[Federal Register Volume 61, Number 227 (Friday, November 22, 1996)]
[Rules and Regulations]
[Pages 59490-59716]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 96-29558]



[[Page 59489]]

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Part II





Department of Health and Human Services





_______________________________________________________________________



Health Care Financing Administration



_______________________________________________________________________



42 CFR Parts 410 and 415



Medicare Program; Revisions to Payment Policies and Five-Year Review of 
and Adjustments to the Relative Value Units Under the Physician Fee 
Schedule for Calendar Year 1997, Final Rule; Physician Fee Schedule 
Update for Calendar Year 1997 and Physician Volume Performance Standard 
Rates of Increase for Federal Fiscal Year 1997, Notice

Federal Register / Vol. 61, No. 227 / Friday, November 22, 1996 / 
Rules and Regulations

[[Page 59490]]



DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Parts 410 and 415

[BPD-852-FC]
RIN 0938-AH40


Medicare Program; Revisions to Payment Policies and Five-Year 
Review of and Adjustments to the Relative Value Units Under the 
Physician Fee Schedule for Calendar Year 1997

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

ACTION: Final rule with comment period.

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

SUMMARY: This final rule makes several policy changes affecting 
Medicare payment for physician services, including payment for 
diagnostic services and transportation in connection with furnishing 
diagnostic tests. The final rule also makes changes in geographic 
payment areas (localities) and changes in the procedure status codes 
for a variety of services. Since we established the physician fee 
schedule on January 1, 1992, our experience indicates that some of our 
policies may need to be reconsidered. This final rule is intended to 
correct several inequities in physician payment.
    This final rule also makes changes to work relative value units 
(RVUs) affecting payment for physician services. Section 
1848(c)(2)(B)(i) of the Social Security Act requires that we review all 
work 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 completed the 5-year review of work RVUs that 
will be effective for services furnished beginning January 1, 1997. In 
addition, we are finalizing the 1996 interim RVUs and are issuing 
interim RVUs for new and revised procedure codes for 1997.
DATES: Effective Date: This rule is effective January 1, 1997, as 
provided by the Medicare statute. Ordinarily, 5 U.S.C. section 801 
requires that agencies submit major rules to Congress 60 days before 
the rules are scheduled to become effective. However, the 104th 
Congress adjourned on October 4, 1996, and the 105th Congress is not 
scheduled to convene until January 7, 1997. The Department has 
concluded that, in this instance, a further delay in this rule's 
effective date in order to satisfy section 801 would not serve the 
law's intent, since Congress will not be in session during this period, 
and such delay in the effective date established by the Medicare 
statute is unnecessary and contrary to the public interest. The 
Department finds, on this basis, that there is good cause for 
establishing this effective date pursuant to 5 U.S.C. section 808(2).
    Comment Date: We will accept comments on interim RVUs for selected 
procedure codes identified in Addendum C. Comments will be considered 
if we receive them at the appropriate address, as provided below, no 
later than 5 p.m. on January 21, 1997.

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-852-FC, P.O. Box 26688, 
Baltimore, MD 21207-0488.
    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.

    Comments may also be submitted electronically to the following e-
mail address: [email protected] E-mail comments must include the full 
name and address of the sender and must be submitted to the referenced 
address to be considered. All comments must be incorporated in the e-
mail message because we may not be able to access attachments. 
Electronically submitted comments will be available for public 
inspection at the Independence Avenue address below.
    Because of staffing and resource limitations, we cannot accept 
comments by facsimile (FAX) transmission. In commenting, please refer 
to file code BPD-852-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).
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FOR FURTHER INFORMATION CONTACT: Stanley Weintraub, (410) 786-4498.

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 relative value units (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

[[Page 59491]]

physician fee schedule. This year we are making the budget neutrality 
adjustment required by changes in payment policy and CPT through the 
conversion factors (CFs) and the adjustment required by the 5-year 
review through a separate adjuster to the work RVUs. We have determined 
that net increases because of changes to the physician fee schedule 
would have added to projected expenditures in calendar year 1997 by 
approximately $2.7 billion. Therefore, it is necessary to make budget-
neutrality adjustments.
    We have made the two 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 0.985, which 
results in a uniform reduction of 1.5 percent to the CFs for all 
services. The new work adjuster factor is 0.917, which results in a 
reduction of -8.3 percent to all work RVUs.
    A 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.
    Addenda to this rule provide the following information:

Addendum A--Explanation and Use of Addenda B through D.
Addendum B--1997 Relative Value Units and Related Information Used in 
Determining Medicare Payments for 1997.
Addendum C--Codes with Interim Relative Value Units.
Addendum D--1997 Geographic Practice Cost Indices by Medicare Carrier 
and Locality.

    The RVUs and revisions to payment policies in this final rule apply 
to physicians' services furnished on or after January 1, 1997.
    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 preamble 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 History
    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 1997 and Responses to 
Public Comments
    A. Payment Area (Locality) and Corresponding Geographic Practice 
Cost Index Changes
    B. Special Rules for the Payment of Diagnostic Tests, Including 
Diagnostic Radiologic Procedures
    C. Transportation in Connection with Furnishing Diagnostic Tests
    D. Bundled Services
    1. Hot or Cold Packs
    2. Dermatology Procedures
    a. Bundling of Repair Codes into Excision Codes
    b. Skin Lesion Destruction Codes
    E. Change in Coverage Status for Screening and Obsolete 
Procedures
    1. Vital Capacity Testing
    2. Certain Cardiovascular Procedures
    F. Payments for Supervising Physicians in Teaching Settings
    1. Definition of Approved Graduate Medical Education Programs
    2. Evaluation and Management Services Furnished in Certain 
Settings
    G. Change in Global Periods for Four Percutaneous Biliary 
Procedures
III. Refinement of Relative Value Units for Calendar Year 1997 and 
Responses to Public Comments on the Five-Year Review of Work 
Relative Value Units
    A. Summary of the Development of Physician Work Relative Value 
Units
    B. Scope of the Review
    C. Review of Comments (Includes Table 1--Work Relative Value 
Unit Refinements of Five-Year Review Codes Commented on in Response 
to the May 3, 1996 Proposed Notice)
IV. Discussion of Comments and Decisions
    A. Discussion of Comments by Clinical Area
    1. Integumentary System
    2. Orthopedic Surgery
    3. Otolaryngology and Maxillofacial Surgery
    4. Podiatry
    5. Cardiology and Interventional Radiology
    6. General Surgery, Colon and Rectal Surgery, and 
Gastroenterology
    7. Urology
    8. Gynecology
     9. Neurosurgery
     10. Ophthalmology
     11. Imaging
     12. Cardiothoracic and Vascular Surgery
     13. Pathology and Laboratory Procedures
     14. Psychiatry
     15. Other Medical and Therapeutic Services
     16. Speech/Language/Hearing
     B. Other Comments
     1. Evaluation and Management Services
     2. Pediatrics
     3. Anesthesia
     4. Codes Without Work Relative Value Units
     5. Potentially Overvalued Services
     C. Other Issues
     1. Budget Neutrality
     2. Impact of Work Relative Value Unit Changes for Evaluation 
and Management Services on Work Relative Value Units for Global 
Surgical Services
     3. Codes Referred to the Physicians' Current Procedural 
Terminology Editorial Panel
     4. Future Review
V. Refinement of Relative Value Units for Calendar Year 1997 and 
Responses to Public Comments on Interim Relative Value Units for 
1996
     A. Summary of Issues Discussed Related to the Adjustment of 
Relative Value Units
     B. Process for Establishing Work Relative Value Units for the 
1997 Fee Schedule
     1. Work Relative Value Unit Refinements of Interim and Related 
Relative Value Units
     a. Methodology (Includes Table 2--Work Relative Value Unit 
Refinements of 1996 Interim and Related Relative Value Units)
     b. Interim 1996 Codes
     2. Establishment of Interim Work Relative Value Units for New 
and Revised Physicians' Current Procedural Terminology Codes and New 
HCFA Common Procedure Coding System Codes for 1997
     a. Methodology (Includes Table 3--American Medical Association 
Specialty Society Relative Value Update Committee and Health Care 
Professionals Advisory Committee Recommendations and HCFA's 
Decisions for New and Revised 1997 CPT Codes)
     b. Discussion of Interim Relative Value Units for Chiropractic 
Manipulative Treatment
     c. Discussion of Codes for Which the RUC Recommendations Were 
Not Accepted
     d. New HCFA Common Procedure Coding System Codes
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
     C. Payment Area (Locality) and Corresponding Geographic 
Practice Cost Index Changes
     D. Special Rules for the Payment of Diagnostic Tests, Including 
Diagnostic Radiologic Procedures
     E. Transportation in Connection with Furnishing Diagnostic 
Tests
     F. Bundled Services
     1. Hot or Cold Packs
     2. Dermatology Procedures
     a. Bundling of Repair Codes into Excision Codes
     b. Skin Lesion Destruction Codes
    G. Change in Coverage Status for Screening and Obsolete 
Procedures
    1. Vital Capacity Testing
    2. Certain Cardiovascular Procedures
    H. Payments for Supervising Physicians in Teaching Settings
    I. Change in Global Periods for Four Percutaneous Biliary 
Procedures
    J. Impact of Payment Policy Changes, Including Establishment of 
Interim and Final RVUs for CPT Coding Changes

[[Page 59492]]

    K. Effects of Changes Resulting from the Five-Year Review of 
Work Relative Value Units
    L. Net Impact of Changes on Medicare Specialties
    1. Impact Estimation Methodology
    2. Overall Fee Schedule Impact
    3. Specialty Level Effect (Includes Table 4--Five-Year Review 
Impact on Medicare Payments by Specialty)
    M. Rural Hospital Impact Statement
Addendum A--Explanation and Use of Addenda B through D.
Addendum B--1997 Relative Value Units and Related Information Used 
in Determining Medicare Payments for 1997.
Addendum C--Codes with Interim Relative Value Units.
Addendum D--1997 Geographic Practice Cost Indices by Medicare 
Carrier and Locality

    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:

AMA--American Medical Association
CF--Conversion factor
CFR--Code of Federal Regulations
CPT--[Physicians'] Current Procedural Terminology [4th Edition, 
1996, copyrighted by the American Medical Association]
CY--Calendar year
EKG--Electrocardiogram
FSA--Fee Schedule Area
FY--Fiscal year
GAF--Geographic adjustment factor
GPCI--Geographic practice cost index
HCFA--Health Care Financing Administration
HCPAC--Health Care Professionals Advisory Committee
HCPCS--HCFA Common Procedure Coding System
HHS--[Department of] Health and Human Services
MSA--Metropolitan Statistical Area
MVPS--Medicare Volume Performance Standards
OBRA--Omnibus Budget Reconciliation Act
OMB--Office of Management and Budget
PC--Professional component
RUC--[American Medical Association Specialty Society] Relative 
[Value] Update Committee
RVU--Relative value unit
TC--Technical component

I. Background

A. Legislative History

    Since January 1, 1992, Medicare has paid 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(c)(2)(B)(ii)(II) of the Act provides that adjustments 
in RVUs because of changes resulting from a 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. If this tolerance is exceeded, we must make adjustments to 
preserve budget neutrality.

B. Published Changes to the Fee Schedule

    In the May 3, 1996 and July 2, 1996 proposed rules (61 FR 19993 and 
61 FR 34615, respectively), we listed all of the final rules published 
through December 8, 1995 relating to the updates to the RVUs and 
revisions to payment policies under the physician fee schedule. In the 
May 3, 1996 proposed notice (61 FR 19992), we discussed proposed 
changes to work RVUs affecting payment for physician services in 
keeping with the requirement under section 1848(c)(2)(B)(i) of the Act 
that we review all work 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 completed the 5-year review of work 
RVUs that will be effective for services furnished beginning January 1, 
1997. In the July 1996 proposed rule (61 FR 34614), we discussed 
several policy changes affecting Medicare payment for physician 
services including payment for diagnostic services and transportation 
in connection with furnishing diagnostic tests. The proposed rule also 
discussed comprehensive locality changes and changes in the procedure 
status codes for a variety of services.
    This final rule with comment period affects the regulations set 
forth at 42 CFR part 410, which consists of regulations on 
supplementary medical insurance benefits and part 415, which contains 
regulations on services of physicians in provider settings, supervising 
physicians in teaching settings, and residents in certain settings. It 
also discusses changes to work RVUs affecting payment for physician 
services. The information in this final rule updates information in the 
final Federal Register documents listed in the May 1996 and July 1996 
proposed rules (61 FR 19993 and 61 FR 34615, respectively).

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 
(GAF) for each physician fee schedule area; and (3) a nationally 
uniform conversion factor (CF) for the service. There are three CFs--
one for surgical services, one for nonsurgical services, and one for 
primary care services. The CFs 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 (GPCI) for 
each fee schedule area. The GPCIs reflect the relative costs of 
practice expenses, malpractice insurance, and physician work in an area 
compared to the national average for each component. In addition, for 
1997, there is an added adjustment for budget neutrality to work 
reflecting the results of the 5-year review of work RVUs. The work 
adjuster is explained in section IV.C.1. of this final rule.
    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 work adjuster x GPCIwork)
      +(RVUpractice expense
       x GPCIpractice expense)
      +(RVUmalpractice x GPCImalpractice)]
       x CF

The CFs for calendar year 1997 appear in Addendum A. The RVUs for 
calendar year 1997 are in Addendum B. The GPCIs are in Addendum D.
    Section 1848(e) of the Act requires the Secretary to develop GAFs 
for all physician fee schedule areas. The total GAF 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 GPCIs 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 GAF for the physician's work 
reflects one-quarter of the relative cost of physician's work compared 
to the national average.

[[Page 59493]]

    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 1997 and the physician fee schedule update 
for calendar year (CY) 1997 are published elsewhere in this Federal 
Register issue as a final notice (BPD-853-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 while we continue to recognize time 
as a factor in determining payment for these services. As a result, 
there is a separate payment system for anesthesia 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 25, 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 25, 
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 25, 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 25, 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 25, 1992 notice (57 FR 56152) in the December 2, 1993 
final rule (58 FR 63647) for the 1994 physician fee schedule. The 
December 2, 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 2, 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 24, 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 2, 1993 final rule were addressed in the 
December 8, 1994 final rule (59 FR 63432). In addition, the December 8, 
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 1997 and Responses to Public 
Comments

    In response to the publication of the July 1996 proposed rule, we 
received approximately 3,000 comments. We received comments from 
individual physicians and health care workers and professional 
associations and societies. The majority of the comments addressed the 
proposals related to locality changes, transportation in connection 
with furnishing diagnostic tests, and diagnostic testing.
    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 1997. We discuss in detail the 
effects of these changes in the Regulatory Impact Analysis (section 
IX).
    For the convenience of the reader, the headings for the policy 
issues in section II, for the most part, correspond to the headings 
used in the July 1996 proposed rule (61 FR 34614). More detailed 
background information for each issue can be found in the July 1996 
proposed rule.

[[Page 59494]]

A. Payment Area (Locality) and Corresponding Geographic Practice Cost 
Index Changes

    Currently, there are 210 payment localities under the physician fee 
schedule. Twenty-two States have single statewide localities, while the 
number of localities in other States ranges from 2 to 32. The current 
localities were set by local Medicare carriers based on their knowledge 
of local physician charging patterns. Therefore, current localities 
have no consistent basis, and have generally changed little since the 
inception of Medicare in 1966. Currently, we set physician fee schedule 
localities, and local Medicare carriers may not revise them. Over the 
years, we have received numerous complaints from physicians that, since 
the current localities were established, changing economic and 
demographic conditions warrant a comprehensive review and revision of 
payment localities.
    We contracted with Health Economics Research, Inc. to conduct an 
analysis of options for realignment of payment localities. After 
analyzing the Health Economics Research report, we announced in the 
July 1996 proposed rule (61 FR 34618) that we were proposing Option 1i, 
5-percent threshold, with subcounty payment area restructuring in 
certain States with subcounty localities.
    Under this option, current localities are used as building blocks. 
The 22 existing statewide localities remain statewide localities. Our 
proposal sets new localities in the remaining 28 States by comparing 
the area cost differences as represented by the locality GAFs within a 
State. An area's GAF is a weighted composite of the area's work, 
practice expense, and malpractice GPCIs and allows a comparison of 
overall costs among areas. Briefly, a State's localities are ranked 
from the highest to the lowest GAF. The GAF of the highest-price 
locality is compared to the weighted average GAF of all lower-price 
localities. If the percentage difference exceeds 5-percent, the 
highest-price locality remains a distinct locality. If not, the State 
becomes a statewide locality. If the highest-price locality remains a 
distinct locality, the process is repeated for the second highest-price 
locality. Its GAF is compared to the statewide average excluding the 
two highest-price localities. If this difference exceeds 5-percent, the 
second highest-price locality remains a distinct locality. This logic 
is repeated, moving down the ranking of localities by costliness, until 
the highest-price locality does not exceed the combined GAFs of all 
less costly localities by 5-percent and does not remain a distinct 
locality. No further comparisons are made, and the remaining localities 
become a residual rest-of-State locality. The GAF of a locality always 
is compared to the average GAF of all lower-price localities. This 
ensures that the statewide or residual State locality has relatively 
homogeneous resource costs.
    We combined Option 1i, 5-percent, with a restructuring of 
localities in the 11 States that currently contain subcounty 
localities. We proposed to use counties as the basic locality 
structure. The input price data used in computing the GPCIs is not 
available at the subcounty level. The use of subcounty localities 
creates unnecessary complexity and administrative burden. It requires 
laborious mapping of zip codes and city boundaries to localities for 
both claims processing and computing the GPCIs. Using counties as the 
basic locality unit provides a national uniform physician fee schedule 
structure. Option 1i, 5-percent threshold, automatically eliminates 
these subcounty areas in 8 States as it aggregates them into statewide 
or residual State localities. The remaining 3 subcounty States--
Massachusetts, Missouri, and Pennsylvania--are more problematic. 
Currently, each of these States contain noncontiguous localities 
comprised of parts of counties with dissimilar costs. We proposed to 
fundamentally restructure localities in these States by examining 
county level costs as represented by county GAFs and creating new 
localities based on costs with some geographic consideration. A 
detailed discussion of this fundamental restructuring can be found in 
the July 1996 proposed rule (61 FR 34620).
    Our proposed locality structure meets the major goal of simplifying 
payment areas and reducing payment differences among adjacent 
geographic areas while maintaining accuracy in tracking input prices 
among areas. It significantly reduces the number of payment localities 
from 210 to 89 and increases the number of statewide localities from 22 
to 34, thereby simplifying program administration. It also provides a 
more rational and understandable basis for localities, reduces urban/
rural payment differences, and maintains separate payment areas for 
relatively high-priced large and mid-sized cities in large States. It 
decreases the number of payment areas by almost 60 percent while at the 
same time reducing average county boundary differences, yet reduces 
average county input price accuracy by only 0.42 percent.
    The GPCIs for the new localities were calculated to be budget 
neutral within each State. That is, the same total physician fee 
schedule payment will be made within a State that would have been made 
if the current localities were retained. The effect on most localities 
will be minimal. Of the total localities in the 28 States currently 
having multiple localities, 82 percent of the GAFs change less than 3 
percent, 93 percent change less than 4 percent, and 96 percent change 
less than 5 percent. Forty-three percent of the areas will experience 
increases in payments, 33 percent will experience decreases, and 24 
percent will experience no change.
    We proposed phasing in the new localities over a 2-year period in 
States containing a payment area estimated to lose more than 4 percent. 
We proposed that no locality be allowed to lose more than 4 percent in 
the first year. We selected a 4 percent threshold because it is about 
one-half of the largest estimated payment area decrease. This means 
phasing in the new localities over 2 years in Missouri and Pennsylvania 
because they are the only States containing a payment locality 
estimated to lose more than 4 percent. The payment locality changes 
would be fully effective in 1997 in all other States.
    Comment: The single largest number of comments were from commenters 
supporting our proposal because it would reduce or eliminate urban/
rural payment differences in their State. They believed that this would 
help in the recruitment and retention of physicians in underserved 
rural areas, thereby improving access. The commenters stated that 
increased Medicare payments are particularly needed in rural areas as 
these areas tend to have an unusually large percentage of the Medicare 
population.
    Response: We agree that our proposal will reduce urban/rural 
payment differences under the Medicare physician fee schedule, and we 
are hopeful that this may help to improve access to care in rural 
areas.
    Comment: Some commenters from localities estimated to experience 
payment decreases objected to what they termed the ``proposed 
reduction'' in their payment level under Medicare. They were concerned 
about the ripple effect on their payments from other sources, 
especially managed care, as these sources frequently base their 
payments on Medicare payment rates. They gave no rationale for 
objecting to our proposal, other than the payment reduction.
    Response: Our proposal is not intended as a payment reduction 
policy. Rather, it is a restructuring of localities based on area costs 
wherein existing localities with costs that are

[[Page 59495]]

significantly higher than other localities within their State remain 
distinct localities while localities with similar costs within the 
State are collapsed into a residual State locality. Since this will be 
implemented on a budget-neutral basis within a State, some of the 
current localities comprising these newly collapsed localities will 
experience slight increases in payments while others will experience 
slight decreases. Our proposal to aggregate current localities is based 
on the application of statistical criteria comparing area costs. In the 
July 2, 1996 proposed rule (61 FR 34621), we stated that while we 
welcomed comments and would consider other suggested alternatives, 
these alternatives should be based on a statistical analysis 
demonstrating why the alternative is preferable. Merely objecting to 
reductions in payment without accompanying analysis is not a compelling 
reason for not implementing the proposed locality revisions.
    Comment: Commenters from urban areas whose costs were not 
significantly higher than rural areas and, thus, were collapsed into 
statewide or State residual areas were opposed to our proposal, 
maintaining that their expenses such as labor, rent, and taxes are 
higher than in rural areas.
    Response: We agree that our cost data generally show that costs are 
higher in urban than in rural areas. However, urban areas whose costs 
do not meet our statistical criteria, that is, are not more than 5 
percent higher than the combined costs of all lower-price localities in 
their State, are combined with these lower-price localities into a new 
locality. We believe that, for all of the reasons stated in the 
introduction, our proposed locality structure has many advantages over 
the current structure while maintaining an acceptable degree of 
accuracy in tracking area cost differences.
    Comment: Commenters in losing areas objected to our methodology on 
the basis that the GPCIs are based on proxy data that are outdated and 
are not an accurate reflection of area cost differences. Some 
commenters quoted other limited data sources or provided limited local 
data to demonstrate that their costs were higher relative to other 
areas than indicated by the GPCIs. Indeed, some commenters did not 
comment on our locality proposal, but commented on the construction of 
the GPCIs and how the GPCIs understate costs in their area.
    Response: The accuracy of the GPCIs was initially addressed in the 
June 1991 proposed rule (56 FR 25815) and the November 1991 (56 FR 
59511) final rule on the physician fee schedule. It was addressed again 
in the June 24, 1994 proposed rule (59 FR 32756) and the December 1994 
final rule (59 FR 63414) on the physician fee schedule discussing the 
first update of the GPCIs. Those rules discussed in depth the 
formulation of the GPCIs. Those proposed and final rules were the 
appropriate vehicles for commenting on the GPCIs. The next GPCI update 
is scheduled for 1998, and likely will be announced in a proposed rule 
published in 1997. This will provide another opportunity for commenting 
on the formulation of the GPCIs. Our July 2 proposed rule requested 
comments on the proposed locality reconfiguration, not the GPCI 
formulation.
    The GPCIs are based on the best and most recent data available. The 
current GPCIs are based on 1990 census wage data, 1994 rental data, and 
1990 through 1992 malpractice premium data. The current GPCIs were 
required by law to become effective in 1995. We began work on them in 
1993. These data were the best and most recent data available at that 
time. Because of the time necessary to collect and evaluate the data, 
there will always be a time lag between data collection and 
implementation of the GPCIs. It is not possible to be absolutely 
current. The GPCIs have been examined in depth by government and 
private groups and there is general agreement that they are the best 
available measurement of area physician practice cost differences.
    Since the GPCIs reflect practice costs among all areas across the 
country, national data sources that are widely available and are 
updated on a periodic basis are required. Using locally available data 
to demonstrate higher local costs is not acceptable in a national 
program with national indices.
    Comment: Some commenters, while generally agreeing with the intent 
of our locality proposal, stated that we should make an exception to 
furnish the same payment amount for metropolitan areas that cross State 
lines as these areas tend to have relatively homogenous resource costs 
throughout the metropolitan area. Commenters believed that not doing 
this might have a negative impact on health care delivery in the part 
of the metropolitan area in the State with the lower GAF. One commenter 
cited an example of neighboring payment areas across State borders that 
currently have nearly identical GAFs but under our proposal will have a 
nearly 4-percent difference as one of the areas becomes part of a 
statewide locality while the other remains a distinct locality.
    Response: We considered using metropolitan statistical areas as 
locality building blocks in one option for setting localities. For the 
reasons discussed in the July 1996 proposed rule (61 FR 34618), we 
rejected this option as less promising than our proposed option. We 
agree that in many cases resource cost are similar across State lines. 
However, we currently have no localities that cross State lines and see 
no reason to begin establishing them. There are numerous situations 
under the current locality system when there are larger payment 
differences across State boundaries than the 4 percent cited by the 
commenter. We have no evidence that physicians are crossing State 
borders to secure higher Medicare payment. There are many differences 
among States that affect business decisions in addition to the elements 
reflected in our resource costs. For example, States have different 
physician licensing requirements, business licensing requirements, 
safety and health requirements, and different business, corporate, and 
personal income tax rates. We do not believe that a few percentage 
points difference in Medicare payments will cause physicians to 
relocate across State lines.
    Comment: Some commenters in the 16 States that would remain 
multiple locality States under our proposal stated that they would 
prefer that we make their State a single statewide locality.
    Response: Our proposal creates statewide localities except in 
States containing high-price localities whose costs exceed the combined 
costs of all lower-price localities by more than 5 percent. We stated 
in the July 1996 proposed rule (61 FR 34622) that we would consider 
requests to convert multiple locality States to statewide localities if 
there is overwhelming support for a statewide locality among both 
winning and losing physicians in the State. We will be glad to consider 
applications demonstrating such overwhelming support for a statewide 
locality from these States.
    Comment: Some commenters supported our proposal but requested that 
all localities have the changes transitioned in over a 2-year period. 
Other commenters requested a 3-or 4-year transition.
    Response: Transitions are operationally complex and can be very 
confusing to physicians. Most localities experience a negligible or 
minor change in payments under our proposal. We see no need to 
transition such areas. We believe that transitioning only to limit the 
larger losses is reasonable. We also believe that transitioning over 2 
years in these areas is reasonable. The periodic GPCI revisions are 
required by law to be transitioned over 2 years. A longer transition 
will run into the next GPCI

[[Page 59496]]

update and the implementation of resource-based practice expenses. It 
would be very complex and difficult to explain the interaction of these 
simultaneous changes to physicians.
    Comment: While generally supporting our concept of consolidating 
payment areas, some commenters requested that we allow more flexibility 
on a statewide basis. They requested that we accommodate their wishes 
if physicians within a State wish to have a slight modification to our 
proposal, for example, to select a lower threshold than 5 percent to 
allow certain areas that would be part of the State residual area to 
remain a distinct payment area.
    Response: The fee schedule is a national program, with national 
RVUs and national CFs. The GPCIs are based on national data. Therefore, 
we applied the same statistical criteria, Option 1i, 5-percent 
threshold, to all multiple locality States in our locality revision 
proposal. As announced in the proposed rule, we still plan to be 
responsive to the wishes of physicians in multiple locality States by 
accepting requests for a statewide payment area if overwhelmingly 
supported by physicians in both winning and losing areas within the 
State. While we prefer to be responsive to the wishes of physicians 
within a State, commenters failed to state what criteria would be 
applied to demonstrate that physicians within the State desired a 
modification of our proposal.
    Our past experience with converting States to statewide payment 
areas has demonstrated that it is often difficult to develop a 
consensus among physicians for these changes because there are both 
winners and losers. Our criteria for such changes have been to require 
a resolution, passed by the State medical society requesting the 
change, that clearly states that there will be winners and losers, and 
also offers proof of overwhelming support for the change among 
physicians in both winning and losing areas. Then, even if such support 
is demonstrated among State medical society members, we will publish 
the proposed change in the Federal Register to give all physicians in 
the State, medical society members and nonmembers, an opportunity to 
comment because State medical societies usually represent only about 50 
to 60 percent of all physicians in the State. Also, many nonphysician 
practitioners paid under the fee schedule and not represented by State 
medical associations are affected by fee schedule changes. In many 
cases, we have received letters of protest from losing, usually urban, 
physicians as soon as a resolution is passed and before we have even 
proposed a change.
    While we were willing to consider modifications to our proposed 
localities within a State, such modifications would have to be 
statistically based. For example, a request for a modification should 
state why we should use a lower threshold than our 5-percent threshold 
within that State, rather than merely saying that a large city, which 
becomes part of the State residual area under the proposal, should be a 
separate locality because it is similar in size or characteristics to 
other higher-cost cities. We would also need evidence that areas that 
would lose under this modification understood and supported the change.
    Comment: A commenter from California, while generally supporting 
the proposal, requested to return to the designations in Los Angeles 
that existed under the reasonable charge system whereby more expensive 
areas of Los Angeles, namely Beverly Hills, West Los Angeles, and Santa 
Monica had higher prevailing charge allowances than other parts of Los 
Angeles County. The commenter believed that costs are not homogeneous 
across Los Angeles County and are higher in these areas.
    Response: Los Angeles was divided into eight areas under the 
reasonable charge system. These eight areas have the same GPCIs and 
payment amounts under the fee schedule because the lowest level cost 
data we have are county cost data. Thus, combining these eight areas 
into one area under our proposal has no effect on payments in Los 
Angeles. Making Beverly Hills, West Los Angeles, and Santa Monica 
separate payment areas would not change their payments because we would 
still use the Los Angeles County cost data since we do not have 
subcounty cost data. As stated in the July 1996 proposed rule (61 FR 
34618), we are using current counties as the basic locality building 
block and will have no subcounty payment areas under our proposal. We 
believe that limiting localities to at least the county level is 
reasonable. While an individual city, town, or individual physician 
might incur higher costs than the average in their payment locality, 
the choice to locate in high cost space is a business decision.
    Comment: Some commenters in losing areas stated that we should not 
reduce payments in their locality because their locality contained 
numerous teaching hospitals, which have higher costs of providing 
services. Also, these large teaching facilities tend to serve as 
physicians' offices for many poor and indigent people.
    Response: Under the law, physician fee schedule payments do not 
differ by type of provider. All physicians' services, whether furnished 
by solo practitioners, group practices, large multispecialty clinics, 
or hospital-based physicians, are paid at the same rate within a 
locality. The added costs of teaching hospitals are recognized through 
the added Medicare direct and indirect medical education payments made 
to teaching facilities. Likewise, hospitals furnishing a 
disproportionate share of services to indigent patients receive 
additional disproportionate share payments.
    Comment: Some commenters requested we delay implementation of our 
proposal until we can perform a thorough study using more recent cost 
data.
    Response: We see no reason for a delay. As mentioned earlier, in 
response to physicians' concerns, we stated that we would consider a 
comprehensive revision in localities once the transition was completed 
in 1996. We believe that the Health Economics Research, Inc. study was 
extremely comprehensive. The data used when the study was started in 
1995 were the data that formed the basis for the newly revised 1995 
GPCIs. As stated in the previous response about the accuracy of the 
GPCIs, there will always be some time lag because of data collection 
and analysis requirements. The GPCIs are based on the best currently 
available data.
    Comment: Commenters from some losing, relatively low cost urban 
areas that were combined into a residual State area suggested we 
ameliorate the effects on these areas by taking a few percentage points 
away from the higher cost areas that remain distinct localities within 
the State and redistributing this to the residual State area. They 
believed that these higher paid areas can ``afford'' to give up these 
few percentage points, and stated that this is in keeping with our 
stated goal of reducing urban/rural payment differences.
    Response: Our proposal is based strictly on the application of 
statistical methodology comparing area costs. Arbitrarily taking away 
money from a high cost area merely to redistribute it to other areas 
would violate our criteria and underpay the high cost area while 
overpaying the low cost areas. It is true that we generally favor 
statewide payment areas as they result in greater simplicity and ease 
of administration and reduce urban/rural payment differentials; we are 
hopeful that this will improve access in rural underserved areas. 
However, once a statewide area is established, it is given

[[Page 59497]]

the GPCIs justified by the GPCI cost data.
    Comment: Commenters from losing areas that would be retained as 
distinct payment areas under a lower threshold believed that our 
selection of the 5-percent threshold is arbitrary.
    Response: We disagree. We examined various thresholds with various 
options. As stated in the July 1996 proposed rule (61 FR 34619), Option 
1i, 5-percent threshold was selected because it provided the greatest 
simplification while reducing average boundary differences from the 
current structure at a virtually negligible increase in average county 
input price error of only 0.42 percent. This option provided the best 
combination of simplicity, reducing boundary payment differences, and 
maintaining accuracy in tracking area cost differences.
    Comment: While understanding and generally agreeing with our 
statistical methodology, some commenters asked if we planned to change 
localities on a periodic basis to recognize future cost changes. Others 
requested that we commit to such future change as we update the GPCIs.
    Response: There have been no comprehensive studies and revisions of 
physician payment localities in 30 years. We agreed with physicians 
that such a study and revision was necessary, especially since we 
changed from the local carrier pricing system to a national fee 
schedule. We have stated on numerous occasions that we favor statewide 
localities because of their understandability, simplicity, and ease of 
administration, and because they reduce urban/rural payment 
differences. We do not plan to break up statewide payment areas in the 
future. We also do not generally favor fragmenting existing payment 
areas into smaller areas. While we do not plan to routinely revise 
payment areas as we implement new GPCIs, we will review the areas in 
multiple locality States if the newer GPCI data indicates dramatic 
relative cost changes among areas.
    Final decision: Effective January 1, 1997, we will proceed with the 
implementation of our proposed Option 1i, 5-percent threshold, with 
restructuring of subcounty payment areas to reduce the number of 
physician fee schedule payment localities from 210 to 89 as indicated 
in the July 1996 proposed rule (61 FR 34619). A list of the new 
localities with their 1997 GPCIs can be found in Addendum D. These 
GPCIs will be fully effective in all States except Missouri and 
Pennsylvania in 1997. Because Missouri and Pennsylvania contain 
localities whose GPCIs decrease by more than 4 percent under our 
proposal, these States will be phased in over a 2-year period. Because 
the losing areas will have their losses limited to 4 percent in 1997, 
the winning areas in these States will experience slightly less than 
their full expected increases in 1997.
    This policy change does not require a change to the regulations set 
forth in Sec. 414.4 (``Fee schedule areas'').

B. Special Rules for the Payment of Diagnostic Tests, Including 
Diagnostic Radiologic Procedures

    We proposed that, to be covered, diagnostic tests, including 
diagnostic radiologic procedures must be ordered by the physician who 
treats the patient. The physician who treats the patient is the 
physician responsible for the treatment of the patient and who orders 
the test or radiologic procedure to use the results in the management 
of the beneficiary's specific medical problem(s). (Physicians can order 
tests while they are consulting for another physician.) We believe this 
requirement is fundamental for coverage and payment of diagnostic tests 
and, therefore, are including it in the regulations at Sec. 410.32 
(``Diagnostic x-ray tests, diagnostic laboratory tests, and other 
diagnostic tests: Conditions'').
    However, a physician who orders the x-ray that is used by a 
chiropractor to demonstrate the subluxation of the spine in a 
beneficiary who is receiving manual manipulation treatments will be 
exempted from this rule. Because no payment can be made for a 
diagnostic test ordered by a chiropractor under Sec. 410.22(b)(2), we 
will allow payment for the x-ray when ordered by a physician who will 
not be treating the patient for subluxation of the spine. Otherwise, 
beneficiaries would always have to pay out-of-pocket for these x-rays, 
which would frustrate their use of the benefit.
    Further, certain nonphysician practitioners who provide services 
that would be physician services if furnished by a physician under a 
specific enumerated benefit in the statute would be treated the same 
way as the physician treating the beneficiary for the purpose of this 
section. Nonphysician practitioners who meet this definition are 
physician assistants (section 1861(s)(2)(K)(i) of the Act), nurse 
practitioners (section 1861(s)(2)(K)(ii) of the Act), clinical nurse 
specialists (section 1861(s)(2)(K)(iii) of the Act), nurse-midwives 
(sections 1861(s)(2)(L) and 1861(gg) of the Act), clinical 
psychologists (sections 1861(s)(2)(M) and 1861(ii) of the Act), and 
clinical social workers (sections 1861(s)(2)(N) and 1861(hh) of the 
Act) operating within the scope of their statutory benefit and State 
licenses.
    Comment: One commenter suggested that clinical psychologists and 
nurse midwife practitioners be added to the list of nonphysician 
practitioners permitted to order tests.
    Response: The same policy would apply to these nonphysician 
practitioners when working within the scope of their statutory benefit. 
We have added provisions pertaining to these nonphysician practitioners 
to the regulations text.
    Comment: Several primary care physicians were concerned that they 
would be precluded from ordering diagnostic tests if the results of the 
testing leads to referral to a specialist since the referring physician 
would not be the treating physician. Similarly, an ophthalmological 
organization expressed concern about ordering radiologic tests for a 
suspicious area of the eye because the ophthalmologist would not be the 
treating physician. In addition, several commenters indicated that 
radiologic imaging centers, pathological laboratories, and noninvasive 
vascular laboratories often are faced with situations in which the 
patient's physician has ordered one test when another is more 
appropriate or, as a result of the findings of the ordered tests, it 
may be necessary for the reading physician to order additional tests. 
The commenters suggested that the proposal be modified to allow for the 
interpreting physician to modify the order to meet the patient's needs.
    Response: We had proposed that, to be covered, diagnostic tests 
must be ordered by the physician who treats the beneficiary. This 
policy is designed to assure that beneficiaries receive medically 
necessary services and to prevent patterns of abuse, such as the 
furnishing of diagnostic tests that are screening (noncovered) services 
rather than medically necessary services for the diagnosis of the 
individual patient's condition. For example, we have heard of 
situations in which a physician is employed for the sole purpose of 
ordering diagnostic tests (in nursing homes or mobile centers).
    The discussion of our proposal should have indicated that an 
individual may have several treating physicians including a primary 
care physician and a specialist. We would also consider as a ``treating 
physician'' an ``on call'' physician who has been given responsibility 
for a patient's care during a period when the patient's physician is 
unavailable. Our intention was not to preclude the ordering of tests by 
a patient's primary care physician who refers the patient to a 
specialist, or by

[[Page 59498]]

a specialist who is managing only one aspect of the patient's care. 
Further, we do not want to prevent medically necessary testing that is 
a modification of the diagnostic work-up a treating physician orders 
for a specific patient. The intent of the policy is to assure that the 
physician who orders the test is responsible for the management of some 
aspect of the patient's care.
    While we do not think it is necessary to change the language in the 
regulations, we agree that some provision should be made for the 
situations in question. We will publish our interpretations of the 
regulation in the implementing manual instructions.
    Further, we believe that the physician interpreting the diagnostic 
tests has an obligation to discuss any changes in or additions to the 
original order with the patient's physician. In the ideal situation, 
this discussion should take place before the change in orders is 
implemented, but we realize there may be urgent situations when this is 
not possible.
    Comment:  A national medical specialty organization indicated its 
agreement with the concept of the proposal but suggested that another 
approach would be to preclude physicians, nurse practitioners, and 
physician assistants employed by home health agencies and skilled 
nursing facilities from independently ordering laboratory tests without 
the knowledge and consent of the patient's attending physician.
    Response: We will keep this suggestion in mind in case additional 
action is needed in this area but believe it would be difficult to 
enforce this policy. In addition, the suggestion does not address the 
problem of unnecessary testing in nursing facilities and questionable 
testing offered to beneficiaries in public areas such as shopping 
malls.
    Comment: An organization representing medical directors in the 
field of long-term care pointed out that medical directors of nursing 
facilities are responsible for providing oversight and supervision of 
physician services and the medical care of residents. In that capacity 
they may have to order tests to evaluate possible inadequate care.
    Response: We believe that in these unusual cases the medical 
director of the nursing facility would contact the patient's physician 
about the testing and that the medical necessity of the test could be 
ascertained. The facility director should document the medical 
necessity of the testing in the facility's medical records. As indicted 
above, we established this policy to address inappropriate patterns of 
ordering tests, such as the medical director of a nursing facility who 
orders screening diagnostic testing for many patients in the facility.
    Comment: One commenter expressed concern about the effect of the 
policy on the ordering of tests by residents in teaching hospitals. The 
commenter also was concerned about tests ordered by one member of a 
group practice at the time a patient is admitted to a hospital when 
another member of the group is the patient's treating physician in the 
hospital.
    Response: We do not intend for this policy to have a significant 
effect on diagnostic procedures furnished in hospitals. Residents may 
order tests without involving a teaching physician since the ordering 
of tests generally is not a billable service. In addition, we realize 
that, in group practices, different members of the group may treat the 
patient at different times. This policy is not intended to prevent the 
substitution of physicians within a group.
    Comment: One commenter requested clarification of the interaction 
between the ordering of tests by nonphysician practitioners and the 
coverage requirement for direct physician supervision of the 
performance of x-rays and other diagnostic tests.
    Response: While nonphysician practitioners are permitted to order 
diagnostic tests under certain conditions, this does not eliminate the 
requirement for physician supervision.
    Comment: A commenter noted that the proposed rule addresses only 
physicians who order the x-ray used by a chiropractor to demonstrate 
subluxation of the spine. It does not address coverage for other 
diagnostic services that may be ordered by a physician on the referral 
from a chiropractor.
    Response: The purpose of the July 1996 proposed rule was to address 
the x-ray required by section 1861(r)(5) of the Act that limits the 
services of a chiropractor to manual manipulation of the spine to 
correct a subluxation that is demonstrated by x-ray to exist. Because 
the statute requires the x-ray but Sec. 410.22(b)(2) prohibits payment 
to chiropractors for ordering or furnishing the x-ray, beneficiaries, 
in some cases, have incurred the expense for the mandated x-ray. We 
have attempted to resolve this issue in a manner that would be 
equitable and, at the same time, maintain the intent of the Congress in 
establishing the original requirement. Therefore, we proposed an 
exception to the policy that requires the ordering physician to be the 
treating or consulting physician. Thus, we focused on easing the burden 
on the patient for payment of the mandated x-ray: under the rule, the 
chiropractor may send the patient for the x-ray that the radiologist, 
as a physician, may order, even though the radiologist is not the 
treating physician.
    Final Decision: We are adopting our proposal to cover diagnostic 
tests only if ordered by the physician or nonphysician practitioner who 
treats the patient, unless it is a physician who orders an x-ray to be 
used (by a chiropractor) to demonstrate subluxation of the spine that 
is the basis for a beneficiary to receive manual manipulation treatment 
even though the physician does not provide the manual manipulation.

C. Transportation in Connection With Furnishing Diagnostic Tests

    We proposed allowing separate payment only for the transportation 
of x-ray equipment furnished by approved suppliers of portable x-ray 
services. As a result, we proposed not allowing separate payment for 
the transportation of electrocardiogram (EKG) equipment furnished by 
any supplier. Payment for the transportation would be bundled into our 
payment for the EKG service. We proposed this policy because, in our 
judgment, statutory authority existed for separate payments for only 
the transportation of x-ray equipment. Therefore, we proposed to 
eliminate HCFA Common Procedure Coding System (HCPCS) code R0076 
(Transportation of portable EKG equipment and personnel to home or 
nursing home). Payment for CPT codes 93000 (Electrocardiogram, 
complete) and 93005 (Electrocardiogram, tracing) would not change.
    This proposal is consistent with actions taken in our December 1995 
final rule (60 FR 63149). In that rule, we noted that the general 
physician fee schedule policy is that travel is included in the 
practice expense RVUs for a service. However, until issuance of that 
regulation, Medicare carriers had the discretion to make separate or 
additional payments for the transportation of diagnostic equipment. As 
a result of the December 1995 final rule, effective January 1, 1996, we 
standardized our policy for the payment of the transportation costs. We 
precluded separate payment for these costs, except under certain 
circumstances. Those circumstances included paying separately for EKG 
transportation to approved portable x-ray suppliers and independent 
physiological laboratories. As noted above, after further review of 
this policy, we concluded that the statute authorized such separate 
transportation

[[Page 59499]]

payments for only portable x-ray services, and we are now bringing our 
policy into compliance with this interpretation effective January 1, 
1997.
    We believe there is no policy basis for paying for EKG 
transportation in a manner different from our payment for 
transportation of other diagnostic tests. The only exception would be 
portable x-ray transportation, for which, we believe, the Congress 
required separate payment.
    Comment: We have received over a hundred comments from portable x-
ray suppliers, officials of nursing facilities, and family members of 
residents of nursing facilities indicating that:
     These suppliers will have to close either their EKG 
operations or their entire business.
     We will pay 4 or 5 times as much in ambulance payments to 
take patients to hospitals to receive EKGs.
     Transporting patients to a hospital will cause them pain, 
discomfort, and confusion.
     We should discontinue transportation payments to 
independent physiological laboratories for EKGs but continue payment to 
portable x-ray suppliers.
    Response: We believe that the premise that only two alternatives 
are available, that is, portable EKGs and ambulance transportation, is 
erroneous. Patients requiring ambulance transportation will exhibit 
symptoms and signs that require medical evaluation and treatment that 
would make furnishing an EKG alone as a portable test inappropriate. 
Nor can it be assumed that ambulance payments would be made in many of 
these situations since use of an ambulance is medically necessary only 
when other transportation is contraindicated. We regard the use of an 
ambulance simply as a means of transportation to receive a diagnostic 
procedure to be an abusive practice. Therefore, we believe that the 
portrayal of portable EKG and ambulance transportation as the only 
alternatives is not an accurate description of normal, acceptable 
medical practice.
    We believe that, in the case of severe, potentially life 
threatening cardiac problems, a patient should be transported by 
ambulance to the hospital instead of waiting for a van with portable 
equipment to arrive. The comments do not describe the conditions under 
which EKG services should be provided to nursing facility patients on a 
mobile basis. The apparent rationale for such payment would be for 
services furnished in response to symptoms that are significant enough 
to make the procedure medically necessary but not serious enough for 
the patient to be taken to a hospital or to require immediate attention 
by a physician.
    We believe that there are sufficient alternatives to furnishing EKG 
services on a portable basis:
     EKG equipment is lightweight and often carried by 
physicians into nursing facilities.
     Nursing homes (particularly skilled nursing facilities) 
often have this equipment and staff who know how to do the test. (Our 
physicians have advised us that individuals can learn how to hook up 
these devices with on-the-job training and that the training required 
to do these procedures does not compare to that required for a 
radiologic technician). In addition, the results of the test may be 
sent by phone to the interpreting cardiologist or other physician.
     Patients may be transported by family members or others to 
medical facilities in the same way they receive other diagnostic or 
therapeutic services for which we do not make separate transportation 
payments.
    Comment: One commenter described our proposal as ``noncovering'' 
transportation services for EKG equipment.
    Response: That is not an accurate description of our proposed 
policy. The service will still be covered, but we will not pay 
separately for the transportation service. We will bundle payment for 
transportation services into the payment for EKG services.
    Comment: One commenter indicated that the proposal was an 
unconstitutional ``taking'' of the equipment and investment of portable 
x-ray suppliers and independent physiological laboratories. The 
commenter went on to say we would be required to provide fair and 
adequate compensation to indemnify those persons who invested, with a 
reasonable expectation of return in such equipment, personnel, or 
businesses.
    Response: The commenter's position would seem to be that, once 
Medicare makes a decision to pay for something, it is forever locked 
into continuing such payments. However, suppliers have no 
constitutional right to continued Medicare payment for particular 
services. In the case of a service, such as the transportation of EKG 
equipment, for which there is no explicit provision in the law, the 
responsibility to make needed program changes is delegated to us. We 
have exercised this discretion in the case of transportation of EKG 
equipment.
    Comment: A few commenters indicated that the proposal to eliminate 
the transportation payment for EKG equipment was particularly harsh 
since it follows so closely the recent decision by Medicare to disallow 
a set-up fee for EKGs.
    Response: There never was a set-up fee for EKG equipment. HCPCS 
code Q0092 (Set-up portable x-ray equipment) was established in 1992 to 
be billed with radiologic procedures furnished by portable x-ray 
suppliers. It was designed to recognize the historical payment 
differential, on a national basis, between the technical component 
payments under the Medicare radiologist fee schedule for services 
furnished by portable suppliers and stationary entities. If payment was 
made under Q0092 for the set-up of EKG equipment by portable x-ray 
suppliers, it was an erroneous payment that was inconsistent with both 
the HCPCS code description and the instructions in section 15022 of the 
Medicare Carriers Manual.
    Final Decision: We are assigning HCPCS code R0076 (Transportation 
of EKG equipment) a ``B'' or bundled status to indicate that, effective 
January 1, 1997, HCPCS code R0076 will be paid for within the practice 
expense RVUs of the EKG services. Separate payment will no longer be 
made for the transportation of EKG equipment. There are sufficient 
alternatives to provide patients with EKG services. Effective on or 
after January 1, 1997, Medicare payment under the physician fee 
schedule may be made only for the transportation of equipment used to 
perform x-rays and diagnostic mammograms furnished by approved 
suppliers of portable x-ray services.
    This policy change does not require a change in the text of the 
regulations.

D. Bundled Services

1. Hot or Cold Packs
    The results of a comprehensive analysis of Medicare claims data 
indicate that CPT code 97010 (the application of hot or cold packs to 
one or more areas) is being used extensively with a wide variety of 
services such as office visits and physical medicine and rehabilitative 
services. We proposed to bundle payment for CPT code 97010 into the 
payment for all other services including, but not limited to, those 
with which it historically has been billed with the greatest frequency 
(such as office visits and physical therapy).
    We believe that bundling payment and, thus, precluding separate 
payment for the application of hot and cold packs is justified for 
three reasons:
     As a therapy, hot and cold packs are easily self-
administered. Generally, we do not cover procedures that are basically 
self-administered; hot and cold

[[Page 59500]]

packs, by their nature, do not require the level of professional 
involvement as do the other physical medicine and rehabilitation 
modalities.
     Although we acknowledge that professional judgment is 
involved in the use of hot and cold packs, much less judgment is 
demanded for them than for other modalities. These packs are commonly 
used in the home, and, thus, require a minimal level of professional 
attention.
     The application of hot and cold packs is usually a 
precursor to other interventions and, as such, is appropriately used in 
combination with other procedures. Our data analysis supports this 
conclusion because the majority of claims for CPT code 97010 occurred 
in conjunction with claims for other services performed on the same 
day.
    We proposed to change the status indicator for CPT code 97010 to 
``B'' to indicate that the service is covered under Medicare but 
payment for it is bundled into the payment for other services. Separate 
payment for CPT code 97010 would not be permitted under this proposed 
change. This change would be implemented in a budget neutral manner 
across all other procedures. Because the RVUs for this procedure would 
be redistributed across all physician fee schedule services, there 
would be no measurable impact.
    Comment: We received a limited number of comments in response to 
this proposal. Most of the commenters were opposed to our proposal. 
However, several commenters supported the concept of bundling CPT code 
97010 conditionally and one commenter was fully supportive of the 
proposal. Those opposed to bundling stated that distribution of the 
RVUs for CPT code 97010 across all services will result in payment to 
all physicians performing services when, in fact, only very few 
physicians use hot and cold pack modalities. Furthermore, the 
commenters, in supporting the use of hot or cold packs outside of the 
home setting, stated that these modalities are not appropriate in the 
home since they are part of a rehabilitation program that is generally 
not provided in the home. They objected to the proposed bundling of hot 
or cold packs because they are separate and distinct services. Other 
physical modality and physical therapy codes are used without the 
application of hot or cold packs as well, and the packs can be applied 
independent of any other service.
    Response: As indicated in our proposed rule, we analyzed data on 
the use of CPT code 97010. As a result, we identified the distribution 
of CPT code 97010 across specialties and occurrences with other 
procedures. Hot or cold packs were billed by physical therapists, 
occupational therapists, orthopedic surgeons, physical medicine and 
rehabilitation specialists, and many other specialties.
    Our data indicate that the vast majority (approximately 95 percent) 
of hot or cold packs were administered in conjunction with other 
services. Thus, we continue to believe that our data justifies our 
proposal to bundle payment for CPT code 97010 with other services 
performed on the same patient on the same day.
    Comment: Although some commenters supported the bundling of payment 
for CPT code 97010 with other services, they stated that the RVUs 
should be distributed only across other procedures in the CPT code 
97000 series. They concluded that because the use of hot or cold packs 
was not considered in the original RVUs for physical medicine and 
rehabilitation, the value for CPT code 97010 should be included only 
with CPT codes 97012 through 97799.
    Response: As noted above, our analysis indicates that the use of 
hot or cold packs is distributed across many other specialties and 
frequently occurs with a variety of other procedures. Therefore, we 
believe that the most equitable distribution of the RVUs assigned to 
CPT code 97010 is across all services. As we noted, the impact of the 
values for this procedure, distributed across all procedures, is 
minimal.
    Comment: One commenter was concerned about compensating 
practitioners for the supply costs associated with the use of hot and 
cold packs.
    Response: We believe the practice expense costs are very low for 
hot and cold packs. Further, the entire RVUs for CPT code 97010 were 
reallocated including the physician work and the practice expense 
components. Thus, the supply costs are included in the practice expense 
RVUs allocated to other codes.
    Comment: One commenter opposed the inclusion of this modality with 
other codes because use of this modality requires the professional 
skill of a trained therapist.
    Response: Other commenters did not express this concern. In many 
States, therapy assistants with considerably less training than 
therapists may administer these modalities. In institutional settings, 
health care workers other than trained professional therapists also 
administer these modalities. Also, both hot and cold packs are 
available to patients to use in the home and are safely used in this 
setting.
    Comment: One commenter stated that hydrocollator packs should be 
treated differently from self administered hot packs.
    Response: Hydrocollator packs are a type of hot pack that typically 
contains silicon dioxide encased in a canvas covering. It is heated by 
immersion in very hot water. This type of heat pack is still considered 
to be a superficial heat modality and is generally therapeutically 
equivalent to other types of hot packs.
    Comment: We received one comment with unequivocal support for 
bundling payment for CPT code 97010 with payment for other services. 
This commenter, representing a large professional organization, 
concurred based on the belief that these packs do not require the same 
level of professional involvement as do other physical therapy 
modalities, and they represent a precursor to other covered 
interventions.
    Response: We appreciate the support for our proposed policy.
    Final Decision: In response to the comments, we revisited the CPT 
code 97010 utilization data and found no new information to justify 
changing our proposal. Therefore, payment for procedure 97010 will be 
bundled into the payment for other services, and the status indicator 
will be changed to ``B''.
    This policy change does not require a change in the text of the 
regulations.
2. Dermatology Procedures
a. Bundling of Repair Codes into Excision Codes
    Currently, the RVUs for the dermatology excision codes (CPT codes 
11400 through 11446 and 11600 through 11646) include RVUs for services 
described by the simple repair codes (CPT codes 12001 through 12018). 
We proposed to cease paying separately for other types of repair codes 
when billed in conjunction with excision codes. We proposed to bundle 
the RVUs for the intermediate and complex repair codes (CPT codes 12031 
through 12057 and 13100 through 13152, respectively) into both the 
benign and malignant skin lesion excision codes (CPT codes 11400 
through 11446 and 11600 through 11646, respectively). Under our 
proposal, we would redistribute the RVUs for the repair codes across 
CPT codes 11400 through 11446 and 11600 through 11646. We would base 
the number of RVUs for redistribution on the frequency with which the 
repair codes are billed with the excision codes.
    We did not propose to assign these repair codes a ``B'' status 
indicator

[[Page 59501]]

because we acknowledged that these codes are not used exclusively with 
excision services. Instead, we would implement this policy change by 
establishing edits in our claims processing systems that would deny 
payment for a repair code billed on the same date of service as a claim 
for payment for an excision of a skin lesion. This change would 
standardize our policy for payment for wound closure.
    Comment: Commenters opposed the proposal to cease paying separately 
for the intermediate and complex repair codes when billed in 
conjunction with the excision codes. They argued that an average 
payment was not appropriate because the same payment would be made for 
services having substantial differences in physician work. In addition, 
some commenters noted that coding separately for the intermediate and 
complex repair codes corresponded to CPT definitions.
    Response: As a result of our review of the comments on this issue, 
we have decided not to implement this proposal. We agree that there is 
an established hierarchy of work RVUs associated with the families of 
excision of skin lesion codes that would be disrupted by the bundling 
of RVUs for the intermediate and complex repair codes.
    We believe, however, that the definitions of a simple and an 
intermediate repair code need clarification to reflect the differences 
in physician work for these procedures.
    The CPT definitions of simple and intermediate repairs include the 
following:
    Simple repair is used if the wound is superficial; for example, 
involving primarily epidermis or dermis, or subcutaneous tissues 
without significant involvement of deeper structures, and requires 
simple one layer closure/suturing.
    Intermediate repair includes the repair of wounds that, in addition 
to the above, require layered closure of one or more of the deeper 
layers of subcutaneous tissue and superficial (non-muscle) fascia, in 
addition to the skin (epidermal and dermal) closure.
    We do not believe these definitions appropriately distinguish 
simple repairs (which are not separately reported and paid when 
performed after the excision of a skin lesion) from intermediate 
repairs (which are separately reported and paid when performed after 
the excision of a skin lesion) because they allow the reporting of the 
intermediate repair codes for the placement of a single suture in the 
subcutaneous tissue. We do not believe such a suture involves 
significantly more work than a simple one layer closure. Therefore, we 
do not believe the intermediate repairs should be reported in addition 
to the excision codes if the only additional work is a layered closure 
of the subcutaneous tissue.
    We believe the distinction between a simple and intermediate repair 
should be based on anatomical levels of repair. Based on this 
principle, a simple repair should be used if the wound involves the 
skin and subcutaneous tissue and an intermediate repair should be used 
for closure of one or more of the deeper fascial layers, in addition to 
the skin and subcutaneous tissue. For Medicare reporting purposes, 
these definitions will be the basis of payment for the reporting of 
repair codes with excision codes effective January 1, 1997. This 
clarification should reduce the potential for misuse of intermediate 
repair codes. If not, we may need to reconsider this proposal in the 
future.
    Final Decision: We will continue to allow separate payment for the 
intermediate and complex repair codes (CPT codes 12031 through 12057 
and 13100 through 13152, respectively) if they are reported with the 
excision codes. However, we will no longer follow the CPT definitions 
of simple and intermediate repairs. We will follow the revised 
definitions described above while we work with the CPT Editorial Panel 
to incorporate these definitions in the next annual update of the CPT.
b. Skin Lesion Destruction Codes
    There are several CPT codes that describe the destruction of 
various benign or premalignant skin lesions. Within this group of 
codes, the reporting methods vary. We proposed to simplify the 
reporting of and payment for the destruction of benign or premalignant 
skin lesions by assigning a ``G'' status indicator to CPT codes 11050 
through 11052, 11200 and 11201, 17000 through 17105, 17110, and 17200 
and 17201 to indicate that these CPT codes are not valid for Medicare 
purposes and that there is another code to use for the reporting of and 
payment for these services.
    To report the destruction of benign and premalignant skin lesions, 
we proposed to create two HCPCS codes. The first code would describe 
the destruction of up to and including 15 lesions. The second code 
would describe the destruction of each additional 10 lesions. To assign 
RVUs to these codes, we proposed to take a weighted average of the RVUs 
assigned to CPT codes 11050 through 11052, 11200 and 11201, 17000 
through 17105, 17110, and 17200 and 17201 based on the billing 
frequencies and the code descriptors.
    Comment: Several commenters opposed the proposal to combine the 
numerous CPT codes that describe the destruction of various benign or 
premalignant lesions into two HCPCS codes because the work RVUs for 
these procedures are not similar. In addition, some commenters noted 
that the destruction of benign or malignant lesions is a separate 
procedure from paring or curettement of benign hyperkeratotic skin 
lesions.
    Response: In general, we agree that our proposal would consolidate 
services with a wide range of work RVUs and have decided to modify our 
proposal accordingly. We also agree that distinct codes for paring or 
curettement of benign hyperkeratotic skin lesions is appropriate.
    We intend, however, to consolidate the CPT codes with similar work 
RVUs--the destruction of benign or premalignant lesions (CPT codes 
17001 through 17105).
    Comment: Some commenters stated that the proposal would introduce 
administrative problems for claim submission since a dual coding system 
would be needed for Medicare and other insurers.
    Response: We acknowledge that the creation of codes for Medicare 
purposes only might create some administrative problems. However, we 
believe these problems are significantly outweighed by the problems 
associated with the confusing and inconsistent terminology of the 
existing CPT codes for the destruction of benign or premalignant 
lesions (CPT codes 17001 through 17105). Within this group of codes, 
the reporting methods vary and create the potential for misuse. Some 
codes describe the destruction of a single lesion but require reporting 
multiple codes for the destruction of several lesions; other codes 
describe destruction of one or more ``complicated'' lesions regardless 
of the number of lesions destroyed. Thus, it is sometimes not clear how 
many codes to report.
    For example, to report the destruction of 4 benign facial lesions 
and 11 premalignant lesions, a physician must use a combination of 3 
CPT codes with varying units of service on the claim form. In contrast, 
to report the destruction of 15 benign lesions on the trunk, a 
physician would only use one code with one unit of service on the claim 
form. Supporting our concern for potential misuse, 1995 utilization 
data indicate that 2.32 percent of allowed services for CPT code 17002 
were for destruction of more than 15 lesions with a range from 16 to 
115 lesions.
    Further support for consolidation of these CPT codes are the

[[Page 59502]]

recommendations from the 1996 RVU refinement panels for only a 0.03 
difference in work for the destruction of premalignant lesions in any 
location (CPT code 17000, final RVU 0.56) and the destruction of benign 
lesions in locations other than the face (CPT code 17100, final RVU 
0.53). See section IV.A.1. of this final rule for a fuller discussion 
of these work RVUs. We do not believe it is necessary to maintain two 
families of codes when the difference in work between the families is 
so small.
    Final Decision: As a result of our review of the comments on this 
issue, we will modify our proposal. We will maintain the active status 
of CPT codes 11050 through 11052, 11200, 11201, 17200, and 17201. 
Preliminary revision of these CPT codes has begun, and we will continue 
working with the CPT Editorial Panel to clarify these CPT codes.
    Codes for the destruction of benign or premalignant lesions will be 
consolidated into one series of codes, regardless of body location. 
Three new HCPCS codes will be used to report the destruction of benign 
or premalignant lesions, and we will assign a ``G `` status indicator 
to CPT codes 17000 through 17105, indicating that these codes will not 
be valid for Medicare purposes. The following temporary codes will be 
effective January 1, 1997:

G0051: Destruction by any method, including laser, with or without 
surgical curettement, all benign or premalignant lesions (for example, 
actinic keratosis), other than skin tags or cutaneous vascular 
proliferative lesions, including local anesthesia; first lesion
G0052: Destruction by any method, including laser, with or without 
surgical curettement, all benign or premalignant lesions (for example, 
actinic keratosis), other than skin tags or cutaneous vascular 
proliferative lesions, including local anesthesia; second through 
fourteenth lesion, each (report in addition to G0051)
G0053: Destruction by any method, including laser, with or without 
surgical curettement, all benign or premalignant lesions (for example, 
actinic keratosis), other than skin tags or cutaneous vascular 
proliferative lesions, including local anesthesia; fifteen lesions or 
over (includes G0051 and G0052)

    The RVUs for these new codes have been derived from the RVUs for 
CPT codes 17000 through 17105 and distributed so that the total number 
of RVUs in the new family of codes will be the same as in the old 
family of codes. The practice expense and malpractice expense RVUs also 
will be distributed to maintain budget neutrality within the family of 
codes, and they will be proportionate to the work RVUs. Thus, this 
coding change will not affect the total payments made for the 
destruction of skin lesions currently reported with CPT codes 17000 
through 17105.
    The codes and RVUs assigned to them, listed in the following table, 
are considered interim, and we will accept comments on them. We will 
continue to work with the CPT Editorial Panel to standardize this 
coding nomenclature and will share comments on our temporary codes with 
the Panel.

----------------------------------------------------------------------------------------------------------------
                                                                                          Practice              
                Code                               Descriptor               Work RVUs     expense    Malpractice
                                                                                            RVUs         RVUs   
----------------------------------------------------------------------------------------------------------------
G0051                                 Destruction skin lesions, first             0.55         0.41         0.04
                                       lesion.                                                                  
G0052                                 Destruction skin lesions, 2nd to            0.18         0.13         0.01
                                       14th lesion.                                                             
G0053                                 Destruction skin lesions, 15 or             3.05         2.25         0.20
                                       more lesions.                                                            
----------------------------------------------------------------------------------------------------------------

    This policy change does not require a change in the text of the 
regulations.

E. Change in Coverage Status for Screening and Obsolete Procedures

1. Vital Capacity Testing
    CPT code 94150 (Vital capacity, total) is a screening measure and 
is typically performed on patients who are asymptomatic. Because these 
tests are performed on patients who do not have symptoms of breathing 
problems, they represent preventive services that are, by statute, not 
covered by Medicare. However, we inadvertently failed to identify CPT 
code 94150 as noncovered by Medicare. With limited exceptions, sections 
1862(a)(1)(A) and 1862(a)(7) of the Act preclude Medicare coverage for 
screening services. Therefore, we proposed changing the status 
indicator for CPT code 94150 from ``A'' to ``N'' to represent its 
noncovered status.
    Comment: Two commenters expressed the opinion that the proposal was 
in error because vital capacity tests may have some clinical utility in 
monitoring patients who have either congestive heart failure or 
restrictive lung disease. One commenter indicated that vital capacity 
tests might be performed as part of the screening of asymptomatic 
patients for industrial exposure but suggested that most measurements 
of this type are performed on patients to monitor their symptoms or 
underlying disease process. Another commenter stated that a physician's 
charge for performing a simple measurement of vital capacity (CPT code 
94150) should be less than the charge for a full spirogram (CPT code 
94010) because the first test is an integral part of the second test.
    Response: Based on our further evaluation of this issue, we have 
concluded that a simple vital capacity measurement by itself may 
provide a physician with a ``partial look'' when monitoring a patient 
with pulmonary disease or congestive heart failure either as clinical 
documentation, or when assessing a response to therapeutic 
interventions. As a stand-alone service, however, we understand that 
this test provides only a partial assessment of a patient's ventilatory 
function and, thus, has outlived its clinical usefulness. In addition, 
we understand that the information provided by this measurement should 
be readily evident from a carefully performed physical examination of 
the patient and from simple maneuvers at the time of examination (for 
example, in the case of a pulmonary disease patient, a walking test or 
blowing up a balloon).
    Final Decision: Based on our review of the comments received and 
further consultation with our medical staff, we have decided to modify 
our original proposal. Instead of changing the coverage status for 
vital capacity tests from ``active'' to ``noncovered,'' we will change 
it from ``active'' to ``bundled'' to indicate that payment for a 
particular procedure will always be bundled into payment for other 
services furnished to Medicare patients. Simple vital capacity tests 
(CPT code 94150) by themselves are generally considered to be 
clinically incomplete and have outlived their usefulness. To the extent 
that these tests are still performed in medical practice, however, we 
understand that they are routinely performed as a small part of a more 
comprehensive physician's examination of a pulmonary disease or 
congestive heart failure patient. Therefore, we believe it is 
appropriate to

[[Page 59503]]

bundle Medicare payment for these measurements into the payment for 
evaluation and management services.
    In addition, we received a RUC recommendation to decrease the work 
RVUs from 0.11 to 0.07. For a discussion of this recommendation and our 
decision on work RVUs, see section IV.A.15. of this final rule.
    This policy change does not require a change in the text of the 
regulations.
2. Certain Cardiovascular Procedures
    Based on the American College of Cardiology's recommendation, our 
review of recent claims history data, and our consultation with other 
medical specialty groups, we proposed to discontinue coverage for 10 
phonocardiography and vectorcardiography diagnostic tests (CPT codes 
93201 through 93222) that are outmoded and of little clinical value. We 
proposed changing the status indicators for these 10 procedures from 
``A'' to ``N'' to reflect their noncovered status.
    Comment: Two commenters recommended that we clarify the meaning of 
the ``N'' status indicator that was proposed to reflect the noncovered 
status of phonocardiography and vectorcardiography diagnostic tests. 
They expressed confusion as to whether status indicator ``N'' meant 
that the cardiovascular services in question were being excluded from 
Medicare coverage based on the statutory reasonable and necessary 
exclusion in section 1862(a)(1)(A) of the Act, or some other statutory 
exclusion such as section 1862(a)(7) of the Act, which applies to 
routine physical checkups and refractions. The commenters pointed out 
that the statutory basis for the exclusion is important because it 
determines whether the physician is required to file a claim for the 
service and whether the patient must sign a waiver of liability 
statement and, thus, be held financially responsible to the physician 
for payment for the service. They suggested that we may want to 
establish unique status indicators for medical procedures that are 
precluded from coverage based on different statutory exclusions.
    Response: The statutory basis for our proposal to discontinue 
Medicare coverage for the 10 cardiovascular tests should have been 
specifically identified in our preamble of the proposed rule that was 
published on July 2, 1996. In view of the comments received from the 
American College of Cardiology that these tests are outmoded and of 
little clinical value, our proposal to end coverage of these tests was 
based on the assumption that they are no longer considered to have 
clinical utility for Medicare patients, and, thus, should be precluded 
from payment by section 1862(a)(1)(A) of the Act (the reasonable and 
necessary exclusion). Accordingly, under our proposal, physicians would 
have to treat Medicare denials of claims for the 10 cardiovascular 
tests in question as medical necessity denials under section 
1862(a)(1)(A) of the Act.
    Since the physician fee schedule was established in 1992, the ``N'' 
status indicator has always meant that the procedures in question were 
not covered under Medicare because of one or more statutory exclusions 
in the law (for example, either section 1862(a)(1)(A) of the Act or one 
of the other statutory coverage exclusions.) We do not believe it would 
be appropriate to establish unique status indicators in the physician 
fee schedule for various noncovered medical procedures based on 
different statutory exclusions for several reasons. First, the primary 
purpose of the physician fee schedule is to provide general Medicare 
payment information on more than 7,000 medical procedures to the 
physician community and other interested parties and not to provide 
specific claims processing information that Medicare carriers are 
required to provide to the medical community in their localities under 
their Medicare contracts. Second, in the case of certain medical 
procedures (for example, noncovered screening services), it is possible 
for a national noncoverage decision to be based on more than one 
statutory exclusion. It would unduly complicate the status indicator 
process if we had to explain these unique situations.
    Final Decision: We are adopting our proposal to discontinue 
coverage for the 10 phonocardiography and vectorcardiography procedures 
because we did not receive any negative comments. However, we will 
delete the 10 codes from the 1997 fee schedule rather than change the 
status indicators from ``A'' to ``N'' to reflect their noncovered 
status because these codes have been deleted from the American Medical 
Association's Physician's Current Procedural Terminology for 1997. Any 
Medicare claims submitted by physicians for these cardiovascular 
procedures under a miscellaneous code will be denied by local Medicare 
carriers. We will issue instructions to Medicare carriers regarding the 
noncoverage status of these procedures.
    This policy change does not require a change in the text of the 
regulations.

