[Federal Register Volume 62, Number 211 (Friday, October 31, 1997)]
[Rules and Regulations]
[Pages 59048-59260]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-28973]



[[Page 59047]]

_______________________________________________________________________

Part III





Department of Health and Human Services





_______________________________________________________________________



Health Care Financing Administration



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42 CFR Part 400, et al.



Medicare: Physician Fee Schedule for Calendar Year 1998; Payment 
Policies and Relative Value Unit Adjustments and Clinical Psychologist 
Fee Schedule; Final Rule



Medicare: Physician Fee Schedule Conversion Factor for Calendar Year 
1998; Sustainable Growth Rate for Fiscal Year 1998; Notice



Medicare: Physician Fee Schedule for Calendar Year 1998; Payment 
Policies and Relative Value Unit Adjustments; Practice Expense Relative 
Value Units Adjustments; Proposed Rule

Federal Register / Vol. 62, No. 211 / Friday, October 31, 1997 / 
Rules and Regulations

[[Page 59048]]



DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

42 CFR Parts 400, 405, 410, 411, and 414

[BPD-884-FC]
RIN 0938-AH94


Medicare Program; Revisions to Payment Policies and Adjustments 
to the Relative Value Units Under the Physician Fee Schedule, Other 
Part B Payment Policies, and Establishment of the Clinical Psychologist 
Fee Schedule for Calendar Year 1998

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

ACTION: Final rule with comment period.

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

SUMMARY: This final rule makes several policy changes affecting 
Medicare Part B payment. The changes relate to physician services, 
including geographic practice cost index changes, clinical psychologist 
services, physician supervision of diagnostic tests, establishment of 
independent diagnostic testing facilities, the methodology used to 
develop reasonable compensation equivalent limits, payment to 
participating and nonparticipating suppliers, global surgical services, 
caloric vestibular testing, and clinical consultations.
    This rule also implements provisions in the Balanced Budget Act of 
1997 relating to practice expense relative value units, screening 
mammography, colorectal cancer screening, screening pelvic 
examinations, and EKG transportation. In addition, we are finalizing 
the 1997 interim work relative value units and are issuing interim work 
relative value units for new and revised codes for 1998.

DATES: Effective Date: This rule is effective January 1, 1998. This 
rule is a major rule as defined in Title 5, United States Code, section 
804(2). Pursuant to 5 U.S.C. section 801(a)(1)(A), we are submitting a 
report to the Congress on this rule on October 30, 1997.
    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 December 30, 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-884-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.

    Because of staffing and resource limitations, we cannot accept 
comments by facsimile (FAX) transmission. In commenting, please refer 
to file code BPD-884-FC. Comments received timely will be available for 
public inspection as they are received, beginning approximately 3 weeks 
after publication of the 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: For staff in the Center for Health 
Plans and Providers, Plan and Provider Purchasing Policy Group, 
Division of Practitioner and Ambulatory Care:

Jim Menas, (410) 786-4507 (for issues related to practice expense 
relative value units).
Regina Walker-Wren, (410) 786-9160 (for issues related to the clinical 
psychologist fee schedule).
William Morse, (410) 786-4520 (for issues related to the supervision of 
diagnostic tests and independent diagnostic testing facilities).
Ward Pleines, Center for Health Plans and Providers, Chronic Care 
Purchasing Policy Group, Division of Cost Reporting, (410) 786-4528, 
(for issues related to the reasonable compensation equivalent limit 
update factor).
Anita Heygster, Center for Health Plans and Providers, Plan and 
Provider Purchasing Policy Group, Division of Integrated Delivery 
Systems, (410) 786-4486 (for issues related to participating and 
nonparticipating suppliers).
Bill Larson, Office of Clinical Standards and Quality, Coverage and 
Analysis Group, (410) 786-4639 (for issues related to screening 
mammography, screening pelvic examinations, and screening colorectal 
cancer examinations).
Stanley Weintraub, Center for Health Plans and Providers, Plan and 
Provider Purchasing Policy Group, Division of Practitioner and 
Ambulatory Care, (410) 786-4498 (for all other issues).

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

[[Page 59049]]

cause total physician fee schedule payments to differ by more than $20 
million from what they would have been had the adjustments not been 
made. Thus, the statute allows a $20 million tolerance for increasing 
or reducing total expenditures under the physician fee schedule. We 
have determined that net increases because of changes to the physician 
fee schedule would have added to projected expenditures in calendar 
year 1998 by approximately $300 million. Therefore, we are making the 
budget neutrality adjustment required by changes in payment policy and 
Physicians' Current Procedural Terminology (CPT) through the conversion 
factor (CF). A CF is a national value that converts RVUs into payment 
amounts. Effective January 1, 1998, there will be one CF, as specified 
by the Balanced Budget Act of 1997 (BBA 1997) (Public Law 105-33), 
enacted on August 5, 1997. (Anesthesia has a separate CF but is paid 
using a different formula.) The CF is updated annually.
    We have made the adjustment 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.
    Addenda to this rule provide the following information:

Addendum A--Explanation and Use of Addenda B Through G.
Addendum B--1998 Relative Value Units and Related Information Used in 
Determining Medicare Payments for 1998.
Addendum C--Codes with Interim Relative Value Units.
Addendum D--1999 Geographic Practice Cost Indices by Medicare Carrier 
and Locality.
Addendum E--1998 Geographic Practice Cost Indices by Medicare Carrier 
and Locality.
Addendum F--1999 Versus 1997 Geographic Adjustment Factor (GAF) by 1998 
Fee Schedule Area.
Addendum G--Counties Included in 1998 Localities (Alphabetically by 
State and Locality Name Within State).

    The RVUs and revisions to payment policies in this final rule apply 
to physicians' services furnished on or after January 1, 1998.
    To assist readers in referencing sections contained in this 
preamble, 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. Information on the regulation's impact appears throughout 
the preamble and not exclusively in section VIII.

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 1998
    A. Resource-Based Practice Expense Relative Value Units
    1. Phased-In Implementation
    2. Adjustment for Practice Expense Relative Value Units for 1998
    3. Additional Provisions
    B. Geographic Practice Cost Index Changes
    1. Work Geographic Practice Cost Indices
    2. Practice Expense Geographic Practice Cost Indices
    a. Employee Wage Indices
    b. Rent Indices
    c. Medical Equipment, Supplies, and Miscellaneous Expenses
    3. Malpractice Geographic Practice Cost Indices
    C. Fee Schedule for Clinical Psychologist Services
    1. Background
    2. Legislative Changes
    3. Physician Payment Reform
    4. Related Federal Register Document
    5. Policy Pertaining to Clinical Psychologist Services
    6. Rationale and Alternatives Considered
    D. Diagnostic Tests
    1. Ordering of Diagnostic Tests
    2. Supervision of Diagnostic Tests
    3. Independent Diagnostic Testing Facility
    E. Reasonable Compensation Equivalent Limit Update Factor
    1. Background
    2. Change in the Methodology Used to Develop Reasonable 
Compensation Equivalent Limits
    F. Payment to Participating and Nonparticipating Suppliers
    G. Increase in Work Relative Value Units for Global Surgical 
Services to Account for the 1997 Increases for Work Relative Value 
Units in Evaluation and Management Services
    H. Caloric Vestibular Testing
    I. Clinical Consultations
    J. Actual Charges
III. Implementation of the Balanced Budget Act of 1997
    A. Changes in Practice Expense Relative Value Units for 1998
    B. Coverage of Screening Mammography and Related Payment Changes
    C. Colorectal Cancer Screening
    1. Coverage Determination in Screening Barium Enemas
    2. Provisions of the Final Rule
    3. Frequency Limits and Conditions of Coverage
    4. Payment Limits
    5. Screening Colonoscopy in an Ambulatory Surgical Center
    D. Coverage of Screening Pelvic Examination (Including a 
Clinical Breast Examination) and Related Payment Changes
    E. Reinstatement of the Payment for Transportation of EKG 
Equipment
    F. Waiver of Proposed Rulemaking for Provisions in the Balanced 
Budget Act of 1997
IV. Refinement of Relative Value Units for Calendar Year 1998 and 
Responses to Public Comments on Interim Relative Value Units for 
1997
    A. Summary of Issues Discussed Related to the Adjustment of 
Relative Value Units
    B. Process for Establishing Work Relative Value Units for the 
1998 Fee Schedule
    1. Work Relative Value Unit Refinements of Interim and Related 
Relative Value Units (Includes Table 1--Work Relative Value Unit 
Refinements of 1997 Interim and Related Relative Value Units)
    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 1998
    a. Methodology (Includes Table 2--American Medical Association 
Specialty Society Relative Value Update Committee and Health Care 
Professionals Advisory Committee Recommendations and HCFA's 
Decisions for New and Revised 1998 CPT Codes)
    b. Discussion of Codes for Which the RUC Recommendations Were 
Not Accepted
    C. Other Changes to the 1998 Physician Fee Schedule and 
Clarification of CPT Definitions
V. Provisions of the Final Rule
VI. Collection of Information Requirements
VII. Waiver of Proposed Rulemaking and Response to Comments
VIII. Regulatory Impact Analysis
    A. Regulatory Flexibility Act
    B. Geographic Practice Cost Index Changes
    C. Fee Schedule for Clinical Psychologist Services
    D. Diagnostic Tests
    E. Reasonable Compensation Equivalent Limit Update Factor
    F. Payment to Participating and Nonparticipating Suppliers
    G. Increase in Work Relative Value Units for Global Surgical 
Services to Account for the 1997 Increases for Work Relative Value 
Units in Evaluation and Management Services
    H. Caloric Vestibular Testing
    I. Clinical Consultations
    J. Changes in Practice Expense Relative Value Units for 1998
    K. Coverage of Screening Mammography and Related Payment Changes
    L. Colorectal Cancer Screening
    M. Coverage of Screening Pelvic Examination (Including a 
Clinical Breast Examination) and Related Payment Changes
    N. Reinstatement of the Payment for Transportation of EKG 
Equipment

[[Page 59050]]

    O. Elimination of the Separate Budget-Neutrality Adjuster for 
the Work Relative Value Units
    P. Effect of Changes Resulting from Adjustments to the Relative 
Value Units
    Q. Net Impact of Relative Value Unit Changes on Medicare 
Specialties
    1. Impact Estimation Methodology
    2. Overall Fee Schedule Impact
    3. Specialty Level Effect (Includes Table 3-- Impact on Medicare 
Payments by Specialty Due to Changes in Relative Value Units)
    R. Five-Year Impacts of Benefit Changes (Includes Table 4--
Projected Budget Impact of New Benefits)
    S. Rural Hospital Impact Statement
Addendum A--Explanation and Use of Addenda B Through G.
Addendum B--1998 Relative Value Units and Related Information Used 
in Determining Medicare Payments for 1998.
Addendum C--Codes with Interim Relative Value Units.
Addendum D--1999 Geographic Practice Cost Indices by Medicare 
Carrier and Locality.
Addendum E--1998 Geographic Practice Cost Indices by Medicare 
Carrier and Locality.
Addendum F--1999 Versus 1997 Geographic Adjustment Factor (GAF) by 
1998 Fee Schedule Area.
Addendum G--Counties Included in 1998 Localities (Alphabetically by 
State and Locality Name Within State).

    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.
BBA--1997 Balanced Budget Act of 1997
CF--Conversion factor.
CFR--Code of Federal Regulations.
CPI--Consumer Price Index.
CPI-U--Consumer Price Index for All Urban Consumers.
CPT--[Physicians'] Current Procedural Terminology [4th Edition, 
1997, copyrighted by the American Medical Association].
CT--Computerized axial tomography.
FDA--Food and Drug Administration.
GAF--Geographic adjustment factor.
GPCI--Geographic practice cost index.
HCFA--Health Care Financing Administration.
HCPCS--HCFA Common Procedure Coding System.
HHS--[Department of] Health and Human Services.
HUD--[Department of] Housing and Urban Development.
IDTF--Independent Diagnostic Testing Facility.
IPL--Independent Physiological Laboratory.
MEI--Medicare Economic Index.
MRI--Magnetic resonance imaging.
OBRA--Omnibus Budget Reconciliation Act.
PC--Professional component.
RUC--[AMA's 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 Social Security Act (the Act), ``Payment for 
Physicians' Services.'' This section contains three major elements: (1) 
A fee schedule for the payment of physician services; (2) a method to 
control the rates of increase in Medicare expenditures for physicians' 
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. As noted above, if this tolerance is exceeded, we must make an 
adjustment to the conversion factor (CF) to preserve budget neutrality.
    Section 1848(e)(1)(C) of the Act requires us to review and, if 
necessary, adjust the geographic practice cost indices (GPCIs) at least 
every 3 years. This section also requires us to phase in the adjustment 
over 2 years and implement only one-half of any adjustment if more than 
1 year has elapsed since the last GPCI revision. The GPCIs were first 
implemented in 1992 and were reviewed and revised in 1995. Thus, we are 
required to complete the second GPCI review and implement only one-half 
of any adjustment by 1998 and one-half in 1999.
    The Act requires that payments vary among fee schedule areas 
according to geographic indices. In general, the fee schedule areas 
that existed under the prior reasonable charge system were retained 
under the fee schedule. A detailed discussion of fee schedule areas can 
be found in the June 5, 1991 proposed rule (56 FR 25832) and in the 
November 25, 1991 final rule (56 FR 59514). We are required by section 
1848(e)(1)(A) of the Act to develop separate indices to measure 
relative cost differences among fee schedule areas compared to the 
national average for each of the three fee schedule components. While 
requiring that the practice expense GPCIs and malpractice GPCIs reflect 
the full relative cost differences, the Act requires that the work 
indices reflect only one-quarter of the relative cost differences 
compared to the national average.

B. Published Changes to the Fee Schedule

    In the June 18, 1997 proposed rule (62 FR 33159), we listed all of 
the final rules published through November 22, 1996 relating to the 
updates to the RVUs and revisions to payment policies under the 
physician fee schedule. In the June 1997 proposed rule (62 FR 33158), 
we discussed several policy options affecting Medicare payment for 
physicians' services including resource-based practice expense RVUs, 
geographic practice cost index changes, clinical psychologist services, 
supervision of diagnostic tests, establishment of independent 
diagnostic testing facilities, the methodology used to develop 
reasonable compensation equivalent limits, payment to participating and 
nonparticipating suppliers, global surgical services, caloric 
vestibular testing, clinical consultations, and payments based on 
actual charges.
    This final rule affects the regulations set forth at part 400, 
which consists of an introduction and definitions; part 405, which 
consists of regulations on Federal health insurance for the aged and 
disabled; part 410, which consists of regulations pertaining to 
supplementary medical insurance benefits (Part B); part 411, which 
consists of regulations pertaining to exclusions from Medicare and 
limitations on Medicare payment; and part 414, which consists of 
regulations pertaining to the payment for Part B medical and other 
health services. It also discusses changes to work RVUs affecting 
payment of physician services. The information in this final rule 
updates information in the June 18, 1997 proposed rule (62 FR 33158).

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 CF for the service. The CF converts 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

[[Page 59051]]

of these components of the fee schedule there is a 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.
    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 CF for calendar year 1998 appears in Addendum A. The RVUs for 
calendar year 1998 are in Addendum B. The GPCIs for calendar year 1998 
are in Addendum E.
    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.

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 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 December 
8, 1995 final rule (60 FR 63124) addressed comments on RVUs published 
as interim in the December 8, 1994 final rule. In addition, the 
December 8, 1995 final rule discussed the process used to establish 
RVUs for codes that were new or revised for 1996. The November 22, 1996 
final rule (61 FR 59490) addressed all comments received in response to 
our May 3, 1996 proposed notice (61 FR 19992) on the 5-year review of 
work RVUs, finalized the 1996 interim work RVUs, and issued interim 
RVUs for new and revised procedure codes for 1997.
2. Practice Expense and Malpractice Expense Relative Value Units
    Section 1848(c)(2)(C) of the Act required 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.
    Section 121 of the Social Security Act Amendments of 1994 (Pub. L. 
103-432), enacted on October 31, 1994, and amended by the BBA 1997, 
requires us to develop a methodology for a resource-based system for 
determining practice expense RVUs for each physician service. In 
developing the methodology, we considered the staff, equipment, and 
supplies used in providing medical and surgical services in various 
settings. The legislation required the new payment methodology to be 
phased in over 4 years, effective for services furnished in 1999.

II. Specific Proposals for Calendar Year 1998

    In response to the publication of the June 1997 proposed rule, we 
received approximately 8,600 comments. We received comments from 
individual physicians, health care workers, and professional 
associations and societies. The majority of the comments addressed the 
proposals related to resource-based practice expense RVUs, supervision 
of diagnostic tests, and payments based on actual charges.
    The proposed rule discussed policies that affect the number of RVUs 
on which payment for certain services would be based. Certain changes 
implemented through this final rule are subject to the $20 million 
limitation on annual adjustments 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 1998. We discuss in detail the 
effects of these changes in the

[[Page 59052]]

Regulatory Impact Analysis (section VIII).
    For the convenience of the reader, the headings for the policy 
issues in section II correspond to the headings used in the June 1997 
proposed rule (62 FR 33158). More detailed background information for 
each issue can be found in the June 1997 proposed rule.

A. Resource-Based Practice Expense Relative Value Units

    Section 121 of the Social Security Act Amendments of 1994 (Public 
Law 103-432), enacted on October 31, 1994, requires us to develop a 
methodology for a resource-based system for determining practice 
expense RVUs for each physician service. The June 1997 proposed rule 
(62 FR 33160), contained the proposed resource-based practice expense 
RVUs. We received a substantial number of comments on our proposal, 
both favorable and unfavorable.
    Before the close of the comment period on August 18, 1997, the 
Balanced Budget Act (BBA) of 1997 (Pub. L. 105-33) was enacted on 
August 5, 1997. The BBA 1997 delayed implementation of the resource-
based practice expense system until 1999. The BBA 1997 contained 
additional requirements.
1. Phased-in Implementation
    Instead of paying for all services entirely under a resource-based 
practice expense system in 1999, the system will be implemented over a 
4-year period. The practice expense RVUs for 1999 will be based on the 
product of 75 percent of the previous year's practice expense RVUs 
(1998) and 25 percent of the resource-based practice expense RVUs. For 
the year 2000, the percentages will be 50 percent of the charge-based 
practice expense RVUs and 50 percent of the resource-based practice 
expense RVUs. For 2001, the percentages will be 25 percent of the 
charge-based practice expense RVUs and 75 percent of the resource-based 
practice expense RVUs. For subsequent years, the RVUs will be based 
totally on resource-based practice expense RVUs.
2. Adjustment for Practice Expense Relative Value Units for 1998
    Section 4505 of the BBA 1997 specifies the manner in which practice 
expense RVUs in 1998 are adjusted.
    Section 4505 of the BBA 1997 enacted a provision that would in 1998 
redistribute practice expense RVUs in the direction of the resource-
based RVUs that are to be implemented in 1999. The 1998 practice 
expense RVUs for certain services are reduced to 110 percent of their 
work RVUs for the service, and the monies are used to raise the 
practice expense RVUs for office visit procedures. (Section 4505 of the 
BBA 1997 also gives us the authority to adjust this percentage if the 
aggregate amount of reductions exceeds $390 million. Since the 
application of the 110 percent results in reductions of approximately 
$330 million, no further adjustment is necessary.) A detailed 
discussion of this provisions is discussed in section III, 
``Implementation of the Balanced Budget Act of 1997.''
3. Additional Provisions
    Several additional provisions relating to the development of 
resource-based practice expense RVUs will be published in the Federal 
Register in the spring of 1998. These provisions will be discussed in a 
notice of intent to regulate that is being published elsewhere in this 
issue of the Federal Register.
    We are not adopting the resource-based practice expense system 
proposal published in the June 1997 proposed rule. However, we will 
publish a new proposed rule in the spring of 1998 with a new set of 
resource-based practice expense RVUs.

B. Geographic Practice Cost Index Changes

    The Act requires that payments vary among fee schedule areas to the 
extent that resource costs vary as measured by the GPCIs. As stated 
earlier, section 1848(e)(1)(C) of the Act requires us to review and, if 
necessary, adjust the GPCIs at least every 3 years. This section of the 
Act also requires us to phase in the adjustment over 2 years and 
implement only one-half of any adjustment in the first year if more 
than 1 year has elapsed since the last GPCI revision. The GPCIs were 
first implemented in 1992, and the first review and revision was 
implemented in 1995. (A detailed discussion of the development of the 
GPCIs and references to obtaining studies on the development of the 
GPCIs can be found in the June 1997 proposed rule (62 FR 33172.)
    The 1998 through 2000 GPCIs represent the second GPCI update. The 
1999 GPCIs (Addendum D) are the fully revised GPCIs. The 1998 GPCIs 
(Addendum E) represent the one-half transition GPCIs. Addendum F shows 
the estimated effects on area payments of the fully revised 1999 GPCIs. 
The payment effects in 1998 will be about one-half of these amounts.
    The same data sources and methodology used for the 1995 through 
1997 GPCIs were used for the 1998 through 2000 GPCIs with a few very 
minor modifications. No acceptable additional data sources were found.
1. Work Geographic Practice Cost Indices
    The work GPCIs are based on the decennial census. The 1992 through 
1994 work GPCIs were based on 1980 census data, because 1990 census 
data were not yet available. The work GPCIs were revised in 1995 with 
new data from the 1990 census. New census data will not be available 
again until after the 2000 census. We searched for other data that 
would enable us to update the work GPCIs between the decennial census. 
No acceptable data sources were found.
    Therefore, we are making no changes in the work GPCIs, other than 
the generally negligible changes resulting from using 1994, rather than 
1992, RVUs in mapping counties to localities for this GPCI update. We 
believe it is preferable to make no changes rather than making 
inaccurate changes based on unacceptable data. We believe that this is 
a particularly reasonable position given the generally small magnitude 
of the changes in payments resulting from the changes in the work GPCIs 
from the 1980 to the 1990 census data.
2. Practice Expense Geographic Practice Cost Indices
    a. Employee Wage Indices. As with the work GPCIs, the employee wage 
portion of the practice expense GPCIs is based on decennial census 
data. Like the work GPCIs, the employee wage indices are not being 
changed during this GPCI update.
    b. Rent Indices. The office rental indices are again based on HUD 
residential rent data. The revised rental indices are based on 1996 HUD 
data as opposed to 1994 HUD data used in the 1995 through 1997 GPCIs.
    c. Medical Equipment, Supplies, and Miscellaneous Expenses. As with 
the 1992 through 1994 and 1995 through 1997 GPCIs, this component was 
given a national value of 1.000, indicating no measurable difference 
among areas in costs. (For previously published Federal Register 
documents that discuss these issues, see section I.B. of this final 
rule, ``Published Changes to the Fee Schedule.'')
3. Malpractice Geographic Practice Cost Indices
    Again, malpractice premium data were collected for a mature 
``claims made'' policy with $1 million to $3 million limits of 
coverage, with adjustments made for mandatory patient compensation 
funds. The proposed malpractice indices were based on 1992

[[Page 59053]]

through 1994 premium data, the latest years available when this study 
was being conducted in 1995 through 1996, compared to the 1990 through 
1992 data used in the current 1995 through 1997 indices.
    Fee schedule areas are described by carrier and locality number 
with a short geographic description such as ``Atlanta.'' We received 
numerous inquiries about the geographic areas that comprise our fee 
schedule areas. Addendum G lists alphabetically by State and fee 
schedule area the counties included in each fee schedule area.
    Comment: The majority of commenters expressed concern about the 
continued use of proxy data, especially the HUD residential rent data, 
rather than commercial rent data, in the GPCIs. They suggested we 
collect actual data on physician earnings and expenses.
    Response: In both the 1995 and this GPCI revision we conducted an 
extensive search for alternative data sources as well as for more 
recent data. The search led us to conclude that the current GPCI 
proxies are still the best available data to measure practice cost 
differences among areas. As stated in all previous proposed and final 
rules on the GPCIs, the actual earnings of physicians were not used to 
adjust geographical differences in fees because these fees are, in 
large part, the determinants of the earnings. That is, the use of 
actual physician earnings would be ``circular.'' As also discussed in 
all previous proposed and final rules on the GPCIs, no acceptable 
sources of commercial rent data were found.
    We believe the current GPCI data sources are an accurate reflection 
of area practice cost differences. We believe physician earnings will 
vary among areas as do the earnings of other highly educated 
professionals, and commercial rents will vary among areas as do 
residential rents. The employee wage portion of the GPCIs is based on 
census data on the actual earnings of the type of employees found in 
physicians' offices. The malpractice index is based on actual 
malpractice premiums. The current GPCI data sources reflect costs 
across the country and are updated on a regular basis. Any data 
collection of actual physician costs of sufficient breadth to cover all 
counties and be updated on a regular basis would be massive and 
extremely costly. We are unconvinced that such an effort would produce 
a result so significantly at variance with the present GPCIs as to 
justify the resources required to collect the data.
    Comment: Commenters stated that there should be no geographic 
payment differences under the physician fee schedule. They believe that 
in a national program with the same Medicare Part B premium everywhere, 
that equivalent services should have equivalent payment regardless of 
geographic area.
    Response: Section 1848(e)(1)(A) of the Act requires that payments 
vary among areas as resource costs vary as reflected by the GPCIs.
    Comment: One commenter stated that the GPCIs did not accurately 
reflect area cost differences because uniform GPCI component cost share 
weights were used. The commenter stated that use of the same cost 
shares everywhere fails to recognize that component weights might vary 
among areas, specialties, and services depending upon factors such as 
case mix, availability of other health care resources, and individual 
practice styles.
    Response: We agree that different specialties and individual 
practitioners utilize resources differently and may have expenses in 
different proportions from the component weights used in the GPCIs as 
discussed in the June 1997 proposed rule at 62 FR 33172. The physician 
fee schedule was established in 1992 specifically to eliminate the 
large unjustifiable payment differences that existed among services, 
specialties, and geographic areas by establishing a uniform national 
payment system. Payments under the physician fee schedule are based on 
uniform national RVUs for a service and a national dollar conversion 
factor and can vary only as area resource costs vary as demonstrated by 
the GPCIs. The law prohibits any specialty payment differential. The 
RVUs for a service represent the typical service. The GPCI component 
weights represent the average practice expense component weights across 
all physician specialties and are intended to reflect average costs 
across all services and specialties in an area and not to reflect 
exactly the costs of each individual practitioner. Thus, physician fee 
schedule payments are designed by law to reflect the resources involved 
with provision of the typical service across all specialties and 
physicians in an area. It would not be in keeping with the intent of 
the law nor would it be practical or desirable in a national program to 
attempt to recognize individual practice patterns.
    Comment: One commenter stated that contrary to the GPCIs, which 
show that costs tend to be higher in urban areas, rural physicians may 
actually have higher costs than urban or suburban physicians. The 
commenter attributed this to such factors as higher shipping costs, 
higher equipment maintenance costs, higher continuing education costs, 
and less efficient use of medical equipment.
    Response: While we have heard this argument since the inception of 
the physician fee schedule, we have no data demonstrating that 
physicians in rural areas have higher costs of practice than physicians 
in urban or suburban areas. Physician work, rents, employee wages, and 
malpractice insurance represent about 86 percent of physician costs as 
reflected in the GPCIs. Our data show that wages, both physician wages 
as reflected by wages of other highly educated professionals and the 
wages of medical and clerical personnel in physicians' offices, and 
rents are higher in urban and suburban areas than in rural areas. While 
malpractice premiums are the same statewide in many States, in those 
States where premiums do vary geographically they are higher in urban 
areas. The types of expenses mentioned as higher in rural areas, 
continuing education, higher shipping costs, higher equipment 
maintenance costs, and less efficient use of equipment, represent only 
a very small portion of physician practice costs.
    Comment: One commenter recommended that changes in malpractice 
GPCIs reflect actual changes in costs from year to year.
    Response: We interpret this comment to mean that the malpractice 
GPCIs should reflect actual changes in malpractice premiums from the 
prior year. That is, the 1998 malpractice GPCIs should reflect actual 
changes in malpractice premiums from 1997 to 1998, and the malpractice 
GPCIs should be changed each year to reflect annual premium changes. 
The law requires that we review and revise the GPCIs at least every 3 
years. This revision involves substantial data collection and analysis 
and must be published in a proposed rule. For example, the last GPCI 
revision was in 1995, meaning that the next revision is required in 
1998. This requires publication of the proposed changes in the Federal 
Register in early 1997 to allow for public comment. To meet this 
timeframe, data collection begins in 1995 to allow time for data 
analysis and drafting of the proposed rule. Therefore, given the time 
frame for the process to utilize updated data, this is the most current 
data that could be used. Thus, the revised malpractice GPCIs are based 
on 1992 through 1994 malpractice premium data, the most recent data 
available at the time the revision process was begun in 1995. As 
discussed in the proposed rule, we use a 3-year average rather than the 
most recent single year of malpractice data to smooth the annual 
volatility of

[[Page 59054]]

malpractice premiums and present a more accurate indication of 
malpractice premium trends over time. We do not plan to revise the 
GPCIs more frequently than every 3 years as required by law.
    Result of evaluation of comments: The GPCIs proposed on June 18, 
1997 will be effective beginning in 1998.

C. Fee Schedule for Clinical Psychologist Services

1. Background
    Until 1997, the fee schedule for clinical psychologist services was 
a locality-based fee schedule developed by the individual Medicare 
carriers. The Medicare carriers established the locality-based fee 
schedule in 1988 after section 4077(b) of the Omnibus Budget 
Reconciliation Act of 1987 (OBRA 1987) (Public Law 100-203), enacted on 
December 22, 1987, first provided for direct payment for clinical 
psychologist services furnished in a community mental health center. 
Section 4077(b)(3)(D) of OBRA 1987 amended section 1833(a)(1) of the 
Act by providing that payment for clinical psychologist services be 
based at 80 percent of the lower of the actual charge or a fee 
schedule.
    The Act provides that the Secretary determine the fee schedule. As 
a result, we furnished guidance to all Medicare Part B carriers to 
establish the initial, that is, baseline, clinical psychologist fee 
schedule as follows:
     Set the fee schedule for therapeutic services at 80 
percent of the adjusted prevailing charge for participating 
psychiatrists in a locality; and
     Set the fee schedule for diagnostic services at 90 percent 
of the adjusted prevailing charge for participating psychologists in a 
locality.
    We also advised the Medicare Part B carriers to update the clinical 
psychologist fee schedule in subsequent years by the annual change in 
the Consumer Price Index for All Urban Consumers (CPI-U). We adopted 
the CPI-U to update the clinical psychologist fee schedule because it 
was the economic index used for updating most other nonphysician 
practitioner charges at that time.
    Since that time, there have been two significant changes to the fee 
schedule for clinical psychologist services. First, effective January 
1, 1992, we implemented the policy to base payment for psychological 
testing services furnished by clinical psychologists on the amounts in 
the physician fee schedule. Second, effective January 1, 1997, we 
linked the fee schedule for clinical psychologist services to the 
physician fee schedule in the same manner as for most other health care 
practitioner services. We describe these changes in more detail in the 
sections that follow.
2. Legislative Changes
    Although section 4077(b) of OBRA 1987 provided for clinical 
psychologist services as separately payable under Medicare Part B under 
a fee schedule, direct payment was limited to services furnished in 
community mental health centers. Subsequent amendments to the law 
expanded the scope of the benefit. These amendments were discussed in a 
related Federal Register document described in section II.C.4. below.
3. Physician Payment Reform
    As noted in section I.A., since January 1, 1992, Medicare Part B 
has paid for physician services based on a fee schedule. Until 1992, 
physician services had been paid on the basis of a reasonable charge 
system. This system led to significant payment variations among types 
of services, physician specialties, and localities. Section 6102 of 
OBRA 1989 added a new section 1848 to the Act, ``Payment for 
Physicians'' Services,'' which replaced the reasonable charge system 
with a fee schedule that reflected the resources required to perform a 
given service. Although this legislation linked the payment methodology 
for most practitioner services to the physician fee schedule, it did 
not address payment for clinical psychologist services. Nevertheless, 
because amounts established under the physician fee schedule for 
psychological testing were heavily based on combined charge data for 
psychiatrists and psychologists, we wished to ensure that clinical 
psychologists would receive 100 percent of the physician fee schedule 
amount for those services. Therefore, effective January 1, 1992, fee 
schedule amounts for psychological testing services furnished by 
clinical psychologists are set at 100 percent of the physician fee 
schedule. However, before 1997, no change was made to the clinical 
psychologist fee schedule for therapeutic and other diagnostic 
services.
4. Related Federal Register Document
    We discussed several aspects of payment for clinical psychologist 
services in a proposed rule published in the Federal Register on 
December 29, 1993 (Medicare Coverage and Payment for Clinical 
Psychologist, Other Psychologist, and Clinical Social Worker Services 
(BPD-706-P)) (58 FR 68829). That document addressed issues such as 
coinsurance, the outpatient mental health treatment limitation in 
section 1833(c) of the Act, and assignment of claims. In the December 
1993 proposed rule, we indicated that we would address the calculation 
of the clinical psychologist fee schedule amounts set forth under 
section 1833(a)(1)(L) of the Act in a separate proposed rule (58 FR 
68837). Below, we discuss establishing the fee schedule for clinical 
psychologist services as referred to in the December 1993 proposed 
rule.
5. Policy Pertaining to Clinical Psychologist Services
    There are two types of services billed directly to Medicare Part B 
by clinical psychologists: diagnostic services and therapeutic 
services. Medicare direct payment for services furnished by clinical 
psychologists became effective July 1, 1988. From 1988 through 1996, 
Medicare Part B payment to clinical psychologists for therapeutic 
services was subject to a locality-based fee schedule calculated by 
each Medicare carrier. In 1988, the Medicare carriers developed the 
clinical psychologist fee schedule on the basis of a HCFA analysis of 
charging practices of psychologists and psychiatrists. Because no 
Medicare charge data for therapeutic services furnished by clinical 
psychologists existed at that time, we compared psychologist and 
psychiatrist charges from other payor sources as a gap-filling measure 
for Medicare pricing purposes. The resulting clinical psychologist fee 
schedule amounts for therapeutic services, as shown in section II.C.1. 
above, were set at 80 percent of the adjusted prevailing charge for 
similar services of Medicare-participating psychiatrists in the 
locality. (The ``adjusted prevailing charge'' for physicians means the 
locality prevailing charge that is calculated by applying the Medicare 
Economic Index (MEI) to the base year prevailing charge. In this way, 
Medicare reasonable charges for physician services are increased above 
the base year rates only to the extent determined to be justified by 
appropriate economic data.)
    Initially, the fee schedule amounts for diagnostic services 
furnished by clinical psychologists were set at 90 percent of the 
Medicare prevailing charge for independently practicing psychologists 
in a locality. In contrast to therapeutic services, Medicare charge 
data had existed for diagnostic testing because psychological testing 
furnished by independent psychologists under a physician's order had 
been covered as ``other diagnostic tests'' under section 1861(s)(3) of 
the Act.

[[Page 59055]]

    The amounts established under the physician fee schedule for 
diagnostic psychological testing were largely based on blended charge 
data for both psychologists and physicians. Furthermore, because 
psychologists are the predominant suppliers of psychological testing 
services, the physician fee schedule amounts for those services were 
based in large part on psychologist charge data. In the November 25, 
1991 final rule that established the physician fee schedule, we stated 
(56 FR 59507) that diagnostic tests furnished by clinical psychologists 
would be paid under the physician fee schedule. Since January 1, 1992, 
amounts for diagnostic psychological testing services furnished by 
psychologists are equivalent to the amounts established under the 
physician fee schedule authorized by section 1848 of the Act. 
(Diagnostic psychological testing services are listed in the 
Physicians' Current Procedural Terminology (CPT) '97 as CPT codes 96100 
through 96117.)
    A variety of health care practitioners under Medicare have payment 
levels that are tied, by law, to the physician fee schedule. These 
practitioners include nurse practitioners, nurse midwives, and 
physician assistants. We believe that it is also appropriate to 
establish a clinical psychologist fee schedule that is linked to the 
physician fee schedule. The implementation of 24 new billing codes for 
psychotherapy services effective January 1, 1997 required us to 
establish relative values under the physician fee schedule for each 
code. We established the clinical psychologist fee schedule value for 
all services at 100 percent of the physician fee schedule amount for 
the corresponding service. Consequently, this rule sets forth the fee 
schedule for covered clinical psychologist services at 100 percent of 
the physician fee schedule amount for the corresponding service. The 
rationale for this payment level appears in section II.C.6. below. 
Although this payment policy was implemented January 1, 1997, we are 
including it in this final rule in order to codify in regulations the 
methodology for the clinical psychologist fee schedule.
6. Rationale and Alternatives Considered
    As noted in section II.C.1., we recommended in 1988 that Medicare 
carriers set clinical psychologist fee schedule amounts for therapeutic 
services at 80 percent of the MEI-adjusted prevailing charge for 
psychiatrists. That level had been primarily based on the fee 
differential found in a review of psychologist and psychiatrist fees 
from 1985 through 1988.
    Effective January 1, 1992, physicians' services are paid under a 
resource-based fee schedule rather than a reasonable charge 
methodology. The physician fee schedule establishes payment amounts for 
all physician services as defined in section 1848(j)(3) of the Act. One 
effect of the physician fee schedule is that payment for physician 
services is now standardized. We believe that the clinical psychologist 
fee schedule amounts for therapeutic services should be tied to the 
physician fee schedule.
    As noted earlier, effective for services furnished on or after 
January 1, 1992, payment for diagnostic psychological tests furnished 
by clinical psychologists is based on the physician fee schedule. The 
clinical psychologist fee schedule for therapeutic services, which was 
in use until January 1, 1997, was not resource-based but was derived 
from the initial linkage between psychologist and psychiatrist 
prevailing charges. However, with the implementation of the physician 
fee schedule, prevailing charges no longer apply for physician 
services. Furthermore, because the prevailing charge was based on 
actual charging patterns, it frequently resulted in large differences 
in charges from one area to another. With implementation of the 
physician fee schedule, the GAF used to adjust the RVUs for physician 
services has changed the geographic distribution of fees. The purpose 
of the GAF is to recognize only justifiable differences in the cost of 
operating a medical practice in different areas.
    Finally, once the clinical psychologist fee schedule is linked 
directly to the physician fee schedule, the annual physician update 
factor used to update fees for clinical psychologist services will be 
the same as the index used to update fees for physicians and other 
health care practitioners. The following table illustrates that, for 
the years between 1989 through 1991 (during which the prevailing charge 
system applied), the CPI-U update factor exceeded the congressionally 
imposed limits on the MEI that was used to adjust Medicare prevailing 
charges for nonprimary care physician services:

------------------------------------------------------------------------
                                            1989       1990       1991  
            Annual increase              (percent)  (percent)  (percent)
------------------------------------------------------------------------
CPI-U..................................       4.0        5.2        4.7 
MEI (for other than primary care)......       1.0        2.0        0.0 
------------------------------------------------------------------------

    Using a hypothetical prevailing charge of $100 for psychiatrists in 
1988, we illustrate the relationship of the clinical psychologist fee 
schedule to psychiatrist prevailing charges in 1991 in the following 
table:

------------------------------------------------------------------------
                                       1989         1990         1991   
------------------------------------------------------------------------
Psychiatrists (1988 prevailing                                          
 charge = $100):                                                        
    MEI update factor............         1.01         1.02         1.00
    Updated prevailing charge....      $101.01      $103.02      $103.02
Clinical Psychologists (1988 fee                                        
 = $80):                                                                
    CPI-U update factor..........         1.04        1.052        1.047
    Updated fee..................       $83.20       $87.53       $91.64
Psychologist/Psychiatrist (1988 =                                       
 80%)............................        82.4%        85.0%        89.0%
------------------------------------------------------------------------

    By 1991, the combined effect of using the CPI-U to update the 
clinical psychologist fee schedule and the MEI to update psychiatrist 
prevailing charges resulted in a clinical psychologist fee schedule 
that was equivalent to 89 percent of the psychiatrist prevailing 
charge. Additionally, implementation of the physician fee schedule 
resulted in slight payment decreases for psychiatrist services in 1992. 
In 1993 and 1994, moreover, the physician fee schedule amounts for 
nonsurgical services other than primary care services were increased by 
0.8 percent and 5.3 percent, respectively. By comparison, during the 
first 3 years that the physician fee schedule was in effect, clinical 
psychologist fee schedule amounts increased by 4.7 percent, 3.1 
percent, and 3.0 percent, respectively, for 1992, 1993, and 1994, 
because clinical psychologist fee schedule amounts were adjusted by a 
different economic index, the Consumer Price Index (CPI). Consequently, 
through 1994, clinical psychologist fee schedule increases outpaced 
those for physicians furnishing nonsurgical services other than primary 
care as well as those for

[[Page 59056]]

other nonphysician practitioners whose payments are tied to the 
physician fee schedule.
    The combined effect of all these factors is that the clinical 
psychologist fee schedule no longer reflected the original fee 
differentials between psychologists and psychiatrists that had been 
found in the health care marketplace and factored into the initial 
clinical psychologist fee schedule. As a result, the clinical 
psychologist fee schedule was marked by disparities with the physician 
fee schedule for similar services as well as by wide geographic 
variations that reflected historical charging patterns in different 
areas.
    We had previously considered setting the clinical psychologist fee 
schedule at the level established under the physician fee schedule for 
similar services. However, at that time, the CPT descriptors for 
individual psychotherapy services (CPT codes 90841 through 90844) 
included the term ``* * * [with] continuing medical diagnostic 
evaluation, and drug management, when indicated.'' These are medical 
aspects of a psychotherapeutic service that are outside the scope of 
clinical psychologist licensure. Therefore, we were concerned that it 
would be inappropriate to set the clinical psychologist fee schedule 
amounts at the same level as the physician fee schedule when clinical 
psychologists were unable to perform the full service described in the 
codes.
    During 1996, as part of the statutorily mandated 5-year refinement 
of the RVUs for the physician fee schedule, the American Medical 
Association's (AMA's) Specialty Society Relative Value Scale Update 
Committee (RUC) recommended increases for a number of psychotherapy 
codes. (The RUC, which is comprised of representatives of various 
medical specialty societies, the AMA, the American Osteopathic 
Association, and the CPT Editorial Panel, makes recommendations to us 
concerning the assignment of RVUs to new and revised CPT codes.) As a 
prelude to accepting the RUC recommendations, we examined the coding of 
psychiatry services. We concluded that the CPT code descriptors for 
individual psychotherapy needed to be changed to define the service 
more clearly, recognize the variations in work associated with 
different types of psychotherapy as well as the settings in which the 
types of psychotherapy are furnished, and assign face-to-face time 
values for the service. As a result, effective January 1, 1997, CPT 
codes 90842, 90843, 90844, and 90855 for individual psychotherapy are 
no longer recognized for Medicare purposes. These codes have been 
replaced by 24 alphanumeric codes that include 12 codes for therapy 
furnished in the office and other outpatient settings and 12 codes for 
therapy furnished in inpatient hospital, partial hospital, or 
residential care settings. These two categories were further broken 
down into the types of psychotherapy services. A full listing and 
discussion of these codes was included in the final rule (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 (BPD-852-FC)), published November 22, 
1996. (See 61 FR 59521 through 59523.)
    One of the effects of the coding system changes for psychiatric 
services is that now there are codes for reporting psychotherapy both 
with and without medical evaluation and management services. Under 
Medicare, clinical psychologists may bill for individual psychotherapy 
without medical evaluation and management services. Consequently, when 
clinical psychologists bill for individual psychotherapy without 
medical evaluation and management, those services are equivalent to 
individual psychotherapy without medical evaluation and management 
services when furnished by a physician. As a result, we believe that it 
is both reasonable and equitable to pay clinical psychologists the same 
amount as physicians for equivalent services.
    Alternatively, we considered retaining the previous clinical 
psychologist fee schedule for therapeutic services. We also considered 
setting the clinical psychologist fee schedule at a level other than 
100 percent of the physician fee schedule. However, we rejected these 
options because the resulting fee schedule amounts would have 
essentially continued to be derived from physician prevailing charges, 
which are no longer relevant under the physician fee schedule and would 
only serve to perpetuate geographic variations in charges that are a 
residual effect of the reasonable charge payment system.
    We received a few comments on the clinical psychologist fee 
schedule from five separate major professional associations and 
federations at the national and State level.
    Comment: One commenter urged us to develop an equitable payment 
methodology for clinical social workers that takes into account the 
practitioner's investment in education and training, office expenses, 
and malpractice costs instead of a methodology that is based on a 
percentage of what is paid to another nonphysician provider. The 
commenter noted that payment for clinical social worker services seems 
to be the only instance under the Medicare statute when one G48 
nonphysician's payment rate is tied to that of another nonphysician 
provider.
    Response: The Medicare statute requires that payment be made to 
clinical social workers at 80 percent of the lesser of the actual 
charge for the services or 75 percent of the amount determined for 
payment for clinical psychologist services. Under the circumstances, it 
would be inappropriate to develop an alternative payment amount for 
clinical social worker services.
    Comment: Several commenters stated that they are pleased that we 
have addressed the problem of the clinical psychologist fee schedule 
and the inequitable situation that in some areas of the country fees 
for psychology services were higher than the fees for the same services 
provided by a psychiatrist. Accordingly, these commenters are 
supportive of our requirement that psychologists may bill only for 
psychotherapy without medical evaluation and management. However, two 
of the commenters suggested that we consider our policy of a fee 
schedule for psychologists' services set at 100 percent of the 
physician fee schedule amount to be an interim policy, pending 
completion of ongoing survey work and the RUC's deliberations. 
Completion of the RUC's review of the work involved in the new codes 
will help inform decision makers about whether the coding changes and 
RVUs have adequately captured the resource cost differences between 
psychotherapy provided by psychiatrists and that provided by 
psychologists.
    Additionally, one of these commenters stated that it is illogical 
to permit psychologists to be paid at 100 percent of the physician fee 
schedule for comparable services using the same malpractice expense 
RVUs assigned to physician codes. Malpractice insurance premiums for 
psychologists are as low as 10 percent of the premiums charged to 
leading psychiatrists. Even when psychiatrists provide psychotherapy 
without evaluation and management, their professional standard of care 
exceeds the standard of care applicable to psychologists. Psychologists 
do not have the same responsibility as psychiatrists in terms of being 
accountable for failure to furnish medications or recognize a non-
psychiatric medical condition when providing psychotherapy without 
medical evaluation and management.

[[Page 59057]]

Accordingly, this commenter believes that the malpractice expense and 
practice expense associated with the significantly higher standard of 
care required of psychiatrists requires that we set payment for 
psychologists' services at less than 100 percent of the physician fee 
schedule amount.
    Response: The temporary psychotherapy ``G'' HCFA Common Procedure 
Coding System (HCPCS) codes (G0071 through G0094) were implemented as 
interim codes, and the RUC-recommended RVUs for these services were 
also considered as interim. Although these temporary ``G'' codes will 
be crosswalked directly to permanent numeric HCPCS codes effective 
January 1, 1998, the codes and the assigned RVUs will continue to be 
considered interim.
    We believe that, for the most part, we have addressed the situation 
when malpractice insurance premiums for psychiatrists are higher than 
the cost of malpractice insurance for psychologists by establishing an 
entire set of psychotherapy codes that are exclusive to physicians that 
psychologists are precluded from billing under the Medicare program. We 
established this set of codes because the services that both physicians 
and psychologists can furnish are probably not the services that are 
contributing to the psychiatrist's higher malpractice costs. The 
services that are reserved to physicians alone are those involving 
medications and complexities that would contribute to the higher 
malpractice costs.
    Comment: One commenter expressed that it has a major concern about 
our continued exclusion of psychologists from the use of CPT evaluation 
and management codes as well as the ``G'' HCPCS codes that encompass an 
evaluation and management component. The commenter believes that we 
should remove our longstanding restriction on the use of these codes by 
psychologists and, instead, incorporate into our coding system a 
realistic reflection of the present day practice of psychology.
    Moreover, the commenter believes that since psychologists play an 
important evaluative role, we should seriously reconsider our 
longstanding exclusionary policy and permit payment to psychologists 
for evaluation and management codes that represent services that 
psychologists are already providing under the Medicare program.
    Response: We believe that the CPT diagnostic psychological testing 
CPT codes 96100 through 96117 and the CPT psychotherapy codes 90801 
through 90899 capture the range of mental health services, including 
nonmedical evaluation services, that clinical psychologists are 
expected to provide for purposes of the Medicare clinical psychologist 
benefit and that clinical psychologists are authorized by law to 
furnish. The evaluation and management services included in the codes 
that psychologists cannot bill Medicare are services involving medical 
evaluation and management. Psychologists are not licensed to perform 
these types of services.
    Result of evaluation of comments: We are finalizing our proposal to 
maintain the clinical psychologist fee schedule at 100 percent of the 
physician fee schedule amount for comparable services. The RVUs for 
individual psychotherapy services remain in effect on an interim basis.

