
50722...  ..................  A                   Release of ureter...........      15.11     10.32        1.97      27.40       090  S                 
50725...  ..................  A                   Release/revise ureter.......      17.12     12.05        1.75      30.92       090  S                 
50727...  ..................  A                   Revise ureter...............       7.57      5.37        0.51      13.45       090  S                 
50728...  ..................  A                   Revise ureter...............      11.13      7.90        0.77      19.80       090  S                 
50740...  ..................  A                   Fusion of ureter & kidney...      17.12     13.03        1.88      32.03       090  S                 
50750...  ..................  A                   Fusion of ureter & kidney...      18.14     14.04        1.26      33.44       090  S                 
50760...  ..................  A                   Fusion of ureters...........      17.12     13.47        1.48      32.07       090  S                 
50770...  ..................  A                   Splicing of ureters.........      18.14     15.23        1.53      34.90       090  S                 

[[Page 63243]]
                                                                                                                                                        
50780...  ..................  A                   Reimplant ureter in bladder.      17.12     13.78        1.46      32.36       090  S                 
50782...  ..................  A                   Reimplant ureter in bladder.      18.23     13.78        1.46      33.47       090  S                 
50783...  ..................  A                   Reimplant ureter in bladder.      19.17     13.78        1.46      34.41       090  S                 
50785...  ..................  A                   Reimplant ureter in bladder.      19.15     15.42        1.80      36.37       090  S                 
50800...  ..................  A                   Implant ureter in bowel.....      13.10     14.67        1.51      29.28       090  S                 
50810...  ..................  A                   Fusion of ureter & bowel....      18.14     12.57        1.75      32.46       090  S                 
50815...  ..................  A                   Urine shunt to bowel........      18.14     19.76        2.75      40.65       090  S                 
50820...  ..................  A                   Construct bowel bladder.....      20.15     18.97        2.50      41.62       090  S                 
50825...  ..................  A                   Construct bowel bladder.....      26.19     30.54        3.33      60.06       090  S                 
50830...  ..................  A                   Revise urine flow...........      29.29     20.93        2.27      52.49       090  S                 
50840...  ..................  A                   Replace ureter by bowel.....      18.14     13.32        1.35      32.81       090  S                 
50845...  ..................  A                   Appendico-vesicostomy.......      19.52     13.87        1.35      34.74       090  S                 
50860...  ..................  A                   Transplant ureter to skin...      13.99     10.92        1.16      26.07       090  S                 
50900...  ..................  A                   Repair of ureter............      12.58      9.98        1.15      23.71       090  S                 
50920...  ..................  A                   Closure ureter/skin fistula.      13.22      9.52        0.99      23.73       090  S                 
50930...  ..................  A                   Closure ureter/bowel fistula      17.61     12.50        1.22      31.33       090  S                 
50940...  ..................  A                   Release of ureter...........      13.47      9.90        0.95      24.32       090  S                 
50951...  ..................  A                   Endoscopy of ureter.........       5.84      1.67        0.17       7.68       000  S                 
50953...  ..................  A                   Endoscopy of ureter.........       6.24      1.66        0.16       8.06       000  S                 
50955...  ..................  A                   Ureter endoscopy & biopsy...       6.75      2.55        0.25       9.55       000  S                 
50957...  ..................  A                   Ureter endoscopy & treatment       6.79      2.50        0.25       9.54       000  S                 
50959...  ..................  A                   Ureter endoscopy & tracer...       4.40      3.38        0.29       8.07       000  S                 
50961...  ..................  A                   Ureter endoscopy & treatment       6.05      2.62        0.26       8.93       000  S                 
50970...  ..................  A                   Ureter endoscopy............       7.14      5.17        0.52      12.83       000  S                 
50972...  ..................  A                   Ureter endoscopy & catheter.       6.89      1.54        0.16       8.59       000  S                 
50974...  ..................  A                   Ureter endoscopy & biopsy...       9.17      7.01        0.65      16.83       000  S                 
50976...  ..................  A                   Ureter endoscopy & treatment       9.04      6.41        0.62      16.07       000  S                 
50978...  ..................  A                   Ureter endoscopy & tracer...       5.10      4.05        0.48       9.63       000  S                 
50980...  ..................  A                   Ureter endoscopy & treatment       6.85      3.13        0.30      10.28       000  S                 
51000...  ..................  A                   Drainage of bladder.........       0.78      0.48        0.05       1.31       000  S                 