F. Payments for Supervising Physicians in Teaching Settings

1. Definition of Approved Graduate Medical Education Programs
    Since publication of the December 8, 1995 (60 FR 63182) final rule, 
we have received questions about the difference in the definition of an 
approved residency program for purposes of the teaching physician rules 
under Sec. 415.152 (``Definitions'') and the definition used in the 
direct medical education rules under Sec. 413.86(b) (``Direct graduate 
medical education payments''). To be consistent, we proposed to modify 
Sec. 415.152 to match the definition of an approved graduate medical 
education program in Sec. 413.86(b). We proposed adding a reference to 
programs that are recognized as an ``approved medical residency 
program'' under Sec. 413.86(b). By making this change, the regulations 
text will reflect a common definition of approved graduate medical 
education programs for Medicare Part A and Part B. This is a technical 
change and will have no effect on the implementation of our revised 
policy regarding the payment for supervising physicians in teaching 
settings that is effective July 1, 1996.
    Comment: Commenters, including an organization representing 
physicians in a subspecialty of internal medicine, objected to this 
proposal because residents in subspecialty programs (often called 
``fellows'') who provide direction to interns and residents would be 
included in the definition of residents in an approved program. The 
organization argued that fellows are teaching physicians who must be 
allowed to bill for their direction of interns and residents. A few of 
the commenters objected to the proposal and suggested that each 
individual residency program should be allowed to decide whether to 
bill for the services as physicians' services or to have the services 
included in the hospital's count used to compute direct graduate 
medical education payments since a teaching hospital may receive only 
partial credit for its advanced residents in some cases. The commenter 
pointed out that this approach was consistent with our policy for 
services when furnished in nonprovider settings (section 1886(h)(4)(E) 
of the Act and Sec. 413.86(f)(1)(iii)).
    Response: Contrary to the suggestion of the commenters, we are not 
changing our policy on the definition of an approved residency program 
for purposes of determining payments for the services of teaching 
physicians. Rather, we proposed to revise the

[[Page 59504]]

regulations text because questions have been raised about the different 
language used to define an approved residency program in different 
contexts. We believe it is reasonable and appropriate to have 
consistent definitions and, in fact, it would make little sense to 
apply one definition of an approved residency program in one context 
and a substantively different definition in another context.
    It is our position that, to the extent Medicare pays for the 
services of residents in an approved residency program under section 
1886(h) of the Act, we should not make a separate Medicare Part B 
payment for the same services under the physician fee schedule. We see 
no reason to treat fellows in a way that is different from other 
residents. ``Fellows'' are residents in subspecialty programs, and the 
costs of fellows, like other residents, are addressed by section 
1886(h) of the Act. Section 1886(h)(5)(A) of the Act specifically cites 
subspecialty programs. While we understand the comments about the 
partial crediting of residents beyond their initial residency period 
limitation, this reflects a judgment by the Congress concerning the 
appropriate level of Medicare payment for such activities. As was 
pointed out in the preamble discussion in the September 29, 1989 final 
rule (54 FR 40312) on the direct graduate medical education payment 
provision:

    We believe that the enactment of section 1886(h) of the Act was 
a clear statement from the Congress that a limitation on the growth 
in Medicare GME expenditures was necessary. Further, although not 
explicitly stated, it reflects a decision on the part of the 
Congress to focus reductions on subspecialty programs beyond the 
initial residency periods rather than on primary care programs.

We believe it would be inappropriate to allow Medicare Part B billing 
for the services of fellows simply because Congress has chosen to limit 
the amount of GME payments for such activities. We note that teaching 
physicians that involve these residents or fellows in the care of the 
teaching physician's patients can bill Medicare Part B if the criteria 
addressed in the December 8, 1995 final rule are met.
    Final Decision: We will revise the regulations text as proposed.
2. Evaluation and Management Services Furnished in Certain Settings
    In the December 8, 1995 final rule (60 FR 63135), we revised our 
policy regarding the payment for supervising physicians in teaching 
settings. We eliminated the attending physician criteria but clarified 
the physician presence requirement for services billed to the Medicare 
carrier. As part of our revised policy, we created a limited exception 
for residency programs that are fundamentally incompatible with a 
physical presence requirement. The exception to the physician presence 
requirement is for certain evaluation and management services (CPT 
codes 99201, 99202, 99203, 99211, 99212, and 99213) furnished in 
ambulatory care centers within the context of specific types of 
residency training programs. The exception is set forth in Sec. 415.174 
(``Exception: Evaluation and management services furnished in certain 
centers'').
    As the exception currently reads, one of the criteria is that ``The 
range of services furnished by residents in the center includes * * * 
Comprehensive care not limited by organ system, diagnosis, or gender.'' 
(Sec. 415.174(a)(4)(iii)). It has come to our attention that many 
obstetric and gynecological residency programs have been restructured 
over the years to have a greater primary care focus. Some of these 
programs that otherwise qualify for an exception might be denied 
payment if the gender limitation were strictly applied.
    Contrary to suggestions in correspondence we received after 
publication of the final rule, it was not our intention to prevent 
obstetric and gynecological residency programs or other residency 
programs focusing on women's health care from qualifying for the 
exception solely because of the patient's gender. Thus, we proposed to 
make a technical change to the regulations text to delete the reference 
to gender in Sec. 415.174(a)(4)(iii) and change the text to 
``Comprehensive care not limited by organ system or diagnosis.'' Of 
course, such programs must satisfy the otherwise applicable criteria to 
qualify for an exception.
    Comment: All of the commenters supported the proposal to delete the 
word ``gender'' from the primary care exception criteria.
    Response:
    We agree with the commenters.
    Final Decision:
    We will delete the word ``gender'' from the primary care exception 
criteria in Sec. 415.174(a)(4)(iii). We will not include the word 
``gender'' in any program directive on the primary care exception.

G. Change in Global Periods for Four Percutaneous Biliary Procedures

    The Society of Cardiovascular and Interventional Radiology advised 
us that a 90-day global period is inappropriate for four percutaneous 
biliary procedures. The four procedures are CPT codes 47490 
(percutaneous cholecystectomy), 47510 (introduction of percutaneous 
transhepatic catheter for biliary drainage), 47511 (introduction of 
percutaneous transhepatic stent for internal and external biliary 
drainage), and 47630 (biliary duct stone extraction, percutaneous via 
T-tube tract, basket, or snare (for example, Burhenne technique)). The 
Society believes that these four procedures should have a ``0-day'' 
global period. We agreed with the Society's arguments that a 90-day 
global period is contrary to the widespread practice conventions of 
percutaneous biliary intervention and is inconsistent with other 
similar interventions in the biliary tract and urinary tract.
    We believed that the global periods for these four codes should be 
changed. Therefore, we proposed changing the global periods for these 
services from 90 days to 0 days. To make this change, we proposed to 
reduce the work RVUs assigned to these procedures to reflect the lack 
of postsurgical work in the shortened global period. We proposed to 
reduce the work RVUs for CPT codes 47490, 47510, 47511, and 47630 by 17 
percent if we changed the global periods. The 17 percent figure (as the 
measure of the postsurgical work associated with these codes) was taken 
from the original data in a study by the Harvard School of Public 
Health (``A National Study of Resource-Based Relative Value Scales for 
Physician Services'').
    Comment: Several commenters indicated that, while they agreed with 
the proposal to reduce the global surgery period from 90 days to 0 days 
for the percutaneous biliary procedures under CPT codes 47490, 47510, 
47511 and 47630, they disagreed with reducing the work RVUs by 17 
percent to take into account the portion of the current RVUs 
attributable to postsurgical work. One physician organization indicated 
that a global period of 0 days was assumed in the Harvard study of CPT 
code 47630 and that the Harvard study included these procedures in its 
study of general surgeons rather than interventional radiologists. The 
Society of Cardiovascular and Interventional Radiology commented that 
its 1991 recommendations on these procedures, based on surveys by a 
consulting firm, were made without the inclusion of postsurgical work 
in the RVUs, and that reducing RVUs would lower the value of these 
procedures relative to analogous endoscopic procedures in the biliary 
tract.

[[Page 59505]]

    Response: We reviewed the data in the Harvard study to determine 
whether a global period of 0 days was assumed for CPT code 47630. Three 
of the codes (CPT codes 47490, 47510 and 47630) were studied and all 
three were assumed to have 90 day global periods. The fourth code (CPT 
code 47511) was new in 1992 and was not part of the Harvard study.
    The following table shows the percent of total work associated with 
each of the components of work for which Harvard provided data:

                                       Percent of Total Work by Component                                       
----------------------------------------------------------------------------------------------------------------
                                                                              Post-        Post-        Post-   
                                                     Pre-        Intra-     operative    operative    operative 
                      Code                        operative    operative     same day     hospital      office  
                                                  (percent)    (percent)    (percent)    (percent)    (percent) 
----------------------------------------------------------------------------------------------------------------
47490..........................................           10           40            8           33            9
47510..........................................           16           36           12           19           17
47630..........................................           10           56            9           14           11
----------------------------------------------------------------------------------------------------------------

These data show that if the current RVUs were based on Harvard data and 
we were to reduce the global period from 90 days to 0 days, we would 
need to reduce the RVUs by the amount attributed to postoperative 
hospital work (other than the same day) and postoperative office work. 
For these three codes, the reductions would not be 17 percent as 
described in our proposal but 42 percent for CPT code 47490, 36 percent 
for CPT code 47510 and 25 percent for CPT code 47630.
    We also reviewed the results of the refinement panel meeting held 
in May 1992 for CPT codes 47510, 47511 and 47630. CPT code 47490 was 
not reviewed by the refinement panel. For the insertion of a catheter 
in a bile duct (CPT code 47510), we agreed that the work is equivalent 
to the work of inserting a drainage tube endoscopically (CPT code 
43267). For inserting a stent for biliary drainage (CPT code 47511), we 
agreed that the work was more than the work of the comparable 
endoscopic procedure (CPT code 43267) and assigned a higher RVU. We did 
not accept the argument that the global period should be reduced from 
90 to 0 days, because we believed a physician performing this procedure 
should be responsible for following the patient even if other 
physicians are involved in the care of the patient. For the extraction 
of a bile duct stone (CPT code 47630), the RVUs that emerged from the 
panel's ratings were less than the corresponding endoscopic procedure 
(CPT code 43264).
    We also reviewed the RVUs assigned to the radiological supervision 
and interpretation (S & I) codes that are reported in addition to the 
procedure codes. These codes are not used with endoscopic procedures. 
In stating that the percutaneous biliary procedures should have 
comparable global periods and RVUs to endoscopic procedures, the 
commenter appears to have overlooked the additional RVUs associated 
with the supervision and interpretation codes. The following table 
shows the codes and RVUs associated with each of the codes and the 
total RVUs associated with the complete percutaneous procedures.

------------------------------------------------------------------------
                                                                 Total  
                                     RVUs for    S&I    RVUs    RVUs for
          Procedure codes           procedure   codes    for    complete
                                                         S&I   procedure
------------------------------------------------------------------------
47450.............................      6.04    75989    1.19      7.23 
47510.............................      7.39    75980    1.44      8.83 
47511.............................      9.91    75982    1.44     11.35 
47630.............................      8.31    74327    0.70      9.01 
------------------------------------------------------------------------

    Based on our re-analysis of the Harvard study data, the May 1992 
refinement panel results and the total RVUs associated with these 
procedures, we now believe that a change in global periods from 90 to 0 
days may be inappropriate because of uncertainty about the reduction in 
RVUs, if any, that should be made in conjunction with the change in 
global periods.
    Final decision: We will maintain the current global period of 90 
days and the current RVUs for these four percutaneous biliary 
procedures. We plan to refer to the Relative Value Update Committee for 
its consideration the issue of work RVUs and global periods for 
procedures that can be performed endoscopically, percutaneously, and 
open. For a more detailed discussion of our plans to review these 
procedures, see section IV.C.4 of this final rule.

III. Refinement of Relative Value Units for Calendar Year 1997 and 
Responses to Public Comments on the Five-Year Review of Work Relative 
Value Units

A. Summary of the Development of Physician Work Relative Value Units

    We discussed in detail the development of the concepts and 
methodology underlying the physician fee schedule in our May 3, 1996 
proposed notice (61 FR 19993 through 19994).

B. Scope of the Review

    This final rule is the culmination of the 5-year review of work 
RVUs required by section 1848(c)(2)(B)(i) of the Act. The work RVUs 
affected by this review will be effective for services furnished 
beginning January 1, 1997.
    We initiated the 5-year review by soliciting public comments on all 
work RVUs for approximately 7,000 CPT/HCPCS (HCFA Common Procedure 
Coding System) codes published in our December 8, 1994 final rule (59 
FR 63410). The process for evaluating codes included in the 5-year 
review involved the same basic methodology as the process for the 
annual physician fee schedule update, with some important changes. 
Because the 5-year review involved evaluating the physician work of 
established codes with established work RVUs, we required compelling 
arguments to support changes from the existing assignment of work RVUs. 
To gather evidence to support these arguments, in addition to comparing 
the total physician work involved in the services under review to key 
reference services, we asked commenters to provide a detailed 
comparison of the preservice, intraservice, and postservice time 
involved in the key reference services selected. For this purpose, for 
surgical procedures, we further divided postservice time into time on 
the day of the procedure, time in the intensive care unit, hospital 
visits, and office or other outpatient visits following discharge.
    We also requested comments regarding other elements of physician 
work, in addition to time, and the extent to which the service had 
changed over the last 5 years. We considered the commenters' statements 
regarding the complexity of each nontemporal component for the services 
under review and the services used as key

[[Page 59506]]

references. The nontemporal components of work are the physician's 
mental effort and judgment, technical skill and physical effort, and 
stress resulting from the risk of mortality or iatrogenic harm to the 
patient. We also considered whether the service had changed over the 
past 5 years as the result of one of the following conditions: new 
technology that had become more familiar to physicians, the service 
having been furnished to patients who had more or less complex medical 
conditions, or a change in the site where the service had usually been 
furnished.
    During the comment period, we received more than 500 public 
comments on approximately 1,100 individual codes. In addition, three 
specialty societies (the American Academy of Orthopedic Surgeons, the 
American Society of Anesthesiologists, and the American Academy of 
Otolaryngology--Head and Neck Surgery, Inc.) submitted studies 
conducted for them by Abt Associates, Inc., which spanned all of the 
more than 2,000 codes used by physicians in those specialties. The 
American Academy of Pediatrics also submitted comments asserting that 
the physician work involved in furnishing 480 services to pediatric 
patients is different than the physician work involved in furnishing 
the same services to adult patients.
    After a preliminary screening, we referred approximately 3,500 
codes to the AMA Specialty Society Relative Value Update Committee 
(RUC) for its review. The codes included those found in public comments 
(700 codes), the American Academy of Pediatrics' comments (480 codes); 
three special studies by Abt Associates, Inc. (about 2,000 codes); and 
those we identified as potentially misvalued (300 codes).
    The RUC was formed in November 1991 and grew out of a series of 
discussions between the AMA 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 AMA, 
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 AMA's House of 
Delegates.
    We shared the comments we received with the RUC, which currently 
makes recommendations to us on the assignment of RVUs to new and 
revised CPT codes and offered to advise us on the assignment of RVUs to 
procedures for which we received substantive comments. We believed that 
the RUC's perspective would be helpful because of the RUC's experience 
in recommending RVUs for the codes that have been added to, or revised 
by, the CPT since we implemented the physician fee schedule in 1992. 
Furthermore, the RUC, by virtue of its multispecialty membership and 
consultation with approximately 65 specialty societies, represents the 
family of medicine in the refinement process.
    We wish to acknowledge the extraordinary efforts of the RUC, the 
RUC Advisory Committee, the HCPAC, the specialty societies and the 
staffs of these organizations in assisting us in the completion of this 
5-year review process. While we did not delegate to the RUC or any 
other organization our responsibility for analyzing the comments and 
deciding whether to revise RVUs, it is doubtful that we could have 
completed the 5-year review in a timely manner and with such extensive 
clinical input without their assistance.
    In our May 3, 1996 proposed notice (61 FR 19992), we identified 
more than 1,000 codes included in the 5-year review and for which we 
had received recommendations from the RUC for work RVUs. With this 
notice, we provided the public with an opportunity to comment on our 
proposed work RVUs for these codes.
    We divided the CPT codes into clinical groups and another group 
containing all the codes identified by the RUC as potentially 
overvalued services. (Additional codes from the Abt Associates, Inc. 
studies and from the American Academy of Pediatrics' comments were 
discussed in sections II.C.2. and II.C.3. of the May 3, 1996 proposed 
notice, respectively.) In addition, the AMA is submitting approximately 
65 CPT codes to its CPT Editorial Panel. The RUC was unable to 
recommend work RVUs for these codes because the services were not 
clearly described or could vary widely from patient to patient. We 
announced our plans to address these codes in a future annual update of 
the physician fee schedule.
    The following is a categorization of our decisions and how they 
related to the comments received from the public (including medical 
specialty societies) and the RUC as published in the May 3, 1996 
notice:
     For 28 percent of the codes, we proposed to increase the 
work RVUs.
     For 61 percent of the codes, we proposed to maintain the 
current work RVUs. We also proposed to maintain the values for the 
anesthesia codes.
     For 11 percent of the codes, we proposed to decrease the 
work RVUs.

Our proposed work RVUs agreed with the RUC recommendations for 93 
percent of the codes.

C. Review of Comments (Includes Table 1--Work Relative Value Unit 
Refinements of Five-Year Review Codes Commented on in Response to the 
May 3, 1996 Proposed Notice)

    During the comment period for our May 3, 1996 proposed notice, we 
received more than 2,900 public comments on approximately 133 codes 
plus all anesthesia services. Over 2,000 of these comments addressed 
our not having accepted the RUC recommendations for evaluation and 
management services.
    We convened three multispecialty panels of physicians to assist us 
in the review of the comments. The comments that we did not submit to 
panel review are discussed at the end of this section as well as those 
that we did send to the panels. The panels were 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. This same clinician also provided ratings for the other 
procedures being considered. Thus, depending on the codes in question, 
this clinician was in one of two groups: ``specialist'' or ``other 
specialist.'' 19 specialty societies and one individual commenter, 
including primary care, were represented on the panels.
     Primary care clinicians nominated by the American Academy 
of Family Physicians, the American Society of Internal Medicine, the 
American College of Physicians, the American Osteopathic Association, 
the American Academy of Pediatrics, and the American College of 
Obstetricians and Gynecologists.
     Carrier medical directors.
    We submitted 33 codes for evaluation by the panels. 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 the 
panel members to compare the clinical aspects of the work of services 
they believed were incorrectly valued to one or more of the reference 
services. In compiling the reference 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

[[Page 59507]]

be represented. The set listed approximately 300 services. Panelists 
were encouraged to make comparisons to these 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 reach consensus among the panel members.
    We then analyzed the ratings based on a presumption that the 
proposed notice RVUs were correct. To overcome this presumption, the 
inaccuracy of the proposed 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 proposed RVUs. We did not modify the RVUs unless there was a 
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 three 
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 33 codes reviewed by our multispecialty panels, all of the requests 
were for increased values.
    We also received comments that we did not submit to the panels for 
review for a variety of reasons. These comments are discussed in 
section IV.B of this final rule. Of the 131 proposed RVUs that were 
reviewed, approximately 60 percent were increased, 13 percent were 
decreased, and 27 percent were not changed. These numbers excluded the 
changes that were made to the anesthesia services. The anesthesia 
changes are discussed in section IV.B.3. of this final rule.

Table 1--Work Relative Value Unit Refinements of Five-Year Review Codes 
Commented on in Response to the May 3, 1996 Proposed Notice

    Table 1 lists the codes reviewed during this 5-year review process 
described in this section. This table includes the following 
information:
     CPT/HCPCS (HCFA Common Procedure Coding System) Code. This 
is the CPT or alphanumeric HCPCS code for a service.
     Mod (Modifier). A modifier -26 is shown if the work RVUs 
represent the professional component of the service.
     Description. This is an abbreviated version of the 
narrative description of the code.
     Proposed Work RVU. This column includes the work RVUs 
proposed in the May 3, 1996 proposed notice for each reviewed code.
     Requested Work RVU. 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. This table lists the highest requested RVUs. For some codes, we 
received recommendations for an increase but by no specific RVU 
recommendations.
     RUC Recommendation. This column identifies the work RVUs 
recommended by the RUC if the RUC made a recommendation as part of its 
comments on the May 3, 1996 proposed notice.
     1997 Work RVU. 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 proposed work RVUs published in the May 3, 1996 
proposed notice should be retained (indicator 1);
--A new value emerged from our analysis of the refinement panel ratings 
(indicator 2);
--A new or retained value came from the review of a comment (indicator 
3);
--A new value came from the need to make a rank order change to 
maintain or correct existing relationships among services (indicator 
4);
--A value is retained because the code has been referred back to the 
CPT Editorial Panel (indicator 5);
--A new value came from adjusting the work of services with MMM global 
periods as a result of changes in evaluation and management service 
work RVUs (indicator 6); or
--There is no value because of a 1997 CPT coding change that deletes 
the code (indicator 7). These deleted codes were replaced by new 1997 
CPT codes.

                  Table 1.--Work RVU Refinements of Five-year Review Codes Commented on in Response to the May 3, 1996 Proposed Notice                  
--------------------------------------------------------------------------------------------------------------------------------------------------------
   CPT/HCPCS                                                               Proposed work     Requested          RUC                          Basis for  
     code*       MOD                      Description                           RVU          work RVU     recommendation   1997 work RVU     decision   
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                           Increase work   Increase work   Increase work                
00100-01999...  .....  Anesthesia Services..............................             n/a       by 28.97%       by 22.76%      by 22.76%a               3
10040.........  .....  Acne surgery of skin abcess......................            0.80            1.15          Review            1.15               3
11971.........  .....  Remove tissue expander(s)........................            1.51  ..............  ..............          a 1.51               5
13300.........  .....  Repair of wound or lesion........................            5.11  ..............  ..............          a 5.11               5
14300.........  .....  Skin tissue rearrangement........................           10.76  ..............  ..............         a 10.76               5
15000.........  .....  Skin graft procedure.............................            1.95  ..............  ..............           a1.95               5
15101.........  .....  Skin split graft procedure.......................            1.72  ..............  ..............          a 1.72               5
15121.........  .....  Skin split graft procedure.......................            2.67  ..............  ..............          a 2.67               5
15201.........  .....  Skin full graft procedure........................            1.32  ..............  ..............          a 1.32               5
15221.........  .....  Skin full graft procedure........................            1.19  ..............  ..............          a 1.19               5
15241.........  .....  Skin full graft procedure........................            1.86  ..............  ..............          a 1.86               5
15261.........  .....  Skin full graft procedure........................            2.23  ..............  ..............          a 2.23               5

[[Page 59508]]

                                                                                                                                                        
15570.........  .....  Form skin pedicle flap...........................            3.75            9.85            8.39            8.39               2
15572.........  .....  Form skin pedicle flap...........................            3.80            9.63            8.59            8.59               2
15574.........  .....  Form skin pedicle flap...........................            3.85           10.50            8.79            8.97               2
15576.........  .....  Form skin pedicle flap...........................            4.27            8.50            7.85            8.14               2
15580.........  .....  Attach skin pedicle graft........................            5.40            9.00            9.00            8.84               2
15755.........  .....  Microvascular flap graft.........................           28.33           41.68  ..............  ..............               7
17000.........  .....  Destroy benign/premal lesion.....................            0.36            0.64            0.64            0.56             b 2
17001.........  .....  Destruction of add'l lesions.....................            0.14            0.19            0.19            0.19             b 2
17002.........  .....  Destruction of add'l lesions.....................            0.14            0.19            0.19            0.19             b 2
17100.........  .....  Destruction of skin lesion.......................            0.53  ..............  ..............            0.53             b 1
17101.........  .....  Destruction of 2nd lesion........................            0.11  ..............  ..............            0.11             b 1
17102.........  .....  Destruction of add'l lesion......................            0.11  ..............  ..............            0.11             b 1
21025.........  .....  Excision of bone, lower jaw......................            5.03            8.98  ..............            8.98               2
21125.........  .....  Augmentation lower jaw bone......................            6.22           10.00           10.00           10.00             3,4
21270.........  .....  Augmentation cheek bone..........................           12.10            9.56            9.56            9.56             3,4
28010.........  .....  Incision of toe tendon...........................            2.97  ..............            2.71            2.71             3,4
28114.........  .....  Removal of metatarsal heads......................            7.16  ..............            8.65          a 8.65               4
29848.........  .....  Wrist arthroscopy/surgery........................            4.04            5.70  ..............            5.14               2
31090.........  .....  Exploration of sinuses...........................            8.65  ..............  ..............          a 8.65               5
31531.........  .....  Operative laryngoscopy...........................            3.39            3.79  ..............            3.59               2
31536.........  .....  Operative laryngoscopy...........................            3.16            3.56  ..............            3.56               2
31541.........  .....  Operative laryngoscopy...........................            4.13            6.00  ..............            4.53               2
31561.........  .....  Operative laryngoscopy...........................            5.46            8.13  ..............            6.00               2
31571.........  .....  Laryngoscopy with injection......................            3.87            5.90  ..............            4.27               2
33970.........  .....  Aortic circulation assist........................            8.05  ..............            6.75          a 6.75               4
33971.........  .....  Aortic circulation assist........................            4.04  ..............            8.40          a 8.40               4
35556.........  .....  Artery bypass graft..............................           19.37  ..............           19.37          a19.84               4
35566.........  .....  Artery bypass graft..............................           24.45  ..............           24.45         a 25.00               4
35571.........  .....  Artery bypass graft..............................           16.66  ..............  ..............         a 17.14               4
35583.........  .....  Vein bypass graft................................           15.97  ..............           20.03         a 20.50               4
35585.........  .....  Vein bypass graft................................           25.92  ..............           25.95         a 26.47               4
35587.........  .....  Vein bypass graft................................           17.07  ..............  ..............          a17.55               4
35656.........  .....  Artery bypass graft..............................           17.84  ..............           17.84         a 18.42               4
35666.........  .....  Artery bypass graft..............................           15.97  ..............  ..............         a 17.60               4
35671.........  .....  Artery bypass graft..............................           12.18  ..............  ..............         a 13.39               4
35681.........  .....  Artery bypass graft..............................            3.93            8.05  ..............          a 8.05               2
35875.........  .....  Removal of clot in graft.........................            8.19            9.07  ..............           a9.07               2
37201.........  .....  Transcatheter therapy infuse.....................            5.00            7.25            7.25            5.00               1
46900.........  .....  Destruction, anal lesion(s)......................            1.81  ..............  ..............          a 1.81               5
50590.........  .....  Fragmenting of kidney stone......................            7.13            9.62            9.62            8.79               2
54100.........  .....  Biopsy of penis..................................            1.90  ..............  ..............          1.90a                5
56312.........  .....  Laparoscopic lymphadenectomy.....................           12.06           12.10  ..............           12.06               3
56805.........  .....  Repair clitoris..................................           15.49  ..............           18.00         a 18.00               4
57265.........  .....  Extensive repair of vagina.......................            7.36           10.66  ..............           10.66               4
57335.........  .....  Repair vagina....................................            9.11  ..............           18.00         a 18.00               4
58200.........  .....  Extensive hysterectomy...........................           20.34           22.37  ..............           20.34               3
59400.........  .....  Obstetrical care.................................           20.99        Increase  ..............           23.06               6
59409.........  .....  Obstetrical care.................................           13.28        Increase  ..............           13.50               6
59410.........  .....  Obstetrical care.................................           14.44        Increase  ..............           14.78               6
59425.........  .....  Antepartum care only.............................            4.04        Increase  ..............            4.81               6
59426.........  .....  Antepartum care only.............................            6.91        Increase  ..............            8.28               6
59430.........  .....  Care after delivery..............................            2.01  ..............  ..............            2.13               6
59510.........  .....  Cesarean delivery................................           23.67        Increase  ..............           26.22               6
59514.........  .....  Cesarean delivery only...........................           15.39        Increase  ..............           15.97               6
59515.........  .....  Cesarean delivery................................           16.55        Increase  ..............           17.37               6
59525.........  .....  Remove uterus after cesarean.....................            8.54  ..............  ..............            8.54               6
59610.........  .....  Vbac delivery....................................           22.55  ..............  ..............           24.62               6
59612.........  .....  Vbac delivery only...............................           14.84  ..............  ..............           15.06               6
59614.........  .....  Vbac care after delivery.........................           15.96  ..............  ..............           16.34               6
59618.........  .....  Attempted vbac delivery..........................           25.23  ..............  ..............           27.78               6
59620.........  .....  Attempted vbac delivery only.....................           16.95  ..............  ..............           17.53               6
59622.........  .....  Attempted vbac after care........................           18.11  ..............  ..............           18.93               6
63030.........  .....  Low back disk surgery............................           11.10           12.11  ..............           11.10               3
63042.........  .....  Low back disk surgery............................           16.56           17.27  ..............           16.56               3
67210.........  .....  Treatment of retinal lesion......................            9.48  ..............  ..............          a 9.48               5
68820.........  .....  Explore tear duct system.........................            1.47            1.27  ..............  ..............               7

[[Page 59509]]

                                                                                                                                                        
68825.........  .....  Explore tear duct system.........................            1.53            2.25  ..............  ..............               7
68830.........  .....  Reopen tear duct channel.........................            2.12            3.00  ..............  ..............               7
77420.........  .....  Weekly radiation therapy.........................            1.61            1.61  ..............          a 1.61             3,5
77425.........  .....  Weekly radiation therapy.........................            2.44            2.44  ..............          a 2.44             3,5
77430.........  .....  Weekly radiation therapy.........................            3.60            3.60  ..............          a 3.60             3,5
78806.........     26  Abscess imaging, whole body......................            0.73            0.86            0.86            0.86               3
85390.........     26  Fibrinolysins screen.............................            0.37            0.75            0.75            0.37               1
86327.........     26  Immunoelectrophoresis assay......................            0.37            0.45            0.45            0.42               2
88173.........     26  Interpretation of smear..........................            1.08            1.59  ..............            1.39               2
90801.........  .....  Psychiatric interview............................            2.21            2.80            2.80            2.80              b3
90820.........  .....  Diagnostic interview.............................            2.27            3.01            3.01            3.01              b3
90842.........  .....  Psychotherapy, 75-80 min.........................            2.76            2.76            2.76            3.13              b4
90843.........  .....  Psychotherapy, 20-30 min.........................            1.11            1.47            1.47            1.47              b3
90844.........  .....  Psychotherapy, 45-50 min.........................            1.73            2.00            2.00            2.00              b3
90853.........  .....  Special group therapy............................            0.43            0.59            0.59            0.59              b3
90855.........  .....  Individual psychotherapy.........................            1.82            2.15            2.15            2.15              b3
90857.........  .....  Special group therapy............................            0.43  ..............  ..............            0.63              b4
90911.........  .....  Anorectal biofeedback............................            0.89            2.15  ..............            0.89               3
92002.........  .....  Eye exam, new patient............................            0.88            1.34  ..............            0.88               3
92004.........  .....  Eye exam, new patient............................            1.34            1.67            1.67            1.67               3
92225.........  .....  Special eye exam, initial........................            0.58            0.58  ..............            0.38               2
92226.........  .....  Special eye exam, subsequent.....................            0.50            0.50  ..............            0.33               2
92260.........  .....  Ophthalmoscopy/dynamometry.......................            0.50            0.50  ..............            0.20               2
93307.........  .....  Echo exam of heart...............................            0.78            1.06            1.06            0.92               2
93312.........  .....  Echo transesophageal.............................            1.90            2.39            2.39            2.20               2
93314.........  .....  Echo transesophageal.............................            0.95  ..............  ..............            1.25               4
93503.........  .....  Insert/place heart catheter......................            2.43            3.02            2.43            2.91               2
93621.........     26  Electrophysiology evaluation.....................           12.66  ..............  ..............          a12.66               5
94150.........  .....  Vital capacity test..............................            0.11            0.11            0.07            0.07               3
99211.........  .....  Office/outpatient visit, est.....................            0.17        Increase  ..............            0.17               3
99241.........  .....  Office consultation..............................            0.64    Inc pre-post  ..............            0.64               3
99242.........  .....  Office consultation..............................            1.28    Inc pre-post  ..............            1.29               3
99243.........  .....  Office consultation..............................            1.71    Inc pre-post  ..............            1.72               3
99244.........  .....  Office consultation..............................            2.56    Inc pre-post  ..............            2.58               3
99245.........  .....  Office consultation..............................            3.41    Inc pre-post  ..............            3.43               3
99281.........  .....  Emergency dept visit.............................            0.33            0.33            0.45            0.33               3
99282.........  .....  Emergency dept visit.............................            0.55            0.55            0.88            0.55               3
99283.........  .....  Emergency dept visit.............................            1.24            1.24            1.34            1.24               3
99284.........  .....  Emergency dept visit.............................            1.95            1.95            2.00            1.95               3
99285.........  .....  Emergency dept visit.............................            3.06            3.06            2.90            3.06               3
99321.........  .....  Rest home visit, new patient.....................            0.89            1.12  ..............            0.71               3
99322.........  .....  Rest home visit, new patient.....................            1.34            1.76  ..............            1.01               3
99323.........  .....  Rest home visit, new patient.....................            1.78            2.40  ..............            1.28               3
99331.........  .....  Rest home visit, estab pat.......................            0.45            1.05  ..............            0.60               3
99332.........  .....  Rest home visit, estab pat.......................            0.73            1.65  ..............            0.80               3
99333.........  .....  Rest home visit, estab pat.......................            1.18            2.25  ..............            1.00               3
99341.........  .....  Home visit, new patient..........................            1.34            1.12            1.12            1.12               3
99342.........  .....  Home visit, new patient..........................            2.00            1.76            1.76            1.58               3
99343.........  .....  Home visit, new patient..........................            2.67            2.40             2.4            2.09               3
99351.........  .....  Home visit, estab patient........................            0.67            1.05            1.05            0.83               3
99352.........  .....  Home visit, estab patient........................            1.10            1.65            1.65            1.12               3
99353.........  .....  Home visit, estab patient........................            1.77            2.25            2.25            1.48               3
A2000.........  .....  Chiropractor manip of spine......................            0.45  ..............  ..............             n/a               7
M0101.........  .....  Cutting or removal of corns......................            0.37            0.45            0.45            0.43               2
--------------------------------------------------------------------------------------------------------------------------------------------------------
* All CPT codes and descriptors copyright 1996 American Medical Association                                                                             
a RVUs to remain interim in 1997                                                                                                                        
b CPT codes not used for 1997 Medicare payment, refer to sections II.D.2.b and IV.A.14 for explanation                                                  

IV. Discussion of Comments and Decisions

A. Discussion of Comments by Clinical Area

    In this section, we discuss the comments we received on the 
approximately 133 codes of the more than 1,000 codes for which we 
sought public comment. For the 800 or more codes for which we did not 
receive any comments, our proposed RVUs are being made final. We have 
sorted the comments into the same clinical areas we used in the May 3, 
1996 notice. Within each clinical area, we discuss the comments we 
received in CPT code order.
1. Integumentary System
    CPT 10040 (Acne surgery (e.g., marsupialization, opening or removal 
of multiple milia, comedones, cysts, pustules)).

[[Page 59510]]

    Comment: One commenter questioned the validity of the survey used 
to determine the work RVUs for CPT code 10040 (Acne surgery). The 
commenter stated that this survey was invalid due to insufficient 
volume (less than the requisite 30 respondents), the failure to take 
into account the more intensive work associated with the treatment of 
the typical patient, the absence of review of the Harvard data, and the 
fact that the data were seriously flawed. Data flaws resulted from 
discrepancies between the number of preservice and postservice visits 
and the time spent with the patient. Thus, the commenter believed that 
the work RVUs do not accurately reflect the true physician work 
involved in the treatment. The commenter included survey data to 
support the commenter's recommendation that the work RVUs for CPT code 
10040 not be reduced to the proposed 0.80 work RVUs, but, rather, be 
reduced to 1.15 work RVUs from the current 1.34 work RVUs.
    Response: Our proposed RVUs for CPT code 10040 were based on the 
results of the earlier survey data and the recommendations of the RUC 
to decrease the work RVUs from 1.34 to 0.80. After review of the survey 
data submitted by this commenter, we reevaluated the original data. We 
agree with the commenter's observations as to the quality and validity 
of these data. On further examination of the survey included with this 
comment, we agree with the recommendation that the work RVUs for CPT 
code 10040 be established at 1.15. Thus, the final work RVUs for this 
procedure will reflect this recommendation.
    Final decision: The final work RVUs for CPT code 10040 are being 
established as 1.15.
    CPT codes 15570 through 15576 (Formation of direct or tubed 
pedicles, with or without transfer).
    Comment: There are four codes in this family that are used to 
report the formation of direct or tubed pedicles in different body 
areas. We received a comment that all of these codes are undervalued 
when compared to the corresponding adjacent flap codes: CPT code 14001 
with 7.78 work RVUs, CPT code 14021 with 9.37 work RVUs, and CPT code 
14040 with 7.18 work RVUs.
    Response: In its initial recommendation to us, the RUC indicated 
that several old codes, CPT codes 15500 through 15515, which were 
valued by Harvard, were deleted in 1992 and replaced with CPT codes 
15570 through 15576. The RUC also noted that the new codes are 
misvalued and that no explanation had been received describing how the 
work RVUs of these codes were determined. Based on the survey results 
and the lack of rationale for the current work RVUs, the RUC 
recommended that the codes be valued at the same level established by 
Harvard for the original deleted codes.
    We did not accept the RUC recommendations for two reasons. First, 
the RUC's understanding of the source of the work RVUs for the current 
codes was incorrect and, second, we believed the vignettes that were 
surveyed may have led to an overestimation of the work.
    We were concerned that the survey respondents may have considered 
the work of debridement, fracture stabilization, initial emergency room 
evaluation, and immobilization of the hand, flap, and abdomen in their 
estimates of work. If so, the work RVUs would be excessive because 
those other services can be reported and paid separately. Therefore, we 
proposed to maintain the current work RVUs.
    However, in light of the comments we received, we referred these 
codes to a refinement panel for review and discussion of the correct 
coding for these services.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are assigning the final work RVUs listed below:

------------------------------------------------------------------------
                                                       HCFA             
                     CPT code                        proposed    Final  
                                                    work RVUs  work RVUs
------------------------------------------------------------------------
15570.............................................       3.75       8.39
15572.............................................       3.80       8.59
15574.............................................       3.85       8.97
15576.............................................       4.27       8.14
------------------------------------------------------------------------

    CPT code 15580 (Cross finger flap, including free graft to donor 
site).
    Comment: One commenter stated that this code is undervalued when 
compared to CPT code 15240 (Skin full graft procedure) and CPT code 
15100 (Skin split graft procedure). The commenter argued that the 
current work RVUs do not account for the intraservice time and work 
involved in harvesting and applying the skin graft. Survey data showed 
a median intraservice time of 90 minutes and 9.00 median work RVUs. The 
RUC recommended that the work RVUs be increased based on the survey 
results and its conclusion that the comparison to skin graft procedures 
was appropriate.
    Response: We did not propose a change in the work RVUs for this 
code because we were concerned that the CPT is not clear regarding the 
separate reporting of a graft to the donor site, and the vignette may 
have led to an overestimation of work. There is a note in the 
introductory paragraphs for the flap codes that states: ``Repair of 
donor site requiring skin graft or local flaps is considered an 
additional separate procedure.'' This contradicts the terminology of 
CPT code 15580 and could be a source of confusion.
    We also were concerned that the survey respondents may have 
considered the work of debridement, initial emergency room evaluation, 
and immobilization of the fingers in their estimates of work. If so, 
the work RVUs are excessive because the other services can be reported 
separately. Therefore, we proposed to maintain the current work RVUs.
    However, in light of the comments we received, we referred this 
code to a refinement panel for review and discussion of the correct 
coding of this service.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are increasing the work RVUs from the 5.40 proposed work 
RVUs to 8.84 for CPT code 15580. We also will work with the CPT 
Advisory Committee and Editorial Panel to improve the clarity of the 
codes and the accompanying instructions in the CPT.
    CPT code 15755 (Free flap (microvascular transfer)).
    Comment: One commenter disagreed with our decision to maintain the 
current work RVUs of 28.33 for CPT code 15755 (Free flap (microvascular 
transfer)), instead of the requested change of 41.68 work RVUs. The 
commenter contended that the work RVUs are too low because of the 
amount of time and skill required for two surgeons to perform this 
highly complex procedure.
    The commenter also stated that this surgical procedure requires two 
surgeons, with two separate teams working simultaneously for a period 
of several hours. According to the commenter, one surgeon and team 
prepare the recipient site, while the second surgeon and team is 
harvesting the free flap. This reduces the amount of time the patient 
is under anesthesia. Also, the surgeons have had additional training in 
performing microvascular procedures. Accordingly, the commenter 
believed that this procedure should reflect higher work RVUs for the

[[Page 59511]]

extra training and the amount of time spent performing the surgery.
    Response: This code was referred by the RUC to the CPT Editorial 
Panel because the code lacked sufficient specificity for the RUC to 
establish appropriate work RVUs. The CPT Editorial Panel deleted this 
code and replaced it with three new CPT codes that were subsequently 
reviewed by the RUC. The RUC recommendations for the three new codes 
follow: for CPT code 15756, 33.23 work RVUs; for CPT code 15757, 33.23 
work RVUs; and for CPT code 15758, 33.23 work RVUs. We reviewed and 
accepted these three recommendations. (See Table 3). We believe the new 
work RVUs are consistent with the commenter's concern that the work 
RVUs for the now deleted CPT code 15755 were too low.
    Final decision: CPT code 15755 was deleted. We have reviewed and 
accepted the RUC recommendations of 33.23 work RVUs for CPT codes 
15756, 15757, and 15758, respectively.
    CPT codes 17000, 17001, 17002 (Destruction of benign facial and 
premalignant lesions) and CPT codes 17100, 17101, and 17102 
(Destruction of benign non-facial lesions).
    Comment: Several commenters objected to our proposed reductions to 
the work RVUs for this family of codes.
    Response: The following is a summary of the background of our 
proposed reductions. In response to our original request for comments 
in 1995, an individual who underwent the destruction of skin lesions 
commented that the physician charges for these procedures were 
excessive. He stated that the application of liquid nitrogen is not 
time consuming and is an insignificant cost and that the physician work 
involved is minimal and does not require great skill. We forwarded the 
comment to the RUC. The specialty society recommended to the RUC that 
the work RVUs for these codes be maintained.
    The RUC responded by indicating that the intention of the RUC and 
the 5-year review is to examine work RVUs. The RUC concluded that the 
comment we forwarded was based on charges the commenter incurred, a 
matter which is not directly related to the mission of the RUC. 
Therefore, the RUC recommended that the current work RVUs be 
maintained.
    We acknowledge that part of the individual's comments related to 
the charges he incurred. However, we believe that the commenter raised 
a legitimate concern about the amount of physician work when he made 
reference to the amount of time, physician involvement, and skill 
required to destroy a skin lesion. Therefore, we reexamined the work 
RVUs assigned to these codes and concluded they were too high when 
compared to other services on the fee schedule. CPT code 17000 
(Destruction of a single benign facial or premalignant lesion) 
currently has work RVUs that are approximately 3.5 times higher than 
the work RVUs assigned to the destruction of a second similar lesion 
(CPT code 17001).
    There are no other services with this variance. A more appropriate 
valuation of CPT code 17000 would set the initial lesion destruction at 
about twice the level of the work RVUs for a subsequent lesion. 
Therefore, we proposed 0.36 work RVUs. This downward revaluation of CPT 
code 17000 was supported by comparing the proposed work RVUs to the 
following reference services: CPT code 11700 (Debridement of nails), 
with 0.32 work RVUs, and CPT code 11050 (Paring of skin lesion), with 
0.43 work RVUs. These services are comparable to CPT code 17000 in 
terms of set-up time, procedure time, risk, and aftercare.
    We also believed that CPT code 17001 (Destruction of second and 
third benign facial or premalignant lesion, each) and CPT code 17002 
(Destruction of over three lesions, each additional lesion) were 
overvalued. We proposed to reduce the work RVUs of these codes to 0.14. 
The proposed work RVUs for these codes would maintain approximately the 
same ratio to CPT code 17101, with 0.11 work RVUs, and CPT code 17102, 
also with 0.11 work RVUs, as CPT code 17000, with 0.64 work RVUs, now 
has to CPT code 17100, with 0.53 work RVUs, that is, about 1.2. In 
other words, we believed the current relative relationship of work RVUs 
for CPT code 17000 (Destruction of benign facial or premalignant 
lesions) to the work RVUs for the CPT code 17100 (Destruction of benign 
lesions in areas other than the face) is correct but the work RVUs are 
too high.
    In order to properly evaluate not only the individual codes but 
also the relationship between the facial codes and codes for other body 
regions, we requested the refinement panel to consider CPT codes 17000, 
17001, 17002, 17100, 17101, and 17102.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are assigning the final work RVUs listed below:

------------------------------------------------------------------------
                                                       HCFA             
                     CPT code                        proposed    Final  
                                                    work RVUs  work RVUs
------------------------------------------------------------------------
17000.............................................       0.36       0.56
17001.............................................       0.14       0.19
17002.............................................       0.14       0.19
17100.............................................       0.53       0.53
17101.............................................       0.11       0.11
17102.............................................       0.11       0.11
------------------------------------------------------------------------

    These values will serve as the basis of the RVUs we propose for 
three temporary codes, HCPCS codes G0051, G0052, and G0053, that will 
be used for Medicare purposes to report the destruction of benign or 
premalignant lesions in any location. For a discussion of these codes, 
see section II.D.2.b. of this final rule.
2. Orthopedic Surgery
    CPT code 29848 (Arthroscopy, wrist, surgical; with release of 
transverse carpal ligament).
    Comment: A commenter objected to the 4.04 proposed work RVUs and 
requested an increase to 5.70. A comparison was made to CPT code 64761, 
the code used to report open carpal tunnel surgery. The work RVUs for 
CPT code 64721 are 3.99, whereas the work RVUs for CPT code 29848 are 
4.04. The commenter argued that this differential does not sufficiently 
recognize the greater physician time and intensity required by CPT code 
29848.
    Response: Our 4.04 proposed work RVUs were based on a 
recommendation from the RUC that we accepted. However, in light of the 
comments we received, we referred this code to a refinement panel for 
review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we will increase the work RVUs from the 4.04 proposed work 
RVUs to 5.14 for CPT code 29848.
3. Otolaryngology and Maxillofacial Surgery
    CPT code 21025 (Excision of bone (e.g., for osteomyelitis or bone 
abscess); mandible).
    Comment: A commenter recommended an increase from 5.03 to 8.98 work 
RVUs based on a comparison to CPT code 24134 (Sequestrectomy (e.g., for 
osteomyelitis or bone abscess), shaft or distal humerus). The RUC noted 
that a rank order anomaly exists between this service and CPT code 
21030 (Excision of benign tumor or cyst of facial bone other than 
mandible) and CPT code 21041 (Excision of benign cyst or tumor of 
mandible; complex). The

[[Page 59512]]

American Academy of Oral and Maxillofacial Surgeons' survey median for 
intraservice time is 120 minutes, which is significantly higher than 
CPT code 21041 and reference service CPT code 24134. Thus, the RUC 
recommended that the American Academy of Oral and Maxillofacial 
Surgeons' survey median of 8.92 work RVUs be adopted.
    Response: We did not accept the RUC recommendation because we did 
not believe that the surveyed vignette represented the typical patient; 
further, it included services for which other codes can be reported. 
The vignette described a patient with intraoral and extraoral swelling 
and suppuration from multiple fistulae. Dissection of the inferior 
alveolar nerve is required, and hyperbaric oxygen is initiated. We 
believed this vignette described a patient with much more extensive 
infection than the typical patient. It was also our view that CPT code 
21030, with 7.05 work RVUs, is more difficult than this procedure. 
Therefore, we proposed to retain the current 5.03 work RVUs for CPT 
code 21025. However, in light of the comments we received, we referred 
this code to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are increasing the work RVUs from the 5.03 proposed work 
RVUs to 8.98 for CPT code 21025.
    CPT code 21125 (Augmentation, mandibular body or angle; prosthetic 
material) and CPT code 21270 (Malar augmentation, prosthetic material).
    Comment: We received one comment regarding CPT codes 21125 and 
21270. The commenter disagreed with the proposed work RVUs assigned to 
these procedures, 6.22 and 12.10, respectively. The commenter submitted 
survey data supporting the commenter's contention that the rank order 
between these services is out of alignment. That is, procedures 
represented by CPT codes 21270 and 21125 are similar in preoperative 
and postoperative time and degree of difficulty to CPT code 21208 
(Osteoplasty, facial bones; augmentation (autograft, allograft, or 
prosthetic implant)), with 9.56 work RVUs, and CPT code 21210 (Graft, 
bone; nasal, maxillary or malar areas (includes obtaining graft)), with 
9.56 work RVUs.
    CPT code 21125, according to this commenter, although similar to 
CPT code 21270, is more difficult in work, stress, and effort, and, 
also, requires longer intraservice time due to the location of the 
incision and augmentation. Therefore, the commenter recommended 
reducing the work RVUs of CPT code 21270 to 9.56 and increasing the 
work RVUs of CPT code 21125 to 10.00.
    Response: Based on our evaluation of the survey data submitted by 
the commenter, we concur with the recommendation. Although the sample 
size was relatively small for both CPT procedure codes, it did serve to 
document the rank order position for CPT codes 21125 and 21270. We 
believe the data provided sufficiently support the recommendations to 
increase the work RVUs for CPT code 21125 and decrease the work RVUs 
for CPT code 21270.
    Final decision: We accepted this recommendation and will increase 
the work RVUs of CPT code 21125 to 10.00 and decrease the work RVUs of 
CPT code 21270 to 9.56.
    CPT codes 31531, 31536, 31541, 31561, and 31571 (Operative 
laryngoscopies).
    Comment: Commenters stated that CPT codes 31541, 31561, and 31571 
are undervalued because of increased patient complexity and greater 
emphasis on acceptable vocal results.
    Response: When the RUC initially reviewed these codes, it did not 
find the arguments compelling enough to suggest a change in work RVUs. 
However, the RUC identified rank order anomalies in the work RVUs for 
direct laryngoscopies and the corresponding procedures using an 
operating microscope. Among the five pairs of procedures, the 
difference in work RVUs for use of the operating microscope varies from 
-0.57 to +0.34 work RVUs. The RUC recommended retaining the 1995 work 
RVUs for the direct laryngoscopies (CPT codes 31530, 31535, 31540, 
31560, and 31570) and adding a constant 0.40 work RVUs to arrive at the 
work RVUs for the corresponding procedures using an operating 
microscope (CPT codes 31531, 31536, 31541, 31561, and 31571).
    We disagreed with the concept of increasing the work RVUs for 
procedures using an operating microscope and believed that the work 
RVUs for a procedure generally should be the same, regardless of the 
technique used. For example, CPT codes 17000 through 17105 (Destruction 
of skin lesions) are valued the same regardless of the method of 
destruction. Therefore, we proposed work RVUs that would be the same 
for both codes in a pair.
    However, in light of the comments that objected to our rationale, 
we referred these codes to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are assigning the final work RVUs listed below:

------------------------------------------------------------------------
                                                       HCFA             
                     CPT code                        proposed    Final  
                                                    work RVUs  work RVUs
------------------------------------------------------------------------
31531.............................................       3.39       3.59
31536.............................................       3.16       3.56
31541.............................................       4.13       4.53
31561.............................................       5.46       6.00
31571.............................................       3.87       4.27
------------------------------------------------------------------------

4. Podiatry
    HCPCS code M0101 (Cutting or removal of corns).
    Comment: In response to our proposal to maintain the current 0.37 
work RVUs, many commenters objected to our view that the vignette did 
not represent a typical patient and requested an increase to the RUC-
recommended level of 0.45 work RVUs.
    Response: In response to our original request for comments in 1995 
as part of the 5-year review, a commenter recommended that we increase 
the work RVUs to 0.70 based on the view that this service is 
significantly more difficult than the work for CPT code 11050 (Paring 
or curettement of benign hyperkeratotic skin lesion with or without 
chemical cauterization (such as verrucae or clavi) not extending 
through the stratum corneum (e.g., callus or wart) with or without 
local anesthesia; single lesion), which is valued at 0.43 work RVUs, 
and CPT code 11700 (Debridement of nails, manual; five or less), which 
is valued at 0.32 work RVUs.
    The RUC agreed that HCPCS code M0101 involves more work than 
treating 2 skin lesions and trimming 10 toenails and that this service 
is undervalued. However, it disagreed with the request for an increase 
to 0.70 and recommended 0.45 work RVUs.
    We disagreed with these proposed work RVUs. The description of this 
service is ``cutting or removal of corns, calluses and/or trimming of 
nails, application of skin creams and other hygienic and preventive 
maintenance care (excludes debridement of nail(s)).''
    In our May 3, 1996 proposed notice (61 FR 20022), we expressed our 
belief that the service most often reported by this code is trimming of 
nails, which is of less intensity than the work associated with cutting 
or removal of

[[Page 59513]]

corns and calluses. The typical service involves the less intense 
portions of this complex definition. The surveys conducted by the 
American Podiatric Medical Association used vignettes of patients with 
circulatory impairment and neurologic deficit accompanying systemic 
disease. The existence of these comorbid conditions may not accurately 
reflect the work RVUs for the typical patient.
    Throughout the fee schedule, we base the work RVUs on the typical 
patient. The RUC survey methodology is also based on vignettes that are 
intended to describe the typical patient and service. To value the work 
of procedures based on atypical patients would skew the values assigned 
to those codes as well as their relationship to other codes. This is 
true even where, as here, current Medicare coverage is restricted to 
the more difficult patients with coexisting disease. In this case, we 
believed the vignette described an unusual or atypical patient; the RVU 
recommendation based on the vignette exceeds the current work RVUs. We 
believed that the usual service of trimming of nails is less work than 
the paring or curettement or other less common procedures such as 
benign hyperkeratotic skin lesions and, therefore, proposed to maintain 
the current 0.37 work RVUs.
    However, in light of the comments that objected to our rationale, 
we referred this code to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are increasing the work RVUs from the 0.37 proposed work 
RVUs to 0.43 for HCPCS code M0101.
    CPT code 28010 (Tenotomy, subcutaneous, toe; single).
    Comment: This code, with 2.97 work RVUs, was identified by the RUC 
as a potentially overvalued service but it did not submit recommended 
RVUs in time for publication in the May 3, 1996 proposed notice. The 
RUC subsequently recommended that the work RVUs be reduced to 2.71 as 
it is similar in work to CPT code 26060 (Tenotomy, subcutaneous, 
single, each digit), with 2.71 work RVUs. All four components of 
physician work (time, mental effort and judgment, technical skill, and 
physical effort and stress) are the same for these soft tissue 
operations.
    Response: We agree with this comparison and recommendation.
    Final decision: The final work RVUs for CPT code 28010 are changed 
to 2.71.
    CPT code 28114 (Ostectomy, complete excision; all metatarsal heads, 
with partial proximal phalangectomy, excluding first metatarsal 
(Clayton type procedure)).
    Comment: Last year, the RUC submitted an interim recommendation 
that the current work RVUs for CPT code 28114 (Removal of metartasal 
heads) be maintained until the American Podiatric Medical Association 
presented recommendations for this code at the February 1996 RUC 
meeting. We agreed and published proposed RVUs of 7.16 for CPT code 
28114. We subsequently received a comment from the RUC recommending 
that the work RVUs for CPT code 28114 be increased to 8.65. In a survey 
of 66 podiatrists, 10.60 median work RVUs were recommended for CPT code 
28114, suggesting that the current 7.16 work RVUs for this code are too 
low.
    The basis for the RUC's recommendation was comparison of this 
service to CPT code 28113 (Ostectomy, complete excision; fifth 
metatarsal head), with 4.09 work RVUs. The RUC believed that the 
intraservice work per unit of time of the two services should be equal. 
The RUC then used the surveyed intraservice time of CPT code 28114 to 
calculate the recommended 8.65 work RVUs.
    Response: We agree with the RUC recommendation.
    Final decision: We are assigning 8.65 work RVUs to CPT code 28114. 
Because the public has not had an opportunity to comment on these work 
RVUs, we will consider them to be interim RVUs and will accept comments 
on our revision.
5. Cardiology and Interventional Radiology
    CPT code 37201 (Transcatheter therapy, infusion for thrombolysis 
other than coronary).
    Comment: A commenter objected to our proposed reduction in work 
RVUs from 7.25 to 5.00, which the commenter believed was based on the 
use of an incorrect reference service.
    Response: The RUC identified this code as a potentially overvalued 
service, in part, because of an increasing frequency of claims since 
1992. The current work RVUs are 7.25. After reviewing the issue, the 
RUC agreed with the Society for Cardiovascular and Interventional 
Radiology that the frequency of claims for this code is growing because 
thrombolytic infusion is an effective therapy for thrombosed arteries 
and grafts, allowing physicians to save patient limbs. The service is 
still a relatively new technology, and the RUC believed that it is 
appropriately valued.
    We disagreed with this recommendation. Unlike CPT code 34111 
(Removal of arm artery clot), a similar open procedure with a 90-day 
global period, CPT code 37201 is billed with an evaluation and 
management code and a supervision and interpretation code. Therefore, 
we believe that the work RVUs for CPT code 37201 should approximate the 
work RVUs for CPT code 34111 (7.18) minus the work RVUs for a level-two 
subsequent hospital visit (0.88) and the work RVUs for the radiological 
supervision and interpretation, CPT code 75894 (1.31). We proposed 5.00 
work RVUs for CPT code 37201.
    In light of the comments that objected to our rationale, we 
referred this code to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are decreasing the work RVUs from the current 7.25 work 
RVUs to our proposed 5.00 work RVUs for CPT code 37201.
    CPT code 93307 (Echocardiography, real-time with image 
documentation (2D) with or without M-Mode recording; complete).
    Comment: Several commenters objected to our proposal to maintain 
the current 0.78 work RVUs and recommended that we accept the RUC 
recommendation of 1.06 work RVUs. They argued that the field of 
echocardiography has changed significantly in the past 5 years, in both 
clinical utility and diagnostic complexity. Although the technical 
innovations of the past 5 years have made this an easier service to 
perform, the patients that require this service are more complex, which 
has resulted in an increased amount of physician work. The physicians 
are viewing and making judgments on constantly moving objects, which 
increases the possibility of misinterpretation. Often this service is 
furnished in acute care settings or emergency situations, which 
increase physician stress. The information derived from this study is 
used in the development of critical management decisions. The risk of 
misdiagnosis, in both emergent and nonemergent situations, can lead to 
potentially fatal events.
    Response: The current work RVUs for echocardiography are 0.78. The 
RUC agreed that the code is undervalued based on the amount of 
physician work

[[Page 59514]]

that is required to perform this study and the increased amount of 
information that can now be derived from echocardiography. However, the 
RUC believed that the specialty society recommendation of 1.48 work 
RVUs was too high and recommended the Harvard value for this procedure, 
which was 1.06 work RVUs.
    We did not agree that echocardiography is undervalued. We believed 
that technical innovations have made physician interpretations of 
echocardiograms less difficult than in the past. We also believed that 
some of the work that is being reported as physician work is actually 
the work of technicians. For example, the description of intraservice 
work provided to the RUC implies that physicians review entire tapes 
and analyze and measure the structure and dynamics of the chambers, 
valves, and great vessels. It is our understanding that much of this 
information is prepared by technicians for subsequent review by 
physicians. We considered the work of technicians to be a practice 
expense that is reflected in the practice expense RVUs, not the 
physician work RVUs. We also questioned whether the vignette surveyed 
by the specialty society, which describes an echocardiogram performed 
on an acutely ill patient in need of emergency echocardiography, 
represented the typical patient requiring echocardiography. Medicare 
claims data from calendar year 1995 indicate that 50 percent of claims 
for CPT code 93307 are billed with place of service as office or 
outpatient hospital and 49 percent are billed with place of service as 
inpatient hospital. This suggested that the typical patient is not 
critically ill or that there is a bimodal distribution of patients. 
Therefore, we did not believe that an increase in work RVUs was 
justified.
    However, in light of the comments we received, we referred this 
code to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are increasing the work RVUs from the 0.78 proposed work 
RVUs to 0.92 for CPT code 93307.
    CPT code 93312 (Echocardiography, real-time with image 
documentation (2D) (with or without M-Mode recording), transesophageal; 
including probe placement, image acquisition, interpretation and 
report).
    Comment: Several commenters objected to our 1.90 proposed work RVUs 
and recommended that we accept the RUC recommendation of 2.39. The 
commenters argued that transesophageal echocardiography is undervalued 
in comparison to other services that require similar physician work 
effort and that performance of this procedure requires considerable 
mental effort. As described above in the discussion of CPT code 93307, 
the heart is constantly moving, increasing the possibility of 
misinterpretation, which could lead to misdiagnosis. There is an added 
technical skill required by the physician to insert the probe into the 
esophagus and the stomach of a critically ill patient. This procedure 
is often performed in the emergency setting while the patient is under 
conscious sedation.
    Response: Before submitting its original recommendation to us, the 
RUC reviewed Harvard Phase III data that show 2.76 work RVUs (adjusted 
to be on a scale equivalent to 1995 work RVUs) for upper 
gastrointestinal endoscopy (CPT code 43235), the reference code being 
used in this comparison. These work RVUs are higher than both the 
existing 1.57 work RVUs and the 2.39 work RVUs recommended by the 
specialty society. The RUC agreed with the specialty society rationale 
and recommended an increase to 2.39 work RVUs.
    For reasons similar to those described above for CPT code 93307, we 
did not believe that transesophageal echocardiography was undervalued. 
A refinement panel considered this service in 1993, and, based on the 
ratings of the panel, we did not increase the work RVUs. We did not 
find the new evidence submitted by the RUC to be sufficient to warrant 
an increase in work RVUs.
    However, in light of the comments we received, we referred this 
code to a refinement panel for review. As a result of our analysis of 
the refinement panel ratings, we are increasing the work RVUs for CPT 
code 93312 from 1.90 to 2.20.
    During the refinement panel discussions, the coding of other 
transesophageal echocardiography services was discussed. CPT includes 
three codes for transesophageal echocardiography. The codes are CPT 
code 93312 (Echocardiography, real time with image documentation (2D) 
(with or without M-mode recording), transesophageal; including probe 
placement, image acquisition, interpretation and report), CPT code 
93313 (Echocardiography, real time with image documentation (2D) (with 
or without M-modeing recording), transesophageal; placement of 
transesophageal probe only), and CPT code 93314 (Echocardiography, real 
time with image documentation (2D) (with or without M-mode recording), 
transesophageal; image acquisition, interpretation and report only).
    We received no comments as part of the 5-year review that the work 
RVUs for the code used to report only the placement of a 
transesophageal probe (CPT code 93313) should be revised. Therefore, we 
are maintaining the current 0.95 work RVUs. By subtracting these work 
RVUs from the new work RVUs for CPT code 93312, we can calculate new 
work RVUs for CPT code 93314, which is used to report image 
acquisition, interpretation and report only. The result is 1.25 work 
RVUs.
    It was necessary to calculate these RVUs because the refinement 
panel did not specifically address CPT code 93314. However, it was 
clear during the discussions of the refinement panel that the service 
considered by the American College of Cardiology and the American 
Society of Echocardiography to be undervalued was the image 
acquisition, interpretation and report and not the probe placement.
    We also revised the relationship of the three codes in this family 
so that the work RVUs for CPT code 93312 equal the sum of the work RVUs 
for CPT codes 93313 and 93314. When we first assigned work RVUs to 
these codes, we assigned 20 percent more work RVUs to both CPT codes 
93313 and 93314 because two different physicians were often involved in 
the procedure and each would have a certain amount of preservice and 
postservice work that could not be considered duplicative.
    Consequently, the sum of these two codes exceeded the work RVUs 
assigned to CPT code 93312. We now believe that most transesophageal 
echocardiographies are performed by a single physician. Therefore, we 
have adjusted the work RVUs so that the work RVUs for CPT code 93312 
equal the sum of the work RVUs for CPT codes 93313 and 93314.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are increasing the work RVUs for CPT code 93312 from the 
1.90 proposed work RVUs to 2.20. In addition, the work RVUs for CPT 
codes 93313 and 93314 are established as 0.95 and 1.25, respectively, 
based on the above decisions.
    CPT code 93503 (Insertion and placement of flow directed catheter

[[Page 59515]]

(e.g., Swan-Ganz) for monitoring purposes).
    Comment: Several commenters objected to our proposal to maintain 
the current 2.43 work RVUs. Our proposal was based, in part, on 
acceptance of a RUC recommendation to maintain current work RVUs. 
Several specialty societies argued that the physician work involved in 
a Swan-Ganz catheter was greater than the work associated with a right 
heart catheterization (CPT code 93501), with 3.02 work RVUs.
    The commenters stated that as compared to the right heart catheter, 
which is usually inserted in the catheter laboratory, the Swan-Ganz 
catheter is usually inserted when the patient is in an unstable 
condition. Proper positioning of the acutely ill patient for insertion 
is usually more difficult. In addition, the physician usually inserts 
the Swan-Ganz catheter without the aid of an imaging device, in 
contrast to the right heart catheter, making location of the tip of the 
catheter significantly more challenging.
    Moreover, after insertion, the physician must interpret data 
quickly and make immediate important judgments. Finally, the commenters 
argued that the risk of complications with the Swan-Ganz catheter is 
considerably greater than with the right heart catheter.
    Response: In light of the comments we received, we referred this 
code to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are increasing the work RVUs from 2.43 to 2.91 for CPT code 
93503.
6. General Surgery, Colon and Rectal Surgery, and Gastroenterology
    We received no comments on these codes. Therefore, we will finalize 
all of the proposed work RVUs for the general surgery, colon and rectal 
surgery, and gastroenterology codes.
7. Urology
    CPT code 50590 (Lithotripsy, extracorporeal shock wave).
    Comment: Several commenters objected to our proposed reduction in 
work RVUs from 9.62 to 7.13. They objected to our argument that the 
work of extracorporeal shock wave lithotripsy is more comparable to the 
work of evaluation and management services than surgical services.
    Response: We referred this code to the RUC last year as a 
potentially overvalued service. The RUC reviewed it and concluded that 
it is similar to a surgical procedure in that anesthesia is used and a 
urologist is always present. Based on its analysis of survey data 
showing a median intraservice time of 80 minutes, the RUC concluded 
that the current work RVUs should not be reduced.
    We disagreed with the RUC recommendation to maintain the 9.62 work 
RVUs. We believed the intraservice intensity of extracorporeal shock 
wave lithotripsy is more comparable to evaluation and management 
services than traditional surgical services. For example, the current 
9.62 work RVUs are higher than those for CPT code 49000 (Exploratory 
laparotomy, exploratory celiotomy with or without biopsy(s) (separate 
procedure)), with 8.99 work RVUs. We proposed 7.13 work RVUs for CPT 
code 50590 based on 90 minutes of critical care (CPT codes 99291 and 
99292), with work RVUs of 3.64 and 1.84, respectively, and three mid-
level office visits (CPT code 99213), with 0.55 work RVUs.
    However, in light of the comments that objected to our rationale, 
we referred this code to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are increasing our proposed work RVUs of 7.13 for CPT code 
50590 to 8.79.
8. Gynecology
    CPT code 56312 (Laparoscopic lymphadenectomy).
    Comment: The current work RVUs assigned to this code are 12.06. It 
was referred to the RUC as part of the 5-year review. The RUC 
recommended that the 12.06 work RVUs be maintained. In our May 3, 1996 
proposed notice (61 FR 20006), we agreed with this recommendation. A 
commenter objected to the retention of 12.06 work RVUs for this 
service. The commenter noted a discrepancy between the work RVUs for 
comparable procedures performed laparoscopically or via open 
laparotomy. The commenter stated that we have indicated that these 
procedures should be valued the same, regardless of the approach for 
their performance. The commenter agreed with this premise and 
recommended adjustment of the work RVUs for this laparoscopic 
procedure, which the commenter believed is undervalued when compared to 
its counterpart performed at laparotomy. The counterpart code, CPT code 
38870, is assigned 12.10 work RVUs. Thus, the commenter recommended 
that the work RVUs for CPT code 56312 be increased from 12.06 to 12.10.
    Response: In our May 3, 1996 proposed notice (61 FR 20046), we 
announced our intention to reexamine the relationship between 
endoscopic and comparable open procedures before the next 5-year 
review. This will provide the opportunity to address the discrepancy in 
work RVUs between CPT codes 56312 and 38870. We are retaining the 
existing 12.06 work RVUs for laparoscopic lymphadenectomy in spite of 
the slight difference in work RVUs between the two procedures.
    Final decision: We are making final the proposed work RVUs for CPT 
code 56312.
    CPT code 57265 (Combined anteroposterior colporraphy; with 
enterocele repair).
    Comment: This code is used to report complex vaginal repairs. A 
commenter stated that their recommendation for this code was mistakenly 
not submitted to the RUC. The commenter believed that the current 7.36 
work RVUs undervalue the service in comparison to CPT code 57260 
(Combined anteroposterior colporraphy without enterocele repair), which 
is assigned 7.59 work RVUs. Since CPT code 57265 includes CPT code 
57260 plus CPT code 57268 (Repair of enterocele, vaginal approach 
(separate procedure)), with 6.14 work RVUs, the commenter recommended 
10.66 work RVUs for CPT code 57265. These work RVUs reflect the sum of 
the work RVUs for CPT code 57260 and, with the application of the 
multiple surgical rules, one-half of the work RVUs for CPT code 57268.
    Response: The current work RVUs for CPT code 57265 represent an 
obvious rank order anomaly within this family of procedures.
    Final decision: We accept the recommendation of 10.66 work RVUs for 
CPT code 57265.
    CPT code 58200 (Total abdominal hysterectomy including partial 
vaginectomy with para-aortic and pelvic lymph node sampling, with or 
without removal of tube(s), with or without removal of ovary(s)).
    Comment: Several commenters stated that the 20.34 work RVUs 
currently assigned to CPT code 58200 exceed the 13.00 work RVUs 
currently assigned to CPT code 58150 (Total abdominal hysterectomy 
(corpus and cervix), with or without removal of tube(s), with or 
without removal of ovary(s)) by approximately 56 percent, accurately 
reflecting the difference in physician