D. Diagnostic Tests

1. Ordering of Diagnostic Tests
    In our November 22, 1996 final rule for the 1997 physician fee 
schedule (61 FR 59490), we revised Sec. 410.32 (Diagnostic x-ray tests, 
diagnostic laboratory tests, and other diagnostic tests: Conditions) to 
state that, to be covered, diagnostic tests had to be ordered by the 
physician who treats the patient. Section 410.32 contained exceptions 
for x-rays used by chiropractors to demonstrate the subluxation of the 
spine and for certain nonphysician practitioners operating within the 
scope of their statutory benefit and State licenses. We are adding an 
additional exception to Sec. 410.32 to indicate that a physician who 
meets the qualification requirements for an interpreting physician 
under section 354 of the Public Health Service Act as provided in 
Sec. 410.34 (Mammography services: Conditions for and limitations on 
coverage), paragraph (a)(7), may order a diagnostic mammogram based on 
the findings of a screening mammogram even though the physician does 
not treat the beneficiary. We believe this is appropriate because the 
Food and Drug Administration, rather than HCFA, is responsible for the 
conditions under which mammograms are covered. It would also facilitate 
additional and necessary diagnostic testing to investigate suspicious 
findings at the time the beneficiary is present at the testing site 
rather than requiring the beneficiary to return at a later date for 
follow-up testing.
    In addition, commenters have asked about the statutory basis for 
denial of claims under the ordering rule adopted in the 1996 physician 
fee schedule final rule. We have determined that tests are not 
demonstrably reasonable and medically necessary unless they are ordered 
by the patient's physician who will employ the tests to manage the 
patient's care. Thus, we are clarifying in Sec. 410.32(a) that the 
denials are based on the exclusion in section 1862(a)(1)(A) of the Act, 
and contained in Sec. 411.15(k)(1), that is, the services ``are not 
reasonable and necessary for the diagnosis and treatment of illness or 
injury or to improve the functioning of a malformed body member.'' 
Beneficiaries may be protected from liability for claims denied on this 
basis by the limitation on liability provision of section 1879 of the 
Act.
    All commenters addressing the proposal to permit certain physicians 
to order a diagnostic mammogram based on the findings of a screening 
mammogram even though the physician does not treat the beneficiary 
enthusiastically supported the proposal. We received no comments on the 
proposal to clarify that denial of claims by carriers because the tests 
were not ordered by a physician who uses the findings in the management 
of the beneficiary's care are based on the reasonable and necessary 
exclusion in section 1862(a)(1)(A) of the Act and in Sec. 411.15(k)(1).
    Below is a discussion of the public comments we received on our 
proposal relating to ordering of diagnostic tests and our responses:
    Comment: Several commenters requested clarification of the 
applicability of the diagnostic test ordering provision, adopted in the 
final rule of November 22, 1996, to diagnostic procedures performed in 
hospital settings: the responses to comments seemed to indicate that, 
although the intent of the new policy was primarily directed at 
nonhospital testing, the requirement applied in all settings.
    Response: The policy was set forth in Sec. 410.32, which generally 
addresses diagnostic tests covered under section 1861(s)(3) of the Act 
and payable by Part B carriers rather than fiscal intermediaries. 
Regulations other than Sec. 410.32 govern the coverage of diagnostic 
tests furnished to hospital patients, which are payable through fiscal 
intermediary payment mechanisms. Specifically, the coverage of 
diagnostic tests furnished to hospital outpatients is addressed in 
Sec. 410.28, and the coverage of diagnostic tests furnished to hospital 
inpatients is addressed in Sec. 409.16. Therefore, the test ordering 
policy adopted in the final rule of November 22, 1996, effective for 
procedures furnished beginning January 1, 1997, does not apply to 
diagnostic tests furnished in hospitals.
    Comment: A few commenters expressed concern that manual sections

[[Page 59058]]

implementing the ordering rule have not been issued. One commenter 
indicated that interpreting physicians are in the untenable position of 
having to choose between performing additional tests they know the 
patient needs based on the findings of the initial procedure or 
postponing procedures to ensure that they do not violate HCFA rules. 
Another indicated that there are times that the referring physician 
cannot be reached and delaying a procedure would not be in the best 
interests of the patient.
    Response: In adopting the test-ordering proposal, we intended to 
establish the general principle that, to be covered under Medicare, a 
diagnostic test must be ordered by a physician who will use the 
findings in the medical management of the patient. The policy did not 
require that the order be in writing or instruct carriers to 
investigate claims prior to payment to ensure the existence of such an 
order. It was intended for use by carriers in situations in which a 
problem has been identified, or is strongly suspected, as a basis for 
recovery of payments for tests that did not meet the reasonable and 
necessary criteria of section 1862(a)(1)(A) of the Act. In the 
situations cited by the commenters, we do not think it would be 
unreasonable to ask for the testing physician to receive authorization 
from the ordering physician's office (either by phone or FAX) for the 
additional tests he or she believes to be necessary. Certainly, 
provision could be made for an emergency situation. We are trying to 
address situations in which there is a pattern of the testing entity's 
adding procedures to those ordered by the patient's personal physician.
    Comment: Commenters representing the interests of entities that 
furnish nuclear medicine procedures indicated a continuing problem with 
the ordering requirement and stated that nuclear medicine physicians, 
by State and Federal regulations, are the only physicians who can 
actually order nuclear medicine tests.
    Response: We see no conflict between our proposal and State and 
Federal regulations. However, in order to address these concerns more 
fully we would need more specific information as to the State and 
Federal regulations in question.
    Comment: A national organization representing psychologists 
indicated that Sec. 410.32 addresses the ordering and supervision of 
diagnostic tests and objected to some of the wording relating to 
nonphysician practitioners, such as clinical psychologists. The 
commenter pointed out that Sec. 410.32(a)(3) indicates that certain 
nonphysician practitioners who furnish 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.'' The commenter 
suggested that the wording be changed to ``shall be treated the same .  
.  .'' because, as written, the wording does not require that these 
individuals always be treated as physicians for purposes of this 
section.
    Response: The commenter raises an interesting point that we agree 
needs further clarification. The purpose of Sec. 410.32(a)(3) is to 
ensure that the nonphysician practitioners in question may order tests 
for the beneficiaries they are treating. (We are adding the same 
wording to the section on independent diagnostic testing facilities 
(IDTFs) to clarify that the nonphysician practitioners in question may 
order diagnostic testing by IDTFs.) However, we did not intend to 
permit these same nonphysician practitioners to supervise diagnostic 
testing performed by others. Under the rule we are adopting, all 
diagnostic tests payable under the physician fee schedule must be 
performed under the supervision of a physician (as defined in section 
1861(r) of the Act) with certain exceptions set forth in 
Sec. 410.32(b). Therefore, we are modifying the wording of 
Sec. 410.32(a)(3) to change the last word from ``section'' to 
``paragraph.'' In other words, the nonphysician practitioners are 
treated as physicians as far as the ordering of tests for the patients 
they are treating is concerned but not for the other subject of 
Sec. 410.32, that is, the supervision of the performance of tests. 
(However, certain nonphysician practitioners may personally perform 
certain diagnostic tests without physician supervision. This subject is 
addressed in the discussion of the comments on both the physician 
supervision and IDTF proposals.)
    Result of evaluation of comments: We are adopting the proposals 
(with the wording clarification indicated above) to (1) permit certain 
physicians to order a diagnostic mammogram based on the findings of a 
screening mammogram even though the physician does not treat the 
beneficiary and (2) clarify that carrier denial of claims because the 
tests were not ordered by a physician who uses the findings in the 
management of the beneficiary's care are based on the reasonable and 
necessary exclusion in section 1862(a)(1)(A) of the Act and in 
Sec. 411.15(k)(1).
2. Supervision of Diagnostic Tests
    We are clarifying in Sec. 410.32 the policy on physician 
supervision of diagnostic x-ray and other diagnostic tests that are 
payable under the physician fee schedule. (Diagnostic procedures may be 
split into professional components (PCs) and technical components (TCs) 
or be TC-only.) The clarification is applicable to the TCs of 
diagnostic procedures covered under section 1861(s)(3) of the Act 
(whether billed separately or as part of a ``global'' charge with the 
PC) that are furnished in settings in which the Part B carrier pays for 
the TCs under the physician fee schedule. The coverage of diagnostic 
procedures furnished to hospital patients is addressed in other 
regulations and is not affected by this clarification. In addition, 
diagnostic laboratory tests as described in paragraph (d) of 
Sec. 410.32 are not affected by this clarification. This final rule 
represents our judgment that diagnostic procedures are safe and 
effective only when they are furnished with appropriate physician 
supervision. Therefore, denials of claims for failure to meet the 
required level of physician supervision would be based on the exclusion 
in section 1862(a)(1)(A) of the Act and in Sec. 411.15(k)(1), that is, 
they ``are not reasonable and necessary for the diagnosis and treatment 
of illness or injury or to improve the functioning of a malformed body 
member.'' This means that the beneficiary may be protected under the 
limitation on liability provisions in section 1879 of the Act.
    We believe that the requirements of Sec. 410.32 should be revised 
because, except for the reference to ``other diagnostic tests'' in the 
heading of Sec. 410.32, x-rays are the only diagnostic tests payable 
under the physician fee schedule that are discussed in the current 
Sec. 410.32. We are clarifying that some degree of physician 
supervision is required for every diagnostic test payable under the 
physician fee schedule with a few exceptions.
    Our specific revisions to the regulations are:
     The definition and discussion of the term ``general 
supervision'' currently appears only in Sec. 410.32(a)(2) (concerning 
portable x-ray services). We are clarifying that this level of 
supervision is the minimal level required for all diagnostic tests 
payable under the physician fee schedule unless specific exception is 
made by regulation.
     The definition and discussion of the term ``direct 
supervision'' is set forth in revised Sec. 410.32(b)(3)(ii), concerning

[[Page 59059]]

diagnostic x-ray and other diagnostic tests. We are clarifying that 
this level of supervision is required for some types of diagnostic 
procedures that are not x-rays.
     We are incorporating into regulations at 
Sec. 410.32(b)(3)(iii) the existing policy that there are some 
diagnostic procedures that require a physician's presence with the 
patient at the time of performance of the procedure for the procedure 
to be covered.
    We are setting forth a general rule that diagnostic tests payable 
under the physician fee schedule require at least general supervision 
(and in some cases either direct or personal supervision, as defined in 
this final rule) by a physician (as defined in section 1861(r) of the 
Act). Because of the restrictive definitions in section 1861(r), we 
believe that nearly all tests will be supervised by doctors of medicine 
or osteopathy, or, in the case of procedures related to the eyes and 
consistent with State licensure, doctors of optometry. We do not 
perceive a significant impact on doctors of dentistry and chiropractic 
in this regard since Medicare covers limited services for these 
specialties and we believe diagnostic test supervision will not be an 
issue for these specialties.
    We are excluding three types of diagnostic tests from the physician 
supervision requirements:
     Diagnostic mammography procedures, which are regulated by 
the Food and Drug Administration.
     Diagnostic tests personally furnished by a ``qualified 
audiologist'' as defined in section 1861(ll)(3) of the Act. These 
include ``audiology services'' as defined in section 1861(ll)(2) of the 
Act that are payable by Medicare carriers under the physician fee 
schedule. We are excluding these diagnostic tests from the physician 
supervision requirement because the Congress has defined these services 
without requiring physician supervision of their performance.
     Diagnostic psychological testing services personally 
performed by a qualified psychologist practicing independently of an 
institution, agency, or physician's office as currently defined in 
section 2070.2 of the Medicare Carriers Manual (HCFA Pub. 14-3). These 
services are distinguished from services of clinical psychologists, 
which are covered under section 1861(ii) of the Act, rather than 
section 1861(s)(3). We are excluding these tests from the physician 
supervision requirement because we do not believe that these services 
require physician supervision of their performance.
    We are setting forth the policy that the minimal level of physician 
supervision, which is applicable to all diagnostic procedures payable 
under the physician fee schedule, with the exceptions cited above, is 
general supervision. ``General supervision'' means the procedure is 
furnished under the physician's overall direction and control, but 
physician presence is not required during the performance of the 
procedure. Under general supervision, the training of the nonphysician 
personnel who actually perform the diagnostic procedure and the 
maintenance of the necessary equipment and supplies are the continuing 
responsibility of the physician. Examples of procedures requiring only 
general physician supervision include the following:
     Plain films (x-rays) involving the extremities, pelvis, 
vertebral column, or skull.
     Plain films of the chest and abdomen that do not involve 
the use of contrast media.
     Electrocardiograms except when the code description 
specifies physician supervision such as with a cardiovascular stress 
test.
     Ultrasound diagnostic procedures except when the code 
description specifies a physician's service such as the placement of a 
probe in the case of transesophageal echocardiography.
     Electroencephalograms, polysomnography, and sleep studies.
    We are setting forth the policy that the existing definition of 
``direct supervision'' in Sec. 410.32 be applied to types of services 
other than diagnostic x-rays. ``Direct supervision'' in the office 
setting does not mean that the physician must be present in the room 
when the procedure is performed; however, the physician must be present 
in the office suite and immediately available to furnish assistance and 
direction throughout the performance of the procedure. Examples of 
diagnostic procedures requiring both general and direct supervision 
include the following:
     Magnetic resonance imaging, computerized axial tomography, 
and nuclear medicine procedures.
     Procedures in which contrast materials are used.
     X-rays other than skeletal, abdominal, and chest x-rays 
cited in the discussion of ``general supervision.''
    We are defining ``personal supervision'' as follows: ``Personal 
supervision'' means a physician must be in attendance in the room 
during the performance of the procedure. Examples of procedures 
requiring both general and personal supervision include the following:
     Cardiovascular stress tests including those furnished with 
nuclear medicine and echocardiography procedures.
     Cardiac catheterization.
     Radiological supervision and interpretation procedures.
    Under the changes made to section 1861(s)(3) of the Act by section 
145(b) of Public Law 103-432, the Congress has added diagnostic 
mammography as part of the portable x-ray benefit. Therefore, we are 
adding diagnostic mammograms (but not screening mammograms) to the list 
of services a portable x-ray supplier may furnish in Sec. 410.32(c). 
However, the supplier must meet the certification requirements of 
section 354 of the Public Health Service Act, as implemented by 21 CFR 
part 900, subpart B.
    These supervision requirements are applicable only for diagnostic 
tests under section 1861(s)(3) of the Act. Other statutory provisions 
such as CLIA, the physician self-referral rules, etc., which contain 
supervisory standards for physicians, are not affected by this rule, 
and continue to be required, if applicable.
    Several commenters who objected to various aspects of the physician 
supervision proposal were obviously addressing procedures performed in 
hospitals, and we would like to clarify this situation for them. As 
pointed out in the first paragraph of the preamble discussion of this 
proposal in the June 18, 1997 proposed rule (62 FR 33179), we proposed 
to modify and clarify the policy in Sec. 410.32 on physician 
supervision of diagnostic procedures that are covered under section 
1861(s)(3) of the Act and payable under the physician fee schedule. 
Regulations other than Sec. 410.32 govern the coverage of diagnostic 
tests furnished to hospital patients. Specifically, the coverage of 
diagnostic tests furnished to hospital outpatients is addressed in 
Sec. 410.28, and the coverage of diagnostic tests furnished to hospital 
inpatients is addressed in Sec. 409.16. Further, this proposal 
addressed the coverage of the technical component (TC) (including TCs 
billed with the professional component (PC) of the procedure in a 
global bill) and other diagnostic procedures that are not split into PC 
or TC components and that do not have RVUs reflecting physician work. 
Diagnostic services that have physician work RVUs are not ``other 
diagnostic tests'' covered under section 1861(s)(3) of the Act but 
physician services and services incident to a physician's services 
covered under sections 1861(s)(1) and 1861(s)(2)(A) of the Act. These 
services are either personally

[[Page 59060]]

furnished by the physician or furnished as an ``incident to'' service. 
In both cases, the policy has been established and is unaffected by 
this rule. Either the physician is present because he or she is 
personally furnishing the service or, in the case of ``incident to'' 
services, the physician is in the suite (the same standard as proposed 
for direct supervision under the proposal) during the time the 
diagnostic service is performed. To summarize, neither the technical 
services associated with diagnostic tests furnished in hospitals nor 
diagnostic service codes containing physician work RVUs (other than 
global billings) are affected by this proposal.
    Comment: Many physician commenters disagreed with our proposal to 
place diagnostic ultrasound procedures in the category of tests 
requiring general supervision. We received the following comments:
     Most ultrasound diagnostic procedures should be placed in 
the direct or personal supervision categories. The requirement for 
general supervision is not sufficient to achieve the needed degree of 
physician input in the final product of the ultrasound examination.
     Good ultrasound can only be performed through a working 
partnership between the technologist and the supervising physician. 
Commenters pointed out that radiologists frequently will examine the 
patient in real time to clarify uncertain findings or to further 
characterize pathology detected during the technologist's examination. 
If the physician does not go back to scan these patients himself, 
critical diagnoses would be missed. The common and correct practice of 
ultrasound is for a technologist to perform the examination and for a 
physician to check the study before the patient leaves the examining 
area.
     The performance of ultrasound procedures requires more 
physician supervision than magnetic resonance imaging (MRIs), 
computerized axial tomography (CTs), or nuclear medicine procedures.
     One commenter referred to unregulated ultrasound 
procedures in the U.S. as a ``cesspool of poor medical practice.''
     One commenter suggested that Medicare should prohibit 
payments for self-referred sonographic procedures performed by 
physicians who purchase this equipment for their offices and find 
reasons to use the equipment on their patients even though they are 
poorly-trained in the interpretations of the findings.
     Several physicians commented that they often performed 
these tests personally without a technologist present.
    Response: In developing our proposal on levels of physician 
supervision for out-of-hospital diagnostic testing, we placed 
ultrasound procedures in the general category on the basis that it was 
safe to perform these procedures without the presence, either in the 
room or in the suite, of a physician. However, in determining whether 
services and procedures are reasonable and necessary, we also consider 
whether a service or procedure is effective. Based on the comments we 
received on the proposal, primarily from physicians who utilize 
ultrasound procedures in diagnosing patients, we have become convinced 
that the effectiveness of ultrasound procedures is enhanced when the 
performance of these tests is supervised by a physician who is not only 
on-site when the procedure is performed, but who also monitors the 
performance of the procedure. Therefore, we are modifying our proposal 
and are placing ultrasound diagnostic procedures in the direct category 
that requires the presence of the physician in the office suite when an 
individual procedure is performed.
    Comment: Some commenters objected to our proposal to place CTs, 
MRIs, and nuclear medicine procedures in the category of procedures 
requiring the direct supervision of a physician. Some commenters 
indicated that CTs and MRIs required direct supervision only when 
contrast media are used to perform the tests. Commenters suggested that 
such a requirement would cause a dramatic reduction in the availability 
of these services furnished through mobile entities in rural areas. It 
was alleged that the physician supervision requirements contradict 
those established by the United States Nuclear Regulatory Commission 
for nuclear medicine procedures. Some commenters indicated that some 
nuclear medicine procedures required direct supervision, some required 
only general supervision, and some required a mid-level of supervision 
in which the physician could monitor the performance of the test by 
telephone.
    Response: Based on the comments received, we have decided to move 
the required level of supervision for computerized axial tomography 
procedures (CTs) and magnetic resonance imagery procedures (MRIs) 
performed without the introduction of contrast media into the category 
of general supervision. We have become convinced that general 
supervision by a physician has become the established standard of 
practice for CTs and MRIs performed without contrast media. CT and MRI 
procedures in which contrast materials are utilized will remain in the 
direct category. We are adopting our proposal of direct supervision 
with regard to all nuclear medicine procedures. (Also, see comment 
below addressing supervision of nuclear cardiology procedures.)
    Comment: Several commenters objected to the assignment of 
cardiovascular stress tests, including those furnished with nuclear 
medicine and echocardiography procedures, to the category of tests 
requiring performance under the personal supervision of a physician. 
Their comments included the following:
     Cardiovascular stress tests performed by well-trained 
physician extenders, such as registered nurses and physician 
assistants, using established protocols and under the direct 
supervision of a physician have proved to be safe and effective.
     The use of exercise physiologists, B.S.N. degree nurses, 
or physician assistants was the ``standard of care'' in their hospital.
     In the absence of data to suggest that direct supervision 
is less safe than personal supervision, only direct supervision should 
be required.
     The requirement is contrary to the position of the 
American College of Physicians, the American College of Cardiology, and 
the American Heart Association, set forth in a 1990 task force 
statement that endorses the position that ``exercise testing in 
selected patients can be safely performed by properly trained nurses, 
exercise physiologists, physical therapists, or medical technicians 
working directly under the supervision of a physician who should be in 
the immediate vicinity and available for emergencies.''
     The success of cardiac rehabilitation programs has 
demonstrated the success of nonsupervised exercise in the cardiac 
patient.
     One physician commenter agreed with our placing of stress 
tests in the personal supervision category and indicated that personal 
physician supervision was absolutely essential for the safety of the 
patient and for the test to be of maximal diagnostic utility.
    Response: We do not agree with the general tone of the comments. It 
is established policy under Medicare that cardiovascular stress tests 
must be performed under the direct supervision of a physician to be 
covered. (For example, the interim teaching physician instructions, 
issued June 28, 1996,

[[Page 59061]]

placed the procedures in the category of complex and dangerous 
procedures requiring the presence of a teaching physician (rather than 
a resident) during their performance.) In addition, we do not believe 
that the reference to ``exercise'' and cardiac rehabilitation programs 
is the same thing as a cardiovascular stress test. With regard to the 
1990 task force statement by the three organizations cited above, we 
believe that the reference to ``selected patients'' being safely tested 
by nonphysicians is a telling one. It is not at all clear to us that 
the appropriate level for ``selected patients'' should be the general 
standard applicable to all patients, particularly patients in the age 
group of most Medicare beneficiaries.
    The circumstances surrounding cardiovascular stress tests are 
unusual because, although the issue at hand for Medicare coverage 
purposes is the supervision of the performance of the technical 
component of the test, this supervision is described by the AMA's CPT 
coding system with a specific code (CPT code 93016) for use in billing 
for physician supervision of cardiovascular stress tests when the 
physician who supervises the performance of the test differs from the 
physician who bills for the interpretation and report of the procedure. 
This means that the in-person supervision by a physician of this 
particular procedure has been determined to be so essential that it was 
necessary to establish a separate code for it. This code should be 
billed in connection with a stress test that will be interpreted and 
used in the diagnosis of the patient. It may not be used to bill for 
``supervision'' of exercise in connection with a cardiac rehabilitation 
program.
    We firmly believe that there should be a physician in attendance 
during the performance of cardiovascular stress tests to provide--
     Medical expertise required for the performance of the 
test;
     Medical treatment for complications and side effects of 
the test;
     Medical services required as part of the test, for 
example, injections or the administration of medications; and
     Medical expertise in the interpretation of the test (some 
of which may have to be provided while the test is actually being 
performed).
    We do not believe that nonphysician personnel, even well-trained 
personnel, possess the knowledge and skills to immediately address all 
complications that may occur.
    The reference to cardiovascular stress tests performed in hospitals 
indicates a misunderstanding of the physician supervision proposal. 
This proposal does not apply in hospitals; it only applies in settings 
in which the TC of the procedure is payable by the carrier. However, 
even in hospitals, if a physician wishes to bill the carrier for the 
supervision of the procedure using CPT code 93016 (a physician's 
service covered under section 1861(s)(1) of the Act rather than a 
diagnostic test covered under 1861(s)(3) of the Act), the physician 
must have been present for the performance of the test. It is our view 
that the physician's presence to deal with emergencies, as well as the 
other activities listed above, is the service that CPT code 93016 
describes and the appropriate level of physician supervision for 
cardiovascular stress tests.
    Comment: Several commenters indicated that it was inappropriate to 
require direct supervision of nuclear cardiology imaging procedures. 
Commenters indicated that these procedures can be provided under the 
general supervision of a nuclear cardiologist who is close at hand (but 
not in the suite during the performance of the procedure) or through 
supervision of the procedure through telemedicine. This latter position 
was described as a mid-level of physician supervision between general 
and direct. One commenter indicated that ready availability (within 
minutes) was sufficient to address any procedural, clinical, or 
radiation safety concerns that arise. One commenter indicated that the 
proposal was not rational and that the requirement for the physician to 
be in the office during a nuclear cardiology imaging procedure would 
make excessive demands upon a physician's schedule flexibility. The 
commenters indicated that no data exist to show that nuclear cardiology 
imaging provided with direct supervision was in any way superior to 
this imaging provided under general supervision. Some commenters made a 
distinction between their comments on the direct level of supervision 
standard applicable to nuclear cardiology procedures generally (as well 
as all other nuclear medicine procedures) and the personal supervision 
standard applicable to nuclear cardiology procedures involving 
cardiovascular stress tests. The commenters cited the passage from the 
1990 American College of Physicians/American College of Cardiology/
American Heart Association Task Force quoted in the prior discussion on 
stress tests to justify their position that some level of physician 
supervision between general and direct was all that was required. 
Finally, some commenters suggested that the goal of improving quality 
while reducing costs to the Medicare program would be better served by 
tightening standards for physicians eligible to be paid for the 
procedures.
    Response: As stated earlier in these comments, we believe that 
direct supervision is the minimum level for all diagnostic tests 
involving the use of contrast materials including the radionuclides 
used in nuclear medicine procedures. We are not persuaded by the 
comments that there is something about nuclear cardiology procedures 
that should, instead, require only general physician supervision. With 
regard to the statement used to support only general and direct 
physician supervision for stress testing, we would point out that the 
July 1997 American College of Cardiology/American Heart Association 
Guidelines for Exercise Testing in its introduction states:

    For the purpose of this document, exercise testing is a 
cardiovascular stress test using treadmill or bicycle exercise and 
electrocardiographic and blood pressure monitoring. Pharmacological 
stress and the use of imaging modalities (radionuclide imaging, 
echocardiography) are beyond the scope of these guidelines. 
(Emphasis added.)

This statement leads us to believe that the argument with respect to 
stress testing of ``selected patients'' by nonphysicians was being 
quoted out of context with respect to nuclear cardiology procedures. We 
are not persuaded that our proposal was wrong, and we are adopting the 
proposed standards of physician supervision for the procedures. When 
the nuclear cardiology procedure in question involves a stress test and 
separate nuclear medicine and cardiovascular codes are used, personal 
supervision is required for the portion of the procedure involving 
stress, and the direct supervision standard applies to the nuclear 
portions of the overall procedure.
    Comment: One commenter objected to the term ``other diagnostic 
tests'' in the title of Sec. 410.32, questioned why x-rays are listed, 
and suggested that the term ``ultrasound'' be specifically cited. The 
commenter argued that the level of supervision cannot be appropriately 
indicated unless ultrasound is specifically named and the tests 
requiring supervision indicated.
    Response: ``X-rays and other diagnostic tests'' is the term used in 
section 1861(s)(3) of the Act. We will indicate the appropriate level 
of supervision for a code in the data base, as indicated above. With 
regard to ultrasound procedures, direct supervision is required.

[[Page 59062]]

    Comment: Several commenters suggested that direct supervision be 
defined to include the presence of a physician in a remote office suite 
to accommodate teleradiology. The physician would review the 
examination remotely, in real time, and arrange for a response team to 
handle patient care or contrast media emergencies at the site where the 
procedure is performed.
    Response: Medicare currently pays for the interpretation of 
diagnostic procedures using images or other data transmitted via 
teleradiology. We would have to have more information about the 
arrangement the commenters have in mind, but, under the policy we are 
adopting, a physician cannot appropriately provide direct or personal 
supervision of diagnostic tests through telemedicine.
    Comment: One commenter suggested that, for uroradiology procedures, 
the radiologist may not be present for the entire procedure; however, 
because of the use of contrast material, the appropriate level of 
supervision is direct.
    Response: We have placed some uroradiology procedures in the direct 
category and others in the personal category. This is consistent with 
our general policy of requiring the presence of the physician during 
the imaging portion of any procedure described with a supervision and 
interpretation code.
    Comment: One commenter suggested that the definition of ``personal 
supervision'' be clarified to provide for situations in which a 
radiologist must leave the procedure room for either clinical or safety 
reasons. The example was given of a radiologist leaving the procedure 
room during filming due to radiation exposure.
    Response: If it is the customary practice for radiologists to leave 
the room for a short period of time for safety reasons to avoid 
radiation exposure, we would, of course, have no problem with them 
continuing to do so. We would expect the supervising physician to be 
present for all portions of the procedure that do not present a safety 
problem.
    Comment: One commenter asked for clarification of whether the 
personal supervision standard applicable to cardiac stress tests should 
be required for pulmonary stress tests. The example of ambulating the 
patient to obtain oxygen saturation for oxygen recertification was 
given.
    Response: We are not exactly sure of the specific procedures about 
which the commenter is inquiring. If it is CPT code 94620 (Pulmonary 
stress testing, simple or complex), the level is personal. For CPT 
codes 94760 through 94762 for noninvasive oximetry, the level is 
general.
    Comment: A national organization representing psychologists 
questioned our decision not to provide an exception from the physician 
supervision requirement for procedures performed by clinical 
psychologists in the same way that we did for qualified independent 
psychologists (who are not clinical psychologists as defined in 
Medicare instructions). They requested that the rules be rewritten to 
clarify that both types of psychologists may perform services without 
physician supervision.
    Response: Under our proposal, we explained that we were regulating 
diagnostic procedures covered under section 1861(s)(3) of the Act and 
payable under the physician fee schedule. We provided an exception to 
the physician supervision requirement in the case of diagnostic 
psychological testing services personally performed by qualified 
independent psychologists because these tests are covered under section 
1861(s)(3), and there had been longstanding specific national coverage 
policy in the Medicare Carriers Manual regarding these billings without 
any requirement for physician supervision. We pointed out in the 
proposal that diagnostic tests performed by clinical psychologists (the 
same range of tests as those that qualified independent psychologists 
are permitted to bill) were covered under section 1861(ii) of the Act, 
rather than section 1861(s)(3), and we meant to convey the point that 
diagnostic tests performed by clinical psychologists were unaffected by 
the proposal. That is, clinical psychologists could continue to perform 
these tests without physician supervision. We were concerned about the 
logical consistency of providing an exception to a requirement in the 
regulations for a class of services to which that regulation did not 
apply. However, to clarify the policy, we have decided to explicitly 
include diagnostic psychological testing personally performed by 
clinical psychologists in the exception to the physician supervision 
requirement.
    Comment: Several commenters indicated that physical therapists have 
performed electromyography procedures consistent with State laws for 
years without physician supervision. They pointed out that eliminating 
the availability of physical therapist-provided electromyography 
services would create a severe hardship for Medicare enrolles in rural 
areas.
    Response: We did not intend to limit access to care in rural areas, 
and therefore, we have modified our proposal to provide two additional 
exceptions to the requirement for physician supervision for diagnostic 
procedures in which physical therapists are involved. These exceptions 
apply to codes in the range of CPT codes 95860 through 95937. Under one 
exception with a physician fee schedule data base indicator of 6, that 
is, the procedure must be personally performed by a physician or a 
physical therapist who is certified by the American Board of Physical 
therapy Specialties as a qualified electrophysiologic clinical 
specialist and is permitted to provide the service under State law. 
Under the second exception with a data base indicator of 7, the 
procedure must be personally performed by a physical therapist who is 
certified by the American Board of Physical Therapy Specialties as a 
qualified electrophysiologic clinical specialist or performed under the 
direct supervision of a physician. We recognize that these categories 
were not contained in the proposed rule and specifically invite further 
comment on the appropriateness of these two exceptions to the CPT codes 
95860 through 95937.
    Comment: Several commenters expressed support for the physician 
supervision proposal but pointed out that we should state by CPT code 
into which category each procedure falls. One commenter pointed to the 
lack of specific information about the category of physician 
supervision into which pulmonary and neurology testing procedures 
should be placed and suggested that the final rule address these 
procedures to promote consistency among carriers.
    Response: We are providing such a listing as a part of this 
preamble. It will become a part of the physician fee schedule data base 
and may be modified from time to time in the same way other data base 
indicators are changed; therefore, there should be consistency among 
carriers.
    Result of evaluation of comments: We are adopting our proposal to 
assign an appropriate level of physician supervision to every 
diagnostic test payable under the physician fee schedule with 
exceptions for certain procedures personally performed by qualified 
independent psychologists, clinical psychologists, qualified 
audiologists, and physical therapists who are certified as qualified 
electrophysiologic clinical specialists. With respect to several 
groupings of diagnostic codes, we have changed our proposed policy 
based on comments from the physician specialties most involved with 
particular groups of codes. In some cases, such as CTs and MRIs 
performed without the use of contrast materials, we have lowered the

[[Page 59063]]

level of required physician supervision. In others, such as ultrasound 
procedures, we have increased the level of required supervision. We are 
publishing a listing of diagnostic codes in this preamble with the 
level of physician supervision we have determined to be appropriate. In 
addition, we are adding a field to the physician fee schedule data base 
indicating the appropriate level of supervision. We anticipate that 
there will continue to be discussions among HCFA, physician specialty 
groups, and others about these levels of supervision, and we expect 
that the indicators applicable to individual procedures will be changed 
from time to time as is currently the case with other data base 
indicators.

Physician Fee Schedule Data Base Indicator

Physician Supervision of Diagnostic Procedures
0=Vacant
1=Procedure must be performed under the general supervision of a 
physician
2=Procedure must be performed under the direct supervision of a 
physician
3=Procedure must be performed under the personal supervision of a 
physician
4=Physician supervision policy does not apply when procedure personally 
furnished by a qualified, independent psychologist or a clinical 
psychologist; otherwise must be performed under the general supervision 
of a physician
5=Physician supervision policy does not apply when procedure personally 
furnished by a qualified audiologist; otherwise must be performed under 
the general supervision of a physician
6=Procedure must be personally performed by a physician OR a physical 
therapist who is certified by the American Board of Physical Therapy 
Specialties as a qualified electrophysiologic clinical specialist AND 
is permitted to provide the service under State law
7=Procedure must be personally performed by a physical therapist who is 
certified by the American Board of Physical Therapy Specialties as a 
qualified electrophysiologic clinical specialist AND is permitted to 
provide the service under State law OR performed under the direct 
supervision of a physician
9=Medicare physician diagnostic supervision policy does not apply
P=Decision pending

                               Level of Physician Supervision of Diagnostic Tests                               
----------------------------------------------------------------------------------------------------------------
              HCPCS                  Level            HCPCS            Level            HCPCS           Level   
----------------------------------------------------------------------------------------------------------------
                                              DIAGNOSTIC RADIOLOGY                                              
----------------------------------------------------------------------------------------------------------------
                                                  HEAD AND NECK                                                 
----------------------------------------------------------------------------------------------------------------
70010 & TC......................            3  70015 & TC.........            3  70030 & TC........            1
70100 & TC......................            1  70110 & TC.........            1  70120 & TC........            1
70130 & TC......................            1  70134 & TC.........            1  70140 & TC........            1
70150 & TC......................            1  70160 & TC.........            1  70170 & TC........            3
70190 & TC......................            1  70200 & TC.........            1  70210 & TC........            1
70220 & TC......................            1  70240 & TC.........            1  70250 & TC........            1
70260 & TC......................            1  70300 & TC.........            1  70310 & TC........            1
70320 & TC......................            1  70328 & TC.........            1  70330 & TC........            1
70332 & TC......................            3  70336 & TC.........            1  70350 & TC........            1
70355 & TC......................            1  70360 & TC.........            1  70370 & TC........            3
70371 & TC......................            3  70373 & TC.........            3  70380 & TC........            1
70390 & TC......................            3  70450 & TC.........            1  70460 & TC........            2
70470 & TC......................            2  70480 & TC.........            1  70481 & TC........            2
70482 & TC......................            2  70486 & TC.........            1  70487 & TC........            2
70488 & TC......................            2  70490 & TC.........            1  70491 & TC........            2
70492 & TC......................            2  70540 & TC.........            1  70541 & TC........            2
70551 & TC......................            1  70552 & TC.........            2  70553 & TC........            2
----------------------------------------------------------------------------------------------------------------
                                                      CHEST                                                     
----------------------------------------------------------------------------------------------------------------
71010 & TC......................            1  71015 & TC.........            1  71020 & TC........            1
71021 & TC......................            1  71022 & TC.........            1  71023 & TC........            3
71030 & TC......................            1  71034 & TC.........            3  71035 & TC........            1
71036 & TC......................            3  71038 & TC.........            3  71040 & TC........            3
71060 & TC......................            3  71090 & TC.........            3  71100 & TC........            1
71101 & TC......................            1  71110 & TC.........            1  71111 & TC........            1
71120 & TC......................            1  71130 & TC.........            1  71250 & TC........            1
71260 & TC......................            2  71270 & TC.........            2  71550 & TC........            1
71555 & TC......................            9                                                                   
----------------------------------------------------------------------------------------------------------------
                                                SPINE AND PELVIS                                                
----------------------------------------------------------------------------------------------------------------
72010 & TC......................            1  72020 & TC.........            1  72040 & TC........            1
72050 & TC......................            1  72052 & TC.........            1  72069 & TC........            1
72070 & TC......................            1  72072 & TC.........            1  72074 & TC........            1
72080 & TC......................            1  72090 & TC.........            1  72100 & TC........            1
72110 & TC......................            1  72114 & TC.........            1  72120 & TC........            1
72125 & TC......................            1  72126 & TC.........            2  72127 & TC........            2
72128 & TC......................            1  72129 & TC.........            2  72130 & TC........            2
72131 & TC......................            1  72132 & TC.........            2  72133 & TC........            2
72141 & TC......................            1  72142 & TC.........            2  72146 & TC........            1

[[Page 59064]]

                                                                                                                
72147 & TC......................            2  72148 & TC.........            1  72149 & TC........            2
72156 & TC......................            2  72157 & TC.........            2  72158 & TC........            2
72159 & TC......................            9  72170 & TC.........            1  72190 & TC........            1
72192 & TC......................            1  72193 & TC.........            2  72194 & TC........            2
72196 & TC......................            1  72198 & TC.........            9  72200 & TC........            1
72202 & TC......................            1  72220 & TC.........            1  72240 & TC........            3
72255 & TC......................            3  72265 & TC.........            3  72270 & TC........            3
72285 & TC......................            3  72295 & TC.........            3                                 
----------------------------------------------------------------------------------------------------------------
                                                UPPER EXTREMITIES                                               
----------------------------------------------------------------------------------------------------------------
73000 & TC......................            1  73010 & TC.........            1  73020 & TC........            1
73030 & TC......................            1  73040 & TC.........            3  73050 & TC........            1
73060 & TC......................            1  73070 & TC.........            1  73080 & TC........            1
73085 & TC......................            3  73090 & TC.........            1  73092 & TC........            1
73100 & TC......................            1  73110 & TC.........            1  73115 & TC........            3
73120 & TC......................            1  73130 & TC.........            1  73140 & TC........            1
73200 & TC......................            1  73201 & TC.........            2  73202 & TC........            2
73220 & TC......................            1  73221 & TC.........            1  73225 & TC........            9
----------------------------------------------------------------------------------------------------------------
                                                LOWER EXTREMITIES                                               
----------------------------------------------------------------------------------------------------------------
73500 & TC......................            1  73510 & TC.........            1  73520 & TC........            1
73525 & TC......................            3  73530 & TC.........            3  73540 & TC........            1
73550 & TC......................            3  73560 & TC.........            1  73562 & TC........            1
73564 & TC......................            1  73565 & TC.........            1  73580 & TC........            3
73590 & TC......................            1  73592 & TC.........            1  73600 & TC........            1
73610 & TC......................            1  73615 & TC.........            3  73620 & TC........            1
73630 & TC......................            1  73650 & TC.........            1  73660 & TC........            1
73700 & TC......................            1  73701 & TC.........            2  73702 & TC........            2
73720 & TC......................            1  73721 & TC.........            1  73725 & TC........            2
----------------------------------------------------------------------------------------------------------------
                                                     ABDOMEN                                                    
----------------------------------------------------------------------------------------------------------------
74000 & TC......................            1  74010 & TC.........            1  74020 & TC........            1
74022 & TC......................            1  74150 & TC.........            1  74160 & TC........            2
74170 & TC......................            2  74181 & TC.........            1  74185 & TC........            9
74190 & TC......................            3                                                                   
----------------------------------------------------------------------------------------------------------------
                                             GASTROINTESTINAL TRACT                                             
----------------------------------------------------------------------------------------------------------------
74210 & TC......................            3  74220 & TC.........            3  74230 & TC........            3
74235 & TC......................            3  74240 & TC.........            3  74241 & TC........            3
74245 & TC......................            3  74246 & TC.........            3  74247 & TC........            3
74249 & TC......................            3  74250 & TC.........            2  74251 & TC........            3
74260 & TC......................            3  74270 & TC.........            3  74280 & TC........            3
74283 & TC......................            3  74290 & TC.........            2  74291 & TC........            2
74300 & TC......................            3  74301 & TC.........            3  74305 & TC........            3
74320 & TC......................            3  74327 & TC.........            3  74328 & TC........            3
74329 & TC......................            3  74330 & TC.........            3  74340 & TC........            3
74350 & TC......................            3  74355 & TC.........            3  74360 & TC........            3
74363 & TC......................            3                                                                   
----------------------------------------------------------------------------------------------------------------
                                                  URINARY TRACT                                                 
----------------------------------------------------------------------------------------------------------------
74400 & TC......................            2  74405 & TC.........            2  74410 & TC........            2
74415 & TC......................            2  74420 & TC.........            3  74425 & TC........            3
74430 & TC......................            3  74440 & TC.........            3  74445 & TC........            3
74450 & TC......................            3  74455 & TC.........            3  74470 & TC........            3
74475 & TC......................            3  74480 & TC.........            3  74485 & TC........            3
----------------------------------------------------------------------------------------------------------------
                                          GYNECOLOGICAL AND OBSTETRICAL                                         
----------------------------------------------------------------------------------------------------------------
74710 & TC......................            1  74740 & TC.........            3  74742 & TC........            3
74775 & TC......................            3                                                                   
----------------------------------------------------------------------------------------------------------------
                                                      HEART                                                     
----------------------------------------------------------------------------------------------------------------
75552 & TC......................            1  75553 & TC.........            2  75554 & TC........            1
75555 & TC......................            1  75556..............            9                                 
----------------------------------------------------------------------------------------------------------------

[[Page 59065]]

                                                                                                                
                                               AORTA AND ARTERIES                                               
----------------------------------------------------------------------------------------------------------------
75600 & TC......................            3  75605 & TC.........            3  75625 & TC........            3
75630 & TC......................            3  75650 & TC.........            3  75658 & TC........            3
75660 & TC......................            3  75662 & TC.........            3  75665 & TC........            3
75671 & TC......................            3  75676 & TC.........            3  75680 & TC........            3
75685 & TC......................            3  75705 & TC.........            3  75710 & TC........            3
75716 & TC......................            3  75722 & TC.........            3  75724 & TC........            3
75726 & TC......................            3  75731 & TC.........            3  75733 & TC........            3
75736 & TC......................            3  75741 & TC.........            3  75743 & TC........            3
75746 & TC......................            3  75756 & TC.........            3  75774 & TC........            3
75790 & TC......................            3                                                                   
----------------------------------------------------------------------------------------------------------------
                                              VEINS AND LYMPHATICS                                              
----------------------------------------------------------------------------------------------------------------
75801 & TC......................            3  75803 & TC.........            3  75805 & TC........            3
75807 & TC......................            3  75809 & TC.........            3  75810 & TC........            3
75820 & TC......................            3  75822 & TC.........            3  75825 & TC........            3
75827 & TC......................            3  75831 & TC.........            3  75833 & TC........            3
75840 & TC......................            3  75842 & TC.........            3  75860 & TC........            3
75870 & TC......................            3  75872 & TC.........            3  75880 & TC........            3
75885 & TC......................            3  75887 & TC.........            3  75889 & TC........            3
75891 & TC......................            3  75893 & TC.........            3                                 
----------------------------------------------------------------------------------------------------------------
                                            TRANSCATHETER PROCEDURES                                            
----------------------------------------------------------------------------------------------------------------
75894 & TC......................            3  75896 & TC.........            3  75898 & TC........            3
75900 & TC......................            3  75940 & TC.........            3  75945 & TC........            3
75946 & TC......................            3  75960 & TC.........            3  75961 & TC........            3
75962 & TC......................            3  75964 & TC.........            3  75966 & TC........            3
75968 & TC......................            3  75970 & TC.........            3  75978 & TC........            3
75980 & TC......................            3  75982 & TC.........            3  75984 & TC........            3
75989 & TC......................            3                                                                   
----------------------------------------------------------------------------------------------------------------
                                            TRANSLUMINAL ATHERECTOMY                                            
----------------------------------------------------------------------------------------------------------------
75992 & TC......................            3  75993 & TC.........            3  75994 & TC........            3
75995 & TC......................            3  75996 & TC.........            3                                 
----------------------------------------------------------------------------------------------------------------
                                                OTHER PROCEDURES                                                
----------------------------------------------------------------------------------------------------------------
76000 & TC......................            3  76001 & TC.........            3  76003 & TC........            3
76010 & TC......................            1  76020 & TC.........            1  76040 & TC........            1
76061 & TC......................            1  76062 & TC.........            1  76065 & TC........            1
76066 & TC......................            1  76070 & TC.........            1                                 
76075 & TC......................            1  76076 & TC.........            1  76078 & TC........            1
76080 & TC......................            3  76086 & TC.........            3  76088 & TC........            3
76090 & TC......................            9  76091 & TC.........            9  76092.............            9
76093 & TC......................            1  76094 & TC.........            1  76095 & TC........            3
76096 & TC......................            3  76098 & TC.........            1  76100 & TC........            2
76101 & TC......................            2  76102 & TC.........            2  76120 & TC........            2
76125 & TC......................            2  76140..............            9  76150.............            1
76350...........................            2  76355 & TC.........            3  76360 & TC........            3
76365 & TC......................            3  76370 & TC.........            2  76375 & TC........            1
76380 & TC......................            1  76400 & TC.........            1  76499 & TC........            9
----------------------------------------------------------------------------------------------------------------
                                              DIAGNOSTIC ULTRASOUND                                             
----------------------------------------------------------------------------------------------------------------
                                                  HEAD AND NECK                                                 
----------------------------------------------------------------------------------------------------------------
76506 & TC......................            2  76511 & TC.........            2  76512 & TC........            2
76513 & TC......................            2  76516 & TC.........            2  76519 & TC........            2
76529 & TC......................            2  76536 & TC.........            2    ................             
----------------------------------------------------------------------------------------------------------------
                                                      CHEST                                                     
----------------------------------------------------------------------------------------------------------------
76604 & TC......................            2  76645 & TC.........            2                                 
----------------------------------------------------------------------------------------------------------------
                                           ABDOMEN AND RETROPERITONEUM                                          
----------------------------------------------------------------------------------------------------------------
76700 & TC......................            2  76705 & TC.........            2  76770 & TC........            2
76775 & TC......................            2  76778 & TC.........            2    ................             
----------------------------------------------------------------------------------------------------------------

[[Page 59066]]

                                                                                                                
                                                  SPINAL CANAL                                                  
----------------------------------------------------------------------------------------------------------------
76800 & TC......................            2                                                                   
----------------------------------------------------------------------------------------------------------------
                                                     PELVIS                                                     
----------------------------------------------------------------------------------------------------------------
76805 & TC......................            2  76810 & TC.........            2  76815 & TC........            2
76816 & TC......................            2  76818 & TC.........            2  76825 & TC........            2
76826 & TC......................            2  76827 & TC.........            2  76828 & TC........            2
76830 & TC......................            3  76856 & TC.........            2  76857 & TC........            2
76870 & TC......................            2  76872 & TC.........            3    ................             
----------------------------------------------------------------------------------------------------------------
                                                   EXTREMITIES                                                  
----------------------------------------------------------------------------------------------------------------
76880 & TC......................            2                                                                   
----------------------------------------------------------------------------------------------------------------
                                                VASCULAR STUDIES                                                
----------------------------------------------------------------------------------------------------------------
                                          ULTRASONIC GUIDANCE PROCEDURES                                        
----------------------------------------------------------------------------------------------------------------
76930 & TC......................            3  76932 & TC.........            3  76934 & TC........            3
76936 & TC......................            3  76938 & TC.........            3  76941 & TC........            3
76942 & TC......................            3  76945 & TC.........            3  76946 & TC........            3
76948 & TC......................            3  76950 & TC.........            2  76960 & TC........            2
76965 & TC......................            3    .................                 ................             
----------------------------------------------------------------------------------------------------------------
                                                 OTHER PROCEDURES                                               
----------------------------------------------------------------------------------------------------------------
76970 & TC......................            9  76975 & TC.........            3  76986 & TC........            3
76999 & TC......................            9    .................                 ................             
----------------------------------------------------------------------------------------------------------------
                                               RADIATION ONCOLOGY                                               
----------------------------------------------------------------------------------------------------------------
77417...........................            1                                                                   
----------------------------------------------------------------------------------------------------------------
                                           DIAGNOSTIC NUCLEAR MEDICINE                                          
----------------------------------------------------------------------------------------------------------------
                                                ENDOCRINE SYSTEM                                                
----------------------------------------------------------------------------------------------------------------
78000 & TC......................            2  78001 & TC.........            2  78003 & TC........            2
78006 & TC......................            2  78007 & TC.........            2  78010 & TC........            2
78011 & TC......................            2  78015 & TC.........            2  78016 & TC........            2
78017 & TC......................            2  78018 & TC.........            2  78070 & TC........            2
78075 & TC......................            2  78099 & TC.........            9    ................             
----------------------------------------------------------------------------------------------------------------
                             HEMATOPOIETIC, RETICULOENDOTHELIAL, AND LYMPHATIC SYSTEM                           
----------------------------------------------------------------------------------------------------------------
78102 & TC......................            2  78103 & TC.........            2  78104 & TC........            2
78110 & TC......................            2  78111 & TC.........            2  78120 & TC........            2
78121 & TC......................            2  78122 & TC.........            2  78130 & TC........            2
78135 & TC......................            2  78140 & TC.........            2  78160 & TC........            2
78162 & TC......................            2  78170 & TC.........            2  78172 & TC........            2
78185 & TC......................            2  78190 & TC.........            2  78191 & TC........            2
78195 & TC......................            2  78199 & TC.........            9    ................             
----------------------------------------------------------------------------------------------------------------
                                             GASTROINTESTINAL SYSTEM                                            
----------------------------------------------------------------------------------------------------------------
78201 & TC......................            2  78202 & TC.........            2  78205 & TC........            2
78215 & TC......................            2  78216 & TC.........            2  78220 & TC........            2
78223 & TC......................            2  78230 & TC.........            2  78231 & TC........            2
78232 & TC......................            2  78258 & TC.........            2  78261 & TC........            2
78262 & TC......................            2  78264 & TC.........            2  78270 & TC........            2
78271 & TC......................            2  78272 & TC.........            2  78278 & TC........            2
78282 & TC......................            2  78290 & TC.........            2  78291 & TC........            2
78299 & TC......................            9    .................                 ................             
----------------------------------------------------------------------------------------------------------------
                                              MUSCULOSKELETAL SYSTEM                                            
----------------------------------------------------------------------------------------------------------------
78300 & TC......................            2  78305 & TC.........            2  78306 & TC........            2
78315 & TC......................            2  78320 & TC.........            2  78350 & TC........            2
78351...........................            9  78399 & TC.........            9    ................             
----------------------------------------------------------------------------------------------------------------
 
[[Page 59067]]

                                                                                                                
                                              CARDIOVASCULAR SYSTEM                                             
----------------------------------------------------------------------------------------------------------------
78414 & TC......................            2  78428 & TC.........            2  78445 & TC........            2
78455 & TC......................            2  78457 & TC.........            2  78458 & TC........            2
78459 & TC......................            9  78460 & TC.........            2  78461 & TC........            2
78464 & TC......................            2  78465 & TC.........            2  78466 & TC........            2
78468 & TC......................            2  78469 & TC.........            2  78472 & TC........            2
78473 & TC......................            2  78478 & TC.........            2  78480 & TC........            2
78481 & TC......................            2  78483 & TC.........            2  78499 & TC........            9
----------------------------------------------------------------------------------------------------------------
                                               RESPIRATORY SYSTEM                                               
----------------------------------------------------------------------------------------------------------------
78580 & TC......................            2  78584 & TC.........            2  78585 & TC........            2
78586 & TC......................            2  78587 & TC.........            2  78591 & TC........            2
78593 & TC......................            2  78594 & TC.........            2  78596 & TC........            2
78599 & TC......................            9                                                                   
----------------------------------------------------------------------------------------------------------------
                                                 NERVOUS SYSTEM                                                 
----------------------------------------------------------------------------------------------------------------
78600 & TC......................            2  78601 & TC.........            2  78605 & TC........            2
78606 & TC......................            2  78607 & TC.........            2  78608.............            9
78609...........................            9  78610 & TC.........            2  78615 & TC........            2
78630 & TC......................            2  78635 & TC.........            2  78645 & TC........            2
78647 & TC......................            2  78650 & TC.........            2  78660 & TC........            2
78699 & TC......................            9                                                                   
----------------------------------------------------------------------------------------------------------------
                                              GENITOURINARY SYSTEM                                              
----------------------------------------------------------------------------------------------------------------
78700 & TC......................            2  78701 & TC.........            2  78704 & TC........            2
78707 & TC......................            2  78710 & TC.........            2  78715 & TC........            2
78725 & TC......................            2  78726 & TC.........            2  78727 & TC........            2
78730 & TC......................            2  78740 & TC.........            2  78760 & TC........            2
78761 & TC......................            2  78799 & TC.........            9                                 
----------------------------------------------------------------------------------------------------------------
                                  OTHER DIAGNOSTIC NUCLEAR MEDICINE PROCEDURES                                  
----------------------------------------------------------------------------------------------------------------
78800 & TC......................            2  78801 & TC.........            2  78802 & TC........            2
78803 & TC......................           2`  78805 & TC.........            2  78806 & TC........            2
78807 & TC......................            2  78810 & TC.........            9  78891 & TC........            9
78990...........................            9  78999 & TC.........            9                                 
----------------------------------------------------------------------------------------------------------------
                                            PATHOLOGY AND LABORATORY                                            
----------------------------------------------------------------------------------------------------------------
85060...........................            9  85095..............            9  85102.............            9
86485...........................            1  86490..............            1  86510.............            1
86580...........................            1  86585..............            1  86586.............            9
88104 & TC......................            9  88106 & TC.........            9  88107 & TC........            9
88108 & TC......................            9  88125 & TC.........            1  88160 & TC........            9
88161 & TC......................            9  88162 & TC.........            9  88170 & TC........            1
88171 & TC......................            1  88172 & TC.........            9  88173 & TC........            9
88180 & TC......................            9  88182 & TC.........            9  88300 & TC........            9
88302 & TC......................            9  88304 & TC.........            9  88305 & TC........            9
88307 & TC......................            9  88309 & TC.........            9  88311 & TC........            1
88312 & TC......................            9  88313 & TC.........            9  88314 & TC........            9
88318 & TC......................            9  88319 & TC.........            9  88323 & TC........            9
88331 & TC......................            9  88332 & TC.........            9  88342 & TC........            9
88346 & TC......................            9  88347 & TC.........            9  88348 & TC........            9
88349 & TC......................            9  88355 & TC.........            9  88356 & TC........            9
88358 & TC......................            9  88362 & TC.........            9  88365 & TC........            9
89350...........................            1  89360..............            9                                 
----------------------------------------------------------------------------------------------------------------
                                                    MEDICINE                                                    
----------------------------------------------------------------------------------------------------------------
                                                GASTROINTESTINAL                                                
----------------------------------------------------------------------------------------------------------------
91000 & TC......................            3  91010 & TC.........            3  91011 & TC........            3
91012 & TC......................            3  91020 & TC.........            3  91030 & TC........            3
91032 & TC......................            3  91033 & TC.........            3  91052 & TC........            3
91055 & TC......................            3  91060 & TC.........            3  91065 & TC........            1
91100...........................            9  91105..............            9  91122 & TC........            3
----------------------------------------------------------------------------------------------------------------

[[Page 59068]]

                                                                                                                
                                        SPECIAL OPHTHALMOLOGICAL SERVICES                                       
----------------------------------------------------------------------------------------------------------------
92015...........................            9  92081 & TC.........            1  92082 & TC........            1
92083 & TC......................            1  92100..............            9  92120.............            9
92130...........................            9  92140..............            9  92230.............            9
92235 & TC......................            2  92240 & TC.........            2  92250 & TC........            2
92260...........................            9                                                                   
----------------------------------------------------------------------------------------------------------------
                                           OTHER SPECIALIZED SERVICES                                           
----------------------------------------------------------------------------------------------------------------
92265 & TC......................            3  92270 & TC.........            3  92275 & TC........            3
92283 & TC......................            1  92284 & TC.........            3  92285 & TC........            2
92286 & TC......................            3  92287..............            9                                 
----------------------------------------------------------------------------------------------------------------
                                     SPECIAL OTORHINOLARYNGOLOGIC SERVICES                                      
----------------------------------------------------------------------------------------------------------------
92506...........................            9  92507..............            9  92508.............            9
92511...........................            9  92512..............            9  92516.............            9
92520...........................            9  92525..............            9  92526.............            9
----------------------------------------------------------------------------------------------------------------
                                   VESTIBULAR FUNCTION TESTS WITH OBSERVATION                                   
----------------------------------------------------------------------------------------------------------------
92531...........................            9  92532..............            9  92533.............            9
92534...........................            9                                                                   
----------------------------------------------------------------------------------------------------------------
                                   VESTIBULAR FUNCTION TESTS WITH OBSERVATION                                   
----------------------------------------------------------------------------------------------------------------
92531...........................            9  92532..............            9  92533.............            9
92534...........................            9                                                                   
----------------------------------------------------------------------------------------------------------------
                                    VESTIBULAR FUNCTION TESTS WITH RECORDING                                    
----------------------------------------------------------------------------------------------------------------
92541 & TC......................            2  92542 & TC.........            2  92543 & TC........            2
92544 & TC......................            2  92545 & TC.........            2  92546 & TC........            2
92547...........................            2  92548 & TC.........            2                                 
----------------------------------------------------------------------------------------------------------------
                                            AUDIOLOGIC FUNCTION TESTS                                           
----------------------------------------------------------------------------------------------------------------
92551...........................            9  92552..............            5  92553.............            5
92555...........................            5  92556..............            5  92557.............            5
92559...........................            9  92560..............            9  92561.............            5
92562...........................            5  92563..............            5  92564.............            5
92565...........................            5  92567..............            5  92568.............            5
92569...........................            5  92571..............            5  92572.............            5
92573...........................            5  92575..............            5  92576.............            5
92577...........................            5  92579..............            5  92582.............            5
92583...........................            5  92584..............            5  92585 & TC........            5
92587 & TC......................            5  92588 & TC.........            5  92589.............            5
92590...........................            9  92591..............            9  92592.............            9
92593...........................            9  92594..............            9  92595.............            9
92596...........................            5  92597..............            9  92598.............            9
----------------------------------------------------------------------------------------------------------------
                                                  CARDIOGRAPHY                                                  
----------------------------------------------------------------------------------------------------------------
93000...........................            1  93005..............            1  93010.............            9
93012...........................            1  93014..............            9  93015.............            3
93016...........................            3  93017..............            3  93018.............            9
93024 & TC......................            3  93040..............            1  93041.............            1
93042...........................            9  93224..............            1  93225.............            1
93226...........................            1  93227..............            9  93230.............            1
93231...........................            1  93232..............            9  93233.............            9
93235...........................            1  93236..............            1  93237.............            9
93268...........................            1  93270..............            1  93271.............            1
93272...........................            9  93278 & TC.........            1                                 
----------------------------------------------------------------------------------------------------------------
                                                ECHOCARDIOGRAPHY                                                
----------------------------------------------------------------------------------------------------------------
93303 & TC......................            2  93304 & TC.........            2  93307.............            2
93308 & TC......................            2  93312 & TC.........            3  93313.............            9
93314...........................            9  93315 & TC.........            3  93316.............            9
93317...........................            9  93320 & TC.........            2  93321 & TC........            2
93325 & TC......................            2  93350 & TC.........            3                                 
----------------------------------------------------------------------------------------------------------------

[[Page 59069]]