51005...  ..................  A                   Drainage of bladder.........       1.02      0.46        0.04       1.52       000  S                 
51010...  ..................  A                   Drainage of bladder.........       2.54      0.97        0.11       3.62       010  S                 
51020...  ..................  A                   Incise & treat bladder......       6.04      6.85        0.71      13.60       090  S                 
51030...  ..................  A                   Incise & treat bladder......       6.04      4.53        0.43      11.00       090  S                 
51040...  ..................  A                   Incise & drain bladder......       4.08     *5.23        0.75      10.06       090  S                 
51045...  ..................  A                   Incise bladder, drain ureter       6.04      4.96        0.50      11.50       090  S                 
51050...  ..................  A                   Removal of bladder stone....       6.04      7.12        0.70      13.86       090  S                 
51060...  ..................  A                   Removal of ureter stone.....       8.05    *10.31        1.19      19.55       090  S                 
51065...  ..................  A                   Removal of ureter stone.....       8.05      7.08        0.71      15.84       090  S                 
51080...  ..................  A                   Drainage of bladder abscess.       5.41      5.18        0.57      11.16       090  S                 
51500...  ..................  A                   Removal of bladder cyst.....       9.54      6.86        1.21      17.61       090  S                 
51520...  ..................  A                   Removal of bladder lesion...       8.69      8.53        0.87      18.09       090  S                 
51525...  ..................  A                   Removal of bladder lesion...      12.78     10.67        1.06      24.51       090  S                 
51530...  ..................  A                   Removal of bladder lesion...      11.32      9.25        1.02      21.59       090  S                 
51535...  ..................  A                   Repair of ureter lesion.....      11.51      7.68        1.14      20.33       090  S                 
51550...  ..................  A                   Partial removal of bladder..      14.34     10.71        1.17      26.22       090  S                 
51555...  ..................  A                   Partial removal of bladder..      19.60     12.26        1.31      33.17       090  S                 
51565...  ..................  A                   Revise bladder & ureter(s)..      20.01     15.84        1.67      37.52       090  S                 
51570...  ..................  A                   Removal of bladder..........      22.16     15.66        1.62      39.44       090  S                 
51575...  ..................  A                   Removal of bladder & nodes..      27.93     22.87        2.25      53.05       090  S                 
51580...  ..................  A                   Remove bladder; revise tract      28.20     19.95        2.04      50.19       090  S                 
51585...  ..................  A                   Removal of bladder & nodes..      32.22     25.12        2.42      59.76       090  S                 
51590...  ..................  A                   Remove bladder; revise tract      30.21     24.52        2.56      57.29       090  S                 
51595...  ..................  A                   Remove bladder; revise tract      34.25     33.80        3.34      71.39       090  S                 
51596...  ..................  A                   Remove bladder, create pouch      36.27     34.89        3.45      74.61       090  S                 
51597...  ..................  A                   Removal of pelvic structures      35.27     30.63        4.31      70.21       090  S                 
51600...  ..................  A                   Injection for bladder x-ray.       0.88      0.28        0.03       1.19       000  S                 
51605...  ..................  A                   Preparation for bladder xray       1.13      0.30        0.03       1.46       000  S                 
51610...  ..................  A                   Injection for bladder x-ray.       1.59      0.27        0.02       1.88       000  S                 
51700...  ..................  A                   Irrigation of bladder.......       0.88      0.22        0.02       1.12       000  S                 
51705...  ..................  A                   Change of bladder tube......       0.99      0.38        0.04       1.41       010  S                 
51710...  ..................  A                   Change of bladder tube......       1.46      0.57        0.06       2.09       010  S                 
51715...  ..................  A                   Endoscopic injection/implant       3.74      2.65        0.27       6.66       000  S                 
51720...  ..................  A                   Treatment of bladder lesion.       1.96      0.45        0.05       2.46       000  S                 
51725...  ..................  A                   Simple cystometrogram.......       1.51      1.01        0.11       2.63       000  S                 
51725...  26                  A                   Simple cystometrogram.......       1.51      0.63        0.07       2.21       000  S                 

[[Page 63244]]
                                                                                                                                                        
51725...  TC                  A                   Simple cystometrogram.......       0.00      0.38        0.04       0.42       000  S                 
51726...  .....