[[Page 59516]]

work. The commenters objected to our proposal to increase the work RVUs 
assigned to CPT code 58150 to 14.30 without also increasing the work 
RVUs assigned to CPT code 58200. Therefore, to maintain what they 
believed to be the correct relationship between these two codes, the 
commenters recommended that the work RVUs for CPT code 58200 be 
increased from 20.34 to 22.37.
    Response: The RUC reviewed both CPT codes 58150 and 58200. We 
received and agreed with the RUC's recommendations to increase the work 
RVUs for CPT code 58150 and maintain the work RVUs for CPT code 58200. 
We did not refer the codes to the RUC with the expectation that their 
relative relationship would be maintained. Rather, we referred them to 
the RUC with the expectation that the appropriateness of the work RVUs 
currently assigned to each code would be evaluated. We believe the RUC 
appropriately evaluated both codes, and we do not believe the 
commenters provided sufficient rationale to increase the work RVUs for 
CPT code 58200.
    Final decision: We are maintaining the current 20.34 work RVUs for 
CPT code 58200.
9. Neurosurgery
    CPT code 63030 (Laminotomy (hemilaminectomy), with decompression of 
nerve root(s), including partial facetectomy, foraminotomy and/or 
excision of herniated intervertebral disk; one interspace, lumbar) and 
CPT code 63042 (Laminotomy (hemilaminectomy), with decompression of 
nerve root(s), including partial facetectomy, foraminotomy and/or 
excision of herniated intervertebral disk, re-exploration, lumbar).
    Comment: The American Academy of Orthopedic Surgeons objected to 
our proposed reductions in the work RVUs for CPT code 63030 from 12.11 
to 11.10 and for CPT code 63042 from 17.27 to 16.56. The RUC 
recommendations for these work RVUs, which we accepted, were based on 
the recommendations of the American Academy of Neurological Surgeons/
Congress of Neurological Surgeons. The American Academy of Orthopedic 
Surgeons stated that the methodology used by the American Academy of 
Neurological Surgeons/Congress of Neurological Surgeons to develop the 
recommended work RVUs has not been validated. The American Academy of 
Orthopedic Surgeons also stated these codes were not identified as 
overvalued procedures by the carrier medical directors, AMA trend 
analysis, AMA intraservice work per unit of time analysis, nor by a 
comparison of Harvard with the 1992 work RVUs. The American Academy of 
Orthopedic Surgeons noted a study done for them (``The Abt Restudy of 
Physician Work Values for Orthopedic Surgery'') further stated that the 
current relationship between CPT codes 63030 (with 12.11 work RVUs), 
63042 (with 17.27 work RVUs), and 63047 (with 12.76 work RVUs) more 
properly represents the work differential between these codes and that 
the proposed work RVUs provide an incentive for upcoding.
    Response: We discussed the American Academy of Neurological 
Surgeons/Congress of Neurological Surgeons' recommendations in detail 
in our May 3, 1996 proposed notice (61 FR 20025 through 20027). The 
American Academy of Neurological Surgeons/Congress of Neurological 
Surgeons' approach, which in general HCFA and the RUC found to be 
reasonable for these codes, focused on intensity and time data gathered 
from detailed operative logs. The American Academy of Orthopedic 
Surgeons stated that the approach has not been validated, but it does 
not provide compelling evidence why the approach is invalid for these 
codes and why the relationship between the current work RVUs is more 
accurate than the proposed work RVUs.
    We also note that the Abt study done for the American Academy of 
Orthopedic Surgeons contains 12.34 work RVUs for CPT code 63030 and 
13.20 work RVUs for CPT code 63042. These values would alter the 
current work relationship between CPT codes 63030, 63042, and 63047 
significantly more than the RUC-recommended work RVUs. Given the 
differing work RVUs in the two studies, we believe the prudent action 
is to accept the RUC recommendations that reflect the judgment of all 
the major specialties of medicine.
    Final decision: We are making final our proposed work RVUs of 11.10 
for CPT code 63030 and 16.56 for CPT code 63042.
10. Ophthalmology
    CPT Codes 68820, 68825, and 68830 (Probing of nasolacrimal duct.
    Comment: These three codes have been deleted and replaced by three 
new codes in CPT 1997. The three new codes and the RUC recommendations 
for them are: CPT code 68810 (1.27 work RVUs); CPT code 68811 (2.25 
work RVUs); and CPT code 68815 (3.00 work RVUs).
    Response: Because the development of new codes was initiated by the 
5-year refinement and because the codes describe pediatric services for 
which we are particularly interested in developing appropriate work 
RVUs, we reviewed them in the context of the 5-year review. As part of 
the 5-year refinement, we forwarded to the RUC comments on two codes 
(CPT codes 68825 and 68830) that are part of the following existing 
family of codes for probing of nasolacrimal ducts:

------------------------------------------------------------------------
                 CPT Code                            Descriptor         
------------------------------------------------------------------------
68820.....................................  Probing of nasolacrimal     
                                             duct, with or without      
                                             irrigation, unilateral or  
                                             bilateral.                 
68825.....................................  Probing of nasolacrimal     
                                             duct, with or without      
                                             irrigation, unilateral or  
                                             bilateral; requiring       
                                             general anesthesia.        
68830.....................................  Probing of nasolacrimal     
                                             duct, with or without      
                                             irrigation, unilateral or  
                                             bilateral; with insertion  
                                             of tube or stent.          
------------------------------------------------------------------------

The RUC reviewed a recommendation to increase the work RVUs for CPT 
code 68830 and concluded that the work RVUs should not be increased. We 
reviewed and accepted that recommendation.
    The RUC reviewed a recommendation to increase the work RVUs for CPT 
code 68825 from 1.53 to 2.50 and concluded there was a problem with the 
current descriptor in that unilateral and bilateral procedures were 
valued the same. Therefore, the code was referred to the CPT Editorial 
Panel. In our May 3, 1996 proposed notice (61 FR 20009), we noted that 
the code was referred to CPT and proposed maintaining the current work 
RVUs.
    Because the code in question was part of a family of codes, the 
deletion of the phrase ``unilateral or bilateral'' by the CPT Editorial 
Panel affected all the codes in the family. Subsequently, the revised 
family of codes was referred from the CPT Editorial Panel back to the 
RUC.
    The codes for probing of a nasolacrimal duct (CPT codes 68820, 
68825, and 68830) have been deleted and replaced with new codes (CPT 
codes 68810, 68811, and 68815) to indicate that these codes should be 
used to report unilateral procedures. Bilateral procedures will be 
reported using the code with the -50 modifier.
    The RUC accepted the work RVU recommendation of 1.27 for CPT code

[[Page 59517]]

68810, presented by commenters practicing ophthalmology and optometry, 
that was based on budget neutral calculations assuming that 31 percent 
of procedures represented by CPT code 68810 (Probing of nasolacrimal 
duct, with or without irrigation) are performed bilaterally and would 
be subject to the multiple surgery reduction.
    The RUC also accepted the American Academy of Ophthalmology's 
request to increase the work RVUs for CPT code 68811 (Probing of 
nasolacrimal duct, with or without irrigation; requiring general 
anesthesia) from 1.53 to 2.25. The American Academy of Ophthalmology 
estimated that 62 percent of these procedures are performed 
unilaterally. The preservice, intraservice, and postservice work of 
this service were considered to be comparable to CPT code 67345 
(Chemodenervation of extraocular muscle), with 2.91 work RVUs.
    CPT code 68815 (Probing of nasolacrimal duct, with or without 
irrigation; with insertion of tube or stent) is performed when CPT code 
68811 has failed. The RUC agreed that the work RVUs for this service 
should be increased from 2.12 to 3.00 to maintain relativity with CPT 
codes 68810 and 68811. This increase was considered to be justified by 
the degree of preservice, intraservice, and postservice work involved 
in this procedure; the complications of intranasal bleeding; the 
possibility of aspirating blood intraoperatively or postoperatively; 
and the morbidity associated with drawing metallic probes through the 
nasolacrimal system.
    We accepted the RUC's recommendation for CPT code 68810. For CPT 
codes 68811 and 68815, we believed the recommended work RVUs were too 
high in light of the fact that most of the procedures will be performed 
bilaterally resulting in payment based on 150 percent of the listed 
work RVUs.
    Because these codes were originally commented on as part of the 5-
year refinement, we would like to assign final work RVUs effective 
January 1, 1997. Therefore, we referred these codes to a refinement 
panel for a full discussion of the issues.
    The following tables identify the codes and work RVUs for 1996 and 
1997:

                                                              1996 CPT Codes and Work RVUs                                                              
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                          1996 work                                                     
              CPT code                                   Descriptor                          RVUs                    Recommended work RVUs              
--------------------------------------------------------------------------------------------------------------------------------------------------------
68820..............................  Probing of nasolacrimal duct, with or without              1.47  Not applicable; code deleted.                     
                                      irrigation, unilateral or bilateral.                                                                              
68825..............................  Probing of nasolacrimal duct, with or without              1.53  Not applicable; code deleted.                     
                                      irrigation, unilateral or bilateral; requiring                                                                    
                                      general anesthesia.                                                                                               
68830..............................  Probing of nasolacrimal duct, with or without              2.12  Not applicable; code deleted.                     
                                      irrigation, unilateral or bilateral; with                                                                         
                                      insertion of tube or stent.                                                                                       
--------------------------------------------------------------------------------------------------------------------------------------------------------


                                                              1997 CPT Codes and Work RVUs                                                              
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                           1996 work                                                    
             CPT code                                    Descriptor                           RVUs                   Recommended work RVUs              
--------------------------------------------------------------------------------------------------------------------------------------------------------
68810.............................  Probing of nasolacrimal duct, with or without                1.27  Not applicable; new code.                        
                                     irrigation.                                                                                                        
68811.............................  Probing of nasolacrimal duct, with or without                2.25  Not applicable; new code.                        
                                     irrigation; requiring general anesthesia.                                                                          
68815.............................  Probing of nasolacrimal duct, with or without                3.00  Not applicable; new code.                        
                                     irrigation,; with insertion of tube or stent.                                                                      
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Final decision: We have reviewed and accepted the RUC 
recommendation to decrease the RVUs for deleted CPT code 68820, which 
will now be reported with new CPT code 68810, from 1.47 to 1.27 work 
RVUs. As a result of our analysis of the refinement panel ratings, we 
increase the work RVUs for deleted CPT code 68825, which will now be 
reported with new CPT code 68811, from 1.53 to 2.25 work RVUs. For 
deleted CPT code 68830, which will now be reported with new CPT code 
68815, we increase the work RVUs from 2.12 to 3.00 work RVUs.
    CPT code 92002 (Ophthalmological services; medical examination and 
evaluation with initiation of diagnostic and treatment program; 
intermediate, new patient).
    Comment: Two commenters objected to linking the intermediate new 
patient eye examination, CPT code 92002, with the a level-two new 
patient office visit (CPT code 99202) and recommended linking CPT code 
92002 with a level-three new patient office visit (CPT code 99203). 
This would result in an increase from our proposed 0.88 work RVUs to 
1.34 work RVUs. The commenters stated that a level-two service is the 
lowest level evaluation and management service requiring a physician's 
presence and that our proposal would force providers to bill at level-
two for all less than comprehensive eye examinations. They pointed to 
the times reported in the RUC surveys as support for a linkage to a 
level-three evaluation and management service; the RUC surveys reported 
intraservice times of 24 minutes for CPT code 99203 and 20 minutes for 
CPT code 92002.
    Response: The current work RVUs for CPT code 92002 are 1.01. We 
referred this code to the RUC last year because we believed it was 
overvalued compared to the evaluation and management services for new 
patient office visits. The RUC agreed with us and recommended that we 
assign the same work RVUS to the intermediate new patient eye 
examination (CPT code 92002) as we would assign to a level-two new 
patient office visit (CPT code 99202).
    We disagree with the arguments that a level-two service is the 
lowest level evaluation and management service requiring a physician's 
presence and

[[Page 59518]]

that our proposal would force providers to bill at level-two for all 
less than comprehensive eye examinations. First, every level of new 
patient office visits requires a physician's presence. Second, there 
are only two levels of eye examinations: intermediate and 
comprehensive. Thus, by definition, every eye examination that is less 
than comprehensive must be billed as an intermediate eye examination.
    We reviewed the survey data and have concluded that the data 
support our proposal. The median intraservice time for CPT code 92002 
was 20 minutes. This is the typical time of a level-two new patient 
office visit. The work RVUs we have assigned to a level-two new patient 
visit are based on 20 minutes of intraservice time, not the RUC survey 
time. The typical time of a level-three new patient office visit is 30 
minutes which is 50 percent greater than the time of a level-two visit 
and 50 percent greater than the surveyed time of CPT code 92002. We 
believe that acceptance of the comment would result in work RVUs that 
are inconsistent with all other evaluation and management services. To 
increase the work RVUs above the current 1.01 work RVUs by more than 30 
percent is clearly inconsistent with our conclusion, as well as that of 
the RUC, that the current work RVUs are too high.
    Final decision: We make final our proposed 0.88 work RVUs for CPT 
code 92002.
    CPT code 92004 (Ophthalmological services: medical examination and 
evaluation with initiation of diagnostic and treatment program; 
comprehensive, new patient, one or more visits).
    Comment: Two commenters noted that the 1.34 work RVUs for CPT code 
92004 were incorrectly calculated.
    Response: The work RVUs published in the May 3, 1996 proposed 
notice (61 FR 20039) were a technical error. We agree with the 
commenter that the correct work RVUs are 1.67, as recommended by the 
RUC.
    Final decision: We correct the work RVUs to 1.67.
    CPT codes 92225 and 92226 (Ophthalmoscopy, extended, with retinal 
drawing (eg, for retinal detachment, melanoma), with interpretation and 
report; initial and subsequent).
    Comment: Several commenters objected to our proposal to reduce the 
work RVUs for these codes to 0.38 and 0.33, respectively. They 
recommended that the current work RVUs of 0.58 and 0.50 be maintained 
and indicated that they would be willing to work with us to develop 
more detailed medical necessity review criteria for these procedures.
    Response: Carrier medical directors identified these two codes as 
potentially overvalued, and we referred the codes to the RUC. The 
current work RVUs are 0.58 and 0.50, respectively. The carrier medical 
directors recommended 0.38 and 0.33 and offered the following 
justification: ``The records that we have reviewed on this have shown 
no more diligence or attentiveness to the drawing than what any 
physician draws when describing a physical finding.''
    The RUC reviewed the comment and intended to refer the code to the 
CPT Editorial Panel for further clarification. In our May 3, 1996 
proposed notice (61 FR 20038 through 20039), we erroneously noted that 
the codes were referred to CPT and proposed maintaining the current 
work RVUs. However, the codes were never referred to CPT.
    At a subsequent meeting of the RUC, the American Academy of 
Ophthalmology recommended that, when properly performed, these 
procedures are appropriately valued. It attempted to develop a coding 
change proposal to address the possible abuse scenarios cited by the 
commenter. The American Academy of Ophthalmology has now concluded that 
coding changes would not be sufficient to solve this problem.
    While we appreciate the willingness of both specialty societies to 
work with us to develop more detailed medical necessity review criteria 
for these procedures, we do not believe that the carrier medical 
directors' recommendations for reduced work RVUs have been fully 
addressed.
    Since the codes will not be referred to the CPT and since they were 
originally commented on as part of the 5-year refinement, we referred 
the codes to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are decreasing the work RVUs for CPT codes 92225 and 92226 
from their current 0.58 and 0.50 work RVUs to 0.38 and 0.33 work RVUs, 
respectively. These represent the work RVUs for appropriately performed 
retinal drawings. We plan to work with the specialty societies to 
develop more detailed medical necessity review criteria for these 
procedures.
    CPT code 92260 (Ophthalmodynamometry).
    Comment: Several commenters recommended that the current 0.50 work 
RVUs be maintained.
    Response: Carrier medical directors originally identified this code 
as potentially overvalued, and we referred the code to the RUC. The 
current work RVUs are 0.50. The carrier medical directors recommended 
0.20 work RVUs and offered the following justification:
    ``Ophthalmodynamometry gives an approximate measurement of the 
relative pressures in the central retinal arteries and is an indirect 
means of assessing carotid artery flow on either side. The test 
consists of exerting pressure on the sclera with a spring plunger while 
observing with an ophthalmoscope the vessels emerging from the optic 
disks. This is included in 93875 which has an RVU of 0.16.''
    The RUC reviewed the comment and referred the code to the CPT 
Editorial Panel with a recommendation that consideration be given to 
deleting the code. The RUC stated that this service is rarely performed 
and may be an obsolete procedure. In our May 3, 1996 proposed notice 
(61 FR 20038 through 20039), we noted that the code was referred to CPT 
and proposed maintaining the current work RVUs. However, the code was 
never referred to CPT.
    The American Academy of Ophthalmology's CPT committee decided 
against recommending deletion of this code because it is still being 
used frequently by some groups of ophthalmologists. (In 1995, we 
received over 8,000 claims.) The American Academy of Ophthalmology 
stated that this code is more like CPT code 76519 (Ophthalmic biometry 
by ultrasound echography, A-scan; with intraocular lens power 
calculation), with 0.54 work RVUs, than the newer Doppler-type 
technology that has replaced it. For example, the service is performed 
entirely by a physician face-to-face with the patient, unlike Doppler, 
which involves more technician time. The RUC and the American Academy 
of Ophthalmology recommended, therefore, that the current 0.50 work 
RVUs be retained.
    We do not believe that the carrier medical directors' 
recommendations for reduced work RVUs have been fully addressed. Since 
the code will not be referred to the CPT and since the code was 
originally commented on as part of the 5-year refinement, we referred 
the code to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings,

[[Page 59519]]

we are decreasing the work RVUs for CPT code 92260 from 0.50 to 0.20.
11. Imaging
    CPT code 78806 (Radiopharma-ceutical localization of abscess; whole 
body).
    Comment: A commenter indicated that we made an apparent technical 
error by assigning the same work RVUs to CPT codes 78805 and 78806. The 
correct work RVUs for CPT codes 78805 and 78806 should be 0.73 and 
0.86, respectively.
    Response: We agree that a technical error was made.
    Final decision: CPT code 78806 is corrected to 0.86 work RVUs.
12. Cardiothoracic and Vascular Surgery
    CPT code 35700 (Reoperation for vascular infrainguinal bypass 
grafts) and CPT codes 35556, 35566, 35571, 35583, 35585, 35587, 35656, 
35666, and 35671 (Vascular infrainguinal bypass grafts).
    Comment: As part of the 5-year refinement, the RUC examined several 
of the codes for infrainguinal bypass procedures. In addition, we 
received a request from the Society for Vascular Surgery/International 
Society for Cardiovascular Surgery to reexamine the work RVUs that were 
assigned to the nine CPT codes that can be reported with the 
reoperation CPT code 35700.
    The descriptor for CPT code 35700 reads: ``Reoperation, femoral-
popliteal or femoral (popliteal) -anterior tibial, posterior tibial, 
peroneal artery or other distal vessels, more than one month after 
original operation.'' This code is to be listed separately in addition 
to any one of the nine CPT codes for the primary procedure (CPT codes 
35556, 35566, 35571, 35583, 35585, 35587, 35656, 35666, or 35671). The 
reoperation code was new in 1994. At that time, we estimated that 
approximately 22 percent of the primary procedures represent 
reoperations for which the new add-on code would be used in the future. 
To maintain the same number of work RVUs in 1994, we reduced the work 
RVUs of the primary procedures by approximately 3.5 percent.
    The Society for Vascular Surgery/International Society for 
Cardiovascular Surgery believed that an analysis of current data would 
prove that our estimates on the probable number of reoperations were 
too high. They requested that we make appropriate adjustments to the 
work RVUs based on actual utilization of the code.
    Response: Our analysis of the data revealed the following:
    In 1994, CPT code 35700 was billed in conjunction with the primary 
procedure codes listed above 3.47 percent of the time. There were 
67,482 primary services performed in 1994 and 2,343 reoperations (CPT 
code 35700).
    In the first three quarters of 1995, CPT code 35700 was billed in 
conjunction with the above listed primary procedure codes 4.12 percent 
of the time. There was a total of 44,684 primary services performed 
while 1,839 reoperations (CPT code 35700) were billed. These data 
confirm that our original estimates regarding the utilization of the 
reoperation CPT code 35700 were too high.
    Final decision: The following table identifies the nine codes, 
lists the 1996 work RVUs and lists the corrected work RVUs based on the 
actual utilization of the reoperation code. The differences in work 
RVUs between 1996 and the corrected work RVUs are also shown. Some of 
these codes were reviewed as part of the 5-year refinement, and we 
accepted the RUC recommendations for them. To determine the final work 
RVUs, we added the differences in work RVUs between 1996 and the 
rescaled work RVUs to either the RUC-recommended work RVUs or the 
current work RVUs for codes that were not part of the 5-year review.

----------------------------------------------------------------------------------------------------------------
                                                           1996                                            Final
                        CPT code                           work   Corrected  Difference     5-year RUC     work 
                                                           RVUs   work RVUs              recommendations   RVUs 
----------------------------------------------------------------------------------------------------------------
35556...................................................   15.47     15.94       0.47          19.37       19.84
35566...................................................   20.21     20.76       0.55          24.45       25.00
35571...................................................   16.66     17.14       0.48           None       17.14
35583...................................................   15.97     16.44       0.47          20.03       20.50
35585...................................................   19.05     19.60       0.55          25.95       26.47
35587...................................................   17.07     17.55       0.48           None       17.55
35656...................................................   13.86     14.44       0.58          17.84       18.42
35666...................................................   15.97     17.60       1.63           None       17.60
35671...................................................   12.18     13.39       1.21           None       13.39
----------------------------------------------------------------------------------------------------------------

    CPT code 35681 (Bypass graft, composite).
    Comment: We received comments from the Society for Vascular 
Surgery/International Society for Cardiovascular Surgery and the 
American College of Surgeons that provided the following explanation 
for the RUC's recommendations, which the commenters believed was an 
error. The American College of Surgeons identified CPT code 35681 as an 
overvalued service based on an Abt survey of surgical procedures. In 
its 5-year review letter dated February 3, 1995, the American College 
of Surgeons recommended a decrease in work RVUs from 8.00 to 3.93. A 
RUC work group endorsed this decrease with virtually no discussion, and 
the full RUC accepted it by consent decree.
    We accepted the recommended decrease in work RVUs in the May 3, 
1996 proposed notice (61 FR 20028). The Society for Vascular Surgery/
International Society for Cardiovascular Surgery believed that the 
American College of Surgeons' data identifying CPT code 35681 as 
overvalued were faulty because the American College of Surgeons used an 
inappropriate clinical vignette in the Abt survey.
    The American College of Surgeons' vignette described the splicing 
of a 6 cm segment of synthetic conduit into what is primarily a bypass 
graft constructed

[[Page 59520]]

with autogenous vein. The Society for Vascular Surgery/International 
Society for Cardiovascular Surgery stated that the use of synthetic 
conduits in this situation is not standard surgical practice. Instead, 
most surgeons performing this operation would harvest a separate 
segment of vein to use as the additional segment of conduit since the 
long term graft patency of the all-vein combination is far superior. 
Harvesting additional vein requires a separate skin incision, 
identification of another segment of acceptable vein, harvest of that 
vein with ligation of branches, and skin closure of the additional 
site. This is obviously far more work than opening a box of synthetic 
conduits to obtain the additional required conduit, yet the only code 
available for either procedure is CPT code 35681.
    In order to determine exactly how this code is used clinically, the 
Society for Vascular Surgery/International Society for Cardiovascular 
Surgery reviewed operative records from 16 practices across the country 
and found that the American College of Surgeons' vignette represents 
only 3 percent of the actual use of this code, and in 97 percent of 
cases the work involved is actually far greater than that described in 
the American College of Surgeons' vignette.
    Response: In light of the comments we received, we referred this 
code to a refinement panel for review of the coding issues and ratings 
of physician work.
    Final decision: As a result of our analysis of the refinement panel 
ratings, we are increasing the work RVUs assigned to CPT code 35681 
from the proposed 3.93 work RVUs to 8.05, the current work RVUs for the 
code. In addition, we are referring CPT code 35681 to CPT for division 
into two codes, one to represent addition of a segment of synthetic 
conduit to a primary bypass constructed of vein, and another to 
represent harvest and addition of a segment of vein conduit to a 
primary bypass constructed of vein or synthetic conduit. Once the codes 
have been accurately defined, they will be referred to the RUC for work 
evaluation. The work RVUs for CPT code 35681 are interim values until 
we receive the final RUC recommendations.
    CPT code 35875 (Thrombectomy of arterial or venous graft).
     Comment: The American College of Surgeons submitted CPT code 35875 
for review in its letter to us, dated February 3, 1995. Its 
identification of this code as being overvalued was based on a survey 
of the work involved in a vignette that described a thrombectomy of a 
clotted hemodialysis shunt. The American College of Surgeons 
recommended a decrease in work RVUs for CPT code 35875 from 9.07 to 
8.19. A RUC work group adopted the decrease without discussion, and the 
full RUC accepted it by consent decree. We subsequently accepted the 
decrease in our May 3, 1996 proposed notice (61 FR 20002).
     In a comment, the Society for Vascular Surgery/International 
Society for Cardiovascular Surgery provided the following explanation 
of the proper use of the codes. Thrombectomy and revision of a dialysis 
graft as described in the American College of Surgeons' vignette is 
actually CPT code 36832 (Revision of an arteriovenous fistula, with or 
without thrombectomy, autogenous or nonautogenous graft (separate 
procedure)), not CPT code 35875. CPT code 36832 falls within the family 
of hemodialysis graft codes in CPT and exactly fits the American 
College of Surgeons' vignette. It has only 5.84 work RVUs. The 
commenter believed that this error had caused the RUC to recommend a 
value that was too low.
     In contrast, the commenter explained, CPT code 35875 is defined as 
thrombectomy of arterial or venous graft, and it lies numerically 
within the CPT family of codes that describes bypass grafts performed 
for arterial insufficiency. CPT code 35875 requires significantly more 
work than CPT code 36832, and it has 9.07 work RVUs. It was, therefore, 
no surprise to the commenter that the surgeons participating in the 
American College of Surgeons' study considered that 9.07 work RVUs were 
too high when asked to evaluate the work involved in thrombectomy of a 
dialysis graft since they were actually being asked to rate a service 
that has only 5.84 work RVUs.
     In order to identify exactly how CPT code 35875 is used by 
practicing surgeons, the Society for Vascular Surgery/International 
Society for Cardiovascular Surgery reviewed charts of patients 
receiving this service over a period of 1 year at 16 surgical practices 
from across the country. The study identified 209 consecutive cases. 
CPT code 35875 was used for thrombectomy of arterial bypass grafts in 
patients with peripheral vascular disease in 60 percent of the cases, 
and, somewhat to their surprise, in 40 percent of cases, CPT code 35875 
was claimed when thrombectomy of a dialysis graft was performed in 
renal failure patients. The review indicated that some carrier medical 
directors also are confused regarding appropriate use of this code.
     Response: In light of the comments we received, we referred this 
code to a refinement panel for review of the coding issues and ratings 
of physician work.
     Final decision: As a result of our analysis of the refinement 
panel ratings, we are increasing the work RVUs assigned to CPT code 
35875 from the proposed 8.19 work RVUs to 9.07, which are the current 
work RVUs for the code. In addition, we will refer CPT code 35875 to 
CPT for redefinition by adding the term ``not for hemodialysis graft.'' 
We are also referring CPT code 36832 to CPT to be split into three 
separate codes, one specifically for thrombectomy of hemodialysis 
grafts, one for revision of hemodialysis grafts without thrombectomy, 
and one for thrombectomy and revision of hemodialysis grafts.
     Once the codes have been accurately defined, they will be referred 
to the RUC for work evaluation. We are keeping the work RVUs for CPT 
code 35875 interim until we receive the final RUC recommendations.
13. Pathology and Laboratory Procedures
    CPT code 85390-26 (Fibrinolysins or coagulopathy screen, 
interpretation and report).
    Comment: We received several comments objecting to our proposal to 
maintain the current 0.37 work RVUs rather than to accept the RUC 
recommendation of 0.75 work RVUs.
    Response: In its original recommendation to us, the RUC noted that 
this procedure had never been surveyed and the current work RVUs were 
established by HCFA. The RUC agreed that the physician work of 
furnishing this service has changed during the past few years. The 
clinical problems presented by patients are more complex, the tests are 
more technical, and the physician is required to perform more tests. 
However, the RUC did not believe that these changes warranted an 
increase to 1.20 work RVUs, as requested by a specialty society. 
Instead, the RUC believed that the service is comparable in physician 
work to the key reference service CPT code 88305 (Tissue exam by 
pathologist), with 0.75 work RVUs. Therefore, the RUC recommended 0.75 
work RVUs.
     Clinical laboratory tests are covered by the Medicare program and 
paid for under the clinical laboratory fee

[[Page 59521]]

schedule; performance of the test itself does not require the services 
of a physician and does not have physician work associated with it. 
However, we have recognized that there are a limited number of clinical 
laboratory codes for which it is almost always necessary for the 
laboratory physician to furnish an interpretation, and we have assigned 
0.37 work RVUs to these interpretations. We were not persuaded that the 
work has changed over time. The vignette used to survey this code 
appeared to represent services well beyond interpretation of a single 
test and seemed to describe a typical consultation. CPT code 80502 (Lab 
pathology consultation) describes the surveyed vignette and is valued 
at 1.33 work RVUs, which is similar to the 1.20 work RVUs from the RUC 
survey. Therefore, we proposed to retain the current 0.37 work RVUs for 
CPT code 85390-26. However, in light of the comments we received, we 
referred this code to a refinement panel for review.
     Final decision: As a result of our analysis of the refinement 
panel ratings, we maintain our current 0.37 work RVUs for CPT code 
85390-26.
    CPT code 86327-26 (Immunoelectrophoresis; crossed (2-dimensional 
assay)).
     Comment: We received several comments objecting to our proposal to 
maintain the current 0.37 work RVUs rather than to accept the RUC 
recommendation of 0.45 work RVUs.
     Response: In its original recommendation to us, the RUC noted that 
this procedure had never been surveyed and the current work RVUs were 
established by HCFA. The RUC agreed that the physician work of 
furnishing this service has changed during the past few years.
     The current work RVUs are 0.37. Pathology interpretation of 
laboratory tests was originally valued at 0.37 work RVUs. (See comment 
for CPT code 85390 above.) We were not persuaded that the work has 
changed over time. However, in light of the comments we received, we 
referred this code to a refinement panel for review.
     Final decision: As a result of our analysis of the refinement 
panel ratings, we are increasing the work RVUs from 0.37 to 0.42 for 
CPT code 86327-26.
    CPT code 88173-26 (Evaluation of fine needle aspirate with or 
without preparation of smears; interpretation and report).
     Comment: We received several comments objecting to our proposal to 
maintain the current 1.08 work RVUs. Our proposal was based, in part, 
on acceptance of a RUC recommendation to maintain the current work 
RVUs. A specialty society argued that the physician work involved in 
the interpretation of a fine needle aspiration has increased because of 
a change in the way the service is used in the continuum of diagnosis 
and treatment.
     When the service was first studied by the Harvard study team, fine 
needle aspiration was relatively new, performed primarily on advanced 
tumors and used as a screening service to be followed by confirmatory 
biopsy. Now, the fine needle aspiration specimen received for 
interpretation is from an earlier stage in the disease process, often 
from lesions that are borderline in their presentation. In addition, 
the procedure is now used as a definitive diagnostic procedure from 
which treatment decisions are made. These two changes lead to increased 
work for the pathologist.
     Response: In light of the comments we received, we referred this 
code to a refinement panel for review.
     Final decision: As a result of the our analysis of the refinement 
panel ratings, we are increasing the work RVUs from 1.08 to 1.39 for 
CPT code 88173-26.
14. Psychiatry
     Comment: In our May 3, 1996 proposed notice (61 FR 20029 through 
20030), we described the RUC's review of the comments submitted by the 
American Psychiatric Association and the American Academy of Child and 
Adolescent Psychiatry as part of the 5-year refinement. The American 
Psychiatric Association, in its comments and during its presentation to 
the RUC, presented the following evidence to support increasing the 
work RVUs of the psychiatric codes:
     Patient type and mix have changed dramatically during the 
past 5 years. The American Psychiatric Association reported that before 
1990, for the most part, ``stable'' patients were seen in an office 
outpatient setting. Patients that were considered unstable, and 
otherwise hard to manage, were treated as inpatients, allowing the 
physician to coordinate with the hospital staff, if necessary. In the 
past, patients tended to seek treatment earlier and physicians were 
able to make referrals to psychiatrists earlier. The onset of managed 
care has increased the likelihood that many patients are referred to 
non-physician mental health providers, which has translated into 
psychiatrists treating only severely ill patients.
     Decreasing inpatient hospital admissions has resulted in 
increased patient morbidity. Again, the American Psychiatric 
Association noted that shifting insurance industry patterns have played 
a significant role in this trend. Although many insurance policies 
offer mental health coverage, the coverage is often very restrictive. 
For example, most policies have strict limits on the number of 
inpatient hospital days. Many managed care policies have shifted away 
from long-term psychotherapy in favor of short intermittent treatment 
therapies.
     Since many more patients are seen on an outpatient basis, 
there is an increasing amount of coordination of care with other 
providers. The American Psychiatric Association noted that the time 
spent dealing with coordination of care issues has resulted in an 
increase of physician preservice and postservice work.
     During the past 5 years, new, highly sophisticated 
neuroleptic and antidepressant medications have been introduced. The 
American Psychiatric Association noted that, because of the advances in 
psychopharmacology, a greater number of individual psychotherapy 
patients will likely utilize these medications than was the case 5 
years ago. The greater reliance on these medications has increased the 
complexity of the medical decision making during an individual 
psychotherapy visit. Many of these new drugs require constant 
monitoring, such as weekly blood monitoring in the case of Clorazil. 
The failure to monitor these drugs appropriately could result in 
adverse side effects and possibly death.
     The RUC reviewed 18 services in the psychiatry section of CPT. For 
13 of those services, the RUC recommended no change from the current 
work RVUs. For the other five services, the RUC believed that the 
points cited above provided a compelling argument for increasing the 
work RVUs from their current levels.
     In our response to the RUC recommendations for the 18 codes, we 
agreed with the RUC that the current work RVUs for 13 of the 
psychiatric services should be maintained. However, we did not agree 
that there was compelling evidence to increase the work RVUs for the 
following five psychiatric services: Psychiatric interview (CPT code 
90801), Psychotherapy, 20-30 minutes (CPT code 90843), Psychotherapy 
45-50

[[Page 59522]]

minutes (CPT code 90844), Special group therapy (CPT code 90853), and 
Individual psychotherapy (CPT code 90855). Therefore, we did not accept 
the RUC-recommended increases for these five psychiatry codes.
     Commenters expressed concern that we provided no rationale for our 
disagreement and argued that the RUC and the American Psychiatric 
Association had provided compelling evidence for the recommended 
increases.
     The RUC and the American Psychiatric Association reaffirmed their 
previous recommendations for these services and provided the following 
arguments for increasing the codes in question:
     The shifts from inpatient to outpatient care in psychiatry 
have shifted a major burden of work to the codes proposed for increase.
     Selectivity and complexity factors clearly apply to this 
family of codes.
     Many of the work changes that we accepted for increasing 
the evaluation and management services apply to these codes as well.
    Response: We agree that we did not provide a thorough rationale for 
rejecting the RUC recommendations. At the time we were preparing the 
May 3, 1996 proposed notice, we had initiated informal discussions with 
the American Psychiatric Association about the need to revise the 
existing psychotherapy codes to reflect the variation in work 
associated with the type of psychotherapy and the setting in which it 
is furnished. In anticipation of new and revised codes, we did not 
review the RUC recommendations at that time as thoroughly as we now 
have. We now accept the arguments of the RUC and the American 
Psychiatric Association that the work of the five codes has increased 
over time and that the work RVUs should be adjusted accordingly. In the 
next two sections, we discuss the coding of psychiatric services and 
the assignment of work RVUs to the psychotherapy codes.

Coding of Psychiatric Services

    It now appears that the American Psychiatric Association has 
decided against pursuing a change in the CPT codes for psychiatric 
services at this time. However, we believe that a change in the code 
descriptors is essential as part of the 5-year refinement of the work 
RVUs in order for us to properly recognize the variations in work 
associated with the different types of psychotherapy as well as the 
settings in which the different types of psychotherapy are furnished. 
Also, the problems with the coding of psychiatric services have been 
known for several years. The following is a summary of the most 
important problems that have been identified with the current codes:
     The current psychotherapy codes do not distinguish the 
settings in which psychotherapy is furnished because the same codes are 
used to report office and inpatient psychotherapy. In 1990, the 
American Psychiatric Association submitted a request to CPT to create 
new codes for psychiatric care in a facility. Those codes would have 
recognized the difference in work associated with psychotherapy 
furnished to inpatients. However, the codes were not approved.
     In 1990, the American Psychiatric Association noted the 
need to refine the CPT codes in its comments on the Medicare model fee 
schedule that was published in our September 4, 1990 notice with 
comment period (55 FR 36178). The American Psychiatric Association 
expressed the need for codes to report inpatient psychiatric services 
and objected to the use of the existing psychotherapy codes by non-
physician providers (psychologists and clinical social workers). The 
American Psychiatric Association cited the following terminology in the 
codes to support their argument: ``Individual medical psychotherapy by 
a physician, with continuing medical diagnostic evaluation, and drug 
management when indicated.'' The American Psychiatric Association 
argued that while non-physician providers do provide psychotherapy 
services, those services cannot be interpreted as ``medical 
psychotherapy.'' For Medicare purposes, the existing psychotherapy 
codes are used by psychologists and clinical social workers even though 
the code descriptors attempt to limit their use to physicians. We 
believe that services that can be furnished by both physicians and non-
physician providers should be described by codes with descriptors that 
do not limit their use to physicians.
     In January 1991, the Harvard study team published a final 
report entitled ``Refinement of the Development of a Resource Based 
Relative Value Scale for Psychiatric Services.'' In the Executive 
Summary, it states: ``The data from the national survey of psychiatry 
tend to suggest the need for further examination of coding of services 
for psychiatry. First, the findings are especially strong for the need 
to distinguish between services provided in the hospital and those 
provided in the office. Second, the findings indicate that, controlling 
for subspecialty of the provider, services delivered to young children 
differ in the amount of work required, suggesting the possible need for 
new or modified service codes for child psychiatry.'' The first finding 
has not been resolved. The second has been partially resolved by the 
addition of a new code in CPT 1992 for reporting ``interactive 
psychotherapy.'' However, there are two major problems with this new 
code. First, it is not clearly defined, and the lack of clear 
definition has led to the submission of approximately 500,000 claims 
for interactive therapy. We believe that most of those claims were 
improperly coded since the typical interactive psychotherapy session is 
furnished to children. Second, the code does not distinguish the time 
of the session as do the other psychotherapy codes. Because we have 
assigned work RVUs to this code that are higher than those for CPT code 
90844 (Psychotherapy, 45-50 minutes), a claim for psychotherapy of 20-
30 minutes, that is improperly reported as interactive psychotherapy, 
will be significantly overpaid. Consequently, we view our inability to 
properly assign work RVUs, based on the length of the sessions, to be a 
significant problem that must be corrected as soon as possible.
     We do not permit the reporting of an evaluation and 
management service on the same day of service that psychotherapy is 
furnished. We announced this policy in our November 25, 1991 final rule 
(56 FR 59502) for the 1992 physician fee schedule. The policy was based 
in part on our need to standardize payment policies because there was 
considerable variation across carriers in their policies regarding 
payment for hospital care and psychiatric care on the same day of 
service. In addition, we were concerned that there was considerable 
overlap in the preservice and postservice work of psychotherapy and 
evaluation and management services that could lead to two payments for 
the same service. Therefore, we increased the work RVUs assigned to the 
psychotherapy codes but precluded the reporting of an evaluation and 
management service on the same day as psychotherapy. We acknowledged in 
the final rule that our policy is not consistent with the introductory 
notes to the psychiatric section of CPT. However, we also stated

[[Page 59523]]

that, if the CPT codes were revised, we would consider revising the 
work RVUs to be consistent with the new or revised codes.
    To address these problems, we have developed new alpha-numeric 
codes to report psychotherapy services. These codes will go into effect 
on January 1, 1997. For Medicare purposes, they will replace CPT codes 
90842 (Psychotherapy, 75-80 minutes), 90843 (Psychotherapy, 20-30 
minutes), 90844 (Psychotherapy, 45-50 minutes), and 90855 (Interactive 
individual medical psychotherapy). We will no longer recognize these 
CPT codes for Medicare payment purposes. The objectives of our new 
codes and the introductory paragraphs that precede them are the 
following:
     Distinguish psychotherapy furnished in an office from 
psychotherapy furnished in an inpatient or other facility by creating 
two families of codes.
     Distinguish interactive psychotherapy services based on 
the duration of the face-to-face time with the patient by creating 
three time-based codes that would parallel the three time-based codes 
for the other psychotherapy services, that is, 20-30 minutes, 45-50 
minutes, and 75-80 minutes.
     Distinguish between interactive psychotherapy and other 
forms of psychotherapy by providing clearer definitions.
     Unbundle the existing psychotherapy codes to allow the 
reporting of psychotherapy that is furnished without medical evaluation 
and management services from psychotherapy that is furnished with 
medical evaluation and management services.
     Eliminate the word ``medical'' from ``medical 
psychotherapy'' and eliminate the phrase ``by a physician'' to make it 
clear that the use of the codes to report psychotherapy without medical 
evaluation and management services is not restricted to physicians. The 
use of these codes will be open to physicians, psychologists, and 
clinical social workers.
     Serve as a basis for assigning appropriate work RVUs to 
psychotherapy services as part of the 5-year refinement of work RVUs.
    In the following section, we provide a listing of the new codes 
including the complete descriptors and several introductory paragraphs. 
Our new coding structure establishes 12 codes for office and other 
outpatient services and 12 codes for inpatient hospital, partial 
hospital, or residential care facilities. We have included partial 
hospital services with inpatient hospital services because we believe 
the work of a physician in a partial hospital setting is more 
comparable to the work in an inpatient setting than it is to the work 
in an office setting. In particular, in both the inpatient and partial 
hospital setting, physicians are responsible for admitting patients, 
developing and revising treatment plans, supervising multi-disciplinary 
treatment and planning for discharge.
    Within each setting there are six codes for insight oriented, 
behavior modifying, and/or supportive psychotherapy and six codes for 
interactive psychotherapy. Each family of six codes is further divided 
based on the face-to-face time spent with the patient and whether 
evaluation and management services are furnished in addition to the 
psychotherapy. We plan to submit these codes to the CPT Editorial Panel 
as part of a comprehensive revision of the psychiatry section of CPT. 
For a discussion of the work RVUs that we have assigned to the new 
codes, see the section below entitled, ``Assignment of Work RVUs to the 
Psychiatric Codes.''

Psychiatric Therapeutic Procedures

    Psychotherapy is the treatment for mental illness and behavioral 
disturbances in which the therapist establishes a professional contract 
with the patient and, through definitive therapeutic communication, 
attempts to alleviate the emotional disturbances, reverse or change 
maladaptive patterns of behavior, and encourage personality growth and 
development. The codes for reporting psychotherapy are divided into two 
broad categories: Interactive Psychotherapy; and Insight Oriented, 
Behavior Modifying and/or Supportive Psychotherapy.
    Interactive psychotherapy is typically furnished to children. It 
involves the use of physical aids and non-verbal communication to 
overcome barriers to therapeutic interaction between the physician and 
a patient who has lost, or has not yet developed, either the expressive 
language communication skills to explain his/her symptoms and response 
to treatment, or the receptive communication skills to understand the 
physician if he/she were to use ordinary adult language for 
communication.
    Insight oriented, behavior modifying and/or supportive 
psychotherapy refers to the development of insight or affective 
understanding, the use of behavior modification techniques, the use of 
supportive interactions, the use of cognitive discussion of reality, or 
any combination of the above to provide therapeutic change.
    Some patients receive psychotherapy only and others receive 
psychotherapy and medical evaluation and management services. These 
evaluation and management services involve a variety of 
responsibilities unique to the medical management of psychiatric 
patients, such as medical diagnostic evaluation, drug management when 
indicated, physician orders, interpretation of laboratory or other 
medical diagnostic studies and observations, review of activity therapy 
reports, the supervision of nursing and ancillary personnel, the 
programming of all hospital resources for diagnosis and treatment, and 
activity in leadership or direction of a treatment team as related to 
that patient.
    In reporting psychotherapy, the appropriate code is chosen on the 
basis of the type of psychotherapy (interactive using non-verbal 
techniques versus insight oriented, behavior modifying and/or 
supportive using verbal techniques), the place of service (office 
versus inpatient), the face-to-face time spent with the patient during 
psychotherapy, and whether evaluation and management services are 
furnished on the same date of service as psychotherapy.
    To report medical evaluation and management services furnished on a 
day when psychotherapy is not provided, providers select the 
appropriate code from the ``Evaluation and Management (E/M) Services 
Guidelines'' section of CPT.

Office or Other Outpatient Psychotherapy

Insight Oriented, Behavior Modifying and/or Supportive Psychotherapy
G0071--Individual psychotherapy, insight oriented, behavior modifying 
and/or supportive, in an office or outpatient facility, approximately 
20 to 30 minutes face-to-face with the patient
G0072--Individual psychotherapy, insight oriented, behavior modifying 
and/or supportive, in an office or outpatient facility, approximately 
20 to 30 minutes face-to-face with the patient, with medical evaluation 
and management services
G0073--Individual psychotherapy, insight oriented, behavior

[[Page 59524]]

modifying and/or supportive, in an office or outpatient facility, 
approximately 45 to 50 minutes face-to-face with the patient
G0074--Individual psychotherapy, insight oriented, behavior modifying 
and/or supportive, in an office or outpatient facility, approximately 
45 to 50 minutes face-to-face with the patient, with medical evaluation 
and management services
G0075--Individual psychotherapy, insight oriented, behavior modifying 
and/or supportive, in an office or outpatient facility, approximately 
75 to 80 minutes face-to-face with the patient
G0076--Individual psychotherapy, insight oriented, behavior modifying 
and/or supportive, in an office or outpatient facility, approximately 
75 to 80 minutes face-to-face with the patient, with medical evaluation 
and management services
Interactive Psychotherapy
G0077--Individual psychotherapy, interactive, in an office or 
outpatient facility, approximately 20 to 30 minutes face-to-face with 
the patient
G0078--Individual psychotherapy, interactive, in an office or 
outpatient facility, approximately 20 to 30 minutes face-to-face with 
the patient, with medical evaluation and management services
G0079--Individual psychotherapy, interactive, in an office or 
outpatient facility, approximately 45 to 50 minutes face-to-face with 
the patient
G0080--Individual psychotherapy, interactive, in an office or 
outpatient facility, approximately 45 to 50 minutes face-to-face with 
the patient, with medical evaluation and management services
G0081--Individual psychotherapy, interactive, in an office or 
outpatient facility, approximately 75 to 80 minutes face-to-face with 
the patient
G0082--Individual psychotherapy, interactive, in an office or 
outpatient facility, approximately 75 to 80 minutes face-to-face with 
the patient, with medical evaluation and management services

Inpatient Hospital, Partial Hospital or Residential Care Facility

Insight Oriented, Behavior Modifying and/or Supportive Psychotherapy
G0083--Individual psychotherapy, insight oriented, behavior modifying 
and/or supportive, in an inpatient hospital, partial hospital or 
residential care setting, approximately 20 to 30 minutes face-to-face 
with the patient
G0084--Individual psychotherapy, insight oriented, behavior modifying 
and/or supportive, in an inpatient hospital, partial hospital or 
residential care setting, approximately 20 to 30 minutes face-to-face 
with the patient, with medical evaluation and management services
G0085--Individual psychotherapy, insight oriented, behavior modifying 
and/or supportive, in an inpatient hospital, partial hospital or 
residential care setting, approximately 45 to 50 minutes face-to-face 
with the patient
G0086--Individual psychotherapy, insight oriented, behavior modifying 
and/or supportive, in an inpatient hospital, partial hospital or 
residential care setting, approximately 45 to 50 minutes face-to-face 
with the patient, with medical evaluation and management services
G0087--Individual psychotherapy, insight oriented, behavior modifying 
and/or supportive, in an inpatient hospital, partial hospital or 
residential care setting, approximately 75 to 80 minutes face-to-face 
with the patient
G0088--Individual psychotherapy, insight oriented, behavior modifying 
and/or supportive, in an inpatient hospital, partial hospital or 
residential care setting, approximately 75 to 80 minutes face-to-face 
with the patient, with medical evaluation and management services
Interactive Psychotherapy
G0089--Individual psychotherapy, interactive, in an inpatient hospital, 
partial hospital or residential care setting, approximately 20 to 30 
minutes face-to-face with the patient
G0090--Individual psychotherapy, interactive, in an inpatient hospital, 
partial hospital or residential care setting, approximately 20 to 30 
minutes face-to-face with the patient, with medical evaluation and 
management services
G0091--Individual psychotherapy, interactive, in an inpatient hospital, 
partial hospital or residential care setting, approximately 45 to 50 
minutes face-to-face with the patient
G0092--Individual psychotherapy, interactive, in an inpatient hospital, 
partial hospital or residential care setting, approximately 45 to 50 
minutes face-to-face with the patient, with medical evaluation and 
management services
G0093--Individual psychotherapy, interactive, in an inpatient hospital, 
partial hospital or residential care setting, approximately 75 to 80 
minutes face-to-face with the patient
G0094--Individual psychotherapy, interactive, in an inpatient hospital, 
partial hospital or residential care setting, approximately 75 to 80 
minutes face-to-face with the patient, with medical evaluation and 
management services

Assignment of Work RVUs to the Psychiatric Codes

    The RUC, American Psychiatric Association, and other commenters 
recommended an increase from 2.18 to 2.80 in the work RVUs assigned to 
CPT code 90801 (Psychiatric diagnostic interview examination including 
history, mental status, or disposition (may include communication with 
family or other sources, ordering and medical interpretation of 
laboratory or other medical diagnostic studies)). We accepted this 
recommendation.
    We also received a final work RVU recommendation for CPT code 90820 
(Interactive medical psychiatric diagnostic interview examination). In 
September, the RUC recommended that the current 2.27 work RVUs be 
maintained until the American Academy of Child and Adolescent 
Psychiatry had an opportunity to conduct a survey. A survey of nearly 
40 child psychiatrists resulted in a median of 3.25 work RVUs. CPT code 
90820 requires more work than CPT code 90801 (Psychiatric interview), 
for which the 5-year review RUC recommendation was 2.80 work RVUs. The 
survey indicated 170 minutes of total time for this service, compared 
to 135 minutes for CPT code 90801. The preservice time is greater for 
CPT code 90820 because the psychiatrist must contact not only the 
child's pediatrician, but also the child's school and, in some 
instances, a

[[Page 59525]]

non-custodial parent. The intraservice time is longer and the service 
requires more work to develop a relationship with the child using non-
verbal techniques and to collect and interpret data. Drawing inferences 
from the data requires the child psychiatrist to generate and test a 
series of developmental and dynamic hypotheses. There is also increased 
technical skill required to use the play equipment during this 
interactive interview. The postservice time is greater than that for 
CPT code 90801 because the psychiatrist must again contact the school 
and, perhaps, the non-custodial parent.
    The RUC agreed that CPT code 90820 requires more work than CPT code 
90801 (Psychiatric interview), with 2.80 work RVUs, and recommended 
3.01 work RVUs to maintain a consistent relationship between the RUC 
recommendations for CPT code 90855 (Interactive individual medical 
psychotherapy), with 2.15 work RVUs, and CPT code 90844 (Psychotherapy, 
45-50 minutes), with 2.00 work RVUs. We agree with this recommendation 
and have assigned 3.01 work RVUs to CPT code 90820 (Interactive medical 
psychiatric diagnostic interview examination).
    The RUC, American Psychiatric Association, and other commenters 
recommended increases in the work RVUs assigned to CPT code 90843 
(Psychotherapy, 20-30 minutes) and CPT code 90844 (Psychotherapy, 45-50 
minutes) from 1.10 and 1.72 to 1.47 and 2.00, respectively. We accepted 
these recommendations and have assigned them to new HCPCS codes G0072 
and G0074 that are the codes for reporting psychotherapy with medical 
evaluation and management services of 20-30 and 45-50 minutes, 
respectively, in an office or outpatient facility. We believe these two 
codes correspond most closely to the vignettes for CPT codes 90843 and 
90844 that were surveyed as part of the RUC process. The vignettes were 
for office psychotherapy and included medical evaluation and management 
services.
    For the codes used to report psychotherapy without medical 
evaluation and management services of 20-30 minutes and 45-50 minutes 
duration (HCPCS codes G0071 and G0073), we have assigned 1.11 and 1.73 
work RVUs. These are the work RVUs currently assigned to CPT codes 
90843 and 90844. We considered lowering the work RVUs for HCPCS codes 
G0071 and G0073 since the codes describe services (psychotherapy alone) 
that require less work than the existing CPT codes 90843 and 90844 
(psychotherapy with continuing medical diagnostic evaluation and drug 
management when indicated). However, we decided to maintain the current 
work RVUs out of recognition that the work of psychotherapy alone also 
may have increased over time.
    The RUC has recommended that the work RVUs for CPT code 90842 
(Psychotherapy, 75-80 minutes) be maintained at their current level of 
2.76. In our May 3, 1996 proposed notice (61 FR 20014), we accepted 
that recommendation. We now believe these are the appropriate work RVUs 
for psychotherapy without medical evaluation and management services 
and have assigned 2.76 work RVUs to HCPCS code G0075. For HCPCS code 
G0076, which is the code for reporting psychotherapy of 75-80 minutes 
with medical evaluation and management services, we have assigned 3.15 
work RVUs. These work RVUs are 14 percent higher than those for HCPCS 
code G0075 and correspond to the increases we established for the other 
psychotherapy codes with medical evaluation and management services 
relative to the codes for psychotherapy alone.
    For the interactive psychotherapy codes in an office or outpatient 
facility (HCPCS codes G0077 through G0082), we looked to the 
relationship established by the RUC for interactive psychiatric 
services relative to other psychiatric services. CPT code 90820 
(Interactive medical psychiatric diagnostic interview examination) was 
valued by the RUC 7.5 percent higher than CPT code 90801 (Psychiatric 
interview); and CPT code 90855 (Interactive individual medical 
psychotherapy) was valued 7.5 percent higher than CPT code 90844 
(Psychotherapy, 45-50 minutes duration). Therefore, we have assigned 
work RVUs to HCPCS codes G0077 through G0082 that are 7.5 percent 
higher than those for the corresponding psychotherapy codes.
    Our new coding structure establishes 12 codes for office and other 
outpatient services and 12 codes for inpatient hospital, partial 
hospital, or residential care facilities. Within each setting there are 
six codes for psychotherapy and six codes for interactive 
psychotherapy. There were no inpatient vignettes surveyed as part of 
the 5-year refinement. Therefore, we looked to the Harvard study of 
psychiatric services as a basis for assigning work RVUs to the 12 
inpatient codes. Based on our analysis of the findings of that study, 
we have concluded that inpatient psychiatric services require 
approximately 12 percent more work than office based services. 
Therefore, we have assigned work RVUs to the new inpatient codes that 
are 12 percent higher than those for the corresponding office codes.
    Finally, we have examined further our decisions regarding the group 
psychotherapy codes. For CPT code 90853 (Group psychotherapy (other 
than of a multiple-family group) by a physician, with continuing 
medical diagnostic evaluation and drug management when indicated), we 
initially rejected the RUC recommendation to increase the work RVUs 
from 0.43 to 0.59. Based on the comments we received, we now accept 
that recommendation. For CPT code 90857 (Interactive group medical 
psychotherapy), we initially accepted the RUC recommendation for no 
increase above the current 0.43 work RVUs. We now believe these work 
RVUs should be increased to be 7.5 percent more than the work RVUs for 
CPT code 90853 (Group psychotherapy (other than of a multiple-family 
group) by a physician, with continuing medical diagnostic evaluation 
and drug management when indicated) so that the relationship of 
interactive psychiatric services to other psychiatric services will be 
maintained. Therefore, we have assigned 0.63 work RVUs to CPT code 
90857.
    Final decision: We have accepted or increased the RUC-recommended 
RVUs for psychiatry services. The RUC-recommended RVUs are the basis of 
the RVUs we have assigned to temporary HCPCS codes G0071 through G0094. 
We have issued temporary codes so that we may properly recognize the 
variations in work associated with the different types of psychotherapy 
as well as the settings in which the different types of psychotherapy 
are furnished.
    The codes and assigned RVUs are considered interim, and we will 
accept comments on them. We plan to submit the codes to the CPT 
Editorial Panel as part of a comprehensive review of the psychiatry 
section, and we will share any comments we receive on the temporary 
HCPCS ``G'' codes with the Editorial Panel.
    We will no longer recognize CPT codes 90842 (Psychotherapy, 75-80

[[Page 59526]]

minutes), 90843 (Psychotherapy, 20-30 minutes), 90844 (Psychotherapy, 
45-50 minutes), and 90855 (Interactive individual medical 
psychotherapy). An abbreviated descriptor for the new codes and the 
values are shown below.

----------------------------------------------------------------------------------------------------------------
               HCPCS code                                        Descriptor                           Work RVUs 
----------------------------------------------------------------------------------------------------------------
G0071                                    Individual psychotherapy (e.g., insight oriented), office          1.11
                                          or outpatient, 20-30 minutes.                                         
G0072                                    Individual psychotherapy (e.g., insight oriented), office          1.47
                                          or outpatient, 20-30 minutes, with medical evaluation and             
                                          management.                                                           
G0073                                    Individual psychotherapy (e.g., insight oriented), office          1.73
                                          or outpatient, 45-50 minutes.                                         
G0074                                    Individual psychotherapy (e.g., insight oriented), office          2.00
                                          or outpatient, 45-50 minutes, with medical evaluation and             
                                          management.                                                           
G0075                                    Individual psychotherapy (e.g., insight oriented), office          2.76
                                          or outpatient, 75-80 minutes.                                         
G0076                                    Individual psychotherapy (e.g., insight oriented), office          3.15
                                          or outpatient, 75-80 minutes, with medical evaluation and             
                                          management.                                                           
G0077                                    Individual psychotherapy, interactive (non-verbal), office         1.19
                                          or outpatient, 20-30 minutes.                                         
G0078                                    Individual psychotherapy, interactive (non-verbal), office         1.58
                                          or outpatient, 20-30 minutes, with medical evaluation and             
                                          management.                                                           
G0079                                    Individual psychotherapy, interactive (non-verbal), office         1.86
                                          or outpatient, 45-50 minutes.                                         
G0080                                    Individual psychotherapy, interactive (non-verbal), office         2.15
                                          or outpatient, 45-50 minutes, with medical evaluation and             
                                          management.                                                           
G0081                                    Individual psychotherapy, interactive (non-verbal), office         2.97
                                          or outpatient, 75-80 minutes.                                         
G0082                                    Individual psychotherapy, interactive (non-verbal), office         3.39
                                          or outpatient, 75-80 minutes, with medical evaluation and             
                                          management.                                                           
G0083                                    Individual psychotherapy (e.g., insight oriented),                 1.24
                                          inpatient or partial hospital, 20-30 minutes.                         
G0084                                    Individual psychotherapy (e.g., insight oriented),                 1.65
                                          inpatient or partial hospital, 20-30 minutes, with                    
                                          medical evaluation and management.                                    
G0085                                    Individual psychotherapy (e.g., insight oriented),                 1.94
                                          inpatient or partial hospital, 45-50 minutes.                         
G0086                                    Individual psychotherapy (e.g., insight oriented),                 2.24
                                          inpatient or partial hospital, 45-50 minutes, with                    
                                          medical evaluation and management.                                    
G0087                                    Individual psychotherapy (e.g., insight oriented),                 3.09
                                          inpatient or partial hospital, 75-80 minutes.                         
G0088                                    Individual psychotherapy (e.g., insight oriented),                 3.53
                                          inpatient or partial hospital, 75-80 minutes, with                    
                                          medical evaluation and management.                                    
G0089                                    Individual psychotherapy, interactive (non-verbal),                1.33
                                          inpatient or partial hospital, 20-30 minutes.                         
G0090                                    Individual psychotherapy, interactive (non-verbal),                1.77
                                          inpatient or partial hospital, 20-30 minutes, with                    
                                          medical evaluation and management.                                    
G0091                                    Individual psychotherapy, interactive (non-verbal),                2.08
                                          inpatient or partial hospital, 45-50 minutes.                         
G0092                                    Individual psychotherapy, interactive (non-verbal),                2.41
                                          inpatient or partial hospital, 45-50 minutes, with                    
                                          medical evaluation and management.                                    
G0093                                    Individual psychotherapy, interactive (non-verbal),                3.32
                                          inpatient or partial hospital, 75-80 minutes.                         
G0094                                    Individual psychotherapy, interactive (non-verbal),                3.80
                                          inpatient or partial hospital, 75-80 minutes, with                    
                                          medical evaluation and management.                                    
----------------------------------------------------------------------------------------------------------------

15. Other Medical and Therapeutic Services
    CPT code 90911 (Anorectal biofeedback).
    Comment: A commenter objected to our proposed reduction of the work 
RVUs from 2.15 to 0.89. We rejected the RUC recommendation to retain 
the current 2.15 work RVUs because this procedure involves little 
physician work. We believe the physician work involved in CPT code 
90911 to be similar to that in all the other biofeedback codes, which 
all have 0.89 work RVUs. The commenter pointed out that the typical 
patient treatment time for this procedure is 1 hour. The commenter 
stated that during this time, detailed office notes, patient progress 
and goals, analysis of the electromyogram data printouts, and patient 
billing information must be completed by the highly trained nurses that 
deliver the treatment under physician supervision. The commenter stated 
that the reduction in physician work RVUs would result in an overall 
payment for this procedure that would be insufficient to cover the 
overhead associated with this procedure.
    Response: We agree that the actual biofeedback therapy is delivered 
by a nurse or other auxiliary medical personnel under the general 
supervision of a physician. As such, the physician work involved is 
minimal as we stated in our proposal in our May 3, 1996 proposed notice 
(61 FR 20030 through 20031) to reduce the physician work RVUs. The 
nurse's efforts in delivering the treatment and the other overhead 
associated with this procedure are included in the practice expense 
RVUs, not the work RVUs, and are thus not within the scope of the 5-
year work RVU refinement as we stated in our May 3, 1996 proposed 
notice (61 FR 19994).
    Final decision: We make final our 0.89 proposed work RVUs for CPT 
code 90911.
    CPT code 94150 (Vital capacity, total (separate procedure)).
    Comment: Several commenters expressed support for our proposal to 
retain the current 0.11 work RVUs for CPT code 94150.
    Response: We believe the commenters may have misunderstood the work 
RVUs we proposed in July 1996. When the RUC reviewed this code, it 
identified a CPT coding issue and referred it to the CPT Editorial 
Panel for review. In July, at the time of publication of our proposal, 
we had not received the RUC's recommendations following the CPT 
Editorial Panel's revision so we listed the current RVUs of 0.11 as 
proposed work RVUs. During the comment period of our May 3, 1996 
proposed notice, we received the RUC's recommendation to decrease the 
work RVUs from 0.11 to 0.07.
    Final decision: We reviewed and agreed with the RUC recommendation 
and are decreasing the work RVUs to 0.07 for CPT code 94150.

[[Page 59527]]

    In addition, in our July 2, 1996 proposed rule (61 FR 34626), we 
proposed to remove from Medicare coverage, the services represented by 
CPT code 94150. Our final decision, after review of the comments 
received, is to make CPT code 94150 a bundled service rather than a 
non-covered service. See section II.E.1. of this final rule for a more 
complete discussion of this code.
16. Speech/Language/Hearing
    We received no comments on the speech, language, and hearing codes 
and have accepted all of the RUC recommendations as final.