                                                                                                                
                                             CARDIAC CATHETERIZATION                                            
----------------------------------------------------------------------------------------------------------------
93501 & TC......................            3  93503..............            9  93505 & TC........            3
93510 & TC......................            3  93511 & TC.........            3  93514 & TC........            3
93524 & TC......................            3  93526 & TC.........            3  93527 & TC........            3
93528 & TC......................            3  93529 & TC.........            3  93536.............            9
93539...........................            9  93540..............            9  93541.............            9
93542...........................            9  93543..............            9  93544.............            9
93545...........................            9  93555 & TC.........            3  93556 & TC........            3
93561 & TC......................            3  93562 & TC.........            3                                 
----------------------------------------------------------------------------------------------------------------
                                  INTRACARDIAC ELECTROPHYSIOLOGICAL PROCEDURES                                  
----------------------------------------------------------------------------------------------------------------
93600 & TC......................            3  93602 & TC.........            3  93603 & TC........            3
93607 & TC......................            3  93609 & TC.........            3  93610 & TC........            3
93612 & TC......................            3  93615 & TC.........            3  93616 & TC........            3
93618 & TC......................            3  93619 & TC.........            3  93620 & TC........            3
93621 & TC......................            3  93622 & TC.........            3  93623 & TC........            3
93624 & TC......................            3  93631 & TC.........            3  93640 & TC........            3
93641 & TC......................            3  93642 & TC.........            3  93650.............            9
93651...........................            9  93652..............            9  93660 & TC........            3
----------------------------------------------------------------------------------------------------------------
                                             OTHER VASCULAR STUDIES                                             
----------------------------------------------------------------------------------------------------------------
93720...........................            1  93721..............            1  93722.............            9
93724 & TC......................            3  93731..............            2  93732.............            3
93733 & TC......................            2  93734 & TC.........            2  93735 & TC........            3
93736 & TC......................            2  93737 & TC.........            3  93738 & TC........            3
93740 & TC......................            2  93760..............            9  93762.............            9
93770 & TC......................            3  93784..............            9  93786.............            9
93788...........................            9  93790..............            9                                 
----------------------------------------------------------------------------------------------------------------
                                        CEREBROVASCULAR ARTERIAL STUDIES                                        
----------------------------------------------------------------------------------------------------------------
93875 & TC......................            2  93880 & TC.........            2  93882 & TC........            2
93886 & TC......................            2  93888 & TC.........            2                                 
----------------------------------------------------------------------------------------------------------------
                                           EXTREMITY ARTERIAL STUDIES                                           
----------------------------------------------------------------------------------------------------------------
                                                                                                                
93922 & TC......................            2  93923 & TC.........            2  93924 & TC........            2
93925 & TC......................            2  93926 & TC.........            2  93930 & TC........            2
93931 & TC......................            2                                                                   
----------------------------------------------------------------------------------------------------------------
                                            EXTREMITY VENOUS STUDIES                                            
----------------------------------------------------------------------------------------------------------------
93965 & TC......................            2  93970 & TC.........            2  93971 & TC........            2
----------------------------------------------------------------------------------------------------------------
                                      VISCERAL AND PENILE VASCULAR STUDIES                                      
----------------------------------------------------------------------------------------------------------------
93975 & TC......................            2  93976 & TC.........            2  93978 & TC........            2
93979 & TC......................            2  93980 & TC.........            2  93981 & TC........            2
----------------------------------------------------------------------------------------------------------------
                                                   PULMONARY                                                    
----------------------------------------------------------------------------------------------------------------
94010 & TC......................            1  ...................  ...........  94070 & TC........            3
94150 & TC......................            9  94200 & TC.........            1  94240 & TC........            1
94250 & TC......................            1  94260 & TC.........            1  94350 & TC........            1
94360 & TC......................            1  94370 & TC.........            1  94375 & TC........            1
94400 & TC......................            2  94450 & TC.........            2  94620 & TC........            3
94640...........................            9  94642..............            9  94650.............            9
94651...........................            9  94652..............            9  94656.............            9
94657...........................            9  94660..............            9  94662.............            9
94664...........................            2  94665..............            2  94667.............            9
94668...........................            9  94680 & TC.........            2  94681 & TC........            2
94690 & TC......................            1  94720 & TC.........            1  94725 & TC........            1
94750 & TC......................            1  94760..............            1  94761.............            1
94762...........................            1  94770 & TC.........            1  94772 & TC........            1
94799 & TC......................            9                                                                   
----------------------------------------------------------------------------------------------------------------
                                                    ALLERGY                                                     
----------------------------------------------------------------------------------------------------------------
95004...........................            2  95010..............            9  95015.............            9

[[Page 59070]]

                                                                                                                
95024...........................            2  95027..............            2  95028.............            2
95044...........................            2  95052..............            2  95056.............            2
95060...........................            3  95065..............            3  95070.............            3
95071...........................            3  95075..............            9  95078.............            3
----------------------------------------------------------------------------------------------------------------
                                     NEUROLOGY AND NEUROMUSCULAR PROCEDURES                                     
----------------------------------------------------------------------------------------------------------------
                                                 SLEEP TESTING                                                  
----------------------------------------------------------------------------------------------------------------
95805 & TC......................            1  95807 & TC.........            1  95808 & TC........            1
95810 & TC......................            1  95812 & TC.........            1  95813 & TC........            1
95816 & TC......................            2  95819 & TC.........            2  95822 & TC........            1
95824 & TC......................            1  95827 & TC.........            1  95829 & TC........            1
95830...........................            9  95831..............            9  95832.............            9
95833...........................            9  95834..............            9  95851.............            9
95852...........................            9  95857..............            9  95858 & TC........            3
95860 & TC......................            6  95861 & TC.........            6  95863 & TC........            6
95864 & TC......................            6  95867 & TC.........            6  95868 & TC........            6
95869 & TC......................            6  95870 & TC.........            6  95872 & TC........            3
95875 & TC......................            3                                                                   
95900 & TC......................            7  95903 & TC.........            7  95904 & TC........            7
95920 & TC......................            2  95921 & TC.........            2  95922 & TC........            3
95923 & TC......................            3  95925 & TC.........            2  95926 & TC........            2
95927 & TC......................            2  95930 & TC.........            2  95933 & TC........            7
95934 & TC......................            7  95936 & TC.........            7  95937 & TC........            7
95950 & TC......................            1  95951 & TC.........            1  95953 & TC........            1
95954 & TC......................            3  95955 & TC.........            2  95956 & TC........            1
95957 & TC......................            1  95958 & TC.........            3  95961 & TC........            3
95962 & TC......................            3  95999..............            9                                 
----------------------------------------------------------------------------------------------------------------
                                       CENTRAL NERVOUS SYSTEM ASSESSMENTS                                       
----------------------------------------------------------------------------------------------------------------
96100...........................            4  96105..............            4  96110.............            4
96111...........................            4  96115..............            4  96117.............            4
----------------------------------------------------------------------------------------------------------------
                                                 ALPHA-NUMERICS                                                 
----------------------------------------------------------------------------------------------------------------
G0001...........................            9  G0002..............            9  G0004.............            1
G0005...........................            1  G0006..............            1  G0007.............            9
G0015...........................            1  G0016..............            9  G0026.............            9
G0027...........................            9  G0030 & TC.........            2  G0031 & TC........            2
G0032 & TC......................            2  G0033 & TC.........            2  G0034 & TC........            2
G0035 & TC......................            2  G0036 & TC.........            2  G0037 & TC........            2
G0038 & TC......................            2  G0039 & TC.........            2  G0040 & TC........            2
G0041 & TC......................            2  G0042 & TC.........            2  G0043 & TC........            2
G0044 & TC......................            2  G0045 & TC.........            2  G0046 & TC........            2
G0047 & TC......................            2  G0050..............            1  M0302.............            9
P2028...........................            9  P2029..............            9  P2031.............            9
P2033...........................            9  P2038..............            9  P3000.............            9
P3001...........................            9  P7001..............            9  P9610.............            9
P9615...........................            9  Q0035 & TC.........            1  Q0091.............            1
Q0092...........................            9  Q0111..............            9  Q0112.............            9
Q0113...........................            9  Q0114..............            9  Q0115.............            9
R0070...........................            9  R0075..............            9  R0076.............            9
V5008...........................            9  V5010..............            9  V5011.............            9
V5014...........................            9  V5020..............            9  V5362.............            9
V5363...........................            2  V5364..............            2                                 
----------------------------------------------------------------------------------------------------------------

3. Independent Diagnostic Testing Facility
    Section 2070.5 of the Medicare Carriers Manual (HCFA Pub. 14-3) is 
the current policy basis for the coverage of Independent Physiological 
Laboratory (IPL) services. The section does not define the term 
``physiological'' and specifically mentions only electrocardiograms and 
electroencephalograms as types of services the entity that has come to 
be known as an IPL may furnish. The section says little about the 
nature of IPLs other than that they operate independently of a 
hospital, physician's office, or rural health clinic and meet 
applicable State and local licensure laws. Few States regulate 
diagnostic services, other than x-rays, and the requirement for State 
and local licensure has had little meaning in practice. The other 
requirements for the coverage of IPL services are that the services be 
ordered by a ``referring'' physician and that the services be 
determined by the carrier to be reasonable and necessary. The 
requirement that the diagnostic services must be ordered by a referring 
physician has been addressed by the policy we adopted in the final rule 
for the 1997

[[Page 59071]]

physician fee schedule published in the Federal Register November 22, 
1996 (61 FR 59497 through 59498), under which the physician who orders 
a diagnostic service must be a physician who is treating the patient.
    We are setting aside the term ``IPL'' and are defining a new entity 
independent of a hospital or physician's office in which diagnostic 
tests are performed by licensed, certified nonphysician personnel under 
appropriate physician supervision. We are calling this entity an 
Independent Diagnostic Testing Facility (IDTF). The new entity will 
replace the IPL. The regulations are intended to resolve confusion 
surrounding the structure of entities Medicare previously classified as 
IPLs, as well as the services they furnish and to address the potential 
for abuse and the quality and safety concerns raised by the lack of 
Federal and State IPL licensure and certification requirements. The 
regulations will not apply to approved portable x-ray suppliers or to 
procedures furnished in physicians' offices including group practices 
or multispecialty clinics.
    We are defining an IDTF as a fixed location, a mobile entity, or an 
individual nonphysician practitioner. The following diagnostic tests, 
which are payable under the physician fee schedule, are not required to 
be furnished in accordance with the IDTF criteria when furnished by a 
nonhospital entity:
     Diagnostic mammograms, the coverage of which is required 
by law to be regulated by the Food and Drug Administration rather than 
by HCFA.
     Diagnostic tests personally furnished by a ``qualified 
audiologist'' as defined in section 1861(ll)(3) of the Act. These 
include ``audiology services'' as defined in section 1861(ll)(2) of the 
Act that are payable by Medicare carriers under the physician fee 
schedule. We are excluding these diagnostic tests from the physician 
supervision requirement because the Congress has defined these services 
without requiring physician supervision of their performance.
     Diagnostic psychological testing services personally 
furnished by a qualified psychologist practicing independently of an 
institution, agency, or physician's office as currently defined in 
section 2070.2 of the Medicare Carriers Manual (HCFA Pub. 14-3). The 
services are distinguished from services of clinical psychologists, 
which are covered under section 1861(ii) of the Act rather than 
1861(s)(3). We are excluding these tests from the physician supervision 
requirement because we do not believe that these services require 
physician supervision of their performance.
    IDTFs must meet the following requirements:
     An IDTF must have one or more supervising physicians who 
are responsible for the direct and ongoing oversight of the quality of 
the testing performed, the proper operation and calibration of the 
equipment used to perform tests, and the qualification of nonphysician 
personnel who use the equipment. This level of supervision equates to 
general supervision as discussed in this section II.D. and 
Sec. 410.32(b)(3)(i).
     The supervising physician must evidence proficiency in the 
performance and interpretation of each type of diagnostic procedure 
performed by the IDTF; however, there is no requirement that the IDTF's 
supervising physician actually furnish the interpretation. (For 
example, a physician might purchase tests from the IDTF that he or she 
will interpret.) Proficiency may be documented by certification in 
specific medical specialties or subspecialties or by criteria 
established by the carrier for the service area in which the IDTF is 
located. In the case of a procedure which would require the direct or 
personal supervision of a physician pursuant to II.D. in this section 
and Sec. 410.32(b)(3)(ii) and (b)(3)(iii), respectively, the IDTF's 
supervising physician must personally furnish this level of supervision 
whether the procedure is performed in the IDTF or, in the case of 
mobile services, at a remote location. The IDTF must maintain 
documentation to demonstrate sufficient physician attendance during all 
hours of operation to assure that the required physician supervision is 
furnished. In the case of procedures requiring direct supervision, the 
supervising physician may oversee concurrent procedures.
     Any nonphysician personnel used by the IDTF to perform 
tests must demonstrate the basic qualifications to perform the tests in 
question and have appropriate training and proficiency as evidenced by 
licensure or certification by the appropriate State health or education 
department. In the absence of a State licensing board, the technician 
must be certified by the appropriate national credentialing body. The 
IDTF must maintain documentation available for review that these 
requirements are met.
     All procedures performed by the IDTF must be specifically 
ordered in writing by a physician who treats the beneficiary, that is, 
the physician who is 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. This 
requirement would be met when a beneficiary's primary care physician 
orders testing the results of which may determine whether or not the 
physician refers the beneficiary to a specialist. In other words, that 
physician is managing the patient's care. The order must specify the 
diagnosis or other basis for the testing. The supervising physician for 
the IDTF may not order tests performed by the IDTF, and the IDTF may 
not add any procedures based on internal protocols without written 
order from the treating physician.
     An IDTF that operates across State boundaries must 
maintain documentation that its supervising physicians and technicians 
are licensed and certified in each of the States in which it is 
furnishing services.
    Below is a discussion of the public comments we received on this 
proposal and our responses:
    Comment: We received many favorable comments (with reservations) 
from representatives of existing IPLs who indicated their preference 
for national standards rather than different standards in each carrier 
service area. Many expressed frustration with the current situation in 
which there is no national policy on the procedures an IPL may perform, 
and carriers have differing local medical review policies on these 
procedures.
    One commenter indicated that limiting the types of diagnostic tests 
an IPL or IDTF can furnish is a better way to prevent unneeded and 
medically unnecessary testing than our proposal. He stated that 
adoption of the IDTF proposal will produce a rise in expenditures for 
diagnostic testing without a concomitant decrease in expenditures from 
other entities that currently bill Medicare for diagnostic tests.
    Response: We believe that the time has come to change the current 
situation under which there are different local medical review policies 
on the services an IPL may perform in different carrier service areas. 
If a facility meets the standards established for IDTFs, including the 
appropriate level of physician supervision, it should be able to 
furnish the same range of procedures as other entities in the service 
area. Carriers should be denying claims for procedures that are not 
reasonable and necessary for individual patients.
    Comment: A supplier of mobile bone density procedures commented 
that it had been erroneously classified as a portable x-ray supplier 
and supported the proposal as a clarification of its

[[Page 59072]]

mobile status under Medicare as an IDTF. The commenter supported the 
proposal.
    Response: Under the IDTF policy, a mobile diagnostic facility may 
furnish the same procedures as a stationary facility unless there is a 
national policy indicating otherwise.
    Comment: With regard to the credentialing criteria for IDTF 
personnel, several commenters questioned the need for the IDTF proposal 
and pointed out that there already were voluntary certification 
organizations in existence that possessed greater expertise than we did 
in these matters. Commenters cited organizations that have been granted 
membership by the National Commission for Certifying Agencies, such as 
The American Registry of Diagnostic Medical Sonographers for 
ultrasonography physician and nonphysician personnel, the Intersocietal 
Commission for the Accreditation of Vascular Laboratories, which deals 
with noninvasive vascular procedures, and the Intersocietal Commission 
for the Accreditation of Echocardiographic Laboratories for 
echocardiographic procedures. The commenters indicated that criteria 
established by these organizations are more specific than the vague 
criteria we proposed.
    Response: We have no desire to interfere with these private 
accreditation activities. The IDTF should maintain documentation of 
recognition by these organizations for verification by the carrier as 
necessary. However, we do not believe that the standards for 
accreditation by these agencies are equivalent to ours. For example, in 
commenting on our proposal, one of the listed organizations indicated 
that it required records of the source of the order for the test in the 
accredited laboratories. However, this requirement is not the same as 
assuring that all tests are ordered by a physician who is treating the 
patient.
    Comment: One commenter indicated that the proposal that the 
supervising physician in an IDTF cannot order tests performed by the 
IDTF is unrealistic. The commenter stated that if the IDTF is 
appropriately accredited and the supervising physician's income is 
fixed (rather than related to volume of testing), the supervising 
physician should be able to order any necessary test for his or her 
patients.
    Response: We have decided to modify the prohibition in 
Sec. 410.33(d) against the supervising physician's ordering of tests to 
be performed by the IDTF although we continue to believe there are 
potential problems in permitting such a practice. However, we 
acknowledge that there could be situations in which the IDTF's 
supervising physician is, in fact, the beneficiary's treating 
physician. The modified wording of the requirement indicates that, in 
these situations, the physician in question would have had a 
relationship with the beneficiary prior to the testing and would be 
treating the beneficiary for a specific medical problem.
    Comment: Some commenters expressed concern that the policy requires 
State-credentialed nonphysician personnel to perform tests; commenters 
point out the varying State standards that may be applied. Some 
believed that credentialing by a national standardized body was 
preferable.
    Response: We believe that credentialing of nonphysician 
technologists by either a State government or a recognized national 
organization should be sufficient.
    Comment: Several commenters stated that the requirement that all 
procedures performed by IDTFs must be specifically ordered in writing 
by the treating physician would be very burdensome for the referring 
physician, patient, and the examiner if it is found that the patient 
needs additional tests and has to come back another day with written 
orders for them. Some indicated that the generally-applicable ordering 
provisions of Sec. 410.32(a) were sufficient.
    One commenter indicated that the requirement for written orders was 
redundant, time-consuming, and costly, and requested the rationale for 
the additional requirement applicable only to IDTFs.
    Response: We believe that the physician responsible for the 
management of the patient's care (or some aspect of the patient's care) 
should be aware of the testing being performed. For that reason, we 
adopted a modification to Sec. 410.32 to that effect in the physician 
fee schedule final rule of November 22, 1996. That rule did not 
explicitly require written orders but served to establish the link 
between test ordering and the treating physician as a matter of 
national Medicare law. If the testing entity chose not to maintain a 
file of written orders from physicians for the tests it performed, the 
entity might not be able to demonstrate the medical necessity of the 
tests to a reviewer from a Medicare carrier or another government 
agency. Some commenters have requested the rationale for requiring 
specific written orders for tests performed by IDTFs while not imposing 
the same requirement on testing in physicians' offices.
    The rationale for requiring testing by IDTFs to be ordered in 
writing by the treating physician is based in our (and, more 
specifically, HCFA's contractors') experience with IPLs. There have 
been instances in which IPLs have offered ``free'' screening to 
Medicare beneficiaries in shopping malls and senior citizen centers, 
which meant that the IPL accepted the carrier payment for the procedure 
and waived billing the beneficiary for the coinsurance. There have been 
instances of mass testing in nursing facilities with questionable 
orders for the tests performed and little regard for the medical 
necessity of the tests. There have been numerous instances of IPLs 
performing tests in addition to those ordered by referring physicians.
    The manual (Medicare Carriers Manual section 2070.5) has always 
required that the diagnostic services be ordered by a referring 
physician. Therefore, we believe there is little in this requirement 
that is new other than the explicit provision that the orders be in 
writing. While we are certain that many IPLs did not engage in the 
practices referred to above, we anticipate that the new rules will give 
the carriers tools to use to address abusive situations, when they do 
occur, through post-payment reviews. We believe that our experiences 
with waste and abuse in IPLs justify these requirements, including 
requiring the treating physician's order for a procedure.
    In response to the absence of regulation of IPLs, we are creating 
the IDTF designation to establish a degree of national regulation of a 
diagnostic facility that is distinct from a physician's office and does 
not directly use the test results to treat a beneficiary. The 
facility's sole purpose is to furnish a test. We believe that any 
distinctions in treatment between IDTFs and physicians' offices or 
hospitals are justified by our experiences with the entities and the 
different degrees of regulation to which the entities have been 
subject.
    We do not agree that the requirement for written orders is an 
unnecessarily burdensome requirement, or that there is any necessity 
for a beneficiary to return with written orders on another day. If an 
IDTF determines that a patient needs further testing, the IDTF may 
contact the ordering physician's office and receive a FAX order for the 
additional testing.
    Comment: One commenter indicated that the term ``referring 
physician'' must be broadened to include appropriate ``licensed medical 
practitioners,'' including podiatrists, chiropractors,

[[Page 59073]]

optometrists and other similar allied-health care professionals. The 
commenter further stated that IDTF testing procedures should be ordered 
only by an appropriately licensed medical professional.
    Response: The term ``referring physician'' was used in the proposal 
only in the description of the existing IPL policy. The current 
proposals refer to ``ordering physician'' and ``supervising 
physician.'' Podiatrists and optometrists (when operating within the 
scope of their State licensure) are included in the Medicare definition 
of a ``physician'' set forth in section 1861(r) of the Act and do not 
need to be singled out as appropriate persons to order tests. 
Chiropractors may not order tests for Medicare beneficiaries under any 
circumstances. The changes made to Sec. 410.32 by the physician fee 
schedule final rule of November 22, 1996 (61 FR 59490) provided for the 
ordering of diagnostic tests by nonphysician practitioners under 
certain conditions. We have modified proposed Sec. 410.33(d) in this 
final rule to make it clear that nonphysician practitioners who are 
working within the scope of the laws of their States may order testing 
from IDTFs.
    Comment: Several commenters expressed concern about the exemption 
of physicians' offices, group practices, and multispecialty groups from 
the rules governing IDTFs. One commenter indicated that such an 
exemption would lead to the potential for abuse and quality and safety 
concerns. Others said that the proposed rules would put IDTFs at a 
competitive disadvantage with entities such as hospitals and 
physicians' offices in the furnishing of diagnostic tests and that the 
same rules should apply in all settings.
    Response: In several responses immediately preceding this one, we 
have given our reasoning regarding the application of specific 
requirements to IDTFs that do not apply to physicians' offices. Our 
reasoning is that hospitals are currently regulated, and physicians 
must have State licensure to perform the services they furnish. (We 
would like to reiterate here, however, that the physician supervision 
requirements for specific tests discussed elsewhere in this rule apply 
to all diagnostic tests payable under the physician fee schedule 
whether they are performed in an IDTF, physicians' office, or other 
setting.)
    On the other hand, IPLs do not exist because of a specific 
statutory provision but because of unique circumstances. HCFA has, for 
a number of years, permitted payment for diagnostic tests to entities 
that were not created by law. The implementing manual instruction for 
IPLs (section 2070.5 of the Medicare Carriers Manual) clearly presumes 
the existence of ``applicable State and local licensure laws'' for 
these facilities although very little regulation actually exists.
    Comment: A commenter objected to the requirement in 
Sec. 410.33(b)(2) that the supervising physician must have demonstrated 
proficiency in the performance and interpretation of each type of 
diagnostic test performed by the IDTF when there is no such requirement 
for hospital outpatient departments or physician groups. The commenter 
indicated that, for radiology procedures, State Board Certification in 
Radiology should be deemed sufficient for supervision of procedures 
requiring direct or general supervision.
    Response: As we have pointed out elsewhere in this discussion, 
hospitals are regulated through the accreditation process. For example, 
Sec. 482.26(c) of the Medicare Conditions of Participation for 
Hospitals establishes standards for a qualified supervisory radiologist 
in a hospital. Further, all States have licensure requirements that 
apply to physicians' offices, and we are not aware of significant 
problems with physicians and physician groups performing tests they are 
not qualified to perform.
    On the other hand, the performance of diagnostic tests in IPLs 
(including the physician supervision of this testing) is generally not 
regulated by State or local laws. Our regional offices and carriers 
cite many problems with the way diagnostic procedures have been 
furnished in IPLs, such as IPLs entering into arrangements with 
physicians to serve as pro forma supervisors when these physicians had 
little expertise in the area of diagnostic testing involved. Because of 
systemic problems in IPLs, we believe that it is reasonable for 
Medicare to require physicians who supervise the performance of tests 
in IDTFs to demonstrate proficiency in the type of testing being 
performed while not imposing the same requirement on physicians' 
offices, which operate under the authority of the physician's State 
licensure.
    Comment: A commenter indicated that the nonphysician credentialing 
requirements would impose significant additional costs and requirements 
on IDTFs that would not be borne by medical groups or hospitals.
    Response: Most commenters from existing IPLs, many of whom 
indicated that their employees had already met these standards, did not 
raise this issue, and, therefore, we believe that any burden on IPLs 
will not be widespread. We believe it to be entirely appropriate to 
require the technologists who perform tests in IDTFs to possess 
appropriate credentialing while not imposing the same requirements on 
hospitals that must meet accreditation standards imposed by 
governmental and other bodies or on physicians' offices that operate 
under the authority of the physician's State licensure.
    Comment: One commenter objected to the proposed requirement for 
documentation of physician supervision in IDTFs not being required of 
other entities.
    Response: We believe that this requirement is justified by the past 
performance of IPLS. Moreover, when carriers identify a problem with 
lack of supervision of diagnostic testing in physicians' offices, they 
may request this information from the physician in the same way they 
currently request additional information on the medical necessity of a 
service or procedure.
    Comment: One commenter indicated that record retention for CLIA 
laboratories was determined to be 2 years and that the same requirement 
should apply to IDTFs.
    Response: We will review our record retention guidelines and will 
provide further advice through program instructions.
    Comment: One commenter indicated that an IDTF should be allowed to 
bill globally for radiological procedures when it contracts with a 
medical group for interpretations and the medical group reassigns 
benefits to the IDTF.
    Response: These billings are permitted under the policy in section 
3060.5 of the Medicare Carriers Manual. In these situations, the IDTF 
would bill the carrier in such a way as to identify itself as an IDTF.
    Comment: One commenter objected to the proposed requirement that an 
IDTF that operates across State boundaries maintain documentation that 
its supervising physicians are licensed in each of the States in which 
it is furnishing services. The commenter indicated that this 
requirement would be unnecessarily burdensome and cost prohibitive if 
the facility must engage physicians licensed in every State the 
facility serves.
    Response: We believe it appropriate for a physician who is 
supervising the performance of tests performed in State to be licensed 
in that State.
    Comment: One commenter indicated that we are creating a new 
regulatory scheme without Congressional authorization. The commenter 
stated that if a problem exists with respect to independent diagnostic 
facilities, the problem should be explored and

[[Page 59074]]

debated in public before rules are established.
    Response: The commenter is correct in recognizing that IPLs are not 
created in the Medicare statute. Nonetheless, we have paid for services 
they furnish for a number of years. Over the years, however, a number 
of problems have become manifest in the operation of these entities. We 
believe that our general rulemaking authority is sufficient to permit 
us to deal with these problems and that the facts require our exercise 
of that authority. In addition, the publication of a proposed rule has 
provided the opportunity for public comment and debate.
    Comment: Several commenters indicated that the regulation should 
address the competency of physicians to perform interpretations of, 
rather than supervision of, diagnostic tests. Some suggested that the 
responsibilities of the supervising physician in an IDTF include 
interpretation of the results of the procedures. One commenter 
supported the proposal that technologists in IDTFs be certified and 
recommended a requirement that radiologic procedures performed in IDTFs 
be interpreted by physicians who are qualified through: (1) Completing 
an approved residency program, (2) postresidency training, or (3) 
sufficient clinical experience.
    Response: The performance of the interpretation (the physician's 
service covered under section 1861(s)(1) of the Act, as opposed to the 
diagnostic test covered under section 1861(s)(3) of the Act) is beyond 
the scope of this proposal except for the requirement that an IDTF's 
supervising physician evidence proficiency in the interpretation of 
each type of diagnostic procedure performed by the facility. In 
developing the IDTF proposal, we considered requiring IDTFs to furnish 
the interpretation as well as the test, but we decided not to include 
such a requirement because of the likelihood it would lead to 
unintended problems. For example, the physician who provides the 
general supervision for an IDTF may not be available to furnish an 
interpretation for a period of time and that could unnecessarily delay 
making a diagnosis in an urgent situation. In another situation, a 
beneficiary might want his or her test interpreted by a particular 
physician he or she has dealt with in the past.
    Comment: One commenter pointed out that the proposal indicated that 
the IDTF policy did not apply to procedures furnished in physicians' 
offices and suggested that we clarify the status of procedures 
performed by IDTFs in physicians' offices.
    Response: The IDTF requirements would apply to any procedures 
furnished by the IDTF either in its own facility or in a physician's 
office, clinic, or other nonprovider setting. For example, if a 
procedure requires direct supervision, it would be necessary for the 
IDTF's supervising physician to be present in the suite during 
performance. We have modified Sec. 410.33(a)(1) to state that the IDTF 
policy applies to procedures performed by IDTFs in physicians' offices.
    Comment: One commenter indicated that the IDTF proposal should 
apply to any noninvasive vascular procedure performed by portable x-ray 
suppliers.
    Response: Noninvasive vascular procedures (or any test other than 
certain x-rays, diagnostic mammography, and EKGs) are not included in 
the portable x-ray benefit. If an approved portable x-ray supplier 
wishes to furnish these procedures, it would have to become an IDTF. No 
transportation payment would be made in connection with these types of 
procedures.
    Comment: A national organization representing psychologists pointed 
out that, as written, the IDTF proposal would apply to individual 
nonphysician practitioners, including clinical psychologists and asked 
us to clarify that clinical psychologists do not have to become IDTFs 
and perform diagnostic psychological testing under physician 
supervision.
    Response: We did not intend the IDTF proposal to apply to 
diagnostic psychological testing personally performed by clinical 
psychologists because these services are not covered under section 
1861(s)(3) of the Act. However, in order to promote understanding of 
the policy by all concerned, we are explicitly excluding diagnostic 
psychological testing personally performed by clinical psychologists 
from the requirement that out-of-hospital, out-of-physician-office 
tests that must be performed under the supervision of a physician in an 
IDTF. In other words, a clinical psychologist does not have to become 
an IDTF to be paid by the carrier for the performance of diagnostic 
psychological testing.
    Comment: A State Department of Health cited several aspects of the 
IDTF proposal that would conflict with the laws of its State. The 
commenter also indicated that the proposed rule did not define the 
types of diagnostic tests that could be covered by Medicare when 
performed by an IDTF, whether IDTFs can furnish radiologic services, or 
who will receive the Medicare payments for services performed by an 
IDTF.
    Response: In making the IDTF proposal, we were recognizing the 
problems with the existing situation of largely unregulated entities 
that performed diagnostic tests. Neither IDTFs nor IPLs were 
established because of statutory mandate from the Congress. In making 
this proposal, it is not our intention to preempt any State licensing 
requirements; however, it is not clear to us how IPLs could have 
operated in a State and IDTFs cannot. However, in order to address 
these concerns, we have added an additional requirement in paragraph 
(f) of Sec. 410.33 (Independent Diagnostic Testing Facility). Under 
this requirement, an IDTF must comply with the applicable laws of any 
State in which it operates. In IDTFs, Medicare would cover all tests 
payable under the Medicare physician fee schedule, including radiologic 
procedures, other than clinical laboratory tests. In many cases, the 
carrier will pay the IDTF for the technical component of the 
procedures. In some cases, an IDTF may purchase the interpretation of 
the test from a physician and bill for both professional and technical 
components, while in other cases, an interpreting physician may 
purchase the test from the IDTF and bill for both professional and 
technical components.
    Comment: Some commenters expressed concern about the January 1, 
1998 effective date of the IDTF proposal. They suggested transition 
periods of up to 1 year.

Response: We are addressing these comments in the discussion below.

    Result of evaluation of comments: We are adopting the proposal to 
have IDTFs replace IPLs with the modifications or clarifications 
discussed above. In addition, we are providing that the replacement 
occur on a phased-in basis scheduled to be completed on July 1, 1998. 
Entities wishing to be recognized as IDTFs must send a letter to the 
Part B carrier for their service areas attesting that they meet all 
IDTF criteria. As soon as a carrier accepts the entity as an IDTF, the 
carrier notifies the entity of its new status and billing number. Once 
an entity becomes an IDTF, it is no longer subject to local medical 
review policies that currently preclude IPLs from furnishing procedures 
or groups of procedures while allowing other entities to perform them. 
An IDTF must comply with the applicable laws of any State in which it 
operates.

[[Page 59075]]

E. Reasonable Compensation Equivalent Limit Update Factor

1. Background
    Section 1887(a)(2)(B) of the Act provided for the reasonable 
compensation equivalent limits used to determine the reasonableness of 
costs incurred by providers for professional services furnished by 
physicians for the benefit of provider patients in a hospital or 
skilled nursing facility. Regulations set forth at Sec. 415.70 (Limits 
on compensation for physician services in providers), paragraph (b), 
concerning the methodology for establishing limits, established a 
methodology for determining reasonable annual compensation equivalents, 
considering average physician incomes by specialty and type of 
location, to the extent possible using the best available data. The 
regulations also expanded the application of the reasonable 
compensation equivalent limits to include comprehensive outpatient 
rehabilitation facilities. The initial and still current methodology 
for establishing reasonable compensation equivalent limits is based on 
an internal working paper (``A Methodology for Determination of 
Reasonable FTE Compensation for Hospital-Based Physicians'' by James R. 
Cantwell and William J. Sobaski (Working Paper No. OR-32, revised 
December 1982)) developed by HCFA's Office of Strategic Planning, 
(formerly the Office of Research and Demonstrations). Copies of this 
paper are available on request from: OSP Publications, Office of 
Strategic Planning, Health Care Financing Administration, Room C3-20-
11, 7500 Security Boulevard, Baltimore, MD 21244, (410) 786-6588. The 
inflation factor employed in the methodology used to develop the 
initial limits and, subsequently, to update those limits to reflect 
increases in net physician compensation was the Consumer Price Index 
for All Urban Consumers (CPI-U).
2. Change in the Methodology Used to Develop Reasonable Compensation 
Equivalent Limits
    The methodology currently employed to update the physician fee 
schedule uses an inflation factor distinct from the CPI-U, which is 
used to update the reasonable compensation equivalent limits. To 
achieve a measure of consistency in the methodologies employed to 
determine reasonable payments to physicians for physicians' direct 
medical and surgical services furnished to individual patients and 
reasonable compensation levels for physicians' services that benefit 
provider patients generally, we are revising the methodology used to 
update the reasonable compensation equivalent limits that would entail 
the adoption of the physician fee schedule's inflation factor (the MEI) 
to update the reasonable compensation equivalent limits. For cost 
reporting periods beginning on or after January 1, 1998, updates to the 
reasonable compensation equivalent limits would be calculated using the 
MEI.
    Comment: One association favored the adoption of the MEI in place 
of the CPI-U as the update factor for the reasonable compensation 
equivalent limits. Another medical association stated that, while it 
did not object to the adoption of the MEI, it recommended that the 
reasonable compensation equivalent limits methodology be replaced with 
a relative value based methodology.
    Response: We will consider the development of a relative value 
based reasonable compensation equivalent limits methodology in the 
immediate future, but we are proceeding with the adoption of the MEI as 
the reasonable compensation equivalent limits update factor at the 
present time.
    Result of evaluation of comments: As proposed, we are revising the 
reasonable compensation equivalent limits update methodology by 
replacing the CPI-U with the MEI as the update factor.

F. Payment to Participating and Nonparticipating Suppliers

    Section 1848(a)(1) of the Act requires that payment for physician 
services (as defined in 1848(j)(3)) be based on the lesser of the 
actual charge for the service or the fee schedule amount. We proposed 
to revise the regulations at Sec. 414.21 (Medicare payment basis) to 
ensure that they contain this statutory provision. (Our proposed 
definition of ``actual charges'' was discussed separately in section 
II.J. of our June 18, 1997 proposed rule (62 FR 33192).)
    Section 1848(a)(3) of the Act provides incentives for participating 
physicians and suppliers by setting the fee schedule amount for those 
who participate at 100 percent of the amount calculated under the fee 
schedule for the service as provided in the formula at section 
1848(b)(1) of the Act. It also provides that the fee schedule amount 
for nonparticipating physicians and suppliers be set at 95 percent of 
the amount for participating physicians and suppliers. Since 
regulations at Sec. 400.202 (Definitions specific to Medicare) define 
the term ``supplier'' as including physicians and all other persons who 
provide services for which payment may be made under Part B except for 
``providers of services'' as defined in 1861(u) of the Act, we proposed 
to define nonparticipating suppliers in Sec. 400.202 as being suppliers 
who do not have a Part B participation agreement in effect on the date 
of the service. We also proposed to define participating suppliers as 
being suppliers who have an agreement to participate in Part B in 
effect on the date of the service. These definitions mirror the 
definitions of participating and nonparticipating physicians, 
suppliers, and other persons that are in section 1842(h) of the Act.
    Section 1848(g)(2)(C) of the Act states that the Medicare limiting 
charge is to be set at 115 percent of the ``* * * payment amount for 
nonparticipating physicians or nonparticipating suppliers or other 
persons.'' Hence, we proposed to reflect this requirement in 
regulations in proposed Sec. 414.48(b) (concerning specific limits on 
actual charges of nonparticipating suppliers).
    We received two comments related to these proposed changes.
    Comment: Some physicians objected to being considered 
``suppliers,'' and some physicians did not recognize that, under 
current regulations, the term ``supplier'' includes physicians. These 
commenters wanted us to revise the terminology in the regulations to 
consider physicians not to be ``suppliers.''
    Response: We did not accept this comment because the term 
``supplier'' is used to include physicians for all other Medicare 
regulations (except where otherwise specified), all of which would have 
to be revised if we were to remove physicians from the definition of 
``supplier'' for general Medicare regulations. Doing this would be 
impractical and would risk removing rules that apply to physicians in 
the same manner in which they apply to other persons who bill and are 
paid for services covered under Part B of Medicare.
    Comment: Some commenters objected to the requirement that Medicare 
fee schedule payment be based on the lower of the actual charge or the 
fee schedule amount. They argued that the fee schedule amount should be 
the only basis for payment.
    Response: We did not accept this comment because the law requires 
that the payment be based on the lesser of the actual charge or the fee 
schedule amount. Including it should have no practical effect on 
payment since carriers are already instructed to compare the submitted 
charge to the fee schedule amount and to base payment on the lesser of 
the two amounts. Moreover, we believe that some of these commenters may 
have confused this

[[Page 59076]]

general requirement with our proposed definition of ``actual charges'' 
(which is discussed in section II. J. of this preamble).
    Result of evaluation of comments: We are making final the technical 
change to the regulations to conform them to statutory provisions and 
operating instructions (Medicare Carriers Manual).

G. Increase in Work Relative Value Units for Global Surgical Services 
to Account for the 1997 Increases for Work Relative Value Units in 
Evaluation and Management Services

    In our November 22, 1996 final rule with comment period, as part of 
the 5-year review of all physician work RVUs, we increased most of the 
work RVUs for evaluation and management services for hospital and 
office or other outpatient visits. We revised the work RVUs for 
evaluation and management services partly in recognition of the 
increase in preservice and postservice work. At that time, we made no 
adjustments to the work RVUs assigned to global surgical services, 
which, in addition to the surgical procedure, include the related 
preservice and postservice evaluation and management visits a surgeon 
provides within a defined period of time.
    Upon further examination of this issue, we are increasing the work 
RVUs for global surgical services to be consistent with the 1997 
increases in the work RVUs for evaluation and management services.
    Because the increases in the work RVUs for global surgical services 
will cause an increase in payments for those services, we must reduce 
all work payments by 0.7 percent to maintain budget neutrality.
    We received the following public comments on this proposal:
    Comment: Several commenters, ranging from individual physicians to 
physician specialty societies, expressed support for our proposal 
because it makes the increased work associated with the preservice and 
postservice work of global surgical services consistent with the 
increases that were made to evaluation and management services for the 
1997 physician fee schedule.
    Response: We agree that our proposal will make payment amounts for 
the increased evaluation and management services present in the 
preservice and postservice work of global surgical services more 
consistent with the increases in work that were made to evaluation and 
management services.
    Comment: Several commenters expressed concerns that our proposal 
did not include all global surgical services. Commenters requested that 
we review our list of global surgical services to be affected by these 
work RVU increases.
    Response: We agree with commenters that we inadvertently omitted 
certain global surgical services from our proposal. We addressed this 
oversight by reviewing the list of global surgical services, 
identifying those services which were omitted. After this residual list 
of services was compiled, we contacted the specialty societies most 
closely identified with the omitted CPT codes in order to attach the 
appropriate number of office visits associated with each individual CPT 
code.
    Result of evaluation of comments: We are adopting our proposal to 
increase the work RVUs associated with global surgical services to 
reflect the increased evaluation and management present in the 
preservice and postservice portions of these services. We have added 
the services referred to above. This will assure that the evaluation 
and management portions of global surgical services are consistent with 
our 1997 increases to evaluation and management services. Those codes 
that have been changed due to the increase of work RVUs of global 
surgical services are identified in Addendum B.

H. Caloric Vestibular Testing

    We proposed to reduce the RVUs for caloric vestibular testing, CPT 
code 92543, to 25 percent of what the values would have otherwise been. 
We made this proposal in order to permit physicians and suppliers to 
bill four units of service instead of the one unit now permitted. The 
use of four units is consistent with the AMA's interpretation of the 
code.
    Addendum C in the June 18, 1997 proposed rule contained an error. 
The reduction to 25 percent of the RVUs otherwise applicable was 
reflected for the practice expense RVUs, but we incorrectly published 
unreduced RVUs for work and malpractice. On August 18, 1997, we 
published a correction notice (62 FR 43962) to reflect the correct 
values. The new values for work and malpractice were 25 percent of the 
numbers previously published.
    The reduction to the direct practice expense RVUs had been 
correctly noted in the proposed rule. However, because the indirect 
practice expense RVUs are partially based on the work RVUs, the 
reduction to the work RVUs caused a reduction to the indirect practice 
expense RVUs. The new total practice expense RVUs published in the 
correction notice reflect the reduced indirect practice expense RVUs.
    Because resource-based practice expense RVUs will not be 
implemented effective January 1998, the practice expense RVUs published 
in this final rule differ from those published in the proposed rule and 
the correction notice. The final practice expense RVUs continue to be 
based on charge-based data and are simply 25 percent of the charge-
based RVUs currently in effect. The final work and malpractice RVUs are 
those published in the correction notice. They too are 25 percent of 
the values currently in effect.
    Two physician organizations expressed support for this change. 
Other comments are discussed below.
    Comment: One commenter suggested that Medicare should recognize 
four units of service when four irrigations are performed but that we 
should not make a reduction in RVU amounts.
    Response: This change is not intended to reflect a decision that 
our relative payment amounts are too low for caloric vestibular 
testing. Medicare has not made such a decision. Instead, we are simply 
reconciling our interpretation of the code with the AMA's 
interpretation and, in order to do this in a budget neutral fashion, we 
are reducing the RVUs to 25 percent of the amount otherwise applicable.
    Comment: Another commenter did not oppose this proposal but opposed 
the proposed resource-based practice expense RVUs for the service.
    Response: Since we are no longer proceeding with resource-based 
practice expense RVUs for 1998, the merits of these comments will not 
be addressed in this final rule.
    Result of evaluation of comments: Beginning in 1998, when a 
physician performs and interprets four irrigations, the physician will 
bill Medicare for four units of CPT code 92543 (that is, the global 
service). When a physician interprets four irrigations, the physician 
will bill four units of CPT code 92543-26. When a physician or supplier 
performs four irrigations, the physician or supplier will bill four 
units of CPT code 92543-TC.

I. Clinical Consultations

    There are two CPT codes for clinical consultations, CPT codes 80500 
(Clinical pathology consultation; limited, without review of patient's 
history and medical records) and 80502 (Clinical pathology 
consultation; comprehensive, for a complex diagnostic problem, with 
review of patient's history and medical records), which were added to 
the CPT in 1985.
    The regulations set forth at Sec. 415.130 (Conditions for payment: 
Physician pathology services), paragraph (b)

[[Page 59077]]

(Clinical consultation services), require that a clinical consultation 
meet four criteria before it can be paid. One of these criteria is that 
the clinical consultation must be requested by the patient's attending 
physician. As we indicated in the preamble to the proposed rule, we 
have allowed a standing order policy to be used as a substitute for the 
individual request by the patient's attending physician since a 1984 
law suit. However, we believe that this policy is no longer 
appropriate. Because the policy was not embodied in the court's 
judgment or otherwise required by law and because we view it as 
creating opportunities for abuse and waste, effective January 1, 1998, 
we are not accepting a standing order as a substitute for the 
individual request by the attending physician. We are instructing the 
Medicare carriers to enforce Sec. 415.130(b) as it is presently 
written.
    Comment: We received comments from two organizations and many 
individual pathologists from Florida. These commenters argue that 
standing orders are an efficient mechanism of providing interpretive 
reports of specific clinical laboratory tests to attending physicians 
without prolonging care or the length of a hospital stay. Therefore, 
the proposed elimination of standing orders would create unnecessary 
delays and could adversely affect patient care and increase the cost of 
care.
    Response: As we explained in the June 1997 proposed rule, 
pathologists could use a standing order policy to generate unnecessary 
consultations. These consultations may occur even though the attending 
physician can properly interpret the test results and does not need the 
assistance of the pathologist. We readily admit that standing orders 
can offer efficiencies over individual requests by attending physicians 
when attending physicians need interpretations from pathologists. 
However, we must balance this concern with the risk that the Medicare 
program may be inappropriately paying for medically unnecessary 
services under a standing order policy.
    Comment: Individual commenters stated that there are several tests 
when prompt interpretation of tests is needed and the tests require 
interpretation by pathologists. Examples of these tests include cardiac 
enzymes, serum protein electrophoresis, and immunoelectrophoresis.
    Response: These commenters appear to be confusing our policy on 
clinical laboratory interpretation services with clinical 
consultations. Before the implementation of the physician fee schedule 
in 1992, we worked with the College of American Pathologists and our 
carrier medical directors to identify those clinical laboratory tests 
for which the attending physician would ordinarily need the 
pathologist's interpretation. The clinical laboratory tests, which the 
commenters mentioned, were on the original list of tests which our 
carrier medical directors reviewed. Working with the carrier medical 
directors, we identified a list of 15 clinical laboratory tests for 
which we would recognize a clinical laboratory interpretation service. 
These tests were listed in the November 1991 final rule (56 FR 59565) 
and can be found at section 15020 E of the Medicare Carriers Manual. 
The list includes CPT codes 86320, 86325 and 86327, which describe 
immunoelectrophoresis services, and CPT code 84165, which describes 
serum protein electrophoresis. Since these tests are ordinarily 
interpreted by a pathologist, we allow a standing order policy to be 
used in place of an individual request by an attending physician.
    Result of evaluation of comments: Except for the clinical 
laboratory tests mentioned above, we will not accept a standing order 
as a substitute for the individual request by the attending physician. 
We will instruct the Medicare carriers to enforce Sec. 415.130(b) as it 
is presently written.

J. Actual Charges

    In the June 18, 1997 proposed rule (62 FR 33184), we defined the 
term ``actual charge'' to be the lesser of the amount the physician, 
supplier, or other person charges for the service to a particular 
beneficiary or the amount they have voluntarily agreed to accept as 
payment in full under a private plan contract that also covers the 
beneficiary when Medicare is primary and the private plan is secondary. 
We proposed this policy to protect Medicare beneficiaries from 
incurring greater deductible and coinsurance expenses as a result of 
enrollment in Part B of Medicare if the private plan's payment amount 
is less than the Medicare payment, and the Medicare coinsurance is more 
than the private plan's copayment.
    For example, a retiree age 64, enrolled in a managed care plan, has 
a cataract removed by a physician who participates in Medicare and in 
the managed care plan. The managed care plan pays $800 of the 
physician's $1,500 actual charge. The retiree pays a $5 copayment. The 
physician cannot bill the retiree for the remaining amount under the 
terms of the contract with the managed care plan.
    The retiree reaches age 65 and enrolls in Medicare Part B, which is 
usually required by the employer or the plan in order for the 
beneficiary to stay in the managed care plan. The beneficiary pays the 
Medicare premium each month and has the second cataract removed. 
Medicare is now the primary payer and the managed care plan is a 
secondary payer. The physician takes assignment on the Medicare claim 
and Medicare allows $1,000 of the physician's $1,500 charge. Medicare 
pays $800, its share of the payment. The physician bills the managed 
care plan for the $200 coinsurance but the plan may refuse to pay 
because the physician has already received the $800 that the plan 
considers to be payment in full. The physician may attempt to collect 
the coinsurance from the beneficiary. When this occurs, the beneficiary 
may have more out-of-pocket expense after age 65 than before. The 
potential for higher out-of-pocket expenses occurs also with the 
services of other practitioners and suppliers, especially suppliers of 
durable medical equipment, prosthetics, orthotics, and supplies, who 
often deeply discount the price they charge managed care organizations 
in exchange for exclusivity and guaranteed business.
    We received numerous comments from individual physicians and 
suppliers and the organizations that represent them in opposition of 
this proposal. In general, the comments have the following common 
themes:
     Physicians and suppliers do not know what the plans will 
pay for their services, either because the plans change the payment 
amounts without notice or, in the case of physicians, because of 
withholds and bonuses that do not permit establishing actual payment 
for the service until after the end of the year--certainly not in time 
for the actual payment to be placed on the claim for Medicare payment.
     The proposal would increase physicians' and suppliers' 
administrative cost and burden to bill Medicare.
     There is no statutory basis for interpreting the term 
``actual charges'' in any manner other than the plain meaning of the 
words, for example, whatever the physician or supplier chooses to 
charge.
     There is no standard coding and/or bundling among payers, 
hence, there is no standard description of services on which to base a 
comparison of Medicare and managed care payments.
     The proposal constitutes a breach of faith with the 
physician community that supports the physician fee schedule because of 
the participatory nature of its development.
    As a result of our review of the comments, we have decided that the

[[Page 59078]]

actual charge issue, including the implications for beneficiary out-of-
pocket expense, requires further study. Although we are not issuing a 
final rule requiring physicians and suppliers to show the lower 
negotiated payment as their submitted charge for the service, we 
continue to believe that the lower negotiated rate should be the 
submitted charge in this situation.

III. Implementation of the Balanced Budget Act of 1997

    In addition to the physician fee schedule provisions of the 
Balanced Budget Act of 1997, the new legislation expands the previously 
enacted Medicare screening mammography benefit and adds several new 
screening benefits to the law--the colorectal cancer screening benefit 
and the screening pelvic examination benefit effective January 1, 1998. 
For many years physicians have understood the value of prevention and 
early detection measures in dealing with medical problems. Preventive 
services for the early detection of disease have also been associated 
with substantial reductions in morbidity. For example, dramatic 
reductions in the incidence of invasive cervical cancer and in cervical 
cancer mortality have occurred following the implementation of 
screening programs using Papanicolaou testing to detect cervical 
dysplasia.
    Although sound clinical reasons exist for emphasizing prevention in 
medicine, studies have shown that clinicians often fail to provide 
recommended clinical preventive services. This is due to a variety of 
factors, including inadequate reimbursement for preventive services, 
fragmentation of health care delivery, and insufficient time with 
patients to deliver the range of preventive services that are 
recommended. It is our expectation that implementation of the recently 
enacted new Medicare benefit provisions should help to overcome at 
least some of the barriers to the use of preventive services, and may 
lead to substantial reductions in morbidity and mortality.

A. Changes in Practice Expense Relative Value Units for 1998

    Section 4505 of the Balanced Budget Act of 1997 delays the 
implementation of the resource-based practice expense RVU system until 
January 1, 1999 and specifies the manner in which practice expense RVUs 
in 1998 are adjusted.
    The 1998 practice expense RVUs for certain services are reduced to 
110 percent of their work RVUs for the service. The reductions are used 
to increase practice expense RVUs for office visits. (Section 4505 of 
the BBA 1997 also provides the Secretary with the authority to adjust 
the 110 percent figure if the aggregate amount of reductions exceeds 
$390 million. Since the application of the 110 percent results in 
reductions of about $330 million, we did not need to make an additional 
adjustment.)
    There are two categories of services that are excluded from this 
limitation: (1) The service provided more than 75 percent of the time 
in an office setting; and (2) the service had a proposed resource-based 
practice expense RVU (that is, the practice expense RVU for the service 
published in the June 18, 1997 proposed rule (62 FR 33158 et seq.)) 
that was an increase from its 1997 practice expense RVU.
    In addition, there are services whose work RVU is zero and 
therefore are not affected by this provision. These services include 
technical component (TC) services (such as the TC of radiology 
services, surgical pathology services, and other services that have a 
corresponding PC service) and diagnostic tests, such as psychological 
tests, that are not TC services (because there is no corresponding PC 
service).
    The exclusion for services because they have a value that increased 
in the June 1997 proposed rule (62 FR 33160) is applied separately by 
site-of-service with the distinction made between in-office and out-of-
office services. For most codes, the June 1997 proposed rule provided a 
practice expense RVU for both the in-office and the out-of-office 
setting. Thus, if the proposed 1998 resource-based practice expense RVU 
for a code for the in-office setting increased in relation to its 1997 
practice expense RVU even though the proposed value exceeded 110 
percent of the work RVU, this code, for this service and this site, was 
excluded from the practice expense RVU reduction. Similarly, if the 
proposed 1998 resource-based practice expense RVU for the same code for 
the out-of-office setting decreased in relation to its 1997 practice 
expense RVU and the proposed value exceeded 110 percent of the work 
RVU, then this code, for this service and this site, was subject to the 
practice expense RVU reduction.
    For 1998, the carriers will apply the same site-of-service 
differential policy they applied in 1997. Under the site-of-service 
differential, the practice expense RVUs for a procedure code that is 
furnished outside the office are reduced by 50 percent. There are 
approximately 700 codes affected by this policy. To coordinate this 
policy with the site-of-service distinctions in the June 1997 proposed 
rule and the interaction of the provisions of section 4505 of the BBA 
1997, we are listing in Addendum B the practice expense RVUs for the 
two sites for the 700 procedure codes instead of allowing the carrier 
to calculate the 50 percent reduction.
    The practice expense RVUs for office visit procedure codes are 
increased by a uniform percentage. This uniform percentage (13 percent) 
is calculated so that the aggregate increase in practice expense RVUs 
for office visit procedures is equal to the decrease in Practice 
expense RVUs for services whose practice expense RVUs are reduced. This 
results in an increase in total payments of between 3 percent and 5 
percent for the office visit codes.

B. Coverage of Screening Mammography and Related Payment Changes

    Before the enactment of the BBA 1997, section 1834(c)(2) of the Act 
prescribed certain limitations on the frequency of coverage of 
mammography screenings for women over 39 years of age with no waiver of 
the yearly Part B deductible requirement. Specifically, for a woman 
over age 39 but under 50 years of age, the law provided for coverage of 
screening mammography either once a year or twice a year depending upon 
whether the woman was considered to be at high risk of developing 
breast cancer, as determined pursuant to factors identified by the 
Secretary and specified in regulations. In the case of a woman over 49 
years of age but under 65 years of age, the law specified that payment 
could be made for a screening mammography once a year (that is, if at 
least 11 months had passed following the month in which the last 
screening mammography was performed). Finally, in the case of a woman 
over 64 years of age, the law provided that payment could be made for a 
screening mammography once every 2 years following the month in which 
the last screening mammography was performed.
    Section 4101(a) of the BBA 1997 amends section 1834(c)(2)(A) of the 
Act effective January 1, 1998 to simply provide that in the case of any 
woman over 39 years of age, payment may be made for a screening 
mammography if at least 11 months have passed following the month in 
which the last screening mammography was performed. Section 4101(b) of 
the BBA 1997 amends sections 1833(b) and 1834(c)(1)(C) of the Act to 
waive the Part B deductible requirement.
    In view of the statutory changes in the (1) limitations on the 
frequency of coverage of screening mammographies for all women over 39 
years of age and (2) the Part B deductible requirement as

[[Page 59079]]

it relates to all screening mammography services, we are amending 
Sec. 410.34(d) (relating to limitations on coverage of screening 
mammography) and are adding a new exception as paragraph (5) in 
Sec. 410.160(b) (relating to exceptions to the Part B annual 
deductible) to reflect these changes in the regulations.

C. Colorectal Cancer Screening

    Section 4104 of the BBA 1997 provides for Medicare coverage of 
colorectal cancer screening tests effective for services provided on or 
after January 1, 1998. The law provides for coverage for screening 
fecal-occult blood tests, screening flexible sigmoidoscopy, screening 
colonoscopy, and other tests we determined to be appropriate, subject 
to certain frequency and payment limits.
    Present Medicare coverage policy allows payment for diagnostic 
tests to diagnose colorectal cancer and related medically necessary 
services that are furnished to beneficiaries. Under this policy, 
diagnostic colorectal cancer tests are covered if they are medically 
necessary to evaluate a specific complaint from or monitor an existing 
medical condition of an individual who has had a history of colon 
cancer or inflammatory bowel disease. This coverage is based, in part, 
on section 1861(s)(3) of the Act, which provides general Medicare 
coverage for diagnostic x-ray, clinical laboratory, and other 
diagnostic tests. However, prior to the enactment of the BBA 1997, 
screening colorectal cancer tests have been excluded from coverage 
based on section 1862(a)(7) of the Act, which states that routine 
physical checkups are excluded services. This exclusion is described in 
Medicare regulations in Sec. 411.15(a).
1. Coverage Determination in Screening Barium Enemas
    Section 4104(a)(2) of the BBA 1997 requires us to publish a notice 
in the Federal Register related to the coverage of screening barium 
enema as a colorectal cancer screening test. As provided by section 
4104(a)(2) of the BBA 1997, this notice is to be published in the 
Federal Register by November 3, 1997, within 90 days after the date of 
enactment.
    To the three colorectal cancer screening tests specifically 
designated as covered under sections 1861(pp)(1)(A), (B), and (C) of 
the Act, section 4104(a)(2) of the BBA 1997 added a new section 
1861(pp)(1)(D) to the Act to provide that colorectal cancer screening 
tests may also include coverage of other tests or procedures the 
Secretary determines to be appropriate based on consultation with 
appropriate organizations.
    As required by section 1861(pp)(1)(D) of the Act, we, acting on 
behalf of the Secretary, consulted with appropriate Federal government 
organizations and other organizations regarding the efficacy of a 
barium enema examination for detecting colorectal cancer. We also 
inquired about how this coverage should be included under Medicare. We 
contacted representatives of various Federal agencies, including the 
Agency for Health Care Policy and Research, the Centers for Disease 
Control and Prevention, the Food and Drug Administration, and the 
National Cancer Institute, knowledgeable about using a barium enema as 
a screening test to detect colorectal cancer. We also consulted with 
staff from the American Cancer Society. In addition, the American 
Medical Association convened a preventive medicine expert panel that 
included representatives from the United States Preventive Services 
Task Force and various medical specialty organizations, such as the 
American Medical Association Council on Scientific Affairs, the 
American Medical Association Council on Medical Services, the American 
Academy of Family Physicians, the American College of Physicians, the 
American College of Preventive Medicine, the American College of 
Radiology, and the American Society of Colon and Rectal Surgeons.
    Based on our review of this information and our evaluation of other 
data, we concluded that while there is not a consensus in the medical 
community regarding the specific role of a barium enema examination 
under the Medicare colorectal cancer screening benefit when compared to 
the use of the flexible sigmoidoscopy and colonoscopy examinations, 
there is a sufficient basis for us to include the use of barium enema 
as part of the new national Medicare coverage for colorectal screening.
    In its Executive Summary, (AHCPR Publication Number 97-0302) 
Evidence Report No. 1: Colorectal Cancer Screening, the Agency for 
Health Care Policy and Research concluded that there is indirect 
evidence that supports the use of double contrast barium enema in 
screening for colorectal cancer. They also noted that the double 
contrast barium enema can image the entire colon and detect cancers and 
large polyps. (Medicare policy already allows payment for diagnostic 
barium enemas that are performed to evaluate a beneficiary's specific 
complaint or to monitor an existing medical condition for an individual 
with a history of colon cancer.) Additionally, the role of the barium 
enema examination as a colorectal cancer screening examination has 
recently been studied by several multi-disciplinary expert panels and, 
as a result of those studies, it appears that the usefulness of the 
examination is becoming widely accepted in the United States. First, 
the American Gastroenterological Association initially in conjunction 
with the Agency for Health Care Policy and Research, completed their 
report earlier this year. The double contrast barium enema was 
recommended as a screening option for all average risk patients (those 
with no predisposing factors) and selected groups of high risk patients 
(those with a history of prior polyps, or those with a first degree 
relative with colorectal cancer). Only in the case of the subset of 
patients at high risk with a family history of familial adenomatous 
polyposis, hereditary non-polyposis colorectal cancer, and inflammatory 
bowel disease was a colonoscopy recommended as the only screening 
modality. (This subset of patients represents a minority of the high 
risk population as defined by statute.) Second, earlier this year the 
American Cancer Society recently revised their guidelines to include 
the double contrast barium enema as an option for patients at average 
and moderate risk (nearly identical to the above described American 
Gastroenterological Association guidelines).
    The American Gastroenterological Association and the National 
Cancer Institute studies have indicated that one of the major 
advantages of the barium enema examination is that it permits the 
imaging of the entire colorectum and it appears to have the ability to 
detect precursor adenomas as well as colorectal cancers. Anatomic 
visualization of the entire colorectum is believed to be highly 
desirable and is widely considered optimum for evaluating the colon. 
(It is generally acknowledged that one limitation of the flexible 
sigmoidoscopy examination is that it only allows for direct examination 
of the lower third to one-half of the colorectum.) There is also some 
evidence that racial differences exist in the distribution of 
colorectal cancers, with African-Americans having a higher proportion 
of cancers in the right side of the colon than Caucasians. Thus, tests 
that allow full structural coverage of the entire colorectum are needed 
as a choice for certain segments of the population.
    Furthermore, on the basis of the information we have reviewed, the 
barium enema screening examination appears to have a superior safety 
profile

[[Page 59080]]

when compared to the screening flexible sigmoidoscopy and colonoscopy 
examinations, and it does not require sedation as is the case with 
colonoscopy examinations. Our information indicates that patients are 
typically exposed to 300 to 500 mrad of radiation during a barium enema 
examination, which is about equivalent to the dose of radiation that 
results from a single screening mammography examination. Considering 
the age and frequency at which screening is recommended for a barium 
enema examination, it is estimated by the American College of Radiology 
that a screening strategy using a barium enema x-ray every 2 or 4 years 
would deliver a lifetime dose of radiation that is lower than the 
radiation that would result from use of the annual Medicare screening 
mammography benefit.
    Specifically, in view of the information summarized above, we have 
determined that a barium enema is a reasonable and necessary screening 
test for colorectal cancer, and have decided to cover screening barium 
enema examinations in the following manner:
    First, such a screening examination may be covered as an 
alternative to a flexible sigmoidoscopy examination (that is, as a 
substitute for, and not as an added optional benefit) for an individual 
attaining age 50 and not at high risk for colorectal cancer, if the 
individual's attending physician orders the test in writing after a 
determination that the test is the appropriate screening test. That is, 
the attending physician must determine that, in the case of a 
particular individual, the estimated screening potential for the barium 
enema is equal to or greater than the screening potential that has been 
estimated for a flexible sigmoidoscopy for that same individual. For 
example, in the case of an individual who is taking anti-coagulant 
medications, the individual's attending physician may decide to order a 
barium enema instead of a flexible sigmoidoscopy because it is less 
likely to produce bleeding and typically allows for a total inspection 
of the colon, while the flexible sigmoidoscopy does not.
    Second, we are establishing a frequency limitation for the coverage 
of the screening barium enema for an individual age 50 and over who is 
not at high risk for colorectal cancer at the same time interval that 
is specified in the statute for screening flexible sigmoidoscopy 
examination (that is, once every 48 months for the same individual.)
    Third, we are providing that a screening barium enema may be 
covered as an alternative to a screening colonoscopy (that is, as a 
substitute and not as an added optional benefit) for individuals at 
high risk for colorectal cancer, if the individual's attending 
physician orders the test in writing following a determination that the 
screening barium enema is the appropriate test for that particular 
individual. This means that the attending physician must determine, in 
the case of a particular individual, that the estimated screening 
potential for the barium enema examination is equal to or greater than 
the screening potential that has been estimated for the colonoscopy 
examination. For instance, in the case of an individual at high risk 
for colorectal cancer who may not be able to receive a complete 
colonoscopy due to a markedly long and twisting loop(s) of colon, the 
individual's attending physician may decide to order a barium enema in 
lieu of a screening colonoscopy because it is more likely to permit a 
complete view of the entire colon.
    Fourth, we are establishing the frequency limitation for coverage 
of the screening barium enema for an individual who is at high risk for 
colorectal cancer at the same time interval that is specified in the 
statute for screening colorectal examinations (that is, once every 24 
months for the same individual.)
    Fifth, we are establishing the double contrast barium enema as the 
standard type of screening barium enema that will be covered under the 
Medicare program because, based on information obtained from the 
American College of Radiology, we understand that it is regarded as the 
most sensitive for small colonic lesions in patients who are adequately 
prepared and optimally imaged. In the case of some patients who are 
infirm, immobile, or debilitated, however, a technically optimal double 
contrast examination may not be possible. In these patients a single 
contrast barium examination may be performed with high quality results 
despite the limitations of the patient's condition. In these 
situations, we are covering the single contrast method if it would 
satisfy the test described above for allowing coverage of the barium 
enema examination as an alternative to one of the other two colorectal 
cancer screening tests. That is, the individual's attending physician 
would have to determine that the estimated screening potential from the 
use of the single contrast barium enema is equal to or exceeds the 
estimated screening potential that would result from the use of the 
flexible sigmoidoscopy and the colonoscopy examinations.
    In summary, effective January 1, 1998, we will pay for screening 
barium enemas as an alternative to either a screening flexible 
sigmoidoscopy or a screening colonoscopy, in accordance with the same 
frequency parameters specified in the law for the other two colorectal 
screening services identified.
2. Provisions of the Final Rule
    We are specifying an exception to the list of examples of routine 
physical checkups excluded from coverage in Sec. 411.15(a)(1) 
(Particular services excluded from coverage). The exception is for 
colorectal cancer screening tests that meet the frequency limitations 
and the conditions for coverage that we are specifying under 
Sec. 410.37. Coverage of colorectal cancer screening tests is provided 
under Medicare Part B only.
3. Frequency Limits and Conditions of Coverage
    Section 4104 of the BBA 1997 adds new subparagraph (R) to section 
1861(s)(2) of the Act authorizing Medicare coverage of certain 
colorectal screening services as defined in section 1861(pp) that are 
furnished on or after January 1, 1998. These statutorily mandated 
colorectal services include screening fecal-occult blood tests, 
screening flexible sigmoidoscopy examinations, and screening 
colonoscopy examinations. Section 4104(b) of the BBA 1997 also 
establishes frequency of coverage limitations for all three of these 
colorectal screening services. The frequency of coverage limitations 
specified for fecal-occult blood tests is that payment may be made only 
for an individual 50 years of age or over, if the test has not been 
performed within the 11 months that have passed following the month in 
which the last screening fecal-occult blood test was performed. The 
frequency of coverage limitation indicated for screening flexible 
sigmoidoscopy examinations is that payment may be made only for an 
individual age 50 years of age or over, if the procedure has not been 
performed within the 47 months that have passed following the month in 
which the last screening flexible sigmoidoscopy examination was 
performed. In the case of screening colonoscopy examinations, section 
4104 of the BBA 1997 provides for coverage of screening colonoscopies 
for individuals at high risk for developing colorectal cancer (as now 
defined in section 1861(pp)(2) of the Act), if the screening 
examination has not been performed within the 23 months that have 
passed following the month in which the last screening colonoscopy was 
performed.

[[Page 59081]]

    We have added Sec. 410.37 to provide for coverage of four types of 
colorectal cancer screening tests. First, we are specifying several 
definitions of terms that are included to implement the statutory 
provisions and to help the reader in understanding the regulation 
provisions. These include definitions of the terms (1) colorectal 
cancer screening tests, (2) fecal-occult blood test, (3) individual at 
high risk for colorectal cancer, (4) screening barium enema, and (5) 
attending physician. Second, we are establishing conditions of coverage 
for all four of the colorectal cancer screening tests that we will be 
paying for, effective January 1, 1998. Under our authority under the 
``reasonable and necesary'' clause of the Act, section 1862(a)(1)(A), 
we are establishing conditions under which we would cover colorectal 
screening services. In Sec. 410.37(b) (Conditions for coverage of 
screening fecal-occult blood tests) and Sec. 410.37 (h) (Conditions for 
coverage of screening barium enemas) we are specifying that coverage is 
available for screening fecal-occult blood tests and screening barium 
enema examinations only if they are ordered in writing by the 
beneficiary's attending physician. We are including these coverage 
requirements to make certain that beneficiaries receive appropriate 
preventive counseling about the implications and possible results of 
having these examinations performed. In addition, in the case of the 
screening barium enema, which we will cover as an alternative to either 
the screening flexible sigmoidoscopy or the colonoscopy examination, we 
want to ensure that the beneficiary's attending physician has made a 
determination that the screening potential of that exam is at least 
equal to or greater than the screening potential for the alternative 
examination. Third, in order to ensure that the screening flexible 
sigmoidoscopy and screening colonoscopy exams are performed as safely 
and accurately as possible, we are requiring in Sec. 410.37(d) 
(Conditions for coverage of screening flexible sigmoidoscopies) and 
Sec. 410.37(f) (Conditions for coverage of screening colonoscopies) 
that the examinations must be performed by a doctor of medicine or 
osteopathy (as defined in section 1861(r)(1) of the Act.)
    Additionally, in Secs. 410.37(c), 410.37(e), 410.37(g), and 
410.37(i) (Limitations on coverage of screening fecal-occult blood 
tests, Limitations on coverage of screening flexible sigmoidoscopies, 
Limitations on coverage of screening colonoscopies, and limitations on 
coverage of screening barium enemas, respectively), we are setting 
forth the following frequency and payment restrictions for the four 
types of colorectal cancer screening test covered, which are mandated 
by sections 1834(d)(1)(B), 1834(d)(2)(E) and 1834(d)(3)(E) of the Act, 
except for those relating to screening barium enema examinations, which 
the law did not specifically address.

Limits on Fecal-Occult Blood Tests

     Payment may not be made for a screening fecal-occult blood 
test performed for an individual under age 50.
     For an individual 50 years of age or over, payment may be 
made for a screening fecal-occult blood test performed after at least 
11 months have passed following the month in which the last fecal-
occult blood test was performed.

Limits on Flexible Sigmoidoscopies

     Payment may not be made for a screening flexible 
sigmoidoscopy performed for an individual under age 50.
     For an individual 50 years of age or over, payment may be 
made for a screening flexible sigmoidoscopy performed after at least 47 
months have passed following the month in which the last screening 
flexible sigmoidoscopy, or the last screening barium enema was 
performed.

Limits on Colonoscopies

     Payment may not be made for a screening colonoscopy 
performed for an individual who is not at high risk for colorectal 
cancer.
     Payment may be made for a screening colonoscopy performed 
for an individual at high risk for colorectal cancer after at least 23 
months have passed following the month in which the last screening 
colonoscopy or the last screening barium enema was performed.

Limits for Barium Enemas

     In the case of an individual age 50 and over who is not at 
high risk for colorectal cancer, payment may be made for a screening 
barium enema after 47 months have passed following the month in which 
the last screening barium enema, or the last screening flexible 
sigmoidoscopy was performed.
     In the case of an individual who is at high risk for 
colorectal cancer, payment may be made for a screening barium enema 
after at least 23 months have passed following the month in which the 
last screening barium enema, or the last screening colonoscopy was 
performed.
    As indicated previously, in explaining our national coverage 
determination on screening barium enemas, we have decided to pay for 
this examination as an alternative to either the flexible sigmoidoscopy 
or the colonoscopy coverage provisions (that is, as a substitute for, 
and not as add-on coverage.) In reviewing the matter of the appropriate 
frequency limits for screening barium enemas, we did consider the 
possibility of providing for payment for these services as an add-on to 
the other two major screening coverage provisions. However, since the 
screening barium enema allows for a complete examination of the colon, 
we have not adopted this alternative because we believe it would be 
duplicative for us to permit coverage of both a screening barium enema 
and a screening flexible sigmoidoscopy (or a screening colonoscopy for 
an individual at high risk of colorectal cancer) during the same 2 or 4 
year time period, respectively. In the case of a suspicious or 
equivocal examination, other tests would be necessary but would be 
considered diagnostic tests, not screening, and would be covered under 
Medicare. It is generally unnecessary to perform duplicate screening 
tests.
4. Payment Limits
    Payment amounts for screening fecal-occult blood tests, screening 
sigmoidoscopies, screening colonoscopies, and barium enemas as follows:
     Screening fecal occult blood tests are covered at a 
frequency of once every 12 months for beneficiaries who have attained 
age 50. Section 1834(d)(1) of the Act provides that screening fecal 
occult blood tests are paid at the same rate as diagnostic fecal-occult 
blood tests (CPT code 82270) are paid under the clinical laboratory fee 
schedule. We have created a new HCPCS code G0107, colorectal cancer 
screening; fecal-occult blood test, one to three simultaneous 
determinations, to be used for screening fecal-occult blood tests. This 
code will be carrier-priced at the payment amount that the Medicare 
carrier pays for CPT code 82270 under the clinical laboratory fee 
schedule.
     Screening flexible sigmoidoscopy is covered at a frequency 
of once every 48 months for beneficiaries who have attained age 50. 
Section 1861(pp)(2) of the Act provides that payment for screening 
flexible sigmoidoscopies be paid at rates consistent with payment for 
similar or related services under the physician fee schedule, not to 
exceed the rates for a diagnostic flexible sigmoidoscopy (CPT code 
45330).

[[Page 59082]]

    We have created a new HCPCS code G0104, colorectal cancer 
screening; flexible sigmoidoscopy, to be used for screening flexible 
sigmoidoscopy. We believe that the work is the same whether the 
procedure is a screening or a diagnostic sigmoidoscopy and are, 
therefore, assigning the same RVUs to HCPCS code G0104 as those 
assigned to CPT code 45330 in Addendum B. If during the course of the 
screening flexible sigmoidoscopy a lesion or a growth is detected that 
results in a biopsy or removal of the growth, section 1834(d)(2)(D) of 
the Act provides that the physician should bill for a flexible 
sigmoidoscopy with biopsy or removal, rather than using the screening 
HCPCS code G0104.
     Screening colonoscopy is covered at a frequency of once 
every 24 months for beneficiaries at high risk for colorectal cancer 
under section 1834(d)(3)(E) of the Act. Section 1861(pp)(2) of the Act 
defines high risk as a person who, because of family history, prior 
experience of cancer or precursor neoplastic polyps, a history of 
chronic digestive disease condition (including inflammatory bowel 
disease, Crohn's disease, or ulcerative colitis), the presence of any 
appropriate recognized gene markers for colorectal cancer, or other 
predisposing factors, faces a high risk for colorectal cancer. The law 
provides that payment for screening colonoscopies be paid at rates 
consistent with payment for similar or related services under the 
physician fee schedule, not to exceed the rates for a diagnostic 
colonoscopy (CPT code 45378).
    We have created a new HCPCS code G0105, colorectal cancer 
screening; colonoscopy for an individual at high risk, to be used for 
screening colonoscopy. We believe that the work is the same whether the 
procedure is a screening or a diagnostic colonoscopy, and we are, 
therefore, assigning the same RVUs to HCPCS code G0105 as those 
assigned to CPT code 45378 in Addendum B. If during the course of the 
screening colonoscopy a lesion or growth is detected that results in a 
biopsy or removal of the growth, section 1834(d)(3)(D) of the Act 
provides that the physician should bill for a colonoscopy with biopsy 
or removal, rather than using the screening HCPCS code G0105.
     The frequency of payment limitations for the screening 
barium exams will be exactly the same as the frequency of payment 
limitations that would apply if the barium examination were not being 
substituted for the other screening service (that is, once every 4 
years for a flexible sigmoidoscopy examination for individuals age 50 
or over and once every 2 years for colonoscopy screening for 
individuals at high risk for colorectal cancer).
    We have created the following new HCPCS codes:

------------------------------------------------------------------------
            HCPCS code                           Descriptor             
------------------------------------------------------------------------
G0106.............................  Colorectal cancer screening;        
                                     alternative to G0104, screening    
                                     sigmoidoscopy, barium enema.       
G0120.............................  Colorectal cancer screening;        
                                     alternative to G0105, screening    
                                     colonoscopy, barium enema.         
G0121.............................  Colorectal cancer screening;        
                                     colonoscopy on individual not      
                                     meeting criteria for high risk (non-
                                     covered).                          
G0122.............................  Colorectal cancer screening; barium 
                                     enema (non-covered).               
------------------------------------------------------------------------

The first two codes (G0106, and G0120) are to be used for the barium 
enema when the barium enema is being substituted for either the 
sigmoidoscopy or the colonoscopy, as indicated by the code 
nomenclature. The RVUs for these procedures will be the same as for the 
diagnostic barium enema procedure, CPT code 74280, and are shown in 
Addendum B.
    The second two codes are to be used when the high risk criteria are 
not met, or a barium enema is performed but not a substitute for either 
a sigmoidoscopy or colonoscopy. These are non-covered services.
5. Screening Colonoscopy in an Ambulatory Surgical Center
    CPT code 45378, which is used to code a diagnostic colonoscopy, is 
on the list of procedures approved by Medicare for payment of an 
ambulatory surgical center (ASC) facility fee under section 1833(I) of 
the Act. CPT code 45378 is currently assigned to ASC payment group 2. 
We propose to add the new HCPCS code G0105, colorectal cancer 
screening; colonoscopy on individual at high risk, to the ASC list. We 
believe that the facility services are the same whether the procedure 
is a screening or a diagnostic colonoscopy and are, therefore, 
assigning HCPCS code G0105 to payment group 2, which is the same 
payment rate assigned to CPT code 45378. If during the course of the 
screening colonoscopy performed at an ASC a lesion or growth is 
detected which results in a biopsy or removal of the growth, the 
appropriate procedure classified as a colonoscopy with biopsy or 
removal should be billed and paid rather than HCPCS code G0105.

D. Coverage of Screening Pelvic Examination (Including a Clinical 
Breast Examination) and Related Payment Changes

    Section 4102 of the BBA 1997 provides for coverage of screening 
pelvic examinations (including a clinical breast examination) for all 
female beneficiaries, effective January 1, 1998, subject to certain 
frequency and other limitations. A screening pelvic examination 
(including a clinical breast examination) should include at least seven 
of the following eleven elements:
     Inspection and palpation of breasts for masses or lumps, 
tenderness, symmetry, or nipple discharge.
     Digital rectal examination including sphincter tone, 
presence of hemorrhoids, and rectal masses. Pelvic examination (with or 
without specimen collection for smears and cultures) including:
     External genitalia (for example, general appearance, hair 
distribution, or lesions).
     Urethral meatus (for example, size, location, lesions, or 
prolapse).
     Urethra (for example, masses, tenderness, or scarring).
     Bladder (for example, fullness, masses, or tenderness).
     Vagina (for example, general appearance, estrogen effect, 
discharge, lesions, pelvic support, cystocele, or rectocele).
     Cervix (for example, general appearance, lesions, or 
discharge).
     Uterus (for example, size, contour, position, mobility, 
tenderness, consistency, descent, or support).
     Adnexa/parametria (for example, masses, tenderness, 
organomegaly, or nodularity).
     Anus and perineum.
    This description is from Documentation Guidelines for Evaluation 
and Management Services, published in May 1997, and was developed by 
the Health Care Financing Administration and the American Medical 
Association. Section 1862(a)(1)(A) of the Act provides that Medicare 
cover only services that are reasonable and necessary for the diagnosis 
or treatment of illness or injury. We believe that a pelvic screening 
procedure should examine

[[Page 59083]]

various anatomical structures to avoid missing detection of as many 
potential disorders as practical. We will be including this description 
in instructions in the Medicare Carriers Manual.
    This coverage allows payment for one pelvic examination for every 
female beneficiary every 3 years but includes the allowance of payment 
once every year for certain women of childbearing age as well as 
certain women at high risk for cervical or vaginal cancer. 
Specifically, section 4102(a) of the BBA 1997 provides for the 
following frequency of coverage limitations:
    As reflected in the law, payment may be made for a screening pelvic 
examination on an annual basis if one of the following occurs:
     The woman is of childbearing age and has had an 
examination indicating the presence of cervical or vaginal cancer or 
other abnormality during any of the preceding 3 years.
     The woman is considered by her physician or other 
practitioner to be at high risk of developing cervical or vaginal 
cancer as we have defined in these regulations.
    We are adding Sec. 410.56 (Screening pelvic examinations) to 
include this new coverage. In Sec. 410.56(a) (Conditions for screening 
pelvic examinations), we are requiring that to be covered by Medicare 
Part B the screening pelvic examination must be performed by a doctor 
of medicine or osteopathy (as defined in section 1861(r)(1) of the 
Act), or by a certified nurse midwife (as defined in section 1861(gg) 
of the Act), or a physician assistant, nurse practitioner, or clinical 
nurse specialist (as defined in section 1861(aa) of the Act) who is 
authorized under State law to perform the examination. We have included 
this requirement to ensure that the screening exam is performed as 
safely and accurately as possible.
    To implement the statutory mandate that requires us to identify in 
regulations the high risk factors for cervical and vaginal cancer, we 
are specifying in Sec. 410.56(b)(2) (More frequent screening based on 
high-risk factors), the following factors that have been recommended to 
us by the National Cancer Institute and the Centers for Disease 
Prevention and Control. While other factors may have been identified 
such as low socioeconomic status, the lack of precise and verifiable 
definitions does not make them amenable to regulation at this time.
1. High Risk Factors for Cervical Cancer
     Early onset of sexual activity (under 16 years of age).
     Multiple sexual partners (five or more in a lifetime).
     History of a sexually transmitted disease (including the 
human immunodeficiency virus (HIV).
     Absence of three negative Pap smears or any Pap smears 
within the previous 7 years.
2. High Risk Factors for Vaginal Cancer
     Prenatal exposure to diethylstilbestrol.
    Based on consultation with representatives of the American College 
of Gynecologists and Obstetricians and others, we have defined a woman 
of childbearing age in Sec. 410.56(b)(3) (More frequent screening for 
women of childbearing age) to mean a woman who is premenopausal, and 
has been determined by her physician or other practitioner, as 
specified in Sec. 410.56(a), to be of childbearing age, based on her 
medical history or other findings.
    This new section also provides for a waiver of the Part B 
deductible requirement that would otherwise be applicable to these 
services.

E. Reinstatement of the Payment for Transportation of EKG Equipment

    As set forth in section 4559 of the BBA 1997, effective for 
services furnished after December 31, 1997 and before January 1, 1999, 
carriers will make separate payments for HCPCS code R0076 
(Transportation of portable EKG to facility or location, per patient) 
based upon payment methods in effect for these services as of December 
31, 1996. EKG transportation payments are made at the carrier-priced 
level that was in effect on December 31, 1996. The procedure codes 
involved are CPT code 93000 (a 12-lead EKG with interpretation and 
report) or CPT code 93005 (a 12-lead EKG, tracing only, without 
interpretation and report). When multiple patients receive services at 
the same site, the transportation payment amount must be prorated among 
all patients seen. These payments may be made only under the following 
circumstances:
     The transportation service is furnished in connection with 
standard EKG procedures furnished by approved suppliers of portable x-
ray services as set forth in section 2070.4.F. of the Medicare Carriers 
Manual.
     The transportation service is furnished in connection with 
standard EKG procedures by an independent diagnostic testing facility 
or an independent physiological laboratory under the conditions set 
forth in section 2070.1.G. of the Medicare Carriers Manual.

F. Waiver of Proposed Rulemaking for Provisions in the Balanced Budget 
Act of 1997

    We ordinarily publish a notice of proposed rulemaking in the 
Federal Register and invite prior public comment on proposed rules. We 
have found good cause that a notice-and-comment procedure can be waived 
for the BBA 1997 provisions discussed above. A complete explanation of 
reasons is given in section VII. of this preamble.

IV. Refinement of Relative Value Units for Calendar Year 1998 and 
Responses to Public Comments on Interim Relative Value Units for 1997

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

    Section IV.B. of this final rule describes the methodology used to 
review the comments received on the 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, 1998.

B. Process for Establishing Work Relative Value Units for the 1998 Fee 
Schedule

    Our November 22, 1996 final rule on the 1997 physician fee schedule 
(61 FR 59490) 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, 1997. We announced 
that we considered the RVUs for the interim codes to be subject to 
public comment under the annual refinement process. In this section, we 
summarize the refinements to the interim work RVUs that have occurred 
since publication of the November 1996 final rule and our establishment 
of the work RVUs for new and revised codes for the 1998 fee schedule.
1. Work Relative Value Unit Refinements of Interim and Related Relative 
Value Units (Includes Table 1--Work Relative Value Unit Refinements of 
1997 Interim and Related Relative Value Units)
    Although the RVUs in the November 1996 final rule were used to 
calculate 1997 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

[[Page 59084]]

approximately five specialty societies on approximately nine CPT codes 
with interim RVUs. Only comments received on codes listed in Addendum C 
of the November 1996 final rule were considered this year.
    Due to the low volume of comments we received for 1997 CPT codes 
with interim RVUs, we adjusted the refinement process we have used in 
previous years. (See the November 22, 1996 final rule on the physician 
fee schedule (61 FR 59536) for a detailed explanation of the refinement 
of CPT codes with interim RVUs.) Instead, we invited one representative 
from each of the five specialty societies from which comments were 
received to attend a discussion of the codes commented on by their 
respective societies. In attendance at this meeting were the following 
representatives:
     A clinician representing each of the specialties most 
identified with the procedures in question. Each specialist was 
nominated by the specialty society that submitted the comments.
     Representatives from the AMA's RUC.
     Carrier medical directors.
     HCFA medical officers.
     HCFA staff.
    The group 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 group 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. Group 
members were encouraged to make comparisons to reference services.
    The specialty society's recommendations were accepted for all nine 
of the CPT codes that were reviewed. We will continue with the regular 
refinement process for future years.

Table 1--Work Relative Value Unit Refinements of 1997 Interim and 
Related Relative Value Units

    Table 1 lists the interim and related codes reviewed during the 
1997 refinement process described in this section. 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.
     1997 Work RVU. The work RVUs that appeared in the November 
1996 rule are shown for each reviewed code.
     Requested Work RVU. This column identifies the work RVUs 
requested by commenters.
     1998 Work RVU. This column contains the final RVUs for 
physician work.
    The new values emerged from analysis of the specialty 
representative's presentation.

                         Table 1.--Work RVU Refinement of 1997 Interim and Related RVUs                         
----------------------------------------------------------------------------------------------------------------
                                                                            1997 work    Requested    1998 work 
  CPT*              MOD                          Description                   RVU        work RVU       RVU    
----------------------------------------------------------------------------------------------------------------
37250..  .........................  Intravascular us.....................         1.51         2.10         2.10
37251..  .........................  Intravascular us.....................         1.15         1.60         1.60
56300..  .........................  Pelvis laparoscopy, dx...............         3.65         5.00         5.00
56305..  .........................  Pelvic laparoscopy, biopsy...........         3.97         5.30         5.30
75945..  26                         Intravascular us.....................         0.29         0.40         0.40
75946..  26                         Intravascular us.....................         0.29         0.40         0.40
95921..  26                         Autonomic nerve function test........         0.45         0.90         0.90
95922..  26                         Autonomic nerve function test........         0.48         0.96         0.96
95923..  26                         Autonomic nerve function test........         0.45         0.90        0.90 
----------------------------------------------------------------------------------------------------------------
* All CPT and descriptors copyright 1997 American Medical Association                                           

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 1998
    a. Methodology (Includes Table 2--American Medical Association 
Specialty Society Relative Value Update Committee and Health Care 
Professionals Advisory Committee Recommendations and HCFA's Decisions 
for New and Revised 1998 CPT Codes). One aspect of establishing work 
RVUs for 1998 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 
our November 26, 1996 final rule (61 FR 59505 through 59506), we 
established a process, based on recommendations received from the AMA's 
Specialty Society Relative Value Update Committee (RUC), for 
establishing interim RVUs for new and revised codes.
    We received work RVU recommendations for approximately 208 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 96 percent of the RUC 
recommendations, proposed work RVUs were accepted or increased, and, 
for approximately 4 percent, work RVUs were decreased.
    We received 11 recommendations from the Health Care Professionals 
Advisory Committee (HCPAC) for new or revised codes for which the RUC 
did not provide a recommendation. For 7 of the HCPAC's recommendations, 
the proposed work RVUs were accepted.

[[Page 59085]]

    There were also 5 CPT codes for which HCFA did not receive a RUC 
recommendation. HCFA established interim work RVUs for 3 of these 
codes.
    Table 2 is a listing of those codes that will be new or revised in 
1998 as well as their associated work RVUs. This table includes the 
following information:
     A ``#'' identifies a new code for 1998.
     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 (``agree''); we established work RVUs that 
are higher than the RUC recommendation (``increase''); or we 
established work RVUs that were less than the RUC recommendation 
(``decrease''). Codes for which we did not accept the RUC 
recommendation are discussed in greater detail following Table 2 in 
section IV.B.2.b. below. An ``(a)'' indicates that no RUC 
recommendation was provided. A discussion follows the table in section 
IV.B.2.b.
     HCFA work RVUs. This column contains the RVUs for 
physician work based on our reviews of the RUC recommendations. The 
RVUs shown for global surgical services have not been adjusted to 
account for the 1997 increases for work RVUs in evaluation and 
management services.
    1998 work RVUs. This column contains the 1998 RVUs for physician 
work. The RVUs shown for global surgical services have been adjusted to 
account for the 1997 increases for work RVUs in evaluation and 
management.
    This table includes only those codes that were reviewed by the full 
RUC or for which we received a recommendation from the HCPAC.

                            Table 2.--AMA RUC and HCPAC Recommendations and HCFA Decisions for New and Revised 1998 CPT Codes                           
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               RUC              HCPAC                                                                   
    CPT* code           MOD            Description       recommendation    recommendation         HCFA decision         HCFA work RVU    1998 work b RVU
--------------------------------------------------------------------------------------------------------------------------------------------------------
11055#...........  .............  Paring, Cutting, and  ................              0.43  Decrease................              0.27              0.27
                                   Trimming of Nails.                                                                                                   
11056#...........  .............  Paring, Cutting, and  ................              0.61  Decrease................              0.39              0.39
                                   Trimming of Nails.                                                                                                   
11057#...........  .............  Paring, Cutting, and  ................              0.79  Decrease................              0.50              0.50
                                   Trimming of Nails.                                                                                                   
11719#...........  .............  Paring, Cutting, and  ................              0.17  Decrease................              0.06              0.06
                                   Trimming of Nails.                                                                                                   
11200............  .............  Destruction of                    0.69  ................  Decrease................              0.67              0.77
                                   lesions.                                                                                                             
11201............  .............  Destruction of                    0.35  ................  Decrease................              0.29              0.29
                                   lesions.                                                                                                             
15756............  .............  Free muscle flap....             33.23  ................  Agree...................             33.23             35.23
17000............  .............  Destruction of                    0.55  ................  Agree...................              0.55              0.60
                                   lesions.                                                                                                             
17003#...........  .............  Destruction of                    0.15  ................  Agree...................              0.15              0.15
                                   lesions.                                                                                                             
17004#...........  .............  Destruction of                    2.65  ................  Agree...................              2.65              2.79
                                   lesions.                                                                                                             
17110............  .............  Destruction of                    0.55  ................  Agree...................              0.55              0.65
                                   lesions.                                                                                                             
17111#...........  .............  Destruction of                    0.82  ................  Agree...................              0.82              0.92
                                   lesions.                                                                                                             
17250............  .............  Destruction of                    0.50  ................  Agree...................              0.50              0.50
                                   lesions.                                                                                                             
19120............  .............  Excision of cyst....              5.35  ................  Agree...................              5.35              5.56
20664#...........  .............  Application of halo.              7.00  ................  Agree...................              7.00              8.06
22818#...........  .............  Kyphectomy..........             30.00  ................  Agree...................             30.00             31.83
22819#...........  .............  Kyphectomy..........             34.50  ................  Agree...................             34.50             36.44
29860#...........  .............  Arthroscopy of hip..              7.75  ................  Agree...................              7.75              8.05
29861#...........  .............  Arthroscopy of hip..              9.00  ................  Agree...................              9.00              9.15
29862#...........  .............  Arthroscopy of hip..              9.50  ................  Agree...................              9.50              9.90
29863#...........  .............  Arthroscopy of hip..              9.50  ................  Agree...................              9.50              9.90
29891#...........  .............  Arthroscopy of ankle              8.00  ................  Agree...................              8.00              8.40
29892#...........  .............  Arthroscopy of ankle              8.60  ................  Agree...................              8.60              9.00
29893#...........  .............  Arthroscopy of ankle  ................              4.92  Agree...................              4.92              5.22
32200............  .............  Percutaneous abscess             13.10  ................  Agree...................             13.10             15.29
                                   drainage.                                                                                                            
32201#...........  .............  Percutaneous abscess              4.00  ................  Agree...................              4.00              4.00
                                   drainage.                                                                                                            
33496#...........  .............  Repair of non-                   25.64  ................  Agree...................             25.64             27.25
                                   structural valve                                                                                                     
                                   dysfunction.                                                                                                         
33530............  .............  Repair of non-                    5.86  ................  Agree...................              5.86              5.86
                                   structural valve                                                                                                     
                                   dysfunction.                                                                                                         
35400#...........  .............  Intraoperative                    3.00  ................  Agree...................              3.00              3.00
                                   Endovascular                                                                                                         
                                   Angioscopy.                                                                                                          
36215............  .............  Coronary Angiography              4.68  ................  Agree...................              4.68              4.68
37195#...........  .............  Thrombolytic therapy              0.00  ................  Agree...................              0.00              0.00
                                   for acute ischemic.                                                                                                  
37250............  .............  Intravascular us....              1.51  ................  Agree...................              1.51              2.10
37251............  .............  Intravascular us....              1.15  ................  Agree...................              1.15              1.60
43116............  .............  Partial                          29.67  ................  Agree...................             29.67             31.22
                                   esophagectomy.                                                                                                       
43496............  .............  Free jejunum                   carrier  ................  Agree...................           carrier           carrier
                                   transfer.                                                                                                            
43635............  .............  Vagotomy............              2.06  ................  Agree...................              2.06              2.06
44625............  .............  Closure of colostomy             12.10  ................  Agree...................             12.10             13.41
44626#...........  .............  Closure of colostomy             21.29  ................  Agree...................             21.29             22.59
44700#...........  .............  Intestinal sling                 13.00  ................  Agree...................             13.00             14.35
                                   procedure.                                                                                                           
44900............  .............  Percutaneous abscess              7.86  ................  Agree...................              7.86              8.82
                                   drainage.                                                                                                            
44901#...........  .............  Percutaneous abscess              3.38  ................  Agree...................              3.38              3.38
                                   drainage.                                                                                                            
45112............  .............  Proctectomy with                 24.02  ................  Agree...................             24.02             25.96
                                   coloanal                                                                                                             
                                   anastomosis.                                                                                                         
45119#...........  .............  Proctectomy with                 23.50  ................  Increase................             24.50             26.21
                                   coloanal                                                                                                             
                                   anastomosis.                                                                                                         
47010............  .............  Percutaneous abscess              8.75  ................  Agree...................              8.75             10.28
                                   drainage.                                                                                                            
47011#...........  .............  Percutaneous abscess              3.70  ................  Agree...................              3.70              3.70
                                   drainage.                                                                                                            
48510............  .............  Percutaneous abscess             11.22  ................  Agree...................             11.22             12.96
                                   drainage.                                                                                                            
48511#...........  .............  Percutaneous abscess              4.00  ................  Agree...................              4.00              4.00
                                   drainage.                                                                                                            
49040............  .............  Percutaneous abscess              8.74  ................  Agree...................              8.74              9.94
                                   drainage.                                                                                                            
49041#...........  .............  Percutaneous abscess              4.00  ................  Agree...................              4.00              4.00
                                   drainage.                                                                                                            
49060............  .............  Percutaneous abscess             10.55  ................  Agree...................             10.55             11.66
                                   drainage.                                                                                                            
49061#...........  .............  Percutaneous abscess              3.70  ................  Agree...................              3.70              3.70
                                   drainage.                                                                                                            
49062#...........  .............  Lymphocele drainage.             10.78  ................  Agree...................             10.78             11.36
49423#...........  .............  Percutaneous abscess              1.46  ................  Agree...................              1.46              1.46
                                   drainage.                                                                                                            

[[Page 59086]]

                                                                                                                                                        
49424#...........  .............  Percutaneous abscess              0.76  ................  Agree...................              0.76              0.76
                                   drainage.                                                                                                            
49560............  .............  Ventral                           9.48  ................  Agree...................              9.48              9.88
                                   herniorgraphy.                                                                                                       
49565............  .............  Ventral                           9.48  ................  Agree...................              9.48              9.88
                                   herniorgraphy.                                                                                                       
49568............  .............  Ventral                           4.89  ................  Agree...................              4.89              4.89
                                   herniorgraphy.                                                                                                       
50020............  .............  Percutaneous abscess             12.41  ................  Agree...................             12.41             14.66
                                   drainage.                                                                                                            
50021#...........  .............  Percutaneous abscess              3.38  ................  Agree...................              3.38              3.38
                                   drainage.                                                                                                            
51840............  .............  Burch procedure.....              9.78  ................  Agree...................              9.78             10.71
52281............  .............  Cystourethroscopy...              2.80  ................  Agree...................              2.80              2.80
52282#...........  .............  Urethral                          6.40  ................  Agree...................              6.40              6.40
                                   endoprosthesis.                                                                                                      
53850#...........  .............  Transurethral                     9.58  ................  Decrease................              9.25              9.45
                                   destruction of                                                                                                       
                                   prostate.                                                                                                            
53852#...........  .............  Transurethral                     9.58  ................  Agree...................              9.58              9.88
                                   destruction of                                                                                                       
                                   prostate.                                                                                                            
56300............  .............  Laparoscopic surgery              5.00  ................  Agree...................              5.00              5.10
56301............  .............  Laparoscopic surgery              5.50  ................  Agree...................              5.50              5.60
56302............  .............  Laparoscopic surgery              5.50  ................  Agree...................              5.50              5.60
56303............  .............  Laparoscopic surgery             10.50  ................  Increase................             10.95             11.79
56304............  .............  Laparoscopic surgery             10.00  ................  Increase................             10.45             11.29
56305............  .............  Laparoscopic surgery              5.30  ................  Agree...................              5.30              5.40
56306............  .............  Laparoscopic surgery              5.60  ................  Agree...................              5.60              5.70
56309............  .............  Laparoscopic surgery             13.79  ................  Agree...................             13.79             14.21
56310#...........  .............  Laparoscopic surgery             13.50  ................  Agree...................             13.50             14.44
56314#...........  .............  Laparoscopic surgery              8.93  ................  Agree...................              8.93              9.48
56318#...........  .............  Laparoscopic surgery             10.63  ................  Agree...................             10.63             10.96
56345#...........  .............  Laparoscopic surgery  ................  ................  (a).....................           carrier           carrier
56346#...........  .............  Laparoscopic surgery              7.18  ................  Agree...................              7.18              7.73
56347#...........  .............  Laparoscopic surgery  ................  ................  (a).....................           carrier           carrier
56348#...........  .............  Laparoscopy with                 20.00  ................  Increase................             21.00             22.04
                                   intestinal                                                                                                           
                                   resection.                                                                                                           
56349#...........  .............  Laparoscopic surgery             17.75  ................  Decrease................             16.47             17.25
56350............  .............  Hysteroscopy........              3.33  ................  Agree...................              3.33              3.33
56351............  .............  Hysteroscopy........              4.75  ................  Agree...................              4.75              4.75
56352............  .............  Hysteroscopy........              6.17  ................  Agree...................              6.17              6.17
56353............  .............  Hysteroscopy........              7.00  ................  Agree...................              7.00              7.00
56354............  .............  Hysteroscopy........             10.00  ................  Agree...................             10.00             10.00
56355............  .............  Hysteroscopy........              5.21  ................  Agree...................              5.21              5.21
56356............  .............  Hysteroscopy........              9.50  ................  Decrease................              6.17              6.17
57308............  .............  Closure of                        9.31  ................  Agree...................              9.31              9.94
                                   rectovaginal                                                                                                         
                                   fistula.                                                                                                             
57531............  .............  Radical                          28.00  ................  Agree...................             28.00             29.60
                                   trachelectomy.                                                                                                       
58152............  .............  Burch procedure.....             14.10  ................  Agree...................             14.10             15.09
58340............  .............  Hysterosonography...              0.88  ................  Agree...................              0.88              0.88
58820............  .............  Percutaneous abscess              3.96  ................  Agree...................              3.96              4.22
                                   drainage.                                                                                                            
58822............  .............  Percutaneous abscess              9.06  ................  Agree...................              9.06             10.13
                                   drainage.                                                                                                            
58823#...........  .............  Percutaneous abscess              3.38  ................  Agree...................              3.38              3.38
                                   drainage.                                                                                                            
59050............  .............  Fetal monitoring....              0.89  ................  Agree...................              0.89              0.89
59051............  .............  Fetal monitoring....              0.74  ................  Agree...................              0.74              0.74
59160............  .............  Curettage,                        2.66  ................  Agree...................              2.66              2.71
                                   postpartum.                                                                                                          
59871#...........  .............  Removal of cerclage               2.13  ................  Agree...................              2.13              2.13
                                   suture.                                                                                                              
61793............  .............  Stereotactic                     16.70  ................  Agree...................             16.70             17.24
                                   radiosurgery.                                                                                                        
67027#...........  .............  Ganciclovir implant.             10.35  ................  Agree...................             10.35             10.85
70553............  26             MI, brain...........              2.36  ................  Agree...................              2.36              2.36
74283............  26             Therapeutic Enema...              2.02  ................  Agree...................              2.02              2.02
74740............  26             Hysterosonography...              0.38  ................  Agree...................              0.38              0.38
75989............  26             Percutaneous Abscess              1.19  ................  Agree...................              1.19              1.19
                                   drainage.                                                                                                            
76070............  26             Bone density studies              0.25  ................  Agree...................              0.25              0.25
76075............  26             Bone density studies              0.30  ................  Agree...................              0.30              0.30
76076#...........  26             Bone density studies              0.22  ................  Agree...................              0.22              0.22
76078#...........  26             Bone density studies              0.20  ................  Agree...................              0.20              0.20
76080............  26             Percutaneous Abscess              0.54  ................  Agree...................              0.54              0.54
                                   drainage.                                                                                                            
76095............  26             Stereotactic breast               1.59  ................  Agree...................              1.59              1.59
                                   biopsy.                                                                                                              
76375............  26             Medical holography..              0.16  ................  Agree...................              0.16              0.16
76390#...........  26             Magnetic resonance                1.40  ................  Agree...................              1.40              1.40
                                   spectroscopy.                                                                                                        
76815............  26             Echography, pregant               0.65  ................  Agree...................              0.65              0.65
                                   uterus.                                                                                                              
76830............  26             Hysterosonography...              0.69  ................  Agree...................              0.69              0.69
76831#...........  26             Hysterosonography...              0.72  ................  Agree...................              0.72              0.72
76885#...........  26             Echography of infant              0.74  ................  Agree...................              0.74              0.74
                                   hip.                                                                                                                 
76886#...........  26             Echography of infant              0.62  ................  Agree...................              0.62              0.62
                                   hip.                                                                                                                 
77295............  26             Therapeutic                       4.57  ................  Agree...................              4.57              4.57
                                   radiology                                                                                                            
                                   simulation-aided.                                                                                                    
78350............  26             Bone density studies              0.22  ................  Agree...................              0.22              0.22
78351............  .............  Bone density studies              0.30  ................  Agree...................              0.30              0.30
78459............  26             PET myocardial                    1.88  ................  Agree...................              1.88              1.88
                                   perfusion imaging.                                                                                                   
78491#...........  26             PET myocardial                    1.50  ................  Agree...................              1.50              1.50
                                   perfusion imaging.                                                                                                   
78492#...........  26             PET myocardial                    1.87  ................  Agree...................              1.87              1.87
                                   perfusion imaging.                                                                                                   
78707............  26             Renal nuclear                     0.96  ................  Agree...................              0.96              0.96
                                   medicine.                                                                                                            
78708#...........  26             Renal nuclear                     1.21  ................  Agree...................              1.21              1.21
                                   medicine.                                                                                                            
78709#...........  26             Renal nuclear                     1.41  ................  Agree...................              1.41              1.41
                                   medicine.                                                                                                            
78710............  26             Kidney imaging......              0.66  ................  Agree...................              0.66              0.66
88108............  26             Cervical or vaginal               0.56  ................  Agree...................              0.56              0.56
                                   cytopathology.                                                                                                       
88141#...........  .............  Cervical or vaginal               0.42  ................  Agree...................              0.42              0.42
                                   cytopathology.                                                                                                       
90801............  .............  Psychotherapy.......              2.80  ................  Agree...................              2.80              2.80
90802#...........  .............  Psychotherapy.......              3.01  ................  Agree...................              3.01              3.01
90804#...........  .............  Psychotherapy.......              1.11  ................  Agree...................              1.11              1.11

[[Page 59087]]

                                                                                                                                                        
90805#...........  .............  Psychotherapy.......              1.47  ................  Agree...................              1.47              1.47
90806#...........  .............  Psychotherapy.......              1.72  ................  Agree...................              1.72              1.72
90807#...........  .............  Psychotherapy.......              2.00  ................  Agree...................              2.00              2.00
90808#...........  .............  Psychotherapy.......              2.76  ................  Agree...................              2.76              2.76
90809#...........  .............  Psychotherapy.......              3.15  ................  Agree...................              3.15              3.15
90810#...........  .............  Psychotherapy.......              1.19  ................  Agree...................              1.19              1.19
90811#...........  .............  Psychotherapy.......              1.58  ................  Agree...................              1.58              1.58
90812#...........  .............  Psychotherapy.......              1.86  ................  Agree...................              1.86              1.86
90813#...........  .............  Psychotherapy.......              2.15  ................  Agree...................              2.15              2.15
90814#...........  .............  Psychotherapy.......              2.97  ................  Agree...................              2.97              2.97
90815#...........  .............  Psychotherapy.......              3.39  ................  Agree...................              3.39              3.39
90816#...........  .............  Psychotherapy.......              1.24  ................  Agree...................              1.24              1.24
90817#...........  .............  Psychotherapy.......              1.65  ................  Agree...................              1.65              1.65
90818#...........  .............  Psychotherapy.......              1.94  ................  Agree...................              1.94              1.94
90819#...........  .............  Psychotherapy.......              2.24  ................  Agree...................              2.24              2.24
90821#...........  .............  Psychotherapy.......              3.09  ................  Agree...................              3.09              3.09
90822#...........  .............  Psychotherapy.......              3.53  ................  Agree...................              3.53              3.53
90823#...........  .............  Psychotherapy.......              1.33  ................  Agree...................              1.33              1.33
90824#...........  .............  Psychotherapy.......              1.77  ................  Agree...................              1.77              1.77
90826#...........  .............  Psychotherapy.......              2.08  ................  Agree...................              2.08              2.08
90827#...........  .............  Psychotherapy.......              2.41  ................  Agree...................              2.41              2.41
90828#...........  .............  Psychotherapy.......              3.32  ................  Agree...................              3.32              3.32
90829#...........  .............  Psychotherapy.......              3.80  ................  Agree...................              3.80              3.80
90845............  .............  Psychotherapy.......              1.79  ................  Agree...................              1.79              1.79
90846............  .............  Psychotherapy.......              1.83  ................  Agree...................              1.83              1.83
90847............  .............  Psychotherapy.......              2.21  ................  Agree...................              2.21              2.21
90849............  .............  Psychotherapy.......              0.59  ................  Agree...................              0.59              0.59
90853............  .............  Psychotherapy.......              0.59  ................  Agree...................              0.59              0.59
90857............  .............  Psychotherapy.......              0.63  ................  Agree...................              0.63              0.63
90865#...........  .............  Psychotherapy.......              2.84  ................  Agree...................              2.84              2.84
90875............  .............  Psychotherapy.......  ................              1.20  Agree...................              1.20              1.20
90876............  .............  Psychotherapy.......  ................              1.90  Agree...................              1.90              1.90
90880............  .............  Psychotherapy.......              2.19  ................  Agree...................              2.19              2.19
90885#...........  .............  Psychotherapy.......              0.97  ................  Agree...................              0.97              0.97
90911............  .............  Biofeedback training              0.89  ................  Agree...................              0.89              0.89
91010............  .............  Esophageal motility               1.25  ................  Agree...................              1.25              1.25
                                   studies.                                                                                                             
91020............  .............  Esophageal motility               1.44  ................  Agree...................              1.44              1.44
                                   studies.                                                                                                             
92978............  26             Intravascular us....              1.80  ................  Agree...................              1.80              1.80
92979............  26             Intravascular us....              1.44  ................  Agree...................              1.44              1.44
92992............  .............  Atrial septectomy of           carrier  ................  Agree...................           carrier           carrier
                                   septostomy.                                                                                                          
92997#...........  .............  Pulmonary artery                 12.00  ................  Agree...................             12.00             12.00
                                   angioplasty.                                                                                                         
92998#...........  .............  Pulmonary artery                  6.00  ................  Agree...................              6.00              6.00
                                   angioplasty.                                                                                                         
93320............  .............  Doppler echo........              0.38  ................  Agree...................              0.38              0.38
93325............  .............  Doppler echo........              0.07  ................  Agree...................              0.07              0.07
93508#...........  26             Coronary angiography              4.10  ................  Agree...................              4.10              4.10
93530#...........  26             Pediatric cardiac                 4.23  ................  Agree...................              4.23              4.23
                                   catheterization.                                                                                                     
93531#...........  26             Pediatric cardiac                 8.35  ................  Agree...................              8.35              8.35
                                   catheterization.                                                                                                     
93532#...........  26             Pediatric cardiac                10.00  ................  Agree...................             10.00             10.00
                                   catheterization.                                                                                                     
93533#...........  26             Pediatric cardiac                 6.70  ................  Agree...................              6.70              6.70
                                   catheterization.                                                                                                     
94010............  26             Spirometry..........              0.17  ................  Agree...................              0.17              0.17
94070............  26             Pulmonary procedures              0.60  ................  Agree...................              0.60              0.60
95805............  26             Sleep studies.......              1.88  ................  Agree...................              1.88              1.88
95806............  26             Sleep studies.......              1.85  ................  Decrease................              1.66              1.66
95807............  26             Sleep studies.......              1.66  ................  Agree...................              1.66              1.66
95811#...........  26             Sleep studies.......              3.80  ................  Agree...................              3.80              3.80
95860............  26             Needle EMG..........              0.96  ................  Agree...................              0.96              0.96
95861............  26             Needle EMG..........              1.54  ................  Agree...................              1.54              1.54
95863............  26             Needle EMG..........              1.87  ................  Agree...................              1.87              1.87
95864............  26             Needle EMG..........              1.99  ................  Agree...................              1.99              1.99
95869............  26             Needle EMG..........              0.37  ................  Agree...................              0.37              0.37
95870#...........  26             Needle EMG..........  ................  ................  (a).....................              0.37              0.37
96902#...........  .............  Trichogram..........              0.41  ................  Agree...................              0.41              0.41
97001#...........  .............  Occupational and      ................              1.20  Agree...................              1.20              1.20
                                   Physical Therapy.                                                                                                    
97002#...........  .............  Occupational and      ................              0.60  Agree...................              0.60              0.60
                                   Physical Therapy.                                                                                                    
97003#...........  .............  Occupational and      ................              1.20  Agree...................              1.20              1.20
                                   Physical Therapy.                                                                                                    
97004#...........  .............  Occupational and      ................              0.60  Agree...................              0.60              0.60
                                   Physical Therapy.                                                                                                    
97780#...........  .............  Acupuncture.........  ................  ................  (a).....................              0.00              0.00
97781#...........  .............  Acupuncture.........  ................  ................  (a).....................              0.00              0.00
99141#...........  .............  Conscious sedation..              0.80  ................  Agree...................              0.80              0.80
99142#...........  .............  Conscious sedation..              0.60  ................  Agree...................              0.60              0.60
99217............  .............  Observation same day              1.28  ................  Agree...................              1.28              1.28
                                   discharge.                                                                                                           
99234#...........  .............  Observation same day              2.56  ................  Agree...................              2.56              2.56
                                   discharge.                                                                                                           
99235#...........  .............  Observation same day              3.42  ................  Agree...................              3.42              3.42
                                   discharge.                                                                                                           
99236#...........  .............  Observation same day              4.27  ................  Agree...................              4.27              4.27
                                   discharge.                                                                                                           
99315#...........  .............  Nursing facility                  1.20  ................  Decrease................              1.13              1.13
                                   discharge.                                                                                                           
99316#...........  .............  Nursing facility                  1.60  ................  Decrease................              1.50              1.50
                                   discharge.                                                                                                           
99341............  .............  Home care visits....              0.89  ................  Increase................              1.01              1.01
99342............  .............  Home care visits....              1.33  ................  Increase................              1.52              1.52
99343............  .............  Home care visits....              1.99  ................  Increase................              2.27              2.27

[[Page 59088]]

                                                                                                                                                        
99344#...........  .............  Home care visits....              2.66  ................  Increase................              3.03              3.03
99345#...........  .............  Home care visits....              3.32  ................  Increase................              3.79              3.79
99347............  .............  Home care visits....              0.66  ................  Increase................              0.76              0.76
99348............  .............  Home care visits....              1.11  ................  Increase................              1.26              1.26
99349............  .............  Home care visits....              1.77  ................  Increase................              2.02              2.02
99350#...........  .............  Home care visits....              2.66  ................  Increase................              3.03              3.03
99374#...........  .............  Care plan oversight.              1.10  ................  Agree...................              1.10              1.10
99375............  .............  Care plan oversight.              1.73  ................  Agree...................              1.73              1.73
99377#...........  .............  Care plan oversight.              1.10  ................  Agree...................              1.10              1.10
99378#...........  .............  Care plan oversight.              1.73  ................  Agree...................              1.73              1.73
99379#...........  .............  Care plan oversight.              1.10  ................  Agree...................              1.10              1.10
99380#...........  .............  Care plan oversight.              1.73  ................  Agree...................              1.73              1.73
99436#...........  .............  Attendance at                     1.50  ................  Agree...................              1.50              1.50
                                   delivery.                                                                                                            
--------------------------------------------------------------------------------------------------------------------------------------------------------
a No RUC recommendation provided                                                                                                                        
b Work RVU changes due to global surgery evaluation and management increases.                                                                           
# New Codes                                                                                                                                             
* All numeric HCPCS CPT Copyright 1997 American Medical Association                                                                                     

    b. 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 codes 11055 (Paring or cutting of benign hyperkeratotic lesion 
(eg, corn or callus), single lesion), 11056 (two to four lesions), 
11057 (more than four lesions), and 11719 (Trimming of nails)).
    CPT 1998 will include three new codes for paring or cutting of 
benign hyperkeratotic lesion(s) and one new code for trimming of nails. 
These new CPT codes will replace CPT codes 11050 through 11052 (Paring 
or curettement of benign hyperkeratotic skin lesion(s)) and HCFA Common 
Procedure Coding System (HCPCS) code M0101 (Cutting or removal of 
corns, calluses and/or trimming of nails, application of skin creams 
and other hygienic and preventive maintenance care).
    We agreed with the work RVU relationship established by the RUC 
HCPAC Review Board for these four codes. However, we have not accepted 
the actual work RVUs recommended because the total number of RVUs 
associated with the new codes would exceed the total number of RVUs 
associated with code M0101. We believe the expectation of the RUC HCPAC 
Review Board was that the RVU recommendations would achieve work 
neutrality within the family of codes. However, some of the services 
previously reported with M0101 will now be reported with codes used to 
report the destruction of skin lesions. These codes, for example, CPT 
code 17000, have higher work RVUs than M0101. Thus, the result of the 
coding changes and the recommended work RVUs would be an increase in 
the total number of RVUs for these services. Consequently, we revised 
the work RVUs recommended by the RUC HCPC Review Board in order to 
achieve work neutrality within this family of codes. That is, the work 
RVUs have been adjusted so that the sum of the new work RVUs (weighted 
by projected frequency of use) for this family of codes will be the 
same as the sum of the current work RVUs (weighted by their current 
frequency of use).