B. Other Comments

1. Evaluation and Management Services
    In our May 3, 1996 proposed notice (61 FR 20031 through 20039), we 
reevaluated the work RVUs for all 98 of the evaluation and management 
services that have RVUs. We only accepted two of the RUC's 39 
recommendations for evaluation and management services. However, we 
agreed with many of the RUC's arguments for increasing the work RVUs 
for evaluation and management services and used those arguments as the 
basis for our proposed changes.
    Comment: We received voluminous identical comments from family 
practitioners stating that we ``dismissed the RUC recommendations'' and 
used an arbitrary method for revising the work RVUs.
    Response: We provided a lengthy rationale in our May 3, 1996 
proposed notice (61 FR 200310 through 20039) for why we rejected the 
RUC-recommended work RVUs and how we arrived at our proposed work RVUs. 
We did not ``dismiss'' the RUC recommendations. In its comments, the 
RUC expressed its pleasure at our acceptance of its arguments about why 
evaluation and management services were undervalued. In fact, the RUC 
stated, ``. . . we believe that the overall results for evaluation and 
management services are consistent with the RUC recommendations and 
supporting rationale.'' Most primary care specialties, while preferring 
the RUC-recommended RVUs, supported our decision to increase the work 
RVUs for evaluation and management services. With a few exceptions, 
noted below, we are making the proposed work RVUs for evaluation and 
management services final.
    Comment: One commenter stated that we did not specify in what ways 
we thought the RUC data were ``flawed.''
    Response: In our May 3, 1996 proposed notice (61 FR 20032), we 
identified several flaws, including overstated postservice times.
    Comment: One commenter stated that we were inconsistent in our 
characterization of preservice and postservice work. In one place, we 
stated that preservice and postservice work intensity is a fixed 
percentage of intraservice work intensity while elsewhere we stated 
that preservice work and postservice work is a fixed percentage of 
intraservice work.
    Response: The commenter has identified a proofreading error on our 
part. Our assumption is that preservice work and postservice work is a 
fixed percentage of intraservice work. This assumption was articulated 
in the November 25, 1992 final notice for the 1993 physician fee 
schedule (57 FR 55949 through 55951) and was based largely on the 
Harvard resource-based relative value scale study and comments from 
primary care groups.
    Comment: Several primary care groups requested that we recognize 
that the data on evaluation and management services the RUC presented 
are sufficient evidence for us to remain open to receiving further 
information that shows the relationships between some families of these 
services have changed.
    Response: As we explained in our May 3, 1996 proposed notice (61 FR 
20032), we do not believe that the data the RUC presented as part of 
the 5-year review were sufficient for us to change the existing 
relationships among the evaluation and management service families. 
However, we will remain open to data regarding evaluation and 
management services. If, in the future, the data convince us that the 
relationships have changed, we will go through the public notice and 
comment procedures to make the necessary changes to the work RVUs for 
evaluation and management services.
    CPT codes 99201 through 99215 (Office visits).
    Comment: Some commenters requested that we apply the same increases 
to CPT code 99211 that we applied to the other office visit codes.
    Response: Because CPT code 99211 does not require the presence of a 
physician, we had considered making it a code with zero work. Instead, 
we are maintaining the current work RVUs for CPT code 99211 and will 
reevaluate this as we develop our proposals for resource-based practice 
expense. We recognize that we have deviated from our approach to the 
rest of the evaluation and management services. While we have raised 
the RVUs for other evaluation and management services, we are not 
raising the RVUs for CPT code 99211 because the use of this code has 
changed since it was first introduced with all other evaluation and 
management changes in January 1992. Over time, the code has been used 
increasingly to report services furnished by physicians' office staff 
rather than by physicians themselves. Given this change, we do not 
believe that an increase in the physician work RVUs is warranted.
    CPT codes 99241 through 99245 (Office or other outpatient 
consultations).
    Comment: Several commenters objected to our assumption that the 
preservice and postservice work associated with outpatient 
consultations was less than that of office visits. Specific specialties 
provided examples illustrating that the preservice and postservice work 
of an outpatient consultation is more like a visit, and as such, should 
have been given the same percentage increase in preservice and 
postservice work as the office visits. The RUC incorrectly stated that 
we based our proposed RVUs on the assumption that preservice and 
postservice work for outpatient consultations had not increased at all. 
Several other commenters strongly approved of the approach we took when 
valuing outpatient consultations.
    Response: Our proposed work RVUs for outpatient consultations 
included a recognition that the preservice and postservice work had 
increased. We increased the preservice and postservice work (expressed 
as a percentage of intraservice work) by 10 percent rather than the 25 
percent increase we included for the office visits. Our assumption was, 
and still is, that the preservice and postservice work associated with 
the typical patient is less for an outpatient consultation than for an 
office visit for the reasons outlined in the May 3, 1996 proposed 
notice (61 FR 20037). However, based on the comments provided to us, we 
acknowledge that for some specific specialties the preservice and 
postservice work associated with the consultations is greater. Because 
the physician fee schedule has no specialty differential, we cannot 
assign different

[[Page 59528]]

work RVUs for the same service for different specialties. Therefore, we 
are increasing the percentage of intraservice work slightly more than 
we did with our proposed work RVUs.
    The final work RVUs for CPT codes 99241 through 99245 will include 
a 12.5 percent increase in the percentage of intraservice work to 
reflect the added preservice and postservice work rather than the 10 
percent increase we proposed. This change reflects that the increase in 
preservice and postservice work over the past 5 years for outpatient 
consultations is half of that for office visits. If we had increased 
the preservice and postservice work percentage further, the current 
relationship between outpatient consultations and inpatient 
consultations would be lost since outpatient consultations would be 
valued higher than the inpatient consultations. As stated in previous 
regulations, we believe that the work of inpatient consultations is 
slightly higher than the work of outpatient consultations at the 
highest levels of service.
    CPT codes 99281 through 99285 (Emergency department services).
    Comment: We received a comment from the American College of 
Emergency Physicians expressing support for our proposed changes. 
However, the RUC, in its comments, made new recommendations for the 
emergency department services. In its recommendations, the RUC equated 
CPT codes 99281 through 99283 with CPT codes 99201 through 99203, and 
assigned 2.00 work RVUs for CPT code 99284 and 2.90 work RVUs for CPT 
code 99285. These work RVUs, with the exception of the work RVUs for 
CPT code 99285, are higher than the proposed work RVUs.
    Response: We believe our proposed work RVUs maintain the proper 
relationship with other evaluation and management services. These 
values are also supported by the American College of Emergency 
Physicians. Therefore, we are making the proposed work RVUs final.
    CPT codes 99321 through 99333 (Domiciliary, rest home (e.g., 
boarding home), or custodial care services).
    Comment: One commenter suggested that domiciliary visits should 
have the same value as the home visit codes because there is very 
little difference between these two families of services. The commenter 
held the view that our assumption that domiciliary visits require less 
work than home visits because of the availability of personal assistant 
services is incorrect. The staff, the commenter maintained, is 
essentially unskilled and too busy to assist the physician.
    Response: We are unclear as to why there are separate families of 
codes if home visits and domiciliary visits require similar work. In 
our May 3, 1996 proposed notice (61 FR 20038), we maintained the 
current relationship between domiciliary visits and home visits. Until 
the comment period for our May 3, 1996 proposed notice, we had not 
received any comments suggesting that the existing relationship was 
incorrect. Because we are waiting until the CPT Editorial Panel reworks 
the home visit codes before revaluing the services, we will also wait 
until the Panel reworks the domiciliary visit codes before revaluing 
them. Therefore, we will maintain the 1996 work RVUs for CPT codes 
99321 through 99333 until after the CPT Editorial Panel reviews these 
codes.
    CPT codes 99341 through 99353 (Home services).
    Comment: Commenters challenged the assumptions that we used in 
reevaluating all the evaluation and management codes with respect to 
home visits. They stated that equating home visits with office visits 
of greater length is not appropriate since home visits were not part of 
the early stages of the Harvard study. Also, in developing the May 3, 
1996 proposed notice, we did not review the RUC recommendations and 
survey data that were made available in April. The commenters suggested 
that the difference between new and established patient home visits is 
less than that seen in other families of evaluation and management 
services and that the preservice and postservice work is proportionally 
higher for home visits than for other evaluation and management 
services. In particular, commenters opposed our proposed reductions in 
the work RVUs for CPT codes 99351 and 99352.
    In its comments, the RUC made its final recommendations for the 
home visit codes. Whereas the RUC had previously recommended no change 
in the work RVUs for these services, the new recommendations were for 
substantial increases. The RUC's comments indicated that the current 
CPT descriptors do not accurately describe the home visits, and the RUC 
has referred these codes back to CPT. With its recommendations, the RUC 
noted ``* * * that there are significant differences between the home 
visits and other visits, including the severe and multiple disabilities 
of the patients, the need to assess patients' functional and mental 
status, to train both patients and untrained caregivers, and the need 
to manage problems related to patient dementia, other psychiatric 
problems and the care giver pathologies.'' Other arguments used in the 
development of the RUC's recommended work RVUs are that because the 
physician is in the home, he or she must evaluate the environment and 
its effect on the illness and care plan; ancillary services such as 
laboratory, EKG, and oximetry that are normally done by a technician in 
the office must be performed by the physician; the physician has no on-
site staff to reduce the time for such functions as dressing and 
undressing the patient, counseling patients, family members, and 
caregivers, and taking vital signs; and patients and families have 
higher intensity needs when a home visit is furnished.
    Response: The work RVUs we proposed were created in an effort to 
maintain the current relationship between home visits and office 
visits. We had not reviewed the most recent RUC recommendations because 
they had not been submitted to us as part of the RUC's 5-year review 
recommendations received in late 1995. Our proposed work RVUs were also 
based on the current CPT code descriptors. We recognized that there was 
something intangible about the work of home visits that was not 
captured in the descriptors but was captured, we had thought, in the 
current relationship of work RVUs between home and office visits. For 
the family of home visit services, it appears from the comments that 
the CPT descriptors do not accurately describe the nature of the 
services furnished in the typical case. Therefore, because the CPT 
Editorial Panel is going to reexamine these codes, we are not adjusting 
the 1996 work RVUs for CPT codes 99341 through 99353, and the work RVUs 
for CPT codes 99351 and 99352 are not being decreased as proposed. We 
will revalue these services once the code descriptors are changed. We 
anticipate that the new descriptors and new work RVUs will become 
effective in 1998. Simultaneously, the adoption of a practice expense 
RVU schedule in 1998 will allow us to address the increased physician 
work and decreased use of clinical staff for these codes in a uniform 
manner. Only when we have a more accurate description of the service

[[Page 59529]]

can we fairly assign work RVUs to the home visits.
    Comment: A commenter requested that we allow physician assistants 
and nurse practitioners to furnish home visits ``incident to'' a 
physician's practice. The physician would have to be available 
immediately by telephone.
    Response: This issue was not subject to comment. Our current policy 
stands. A home visit cannot be billed by a physician unless the 
physician was actually present in the beneficiary's home.
    Final decision: With the exception of CPT codes 99241 through 99245 
(Office or other outpatient consultations) and 99321 through 99353 
(Domiciliary and home care), we finalize the work RVUs we proposed for 
the evaluation and management services. We are slightly increasing the 
work RVUs for CPT codes 99241 through 99245, and we will maintain the 
1996 work RVUs for 99321 through 99353. The final work RVUs follow:

------------------------------------------------------------------------
                                                     Proposed    Final  
                     CPT code                       work RVUs  work RVUs
------------------------------------------------------------------------
99201.............................................       0.45       0.45
99202.............................................       0.88       0.88
99203.............................................       1.34       1.34
99204.............................................       2.00       2.00
99205.............................................       2.67       2.67
99211.............................................       0.17       0.17
99212.............................................       0.45       0.45
99213.............................................       0.67       0.67
99214.............................................       1.10       1.10
99215.............................................       1.77       1.77
99217.............................................       1.28       1.28
99218.............................................       1.28       1.28
99219.............................................       2.14       2.14
99220.............................................       2.99       2.99
99221.............................................       1.28       1.28
99222.............................................       2.14       2.14
99223.............................................       2.99       2.99
99231.............................................       0.64       0.64
99232.............................................       1.06       1.06
99233.............................................       1.51       1.51
99238.............................................       1.28       1.28
99239.............................................       1.75       1.75
99241.............................................       0.64       0.64
99242.............................................       1.28       1.29
99243.............................................       1.71       1.72
99244.............................................       2.56       2.58
99245.............................................       3.41       3.43
99251.............................................       0.66       0.66
99252.............................................       1.32       1.32
99253.............................................       1.82       1.82
99254.............................................       2.64       2.64
99255.............................................       3.65       3.65
99261.............................................       0.42       0.42
99262.............................................       0.85       0.85
99263.............................................       1.27       1.27
99271.............................................       0.45       0.45
99272.............................................       0.84       0.84
99273.............................................       1.19       1.19
99274.............................................       1.73       1.73
99275.............................................       2.31       2.31
99281.............................................       0.33       0.33
99282.............................................       0.55       0.55
99283.............................................       1.24       1.24
99284.............................................       1.95       1.95
99285.............................................       3.06       3.06
99291.............................................       4.00       4.00
99292.............................................       2.00       2.00
99295.............................................      16.00      16.00
99296.............................................       8.00       8.00
99297.............................................       4.00       4.00
99301.............................................       1.28       1.28
99302.............................................       1.71       1.71
99303.............................................       2.14       2.14
99311.............................................       0.64       0.64
99312.............................................       1.06       1.06
99313.............................................       1.51       1.51
99321.............................................       0.89       0.71
99322.............................................       1.34       1.01
99323.............................................       1.78       1.28
99331.............................................       0.45       0.60
99332.............................................       0.73       0.80
99333.............................................       1.18       1.00
99341.............................................       1.34       1.12
99342.............................................       2.00       1.58
99343.............................................       2.67       2.09
99351.............................................       0.67       0.83
99352.............................................       1.10       1.12
99353.............................................       1.77       1.48
99354.............................................       1.77       1.77
99355.............................................       1.77       1.77
99356.............................................       1.71       1.71
99357.............................................       1.71       1.71
99375.............................................       1.73       1.73
99381.............................................       1.19       1.19
99382.............................................       1.36       1.36
99383.............................................       1.36       1.36
99384.............................................       1.53       1.53
99385.............................................       1.53       1.53
99386.............................................       1.88       1.88
99387.............................................       2.06       2.06
99391.............................................       1.02       1.02
99392.............................................       1.19       1.19
99393.............................................       1.19       1.19
99394.............................................       1.36       1.36
99395.............................................       1.36       1.36
99396.............................................       1.53       1.53
99397.............................................       1.71       1.71
99401.............................................       0.48       0.48
99402.............................................       0.98       0.98
99403.............................................       1.46       1.46
99404.............................................       1.95       1.95
99411.............................................       0.15       0.15
99412.............................................       0.25       0.25
99431.............................................       1.17       1.17
99432.............................................       1.26       1.26
99433.............................................       0.62       0.62
99435.............................................       1.50       1.50
99440.............................................       2.93       2.93
------------------------------------------------------------------------

    Although the work RVUs for CPT code 99375 (Care plan oversight) 
have not changed, we are replacing this code with three HCPCS codes, in 
an effort to eliminate confusion about proper reporting of this 
service. Our 1995 and 1996 data reveal inappropriate use of CPT code 
99375. Physicians billed it for services furnished to beneficiaries who 
were not receiving Medicare-covered home health or hospice benefits. 
The new codes are much more specific than CPT code 99375. They will 
have the same final work RVUs assigned to them as CPT code 99375. 
Existing CPT code 99375 will no longer be recognized for Medicare 
reporting services. We plan to forward the temporary codes to the CPT 
Editorial Panel for consideration of their inclusion in the CPT. The 
new codes, effective January 1, 1997, follow:

------------------------------------------------------------------------
        HCPCS code                           Descriptor                 
------------------------------------------------------------------------
G0064....................  Physician supervision of a patient under care
                            of home health agency (patient not present) 
                            requiring complex and multidisciplinary care
                            modalities involving regular physician      
                            development and/or revision of care plans,  
                            review of subsequent reports of patient     
                            status, review of related laboratory and    
                            other studies, communication (including     
                            telephone calls) with other health care     
                            professionals involved in patient's care,   
                            integration of new information into the     
                            medical treatment plan and/or adjustment of 
                            medical therapy, within a calendar month; 30
                            minutes or more.                            
G0065....................  Physician supervision of a hospice patient   
                            (patient not present) requiring complex and 
                            multidisciplinary care modalities involving 
                            regular physician development and/or        
                            revision of care plans, review of subsequent
                            reports of patient status, review of related
                            laboratory and other studies, communication 
                            (including telephone calls) with other      
                            health care professionals involved in       
                            patient's care, integration of new          
                            information into the medical treatment plan 
                            and/or adjustment of medical therapy, within
                            a calendar month; 30 minutes or more.       

[[Page 59530]]

                                                                        
G0066....................  Physician supervision of a nursing facility  
                            patient (patient not present) requiring     
                            complex and multidisciplinary care          
                            modalities involving regular physician      
                            development and/or revision of care plans,  
                            review of subsequent reports of patient     
                            status, review of related laboratory and    
                            other studies, communication (including     
                            telephone calls) with other health care     
                            professionals involved in patient's care,   
                            integration of new information into the     
                            medical treatment plan and/or adjustment of 
                            medical therapy, within a calendar month; 30
                            minutes or more.                            
------------------------------------------------------------------------

The codes for home health and hospice patients, HCPCS codes G0064 and 
G0065, will be active codes on our fee schedule with 1.73 work RVUs 
each. The third code, HCPCS code G0066, will be considered a bundled 
service because we do not recognize separate payment for care plan 
oversight services furnished to beneficiaries in nursing facilities. 
This policy is explained in the December 8, 1994 physician fee schedule 
final rule (59 FR 63418 through 63423). Therefore, there is no separate 
payment for HCPCS code G0066. Only one of these codes may be billed per 
month per Medicare beneficiary. All of the policies regarding CPT code 
99375 apply to HCPCS codes G0064 and G0065.
2. Pediatrics
    Comment: We received a comment from the RUC on the importance of 
properly valuing pediatric services. The RUC first expressed concern 
about the need for the Medicare relative value scale to be complete and 
accurate for pediatric services in 1993. Since then, the RUC has 
developed work RVU recommendations for several hundred pediatric and 
pediatric subspecialty services that were previously listed with 0.00 
work RVUs. Consistent with our proposal to refine the relative value 
scale on a periodic basis as necessary rather than waiting until the 
10-year review to make additional needed corrections, the RUC urged us 
to continue to accept coding changes and work RVU recommendations for 
the pediatric services over the coming year as the American Academy of 
Pediatrics, the CPT Editorial Panel, and the RUC complete remaining 
work on these issues.
    Response: In our May 3, 1996 proposed notice (61 FR 20039), we 
restated our belief that the work RVUs for the full range of pediatric 
services are essentially complete. However, we also indicated our 
intention to review RUC recommendations for any new or revised CPT 
codes for pediatric services in future annual physician fee schedule 
updates. We remain committed to that position.
    CPT codes 56805 (Clitoroplasty for intersex state) and 57335 
(Vaginoplasty for intersex state).
    Comment: The RUC recommended an increase in CPT code 56805 
(Clitoroplasty for intersex state), with 15.49 work RVUs in 1996, and 
CPT code 57335 (Vaginoplasty for intersex state), with 9.11 work RVUs 
in 1996, to 18.00 to correct a current rank order anomaly and to 
appropriately value these services that are performed on children less 
than 1 year of age.
    CPT code 56805 is similar in time and intensity to CPT code 54336 
(One stage perineal hypospadias repair requiring extensive dissection 
to correct chordee and urethroplasty by use of skin graft tube and/or 
island flap), with 18.95 work RVUs, and is more work than CPT code 
54125 (Amputation of penis; complete), with 12.80 work RVUs, a 
destructive procedure to treat carcinoma of the penis.
    CPT code 57335 has a substantially longer intraservice time and is 
more intense than CPT code 57292 (Construction of artificial vagina; 
with graft), with 12.34 work RVUs, and is more work than CPT code 45123 
(Proctectomy, partial, without anastomosis, perineal approach), with 
13.27 work RVUs, which describes a destructive procedure. CPT code 
57335 also includes the endocrine management of the adenogenital 
syndrome.
    Response: We have reviewed the RUC recommendations, and we agree 
with them.
    Final decision: We are assigning 18.00 work RVUs to CPT codes 56805 
and 57335. Because the public has not had an opportunity to comment on 
these work RVUs, we consider them to be interim work RVUs and will 
accept comments on these codes.
3. Anesthesia
    Comment: In response to our request for public comments at the 
beginning of the 5-year review process in December 1994, the American 
Society of Anesthesiologists furnished comments based on a study by Abt 
Associates. The Abt study advocated that the anesthesia work under the 
physician fee schedule be increased by an average of 34.8 percent. We 
referred that proposal and the Abt study to the RUC for its 
recommendation. On February 10, 1996, the RUC unanimously recommended 
that anesthesia work RVUs be increased by 22.8 percent or about two-
thirds of the size of the increase recommended by the Abt study.
    We did not include the RUC recommendation for increased work RVUs 
for anesthesia services in the May 3, 1996 proposed notice because it 
was not included in the RUC's initial recommendation for codes under 
the 5-year review. The anesthesia recommendation was one of several 
recommendations that the RUC made to us on June 27, 1996, which we 
received as a comment in response to the May 3, 1996 proposed notice.
    The Abt study evaluated anesthesia work in relation to other 
services by partitioning an anesthesia service uniformly into five 
distinct components, assigning intensity values to these components 
based on the intensity values of benchmark procedures, and multiplying 
anesthesia time per component by its corresponding intensity. The five 
components are preanesthesia, induction, procedure, emergence, and 
postanesthesia.
    There was considerable discussion by the RUC about the intensity 
values for anesthesia services. The RUC accepted the intensity values 
for the preanesthesia, postanesthesia, emergence, and induction 
intervals. However, the RUC did not accept the minimum intensity value 
(that is, 0.25) proposed in the final Abt study for most of the 
procedure interval. Instead, the RUC assigned an intensity value of 
0.017.
     For half of the 15 procedures reviewed by the Abt 
multidisciplinary panel, the procedure interval was consistently valued 
at one intensity value, namely the minimum intensity value. However, 
for some anesthesia services, the intensity values for the procedure 
interval represented a weighted average because the intensity value 
fluctuated as a result of the underlying complexity of the activities 
performed in this period.

[[Page 59531]]

     Since the procedure interval represents the largest portion of the 
anesthesia service, the relative value for an anesthesia service is 
most sensitive to the minimum intensity value assigned to the procedure 
interval. The use of the intensity value of 0.017 means that the 
intensity of the procedure interval is kept at its current value (that 
is, pre- 5-year review level) although the increased intensity values 
of other portions of the anesthesia service are recognized.
     The American Society of Anesthesiologists commented that they 
continue to believe that the minimum procedure intensity benchmark 
should be 0.025 but recommended that, at the very least, this benchmark 
should be 0.021. If this latter approach were accepted, application of 
the Abt methodology would result in increasing the anesthesia work by 
29 percent.
    Response: While the RUC eventually accepted the Abt methodology and 
the intensity values, we are somewhat concerned with an approach in 
which physicians estimate intensity values for an entire service or a 
component of a service. Research by Harvard that led to the original 
physician fee schedule values illustrated that work can be overvalued 
when physician estimates of intensity are matched with service time.
     However, in light of the fact that the RUC conducted a thorough 
and detailed review of this issue, having looked at this issue on three 
separate occasions, and relied heavily on the expertise of its research 
committee, we have accepted the RUC recommendation. We agree that the 
minimum intensity of the procedure interval should be 0.017 because the 
intensity of this interval is less than the intensity of evaluation and 
management services.
     Because anesthesia services have base and time units, and, thus, 
are not on the same system as are all other physicians' services, the 
adjustment is more complicated. This adjustment must be made, in the 
aggregate, on the anesthesia CF since there is no defined work RVU per 
code for anesthesia services. In addition, the budget neutrality 
adjuster will be applied to the anesthesia CF.
    Final decision: We have reviewed and accepted the RUC 
recommendation and are increasing the work for anesthesia services by 
22.76 percent. Since the adjustment was not proposed in the May 3, 1996 
proposed notice, we will accept comments as we do for interim work 
RVUs.
4. Codes Without Work Relative Value Units
    Comment: The Joint Council for Allergy, Asthma and Immunology 
commented that work RVUs should be reflected in CPT codes 95004 and 
95024 (allergy skin tests) and CPT codes 95115 and 95117 (allergy 
shots). Currently those codes have zero work RVUs. In our May 3, 1996 
proposed notice (61 FR 19994), we advised that codes with zero work 
RVUs were not subject to review as part of the 5-year review. The Joint 
Council for Allergy, Asthma and Immunology disagreed with that 
position. It stated that there is no statutory authority for us to 
limit the scope of the 5-year review in that manner and that we have 
not provided an alternative process for the review of codes with zero 
work RVUs.
    Response: We believe that we have the authority to establish 
reasonable limits on the scope of services reviewed within the 5-year 
review. As we explained in our May 3, 1996 proposed notice (61 FR 
20041), the work RVUs represent primarily the work of physicians. We 
believe that codes that do not include the work of physicians are more 
appropriately included as part of the process of developing resource-
based practice expense RVUs, Therefore, we plan to invite comments on 
codes with zero work RVUs during that process. We will also invite 
comments on codes for which commenters might believe that work now 
reflected in practice expenses, such as the work of a nurse or 
technician, is, instead, work that physicians are and should be doing.
5. Potentially Overvalued Services
    Comment: The RUC submitted recommendations for several potentially 
overvalued codes that had not been reviewed in time for consideration 
before publication of the May 3, 1996 proposed notice. The RUC's 
recommendations for these codes follow:
    CPT code 33970 (Insertion of intra-aortic balloon assist device 
through the femoral artery, open approach) and CPT code 33971 (Removal 
of intra-aortic balloon assist device including repair of femoral 
artery, with or without graft).
    Comment: The RUC identified CPT code 33970 (Insertion of intra-
aortic balloon assist device through femoral artery, open approach) 
with 8.05 work RVUs, as a potentially overvalued service. The RUC 
determined that there are rank order anomalies in the intra-aortic 
balloon insertion and removal codes. The relationship between CPT codes 
33970 and 33971 should be similar to CPT code 33973 (Insertion of 
intra-aortic balloon assist device through the ascending aorta), with 
9.76 work RVUs, and CPT code 33974 (Removal of intra-aortic balloon 
assist device from the ascending aorta, including repair of the 
ascending aorta, with or without graft), with 12.69 work RVUs.
    To correct this rank order problem, the RUC recommended a decrease 
to 6.75 work RVUs for CPT code 33970. In addition, the RUC compared CPT 
code 33971 (Removal of intra-aortic balloon assist device including 
repair of femoral artery, with or without graft), with 4.04 work RVUs, 
to the family of codes and determined that it is currently undervalued 
and should be increased to 8.40 work RVUs since it is more work than 
CPT codes 33970 and 35226 (Repair blood vessel, direct; lower 
extremity), with 8.17 work RVUs.
    Response: We have reviewed the RUC recommendations, and we agree 
with them.
    Final decision: We are assigning 6.75 work RVUs to CPT code 33970 
and 8.40 work RVUs to CPT code 33971. Because the public has not had an 
opportunity to comment on these work RVUs, we will consider them to be 
interim work RVUs and will accept comments on our proposal.
    CPT code 67210 (Treatment of retinal lesion).
    Comment: In September 1995, the RUC recommended that the current 
work RVUs for this code be maintained and the issue be referred to CPT. 
The intraservice work per unit of time analysis and the original work 
RVUs failed to take into account that the code includes multiple 
treatments that are bundled into the 90-day global period and cannot be 
billed separately. There is a bimodal distribution of patients treated 
within this code. The code includes treatment of acute macular 
degeneration and diabetic retinopathy. The RUC referred the issue to 
CPT to consider addition of a code for the treatment of the less 
complex retinal lesions. The American Academy of Ophthalmology is 
proceeding with development of two replacement codes for this 
procedure.
    Response: We agree that this code should be reviewed by the CPT 
Editorial Panel.
    Final decision: We are maintaining the current work RVUs of 9.48 
for CPT code 67210 as interim until they have

[[Page 59532]]

been reviewed by CPT and the RUC. We anticipate assigning final work 
RVUs that would go into effect on January 1, 1998.
    CPT codes 77420, 77425, and 77430 (Weekly radiation therapy 
management).
    Comment: The RUC recommended that the current work RVUs for these 
codes be maintained on an interim basis until the radiation oncology 
codes are reviewed by the CPT Editorial Panel. The assignment of 
complexity levels of weekly radiation treatment currently requires the 
consideration of equipment that is used for treatment setup (for 
example, beam arrangement, number of ports, use of blocks, wedges, and 
other beam attenuation devices). The descriptors should be revised to 
adequately reflect different levels of complexity in managing the 
treatment of these patients. The current global period of XXX should 
also be considered because weekly treatment management includes 
evaluation and management services during treatment and 90 days 
posttreatment, the interpretation of port-films, and continuous 
supervision and management of physics and technical factors.
    Another commenter indicated a concern that the section in our May 
3, 1996 proposed notice entitled ``Future Review'' (61 FR 20046) had 
included radiation oncology. The commenter stated the following:
     The three levels of radiation therapy treatment management 
were included in the 5-year review; further reconsideration would be a 
violation of the established process for review of work RVUs.
     The identification of the treatment management codes as 
potentially overvalued was based on faulty data, and no justification 
was given for further review.
     A significant portion of radiation oncology codes (the 
technical components and technical only codes) are being addressed 
under the practice expense study.
     We had accepted the relative value of these procedures 
without modification when the American College of Radiology and HCFA 
were jointly developing the Medicare radiologist fee schedule.
    Response: We agree with the RUC's recommendation and will leave the 
current work RVUs for radiation therapy treatment management in place 
as interim work RVUs with the understanding that the codes will be 
referred by the RUC to CPT and that the RUC and HCFA may want to 
revisit the whole area of work RVUs for radiation oncology services at 
a later date. There continues to be some disagreement or 
misunderstanding about which services are payable through the weekly 
treatment management codes and which are separately billable. In fact, 
the American College of Radiology's examples of treatment management 
activities that were presented to the RUC included services we thought 
were paid through the professional component of the treatment devices 
and physics codes. We continue to believe that there is a reasonable 
basis to more closely define the work of the exact services payable 
through the weekly management codes and to consider the bundling of 
codes when appropriate.
    Final decision: We are maintaining the work RVUs of the weekly 
radiation therapy management codes (CPT codes 77420, 77425, and 77430) 
as interim pending review of the codes by the CPT Editorial Panel.

C. Other Issues

1. Budget Neutrality
    In past years, we have made budget neutrality adjustments across 
the entire physician fee schedule: to all RVUs (initially) and, 
beginning in 1996, to the CFs. We generally prefer to make adjustments 
across the entire fee schedule.
    In the May 3, 1996 proposed notice (61 FR 20044 through 20045), we 
reiterated the policy of making budget neutrality adjustments required 
by changes in payment policy through adjustments to the CFs. However, 
since this 5-year review covered work RVUs, we proposed making the 
required budget neutrality adjustment from the 5-year review only on 
the work RVUs. We indicated that we proposed simply to rescale the work 
RVUs. We noted, however, that this rescaling could cause administrative 
problems for other payers using the RVUs and stated that we would 
consider developing a new budget neutrality adjuster that would be 
applied only to the work RVUs.
    Comment: No comments questioned our making budget neutrality 
adjustments required by changes in payment policy through adjustments 
to the CFs. Regarding the budget neutrality adjustment required for RVU 
changes resulting from the 5-year refinement, the bulk of the comments 
focused on making the adjustment to work RVUs (that is, rescaling work 
RVUs). Most commenters favored achieving budget neutrality through a 
special separate budget neutrality adjuster for work RVUs. Many 
commenters, including two payers, indicated that rescaling RVUs would 
cause administrative difficulties in other programs using the RVUs. One 
payer stated that lowering RVUs to achieve budget neutrality might 
cause payers to develop their own RVUs. The other payer emphasized the 
need for continuity and clear relativity in the relative value scale.
    Response: We will continue our policy of making adjustments to the 
CF for budget neutrality adjustments required by changes in payment 
policy. However, instead of the policy of rescaling the work RVUs for 
the 5-year refinement that we proposed in the May 3, 1996 proposed 
notice, we will use a separate work budget neutrality adjuster in 1997. 
We emphasize that this is a 1-year policy. We plan to eliminate the 
separate adjuster in 1998 simultaneously with the implementation of 
resource-based practice expense payments. We agree with commenters that 
it will reduce confusion among other payers and enable easier tracking 
and analysis of work RVUs over time if we can minimize the rescaling of 
RVUs. While making a separate adjustment to the work RVUs for 1997 
introduces an additional term in the payment formula, the term is 
temporary. In years subsequent to 1998, we plan to make the budget 
neutrality adjustments to the CFs.
    The payment formula for 1997 will be [(work RVU) (work adjuster) 
(work geographic practice cost expense)] + [(practice expense RVU) 
(practice expense geographic practice cost expense)] + [(malpractice 
RVU) (malpractice geographic practice expense)]  x  conversion factor.
    Comment: Several commenters stated that the purpose of the 5-year 
review is to ensure that the RVUs are correct and reflect the relative 
difference in work among procedures. They stated that rescaling RVUs 
would distort the integrity of the RVUs and undermine the relationships 
among procedures.
    Response: We disagree that rescaling work RVUs would distort the 
integrity of the work RVUs and undermine the relationships among 
procedures. Because such an adjustment uniformly changes the work RVUs, 
it does not alter the relationship between them.
    Comment: About a quarter of the commenters suggested achieving 
budget neutrality by adjusting the CFs as an alternative to rescaling 
RVUs. A few of

[[Page 59533]]

the commenters stated that the simplicity of this approach was 
appealing. A few others observed that we have used different methods to 
achieve budget neutrality and urged adjusting the CFs to be consistent 
with the method we used for 1996. One commenter proposed a single 
budget neutrality adjuster that would, in effect, be applied to the 
CFs. A few commenters recommended that we make the budget neutrality 
adjustment without rescaling RVUs but did not recommend a specific 
method.
    Response: We agree that it would be preferable to make adjustments 
at the CF level as we did in 1996 (and in a similar overall way in 
prior years, but by adjusting all RVUs). However, achieving budget 
neutrality by adjusting the CFs would have the effect of reducing 
payment for all services on the fee schedule. This would include a 
number of services that have no physician work and are, therefore, 
outside the scope of the 5-year review. Examples of these services 
include radiology and other diagnostic tests where the technical 
component may be reported separately; certain diagnostic tests, such as 
audiologic function tests; and certain therapeutic services, such as 
chemotherapy administration. Our goal is to make overall adjustments in 
the future.
    Comment: Several commenters recommended that we maintain the 
integrity of the three pools of RVUs; some thought this was especially 
important when we adopt resource-based practice expense RVUs. However, 
one commenter disagreed, maintaining that the three pools of RVUs are 
not coherent and independent and noting that gap-filling techniques 
have relied on a dependable relationship among the three pools.
    Response: The Physician Payment Review Commission recommended 
applying the budget neutrality adjustment from the 5-year review only 
to work RVUs to preserve the integrity of the three pools of RVUs. (As 
discussed above, applying the adjustment to the CFs would, in effect, 
spread the adjustment across all RVUs.) The separate work adjuster will 
enable us to do that for 1997, prior to the implementation of resource-
based practice expense RVUs in 1998, after which time it would be 
preferable to make budget neutrality adjustments on the CFs as 
discussed above.
    The existing practice expense RVUs were based on historical charges 
and the historical practice expense shares for the specialities 
performing the service. (The same is true of malpractice expense RVUs, 
but the size of that pool is very small.) The commenter is correct that 
there are some relationships between the work and practice expense 
RVUs, although we would characterize them as fairly tenuous.
    Comment: One commenter observed that the separate budget neutrality 
adjuster is only for the Medicare program and requested that it not be 
displayed in tables of RVUs that are published for general information.
    Response: Because the adjuster is a constant to be applied to all 
work RVUs, we will not display it in tables of RVUs. We will provide 
the value of the adjuster in the text describing the tables of RVUs, 
just as we provide the values of the CFs.
    Comment: Two commenters requested that we restore previous budget 
neutrality adjustments to the work RVUs and incorporate them into the 
new budget neutrality adjuster.
    Response: We intend to use the new adjuster only for 1 year and 
only for the budget neutrality adjustment required by changes due to 
the 5-year review of work RVUs. The previous budget neutrality 
adjustments generally have been related to changes in payment policy 
and not specifically to changes in work RVUs.
    Comment: One commenter suggested that we perform analyses comparing 
the impact of the two options for achieving budget neutrality (that is, 
applying the adjustment to the work RVUs or to the CFs) and invite 
public comment on those analyses.
    Response: The statute requires that we implement the results of the 
5-year review in 1997. Time does not permit preparation of impact 
analyses of the types described, opportunity for public comment, and 
analysis of those comments prior to January 1, 1997. In our May 3, 1996 
proposed notice (61 FR 20045), we indicated that a 7.63 percent 
decrease in RVUs would be required (based on proposed work RVUs) if the 
adjustment were applied only to work. We also indicated that the 
services with no work or with a practice expense percentage of total 
RVUs greater than average for the fee schedule would be adversely 
affected by applying the adjustment to the CFs.
    Final decision: A separate budget neutrality adjuster is being 
applied to the work RVUs for 1 year, after which time we plan to 
eliminate it simultaneously with the implementation of the new practice 
expense RVUs in 1998. In years subsequent to 1998, we plan to make the 
budget neutrality adjustments to the CFs.
2. Impact of Work Relative Value Unit Changes for Evaluation and 
Management Services on Work Relative Value Units for Global Surgical 
Services
    We proposed not to make a change to the values of global surgical 
packages in connection with the increase in RVUs for evaluation and 
management services. In the May 3, 1996 proposed notice (61 FR 20045 
through 20046), we articulated several arguments for why global 
surgical packages should be valued solely on their own merit.
    Comment: Several commenters supported our proposal to maintain 
current work RVUs for global surgical services. These groups agreed 
with the underlying rationale that although increases to the work RVUs 
for evaluation and management services were warranted, corresponding 
across-the-board increases in the work RVUs for all global surgical 
packages would be inappropriate. Other commenters expressed the 
following opposing comments: the decision not to raise the work RVUs 
for global surgical services unfairly penalizes physicians whose 
clinical activities focus primarily on the performance of surgical 
procedures; evaluation and management services related to a procedure 
have been subjected to the same increasing complexity as non-procedural 
evaluation and management services due to such factors as reduced 
inpatient lengths of stay, same day admissions for major surgery, and 
increased utilization of home health care programs requiring far more 
involved and extensive postservice planning and management; and the 
amount of preoperative and postoperative work required in the provision 
of these services is the same whether it is performed separately or as 
part of the global surgical package. However, another group of 
commenters encouraged further study of this issue. They recommended 
including an examination of the work involved in furnishing specific 
global services, changes in practice patterns that may have shifted 
some of the postoperative care from the surgeon who performed the 
procedure to other physicians (for example, primary care or medical 
subspecialists) who are participating in the medical management of the 
patient during the postoperative period, external data such as changes 
in length

[[Page 59534]]

of stay and an increase in the number of laparoscopic procedures, the 
number of preoperative and postoperative visits that are assumed to be 
included in the global surgical period, and the complexity associated 
with the history, physical examination, and medical decision-making 
involved in the evaluation and management services of a surgeon during 
a global period.
    Response: The widely divergent comments indicate the need for a 
more thorough review before we make adjustments to the global surgical 
services.
    Comment: The RUC recommended that we include the relationship 
between evaluation and management services and global surgical services 
in a future review of work RVUs so that this aspect of the Medicare 
physician fee schedule can be updated in 1998. We plan to revisit this 
issue next year.
    Response: We look forward to a RUC recommendation on this issue. We 
hope to receive the recommendation next year to assist us as we further 
examine whether a change in the work RVUs for global surgical services 
is warranted because of the increases in the RVUs for evaluation and 
management services.
    Comment: A commenter stated that if we choose not to revalue global 
surgical services on the basis of changes in the work RVUs for 
evaluation and management services, we should, alternatively, 
discontinue the use of a surgical bundle and return to the practice of 
separate billing of the component services.
    Response: Section 1848(c)(1)(A)(ii) of the Act requires that we use 
a global definition of surgical services.
    Comment: Several commenters requested that we make interim across-
the-board adjustments to the values for global surgical services until 
the RUC presents its recommendations on the issue. This interim 
adjustment should be utilized until further study results in a precise 
methodology. One possible approach would be to begin with our existing 
methodology for identifying the relative value share believed to be 
attributable to postoperative office visits. A percentage adjustment 
equivalent to the increase being proposed for physician office visits, 
perhaps CPT code 99213, a mid-level visit, could be applied. For global 
services typically furnished on an in-patient basis, available length-
of-stay data could be used assuming that at least one inpatient 
hospital visit occurred on each day of the patient's inpatient stay. 
The length-of-stay could then be multiplied by the planned increase in 
RVUs for subsequent hospital care.
    Response: Although we believe there may be some merit to the 
approach recommended by the commenter, we do not believe that an 
interim adjustment should be made while we are studying the issue more 
completely during 1997.
    Comment: One commenter recommended increasing the RVUs assigned to 
CPT codes 59400, 59409, 59410, 59510, 59514, 59515, 59425, and 59426 
(maternity care and delivery services). The commenter stated that when 
we valued these services, we explicitly added work RVUs based on 
specific evaluation and management services as articulated in the 
December 2, 1993 final rule.
    Response: The commenter has correctly identified an area where we 
should make adjustments to the RVUs assigned to these global services. 
Therefore, we are accepting this comment and modifying the work RVUs 
for maternity services. The new work RVUs maintain the relationships 
that we published in the December 1993 final rule. The commenter did 
not request that we modify the work RVUs for CPT code 59430 (postpartum 
care only), but we have adjusted them to be consistent within the 
family. The following table shows the adjustments that we have made.

------------------------------------------------------------------------
                                                   Adjustment           
                                                       for              
                                        1996 work  evaluation  1997 work
               CPT code                    RVUs        and        RVUs  
                                                   management           
                                                    increase            
------------------------------------------------------------------------
59400.................................      20.99        2.07      23.06
59409.................................      13.28        0.22      13.50
59410.................................      14.44        0.34      14.78
59425.................................       4.04        0.77       4.81
59426.................................       6.91        1.37       8.28
59430.................................       2.01        0.12       2.13
59510.................................      23.67        2.55      26.22
59514.................................      15.39        0.58      15.97
59515.................................      16.55        0.82      17.37
------------------------------------------------------------------------

The percent increase varies across the services because the number and 
type of evaluation and management services included in each CPT code 
are different. Therefore, an across-the-board adjustment would have 
been inappropriate.
    Because we have made these adjustments to the delivery codes, we 
also need to adjust the work RVUs for the vaginal birth after cesarean 
services in order to maintain the existing relationship. As explained 
in the December 8, 1995 final rule (60 FR 63165 through 61366), we 
added 1.56 work RVUs to the delivery codes to establish the values for 
the corresponding vaginal birth after cesarean services. Therefore, we 
will add 1.56 work RVUs to the new values for the delivery services to 
reassign RVUs to the vaginal birth after cesarean codes.

------------------------------------------------------------------------
                                                                New work
                                                                RVUs for
                                                     New work   vaginal 
  CPT code for vaginal birth after   Corresponding   RVUs for    birth  
          cesarean service           delivery code   delivery    after  
                                                       code     cesarean
                                                                  code  
------------------------------------------------------------------------
59610..............................        59400        23.06      24.62
59612..............................        59409        13.50      15.06
59614..............................        59410        14.78      16.34
59618..............................        59510        26.22      27.78
59620..............................        59514        15.97      17.53
59622..............................        59515        17.37      18.93
------------------------------------------------------------------------

The aforementioned adjustments correct the services with an MMM global 
period (maternity) to reflect the increases in the work RVUs for the 
evaluation and management services. We did not modify the work RVUs for 
CPT code 59525 (removal of uterus after cesarean) because this service 
is billed in conjunction with either CPT code 59510 or 59515, both of 
which have had their work RVUs adjusted. We will consider all of these 
changes to be final.
    Final Decision: With the exception of the services described above 
that have an MMM global period, at present we are making no adjustments 
to the work RVUs assigned to global surgical services as a result of 
the increases in the RVUs of evaluation and management services. 
However, we will reevaluate this policy next year. The extra year will 
allow time for us to closely examine our data and for the RUC to 
present us with additional data and a recommendation on this issue. Any 
further changes that we may make will be effective in 1998.
3. Codes Referred to the Physicians' Current Procedural Terminology 
Editorial Panel
    Comment: We received a comment from the RUC indicating that the RUC 
has referred to the CPT Editorial Panel the following issues:
     CPT code 11971 (Removal of tissue expander(s) without 
insertion of prosthesis).
     CPT codes 13300 (Repair of wound or lesion) and 14300 
(Skin tissue rearrangement).

[[Page 59535]]

     CPT codes 15000, 15101, 15121, 15201, 15221, 15241, and 
15261 (Skin graft procedures).
     CPT code 31090 (Sinusotomy combined, three or more 
sinuses).
     CPT code 46900 (Destruction, anal lesion(s)).
     CPT code 54100 (Biopsy of penis).
     CPT code 93621 (Comprehensive electrophysiologic 
evaluation with right atrial pacing and recording, right ventricular 
pacing and recording, His bundle recording, including insertion and 
repositioning of multiple electrode catheters; with left atrial 
recordings from coronary sinus or left atrium, with or without pacing).
    For these issues, the RUC believes the codes should be reviewed by 
the CPT Editorial Panel and the definitions and/or instructions for use 
be clarified.
    Response: We agree that these codes should be reviewed by the CPT 
Editorial Panel.
    Final decision: We are maintaining the work RVUs for these codes as 
interim during 1997 because we consider them to be 5-year review issues 
that have not yet been finalized. If the CPT adds, deletes, or revises 
any of the codes in response to the RUC's referral, then the RUC will 
have the opportunity to submit work RVU recommendations to us on those 
new or revised codes. In the event that no action is taken by the CPT 
Editorial Panel on any of the issues, we anticipate assigning final 
work RVUs that would go into effect on January 1, 1998.
4. Future Review
    Since the physician fee schedule was implemented in 1992, we have 
undertaken significant annual revisions to the work RVUs for large 
numbers of codes, and, with the publication of this final rule, we have 
completed the first 5-year review. We believe that through these 
extensive efforts the work RVUs are now largely correct, and a 
significant case would need to be made to convince us to change the 
work RVUs for the overwhelming bulk of procedures.
    For the future, we are considering periodic review of the physician 
fee schedule as necessary. However, there are several categories of 
codes and issues that we have tentative plans to review prior to the 
next 5-year review: Services that typically require reporting more than 
one code to describe the service correctly; the relationship of 
physician work between analogous open and closed procedures; radiation 
oncology; and rank order anomalies within families.
    We described these tentative plans in our May 3, 1996 proposed 
notice (61 FR 20046), and several specialty societies submitted 
comments on codes that they believe fit into one of the above 
categories. Most of the codes for which they submitted comments were 
not subject to comment. Although we typically do not respond to 
comments on codes that are not subject to comment, we believe that some 
general responses would be appropriate to provide the public with some 
insights as to the direction future reviews might take.
    Comment: The rapid development of endoscopy and minimally invasive 
approaches to surgery has led to widespread adoption of these 
alternative approaches. As these new procedures have become recognized 
and have been designated by unique procedure codes, we have often but 
not always adopted work RVUs that were equal to the traditional open 
approach for the same procedure. Several commenters identified codes 
that describe procedures performed using a traditional approach whose 
RVUs are higher than similar procedures that can be performed with 
endoscopes or minimally invasive techniques. The commenters argued that 
we should increase the work RVUs of the endoscopic or minimally 
invasive procedure codes to equal the work RVUs assigned to procedures 
that accomplish the same result by incision (open procedures). The 
commenters requested that we make these changes now, as part of the 5-
year review process, so that the increased work RVUs would be effective 
January 1, 1997.
    Response: While we agreed with this approach in the past, we now 
believe it is appropriate to examine the actual work relationship 
between open and closed procedures. The intent of the relative value 
scale is to value each procedure based on the work involved, not based 
on the clinical result. It is not clear that the work involved is in 
fact the same. We believe that there may be significant differences in 
the postoperative care between open and minimally invasive procedures. 
One of the claimed advantages of closed procedures is the rapid patient 
recovery, which may also represent a decrease in physician 
postoperative work. The actual work involved in the procedure itself, 
however, may be greater, resulting in no net difference in total work. 
Some closed procedures may have greater total work than the analogous 
open procedure and some may be less. Finally, it is not clear what 
impact the selection of patients for one approach over another has on 
the total physician work involved.
    The continued clinical use of two different techniques may in part 
be due to the selection of procedures based on patient risk factors, 
severity of disease, and the presence or absence of comorbidities. 
These selection criteria may account for differences in the work when 
comparing open and closed procedures. For these reasons, we believe it 
is time to reexamine the assumption that open and closed procedures 
should be valued equally. With the assistance and advice of the RUC, we 
plan to revisit this issue before the next 5-year review. In the 
interim, we will retain the existing work RVUs for codes in these 
categories unless we have specifically dealt with them in the 5-year 
review.
    Comment: We received some comments supporting our proposed 
increases for individual codes and advocating increases within the 
entire family of codes to maintain existing relationships even when the 
other codes in the family had not been identified as undervalued when 
the 5-year review began.
    Response: In our May 3, 1996 proposed notice, we invited comments 
on rank order anomalies created as a result of the 5-year review. We 
expressed our intention to consider correcting anomalies before the 
next 5-year review. We do not believe that the revaluation of a single 
code necessarily requires all other codes in a family to be revalued as 
this comment implies. We believe that the original comments were 
submitted to identify codes that were under or overvalued. In some 
cases, commenters requesting 5-year refinement identified groups of 
related codes. The 5-year review considered groups of codes when groups 
of codes were thus identified. Alternatively, when a single code was 
identified, we believe it was appropriate to view that code as a single 
misvalued code, and we considered the evidence presented. When rank 
order anomalies have appeared, we have sought to correct them. An 
example of a rank order problem that we corrected (CPT codes 57260 and 
57265) can be found in section IV.A.8. of this final rule.
    When recommendations to increase a code resulted in a change in the 
relationship between that code and other codes, we presume that the new

[[Page 59536]]

work RVUs represent a refined relationship. One purpose of the 5-year 
refinement is to improve the accuracy of relationships by revaluing 
codes that are under or overvalued. We do not believe it is reasonable 
to make recommended changes intended to refine existing relationships 
and then to change all other codes to maintain existing relationships. 
The following comments illustrate recommendations for revised work RVUs 
that we do not believe should be accepted without survey or other data 
that would support the requested change. This will be appropriate for 
the next 5-year review.
    Comment: We received comments related to CPT code 57410 (Pelvic 
examination under anesthesia). The current work RVUs assigned to this 
code are 0.59. It was referred to the RUC as part of the 5-year review. 
The RUC recommended that the work RVUs be increased to 1.75. In our May 
3, 1996 proposed notice (61 FR 20006), we agreed with this 
recommendation. Commenters expressed support for the increase in work 
RVUs for this service. However, the commenters stated that all 
gynecological surgical procedures include an examination under 
anesthesia as part of the procedure. Therefore, they believed that all 
gynecological procedures should have their work RVUs adjusted to 
account for the increased work attributable to the examination under 
anesthesia.
    Response: Although a pelvic examination under anesthesia is a 
common element of many pelvic surgical procedures, it is not clear how 
this compares to the work assigned to CPT code 57410 (Pelvic 
examination under anesthesia). The examination performed at the time of 
other surgery is often such an inherent part of the procedure that we 
believe it has been properly considered as part of the total work of 
the surgical procedure.
    It could be argued that during the course of a surgical procedure 
by a vaginal approach, a pelvic examination is performed many times--
before, during, and at the end of the procedure. Adding the work RVUs 
of three CPT 57410 codes to this procedure is clearly not reasonable. 
The revaluation of CPT code 57410 was based on the evidence presented 
regarding the performance of a pelvic examination alone, as described 
by the CPT code. We believe the other procedures to which the commenter 
alluded should be revalued based on independent evidence of total work, 
not based on the assumption that if one code is revalued all similar 
codes should be revalued. We see no evidence that the change in CPT 
code 57410 creates significant rank order anomalies. If other more 
complex codes involving examination at the time of surgery are 
undervalued in their own right, they can be corrected at the next 
opportunity for refinement.
    Comment: We received similar comments stating that the proposed 
increase in work RVUs from 2.45 to 2.91 for CPT code 58120 (Dilation 
and curettage (D&C), diagnostic and/or therapeutic (nonobstetrical)) 
should result in corresponding increases in work RVUs for a code that 
was not identified as undervalued during the 5-year review: CPT code 
56351 (Hysteroscopy, surgical; with sampling (biopsy) of endometrium 
and/or polypectomy, with or without D&C) since a D&C is included in CPT 
code 56351.
    Response: We believe the requested increase in work RVUs for this 
code is not warranted. First, the CPT definition is clear that not all 
hysteroscopies involve a dilation and curettage. Second, we are not 
convinced that the work involved in performing a dilation and curettage 
as an independent procedure can be equated to the curettage of the 
uterus following direct visualization of the endometrial cavity. The 
work involved may be considerably different. The commenter presented no 
compelling evidence to support the equality of work. The existing work 
RVUs for CPT code 56531 (2.85) now will be slightly less than the new 
RVUs for CPT code 58120 (2.91). This reverses the prior relationship. 
Finally, since we have announced in this rule our intention to examine 
the proper relationship of open and closed procedures, we believe that 
it is appropriate to evaluate the relationship between these codes as 
part of that process rather than change the work RVUs for CPT code 
56531 at this time.

V. Refinement of Relative Value Units for Calendar Year 1997 and 
Responses to Public Comments on Interim Relative Value Units for 1996

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

    Section V.B. of this final rule describes the methodology used to 
review the comments received on the RVUs for physician work and the 
process used to establish RVUs for new and revised CPT codes. Changes 
to codes on the physician fee schedule reflected in Addendum B are 
effective for services furnished beginning January 1, 1997.

B. Process for Establishing Work Relative Value Units for the 1997 Fee 
Schedule

    Our December 8, 1995 final rule on the 1996 physician fee schedule 
(60 FR 63124) 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, 1996. We announced 
that we would accept comments on interim RVUs for these 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 1995 final rule and our 
establishment of the work RVUs for new and revised codes for the 1997 
fee schedule.
1. Work Relative Value Unit Refinements of Interim and Related Relative 
Value Units
    a. Methodology (Includes Table 2--Work Relative Value Unit 
Refinements of 1996 Interim and Related Relative Value Units).
    Although the RVUs in the December 1995 final rule were used to 
calculate 1996 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 substantive comments from approximately 10 specialty 
societies on approximately 50 CPT codes with interim RVUs.
    Only comments received on codes listed in Addendum C of the 
December 1995 final rule were considered this year. (We also considered 
comments we received on other codes under the 5-year refinement 
process.) We convened multispecialty panels of physicians to assist us 
in the review of comments. The comments that we did not submit to panel 
review are discussed at the end of this section. The panels were 
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

[[Page 59537]]

comments. This same clinician also provided ratings for the other 
procedures being considered. Thus, depending on the codes in question, 
this clinician was in one of two groups: ``specialist'' or ``other 
specialist.''
     Primary care clinicians nominated by the American Academy 
of Family Physicians, the American Society of Internal Medicine, the 
American College of Physicians, the American Academy of Pediatrics, the 
American Osteopathic Association, and the American College of 
Obstetricians and Gynecologists.
     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 40 
codes for evaluation by the panels. The panels 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 the panel members to compare the 
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 300 
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 
interim 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 1995 
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 three 
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 40 codes reviewed by our multispecialty panel, all but two of the 
requests were for increased values.
    We also received comments on RVUs that were interim for 1996 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 V.B.1.b. of this final rule. Of 
the 59 interim work RVUs that were reviewed, approximately 27 percent 
were increased, and approximately 42 percent were not changed.

Table 2--Work Relative Value Unit Refinements of 1996 Interim and 
Related Relative Value Units

    Table 2 lists the interim and related codes reviewed during the 
1996 refinement process described in this section. All of these codes 
are discussed in code order following Table 2, in section V.B.1.b. of 
this final rule. This table includes the following information:
     CPT Code. This is the CPT code for a service.
     Description. This is an abbreviated version of the 
narrative description of the code.
     1996 Work RVU. The work RVUs that appeared in the December 
1995 rule are shown for each reviewed code.
     Requested Work RVU. 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 but no specific RVU 
recommendations.
     1997 Work RVU. 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 1995 
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).

                         Table 2.--Work RVU Refinements of 1996 Interim and Related RVUs                        
----------------------------------------------------------------------------------------------------------------
  CPT                                                                 1996 work  Requested  1997 work  Basis for
 *code                           Description                             RVU      work RVU     RVU      decision
----------------------------------------------------------------------------------------------------------------
20930..  Spinal bone allograft......................................       0.00   Increase       0.00          3
20931..  Spinal bone allograft......................................       1.81   Increase       1.81          3
20936..  Spinal bone allograft......................................       0.00   Increase       0.00          3
20937..  Spinal bone allograft......................................       2.79   Increase       2.79          3
20938..  Spinal bone allograft......................................       3.02   Increase       3.02          3
22554..  Neck spine fusion..........................................      17.24   Increase      17.24          3
22556..  Thorax spine fusion........................................      22.27   Increase      22.27          3
22558..  Lumbar spine fusion........................................      21.22   Increase      21.22          3
22600..  Neck spine fusion..........................................      14.74   Increase      14.74          3

[[Page 59538]]

                                                                                                                
22610..  Thorax spine fusion........................................      14.62   Increase      14.62          3
22612..  Lumbar spine fusion........................................      20.19   Increase      20.19          3
22840..  Insert spine fixation device...............................       6.27      12.54      12.54          3
22842..  Insert spine fixation device...............................       7.19      12.58      12.58          3
22843..  Insert spine fixation device...............................       8.97      13.46      13.46          3
22844..  Insert spine fixation device...............................      10.96      16.44      16.44          3
22845..  Insert spine fixation device...............................       5.98      11.96      11.96          3
22846..  Insert spine fixation device...............................       8.28      12.42      12.42          3
22847..  Insert spine fixation device...............................       9.20      13.80      13.80          3
22851..  Apply spine prosth device..................................       6.71   Increase       6.71          3
55859..  Percut/needle insert, pros.................................       8.29      14.00      12.00          2
56343..  Laproscopic salpingostomy..................................       6.96      13.34      13.34          3
56344..  Laproscopic fimbrioplasty..................................       7.16      12.50      12.50          3
92525..  Oral function evaluation...................................       1.13       1.61       1.50          2
92526..  Oral function therapy......................................       0.52       0.64       0.55          2
92597..  Oral speech device eval....................................       1.11       1.50       1.35          2
92598..  Modify oral speech device..................................       0.73       0.99       0.99          2
97010..  Hot or cold packs therapy..................................       0.11       0.11       0.06          2
97012..  Mechanical traction therapy................................       0.25       0.25       0.25          1
97014..  Electric stimulation therapy...............................       0.18       0.18       0.18          1
97016..  Vasopneumatic device therapy...............................       0.18       0.18       0.18          1
97018..  Paraffin bath therapy......................................       0.11       0.11       0.06          2
97020..  Microwave therapy..........................................       0.11       0.11       0.06          2
97022..  Whirlpool therapy..........................................       0.25       0.25       0.17          2
97024..  Diathermy treatment........................................       0.11       0.11       0.06          2
97026..  Infrared therapy...........................................       0.11       0.11       0.06          2
97028..  Ultraviolet therapy........................................       0.20       0.20       0.08          2
97032..  Electrical stimulation.....................................       0.25       0.25       0.25          1
97033..  Electric current therapy...................................       0.26       0.26       0.26          1
97034..  Contrast bath therapy......................................       0.21       0.21       0.21          1
97035..  Ultrasound therapy.........................................       0.21       0.21       0.21          1
97036..  Hydrotherapy...............................................       0.38       0.28       0.28          2
97039..  Physical therapy treatment.................................       0.29       0.20       0.20          2
97110..  Therapeutic exercises......................................       0.45       0.45       0.45          1
97112..  Neuromuscular reeducation..................................       0.45       0.45       0.45          1
97113..  Aquatic therapy/exercises..................................       0.44       0.44       0.44          1
97116..  Gait training therapy......................................       0.40       0.40       0.40          1
97122..  Manual traction therapy....................................       0.45       0.45       0.42          2
97124..  Massage therapy............................................       0.35       0.35       0.35          1
97139..  Physical medicine procedure................................       0.21       0.35       0.21          1
97150..  Group therapeutic procedures...............................       0.27       0.27       0.27          1
97250..  Myofascial release.........................................       0.45       0.45       0.45          1
97265..  Joint mobilization.........................................       0.45       0.45       0.45          1
97530..  Therapeutic activities.....................................       0.44       0.44       0.44          1
97535..  Self care management training..............................       0.33       0.45       0.45          2
97537..  Community/work reintegration...............................       0.33       0.45       0.45          2
97542..  Wheelchair management training.............................       0.25       0.45       0.25          1
97703..  Prosthetic checkout........................................       0.25       0.45       0.25          1
97750..  Physical performance test..................................       0.45       0.45       0.45          1
97770..  Cognitive skills development...............................       0.44       0.44       0.44          1
----------------------------------------------------------------------------------------------------------------
*All CPT codes and descriptors copyright 1996 American Medical Association.                                     

    b. Interim 1996 Codes.
    CPT codes 22840, 22842, 22843, 22844, 22845, 22846, and 22847 
(Insert spine fixation device).
    Comment: Effective 1996, substantial changes were made in the CPT 
codes for spine surgery. The RUC recommended work RVUs for these new 
and revised codes, and we accepted those recommendations as interim 
work RVUs, which were subject to comment. (When appropriate, 
malpractice and practice expense RVUs for these new and revised codes 
were calculated using the weighted average data from predecessor codes 
or by imputing the RVUs based on the experience of the dominant 
specialty, in this case, orthopedic surgery.)
    We received comments on the interim work RVUs for the spinal 
instrumentation codes. All commenters indicated that the RUC 
recommendations for the instrumentation codes, which we had accepted, 
were based on erroneous assumptions. Those assumptions had, according 
to the commenters, resulted in the RUC recommending work RVUs

[[Page 59539]]

that were, for some codes, half of what they should have been. 
Specifically, two commenters recommended the following:
     The work RVUs for CPT code 22840 should be increased by 
100 percent.
     The work RVUs for CPT code 22842 should be increased by 75 
percent.
     The work RVUs for CPT code 22843 should be increased by 50 
percent.
     The work RVUs for CPT code 22844 should be increased by 50 
percent.
     The work RVUs for CPT code 22845 should be increased by 
100 percent.
     The work RVUs for CPT code 22846 should be increased by 50 
percent.
     The work RVUs for CPT code 22847 should be increased by 50 
percent.
    Other commenters recommended that we consider appropriate work RVUs 
for these codes. The commenters suggested that we ask the RUC or 
another physician panel to review the matter. Also, one commenter 
suggested that any increases in the work RVUs be retroactive to January 
1, 1996.
    Response: We convened a panel that included our medical staff and 
carrier medical directors to consider the issue of the appropriateness 
of the instrumentation work RVUs. Members of that panel reviewed the 
comments and agreed with the commenters who requested 50 percent 
increases in work RVUs for CPT codes 22843, 22844, 22846, and 22847, a 
75 percent increase in work RVUs for CPT code 22842, and 100 percent 
increases in work RVUs for CPT codes 22840 and 22845. The panel members 
believed that the resulting work RVUs are an accurate reflection of the 
relative resource intensity of the work involved in the codes.
    In accepting this recommendation for change, the panel members 
noted that the posterior and anterior segmental codes were in two 
groups. One group is the posterior segmental, comprised of CPT codes 
22842, 22843, and 22844, with CPT code 22842 being the lowest number of 
segments and CPT code 22844, the highest. Similarly, for the anterior 
codes, CPT code 22845 is the lowest number of segments, CPT code 22846, 
the next highest number of segments, and CPT code 22847, the highest 
number of segments. The panel members concluded that the highest codes 
in the posterior instrumentation group should be valued, for work, at 
approximately 25 percent more than the lowest code in the series. They 
believed that to be the appropriate work differential between the 
highest and the lowest code. For the anterior group, they concluded 
that the work for the code representing the highest number of segments 
should be valued at approximately 15 percent more than the code 
representing the lowest number of segments. Thus, we accepted the 
recommendations of the commenters based, in part, on the opinions of 
the panel members.
    However, there is nothing in the law that would permit fee schedule 
determinations to be made retroactive. Indeed, the entire thrust of 
section 1848 of the Act is prospective: in accordance with the law, the 
codes, RVUs, updates, CFs, and volume performance standards are 
announced in advance of a fee schedule year, and adjustments are 
prospective only. In our view, the Congress did not intend that there 
be retroactive ``correction'' of any elements of the fee schedule. 
Thus, as in the past, we are not retroactively adjusting claims for 
instrumentation services furnished in 1996.
    CPT code 22851 (Application of prosthetic device (eg, metal cages, 
methylmethacrylate) to vertebral defect or interspace).
    Comment: One commenter stated that the proposed work RVUs for this 
code are too low. The interim work RVUs for 1996 are 6.71.
    Response: The interim work RVUs were based, in part, on the RUC 
recommendation that we accepted. The commenter presented no compelling 
arguments that would support increasing the work RVUs, which we believe 
are appropriate for CPT code 22851.
    Comment: One commenter objected to our use of a formula that 
imputes malpractice and practice expense RVUs for new and substantially 
revised codes. That formula relies on the malpractice and practice 
expense experience of the specialty or specialties that perform the 
service. In this case, we relied upon the overall practice experience 
of orthopedic surgeons. The commenter stated that for spine codes this 
resulted in inappropriate reductions in practice expense and 
malpractice expense RVUs.
    Response: We believe that the continued use of charge-based 
practice expense and malpractice expense RVUs is generally 
inappropriate when codes have substantially changed. The use of the 
formula that relies on the overall practice expense experience of the 
specialty performing the service is, in our judgment, the most 
reasonable approach to pricing until we develop resource-based practice 
expense RVUs.
    CPT codes 20930 through 20938 (Bone grafts).
    Comment: One commenter objected to the CPT instruction for 
reporting spine surgery bone graft codes, beginning with CPT code 
20930, that only one bone graft code should be reported per operative 
session.
    Response: The RUC was aware of this coding rule. The recommended 
work RVUs took into account that only one bone graft code can be 
reported per operative session. The commenter would have to submit any 
proposed changes to this coding rule to the CPT Editorial Panel.
    CPT codes 22554, 22556, and 22558 (Anterior arthrodesis 
procedures).
    Comment: A commenter expressed concern about the reduction in the 
work RVUs for CPT codes 22554, 22556, and 22558. The commenter stated 
that we made this reduction in work RVUs because we assumed that the 
coding change would result in providers' billing additionally for bone 
grafts that were not previously billed separately. According to the 
commenter, bone grafts were billed separately before and will be billed 
separately now. Therefore, we should not have made the adjustment in 
work RVUs based on a billing change.
    Response: Through the RUC, the specialty societies recommended a 
reduction in work RVUs because of the expectation that the new bone 
graft codes would be billed in half of the anterior arthrodesis cases, 
when in fact there had not been separate bone graft billing before.
    Final decision: The following table lists the final work RVUs only 
for those codes whose work RVUs will be changed in response to our 
consideration of the public comments:

------------------------------------------------------------------------
                                        Current/                        
                                          1996    Recommended    Final/ 
               CPT code                 interim    percentage  1997 work
                                       work RVUs    increase      RVUs  
------------------------------------------------------------------------
22840................................       6.27         100       12.54
22842................................       7.19          75       12.58
22843................................       8.97          50       13.46
22844................................      10.96          50       16.44
22845................................       5.98         100       11.96
22846................................       8.28          50       12.42
22847................................       9.20          50       13.80
------------------------------------------------------------------------

    CPT codes 22600, 22610, and 22612 (Posterior arthrodesis 
procedures).
    Comment: One commenter expressed concern that the reductions in the 
work RVUs for CPT codes 22600, 22610, and 22612 are inappropriate 
because no other codes may be billed in addition.
    Response: In making its recommendations regarding these codes,

[[Page 59540]]

which we accepted, the RUC pointed out that the reporting of bone 
grafts and use of spinal instrumentation with some of these services 
will be appropriate.
    CPT code 55859 (Transperineal placement of needles or catheters 
into prostate for interstitial radioelement application, with or 
without cystoscopy).
    Comment: Several commenters expressed concern about our rejection 
of the RUC recommendation of 14.00 work RVUs and our proposed 8.29 work 
RVUs.
    Response: The RUC's initial recommendation of 14.00 work RVUs was 
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 believed that 14.00 work 
RVUs were too high and disagreed with the RUC's use of CPT code 61770 
as a reference procedure; we viewed that procedure as requiring greater 
technical skill, mental effort, and judgment. The recommended 14.00 
work RVUs are higher than the work RVUs assigned to CPT code 55860 
(Exposure of prostate, any approach, for insertion of radioactive 
substance), with 13.33 work RVUs. This is an open surgical procedure 
with significantly more postservice 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 work 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 work RVUs to this code. Thus, we believed a physician 
performing all aspects of this procedure would report all three codes 
with 25.80 total work RVUs if we accepted the RUC recommendation of 
14.00 work RVUs for CPT code 55859.
    We believed it was 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 believed 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), with 1.57 
work RVUs. Because of the increased intraoperative time and complexity 
as well as the increased surgical risk associated with CPT code 55859, 
we increased the work RVUs four-fold to 6.28 work RVUs. In addition, we 
added 2.01 work RVUs, the work RVUs assigned to CPT code 52000, to 
reflect the added work of the cystoscopy. This addition resulted in the 
proposed 8.29 work RVUs for CPT code 55859.
    In light of the comments that objected to our rationale, we 
referred this code to a refinement panel for review.
    Final decision: During the panel discussion and before the service 
was rated, the panel members agreed that the physician inserting 
needles or catheters into a prostate for interstitial radioelement 
application could not also report an interstitial brachytherapy code, 
for example, CPT code 77778, because a radiation oncologist must 
perform that service.
    As a result of our analysis of the refinement panel ratings, we are 
increasing the interim work RVUs from 8.29 RVUs to 12.00 for CPT code 
55859.
    CPT code 56343 (Laparoscopy, surgical; with salpingostomy) and CPT 
code 56344 (Laparoscopy, surgical; with fimbrioplasty).
    Comment: We received a recommendation to increase the work RVUs 
assigned to these two codes from 6.96 and 7.16 to 13.34 and 12.50, 
respectively, based on a comparison to the work RVUs that were proposed 
as part of the 5-year review for the corresponding open procedures, CPT 
code 58760 (Fimbrioplasty), with 12.50 work RVUs, and CPT code 58770 
(Salpingostomy (salpingoneostomy)), with 13.34 work RVUs.
    Response: CPT 1996 added new CPT codes 56343 and 56344 to allow the 
reporting of these procedures when they are performed laparoscopically. 
We reviewed and accepted the RUC recommendation to assign the same work 
RVUs to the two new codes that were then assigned to the corresponding 
open procedures, CPT code 58760, with 7.16 work RVUs, and CPT code 
58770, with 6.96 work RVUs.
    CPT codes 58760 and 58770 were then being evaluated as part of the 
5-year review and, based on the RUC's recommendation, these codes were 
increased in value from 7.16 to 12.50 work RVUs for CPT code 58760 and 
6.96 to 13.34 work RVUs for CPT code 58770. We believe that the RUC 
adequately considered the work relationships between these open and 
closed procedures and, in spite of our intention to reexamine the 
general relationships of open versus closed procedures, as described in 
section IV.C.4. of this final rule, ``Future Review,'' we accept the 
recommendation to assign the same work RVUs to CPT codes 56343 and 
56344 as we have assigned to CPT codes 58770 and 58760.
    Final decision: We are assigning 13.34 work RVUs to CPT code 56343 
and 12.50 work RVUs to CPT code 56344.
    CPT codes 59610, 59612, 59614, 59618, 59620, and 59622 (Vaginal 
birth after cesarean).
    Comment: We received a comment recommending that we assign work 
RVUs to these codes by increasing the work RVUs for each of the 
existing delivery codes by 8.5 percent rather than by adding the fixed 
amount of 1.56 work RVUs to each of the codes as we proposed.
    Response: The CPT 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, either CPT code 
59610, 59612, or 59614 is reported. If the attempt is unsuccessful and 
another cesarean delivery is carried out, either CPT code 59618, 59620, 
or 59622 is reported. The RUC recommended work RVUs for all six codes 
that added varying increments of work to the work RVUs of the six 
existing codes that are used to report routine vaginal and cesarean 
deliveries.
    While we accepted the RUC conclusion that a vaginal delivery after 
a previous cesarean delivery entails more physician work and that the 
existing delivery codes are appropriate reference points, we disagreed 
with the variable and small differences in work from one code to the 
next. We believed the increased stress, mental effort, and judgment 
associated with a vaginal delivery after a previous cesarean delivery 
is the same regardless of the particular delivery service furnished. 
Therefore, we added 1.56 work RVUs

[[Page 59541]]

(the median work RVUs of the above differences) to each of the existing 
delivery codes.
    We continue to believe that our approach is correct since the 
increased stress, mental effort, and judgment associated with a vaginal 
delivery after a previous cesarean delivery is the same regardless of 
the particular delivery service furnished. Adding a fixed percentage of 
8.5 percent to each of the codes would result in additional work RVUs 
for each of the codes for a vaginal delivery after a previous cesarean 
delivery that would range from 1.13 work RVUs to 2.01 work RVUs. We do 
not believe these differences are warranted. We also note that this 
request would result in lower work RVUs than we proposed for four of 
the six codes.
    Final decision: We are not revising our proposed work RVUs based on 
our consideration of this comment. However, as part of the 5-year 
review and the changes we are making in the work RVUs for evaluation 
and management services, we are increasing the work RVUs for all 
delivery codes including a vaginal delivery after a previous cesarean 
delivery. See section IV.C.2. of this final rule for a discussion of 
these changes and Table 1 for a listing of the new work RVUs.
    CPT code 92525 (Evaluation of swallowing and oral function for 
feeding).
    Comment: Commenters objected to our decision to decrease the work 
RVUs to a value lower than the RUC recommendation.
    Response: The RUC recommended 1.61 work 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 barium swallow might not be done. We believed that the 
work RVUs recommended, which were between the work RVUs of a level-
three inpatient consultation (CPT code 99253), with 1.56 work RVUs, and 
a level-four inpatient consultation (CPT code 99254), with 2.27 work 
RVUs, were too high. While we believed that the intraservice work 
determined by the survey for the vignette may have been reasonable, we 
did not agree that the surveyed vignette represents 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 work 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), with 0.54 work RVUs, to the 0.86 work 
RVUs for CPT code 92506, resulting in an assignment of 1.13 work RVUs 
for CPT code 92525. These proposed work RVUs are slightly higher than 
the work RVUs of CPT code 99242, which is the code for a level-two 
office consultation, the components of which include an expanded 
problem-focused history, an expanded problem-focused examination, and 
straightforward medical decision making.
    However, in light of the comments that objected to our rationale, 
we referred this code to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, the final work RVUs are established as 1.50 for CPT code 
92525.
    CPT code 92526 (Treatment of swallowing dysfunction and/or oral 
function for feeding).
    Comment: Several commenters objected to our decision to decrease 
the work RVUs to a value lower than the RUC recommendation. Commenters 
stated that the vignette describes a typical patient and that it is not 
proper to equate speech-language pathology treatment (CPT code 92507) 
with the treatment of swallowing disorders.
    Response: The RUC recommended 0.64 work 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 believed the 
surveyed vignette did not describe a typical patient, we reduced the 
RUC recommendation for CPT code 92526 to 0.52 work RVUs, which are the 
same work RVUs as those for CPT code 92507 (Treatment of speech, 
language, voice, communication, and/or auditory processing disorder 
(includes aural rehabilitation); individual). These work RVUs are 
slightly less than the work RVUs assigned to a mid-level office visit 
(CPT code 99213), with 0.55 work RVUs, which typically requires 15 
minutes of face-to-face time with a physician.
    In light of the comments that objected to our rationale, we 
referred this code to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, the final work RVUs are established as 0.55 for CPT code 
92526.
    CPT code 92597 (Evaluation for use and/or fitting of voice 
prosthetic or augmentative/alternative communication device to 
supplement oral speech).
    Comment: Several commenters objected to our comparison of this 
service to a level-three new patient office visit. The commenters 
provided an extensive description of the elements included in the 
vignette.
    Response: The RUC originally recommended 1.50 work RVUs. We 
believed the recommended work RVUs were 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 did not believe the work of these two services is 
comparable. Rather, we believed the work associated with CPT code 92597 
is slightly less than the work associated with a level-three new 
patient office visit (CPT code 99203), with 1.14 work RVUs, and a 
level-two inpatient consultation (CPT code 99252), with 1.13 work RVUs. 
Therefore, we proposed 1.11 work RVUs for CPT code 92597.
    In light of the comments that objected to our rationale, we 
referred this code to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, the final work RVUs are established as 1.35 for CPT code 
92597.
    CPT code 92598 (Modification of voice prosthetic or augmentative/
alternative communication device to supplement oral speech).
    Comment: Several commenters objected to our decision to decrease 
the work RVUs to a value lower than the RUC recommendation.
    Response: The RUC recommended 0.99 work RVUs, which are higher than 
the work RVUs assigned to a level-four established patient office visit 
(CPT code 99214), with 0.94 work RVUs. We believed that the 
recommendation is too high. However, we believed that the relative 
relationship between this service and CPT code 92597, as

[[Page 59542]]

established by the RUC, should be maintained. Thus, we calculated the 
interim work RVUs by multiplying the recommended 0.99 work RVUs by 74 
percent (0.99 x 1.11/1.5) representing the percentage of the RUC-
recommended work RVUs, which we accepted for the preceding code. This 
calculation resulted in 0.73 interim work RVUs for CPT code 92598.
    In light of the comments that objected to our rationale, we 
referred this code to a refinement panel for review.
    Final decision: As a result of our analysis of the refinement panel 
ratings, the final work RVUs are established as 0.99 for CPT code 
92598.
    CPT codes 97010 through 97770 (Physical medicine and rehabilitation 
codes).