------------------------------------------------------------------------
                                                                    Work
          CPT code                         Descriptor               RVUs
------------------------------------------------------------------------
11055.......................  Paring or cutting of benign           0.27
                               hyperkeratotic lesion (single).          
11056.......................  Two to four lesions................   0.39
11057.......................  More than four lesions.............   0.50
11719.......................  Trimming of nails..................   0.06
------------------------------------------------------------------------

    CPT codes 11200 (Removal of skin tags, multiple fibrocutaneous 
tags, any area; up to and including 15 lesions) and 11201 (each 
additional ten lesions).
    The RUC recommended 0.69 work RVUs for CPT code 11200 and 0.35 work 
RVUs for CPT code 11201. These codes encompass services that were 
previously reported using CPT codes 11200, 11201, 17200, and 17201. 
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 and revised codes in order to arrive at weighted average 
values for the revised codes in a budget neutral fashion. We have used 
this method to arrive at the work RVUs for revised CPT codes 11200 and 
11201. We are establishing 0.67 work RVUs for CPT code 11200, which is 
a weighted average of CPT codes 17200 and 11200. We are establishing 
0.29 work RVUs for CPT code 11201, which is the weighted average of CPT 
codes 17201 and 11201.
    CPT code 45119  (Proctectomy, combined abdominoperineal pull 
through procedure (eg, colo-anal anastomosis) with creation of colonic 
reservoir (eg, J-pouch), with or without proximal diverting ostomy).
    CPT 1998 will include a new code for proctectomy with colo-anal 
anastomosis. The RUC recommended 23.50 work RVUs for CPT code 45119. 
Upon review of these values, we concluded that CPT code 45119 was 
undervalued. CPT code 45119 is nearly an identical procedure to CPT 
code 45112 with the exception of the creation of the colonic reservoir 
included in CPT code 45119. We agree with the current work value for 
CPT code 45112 (24.02 work RVUs). CPT code 45119 is a more extensive 
procedure and should be valued higher than CPT code 45112. We believe 
CPT code 45119 is undervalued, and we are increasing the RUC-
recommended work RVUs from 23.50 work RVUs to 24.50 work RVUs for the 
1998 physician fee schedule.
    CPT code 53850  (Transurethral destruction of prostate tissue; by 
microwave therapy) and 53852 (Transurethral destruction of prostate 
tissue; by radiofrequency thermotherapy).
    CPT 1998 will include two new codes for the transurethral 
destruction of prostate tissue. We agree with the RUC value for CPT 
code 53852 (the RUC recommended 9.58 work RVUs) but not with the work 
value assigned to CPT code 53850. The RUC recommendations would make 
the work values for these two codes identical. While both procedures 
require skillful technique, we believe the actual physician work 
involved for microwave therapy (CPT code 53850) is less than that of 
radiofrequency thermotherapy (CPT

[[Page 59089]]

code 53852). Radiofrequency thermotherapy requires the physician to 
retract and reposition an electrode numerous times in order to destroy 
selected prostate tissue. Microwave therapy on the other hand does not 
require the repositioning of an electrode throughout the procedure. We 
are decreasing the RUC recommendation of 9.58 work RVUs to 9.25 interim 
work RVUs for CPT code 53850.
    CPT codes 56300 through 56349  (Laparoscopic surgery) and CPT code 
56356 (Hysteroscopy).
    The RUC submitted recommendations to us during the 5-year review of 
the resource-based relative value scale for increases in the work RVUs 
for CPT code 56300 (Laparoscopy (peritoneoscopy), diagnostic; (separate 
procedure)) and CPT code 56305 (with biopsy (single or multiple)). At 
that time, we did not adopt those recommendations because we believed 
they would create rank order anomalies within the laparoscopy and 
hysteroscopy family of codes. Subsequently, at the request of HCFA, the 
entire family of codes was reviewed by the RUC. Following is a 
discussion of all of the codes that were affected by this review. The 
discussion is in order by CPT code. In some instances, global periods 
or work RVUs were changed in order to address inconsistencies within 
this family of codes. We believe additional review of the global period 
may be warranted and invite comment on this issue.
    CPT codes 56300  (Laparoscopy, diagnostic; (separate procedure)) 
and 56305 (with biopsy (single or multiple)).
    The RUC recommended 5.00 work RVUs for CPT code 56300 and 5.50 work 
RVUs for CPT code 56305. We agree with these work RVUs but will be 
changing the global period of both of these codes to 010 days.
    CPT code 56304  Laparoscopy, surgical; with fulguration of oviducts 
(with or without transection), with lysis of adhesions).
    The RUC recommended 10.00 work RVUs for this CPT code. We generally 
agree with the rank order of this recommendation but are increasing it 
to 10.45 work RVUs. We are increasing this recommendation because we 
added a level 2 office visit to the RUC recommendation (0.45 RVUs) to 
account for changing the global period from 010 to 090 days. 
Additionally, we will be discussing a change in the descriptor 
associated with CPT code 56304 with the CPT Editorial Panel. We will be 
asking the CPT Editorial Panel to revised the code descriptor to 
specify that it includes an extensive lysis of adhesions. A limited 
lysis of adhesions is included in CPT codes 56300 and 56305 and is not 
paid separately. CPT code 56304 should only be used for extensive lysis 
of adhesions.
    CPT code 56303  (Laparoscopy, surgical; with fulguration of 
oviducts (with or without transection); with fulguration or excision of 
lesions of the ovary, pelvic viscera, or peritoneal surface by any 
method).
    The RUC recommended 10.50 work RVUs to CPT code 56303. We changed 
this CPT code from a 010 day global period to a 090 day global period. 
Due to this increase in the global period, we are adding a level 2 
office visit to the RUC recommendation. The resulting work RVUs for CPT 
code 56303 are 10.95.
    CPT code 56345  (Laparoscopy, surgical; splenectomy) and CPT code 
56347 (Laparoscopy, surgical; jejunostomy (eg, for decompression or 
feeding)).
    We did not receive a RUC recommendation for CPT codes 56345 and 
56347. We decided that we will make these as carrier-priced codes until 
we receive recommended RVUs from the RUC. Therefore, no RVUs are shown 
for these codes.
    CPT code 56348  (Laparoscopy with intestinal resection).
    The RUC recommended 20.00 work RVUs for CPT code 56348. We believe 
that the work involved with this procedure is comparable to that of CPT 
code 44145 (Partial removal of colon), which is valued at 21.29 work 
RVUs. We decided to value CPT code 56348 at the median value extracted 
from a RUC survey issued to colorectal surgeons. For the 1998 physician 
fee schedule, we are assigning 21.00 work RVUs to CPT code 56348.
    CPT code 56349  (Laparoscopy, surgical, esophagogastric fundoplasty 
(eg, Nissen, Belsey IV, Hill, Toupet procedures)).
    The RUC stated that the work represented by CPT code 56349 is more 
difficult than that in its corresponding open procedure (CPT code 43324 
valued at 15.18 work RVUs). We do not agree that this procedure has 
more work involved than either a lobectomy (CPT code 32540 valued at 
13.31 work RVUs) or colon resection (CPT code 44140 valued at 16.97 
work RVUs). We are reducing the RUC recommendation of 17.75 work RVUs 
to 16.47 work RVUs for the 1998 physician fee schedule.
    CPT code 56356  (Hysteroscopy, ablation).
    The RUC recommended 9.50 work RVUs for CPT code 56356. Upon 
comparison of CPT code 56356 to other codes within this family, we 
decided to reduce the work RVUs to 6.17. This decision was based upon a 
comparison of CPT code 56356 to CPT code 56352 (Hysteroscopy, surgical; 
with sampling (biopsy) of endometrium and/or polypectomy, with or 
without D&C, with lysis of intrauterine adhesions (any method)) which 
is valued at 6.17 work RVUs. These codes had identical times and 
intensities identified in the survey of the clinical vignettes supplied 
to the RUC. Therefore, we decided to reduce the work RVU of CPT code 
56356 to 6.17 work RVUs for the 1998 physician fee schedule.
    CPT codes 59150  (Laparoscopic treatment of ectopic pregnancy; 
without salpingectomy and/or oophorectomy) and 59151 (Laparoscopic 
treatment of ectopic pregnancy; with salpingectomy and/or 
oophorectomy).
    The RUC stated that the survey respondents substantially 
underestimated the number of post-procedure office visits associated 
with these procedures. We agree with the RUC and are increasing the 
work RVUs for both of these codes. We are assigning 11.20 work RVUs to 
CPT code 59150, and 11.10 work RVUs to CPT code 59151 for the 1998 
physician fee schedule.
    CPT code 95806  (Sleep study, simultaneous recording of 
ventilation, respiratory effort, ECG or heart rate, and oxygen 
saturation, unattended by a technologist).
    CPT 1998 will include a new code for an unattended sleep study. 
Currently, CPT code 95807 (1.66 work RVUs) is used for a sleep study 
that is attended by a technologist. The RUC recommended 1.85 work RVUs 
for CPT code 95806. We do not agree that there is more work involved in 
an unattended sleep study as opposed to an attended sleep study. We are 
assigning 1.66 interim work RVUs to CPT code 95806, which will make the 
work RVUs identical to those of CPT code 95807.
    CPT codes 99315  (Nursing facility discharge day management; 30 
minutes or less) and 99316 (Nursing facility discharge day management; 
more than 30 minutes).
    CPT 1998 will include two new codes for nursing facility discharge 
day management. The RUC recommended 1.20 work RVUs for CPT code 99315 
and 1.60 work RVUs for CPT code 99316. Upon review of these values, we 
found that the projected utilization of these new nursing facility 
discharge codes causes a significant work neutrality problem within the 
family of nursing facility CPT codes. While the codes are new, the work 
is already reflected within the current codes. In order to maintain the 
same total pool of work RVUs within this family, we are

[[Page 59090]]

reducing the two new CPT codes (that is, CPT codes 99315 and 99316), as 
well as six existing codes within the nursing facility family of codes 
(CPT codes 99301, 99302, 99303, 99311, 99312, and 99313), by 6.0 
percent.

------------------------------------------------------------------------
                                                                    Work
          CPT code                         Descriptor               RVUs
------------------------------------------------------------------------
99301.......................  Comprehensive nursing facility        1.20
                               assessment.                              
99302.......................  Comprehensive nursing facility        1.61
                               assessment.                              
99303.......................  Comprehensive nursing facility        2.01
                               assessment.                              
99311.......................  Subsequent nursing facility care...   0.60
99312.......................  Subsequent nursing facility care...   1.00
99313.......................  Subsequent nursing facility care...   1.42
99315.......................  Nursing facility discharge day        1.13
                               management; 30 minutes or less.          
99316.......................  Nursing facility discharge day        1.50
                               management; more than 30 minutes.        
------------------------------------------------------------------------

    CPT codes 99341 through 99345  (Home care visits; new patient) and 
99347 through 99350 (Home care visits; established patient).
    The RUC-recommended RVUs for the home care visit codes were 
established through comparisons to CPT's current office visit codes. 
Although we agree with the use of the office visit codes as key 
reference services, we believe that the RUC underestimated the pre-, 
intra-, and post-service intensities associated with the home visit 
codes. We note that the intensity values of the survey respondents were 
higher for the home visit codes than the reference codes for office 
visits. We increased the RUC recommendations by applying a uniform 
intensity factor increase of 10 percent to the pre-, intra-, and post-
service times of the office visits codes. These increased intensities 
were then multiplied by the typical times specified in the new and 
revised CPT codes for the home visits.

------------------------------------------------------------------------
                                                                    Work
          CPT code                         Descriptor               RVUs
------------------------------------------------------------------------
99341.......................  Home services; new patient.........   1.01
99342.......................  Home services; new patient.........   1.52
99343.......................  Home services; new patient.........   2.27
99344.......................  Home services; new patient.........   3.03
99345.......................  Home services; new patient.........   3.79
99347.......................  Home services; established patient.    .76
99348.......................  Home services; established patient.   1.26
99349.......................  Home services; established patient.   2.02
99350.......................  Home services; established patient.   3.03
------------------------------------------------------------------------

C. Other Changes to the 1998 Physician Fee Schedule and Clarification 
of CPT Definitions

    For the 1998 physician fee schedule, we are establishing or 
revising several alpha-numeric HCPCS codes for the reporting of certain 
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. 
Additionally, included in this section are some clarifications of 
proper usages of some new or revised codes.
    HCPCS codes G0062  (peripheral bone mineral density) and G0063 
(central bone density).
    Effective January 1, 1998, HCPCS codes G0062, G0062-26, G0062-TC, 
G0063, G0063-26, and G0063-TC have been deleted. Use the appropriate 
code from the 70000 section of the CPT to bill for bone mineral density 
studies.
    CPT code 35400  (Intraoperative endovascular angioscopy non-
coronary vessels or grafts).
    Although we agree with the recommended RUC work RVUs for this CPT 
code, some clarification of proper usage is needed. When billing CPT 
code 35400, units can only equal 1.00 because the code descriptor 
specifies vessels or grafts. The RVUs assigned are based on an 
assumption that angioscopy may be performed on multiple vessels.
    CPT codes 44625 and 44626 (Closure of colostomy).
    CPT codes 44625 and 44626 should not be billed with CPT code 44139, 
which is used to report the immobilization (take down) of the splenic 
flexure. By CPT definition, code 44139 can be used only in conjunction 
with the partial colectomy codes 44140 through 44147. We will be 
establishing a national claims edit to ensure that neither of these two 
codes are billed with CPT code 44139.
    CPT codes 99217 and 99234 through 99236  (Observation same day 
discharge).
    We will be consulting with the CPT Editorial Panel to clarify that 
the use of these codes should be restricted to observation care 
services of at least 12 hours duration.
    CPT code 49021  (Percutaneous abscess drainage).
    Based on the recommendation of the RUC, we are changing the global 
period of CPT code 49021 from 010 days to 000 days. Post-operative care 
during the 90 day period following the procedure is not typically 
provided for this procedure.
    CPT codes 95860 through 95870  (Needle EMGs).
    Although we have accepted the RUC recommendations for this family 
of codes, we believe some clarification on the proper use of these 
codes would be beneficial.
    CPT codes 95860, 95861, 95863, and 95864 (Needle electromyogram of 
1, 2, 3, or 4 limbs with or without paraspinals (cannot bill 
paraspinals separately--unless studying paraspinals between T3-T11)).
    To bill these codes, extremity muscles innervated by three nerves 
(for example, radial, ulnar, median, tibial, peroneal, femoral, not sub 
branches) or four spinal levels must be evaluated, with a minimum of 
five muscles studied.
    CPT code 95869  (Needle electromyography, thoracic paraspinals).
    This CPT code should be used when exclusively studying thoracic 
paraspinals. One unit can be billed, despite the number of levels 
studied or whether unilateral or bilateral. This cannot be billed with 
CPT codes 95860, 95861, 95863, or 95864 if only T1 and/or T2 are 
studied when an upper extremity was also studied.
    CPT code 95870  (Needle electromyography, limited study).
    This CPT code can be billed at one unit per extremity. Muscles on 
the thorax or abdomen (unilateral or bilateral). One unit may be billed 
for studying cervical or lumbar paraspinal muscles (unilateral or 
bilateral), regardless of the number of level tested. This code should 
not be billed when the paraspinal muscles corresponding to an extremity 
are tested and when the extremity codes 95860, 95861, 95863, or 95864 
are also billed.

PET Myocardial Perfusion Imaging (HCPCS Codes G0030 Through G0047)

    When the PET myocardial perfusion imaging tests were originally 
valued, they were considered analogous to the SPECT codes. In 
consultation with the RUC, we have decided to raise the values of the 
PET procedures. Unlike the large field of view of SPECT scanners, PET 
scanners have a much smaller field. In addition, due to the short half-
life of the Rb-82 tracer, physician involvement in patient positioning 
is critical when using the PET scanner. For these reasons, we are 
raising the single PET myocardial perfusion image to 1.50 work RVUs and 
the multiple PET myocardial perfusion image to 1.87 work RVUs.

Cervical or Vaginal Cancer Screening; Pelvic and Clinical Breast 
Examination (HCPCS Code G0101)

    The law provides for coverage and payment of screening pelvic and 
clinical

[[Page 59091]]

breast examinations effective January 1, 1998. We decided that this 
service is comparable to a level 2 evaluation and management new 
patient office visit.

------------------------------------------------------------------------
                                                  Practice   Malpractice
              HCPCS code                 Work     Expense      Expense  
                                         RVUs       RVUs         RVUs   
------------------------------------------------------------------------
G0101.................................   0.45         0.28         0.02 
------------------------------------------------------------------------

Colorectal Cancer Screening (HCPCS Codes G0104 Through G0107)

    Section 4104 of the BBA 1997 provides for Medicare coverage of 
colorectal cancer screening tests effective for services provided on or 
after January 1, 1998. The law provides for coverage and payment for 
screening fecal-occult blood tests, screening flexible sigmoidoscopy, 
screening colonoscopy, and other such tests determined to be 
appropriate by the Secretary. We are setting payment amounts for 
screening sigmoidoscopy, screening colonoscopy, barium enema, and 
screening fecal-occult blood tests, as follows:

Flexible Sigmoidoscopy (HCPCS Code G0104)

    The law provides that payment for screening flexible 
sigmoidoscopies be made at rates consistent with payment for similar or 
related services under the physician fee schedule, not to exceed the 
rates for a diagnostic flexible sigmoidoscopy (CPT 45330). We have 
created a new code-- HCPCS code G0104 (Colorectal cancer screening; 
flexible sigmoidoscopy)--to be used for screening flexible 
sigmoidoscopy. We believe that the work is the same whether the 
procedure is a screening or a diagnostic sigmoidoscopy and are 
therefore assigning the same RVUs to HCPCS code G0104 as those assigned 
to CPT code 45330 in Addendum B.

Screening Colonoscopy (HCPCS Code G0105)

    The law provides that payment for screening colonoscopies be paid 
at rates consistent with payment for similar or related services under 
the physician fee schedule, not to exceed the rates for a diagnostic 
colonoscopy (CPT 45378). We have created a new code-- HCPCS code G0105 
(Colorectal cancer screening; colonoscopy on individual at high risk)--
to be used for screening colonoscopy. We believe that the work is the 
same whether the procedure is a screening or a diagnostic colonoscopy, 
and we are therefore assigning the same RVUs to HCPCS code G0105 as 
those assigned to CPT code 45378 in Addendum B.

Barium Enema (HCPCS Code G0106)

    The law provides that payment for colorectal cancer screening-
barium enema be paid at rates consistent with payment for similar or 
related services under the physician fee schedule. We believe that the 
work is analogous to CPT code 74280 (Contrast x-ray exam of the colon), 
and we are therefore assigning the same RVUs to HCPCS code G0106 as 
those assigned to CPT code 74280 in Addendum B.

Fecal-Occult Blood Tests (HCPCS Code G0107)

    The law provides that screening fecal-occult blood tests be paid at 
the same rate as diagnostic fecal-occult blood tests (CPT code 82270) 
paid under the clinical laboratory fee schedule. We have created a new 
code-- HCPCS code G0107 (Colorectal cancer screening; fecal-occult 
blood test, 1-3 simultaneous determinations)--to be used for screening 
fecal-occult blood tests. This code will be carrier-priced at the 
payment amount that the carrier pays for CPT code 82270 under the 
clinical laboratory fee schedule.

------------------------------------------------------------------------
                                                  Practice   Malpractice
              HCPCS code                 Work     expense      expense  
                                         RVUs       RVUs         RVUs   
------------------------------------------------------------------------
G0104.................................   0.96         1.23         0.12 
G0105.................................   3.70         4.13         0.39 
G0106.................................   0.99         2.58         0.21 
G0107.................................                                  
(2) Lab Fee Schedule                                                    
------------------------------------------------------------------------

National Emphysema Treatment Trials (NETT) (CPT Codes G0110 Through 
G0116)

    The following codes have been added to the physician fee schedule 
for the use of physicians participating in the NETT study. The National 
Emphysema Treatment Trials (NETT) are co-sponsored by HCFA and the 
National Heart, Lung, and Blood Institute with the Johns Hopkins 
University as the coordinating center for the study. The study is to 
last 7 years starting August 1, 1997. Since the use of these codes will 
be limited to some 18 clinical centers and physicians associated with 
these centers, either directly, as in furnishing services in the 
centers' outpatient departments or in rural areas where some of the 
participating beneficiaries live, these codes will be listed as 
restricted and can only be billed by those participating in the NETT 
study.

------------------------------------------------------------------------
                                                 Practice               
    HCPCS code        Descriptor     Work RVUs    expense    Malpractice
                                                   RVUs     expense RVUs
------------------------------------------------------------------------
G0110............  NETT Pulm              0.90        0.26          0.04
                    Rehab;                                              
                    education/                                          
                    skills                                              
                    training,                                           
                    individual.                                         
G0111............  NETT Pulm              0.27        0.20          0.02
                    Rehab;                                              
                    education/                                          
                    skills                                              
                    training,                                           
                    group.                                              
G0112............  NETT Pulm              1.72        0.97          0.10
                    Rehab;                                              
                    nutritional                                         
                    guidance--init                                      
                    ial.                                                
G0113............  NETT Pulm              1.29        0.77          0.09
                    Rehab;                                              
                    nutritional                                         
                    guidance--subs                                      
                    equent.                                             
G0114............  NETT Pulm              1.20        0.35          0.11
                    Rehab;                                              
                    psychosocial                                        
                    consultation.                                       
G0115............  NETT Pulm              1.20        0.35          0.11
                    Rehab;                                              
                    psychological                                       
                    testing.                                            
G0116............  NETT Pulm              1.11        0.35          0.05
                    Rehab; Psycho-                                      
                    social                                              
                    counseling--in                                      
                    dividual.                                           
------------------------------------------------------------------------

V. Provisions of the Final Rule

    The provisions of this final rule restate the provisions of the 
June 18, 1997, proposed rule except as noted elsewhere in this 
preamble. Following is a highlight of the exceptions:
    For our proposal relating to physician supervision, we are adopting 
our proposal to assign an appropriate level of physician supervision to 
every diagnostic test payable under the physician fee schedule with 
exceptions for certain procedures personally performed by qualified 
independent psychologists, clinical psychologists, qualified 
audiologists, and physical therapists who are certified as qualified 
electrophysiologic clinical specialists. With respect to several 
groupings of diagnostic codes, we have changed our proposed policy 
based on comments from the physician specialities most involved with 
particular groups of codes. In some cases, such as CTs and MRIs 
performed without the use of contrast materials, we have lowered the 
level of required physician supervision. In others, such as ultrasound 
procedures, we have increased the level of required supervision. We are 
publishing a listing of diagnostic codes in the preamble of this 
document with the level of physician supervision we

[[Page 59092]]

have determined to be appropriate. In addition, we are adding a field 
to the physician fee schedule data base indicating the appropriate 
level of supervision. We anticipate that there will continue to be 
discussions among HCFA, physician specialty groups, and others about 
these levels of supervision, and we expect that the indicators 
applicable to individual procedures will be changed from time to time 
as is currently the case with other data base indicators.
    As a result of our review of the comments, we have decided that the 
actual charge issue, including the implications for beneficiary out-of-
pocket expense, requires further study. We received numerous comments 
from individual physicians and suppliers and the organizations that 
represent them in opposition to this proposal.
    Based on provisions in the BBA 1997, we are not implementing the 
system of resource-based practice expense RVUs contained in the 
proposed rule for 1998. Rather, we are implementing the provision of 
the BBA 1997 that reduces practice expense RVUs for certain services 
and uses the monies to increase practice expense RVUs for office 
visits. Specifically, we are making the following changes from the 
regulations proposed in our June 18, 1997 proposed rule:
     In Sec. 414.22 (Relative value units (RVUs)), we are 
stating that the practice expense RVUs for certain services are reduced 
to 110 percent of the work RVUs for those services. We are also stating 
that the following two categories of services are excluded from this 
limitation:
     The service is provided more than 75 percent of the time 
in an office setting; or
     The 1998 proposed resource-based practice expense RVUs (as 
specified in the June 18, 1997 physician fee schedule proposed rule) 
for the specific site, either in-office or out-of-office, increased 
from its 1997 practice expense RVUs.
    In Sec. 414.32 (Determining payments for certain physician services 
furnished in facility settings), we are revising paragraph (b) to state 
that if physician services of the type routinely furnished in a 
physician's office are furnished in facility settings, the fee schedule 
amount for those services is determined by reducing the applicable 
practice expense RVUs for the service by 50 percent.
    We are not revising Sec. 414.34 (Payment for services and supplies 
incident to a physician's service) because our resource-based practice 
expense system is not being implemented as proposed in the June 18, 
1997 proposed rule.
    We are adding the following changes to regulations required by the 
BBA 1997:
     In Sec. 410.34 (Mammography services: Conditions for and 
limitations on coverage), we are expanding coverage of screening 
mammography services, effective January 1, 1998, to provide for payment 
for annual screening for all women beneficiaries age 40 and over.
     We are adding a new Sec. 410.37 (Colorectal cancer 
screening tests: Conditions for and limitations on coverage) to provide 
for Medicare coverage of colorectal cancer screening tests effective 
for services provided on or after January 1, 1998.
     We are adding a new Sec. 410.56 (Screening pelvic 
examinations) to provide for new coverage of screening pelvic exams 
(including a clinical breast exam) for all women beneficiaries subject 
to certain frequency and payment limitations.

VI. Collection of Information Requirements

    Under the Paperwork Reduction Act of 1995 (PRA), agencies are 
required to provide a 60-day notice in the Federal Register and solicit 
public comment before a collection of information requirement is 
submitted to the Office of Management and Budget (OMB) for review and 
approval. In order to fairly evaluate whether an information collection 
should be approved by OMB, section 3506(c)(2)(A) of the PRA requires 
that we solicit comment on the following issues:
     Whether the information collection is necessary and useful 
to carry out the proper functions of the agency;
     The accuracy of the agency's estimate of the information 
collection burden;
     The quality, utility, and clarity of the information to be 
collected; and
     Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
    Therefore, we are soliciting public comment on each of these issues 
for the information collection requirements discussed below.
    Under 5 CFR 1320.3(b)(2), the burden associated with the time, 
effort and financial resources necessary to comply with a collection of 
information that would be incurred by persons in the normal course of 
business is excluded from an information collection. The burden in 
connection with such types of collection activities can be disregarded 
if it can be demonstrated that such collection activities are usual and 
customary. Each of the collection requirements referenced below are of 
the type that are usual and customary in the conduct of commercial 
business. Thus, we believe they fall under this exception.
    Under 5 CFR 1320.3(b)(3), a collection of information conducted or 
sponsored by a Federal agency that is also conducted or sponsored by a 
unit of State, local or tribal government is presumed to impose a 
Federal burden except to the extent that the agency shows that such 
State, local, or tribal requirement would be imposed even in the 
absence of a Federal requirement.
    The following sections contain information collection requirements 
that we believe meet these requirements listed above; therefore, the 
burden is exempt from the Act.
    Section 410.33(b)(2) (Supervising physicians) must maintain 
documentation of sufficient physician resources during all hours of 
operation to assure that the required physician supervision is 
furnished.
    Section 410.33(c) (Non-physician personnel) must maintain 
documentation available for review certifying that non-physician 
personnel have the training and proficiency as evidenced by licensure 
or certification by the appropriate State health or education 
department or, in the absence of a State licensing board, a national 
credentialing body.
    Section 410.33(e) (Multi-State entities) that operate across State 
boundaries must maintain documentation that its supervising physicians 
and technicians are licensed and certified in each of the States in 
which it is furnishing services.
    The information collection requirement and associated burden as 
summarized below is subject to the PRA:
    Section 410.33(b)(2) (Supervising physicians) must evidence 
proficiency in the performance and interpretation of each type of 
diagnostic procedure performed by the IDTF. The proficiency may be 
documented by certification in specific medical specialties or 
subspecialties or by criteria established by the carrier for the 
service area in which the IDTF is located.
    The public reporting burden for this record keeping requirement is 
minimal. There are about 500 IPLs, which we assume will wish to become 
IDTFs, each requiring five minutes to document proficiency by 
certification in specific medical specialties or subspecialties or by 
criteria established by the carrier for the service area in which the 
IDTF is

[[Page 59093]]

located. The total public burden is 42 hours.
    We have submitted a copy of this final rule with comment to OMB for 
its review of the information collection requirements in 
Sec. 410.33(b)(2). This requirement is not effective until it has been 
approved by OMB.
    If you comment on any of these information collection and 
recordkeeping requirements, please mail copies directly to the 
following:

Health Care Financing Administration, Office of Information Services, 
Information Technology Investment Management Group, Division of HCFA 
Enterprise Standards, Room C2-26-17, 7500 Security Boulevard, 
Baltimore, MD 21244-1850, Attn: Louis Blank BPD-884
Office of Information and Regulatory Affairs, Office of Management and 
Budget, Room 10235, New Executive Office Building, Washington, DC 
20503, Attn.: Allison Herron Eydt, HCFA Desk Officer

VII. Waiver of Proposed Rulemaking and Response to Comments

    We ordinarily publish a notice of proposed rulemaking in the 
Federal Register and invite prior public comment on proposed rules. The 
notice of proposed rulemaking can be waived, however, if an agency 
finds good cause that a notice-and-comment procedure is impracticable, 
unnecessary, or contrary to the public interest and it incorporates a 
statement of the finding and its reasons in the rule issued. We find 
good cause to waive the notice-and-comment procedure with respect to a 
number of provisions included in this final rule, as explained below.
    With respect to the BBA 1997 provisions in this final rule 
affecting payment under the RVU system, we noted that the BBA 1997 was 
enacted shortly after the proposed rule was published. It delayed the 
implementation of the resource-based practice expense RVU system until 
January 1, 1999 and specifies the manner in which practice expense RVUs 
in 1998 are adjusted. As explained in section III. A. of this preamble, 
we are conforming the rules to be in compliance with these provisions 
of the statute. Our change is technical in nature and does not 
interpret the law. To submit such a technical, conforming change to 
notice-and-comment rulemaking would be both impracticable and 
unnecessary. Since the Congress intended that these provisions be 
effective on January 1, 1998 and intended to forestall significant 
adjustments in payment that would have occurred under the pre-amendment 
practice expense provision, it is in the public interest to issue this 
rule in final form.
    With respect to the BBA 1997 provisions relating to coverage of 
screening mammography, coverage of screening pelvic examinations and 
colorectal cancer screening, and the related payment changes, our 
reasoning is somewhat similar. This rule conforms the regulations to 
the revisions contained in sections 4104 and 4102 of the BBA 1997. In 
addition, insofar as these regulations relate to coverage conditions 
under authority granted by section 1862(a)(1)(A) of the Act, they are 
exempted from public comment requirements pursuant to section 
1869(b)(3)(B) of the Act. If we were to delay issuing a final rule 
beyond January, 1998, the statutory effective date of the benefit, our 
rules would be in conflict with the statute, which could cause 
confusion and would not be in the public interest.
    We also note that, under express authority contained in section 
1871(b)(2)(B) of the Act (42 U.S.C. 1395hh(b)(2)(B)) issuing a proposed 
rule is unnecessary if a statute establishes a specific deadline for 
the implementation of a provision and the deadline is less than 150 
days after the enactment of the statute in which the deadline is 
contained. The BBA 1997 was enacted on August 5, 1997, less than 150 
days from the statute's effective date of January 1, 1998.
    The BBA 1997 provision related to colorectal cancer screening, as 
described in section III. C. of this preamble, requires us to publish a 
statement of coverage or noncoverage of screening barium enemas in the 
Federal Register by November 3, 1997. As noted in our preamble 
discussion, there was extensive consultation before we reached our 
decision. According to the National Cancer Institute, colorectal cancer 
is the second leading cause of death from cancer in the United States. 
It is clearly in the public interest to make this benefit available 
without delay and to bring our regulations into line with the expanded 
coverage.
    In part IV. B. 2. of this preamble, we identify a number of interim 
1997 codes. Since medical practice is dynamic, changes occur in coding 
or procedures and it is always possible that some changes occur after 
we have submitted our proposal for public comment. To address these 
changes, we identify ``interim'' RVUs for new and revised codes. To the 
extent possible, we subject these interim RVUs to all the procedures 
and considerations applicable to all RVUs, except publishing them in 
the Federal Register for public comment. It has been our practice to 
implement these interim RVUs, along with the ``final'' RVUs so that 
payment can be consistently made during the upcoming fee schedule year, 
and to solicit comments on the interim codes. We evaluate and respond 
to the comments in the next annual final rule. The public has 
recognized over the years that this approach has been in the public 
interest by allowing public participation yet permitting immediate, 
consistent payment to be made.
    For the above reasons, we find good cause to waive notice-and-
comment rulemaking. We invite written comments on the BBA 1997 
provisions and the interim RVUs for selected procedures identified in 
Addendum C.
    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.

VIII. Regulatory Impact Analysis

    We have examined the impacts of this final rule under Executive 
Order (E.O.) 12866, the Unfunded Mandates Act of 1995, and the 
Regulatory Flexibility Act. E.O. 12866 directs agencies to assess all 
costs and benefits of available regulatory alternatives and, when 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects; distributive impacts and equity). A 
regulatory impact analysis (RIA) must be prepared for major rules with 
economically significant effects ($100 million or more annually). The 
benefit changes in this final rule due to the BBA 1997 will result in 
additional expenditures for calendar year 1998 in excess of $100 
million.
    Because the expenditures resulting from this final rule are 
expected to exceed $100 million, it is considered a major rule, and, as 
required by law, this final rule is subject to congressional review. 
Therefore, this final rule is being forwarded to the Congress for a 60-
day review period.
    The Unfunded Mandates Reform Act of 1995 also requires (in section 
202) that agencies prepare an assessment of anticipated costs and 
benefits for any rule that may result in an annual expenditure by 
State, local, or tribal governments, in the aggregate, or by the 
private sector, of $100 million. The final

[[Page 59094]]

rule has no consequential effect on State, local, or tribal 
governments. We believe the private sector costs of this rule fall 
below these thresholds, as well.

A. Regulatory Flexibility Act

    Consistent with the provisions of the Regulatory Flexibility Act we 
analyze options for regulatory relief for small businesses and other 
small entities. We prepare a Regulatory Flexibility Analysis (RFA) 
unless we certify that a rule will not have a significant economic 
impact on a substantial number of small entities. The RFA is to include 
a justification of why action is being taken, the kinds and number of 
small entities the final rule will affect, and an explanation of any 
considered meaningful options that achieve the objectives and will 
lessen any significant adverse economic impact on the small entities.
    For purposes of the Act, all physicians are considered to be small 
entities. Thus, we have prepared the following analysis, which, 
together with the rest of this preamble, meets all three assessment 
requirements. It explains the rationale for and purposes of the rule, 
details the costs and benefits of the rule, analyzes alternatives, and 
presents the measures to minimize the burden on small entities.

B. Geographic Practice Cost Index Changes

    Changes in GPCIs do not affect total payments under the physician 
fee schedule but rather redistribute payments among payment localities. 
An estimate of the overall redistributive effects can be seen by 
examining the changes in locality geographic adjustment factors or 
GAFs. The GAFs are a weighted composite of the locality GPCIs. Addendum 
F is a comparison of 1997 and 1999 locality GAFs. As this comparison 
shows, 58 of the 89 localities will experience changes in payments of 
less than 0.5 percent; 76 of the 89 localities will experience changes 
in payments of less than 1 percent; and only 3 of the 89 localities 
will experience changes in payment of 2 percent. The effects will be 
even less in 1998 as the GPCI revisions are phased in equally over a 2-
year period. The effects of the GPCI revisions are thus negligible in 
most cases, and very minimal in all others.

C. Fee Schedule for Clinical Psychologist Services

    Before January 1, 1997, the clinical psychologist fee schedule was 
derived from the reasonable charge payment system and was updated by an 
economic index different from that used for the physician fee schedule. 
As a result, relative to physicians' services, Medicare allowances for 
certain clinical psychologist services in many localities were 
artificially high or low. Moreover, there were wide geographic 
variations in Medicare rates for clinical psychologists as well as for 
clinical social workers, whose rates are set, by statute, at 75 percent 
of clinical psychologists' rates.
    Effective January 1, 1997, the fee schedule for clinical 
psychologist services is linked to the physician fee schedule. The fee 
schedule for clinical psychologist services is set at 100 percent of 
the physician fee schedule amount for the corresponding service. This 
payment policy was prompted by the creation of new psychotherapy codes 
that make a distinction between services that include or exclude 
medical evaluation and management.
    Both previous and current clinical psychologist fee schedules were 
implemented through carrier instruction. Because this final rule will 
codify current payment policy, there will be no impact on Medicare 
program or beneficiary expenditures.

D. Diagnostic Tests

    Our policy specifies the level of physician supervision required 
for diagnostic tests furnished in settings in which such services are 
payable under the physician fee schedule. All of these tests will 
require at least a general level of physician supervision (that is, 
responsibility for the equipment and nonphysician personnel). The 
following services will be excepted from this provision:
     Diagnostic mammography procedures regulated by the FDA.
     Certain tests personally performed by qualified 
audiologists as discussed earlier.
     Certain testing services personally performed by qualified 
independent psychologists and clinical psychologists as discussed 
earlier.
    This policy may result in some program savings due to the denial of 
payments for tests that are not reasonable and necessary because the 
required level of physician supervision was not furnished. However, we 
do not have data on which to base an estimate of savings. We expect 
that most testing entities that did not previously furnish testing with 
the level of physician supervision required under the proposal in our 
June 18, 1997 proposed rule (62 FR 33179 through 33181) will modify the 
way they furnish testing services to conform to the new policy.
    We will also create a new type of entity known as an independent 
diagnostic testing facility (IDTF) with specific national standards. It 
will replace the existing IPL. Since the current IPL national policy is 
based on State law and local Medicare carrier policy, it is likely that 
some IPLs in certain areas will be more affected by this proposal than 
others. We do not have any data upon which to base any estimates of 
savings at this time. There are wide-spread allegations of unnecessary 
testing furnished by IPLs under the current policy. Our new policy is 
designed to assist Medicare carriers in addressing these allegations.

E. Reasonable Compensation Equivalent Limit Update Factor

    The methodology currently employed to update the physician fee 
schedule uses an inflation factor distinct from the CPI-U used to 
update the reasonable compensation equivalent limits. To achieve a 
measure of consistency in the methodologies employed to determine 
reasonable payments to physicians for physicians' direct medical and 
surgical services furnished to individual patients and reasonable 
compensation levels for physicians' services that benefit provider 
patients generally, we are revising the methodology used to update the 
reasonable compensation equivalent limits by adopting the physician fee 
schedule's inflation factor (the MEI) to update the reasonable 
compensation equivalent limits. For cost reporting periods beginning on 
or after January 1, 1998, updates to the reasonable compensation 
equivalent limits will be calculated using the MEI.
    Because we are not making an actual update to the reasonable 
compensation equivalent limits at this time that is based on the MEI 
for cost reporting periods beginning on or after January 1, 1998, this 
change in policy will not have an impact on Medicare program or 
beneficiary expenditures at this time.

F. Payment to Participating and Nonparticipating Suppliers

    We are revising the definitions at Sec. 414.2 (Definitions) to 
define a ``participating supplier'' as being a supplier as defined in 
Sec. 400.202, which includes physicians as suppliers, when they have an 
agreement with HCFA to participate in Part B of Medicare in effect on 
the date of the service. Similarly, we are defining ``nonparticipating 
supplier'' as a supplier that does not have an agreement with HCFA to 
participate in Part B of Medicare in effect on the date of the service.
    We are also revising Sec. 414.20 (Formula for computing payment 
amounts) to clarify that the formula in

[[Page 59095]]

the section computes the fee schedule amount, which may differ from the 
payment basis, and to clarify that the fee schedule amount for a 
nonparticipating supplier is 95 percent of the fee schedule amount for 
a participating supplier. We are also revising the heading of 
Sec. 414.20 to read ``Formula for computing fee schedule amounts'' to 
reflect more accurately the content of the section.
    We are revising Sec. 414.48 (Limits on actual charges of 
nonparticipating suppliers), which describes the Medicare limiting 
charge for nonparticipating suppliers to clarify that the limiting 
charge is 115 percent of the fee schedule amount for nonparticipating 
physicians as calculated in Sec. 414.20(b).
    The changes to Secs. 414.2, 414.20, and 414.48 will have no impact 
on Medicare payment, beneficiaries, physicians, other suppliers of 
physician services, Medicare carriers, or other insurers. We believe 
that Medicare carriers are currently properly calculating the fee 
schedule amounts for participating and nonparticipating suppliers and 
are paying based on those properly calculated amounts. These changes 
are intended to conform our regulations to the law and current 
practice.

G. Increase in Work Relative Value Units for Global Surgical Services 
to Account for the 1997 Increases for Work Relative Value Units in 
Evaluation and Management Services

    In our November 22, 1996 final rule with comment period, as part of 
the 5-year review of all physician work RVUs, we increased most of the 
work RVUs for evaluation and management services for hospital and 
office or other outpatient visits. We revised the work RVUs for 
evaluation and management services partly in recognition of the 
increase in preservice and postservice work. At that time, we made no 
adjustments to the work RVUs assigned to global surgical services, 
which, in addition to the surgical procedure, include the related 
preservice and postservice evaluation and management visits a surgeon 
provides within a defined period of time.
    Upon further examination of this issue, we are increasing the work 
RVUs for global surgical services to be consistent with the 1997 
increases in the work RVUs for evaluation and management services.
    Because the increases in the work RVUs for global surgical services 
will cause an increase in payments for those services, we must reduce 
all payments by 0.7 percent to maintain budget neutrality.

H. Caloric Vestibular Testing

    We are reducing the work and malpractice RVUs for CPT code 92543 
global service and CPT code 92543-26, and the malpractice RVUs for CPT 
code 92543-TC to 25 percent of what they would otherwise be. Therefore, 
beginning in 1998, when a physician performs and interprets four 
irrigations, the physician will bill Medicare for four units of CPT 
code 92543 (that is, the global service). When a physician interprets 
four irrigations, the physician will bill four units of CPT code 92543-
26. When a physician or supplier performs four irrigations, the 
physician or supplier will bill four units of CPT code 92543-TC.
    As part of the overall policy of resource-based practice expense 
RVUs for all codes, we are establishing practice expense RVUs for CPT 
code 92543 global service, -26, and -TC based on the assumption that 
one unit of the service equals one irrigation or the interpretation of 
one irrigation.
    We expect the changes to the RVUs for caloric vestibular testing to 
have no impact on Medicare program or beneficiary expenditures because 
this is actually a change in coding interpretation rather than a change 
in value. Medicare has interpreted one unit of CPT code 92543 to mean 
up to four irrigations and has established its RVUs based on that 
interpretation. The AMA interprets one unit to mean one irrigation. 
Therefore, when the usual service is furnished (that is, a total of 
four irrigations--two to each ear), Medicare instructed physicians to 
bill for that as one unit of service, while the AMA's instructions 
considered it four. We are now, in a budget-neutral fashion, adopting 
the AMA interpretation to reduce billing confusion regarding this code. 
The change is being made by having what used to be one service--for 
Medicare purposes--now equal four services, while at the same time 
establishing the RVU levels at 25 percent of what they would have 
otherwise been.

I. Clinical Consultations

    The regulations set forth at Sec. 415.130 (Conditions for payment: 
Physician pathology services), paragraph (b) (Clinical consultation 
services), require that a clinical consultation meet four criteria 
before it can be paid. One of these criteria is that the clinical 
consultation must be requested by the patient's attending physician. We 
have allowed a standing order policy to be used as a substitute for the 
individual request by the patient's attending physician. However, 
effective January 1, 1998, we will not accept a standing order as a 
substitute for the individual request by the attending physician. We 
will instruct the Medicare carriers to enforce Sec. 415.130(b) as it is 
presently written.
    The national allowed charges for CPT code 80500 (Clinical pathology 
consultation; limited, without review of patient's history and medical 
records) for 1996 are $5.6 million. Of this amount, 70 percent of total 
allowed charges are from seven States. These are: Florida, Texas, 
Oklahoma, Illinois, Kentucky, California, and Missouri. Florida 
accounts for $2.5 million or 45 percent of the total.
    We believe that the use of standing orders has clearly contributed 
to increased payments for clinical consultations in Florida relative to 
other States. We do not know the prevalence of standing orders in other 
States but, generally, the data do not seem to indicate a widespread 
problem.

J. Changes in Practice Expense Relative Value Units for 1998

    As discussed earlier, section 4505 of the BBA 1997 specifies the 
manner in which practice expense RVUs in 1998 are adjusted. The 1998 
practice expense RVUs for certain services are reduced to 110 percent 
of their work RVUs for the service. The reductions are used to increase 
practice expense RVUs for office visits. We estimate that the aggregate 
reduction in the practice expense RVUs for services subject to this 110 
percent is about $330 million. (See section III. A. above for a 
detailed explanation of the calculation of this provision of the BBA 
1997.) Because these funds are used to increase the practice expense 
RVUs for office visits, there is no change in total spending as a 
result of this provision.

K. Coverage of Screening Mammography and Related Payment Changes

    Section 4101 of the BBA 1997 provides for expanded coverage and 
waiver of the Part B deductible for screening mammography services 
furnished on or after January 1, 1998. Specifically, the revised 
benefit will allow for annual coverage of screening mammographies for 
all women age 40 and over, including women age 65 and over. Before 
enactment of the BBA 1997, biennial coverage of screening mammograms 
was available for (1) women at least age 40 but not yet age 50 who were 
not at high risk for breast cancer, and (2) women age 65 and over. 
Annual coverage of screening mammograms was only available for (1) 
women at least age 40 but not yet age 50 who were at high risk for 
breast

[[Page 59096]]

cancer, and (2) women at least age 50 but not yet age 65. We estimate 
that these changes in the frequency limitations and in the Part B 
deductible will result in an increase in Medicare payments. These 
payments will be made to many screening mammography suppliers, 
including the physicians who interpret the results of these 
examinations, as well as to other physicians who may be involved in 
providing any medically necessary follow-up tests or treatment that may 
be required as a result of the screening tests.

L. Colorectal Cancer Screening

    Section 4104 of the BBA 1997 authorizes coverage of certain 
colorectal screening tests, effective January 1, 1998, subject to 
certain frequency and payment limits. The new tests include (1) 
screening fecal-occult blood tests, (2) screening flexible 
sigmoidoscopy exams, (3) screening colonoscopy exams, and (4) screening 
barium enema exams. Based on the projected utilization of these various 
screening services and related medically necessary follow-up tests and 
treatment that may be required for the beneficiaries screened, we 
estimate that this new benefit will result in an increase in Medicare 
payments. These payments will be made to many primary care physicians 
for the screening fecal-occult blood tests, and mostly to physician 
specialists such as gastroenterologists (in the case of screening 
flexible sigmoidoscopies and screening colonoscopies) and radiologists 
(in the case of screening barium enema procedures).

M. Coverage of Screening Pelvic Examination (Including a Clinical 
Breast Examination) and Related Payment Changes

    Effective for services furnished beginning January 1, 1998, section 
4102 of the BBA 1997 provides for coverage and waiver of the Part B 
deductible for screening pelvic examinations (including a clinical 
breast examination) subject to certain frequency and payment 
limitations. We estimate that this new coverage provision will increase 
program expenditures. These payments will be made to a large number of 
physicians and other practitioners who provide these tests or any 
medically necessary follow-up tests or treatment that may be required 
as a result of the screening tests throughout the United States.

N. Reinstatement of the Payment for Transportation of EKG Equipment

    As set forth in section 4559 of the BBA 1997, effective for 
services furnished after December 31, 1997 and before January 1, 1999, 
carriers will make separate payments for HCPCS code R0076 
(Transportation of portable EKG to facility or location, per patient) 
based upon payment methods in effect for these services as of December 
31, 1996. EKG transportation payments should be made at the carrier-
priced level that was in effect on December 31, 1996. The procedure 
codes involved are CPT code 93000 (a 12-lead EKG with interpretation 
and report) or CPT code 93005 (a 12-lead EKG, tracing only, without 
interpretation and report). When multiple patients receive services at 
the same site, the transportation payment amount must be prorated among 
all patients seen. These payments may be made only under the following 
circumstances:
     The transportation service is furnished in connection with 
standard EKG procedures furnished by approved suppliers of portable x-
ray services as set forth in section 2070.4.F. of the Medicare Carriers 
Manual.
     The transportation service is furnished in connection with 
standard EKG procedures by an independent diagnostic testing facility 
or an independent physiological laboratory under the condition set 
forth in section 2070.1.G. of the Medicare Carriers Manual. We estimate 
that this provision will result in some increase in program 
expenditures.

O. Elimination of the Separate Budget-Neutrality Adjuster for the Work 
Relative Value Units

    As discussed in the November 22, 1996 final rule (61 FR 59532) for 
the 1997 physician fee schedule, we intend to eliminate the separate 
8.3 percent budget-neutrality adjustment to the work RVUs that resulted 
from changes made during the 5-year review of work RVUs. We will 
accomplish this by increasing the practice and malpractice expense RVUs 
by 8.3 percent and reducing the CF by 8.3 percent. This allows us to 
eliminate the separate adjuster while not changing the payment for any 
service. However, due to the affects of the BBA 1997, we are postponing 
the elimination of the separate budget neutrality adjustment until 
1999.

P. Effect of Changes Resulting From Adjustments to Relative Value Units

    Because the new RVUs cause an increase in total estimated payments 
under the physician fee schedule, we must reduce payments by 0.8 
percent in order to maintain budget neutrality as required by section 
1848(c)(2)(B)(ii)(II) of the Act. This reduction in payments is being 
implemented through a 0.8 percent reduction to the conversion factor.
    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 0.1 percent, requiring an 
offsetting 0.1 percent reduction in the CF to maintain budget 
neutrality. This 0.1 percent reduction is included in the 0.8 percent 
reduction described above.
    We increased the Sustainable Growth Rate target for physician 
spending by the anticipated 0.1 volume and intensity response. Because 
we increased the target, if the anticipated volume and intensity 
response does not occur, the Sustainable Growth Rate system will return 
the 0.1 percent reduction to the CF in the form of higher future 
updates.

Q. Net Impact of Relative Value Unit 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 
to the estimated payments under the new RVUs.
2. Overall Fee Schedule Impact
    As described above, we are making the budget neutrality adjustment 
required for changes in relative value units through an adjustment to 
the CF. In the discussion below of differential impacts by specialty, 
we have incorporated the separate 0.8 percent downward adjustment on 
the CF. The table below does not contain the impacts of the single CF.
3. Specialty Level Effect (Includes Table 3--Impact on Medicare 
Payments by Specialty Due to Changes in Relative Value Units)
    Table 3, ``Impact on Medicare Payments by Specialty Due to Changes 
in Relative Value Units,'' shows the estimated percentage change in 
Medicare physician fees from the current RVUs to the new RVUs and 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

[[Page 59097]]

than impact displayed in Table 3 since physicians provide services to 
Medicare and non-Medicare patients.

  Table 3.--Impact on Medicare Payments by Speciality Due to Changes in 
                          Relative Value Units                          
                              [In percent]                              
------------------------------------------------------------------------
                                                              Impact on 
                                    Impact on    Impact on     practice 
            Specialty                 total         work       expense  
                                     payments     payments     payments 
------------------------------------------------------------------------
M.D./D.O. Physicians:                                                   
    Obstetrics/Gynecology........          3.0          2.8          3.9
    General Surgery..............          1.8          3.8         -0.4
    Plastic Surgery..............          1.7          3.9         -0.6
    Vascular Surgery.............          1.5          4.3          0.7
    Rheumatology.................          1.4         -0.9          5.0
    Family Practice..............          1.3         -1.0          5.3
    General Practice.............          1.2         -0.4          4.1
    Anesthesiology...............          0.9          1.0          0.7
    Hematology/Oncology..........          0.8         -0.6          2.5
    Orthopedic Surgery...........          0.8          4.0         -2.0
    Internal Medicine............          0.6         -0.9          3.0
    Otolaryngology...............          0.6          0.3          1.1
    Urology......................          0.4          0.6          0.3
    Dermatology..................          0.2         -0.6          1.7
    Neurology....................          0.0          0.7          1.2
    Clinics......................         -0.1         -0.3          0.2
    Neurosurgery.................         -0.2          3.2         -3.6
    Thoracic Surgery.............         -0.2          5.0         -4.7
    All Other Physicians.........         -0.2         -0.6          0.5
    Pulmonary....................         -0.4         -0.8          0.4
    Emergency Medicine...........         -0.6         -0.7         -0.5
    Psychiatry...................         -0.7         -0.9         -0.4
    Radiology....................         -0.7         -0.9          0.6
    Cardiac Surgery..............         -0.7          5.4         -5.9
    Radiation Oncology...........         -0.7         -0.7         -0.7
    Pathology....................         -1.1         -0.8         -1.5
    Nephrology...................         -1.2         -0.8         -1.9
    Gastroenterology.............         -1.3         -0.8         -2.0
    Cardiology...................         -1.4         -0.6         -2.3
    Ophthalmology................         -2.6          1.6         -6.8
Others:                                                                 
    Podiatry.....................          0.8          0.5          1.4
    Optometry....................          0.1         -0.9          1.8
    Nonphysician Practitioner....         -0.6          0.3         -2.2
    Chiropractic.................         -0.8         -0.8         -0.8
    Suppliers....................         -1.0         -0.8         -1.1
------------------------------------------------------------------------

R. Five-Year Impacts of Benefit Changes (Includes Table 4--Projected 
Budget Impact of New Benefits)

    We estimate that the benefit changes enacted in the BBA 1997 
described in this final rule will result in the following Medicare 
expenditures over the next 5 fiscal years:

                                Table 4.--Projected Budget Impact of New Benefits                               
                                                  [In millions]                                                 
----------------------------------------------------------------------------------------------------------------
                                               FY 1998       FY 1999       FY 2000       FY 2001       FY 2002  
----------------------------------------------------------------------------------------------------------------
Total budget impact.......................         $160          $385          $510          $685          $780 
----------------------------------------------------------------------------------------------------------------

S. 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 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

[[Page 59098]]

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 
regulation was reviewed by the Office of Management and Budget.

List of Subjects

42 CFR Part 400

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

42 CFR Part 405

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

42 CFR Part 410

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

42 CFR Part 411

    Kidney diseases, Medicare, Reporting and recordkeeping 
requirements.

42 CFR Part 414

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

    42 CFR chapter IV is amended as set forth below:

PART 400--INTRODUCTION; DEFINITIONS

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

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

    2. In Sec. 400.202, the introductory text is republished, and the 
following definitions are added in alphabetical order:


Sec. 400.202  Definitions specific to Medicare.

    As used in connection with the Medicare program, unless the context 
indicates otherwise--
* * * * *
    Nonparticipating supplier means a supplier that does not have an 
agreement with HCFA to participate in Part B of Medicare in effect on 
the date of the service.
    Participating supplier means a supplier that has an agreement with 
HCFA to participate in Part B of Medicare in effect on the date of the 
service.
* * * * *
    B. Part 405 is amended as set forth below:

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

Subpart E--Criteria for Determination of Reasonable Charges

    1. The authority citation for part 405, subpart E, continues to 
read as follows:

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

Sec. 405.535  [Amended]

    2. In Sec. 405.535(b), ``Sec. 414.48(b)(3)'' is removed and 
``Sec. 414.48(b)'' is added in its place.

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS

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

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

    2. Section 410.32 is revised 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 is treating the beneficiary, that is, the 
physician who furnishes a consultation or treats a beneficiary for a 
specific medical problem and who uses the results in the management of 
the beneficiary's specific medical problem. Tests not ordered by the 
physician who is treating the beneficiary are not reasonable and 
necessary (see Sec. 411.15(k)(1) of this chapter).
    (1) Chiropractic 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.
    (2) Mammography exception. A physician who meets the qualification 
requirements for an interpreting physician under section 354 of the 
Public Health Service Act as provided in Sec. 410.34(a)(7) may order a 
diagnostic mammogram based on the findings of a screening mammogram 
even though the physician does not treat the beneficiary.
    (3) Application to nonphysician practitioners. Nonphysician 
practitioners (that is, clinical nurse specialists, clinical 
psychologists, clinical social workers, nurse-midwives, nurse 
practitioners, and physician assistants) who furnish 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.
    (b) Diagnostic x-ray and other diagnostic tests. (1) Basic rule. 
Except as indicated in paragraph (b)(2) of this section, all diagnostic 
x-ray and other diagnostic tests covered under section 1861(s)(3) of 
the Act and payable under the physician fee schedule must be furnished 
under the appropriate level of supervision by a physician as defined in 
section 1861(r) of the Act. Services furnished without the required 
level of supervision are not reasonable and necessary (see 
Sec. 411.15(k)(1) of this chapter).
    (2) Exceptions. The following diagnostic tests payable under the 
physician fee schedule are excluded from the basic rule set forth in 
paragraph (b)(1) of this section:
    (i) Diagnostic mammography procedures, which are regulated by the 
Food and Drug Administration.
    (ii) Diagnostic tests personally furnished by a qualified 
audiologist as defined in section 1861(ll)(3) of the Act.
    (iii) Diagnostic psychological testing services personally 
furnished by a clinical psychologist or a qualified independent 
psychologist as defined in program instructions.
    (iv) Diagnostic tests (as established through program instructions) 
personally performed by a physical therapist who is certified by the 
American Board of Physical Therapy Specialties as a qualified 
electrophysiologic clinical specialist and permitted to provide the 
service under State law.
    (3) Levels of supervision. Except where otherwise indicated, all 
diagnostic x-ray and other diagnostic tests subject to this provision 
and payable under the physician fee schedule must be furnished under at

[[Page 59099]]

least a general level of physician supervision as defined in paragraph 
(b)(3)(i) of this section. In addition, some of these tests also 
require either direct or personal supervision as defined in paragraphs 
(b)(3)(ii) or (b)(3)(iii) of this section, respectively. When direct or 
personal supervision is required, physician supervision at the 
specified level is required throughout the performance of the test.
    (i) General supervision means the procedure is furnished under the 
physician's overall direction and control, but the physician's presence 
is not required during the performance of the procedure. Under general 
supervision, the training of the nonphysician personnel who actually 
perform the diagnostic procedure and the maintenance of the necessary 
equipment and supplies are the continuing responsibility of the 
physician.
    (ii) Direct supervision in the office setting means the physician 
must be present in the office suite and immediately available to 
furnish assistance and direction throughout the performance of the 
procedure. It does not mean that the physician must be present in the 
room when the procedure is performed.
    (iii) Personal supervision means a physician must be in attendance 
in the room during the performance of the procedure.
    (c) Portable x-ray services. Portable x-ray services furnished in a 
place of residence used as the patient's home are covered if the 
following conditions are met:
    (1) These services are furnished under the general supervision of a 
physician, as defined in paragraph (b)(3)(i) of this section.
    (2) The supplier of these services meets the requirements set forth 
in part 486, subpart C of this chapter, concerning conditions for 
coverage for portable x-ray services.
    (3) The procedures are limited to--
    (i) Skeletal films involving the extremities, pelvis, vertebral 
column, or skull;
    (ii) Chest or abdominal films that do not involve the use of 
contrast media; and
    (iii) Diagnostic mammograms if the approved portable x-ray 
supplier, as defined in subpart C of part 486 of this chapter, meets 
the certification requirements of section 354 of the Public Health 
Service Act, as implemented by 21 CFR part 900, subpart B.
    (d) Diagnostic laboratory tests. Medicare Part B pays for covered 
diagnostic laboratory tests that are furnished by any of the following:
    (1) A participating hospital or participating RPCH.
    (2) A nonparticipating hospital that meets the requirements for 
emergency outpatient services specified in subpart G of part 424 of 
this chapter and the laboratory requirements specified in part 493 of 
this chapter.
    (3) The office of the patient's attending or consulting physician 
if that physician is a doctor of medicine, osteopathy, podiatric 
medicine, dental surgery, or dental medicine.
    (4) An RHC.
    (5) A laboratory, if it meets the applicable requirements for 
laboratories of part 493 of this chapter, including the laboratory of a 
nonparticipating hospital that does not meet the requirements for 
emergency outpatient services in subpart G of part 424 of this chapter.
    (6) An FQHC.
    3. New Sec. 410.33 is added to read as follows:


Sec. 410.33  Independent diagnostic testing facility.

    (a) General rule. (1) Effective for diagnostic procedures performed 
on or after July 1, 1998, carriers will pay for diagnostic procedures 
under the physician fee schedule only when performed by a physician, a 
group practice of physicians, an approved supplier of portable x-ray 
services, or an independent diagnostic testing facility (IDTF). An IDTF 
may be a fixed location, a mobile entity, or an individual nonphysician 
practitioner. It is independent of a physician's office or hospital; 
however, these rules apply when an IDTF furnishes diagnostic procedures 
in a physician's office.
    (2) Exceptions. The following diagnostic tests that are payable 
under the physician fee schedule and furnished by a nonhospital testing 
entity are not required to be furnished in accordance with the criteria 
set forth in paragraphs (b) through (e) of this section:
    (i) Diagnostic mammography procedures, which are regulated by the 
Food and Drug Administration.
    (ii) Diagnostic tests personally furnished by a qualified 
audiologist as defined in section 1861(ll)(3) of the Act.
    (iii) Diagnostic psychological testing services personally 
furnished by a clinical psychologist or a qualified independent 
psychologist as defined in program instructions.
    (iv) Diagnostic tests (as established through program instructions) 
personally performed by a physical therapist who is certified by the 
American Board of Physical Therapy Specialties as a qualified 
electrophysiologic clinical specialist and permitted to provide the 
service under State law.
    (b) Supervising physician. (1) An IDTF must have one or more 
supervising physicians who are responsible for the direct and ongoing 
oversight of the quality of the testing performed, the proper operation 
and calibration of the equipment used to perform tests, and the 
qualification of nonphysician personnel who use the equipment. This 
level of supervision is that required for general supervision set forth 
in Sec. 410.32(b)(3)(i).
    (2) The supervising physician must evidence proficiency in the 
performance and interpretation of each type of diagnostic procedure 
performed by the IDTF. The proficiency may be documented by 
certification in specific medical specialties or subspecialties or by 
criteria established by the carrier for the service area in which the 
IDTF is located. In the case of a procedure requiring the direct or 
personal supervision of a physician as set forth in 
Sec. 410.32(b)(3)(ii) or (b)(3)(iii), the IDTF's supervising physician 
must personally furnish this level of supervision whether the procedure 
is performed in the IDTF or, in the case of mobile services, at the 
remote location. The IDTF must maintain documentation of sufficient 
physician resources during all hours of operations to assure that the 
required physician supervision is furnished. In the case of procedures 
requiring direct supervision, the supervising physician may oversee 
concurrent procedures.
    (c) Nonphysician personnel. Any nonphysician personnel used by the 
IDTF to perform tests must demonstrate the basic qualifications to 
perform the tests in question and have training and proficiency as 
evidenced by licensure or certification by the appropriate State health 
or education department. In the absence of a State licensing board, the 
technician must be certified by an appropriate national credentialing 
body. The IDTF must maintain documentation available for review that 
these requirements are met.
    (d) Ordering of tests. All procedures performed by the IDTF must be 
specifically ordered in writing by the physician who is treating the 
beneficiary, that is, the physician who is 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. (Nonphysician practitioners may order tests as set forth in 
Sec. 410.32(a)(3).) The order must specify the diagnosis or other basis 
for

[[Page 59100]]

the testing. The supervising physician for the IDTF may not order tests 
to be performed by the IDTF, unless the IDTF's supervising physician is 
in fact the beneficiary's treating physician. That is, the physician in 
question had a relationship with the beneficiary prior to the 
performance of the testing and is treating the beneficiary for a 
specific medical problem. The IDTF may not add any procedures based on 
internal protocols without a written order from the treating physician.
    (e) Multi-State entities. An IDTF that operates across State 
boundaries must maintain documentation that its supervising physicians 
and technicians are licensed and certified in each of the States in 
which it is furnishing services.
    (f) Applicability of State law. An IDTF must comply with the 
applicable laws of any State in which it operates.
    4. In Sec. 410.34, the introductory text to paragraph (d) and 
paragraph (d)(4) are revised to read as follows:


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

* * * * *
    (d) Limitations on coverage of screening mammography services. The 
following limitations apply to coverage of screening mammography 
services as described in paragraphs (c) and (d) of this section:
* * * * *
    (4) For an asymptomatic woman over 39 years of age, payment may be 
made for a screening mammography performed after at least 11 months 
have passed following the month in which the last screening mammography 
was performed.
* * * * *
    5. A new Sec. 410.37 is added to read as follows:


Sec. 410.37  Colorectal cancer screening tests: Conditions for and 
limitations on coverage.

    (a) Definitions. As used in this section, the following definitions 
apply:
    (1) Colorectal cancer screening tests means any of the following 
procedures furnished to an individual for the purpose of early 
detection of colorectal cancer:
    (i) Screening fecal-occult blood tests.
    (ii) Screening flexible sigmoidoscopies.
    (iii) In the case of an individual at high risk for colorectal 
cancer, screening colonoscopies.
    (iv) Screening barium enemas.
    (v) Other tests or procedures, and modifications to tests under 
this paragraph, with such frequency and payment limits as HCFA 
determines appropriate, in consultation with appropriate organizations.
    (2) Screening fecal-occult blood test means a guaiac-based test for 
peroxidase activity, testing two samples from each of three consecutive 
stools.
    (3) An individual at high risk for colorectal cancer means an 
individual with--
    (i) A close relative (sibling, parent, or child) who has had 
colorectal cancer or an adenomatous polyp;
    (ii) A family history of familial adenomatous polyposis;
    (iii) A family history of hereditary nonpolyposis colorectal 
cancer;
    (iv) A personal history of adenomatous polyps; or
    (v) A personal history of colorectal cancer; or
    (vi) Inflammatory bowel disease, including Crohn's Disease, and 
ulcerative colitis.
    (4) Screening barium enema means--
    (i) A screening double contrast barium enema of the entire 
colorectum (including a physician's interpretation of the results of 
the procedure); or
    (ii) In the case of an individual whose attending physician decides 
that he or she cannot tolerate a screening double contrast barium 
enema, a screening single contrast barium enema of the entire 
colorectum (including a physician's interpretation of the results of 
the procedure).
    (5) An attending physician for purposes of this provision is a 
doctor of medicine or osteopathy (as defined in section 1861(r)(1) of 
the Act) who is fully knowledgeable about the beneficiary's medical 
condition, and who would be responsible using the results of any 
examination performed in the overall management of the beneficiary's 
specific medical problem.
    (b) Condition for coverage of screening fecal-occult blood tests. 
Medicare Part B pays for a screening fecal-occult blood test if it is 
ordered in writing by the beneficiary's attending physician.
    (c) Limitations on coverage of screening fecal-occult blood tests. 
(1) Payment may not be made for a screening fecal-occult blood test 
performed for an individual under age 50.
    (2) For an individual 50 years of age or over, payment may be made 
for a screening fecal-occult blood test performed after at least 11 
months have passed following the month in which the last screening 
fecal-occult blood test was performed.
    (d) Condition for coverage of screening flexible sigmoidoscopies. 
Medicare Part B pays for a screening flexible sigmoidoscopy service if 
it is performed by a doctor of medicine or osteopathy (as defined in 
section 1861(r)(1) of the Act).
    (e) Limitations on coverage of screening flexible sigmoidoscopies. 
(1) Payment may not be made for a screening flexible sigmoidoscopy 
performed for an individual under age 50.
    (2) For an individual 50 years of age or over, payment may be made 
for a screening flexible sigmoidoscopy after at least 47 months have 
passed following the month in which the last screening flexible 
sigmoidoscopy or, as provided in paragraphs (h) and (i) of this 
section, the last screening barium enema was performed.
    (f) Condition for coverage of screening colonoscopies. Medicare 
Part B pays for a screening colonoscopy if it is performed by a doctor 
of medicine or osteopathy (as defined in section 1861(r)(1) of the 
Act).
    (g) Limitations on coverage of screening colonoscopies. (1) Payment 
may not be made for a screening colonoscopy for an individual who is 
not at high risk for colorectal cancer as described in paragraph (a)(3) 
of this section.
    (2) Payment may be made for a screening colonoscopy performed for 
an individual who is at high risk for colorectal cancer as described in 
paragraph (a)(3) of this section, after at least 23 months have passed 
following the month in which the last screening colonoscopy was 
performed, or as provided in paragraphs (h) and (i) of this section, 
the last screening barium enema was performed.
    (h) Conditions for coverage of screening barium enemas. Medicare 
Part B pays for a screening barium enema if it is ordered in writing by 
the beneficiary's attending physician.
    (i) Limitations on coverage of screening barium enemas.
    (1) In the case of an individual age 50 or over who is not at high 
risk of colorectal cancer, payment may be made for a screening barium 
enema examination performed after at least 47 months have passed 
following the month in which the last screening barium enema or 
screening flexible sigmoidoscopy was performed.
    (2) In the case of an individual who is at high risk for colorectal 
cancer, payment may be made for a screening barium enema examination 
performed after at least 23 months have passed following the month in 
which the last screening barium enema or the last screening colonoscopy 
was performed.
    6. A new Sec. 410.56 is added to read as follows:

[[Page 59101]]

Sec. 410.56  Screening pelvic examinations.

    (a) Conditions for screening pelvic examinations. Medicare Part B 
pays for a screening pelvic examination (including a clinical breast 
examination) if it is performed by a doctor of medicine or osteopathy 
(as defined in section 1861(r)(1) of the Act), or by a certified nurse 
midwife (as defined in section 1861(gg) of the Act), or a physician 
assistant, nurse practitioner, or clinic nurse specialist (as defined 
in section 1861(aa) of the Act) who is authorized under State law to 
perform the examination.
    (b) Limits on coverage of screening pelvic examinations. The 
following limitations apply to coverage of screening pelvic examination 
services:
    (1) General rule. Except as specified in paragraphs (b)(2) and 
(b)(3) of this section, payment may be made for a pelvic examination 
performed on an asymptomatic woman only if the individual has not had a 
pelvic examination paid for by Medicare during the preceding 35 months 
following the month in which her last Medicare-covered screening pelvic 
examination was performed and found to be normal.
    (2) More frequent screening based on high-risk factors. Subject to 
the limitation as specified in paragraph (b)(4) of this section, 
payment may be made for a screening pelvic examination performed more 
frequently than once every 36 months if the test is performed by a 
physician or other practitioner specified in paragraph (a) of this 
section, and there is evidence that the woman is at high risk (on the 
basis of her medical history or other findings) of developing cervical 
cancer, or vaginal cancer, as determined in accordance with the 
following risk factors:
    (i) High risk factors for cervical cancer:
    (A) Early onset of sexual activity (under 16 years of age).
    (B) Multiple sexual partners (five or more in a lifetime).
    (C) History of a sexually transmitted disease (including HIV 
infection).
    (D) Absence of three negative or any Pap smears within the previous 
7 years.
    (ii) High risk factor for vaginal cancer: DES (diethylstilbestrol)-
exposed daughters of women who took DES during pregnancy.
    (3) More frequent screening for women of childbearing age. Subject 
to the limitation as specified in paragraph (b)(4) of this section, 
payment may be made for a screening pelvic examination performed more 
frequently than once every 36 months if the test is performed by a 
physician or other practitioner as specified in paragraph (a) of this 
section for a woman of childbearing age who has had such an examination 
that indicated the presence of cervical or vaginal cancer or other 
abnormality during any of the preceding 3 years. The term ``woman of 
childbearing age'' means a woman who is premenopausal, and has been 
determined by a physician, or qualified practitioner as specified in 
paragraph (a) of this section, to be of childbearing age, based on her 
medical history or other findings.
    (4) Limitation applicable to women at high risk and those of 
childbearing age. Payment is not made for a screening pelvic 
examination for women considered to be at high risk (under any of the 
criteria described in paragraph (b)(2) of this section), or who qualify 
for coverage under the childbearing provision (under the criteria 
described in paragraph (b)(3) of this section) more frequently than 
once every 11 months after the month that the last screening pelvic 
examination covered by Medicare was performed and found to be normal.
    7. In Sec. 410.160, the introductory text to paragraph (b) is 
republished, and new paragraphs (b)(5) and (b)(6) are added to read as 
follows:


Sec. 410.160  Part B annual deductible.

* * * * *
    (b) Exceptions. Expenses incurred for the following services are 
not subject to the Part B annual deductible and do not count toward 
meeting that deductible:
* * * * *
    (5) Screening mammography services as described in Sec. 410.34 (c) 
and (d).
    (6) Screening pelvic examinations as described in Sec. 410.56.
* * * * *

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

    D. Part 411 is amended as set forth below:
    1. The authority citation for part 411 continues to read as 
follows:

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

    2. In Sec. 411.15 the introductory text to the section and to 
paragraph (a) is republished, paragraph (a)(1) is revised, the 
introductory text to paragraph (k) is republished, and new paragraphs 
(k)(6), (k)(7), and (k)(8) are added to read as follows:


Sec. 411.15  Particular services excluded from coverage.

    The following services are excluded from coverage.
    (a) Routine physical checkups such as--
    (1) Examinations performed for a purpose other than treatment or 
diagnosis of a specific illness, symptom, complaint, or injury, except 
for screening mammography, colorectal cancer screening tests, or 
screening pelvic examinations that meet the criteria specified in 
paragraphs (k)(6), (k)(7), and (k)(8) of this section.
* * * * *
    (k) Any services that are not reasonable and necessary for one of 
the following purposes:
* * * * *
    (6) In the case of screening mammography, for the purpose of early 
detection of breast cancer subject to the conditions and limitations 
specified in Sec. 410.34 of this chapter.
    (7) In the case of colorectal cancer screening tests, for the 
purpose of early detection of colorectal cancer subject to the 
conditions and limitations specified in Sec. 410.37 of this chapter.
    (8) In the case of screening pelvic examinations, for the purpose 
of early detection of cervical or vaginal cancer subject to the 
conditions and limitations specified in Sec. 410.56 of this chapter.
* * * * *

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

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

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

    2. Section 414.20 is revised to read as follows:


Sec. 414.20  Formula for computing fee schedule amounts.

    (a) Participating supplier. The fee schedule amount for a 
participating supplier for a physician service as defined in Sec. 414.2 
is computed as the product of the following amounts:
    (1) The RVUs for the service.
    (2) The GAF for the fee schedule area.
    (3) The CF.
    (b) Nonparticipating supplier. The fee schedule amount for a 
nonparticipating supplier for a physician service as defined in 
Sec. 414.2 is 95 percent of the fee schedule amount as calculated in 
paragraph (a) of this section.
    3. A new Sec. 414.21 is added to read as follows:


Sec. 414.21  Medicare payment basis.

    Medicare payment is based on the lesser of the actual charge or the 
applicable fee schedule amount.

[[Page 59102]]

    4. In Sec. 414.22, the introductory text to the section and to 
paragraph (b) is republished, and new paragraph (b)(4) is added to read 
as follows:


Sec. 414.22  Relative value units (RVUs).

    HCFA establishes RVUs for physician work, physician practice 
expense, and malpractice insurance.
* * * * *
    (b) Practice expense RVUs. * * *
    (4) For services furnished beginning January 1, 1998, practice 
expense RVUs for certain services are reduced to 110 percent of the 
work RVUs for those services. The following two categories of services 
are excluded from this limitation:
    (i) The service is provided more than 75 percent of the time in an 
office setting; or
    (ii) The service is one described in section 1848(c)(2)(G)(v) of 
the Act, codified at 42 U.S.C. 1395w-4(c)(2)(G). Section 
1848(c)(2)(G)(v) of the Act refers to the 1998 proposed resource-based 
practice expense RVUs (as specified in the June 18, 1997 physician fee 
schedule proposed rule (62 FR 33158)) for the specific site, either in-
office or out-of-office, increased from its 1997 practice expense 
RVUs.)
* * * * *
    5. In Sec. 414.32, paragraph (b) is revised to read as follows:


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

* * * * *
    (b) General rule. If physician services of the type routinely 
furnished in a physician's office are furnished in facility settings, 
the fee schedule amount for those services is determined by reducing 
the applicable practice expense RVUs for the service by 50 percent.
* * * * *
    6. In Sec. 414.48, paragraph (b) is revised to read as follows:


Sec. 414.48  Limits on actual charges of nonparticipating suppliers.

* * * * *
    (b) Specific limits. For items or services paid under the physician 
fee schedule, the limiting charge is 115 percent of the fee schedule 
amount for nonparticipating suppliers. For items or services HCFA 
excludes from payment under the physician fee schedule (in accordance 
with section 1848 (j)(3) of the Act), the limiting charge is 115 
percent of 95 percent of the payment basis applicable to participating 
suppliers as calculated in Sec. 414.20(b).
    7. Section 414.62 is added to read as follows:


Sec. 414.62  Fee schedule for clinical psychologist services.

    The fee schedule for clinical psychologist services is set at 100 
percent of the amount determined for corresponding services under the 
physician fee schedule.

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

    Dated: October 23, 1997.
Nancy-Ann Min DeParle,
Deputy Administrator, Health Care Financing Administration.

    Dated: October 27, 1997.
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 G

    The addenda on the following pages provide various data pertaining 
to the Medicare fee schedule for physician services furnished in 1998. 
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.
    Addendum D contains the 1999 GPCIs by Medicare carrier and 
locality. Addendum E contains the 1998 GPCIs by Medicare carrier and 
locality. Addendum F contains the 1999 versus 1997 geographic 
adjustment factor by 1998 fee schedule area. Addendum G contains 
counties included in 1998 localities (listed alphabetically by State 
and locality name within the State).
    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 
1998 listed in Addendum E of this final rule. In applying the formula, 
use the CF of $36.6873. The work adjuster for 1998 is 0.917.

Addendum B--1998 Relative Value Units and Related Information Used in 
Determining Medicare Payments for 1998

    This addendum contains the following information for each CPT code 
and alphanumeric HCPCS code, except for alphanumeric codes beginning 
with B (enteral and parenteral therapy), E (durable medical equipment), 
K (temporary codes for nonphysician services or items), or L 
(orthotics), and codes for anesthesiology.
    1. CPT/HCPCS code. This is the CPT or alphanumeric HCPCS number for 
the service. Alphanumeric HCPCS codes are included at the end of this 
addendum.
    2. Modifier. A modifier is shown if there is a technical component 
(modifier TC) and a professional component (PC) (modifier -26) for the 
service. If there is a PC and a TC for the service, Addendum B contains 
three entries for the code: One for the global values (both 
professional and technical); one for modifier -26 (PC); and one for 
modifier TC. The global service is not designated by a modifier, and 
physicians must bill using the code without a modifier if the physician 
furnishes both the PC and the TC of the service.
    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.

[[Page 59103]]

    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 1998. 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 1998.
    7. Malpractice expense RVUs. These are the RVUs for the malpractice 
expense for the service for 1998.
    8. Total RVUs. This is the sum of the work, practice expense, and 
malpractice expense RVUs for 1998.
    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 1998 
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.

        \4\ * Work RVUs increased in global surgical 
package.

\5\ # Indicates reduction of Practice Expense RVUs as result of 110% PE 
reduction.

[[Page 59103]]



                                            Addendum B.--Relative Value Units (RVUs) and Related Information                                            
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                           Non-                                                         
                                                                             Physician   facility   Facility     Mal-       Non-                        
CPT \1\/          MOD               Status               Description         work RVUs   practice   practice   practice   facility   Facility    Global 
  HCPCS                                                                       \3\ \4\    expense    expense      RVUs      total      total             
   \2\                                                                                   RVUs \5\   RVUs \5\                                            
--------------------------------------------------------------------------------------------------------------------------------------------------------
10040...  ..................  A                   Acne surgery of skin           *1.18       0.32       0.32       0.03       1.53       1.53        010
                                                   abscess.                                                                                             
10060...  ..................  A                   Drainage of skin abscess       *1.17       0.44       0.44       0.04       1.65       1.65        010
10061...  ..................  A                   Drainage of skin abscess       *2.40       0.64       0.64       0.06       3.10       3.10        010
10080...  ..................  A                   Drainage of pilonidal          *1.17       0.50       0.50       0.05       1.72       1.72        010
                                                   cyst.                                                                                                
10081...  ..................  A                   Drainage of pilonidal          *2.45       1.11       1.11       0.16       3.72       3.72        010
                                                   cyst.                                                                                                
10120...  ..................  A                   Remove foreign body.....       *1.22       0.46       0.46       0.05       1.73       1.73        010
10121...  ..................  A                   Remove foreign body.....       *2.69       1.00       1.00       0.12       3.81       3.81        010
10140...  ..................  A                   Drainage of hematoma/          *1.53       0.48       0.48       0.05       2.06       2.06        010
                                                   fluid.                                                                                               
10160...  ..................  A                   Puncture drainage of           *1.20       0.38       0.38       0.05       1.63       1.63        010
                                                   lesion.                                                                                              
10180...  ..................  A                   Complex drainage, wound.       *2.25       1.05       1.05       0.18       3.48       3.48        010
11000...  ..................  A                   Debride infected skin...        0.60       0.40       0.40       0.04       1.04       1.04        000
11001...  ..................  A                   Debride infect skin add.        0.30       0.26       0.26       0.02       0.58       0.58        ZZZ
11010...  ..................  A                   Debride skin, fx........       *4.20       3.96       3.96       0.65       8.81       8.81        010
11011...  ..................  A                   Debride skin/muscle, fx.        4.95       4.72       4.72       0.77      10.44      10.44        000
11012...  ..................  A                   Debride skin/muscle/            6.88       6.56       6.56       1.07      14.51      14.51        000
                                                   bone, fx.                                                                                            
11040...  ..................  A                   Debride skin partial....        0.50       0.40       0.40       0.04       0.94       0.94        000
11041...  ..................  A                   Debride skin full.......        0.82       0.56       0.56       0.06       1.44       1.44        000
11042...  ..................  A                   Debride skin/tissue.....        1.12       0.65       0.65       0.08       1.85       1.85        000
11043...  ..................  A                   Debride tissue/muscle...       *2.38       1.81       1.81       0.34       4.53       4.53        010
11044...  ..................  A                   Debride tissue/muscle/         *3.06       2.82       2.82       0.49       6.37       6.37        010
                                                   bone.                                                                                                
11050...  ..................  D                   Trim skin lesion........        0.00       0.00       0.00       0.00       0.00       0.00        000
11051...  ..................  D                   Trim 2 to 4 skin lesions        0.00       0.00       0.00       0.00       0.00       0.00        000
11052...  ..................  D                   Trim over 4 skin lesions        0.00       0.00       0.00       0.00       0.00       0.00        000
11055...  ..................  R                   Trim skin lesion........        0.27       0.19       0.19       0.01       0.47       0.47        000
11056...  ..................  R                   Trim 2 to 4 skin lesions        0.39       0.26       0.26       0.02       0.67       0.67        000
11057...  ..................  R                   Trim over 4 skin lesions        0.50       0.21       0.21       0.02       0.73       0.73        000
11100...  ..................  A                   Biopsy of skin lesion...        0.81       0.51       0.51       0.04       1.36       1.36        000
11101...  ..................  A                   Biopsy, each added              0.41       0.29       0.29       0.02       0.72       0.72        ZZZ
                                                   lesion.                                                                                              
11200...  ..................  A                   Removal of skin tags....       *0.77       0.43       0.43       0.04       1.24       1.24        010
11201...  ..................  A                   Removal of added skin           0.29       0.17       0.17       0.02       0.48       0.48        ZZZ
                                                   tags.                                                                                                
11300...  ..................  A                   Shave skin lesion.......        0.51       0.53       0.53       0.05       1.09       1.09        000
11301...  ..................  A                   Shave skin lesion.......        0.85       0.67       0.67       0.06       1.58       1.58        000
11302...  ..................  A                   Shave skin lesion.......        1.05       0.89       0.89       0.09       2.03       2.03        000
11303...  ..................  A                   Shave skin lesion.......        1.24       1.36       1.36       0.17       2.77       2.77        000
11305...  ..................  A                   Shave skin lesion.......        0.67       0.52       0.52       0.05       1.24       1.24        000

[[Page 59104]]

                                                                                                                                                        
11306...  ..................  A                   Shave skin lesion.......        0.99       0.71       0.71       0.07       1.77       1.77        000
11307...  ..................  A                   Shave skin lesion.......        1.14       0.94       0.94       0.10       2.18       2.18        000
11308...  ..................  A                   Shave skin lesion.......        1.41       1.40       1.40       0.17       2.98       2.98        000
11310...  ..................  A                   Shave skin lesion.......        0.73       0.69       0.69       0.06       1.48       1.48        000
11311...  ..................  A                   Shave skin lesion.......        1.05       0.85       0.85       0.08       1.98       1.98        000
11312...  ..................  A                   Shave skin lesion.......        1.20       1.12       1.12       0.11       2.43       2.43        000
11313...  ..................  A                   Shave skin lesion.......        1.62       1.49       1.49       0.15       3.26       3.26        000
11400...  ..................  A                   Removal of skin lesion..       *0.91       0.53       0.53       0.05       1.49       1.49        010
11401...  ..................  A                   Removal of skin lesion..       *1.32       0.67       0.67       0.06       2.05       2.05        010
11402...  ..................  A                   Removal of skin lesion..       *1.61       0.89       0.89       0.09       2.59       2.59        010
11403...  ..................  A                   Removal of skin lesion..       *1.92       1.17       1.17       0.13       3.22       3.22        010
11404...  ..................  A                   Removal of skin lesion..       *2.20       1.38       1.38       0.17       3.75       3.75        010
11406...  ..................  A                   Removal of skin lesion..       *2.76       1.88       1.88       0.33       4.97       4.97        010
11420...  ..................  A                   Removal of skin lesion..       *1.06       0.52       0.52       0.05       1.63       1.63        010
11421...  ..................  A                   Removal of skin lesion..       *1.53       0.71       0.71       0.07       2.31       2.31        010
11422...  ..................  A                   Removal of skin lesion..       *1.76       0.94       0.94       0.10       2.80       2.80        010
11423...  ..................  A                   Removal of skin lesion..       *2.17       1.31       1.31       0.15       3.63       3.63        010
11424...  ..................  A                   Removal of skin lesion..       *2.62       1.39       1.39       0.16       4.17       4.17        010
11426...  ..................  A                   Removal of skin lesion..       *3.78       1.83       1.83       0.29       5.90       5.90        010
11440...  ..................  A                   Removal of skin lesion..       *1.15       0.69       0.69       0.06       1.90       1.90        010
11441...  ..................  A                   Removal of skin lesion..       *1.61       0.85       0.85       0.08       2.54       2.54        010
11442...  ..................  A                   Removal of skin lesion..       *1.87       1.12       1.12       0.11       3.10       3.10        010
11443...  ..................  A                   Removal of skin lesion..       *2.49       1.45       1.45       0.15       4.09       4.09        010
11444...  ..................  A                   Removal of skin lesion..       *3.42       1.47       1.47       0.14       5.03       5.03        010
11446...  ..................  A                   Removal of skin lesion..       *4.49       1.78       1.78       0.18       6.45       6.45        010
11450...  ..................  A                   Removal, sweat gland           *2.73       2.68       2.68       0.44       5.85       5.85        090
                                                   lesion.                                                                                              
11451...  ..................  A                   Removal, sweat gland           *3.95       2.90       2.90       0.46       7.31       7.31        090
                                                   lesion.                                                                                              
11462...  ..................  A                   Removal, sweat gland           *2.51       2.41       2.41       0.36       5.28       5.28        090
                                                   lesion.                                                                                              
11463...  ..................  A                   Removal, sweat gland           *3.95       2.00       2.00       0.34       6.29       6.29        090
                                                   lesion.                                                                                              
11470...  ..................  A                   Removal, sweat gland           *3.25       2.78       2.78       0.45       6.48       6.48        090
                                                   lesion.                                                                                              
11471...  ..................  A                   Removal, sweat gland           *4.41       2.46       2.46       0.48       7.35       7.35        090
                                                   lesion.                                                                                              
11600...  ..................  A                   Removal of skin lesion..       *1.41       1.13       1.13       0.10       2.64       2.64        010
11601...  ..................  A                   Removal of skin lesion..       *1.93       1.39       1.39       0.12       3.44       3.44        010
11602...  ..................  A                   Removal of skin lesion..       *2.09       1.82       1.82       0.16       4.07       4.07        010
11603...  ..................  A                   Removal of skin lesion..       *2.35       2.25       2.25       0.21       4.81       4.81        010
11604...  ..................  A                   Removal of skin lesion..       *2.58       2.59       2.59       0.26       5.43       5.43        010
11606...  ..................  A                   Removal of skin lesion..       *3.43       3.11       3.11       0.49       7.03       7.03        010
11620...  ..................  A                   Removal of skin lesion..       *1.34       1.34       1.34       0.12       2.80       2.80        010
11621...  ..................  A                   Removal of skin lesion..       *1.97       1.75       1.75       0.16       3.88       3.88        010
11622...  ..................  A                   Removal of skin lesion..       *2.34       2.20       2.20       0.19       4.73       4.73        010
11623...  ..................  A                   Removal of skin lesion..       *2.93       2.58       2.58       0.25       5.76       5.76        010
11624...  ..................  A                   Removal of skin lesion..       *3.43       3.21       3.21       0.32       6.96       6.96        010
11626...  ..................  A                   Removal of skin lesion..       *4.30       3.41       3.41       0.51       8.22       8.22        010
11640...  ..................  A                   Removal of skin lesion..       *1.53       1.65       1.65       0.15       3.33       3.33        010
11641...  ..................  A                   Removal of skin lesion..       *2.44       2.09       2.09       0.18       4.71       4.71        010
11642...  ..................  A                   Removal of skin lesion..       *2.93       2.57       2.57       0.23       5.73       5.73        010
11643...  ..................  A                   Removal of skin lesion..       *3.50       3.01       3.01       0.28       6.79       6.79        010
11644...  ..................  A                   Removal of skin lesion..       *4.55       3.51       3.51       0.33       8.39       8.39        010
11646...  ..................  A                   Removal of skin lesion..       *5.95       4.32       4.32       0.60      10.87      10.87        010
11719...  ..................  R                   Trim nail(s)............        0.06       0.18      #0.07       0.01       0.25       0.14        000
11720...  ..................  A                   Debride nail, 1-5.......        0.32       0.32       0.32       0.03       0.67       0.67        000
11721...  ..................  A                   Debride nail, 6 or more.        0.54       0.54       0.54       0.05       1.13       1.13        000
11730...  ..................  A                   Removal of nail plate...        1.13       0.45       0.45       0.04       1.62       1.62        000
11731...  ..................  A                   Removal of second nail          0.57       0.51       0.51       0.05       1.13       1.13        ZZZ
                                                   plate.                                                                                               
11732...  ..................  A                   Remove additional nail          0.57       0.25       0.25       0.02       0.84       0.84        ZZZ
                                                   plate.                                                                                               
11740...  ..................  A                   Drain blood from under          0.37       0.39       0.39       0.04       0.80       0.80        000
                                                   nail.                                                                                                
11750...  ..................  A                   Removal of nail bed.....       *1.86       2.10       2.10       0.19       4.15       4.15        010
11752...  ..................  A                   Remove nail bed/finger         *2.67       2.82       2.82       0.36       5.85       5.85        010
                                                   tip.                                                                                                 
11755...  ..................  A                   Biopsy, nail unit.......        1.31       0.99       0.99       0.12       2.42       2.42        000
11760...  ..................  A                   Reconstruction of nail         *1.58       0.93       0.93       0.09       2.60       2.60        010
                                                   bed.                                                                                                 
11762...  ..................  A                   Reconstruction of nail         *2.89       2.57       2.57       0.24       5.70       5.70        010
                                                   bed.                                                                                                 
11765...  ..................  A                   Excision of nail fold,         *0.69       0.51       0.51       0.05       1.25       1.25        010
                                                   toe.                                                                                                 
11770...  ..................  A                   Removal of pilonidal           *2.61       2.67       2.67       0.44       5.72       5.72        010
                                                   lesion.                                                                                              
11771...  ..................  A                   Removal of pilonidal           *5.74       4.52       4.52       0.92      11.18      11.18        090
                                                   lesion.                                                                                              
11772...  ..................  A                   Removal of pilonidal           *6.98       4.82       4.82       1.01      12.81      12.81        090
                                                   lesion.                                                                                              
11900...  ..................  A                   Injection into skin             0.52       0.25       0.25       0.02       0.79       0.79        000
                                                   lesions.                                                                                             
11901...  ..................  A                   Added skin lesions              0.80       0.41       0.41       0.03       1.24       1.24        000
                                                   injection.                                                                                           
11920...  ..................  R                   Correct skin color              1.61       1.18       1.18       0.23       3.02       3.02        000
                                                   defects.                                                                                             
11921...  ..................  R                   Correct skin color              1.93       1.40       1.40       0.28       3.61       3.61        000
                                                   defects.                                                                                             
11922...  ..................  R                   Correct skin color              0.49       0.36       0.36       0.07       0.92       0.92        ZZZ
                                                   defects.                                                                                             
11950...  ..................  R                   Therapy for contour             0.84       1.19       1.19       0.11       2.14       2.14        000
                                                   defects.                                                                                             
11951...  ..................  R                   Therapy for contour             1.19       1.19       1.19       0.11       2.49       2.49        000
                                                   defects.                                                                                             
11952...  ..................  R                   Therapy for contour             1.69       1.19       1.19       0.11       2.99       2.99        000
                                                   defects.                                                                                             
11954...  ..................  R                   Therapy for contour             1.85       1.19       1.19       0.11       3.15       3.15        000
                                                   defects.                                                                                             

[[Page 59105]]

                                                                                                                                                        
11960...  ..................  A                   Insert tissue                  *9.08       7.73       7.73       1.48      18.29      18.29        090
                                                   expander(s).                                                                                         
11970...  ..................  A                   Replace tissue expander.       *7.06      #7.77      #7.77       1.61      16.44      16.44        090
11971...  ..................  A                   Remove tissue                  *2.13       2.30       2.30       0.82       5.25       5.25        090
                                                   expander(s).                                                                                         
11975...  ..................  N                   Insert contraceptive cap       +1.48       1.06       1.06       0.25       2.79       2.79        XXX
11976...  ..................  R                   Removal of contraceptive        1.78       1.28       1.28       0.30       3.36       3.36        XXX
                                                   cap.                                                                                                 
11977...  ..................  N                   Removal/reinsert contra        +3.30       2.36       2.36       0.55       6.21       6.21        XXX
                                                   cap.                                                                                                 
12001...  ..................  A                   Repair superficial             *1.70       0.57       0.57       0.05       2.32       2.32        010
                                                   wound(s).                                                                                            
12002...  ..................  A                   Repair superficial             *1.86       0.79       0.79       0.07       2.72       2.72        010
                                                   wound(s).                                                                                            
12004...  ..................  A                   Repair superficial             *2.24       1.14       1.14       0.10       3.48       3.48        010
                                                   wound(s).                                                                                            
12005...  ..................  A                   Repair superficial             *2.86       1.47       1.47       0.14       4.47       4.47        010
                                                   wound(s).                                                                                            
12006...  ..................  A                   Repair superficial             *3.67       1.78       1.78       0.19       5.64       5.64        010
                                                   wound(s).                                                                                            
12007...  ..................  A                   Repair superficial             *4.12       1.80       1.80       0.19       6.11       6.11        010
                                                   wound(s).                                                                                            
12011...  ..................  A                   Repair superficial             *1.76       0.74       0.74       0.06       2.56       2.56        010
                                                   wound(s).                                                                                            
12013...  ..................  A                   Repair superficial             *1.99       1.03       1.03       0.08       3.10       3.10        010
                                                   wound(s).                                                                                            
12014...  ..................  A                   Repair superficial             *2.46       1.19       1.19       0.10       3.75       3.75        010
                                                   wound(s).                                                                                            
12015...  ..................  A                   Repair superficial             *3.19       1.62       1.62       0.14       4.95       4.95        010
                                                   wound(s).                                                                                            
12016...  ..................  A                   Repair superficial             *3.93       2.26       2.26       0.19       6.38       6.38        010
                                                   wound(s).                                                                                            
12017...  ..................  A                   Repair superficial             *4.71       3.36       3.36       0.31       8.38       8.38        010
                                                   wound(s).                                                                                            
12018...  ..................  A                   Repair superficial             *5.53       5.15       5.15       0.48      11.16      11.16        010
                                                   wound(s).                                                                                            
12020...  ..................  A                   Closure of split wound..       *2.62       1.19       1.19       0.18       3.99       3.99        010
12021...  ..................  A                   Closure of split wound..       *1.84       0.62       0.62       0.11       2.57       2.57        010
12031...  ..................  A                   Layer closure of               *2.15       0.72       0.72       0.07       2.94       2.94        010
                                                   wound(s).                                                                                            
12032...  ..................  A                   Layer closure of               *2.47       1.05       1.05       0.10       3.62       3.62        010
                                                   wound(s).                                                                                            
12034...  ..................  A                   Layer closure of               *2.92       1.47       1.47       0.15       4.54       4.54        010
                                                   wound(s).                                                                                            
12035...  ..................  A                   Layer closure of               *3.43       1.92       1.92       0.23       5.58       5.58        010
                                                   wound(s).                                                                                            
12036...  ..................  A                   Layer closure of               *4.05       2.32       2.32       0.37       6.74       6.74        010
                                                   wound(s).                                                                                            
12037...  ..................  A                   Layer closure of               *4.67       3.09       3.09       0.48       8.24       8.24        010
                                                   wound(s).                                                                                            
12041...  ..................  A                   Layer closure of               *2.37       0.84       0.84       0.08       3.29       3.29        010
                                                   wound(s).                                                                                            
12042...  ..................  A                   Layer closure of               *2.74       1.17       1.17       0.12       4.03       4.03        010
                                                   wound(s).                                                                                            
12044...  ..................  A                   Layer closure of               *3.14       1.62       1.62       0.17       4.93       4.93        010
                                                   wound(s).                                                                                            
12045...  ..................  A                   Layer closure of               *3.64       2.13       2.13       0.23       6.00       6.00        010
                                                   wound(s).                                                                                            
12046...  ..................  A                   Layer closure of               *4.25       2.82       2.82       0.37       7.44       7.44        010
                                                   wound(s).                                                                                            
12047...  ..................  A                   Layer closure of               *4.65       4.02       4.02       0.56       9.23       9.23        010
                                                   wound(s).                                                                                            
12051...  ..................  A                   Layer closure of               *2.47       1.01       1.01       0.10       3.58       3.58        010
                                                   wound(s).                                                                                            
12052...  ..................  A                   Layer closure of               *2.77       1.47       1.47       0.14       4.38       4.38        010
                                                   wound(s).                                                                                            
12053...  ..................  A                   Layer closure of               *3.12       1.76       1.76       0.17       5.05       5.05        010
                                                   wound(s).                                                                                            
12054...  ..................  A                   Layer closure of               *3.46       2.60       2.60       0.25       6.31       6.31        010
                                                   wound(s).                                                                                            
12055...  ..................  A                   Layer closure of               *4.43       3.24       3.24       0.37       8.04       8.04        010
                                                   wound(s).                                                                                            
12056...  ..................  A                   Layer closure of               *5.24       4.74       4.74       0.52      10.50      10.50        010
                                                   wound(s).                                                                                            
12057...  ..................  A                   Layer closure of               *5.96       5.57       5.57       0.48      12.01      12.01        010
                                                   wound(s).                                                                                            
13100...  ..................  A                   Repair of wound or             *3.12       1.14       1.14       0.13       4.39       4.39        010
                                                   lesion.                                                                                              
13101...  ..................  A                   Repair of wound or             *3.92       2.08       2.08       0.21       6.21       6.21        010
                                                   lesion.                                                                                              
13120...  ..................  A                   Repair of wound or             *3.30       1.35       1.35       0.17       4.82       4.82        010
                                                   lesion.                                                                                              
13121...  ..................  A                   Repair of wound or             *4.33       2.65       2.65       0.33       7.31       7.31        010
                                                   lesion.                                                                                              
13131...  ..................  A                   Repair of wound or             *3.79       1.98       1.98       0.23       6.00       6.00        010
                                                   lesion.                                                                                              
13132...  ..................  A                   Repair of wound or             *5.95       4.57       4.57       0.44      10.96      10.96        010
                                                   lesion.                                                                                              
13150...  ..................  A                   Repair of wound or             *3.81       1.76       1.76       0.23       5.80       5.80        010
                                                   lesion.                                                                                              
13151...  ..................  A                   Repair of wound or             *4.45       2.45       2.45       0.35       7.25       7.25        010
                                                   lesion.                                                                                              
13152...  ..................  A                   Repair of wound or             *6.33       5.13       5.13       0.68      12.14      12.14        010
                                                   lesion.                                                                                              
13160...  ..................  A                   Late closure of wound...      *10.48       3.33       3.33       0.58      14.39      14.39        090
13300...  ..................  A                   Repair of wound or             *5.27       5.71       5.71       0.86      11.84      11.84        010
                                                   lesion.                                                                                              
14000...  ..................  A                   Skin tissue                    *5.89       3.41       3.41       0.38       9.68       9.68        090
                                                   rearrangement.                                                                                       
14001...  ..................  A                   Skin tissue                    *8.47       4.75       4.75       0.76      13.98      13.98        090
                                                   rearrangement.                                                                                       
14020...  ..................  A                   Skin tissue                    *6.59       4.90       4.90       0.49      11.98      11.98        090
                                                   rearrangement.                                                                                       
14021...  ..................  A                   Skin tissue                   *10.06       6.21       6.21       0.94      17.21      17.21        090
                                                   rearrangement.                                                                                       
14040...  ..................  A                   Skin tissue                    *7.87       6.77       6.77       0.65      15.29      15.29        090
                                                   rearrangement.                                                                                       
14041...  ..................  A                   Skin tissue                   *11.49       7.88       7.88       1.02      20.39      20.39        090
                                                   rearrangement.                                                                                       
14060...  ..................  A                   Skin tissue                    *8.50       7.75       7.75       1.04      17.29      17.29        090
                                                   rearrangement.                                                                                       
14061...  ..................  A                   Skin tissue                   *12.29      10.49      10.49       1.27      24.05      24.05        090
                                                   rearrangement.                                                                                       
14300...  ..................  A                   Skin tissue                   *11.76      11.31      11.31       1.84      24.91      24.91        090
                                                   rearrangement.                                                                                       
14350...  ..................  A                   Skin tissue                    *9.61       6.07       6.07       1.05      16.73      16.73        090
                                                   rearrangement.                                                                                       
15000...  ..................  A                   Skin graft procedure....        1.95      #2.15      #2.15       0.53       4.63       4.63        ZZZ
15050...  ..................  A                   Skin pinch graft               *4.30       1.79       1.79       0.30       6.39       6.39        090
                                                   procedure.                                                                                           
15100...  ..................  A                   Skin split graft               *9.05       4.54       4.54       0.89      14.48      14.48        090
                                                   procedure.                                                                                           
15101...  ..................  A                   Skin split graft                1.72       1.59       1.59       0.33       3.64       3.64        ZZZ
                                                   procedure.                                                                                           
15120...  ..................  A                   Skin split graft               *9.83       6.05       6.05       0.94      16.82      16.82        090
                                                   procedure.                                                                                           
15121...  ..................  A                   Skin split graft                2.67       2.91       2.91       0.53       6.11       6.11        ZZZ
                                                   procedure.                                                                                           
15200...  ..................  A                   Skin full graft                *8.03       4.13       4.13       0.69      12.85      12.85        090
                                                   procedure.                                                                                           
15201...  ..................  A                   Skin full graft                 1.32       1.68      #1.45       0.50       3.50       3.27        ZZZ
                                                   procedure.                                                                                           
15220...  ..................  A                   Skin full graft                *7.87       4.84       4.84       0.85      13.56      13.56        090
                                                   procedure.                                                                                           
15221...  ..................  A                   Skin full graft                 1.19       1.59      #1.31       0.50       3.28       3.00        ZZZ
                                                   procedure.                                                                                           
15240...  ..................  A                   Skin full graft                *9.04       6.10       6.10       1.03      16.17      16.17        090
                                                   procedure.                                                                                           
15241...  ..................  A                   Skin full graft                 1.86       2.38      #2.05       0.58       4.82       4.49        ZZZ
                                                   procedure.                                                                                           
15260...  ..................  A                   Skin full graft               *10.06       7.46       7.46       0.99      18.51      18.51        090
                                                   procedure.                                                                                           