Background

    The following is a brief summary of the complex history associated 
with the assignment of work RVUs to all the physical medicine and 
rehabilitation services reported with CPT codes in the range 97010 
through 97770 since the beginning of the physician fee schedule on 
January 1, 1992. By statute, physicians' services, outpatient physical 
therapy services, and outpatient occupational therapy services are paid 
under the physician fee schedule. The work RVUs for physical medicine 
services that were included in the physician fee schedule for 1992, 
1993, and 1994 were based on historic charges rather than the work in 
furnishing the service.
    The CPT codes for physical medicine services were substantially 
revised for 1995 and the codes were organized into a number of 
categories: supervised modalities, constant attendance modalities, 
therapeutic procedures, and other procedures. These revised codes were 
forwarded to the RUC's Health Care Professionals Advisory Committee 
(HCPAC) for evaluation of the work in the services represented by the 
new codes. The HCPAC is a multi-disciplinary committee of nonphysician 
and limited license practitioners, which includes, but is not limited 
to, representatives of the American Physical Therapy Association and 
the American Occupational Therapy Association, both of which had 
recommended work RVUs for these new and revised codes. The HCPAC 
reviewed the work in these services in the context of the work in other 
services on the physician fee schedule and provided us with recommended 
work RVUs for them.
    We base the work RVUs for these services on the expectation that 
the definition of the codes represents how the services will be 
furnished when billed to Medicare. For example, we expect that when 15 
minutes of a service in the constant attendance category is billed, we 
may be confident that the provider furnished the 15 minutes of constant 
one-on-one attendance that is included in the definition of the code. 
If the provider did not furnish 15 minutes of one-on-one constant 
attendance, as the code is defined, he or she may not bill a code for 
15 minutes of constant attendance. If the provider is overseeing the 
therapy of more than one patient during a period of time, he or she 
must bill the code for group therapy (CPT code 97150), since he or she 
is not furnishing constant attendance to a single patient.
    The HCPAC provided recommended work RVUs for 26 of the 28 new or 
revised codes. Of the 26 codes for which the HCPAC provided recommended 
work RVUs, we agreed with or increased the work RVUs for 20 codes, 
mostly therapeutic or other procedures. We decreased the work RVUs for 
six codes, all of which were modalities that do not require the 
constant attendance of a professional. The HCPAC provided recommended 
work RVUs for work hardening/conditioning (CPT codes 97545 and 97546), 
which we set as carrier-priced.
    Thus, the interim work RVUs established for these codes for 1995 
represented the first time that the work RVUs for these codes had been 
based on the work associated with furnishing the service. We accepted 
the HCPAC's recommendations of 0.45 work RVUs for most therapeutic 
procedures.
    Later in 1995, the HCPAC recommended 0.45 work RVUs for the 
following four services: CPT code 97535 (Self care management 
training); CPT code 97537 (Community/work reintegration); CPT code 
97542 (Wheelchair management training); and CPT code 97703 (Prosthetic 
checkout). These recommendations were made 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).
    For CPT codes 97535 and 97537, we believed the recommended 0.45 
work RVUs were too high. Before 1996, they were reported using CPT code 
97540 (Training for daily living), with 0.44 work RVUs. We divided the 
work RVUs for CPT code 97540 by 2 to arrive at work RVUs for 15 minutes 
and added 50 percent to account for the preservice and postservice work 
inherent in the service. This resulted in 0.33 work RVUs for CPT codes 
97535 and 97537.
    For new CPT codes 97542 and 97703, we also believed the recommended 
0.45 work RVUs were too high. We believed these services were 
comparable to attended modality services such as CPT code 97032 
(Application of a modality to one or more areas; with electrical 
stimulation (manual), each 15 minutes), with 0.25 work RVUs. Therefore, 
we assigned 0.25 work RVUs to both CPT codes 97542 and 97703.
    While we agreed that these new services appropriately were compared 
to other therapeutic procedures, our review of the new services caused 
us to believe that the interim work RVUs we previously had assigned to 
the therapeutic procedures may have been too high relative to other 
services on the fee schedule, for example, osteopathic manipulative 
treatments and evaluation and management services. In other words, our 
review of these four new codes caused us to reexamine our previous 
decision to accept the HCPAC's earlier recommendations for the other 
physical medicine services.
    Therefore, we decided to maintain the work RVUs for the physical 
medicine and rehabilitation codes (CPT codes 97010 through 97770) as 
interim work RVUs on the 1996 fee schedule so that we would have 
additional time to reevaluate them. While we acknowledged in our 
December 8, 1995 final rule (60 FR 63167) that we had accepted the 
previous year's recommendations of the HCPAC, we decided to refer these 
codes back to the RUC HCPAC Review Board for its reconsideration and to 
notify the RUC of our concerns. The RUC HCPAC Review Board is composed 
of all members of the HCPAC and three physician representatives of the 
RUC. It is chaired by a physician member of the RUC and provides 
recommendations for services performed primarily by non-physician 
practitioners. In addition, we sought public comments on this issue.
    Comment: In response to our concern that the interim work RVUs we 
previously had assigned to the therapeutic procedures may have been too 
high relative to other services on the physician fee schedule, the RUC 
HCPAC Review Board formed a workgroup to assist in developing a 
response by the American Physical Therapy Association

[[Page 59543]]

and the American Occupational Therapy Association. The workgroup was 
chaired by an AMA representative on the RUC and included members of the 
RUC HCPAC Review Board and members of the RUC representing orthopedic 
surgery, psychiatry, and osteopathic medicine.
    The workgroup's report was approved by the full RUC HCPAC Review 
Board and submitted as a comment on our proposal. The report provided 
rationale for maintaining the current work RVUs for most services or 
increasing the work RVUs for those services that we had reduced below 
the HCPAC's initially recommended work RVUs. The recommended work RVUs 
that were included in the workgroup's report are listed in Table 2.
    We also received recommendations from the HCPAC for three codes 
that will be new in 1997: CPT code 97504 (Orthotics training); CPT code 
97520 (Prosthetic training); and CPT code 90901 (Biofeedback training). 
They recommended 0.45 work RVUs for all three codes.
    Response: In light of the comments we received and the report of 
the workgroup, we referred all of the physical medicine and 
rehabilitation codes to a refinement panel for review. To expedite the 
assignment of final work RVUs effective January 1, 1997 for all 
physical medicine services, we also had the refinement panel review the 
recommendations from the HCPAC for the three codes that will be new in 
1997: CPT code 97504 (Orthotics training); CPT code 97520 (Prosthetic 
training); and CPT code 90901 (Biofeedback training).
    Final decision: The results of the refinement panel ratings for 
existing CPT codes are listed in Table 2 and for new or revised CPT 
codes in Table 3. The two most important results are that the ratings 
for the majority of the therapeutic procedures will be at the level 
recommended by the HCPAC, and the work RVUs for five of the modality 
codes that are used to report the application of heat have been reduced 
from 0.11 to 0.06 work RVUs.
    For CPT code 97010, application of hot or cold packs, we have 
bundled the RVUs across other services, and separate payment will no 
longer be made effective January 1, 1997. For a discussion of this 
bundling service, see section II.D.1. of this final rule.
2. Establishment of Interim Work Relative Value Units for New and 
Revised Physicians' Current Procedural Terminology Codes and New HCFA 
Common Procedure Coding System Codes for 1997
    a. Methodology (Includes Table 3--American Medical Association 
Specialty Society Relative Value Update Committee and Health Care 
Professionals Advisory Committee Recommendations and HCFA's Decisions 
for New and Revised 1997 CPT Codes).
    One aspect of establishing work RVUs for 1997 was related to the 
assignment of interim work RVUs for all new and revised CPT codes. As 
described in our November 25, 1992 notice on the 1993 fee schedule (57 
FR 55938) and in section III.B. of this final rule, we established a 
process, based on recommendations received from the AMA's RUC, for 
establishing interim RVUs for new and revised codes.
    We received work RVU recommendations for approximately 90 new and 
revised codes from the RUC. 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 those relationships 
reflected in the RUC values. In some cases when we agreed with the RUC 
relationships, we revised the work RVUs recommended by the RUC in order 
to achieve work neutrality within families of codes. That is, the work 
RVUs have been adjusted so that the sum of the new or revised work RVUs 
(weighted by projected frequency of use) for a family of codes will be 
the same as the sum of the current work RVUs (weighted by their current 
frequency of use). For approximately 87 percent of the RUC 
recommendations, proposed work RVUs were accepted or increased, and, 
for approximately 13 percent, work RVUs were decreased.
    We received 11 recommendations from the HCPAC for new or revised 
codes for which the RUC did not provide a recommendation. For 8 of the 
HCPAC recommendations, the proposed work RVUs were accepted. A 
discussion of the interim RVUs for chiropractic manipulative treatment 
is discussed in section V.B.2.b. below. For 3 of the recommendations, 
the proposed work RVUs were decreased.
    Table 3 is a listing of those codes that will be new or revised in 
1997 for which we received recommended work RVUs. This table includes 
the following information:
     A ``#'' identifies a new code for 1997.
     CPT code. This is the CPT code for a service.
     Modifier. A ``26'' in this column indicates that the work 
RVUs are for the professional component of the code.
     Description. This is an abbreviated version of the 
narrative description of the code.
     RUC-recommendations. This column identifies the work RVUs 
recommended by the RUC.
     HCPAC recommendations. This column identifies work RVUs 
recommended by the HCPAC.
     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 3 in 
section V.B.2.c. below. An ``(a)'' in this column indicates that work 
RVUs were taken from the 5-year refinement of work RVUs and not from 
the RUC. A ``(b)'' indicates that no RUC recommendation was provided. A 
discussion follows the table in section V.B.2.c.
     1997 work RVUs. This column contains the 1997 RVUs for 
physician work. The 1997 work RVUs shown have not been adjusted for 
budget neutrality.
    This table includes only those codes that were reviewed by the full 
RUC or for which we received a recommendation from the HCPAC.

[[Page 59544]]



        Table 3.--AMA RUC and HCPAC Recommendations and HCFA Decisions for New and Revised 1997 CPT Codes       
----------------------------------------------------------------------------------------------------------------
                                                  RUC            HCPAC                                          
   CPT* code     MOD       Description      recommendation  recommendations     HCFA  decision     1997 work RVU
----------------------------------------------------------------------------------------------------------------
11010#........  .....  Debride skin, fx...            4.15  ...............  Agreed.............            4.15
11011#........  .....  Debride skin/                  4.95  ...............  Agreed.............            4.95
                        muscle, fx.                                                                             
11012#........  .....  Debride skin/muscle/           6.88  ...............  Agreed.............            6.88
                        bone, fx.                                                                               
11720#........  .....  Debride nail, 1-5..  ..............             0.45  Decreased..........            0.32
11721#........  .....  Debride nail, 6 or   ..............             0.60  Decreased..........            0.54
                        more.                                                                                   
15756#........  .....  Free muscle flap,             33.23  ...............  Agreed.............           33.23
                        microvasc.                                                                              
15757#........  .....  Free skin flap,               33.23  ...............  Agreed.............           33.23
                        microvasc.                                                                              
15758#........  .....  Free facial flap,             33.23  ...............  Agreed.............           33.23
                        microvasc.                                                                              
20150#........  .....  Excise epiphyseal             13.00  ...............  Agreed.............           13.00
                        bar.                                                                                    
20956#........  .....  Iliac bone graft,             37.00  ...............  Agreed.............           37.00
                        microvasc.                                                                              
20957#........  .....  Mt bone graft,                38.33  ...............  Agreed.............           38.33
                        microvasc.                                                                              
20962.........  .....  Other bone graft,           Carrier  ...............  (b)................           37.00
                        microvasc.                                                                              
20969.........  .....  Bone/skin graft,              42.08  ...............  Agreed.............           42.08
                        microvasc.                                                                              
20970.........  .....  Bone/skin graft,              41.22  ...............  Agreed.............           41.22
                        iliac crest.                                                                            
24149#........  .....  Radical resection             13.25  ...............  Agreed.............           13.25
                        of elbow.                                                                               
24341#........  .....  Repair tendon/                 7.33  ...............  Agreed.............            7.33
                        muscle arm.                                                                             
24342.........  .....  Repair of ruptured            10.13  ...............  Agreed.............           10.13
                        tendon.                                                                                 
25332.........  .....  Revise wrist joint.           10.83  ...............  Agreed.............           10.83
26040.........  .....  Release palm                   3.09  ...............  Agreed.............            3.09
                        contracture.                                                                            
26060.........  .....  Incision of finger             2.71  ...............  Agreed.............            2.71
                        tendon.                                                                                 
26070.........  .....  Explore/treat hand             3.34  ...............  Agreed.............            3.34
                        joint.                                                                                  
26121.........  .....  Release palm                   7.34  ...............  Agreed.............            7.34
                        contracture.                                                                            
26123.........  .....  Release palm                   8.64  ...............  Agreed.............            8.64
                        contracture.                                                                            
26125.........  .....  Release palm                   4.61  ...............  Agreed.............            4.61
                        contracture.                                                                            
26185#........  .....  Remove finger bone.            5.00  ...............  Agreed.............            5.00
26540.........  .....  Repair hand joint..            6.03  ...............  Agreed.............            6.03
26541.........  .....  Repair hand joint              8.20  ...............  Agreed.............            8.20
                        with graft.                                                                             
26546#........  .....  Repair non-union               8.50  ...............  Agreed.............            8.50
                        hand.                                                                                   
26551#........  .....  Great toe-hand                44.31  ...............  Agreed.............           44.31
                        transfer.                                                                               
26553#........  .....  Single toe-hand               44.00  ...............  Agreed.............           44.00
                        transfer.                                                                               
26554#........  .....  Double toe-hand               52.50  ...............  Agreed.............           52.50
                        transfer.                                                                               
26556#........  .....  Toe joint transfer.           44.75  ...............  Agreed.............           44.75
27036#........  .....  Excision of hip               12.00  ...............  Agreed.............           12.00
                        joint/muscle.                                                                           
32491#........  .....  Lung volume                   21.25  ...............  Agreed.............           21.25
                        reduction.                                                                              
33234.........  .....  Removal of                     5.72  ...............  Increased..........            7.50
                        pacemaker system.                                                                       
33235.........  .....  Removal pacemaker              6.96  ...............  Increased..........            8.74
                        electrode.                                                                              
37250#........  .....  Intravascular us...            2.10  ...............  Decreased..........            1.51
37251#........  .....  Intravascular us...            1.60  ...............  Decreased..........            1.15
43496#........  .....  Free jejunum flap,          Carrier  ...............  Agreed.............         Carrier
                        microvasc.                                                                              
49020.........  .....  Drain abdominal               14.25  ...............  Agreed.............           14.25
                        abscess.                                                                                
49021#........  .....  Drain abdominal      ..............  ...............  (a)................            9.06
                        abscess.                                                                                
49906#........  .....  Free omental flap,          Carrier  ...............  Agreed.............         Carrier
                        microvasc.                                                                              
52300.........  .....  Cystoscopy and                 5.31  ...............  Agreed.............            5.31
                        treatment.                                                                              
52301#........  .....  Cystoscopy and                 5.51  ...............  Agreed.............            5.51
                        treatment.                                                                              
52340.........  .....  Cystoscopy and                 9.00  ...............  Agreed.............            9.00
                        treatment.                                                                              
56300.........  .....  Pelvic laparoscopy,            5.00  ...............  Decreased..........            3.65
                        dx.                                                                                     
56305.........  .....  Pelvic laparoscopy,            5.30  ...............  Decreased..........            3.97
                        biopsy.                                                                                 
56362.........  .....  Laparoscopy w/                 4.89  ...............  Agreed.............            4.89
                        cholangio.                                                                              
56363.........  .....  Laparoscopy w/                 5.18  ...............  Agreed.............            5.18
                        biopsy.                                                                                 
56399.........  .....  Laparoscopy                 Carrier  ...............  Agreed.............         Carrier
                        procedure.                                                                              
57160.........  .....  Insertion of                   0.89  ...............  Agreed.............            0.89
                        pessary/device.                                                                         
59525.........  .....  Remove uterus after            8.54  ...............  Agreed.............            8.54
                        cesarean.                                                                               
59866#........  .....  Abortion...........            4.00  ...............  Agreed.............            4.00
61586#........  .....  Resect nasopharynx,           23.60  ...............  Agreed.............           23.60
                        skull.                                                                                  
61793.........  .....  Focus radiation               16.70  ...............  Agreed.............           16.70
                        beam.                                                                                   
68801#........  .....  Dilate tear duct               0.89  ...............  Agreed.............            0.89
                        opening.                                                                                
68810#........  .....  Probe nasolacrimal             1.27  ...............  Agreed.............            1.27
                        duct.                                                                                   
68811#........  .....  Probe nasolacrimal             2.25  ...............  Agreed.............            2.25
                        duct.                                                                                   
68815#........  .....  Probe nasolacrimal             3.00  ...............  Agreed.............            3.00
                        duct.                                                                                   
69801.........  .....  Incise inner ear...            8.19  ...............  Agreed.............            8.19
75554.........     26  Cardiac mri/                   1.83  ...............  Agreed.............            1.83
                        function.                                                                               
75555.........     26  Cardiac mri/limited            1.74  ...............  Agreed.............            1.74
                        study.                                                                                  
75945#........     26  Intravascular us...            0.40  ...............  Decreased..........            0.29
75946#........     26  Intravascular us...            0.40  ...............  Decreased..........            0.29
78445.........     26  Vascular flow                  0.49  ...............  Agreed.............            0.49
                        imaging.                                                                                
78460.........     26  Heart muscle blood             0.86  ...............  Agreed.............            0.86
                        single.                                                                                 

[[Page 59545]]

                                                                                                                
78461.........     26  Heart muscle blood             1.23  ...............  Agreed.............            1.23
                        multiple.                                                                               
78464.........     26  Heart image (3d)               1.09  ...............  Agreed.............            1.09
                        single.                                                                                 
78465.........     26  Heart image (3d)               1.46  ...............  Agreed.............            1.46
                        multiple.                                                                               
78469.........     26  Heart infarct image            0.92  ...............  Agreed.............            0.92
                        (3d).                                                                                   
78481.........     26  Heart first pass               0.98  ...............  Agreed.............            0.98
                        single.                                                                                 
78483.........     26  Heart first pass               1.47  ...............  Agreed.............            1.47
                        multiple.                                                                               
90875#........  .....  Psychophysiological  ..............             1.11  Agreed.............            1.11
                        therapy.                                                                                
90876#........  .....  Psychophysiological  ..............             1.73  Agreed.............            1.73
                        therapy.                                                                                
90901#........  .....  Biofeedback          ..............             0.45  Decreased..........            0.41
                        training, any                                                                           
                        method.                                                                                 
92240#........     26  Icg angiography....            1.10  ...............  Agreed.............            1.10
92548#........     26  Posturography......            0.50  ...............  Agreed.............            0.50
92978#........     26  Intravascular us,              2.50  ...............  Decreased..........            1.80
                        heart.                                                                                  
92979#........     26  Intravascular us,              2.00  ...............  Decreased..........            1.44
                        heart.                                                                                  
92995.........  .....  Coronary                      12.09  ...............  Agreed.............           12.09
                        atherectomy.                                                                            
93303#........     26  Echo transthoracic.  ..............  ...............  (a)................            1.30
93304#........     26  Echo transthoracic.  ..............  ...............  (a)................            0.75
93315#........     26  Echo                 ..............  ...............  (a)................            2.78
                        transesophageal.                                                                        
93316#........  .....  Echo                 ..............  ...............  (a)................            0.95
                        transesophageal.                                                                        
93317#........     26  Echo                 ..............  ...............  (a)................            1.83
                        transesophageal.                                                                        
93619.........     26  Electrophysiology              7.32  ...............  Agreed.............            7.32
                        evaluation.                                                                             
93620.........     26  Electrophysiology             11.59  ...............  Agreed.............           11.59
                        evaluation.                                                                             
93975.........     26  Vascular study.....            1.80  ...............  Agreed.............            1.80
93976.........     26  Vascular study.....            1.21  ...............  Agreed.............            1.21
95921#........     26  Autonomic nervous              0.90  ...............  Decreased..........            0.45
                        function test.                                                                          
95922#........     26  Autonomic nervous              0.96  ...............  Decreased..........            0.48
                        function test.                                                                          
95923#........     26  Autonomic nervous              0.90  ...............  Decreased..........            0.45
                        function test.                                                                          
95950.........     26  Ambulatory eeg                 1.51  ...............  Agreed.............            1.51
                        monitoring.                                                                             
97504#........  .....  Orthotic training..  ..............             0.45  Agreed.............            0.45
97520.........  .....  Prosthetic training  ..............             0.45  Agreed.............            0.45
98940#........  .....  Chiropractic         ..............             0.45  Agreed.............            0.45
                        manipulation.                                                                           
98941#........  .....  Chiropractic         ..............             0.65  Agreed.............            0.65
                        manipulation.                                                                           
98942#........  .....  Chiropractic         ..............             0.87  Agreed.............            0.87
                        manipulation.                                                                           
98943#........  .....  Chiropractic         ..............             0.40  Agreed.............            0.40
                        manipulation.                                                                           
----------------------------------------------------------------------------------------------------------------
a No RUC recommendation provided.                                                                               
b RUC retained as carrier priced but HCFA assigned a value.      #New Codes                                     
* All numeric HCPCS CPT Copyright 1996 American Medical Association.                                            

    b. Discussion of Interim Relative Value Units for Chiropractic 
Manipulative Treatment.
    Comment: We received a comment from the RUC HCPAC Review Board 
recommending RVUs for chiropractic manipulative treatment. Medicare 
coverage of chiropractic services is limited to manual manipulation for 
treatment of subluxation of the spine. HCPCS Level II code, A2000 
(Manipulation of spine by chiropractor) has been used to report this 
service. With the introduction of new CPT procedure codes for 
chiropractic manipulative treatment, a chiropractic professional 
organization submitted a comment during the 5-year review that the 
physician work in the chiropractic manipulative treatment is equivalent 
to the existing osteopathic manipulative treatment codes.
    The RUC HCPAC Review Board reviewed data based on survey responses 
of 106 chiropractors and a previous study performed by Lewin-VHI. The 
Review Board agreed that the work RVUs for the chiropractic 
manipulative treatment should be equivalent to the established RVUs for 
osteopathic manipulative treatment codes as follows:

------------------------------------------------------------------------
                                     Existing osteopathic               
  New chiropractic manipulative     manipulative treatment    Work RVUs 
        treatment CPT code                 CPT code                     
------------------------------------------------------------------------
98940 (Chiropractic manipulative   98925 (Osteopathic               0.45
 treatment; spinal, 1 to 2          manipulative treatment;             
 regions).                          1 to 2 body regions).               
98941 (Chiropractic manipulative   98926 (Osteopathic               0.65
 treatment; spinal, 3 to 4          manipulative treatment;             
 regions).                          3 to 4 body regions).               
98942 (Chiropractic manipulative   98927 (Osteopathic               0.87
 treatment; spinal, 5 regions).     manipulative treatment;             
                                    5 to 6 regions).                    
------------------------------------------------------------------------

The RUC HCPAC Review Board also recommended 0.40 work RVUs for CPT code 
98943 (Chiropractic manipulative treatment, extraspinal, one or more 
regions).
    The chiropractic manipulative treatment codes include a 
premanipulation patient assessment, as do the osteopathic manipulative 
treatment codes. Additional evaluation and management must be reported 
separately using the modifier -25, only if the patient's condition 
requires a significant separately identifiable evaluation and 
management service.
    Response: We agree with the recommendation of the RUC HCPAC Review 
Board that the chiropractic manipulative treatment codes represent 
services and physician work that

[[Page 59546]]

essentially parallel that of the osteopathic manipulation codes. The 
work RVUs based on the survey results appear to be identical to 
osteopathic manipulation treatment, and both the osteopathic 
manipulation treatment work RVUs and the chiropractic manipulation 
treatment work RVUs contain a manipulation component as well as an 
evaluation and management component.
    We note that, for purposes of Medicare coverage and payment, the 
five regions referred to by the CPT codes 98940, 98941, and 98942 are 
the cervical region (includes atlanto-occipital joint); thoracic region 
(includes costovertebral and costotransverse joints); lumbar region; 
sacral region; and pelvic (sacro-iliac joint) region. These are the 
only codes that the Medicare program will recognize for chiropractic 
treatment by manual manipulation for subluxation of the spine. CPT code 
98943 (Chiropractic manipulation treatment, extraspinal) is not covered 
by Medicare. HCPCS code A2000 will no longer be recognized by Medicare.
    In conclusion, we agree with the RUC that the work assigned to the 
chiropractic manipulation treatment codes is sufficiently comparable to 
that assigned to the osteopathic manipulation treatment codes. 
Therefore, we are assigning work RVUs to CPT codes 98940, 98941, and 
98942 according to the RUC recommendation as follows:

------------------------------------------------------------------------
                                                                   Work 
          CPT code                        Descriptor               RVUs 
------------------------------------------------------------------------
98940.......................  Chiropractic manipulative             0.45
                               treatment; spinal, 1 to 2 regions.       
98941.......................  Chiropractic manipulative             0.65
                               treatment; spinal, 3 to 4 regions.       
98942.......................  Chiropractic manipulative             0.87
                               treatment; spinal, 5 regions.            
------------------------------------------------------------------------

For CPT code 98943, extraspinal chiropractic manipulative treatment, we 
agree with the RUC recommendation of 0.40 work RVUs. However, this 
service is not covered by Medicare. These RVUs are considered interim 
for 1997. We welcome comments on the interim RVUs.
    c. Discussion of Codes for Which the RUC Recommendations Were Not 
Accepted.
    The following is a summary of our rationale for not accepting 
particular recommendations. It is arranged by type of service in CPT 
code order. This summary refers only to work RVUs.
    CPT code 11720 (Debridement of nail(s) by any method(s); one to 
five) and CPT code 11721 (Debridement of nail(s) by any method(s); six 
or more).
    The RUC recommended 0.32 work RVUs for CPT code 11720 and 0.45 for 
CPT code 11721. These codes encompass services that were previously 
reported using CPT codes 11700, 11701, 11710, and 11711. The following 
table identifies the codes and the final work RVUs we assigned to them 
for the 1997 physician fee schedule:

------------------------------------------------------------------------
                                                                   Work 
           CPT code                       Description              RVUs 
------------------------------------------------------------------------
11700........................  Debridement of nails, manual;        0.32
                                five or less.                           
11701........................  Debridement of nails, manual:        0.23
                                each additional, five or less.          
11710........................  Debridement of nails, electric       0.32
                                grinder; five or less.                  
11711........................  Debridement of nails, electric       0.20
                                grinder; each additional, five          
                                or less.                                
------------------------------------------------------------------------

There are two sets of codes: one set for manual debridement and one set 
for electric grinder debridement. These codes were initially referred 
to the RUC in 1995 because we received conflicting comments on the work 
RVU assignments for the second code in each set. The American Podiatric 
Medical Association recommended that the correct work RVUs for CPT code 
11711 should be 0.23 and not 0.20 based on the analogy that if CPT code 
11700 (Debridement of nails, manual; five or less) and CPT code 11710 
(Debridement of nails, electric grinder; five or less) have the same 
work RVUs (0.32), then CPT code 11711 should have the same work RVUs as 
CPT code 11701. Based on the same analogy, another commenter 
recommended that the work RVUs for CPT code 11701 be reduced to 0.20.
    This issue was referred by the RUC to CPT where the codes were 
collapsed so that the same codes would be used to report debridement 
regardless of the method of debridement (manual or electric grinder). 
In addition, the codes were revised so that only one code would be used 
to report the debridement of six or more nails. The two new codes then 
went back to the RUC for the development of recommended work RVUs. For 
the debridement of one to five nails, the RUC recommended 0.45 RVUs, 
which represents a 41 percent increase over the work RVUs assigned to 
the current codes used to report the debridement of one to five nails. 
For the debridement of six or more nails, the RUC recommended 0.60 work 
RVUs. Depending on which pair of current codes is used to report the 
debridement of six or more nails (CPT codes 11700 plus 11701 or 11710 
plus 11711), this represents an increase of 9 or 20 percent, 
respectively, in work RVUs. We believe these increases are unjustified 
especially since the codes were not identified as undervalued at the 
beginning of the 5-year review.
    When valuing new and revised codes that replace deleted codes, we 
typically have used Medicare frequency data and used the work RVUs of 
the deleted codes to arrive at weighted average values for the new 
codes in a budget-neutral fashion. We have used this method to arrive 
at the work RVUs for new CPT codes 11720 and 11721. The work RVUs for 
CPT code 11720 are being established as 0.32, which are the same work 
RVUs assigned to both of the predecessor codes. The work RVUs for CPT 
code 11721 are being established as 0.54, which is a weighted average 
of the sum of the work RVUs of the codes used to report the debridement 
of six or more nails in the past.
    CPT code 20962 (Bone graft with microvascular anastomosis; other 
than fibula, iliac crest, or metatarsal).
    This code was revised slightly for CPT 1997. It is currently 
carrier-priced, and the RUC recommended that it remain carrier-priced. 
This is a very low-volume service in a family of low-volume services. 
For two other codes in the family, CPT codes 20956 and 20957, we 
received RUC recommendations of 37.00 and 38.33 work RVUs, 
respectively. We believe the work of CPT code 20962 is comparable to 
these other codes, and we are assigning 37.00 interim work RVUs.
    CPT code 33234 (Removal of transvenous pacemaker electrode(s), 
single lead system, atrial or ventricular) and CPT code 33235 (Removal 
of transvenous pacemaker electrode(s), dual lead system).
    In CPT 1996, the pacemaker removal codes are structured so that the 
removal of a pulse generator is reported with a single code (CPT code 
33233), and the removal of a pulse generator and a lead system is 
reported with a single code (CPT code 33234 or 33235). There is not a 
separate code for the removal of a lead system only. For 1997, the CPT 
Editorial Panel revised the pacemaker section to

[[Page 59547]]

allow physicians to report the removal of a pacemaker lead system only. 
The removal of a pulse generator and a lead system will now be reported 
with two codes (CPT codes 33233 and 33234 or CPT codes 33233 and 
33235).
    The RUC recommendations for CPT code 33234 (Removal of transvenous 
pacemaker electrodes; single lead system, atrial or ventricular) and 
CPT code 33235 (Dual lead system) were calculated by subtracting 2.97 
work RVUs from the work RVUs currently assigned to these two codes. The 
subtraction of 2.97 work RVUs was necessary because those are the work 
RVUs assigned to CPT code 33233, which now will be used to report 
separately the removal of a permanent pacemaker pulse generator. Thus, 
the RUC revised the work RVUs for CPT codes 33234 and 33235 downward so 
that the coding change would not result in a net increase in the total 
work RVUs associated with the removal of a pulse generator and a lead 
system at the same time.
    We agree that the work RVUs should be decreased but we believe the 
RUC's recommendations were too low because they failed to take into 
account the fact that the pacemaker removal codes are subject to our 
multiple surgical reduction policy. If a physician performs the removal 
of a pulse generator and a lead system at the same time, the lower 
valued service (in this case, the removal of the pulse generator) will 
be paid at 50 percent of the current value. Thus, the sum of the 
recommended work RVUs that would be recognized (as a result of the 
multiple surgery reduction), if both procedures were performed, would 
be less than the work RVUs that were in place before the coding change. 
We do not believe this effect is consistent with the RUC's intent.
    To overcome this problem, we made the following adjustments. First, 
we estimate that 80 percent of the time a lead system is removed, the 
pulse generator will be removed. We then used the following 
mathematical formula to calculate RVUs: 0.8( x  + \1/2\*2.97 RVUs) + 
0.2 x  = y where  x  equals the new value for CPT code 33234 or CPT 
code 33235 and y equals the current value of CPT code 33234 or CPT code 
33235. As a result of these calculations, we are increasing the RVUs 
above the RUC's recommendation for CPT code 33234 from 5.72 to 7.50 
work RVUs and the recommendation for CPT code 33235 from 6.96 to 8.74 
work RVUs.
    CPT codes 37250, 37251, 75945, 75946, 92978, and 92979 
(Intravascular ultrasound).
    CPT 1997 will include two new codes for intravascular ultrasound of 
non-coronary vessels during therapeutic interventions (CPT codes 37250 
and 37251) and two new codes for intravascular ultrasound of coronary 
vessels during therapeutic interventions (CPT codes 92978 and 92979). 
In addition, two new codes for the reporting of radiological 
supervision and interpretation were created (CPT codes 75945 and 
75946). They will be reported only with the codes for intravascular 
ultrasound of non-coronary vessels.
    The RUC based its recommendation for intravascular ultrasound on 
the ultrasound portion of CPT code 43259 (Upper gastrointestinal 
endoscopy with endoscopic ultrasound examination), with 4.89 work RVUs. 
If the work RVUs for CPT code 43235 (Upper gastrointestinal endoscopy 
without ultrasound), with 2.39 work RVUs, are subtracted from the work 
RVUs assigned to CPT code 43259, the result is 2.50. The RUC suggested 
that the value of coronary intravascular ultrasound (CPT code 92978) be 
set equal to this calculated value for the ultrasound portion of CPT 
code 43259. For non-coronary intravascular ultrasound, the RUC 
recommended 2.10 work RVUs for CPT code 37250 and 0.40 work RVUs for 
CPT code 75946 (for radiologic supervision and interpretation). The sum 
of these recommendations equals the 2.50 work RVUs recommended for CPT 
code 92978. The RUC intended the work RVUs of CPT code 92978 to be 
equal to the sum of the work RVUs of CPT codes 37250 and 75946 because 
the work of CPT code 92978 includes radiologic supervision and 
interpretation. Thus, for coronary ultrasound, only one code is 
reported while two codes are reported for non-coronary ultrasound.
    We do not agree with the reference procedure used by the RUC 
because we do not view the work associated with intravascular 
ultrasound to be as great as it is for endoscopic ultrasound. First, 
the number of anatomic structures to be studied and the diagnostic 
possibilities are fewer for intravascular ultrasound. Second, physician 
work is reduced since access to the vessels has been established and 
angiographic studies have often been performed.
    We believe more appropriate reference procedures would be CPT code 
78465 (Myocardial perfusion imaging (SPECT), multiple studies at rest 
and/or stress), with 1.46 work RVUs, and CPT code 70541 (Magnetic 
resonance angiography, head and/or neck, with or without contrast 
material), with 1.81 work RVUs. Therefore, for CPT code 92978, we are 
assigning 1.80 work RVUs. This value is 72 percent of the RUC-
recommended 2.50 work RVUs.
    Although we disagree with the recommended work RVUs, we do agree 
with the relative relationship established by the RUC for the codes in 
this family, and we have reduced the remaining codes by 28 percent, 
consistent with the RUC recommendations. Therefore, the interim work 
RVUs for the six intravascular ultrasound codes are as shown in Table 
3.
    CPT code 49021 (Drainage of peritoneal abscess, percutaneous).
    We received no recommendation from the RUC on this code. The 
procedure currently is being reported with CPT code 49020 (Drainage of 
peritoneal abscess, transabdominal), with 9.06 work RVUs. We decided to 
value CPT code 49021 at 9.06 work RVUs and keep these as interim work 
RVUs until we receive a recommendation from the RUC.
    CPT code 56300 (Laparoscopy (peritoneoscopy), diagnostic (separate 
procedure)) and CPT code 56305 (Laparoscopy (peritoneoscopy); with 
biopsy, single or multiple).
    CPT 1996 includes separate codes for reporting diagnostic 
laparoscopic procedures and separate codes for reporting diagnostic 
peritoneoscopic procedures. The peritoneoscopy codes were deleted from 
CPT 1997 because they describe the same services as the corresponding 
laparoscopic procedures. The RUC recommended 5.00 work RVUs for CPT 
code 56300 and 5.30 work RVUs for CPT code 56305 (Laparoscopy with or 
without biopsy, respectively). We disagree with these recommendations 
for two reasons. First, we view the CPT change as editorial. Second, 
the RUC recommendations would put the work RVUs for CPT codes 56300 and 
56305 higher than the work RVUs for CPT codes 56362 and 56363 
(Laparoscopy with guided transhepatic cholangiography without or with 
biopsy, respectively). We believe this would significantly distort the 
relative relationships within the laparoscopy family since CPT codes 
56362 and

[[Page 59548]]

56363 are higher-level, more work-intensive procedures.
    We believe that the work RVUs should be based on an average of the 
work RVUs assigned to the laparoscopic and peritoneoscopic codes 
weighted by the frequency with which they are performed. By calculating 
a weighted average, we can assure that the coding changes will be work-
neutral within the family of codes. These calculations result in 3.65 
work RVUs for CPT code 56300 and 3.97 work RVUs for CPT code 56305. In 
addition, we have reduced the global period for CPT codes 56300 and 
56305 from 10 days to 0 days to correspond to the 0 day global period 
assigned to the peritoneoscopy codes.
    CPT codes 93303 through 93317 (Pediatric echocardiography).
    We did not receive RUC recommendations for CPT code 93303 
(Transthoracic echocardiography for congenital cardiac anomalies; 
complete) or CPT code 93304 (Transthoracic echocardiography for 
congenital cardiac anomalies; follow up or limited study). The RUC 
tabled the issue of pediatric echocardiography at the request of the 
American Academy of Pediatrics and the American College of Cardiology 
pending review of the nomenclature of these codes by the CPT Editorial 
Panel. The societies view modifications made by the CPT Editorial Panel 
to the nomenclature of the proposed pediatric echocardiography codes as 
greatly altering the original intent and proposed application of the 
codes. Until the coding issue is resolved and a survey conducted, the 
RUC will not submit recommended work RVUs for these services.
    Regardless of the outcome of the nomenclature debate, we believe it 
is essential that the new CPT codes have work RVUs assigned to them at 
this time because they are the only codes available to report these 
services. To assign work RVUs to these codes, we looked to a paper 
entitled ``Resource Based Relative Value Scale for Children--Comparison 
of Pediatric and Adult Cardiology Work Values'' published by Garson et 
al. in Cardiology in the Young in 1995 (Vol. 5:210-216). Work RVUs for 
cardiology were found to be different between adults and children in 75 
percent of the 20 CPT codes (echocardiography, cardiac catheterization, 
etc.) that were assessed. For echocardiography, the pediatric median 
work RVUs were an average of 90 percent higher than the adult work RVUs 
for CPT code 93307, the CPT code used to report echocardiography. In 
rating the work of pediatric echocardiography, the codes for cross-
sectional echocardiography (CPT code 93307), Doppler echocardiography 
(CPT code 93320), and Doppler color flow velocity mapping (CPT code 
93325) were combined into a single procedure, and panelists provided a 
single rating for a complex pediatric echocardiogram.
     To arrive at work RVUs for the new pediatric echocardiography 
codes, we looked first to the new work RVUs for echocardiography (CPT 
code 93307) that emerged from the 5-year refinement. Based on the 
individual ratings of the members of a refinement panel that reviewed 
echocardiography services, the new work RVUs for CPT code 93307 will be 
0.92. We first increased this value by 90 percent based on the study 
results described above to arrive at 1.75 work RVUs. We next subtracted 
the work RVUs for Doppler echocardiography (CPT code 93320) and Doppler 
color flow velocity mapping (CPT code 93325), which are 0.38 and 0.07, 
respectively. These work RVUs need to be subtracted because, under the 
new codes, they will be separately reported in addition to the 
pediatric echocardiography. Thus, our proposed interim work RVUs for 
CPT code 93303 (Transthoracic echocardiography for congenital cardiac 
anomalies; complete) are established as 1.30.
     For CPT code 93304 (Transthoracic echocardiography for congenital 
cardiac anomalies; follow up or limited study), we looked to the 
relationship of the work RVUs for CPT code 93307 (Complete adult 
echocardiography) to the work RVUs for CPT code 93308 (Follow up or 
limited adult echocardiography code). The current work RVUs for CPT 
code 93308 are 0.53. This code was not identified as undervalued as 
part of the 5-year review. The 0.53 work RVUs for CPT code 93308 are 58 
percent of the new work RVUs for CPT code 93307, which are established 
as 0.92. To maintain this relationship in the pediatric codes, we 
calculated 0.75 interim work RVUs for CPT code 93304 by multiplying the 
proposed work RVUs for CPT code 93303 (1.30) by 58 percent.
     CPT 1997 will also include three new codes for transesophageal 
echocardiography. The codes are CPT code 93315 (Transesophageal 
echocardiography for congenital cardiac anomalies including probe 
placement, image acquisition, interpretation and report); CPT code 
93316 (Transesophageal echocardiography for congenital cardiac 
anomalies, placement of transesophageal probe only); and CPT code 93317 
(Transesophageal echocardiography for congenital cardiac anomalies, 
image acquisition, interpretation and report only).
     In order to understand how we arrived at the work RVUs for the 
three new pediatric transesophageal echocardiography codes, it is first 
necessary to explain the assignment of work RVUs to the three existing 
codes for adult transesophageal echocardiography that emerged from the 
5-year refinement. Based on the individual ratings of the members of a 
refinement panel that reviewed adult echocardiography services, the new 
work RVUs for CPT code 93312 (Transesophageal echocardiography, 
including probe placement, image acquisition, interpretation and 
report) are established as 2.20. This was the only adult 
transesophageal echocardiography reviewed by the panel.
     We received no comments as part of the 5-year review that the work 
RVUs for the code used to report only the placement of a 
transesophageal probe (CPT code 93313) should be revised. Therefore, we 
have maintained the current 0.95 work RVUs. By subtracting these work 
RVUs from the new work RVUs for CPT code 93312, we can calculate new 
work RVUs for CPT code 93314, which is used to report image 
acquisition, interpretation and report only. The result is 1.25 work 
RVUs.
     It was necessary to calculate these work RVUs because the 
refinement panel did not specifically address CPT code 93314. However, 
it was clear during the discussions of the refinement panel that the 
service considered by the American College of Cardiology and the 
American Society of Echocardiography to be undervalued was the image 
acquisition, interpretation and report and not the probe placement.
     We also revised the relationship of the three codes in this family 
so that the work RVUs for CPT code 93312 will equal the sum of the work 
RVUs for CPT codes 93313 and 93314. When we first assigned work RVUs to 
these codes, we assigned 20 percent more work RVUs to both CPT codes 
93313 and 93314 because two different physicians were often involved in 
the procedure and each would have a certain amount of preservice and 
postservice work that could not be considered duplicative. 
Consequently, the sum of these two codes exceeded the work RVUs 
assigned to CPT code 93312. We now believe that

[[Page 59549]]

most transesophageal echocardiographies are done by a single physician. 
Therefore, we have adjusted the work RVUs so that the work RVUs for CPT 
code 93312 equal the sum of the work RVUs for CPT codes 93313 and 
93314. To summarize, the 1997 work RVUs for the adult echocardiography 
CPT codes 93312, 93313, and 93314 are 2.20, 0.95, and 1.25, 
respectively. These work RVUs are the basis for the work RVUs we 
propose for the three pediatric transesophageal echocardiography codes 
(CPT codes 93315, 93316, and 93317).
     The paper by Garson et al. in Cardiology in the Young did not 
address the issue of transesophageal echocardiography. To establish 
interim work RVUs for image acquisition, interpretation and report only 
(CPT code 93317), we looked to a ``Survey of Physician Work in 
Pediatric Cardiology'' prepared for the American Academy of Pediatrics 
and the American College of Cardiology by Lewin-VHI in 1993. That 
survey found that the work of pediatric transesophageal 
echocardiography was 46 percent more than the work of adult 
transesophageal echocardiography. To arrive at work RVUs for the new 
pediatric transesophageal echocardiography CPT code 93317, we increased 
the work RVUs we assigned to the adult code (CPT code 93314), with 1.25 
work RVUs, by 46 percent. This results in 1.83 interim work RVUs for 
CPT code 93317.
     For CPT code 93316, which is the pediatric code used to report 
only the placement of the transesophageal probe, we looked to CPT code 
93313, which is the code used to report the same service in an adult. 
The 1997 work RVUs for CPT code 93313 are established as 0.95. We have 
assigned these same work RVUs to CPT code 93316 because the work of 
placement of a transesophageal probe in a child was not included in the 
surveys described above.
     For CPT code 93315, which is the pediatric code used to report the 
complete procedure, we calculated interim proposed work RVUs by adding 
the work RVUs for CPT codes 93316 and 93317. This results in 2.78 work 
RVUs.
     We look forward to receiving recommendations from the RUC for 
these services once the coding issues are settled and survey data has 
been considered.
    CPT codes 95921 through 95923 (Testing of autonomic nervous system 
function).
     CPT 1997 will include three new codes to report the testing of 
autonomic nervous system function. The RUC recommendations for these 
codes were as follows: CPT code 95921, 0.90 work RVUs; CPT code 95922, 
0.96 work RVUs; and CPT code 95923, 0.90 work RVUs.
     We believe that the RUC recommendations are too high compared to 
other services on the fee schedule. The RUC compared the service to 
needle electromyography (CPT code 95860), with 0.96 work RVUs. We 
disagree with that comparison because we do not believe the autonomic 
testing codes involve the extensive physician involvement required 
during electromyography. We believe more appropriate reference codes 
would be nerve conduction testing (CPT code 95900), with 0.42 work 
RVUs; visual field examination (CPT code 92083), with 0.50 work RVUs; 
and a 24 hour EKG monitor (CPT code 93224), with 0.52 work RVUs. In 
addition, we believe the vignettes used in the survey may have led to 
overestimating the amount of work because they describe evaluation and 
management services that can be separately reported. The autonomic 
testing codes have a global status of XXX, which means the evaluation 
and management services can be separately reported since codes with XXX 
status are not subject to our global surgery policies.
    Although we disagree with the recommended work RVUs, we agree with 
the relative relationship established by the RUC for the three codes in 
this family. We are reducing the RUC recommendations for the codes by 
50 percent so that the work RVUs will be valued appropriately relative 
to the referenced procedures identified above. Therefore, the interim 
work RVUs are established as follows: CPT code 95921, 0.45 work RVUs; 
CPT code 95922, 0.48 work RVUs; and CPT code 95923, 0.45 work RVUs.
    d. New HCFA Common Procedure Coding System Codes.
    In this final rule, we have created new HCPCS codes that are to be 
used in lieu of existing CPT codes for four categories of services 
furnished on or after January 1, 1997. Three of the categories are 
discussed elsewhere in this rule. The three categories of services and 
the sections of this rule where they are discussed are: destruction of 
benign and premalignant skin lesions (section II.D.2.b.); psychotherapy 
(section IV.A.14.); and care plan oversight (section IV.B.1.). The 
fourth category, bone mineral density studies, is discussed below.
    For the 1997 physician fee schedule, we are establishing several 
new alpha-numeric HCPCS codes and related work RVUs for the reporting 
of peripheral and central skeletal bone mineral density services that 
are not clearly described by existing CPT codes. 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. The related 
interim RVUs will, like other interim values, be subject to comment 
during the 60-day public comment period following publication of this 
rule; however, like other interim values, they will be used for payment 
purposes for procedures furnished after December 31, 1996. We will 
address the public comments on these interim codes in the final rule 
for the 1998 physician fee schedule.
    Currently, there is only one CPT code 76070 for computerized 
tomography bone mineral density studies, only one CPT code 76075 for 
dual energy x-ray absorptiometry bone mineral density studies, and only 
one CPT code 78350 for single photon absorptiometry bone mineral 
density studies. While computerized tomography, dual energy x-ray 
absorptiometry, and single photon absorptiometry studies may be 
performed on the peripheral skeleton, new less expensive devices are 
now being marketed (for example, p-Dexa) that perform studies of 
peripheral (forearm, wrist, or heel) skeletal bones only. The RVUs 
assigned to the existing CPT codes that could be used to report these 
services are excessive when compared to the resources associated with 
their use.
    Recently, a manufacturer, representatives of a specialty society, 
and our Technical Advisory Committee have recommended that we establish 
separate bone mineral density codes to distinguish peripheral scans 
from general pelvic scans because of the belief that Medicare payment 
for CPT codes 76070, 76075, and 78350 is too high when only a 
peripheral scan is done to determine bone density. We agree with the 
recommendation and, thus, are issuing new HCPCS codes for both 
peripheral and general bone mineral density studies as well as 
assigning the appropriate RVUs as outlined below.
    With the issuance of the interim peripheral and central skeletal 
bone mineral density codes and the related work RVUs beginning January 
1, 1997,

[[Page 59550]]

physicians and providers must report all peripheral or skeletal bone 
mineral density studies under the interim codes for those services. To 
eliminate the possibility of confusion regarding whether to use the 
existing CPT codes for these procedures, we will no longer recognize 
the existing codes (CPT codes 76070, 76075, and 78350) for Medicare 
reporting purposes.

----------------------------------------------------------------------------------------------------------------
                                                                             Practice                           
                         HCPCS code                            Work RVUs     expense    Malpractice   Total RVUs
                                                                               RVUs         RVUs                
----------------------------------------------------------------------------------------------------------------
G0062-Peripheral Skeletal Bone Mineral Density Study (e.g.                                                      
 radius, wrist, heel).......................................         0.22         0.82         0.07         1.11
G0062-26....................................................         0.22         0.10         0.02         0.34
G0062-TC....................................................         0.00         0.72         0.05         0.77
G0063--Central Skeletal Bone Mineral Density Study (e.g.                                                        
 spine, pelvis).............................................         0.30         3.07         0.21         3.58
G0063-26....................................................         0.30         0.12         0.02         0.44
G0063-TC....................................................         0.00         2.95         0.19         3.14
----------------------------------------------------------------------------------------------------------------

    We have assigned 0.22 work RVUs to HCPCS code G0062, based on the 
work RVUs assigned to CPT code 78350, which was used to report a single 
photon absorptiometry bone mineral density study. We have assigned 0.82 
practice expense RVUs to HCPCS code G0062, based on the practice 
expense RVUs assigned to CPT code 78350, single photon absorptiometry 
bone mineral density study. HCPCS code G0062 is the only code to be 
used for reporting peripheral bone mineral density studies.
    We have assigned 0.30 work RVUs to HCPCS code G0063, based on the 
work RVUs assigned to CPT code 76075, which is used to report dual 
energy x-ray absorptiometry studies. We have assigned 3.07 practice 
expense RVUs to HCPCS code G0063, based on the practice expense RVUs 
assigned to CPT code 76075, dual energy x-ray absorptiometry studies.
    We would like to emphasize that this is a change in coding policy 
rather than a change in coverage policy. The coverage policy on bone 
density studies in section 50-44 of the Medicare Coverage Issues Manual 
(HCFA-Pub. 6) remains in effect. Under that policy:
     Single photon absorptiometry (CPT code 78350) is covered 
when used in assessing changes in bone density of patients with 
osteodystrophy or osteoporosis when performed on the same individual at 
intervals of 6 to 12 months. Under this coding change, HCPCS code G0062 
would be used to report a single photo absorptiometry on the peripheral 
skeleton, and HCPCS code G0063 would be used to report the procedure 
when performed on the central skeleton.
     Bone biopsy, a physiologic test that is a surgical, 
invasive procedure, is covered when used for the qualitative evaluation 
of bone. Billing for this procedure is unaffected by this change.
     Photodensitometry, a noninvasive radiological procedure 
that attempts to assess bone mass by measuring the optical density of 
extremity radiographs with a photodensitometer, would be reported by 
HCPCS code G0062 under this change.
     Dual photon absorptiometry (CPT code 78351) remains a 1 
noncovered service under Medicare and may not be reported under HCPCS 
code G0062 or HCPCS code G0063. Dual photon absorptiometry should be 
reported with CPT code 78351.
     The coverage of computerized tomography bone mineral 
density studies (CPT code 76070) and dual energy x-ray absorptiometry 
bone mineral density studies (CPT code 76075) is a matter of individual 
carrier discretion. If covered, HCPCS code G0062 would be used to 
report a peripheral skeleton study by either method, and HCPCS code 
G0063 would be used to report either procedure when performed on the 
central skeleton.
    We recognize that the use of these temporary codes for destruction 
of benign and premalignant skin lesions, psychotherapy, care plan 
oversight and bone mineral density studies will place an administrative 
burden on both physicians and payers. However, we do not believe the 
burden will be significant. Also, we believe that our responsibility to 
publish a relative value scale for physician work and to use codes with 
a minimal potential for misuse outweighs our concerns regarding the 
potential administrative burden associated with temporary codes.
    We view these codes as temporary, and we plan to forward them to 
the CPT Editorial Panel as soon as possible. Our statutory 
responsibility to publish the physician fee schedule each year with an 
effective date of January 1 occasionally conflicts with the annual CPT 
publication cycle that precludes consideration of new and revised CPT 
codes later than February before publication of the next year's book. 
Thus, for these four categories of temporary codes, we were unable to 
submit requested new and revised codes to CPT in time for the 1998 
book.

VI. Provisions of the Final Rule

    The provisions of this final rule, for the most part, restate the 
provisions of the July 1996 proposed rule with the exception of changes 
to the regulations text in Sec. 410.32 (``Diagnostic x-ray tests, 
diagnostic laboratory tests, and other diagnostic tests: Conditions''). 
We are also making final the provisions of the May 3, 1996 proposed 
notice with the exception of those issues identified elsewhere in the 
preamble of this final rule.

VII. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.).

 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.

[[Page 59551]]

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 have an economic impact on a substantial 
number of small entities. A substantial number of physicians will 
experience some change in Medicare revenue as a result of one or more 
provisions of this final rule, however, for most physicians the change 
will not be significant. Under the Regulatory Flexibility Act, we 
consider a change to be significant if it results in a difference in 
Medicare payments to a substantial number of entities that equals or 
exceeds from 3 to 5 percent of each of the entities' total revenue. 
Where such effect occurs, we must explain the alternatives considered 
to demonstrate that we considered minimizing adverse effects. However, 
adverse payment effects result from the application of the budget 
neutrality requirements (as described below in section IX.B. of this 
final rule).
    The provisions of this rule are expected to have varying effects on 
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. As illustrated in 
accompanying charts, some specialties experience greater change in 
income from Medicare than others. While we present our estimate of the 
effect of the changes made by this rule on each specialty taken as a 
whole, practicing members of that specialty may experience quite 
different effects, depending on the extent to which their billing 
patterns coincide with changes to codes encompassed by the specialty as 
a whole, and the Medicare percentage of their practice. (This is 
further explained in section L.3. of this impact statement.) 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.
    With few exceptions, we expect that an impact on an individual 
medical practitioner of more than 5 percent of practice income will be 
limited. In instances where there is a likelihood of some 
practitioners' practice income being affected, such as in some 
localities being realigned, we discuss in detail elsewhere in this 
preamble alternate considerations and our conclusions for the policies 
adopted.

B. Budget Neutrality

    Section 1848(c)(2)(B) of the Act requires that adjustments in a 
year may not cause the amount of expenditures for the year to differ by 
more than $20 million from what expenditures would have been in the 
absence of these changes. If this threshold is exceeded, we make 
adjustments to preserve this budget neutrality.
    This year budget neutrality adjustments are required by changes in 
fees resulting from the 5-year refinement and revisions in payment 
policies, including the establishment of interim and final RVUs for CPT 
coding changes.
    In past years, we have made budget neutrality adjustments across 
the entire physician fee schedule: to all relative values (initially) 
and, beginning in 1996, to the CFs. As is discussed in section IV.C.1. 
of this final rule, we are making the budget neutrality adjustment 
required for changes in fees resulting from the 5-year review through a 
temporary separate adjuster to the work RVUs in 1997. We plan on 
eliminating this adjuster in 1998 when we implement the resource-based 
practice expense RVUs. The budget neutrality adjustment required for 
all other changes will be applied to the CF, as in prior years.
    The components of the budget neutrality adjustment to the CFs 
required by payment policy changes are discussed in sections IX.C. 
through IX.J. below. The impact of the changes resulting from the 5-
year refinement is discussed in section IX.K. below.

C. Payment Area (Locality) and Corresponding Geographic Practice Cost 
Index Changes

    As mentioned earlier, our policy change will reduce existing urban/
rural payment differences. Overall, urban areas will experience an 
average decrease in payments of -0.14 percent, while rural areas will 
experience an increase in payments of 1 percent. We analyzed the 
effects of these changes on physicians by specialty. The changes are 
quite small and follow the expected pattern. We estimate that overall, 
physicians in family practice and general practice will experience 
modest increases of about 0.3 percent in payments, while most medical 
and surgical specialties will experience negligible decreases of about 
-0.1 to -0.2 percent. This pattern results from the tendency of 
specialists to be disproportionately concentrated in urban areas, which 
are estimated to experience a slight decrease in payments under our 
policy change.
    The impact on beneficiaries is likewise minor. We examined the 
impact by beneficiary age, gender, race, and income level. Roughly 20 
percent of beneficiaries reside in areas in which payments decrease by 
less than 5 percent, roughly 50 percent live in areas that experience 
no change in payments, roughly 25 percent live in areas where payments 
will increase by less than 5 percent, and about 2 percent live in areas 
where payments will rise by 5 to 10 percent.
    The distribution of beneficiaries by age and gender and of 
Caucasian beneficiaries are nearly identical to this overall 
distribution. Minority beneficiaries are more heavily concentrated in 
areas that experience no change in payments; a lower proportion of 
minority beneficiaries live both in areas experiencing a loss and areas 
experiencing a gain than do Caucasian beneficiaries. For example, 14.4 
percent of minority beneficiaries live in an area experiencing a loss 
compared to 21 percent of all beneficiaries who live in these areas. 
Beneficiaries living below the poverty level are less likely than all 
beneficiaries to be living in an area experiencing a payment decrease 
under our policy change, 16 percent compared to 21 percent. It does not 
appear that vulnerable Medicare groups--minorities, the very old, or 
the poor--will suffer decreases in access resulting from our policy 
change.

 D. Special Rules for the Payment of Diagnostic Tests, Including 
Diagnostic Radiologic Procedures

     One policy change will require that, to be covered under Medicare, 
diagnostic tests, including diagnostic radiologic procedures, must be 
ordered by the physician who treats a beneficiary or furnishes a 
consultation to the physician who treats the beneficiary. Under 
Sec. 410.22(b)(2) (``Limitations on services of a chiropractor''), no 
payment can be made to a chiropractor who orders diagnostic tests. 
However, we are allowing an exception for x-rays that demonstrate 
subluxation of the spine that are ordered for a chiropractor. We are 
allowing

[[Page 59552]]

payment for these x-rays when ordered by a physician who will not be 
treating the patient for subluxation of the spine. Nonphysician 
practitioners functioning within the scope of their State licensure and 
Medicare benefit will be considered a physician treating the 
beneficiary for the purpose of the regulation. The regulation 
(Sec. 410.31 ``Diagnostic x-ray tests, diagnostic laboratory tests, and 
other diagnostic tests: Conditions'') codifies our current manual 
instruction. Implementing this policy by regulation may result in some 
program savings due to the denial of payment for tests that may not be 
medically necessary because they were ordered by a physician who was 
not treating the beneficiary. However, we do not have sufficient data 
to furnish any reliable estimates of savings.

E. Transportation in Connection With Furnishing Diagnostic Tests

     We are eliminating separate payment for the transportation of EKG 
equipment (HCPCS code R0076) by all suppliers. In 1995, we allowed 
236,051 services and paid $10,700,974. Therefore, were it not for our 
budget-neutrality adjustment, we estimate that this policy change would 
result in approximately a $9.2 million reduction in Medicare payments.

F. Bundled Services

1. Hot or Cold Packs
     We are changing the status indicator for CPT code 97010 
(Application of a modality to one or more areas; hot or cold packs) to 
``B'' to indicate that the service is covered under Medicare but 
payment for it is bundled into payment for other services. Separate 
payment for CPT code 97010 will not be permitted under this policy 
change. The annual expenditures for CPT code 97010 under our current 
policy are approximately $41.2 million. Because the RVUs for this 
procedure will be redistributed across all physician fee schedule 
services in a budget neutral manner, there will be no measurable impact 
from this proposal.
2. Dermatology Procedures
a. Bundling of Repair Codes Into Excision Codes
     As a result of our review of the comments related to our proposal 
to bundle the dermatology repair codes into the excision codes, we have 
decided not to implement this proposal. We have clarified the 
definitions of simple and intermediate skin repair codes to reflect the 
differences in physician work for these procedures. These 
clarifications will reduce the potential for misuse of the intermediate 
repair codes but will have no significant impact on Medicare 
expenditures.
b. Skin Lesion Destruction Codes
     We are changing the way Medicare pays for the destruction of 
benign or premalignant skin lesions. Currently there are several CPT 
codes that describe a variety of ways of reporting the destruction of 
skin lesions. We are assigning a ``G'' status code to CPT codes 17000 
through 17105 and create three HCPCS codes to report the destruction of 
skin lesions. Because we will use a weighted average of the final RVUs 
that emerged from the 5-year review process that are assigned to the 
CPT codes for the destruction of benign or premalignant skin lesions in 
valuing the three new codes, this policy change will have no 
significant impact on Medicare expenditures.

G. Change of Coverage Status for Screening and Obsolete Procedures

1. Vital Capacity Testing
     We are changing the status for vital capacity tests (CPT code 
94150) from ``active'' to ``bundled.'' To the extent that these tests 
are still being performed in medical practice today, we understand that 
they are often performed as a part of a comprehensive evaluation. 
Therefore, we are bundling Medicare payment for these tests into 
Medicare payment for evaluation and management services. We do not 
believe that the change in status will have a significant impact on 
Medicare expenditures.
2. Certain Cardiovascular Procedures
     We are discontinuing coverage for certain cardiovascular 
procedures (CPT codes 93201, 93202, 93204, 93205, 93208, 93209, 93210, 
93220, 93221, and 93222). These codes have been deleted from the CPT 
because they are considered to be obsolete. Because there has been a 
decline in the billing of these services in recent years and in 1994, 
we only allowed a total of 17,925 services with $690,326 in allowed 
charges for all 10 diagnostic tests. We do not believe that the change 
in coverage status will have a significant impact on Medicare 
expenditures.

H. Payments for Supervising Physicians in Teaching Settings

     This final rule is making a technical change to Sec. 415.152 
(``Definitions'') to make the definition of an approved graduate 
medical education program consistent with the definition in 
Sec. 413.86(b) (``Direct graduate medical education payments''). 
Because this is only a technical change to standardize almost identical 
definitions, it will have no budgetary impact on Medicare expenditures.
     We are making a technical change to remove the word ``gender'' 
from Sec. 415.174(a)(4)(iii) (``Exception: Evaluation and management 
services furnished in certain centers''). We did not include the 
reference to gender with the intention of excluding obstetric and 
gynecological or other women's care residency programs solely because 
of patient gender. This technical change will make clear that the 
exception criteria will not be applied in such a manner. There will be 
no budgetary effect.

I. Change in Global Period for Four Percutaneous Biliary Procedures

     We are maintaining the current global period of 90 days and the 
current RVUs for these four percutaneous biliary procedures. There will 
be no budgetary effect.

J. Impact of Payment Policy Changes, Including Establishment of Interim 
and Final RVUs for CPT Coding Changes

     We have estimated the net increase in program costs in CY 1997 
resulting from all payment policy changes, prior to application of an 
adjustment factor in order to comply with the budget neutrality 
requirement, to be approximately $250 million. This is a net figure in 
that savings from the reductions for some changes partially offset the 
costs associated with others. This figure requires a reduction of 0.6 
percent in the CFs for all services to comply with the statutory 
limitation on increases in expenditures. Although a $20 million 
tolerance is permitted under the law, this 0.6 percent reduction to all 
CFs is designed to approximate budget neutrality as closely as 
possible, without creating any increase or decrease in expenditures as 
a result of the changes.

K. Effect of Changes Resulting From the Five-Year Review of Work 
Relative Value Units

    Because the new work RVUs resulting from the 5-year review of work 
relative values cause an increase in total estimated payments under the 
physician fee schedule, we must reduce payments in order to maintain 
budget neutrality as required by section 1848(c)(2)(B)(ii)(II) of the 
Act. As is discussed in section

[[Page 59553]]

IV.C.1. of this final rule, we are making a budget neutrality 
adjustment for changes in fees resulting from the 5-year review through 
a separate adjuster to the work RVUs. We plan on eliminating this 
adjuster in 1998 when we implement the resource-based practice expense 
RVUs.
    The separate budget neutrality work adjuster required by changes in 
fees resulting from the 5-year refinement is 8.3 percent. The impact of 
this adjustment on the fees for any individual service will vary 
depending on what percentage the work RVUs represent of the total RVUs 
for the service. The smaller the percentage represented by work, the 
smaller the fee impact. As an extreme example, the payment for CPT code 
96408 (Chemotherapy administration, intravenous; push technique) will 
be unaffected by this adjuster because the service has no work RVUs, 
only practice and malpractice expense RVUs. At the other extreme, the 
average payment for CPT 36500 (Venous catheterization for selective 
organ blood sampling) will decrease by 8.1 percent since the work RVUs 
currently represent almost 98 percent of the total RVUs. On average, 
the fee schedule work RVUs represent approximately 55 percent of the 
total RVUs. A service with work RVUs representing 55 percent of its 
total RVUs will see a 4.6 percent decrease in fees because of the 
separate 8.3 percent budget neutrality adjustment on work.
    We anticipate that the reduction of net Medicare revenues for some 
physician practices due to the changes contained in this regulation 
will result in a volume and intensity response that will cause overall 
physician expenditures to increase by 0.9 percent, requiring an 
offsetting 0.9 percent reduction in the CFs to maintain budget 
neutrality. Although we always take into account anticipated volume and 
intensity responses in our impact analyses, in some prior years the 
magnitude of the CF updates has been sufficient to offset any loss in 
Medicare revenues resulting from fee schedule changes.
    As in previous years, we increased the Medicare Volume Performance 
Standard (MVPS) targets for physician spending by the anticipated 0.9 
volume and intensity response. Because we increased the targets, if the 
anticipated volume and intensity response does not occur, the MVPS 
system will return the 0.9 percent reduction to the CFs in the form of 
higher future updates.