[[Page 59106]]

                                                                                                                                                        
15261...  ..................  A                   Skin full graft                 2.23       2.85      #2.45       0.60       5.68       5.28        ZZZ
                                                   procedure.                                                                                           
15350...  ..................  A                   Skin homograft procedure       *4.36       2.15       2.15       0.42       6.93       6.93        090
15400...  ..................  A                   Skin heterograft               *5.78       1.06       1.06       0.17       7.01       7.01        090
                                                   procedure.                                                                                           
15570...  ..................  A                   Form skin pedicle flap..       *9.21       5.50       5.50       2.08      16.79      16.79        090
15572...  ..................  A                   Form skin pedicle flap..       *9.27       5.38       5.38       1.86      16.51      16.51        090
15574...  ..................  A                   Form skin pedicle flap..       *9.88       5.40       5.40       1.66      16.94      16.94        090
15576...  ..................  A                   Form skin pedicle flap..       *8.69       3.12       3.12       0.60      12.41      12.41        090
15580...  ..................  A                   Attach skin pedicle            *9.46       4.31       4.31       1.30      15.07      15.07        090
                                                   graft.                                                                                               
15600...  ..................  A                   Skin graft procedure....       *1.91       2.51      #2.10       0.88       5.30       4.89        090
15610...  ..................  A                   Skin graft procedure....       *2.42       2.82      #2.66       0.80       6.04       5.88        090
15620...  ..................  A                   Skin graft procedure....       *2.94       3.44      #3.23       0.86       7.24       7.03        090
15625...  ..................  A                   Skin graft procedure....       *1.91      #2.10      #2.10       0.78       4.79       4.79        090
15630...  ..................  A                   Skin graft procedure....       *3.27      #3.60      #3.60       0.90       7.77       7.77        090
15650...  ..................  A                   Transfer skin pedicle          *3.97      #4.37      #4.37       0.93       9.27       9.27        090
                                                   flap.                                                                                                
15732...  ..................  A                   Muscle-skin graft, head/      *17.84      15.48      15.48       3.46      36.78      36.78        090
                                                   neck.                                                                                                
15734...  ..................  A                   Muscle-skin graft, trunk      *17.79      19.01      19.01       3.24      40.04      40.04        090
15736...  ..................  A                   Muscle-skin graft, arm..      *16.27      16.21      16.21       3.02      35.50      35.50        090
15738...  ..................  A                   Muscle-skin graft, leg..      *17.92      12.89      12.89       3.29      34.10      34.10        090
15740...  ..................  A                   Island pedicle flap           *10.25      10.39      10.39       1.62      22.26      22.26        090
                                                   graft.                                                                                               
15750...  ..................  A                   Neurovascular pedicle         *11.41      11.96      11.96       2.03      25.40      25.40        090
                                                   graft.                                                                                               
15756...  ..................  A                   Free muscle flap,             *35.23      30.09      30.09       5.33      70.65      70.65        090
                                                   microvasc.                                                                                           
15757...  ..................  A                   Free skin flap,               *35.23      30.09      30.09       5.33      70.65      70.65        090
                                                   microvasc.                                                                                           
15758...  ..................  A                   Free fascial flap,            *35.10      30.09      30.09       5.33      70.52      70.52        090
                                                   microvasc.                                                                                           
15760...  ..................  A                   Composite skin graft....       *8.74       7.29       7.29       1.11      17.14      17.14        090
15770...  ..................  A                   Derma-fat-fascia graft..       *7.52       7.46       7.46       0.95      15.93      15.93        090
15775...  ..................  R                   Hair transplant punch           3.96       2.88       2.88       0.56       7.40       7.40        000
                                                   grafts.                                                                                              
15776...  ..................  R                   Hair transplant punch           5.54       4.03       4.03       0.79      10.36      10.36        000
                                                   grafts.                                                                                              
15780...  ..................  A                   Abrasion treatment of          *7.29       1.53       1.53       0.13       8.95       8.95        090
                                                   skin.                                                                                                
15781...  ..................  A                   Abrasion treatment of          *4.85       3.77       3.77       0.39       9.01       9.01        090
                                                   skin.                                                                                                
15782...  ..................  A                   Abrasion treatment of          *4.32       1.19       1.19       0.13       5.64       5.64        090
                                                   skin.                                                                                                
15783...  ..................  A                   Abrasion treatment of          *4.29       1.85       1.85       0.19       6.33       6.33        090
                                                   skin.                                                                                                
15786...  ..................  A                   Abrasion treatment of          *2.03       0.62       0.62       0.06       2.71       2.71        010
                                                   lesion.                                                                                              
15787...  ..................  A                   Abrasion, added skin            0.33       0.23       0.23       0.03       0.59       0.59        ZZZ
                                                   lesions.                                                                                             
15788...  ..................  R                   Chemical peel, face,           *2.09       1.48       1.48       0.12       3.69       3.69        090
                                                   epiderm.                                                                                             
15789...  ..................  R                   Chemical peel, face,           *4.92       1.48       1.48       0.12       6.52       6.52        090
                                                   dermal.                                                                                              
15792...  ..................  R                   Chemical peel, nonfacial       *1.86       0.50       0.50       0.05       2.41       2.41        090
15793...  ..................  A                   Chemical peel, nonfacial       *3.74       0.50       0.50       0.05       4.29       4.29        090
15810...  ..................  A                   Salabrasion.............       *4.74       3.80       3.80       0.29       8.83       8.83        090
15811...  ..................  A                   Salabrasion.............       *5.39       3.74       3.74       0.73       9.86       9.86        090
15819...  ..................  A                   Plastic surgery, neck...       *9.38       8.01       8.01       0.87      18.26      18.26        090
15820...  ..................  A                   Revision of lower eyelid       *5.15      #5.67      #5.67       0.64      11.46      11.46        090
15821...  ..................  A                   Revision of lower eyelid       *5.72      #6.29      #6.29       0.68      12.69      12.69        090
15822...  ..................  A                   Revision of upper eyelid       *4.45      #4.90      #4.90       0.56       9.91       9.91        090
15823...  ..................  A                   Revision of upper eyelid       *7.05       7.71       7.71       0.61      15.37      15.37        090
15824...  ..................  R                   Removal of forehead             0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                   wrinkles.                                                                                            
15825...  ..................  R                   Removal of neck wrinkles        0.00       0.00       0.00       0.00       0.00       0.00        XXX
15826...  ..................  R                   Removal of brow wrinkles        0.00       0.00       0.00       0.00       0.00       0.00        XXX
15828...  ..................  R                   Removal of face wrinkles        0.00       0.00       0.00       0.00       0.00       0.00        XXX
15829...  ..................  R                   Removal of skin wrinkles        0.00       0.00       0.00       0.00       0.00       0.00        XXX
15831...  ..................  A                   Excise excessive skin         *12.40       9.84       9.84       2.01      24.25      24.25        090
                                                   tissue.                                                                                              
15832...  ..................  A                   Excise excessive skin         *11.59       8.29       8.29       1.33      21.21      21.21        090
                                                   tissue.                                                                                              
15833...  ..................  A                   Excise excessive skin         *10.64       6.22       6.22       1.12      17.98      17.98        090
                                                   tissue.                                                                                              
15834...  ..................  A                   Excise excessive skin         *10.85       7.18       7.18       1.22      19.25      19.25        090
                                                   tissue.                                                                                              
15835...  ..................  A                   Excise excessive skin         *11.67       7.00       7.00       1.22      19.89      19.89        090
                                                   tissue.                                                                                              
15836...  ..................  A                   Excise excessive skin          *9.34       5.80       5.80       1.10      16.24      16.24        090
                                                   tissue.                                                                                              
15837...  ..................  A                   Excise excessive skin          *8.43       5.97       5.97       0.85      15.25      15.25        090
                                                   tissue.                                                                                              
15838...  ..................  A                   Excise excessive skin          *7.13       5.88       5.88       0.73      13.74      13.74        090
                                                   tissue.                                                                                              
15839...  ..................  A                   Excise excessive skin          *9.38       2.44       2.44       0.46      12.28      12.28        090
                                                   tissue.                                                                                              
15840...  ..................  A                   Graft for face nerve          *13.26     #14.59     #14.59       2.28      30.13      30.13        090
                                                   palsy.                                                                                               
15841...  ..................  A                   Graft for face nerve          *23.26      16.87      16.87       2.76      42.89      42.89        090
                                                   palsy.                                                                                               
15842...  ..................  A                   Graft for face nerve          *37.96      29.00      29.00       2.68      69.64      69.64        090
                                                   palsy.                                                                                               
15845...  ..................  A                   Skin and muscle repair,       *12.57     #13.83     #13.83       2.54      28.94      28.94        090
                                                   face.                                                                                                
15850...  ..................  B                   Removal of sutures......       +0.78       0.36       0.36       0.04       1.18       1.18        XXX
15851...  ..................  A                   Removal of sutures......        0.86       0.30       0.30       0.03       1.19       1.19        000
15852...  ..................  A                   Dressing change, not for        0.86       0.44       0.44       0.07       1.37       1.37        000
                                                   burn.                                                                                                
15860...  ..................  A                   Test for blood flow in          1.95       1.35       1.35       0.25       3.55       3.55        000
                                                   graft.                                                                                               
15876...  ..................  R                   Suction assisted                0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                   lipectomy.                                                                                           
15877...  ..................  R                   Suction assisted                0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                   lipectomy.                                                                                           
15878...  ..................  R                   Suction assisted                0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                   lipectomy.                                                                                           
15879...  ..................  R                   Suction assisted                0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                   lipectomy.                                                                                           
15920...  ..................  A                   Removal of tail bone           *7.95       2.95       2.95       0.63      11.53      11.53        090
                                                   ulcer.                                                                                               
15922...  ..................  A                   Removal of tail bone           *9.90       5.98       5.98       1.19      17.07      17.07        090
                                                   ulcer.                                                                                               
15931...  ..................  A                   Remove sacrum pressure         *9.24       2.93       2.93       0.55      12.72      12.72        090
                                                   sore.                                                                                                
15933...  ..................  A                   Remove sacrum pressure        *10.85       6.92       6.92       1.43      19.20      19.20        090
                                                   sore.                                                                                                

[[Page 59107]]

                                                                                                                                                        
15934...  ..................  A                   Remove sacrum pressure        *12.69       7.46       7.46       1.50      21.65      21.65        090
                                                   sore.                                                                                                
15935...  ..................  A                   Remove sacrum pressure        *14.57      11.24      11.24       2.27      28.08      28.08        090
                                                   sore.                                                                                                
15936...  ..................  A                   Remove sacrum pressure        *12.38      10.27      10.27       2.05      24.70      24.70        090
                                                   sore.                                                                                                
15937...  ..................  A                   Remove sacrum pressure        *14.21      13.47      13.47       2.67      30.35      30.35        090
                                                   sore.                                                                                                
15940...  ..................  A                   Removal of pressure sore       *9.34       3.55       3.55       0.73      13.62      13.62        090
15941...  ..................  A                   Removal of pressure sore      *11.43       7.05       7.05       1.39      19.87      19.87        090
15944...  ..................  A                   Removal of pressure sore      *11.46       9.26       9.26       1.82      22.54      22.54        090
15945...  ..................  A                   Removal of pressure sore      *12.69      11.14      11.14       2.09      25.92      25.92        090
15946...  ..................  A                   Removal of pressure sore      *21.57      16.61      16.61       3.24      41.42      41.42        090
15950...  ..................  A                   Remove thigh pressure          *7.54       3.01       3.01       0.58      11.13      11.13        090
                                                   sore.                                                                                                
15951...  ..................  A                   Remove thigh pressure         *10.72       7.65       7.65       1.58      19.95      19.95        090
                                                   sore.                                                                                                
15952...  ..................  A                   Remove thigh pressure         *11.39       7.13       7.13       1.37      19.89      19.89        090
                                                   sore.                                                                                                
15953...  ..................  A                   Remove thigh pressure         *12.63       9.08       9.08       1.87      23.58      23.58        090
                                                   sore.                                                                                                
15956...  ..................  A                   Remove thigh pressure         *15.52     #17.07     #17.07       3.39      35.98      35.98        090
                                                   sore.                                                                                                
15958...  ..................  A                   Remove thigh pressure         *15.48     #17.03     #17.03       3.76      36.27      36.27        090
                                                   sore.                                                                                                
15999...  ..................  C                   Removal of pressure sore        0.00       0.00       0.00       0.00       0.00       0.00        YYY
16000...  ..................  A                   Initial treatment of            0.89       0.35       0.35       0.03       1.27       1.27        000
                                                   burn(s).                                                                                             
16010...  ..................  A                   Treatment of burn(s)....        0.87       0.32       0.32       0.03       1.22       1.22        000
16015...  ..................  A                   Treatment of burn(s)....        2.35       2.04       2.04       0.38       4.77       4.77        000
16020...  ..................  A                   Treatment of burn(s)....        0.80       0.34       0.34       0.03       1.17       1.17        000
16025...  ..................  A                   Treatment of burn(s)....        1.85       0.45       0.45       0.05       2.35       2.35        000
16030...  ..................  A                   Treatment of burn(s)....        2.08       0.52       0.52       0.08       2.68       2.68        000
16035...  ..................  A                   Incision of burn scab...       *4.82       1.88       1.88       0.34       7.04       7.04        090
16040...  ..................  A                   Burn wound excision.....        1.02       1.56      #1.12       0.53       3.11       2.67        000
16041...  ..................  A                   Burn wound excision.....        2.70      #2.97      #2.97       0.53       6.20       6.20        000
16042...  ..................  A                   Burn wound excision.....        2.35      #2.59      #2.59       0.53       5.47       5.47        000
17000...  ..................  A                   Destroy benign/premal          *0.60       0.42       0.42       0.03       1.05       1.05        010
                                                   lesion.                                                                                              
17001...  ..................  D                   Destruction of added            0.00       0.00       0.00       0.00       0.00       0.00        ZZZ
                                                   lesions.                                                                                             
17002...  ..................  D                   Destruction of added            0.00       0.00       0.00       0.00       0.00       0.00        ZZZ
                                                   lesions.                                                                                             
17003...  ..................  A                   Destroy 2-14 lesions....        0.15       0.13       0.13       0.01       0.29       0.29        ZZZ
17004...  ..................  A                   Destroy 15 & more              *2.79       2.25       2.25       0.20       5.24       5.24        010
                                                   lesions.                                                                                             
17010...  ..................  D                   12 Destruction skin            *0.00       0.00       0.00       0.00       0.00       0.00        010
                                                   lesion(s).                                                                                           
17100...  ..................  D                   12 Destruction of skin         *0.00       0.00       0.00       0.00       0.00       0.00        010
                                                   lesion.                                                                                              
17101...  ..................  D                   Destruction of 2nd              0.00      #0.00      #0.00       0.00       0.00       0.00        ZZZ
                                                   lesion.                                                                                              
17102...  ..................  D                   Destruction of added            0.00       0.00       0.00       0.00       0.00       0.00        ZZZ
                                                   lesions.                                                                                             
17104...  ..................  D                   Destruction of skin            *0.00       0.00       0.00       0.00       0.00       0.00        010
                                                   lesions.                                                                                             
17105...  ..................  D                   Destruction of skin            *0.00       0.00       0.00       0.00       0.00       0.00        010
                                                   lesions.                                                                                             
17106...  ..................  A                   Destruction of skin            *4.59       1.93       1.93       0.18       6.70       6.70        090
                                                   lesions.                                                                                             
17107...  ..................  A                   Destruction of skin            *9.16       3.70       3.70       0.39      13.25      13.25        090
                                                   lesions.                                                                                             
17108...  ..................  A                   Destruction of skin           *13.20       9.32       9.32       0.69      23.21      23.21        090
                                                   lesions.                                                                                             
17110...  ..................  A                   Destruct lesion, 1-14...       *0.65       0.40       0.40       0.03       1.08       1.08        010
17111...  ..................  A                   Destruct lesion, 15 or         *0.92       0.60       0.60       0.05       1.57       1.57        010
                                                   more.                                                                                                
17200...  ..................  D                   1 Electrocautery of skin       *0.00       0.00       0.00       0.00       0.00       0.00        010
                                                   tags.                                                                                                
17201...  ..................  D                   Electrocautery added            0.00       0.00       0.00       0.00       0.00       0.00        ZZZ
                                                   lesions.                                                                                             
17250...  ..................  A                   Chemical cautery, tissue        0.50       0.34       0.34       0.04       0.88       0.88        000
17260...  ..................  A                   Destruction of skin            *0.91       1.13       1.13       0.10       2.14       2.14        010
                                                   lesions.                                                                                             
17261...  ..................  A                   Destruction of skin            *1.17       1.39       1.39       0.12       2.68       2.68        010
                                                   lesions.                                                                                             
17262...  ..................  A                   Destruction of skin            *1.58       1.82       1.82       0.16       3.56       3.56        010
                                                   lesions.                                                                                             
17263...  ..................  A                   Destruction of skin            *1.79       2.25       2.25       0.21       4.25       4.25        010
                                                   lesions.                                                                                             
17264...  ..................  A                   Destruction of skin            *1.94       2.59       2.59       0.26       4.79       4.79        010
                                                   lesions.                                                                                             
17266...  ..................  A                   Destruction of skin            *2.34       3.11       3.11       0.49       5.94       5.94        010
                                                   lesions.                                                                                             
17270...  ..................  A                   Destruction of skin            *1.32       1.34       1.34       0.12       2.78       2.78        010
                                                   lesions.                                                                                             
17271...  ..................  A                   Destruction of skin            *1.49       1.75       1.75       0.16       3.40       3.40        010
                                                   lesions.                                                                                             
17272...  ..................  A                   Destruction of skin            *1.77       2.20       2.20       0.19       4.16       4.16        010
                                                   lesions.                                                                                             
17273...  ..................  A                   Destruction of skin            *2.05       2.58       2.58       0.25       4.88       4.88        010
                                                   lesions.                                                                                             
17274...  ..................  A                   Destruction of skin            *2.59       3.21       3.21       0.32       6.12       6.12        010
                                                   lesions.                                                                                             
17276...  ..................  A                   Destruction of skin            *3.20       3.41       3.41       0.51       7.12       7.12        010
                                                   lesions.                                                                                             
17280...  ..................  A                   Destruction of skin            *1.17       1.65       1.65       0.15       2.97       2.97        010
                                                   lesions.                                                                                             
17281...  ..................  A                   Destruction of skin            *1.72       2.09       2.09       0.18       3.99       3.99        010
                                                   lesions.                                                                                             
17282...  ..................  A                   Destruction of skin            *2.04       2.57       2.57       0.23       4.84       4.84        010
                                                   lesions.                                                                                             
17283...  ..................  A                   Destruction of skin            *2.64       3.01       3.01       0.28       5.93       5.93        010
                                                   lesions.                                                                                             
17284...  ..................  A                   Destruction of skin            *3.21       3.51       3.51       0.33       7.05       7.05        010
                                                   lesions.                                                                                             
17286...  ..................  A                   Destruction of skin            *4.44       4.32       4.32       0.60       9.36       9.36        010
                                                   lesions.                                                                                             
17304...  ..................  A                   Chemosurgery of skin            7.60       4.02       4.02       0.31      11.93      11.93        000
                                                   lesion.                                                                                              
17305...  ..................  A                   2nd stage chemosurgery..        2.85       2.26       2.26       0.17       5.28       5.28        000
17306...  ..................  A                   3rd stage chemosurgery..        2.85       1.40       1.40       0.11       4.36       4.36        000
17307...  ..................  A                   Followup skin lesion            2.85       1.47       1.47       0.12       4.44       4.44        000
                                                   therapy.                                                                                             
17310...  ..................  A                   Extensive skin                  0.95       0.13       0.13       0.01       1.09       1.09        000
                                                   chemosurgery.                                                                                        
17340...  ..................  A                   Cryotherapy of skin.....       *0.76       0.28       0.28       0.02       1.06       1.06        010
17360...  ..................  A                   Skin peel therapy.......       *1.43       0.27       0.27       0.02       1.72       1.72        010
17380...  ..................  R                   Hair removal by                 0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                   electrolysis.                                                                                        
17999...  ..................  C                   Skin tissue procedure...        0.00       0.00       0.00       0.00       0.00       0.00        YYY
19000...  ..................  A                   Drainage of breast              0.84       0.38       0.38       0.07       1.29       1.29        000
                                                   lesion.                                                                                              
19001...  ..................  A                   Drain added breast              0.42       0.24       0.24       0.05       0.71       0.71        ZZZ
                                                   lesion.                                                                                              

[[Page 59108]]

                                                                                                                                                        
19020...  ..................  A                   Incision of breast             *3.57       1.40       1.40       0.28       5.25       5.25        090
                                                   lesion.                                                                                              
19030...  ..................  A                   Injection for breast x-         1.53       0.49       0.49       0.04       2.06       2.06        000
                                                   ray.                                                                                                 
19100...  ..................  A                   Biopsy of breast........        1.27       0.64       0.64       0.13       2.04       2.04        000
19101...  ..................  A                   Biopsy of breast........       *3.18       2.34       2.34       0.45       5.97       5.97        010
19110...  ..................  A                   Nipple exploration......       *4.30       2.46       2.46       0.51       7.27       7.27        090
19112...  ..................  A                   Excise breast duct             *3.67       2.34       2.34       0.35       6.36       6.36        090
                                                   fistula.                                                                                             
19120...  ..................  A                   Removal of breast lesion       *5.56       2.90       2.90       0.60       9.06       9.06        090
19125...  ..................  A                   Excision, breast lesion.       *6.06       2.90       2.90       0.60       9.56       9.56        090
19126...  ..................  A                   Excision, added breast          2.93       1.45       1.45       0.31       4.69       4.69        ZZZ
                                                   lesion.                                                                                              
19140...  ..................  A                   Removal of breast tissue       *5.14       4.29       4.29       0.91      10.34      10.34        090
19160...  ..................  A                   Removal of breast tissue       *5.99       4.13       4.13       0.88      11.00      11.00        090
19162...  ..................  A                   Remove breast tissue,         *13.53       9.38       9.38       1.96      24.87      24.87        090
                                                   nodes.                                                                                               
19180...  ..................  A                   Removal of breast.......       *8.80       5.61       5.61       1.17      15.58      15.58        090
19182...  ..................  A                   Removal of breast.......       *7.73       6.07       6.07       1.27      15.07      15.07        090
19200...  ..................  A                   Removal of breast.......      *15.49      10.22      10.22       2.15      27.86      27.86        090
19220...  ..................  A                   Removal of breast.......      *15.72      10.73      10.73       2.38      28.83      28.83        090
19240...  ..................  A                   Removal of breast.......      *16.00       9.44       9.44       1.99      27.43      27.43        090
19260...  ..................  A                   Removal of chest wall         *15.44       5.05       5.05       1.04      21.53      21.53        090
                                                   lesion.                                                                                              
19271...  ..................  A                   Revision of chest wall..      *18.90      13.95      13.95       2.77      35.62      35.62        090
19272...  ..................  A                   Extensive chest wall          *21.55      12.60      12.60       2.56      36.71      36.71        090
                                                   surgery.                                                                                             
19290...  ..................  A                   Place needle wire,              1.27       0.44       0.44       0.07       1.78       1.78        000
                                                   breast.                                                                                              
19291...  ..................  A                   Place needle wire,              0.63       0.25       0.25       0.04       0.92       0.92        ZZZ
                                                   breast.                                                                                              
19316...  ..................  A                   Suspension of breast....      *10.69     #11.76     #11.76       2.43      24.88      24.88        090
19318...  ..................  A                   Reduction of large            *15.62      14.18      14.18       3.23      33.03      33.03        090
                                                   breast.                                                                                              
19324...  ..................  A                   Enlarge breast..........       *5.85       3.29       3.29       0.67       9.81       9.81        090
19325...  ..................  A                   Enlarge breast with            *8.45       5.87       5.87       1.13      15.45      15.45        090
                                                   implant.                                                                                             
19328...  ..................  A                   Removal of breast              *5.68       3.76       3.76       0.73      10.17      10.17        090
                                                   implant.                                                                                             
19330...  ..................  A                   Removal of implant             *7.59       3.88       3.88       0.75      12.22      12.22        090
                                                   material.                                                                                            
19340...  ..................  A                   Immediate breast                6.33      #6.96      #6.96       2.06      15.35      15.35        ZZZ
                                                   prosthesis.                                                                                          
19342...  ..................  A                   Delayed breast                *11.20      10.81      10.81       2.03      24.04      24.04        090
                                                   prosthesis.                                                                                          
19350...  ..................  A                   Breast reconstruction...       *8.92       7.08       7.08       1.38      17.38      17.38        090
19355...  ..................  A                   Correct inverted               *7.57       4.93       4.93       1.00      13.50      13.50        090
                                                   nipple(s).                                                                                           
19357...  ..................  A                   Breast reconstruction...      *18.16      12.15      12.15       2.37      32.68      32.68        090
19361...  ..................  A                   Breast reconstruction...      *19.26      20.13      20.13       3.88      43.27      43.27        090
19364...  ..................  A                   Breast reconstruction...      *29.04      16.68      16.68       3.58      49.30      49.30        090
19366...  ..................  A                   Breast reconstruction...      *21.28      16.40      16.40       3.18      40.86      40.86        090
19367...  ..................  A                   Breast reconstruction...      *25.73      20.13      20.13       3.88      49.74      49.74        090
19368...  ..................  A                   Breast reconstruction...      *32.42      20.13      20.13       3.88      56.43      56.43        090
19369...  ..................  A                   Breast reconstruction...      *29.82      20.13      20.13       3.88      53.83      53.83        090
19370...  ..................  A                   Surgery of breast              *8.05       6.17       6.17       1.19      15.41      15.41        090
                                                   capsule.                                                                                             
19371...  ..................  A                   Removal of breast              *9.35       7.91       7.91       1.54      18.80      18.80        090
                                                   capsule.                                                                                             
19380...  ..................  A                   Revise breast                  *9.14       8.11       8.11       1.57      18.82      18.82        090
                                                   reconstruction.                                                                                      
19396...  ..................  A                   Design custom breast            2.17       1.57       1.57       0.31       4.05       4.05        000
                                                   implant.                                                                                             
19499...  ..................  C                   Breast surgery procedure        0.00       0.00       0.00       0.00       0.00       0.00        YYY
20000...  ..................  A                   Incision of abscess.....       *2.12       0.85       0.85       0.08       3.05       3.05        010
20005...  ..................  A                   Incision of deep abscess       *3.42       1.83       1.83       0.28       5.53       5.53        010
20100...  ..................  A                   Explore wound, neck.....      *10.08       4.97       4.97       1.16      16.21      16.21        010
20101...  ..................  A                   Explore wound, chest....       *3.22       1.57       1.57       0.37       5.16       5.16        010
20102...  ..................  A                   Explore wound, abdomen..       *3.94       1.92       1.92       0.45       6.31       6.31        010
20103...  ..................  A                   Explore wound, extremity       *5.30       2.59       2.59       0.60       8.49       8.49        010
20150...  ..................  A                   Excise epiphyseal bar...      *13.69      12.40      12.40       2.03      28.12      28.12        090
20200...  ..................  A                   Muscle biopsy...........        1.46       1.12       1.12       0.18       2.76       2.76        000
20205...  ..................  A                   Deep muscle biopsy......        2.35       1.88       1.88       0.33       4.56       4.56        000
20206...  ..................  A                   Needle biopsy, muscle...        0.99       0.96       0.96       0.14       2.09       2.09        000
20220...  ..................  A                   Bone biopsy, trocar/            1.27       1.31       1.31       0.09       2.67       2.67        000
                                                   needle.                                                                                              
20225...  ..................  A                   Bone biopsy, trocar/            1.87       2.39      #2.06       0.28       4.54       4.21        000
                                                   needle.                                                                                              
20240...  ..................  A                   Bone biopsy, excisional.       *3.23       1.88       1.88       0.18       5.29       5.29        010
20245...  ..................  A                   Bone biopsy, excisional.       *3.95       3.58       3.58       0.44       7.97       7.97        010
20250...  ..................  A                   Open bone biopsy........       *5.03       5.07       5.07       0.76      10.86      10.86        010
20251...  ..................  A                   Open bone biopsy........       *5.56       5.84       5.84       0.92      12.32      12.32        010
20500...  ..................  A                   Injection of sinus tract       *1.23       0.36       0.36       0.04       1.63       1.63        010
20501...  ..................  A                   Inject sinus tract for x-       0.76       0.30       0.30       0.02       1.08       1.08        000
                                                   ray.                                                                                                 
20520...  ..................  A                   Removal of foreign body.       *1.85       0.71       0.71       0.08       2.64       2.64        010
20525...  ..................  A                   Removal of foreign body.       *3.50       2.23       2.23       0.33       6.06       6.06        010
20550...  ..................  A                   Inj tendon/ligament/cyst        0.86       0.38       0.38       0.04       1.28       1.28        000
20600...  ..................  A                   Drain/inject joint/bursa        0.66       0.47       0.47       0.05       1.18       1.18        000
20605...  ..................  A                   Drain/inject joint/bursa        0.68       0.45       0.45       0.05       1.18       1.18        000
20610...  ..................  A                   Drain/inject joint/bursa        0.79       0.45       0.45       0.05       1.29       1.29        000
20615...  ..................  A                   Treatment of bone cyst..       *2.28       0.49       0.49       0.06       2.83       2.83        010
20650...  ..................  A                   Insert and remove bone         *2.23       1.08       1.08       0.14       3.45       3.45        010
                                                   pin.                                                                                                 
20660...  ..................  A                   Apply, remove fixation          2.51       1.56       1.56       0.21       4.28       4.28        000
                                                   device.                                                                                              
20661...  ..................  A                   Application of head            *4.89       3.82       3.82       0.65       9.36       9.36        090
                                                   brace.                                                                                               
20662...  ..................  A                   Application of pelvis          *6.07       6.54       6.54       1.03      13.64      13.64        090
                                                   brace.                                                                                               
20663...  ..................  A                   Application of thigh           *5.43       4.64       4.64       0.76      10.83      10.83        090
                                                   brace.                                                                                               

[[Page 59109]]

                                                                                                                                                        
20664...  ..................  A                   Halo brace application..       *8.06       3.82       3.82       0.65      12.53      12.53        090
20665...  ..................  A                   Removal of fixation            *1.31       0.50       0.50       0.07       1.88       1.88        010
                                                   device.                                                                                              
20670...  ..................  A                   Removal of support             *1.74       0.74       0.74       0.11       2.59       2.59        010
                                                   implant.                                                                                             
20680...  ..................  A                   Removal of support             *3.35       3.33       3.33       0.51       7.19       7.19        090
                                                   implant.                                                                                             
20690...  ..................  A                   Apply bone fixation             3.52       3.66       3.66       0.58       7.76       7.76        ZZZ
                                                   device.                                                                                              
20692...  ..................  A                   Apply bone fixation             6.41       5.51       5.51       0.89      12.81      12.81        ZZZ
                                                   device.                                                                                              
20693...  ..................  A                   Adjust bone fixation           *5.86       2.49       2.49       0.42       8.77       8.77        090
                                                   device.                                                                                              
20694...  ..................  A                   Remove bone fixation           *4.16       2.60       2.60       0.41       7.17       7.17        090
                                                   device.                                                                                              
20802...  ..................  A                   Replantation, arm,            *41.15      37.72      37.72       6.17      85.04      85.04        090
                                                   complete.                                                                                            
20805...  ..................  A                   Replant forearm,              *50.00      46.17      46.17       7.56     103.73     103.73        090
                                                   complete.                                                                                            
20808...  ..................  A                   Replantation, hand,           *61.65      57.40      57.40       9.40     128.45     128.45        090
                                                   complete.                                                                                            
20816...  ..................  A                   Replantation digit,           *30.94      28.30      28.30       4.63      63.87      63.87        090
                                                   complete.                                                                                            
20822...  ..................  A                   Replantation digit,           *25.59      23.39      23.39       3.83      52.81      52.81        090
                                                   complete.                                                                                            
20824...  ..................  A                   Replantation thumb,           *30.94      28.30      28.30       4.63      63.87      63.87        090
                                                   complete.                                                                                            
20827...  ..................  A                   Replantation thumb,           *26.41      24.05      24.05       3.94      54.40      54.40        090
                                                   complete.                                                                                            
20838...  ..................  A                   Replantation, foot,           *41.41      37.72      37.72       6.17      85.30      85.30        090
                                                   complete.                                                                                            
20900...  ..................  A                   Removal of bone for            *5.58       2.80       2.80       0.45       8.83       8.83        090
                                                   graft.                                                                                               
20902...  ..................  A                   Removal of bone for            *7.55       4.95       4.95       0.80      13.30      13.30        090
                                                   graft.                                                                                               
20910...  ..................  A                   Remove cartilage for           *5.34       0.79       0.79       0.09       6.22       6.22        090
                                                   graft.                                                                                               
20912...  ..................  A                   Remove cartilage for           *6.35       4.62       4.62       0.64      11.61      11.61        090
                                                   graft.                                                                                               
20920...  ..................  A                   Removal of fascia for          *5.31       3.93       3.93       0.50       9.74       9.74        090
                                                   graft.                                                                                               
20922...  ..................  A                   Removal of fascia for          *6.61       4.39       4.39       0.71      11.71      11.71        090
                                                   graft.                                                                                               
20924...  ..................  A                   Removal of tendon for          *6.48       5.45       5.45       0.85      12.78      12.78        090
                                                   graft.                                                                                               
20926...  ..................  A                   Removal of tissue for          *5.53       2.59       2.59       0.39       8.51       8.51        090
                                                   graft.                                                                                               
20930...  ..................  B                   Spinal bone allograft...        0.00       0.00       0.00       0.00       0.00       0.00        XXX
20931...  ..................  A                   Spinal bone allograft...        1.81       1.73       1.73       0.28       3.82       3.82        ZZZ
20936...  ..................  B                   Spinal bone autograft...        0.00       0.00       0.00       0.00       0.00       0.00        XXX
20937...  ..................  A                   Spinal bone autograft...        2.79       2.66       2.66       0.44       5.89       5.89        ZZZ
20938...  ..................  A                   Spinal bone autograft...        3.02       2.88       2.88       0.47       6.37       6.37        ZZZ
20950...  ..................  A                   Record fluid pressure,          1.26       1.09       1.09       0.17       2.52       2.52        000
                                                   muscle.                                                                                              
20955...  ..................  A                   Fibula bone graft,            *39.21      35.84      35.84       5.87      80.92      80.92        090
                                                   microvasc.                                                                                           
20956...  ..................  A                   Iliac bone graft,             *39.27      26.90      26.90       5.26      71.43      71.43        090
                                                   microvasc.                                                                                           
20957...  ..................  A                   Mt bone graft, microvasc      *40.65      27.87      27.87       5.45      73.97      73.97        090
20962...  ..................  A                   Other bone graft,             *39.27      26.90      26.90       5.26      71.43      71.43        090
                                                   microvasc.                                                                                           
20969...  ..................  A                   Bone/skin graft,              *43.92      40.13      40.13       6.57      90.62      90.62        090
                                                   microvasc.                                                                                           
20970...  ..................  A                   Bone/skin graft, iliac        *43.06      39.31      39.31       6.44      88.81      88.81        090
                                                   crest.                                                                                               
20972...  ..................  A                   Bone-skin graft,              *42.99      39.61      39.61       6.49      89.09      89.09        090
                                                   metatarsal.                                                                                          
20973...  ..................  A                   Bone-skin graft, great        *45.76      42.25      42.25       6.91      94.92      94.92        090
                                                   toe.                                                                                                 
20974...  ..................  A                   Electrical bone                 0.62       3.42       3.42       0.53       4.57       4.57        000
                                                   stimulation.                                                                                         
20975...  ..................  A                   Electrical bone                 2.60      #2.86      #2.86       0.56       6.02       6.02        ZZZ
                                                   stimulation.                                                                                         
20999...  ..................  C                   Musculoskeletal surgery.        0.00       0.00       0.00       0.00       0.00       0.00        YYY
21010...  ..................  A                   Incision of jaw joint...      *10.14      10.24      10.24       0.93      21.31      21.31        090
21015...  ..................  A                   Resection of facial            *5.29      #5.82      #5.82       1.13      12.24      12.24        090
                                                   tumor.                                                                                               
21025...  ..................  A                   Excision of bone, lower       *10.06       4.14       4.14       0.38      14.58      14.58        090
                                                   jaw.                                                                                                 
21026...  ..................  A                   Excision of facial             *4.85       3.14       3.14       0.28       8.27       8.27        090
                                                   bone(s).                                                                                             
21029...  ..................  A                   Contour of face bone           *7.71      #8.48      #8.48       0.78      16.97      16.97        090
                                                   lesion.                                                                                              
21030...  ..................  A                   Removal of face bone           *6.46       3.35       3.35       0.29      10.10      10.10        090
                                                   lesion.                                                                                              
21031...  ..................  A                   Remove exostosis,              *3.24       3.68       3.68       0.32       7.24       7.24        090
                                                   mandible.                                                                                            
21032...  ..................  A                   Remove exostosis,              *3.24       3.88       3.88       0.35       7.47       7.47        090
                                                   maxilla.                                                                                             
21034...  ..................  A                   Removal of face bone          *16.17       6.98       6.98       0.89      24.04      24.04        090
                                                   lesion.                                                                                              
21040...  ..................  A                   Removal of jaw bone            *2.11       2.76       2.76       0.24       5.11       5.11        090
                                                   lesion.                                                                                              
21041...  ..................  A                   Removal of jaw bone            *6.71       5.76       5.76       0.50      12.97      12.97        090
                                                   lesion.                                                                                              
21044...  ..................  A                   Removal of jaw bone           *11.86       9.55       9.55       1.11      22.52      22.52        090
                                                   lesion.                                                                                              
21045...  ..................  A                   Extensive jaw surgery...      *16.17      13.83      13.83       1.58      31.58      31.58        090
21050...  ..................  A                   Removal of jaw joint....      *10.77     #11.85     #11.85       1.08      23.70      23.70        090
21060...  ..................  A                   Remove jaw joint              *10.23     #11.25     #11.25       1.04      22.52      22.52        090
                                                   cartilage.                                                                                           
21070...  ..................  A                   Remove coronoid process.       *8.20       6.81       6.81       0.82      15.83      15.83        090
21076...  ..................  A                   Prepare face/oral             *13.42     #14.76     #14.76       1.35      29.53      29.53        010
                                                   prosthesis.                                                                                          
21077...  ..................  A                   Prepare face/oral             *33.75     #37.13     #37.13       3.39      74.27      74.27        090
                                                   prosthesis.                                                                                          
21079...  ..................  A                   Prepare face/oral             *22.34      27.93      27.93       2.25      52.52      52.52        090
                                                   prosthesis.                                                                                          
21080...  ..................  A                   Prepare face/oral             *25.10      31.38      31.38       2.52      59.00      59.00        090
                                                   prosthesis.                                                                                          
21081...  ..................  A                   Prepare face/oral             *22.88      28.59      28.59       2.30      53.77      53.77        090
                                                   prosthesis.                                                                                          
21082...  ..................  A                   Prepare face/oral             *20.87     #22.96     #22.96       2.10      45.93      45.93        090
                                                   prosthesis.                                                                                          
21083...  ..................  A                   Prepare face/oral             *19.30      24.13      24.13       1.94      45.37      45.37        090
                                                   prosthesis.                                                                                          
21084...  ..................  A                   Prepare face/oral             *22.51      28.14      28.14       2.28      52.93      52.93        090
                                                   prosthesis.                                                                                          
21085...  ..................  A                   Prepare face/oral              *9.00      #9.90      #9.90       0.90      19.80      19.80        010
                                                   prosthesis.                                                                                          
21086...  ..................  A                   Prepare face/oral             *24.92      31.15      31.15       2.51      58.58      58.58        090
                                                   prosthesis.                                                                                          
21087...  ..................  A                   Prepare face/oral             *24.92     #27.41     #27.41       2.51      54.84      54.84        090
                                                   prosthesis.                                                                                          
21088...  ..................  C                   Prepare face/oral               0.00       0.00       0.00       0.00       0.00       0.00        090
                                                   prosthesis.                                                                                          
21089...  ..................  C                   Prepare face/oral               0.00       0.00       0.00       0.00       0.00       0.00        090
                                                   prosthesis.                                                                                          
21100...  ..................  A                   Maxillofacial fixation..       *4.22       1.06       1.06       0.11       5.39       5.39        090
21110...  ..................  A                   Interdental fixation....       *5.21       5.53       5.53       0.46      11.20      11.20        090
21116...  ..................  A                   Injection, jaw joint x-         0.81       0.73       0.73       0.06       1.60       1.60        000
                                                   ray.                                                                                                 
21120...  ..................  A                   Reconstruction of chin..       *4.93       3.59       3.59       0.42       8.94       8.94        090

[[Page 59110]]

                                                                                                                                                        
21121...  ..................  A                   Reconstruction of chin..       *7.64       5.65       5.65       0.66      13.95      13.95        090
21122...  ..................  A                   Reconstruction of chin..       *8.52       6.23       6.23       0.73      15.48      15.48        090
21123...  ..................  A                   Reconstruction of chin..      *11.16       8.14       8.14       0.95      20.25      20.25        090
21125...  ..................  A                   Augmentation lower jaw        *10.62       4.72       4.72       0.54      15.88      15.88        090
                                                   bone.                                                                                                
21127...  ..................  A                   Augmentation lower jaw        *11.12       7.91       7.91       0.92      19.95      19.95        090
                                                   bone.                                                                                                
21137...  ..................  A                   Reduction of forehead...       *9.82       7.11       7.11       0.83      17.76      17.76        090
21138...  ..................  A                   Reduction of forehead...      *12.19       8.86       8.86       1.04      22.09      22.09        090
21139...  ..................  A                   Reduction of forehead...      *14.61      10.64      10.64       1.25      26.50      26.50        090
21141...  ..................  A                   Reconstruct midface,          *18.10      14.34      14.34       1.68      34.12      34.12        090
                                                   lefort.                                                                                              
21142...  ..................  A                   Reconstruct midface,          *18.81      14.84      14.84       1.74      35.39      35.39        090
                                                   lefort.                                                                                              
21143...  ..................  A                   Reconstruct midface,          *19.58      15.40      15.40       1.81      36.79      36.79        090
                                                   lefort.                                                                                              
21145...  ..................  A                   Reconstruct midface,          *19.94      14.34      14.34       1.68      35.96      35.96        090
                                                   lefort.                                                                                              
21146...  ..................  A                   Reconstruct midface,          *20.71      14.84      14.84       1.74      37.29      37.29        090
                                                   lefort.                                                                                              
21147...  ..................  A                   Reconstruct midface,          *21.77      15.40      15.40       1.81      38.98      38.98        090
                                                   lefort.                                                                                              
21150...  ..................  A                   Reconstruct midface,          *25.24      18.46      18.46       2.17      45.87      45.87        090
                                                   lefort.                                                                                              
21151...  ..................  A                   Reconstruct midface,          *28.30      20.68      20.68       2.42      51.40      51.40        090
                                                   lefort.                                                                                              
21154...  ..................  A                   Reconstruct midface,          *30.52      22.15      22.15       2.59      55.26      55.26        090
                                                   lefort.                                                                                              
21155...  ..................  A                   Reconstruct midface,          *34.45      25.11      25.11       2.94      62.50      62.50        090
                                                   lefort.                                                                                              
21159...  ..................  A                   Reconstruct midface,          *42.38      31.02      31.02       3.63      77.03      77.03        090
                                                   lefort.                                                                                              
21160...  ..................  A                   Reconstruct midface,          *46.44      33.96      33.96       3.98      84.38      84.38        090
                                                   lefort.                                                                                              
21172...  ..................  A                   Reconstruct orbit/            *27.80      20.30      20.30       2.37      50.47      50.47        090
                                                   forehead.                                                                                            
21175...  ..................  A                   Reconstruct orbit/            *33.17      24.37      24.37       2.85      60.39      60.39        090
                                                   forehead.                                                                                            
21179...  ..................  A                   Reconstruct entire            *22.25      16.24      16.24       1.90      40.39      40.39        090
                                                   forehead.                                                                                            
21180...  ..................  A                   Reconstruct entire            *25.19      18.46      18.46       2.17      45.82      45.82        090
                                                   forehead.                                                                                            
21181...  ..................  A                   Contour cranial bone           *9.90       7.11       7.11       0.83      17.84      17.84        090
                                                   lesion.                                                                                              
21182...  ..................  A                   Reconstruct cranial bone      *32.19      23.63      23.63       2.77      58.59      58.59        090
21183...  ..................  A                   Reconstruct cranial bone      *35.31      25.85      25.85       3.03      64.19      64.19        090
21184...  ..................  A                   Reconstruct cranial bone      *38.24      28.06      28.06       3.28      69.58      69.58        090
21188...  ..................  A                   Reconstruction of             *22.46      16.24      16.24       1.90      40.60      40.60        090
                                                   midface.                                                                                             
21193...  ..................  A                   Reconstruct lower jaw         *17.15      12.31      12.31       1.44      30.90      30.90        090
                                                   bone.                                                                                                
21194...  ..................  A                   Reconstruct lower jaw         *19.84      14.26      14.26       1.67      35.77      35.77        090
                                                   bone.                                                                                                
21195...  ..................  A                   Reconstruct lower jaw         *17.24      12.34      12.34       1.44      31.02      31.02        090
                                                   bone.                                                                                                
21196...  ..................  A                   Reconstruct lower jaw         *18.91      13.61      13.61       1.58      34.10      34.10        090
                                                   bone.                                                                                                
21198...  ..................  A                   Reconstruct lower jaw         *14.16      14.82      14.82       1.74      30.72      30.72        090
                                                   bone.                                                                                                
21206...  ..................  A                   Reconstruct upper jaw         *14.10      10.14      10.14       1.19      25.43      25.43        090
                                                   bone.                                                                                                
21208...  ..................  A                   Augmentation of facial        *10.23     #11.25     #11.25       1.07      22.55      22.55        090
                                                   bones.                                                                                               
21209...  ..................  A                   Reduction of facial            *6.72       4.59       4.59       0.76      12.07      12.07        090
                                                   bones.                                                                                               
21210...  ..................  A                   Face bone graft.........      *10.23     #11.25     #11.25       1.29      22.77      22.77        090
21215...  ..................  A                   Lower jaw bone graft....      *10.77     #11.85     #11.85       1.42      24.04      24.04        090
21230...  ..................  A                   Rib cartilage graft.....      *10.77      10.37      10.37       1.69      22.83      22.83        090
21235...  ..................  A                   Ear cartilage graft.....       *6.72      #7.39      #7.39       1.09      15.20      15.20        090
21240...  ..................  A                   Reconstruction of jaw         *14.05     #15.46     #15.46       2.09      31.60      31.60        090
                                                   joint.                                                                                               
21242...  ..................  A                   Reconstruction of jaw         *12.95     #14.25     #14.25       2.25      29.45      29.45        090
                                                   joint.                                                                                               
21243...  ..................  A                   Reconstruction of jaw         *20.79      14.40      14.40       1.68      36.87      36.87        090
                                                   joint.                                                                                               
21244...  ..................  A                   Reconstruction of lower       *11.86     #13.05     #13.05       1.93      26.84      26.84        090
                                                   jaw.                                                                                                 
21245...  ..................  A                   Reconstruction of jaw...      *11.86      11.47      11.47       1.31      24.64      24.64        090
21246...  ..................  A                   Reconstruction of jaw...      *12.47       8.83       8.83       1.04      22.34      22.34        090
21247...  ..................  A                   Reconstruct lower jaw         *22.63     #24.89     #24.89       2.27      49.79      49.79        090
                                                   bone.                                                                                                
21248...  ..................  A                   Reconstruction of jaw...      *11.48     #12.63     #12.63       1.75      25.86      25.86        090
21249...  ..................  A                   Reconstruction of jaw...      *17.52     #19.27     #19.27       3.29      40.08      40.08        090
21255...  ..................  A                   Reconstruct lower jaw         *16.72     #18.39     #18.39       1.68      36.79      36.79        090
                                                   bone.                                                                                                
21256...  ..................  A                   Reconstruction of orbit.      *16.19     #17.81     #17.81       1.63      35.63      35.63        090
21260...  ..................  A                   Revise eye sockets......      *16.52     #18.17     #18.17       1.66      36.35      36.35        090
21261...  ..................  A                   Revise eye sockets......      *31.49      17.78      17.78       1.65      50.92      50.92        090
21263...  ..................  A                   Revise eye sockets......      *28.42     #31.26     #31.26       2.86      62.54      62.54        090
21267...  ..................  A                   Revise eye sockets......      *18.90      14.61      14.61       2.13      35.64      35.64        090
21268...  ..................  A                   Revise eye sockets......      *24.48      15.35      15.35       3.13      42.96      42.96        090
21270...  ..................  A                   Augmentation cheek bone.      *10.23       9.60       9.60       1.41      21.24      21.24        090
21275...  ..................  A                   Revision orbitofacial         *11.24       8.95       8.95       1.26      21.45      21.45        090
                                                   bones.                                                                                               
21280...  ..................  A                   Revision of eyelid......       *6.03      #6.63      #6.63       0.61      13.27      13.27        090
21282...  ..................  A                   Revision of eyelid......       *3.49      #3.84      #3.84       0.79       8.12       8.12        090
21295...  ..................  A                   Revision of jaw muscle/        *1.53       0.96       0.96       0.13       2.62       2.62        090
                                                   bone.                                                                                                
21296...  ..................  A                   Revision of jaw muscle/        *4.25       3.62       3.62       0.22       8.09       8.09        090
                                                   bone.                                                                                                
21299...  ..................  C                   Cranio/maxillofacial            0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                   surgery.                                                                                             
21300...  ..................  A                   Treatment of skull              0.72       0.92      #0.79       0.11       1.75       1.62        000
                                                   fracture.                                                                                            
21310...  ..................  A                   Treatment of nose               0.58       0.75      #0.64       0.09       1.42       1.31        000
                                                   fracture.                                                                                            
21315...  ..................  A                   Treatment of nose              *1.51       1.81      #1.66       0.21       3.53       3.38        010
                                                   fracture.                                                                                            
21320...  ..................  A                   Treatment of nose              *1.85       2.33      #2.04       0.34       4.52       4.23        010
                                                   fracture.                                                                                            
21325...  ..................  A                   Repair of nose fracture.       *3.77       4.09       4.09       0.52       8.38       8.38        090
21330...  ..................  A                   Repair of nose fracture.       *5.38      #5.92      #5.92       0.86      12.16      12.16        090
21335...  ..................  A                   Repair of nose fracture.       *8.61      #9.47      #9.47       1.56      19.64      19.64        090
21336...  ..................  A                   Repair nasal septal            *5.72       4.09       4.09       0.52      10.33      10.33        090
                                                   fracture.                                                                                            
21337...  ..................  A                   Repair nasal septal            *2.70       2.82       2.82       0.38       5.90       5.90        090
                                                   fracture.                                                                                            
21338...  ..................  A                   Repair nasoethmoid             *6.46       5.01       5.01       0.66      12.13      12.13        090
                                                   fracture.                                                                                            

[[Page 59111]]