L. Net Impact of Changes on Medicare Specialties

1. Impact Estimation Methodology
    Physician fee schedule impacts were estimated by comparing 
predicted physician payments under a continuation of the current RVUs 
and policies to the estimated payments under the new RVUs and policies 
described above.
2. Overall Fee Schedule Impact
    As described above, we are making the budget neutrality adjustment 
required for changes in fees resulting from the 5-year review through a 
separate adjuster to the work RVUs. The budget neutrality adjustment 
for all other changes is being applied to the CFs. In the discussion 
below of differential impacts by specialty, we have incorporated the 
separate 8.3 percent downward adjustment on the work RVUs and the 1.5 
percent downward adjustment on the CFs.
3. Specialty Level Effect (Includes Table 4--Five-Year Review Impact on 
Medicare Payments by Specialty)
    Table 4, ``Five-Year Review Impact on Medicare Payments by 
Specialty,'' shows the estimated percentage change in Medicare 
physician fees from the current RVUs and policies to the new RVUs and 
policies by specialty. The specialties are ranked according to the 
impact of the changes to Medicare fees. The impact of the changes 
contained in this regulation on the total revenue (Medicare and non-
Medicare) for a given specialty is less than impact displayed in Table 
4 since physicians provide services to Medicare and non-Medicare 
patients.
    The magnitude of the Medicare impact depends on the mix of services 
the specialty provides. In general, because of the changes to the 
evaluation and management services, those specialties that account for 
more visits and fewer procedures are expected to experience larger 
increases in Medicare payments than procedurally oriented specialties, 
including surgical specialties.
    Because the budget neutrality adjustment reduces fees for services 
with work RVUs that did not experience any change as a result of the 5-
year review, specialties that primarily perform these services will 
experience a negative impact. For example, although the work RVUs for 
the majority of procedures performed by radiologists remained unchanged 
(with the exception of the increase in work RVUs for mammography), fees 
for services provided by radiologists will, on average, experience a 
4.4 percent decrease due to the budget neutrality adjustments.

           Table 4.--Impact on Medicare Payments by Specialty           
------------------------------------------------------------------------
                                                              Impact of 
                         Specialty                             changes  
                                                              (percent) 
------------------------------------------------------------------------
Chiropractor...............................................         15.5
Anesthesiology.............................................          5.2
Psychiatry.................................................          3.6
Family Practice............................................          2.5
Internal Medicine..........................................          2.1
Hematology Oncology........................................          1.9
Emergency Medicine.........................................          1.7
Pulmonary..................................................          1.6
General Practice...........................................          1.4
Rheumatology...............................................          1.2
All Other Physician........................................          0.8
Neurology..................................................          0.6
Obstetrics/Gynecology......................................          0.3
Clinics....................................................         -0.1
Cardiology.................................................         -0.5
Otolaryngology.............................................         -0.8
Nonphysician Practitioner..................................         -0.9
Vascular Surgery...........................................         -1.0
Gastroenterology...........................................         -1.6
Neurosurgery...............................................         -1.7
General Surgery............................................         -2.5
Oral Surgery...............................................         -3.0
Suppliers..................................................         -3.1
Plastic Surgery............................................         -3.2
Urology....................................................         -3.2
Orthopedic Surgery.........................................         -3.4
Nephrology.................................................         -3.4
Thoracic Surgery...........................................         -3.5
Cardiac Surgery............................................         -4.0
Podiatry...................................................         -4.3
Dermatology................................................         -4.3
Radiology..................................................         -4.4
Radiation Oncology.........................................         -4.8
Optometrist................................................         -5.1
Ophthalmology..............................................         -5.5
Pathology..................................................         -5.7
                                                            ------------
       Total...............................................         -0.9
------------------------------------------------------------------------

M. 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 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

[[Page 59554]]

payments made to physicians and certain other practitioners under Part 
B of the Medicare program and will make no change in 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.
    In accordance with the provisions of Executive Order 12866, this 
final rule was reviewed by the Office of Management and Budget.

List of Subjects

42 CFR Part 410

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

42 CFR Part 415

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

    42 CFR chapter IV is amended as set forth below:

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS

    A. 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), unless otherwise indicated.

    2. In Sec. 410.32 paragraphs (a) and (b) are redesignated as 
paragraphs (d) and (e), respectively, and new paragraphs (a), (b), and 
(c) are added to read as follows:


Sec. 410.32  Diagnostic x-ray tests, diagnostic laboratory tests, and 
other diagnostic tests: Conditions.

    (a) Ordering diagnostic tests. All diagnostic x-ray tests, 
diagnostic laboratory tests, and other diagnostic tests must be ordered 
by the physician who treats the beneficiary, that is, the physician who 
is actively furnishing a consultation or treating a beneficiary for a 
specific medical problem and who uses the results in the management of 
the beneficiary's specific medical problem.
    (b) Exception. A physician may order an x-ray to be used by a 
chiropractor to demonstrate the subluxation of the spine that is the 
basis for a beneficiary to receive manual manipulation treatments even 
though the physician does not treat the beneficiary.
    (c) Application to non-physician practitioners. Non-physician 
practitioners (that is, clinical nurse specialists, clinical 
psychologists, clinical social workers, nurse-midwives, nurse 
practitioners, and physician assistants) who provide services that 
would be physician services if furnished by a physician, and who are 
operating within the scope of their authority under State law and 
within the scope of their Medicare statutory benefit, may be treated 
the same as physicians treating beneficiaries for the purpose of this 
section.
* * * * *

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

    B. Part 415 is amended as set forth below:
    1. The authority citation for part 415 continues to read as 
follows:

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

    2. In Sec. 415.152 the introductory text is republished, and the 
definition of ``approved graduate medical education (GME) program'' is 
revised to read as follows:


Sec. 415.152  Definitions.

    As used in this subpart--
    Approved graduate medical education (GME) program means one of the 
following:
    (1) 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.
    (2) A program otherwise recognized as an ``approved medical 
residency program'' under Sec. 413.86(b) of this chapter.
* * * * *


Sec. 415.174  [Amended]

    3. In Sec. 415.174, in paragraph (a)(4)(iii), the phrase ``system, 
diagnosis, or gender'' is removed, and the phrase ``system or 
diagnosis'' is added in its place.

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

    Dated: November 7, 1996.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.

    Dated: November 12, 1996.
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 1997. 
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 
1997 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 $40.9603. For primary care services, use a CF of $35.7671. For other 
nonsurgical services, use a CF of $33.8454. The work adjuster for 1997 
is 0.917.

Addendum B--1997 Relative Value Units and Related Information Used in 
Determining Medicare Payments for 1997

    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.

[[Page 59555]]

    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.
    Modifier -53 is shown for a discontinued procedure. There will be 
RVUs for the code (CPT code 45378) with this modifier.
    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.
    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.
    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 1997. 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 1997.
    7. Malpractice expense RVUs. These are the RVUs for the malpractice 
expense for the service for 1997.
    8. Total RVUs. This is the sum of the work, practice expense, and 
malpractice expense RVUs for 1997.
    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 1997 
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 1997 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.

[[Page 59556]]



                                            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        RVUs                  period                     
---\2\--------------------------------------------------------------------------------------------------------------------------------------------------
10040...  ...................  A                    Acne surgery of skin          1.15       0.32        0.03        1.50        010  S                 
                                                     abscess.                                                                                           
10060...  ...................  A                    Drainage of skin              1.12       0.44        0.04        1.60        010  S                 
                                                     abscess.                                                                                           
10061...  ...................  A                    Drainage of skin              2.24       0.64        0.06        2.94        010  S                 
                                                     abscess.                                                                                           
10080...  ...................  A                    Drainage of pilonidal         1.12       0.50        0.05        1.67        010  N                 
                                                     cyst.                                                                                              
10081...  ...................  A                    Drainage of pilonidal         2.40       1.11        0.16        3.67        010  S                 
                                                     cyst.                                                                                              
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/         1.48       0.48        0.05        2.01        010  S                 
                                                     fluid.                                                                                             
10160...  ...................  A                    Puncture drainage of          1.15       0.38        0.05        1.58        010  S                 
                                                     lesion.                                                                                            
10180...  ...................  A                    Complex drainage, wound       2.20       1.05        0.18        3.43        010  S                 
11000...  ...................  A                    Debride infected skin..       0.60       0.40        0.04        1.04        000  S                 
11001...  ...................  A                    Debride infect skin add       0.30       0.26        0.02        0.58        ZZZ  S                 
11010...  ...................  A                    Debride skin, fx.......       4.15       3.96        0.65        8.76        010  S                 
11011...  ...................  A                    Debride skin/muscle, fx       4.95       4.72        0.77       10.44        000  S                 
11012...  ...................  A                    Debride skin/muscle/          6.88       6.56        1.07       14.51        000  S                 
                                                     bone, fx.                                                                                          
11040...  ...................  A                    Debride skin partial...       0.50       0.40        0.04        0.94        000  S                 
11041...  ...................  A                    Debride skin full......       0.82       0.56        0.06        1.44        000  S                 
11042...  ...................  A                    Debride skin/tissue....       1.12       0.65        0.08        1.85        000  S                 
11043...  ...................  A                    Debride tissue/muscle..       1.83       1.81        0.34        3.98        010  S                 
11044...  ...................  A                    Debride tissue/muscle/        2.28       2.82        0.49        5.59        010  S                 
                                                     bone.                                                                                              
11050...  ...................  A                    Trim skin lesion.......       0.43       0.37        0.03        0.83        000  S                 
11051...  ...................  A                    Trim 2 to 4 skin              0.66       0.50        0.05        1.21        000  S                 
                                                     lesions.                                                                                           
11052...  ...................  A                    Trim over 4 skin              0.86       0.41        0.04        1.31        000  S                 
                                                     lesions.                                                                                           
11100...  ...................  A                    Biopsy of skin lesion..       0.81       0.51        0.04        1.36        000  S                 
11101...  ...................  A                    Biopsy, each added            0.41       0.29        0.02        0.72        ZZZ  S                 
                                                     lesion.                                                                                            
11200...  ...................  A                    Removal of skin tags...       0.69       0.43        0.04        1.16        010  S                 
11201...  ...................  A                    Removal of added skin         0.26       0.17        0.02        0.45        ZZZ  S                 
                                                     tags.                                                                                              
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                 
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          2.58       2.68        0.44        5.70        090  S                 
                                                     lesion.                                                                                            
11451...  ...................  A                    Removal, sweat gland          3.80       2.90        0.46        7.16        090  S                 
                                                     lesion.                                                                                            
11462...  ...................  A                    Removal, sweat gland          2.36       2.41        0.36        5.13        090  S                 
                                                     lesion.                                                                                            
11463...  ...................  A                    Removal, sweat gland          3.80       2.00        0.34        6.14        090  S                 
                                                     lesion.                                                                                            
11470...  ...................  A                    Removal, sweat gland          3.10       2.78        0.45        6.33        090  S                 
                                                     lesion.                                                                                            
11471...  ...................  A                    Removal, sweat gland          4.26       2.46        0.48        7.20        090  S                 
                                                     lesion.                                                                                            
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                 

[[Page 59557]]

                                                                                                                                                        
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...  ...................  D                    Scraping of 1-5 nails..       0.00       0.00        0.00        0.00        000  S                 
11701...  ...................  D                    Scraping of additional        0.00       0.00        0.00        0.00        ZZZ  S                 
                                                     nails.                                                                                             
11710...  ...................  D                    Scraping of 1-5 nails..       0.00       0.00        0.00        0.00        000  S                 
11711...  ...................  D                    Scraping of additional        0.00       0.00        0.00        0.00        ZZZ  S                 
                                                     nails.                                                                                             
11720...  ...................  A                    Debride nail, 1-5......       0.32       0.32        0.03        0.67        000  S                 
11721...  ...................  A                    Debride nail, 6 or more       0.54       0.54        0.05        1.13        000  S                 
11730...  ...................  A                    Removal of nail plate..       1.13       0.45        0.04        1.62        000  S                 
11731...  ...................  A                    Removal of second nail        0.57       0.51        0.05        1.13        ZZZ  S                 
                                                     plate.                                                                                             
11732...  ...................  A                    Remove additional nail        0.57       0.25        0.02        0.84        ZZZ  S                 
                                                     plate.                                                                                             
11740...  ...................  A                    Drain blood from under        0.37       0.39        0.04        0.80        000  S                 
                                                     nail.                                                                                              
11750...  ...................  A                    Removal of nail bed....       1.66       2.10        0.19        3.95        010  S                 
11752...  ...................  A                    Remove nail bed/finger        2.37       2.82        0.36        5.55        010  S                 
                                                     tip.                                                                                               
11755...  ...................  A                    Biopsy, nail unit......       1.31       0.99        0.12        2.42        000  S                 
11760...  ...................  A                    Reconstruction of nail        1.53       0.93        0.09        2.55        010  S                 
                                                     bed.                                                                                               
11762...  ...................  A                    Reconstruction of nail        2.84       2.57        0.24        5.65        010  S                 
                                                     bed.                                                                                               
11765...  ...................  A                    Excision of nail fold,        0.64       0.51        0.05        1.20        010  S                 
                                                     toe.                                                                                               
11770...  ...................  A                    Removal of pilonidal          2.56       2.67        0.44        5.67        010  S                 
                                                     lesion.                                                                                            
11771...  ...................  A                    Removal of pilonidal          5.15       4.52        0.92       10.59        090  S                 
                                                     lesion.                                                                                            
11772...  ...................  A                    Removal of pilonidal          6.36       4.82        1.01       12.19        090  S                 
                                                     lesion.                                                                                            
11900...  ...................  A                    Injection into skin           0.52       0.25        0.02        0.79        000  S                 
                                                     lesions.                                                                                           
11901...  ...................  A                    Added skin lesions            0.80       0.41        0.03        1.24        000  S                 
                                                     injection.                                                                                         
11920...  ...................  R                    Correct skin color            1.61       1.18        0.23        3.02        000  S                 
                                                     defects.                                                                                           
11921...  ...................  R                    Correct skin color            1.93       1.40        0.28        3.61        000  S                 
                                                     defects.                                                                                           
11922...  ...................  R                    Correct skin color            0.49       0.36        0.07        0.92        ZZZ  S                 
                                                     defects.                                                                                           
11950...  ...................  R                    Therapy for contour           0.84       1.19        0.11        2.14        000  S                 
                                                     defects.                                                                                           
11951...  ...................  R                    Therapy for contour           1.19       1.19        0.11        2.49        000  S                 
                                                     defects.                                                                                           
11952...  ...................  R                    Therapy for contour           1.69       1.19        0.11        2.99        000  S                 
                                                     defects.                                                                                           
11954...  ...................  R                    Therapy for contour           1.85       1.19        0.11        3.15        000  S                 
                                                     defects.                                                                                           
11960...  ...................  A                    Insert tissue                 8.00       7.73        1.48       17.21        090  S                 
                                                     expander(s).                                                                                       
11970...  ...................  A                    Replace tissue expander       6.65       8.51        1.61       16.77        090  S                 
11971...  ...................  A                    Remove tissue                 1.51       2.30        0.82        4.63        090  S                 
                                                     expander(s).                                                                                       
11975...  ...................  N                    Insert contraceptive         +1.48       1.06        0.25        2.79        XXX  0                 
                                                     cap.                                                                                               
11976...  ...................  R                    Removal of                    1.78       1.28        0.30        3.36        XXX  N                 
                                                     contraceptive cap.                                                                                 
11977...  ...................  N                    Removal/reinsert contra      +3.30       2.36        0.55        6.21        XXX  0                 
                                                     cap.                                                                                               
12001...  ...................  A                    Repair superficial            1.65       0.57        0.05        2.27        010  N                 
                                                     wound(s).                                                                                          
12002...  ...................  A                    Repair superficial            1.81       0.79        0.07        2.67        010  N                 
                                                     wound(s).                                                                                          
12004...  ...................  A                    Repair superficial            2.19       1.14        0.10        3.43        010  N                 
                                                     wound(s).                                                                                          
12005...  ...................  A                    Repair superficial            2.81       1.47        0.14        4.42        010  N                 
                                                     wound(s).                                                                                          
12006...  ...................  A                    Repair superficial            3.62       1.78        0.19        5.59        010  N                 
                                                     wound(s).                                                                                          
12007...  ...................  A                    Repair superficial            4.07       1.80        0.19        6.06        010  S                 
                                                     wound(s).                                                                                          
12011...  ...................  A                    Repair superficial            1.71       0.74        0.06        2.51        010  N                 
                                                     wound(s).                                                                                          
12013...  ...................  A                    Repair superficial            1.94       1.03        0.08        3.05        010  N                 
                                                     wound(s).                                                                                          
12014...  ...................  A                    Repair superficial            2.41       1.19        0.10        3.70        010  N                 
                                                     wound(s).                                                                                          
12015...  ...................  A                    Repair superficial            3.14       1.62        0.14        4.90        010  N                 
                                                     wound(s).                                                                                          
12016...  ...................  A                    Repair superficial            3.88       2.26        0.19        6.33        010  N                 
                                                     wound(s).                                                                                          
12017...  ...................  A                    Repair superficial            4.66       3.36        0.31        8.33        010  N                 
                                                     wound(s).                                                                                          
12018...  ...................  A                    Repair superficial            5.48       5.15        0.48       11.11        010  S                 
                                                     wound(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              2.10       0.72        0.07        2.89        010  S                 
                                                     wound(s).                                                                                          
12032...  ...................  A                    Layer closure of              2.42       1.05        0.10        3.57        010  S                 
                                                     wound(s).                                                                                          
12034...  ...................  A                    Layer closure of              2.87       1.47        0.15        4.49        010  S                 
                                                     wound(s).                                                                                          
12035...  ...................  A                    Layer closure of              3.38       1.92        0.23        5.53        010  S                 
                                                     wound(s).                                                                                          

[[Page 59558]]

                                                                                                                                                        
12036...  ...................  A                    Layer closure of              4.00       2.32        0.37        6.69        010  S                 
                                                     wound(s).                                                                                          
12037...  ...................  A                    Layer closure of              4.62       3.09        0.48        8.19        010  S                 
                                                     wound(s).                                                                                          
12041...  ...................  A                    Layer closure of              2.32       0.84        0.08        3.24        010  N                 
                                                     wound(s).                                                                                          
12042...  ...................  A                    Layer closure of              2.69       1.17        0.12        3.98        010  N                 
                                                     wound(s).                                                                                          
12044...  ...................  A                    Layer closure of              3.09       1.62        0.17        4.88        010  N                 
                                                     wound(s).                                                                                          
12045...  ...................  A                    Layer closure of              3.59       2.13        0.23        5.95        010  N                 
                                                     wound(s).                                                                                          
12046...  ...................  A                    Layer closure of              4.20       2.82        0.37        7.39        010  S                 
                                                     wound(s).                                                                                          
12047...  ...................  A                    Layer closure of              4.60       4.02        0.56        9.18        010  N                 
                                                     wound(s).                                                                                          
12051...  ...................  A                    Layer closure of              2.42       1.01        0.10        3.53        010  S                 
                                                     wound(s).                                                                                          
12052...  ...................  A                    Layer closure of              2.72       1.47        0.14        4.33        010  S                 
                                                     wound(s).                                                                                          
12053...  ...................  A                    Layer closure of              3.07       1.76        0.17        5.00        010  S                 
                                                     wound(s).                                                                                          
12054...  ...................  A                    Layer closure of              3.41       2.60        0.25        6.26        010  S                 
                                                     wound(s).                                                                                          
12055...  ...................  A                    Layer closure of              4.38       3.24        0.37        7.99        010  S                 
                                                     wound(s).                                                                                          
12056...  ...................  A                    Layer closure of              5.19       4.74        0.52       10.45        010  S                 
                                                     wound(s).                                                                                          
12057...  ...................  A                    Layer closure of              5.91       5.57        0.48       11.96        010  S                 
                                                     wound(s).                                                                                          
13100...  ...................  A                    Repair of wound or            3.07       1.14        0.13        4.34        010  S                 
                                                     lesion.                                                                                            
13101...  ...................  A                    Repair of wound or            3.87       2.08        0.21        6.16        010  S                 
                                                     lesion.                                                                                            
13120...  ...................  A                    Repair of wound or            3.25       1.35        0.17        4.77        010  S                 
                                                     lesion.                                                                                            
13121...  ...................  A                    Repair of wound or            4.28       2.65        0.33        7.26        010  S                 
                                                     lesion.                                                                                            
13131...  ...................  A                    Repair of wound or            3.74       1.98        0.23        5.95        010  S                 
                                                     lesion.                                                                                            
13132...  ...................  A                    Repair of wound or            5.75       4.57        0.44       10.76        010  S                 
                                                     lesion.                                                                                            
13150...  ...................  A                    Repair of wound or            3.76       1.76        0.23        5.75        010  S                 
                                                     lesion.                                                                                            
13151...  ...................  A                    Repair of wound or            4.40       2.45        0.35        7.20        010  S                 
                                                     lesion.                                                                                            
13152...  ...................  A                    Repair of wound or            6.28       5.13        0.68       12.09        010  S                 
                                                     lesion.                                                                                            
13160...  ...................  A                    Late closure of wound..       9.53       3.33        0.58       13.44        090  S                 
13300...  ...................  A                    Repair of wound or            5.11       5.71        0.86       11.68        010  S                 
                                                     lesion.                                                                                            
14000...  ...................  A                    Skin tissue                   5.43       3.41        0.38        9.22        090  S                 
                                                     rearrangement.                                                                                     
14001...  ...................  A                    Skin tissue                   7.78       4.75        0.76       13.29        090  S                 
                                                     rearrangement.                                                                                     
14020...  ...................  A                    Skin tissue                   6.08       4.90        0.49       11.47        090  S                 
                                                     rearrangement.                                                                                     
14021...  ...................  A                    Skin tissue                   9.37       6.21        0.94       16.52        090  S                 
                                                     rearrangement.                                                                                     
14040...  ...................  A                    Skin tissue                   7.18       6.77        0.65       14.60        090  S                 
                                                     rearrangement.                                                                                     
14041...  ...................  A                    Skin tissue                  10.74       7.88        1.02       19.64        090  S                 
                                                     rearrangement.                                                                                     
14060...  ...................  A                    Skin tissue                   8.05       7.75        1.04       16.84        090  S                 
                                                     rearrangement.                                                                                     
14061...  ...................  A                    Skin tissue                  11.42      10.49        1.27       23.18        090  S                 
                                                     rearrangement.                                                                                     
14300...  ...................  A                    Skin tissue                  10.76      11.31        1.84       23.91        090  S                 
                                                     rearrangement.                                                                                     
14350...  ...................  A                    Skin tissue                   9.05       6.07        1.05       16.17        090  S                 
                                                     rearrangement.                                                                                     
15000...  ...................  A                    Skin graft procedure...       1.95       2.49        0.53        4.97        ZZZ  S                 
15050...  ...................  A                    Skin pinch graft              3.90       1.79        0.30        5.99        090  S                 
                                                     procedure.                                                                                         
15100...  ...................  A                    Skin split graft              8.05       4.54        0.89       13.48        090  S                 
                                                     procedure.                                                                                         
15101...  ...................  A                    Skin split graft              1.72       1.59        0.33        3.64        ZZZ  S                 
                                                     procedure.                                                                                         
15120...  ...................  A                    Skin split graft              9.14       6.05        0.94       16.13        090  S                 
                                                     procedure.                                                                                         
15121...  ...................  A                    Skin split graft              2.67       2.91        0.53        6.11        ZZZ  S                 
                                                     procedure.                                                                                         
15200...  ...................  A                    Skin full graft               7.46       4.13        0.69       12.28        090  S                 
                                                     procedure.                                                                                         
15201...  ...................  A                    Skin full graft               1.32       1.68        0.50        3.50        ZZZ  S                 
                                                     procedure.                                                                                         
15220...  ...................  A                    Skin full graft               7.42       4.84        0.85       13.11        090  S                 
                                                     procedure.                                                                                         
15221...  ...................  A                    Skin full graft               1.19       1.59        0.50        3.28        ZZZ  S                 
                                                     procedure.                                                                                         
15240...  ...................  A                    Skin full graft               8.30       6.10        1.03       15.43        090  S                 
                                                     procedure.                                                                                         
15241...  ...................  A                    Skin full graft               1.86       2.38        0.58        4.82        ZZZ  S                 
                                                     procedure.                                                                                         
15260...  ...................  A                    Skin full graft               9.56       7.46        0.99       18.01        090  S                 
                                                     procedure.                                                                                         
15261...  ...................  A                    Skin full graft               2.23       2.85        0.60        5.68        ZZZ  S                 
                                                     procedure.                                                                                         
15350...  ...................  A                    Skin homograft                3.89       2.15        0.42        6.46        090  S                 
                                                     procedure.                                                                                         
15400...  ...................  A                    Skin heterograft              4.91       1.06        0.17        6.14        090  S                 
                                                     procedure.                                                                                         
15570...  ...................  A                    Form skin pedicle flap.       8.39       5.50        2.08       15.97        090  S                 
15572...  ...................  A                    Form skin pedicle flap.       8.59       5.38        1.86       15.83        090  S                 
15574...  ...................  A                    Form skin pedicle flap.       8.97       5.40        1.66       16.03        090  S                 
15576...  ...................  A                    Form skin pedicle flap.       8.14       3.12        0.60       11.86        090  S                 
15580...  ...................  A                    Attach skin pedicle           8.84       4.31        1.30       14.45        090  S                 
                                                     graft.                                                                                             
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         3.61       4.62        0.93        9.16        090  S                 
                                                     flap.                                                                                              
15732...  ...................  A                    Muscle-skin graft, head/     16.52      15.48        3.46       35.46        090  S                 
                                                     neck.                                                                                              
15734...  ...................  A                    Muscle-skin graft,           16.52      19.01        3.24       38.77        090  S                 
                                                     trunk.                                                                                             
15736...  ...................  A                    Muscle-skin graft, arm.      15.26      16.21        3.02       34.49        090  S                 
15738...  ...................  A                    Muscle-skin graft, leg.      16.52      12.89        3.29       32.70        090  S                 

[[Page 59559]]

                                                                                                                                                        
15740...  ...................  A                    Island pedicle flap           9.45      10.39        1.62       21.46        090  S                 
                                                     graft.                                                                                             
15750...  ...................  A                    Neurovascular pedicle        10.61      11.96        2.03       24.60        090  S                 
                                                     graft.                                                                                             
15755...  ...................  D                    Microvascular flap            0.00       0.00        0.00        0.00        090  S                 
                                                     graft.                                                                                             
15756...  ...................  A                    Free muscle flap,            33.23      30.09        5.33       68.65        090  S                 
                                                     microvasc.                                                                                         
15757...  ...................  A                    Free skin flap,              33.23      30.09        5.33       68.65        090  S                 
                                                     microvasc.                                                                                         
15758...  ...................  A                    Free fascial flap,           33.23      30.09        5.33       68.65        090  S                 
                                                     microvasc.                                                                                         
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         3.96       2.88        0.56        7.40        000  S                 
                                                     grafts.                                                                                            
15776...  ...................  R                    Hair transplant punch         5.54       4.03        0.79       10.36        000  S                 
                                                     grafts.                                                                                            
15780...  ...................  A                    Abrasion treatment of         6.73       1.53        0.13        8.39        090  S                 
                                                     skin.                                                                                              
15781...  ...................  A                    Abrasion treatment of         4.67       3.77        0.39        8.83        090  S                 
                                                     skin.                                                                                              
15782...  ...................  A                    Abrasion treatment of         4.19       1.19        0.13        5.51        090  S                 
                                                     skin.                                                                                              
15783...  ...................  A                    Abrasion treatment of         4.16       1.85        0.19        6.20        090  S                 
                                                     skin.                                                                                              
15786...  ...................  A                    Abrasion treatment of         1.98       0.62        0.06        2.66        010  S                 
                                                     lesion.                                                                                            
15787...  ...................  A                    Abrasion, added skin          0.33       0.23        0.03        0.59        ZZZ  S                 
                                                     lesions.                                                                                           
15788...  ...................  R                    Chemical peel, face,          1.96       1.48        0.12        3.56        090  S                 
                                                     epiderm.                                                                                           
15789...  ...................  R                    Chemical peel, face,          4.69       1.48        0.12        6.29        090  S                 
                                                     dermal.                                                                                            
15792...  ...................  R                    Chemical peel,                1.73       0.50        0.05        2.28        090  S                 
                                                     nonfacial.                                                                                         
15793...  ...................  A                    Chemical peel,                3.51       0.50        0.05        4.06        090  S                 
                                                     nonfacial.                                                                                         
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             4.80       6.14        0.64       11.58        090  S                 
                                                     eyelid.                                                                                            
15821...  ...................  A                    Revision of lower             5.37       6.87        0.68       12.92        090  S                 
                                                     eyelid.                                                                                            
15822...  ...................  A                    Revision of upper             4.27       5.47        0.56       10.30        090  S                 
                                                     eyelid.                                                                                            
15823...  ...................  A                    Revision of upper             6.65       7.71        0.61       14.97        090  S                 
                                                     eyelid.                                                                                            
15824...  ...................  R                    Removal of forehead           0.00       0.00        0.00        0.00        XXX  S                 
                                                     wrinkles.                                                                                          
15825...  ...................  R                    Removal of neck               0.00       0.00        0.00        0.00        XXX  S                 
                                                     wrinkles.                                                                                          
15826...  ...................  R                    Removal of brow               0.00       0.00        0.00        0.00        XXX  S                 
                                                     wrinkles.                                                                                          
15828...  ...................  R                    Removal of face               0.00       0.00        0.00        0.00        XXX  S                 
                                                     wrinkles.                                                                                          
15829...  ...................  R                    Removal of skin               0.00       0.00        0.00        0.00        XXX  S                 
                                                     wrinkles.                                                                                          
15831...  ...................  A                    Excise excessive skin        11.66       9.84        2.01       23.51        090  S                 
                                                     tissue.                                                                                            
15832...  ...................  A                    Excise excessive skin        10.97       8.29        1.33       20.59        090  S                 
                                                     tissue.                                                                                            
15833...  ...................  A                    Excise excessive skin        10.02       6.22        1.12       17.36        090  S                 
                                                     tissue.                                                                                            
15834...  ...................  A                    Excise excessive skin        10.16       7.18        1.22       18.56        090  S                 
                                                     tissue.                                                                                            
15835...  ...................  A                    Excise excessive skin        10.98       7.00        1.22       19.20        090  S                 
                                                     tissue.                                                                                            
15836...  ...................  A                    Excise excessive skin         8.83       5.80        1.10       15.73        090  S                 
                                                     tissue.                                                                                            
15837...  ...................  A                    Excise excessive skin         8.08       5.97        0.85       14.90        090  S                 
                                                     tissue.                                                                                            
15838...  ...................  A                    Excise excessive skin         6.78       5.88        0.73       13.39        090  S                 
                                                     tissue.                                                                                            
15839...  ...................  A                    Excise excessive skin         8.92       2.44        0.46       11.82        090  S                 
                                                     tissue.                                                                                            
15840...  ...................  A                    Graft for face nerve         12.26      15.54        2.28       30.08        090  S                 
                                                     palsy.                                                                                             
15841...  ...................  A                    Graft for face nerve         21.53      16.87        2.76       41.16        090  S                 
                                                     palsy.                                                                                             
15842...  ...................  A                    Graft for face nerve         35.98      29.00        2.68       67.66        090  S                 
                                                     palsy.                                                                                             
15845...  ...................  A                    Skin and muscle repair,      11.80      15.10        2.54       29.44        090  S                 
                                                     face.                                                                                              
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          0.86       0.44        0.07        1.37        000  N                 
                                                     for burn.                                                                                          
15860...  ...................  A                    Test for blood flow in        1.95       1.35        0.25        3.55        000  S                 
                                                     graft.                                                                                             
15876...  ...................  R                    Suction assisted              0.00       0.00        0.00        0.00        XXX  S                 
                                                     lipectomy.                                                                                         
15877...  ...................  R                    Suction assisted              0.00       0.00        0.00        0.00        XXX  S                 
                                                     lipectomy.                                                                                         
15878...  ...................  R                    Suction assisted              0.00       0.00        0.00        0.00        XXX  S                 
                                                     lipectomy.                                                                                         
15879...  ...................  R                    Suction assisted              0.00       0.00        0.00        0.00        XXX  S                 
                                                     lipectomy.                                                                                         
15920...  ...................  A                    Removal of tail bone          7.37       2.95        0.63       10.95        090  S                 
                                                     ulcer.                                                                                             
15922...  ...................  A                    Removal of tail bone          9.17       5.98        1.19       16.34        090  S                 
                                                     ulcer.                                                                                             
15931...  ...................  A                    Remove sacrum pressure        8.13       2.93        0.55       11.61        090  S                 
                                                     sore.                                                                                              
15933...  ...................  A                    Remove sacrum pressure        9.64       6.92        1.43       17.99        090  S                 
                                                     sore.                                                                                              
15934...  ...................  A                    Remove sacrum pressure       11.40       7.46        1.50       20.36        090  S                 
                                                     sore.                                                                                              
15935...  ...................  A                    Remove sacrum pressure       13.05      11.24        2.27       26.56        090  S                 
                                                     sore.                                                                                              
15936...  ...................  A                    Remove sacrum pressure       11.31      10.27        2.05       23.63        090  S                 
                                                     sore.                                                                                              
15937...  ...................  A                    Remove sacrum pressure       12.98      13.47        2.67       29.12        090  S                 
                                                     sore.                                                                                              
15940...  ...................  A                    Removal of pressure           8.19       3.55        0.73       12.47        090  S                 
                                                     sore.                                                                                              
15941...  ...................  A                    Removal of pressure          10.15       7.05        1.39       18.59        090  S                 
                                                     sore.                                                                                              
15944...  ...................  A                    Removal of pressure          10.18       9.26        1.82       21.26        090  S                 
                                                     sore.                                                                                              
15945...  ...................  A                    Removal of pressure          11.32      11.14        2.09       24.55        090  S                 
                                                     sore.                                                                                              
15946...  ...................  A                    Removal of pressure          19.81      16.61        3.24       39.66        090  S                 
                                                     sore.                                                                                              
15950...  ...................  A                    Remove thigh pressure         6.79       3.01        0.58       10.38        090  S                 
                                                     sore.                                                                                              

[[Page 59560]]

                                                                                                                                                        
15951...  ...................  A                    Remove thigh pressure         9.57       7.65        1.58       18.80        090  S                 
                                                     sore.                                                                                              
15952...  ...................  A                    Remove thigh pressure        10.18       7.13        1.37       18.68        090  S                 
                                                     sore.                                                                                              
15953...  ...................  A                    Remove thigh pressure        11.39       9.08        1.87       22.34        090  S                 
                                                     sore.                                                                                              
15956...  ...................  A                    Remove thigh pressure        13.93      17.17        3.39       34.49        090  S                 
                                                     sore.                                                                                              
15958...  ...................  A                    Remove thigh pressure        13.89      17.77        3.76       35.42        090  S                 
                                                     sore.                                                                                              
15999...  ...................  C                    Removal of pressure           0.00       0.00        0.00        0.00        YYY  S                 
                                                     sore.                                                                                              
16000...  ...................  A                    Initial treatment of          0.89       0.35        0.03        1.27        000  N                 
                                                     burn(s).                                                                                           
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...  ...................  G                    Destroy benign/premal        +0.56       0.42        0.03        1.01        010  S                 
                                                     lesion.                                                                                            
17001...  ...................  G                    Destruction of add'l         +0.19       0.19        0.02        0.40        ZZZ  S                 
                                                     lesions.                                                                                           
17002...  ...................  G                    Destruction of add'l         +0.19       0.10        0.01        0.30        ZZZ  S                 
                                                     lesions.                                                                                           
17010...  ...................  G                    Destruction skin             +1.01       0.48        0.04        1.53        010  S                 
                                                     lesion(s).                                                                                         
17100...  ...................  G                    Destruction of skin          +0.53       0.37        0.03        0.93        010  S                 
                                                     lesion.                                                                                            
17101...  ...................  G                    Destruction of 2nd           +0.11       0.18        0.02        0.31        ZZZ  S                 
                                                     lesion.                                                                                            
17102...  ...................  G                    Destruction of add'l         +0.11       0.08        0.01        0.20        ZZZ  S                 
                                                     lesions.                                                                                           
17104...  ...................  G                    Destruction of skin          +2.01       0.07        0.01        2.09        010  S                 
                                                     lesions.                                                                                           
17105...  ...................  G                    Destruction of skin          +0.76       0.31        0.03        1.10        010  S                 
                                                     lesions.                                                                                           
17106...  ...................  A                    Destruction of skin           4.54       1.93        0.18        6.65        090  S                 
                                                     lesions.                                                                                           
17107...  ...................  A                    Destruction of skin           9.06       3.70        0.39       13.15        090  S                 
                                                     lesions.                                                                                           
17108...  ...................  A                    Destruction of skin          13.10       9.32        0.69       23.11        090  S                 
                                                     lesions.                                                                                           
17110...  ...................  A                    Destruction of skin           0.55       0.40        0.03        0.98        010  S                 
                                                     lesions.                                                                                           
17200...  ...................  A                    Electrocautery of skin        0.59       0.41        0.04        1.04        010  S                 
                                                     tags.                                                                                              
17201...  ...................  A                    Electrocautery added          0.38       0.15        0.01        0.54        ZZZ  S                 
                                                     lesions.                                                                                           
17250...  ...................  A                    Chemical cautery,             0.50       0.34        0.04        0.88        000  S                 
                                                     tissue.                                                                                            
17260...  ...................  A                    Destruction of skin           0.86       1.13        0.10        2.09        010  S                 
                                                     lesions.                                                                                           
17261...  ...................  A                    Destruction of skin           1.12       1.39        0.12        2.63        010  S                 
                                                     lesions.                                                                                           
17262...  ...................  A                    Destruction of skin           1.53       1.82        0.16        3.51        010  S                 
                                                     lesions.                                                                                           
17263...  ...................  A                    Destruction of skin           1.74       2.25        0.21        4.20        010  S                 
                                                     lesions.                                                                                           
17264...  ...................  A                    Destruction of skin           1.89       2.59        0.26        4.74        010  S                 
                                                     lesions.                                                                                           
17266...  ...................  A                    Destruction of skin           2.29       3.11        0.49        5.89        010  S                 
                                                     lesions.                                                                                           
17270...  ...................  A                    Destruction of skin           1.27       1.34        0.12        2.73        010  S                 
                                                     lesions.                                                                                           
17271...  ...................  A                    Destruction of skin           1.44       1.75        0.16        3.35        010  S                 
                                                     lesions.                                                                                           
17272...  ...................  A                    Destruction of skin           1.72       2.20        0.19        4.11        010  S                 
                                                     lesions.                                                                                           
17273...  ...................  A                    Destruction of skin           2.00       2.58        0.25        4.83        010  S                 
                                                     lesions.                                                                                           
17274...  ...................  A                    Destruction of skin           2.54       3.21        0.32        6.07        010  S                 
                                                     lesions.                                                                                           
17276...  ...................  A                    Destruction of skin           3.15       3.41        0.51        7.07        010  S                 
                                                     lesions.                                                                                           
17280...  ...................  A                    Destruction of skin           1.12       1.65        0.15        2.92        010  S                 
                                                     lesions.                                                                                           
17281...  ...................  A                    Destruction of skin           1.67       2.09        0.18        3.94        010  S                 
                                                     lesions.                                                                                           
17282...  ...................  A                    Destruction of skin           1.99       2.57        0.23        4.79        010  S                 
                                                     lesions.                                                                                           
17283...  ...................  A                    Destruction of skin           2.59       3.01        0.28        5.88        010  S                 
                                                     lesions.                                                                                           
17284...  ...................  A                    Destruction of skin           3.16       3.51        0.33        7.00        010  S                 
                                                     lesions.                                                                                           
17286...  ...................  A                    Destruction of skin           4.39       4.32        0.60        9.31        010  S                 
                                                     lesions.                                                                                           
17304...  ...................  A                    Chemosurgery of skin          7.60       4.02        0.31       11.93        000  S                 
                                                     lesion.                                                                                            
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          2.85       1.47        0.12        4.44        000  S                 
                                                     therapy.                                                                                           
17310...  ...................  A                    Extensive skin                0.95       0.13        0.01        1.09        000  S                 
                                                     chemosurgery.                                                                                      
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               0.00       0.00        0.00        0.00        XXX  S                 
                                                     electrolysis.                                                                                      
17999...  ...................  C                    Skin tissue procedure..       0.00       0.00        0.00        0.00        YYY  S                 
19000...  ...................  A                    Drainage of breast            0.84       0.38        0.07        1.29        000  S                 
                                                     lesion.                                                                                            
19001...  ...................  A                    Drain added breast            0.42       0.24        0.05        0.71        ZZZ  S                 
                                                     lesion.                                                                                            
19020...  ...................  A                    Incision of breast            3.37       1.40        0.28        5.05        090  S                 
                                                     lesion.                                                                                            
19030...  ...................  A                    Injection for breast x-       1.53       0.49        0.04        2.06        000  N                 
                                                     ray.                                                                                               
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            3.52       2.34        0.35        6.21        090  S                 
                                                     fistula.                                                                                           

[[Page 59561]]

                                                                                                                                                        
19120...  ...................  A                    Removal of breast             5.35       2.90        0.60        8.85        090  S                 
                                                     lesion.                                                                                            
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             4.85       4.29        0.91       10.05        090  S                 
                                                     tissue.                                                                                            
19160...  ...................  A                    Removal of breast             5.75       4.13        0.88       10.76        090  S                 
                                                     tissue.                                                                                            
19162...  ...................  A                    Remove breast tissue,        12.81       9.38        1.96       24.15        090  S                 
                                                     nodes.                                                                                             
19180...  ...................  A                    Removal of breast......       8.09       5.61        1.17       14.87        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        13.91       5.05        1.04       20.00        090  S                 
                                                     lesion.                                                                                            
19271...  ...................  A                    Revision of chest wall.      17.07      13.95        2.77       33.79        090  S                 
19272...  ...................  A                    Extensive chest wall         19.47      12.60        2.56       34.63        090  S                 
                                                     surgery.                                                                                           
19290...  ...................  A                    Place needle wire,            1.27       0.44        0.07        1.78        000  S                 
                                                     breast.                                                                                            
19291...  ...................  A                    Place needle wire,            0.63       0.25        0.04        0.92        ZZZ  S                 
                                                     breast.                                                                                            
19316...  ...................  A                    Suspension of breast...      10.07      12.84        2.43       25.34        090  S                 
19318...  ...................  A                    Reduction of large           15.00      14.18        3.23       32.41        090  S                 
                                                     breast.                                                                                            
19324...  ...................  A                    Enlarge breast.........       5.55       3.29        0.67        9.51        090  S                 
19325...  ...................  A                    Enlarge breast with           8.05       5.87        1.13       15.05        090  S                 
                                                     implant.                                                                                           
19328...  ...................  A                    Removal of breast             5.32       3.76        0.73        9.81        090  S                 
                                                     implant.                                                                                           
19330...  ...................  A                    Removal of implant            7.18       3.88        0.75       11.81        090  S                 
                                                     material.                                                                                          
19340...  ...................  A                    Immediate breast              6.33       8.10        2.06       16.49        ZZZ  S                 
                                                     prosthesis.                                                                                        
19342...  ...................  A                    Delayed breast               10.64      10.81        2.03       23.48        090  S                 
                                                     prosthesis.                                                                                        
19350...  ...................  A                    Breast reconstruction..       8.52       7.08        1.38       16.98        090  S                 
19355...  ...................  A                    Correct inverted              7.27       4.93        1.00       13.20        090  S                 
                                                     nipple(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                 
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             7.59       6.17        1.19       14.95        090  S                 
                                                     capsule.                                                                                           
19371...  ...................  A                    Removal of breast             8.84       7.91        1.54       18.29        090  S                 
                                                     capsule.                                                                                           
19380...  ...................  A                    Revise breast                 8.63       8.11        1.57       18.31        090  S                 
                                                     reconstruction.                                                                                    
19396...  ...................  A                    Design custom breast          2.17       1.57        0.31        4.05        000  S                 
                                                     implant.                                                                                           
19499...  ...................  C                    Breast surgery                0.00       0.00        0.00        0.00        YYY  S                 
                                                     procedure.                                                                                         
20000...  ...................  A                    Incision of abscess....       1.85       0.85        0.08        2.78        010  S                 
20005...  ...................  A                    Incision of deep              3.02       1.83        0.28        5.13        010  S                 
                                                     abscess.                                                                                           
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,                4.95       2.59        0.60        8.14        010  S                 
                                                     extremity.                                                                                         
20150...  ...................  A                    Excise epiphyseal bar..      13.00      12.40        2.03       27.43        090  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/          1.27       1.31        0.09        2.67        000  N                 
                                                     needle.                                                                                            
20225...  ...................  A                    Bone biopsy, trocar/          1.87       2.39        0.28        4.54        000  N                 
                                                     needle.                                                                                            
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            1.18       0.36        0.04        1.58        010  N                 
                                                     tract.                                                                                             
20501...  ...................  A                    Inject sinus tract for        0.76       0.30        0.02        1.08        000  N                 
                                                     x-ray.                                                                                             
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/          0.86       0.38        0.04        1.28        000  N                 
                                                     cyst.                                                                                              
20600...  ...................  A                    Drain/inject joint/           0.66       0.47        0.05        1.18        000  S                 
                                                     bursa.                                                                                             
20605...  ...................  A                    Drain/inject joint/           0.68       0.45        0.05        1.18        000  S                 
                                                     bursa.                                                                                             
20610...  ...................  A                    Drain/inject joint/           0.79       0.45        0.05        1.29        000  N                 
                                                     bursa.                                                                                             
20615...  ...................  A                    Treatment of bone cyst.       2.23       0.49        0.06        2.78        010  N                 
20650...  ...................  A                    Insert and remove bone        2.07       1.08        0.14        3.29        010  S                 
                                                     pin.                                                                                               
20660...  ...................  A                    Apply,remove fixation         2.51       1.56        0.21        4.28        000  S                 
                                                     device.                                                                                            
20661...  ...................  A                    Application of head           4.27       3.82        0.65        8.74        090  S                 
                                                     brace.                                                                                             
20662...  ...................  A                    Application of pelvis         5.52       6.54        1.03       13.09        090  S                 
                                                     brace.                                                                                             

[[Page 59562]]

                                                                                                                                                        
20663...  ...................  A                    Application of thigh          4.88       4.64        0.76       10.28        090  S                 
                                                     brace.                                                                                             
20665...  ...................  A                    Removal of fixation           1.26       0.50        0.07        1.83        010  S                 
                                                     device.                                                                                            
20670...  ...................  A                    Removal of support            1.69       0.74        0.11        2.54        010  S                 
                                                     implant.                                                                                           
20680...  ...................  A                    Removal of support            3.25       3.33        0.51        7.09        090  S                 
                                                     implant.                                                                                           
20690...  ...................  A                    Apply bone fixation           3.52       3.66        0.58        7.76        ZZZ  S                 
                                                     device.                                                                                            
20692...  ...................  A                    Apply bone fixation           6.41       5.51        0.89       12.81        ZZZ  S                 
                                                     device.                                                                                            
20693...  ...................  A                    Adjust bone fixation          5.42       2.49        0.42        8.33        090  S                 
                                                     device.                                                                                            
20694...  ...................  A                    Remove bone fixation          3.81       2.60        0.41        6.82        090  S                 
                                                     device.                                                                                            
20802...  ...................  A                    Replantation, arm,           39.56      37.72        6.17       83.45        090  S                 
                                                     complete.                                                                                          
20805...  ...................  A                    Replant forearm,             48.41      46.17        7.56      102.14        090  S                 
                                                     complete.                                                                                          
20808...  ...................  A                    Replantation, hand,          60.19      57.40        9.40      126.99        090  S                 
                                                     complete.                                                                                          
20816...  ...................  A                    Replantation digit,          29.67      28.30        4.63       62.60        090  S                 
                                                     complete.                                                                                          
20822...  ...................  A                    Replantation digit,          24.53      23.39        3.83       51.75        090  S                 
                                                     complete.                                                                                          
20824...  ...................  A                    Replantation thumb,          29.67      28.30        4.63       62.60        090  S                 
                                                     complete.                                                                                          
20827...  ...................  A                    Replantation thumb,          25.22      24.05        3.94       53.21        090  S                 
                                                     complete.                                                                                          
20838...  ...................  A                    Replantation, foot,          39.56      37.72        6.17       83.45        090  S                 
                                                     complete.                                                                                          
20900...  ...................  A                    Removal of bone for           5.03       2.80        0.45        8.28        090  S                 
                                                     graft.                                                                                             
20902...  ...................  A                    Removal of bone for           6.74       4.95        0.80       12.49        090  S                 
                                                     graft.                                                                                             
20910...  ...................  A                    Remove cartilage for          5.03       0.79        0.09        5.91        090  S                 
                                                     graft.                                                                                             
20912...  ...................  A                    Remove cartilage for          6.04       4.62        0.64       11.30        090  S                 
                                                     graft.                                                                                             
20920...  ...................  A                    Removal of fascia for         4.87       3.93        0.50        9.30        090  S                 
                                                     graft.                                                                                             
20922...  ...................  A                    Removal of fascia for         6.04       4.39        0.71       11.14        090  S                 
                                                     graft.                                                                                             
20924...  ...................  A                    Removal of tendon for         6.04       5.45        0.85       12.34        090  S                 
                                                     graft.                                                                                             
20926...  ...................  A                    Removal of tissue for         5.03       2.59        0.39        8.01        090  S                 
                                                     graft.                                                                                             
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                  1.26       1.09        0.17        2.52        000  S                 
                                                     pressure,muscle.                                                                                   
20955...  ...................  A                    Fibula bone graft,           37.58      35.84        5.87       79.29        090  S                 
                                                     microvasc.                                                                                         
20956...  ...................  A                    Iliac bone graft,            37.00      26.90        5.26       69.16        090  S                 
                                                     microvasc.                                                                                         
20957...  ...................  A                    Mt bone graft,               38.33      27.87        5.45       71.65        090  S                 
                                                     microvasc.                                                                                         
20960...  ...................  D                    Microvascular rib graft       0.00       0.00        0.00        0.00        090  S                 
20962...  ...................  A                    Other bone graft,            37.00      26.90        5.26       69.16        090  S                 
                                                     microvasc.                                                                                         
20969...  ...................  A                    Bone/skin graft,             42.08      40.13        6.57       88.78        090  S                 
                                                     microvasc.                                                                                         
20970...  ...................  A                    Bone/skin graft, iliac       41.22      39.31        6.44       86.97        090  S                 
                                                     crest.                                                                                             
20971...  ...................  D                    Bone-skin graft, rib...       0.00       0.00        0.00        0.00        090  S                 
20972...  ...................  A                    Bone-skin graft,             41.54      39.61        6.49       87.64        090  S                 
                                                     metatarsal.                                                                                        
20973...  ...................  A                    Bone-skin graft, great       44.31      42.25        6.91       93.47        090  S                 
                                                     toe.                                                                                               
20974...  ...................  A                    Electrical bone               0.62       3.42        0.53        4.57        ZZZ  S                 
                                                     stimulation.                                                                                       
20975...  ...................  A                    Electrical bone               2.60       3.33        0.56        6.49        ZZZ  S                 
                                                     stimulation.                                                                                       
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           4.94       6.32        1.13       12.39        090  S                 
                                                     tumor.                                                                                             
21025...  ...................  A                    Excision of bone, lower       8.98       4.14        0.38       13.50        090  S                 
                                                     jaw.                                                                                               
21026...  ...................  A                    Excision of facial            4.53       3.14        0.28        7.95        090  S                 
                                                     bone(s).                                                                                           
21029...  ...................  A                    Contour of face bone          7.21       9.23        0.78       17.22        090  S                 
                                                     lesion.                                                                                            
21030...  ...................  A                    Removal of face bone          6.04       3.35        0.29        9.68        090  S                 
                                                     lesion.                                                                                            
21031...  ...................  A                    Remove exostosis,             3.14       3.68        0.32        7.14        090  S                 
                                                     mandible.                                                                                          
21032...  ...................  A                    Remove exostosis,             3.14       3.88        0.35        7.37        090  S                 
                                                     maxilla.                                                                                           
21034...  ...................  A                    Removal of face bone         15.11       6.98        0.89       22.98        090  S                 
                                                     lesion.                                                                                            
21040...  ...................  A                    Removal of jaw bone           2.01       2.76        0.24        5.01        090  S                 
                                                     lesion.                                                                                            
21041...  ...................  A                    Removal of jaw bone           6.04       5.76        0.50       12.30        090  S                 
                                                     lesion.                                                                                            
21044...  ...................  A                    Removal of jaw bone          11.08       9.55        1.11       21.74        090  S                 
                                                     lesion.                                                                                            
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              9.56      11.59        1.04       22.19        090  S                 
                                                     cartilage.                                                                                         
21070...  ...................  A                    Remove coronoid process       7.66       6.81        0.82       15.29        090  S                 
21076...  ...................  A                    Prepare face/oral            12.54      16.77        1.35       30.66        010  S                 
                                                     prosthesis.                                                                                        
21077...  ...................  A                    Prepare face/oral            31.54      42.18        3.39       77.11        090  S                 
                                                     prosthesis.                                                                                        
21079...  ...................  A                    Prepare face/oral            20.88      27.93        2.25       51.06        090  S                 
                                                     prosthesis.                                                                                        
21080...  ...................  A                    Prepare face/oral            23.46      31.38        2.52       57.36        090  S                 
                                                     prosthesis.                                                                                        
21081...  ...................  A                    Prepare face/oral            21.38      28.59        2.30       52.27        090  S                 
                                                     prosthesis.                                                                                        
21082...  ...................  A                    Prepare face/oral            19.50      26.08        2.10       47.68        090  S                 
                                                     prosthesis.                                                                                        
21083...  ...................  A                    Prepare face/oral            18.04      24.13        1.94       44.11        090  S                 
                                                     prosthesis.                                                                                        
21084...  ...................  A                    Prepare face/oral            21.04      28.14        2.28       51.46        090  S                 
                                                     prosthesis.                                                                                        

[[Page 59563]]

                                                                                                                                                        
21085...  ...................  A                    Prepare face/oral             8.41      11.25        0.90       20.56        010  S                 
                                                     prosthesis.                                                                                        
21086...  ...................  A                    Prepare face/oral            23.29      31.15        2.51       56.95        090  S                 
                                                     prosthesis.                                                                                        
21087...  ...................  A                    Prepare face/oral            23.29      31.15        2.51       56.95        090  S                 
                                                     prosthesis.                                                                                        
21088...  ...................  C                    Prepare face/oral             0.00       0.00        0.00        0.00        090  S                 
                                                     prosthesis.                                                                                        
21089...  ...................  C                    Prepare face/oral             0.00       0.00        0.00        0.00        090  S                 
                                                     prosthesis.                                                                                        
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-       0.81       0.73        0.06        1.60        000  S                 
                                                     ray.                                                                                               
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       10.00       4.72        0.54       15.26        090  S                 
                                                     bone.                                                                                              
21127...  ...................  A                    Augmentation lower jaw       10.43       7.91        0.92       19.26        090  S                 
                                                     bone.                                                                                              
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,         16.92      14.34        1.68       32.94        090  S                 
                                                     lefort.                                                                                            
21142...  ...................  A                    Reconstruct midface,         17.58      14.84        1.74       34.16        090  S                 
                                                     lefort.                                                                                            
21143...  ...................  A                    Reconstruct midface,         18.30      15.40        1.81       35.51        090  S                 
                                                     lefort.                                                                                            
21145...  ...................  A                    Reconstruct midface,         18.92      14.34        1.68       34.94        090  S                 
                                                     lefort.                                                                                            
21146...  ...................  A                    Reconstruct midface,         19.58      14.84        1.74       36.16        090  S                 
                                                     lefort.                                                                                            
21147...  ...................  A                    Reconstruct midface,         20.30      15.40        1.81       37.51        090  S                 
                                                     lefort.                                                                                            
21150...  ...................  A                    Reconstruct midface,         24.41      18.46        2.17       45.04        090  S                 
                                                     lefort.                                                                                            
21151...  ...................  A                    Reconstruct midface,         27.34      20.68        2.42       50.44        090  S                 
                                                     lefort.                                                                                            
21154...  ...................  A                    Reconstruct midface,         29.28      22.15        2.59       54.02        090  S                 
                                                     lefort.                                                                                            
21155...  ...................  A                    Reconstruct midface,         33.19      25.11        2.94       61.24        090  S                 
                                                     lefort.                                                                                            
21159...  ...................  A                    Reconstruct midface,         40.99      31.02        3.63       75.64        090  S                 
                                                     lefort.                                                                                            
21160...  ...................  A                    Reconstruct midface,         44.90      33.96        3.98       82.84        090  S                 
                                                     lefort.                                                                                            
21172...  ...................  A                    Reconstruct orbit/           26.84      20.30        2.37       49.51        090  S                 
                                                     forehead.                                                                                          
21175...  ...................  A                    Reconstruct orbit/           32.21      24.37        2.85       59.43        090  S                 
                                                     forehead.                                                                                          
21179...  ...................  A                    Reconstruct entire           21.47      16.24        1.90       39.61        090  S                 
                                                     forehead.                                                                                          
21180...  ...................  A                    Reconstruct entire           24.41      18.46        2.17       45.04        090  S                 
                                                     forehead.                                                                                          
21181...  ...................  A                    Contour cranial bone          9.40       7.11        0.83       17.34        090  S                 
                                                     lesion.                                                                                            
21182...  ...................  A                    Reconstruct cranial          31.23      23.63        2.77       57.63        090  S                 
                                                     bone.                                                                                              
21183...  ...................  A                    Reconstruct cranial          34.17      25.85        3.03       63.05        090  S                 
                                                     bone.                                                                                              
21184...  ...................  A                    Reconstruct cranial          37.10      28.06        3.28       68.44        090  S                 
                                                     bone.                                                                                              
21188...  ...................  A                    Reconstruction of            21.47      16.24        1.90       39.61        090  S                 
                                                     midface.                                                                                           
21193...  ...................  A                    Reconstruct lower jaw        16.23      12.31        1.44       29.98        090  S                 
                                                     bone.                                                                                              
21194...  ...................  A                    Reconstruct lower jaw        18.81      14.26        1.67       34.74        090  S                 
                                                     bone.                                                                                              
21195...  ...................  A                    Reconstruct lower jaw        16.27      12.34        1.44       30.05        090  S                 
                                                     bone.                                                                                              
21196...  ...................  A                    Reconstruct lower jaw        17.94      13.61        1.58       33.13        090  S                 
                                                     bone.                                                                                              
21198...  ...................  A                    Reconstruct lower jaw        13.36      14.82        1.74       29.92        090  S                 
                                                     bone.                                                                                              
21206...  ...................  A                    Reconstruct upper jaw        13.36      10.14        1.19       24.69        090  S                 
                                                     bone.                                                                                              
21208...  ...................  A                    Augmentation of facial        9.56      11.26        1.07       21.89        090  S                 
                                                     bones.                                                                                             
21209...  ...................  A                    Reduction of facial           6.28       4.59        0.76       11.63        090  S                 
                                                     bones.                                                                                             
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        13.10      16.77        2.09       31.96        090  S                 
                                                     joint.                                                                                             
21242...  ...................  A                    Reconstruction of jaw        12.10      15.55        2.25       29.90        090  S                 
                                                     joint.                                                                                             
21243...  ...................  A                    Reconstruction of jaw        18.98      14.40        1.68       35.06        090  S                 
                                                     joint.                                                                                             
21244...  ...................  A                    Reconstruction of lower      11.08      14.18        1.93       27.19        090  S                 
                                                     jaw.                                                                                               
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        21.15      27.08        2.27       50.50        090  S                 
                                                     bone.                                                                                              
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        15.63      20.00        1.68       37.31        090  S                 
                                                     bone.                                                                                              
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       9.56       9.60        1.41       20.57        090  S                 

[[Page 59564]]

                                                                                                                                                        
21275...  ...................  A                    Revision orbitofacial        10.50       8.95        1.26       20.71        090  S                 
                                                     bones.                                                                                             
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/       1.43       0.96        0.13        2.52        090  S                 
                                                     bone.                                                                                              
21296...  ...................  A                    Revision of jaw muscle/       3.97       3.62        0.22        7.81        090  S                 
                                                     bone.                                                                                              
21299...  ...................  C                    Cranio/maxillofacial          0.00       0.00        0.00        0.00        YYY  S                 
                                                     surgery.                                                                                           
21300...  ...................  A                    Treatment of skull            0.72       0.92        0.11        1.75        000  S                 
                                                     fracture.                                                                                          
21310...  ...................  A                    Treatment of nose             0.58       0.75        0.09        1.42        000  N                 
                                                     fracture.                                                                                          
21315...  ...................  A                    Treatment of nose             1.41       1.81        0.21        3.43        010  S                 
                                                     fracture.                                                                                          
21320...  ...................  A                    Treatment of nose             1.82       2.33        0.34        4.49        010  S                 
                                                     fracture.                                                                                          
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           5.35       4.09        0.52        9.96        090  S                 
                                                     fracture.                                                                                          
21337...  ...................  A                    Repair nasal septal           2.52       2.82        0.38        5.72        090  S                 
                                                     fracture.                                                                                          
21338...  ...................  A                    Repair nasoethmoid            6.04       5.01        0.66       11.71        090  S                 
                                                     fracture.                                                                                          
21339...  ...................  A                    Repair nasoethmoid            7.56       7.09        0.70       15.35        090  S                 
                                                     fracture.                                                                                          
21340...  ...................  A                    Repair of nose fracture      10.07       8.91        1.04       20.02        090  S                 
21343...  ...................  A                    Repair of sinus              12.10       9.17        1.08       22.35        090  S                 
                                                     fracture.                                                                                          
21344...  ...................  A                    Repair of sinus              18.43       9.17        1.08       28.68        090  S                 
                                                     fracture.                                                                                          
21345...  ...................  A                    Repair of nose/jaw            7.63       7.90        0.81       16.34        090  S                 
                                                     fracture.                                                                                          
21346...  ...................  A                    Repair of nose/jaw            9.92       9.40        1.04       20.36        090  S                 
                                                     fracture.                                                                                          
21347...  ...................  A                    Repair of nose/jaw           11.86      10.36        1.36       23.58        090  S                 
                                                     fracture.                                                                                          
21348...  ...................  A                    Repair of nose/jaw           15.60      11.34        2.22       29.16        090  S                 
                                                     fracture.                                                                                          
21355...  ...................  A                    Repair cheek bone             3.52       1.56        0.17        5.25        010  S                 
                                                     fracture.                                                                                          
21356...  ...................  A                    Repair cheek bone             3.88       4.96        0.89        9.73        010  S                 
                                                     fracture.                                                                                          
21360...  ...................  A                    Repair cheek bone             6.04       7.28        0.89       14.21        090  S                 
                                                     fracture.                                                                                          
21365...  ...................  A                    Repair cheek bone            13.97      12.35        1.63       27.95        090  S                 
                                                     fracture.                                                                                          
21366...  ...................  A                    Repair cheek bone            16.61      12.08        2.36       31.05        090  S                 
                                                     fracture.                                                                                          
21385...  ...................  A                    Repair eye socket             8.56       9.59        1.13       19.28        090  S                 
                                                     fracture.                                                                                          
21386...  ...................  A                    Repair eye socket             8.56       9.07        1.25       18.88        090  S                 
                                                     fracture.                                                                                          
21387...  ...................  A                    Repair eye socket             9.07       7.45        0.96       17.48        090  S                 
                                                     fracture.                                                                                          
21390...  ...................  A                    Repair eye socket             9.47      11.89        1.37       22.73        090  S                 
                                                     fracture.                                                                                          
21395...  ...................  A                    Repair eye socket            11.85       9.63        1.37       22.85        090  S                 
                                                     fracture.                                                                                          
21400...  ...................  A                    Treat eye socket              1.31       1.67        0.17        3.15        090  N                 
                                                     fracture.                                                                                          
21401...  ...................  A                    Repair eye socket             3.05       2.58        0.32        5.95        090  S                 
                                                     fracture.                                                                                          
21406...  ...................  A                    Repair eye socket             6.55       5.21        0.74       12.50        090  S                 
                                                     fracture.                                                                                          
21407...  ...................  A                    Repair eye socket             8.05       7.09        0.78       15.92        090  S                 
                                                     fracture.                                                                                          
21408...  ...................  A                    Repair eye socket            11.57       8.49        0.99       21.05        090  S                 
                                                     fracture.                                                                                          
21421...  ...................  A                    Treat mouth roof              4.80       6.14        0.62       11.56        090  S                 
                                                     fracture.                                                                                          
21422...  ...................  A                    Repair mouth roof             7.78       9.80        1.19       18.77        090  S                 
                                                     fracture.                                                                                          
21423...  ...................  A                    Repair mouth roof             9.72       9.80        1.19       20.71        090  S                 
                                                     fracture.                                                                                          
21431...  ...................  A                    Treat craniofacial            6.59       6.02        0.71       13.32        090  S                 
                                                     fracture.                                                                                          
21432...  ...................  A                    Repair craniofacial           8.05       6.76        0.84       15.65        090  S                 
                                                     fracture.                                                                                          
21433...  ...................  A                    Repair craniofacial          23.69      17.96        2.10       43.75        090  S                 
                                                     fracture.                                                                                          
21435...  ...................  A                    Repair craniofacial          16.12      13.25        1.88       31.25        090  S                 
                                                     fracture.                                                                                          
21436...  ...................  A                    Repair craniofacial          26.21      14.65        2.08       42.94        090  S                 
                                                     fracture.                                                                                          
21440...  ...................  A                    Repair dental ridge           2.52       3.07        0.28        5.87        090  S                 
                                                     fracture.                                                                                          
21445...  ...................  A                    Repair dental ridge           5.03       6.11        0.56       11.70        090  S                 
                                                     fracture.                                                                                          
21450...  ...................  A                    Treat lower jaw               2.78       2.84        0.26        5.88        090  S                 
                                                     fracture.                                                                                          
21451...  ...................  A                    Treat lower jaw               4.55       5.83        0.74       11.12        090  S                 
                                                     fracture.                                                                                          
21452...  ...................  A                    Treat lower jaw               1.85       1.39        0.17        3.41        090  S                 
                                                     fracture.                                                                                          
21453...  ...................  A                    Treat lower jaw               5.18       6.64        0.55       12.37        090  S                 
                                                     fracture.                                                                                          
21454...  ...................  A                    Treat lower jaw               6.04       8.19        1.42       15.65        090  S                 
                                                     fracture.                                                                                          
21461...  ...................  A                    Repair lower jaw              7.56       9.67        1.30       18.53        090  S                 
                                                     fracture.                                                                                          
21462...  ...................  A                    Repair lower jaw              9.15      11.71        1.34       22.20        090  S                 
                                                     fracture.                                                                                          
21465...  ...................  A                    Repair lower jaw             11.13       8.44        0.99       20.56        090  S                 
                                                     fracture.                                                                                          
21470...  ...................  A                    Repair lower jaw             14.19      17.13        1.74       33.06        090  S                 
                                                     fracture.                                                                                          
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              1.19       1.52        0.13        2.84        090  S                 
                                                     fracture.                                                                                          
21494...  ...................  A                    Repair hyoid bone             5.87       7.52        0.63       14.02        090  S                 
                                                     fracture.                                                                                          
21495...  ...................  A                    Repair hyoid bone             5.32       4.82        0.51       10.65        090  S                 
                                                     fracture.                                                                                          
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                 

[[Page 59565]]

                                                                                                                                                        
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/           4.09       1.60        0.25        5.94        090  S                 
                                                     chest.                                                                                             
21556...  ...................  A                    Remove lesion neck/           5.28       3.80        0.64        9.72        090  S                 
                                                     chest.                                                                                             
21557...  ...................  A                    Remove tumor, neck or         8.56       8.50        1.41       18.47        090  S                 
                                                     chest.                                                                                             
21600...  ...................  A                    Partial removal of rib.       6.27       4.50        0.88       11.65        090  S                 
21610...  ...................  A                    Partial removal of rib.      13.66       5.17        0.76       19.59        090  S                 
21615...  ...................  A                    Removal of rib.........       9.03      10.13        1.96       21.12        090  S                 
21616...  ...................  A                    Removal of rib and           11.11       7.26        1.50       19.87        090  S                 
                                                     nerves.                                                                                            
21620...  ...................  A                    Partial removal of            6.04       6.85        1.23       14.12        090  S                 
                                                     sternum.                                                                                           
21627...  ...................  A                    Sternal debridement....       6.06       5.03        0.90       11.99        090  S                 
21630...  ...................  A                    Extensive sternum            15.77      12.89        2.40       31.06        090  S                 
                                                     surgery.                                                                                           
21632...  ...................  A                    Extensive sternum            16.62      11.54        2.22       30.38        090  S                 
                                                     surgery.                                                                                           
21700...  ...................  A                    Revision of neck muscle       5.84       4.16        0.50       10.50        090  S                 
21705...  ...................  A                    Revision of neck muscle/      9.03       4.85        0.96       14.84        090  S                 
                                                     rib.                                                                                               
21720...  ...................  A                    Revision of neck muscle       5.44       3.84        0.52        9.80        090  S                 
21725...  ...................  A                    Revision of neck muscle       6.55       4.84        0.74       12.13        090  S                 
21740...  ...................  A                    Reconstruction of            15.42       8.99        1.64       26.05        090  S                 
                                                     sternum.                                                                                           
21750...  ...................  A                    Repair of sternum            10.07       7.33        1.43       18.83        090  S                 
                                                     separation.                                                                                        
21800...  ...................  A                    Treatment of rib              0.91       0.77        0.07        1.75        090  N                 
                                                     fracture.                                                                                          
21805...  ...................  A                    Treatment of rib              2.62       1.35        0.17        4.14        090  S                 
                                                     fracture.                                                                                          
21810...  ...................  A                    Treatment of rib              6.68       7.33        0.61       14.62        090  N                 
                                                     fracture(s).                                                                                       
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            0.00       0.00        0.00        0.00        YYY  S                 
                                                     procedure.                                                                                         
21920...  ...................  A                    Biopsy soft tissue of         2.01       0.79        0.11        2.91        010  S                 
                                                     back.                                                                                              
21925...  ...................  A                    Biopsy soft tissue of         4.23       1.95        0.32        6.50        090  S                 
                                                     back.                                                                                              
21930...  ...................  A                    Remove lesion, back or        4.82       2.72        0.49        8.03        090  S                 
                                                     flank.                                                                                             
21935...  ...................  A                    Remove tumor of back...      17.12       6.59        1.30       25.01        090  S                 
22100...  ...................  A                    Remove part of neck           9.05       7.64        1.09       17.78        090  S                 
                                                     vertebra.                                                                                          
22101...  ...................  A                    Remove part, thorax           9.00       8.01        1.38       18.39        090  S                 
                                                     vertebra.                                                                                          
22102...  ...................  A                    Remove part, lumbar           9.00       4.50        0.67       14.17        090  S                 
                                                     vertebra.                                                                                          
22103...  ...................  A                    Remove extra spine            2.34       2.23        0.37        4.94        ZZZ  S                 
                                                     segment.                                                                                           
22110...  ...................  A                    Remove part of neck          11.59       9.72        1.64       22.95        090  S                 
                                                     vertebra.                                                                                          
22112...  ...................  A                    Remove part, thorax          11.59       9.90        1.63       23.12        090  S                 
                                                     vertebra.                                                                                          
22114...  ...................  A                    Remove part, lumbar          11.59       7.25        1.17       20.01        090  S                 
                                                     vertebra.                                                                                          
22116...  ...................  A                    Remove extra spine            2.32       2.21        0.36        4.89        ZZZ  S                 
                                                     segment.                                                                                           
22210...  ...................  A                    Revision of neck spine.      22.51      13.83        2.43       38.77        090  S                 
22212...  ...................  A                    Revision of thorax           18.14      17.29        2.83       38.26        090  S                 
                                                     spine.                                                                                             
22214...  ...................  A                    Revision of lumbar           18.14      15.11        2.68       35.93        090  S                 
                                                     spine.                                                                                             
22216...  ...................  A                    Revise, extra spine           6.04       5.07        0.89       12.00        ZZZ  S                 
                                                     segment.                                                                                           
22220...  ...................  A                    Revision of neck spine.      20.15      16.64        2.63       39.42        090  S                 
22222...  ...................  A                    Revision of thorax           20.15      13.61        1.58       35.34        090  S                 
                                                     spine.                                                                                             
22224...  ...................  A                    Revision of lumbar           20.15      14.68        2.66       37.49        090  S                 
                                                     spine.                                                                                             
22226...  ...................  A                    Revise, extra spine           6.04       5.07        0.89       12.00        ZZZ  S                 
                                                     segment.                                                                                           
22305...  ...................  A                    Treat spine process           1.86       2.38        0.37        4.61        090  S                 
                                                     fracture.                                                                                          
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              17.19       8.32        1.34       26.85        090  S                 
                                                     fracture.                                                                                          
22326...  ...................  A                    Repair neck spine            18.43      15.93        2.74       37.10        090  S                 
                                                     fracture.                                                                                          
22327...  ...................  A                    Repair thorax spine          17.56      15.95        2.35       35.86        090  S                 
                                                     fracture.                                                                                          
22328...  ...................  A                    Repair each add spine         4.61       4.40        0.72        9.73        ZZZ  S                 
                                                     fx.                                                                                                
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             5.53       5.40        0.93       11.86        ZZZ  S                 
                                                     fusion.                                                                                            
22590...  ...................  A                    Spine & skull spinal         19.50      21.57        3.44       44.51        090  S                 
                                                     fusion.                                                                                            
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           6.44       5.65        0.92       13.01        ZZZ  S                 
                                                     segment.                                                                                           
22630...  ...................  A                    Lumbar spine fusion....      20.03      18.44        3.15       41.62        090  S                 
22632...  ...................  A                    Spine fusion, extra           5.23       4.99        0.82       11.04        ZZZ  S                 
                                                     segment.                                                                                           

[[Page 59566]]

                                                                                                                                                        
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                 
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                 
22830...  ...................  A                    Exploration of spinal        10.22      13.07        2.18       25.47        090  S                 
                                                     fusion.                                                                                            
22840...  ...................  A                    Insert spine fixation        12.54       5.98        0.98       19.50        ZZZ  S                 
                                                     device.                                                                                            
22841...  ...................  B                    Insert spine fixation         0.00       0.00        0.00        0.00        XXX  0                 
                                                     device.                                                                                            
22842...  ...................  A                    Insert spine fixation        12.58       6.86        1.12       20.56        ZZZ  S                 
                                                     device.                                                                                            
22843...  ...................  A                    Insert spine fixation        13.46       8.55        1.40       23.41        ZZZ  S                 
                                                     device.                                                                                            
22844...  ...................  A                    Insert spine fixation        16.44      10.45        1.71       28.60        ZZZ  S                 
                                                     device.                                                                                            
22845...  ...................  A                    Insert spine fixation        11.96       5.70        0.93       18.59        ZZZ  S                 
                                                     device.                                                                                            
22846...  ...................  A                    Insert spine fixation        12.42       7.90        1.29       21.61        ZZZ  S                 
                                                     device.                                                                                            
22847...  ...................  A                    Insert spine fixation        13.80       8.77        1.44       24.01        ZZZ  S                 
                                                     device.                                                                                            
22848...  ...................  A                    Insert pelvic                 6.00       5.72        0.94       12.66        ZZZ  S                 
                                                     fixationdevice.                                                                                    
22849...  ...................  A                    Reinsert spinal              17.55      11.76        1.97       31.28        090  S                 
                                                     fixation.                                                                                          
22850...  ...................  A                    Remove spine fixation         8.98       9.17        1.50       19.65        090  S                 
                                                     device.                                                                                            
22851...  ...................  A                    Apply spine prosth            6.71       6.40        1.05       14.16        ZZZ  S                 
                                                     device.                                                                                            
22852...  ...................  A                    Remove spine fixation         8.40       9.80        1.57       19.77        090  S                 
                                                     device.                                                                                            
22855...  ...................  A                    Remove spine fixation        14.11       7.46        1.25       22.82        090  S                 
                                                     device.                                                                                            
22899...  ...................  C                    Spine surgery procedure       0.00       0.00        0.00        0.00        YYY  S                 
22900...  ...................  A                    Remove abdominal wall         5.13       3.03        0.60        8.76        090  S                 
                                                     lesion.                                                                                            
22999...  ...................  C                    Abdomen surgery               0.00       0.00        0.00        0.00        YYY  S                 
                                                     procedure.                                                                                         
23000...  ...................  A                    Removal of calcium            4.12       3.24        0.47        7.83        090  S                 
                                                     deposits.                                                                                          
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           7.80       6.22        1.04       15.06        090  S                 
                                                     lesion.                                                                                            
23040...  ...................  A                    Exploratory shoulder          8.39       9.27        1.47       19.13        090  S                 
                                                     surgery.                                                                                           
23044...  ...................  A                    Exploratory shoulder          6.40       6.91        1.18       14.49        090  S                 
                                                     surgery.                                                                                           
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           2.34       1.68        0.29        4.31        010  S                 
                                                     lesion.                                                                                            
23076...  ...................  A                    Removal of shoulder           7.12       3.54        0.65       11.31        090  S                 
                                                     lesion.                                                                                            
23077...  ...................  A                    Remove tumor of              14.65       7.38        1.38       23.41        090  S                 
                                                     shoulder.                                                                                          
23100...  ...................  A                    Biopsy of shoulder            5.63       7.20        1.24       14.07        090  S                 
                                                     joint.                                                                                             
23101...  ...................  A                    Shoulder joint surgery.       5.21       6.68        1.21       13.10        090  S                 
23105...  ...................  A                    Remove shoulder joint         7.74       9.91        1.73       19.38        090  S                 
                                                     lining.                                                                                            
23106...  ...................  A                    Incision of collarbone        5.56       4.75        0.80       11.11        090  S                 
                                                     joint.                                                                                             
23107...  ...................  A                    Explore,treat shoulder        8.13       9.59        1.60       19.32        090  S                 
                                                     joint.                                                                                             
23120...  ...................  A                    Partial removal, collar       6.65       4.61        0.74       12.00        090  S                 
                                                     bone.                                                                                              
23125...  ...................  A                    Removal of collarbone..       8.90       8.49        1.27       18.66        090  S                 
23130...  ...................  A                    Partial removal,              7.10       7.05        1.14       15.29        090  S                 
                                                     shoulderbone.                                                                                      
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            7.80       6.64        1.01       15.45        090  S                 
                                                     lesion.                                                                                            
23155...  ...................  A                    Removal of humerus            9.58       8.80        1.37       19.75        090  S                 
                                                     lesion.                                                                                            
23156...  ...................  A                    Removal of humerus            8.00       7.64        1.25       16.89        090  S                 
                                                     lesion.                                                                                            
23170...  ...................  A                    Remove collarbone             6.27       4.81        0.78       11.86        090  S                 
                                                     lesion.                                                                                            
23172...  ...................  A                    Remove shoulder blade         6.24       5.16        0.73       12.13        090  S                 
                                                     lesion.                                                                                            
23174...  ...................  A                    Remove humerus lesion..       8.71       8.55        1.21       18.47        090  S                 
23180...  ...................  A                    Remove collar bone            7.82       4.30        0.67       12.79        090  S                 
                                                     lesion.                                                                                            
23182...  ...................  A                    Remove shoulder blade         7.44       6.57        1.13       15.14        090  S                 
                                                     lesion.                                                                                            
23184...  ...................  A                    Remove humerus lesion..       8.61       8.83        1.48       18.92        090  S                 
23190...  ...................  A                    Partial removal of            6.78       6.07        0.98       13.83        090  S                 
                                                     scapula.                                                                                           
23195...  ...................  A                    Removal of head of            9.00       8.91        1.45       19.36        090  S                 
                                                     humerus.                                                                                           
23200...  ...................  A                    Removal of collar bone.      11.05       9.17        1.26       21.48        090  S                 
23210...  ...................  A                    Removal of                   11.39       9.01        1.41       21.81        090  S                 
                                                     shoulderblade.                                                                                     
23220...  ...................  A                    Partial removal of           13.31      12.05        2.03       27.39        090  S                 
                                                     humerus.                                                                                           
23221...  ...................  A                    Partial removal of           16.62      18.13        1.19       35.94        090  S                 
                                                     humerus.                                                                                           
23222...  ...................  A                    Partial removal of           22.78      15.02        2.30       40.10        090  S                 
                                                     humerus.                                                                                           
23330...  ...................  A                    Remove shoulder foreign       1.80       0.55        0.07        2.42        010  S                 
                                                     body.                                                                                              
23331...  ...................  A                    Remove shoulder foreign       6.89       2.26        0.38        9.53        090  S                 
                                                     body.                                                                                              
23332...  ...................  A                    Remove shoulder foreign      10.59       9.72        1.57       21.88        090  S                 
                                                     body.                                                                                              
23350...  ...................  A                    Injection for shoulder        1.00       0.52        0.05        1.57        000  N                 
                                                     x-ray.                                                                                             

[[Page 59567]]

                                                                                                                                                        
23395...  ...................  A                    Muscle transfer,             16.00      11.13        1.84       28.97        090  S                 
                                                     shoulder/arm.                                                                                      
23397...  ...................  A                    Muscle transfers.......      15.23      13.97        2.34       31.54        090  S                 
23400...  ...................  A                    Fixation of shoulder         12.96       9.84        1.68       24.48        090  S                 
                                                     blade.                                                                                             
23405...  ...................  A                    Incision of tendon &          7.97       7.49        0.99       16.45        090  S                 
                                                     muscle.                                                                                            
23406...  ...................  A                    Incise tendon(s) &           10.33       9.41        1.58       21.32        090  S                 
                                                     muscle(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           9.51       5.18        0.83       15.52        090  S                 
                                                     ligament.                                                                                          
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           10.08       7.17        1.17       18.42        090  S                 
                                                     tendon.                                                                                            
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         16.12      16.76        2.65       35.53        090  S                 
                                                     joint.                                                                                             
23472...  ...................  A                    Reconstruct shoulder         16.09      20.60        4.89       41.58        090  S                 
                                                     joint.                                                                                             
23480...  ...................  A                    Revision of collarbone.      10.56       6.59        1.02       18.17        090  S                 
23485...  ...................  A                    Revision of collar bone      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           13.63      12.70        2.11       28.44        090  S                 
                                                     bones.                                                                                             
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               7.01       6.93        1.12       15.06        090  S                 
                                                     fracture.                                                                                          
23520...  ...................  A                    Treat clavicle                2.03       1.38        0.19        3.60        090  S                 
                                                     dislocation.                                                                                       
23525...  ...................  A                    Treat clavicle                3.40       1.98        0.27        5.65        090  S                 
                                                     dislocation.                                                                                       
23530...  ...................  A                    Repair clavicle               7.02       6.58        0.91       14.51        090  S                 
                                                     dislocation.                                                                                       
23532...  ...................  A                    Repair clavicle               7.59       7.23        1.19       16.01        090  S                 
                                                     dislocation.                                                                                       
23540...  ...................  A                    Treat clavicle                2.10       1.55        0.19        3.84        090  S                 
                                                     dislocation.                                                                                       
23545...  ...................  A                    Treat clavicle                3.07       1.98        0.29        5.34        090  S                 
                                                     dislocation.                                                                                       
23550...  ...................  A                    Repair clavicle               6.65       8.51        1.46       16.62        090  S                 
                                                     dislocation.                                                                                       
23552...  ...................  A                    Repair clavicle               7.83       7.29        1.17       16.29        090  S                 
                                                     dislocation.                                                                                       
23570...  ...................  A                    Treat shoulderblade           2.10       1.70        0.25        4.05        090  S                 
                                                     fracture.                                                                                          
23575...  ...................  A                    Treat shoulderblade           3.88       2.75        0.43        7.06        090  S                 
                                                     fracture.                                                                                          
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                3.24       2.10        0.24        5.58        090  S                 
                                                     dislocation.                                                                                       
23655...  ...................  A                    Treat shoulder                4.26       2.93        0.44        7.63        090  S                 
                                                     dislocation.                                                                                       
23660...  ...................  A                    Repair shoulder               7.09       9.07        1.40       17.56        090  S                 
                                                     dislocation.                                                                                       
23665...  ...................  A                    Treat dislocation/            4.16       3.35        0.51        8.02        090  S                 
                                                     fracture.                                                                                          
23670...  ...................  A                    Repair dislocation/           7.44       9.52        1.85       18.81        090  S                 
                                                     fracture.                                                                                          
23675...  ...................  A                    Treat dislocation/            5.60       3.93        0.61       10.14        090  S                 
                                                     fracture.                                                                                          
23680...  ...................  A                    Repair dislocation/           9.44      12.09        2.13       23.66        090  S                 
                                                     fracture.                                                                                          
23700...  ...................  A                    Fixation of shoulder...       2.47       2.09        0.34        4.90        010  S                 
23800...  ...................  A                    Fusion of shoulder           13.32      16.35        2.63       32.30        090  S                 
                                                     joint.                                                                                             
23802...  ...................  A                    Fusion of shoulder           15.62      14.07        2.24       31.93        090  S                 
                                                     joint.                                                                                             
23900...  ...................  A                    Amputation of arm &          18.40      12.57        2.40       33.37        090  S                 
                                                     girdle.                                                                                            
23920...  ...................  A                    Amputation at shoulder       13.60      13.85        2.54       29.99        090  S                 
                                                     joint.                                                                                             
23921...  ...................  A                    Amputation follow-up          5.03       4.27        0.74       10.04        090  S                 
                                                     surgery.                                                                                           
23929...  ...................  C                    Shoulder surgery              0.00       0.00        0.00        0.00        YYY  S                 
                                                     procedure.                                                                                         
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          5.56       4.69        0.78       11.03        090  S                 
                                                     lesion.                                                                                            
24000...  ...................  A                    Exploratory elbow             5.32       6.81        1.44       13.57        090  S                 
                                                     surgery.                                                                                           
24006...  ...................  A                    Release elbow joint....       8.70       7.14        1.17       17.01        090  S                 
24065...  ...................  A                    Biopsy arm/elbow soft         2.03       0.79        0.10        2.92        010  S                 
                                                     tissue.                                                                                            
24066...  ...................  A                    Biopsy arm/elbow soft         4.95       2.71        0.41        8.07        090  S                 
                                                     tissue.                                                                                            
24075...  ...................  A                    Remove arm/elbow lesion       3.79       1.98        0.35        6.12        090  S                 
24076...  ...................  A                    Remove arm/elbow lesion       6.01       3.68        0.67       10.36        090  S                 

[[Page 59568]]

                                                                                                                                                        
24077...  ...................  A                    Remove tumor of arm/         11.18       9.79        1.87       22.84        090  S                 
                                                     elbow.                                                                                             
24100...  ...................  A                    Biopsy elbow joint            4.67       4.23        0.69        9.59        090  S                 
                                                     lining.                                                                                            
24101...  ...................  A                    Explore/treat elbow           5.84       7.47        1.41       14.72        090  S                 
                                                     joint.                                                                                             
24102...  ...................  A                    Remove elbow joint            7.57       9.68        1.81       19.06        090  S                 
                                                     lining.                                                                                            
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             8.88       7.68        1.33       17.89        090  S                 
                                                     lesion.                                                                                            
24116...  ...................  A                    Remove/graft bone            11.13       9.72        1.47       22.32        090  S                 
                                                     lesion.                                                                                            
24120...  ...................  A                    Remove elbow lesion....       6.36       6.02        0.98       13.36        090  S                 
24125...  ...................  A                    Remove/graft bone             7.40       5.79        0.61       13.80        090  S                 
                                                     lesion.                                                                                            
24126...  ...................  A                    Remove/graft bone             7.76       7.40        1.21       16.37        090  S                 
                                                     lesion.                                                                                            
24130...  ...................  A                    Removal of head of            5.96       6.72        1.08       13.76        090  S                 
                                                     radius.                                                                                            
24134...  ...................  A                    Removal of arm bone           8.98       8.69        1.24       18.91        090  S                 
                                                     lesion.                                                                                            
24136...  ...................  A                    Remove radius bone            7.33       8.78        0.92       17.03        090  S                 
                                                     lesion.                                                                                            
24138...  ...................  A                    Remove elbow bone             7.36       6.39        1.06       14.81        090  S                 
                                                     lesion.                                                                                            
24140...  ...................  A                    Partial removal of arm        8.56       8.77        1.45       18.78        090  S                 
                                                     bone.                                                                                              
24145...  ...................  A                    Partial removal of            7.12       6.38        1.03       14.53        090  S                 
                                                     radius.                                                                                            
24147...  ...................  A                    Partial removal of            7.00       6.61        1.08       14.69        090  S                 
                                                     elbow.                                                                                             
24149...  ...................  A                    Radical resection of         13.25      12.64        2.07       27.96        090  S                 
                                                     elbow.                                                                                             
24150...  ...................  A                    Extensive humerus            12.43      14.08        2.24       28.75        090  S                 
                                                     surgery.                                                                                           
24151...  ...................  A                    Extensive humerus            14.65      13.83        2.11       30.59        090  S                 
                                                     surgery.                                                                                           
24152...  ...................  A                    Extensive radius              9.51       6.80        1.16       17.47        090  S                 
                                                     surgery.                                                                                           
24153...  ...................  A                    Extensive radius             10.96      10.44        1.71       23.11        090  S                 
                                                     surgery.                                                                                           
24155...  ...................  A                    Removal of elbow joint.      11.11      10.75        1.72       23.58        090  S                 
24160...  ...................  A                    Remove elbow joint            7.43       4.84        0.80       13.07        090  S                 
                                                     implant.                                                                                           
24164...  ...................  A                    Remove radius head            5.79       5.53        0.90       12.22        090  S                 
                                                     implant.                                                                                           
24200...  ...................  A                    Removal of arm foreign        1.71       0.56        0.06        2.33        010  N                 
                                                     body.                                                                                              
24201...  ...................  A                    Removal of arm foreign        4.30       3.06        0.49        7.85        090  S                 
                                                     body.                                                                                              
24220...  ...................  A                    Injection for elbow x-        1.31       0.51        0.05        1.87        000  N                 
                                                     ray.                                                                                               
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                 
24341...  ...................  A                    Repair tendon/muscle          7.33       6.99        1.14       15.46        090  S                 
                                                     arm.                                                                                               
24342...  ...................  A                    Repair of ruptured           10.13      10.38        1.76       22.27        090  S                 
                                                     tendon.                                                                                            
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            6.39       7.28        1.18       14.85        090  S                 
                                                     elbow.                                                                                             
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           7.93       7.52        1.19       16.64        090  S                 
                                                     radius.                                                                                            
24366...  ...................  A                    Reconstruct head of           8.67      11.05        1.80       21.52        090  S                 
                                                     radius.                                                                                            
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          12.19      15.61        2.84       30.64        090  S                 
                                                     graft.                                                                                             
24470...  ...................  A                    Revision of elbow joint       8.32       7.92        1.30       17.54        090  S                 
24495...  ...................  A                    Decompression of              7.59       5.75        1.10       14.44        090  S                 
                                                     forearm.                                                                                           
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 59569]]

                                                                                                                                                        
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                  8.76       9.29        1.48       19.53        090  S                 
                                                     dislocation.                                                                                       
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             2.39       1.95        0.27        4.61        090  S                 
                                                     fracture.                                                                                          
24675...  ...................  A                    Treatment of ulna             4.52       3.51        0.54        8.57        090  S                 
                                                     fracture.                                                                                          
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        12.79      12.18        1.99       26.96        090  S                 
                                                     joint.                                                                                             
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          6.61       6.27        0.75       13.63        090  S                 
                                                     surgery.                                                                                           
24930...  ...................  A                    Amputation follow-up          9.40       8.16        1.17       18.73        090  S                 
                                                     surgery.                                                                                           
24931...  ...................  A                    Amputate upper arm &         11.71      11.17        1.84       24.72        090  S                 
                                                     implant.                                                                                           
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            3.20       3.94        0.62        7.76        090  S                 
                                                     sheath.                                                                                            
25020...  ...................  A                    Decompression of              5.55       4.35        0.77       10.67        090  S                 
                                                     forearm.                                                                                           
25023...  ...................  A                    Decompression of             11.80       5.44        0.94       18.18        090  S                 
                                                     forearm.                                                                                           
25028...  ...................  A                    Drainage of forearm           4.88       2.06        0.36        7.30        090  S                 
                                                     lesion.                                                                                            
25031...  ...................  A                    Drainage of forearm           3.90       0.66        0.09        4.65        090  S                 
                                                     bursa.                                                                                             
25035...  ...................  A                    Treat forearm bone            6.83       6.30        1.01       14.14        090  S                 
                                                     lesion.                                                                                            
25040...  ...................  A                    Explore/treat wrist           6.61       5.69        0.90       13.20        090  S                 
                                                     joint.                                                                                             
25065...  ...................  A                    Biopsy forearm soft           1.94       0.75        0.09        2.78        010  S                 
                                                     tissues.                                                                                           
25066...  ...................  A                    Biopsy forearm soft           3.87       1.54        0.22        5.63        090  S                 
                                                     tissues.                                                                                           
25075...  ...................  A                    Removal of forearm            3.61       2.19        0.37        6.17        090  S                 
                                                     lesion.                                                                                            
25076...  ...................  A                    Removal of forearm            4.77       3.77        0.67        9.21        090  S                 
                                                     lesion.                                                                                            
25077...  ...................  A                    Remove tumor, forearm/        9.25       8.48        1.67       19.40        090  S                 
                                                     wrist.                                                                                             
25085...  ...................  A                    Incision of wrist             5.13       4.62        0.71       10.46        090  S                 
                                                     capsule.                                                                                           
25100...  ...................  A                    Biopsy of wrist joint..       3.66       4.69        0.79        9.14        090  S                 
25101...  ...................  A                    Explore/treat wrist           4.43       5.61        0.98       11.02        090  S                 
                                                     joint.                                                                                             
25105...  ...................  A                    Remove wrist joint            5.56       7.11        1.19       13.86        090  S                 
                                                     lining.                                                                                            
25107...  ...................  A                    Remove wrist joint            5.89       5.28        0.89       12.06        090  S                 
                                                     cartilage.                                                                                         
25110...  ...................  A                    Remove wrist tendon           3.79       2.80        0.46        7.05        090  S                 
                                                     lesion.                                                                                            
25111...  ...................  A                    Remove wrist tendon           3.24       3.22        0.55        7.01        090  S                 
                                                     lesion.                                                                                            
25112...  ...................  A                    Reremove wrist tendon         4.38       3.72        0.66        8.76        090  S                 
                                                     lesion.                                                                                            
25115...  ...................  A                    Remove wrist/forearm          8.00       7.14        1.23       16.37        090  S                 
                                                     lesion.                                                                                            
25116...  ...................  A                    Remove wrist/forearm          6.44       8.17        1.38       15.99        090  S                 
                                                     lesion.                                                                                            
25118...  ...................  A                    Excise wrist tendon           4.11       5.26        1.02       10.39        090  S                 
                                                     sheath.                                                                                            
25119...  ...................  A                    Partial removal of ulna       5.64       7.22        1.32       14.18        090  S                 
25120...  ...................  A                    Removal of forearm            5.70       6.53        1.14       13.37        090  S                 
                                                     lesion.                                                                                            
25125...  ...................  A                    Remove/graft forearm          7.06       6.84        1.04       14.94        090  S                 
                                                     lesion.                                                                                            
25126...  ...................  A                    Remove/graft forearm          7.13       6.80        1.12       15.05        090  S                 
                                                     lesion.                                                                                            
25130...  ...................  A                    Removal of wrist lesion       5.08       4.21        0.67        9.96        090  S                 
25135...  ...................  A                    Remove & graft wrist          6.58       5.46        0.97       13.01        090  S                 
                                                     lesion.                                                                                            
25136...  ...................  A                    Remove & graft wrist          5.68       4.74        0.85       11.27        090  S                 
                                                     lesion.                                                                                            
25145...  ...................  A                    Remove forearm bone           5.97       5.95        0.75       12.67        090  S                 
                                                     lesion.                                                                                            
25150...  ...................  A                    Partial removal of ulna       6.56       6.67        1.12       14.35        090  S                 
25151...  ...................  A                    Partial removal of            6.86       5.75        1.02       13.63        090  S                 
                                                     radius.                                                                                            
25170...  ...................  A                    Extensive forearm            10.45       9.79        1.51       21.75        090  S                 
                                                     surgery.                                                                                           
25210...  ...................  A                    Removal of wrist bone..       5.55       4.88        0.80       11.23        090  S                 

[[Page 59570]]

                                                                                                                                                        
25215...  ...................  A                    Removal of wrist bones.       7.40       8.68        1.42       17.50        090  S                 
25230...  ...................  A                    Partial removal of            4.86       5.57        0.85       11.28        090  S                 
                                                     radius.                                                                                            
25240...  ...................  A                    Partial removal of ulna       4.91       5.30        0.86       11.07        090  S                 
25246...  ...................  A                    Injection for wrist x-        1.45       0.50        0.05        2.00        000  N                 
                                                     ray.                                                                                               
25248...  ...................  A                    Remove forearm foreign        4.96       2.18        0.37        7.51        090  S                 
                                                     body.                                                                                              
25250...  ...................  A                    Removal of wrist              6.31       5.63        0.91       12.85        090  S                 
                                                     prosthesis.                                                                                        
25251...  ...................  A                    Removal of wrist              9.08       8.25        1.39       18.72        090  S                 
                                                     prosthesis.                                                                                        
25260...  ...................  A                    Repair forearm tendon/        7.33       4.61        0.78       12.72        090  S                 
                                                     muscle.                                                                                            
25263...  ...................  A                    Repair forearm tendon/        7.37       5.77        1.03       14.17        090  S                 
                                                     muscle.                                                                                            
25265...  ...................  A                    Repair forearm tendon/        9.54       7.93        1.41       18.88        090  S                 
                                                     muscle.                                                                                            
25270...  ...................  A                    Repair forearm tendon/        5.71       3.36        0.55        9.62        090  S                 
                                                     muscle.                                                                                            
25272...  ...................  A                    Repair forearm tendon/        6.75       3.44        0.54       10.73        090  S                 
                                                     muscle.                                                                                            
25274...  ...................  A                    Repair forearm tendon/        8.44       6.62        1.13       16.19        090  S                 
                                                     muscle.                                                                                            
25280...  ...................  A                    Revise wrist/forearm          6.82       4.22        0.69       11.73        090  S                 
                                                     tendon.                                                                                            
25290...  ...................  A                    Incise wrist/forearm          5.03       2.47        0.41        7.91        090  S                 
                                                     tendon.                                                                                            
25295...  ...................  A                    Release wrist/forearm         6.26       3.05        0.52        9.83        090  S                 
                                                     tendon.                                                                                            
25300...  ...................  A                    Fusion of tendons at          8.46       7.36        1.19       17.01        090  S                 
                                                     wrist.                                                                                             
25301...  ...................  A                    Fusion of tendons at          8.09       6.77        1.18       16.04        090  S                 
                                                     wrist.                                                                                             
25310...  ...................  A                    Transplant forearm            7.68       7.14        1.17       15.99        090  S                 
                                                     tendon.                                                                                            
25312...  ...................  A                    Transplant forearm            9.08       7.63        1.31       18.02        090  S                 
                                                     tendon.                                                                                            
25315...  ...................  A                    Revise palsy hand             9.45       8.06        1.34       18.85        090  S                 
                                                     tendon(s).                                                                                         
25316...  ...................  A                    Revise palsy hand            11.49      10.58        1.78       23.85        090  S                 
                                                     tendon(s).                                                                                         
25320...  ...................  A                    Repair/revise wrist           9.89       8.60        1.45       19.94        090  S                 
                                                     joint.                                                                                             
25330...  ...................  D                    Revise wrist joint.....       0.00       0.00        0.00        0.00        090  S                 
25331...  ...................  D                    Revise wrist joint.....       0.00       0.00        0.00        0.00        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/             9.50       8.60        1.45       19.55        090  S                 
                                                     radioulnar.                                                                                        
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       13.48      12.42        2.02       27.92        090  S                 
                                                     ulna.                                                                                              
25415...  ...................  A                    Repair radius & ulna...      12.64      11.42        1.92       25.98        090  S                 
25420...  ...................  A                    Repair/graft radius &        15.34      14.70        2.28       32.32        090  S                 
                                                     ulna.                                                                                              
25425...  ...................  A                    Repair/graft radius or       12.44      12.02        1.87       26.33        090  S                 
                                                     ulna.                                                                                              
25426...  ...................  A                    Repair/graft radius &        14.92      11.72        2.13       28.77        090  S                 
                                                     ulna.                                                                                              
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           13.78       7.84        1.16       22.78        090  S                 
                                                     implant.                                                                                           
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         11.75      11.20        1.84       24.79        090  S                 
                                                     ulna.                                                                                              
25500...  ...................  A                    Treat fracture of             2.30       2.33        0.29        4.92        090  S                 
                                                     radius.                                                                                            
25505...  ...................  A                    Treat fracture of             4.96       3.57        0.51        9.04        090  S                 
                                                     radius.                                                                                            
25515...  ...................  A                    Repair fracture of            8.63       7.63        1.22       17.48        090  S                 
                                                     radius.                                                                                            
25520...  ...................  A                    Repair fracture of            6.01       5.74        0.94       12.69        090  S                 
                                                     radius.                                                                                            
25525...  ...................  A                    Repair fracture of           11.69      11.15        1.83       24.67        090  S                 
                                                     radius.                                                                                            
25526...  ...................  A                    Repair fracture of           12.43      11.85        1.94       26.22        090  S                 
                                                     radius.                                                                                            
25530...  ...................  A                    Treat fracture of ulna.       1.94       2.44        0.35        4.73        090  S                 
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                 

[[Page 59571]]

                                                                                                                                                        
25560...  ...................  A                    Treat fracture radius &       2.29       2.27        0.27        4.83        090  S                 
                                                     ulna.                                                                                              
25565...  ...................  A                    Treat fracture radius &       5.29       4.66        0.70       10.65        090  S                 
                                                     ulna.                                                                                              
25574...  ...................  A                    Treat fracture radius &       6.03       7.72        1.73       15.48        090  S                 
                                                     ulna.                                                                                              
25575...  ...................  A                    Repair fracture radius/       9.47      10.70        1.73       21.90        090  S                 
                                                     ulna.                                                                                              
25600...  ...................  A                    Treat fracture radius/        2.48       2.84        0.42        5.74        090  S                 
                                                     ulna.                                                                                              
25605...  ...................  A                    Treat fracture radius/        5.36       3.95        0.61        9.92        090  S                 
                                                     ulna.                                                                                              
25611...  ...................  A                    Repair fracture radius/       7.11       6.01        0.97       14.09        090  S                 
                                                     ulna.                                                                                              
25620...  ...................  A                    Repair fracture radius/       8.15       7.13        1.14       16.42        090  S                 
                                                     ulna.                                                                                              
25622...  ...................  A                    Treat wrist bone              2.43       2.28        0.33        5.04        090  S                 
                                                     fracture.                                                                                          
25624...  ...................  A                    Treat wrist bone              4.28       3.67        0.57        8.52        090  S                 
                                                     fracture.                                                                                          
25628...  ...................  A                    Repair wrist bone             7.81       7.13        1.16       16.10        090  S                 
                                                     fracture.                                                                                          
25630...  ...................  A                    Treat wrist bone              2.73       2.19        0.30        5.22        090  S                 
                                                     fracture.                                                                                          
25635...  ...................  A                    Treat wrist bone              4.16       3.36        0.50        8.02        090  S                 
                                                     fracture.                                                                                          
25645...  ...................  A                    Repair wrist bone             6.85       6.68        0.95       14.48        090  S                 
                                                     fracture.                                                                                          
25650...  ...................  A                    Repair wrist bone             2.87       2.66        0.36        5.89        090  S                 
                                                     fracture.                                                                                          
25660...  ...................  A                    Treat wrist dislocation       4.53       1.82        0.26        6.61        090  S                 
25670...  ...................  A                    Repair wrist                  7.52       7.08        1.12       15.72        090  S                 
                                                     dislocation.                                                                                       
25675...  ...................  A                    Treat wrist dislocation       4.44       2.28        0.34        7.06        090  S                 
25676...  ...................  A                    Repair wrist                  7.55       7.32        1.11       15.98        090  S                 
                                                     dislocation.                                                                                       
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                  7.94       7.04        1.17       16.15        090  S                 
                                                     dislocation.                                                                                       
25800...  ...................  A                    Fusion of wrist joint..       9.21      10.94        1.80       21.95        090  S                 
25805...  ...................  A                    Fusion/graft of wrist        10.57      12.85        2.09       25.51        090  S                 
                                                     joint.                                                                                             
25810...  ...................  A                    Fusion/graft of wrist         9.79      12.53        2.06       24.38        090  S                 
                                                     joint.                                                                                             
25820...  ...................  A                    Fusion of hand bones...       7.14       8.91        1.48       17.53        090  S                 
25825...  ...................  A                    Fusion hand bones with        8.60      11.02        1.99       21.61        090  S                 
                                                     graft.                                                                                             
25830...  ...................  A                    Fusion radioulnar jnt/        9.50       8.60        1.45       19.55        090  S                 
                                                     ulna.                                                                                              
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          7.27       5.74        1.00       14.01        090  S                 
                                                     surgery.                                                                                           
25909...  ...................  A                    Amputation follow-up          8.37       5.55        1.06       14.98        090  S                 
                                                     surgery.                                                                                           
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          7.87       7.50        1.22       16.59        090  S                 
                                                     surgery.                                                                                           
25927...  ...................  A                    Amputation of hand.....       8.27       6.29        1.22       15.78        090  S                 
25929...  ...................  A                    Amputation follow-up          7.13       4.74        0.96       12.83        090  S                 
                                                     surgery.                                                                                           
25931...  ...................  A                    Amputation follow-up          7.35       4.54        0.90       12.79        090  S                 
                                                     surgery.                                                                                           
25999...  ...................  C                    Forearm or wrist              0.00       0.00        0.00        0.00        YYY  S                 
                                                     surgery.                                                                                           
26010...  ...................  A                    Drainage of finger            1.49       0.48        0.05        2.02        010  N                 
                                                     abscess.                                                                                           
26011...  ...................  A                    Drainage of finger            2.14       1.54        0.24        3.92        010  S                 
                                                     abscess.                                                                                           
26020...  ...................  A                    Drain hand tendon             4.01       3.72        0.63        8.36        090  S                 
                                                     sheath.                                                                                            
26025...  ...................  A                    Drainage of palm bursa.       4.32       4.51        0.76        9.59        090  S                 
26030...  ...................  A                    Drainage of palm              5.36       5.73        0.98       12.07        090  S                 
                                                     bursa(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                  3.09       2.86        0.49        6.44        090  S                 
                                                     contracture.                                                                                       
26045...  ...................  A                    Release palm                  5.27       4.83        0.81       10.91        090  S                 
                                                     contracture.                                                                                       
26055...  ...................  A                    Incise finger tendon          2.56       3.28        0.56        6.40        090  S                 
                                                     sheath.                                                                                            
26060...  ...................  A                    Incision of finger            2.71       1.13        0.17        4.01        090  S                 
                                                     tendon.                                                                                            
26070...  ...................  A                    Explore/treat hand            3.34       2.76        0.42        6.52        090  S                 
                                                     joint.                                                                                             
26075...  ...................  A                    Explore/treat finger          3.44       3.78        0.62        7.84        090  S                 
                                                     joint.                                                                                             
26080...  ...................  A                    Explore/treat finger          3.78       3.14        0.51        7.43        090  S                 
                                                     joint.                                                                                             
26100...  ...................  A                    Biopsy hand joint             3.54       2.99        0.45        6.98        090  S                 
                                                     lining.                                                                                            
26105...  ...................  A                    Biopsy finger joint           3.58       4.17        0.67        8.42        090  S                 
                                                     lining.                                                                                            
26110...  ...................  A                    Biopsy finger joint           3.40       2.93        0.50        6.83        090  S                 
                                                     lining.                                                                                            
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/           8.24       5.07        0.91       14.22        090  S                 
                                                     finger.                                                                                            
26121...  ...................  A                    Release palm                  7.34       9.40        1.61       18.35        090  S                 
                                                     contracture.                                                                                       
26123...  ...................  A                    Release palm                  8.64       9.10        1.53       19.27        090  S                 
                                                     contracture.                                                                                       
26125...  ...................  A                    Release palm                  4.61       2.62        0.45        7.68        ZZZ  S                 
                                                     contracture.                                                                                       
26130...  ...................  A                    Remove wrist joint            5.13       5.01        0.86       11.00        090  S                 
                                                     lining.                                                                                            
26135...  ...................  A                    Revise finger joint,          6.67       4.86        0.82       12.35        090  S                 
                                                     each.                                                                                              

[[Page 59572]]

                                                                                                                                                        
26140...  ...................  A                    Revise finger joint,          5.88       4.40        0.75       11.03        090  S                 
                                                     each.                                                                                              
26145...  ...................  A                    Tendon excision, palm/        6.03       4.71        0.80       11.54        090  S                 
                                                     finger.                                                                                            
26160...  ...................  A                    Remove tendon sheath          3.00       2.32        0.40        5.72        090  S                 
                                                     lesion.                                                                                            
26170...  ...................  A                    Removal of palm tendon,       4.62       2.83        0.45        7.90        090  S                 
                                                     each.                                                                                              
26180...  ...................  A                    Removal of finger             5.00       4.01        0.71        9.72        090  S                 
                                                     tendon.                                                                                            
26185...  ...................  A                    Remove finger bone.....       5.00       4.24        0.41        9.65        090  S                 
26200...  ...................  A                    Remove hand bone lesion       5.25       4.48        0.72       10.45        090  S                 
26205...  ...................  A                    Remove/graft bone             7.24       6.40        1.03       14.67        090  S                 
                                                     lesion.                                                                                            
26210...  ...................  A                    Removal of finger             4.97       3.90        0.64        9.51        090  S                 
                                                     lesion.                                                                                            
26215...  ...................  A                    Remove/graft finger           6.81       5.55        0.94       13.30        090  S                 
                                                     lesion.                                                                                            
26230...  ...................  A                    Partial removal of hand       5.96       4.26        0.69       10.91        090  S                 
                                                     bone.                                                                                              
26235...  ...................  A                    Partial removal, finger       5.82       4.17        0.71       10.70        090  S                 
                                                     bone.                                                                                              
26236...  ...................  A                    Partial removal, finger       4.95       3.86        0.66        9.47        090  S                 
                                                     bone.                                                                                              
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              6.74       5.73        0.97       13.44        090  S                 
                                                     surgery.                                                                                           
26261...  ...................  A                    Extensive finger              8.54       7.70        1.31       17.55        090  S                 
                                                     surgery.                                                                                           
26262...  ...................  A                    Partial removal of            5.41       4.75        0.76       10.92        090  S                 
                                                     finger.                                                                                            
26320...  ...................  A                    Removal of implant from       3.74       3.54        0.57        7.85        090  S                 
                                                     hand.                                                                                              
26350...  ...................  A                    Repair finger/hand            5.76       5.74        0.99       12.49        090  S                 
                                                     tendon.                                                                                            
26352...  ...................  A                    Repair/graft hand             7.26       6.60        1.10       14.96        090  S                 
                                                     tendon.                                                                                            
26356...  ...................  A                    Repair finger/hand            7.05       7.21        1.24       15.50        090  S                 
                                                     tendon.                                                                                            
26357...  ...................  A                    Repair finger/hand            8.16       6.58        1.19       15.93        090  S                 
                                                     tendon.                                                                                            
26358...  ...................  A                    Repair/graft hand             8.69       7.40        1.27       17.36        090  S                 
                                                     tendon.                                                                                            
26370...  ...................  A                    Repair finger/hand            6.71       6.71        1.13       14.55        090  S                 
                                                     tendon.                                                                                            
26372...  ...................  A                    Repair/graft hand             8.27       6.39        1.15       15.81        090  S                 
                                                     tendon.                                                                                            
26373...  ...................  A                    Repair finger/hand            7.67       6.85        1.11       15.63        090  S                 
                                                     tendon.                                                                                            
26390...  ...................  A                    Revise hand/finger            8.73       7.95        1.23       17.91        090  S                 
                                                     tendon.                                                                                            
26392...  ...................  A                    Repair/graft hand             9.77       8.61        1.26       19.64        090  S                 
                                                     tendon.                                                                                            
26410...  ...................  A                    Repair hand tendon.....       4.37       3.29        0.51        8.17        090  S                 
26412...  ...................  A                    Repair/graft hand             5.91       6.01        0.97       12.89        090  S                 
                                                     tendon.                                                                                            
26415...  ...................  A                    Excision, hand/finger         8.05       6.75        0.90       15.70        090  S                 
                                                     tendon.                                                                                            
26416...  ...................  A                    Graft hand or finger          9.06       8.64        1.41       19.11        090  S                 
                                                     tendon.                                                                                            
26418...  ...................  A                    Repair finger tendon...       4.02       3.58        0.59        8.19        090  S                 
26420...  ...................  A                    Repair/graft finger           6.37       5.68        0.96       13.01        090  S                 
                                                     tendon.                                                                                            
26426...  ...................  A                    Repair finger/hand            5.86       6.31        1.07       13.24        090  S                 
                                                     tendon.                                                                                            
26428...  ...................  A                    Repair/graft finger           6.90       5.50        1.00       13.40        090  S                 
                                                     tendon.                                                                                            
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           5.80       4.95        0.84       11.59        090  S                 
                                                     tendon.                                                                                            
26437...  ...................  A                    Realignment of tendons.       5.53       4.05        0.68       10.26        090  S                 
26440...  ...................  A                    Release palm/finger           4.76       3.57        0.59        8.92        090  S                 
                                                     tendon.                                                                                            
26442...  ...................  A                    Release palm & finger         7.45       3.37        0.59       11.41        090  S                 
                                                     tendon.                                                                                            
26445...  ...................  A                    Release hand/finger           4.16       3.25        0.54        7.95        090  S                 
                                                     tendon.                                                                                            
26449...  ...................  A                    Release forearm/hand          6.39       5.57        0.96       12.92        090  S                 
                                                     tendon.                                                                                            
26450...  ...................  A                    Incision of palm tendon       3.54       2.28        0.36        6.18        090  S                 
26455...  ...................  A                    Incision of finger            3.51       1.89        0.33        5.73        090  S                 
                                                     tendon.                                                                                            
26460...  ...................  A                    Incise hand/finger            3.33       1.72        0.30        5.35        090  S                 
                                                     tendon.                                                                                            
26471...  ...................  A                    Fusion of finger              5.55       4.15        0.67       10.37        090  S                 
                                                     tendons.                                                                                           
26474...  ...................  A                    Fusion of finger              5.14       4.61        0.75       10.50        090  S                 
                                                     tendons.                                                                                           
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           5.62       4.30        0.72       10.64        090  S                 
                                                     tendon.                                                                                            
26479...  ...................  A                    Shortening of hand            5.56       5.29        0.86       11.71        090  S                 
                                                     tendon.                                                                                            
26480...  ...................  A                    Transplant hand tendon.       6.49       6.53        1.11       14.13        090  S                 
26483...  ...................  A                    Transplant/graft hand         7.87       8.50        1.40       17.77        090  S                 
                                                     tendon.                                                                                            
26485...  ...................  A                    Transplant palm tendon.       7.28       6.50        1.08       14.86        090  S                 
26489...  ...................  A                    Transplant/graft palm         9.00       3.40        0.51       12.91        090  S                 
                                                     tendon.                                                                                            
26490...  ...................  A                    Revise thumb tendon....       7.99       7.80        1.28       17.07        090  S                 
26492...  ...................  A                    Tendon transfer with          9.17       8.75        1.21       19.13        090  S                 
                                                     graft.                                                                                             
26494...  ...................  A                    Hand tendon/muscle            8.05       7.28        1.23       16.56        090  S                 
                                                     transfer.                                                                                          
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                 
26499...  ...................  A                    Revision of finger.....       8.56       7.75        1.25       17.56        090  S                 
26500...  ...................  A                    Hand tendon                   5.67       3.49        0.60        9.76        090  S                 
                                                     reconstruction.                                                                                    
26502...  ...................  A                    Hand tendon                   6.74       5.27        0.95       12.96        090  S                 
                                                     reconstruction.                                                                                    

[[Page 59573]]

                                                                                                                                                        
26504...  ...................  A                    Hand tendon                   7.05       6.72        1.11       14.88        090  S                 
                                                     reconstruction.                                                                                    
26508...  ...................  A                    Release thumb                 5.61       4.15        0.72       10.48        090  S                 
                                                     contracture.                                                                                       
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             8.34       7.07        1.23       16.64        090  S                 
                                                     joints.                                                                                            
26518...  ...................  A                    Fusion of knuckle             8.53       6.51        1.22       16.26        090  S                 
                                                     joints.                                                                                            
26520...  ...................  A                    Release knuckle               5.01       4.48        0.71       10.20        090  S                 
                                                     contracture.                                                                                       
26525...  ...................  A                    Release finger                5.04       3.64        0.62        9.30        090  S                 
                                                     contracture.                                                                                       
26530...  ...................  A                    Revise knuckle joint...       6.38       5.16        0.85       12.39        090  S                 
26531...  ...................  A                    Revise knuckle with           7.57       6.65        1.11       15.33        090  S                 
                                                     implant.                                                                                           
26535...  ...................  A                    Revise finger joint....       4.95       4.84        0.58       10.37        090  S                 
26536...  ...................  A                    Revise/implant finger         6.06       7.21        1.19       14.46        090  S                 
                                                     joint.                                                                                             
26540...  ...................  A                    Repair hand joint......       6.03       6.64        1.12       13.79        090  S                 
26541...  ...................  A                    Repair hand joint with        8.20       8.94        1.47       18.61        090  S                 
                                                     graft.                                                                                             
26542...  ...................  A                    Repair hand joint with        6.38       5.67        0.97       13.02        090  S                 
                                                     graft.                                                                                             
26545...  ...................  A                    Reconstruct finger            6.50       5.27        0.94       12.71        090  S                 
                                                     joint.                                                                                             
26546...  ...................  A                    Repair non-union hand..       8.50       8.11        1.33       17.94        090  S                 
26548...  ...................  A                    Reconstruct finger            7.61       5.79        1.00       14.40        090  S                 
                                                     joint.                                                                                             
26550...  ...................  A                    Construct thumb              20.77      19.81        3.24       43.82        090  S                 
                                                     replacement.                                                                                       
26551...  ...................  A                    Great toe-hand transfer      44.31      42.25        6.92       93.48        090  S                 
26552...  ...................  D                    Construct thumb               0.00       0.00        0.00        0.00        090  S                 
                                                     replacement.                                                                                       
26553...  ...................  A                    Single toe-hand              44.00      41.96        6.87       92.83        090  S                 
                                                     transfer.                                                                                          
26554...  ...................  A                    Double toe-hand              52.50      50.06        8.20      110.76        090  S                 
                                                     transfer.                                                                                          
26555...  ...................  A                    Positional change of         16.16      15.41        2.52       34.09        090  S                 
                                                     finger.                                                                                            
26556...  ...................  A                    Toe joint transfer.....      44.75      42.67        6.99       94.41        090  S                 
26557...  ...................  D                    Construct finger              0.00       0.00        0.00        0.00        090  S                 
                                                     replacement.                                                                                       
26558...  ...................  D                    Added finger surgery...       0.00       0.00        0.00        0.00        090  S                 
26559...  ...................  D                    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                6.53       4.28        0.67       11.48        090  S                 
                                                     deformity.                                                                                         
26568...  ...................  A                    Lengthen metacarpal/          8.66       8.45        1.06       18.17        090  S                 
                                                     finger.                                                                                            
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             0.00       0.00        0.00        0.00        090  S                 
                                                     finger.                                                                                            
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         8.64       8.24        1.35       18.23        090  S                 
                                                     tissue.                                                                                            
26597...  ...................  A                    Release of scar               9.37       8.02        1.37       18.76        090  S                 
                                                     contracture.                                                                                       
26600...  ...................  A                    Treat metacarpal              1.81       1.54        0.22        3.57        090  S                 
                                                     fracture.                                                                                          
26605...  ...................  A                    Treat metacarpal              2.67       2.29        0.36        5.32        090  S                 
                                                     fracture.                                                                                          
26607...  ...................  A                    Treat metacarpal              5.12       3.55        0.57        9.24        090  S                 
                                                     fracture.                                                                                          
26608...  ...................  A                    Treat metacarpal              5.12       3.55        0.57        9.24        090  S                 
                                                     fracture.                                                                                          
26615...  ...................  A                    Repair metacarpal             5.18       4.87        0.80       10.85        090  S                 
                                                     fracture.                                                                                          
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                 3.54       0.88        0.10        4.52        090  S                 
                                                     dislocation.                                                                                       
26705...  ...................  A                    Treat knuckle                 3.99       1.78        0.27        6.04        090  S                 
                                                     dislocation.                                                                                       
26706...  ...................  A                    Pin knuckle dislocation       4.92       4.68        0.75       10.35        090  S                 
26715...  ...................  A                    Repair knuckle                5.48       4.13        0.66       10.27        090  S                 
                                                     dislocation.                                                                                       
26720...  ...................  A                    Treat finger fracture,        1.56       1.10        0.15        2.81        090  S                 
                                                     each.                                                                                              
26725...  ...................  A                    Treat finger fracture,        3.18       1.54        0.23        4.95        090  S                 
                                                     each.                                                                                              
26727...  ...................  A                    Treat finger fracture,        4.92       2.45        0.38        7.75        090  S                 
                                                     each.                                                                                              
26735...  ...................  A                    Repair finger fracture,       5.72       3.73        0.61       10.06        090  S                 
                                                     each.                                                                                              
26740...  ...................  A                    Treat finger fracture,        1.81       1.16        0.16        3.13        090  S                 
                                                     each.                                                                                              
26742...  ...................  A                    Treat finger fracture,        3.70       1.98        0.32        6.00        090  S                 
                                                     each.                                                                                              
26746...  ...................  A                    Repair finger fracture,       5.55       4.75        0.80       11.10        090  S                 
                                                     each.                                                                                              

[[Page 59574]]

                                                                                                                                                        
26750...  ...................  A                    Treat finger fracture,        1.60       0.83        0.10        2.53        090  S                 
                                                     each.                                                                                              
26755...  ...................  A                    Treat finger fracture,        2.97       1.08        0.15        4.20        090  S                 
                                                     each.                                                                                              
26756...  ...................  A                    Pin finger fracture,          4.19       1.90        0.33        6.42        090  S                 
                                                     each.                                                                                              
26765...  ...................  A                    Repair finger fracture,       4.04       2.66        0.45        7.15        090  S                 
                                                     each.                                                                                              
26770...  ...................  A                    Treat finger                  2.89       0.76        0.08        3.73        090  S                 
                                                     dislocation.                                                                                       
26775...  ...................  A                    Treat finger                  3.51       1.13        0.17        4.81        090  S                 
                                                     dislocation.                                                                                       
26776...  ...................  A                    Pin finger dislocation.       4.60       2.08        0.35        7.03        090  S                 
26785...  ...................  A                    Repair finger                 4.08       2.97        0.48        7.53        090  S                 
                                                     dislocation.                                                                                       
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          8.24       7.35        1.19       16.78        090  S                 
                                                     joint.                                                                                             
26850...  ...................  A                    Fusion of knuckle......       6.57       4.63        0.76       11.96        090  S                 
26852...  ...................  A                    Fusion of knuckle with        7.97       5.72        1.00       14.69        090  S                 
                                                     graft.                                                                                             
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        7.06       5.16        0.85       13.07        090  S                 
                                                     joint.                                                                                             
26863...  ...................  A                    Fuse/graft added joint.       3.90       3.37        0.57        7.84        ZZZ  S                 
26910...  ...................  A                    Amputate metacarpal           7.18       5.16        0.93       13.27        090  S                 
                                                     bone.                                                                                              
26951...  ...................  A                    Amputation of finger/         4.41       2.87        0.49        7.77        090  S                 
                                                     thumb.                                                                                             
26952...  ...................  A                    Amputation of finger/         6.02       4.00        0.69       10.71        090  S                 
                                                     thumb.                                                                                             
26989...  ...................  C                    Hand/finger surgery....       0.00       0.00        0.00        0.00        YYY  S                 
26990...  ...................  A                    Drainage of pelvis            6.76       3.10        0.51       10.37        090  S                 
                                                     lesion.                                                                                            
26991...  ...................  A                    Drainage of pelvis            6.05       1.81        0.29        8.15        090  S                 
                                                     bursa.                                                                                             
26992...  ...................  A                    Drainage of bone lesion      12.30       6.38        1.05       19.73        090  S                 
27000...  ...................  A                    Incision of hip tendon.       5.27       1.85        0.24        7.36        090  S                 
27001...  ...................  A                    Incision of hip tendon.       6.50       2.34        0.38        9.22        090  S                 
27003...  ...................  A                    Incision of hip tendon.       6.62       6.77        1.08       14.47        090  S                 
27005...  ...................  A                    Incision of hip tendon.       9.00       3.37        0.54       12.91        090  S                 
27006...  ...................  A                    Incision of hip tendons       9.00       4.64        0.77       14.41        090  S                 
27025...  ...................  A                    Incision of hip/thigh        10.16       6.12        1.02       17.30        090  S                 
                                                     fascia.                                                                                            
27030...  ...................  A                    Drainage of hip joint..      12.09      11.42        1.86       25.37        090  S                 
27033...  ...................  A                    Exploration of hip           12.38      11.52        1.85       25.75        090  S                 
                                                     joint.                                                                                             
27035...  ...................  A                    Denervation of hip           15.72      11.86        2.21       29.79        090  S                 
                                                     joint.                                                                                             
27036...  ...................  A                    Excision of hip joint/       12.00      11.44        1.87       25.31        090  S                 
                                                     muscle.                                                                                            
27040...  ...................  A                    Biopsy of soft tissues.       2.71       0.72        0.11        3.54        010  N                 
27041...  ...................  A                    Biopsy of soft tissues.       9.36       2.67        0.44       12.47        090  S                 
27047...  ...................  A                    Remove hip/pelvis             7.16       1.89        0.32        9.37        090  S                 
                                                     lesion.                                                                                            
27048...  ...................  A                    Remove hip/pelvis             5.70       4.33        0.82       10.85        090  S                 
                                                     lesion.                                                                                            
27049...  ...................  A                    Remove tumor, hip/           12.52      10.14        1.87       24.53        090  S                 
                                                     pelvis.                                                                                            
27050...  ...................  A                    Biopsy of sacroiliac          3.73       4.78        0.90        9.41        090  S                 
                                                     joint.                                                                                             
27052...  ...................  A                    Biopsy of hip joint....       5.45       6.97        1.59       14.01        090  S                 
27054...  ...................  A                    Removal of hip joint          7.60       9.72        2.26       19.58        090  S                 
                                                     lining.                                                                                            
27060...  ...................  A                    Removal of ischial            4.73       3.93        0.68        9.34        090  S                 
                                                     bursa.                                                                                             
27062...  ...................  A                    Remove femur lesion/          4.74       4.23        0.70        9.67        090  S                 
                                                     bursa.                                                                                             
27065...  ...................  A                    Removal of hip bone           4.98       5.59        0.90       11.47        090  S                 
                                                     lesion.                                                                                            
27066...  ...................  A                    Removal of hip bone           9.17       7.90        1.30       18.37        090  S                 
                                                     lesion.                                                                                            
27067...  ...................  A                    Remove/graft hip bone        12.64      11.63        1.93       26.20        090  S                 
                                                     lesion.                                                                                            
27070...  ...................  A                    Partial removal of hip        9.58       7.41        1.21       18.20        090  S                 
                                                     bone.                                                                                              
27071...  ...................  A                    Partial removal of hip       10.23       8.50        1.45       20.18        090  S                 
                                                     bone.                                                                                              
27075...  ...................  A                    Extensive hip surgery..      15.85      13.54        2.32       31.71        090  S                 
27076...  ...................  A                    Extensive hip surgery..      20.23      16.37        2.61       39.21        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               10.34       9.09        1.46       20.89        090  S                 
                                                     prosthesis.                                                                                        
27091...  ...................  A                    Removal of hip               20.48      19.81        3.16       43.45        090  S                 
                                                     prosthesis.                                                                                        
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            8.08       7.71        1.26       17.05        090  S                 
                                                     pelvis.                                                                                            
27100...  ...................  A                    Transfer of abdominal        10.57       7.68        1.42       19.67        090  S                 
                                                     muscle.                                                                                            
27105...  ...................  A                    Transfer of spinal           11.26       5.89        1.36       18.51        090  S                 
                                                     muscle.                                                                                            

[[Page 59575]]

                                                                                                                                                        
27110...  ...................  A                    Transfer of iliopsoas        12.49      10.61        1.86       24.96        090  S                 
                                                     muscle.                                                                                            
27111...  ...................  A                    Transfer of iliopsoas        11.44      11.63        1.65       24.72        090  S                 
                                                     muscle.                                                                                            
27120...  ...................  A                    Reconstruction of hip        16.43      18.10        2.95       37.48        090  S                 
                                                     socket.                                                                                            
27122...  ...................  A                    Reconstruction of hip        13.56      17.36        2.94       33.86        090  S                 
                                                     socket.                                                                                            
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             27.00      31.41        5.96       64.37        090  S                 
                                                     replacement.                                                                                       
27137...  ...................  A                    Revise hip joint             20.00      23.90        4.82       48.72        090  S                 
                                                     replacement.                                                                                       
27138...  ...................  A                    Revise hip joint             21.00      24.23        4.58       49.81        090  S                 
                                                     replacement.                                                                                       
27140...  ...................  A                    Transplant of femur          11.43      11.05        1.71       24.19        090  S                 
                                                     ridge.                                                                                             
27146...  ...................  A                    Incision of hip bone...      16.55      10.88        1.35       28.78        090  S                 
27147...  ...................  A                    Revision of hip bone...      19.70      16.97        2.76       39.43        090  S                 
27151...  ...................  A                    Incision of hip bones..      21.50      17.71        2.90       42.11        090  S                 
27156...  ...................  A                    Revision of hip bones..      23.62      18.32        3.08       45.02        090  S                 
27158...  ...................  A                    Revision of pelvis.....      18.10      14.42        2.64       35.16        090  S                 
27161...  ...................  A                    Incision of neck of          15.20      14.31        2.31       31.82        090  S                 
                                                     femur.                                                                                             
27165...  ...................  A                    Incision/fixation of         16.20      16.76        2.63       35.59        090  S                 
                                                     femur.                                                                                             
27170...  ...................  A                    Repair/graft femur head/     14.90      16.41        2.65       33.96        090  S                 
                                                     neck.                                                                                              
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               13.76      12.39        2.05       28.20        090  S                 
                                                     epiphysis.                                                                                         
27178...  ...................  A                    Repair slipped               10.76      10.46        1.55       22.77        090  S                 
                                                     epiphysis.                                                                                         
27179...  ...................  A                    Revise head/neck of          11.69      11.15        1.83       24.67        090  S                 
                                                     femur.                                                                                             
27181...  ...................  A                    Repair slipped               13.80      13.14        2.16       29.10        090  S                 
                                                     epiphysis.                                                                                         
27185...  ...................  A                    Revision of femur             8.30       2.77        0.87       11.94        090  S                 
                                                     epiphysis.                                                                                         
27187...  ...................  A                    Reinforce hip bones....      12.57      16.09        2.76       31.42        090  S                 
27193...  ...................  A                    Treat pelvic ring             4.64       2.41        0.39        7.44        090  S                 
                                                     fracture.                                                                                          
27194...  ...................  A                    Treat pelvic ring             8.73       3.90        0.50       13.13        090  S                 
                                                     fracture.                                                                                          
27200...  ...................  A                    Treat tail bone               1.76       1.49        0.17        3.42        090  S                 
                                                     fracture.                                                                                          
27202...  ...................  A                    Repair tail bone              6.52       6.15        0.89       13.56        090  S                 
                                                     fracture.                                                                                          
27215...  ...................  A                    Pelvic fracture(s)            9.39      12.02        2.33       23.74        090  S                 
                                                     treatment.                                                                                         
27216...  ...................  A                    Treat pelvic ring            14.20       4.30        0.66       19.16        090  S                 
                                                     fracture.                                                                                          
27217...  ...................  A                    Treat pelvic ring            13.19      14.55        2.33       30.07        090  S                 
                                                     fracture.                                                                                          
27218...  ...................  A                    Treat pelvic ring            18.83      14.55        2.33       35.71        090  S                 
                                                     fracture.                                                                                          
27220...  ...................  A                    Treat hip socket              5.26       4.26        0.64       10.16        090  S                 
                                                     fracture.                                                                                          
27222...  ...................  A                    Treat hip socket             10.95       6.37        1.03       18.35        090  S                 
                                                     fracture.                                                                                          
27226...  ...................  A                    Treat hip wall fracture      13.93      15.78        2.52       32.23        090  S                 
27227...  ...................  A                    Treat hip fracture(s)..      22.00      19.70        3.20       44.90        090  S                 
27228...  ...................  A                    Treat hip fracture(s)..      25.59      19.95        3.20       48.74        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              11.02      14.10        2.60       27.72        090  S                 
                                                     fracture.                                                                                          
27236...  ...................  A                    Repair of thigh              14.14      16.91        2.71       33.76        090  S                 
                                                     fracture.                                                                                          
27238...  ...................  A                    Treatment of thigh            5.06       4.91        0.71       10.68        090  S                 
                                                     fracture.                                                                                          
27240...  ...................  A                    Treatment of thigh           10.86       9.70        1.53       22.09        090  S                 
                                                     fracture.                                                                                          
27244...  ...................  A                    Repair of thigh              14.35      16.30        2.62       33.27        090  S                 
                                                     fracture.                                                                                          
27245...  ...................  A                    Repair of thigh              18.72      16.30        2.62       37.64        090  S                 
                                                     fracture.                                                                                          
27246...  ...................  A                    Treatment of thigh            4.36       3.87        0.60        8.83        090  S                 
                                                     fracture.                                                                                          
27248...  ...................  A                    Repair of thigh               9.73      12.46        2.11       24.30        090  S                 
                                                     fracture.                                                                                          
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                11.98      13.14        2.11       27.23        090  S                 
                                                     dislocation.                                                                                       
27254...  ...................  A                    Repair of hip                17.29      13.47        2.27       33.03        090  S                 
                                                     dislocation.                                                                                       
27256...  ...................  A                    Treatment of hip              3.72       1.88        0.31        5.91        010  S                 
                                                     dislocation.                                                                                       
27257...  ...................  A                    Treatment of hip              4.82       4.62        0.73       10.17        010  S                 
                                                     dislocation.                                                                                       
27258...  ...................  A                    Repair of hip                14.40      13.73        2.25       30.38        090  S                 
                                                     dislocation.                                                                                       
27259...  ...................  A                    Repair of hip                20.50      17.20        2.82       40.52        090  S                 
                                                     dislocation.                                                                                       
27265...  ...................  A                    Treatment of hip              4.74       3.46        0.54        8.74        090  S                 
                                                     dislocation.                                                                                       
27266...  ...................  A                    Treatment of hip              6.96       4.45        0.71       12.12        090  S                 
                                                     dislocation.                                                                                       
27275...  ...................  A                    Manipulation of hip           2.00       1.88        0.30        4.18        010  S                 
                                                     joint.                                                                                             
27280...  ...................  A                    Fusion of sacroiliac         11.81      10.06        1.77       23.64        090  S                 
                                                     joint.                                                                                             
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         21.68      25.40        4.70       51.78        090  S                 
                                                     hip.                                                                                               
27295...  ...................  A                    Amputation of leg at         17.32      16.54        2.95       36.81        090  S                 
                                                     hip.                                                                                               

[[Page 59576]]

                                                                                                                                                        
27299...  ...................  C                    Pelvis/hip joint              0.00       0.00        0.00        0.00        YYY  S                 
                                                     surgery.                                                                                           
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 &         5.42       3.80        0.68        9.90        090  S                 
                                                     fascia.                                                                                            
27306...  ...................  A                    Incision of thigh             4.27       1.99        0.32        6.58        090  S                 
                                                     tendon.                                                                                            
27307...  ...................  A                    Incision of thigh             5.30       3.01        0.48        8.79        090  S                 
                                                     tendons.                                                                                           
27310...  ...................  A                    Exploration of knee           8.26       9.60        1.51       19.37        090  S                 
                                                     joint.                                                                                             
27315...  ...................  A                    Partial removal, thigh        6.51       5.38        0.96       12.85        090  S                 
                                                     nerve.                                                                                             
27320...  ...................  A                    Partial removal, thigh        5.90       5.18        0.73       11.81        090  S                 
                                                     nerve.                                                                                             
27323...  ...................  A                    Biopsy thigh soft             2.23       0.91        0.13        3.27        010  S                 
                                                     tissues.                                                                                           
27324...  ...................  A                    Biopsy thigh soft             4.53       2.63        0.45        7.61        090  S                 
                                                     tissues.                                                                                           
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/         13.00      11.69        2.14       26.83        090  S                 
                                                     knee.                                                                                              
27330...  ...................  A                    Biopsy knee joint             4.71       6.02        1.19       11.92        090  S                 
                                                     lining.                                                                                            
27331...  ...................  A                    Explore/treat knee            5.51       7.05        1.49       14.05        090  S                 
                                                     joint.                                                                                             
27332...  ...................  A                    Removal of knee               7.85      10.05        1.73       19.63        090  S                 
                                                     cartilage.                                                                                         
27333...  ...................  A                    Removal of knee               6.81       9.01        2.52       18.34        090  S                 
                                                     cartilage.                                                                                         
27334...  ...................  A                    Remove knee joint             7.95      10.18        1.77       19.90        090  S                 
                                                     lining.                                                                                            
27335...  ...................  A                    Remove knee joint             9.19      11.76        2.05       23.00        090  S                 
                                                     lining.                                                                                            
27340...  ...................  A                    Removal of kneecap            3.92       3.85        0.62        8.39        090  S                 
                                                     bursa.                                                                                             
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/          8.60       8.20        1.34       18.14        090  S                 
                                                     graft.                                                                                             
27357...  ...................  A                    Remove femur lesion/          9.63       8.80        1.43       19.86        090  S                 
                                                     graft.                                                                                             
27358...  ...................  A                    Remove femur lesion/          4.74       4.55        0.72       10.01        ZZZ  S                 
                                                     fixation.                                                                                          
27360...  ...................  A                    Partial removal leg           9.23       8.56        1.40       19.19        090  S                 
                                                     bone(s).                                                                                           
27365...  ...................  A                    Extensive leg surgery..      15.00      13.94        2.43       31.37        090  S                 
27370...  ...................  A                    Injection for knee x-         0.96       0.60        0.05        1.61        000  N                 
                                                     ray.                                                                                               
27372...  ...................  A                    Removal of foreign body       4.81       3.42        0.54        8.77        090  S                 
27380...  ...................  A                    Repair of kneecap             6.63       7.94        1.29       15.86        090  S                 
                                                     tendon.                                                                                            
27381...  ...................  A                    Repair/graft kneecap          9.66      11.27        1.82       22.75        090  S                 
                                                     tendon.                                                                                            
27385...  ...................  A                    Repair of thigh muscle.       7.17       8.84        1.42       17.43        090  S                 
27386...  ...................  A                    Repair/graft of thigh         9.72      12.44        2.02       24.18        090  S                 
                                                     muscle.                                                                                            
27390...  ...................  A                    Incision of thigh             4.89       4.36        0.71        9.96        090  S                 
                                                     tendon.                                                                                            
27391...  ...................  A                    Incision of thigh             6.67       5.42        0.90       12.99        090  S                 
                                                     tendons.                                                                                           
27392...  ...................  A                    Incision of thigh             8.52       7.67        1.28       17.47        090  S                 
                                                     tendons.                                                                                           
27393...  ...................  A                    Lengthening of thigh          5.95       5.67        0.93       12.55        090  S                 
                                                     tendon.                                                                                            
27394...  ...................  A                    Lengthening of thigh          7.97       5.73        0.94       14.64        090  S                 
                                                     tendons.                                                                                           
27395...  ...................  A                    Lengthening of thigh         10.96      10.48        1.65       23.09        090  S                 
                                                     tendons.                                                                                           
27396...  ...................  A                    Transplant of thigh           7.33       7.06        1.11       15.50        090  S                 
                                                     tendon.                                                                                            
27397...  ...................  A                    Transplants of thigh         10.53       8.88        1.45       20.86        090  S                 
                                                     tendons.                                                                                           
27400...  ...................  A                    Revise thigh muscles/         8.47       7.89        1.24       17.60        090  S                 
                                                     tendons.                                                                                           
27403...  ...................  A                    Repair of knee                7.80       8.79        1.44       18.03        090  S                 
                                                     cartilage.                                                                                         
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               11.80      15.10        2.48       29.38        090  S                 
                                                     ligaments.                                                                                         
27418...  ...................  A                    Repair degenerated            9.82      12.23        1.85       23.90        090  S                 
                                                     kneecap.                                                                                           
27420...  ...................  A                    Revision of unstable          9.15      10.99        1.74       21.88        090  S                 
                                                     kneecap.                                                                                           
27422...  ...................  A                    Revision of unstable          9.10      11.45        1.83       22.38        090  S                 
                                                     kneecap.                                                                                           
27424...  ...................  A                    Revision/removal of           9.13      11.68        1.89       22.70        090  S                 
                                                     kneecap.                                                                                           
27425...  ...................  A                    Lateral retinacular           5.04       6.46        1.08       12.58        090  S                 
                                                     release.                                                                                           
27427...  ...................  A                    Reconstruction, knee...       8.68      11.12        2.25       22.05        090  S                 
27428...  ...................  A                    Reconstruction, knee...      13.28      13.67        2.71       29.66        090  S                 
27429...  ...................  A                    Reconstruction, knee...      14.67      11.27        1.83       27.77        090  S                 
27430...  ...................  A                    Revision of thigh             8.92       9.36        1.50       19.78        090  S                 
                                                     muscles.                                                                                           
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          10.29      13.13        2.14       25.56        090  S                 
                                                     implant.                                                                                           
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                 
27447...  ...................  A                    Total knee replacement.      19.69      25.20        4.95       49.84        090  S                 

[[Page 59577]]

                                                                                                                                                        
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         16.55      15.70        2.82       35.07        090  S                 
                                                     bone.                                                                                              
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          12.84      12.24        2.00       27.08        090  S                 
                                                     bone.                                                                                              
27466...  ...................  A                    Lengthening of thigh         15.08      13.43        2.27       30.78        090  S                 
                                                     bone.                                                                                              
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           8.11       7.74        1.27       17.12        090  S                 
                                                     growth.                                                                                            
27477...  ...................  A                    Surgery to stop leg           9.32      11.93        2.57       23.82        090  S                 
                                                     growth.                                                                                            
27479...  ...................  A                    Surgery to stop leg          12.18      11.63        1.89       25.70        090  S                 
                                                     growth.                                                                                            
27485...  ...................  A                    Surgery to stop leg           8.31       7.91        1.30       17.52        090  S                 
                                                     growth.                                                                                            
27486...  ...................  A                    Revise knee joint            18.00      21.28        4.26       43.54        090  S                 
                                                     replace.                                                                                           
27487...  ...................  A                    Revise knee joint            24.00      27.76        5.97       57.73        090  S                 
                                                     replace.                                                                                           
27488...  ...................  A                    Removal of knee              14.48      16.16        2.58       33.22        090  S                 
                                                     prosthesis.                                                                                        
27495...  ...................  A                    Reinforce thigh........      14.26      17.63        2.82       34.71        090  S                 
27496...  ...................  A                    Decompression of thigh/       4.75       4.53        0.74       10.02        090  S                 
                                                     knee.                                                                                              
27497...  ...................  A                    Decompression of thigh/       5.81       5.55        0.91       12.27        090  S                 
                                                     knee.                                                                                              
27498...  ...................  A                    Decompression of thigh/       6.63       6.32        1.04       13.99        090  S                 
                                                     knee.                                                                                              
27499...  ...................  A                    Decompression of thigh/       7.64       7.28        1.19       16.11        090  S                 
                                                     knee.                                                                                              
27500...  ...................  A                    Treatment of thigh            5.29       5.41        0.82       11.52        090  S                 
                                                     fracture.                                                                                          
27501...  ...................  A                    Treatment of thigh            5.29       5.41        0.82       11.52        090  S                 
                                                     fracture.                                                                                          
27502...  ...................  A                    Treatment of thigh            9.51       7.67        1.21       18.39        090  S                 
                                                     fracture.                                                                                          
27503...  ...................  A                    Treatment of thigh            9.51       7.67        1.21       18.39        090  S                 
                                                     fracture.                                                                                          
27506...  ...................  A                    Repair of thigh              15.93      16.02        2.56       34.51        090  S                 
                                                     fracture.                                                                                          
27507...  ...................  A                    Treatment of thigh           12.85      16.02        2.56       31.43        090  S                 
                                                     fracture.                                                                                          
27508...  ...................  A                    Treatment of thigh            5.21       4.22        0.65       10.08        090  S                 
                                                     fracture.                                                                                          
27509...  ...................  A                    Treatment of thigh            6.77       4.22        0.65       11.64        090  S                 
                                                     fracture.                                                                                          
27510...  ...................  A                    Treatment of thigh            8.19       6.82        1.09       16.10        090  S                 
                                                     fracture.                                                                                          
27511...  ...................  A                    Treatment of thigh           12.50      16.00        2.56       31.06        090  S                 
                                                     fracture.                                                                                          
27513...  ...................  A                    Treatment of thigh           16.78      16.02        2.56       35.36        090  S                 
                                                     fracture.                                                                                          
27514...  ...................  A                    Repair of thigh              15.98      15.76        2.53       34.27        090  S                 
                                                     fracture.                                                                                          
27516...  ...................  A                    Repair of thigh growth        4.92       4.82        0.71       10.45        090  S                 
                                                     plate.                                                                                             
27517...  ...................  A                    Repair of thigh growth        8.20       7.82        1.28       17.30        090  S                 
                                                     plate.                                                                                             
27519...  ...................  A                    Repair of thigh growth       13.82      12.68        2.05       28.55        090  S                 
                                                     plate.                                                                                             
27520...  ...................  A                    Treat kneecap fracture.       2.68       3.04        0.45        6.17        090  S                 
27524...  ...................  A                    Repair of kneecap             9.38      10.34        1.65       21.37        090  S                 
                                                     fracture.                                                                                          
27530...  ...................  A                    Treatment of knee             3.23       3.40        0.51        7.14        090  S                 
                                                     fracture.                                                                                          
27532...  ...................  A                    Treatment of knee             6.81       5.68        0.91       13.40        090  S                 
                                                     fracture.                                                                                          
27535...  ...................  A                    Treatment of knee            10.36      11.69        1.88       23.93        090  S                 
                                                     fracture.                                                                                          
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               13.47      12.48        1.95       27.90        090  S                 
                                                     dislocation.                                                                                       
27557...  ...................  A                    Repair of knee               15.80      14.60        2.43       32.83        090  S                 
                                                     dislocation.                                                                                       
27558...  ...................  A                    Repair of knee               16.75      14.60        2.43       33.78        090  S                 
                                                     dislocation.                                                                                       
27560...  ...................  A                    Treat kneecap                 3.64       1.43        0.16        5.23        090  S                 
                                                     dislocation.                                                                                       
27562...  ...................  A                    Treat kneecap                 5.48       5.18        0.76       11.42        090  S                 
                                                     dislocation.                                                                                       
27566...  ...................  A                    Repair kneecap               11.48      10.58        1.67       23.73        090  S                 
                                                     dislocation.                                                                                       
27570...  ...................  A                    Fixation of knee joint.       1.69       1.72        0.28        3.69        010  S                 
27580...  ...................  A                    Fusion of knee.........      18.20      15.70        2.56       36.46        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          6.30       3.65        0.68       10.63        090  S                 
                                                     surgery.                                                                                           
27596...  ...................  A                    Amputation follow-up          9.63       7.37        1.42       18.42        090  S                 
                                                     surgery.                                                                                           
27598...  ...................  A                    Amputate lower leg at         9.56      10.04        1.78       21.38        090  S                 
                                                     knee.                                                                                              
27599...  ...................  C                    Leg surgery procedure..       0.00       0.00        0.00        0.00        YYY  S                 
27600...  ...................  A                    Decompression of lower        5.02       3.39        0.64        9.05        090  S                 
                                                     leg.                                                                                               
27601...  ...................  A                    Decompression of lower        4.98       3.38        0.67        9.03        090  S                 
                                                     leg.                                                                                               
27602...  ...................  A                    Decompression of lower        6.63       4.05        0.77       11.45        090  S                 
                                                     leg.                                                                                               
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                 

[[Page 59578]]

                                                                                                                                                        
27605...  ...................  A                    Incision of achilles          2.82       1.18        0.14        4.14        010  S                 
                                                     tendon.                                                                                            
27606...  ...................  A                    Incision of achilles          3.87       2.12        0.35        6.34        010  S                 
                                                     tendon.                                                                                            
27607...  ...................  A                    Treat lower leg bone          7.05       6.01        0.98       14.04        090  S                 
                                                     lesion.                                                                                            
27610...  ...................  A                    Explore/treat ankle           7.27       7.43        1.13       15.83        090  S                 
                                                     joint.                                                                                             
27612...  ...................  A                    Exploration of ankle          6.23       7.97        1.30       15.50        090  S                 
                                                     joint.                                                                                             
27613...  ...................  A                    Biopsy lower leg soft         2.12       0.67        0.10        2.89        010  S                 
                                                     tissue.                                                                                            
27614...  ...................  A                    Biopsy lower leg soft         5.29       2.26        0.38        7.93        090  S                 
                                                     tissue.                                                                                            
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          5.69       6.03        0.96       12.68        090  S                 
                                                     joint.                                                                                             
27625...  ...................  A                    Remove ankle joint            7.88       8.71        1.27       17.86        090  S                 
                                                     lining.                                                                                            
27626...  ...................  A                    Remove ankle joint            8.49      10.86        1.25       20.60        090  S                 
                                                     lining.                                                                                            
27630...  ...................  A                    Removal of tendon             4.65       3.10        0.46        8.21        090  S                 
                                                     lesion.                                                                                            
27635...  ...................  A                    Remove lower leg bone         7.29       8.04        1.27       16.60        090  S                 
                                                     lesion.                                                                                            
27637...  ...................  A                    Remove/graft leg bone         9.14       8.47        1.40       19.01        090  S                 
                                                     lesion.                                                                                            
27638...  ...................  A                    Remove/graft leg bone         9.89       9.15        1.52       20.56        090  S                 
                                                     lesion.                                                                                            
27640...  ...................  A                    Partial removal of           10.21       9.81        1.57       21.59        090  S                 
                                                     tibia.                                                                                             
27641...  ...................  A                    Partial removal of            8.36       7.13        1.18       16.67        090  S                 
                                                     fibula.                                                                                            
27645...  ...................  A                    Extensive lower leg          13.14      11.64        1.98       26.76        090  S                 
                                                     surgery.                                                                                           
27646...  ...................  A                    Extensive lower leg          11.69      10.75        1.71       24.15        090  S                 
                                                     surgery.                                                                                           
27647...  ...................  A                    Extensive ankle/heel         11.21       9.95        1.35       22.51        090  S                 
                                                     surgery.                                                                                           
27648...  ...................  A                    Injection for ankle x-        0.96       0.52        0.05        1.53        000  N                 
                                                     ray.                                                                                               
27650...  ...................  A                    Repair achilles tendon.       9.07       8.98        1.41       19.46        090  S                 
27652...  ...................  A                    Repair/graft achilles         9.62      10.41        1.56       21.59        090  S                 
                                                     tendon.                                                                                            
27654...  ...................  A                    Repair of achilles            9.34      10.93        1.65       21.92        090  S                 
                                                     tendon.                                                                                            
27656...  ...................  A                    Repair leg fascia             4.31       3.18        0.54        8.03        090  S                 
                                                     defect.                                                                                            
27658...  ...................  A                    Repair of leg tendon,         4.61       4.02        0.60        9.23        090  S                 
                                                     each.                                                                                              
27659...  ...................  A                    Repair of leg tendon,         6.28       5.87        0.86       13.01        090  S                 
                                                     each.                                                                                              
27664...  ...................  A                    Repair of leg tendon,         4.33       3.41        0.52        8.26        090  S                 
                                                     each.                                                                                              
27665...  ...................  A                    Repair of leg tendon,         5.11       4.95        0.76       10.82        090  S                 
                                                     each.                                                                                              
27675...  ...................  A                    Repair lower leg              6.78       6.40        0.94       14.12        090  S                 
                                                     tendons.                                                                                           
27676...  ...................  A                    Repair lower leg              7.87       7.56        1.14       16.57        090  S                 
                                                     tendons.                                                                                           
27680...  ...................  A                    Release of lower leg          5.37       4.12        0.61       10.10        090  S                 
                                                     tendon.                                                                                            
27681...  ...................  A                    Release of lower leg          6.36       5.97        0.86       13.19        090  S                 
                                                     tendons.                                                                                           
27685...  ...................  A                    Revision of lower leg         6.08       3.83        0.41       10.32        090  S                 
                                                     tendon.                                                                                            
27686...  ...................  A                    Revise lower leg              6.93       6.56        0.90       14.39        090  S                 
                                                     tendons.                                                                                           
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         1.87       2.03        0.29        4.19        ZZZ  S                 
                                                     tendon.                                                                                            
27695...  ...................  A                    Repair of ankle               6.09       7.79        1.32       15.20        090  S                 
                                                     ligament.                                                                                          
27696...  ...................  A                    Repair of ankle               7.72       7.06        1.16       15.94        090  S                 
                                                     ligaments.                                                                                         
27698...  ...................  A                    Repair of ankle               8.87      11.35        1.86       22.08        090  S                 
                                                     ligament.                                                                                          
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        14.49      13.82        2.25       30.56        090  S                 
                                                     joint.                                                                                             
27704...  ...................  A                    Removal of ankle              7.20       5.84        0.98       14.02        090  S                 
                                                     implant.                                                                                           
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 &           9.14      11.70        2.14       22.98        090  S                 
                                                     fibula.                                                                                            
27712...  ...................  A                    Realignment of lower         13.20      10.99        1.63       25.82        090  S                 
                                                     leg.                                                                                               
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..      13.88      15.50        2.87       32.25        090  S                 
27725...  ...................  A                    Repair of lower leg....      14.50      10.43        1.53       26.46        090  S                 
27727...  ...................  A                    Repair of lower leg....      12.89       9.38        1.84       24.11        090  S                 
27730...  ...................  A                    Repair of tibia               6.88       3.59        0.84       11.31        090  S                 
                                                     epiphysis.                                                                                         
27732...  ...................  A                    Repair of fibula              5.06       4.84        0.79       10.69        090  S                 
                                                     epiphysis.                                                                                         
27734...  ...................  A                    Repair lower leg              7.89       7.54        1.23       16.66        090  S                 
                                                     epiphyses.                                                                                         
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                 
27750...  ...................  A                    Treatment of tibia            2.90       3.45        0.50        6.85        090  S                 
                                                     fracture.                                                                                          
27752...  ...................  A                    Treatment of tibia            5.16       5.09        0.81       11.06        090  S                 
                                                     fracture.                                                                                          
27756...  ...................  A                    Repair of tibia               5.84       7.48        1.70       15.02        090  S                 
                                                     fracture.                                                                                          

[[Page 59579]]

                                                                                                                                                        
27758...  ...................  A                    Repair of tibia              10.51      13.46        2.22       26.19        090  S                 
                                                     fracture.                                                                                          
27759...  ...................  A                    Repair of tibia              12.60      13.74        2.22       28.56        090  S                 
                                                     fracture.                                                                                          
27760...  ...................  A                    Treatment of ankle            2.81       2.58        0.37        5.76        090  S                 
                                                     fracture.                                                                                          
27762...  ...................  A                    Treatment of ankle            4.80       3.36        0.50        8.66        090  S                 
                                                     fracture.                                                                                          
27766...  ...................  A                    Repair of ankle               7.61       7.87        1.26       16.74        090  S                 
                                                     fracture.                                                                                          
27780...  ...................  A                    Treatment of fibula           2.47       1.97        0.26        4.70        090  S                 
                                                     fracture.                                                                                          
27781...  ...................  A                    Treatment of fibula           4.20       3.29        0.49        7.98        090  S                 
                                                     fracture.                                                                                          
27784...  ...................  A                    Repair of fibula              6.45       5.59        0.87       12.91        090  S                 
                                                     fracture.                                                                                          
27786...  ...................  A                    Treatment of ankle            2.66       2.52        0.38        5.56        090  S                 
                                                     fracture.                                                                                          
27788...  ...................  A                    Treatment of ankle            4.25       3.27        0.50        8.02        090  S                 
                                                     fracture.                                                                                          
27792...  ...................  A                    Repair of ankle               7.04       7.38        1.17       15.59        090  S                 
                                                     fracture.                                                                                          
27808...  ...................  A                    Treatment of ankle            2.63       2.79        0.39        5.81        090  S                 
                                                     fracture.                                                                                          
27810...  ...................  A                    Treatment of ankle            4.82       5.05        0.80       10.67        090  S                 
                                                     fracture.                                                                                          
27814...  ...................  A                    Repair of ankle               9.87      10.00        1.60       21.47        090  S                 
                                                     fracture.                                                                                          
27816...  ...................  A                    Treatment of ankle            2.71       3.47        0.55        6.73        090  S                 
                                                     fracture.                                                                                          
27818...  ...................  A                    Treatment of ankle            5.08       6.51        1.06       12.65        090  S                 
                                                     fracture.                                                                                          
27822...  ...................  A                    Repair of ankle               8.39      10.73        1.88       21.00        090  S                 
                                                     fracture.                                                                                          
27823...  ...................  A                    Repair of ankle              10.90      12.79        2.05       25.74        090  S                 
                                                     fracture.                                                                                          
27824...  ...................  A                    Treat lower leg               2.71       3.47        0.55        6.73        090  S                 
                                                     fracture.                                                                                          
27825...  ...................  A                    Treat lower leg               5.08       6.51        1.06       12.65        090  S                 
                                                     fracture.                                                                                          
27826...  ...................  A                    Treat lower leg               7.43       9.50        1.88       18.81        090  S                 
                                                     fracture.                                                                                          
27827...  ...................  A                    Treat lower leg              12.95      11.71        1.88       26.54        090  S                 
                                                     fracture.                                                                                          
27828...  ...................  A                    Treat lower leg              15.12      12.79        2.05       29.96        090  S                 
                                                     fracture.                                                                                          
27829...  ...................  A                    Treat lower leg joint..       4.87       6.23        1.37       12.47        090  S                 
27830...  ...................  A                    Treat lower leg               3.50       3.25        0.46        7.21        090  S                 
                                                     dislocation.                                                                                       
27831...  ...................  A                    Treat lower leg               4.27       3.98        0.59        8.84        090  S                 
                                                     dislocation.                                                                                       
27832...  ...................  A                    Repair lower leg              5.96       5.70        0.89       12.55        090  S                 
                                                     dislocation.                                                                                       
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                  9.04       8.59        1.37       19.00        090  S                 
                                                     dislocation.                                                                                       
27848...  ...................  A                    Repair ankle                 10.45       8.36        1.32       20.13        090  S                 
                                                     dislocation.                                                                                       
27860...  ...................  A                    Fixation of ankle joint       2.29       1.39        0.23        3.91        010  S                 
27870...  ...................  A                    Fusion of ankle joint..      13.00      13.34        2.22       28.56        090  S                 
27871...  ...................  A                    Fusion of tibiofibular        8.55       7.79        1.21       17.55        090  S                 
                                                     joint.                                                                                             
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          7.40       3.37        0.61       11.38        090  S                 
                                                     surgery.                                                                                           
27886...  ...................  A                    Amputation follow-up          8.35       7.17        1.34       16.86        090  S                 
                                                     surgery.                                                                                           
27888...  ...................  A                    Amputation of foot at         8.70       9.49        1.65       19.84        090  S                 
                                                     ankle.                                                                                             
27889...  ...................  A                    Amputation of foot at         8.82       8.43        1.55       18.80        090  S                 
                                                     ankle.                                                                                             
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...       9.13       4.05        0.77       13.95        090  S                 
27899...  ...................  C                    Leg/ankle surgery             0.00       0.00        0.00        0.00        YYY  S                 
                                                     procedure.                                                                                         
28001...  ...................  A                    Drainage of bursa of          2.68       0.52        0.05        3.25        010  S                 
                                                     foot.                                                                                              
28002...  ...................  A                    Treatment of foot             3.76       2.25        0.33        6.34        010  S                 
                                                     infection.                                                                                         
28003...  ...................  A                    Treatment of foot             7.49       3.50        0.59       11.58        090  S                 
                                                     infection.                                                                                         
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.       2.71       3.62        0.33        6.66        090  S                 
28011...  ...................  A                    Incision of toe tendons       3.99       1.77        0.19        5.95        090  S                 
28020...  ...................  A                    Exploration of a foot         4.75       4.40        0.56        9.71        090  S                 
                                                     joint.                                                                                             
28022...  ...................  A                    Exploration of a foot         4.41       2.74        0.31        7.46        090  S                 
                                                     joint.                                                                                             
28024...  ...................  A                    Exploration of a toe          4.12       2.39        0.24        6.75        090  S                 
                                                     joint.                                                                                             
28030...  ...................  A                    Removal of foot nerve..       5.78       3.93        0.42       10.13        090  S                 
28035...  ...................  A                    Decompression of tibia        4.83       6.18        0.90       11.91        090  S                 
                                                     nerve.                                                                                             
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,           9.41       5.35        0.79       15.55        090  S                 
                                                     foot.                                                                                              
28050...  ...................  A                    Biopsy of foot joint          3.99       3.84        0.53        8.36        090  S                 
                                                     lining.                                                                                            
28052...  ...................  A                    Biopsy of foot joint          3.70       3.82        0.43        7.95        090  S                 
                                                     lining.                                                                                            
28054...  ...................  A                    Biopsy of toe joint           3.21       2.24        0.28        5.73        090  S                 
                                                     lining.                                                                                            
28060...  ...................  A                    Partial removal foot          5.05       4.22        0.53        9.80        090  S                 
                                                     fascia.                                                                                            
28062...  ...................  A                    Removal of foot fascia.       6.23       7.06        0.86       14.15        090  S                 
28070...  ...................  A                    Removal of foot joint         4.73       4.48        0.48        9.69        090  S                 
                                                     lining.                                                                                            
28072...  ...................  A                    Removal of foot joint         4.32       3.21        0.42        7.95        090  S                 
                                                     lining.                                                                                            

[[Page 59580]]

                                                                                                                                                        
28080...  ...................  A                    Removal of foot lesion.       3.18       4.07        0.45        7.70        090  S                 
28086...  ...................  A                    Excise foot tendon            4.52       3.12        0.46        8.10        090  S                 
                                                     sheath.                                                                                            
28088...  ...................  A                    Excise foot tendon            3.62       3.62        0.40        7.64        090  S                 
                                                     sheath.                                                                                            
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         5.37       4.58        0.56       10.51        090  S                 
                                                     lesion.                                                                                            
28102...  ...................  A                    Remove/graft foot             7.31       6.84        0.85       15.00        090  S                 
                                                     lesion.                                                                                            
28103...  ...................  A                    Remove/graft foot             6.10       5.61        0.69       12.40        090  S                 
                                                     lesion.                                                                                            
28104...  ...................  A                    Removal of foot lesion.       4.86       4.33        0.49        9.68        090  S                 
28106...  ...................  A                    Remove/graft foot             6.74       6.42        0.79       13.95        090  S                 
                                                     lesion.                                                                                            
28107...  ...................  A                    Remove/graft foot             5.16       4.86        0.48       10.50        090  S                 
                                                     lesion.                                                                                            
28108...  ...................  A                    Removal of toe lesions.       4.01       4.20        0.38        8.59        090  S                 
28110...  ...................  A                    Part removal of               3.82       3.48        0.39        7.69        090  S                 
                                                     metatarsal.                                                                                        
28111...  ...................  A                    Part removal of               4.64       5.04        0.65       10.33        090  S                 
                                                     metatarsal.                                                                                        
28112...  ...................  A                    Part removal of               4.23       3.96        0.45        8.64        090  S                 
                                                     metatarsal.                                                                                        
28113...  ...................  A                    Part removal of               4.23       4.44        0.48        9.15        090  S                 
                                                     metatarsal.                                                                                        
28114...  ...................  A                    Removal of metatarsal         8.65       9.17        1.42       19.24        090  S                 
                                                     heads.                                                                                             
28116...  ...................  A                    Revision of foot.......       7.00       5.48        0.57       13.05        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/        4.81       5.04        0.67       10.52        090  S                 
                                                     heel.                                                                                              
28122...  ...................  A                    Partial removal of foot       6.62       4.48        0.54       11.64        090  S                 
                                                     bone.                                                                                              
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       1.91       0.52        0.05        2.48        010  S                 
                                                     body.                                                                                              
28192...  ...................  A                    Removal of foot foreign       4.49       1.95        0.24        6.68        090  S                 
                                                     body.                                                                                              
28193...  ...................  A                    Removal of foot foreign       5.44       2.38        0.30        8.12        090  S                 
                                                     body.                                                                                              
28200...  ...................  A                    Repair of foot tendon..       4.45       5.06        0.50       10.01        090  S                 
28202...  ...................  A                    Repair/graft of foot          6.38       5.82        0.77       12.97        090  S                 
                                                     tendon.                                                                                            
28208...  ...................  A                    Repair of foot tendon..       4.11       2.81        0.28        7.20        090  S                 
28210...  ...................  A                    Repair/graft of foot          5.95       5.60        0.60       12.15        090  S                 
                                                     tendon.                                                                                            
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              4.00       2.43        0.22        6.65        090  S                 
                                                     tendon(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                 
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            7.50       4.43        0.48       12.41        090  S                 
                                                     joint.                                                                                             
28261...  ...................  A                    Revision of foot tendon      10.95       5.91        0.58       17.44        090  S                 
28262...  ...................  A                    Revision of foot and         15.00      11.91        1.44       28.35        090  S                 
                                                     ankle.                                                                                             
28264...  ...................  A                    Release of midfoot            9.80       9.56        1.17       20.53        090  S                 
                                                     joint.                                                                                             
28270...  ...................  A                    Release of foot               4.58       2.63        0.23        7.44        090  S                 
                                                     contracture.                                                                                       
28272...  ...................  A                    Release of toe joint,         3.67       2.04        0.18        5.89        090  S                 
                                                     each.                                                                                              
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       4.23       3.75        0.43        8.41        090  S                 
                                                     bone.                                                                                              
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                 
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                 

[[Page 59581]]

                                                                                                                                                        
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           8.67       6.44        0.70       15.81        090  S                 
                                                     bones.                                                                                             
28305...  ...................  A                    Incise/graft midfoot          9.99       9.85        1.03       20.87        090  S                 
                                                     bones.                                                                                             
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      12.00       6.87        1.00       19.87        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           4.60       4.24        0.41        9.25        090  S                 
                                                     bone.                                                                                              
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           6.58       6.34        0.91       13.83        090  S                 
                                                     tissue.                                                                                            
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             2.01       2.57        0.40        4.98        090  S                 
                                                     fracture.                                                                                          
28405...  ...................  A                    Treatment of heel             4.28       3.90        0.58        8.76        090  S                 
                                                     fracture.                                                                                          
28406...  ...................  A                    Treatment of heel             5.82       6.09        0.93       12.84        090  S                 
                                                     fracture.                                                                                          
28415...  ...................  A                    Repair of heel fracture      15.00       9.02        1.39       25.41        090  S                 
28420...  ...................  A                    Repair/graft heel            15.80      10.89        1.63       28.32        090  S                 
                                                     fracture.                                                                                          
28430...  ...................  A                    Treatment of ankle            1.96       2.45        0.35        4.76        090  S                 
                                                     fracture.                                                                                          
28435...  ...................  A                    Treatment of ankle            3.25       3.36        0.50        7.11        090  S                 
                                                     fracture.                                                                                          
28436...  ...................  A                    Treatment of ankle            4.40       4.19        0.68        9.27        090  S                 
                                                     fracture.                                                                                          
28445...  ...................  A                    Repair of ankle               8.78       8.80        1.40       18.98        090  S                 
                                                     fracture.                                                                                          
28450...  ...................  A                    Treat midfoot fracture,       1.77       1.87        0.25        3.89        090  S                 
                                                     each.                                                                                              
28455...  ...................  A                    Treat midfoot fracture,       2.94       2.54        0.34        5.82        090  S                 
                                                     each.                                                                                              
28456...  ...................  A                    Repair midfoot fracture       2.39       2.27        0.38        5.04        090  S                 
28465...  ...................  A                    Repair midfoot                6.55       5.54        0.81       12.90        090  S                 
                                                     fracture, each.                                                                                    
28470...  ...................  A                    Treat metatarsal              1.76       1.80        0.23        3.79        090  S                 
                                                     fracture.                                                                                          
28475...  ...................  A                    Treat metatarsal              2.74       2.34        0.30        5.38        090  S                 
                                                     fracture.                                                                                          
28476...  ...................  A                    Repair metatarsal             3.15       3.37        0.45        6.97        090  S                 
                                                     fracture.                                                                                          
28485...  ...................  A                    Repair metatarsal             5.31       4.68        0.60       10.59        090  S                 
                                                     fracture.                                                                                          
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              1.01       0.89        0.09        1.99        090  S                 
                                                     fracture.                                                                                          
28515...  ...................  A                    Treatment of toe              1.36       1.12        0.11        2.59        090  S                 
                                                     fracture.                                                                                          
28525...  ...................  A                    Repair of toe fracture.       3.08       2.06        0.29        5.43        090  S                 
28530...  ...................  A                    Treat sesamoid bone           1.01       1.00        0.10        2.11        090  S                 
                                                     fracture.                                                                                          
28531...  ...................  A                    Treat sesamoid bone           2.01       1.91        0.32        4.24        090  S                 
                                                     fracture.                                                                                          
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       6.99       4.96        0.78       12.73        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                 
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                 2.68       3.00        0.41        6.09        090  S                 
                                                     dislocation.                                                                                       
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                 

[[Page 59582]]

                                                                                                                                                        
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...       7.40       5.14        0.72       13.26        090  S                 
28750...  ...................  A                    Fusion of big toe joint       6.90       5.32        0.82       13.04        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       7.00       5.40        0.65       13.05        090  S                 
28800...  ...................  A                    Amputation of midfoot..       7.37       6.65        1.19       15.21        090  S                 
28805...  ...................  A                    Amputation thru               7.55       6.32        1.21       15.08        090  S                 
                                                     metatarsal.                                                                                        
28810...  ...................  A                    Amputation toe &              5.53       3.91        0.75       10.19        090  S                 
                                                     metatarsal.                                                                                        
28820...  ...................  A                    Amputation of toe......       3.56       2.58        0.46        6.60        090  S                 
28825...  ...................  A                    Partial amputation of         3.13       2.40        0.41        5.94        090  S                 
                                                     toe.                                                                                               
28899...  ...................  C                    Foot/toes surgery             0.00       0.00        0.00        0.00        YYY  S                 
                                                     procedure.                                                                                         
29000...  ...................  A                    Application of body           2.25       1.85        0.21        4.31        000  S                 
                                                     cast.                                                                                              
29010...  ...................  A                    Application of body           2.06       2.33        0.34        4.73        000  S                 
                                                     cast.                                                                                              
29015...  ...................  A                    Application of body           2.41       2.33        0.33        5.07        000  S                 
                                                     cast.                                                                                              
29020...  ...................  A                    Application of body           2.11       1.82        0.23        4.16        000  S                 
                                                     cast.                                                                                              
29025...  ...................  A                    Application of body           2.40       0.75        0.14        3.29        000  S                 
                                                     cast.                                                                                              
29035...  ...................  A                    Application of body           1.77       1.95        0.32        4.04        000  S                 
                                                     cast.                                                                                              
29040...  ...................  A                    Application of body           2.22       2.02        0.30        4.54        000  S                 
                                                     cast.                                                                                              
29044...  ...................  A                    Application of body           2.12       2.09        0.34        4.55        000  S                 
                                                     cast.                                                                                              
29046...  ...................  A                    Application of body           2.41       2.23        0.36        5.00        000  S                 
                                                     cast.                                                                                              
29049...  ...................  A                    Application of figure         0.89       0.42        0.06        1.37        000  S                 
                                                     eight.                                                                                             
29055...  ...................  A                    Application of shoulder       1.78       1.20        0.17        3.15        000  S                 
                                                     cast.                                                                                              
29058...  ...................  A                    Application of shoulder       1.31       0.65        0.09        2.05        000  S                 
                                                     cast.                                                                                              
29065...  ...................  A                    Application of long arm       0.87       0.80        0.13        1.80        000  S                 
                                                     cast.                                                                                              
29075...  ...................  A                    Application of forearm        0.77       0.61        0.10        1.48        000  S                 
                                                     cast.                                                                                              
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         0.50       0.17        0.02        0.69        000  S                 
                                                     splint.                                                                                            
29131...  ...................  A                    Application of finger         0.55       0.39        0.06        1.00        000  S                 
                                                     splint.                                                                                            
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         0.55       0.23        0.03        0.81        000  S                 
                                                     wrist.                                                                                             
29280...  ...................  A                    Strapping of hand or          0.51       0.21        0.02        0.74        000  S                 
                                                     finger.                                                                                            
29305...  ...................  A                    Application of hip cast       2.03       1.88        0.31        4.22        000  S                 
29325...  ...................  A                    Application of hip            2.32       1.94        0.28        4.54        000  S                 
                                                     casts.                                                                                             
29345...  ...................  A                    Application of long leg       1.40       1.02        0.16        2.58        000  S                 
                                                     cast.                                                                                              
29355...  ...................  A                    Application of long leg       1.53       1.10        0.17        2.80        000  S                 
                                                     cast.                                                                                              
29358...  ...................  A                    Apply long leg cast           1.43       1.84        0.33        3.60        000  S                 
                                                     brace.                                                                                             
29365...  ...................  A                    Application of long leg       1.18       0.86        0.14        2.18        000  S                 
                                                     cast.                                                                                              
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         0.57       0.23        0.03        0.83        000  S                 
                                                     cast.                                                                                              
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          0.69       0.57        0.07        1.33        000  S                 
                                                     splint.                                                                                            
29515...  ...................  A                    Application lower leg         0.73       0.47        0.06        1.26        000  S                 
                                                     splint.                                                                                            
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          0.57       0.79        0.04        1.40        000  S                 
                                                     boot.                                                                                              
29590...  ...................  A                    Application of foot           0.76       0.28        0.03        1.07        000  S                 
                                                     splint.                                                                                            
29700...  ...................  A                    Removal/revision of           0.57       0.32        0.05        0.94        000  S                 
                                                     cast.                                                                                              
29705...  ...................  A                    Removal/revision of           0.76       0.35        0.05        1.16        000  S                 
                                                     cast.                                                                                              
29710...  ...................  A                    Removal/revision of           1.34       0.45        0.07        1.86        000  S                 
                                                     cast.                                                                                              
29715...  ...................  A                    Removal/revision of           0.94       0.86        0.12        1.92        000  S                 
                                                     cast.                                                                                              
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           1.26       0.50        0.07        1.83        000  S                 
                                                     cast.                                                                                              

[[Page 59583]]

                                                                                                                                                        
29799...  ...................  C                    Casting/strapping             0.00       0.00        0.00        0.00        YYY  S                 
                                                     procedure.                                                                                         
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/         7.33       9.38        1.73       18.44        090  S                 
                                                     surgery.                                                                                           
29820...  ...................  A                    Shoulder arthroscopy/         6.81       8.72        1.73       17.26        090  S                 
                                                     surgery.                                                                                           
29821...  ...................  A                    Shoulder arthroscopy/         7.43       9.50        2.13       19.06        090  S                 
                                                     surgery.                                                                                           
29822...  ...................  A                    Shoulder arthroscopy/         7.14       9.14        1.74       18.02        090  S                 
                                                     surgery.                                                                                           
29823...  ...................  A                    Shoulder arthroscopy/         7.86      10.07        2.32       20.25        090  S                 
                                                     surgery.                                                                                           
29825...  ...................  A                    Shoulder arthroscopy/         7.33       9.38        2.05       18.76        090  S                 
                                                     surgery.                                                                                           
29826...  ...................  A                    Shoulder arthroscopy/         8.70      11.14        2.31       22.15        090  S                 
                                                     surgery.                                                                                           
29830...  ...................  A                    Elbow arthroscopy......       5.63       5.32        0.83       11.78        090  S                 
29834...  ...................  A                    Elbow arthroscopy/            6.13       5.84        0.96       12.93        090  S                 
                                                     surgery.                                                                                           
29835...  ...................  A                    Elbow arthroscopy/            6.33       6.03        0.99       13.35        090  S                 
                                                     surgery.                                                                                           
29836...  ...................  A                    Elbow arthroscopy/            7.37       7.03        1.15       15.55        090  S                 
                                                     surgery.                                                                                           
29837...  ...................  A                    Elbow arthroscopy/            6.72       6.40        1.06       14.18        090  S                 
                                                     surgery.                                                                                           
29838...  ...................  A                    Elbow arthroscopy/            7.42       7.05        1.14       15.61        090  S                 
                                                     surgery.                                                                                           
29840...  ...................  A                    Wrist arthroscopy......       5.39       3.29        0.54        9.22        090  S                 
29843...  ...................  A                    Wrist arthroscopy/            5.86       5.60        0.91       12.37        090  S                 
                                                     surgery.                                                                                           
29844...  ...................  A                    Wrist arthroscopy/            6.22       5.59        0.95       12.76        090  S                 
                                                     surgery.                                                                                           
29845...  ...................  A                    Wrist arthroscopy/            7.34       7.00        1.15       15.49        090  S                 
                                                     surgery.                                                                                           
29846...  ...................  A                    Wrist arthroscopy/            6.60       8.45        2.20       17.25        090  S                 
                                                     surgery.                                                                                           
29847...  ...................  A                    Wrist arthroscopy/            6.93       6.78        0.97       14.68        090  S                 
                                                     surgery.                                                                                           
29848...  ...................  A                    Wrist arthroscopy/            5.14       3.85        0.62        9.61        090  S                 
                                                     surgery.                                                                                           
29850...  ...................  A                    Knee arthroscopy/             7.96      10.19        1.74       19.89        090  S                 
                                                     surgery.                                                                                           
29851...  ...................  A                    Knee arthroscopy/            12.38      10.95        1.74       25.07        090  S                 
                                                     surgery.                                                                                           
29855...  ...................  A                    Tibial arthroscopy/           9.48      11.69        1.88       23.05        090  S                 
                                                     surgery.                                                                                           
29856...  ...................  A                    Tibial arthroscopy/          13.28      11.69        1.88       26.85        090  S                 
                                                     surgery.                                                                                           
29870...  ...................  A                    Knee arthroscopy,             4.94       4.02        0.64        9.60        090  S                 
                                                     diagnostic.                                                                                        
29871...  ...................  A                    Knee arthroscopy/             6.29       6.77        0.96       14.02        090  S                 
                                                     drainage.                                                                                          
29874...  ...................  A                    Knee arthroscopy/             6.79       8.69        1.52       17.00        090  S                 
                                                     surgery.                                                                                           
29875...  ...................  A                    Knee arthroscopy/             6.16       7.88        1.61       15.65        090  S                 
                                                     surgery.                                                                                           
29876...  ...................  A                    Knee arthroscopy/             7.51       9.61        1.95       19.07        090  S                 
                                                     surgery.                                                                                           
29877...  ...................  A                    Knee arthroscopy/             7.05       9.03        1.81       17.89        090  S                 
                                                     surgery.                                                                                           
29879...  ...................  A                    Knee arthroscopy/             7.63       9.76        2.19       19.58        090  S                 
                                                     surgery.                                                                                           
29880...  ...................  A                    Knee arthroscopy/             8.09      10.35        2.22       20.66        090  S                 
                                                     surgery.                                                                                           
29881...  ...................  A                    Knee arthroscopy/             7.46       9.54        1.82       18.82        090  S                 
                                                     surgery.                                                                                           
29882...  ...................  A                    Knee arthroscopy/             8.24      10.54        1.90       20.68        090  S                 
                                                     surgery.                                                                                           
29883...  ...................  A                    Knee arthroscopy/             9.00      11.52        2.80       23.32        090  S                 
                                                     surgery.                                                                                           
29884...  ...................  A                    Knee arthroscopy/             6.92       8.86        1.56       17.34        090  S                 
                                                     surgery.                                                                                           
29885...  ...................  A                    Knee arthroscopy/             8.63       8.23        1.35       18.21        090  S                 
                                                     surgery.                                                                                           
29886...  ...................  A                    Knee arthroscopy/             7.13       6.80        1.12       15.05        090  S                 
                                                     surgery.                                                                                           
29887...  ...................  A                    Knee arthroscopy/             8.58      10.52        1.71       20.81        090  S                 
                                                     surgery.                                                                                           
29888...  ...................  A                    Knee arthroscopy/            13.28      17.00        3.18       33.46        090  S                 
                                                     surgery.                                                                                           
29889...  ...................  A                    Knee arthroscopy/            14.41      10.26        1.68       26.35        090  S                 
                                                     surgery.                                                                                           
29894...  ...................  A                    Ankle arthroscopy/            6.95       8.90        1.47       17.32        090  S                 
                                                     surgery.                                                                                           
29895...  ...................  A                    Ankle arthroscopy/            6.73       8.60        1.51       16.84        090  S                 
                                                     surgery.                                                                                           
29897...  ...................  A                    Ankle arthroscopy/            6.92       8.86        1.77       17.55        090  S                 
                                                     surgery.                                                                                           
29898...  ...................  A                    Ankle arthroscopy/            8.03      10.28        1.91       20.22        090  S                 
                                                     surgery.                                                                                           
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               1.58       1.29        0.14        3.01        010  S                 
                                                     polyp(s).                                                                                          
30115...  ...................  A                    Removal of nose               4.25       2.81        0.30        7.36        090  S                 
                                                     polyp(s).                                                                                          
30117...  ...................  A                    Removal of intranasal         3.06       2.84        0.31        6.21        090  S                 
                                                     lesion.                                                                                            
30118...  ...................  A                    Removal of intranasal         9.23       8.01        0.92       18.16        090  S                 
                                                     lesion.                                                                                            
30120...  ...................  A                    Revision of nose.......       5.14       6.59        1.00       12.73        090  S                 
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          3.17       1.67        0.17        5.01        090  S                 
                                                     bones.                                                                                             
30140...  ...................  A                    Removal of turbinate          3.28       3.04        0.34        6.66        090  S                 
                                                     bones.                                                                                             
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        0.78       0.37        0.04        1.19        000  S                 
                                                     nose.                                                                                              
30210...  ...................  A                    Nasal sinus therapy....       1.03       0.26        0.03        1.32        010  S                 
30220...  ...................  A                    Insert nasal septal           1.49       1.51        0.16        3.16        010  S                 
                                                     button.                                                                                            

[[Page 59584]]

                                                                                                                                                        
30300...  ...................  A                    Remove nasal foreign          0.99       0.46        0.05        1.50        010  S                 
                                                     body.                                                                                              
30310...  ...................  A                    Remove nasal foreign          1.91       1.62        0.18        3.71        010  S                 
                                                     body.                                                                                              
30320...  ...................  A                    Remove nasal foreign          4.39       4.29        0.43        9.11        090  S                 
                                                     body.                                                                                              
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              1.21       0.55        0.06        1.82        010  S                 
                                                     adhesions.                                                                                         
30580...  ...................  A                    Repair upper jaw              6.49       6.24        0.57       13.30        090  S                 
                                                     fistula.                                                                                           
30600...  ...................  A                    Repair mouth/nose             5.87       3.77        0.36       10.00        090  S                 
                                                     fistula.                                                                                           
30620...  ...................  A                    Intranasal                    5.55       7.10        1.10       13.75        090  S                 
                                                     reconstruction.                                                                                    
30630...  ...................  A                    Repair nasal septum           6.83       6.24        0.71       13.78        090  S                 
                                                     defect.                                                                                            
30801...  ...................  A                    Cauterization inner           1.02       0.47        0.05        1.54        010  S                 
                                                     nose.                                                                                              
30802...  ...................  A                    Cauterization inner           1.98       0.94        0.11        3.03        010  S                 
                                                     nose.                                                                                              
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             2.45       1.08        0.11        3.64        000  S                 
                                                     nosebleed.                                                                                         
30915...  ...................  A                    Ligation nasal sinus          6.72       4.95        0.52       12.19        090  S                 
                                                     artery.                                                                                            
30920...  ...................  A                    Ligation upper jaw            8.79       9.54        1.32       19.65        090  S                 
                                                     artery.                                                                                            
30930...  ...................  A                    Therapy fracture of           1.21       0.71        0.08        2.00        010  S                 
                                                     nose.                                                                                              
30999...  ...................  C                    Nasal surgery procedure       0.00       0.00        0.00        0.00        YYY  N                 
31000...  ...................  A                    Irrigation maxillary          1.10       0.43        0.05        1.58        010  S                 
                                                     sinus.                                                                                             
31002...  ...................  A                    Irrigation sphenoid           1.86       0.46        0.05        2.37        010  S                 
                                                     sinus.                                                                                             
31020...  ...................  A                    Exploration maxillary         2.81       2.66        0.29        5.76        090  S                 
                                                     sinus.                                                                                             
31030...  ...................  A                    Exploration maxillary         5.60       7.16        0.86       13.62        090  S                 
                                                     sinus.                                                                                             
31032...  ...................  A                    Explore sinus, remove         6.22       7.96        0.99       15.17        090  S                 
                                                     polyps.                                                                                            
31040...  ...................  A                    Exploration behind            8.83       7.98        0.86       17.67        090  S                 
                                                     upper jaw.                                                                                         
31050...  ...................  A                    Exploration sphenoid          5.07       5.96        0.64       11.67        090  S                 
                                                     sinus.                                                                                             
31051...  ...................  A                    Sphenoid sinus surgery.       6.85       8.12        0.85       15.82        090  S                 
31070...  ...................  A                    Exploration of frontal        4.04       4.69        0.50        9.23        090  S                 
                                                     sinus.                                                                                             
31075...  ...................  A                    Exploration of frontal        8.57      10.51        1.10       20.18        090  S                 
                                                     sinus.                                                                                             
31080...  ...................  A                    Removal of frontal           10.73       9.21        1.12       21.06        090  S                 
                                                     sinus.                                                                                             
31081...  ...................  A                    Removal of frontal           11.93      10.32        1.30       23.55        090  S                 
                                                     sinus.                                                                                             
31084...  ...................  A                    Removal of frontal           12.69      14.79        1.62       29.10        090  S                 
                                                     sinus.                                                                                             
31085...  ...................  A                    Removal of frontal           13.38      15.65        1.76       30.79        090  S                 
                                                     sinus.                                                                                             
31086...  ...................  A                    Removal of frontal           11.98      10.87        1.15       24.00        090  S                 
                                                     sinus.                                                                                             
31087...  ...................  A                    Removal of frontal           12.14      10.39        1.33       23.86        090  S                 
                                                     sinus.                                                                                             
31090...  ...................  A                    Exploration of sinuses.       8.65      11.32        2.12       22.09        090  S                 
31200...  ...................  A                    Removal of ethmoid            4.68       4.62        0.48        9.78        090  S                 
                                                     sinus.                                                                                             
31201...  ...................  A                    Removal of ethmoid            7.91       7.01        0.75       15.67        090  S                 
                                                     sinus.                                                                                             
31205...  ...................  A                    Removal of ethmoid            9.65       8.03        0.81       18.49        090  S                 
                                                     sinus.                                                                                             
31225...  ...................  A                    Removal of upper jaw...      17.50      19.44        2.37       39.31        090  S                 
31230...  ...................  A                    Removal of upper jaw...      20.00      21.74        2.48       44.22        090  S                 
31231...  ...................  A                    Nasal endoscopy, dx....       1.10       1.37        0.15        2.62        000  S                 
31233...  ...................  A                    Nasal/sinus endoscopy,        2.18       2.79        0.31        5.28        000  S                 
                                                     dx.                                                                                                
31235...  ...................  A                    Nasal/sinus endoscopy,        2.64       2.39        0.26        5.29        000  S                 
                                                     dx.                                                                                                
31237...  ...................  A                    Nasal/sinus endoscopy,        2.98       3.37        0.37        6.72        000  S                 
                                                     surg.                                                                                              
31238...  ...................  A                    Nasal/sinus endoscopy,        3.26       4.17        0.45        7.88        000  S                 
                                                     surg.                                                                                              
31239...  ...................  A                    Nasal/sinus endoscopy,        8.50      10.88        1.18       20.56        010  S                 
                                                     surg.                                                                                              
31240...  ...................  A                    Nasal/sinus endoscopy,        2.61       3.34        0.37        6.32        000  S                 
                                                     surg.                                                                                              
31254...  ...................  A                    Revision of ethmoid           4.65       5.95        0.69       11.29        000  S                 
                                                     sinus.                                                                                             
31255...  ...................  A                    Removal of ethmoid            6.96       8.91        1.14       17.01        000  S                 
                                                     sinus.                                                                                             
31256...  ...................  A                    Exploration maxillary         3.29       3.77        0.41        7.47        000  S                 
                                                     sinus.                                                                                             
31267...  ...................  A                    Endoscopy, maxillary          5.46       5.23        0.81       11.50        000  S                 
                                                     sinus.                                                                                             
31276...  ...................  A                    Sinus surgical                8.85       6.72        0.73       16.30        000  S                 
                                                     endoscopy.                                                                                         
31287...  ...................  A                    Nasal/sinus endoscopy,        3.92       5.01        0.65        9.58        000  S                 
                                                     surg.                                                                                              
31288...  ...................  A                    Nasal/sinus endoscopy,        4.58       5.86        0.78       11.22        000  S                 
                                                     surg.                                                                                              
31290...  ...................  A                    Nasal/sinus endoscopy,       16.05      16.47        1.80       34.32        010  S                 
                                                     surg.                                                                                              
31291...  ...................  A                    Nasal/sinus endoscopy,       17.00      17.31        1.88       36.19        010  S                 
                                                     surg.                                                                                              

[[Page 59585]]

                                                                                                                                                        
31292...  ...................  A                    Nasal/sinus endoscopy,       13.83      13.38        1.45       28.66        010  S                 
                                                     surg.                                                                                              
31293...  ...................  A                    Nasal/sinus endoscopy,       15.15      14.64        1.59       31.38        010  S                 
                                                     surg.                                                                                              
31294...  ...................  A                    Nasal/sinus endoscopy,       18.00      16.72        1.83       36.55        010  S                 
                                                     surg.                                                                                              
31299...  ...................  C                    Sinus surgery procedure       0.00       0.00        0.00        0.00        YYY  S                 
31300...  ...................  A                    Removal of larynx            13.28      11.58        1.28       26.14        090  S                 
                                                     lesion.                                                                                            
31320...  ...................  A                    Diagnostic incision           4.54       3.87        0.48        8.89        090  S                 
                                                     larynx.                                                                                            
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           18.98      17.22        1.88       38.08        090  S                 
                                                     larynx.                                                                                            
31368...  ...................  A                    Partial removal of           23.72      26.76        3.06       53.54        090  S                 
                                                     larynx.                                                                                            
31370...  ...................  A                    Partial removal of           18.50      17.18        1.88       37.56        090  S                 
                                                     larynx.                                                                                            
31375...  ...................  A                    Partial removal of           18.50      14.84        1.56       34.90        090  S                 
                                                     larynx.                                                                                            
31380...  ...................  A                    Partial removal of           18.50      17.27        1.88       37.65        090  S                 
                                                     larynx.                                                                                            
31382...  ...................  A                    Partial removal of           18.50      16.06        1.78       36.34        090  S                 
                                                     larynx.                                                                                            
31390...  ...................  A                    Removal of larynx &          25.00      27.08        4.05       56.13        090  S                 
                                                     pharynx.                                                                                           
31395...  ...................  A                    Reconstruct larynx &         28.00      33.52        4.42       65.94        090  S                 
                                                     pharynx.                                                                                           
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            0.65       0.58        0.07        1.30        000  S                 
                                                     airway.                                                                                            
31505...  ...................  A                    Diagnostic laryngoscopy       0.61       0.43        0.05        1.09        000  S                 
31510...  ...................  A                    Laryngoscopy with             1.92       0.55        0.07        2.54        000  S                 
                                                     biopsy.                                                                                            
31511...  ...................  A                    Remove foreign body,          2.16       0.96        0.10        3.22        000  S                 
                                                     larynx.                                                                                            
31512...  ...................  A                    Removal of larynx             2.07       1.79        0.20        4.06        000  S                 
                                                     lesion.                                                                                            
31513...  ...................  A                    Injection into vocal          2.10       2.68        0.38        5.16        000  S                 
                                                     cord.                                                                                              
31515...  ...................  A                    Laryngoscopy for              1.80       1.13        0.14        3.07        000  S                 
                                                     aspiration.                                                                                        
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              3.27       2.99        0.30        6.56        000  S                 
                                                     treatment.                                                                                         
31528...  ...................  A                    Laryngoscopy and              2.37       2.66        0.30        5.33        000  S                 
                                                     dilatation.                                                                                        
31529...  ...................  A                    Laryngoscopy and              2.68       2.46        0.25        5.39        000  S                 
                                                     dilatation.                                                                                        
31530...  ...................  A                    Operative laryngoscopy.       3.39       3.63        0.39        7.41        000  S                 
31531...  ...................  A                    Operative laryngoscopy.       3.59       4.78        0.60        8.97        000  S                 
31535...  ...................  A                    Operative laryngoscopy.       3.16       4.01        0.45        7.62        000  S                 
31536...  ...................  A                    Operative laryngoscopy.       3.56       4.06        0.59        8.21        000  S                 
31540...  ...................  A                    Operative laryngoscopy.       4.13       5.29        0.61       10.03        000  S                 
31541...  ...................  A                    Operative laryngoscopy.       4.53       4.56        0.75        9.84        000  S                 
31560...  ...................  A                    Operative laryngoscopy.       5.46       4.99        0.51       10.96        000  S                 
31561...  ...................  A                    Operative laryngoscopy.       6.00       6.27        1.08       13.35        000  S                 
31570...  ...................  A                    Laryngoscopy with             3.87       4.95        0.60        9.42        000  S                 
                                                     injection.                                                                                         
31571...  ...................  A                    Laryngoscopy with             4.27       4.51        0.69        9.47        000  S                 
                                                     injection.                                                                                         
31575...  ...................  A                    Diagnostic laryngoscopy       1.10       1.56        0.17        2.83        000  S                 
31576...  ...................  A                    Laryngoscopy with             1.97       2.52        0.33        4.82        000  S                 
                                                     biopsy.                                                                                            
31577...  ...................  A                    Remove foreign body,          2.47       3.16        0.37        6.00        000  S                 
                                                     larynx.                                                                                            
31578...  ...................  A                    Removal of larynx             2.84       3.63        0.48        6.95        000  S                 
                                                     lesion.                                                                                            
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             18.50      12.72        1.34       32.56        090  S                 
                                                     fracture.                                                                                          
31585...  ...................  A                    Repair of larynx              4.40       3.77        0.40        8.57        090  S                 
                                                     fracture.                                                                                          
31586...  ...................  A                    Repair of larynx              7.24       6.55        0.71       14.50        090  S                 
                                                     fracture.                                                                                          
31587...  ...................  A                    Revision of larynx.....      10.00       7.21        0.79       18.00        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                 
31599...  ...................  C                    Larynx surgery                0.00       0.00        0.00        0.00        YYY  S                 
                                                     procedure.                                                                                         
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                5.03       6.45        1.04       12.52        090  S                 
                                                     prosthesis.                                                                                        
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              2.09       1.95        0.22        4.26        000  S                 
                                                     windpipe.                                                                                          

[[Page 59586]]

                                                                                                                                                        
31622...  ...................  A                    Diagnostic bronchoscopy       2.80       3.57        0.34        6.71        000  N                 
31625...  ...................  A                    Bronchoscopy with             3.37       3.83        0.35        7.55        000  N                 
                                                     biopsy.                                                                                            
31628...  ...................  A                    Bronchoscopy with             3.81       4.88        0.38        9.07        000  N                 
                                                     biopsy.                                                                                            
31629...  ...................  A                    Bronchoscopy with             3.37       4.31        0.34        8.02        000  N                 
                                                     biopsy.                                                                                            
31630...  ...................  A                    Bronchoscopy with             3.82       3.72        0.50        8.04        000  S                 
                                                     repair.                                                                                            
31631...  ...................  A                    Bronchoscopy with             4.37       3.94        0.48        8.79        000  N                 
                                                     dilation.                                                                                          
31635...  ...................  A                    Remove foreign body,          3.68       4.53        0.53        8.74        000  S                 
                                                     airway.                                                                                            
31640...  ...................  A                    Bronchoscopy & remove         4.94       5.02        0.67       10.63        000  S                 
                                                     lesion.                                                                                            
31641...  ...................  A                    Bronchoscopy, treat           5.03       6.45        0.85       12.33        000  N                 
                                                     blockage.                                                                                          
31645...  ...................  A                    Bronchoscopy, clear           3.16       3.62        0.30        7.08        000  N                 
                                                     airways.                                                                                           
31646...  ...................  A                    Bronchoscopy, reclear         2.72       3.06        0.27        6.05        000  N                 
                                                     airways.                                                                                           
31656...  ...................  A                    Bronchoscopy, inject          2.17       2.77        0.31        5.25        000  N                 
                                                     for xray.                                                                                          
31700...  ...................  A                    Insertion of airway           1.34       1.38        0.17        2.89        000  N                 
                                                     catheter.                                                                                          
31708...  ...................  A                    Instill airway contrast       1.41       0.77        0.09        2.27        000  N                 
                                                     dye.                                                                                               
31710...  ...................  A                    Insertion of airway           1.30       0.90        0.12        2.32        000  N                 
                                                     catheter.                                                                                          
31715...  ...................  A                    Injection for bronchus        1.11       0.48        0.04        1.63        000  N                 
                                                     x-ray.                                                                                             
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/          2.85       2.47        0.23        5.55        000  N                 
                                                     tube.                                                                                              
31750...  ...................  A                    Repair of windpipe.....      11.73       8.88        1.09       21.70        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            28.82      18.40        1.12       48.34        090  S                 
                                                     windpipe.                                                                                          
31770...  ...................  A                    Repair/graft of              21.15      15.07        2.08       38.30        090  S                 
                                                     bronchus.                                                                                          
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            6.77       4.90        0.76       12.43        090  S                 
                                                     injury.                                                                                            
31805...  ...................  A                    Repair of windpipe           12.59       9.82        1.41       23.82        090  S                 
                                                     injury.                                                                                            
31820...  ...................  A                    Closure of windpipe           4.10       3.58        0.46        8.14        090  S                 
                                                     lesion.                                                                                            
31825...  ...................  A                    Repair of windpipe            6.31       5.00        0.58       11.89        090  S                 
                                                     defect.                                                                                            
31830...  ...................  A                    Revise windpipe scar...       4.26       3.66        0.42        8.34        090  S                 
31899...  ...................  C                    Airways surgical              0.00       0.00        0.00        0.00        YYY  S                 
                                                     procedure.                                                                                         
32000...  ...................  A                    Drainage of chest......       1.54       0.90        0.08        2.52        000  N                 
32002...  ...................  A                    Treatment of collapsed        2.19       1.34        0.22        3.75        000  N                 
                                                     lung.                                                                                              
32005...  ...................  A                    Treat lung lining             2.19       1.09        0.15        3.43        000  S                 
                                                     chemically.                                                                                        
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          7.13       8.25        1.45       16.83        090  S                 
                                                     wall.                                                                                              
32100...  ...................  A                    Exploration/biopsy of        10.07      11.24        2.10       23.41        090  S                 
                                                     chest.                                                                                             
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              12.14      12.37        2.42       26.93        090  S                 
                                                     lesion(s).                                                                                         
32141...  ...................  A                    Remove/treat lung            12.14      13.42        2.53       28.09        090  S                 
                                                     lesions.                                                                                           
32150...  ...................  A                    Removal of lung              12.42      10.34        2.01       24.77        090  S                 
                                                     lesion(s).                                                                                         
32151...  ...................  A                    Remove lung foreign          12.42       9.15        1.37       22.94        090  S                 
                                                     body.                                                                                              
32160...  ...................  A                    Open chest heart              7.13       9.13        1.52       17.78        090  S                 
                                                     massage.                                                                                           
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                 
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            19.15      18.10        3.40       40.65        090  S                 
                                                     lining.                                                                                            
32400...  ...................  A                    Needle biopsy chest           1.76       1.48        0.12        3.36        000  N                 
                                                     lining.                                                                                            
32402...  ...................  A                    Open biopsy chest             6.55       7.58        1.34       15.47        090  S                 
                                                     lining.                                                                                            
32405...  ...................  A                    Biopsy, lung or               1.93       2.12        0.18        4.23        000  N                 
                                                     mediastinum.                                                                                       
32420...  ...................  A                    Puncture/clear lung....       2.18       1.50        0.13        3.81        000  N                 
32440...  ...................  A                    Removal of lung........      19.15       8.56        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                 

[[Page 59587]]

                                                                                                                                                        
32484...  ...................  A                    Segmentectomy..........      19.52      17.15        3.23       39.90        090  S                 
32486...  ...................  A                    Sleeve lobectomy.......      22.75      16.54        3.23       42.52        090  S                 
32488...  ...................  A                    Completion                   24.41      17.74        3.46       45.61        090  S                 
                                                     pneumonectomy.                                                                                     
32491...  ...................  N                    Lung volume reduction..     +21.25      15.45        3.02       39.72        XXX  0                 
32500...  ...................  A                    Partial removal of lung      13.10      13.47        2.56       29.13        090  S                 
32501...  ...................  A                    Repair bronchus (add-         4.69       4.31        0.70        9.70        ZZZ  S                 
                                                     on).                                                                                               
32520...  ...................  A                    Remove lung & revise         19.42      20.67        3.93       44.02        090  S                 
                                                     chest.                                                                                             
32522...  ...................  A                    Remove lung & revise         21.94      21.90        4.19       48.03        090  S                 
                                                     chest.                                                                                             
32525...  ...................  A                    Remove lung & revise         24.33      23.50        4.61       52.44        090  S                 
                                                     chest.                                                                                             
32540...  ...................  A                    Removal of lung lesion.      13.31      11.67        2.05       27.03        090  S                 
32601...  ...................  A                    Thoracoscopy,                 5.46       3.47        0.57        9.50        000  S                 
                                                     diagnostic.                                                                                        
32602...  ...................  A                    Thoracoscopy,                 5.96       3.87        0.64       10.47        000  S                 
                                                     diagnostic.                                                                                        
32603...  ...................  A                    Thoracoscopy,                 7.81       3.47        0.57       11.85        000  S                 
                                                     diagnostic.                                                                                        
32604...  ...................  A                    Thoracoscopy,                 8.78       3.87        0.64       13.29        000  S                 
                                                     diagnostic.                                                                                        
32605...  ...................  A                    Thoracoscopy,                 6.93       3.47        0.57       10.97        000  S                 
                                                     diagnostic.                                                                                        
32606...  ...................  A                    Thoracoscopy,                 8.40       3.87        0.64       12.91        000  S                 
                                                     diagnostic.                                                                                        
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            11.59       6.50        1.19       19.28        090  S                 
                                                     drainage.                                                                                          
32815...  ...................  A                    Close bronchial fistula      21.36      15.22        2.62       39.20        090  S                 
32820...  ...................  A                    Reconstruct injured          19.78      19.01        3.24       42.03        090  S                 
                                                     chest.                                                                                             
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/           38.11      27.71        5.41       71.23        090  S                 
                                                     bypass.                                                                                            
32853...  ...................  A                    Lung transplant, double      43.93      31.94        6.24       82.11        090  S                 
32854...  ...................  A                    Lung transplant w/           46.90      34.10        6.67       87.67        090  S                 
                                                     bypass.                                                                                            
32900...  ...................  A                    Removal of rib(s)......      18.14       8.47        1.63       28.24        090  S                 
32905...  ...................  A                    Revise & repair chest        19.15      12.74        2.60       34.49        090  S                 
                                                     wall.                                                                                              
32906...  ...................  A                    Revise & repair chest        25.17      15.42        2.92       43.51        090  S                 
                                                     wall.                                                                                              
32940...  ...................  A                    Revision of lung.......      18.14      11.37        1.75       31.26        090  S                 
32960...  ...................  A                    Therapeutic                   1.84       0.93        0.13        2.90        000  N                 
                                                     pneumothorax.                                                                                      
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            2.24       1.11        0.12        3.47        000  N                 
                                                     heart sac.                                                                                         
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           16.62      21.02        3.92       41.56        090  S                 
                                                     heart sac.                                                                                         
33031...  ...................  A                    Partial removal of           19.64      13.25        2.50       35.39        090  S                 
                                                     heart sac.                                                                                         
33050...  ...................  A                    Removal of heart sac         12.70       9.25        1.47       23.42        090  S                 
                                                     lesion.                                                                                            
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           11.08      12.27        1.90       25.25        090  S                 
                                                     pacemaker.                                                                                         
33201...  ...................  A                    Insertion of heart            8.93      11.19        1.67       21.79        090  S                 
                                                     pacemaker.                                                                                         
33206...  ...................  A                    Insertion of heart            6.04       7.73        1.34       15.11        090  S                 
                                                     pacemaker.                                                                                         
33207...  ...................  A                    Insertion of heart            7.28       9.01        1.33       17.62        090  S                 
                                                     pacemaker.                                                                                         
33208...  ...................  A                    Insertion of heart            7.28       9.50        1.54       18.32        090  N                 
                                                     pacemaker.                                                                                         
33210...  ...................  A                    Insertion of heart            3.30       3.30        0.27        6.87        000  N                 
                                                     electrode.                                                                                         
33211...  ...................  A                    Insertion of heart            3.40       3.30        0.27        6.97        000  N                 
                                                     electrode.                                                                                         
33212...  ...................  A                    Insertion of pulse            5.21       5.38        0.88       11.47        090  S                 
                                                     generator.                                                                                         
33213...  ...................  A                    Insertion of pulse            6.15       5.38        0.88       12.41        090  N                 
                                                     generator.                                                                                         
33214...  ...................  A                    Upgrade of pacemaker          7.43       5.40        1.06       13.89        090  N                 
                                                     system.                                                                                            

[[Page 59588]]

                                                                                                                                                        
33216...  ...................  A                    Revision implanted            5.07       5.02        0.55       10.64        090  N                 
                                                     electrode.                                                                                         
33217...  ...................  A                    Insert/revise electrode       5.43       5.02        0.55       11.00        090  N                 
33218...  ...................  A                    Repair pacemaker              5.02       4.59        0.62       10.23        090  S                 
                                                     electrodes.                                                                                        
33220...  ...................  A                    Repair pacemaker              5.10       4.59        0.62       10.31        090  N                 
                                                     electrode.                                                                                         
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          2.97       2.64        0.05        5.66        090  N                 
                                                     system.                                                                                            
33234...  ...................  A                    Removal of pacemaker          7.50       2.84        0.23       10.57        090  S                 
                                                     system.                                                                                            
33235...  ...................  A                    Removal of pacemaker          8.74       3.14        0.33       12.21        090  N                 
                                                     electrode.                                                                                         
33236...  ...................  A                    Remove electrode/            11.71       3.98        0.62       16.31        090  S                 
                                                     thoracotomy.                                                                                       
33237...  ...................  A                    Remove electrode/            12.69       9.60        1.13       23.42        090  S                 
                                                     thoracotomy.                                                                                       
33238...  ...................  A                    Remove electrode/            14.15      10.29        2.01       26.45        090  S                 
                                                     thoracotomy.                                                                                       
33240...  ...................  A                    Insert/replace pulse          7.20       5.38        0.88       13.46        090  S                 
                                                     generator.                                                                                         
33241...  ...................  A                    Remove pulse generator        2.97       2.16        0.43        5.56        090  S                 
                                                     only.                                                                                              
33242...  ...................  A                    Repair pulse generator/       5.85       7.50        1.54       14.89        090  S                 
                                                     leads.                                                                                             
33243...  ...................  A                    Remove generator/            21.47       9.02        1.54       32.03        090  S                 
                                                     thoracotomy.                                                                                       
33244...  ...................  A                    Remove generator.......       8.34       9.02        1.54       18.90        090  S                 
33245...  ...................  A                    Implant heart                12.57      16.09        2.36       31.02        090  S                 
                                                     defibrillator.                                                                                     
33246...  ...................  A                    Implant heart                19.28      20.79        3.19       43.26        090  S                 
                                                     defibrillator.                                                                                     
33247...  ...................  A                    Insert/replace leads...       9.76      12.49        2.36       24.61        090  N                 
33249...  ...................  A                    Insert/replace leads/        12.83      16.42        3.19       32.44        090  S                 
                                                     gener.                                                                                             
33250...  ...................  A                    Ablate heart dysrhythm       19.54      11.56        0.86       31.96        090  S                 
                                                     focus.                                                                                             
33251...  ...................  A                    Ablate heart dysrhythm       22.57      16.41        3.21       42.19        090  S                 
                                                     focus.                                                                                             
33253...  ...................  A                    Reconstruct atria......      30.00      21.81        4.26       56.07        090  S                 
33261...  ...................  A                    Ablate heart dysrhythm       22.57      13.96        2.73       39.26        090  S                 
                                                     focus.                                                                                             
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            17.12      11.28        1.93       30.33        090  S                 
                                                     surgery.                                                                                           
33315...  ...................  A                    Exploratory heart            20.15      14.48        2.57       37.20        090  S                 
                                                     surgery.                                                                                           
33320...  ...................  A                    Repair major blood           15.39      14.14        2.51       32.04        090  S                 
                                                     vessel(s).                                                                                         
33321...  ...................  A                    Repair major vessel....      18.74      21.75        3.61       44.10        090  S                 
33322...  ...................  A                    Repair major blood           18.40      21.75        3.61       43.76        090  S                 
                                                     vessel(s).                                                                                         
33330...  ...................  A                    Insert major vessel          19.15      12.67        1.93       33.75        090  S                 
                                                     graft.                                                                                             
33332...  ...................  A                    Insert major vessel          22.50      15.07        2.39       39.96        090  S                 
                                                     gr