                                                                                                                                                        
21339...  ..................  A                   Repair nasoethmoid             *8.09       7.09       7.09       0.70      15.88      15.88        090
                                                   fracture.                                                                                            
21340...  ..................  A                   Repair of nose fracture.      *10.77       8.91       8.91       1.04      20.72      20.72        090
21343...  ..................  A                   Repair of sinus fracture      *12.95       9.17       9.17       1.08      23.20      23.20        090
21344...  ..................  A                   Repair of sinus fracture      *19.72       9.17       9.17       1.08      29.97      29.97        090
21345...  ..................  A                   Repair of nose/jaw             *8.16       7.90       7.90       0.81      16.87      16.87        090
                                                   fracture.                                                                                            
21346...  ..................  A                   Repair of nose/jaw            *10.61       9.40       9.40       1.04      21.05      21.05        090
                                                   fracture.                                                                                            
21347...  ..................  A                   Repair of nose/jaw            *12.69      10.36      10.36       1.36      24.41      24.41        090
                                                   fracture.                                                                                            
21348...  ..................  A                   Repair of nose/jaw            *16.69      11.34      11.34       2.22      30.25      30.25        090
                                                   fracture.                                                                                            
21355...  ..................  A                   Repair cheek bone              *3.77       1.56       1.56       0.17       5.50       5.50        010
                                                   fracture.                                                                                            
21356...  ..................  A                   Repair cheek bone              *4.15      #4.57      #4.57       0.89       9.61       9.61        010
                                                   fracture.                                                                                            
21360...  ..................  A                   Repair cheek bone              *6.46      #7.11      #7.11       0.89      14.46      14.46        090
                                                   fracture.                                                                                            
21365...  ..................  A                   Repair cheek bone             *14.95      12.35      12.35       1.63      28.93      28.93        090
                                                   fracture.                                                                                            
21366...  ..................  A                   Repair cheek bone             *17.77      12.08      12.08       2.36      32.21      32.21        090
                                                   fracture.                                                                                            
21385...  ..................  A                   Repair eye socket              *9.16       9.59       9.59       1.13      19.88      19.88        090
                                                   fracture.                                                                                            
21386...  ..................  A                   Repair eye socket              *9.16       9.07       9.07       1.25      19.48      19.48        090
                                                   fracture.                                                                                            
21387...  ..................  A                   Repair eye socket              *9.70       7.45       7.45       0.96      18.11      18.11        090
                                                   fracture.                                                                                            
21390...  ..................  A                   Repair eye socket             *10.13     #11.14     #11.14       1.37      22.64      22.64        090
                                                   fracture.                                                                                            
21395...  ..................  A                   Repair eye socket             *12.68       9.63       9.63       1.37      23.68      23.68        090
                                                   fracture.                                                                                            
21400...  ..................  A                   Treat eye socket               *1.40       1.67      #1.54       0.17       3.24       3.11        090
                                                   fracture.                                                                                            
21401...  ..................  A                   Repair eye socket              *3.26       2.58       2.58       0.32       6.16       6.16        090
                                                   fracture.                                                                                            
21406...  ..................  A                   Repair eye socket              *7.01       5.21       5.21       0.74      12.96      12.96        090
                                                   fracture.                                                                                            
21407...  ..................  A                   Repair eye socket              *8.61       7.09       7.09       0.78      16.48      16.48        090
                                                   fracture.                                                                                            
21408...  ..................  A                   Repair eye socket             *12.38       8.49       8.49       0.99      21.86      21.86        090
                                                   fracture.                                                                                            
21421...  ..................  A                   Treat mouth roof               *5.14       6.14      #5.65       0.62      11.90      11.41        090
                                                   fracture.                                                                                            
21422...  ..................  A                   Repair mouth roof              *8.32      #9.15      #9.15       1.19      18.66      18.66        090
                                                   fracture.                                                                                            
21423...  ..................  A                   Repair mouth roof             *10.40       9.80       9.80       1.19      21.39      21.39        090
                                                   fracture.                                                                                            
21431...  ..................  A                   Treat craniofacial             *7.05       6.02       6.02       0.71      13.78      13.78        090
                                                   fracture.                                                                                            
21432...  ..................  A                   Repair craniofacial            *8.61       6.76       6.76       0.84      16.21      16.21        090
                                                   fracture.                                                                                            
21433...  ..................  A                   Repair craniofacial           *25.35      17.96      17.96       2.10      45.41      45.41        090
                                                   fracture.                                                                                            
21435...  ..................  A                   Repair craniofacial           *17.25      13.25      13.25       1.88      32.38      32.38        090
                                                   fracture.                                                                                            
21436...  ..................  A                   Repair craniofacial           *28.04      14.65      14.65       2.08      44.77      44.77        090
                                                   fracture.                                                                                            
21440...  ..................  A                   Repair dental ridge            *2.70       3.07      #2.97       0.28       6.05       5.95        090
                                                   fracture.                                                                                            
21445...  ..................  A                   Repair dental ridge            *5.38       6.11      #5.92       0.56      12.05      11.86        090
                                                   fracture.                                                                                            
21450...  ..................  A                   Treat lower jaw fracture       *2.97       2.84       2.84       0.26       6.07       6.07        090
21451...  ..................  A                   Treat lower jaw fracture       *4.87       5.83      #5.36       0.74      11.44      10.97        090
21452...  ..................  A                   Treat lower jaw fracture       *1.98       1.39       1.39       0.17       3.54       3.54        090
21453...  ..................  A                   Treat lower jaw fracture       *5.54       6.64      #6.09       0.55      12.73      12.18        090
21454...  ..................  A                   Treat lower jaw fracture       *6.46      #7.11      #7.11       1.42      14.99      14.99        090
21461...  ..................  A                   Repair lower jaw               *8.09      #8.90      #8.90       1.30      18.29      18.29        090
                                                   fracture.                                                                                            
21462...  ..................  A                   Repair lower jaw               *9.79     #10.77     #10.77       1.34      21.90      21.90        090
                                                   fracture.                                                                                            
21465...  ..................  A                   Repair lower jaw              *11.91       8.44       8.44       0.99      21.34      21.34        090
                                                   fracture.                                                                                            
21470...  ..................  A                   Repair lower jaw              *15.34     #16.87     #16.87       1.74      33.95      33.95        090
                                                   fracture.                                                                                            
21480...  ..................  A                   Reset dislocated jaw....        0.61       0.78      #0.67       0.09       1.48       1.37        000
21485...  ..................  A                   Reset dislocated jaw....       *3.99       2.19       2.19       0.20       6.38       6.38        090
21490...  ..................  A                   Repair dislocated jaw...      *11.86       6.31       6.31       0.52      18.69      18.69        090
21493...  ..................  A                   Treat hyoid bone               *1.27       1.52      #1.40       0.13       2.92       2.80        090
                                                   fracture.                                                                                            
21494...  ..................  A                   Repair hyoid bone              *6.28       7.52       7.52       0.63      14.43      14.43        090
                                                   fracture.                                                                                            
21495...  ..................  A                   Repair hyoid bone              *5.69       4.82       4.82       0.51      11.02      11.02        090
                                                   fracture.                                                                                            
21497...  ..................  A                   Interdental wiring......       *3.86       3.97       3.97       0.38       8.21       8.21        090
21499...  ..................  C                   Head surgery procedure..        0.00       0.00       0.00       0.00       0.00       0.00        YYY
21501...  ..................  A                   Drain neck/chest lesion.       *3.81       1.82       1.82       0.26       5.89       5.89        090
21502...  ..................  A                   Drain chest lesion......       *7.12       4.22       4.22       0.75      12.09      12.09        090
21510...  ..................  A                   Drainage of bone lesion.       *5.74       3.82       3.82       0.50      10.06      10.06        090
21550...  ..................  A                   Biopsy of neck/chest....       *2.06       0.85       0.85       0.12       3.03       3.03        010
21555...  ..................  A                   Remove lesion neck/chest       *4.35       1.60       1.60       0.25       6.20       6.20        090
21556...  ..................  A                   Remove lesion neck/chest       *5.57       3.80       3.80       0.64      10.01      10.01        090
21557...  ..................  A                   Remove tumor, neck or          *8.88       8.50       8.50       1.41      18.79      18.79        090
                                                   chest.                                                                                               
21600...  ..................  A                   Partial removal of rib..       *6.89       4.50       4.50       0.88      12.27      12.27        090
21610...  ..................  A                   Partial removal of rib..      *14.61       5.17       5.17       0.76      20.54      20.54        090
21615...  ..................  A                   Removal of rib..........       *9.87      10.13      10.13       1.96      21.96      21.96        090
21616...  ..................  A                   Removal of rib and            *12.04       7.26       7.26       1.50      20.80      20.80        090
                                                   nerves.                                                                                              
21620...  ..................  A                   Partial removal of             *6.79       6.85       6.85       1.23      14.87      14.87        090
                                                   sternum.                                                                                             
21627...  ..................  A                   Sternal debridement.....       *6.81       5.03       5.03       0.90      12.74      12.74        090
21630...  ..................  A                   Extensive sternum             *17.38      12.89      12.89       2.40      32.67      32.67        090
                                                   surgery.                                                                                             
21632...  ..................  A                   Extensive sternum             *18.14      11.54      11.54       2.22      31.90      31.90        090
                                                   surgery.                                                                                             
21700...  ..................  A                   Revision of neck muscle.       *6.19       4.16       4.16       0.50      10.85      10.85        090
21705...  ..................  A                   Revision of neck muscle/       *9.60       4.85       4.85       0.96      15.41      15.41        090
                                                   rib.                                                                                                 
21720...  ..................  A                   Revision of neck muscle.       *5.68       3.84       3.84       0.52      10.04      10.04        090
21725...  ..................  A                   Revision of neck muscle.       *6.99       4.84       4.84       0.74      12.57      12.57        090
21740...  ..................  A                   Reconstruction of             *16.50       8.99       8.99       1.64      27.13      27.13        090
                                                   sternum.                                                                                             
21750...  ..................  A                   Repair of sternum             *10.77       7.33       7.33       1.43      19.53      19.53        090
                                                   separation.                                                                                          
21800...  ..................  A                   Treatment of rib               *0.96       0.77       0.77       0.07       1.80       1.80        090
                                                   fracture.                                                                                            
21805...  ..................  A                   Treatment of rib               *2.75       1.35       1.35       0.17       4.27       4.27        090
                                                   fracture.                                                                                            
21810...  ..................  A                   Treatment of rib               *6.86       7.33       7.33       0.61      14.80      14.80        090
                                                   fracture(s).                                                                                         

[[Page 59112]]

                                                                                                                                                        
21820...  ..................  A                   Treat sternum fracture..       *1.28       1.36       1.36       0.17       2.81       2.81        090
21825...  ..................  A                   Repair sternum fracture.       *7.41       6.90       6.90       1.12      15.43      15.43        090
21899...  ..................  C                   Neck/chest surgery              0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                   procedure.                                                                                           
21920...  ..................  A                   Biopsy soft tissue of          *2.06       0.79       0.79       0.11       2.96       2.96        010
                                                   back.                                                                                                
21925...  ..................  A                   Biopsy soft tissue of          *4.49       1.95       1.95       0.32       6.76       6.76        090
                                                   back.                                                                                                
21930...  ..................  A                   Remove lesion, back or         *5.00       2.72       2.72       0.49       8.21       8.21        090
                                                   flank.                                                                                               
21935...  ..................  A                   Remove tumor of back....      *17.96       6.59       6.59       1.30      25.85      25.85        090
22100...  ..................  A                   Remove part of neck            *9.73       7.64       7.64       1.09      18.46      18.46        090
                                                   vertebra.                                                                                            
22101...  ..................  A                   Remove part, thorax            *9.81       8.01       8.01       1.38      19.20      19.20        090
                                                   vertebra.                                                                                            
22102...  ..................  A                   Remove part, lumbar            *9.81       4.50       4.50       0.67      14.98      14.98        090
                                                   vertebra.                                                                                            
22103...  ..................  A                   Remove extra spine              2.34       2.23       2.23       0.37       4.94       4.94        ZZZ
                                                   segment.                                                                                             
22110...  ..................  A                   Remove part of neck           *12.74       9.72       9.72       1.64      24.10      24.10        090
                                                   vertebra.                                                                                            
22112...  ..................  A                   Remove part, thorax           *12.81       9.90       9.90       1.63      24.34      24.34        090
                                                   vertebra.                                                                                            
22114...  ..................  A                   Remove part, lumbar           *12.81       7.25       7.25       1.17      21.23      21.23        090
                                                   vertebra.                                                                                            
22116...  ..................  A                   Remove extra spine              2.32       2.21       2.21       0.36       4.89       4.89        ZZZ
                                                   segment.                                                                                             
22210...  ..................  A                   Revision of neck spine..      *23.82      13.83      13.83       2.43      40.08      40.08        090
22212...  ..................  A                   Revision of thorax spine      *19.42      17.29      17.29       2.83      39.54      39.54        090
22214...  ..................  A                   Revision of lumbar spine      *19.45      15.11      15.11       2.68      37.24      37.24        090
22216...  ..................  A                   Revise, extra spine             6.04       5.07       5.07       0.89      12.00      12.00        ZZZ
                                                   segment.                                                                                             
22220...  ..................  A                   Revision of neck spine..      *21.37      16.64      16.64       2.63      40.64      40.64        090
22222...  ..................  A                   Revision of thorax spine      *21.52      13.61      13.61       1.58      36.71      36.71        090
22224...  ..................  A                   Revision of lumbar spine      *21.52      14.68      14.68       2.66      38.86      38.86        090
22226...  ..................  A                   Revise, extra spine             6.04       5.07       5.07       0.89      12.00      12.00        ZZZ
                                                   segment.                                                                                             
22305...  ..................  A                   Treat spine process            *2.05      #2.26      #2.26       0.37       4.68       4.68        090
                                                   fracture.                                                                                            
22310...  ..................  A                   Treat spine fracture....       *2.61       2.52       2.52       0.69       5.82       5.82        090
22315...  ..................  A                   Treat spine fracture....       *8.84       5.51       5.51       0.86      15.21      15.21        090
22325...  ..................  A                   Repair of spine fracture      *18.30       8.32       8.32       1.34      27.96      27.96        090
22326...  ..................  A                   Repair neck spine             *19.59      15.93      15.93       2.74      38.26      38.26        090
                                                   fracture.                                                                                            
22327...  ..................  A                   Repair thorax spine           *19.20      15.95      15.95       2.35      37.50      37.50        090
                                                   fracture.                                                                                            
22328...  ..................  A                   Repair each add spine fx        4.61       4.40       4.40       0.72       9.73       9.73        ZZZ
22505...  ..................  A                   Manipulation of spine...       *1.87       1.31       1.31       0.17       3.35       3.35        010
22548...  ..................  A                   Neck spine fusion.......      *25.82      22.74      22.74       3.82      52.38      52.38        090
22554...  ..................  A                   Neck spine fusion.......      *18.62      19.81      19.81       3.52      41.95      41.95        090
22556...  ..................  A                   Thorax spine fusion.....      *23.46      21.68      21.68       3.58      48.72      48.72        090
22558...  ..................  A                   Lumbar spine fusion.....      *22.28      20.17      20.17       3.38      45.83      45.83        090
22585...  ..................  A                   Additional spinal fusion        5.53       5.40       5.40       0.93      11.86      11.86        ZZZ
22590...  ..................  A                   Spine & skull spinal          *20.51      21.57      21.57       3.44      45.52      45.52        090
                                                   fusion.                                                                                              
22595...  ..................  A                   Neck spinal fusion......      *19.39     #21.33     #21.33       3.87      44.59      44.59        090
22600...  ..................  A                   Neck spine fusion.......      *16.14     #17.75     #17.75       3.32      37.21      37.21        090
22610...  ..................  A                   Thorax spine fusion.....      *16.02     #17.62     #17.62       2.75      36.39      36.39        090
22612...  ..................  A                   Lumbar spine fusion.....      *21.00      20.60      20.60       3.33      44.93      44.93        090
22614...  ..................  A                   Spine fusion, extra             6.44       5.65       5.65       0.92      13.01      13.01        ZZZ
                                                   segment.                                                                                             
22630...  ..................  A                   Lumbar spine fusion.....      *20.84      18.44      18.44       3.15      42.43      42.43        090
22632...  ..................  A                   Spine fusion, extra             5.23       4.99       4.99       0.82      11.04      11.04        ZZZ
                                                   segment.                                                                                             
22800...  ..................  A                   Fusion of spine.........      *18.25     #20.08     #20.08       3.58      41.91      41.91        090
22802...  ..................  A                   Fusion of spine.........      *30.88      28.32      28.32       4.61      63.81      63.81        090
22804...  ..................  A                   Fusion of spine.........      *36.27      28.32      28.32       4.61      69.20      69.20        090
22808...  ..................  A                   Fusion of spine.........      *26.27      18.41      18.41       3.15      47.83      47.83        090
22810...  ..................  A                   Fusion of spine.........      *30.27      18.41      18.41       3.15      51.83      51.83        090
22812...  ..................  A                   Fusion of spine.........      *32.70      25.93      25.93       4.24      62.87      62.87        090
22818...  ..................  A                   Kyphectomy, 1-2 segments      *31.83      28.25      28.25       4.85      64.93      64.93        090
22819...  ..................  A                   Kyphectomy, 3 & more          *36.44      28.25      28.25       4.85      69.54      69.54        090
                                                   segment.                                                                                             
22830...  ..................  A                   Exploration of spinal         *10.85     #11.94     #11.94       2.18      24.97      24.97        090
                                                   fusion.                                                                                              
22840...  ..................  A                   Insert spine fixation          12.54       5.98       5.98       0.98      19.50      19.50        ZZZ
                                                   device.                                                                                              
22841...  ..................  B                   Insert spine fixation           0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                   device.                                                                                              
22842...  ..................  A                   Insert spine fixation          12.58       6.86       6.86       1.12      20.56      20.56        ZZZ
                                                   device.                                                                                              
22843...  ..................  A                   Insert spine fixation          13.46       8.55       8.55       1.40      23.41      23.41        ZZZ
                                                   device.                                                                                              
22844...  ..................  A                   Insert spine fixation          16.44      10.45      10.45       1.71      28.60      28.60        ZZZ
                                                   device.                                                                                              
22845...  ..................  A                   Insert spine fixation          11.96       5.70       5.70       0.93      18.59      18.59        ZZZ
                                                   device.                                                                                              
22846...  ..................  A                   Insert spine fixation          12.42       7.90       7.90       1.29      21.61      21.61        ZZZ
                                                   device.                                                                                              
22847...  ..................  A                   Insert spine fixation          13.80       8.77       8.77       1.44      24.01      24.01        ZZZ
                                                   device.                                                                                              
22848...  ..................  A                   Insert pelvic                   6.00       5.72       5.72       0.94      12.66      12.66        ZZZ
                                                   fixationdevice.                                                                                      
22849...  ..................  A                   Reinsert spinal fixation      *18.51      11.76      11.76       1.97      32.24      32.24        090
22850...  ..................  A                   Remove spine fixation          *9.52       9.17       9.17       1.50      20.19      20.19        090
                                                   device.                                                                                              
22851...  ..................  A                   Apply spine prosth              6.71       6.40       6.40       1.05      14.16      14.16        ZZZ
                                                   device.                                                                                              
22852...  ..................  A                   Remove spine fixation          *9.01       9.80       9.80       1.57      20.38      20.38        090
                                                   device.                                                                                              
22855...  ..................  A                   Remove spine fixation         *15.13       7.46       7.46       1.25      23.84      23.84        090
                                                   device.                                                                                              
22899...  ..................  C                   Spine surgery procedure.        0.00       0.00       0.00       0.00       0.00       0.00        YYY
22900...  ..................  A                   Remove abdominal wall          *5.80       3.03       3.03       0.60       9.43       9.43        090
                                                   lesion.                                                                                              
22999...  ..................  C                   Abdomen surgery                 0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                   procedure.                                                                                           
23000...  ..................  A                   Removal of calcium             *4.36       3.24       3.24       0.47       8.07       8.07        090
                                                   deposits.                                                                                            
23020...  ..................  A                   Release shoulder joint..       *8.93       7.27       7.27       1.09      17.29      17.29        090
23030...  ..................  A                   Drain shoulder lesion...       *3.43       2.16       2.16       0.35       5.94       5.94        010
23031...  ..................  A                   Drain shoulder bursa....       *2.74       0.50       0.50       0.05       3.29       3.29        010

[[Page 59113]]

                                                                                                                                                        
23035...  ..................  A                   Drain shoulder bone            *8.61       6.22       6.22       1.04      15.87      15.87        090
                                                   lesion.                                                                                              
23040...  ..................  A                   Exploratory shoulder           *9.20       9.27       9.27       1.47      19.94      19.94        090
                                                   surgery.                                                                                             
23044...  ..................  A                   Exploratory shoulder           *7.12       6.91       6.91       1.18      15.21      15.21        090
                                                   surgery.                                                                                             
23065...  ..................  A                   Biopsy shoulder tissues.       *2.27       0.66       0.66       0.09       3.02       3.02        010
23066...  ..................  A                   Biopsy shoulder tissues.       *4.16       1.18       1.18       0.10       5.44       5.44        090
23075...  ..................  A                   Removal of shoulder            *2.39       1.68       1.68       0.29       4.36       4.36        010
                                                   lesion.                                                                                              
23076...  ..................  A                   Removal of shoulder            *7.63       3.54       3.54       0.65      11.82      11.82        090
                                                   lesion.                                                                                              
23077...  ..................  A                   Remove tumor of shoulder      *16.09       7.38       7.38       1.38      24.85      24.85        090
23100...  ..................  A                   Biopsy of shoulder joint       *6.03      #6.63      #6.63       1.24      13.90      13.90        090
23101...  ..................  A                   Shoulder joint surgery..       *5.58      #6.14      #6.14       1.21      12.93      12.93        090
23105...  ..................  A                   Remove shoulder joint          *8.23      #9.05      #9.05       1.73      19.01      19.01        090
                                                   lining.                                                                                              
23106...  ..................  A                   Incision of collarbone         *5.96       4.75       4.75       0.80      11.51      11.51        090
                                                   joint.                                                                                               
23107...  ..................  A                   Explore,treat shoulder         *8.62      #9.48      #9.48       1.60      19.70      19.70        090
                                                   joint.                                                                                               
23120...  ..................  A                   Partial removal, collar        *7.11       4.61       4.61       0.74      12.46      12.46        090
                                                   bone.                                                                                                
23125...  ..................  A                   Removal of collarbone...       *9.39       8.49       8.49       1.27      19.15      19.15        090
23130...  ..................  A                   Partial                        *7.55       7.05       7.05       1.14      15.74      15.74        090
                                                   removal,shoulderbone.                                                                                
23140...  ..................  A                   Removal of bone lesion..       *6.89       4.16       4.16       0.73      11.78      11.78        090
23145...  ..................  A                   Removal of bone lesion..       *9.09       8.13       8.13       1.33      18.55      18.55        090
23146...  ..................  A                   Removal of bone lesion..       *7.83       5.23       5.23       1.01      14.07      14.07        090
23150...  ..................  A                   Removal of humerus             *8.48       6.64       6.64       1.01      16.13      16.13        090
                                                   lesion.                                                                                              
23155...  ..................  A                   Removal of humerus            *10.35       8.80       8.80       1.37      20.52      20.52        090
                                                   lesion.                                                                                              
23156...  ..................  A                   Removal of humerus             *8.68       7.64       7.64       1.25      17.57      17.57        090
                                                   lesion.                                                                                              
23170...  ..................  A                   Remove collarbone lesion       *6.86       4.81       4.81       0.78      12.45      12.45        090
23172...  ..................  A                   Remove shoulder blade          *6.90       5.16       5.16       0.73      12.79      12.79        090
                                                   lesion.                                                                                              
23174...  ..................  A                   Remove humerus lesion...       *9.51       8.55       8.55       1.21      19.27      19.27        090
23180...  ..................  A                   Remove collar bone             *8.53       4.30       4.30       0.67      13.50      13.50        090
                                                   lesion.                                                                                              
23182...  ..................  A                   Remove shoulder blade          *8.15       6.57       6.57       1.13      15.85      15.85        090
                                                   lesion.                                                                                              
23184...  ..................  A                   Remove humerus lesion...       *9.38       8.83       8.83       1.48      19.69      19.69        090
23190...  ..................  A                   Partial removal of             *7.24       6.07       6.07       0.98      14.29      14.29        090
                                                   scapula.                                                                                             
23195...  ..................  A                   Removal of head of             *9.81       8.91       8.91       1.45      20.17      20.17        090
                                                   humerus.                                                                                             
23200...  ..................  A                   Removal of collar bone..      *12.08       9.17       9.17       1.26      22.51      22.51        090
23210...  ..................  A                   Removal of shoulderblade      *12.49       9.01       9.01       1.41      22.91      22.91        090
23220...  ..................  A                   Partial removal of            *14.56      12.05      12.05       2.03      28.64      28.64        090
                                                   humerus.                                                                                             
23221...  ..................  A                   Partial removal of            *17.74      18.13      18.13       1.19      37.06      37.06        090
                                                   humerus.                                                                                             
23222...  ..................  A                   Partial removal of            *23.92      15.02      15.02       2.30      41.24      41.24        090
                                                   humerus.                                                                                             
23330...  ..................  A                   Remove shoulder foreign        *1.85       0.55       0.55       0.07       2.47       2.47        010
                                                   body.                                                                                                
23331...  ..................  A                   Remove shoulder foreign        *7.38       2.26       2.26       0.38      10.02      10.02        090
                                                   body.                                                                                                
23332...  ..................  A                   Remove shoulder foreign       *11.62       9.72       9.72       1.57      22.91      22.91        090
                                                   body.                                                                                                
23350...  ..................  A                   Injection for shoulder x-       1.00       0.52       0.52       0.05       1.57       1.57        000
                                                   ray.                                                                                                 
23395...  ..................  A                   Muscle transfer,              *16.85      11.13      11.13       1.84      29.82      29.82        090
                                                   shoulder/arm.                                                                                        
23397...  ..................  A                   Muscle transfers........      *16.13      13.97      13.97       2.34      32.44      32.44        090
23400...  ..................  A                   Fixation of shoulder          *13.54       9.84       9.84       1.68      25.06      25.06        090
                                                   blade.                                                                                               
23405...  ..................  A                   Incision of tendon &           *8.37       7.49       7.49       0.99      16.85      16.85        090
                                                   muscle.                                                                                              
23406...  ..................  A                   Incise tendon(s) &            *10.79       9.41       9.41       1.58      21.78      21.78        090
                                                   muscle(s).                                                                                           
23410...  ..................  A                   Repair of tendon(s).....      *12.45      10.94      10.94       1.75      25.14      25.14        090
23412...  ..................  A                   Repair of tendon(s).....      *13.31      13.37      13.37       2.16      28.84      28.84        090
23415...  ..................  A                   Release of shoulder            *9.97       5.18       5.18       0.83      15.98      15.98        090
                                                   ligament.                                                                                            
23420...  ..................  A                   Repair of shoulder......      *13.30     #14.63     #14.63       2.34      30.27      30.27        090
23430...  ..................  A                   Repair biceps tendon....       *9.98       7.34       7.34       1.19      18.51      18.51        090
23440...  ..................  A                   Removal/transplant            *10.48       7.17       7.17       1.17      18.82      18.82        090
                                                   tendon.                                                                                              
23450...  ..................  A                   Repair shoulder capsule.      *13.40      12.75      12.75       2.04      28.19      28.19        090
23455...  ..................  A                   Repair shoulder capsule.      *14.37      15.56      15.56       2.50      32.43      32.43        090
23460...  ..................  A                   Repair shoulder capsule.      *15.37      14.07      14.07       2.24      31.68      31.68        090
23462...  ..................  A                   Repair shoulder capsule.      *15.30      15.13      15.13       2.48      32.91      32.91        090
23465...  ..................  A                   Repair shoulder capsule.      *15.85      14.15      14.15       2.27      32.27      32.27        090
23466...  ..................  A                   Repair shoulder capsule.      *14.22     #15.64     #15.64       2.67      32.53      32.53        090
23470...  ..................  A                   Reconstruct shoulder          *17.15      16.76      16.76       2.65      36.56      36.56        090
                                                   joint.                                                                                               
23472...  ..................  A                   Reconstruct shoulder          *16.92     #18.61     #18.61       4.89      40.42      40.42        090
                                                   joint.                                                                                               
23480...  ..................  A                   Revision of collarbone..      *11.18       6.59       6.59       1.02      18.79      18.79        090
23485...  ..................  A                   Revision of collar bone.      *13.43      11.35      11.35       1.87      26.65      26.65        090
23490...  ..................  A                   Reinforce clavicle......      *11.86       9.98       9.98       0.80      22.64      22.64        090
23491...  ..................  A                   Reinforce shoulder bones      *14.21      12.70      12.70       2.11      29.02      29.02        090
23500...  ..................  A                   Treat clavicle fracture.       *2.08       1.65       1.65       0.21       3.94       3.94        090
23505...  ..................  A                   Treat clavicle fracture.       *3.69       2.57       2.57       0.38       6.64       6.64        090
23515...  ..................  A                   Repair clavicle fracture       *7.41       6.93       6.93       1.12      15.46      15.46        090
23520...  ..................  A                   Treat clavicle                 *2.16       1.38       1.38       0.19       3.73       3.73        090
                                                   dislocation.                                                                                         
23525...  ..................  A                   Treat clavicle                 *3.60       1.98       1.98       0.27       5.85       5.85        090
                                                   dislocation.                                                                                         
23530...  ..................  A                   Repair clavicle                *7.31       6.58       6.58       0.91      14.80      14.80        090
                                                   dislocation.                                                                                         
23532...  ..................  A                   Repair clavicle                *8.01       7.23       7.23       1.19      16.43      16.43        090
                                                   dislocation.                                                                                         
23540...  ..................  A                   Treat clavicle                 *2.23       1.55       1.55       0.19       3.97       3.97        090
                                                   dislocation.                                                                                         
23545...  ..................  A                   Treat clavicle                 *3.25       1.98       1.98       0.29       5.52       5.52        090
                                                   dislocation.                                                                                         
23550...  ..................  A                   Repair clavicle                *7.24      #7.96      #7.96       1.46      16.66      16.66        090
                                                   dislocation.                                                                                         
23552...  ..................  A                   Repair clavicle                *8.45       7.29       7.29       1.17      16.91      16.91        090
                                                   dislocation.                                                                                         
23570...  ..................  A                   Treat shoulderblade            *2.23       1.70       1.70       0.25       4.18       4.18        090
                                                   fracture.                                                                                            

[[Page 59114]]

                                                                                                                                                        
23575...  ..................  A                   Treat shoulderblade            *4.06       2.75       2.75       0.43       7.24       7.24        090
                                                   fracture.                                                                                            
23585...  ..................  A                   Repair scapula fracture.       *8.96       7.70       7.70       1.29      17.95      17.95        090
23600...  ..................  A                   Treat humerus fracture..       *2.93       2.90       2.90       0.43       6.26       6.26        090
23605...  ..................  A                   Treat humerus fracture..       *4.87       4.76       4.76       0.76      10.39      10.39        090
23615...  ..................  A                   Repair humerus fracture.       *9.35     #10.29     #10.29       1.78      21.42      21.42        090
23616...  ..................  A                   Repair humerus fracture.      *21.27      22.32      22.32       3.54      47.13      47.13        090
23620...  ..................  A                   Treat humerus fracture..       *2.40       2.88      #2.64       0.46       5.74       5.50        090
23625...  ..................  A                   Treat humerus fracture..       *3.93       3.82       3.82       0.60       8.35       8.35        090
23630...  ..................  A                   Repair humerus fracture.       *7.35      #8.09      #8.09       1.40      16.84      16.84        090
23650...  ..................  A                   Treat shoulder                 *3.39       2.10       2.10       0.24       5.73       5.73        090
                                                   dislocation.                                                                                         
23655...  ..................  A                   Treat shoulder                 *4.57       2.93       2.93       0.44       7.94       7.94        090
                                                   dislocation.                                                                                         
23660...  ..................  A                   Repair shoulder                *7.49      #8.24      #8.24       1.40      17.13      17.13        090
                                                   dislocation.                                                                                         
23665...  ..................  A                   Treat dislocation/             *4.47       3.35       3.35       0.51       8.33       8.33        090
                                                   fracture.                                                                                            
23670...  ..................  A                   Repair dislocation/            *7.90      #8.69      #8.69       1.85      18.44      18.44        090
                                                   fracture.                                                                                            
23675...  ..................  A                   Treat dislocation/             *6.05       3.93       3.93       0.61      10.59      10.59        090
                                                   fracture.                                                                                            
23680...  ..................  A                   Repair dislocation/           *10.06     #11.07     #11.07       2.13      23.26      23.26        090
                                                   fracture.                                                                                            
23700...  ..................  A                   Fixation of shoulder....       *2.52       2.09       2.09       0.34       4.95       4.95        010
23800...  ..................  A                   Fusion of shoulder joint      *14.16     #15.58     #15.58       2.63      32.37      32.37        090
23802...  ..................  A                   Fusion of shoulder joint      *16.60      14.07      14.07       2.24      32.91      32.91        090
23900...  ..................  A                   Amputation of arm &           *19.72      12.57      12.57       2.40      34.69      34.69        090
                                                   girdle.                                                                                              
23920...  ..................  A                   Amputation at shoulder        *14.61      13.85      13.85       2.54      31.00      31.00        090
                                                   joint.                                                                                               
23921...  ..................  A                   Amputation follow-up           *5.49       4.27       4.27       0.74      10.50      10.50        090
                                                   surgery.                                                                                             
23929...  ..................  C                   Shoulder surgery                0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                   procedure.                                                                                           
23930...  ..................  A                   Drainage of arm lesion..       *2.94       1.61       1.61       0.24       4.79       4.79        010
23931...  ..................  A                   Drainage of arm bursa...       *1.79       0.75       0.75       0.11       2.65       2.65        010
23935...  ..................  A                   Drain arm/elbow bone           *6.09       4.69       4.69       0.78      11.56      11.56        090
                                                   lesion.                                                                                              
24000...  ..................  A                   Exploratory elbow              *5.82      #6.40      #6.40       1.44      13.66      13.66        090
                                                   surgery.                                                                                             
24006...  ..................  A                   Release elbow joint.....       *9.31       7.14       7.14       1.17      17.62      17.62        090
24065...  ..................  A                   Biopsy arm/elbow soft          *2.08       0.79       0.79       0.10       2.97       2.97        010
                                                   tissue.                                                                                              
24066...  ..................  A                   Biopsy arm/elbow soft          *5.21       2.71       2.71       0.41       8.33       8.33        090
                                                   tissue.                                                                                              
24075...  ..................  A                   Remove arm/elbow lesion.       *3.92       1.98       1.98       0.35       6.25       6.25        090
24076...  ..................  A                   Remove arm/elbow lesion.       *6.30       3.68       3.68       0.67      10.65      10.65        090
24077...  ..................  A                   Remove tumor of arm/          *11.76       9.79       9.79       1.87      23.42      23.42        090
                                                   elbow.                                                                                               
24100...  ..................  A                   Biopsy elbow joint             *4.93       4.23       4.23       0.69       9.85       9.85        090
                                                   lining.                                                                                              
24101...  ..................  A                   Explore/treat elbow            *6.13      #6.74      #6.74       1.41      14.28      14.28        090
                                                   joint.                                                                                               
24102...  ..................  A                   Remove elbow joint             *8.03      #8.83      #8.83       1.81      18.67      18.67        090
                                                   lining.                                                                                              
24105...  ..................  A                   Removal of elbow bursa..       *3.61       3.77       3.77       0.63       8.01       8.01        090
24110...  ..................  A                   Remove humerus lesion...       *7.39       7.69       7.69       1.22      16.30      16.30        090
24115...  ..................  A                   Remove/graft bone lesion       *9.63       7.68       7.68       1.33      18.64      18.64        090
24116...  ..................  A                   Remove/graft bone lesion      *11.81       9.72       9.72       1.47      23.00      23.00        090
24120...  ..................  A                   Remove elbow lesion.....       *6.65       6.02       6.02       0.98      13.65      13.65        090
24125...  ..................  A                   Remove/graft bone lesion       *7.89       5.79       5.79       0.61      14.29      14.29        090
24126...  ..................  A                   Remove/graft bone lesion       *8.31       7.40       7.40       1.21      16.92      16.92        090
24130...  ..................  A                   Removal of head of             *6.25       6.72       6.72       1.08      14.05      14.05        090
                                                   radius.                                                                                              
24134...  ..................  A                   Removal of arm bone            *9.73       8.69       8.69       1.24      19.66      19.66        090
                                                   lesion.                                                                                              
24136...  ..................  A                   Remove radius bone             *7.99       8.78       8.78       0.92      17.69      17.69        090
                                                   lesion.                                                                                              
24138...  ..................  A                   Remove elbow bone lesion       *8.05       6.39       6.39       1.06      15.50      15.50        090
24140...  ..................  A                   Partial removal of arm         *9.18       8.77       8.77       1.45      19.40      19.40        090
                                                   bone.                                                                                                
24145...  ..................  A                   Partial removal of             *7.58       6.38       6.38       1.03      14.99      14.99        090
                                                   radius.                                                                                              
24147...  ..................  A                   Partial removal of elbow       *7.54       6.61       6.61       1.08      15.23      15.23        090
24149...  ..................  A                   Radical resection of          *14.20      12.64      12.64       2.07      28.91      28.91        090
                                                   elbow.                                                                                               
24150...  ..................  A                   Extensive humerus             *13.27      14.08      14.08       2.24      29.59      29.59        090
                                                   surgery.                                                                                             
24151...  ..................  A                   Extensive humerus             *15.58      13.83      13.83       2.11      31.52      31.52        090
                                                   surgery.                                                                                             
24152...  ..................  A                   Extensive radius surgery      *10.06       6.80       6.80       1.16      18.02      18.02        090
24153...  ..................  A                   Extensive radius surgery      *11.54      10.44      10.44       1.71      23.69      23.69        090
24155...  ..................  A                   Removal of elbow joint..      *11.73      10.75      10.75       1.72      24.20      24.20        090
24160...  ..................  A                   Remove elbow joint             *7.83       4.84       4.84       0.80      13.47      13.47        090
                                                   implant.                                                                                             
24164...  ..................  A                   Remove radius head             *6.23       5.53       5.53       0.90      12.66      12.66        090
                                                   implant.                                                                                             
24200...  ..................  A                   Removal of arm foreign         *1.76       0.56       0.56       0.06       2.38       2.38        010
                                                   body.                                                                                                
24201...  ..................  A                   Removal of arm foreign         *4.56       3.06       3.06       0.49       8.11       8.11        090
                                                   body.                                                                                                
24220...  ..................  A                   Injection for elbow x-          1.31       0.51       0.51       0.05       1.87       1.87        000
                                                   ray.                                                                                                 
24301...  ..................  A                   Muscle/tendon transfer..      *10.20       7.90       7.90       1.23      19.33      19.33        090
24305...  ..................  A                   Arm tendon lengthening..       *7.45       3.08       3.08       0.29      10.82      10.82        090
24310...  ..................  A                   Revision of arm tendon..       *5.98       2.95       2.95       0.48       9.41       9.41        090
24320...  ..................  A                   Repair of arm tendon....      *10.56       9.20       9.20       1.29      21.05      21.05        090
24330...  ..................  A                   Revision of arm muscles.       *9.60       8.74       8.74       1.43      19.77      19.77        090
24331...  ..................  A                   Revision of arm muscles.      *10.65       9.62       9.62       1.57      21.84      21.84        090
24340...  ..................  A                   Repair of biceps tendon.       *7.89       7.00       7.00       1.13      16.02      16.02        090
24341...  ..................  A                   Repair tendon/muscle arm       *7.90       6.99       6.99       1.14      16.03      16.03        090
24342...  ..................  A                   Repair of ruptured            *10.62      10.38      10.38       1.76      22.76      22.76        090
                                                   tendon.                                                                                              
24350...  ..................  A                   Repair of tennis elbow..       *5.25       4.23       4.23       0.69      10.17      10.17        090
24351...  ..................  A                   Repair of tennis elbow..       *5.91       4.57       4.57       0.73      11.21      11.21        090
24352...  ..................  A                   Repair of tennis elbow..       *6.43       5.69       5.69       0.93      13.05      13.05        090
24354...  ..................  A                   Repair of tennis elbow..       *6.48       5.61       5.61       0.94      13.03      13.03        090

[[Page 59115]]

                                                                                                                                                        
24356...  ..................  A                   Revision of tennis elbow       *6.68       7.28       7.28       1.18      15.14      15.14        090
24360...  ..................  A                   Reconstruct elbow joint.      *12.34     #13.57     #13.57       2.47      28.38      28.38        090
24361...  ..................  A                   Reconstruct elbow joint.      *14.08      13.13      13.13       2.00      29.21      29.21        090
24362...  ..................  A                   Reconstruct elbow joint.      *14.99      13.14      13.14       0.80      28.93      28.93        090
24363...  ..................  A                   Replace elbow joint.....      *18.49     #20.34     #20.34       4.13      42.96      42.96        090
24365...  ..................  A                   Reconstruct head of            *8.39       7.52       7.52       1.19      17.10      17.10        090
                                                   radius.                                                                                              
24366...  ..................  A                   Reconstruct head of            *9.13     #10.04     #10.04       1.80      20.97      20.97        090
                                                   radius.                                                                                              
24400...  ..................  A                   Revision of humerus.....      *11.06       8.43       8.43       1.37      20.86      20.86        090
24410...  ..................  A                   Revision of humerus.....      *14.82      14.04      14.04       2.06      30.92      30.92        090
24420...  ..................  A                   Revision of humerus.....      *13.44      12.30      12.30       2.01      27.75      27.75        090
24430...  ..................  A                   Repair of humerus.......      *12.81     #14.09     #14.09       2.34      29.24      29.24        090
24435...  ..................  A                   Repair humerus with           *13.17     #14.49     #14.49       2.84      30.50      30.50        090
                                                   graft.                                                                                               
24470...  ..................  A                   Revision of elbow joint.       *8.74       7.92       7.92       1.30      17.96      17.96        090
24495...  ..................  A                   Decompression of forearm       *8.12       5.75       5.75       1.10      14.97      14.97        090
24498...  ..................  A                   Reinforce humerus.......      *11.92      10.37      10.37       1.62      23.91      23.91        090
24500...  ..................  A                   Treat humerus fracture..       *3.21       2.54       2.54       0.36       6.11       6.11        090
24505...  ..................  A                   Treat humerus fracture..       *5.17       4.50       4.50       0.71      10.38      10.38        090
24515...  ..................  A                   Repair humerus fracture.      *11.65       9.65       9.65       1.54      22.84      22.84        090
24516...  ..................  A                   Repair humerus fracture.      *11.65       9.65       9.65       1.54      22.84      22.84        090
24530...  ..................  A                   Treat humerus fracture..       *3.50       2.73       2.73       0.42       6.65       6.65        090
24535...  ..................  A                   Treat humerus fracture..       *6.87       4.85       4.85       0.78      12.50      12.50        090
24538...  ..................  A                   Treat humerus fracture..       *9.43       7.98       7.98       1.26      18.67      18.67        090
24545...  ..................  A                   Repair humerus fracture.      *10.46       9.97       9.97       1.59      22.02      22.02        090
24546...  ..................  A                   Repair humerus fracture.      *15.69       9.97       9.97       1.59      27.25      27.25        090
24560...  ..................  A                   Treat humerus fracture..       *2.80       2.16       2.16       0.30       5.26       5.26        090
24565...  ..................  A                   Treat humerus fracture..       *5.56       3.45       3.45       0.54       9.55       9.55        090
24566...  ..................  A                   Treat humerus fracture..       *7.79       6.06       6.06       0.96      14.81      14.81        090
24575...  ..................  A                   Repair humerus fracture.      *10.66       7.79       7.79       1.24      19.69      19.69        090
24576...  ..................  A                   Treat humerus fracture..       *2.86       2.16       2.16       0.33       5.35       5.35        090
24577...  ..................  A                   Treat humerus fracture..       *5.79       4.00       4.00       0.61      10.40      10.40        090
24579...  ..................  A                   Repair humerus fracture.      *11.60       8.37       8.37       1.35      21.32      21.32        090
24582...  ..................  A                   Treat humerus fracture..       *8.55       6.62       6.62       1.06      16.23      16.23        090
24586...  ..................  A                   Repair elbow fracture...      *15.21      14.72      14.72       2.36      32.29      32.29        090
24587...  ..................  A                   Repair elbow fracture...      *15.16      13.72      13.72       2.17      31.05      31.05        090
24600...  ..................  A                   Treat elbow dislocation.       *4.23       1.95       1.95       0.26       6.44       6.44        090
24605...  ..................  A                   Treat elbow dislocation.       *5.42       2.29       2.29       0.37       8.08       8.08        090
24615...  ..................  A                   Repair elbow dislocation       *9.42       9.29       9.29       1.48      20.19      20.19        090
24620...  ..................  A                   Treat elbow fracture....       *6.98       3.78       3.78       0.57      11.33      11.33        090
24635...  ..................  A                   Repair elbow fracture...      *13.19      11.06      11.06       1.78      26.03      26.03        090
24640...  ..................  A                   Treat elbow dislocation.       *1.20       1.01       1.01       0.08       2.29       2.29        010
24650...  ..................  A                   Treat radius fracture...       *2.16       2.25       2.25       0.33       4.74       4.74        090
24655...  ..................  A                   Treat radius fracture...       *4.40       3.01       3.01       0.45       7.86       7.86        090
24665...  ..................  A                   Repair radius fracture..       *8.14       7.13       7.13       1.14      16.41      16.41        090
24666...  ..................  A                   Repair radius fracture..       *9.49      10.27      10.27       1.60      21.36      21.36        090
24670...  ..................  A                   Treatment of ulna              *2.54       1.95       1.95       0.27       4.76       4.76        090
                                                   fracture.                                                                                            
24675...  ..................  A                   Treatment of ulna              *4.72       3.51       3.51       0.54       8.77       8.77        090
                                                   fracture.                                                                                            
24685...  ..................  A                   Repair ulna fracture....       *8.80       8.40       8.40       1.34      18.54      18.54        090
24800...  ..................  A                   Fusion of elbow joint...      *11.20      10.59      10.59       1.55      23.34      23.34        090
24802...  ..................  A                   Fusion/graft of elbow         *13.69      12.18      12.18       1.99      27.86      27.86        090
                                                   joint.                                                                                               
24900...  ..................  A                   Amputation of upper arm.       *9.60       7.68       7.68       1.39      18.67      18.67        090
24920...  ..................  A                   Amputation of upper arm.       *9.54       6.78       6.78       1.19      17.51      17.51        090
24925...  ..................  A                   Amputation follow-up           *7.07       6.27       6.27       0.75      14.09      14.09        090
                                                   surgery.                                                                                             
24930...  ..................  A                   Amputation follow-up          *10.25       8.16       8.16       1.17      19.58      19.58        090
                                                   surgery.                                                                                             
24931...  ..................  A                   Amputate upper arm &          *12.72      11.17      11.17       1.84      25.73      25.73        090
                                                   implant.                                                                                             
24935...  ..................  A                   Revision of amputation..      *15.56      13.70      13.70       2.24      31.50      31.50        090
24940...  ..................  C                   Revision of upper arm...        0.00       0.00       0.00       0.00       0.00       0.00        090
24999...  ..................  C                   Upper arm/elbow surgery.        0.00       0.00       0.00       0.00       0.00       0.00        YYY
25000...  ..................  A                   Incision of tendon             *3.38      #3.72      #3.72       0.62       7.72       7.72        090
                                                   sheath.                                                                                              
25020...  ..................  A                   Decompression of forearm       *5.92       4.35       4.35       0.77      11.04      11.04        090
25023...  ..................  A                   Decompression of forearm      *12.96       5.44       5.44       0.94      19.34      19.34        090
25028...  ..................  A                   Drainage of forearm            *5.25       2.06       2.06       0.36       7.67       7.67        090
                                                   lesion.                                                                                              
25031...  ..................  A                   Drainage of forearm            *4.14       0.66       0.66       0.09       4.89       4.89        090
                                                   bursa.                                                                                               
25035...  ..................  A                   Treat forearm bone             *7.36       6.30       6.30       1.01      14.67      14.67        090
                                                   lesion.                                                                                              
25040...  ..................  A                   Explore/treat wrist            *7.18       5.69       5.69       0.90      13.77      13.77        090
                                                   joint.                                                                                               
25065...  ..................  A                   Biopsy forearm soft            *1.99       0.75       0.75       0.09       2.83       2.83        010
                                                   tissues.                                                                                             
25066...  ..................  A                   Biopsy forearm soft            *4.13       1.54       1.54       0.22       5.89       5.89        090
                                                   tissues.                                                                                             
25075...  ..................  A                   Removal of forearm             *3.74       2.19       2.19       0.37       6.30       6.30        090
                                                   lesion.                                                                                              
25076...  ..................  A                   Removal of forearm             *4.92       3.77       3.77       0.67       9.36       9.36        090
                                                   lesion.                                                                                              
25077...  ..................  A                   Remove tumor, forearm/         *9.76       8.48       8.48       1.67      19.91      19.91        090
                                                   wrist.                                                                                               
25085...  ..................  A                   Incision of wrist              *5.50       4.62       4.62       0.71      10.83      10.83        090
                                                   capsule.                                                                                             
25100...  ..................  A                   Biopsy of wrist joint...       *3.90      #4.29      #4.29       0.79       8.98       8.98        090
25101...  ..................  A                   Explore/treat wrist            *4.69      #5.16      #5.16       0.98      10.83      10.83        090
                                                   joint.                                                                                               
25105...  ..................  A                   Remove wrist joint             *5.85      #6.44      #6.44       1.19      13.48      13.48        090
                                                   lining.                                                                                              
25107...  ..................  A                   Remove wrist joint             *6.43       5.28       5.28       0.89      12.60      12.60        090
                                                   cartilage.                                                                                           

[[Page 59116]]

                                                                                                                                                        
25110...  ..................  A                   Remove wrist tendon            *3.92       2.80       2.80       0.46       7.18       7.18        090
                                                   lesion.                                                                                              
25111...  ..................  A                   Remove wrist tendon            *3.39       3.22       3.22       0.55       7.16       7.16        090
                                                   lesion.                                                                                              
25112...  ..................  A                   Reremove wrist tendon          *4.53       3.72       3.72       0.66       8.91       8.91        090
                                                   lesion.                                                                                              
25115...  ..................  A                   Remove wrist/forearm           *8.82       7.14       7.14       1.23      17.19      17.19        090
                                                   lesion.                                                                                              
25116...  ..................  A                   Remove wrist/forearm           *7.11      #7.82      #7.82       1.38      16.31      16.31        090
                                                   lesion.                                                                                              
25118...  ..................  A                   Excise wrist tendon            *4.37      #4.81      #4.81       1.02      10.20      10.20        090
                                                   sheath.                                                                                              
25119...  ..................  A                   Partial removal of ulna.       *6.04      #6.64      #6.64       1.32      14.00      14.00        090
25120...  ..................  A                   Removal of forearm             *6.10       6.53       6.53       1.14      13.77      13.77        090
                                                   lesion.                                                                                              
25125...  ..................  A                   Remove/graft forearm           *7.48       6.84       6.84       1.04      15.36      15.36        090
                                                   lesion.                                                                                              
25126...  ..................  A                   Remove/graft forearm           *7.55       6.80       6.80       1.12      15.47      15.47        090
                                                   lesion.                                                                                              
25130...  ..................  A                   Removal of wrist lesion.       *5.26       4.21       4.21       0.67      10.14      10.14        090
25135...  ..................  A                   Remove & graft wrist           *6.89       5.46       5.46       0.97      13.32      13.32        090
                                                   lesion.                                                                                              
25136...  ..................  A                   Remove & graft wrist           *5.97       4.74       4.74       0.85      11.56      11.56        090
                                                   lesion.                                                                                              
25145...  ..................  A                   Remove forearm bone            *6.37       5.95       5.95       0.75      13.07      13.07        090
                                                   lesion.                                                                                              
25150...  ..................  A                   Partial removal of ulna.       *7.09       6.67       6.67       1.12      14.88      14.88        090
25151...  ..................  A                   Partial removal of             *7.39       5.75       5.75       1.02      14.16      14.16        090
                                                   radius.                                                                                              
25170...  ..................  A                   Extensive forearm             *11.09       9.79       9.79       1.51      22.39      22.39        090
                                                   surgery.                                                                                             
25210...  ..................  A                   Removal of wrist bone...       *5.95       4.88       4.88       0.80      11.63      11.63        090
25215...  ..................  A                   Removal of wrist bones..       *7.89       8.68       8.68       1.42      17.99      17.99        090
25230...  ..................  A                   Partial removal of             *5.23       5.57       5.57       0.85      11.65      11.65        090
                                                   radius.                                                                                              
25240...  ..................  A                   Partial removal of ulna.       *5.17       5.30       5.30       0.86      11.33      11.33        090
25246...  ..................  A                   Injection for wrist x-          1.45       0.50       0.50       0.05       2.00       2.00        000
                                                   ray.                                                                                                 
25248...  ..................  A                   Remove forearm foreign         *5.14       2.18       2.18       0.37       7.69       7.69        090
                                                   body.                                                                                                
25250...  ..................  A                   Removal of wrist               *6.60       5.63       5.63       0.91      13.14      13.14        090
                                                   prosthesis.                                                                                          
25251...  ..................  A                   Removal of wrist               *9.57       8.25       8.25       1.39      19.21      19.21        090
                                                   prosthesis.                                                                                          
25260...  ..................  A                   Repair forearm tendon/         *7.80       4.61       4.61       0.78      13.19      13.19        090
                                                   muscle.                                                                                              
25263...  ..................  A                   Repair forearm tendon/         *7.82       5.77       5.77       1.03      14.62      14.62        090
                                                   muscle.                                                                                              
25265...  ..................  A                   Repair forearm tendon/         *9.88       7.93       7.93       1.41      19.22      19.22        090
                                                   muscle.                                                                                              
25270...  ..................  A                   Repair forearm tendon/         *6.00       3.36       3.36       0.55       9.91       9.91        090
                                                   muscle.                                                                                              
25272...  ..................  A                   Repair forearm tendon/         *7.04       3.44       3.44       0.54      11.02      11.02        090
                                                   muscle.                                                                                              
25274...  ..................  A                   Repair forearm tendon/         *8.75       6.62       6.62       1.13      16.50      16.50        090
                                                   muscle.                                                                                              
25280...  ..................  A                   Revise wrist/forearm           *7.22       4.22       4.22       0.69      12.13      12.13        090
                                                   tendon.                                                                                              
25290...  ..................  A                   Incise wrist/forearm           *5.29       2.47       2.47       0.41       8.17       8.17        090
                                                   tendon.                                                                                              
25295...  ..................  A                   Release wrist/forearm          *6.55       3.05       3.05       0.52      10.12      10.12        090
                                                   tendon.                                                                                              
25300...  ..................  A                   Fusion of tendons at           *8.80       7.36       7.36       1.19      17.35      17.35        090
                                                   wrist.                                                                                               
25301...  ..................  A                   Fusion of tendons at           *8.40       6.77       6.77       1.18      16.35      16.35        090
                                                   wrist.                                                                                               
25310...  ..................  A                   Transplant forearm             *8.14       7.14       7.14       1.17      16.45      16.45        090
                                                   tendon.                                                                                              
25312...  ..................  A                   Transplant forearm             *9.57       7.63       7.63       1.31      18.51      18.51        090
                                                   tendon.                                                                                              
25315...  ..................  A                   Revise palsy hand             *10.20       8.06       8.06       1.34      19.60      19.60        090
                                                   tendon(s).                                                                                           
25316...  ..................  A                   Revise palsy hand             *12.33      10.58      10.58       1.78      24.69      24.69        090
                                                   tendon(s).                                                                                           
25320...  ..................  A                   Repair/revise wrist           *10.77       8.60       8.60       1.45      20.82      20.82        090
                                                   joint.                                                                                               
25332...  ..................  A                   Revise wrist joint......      *11.41       9.98       9.98       1.61      23.00      23.00        090
25335...  ..................  A                   Realignment of hand.....      *12.88      11.41      11.41       1.56      25.85      25.85        090
25337...  ..................  A                   Reconstruct ulna/             *10.17       8.60       8.60       1.45      20.22      20.22        090
                                                   radioulnar.                                                                                          
25350...  ..................  A                   Revision of radius......       *8.78       7.61       7.61       1.26      17.65      17.65        090
25355...  ..................  A                   Revision of radius......      *10.17       9.12       9.12       1.49      20.78      20.78        090
25360...  ..................  A                   Revision of ulna........       *8.43       6.41       6.41       0.99      15.83      15.83        090
25365...  ..................  A                   Revise radius & ulna....      *12.40      10.31      10.31       1.57      24.28      24.28        090
25370...  ..................  A                   Revise radius or ulna...      *13.36      11.76      11.76       1.92      27.04      27.04        090
25375...  ..................  A                   Revise radius & ulna....      *13.04      13.38      13.38       0.87      27.29      27.29        090
25390...  ..................  A                   Shorten radius/ulna.....      *10.40       8.82       8.82       1.50      20.72      20.72        090
25391...  ..................  A                   Lengthen radius/ulna....      *13.65      11.25      11.25       1.93      26.83      26.83        090
25392...  ..................  A                   Shorten radius & ulna...      *13.95      12.44      12.44       2.04      28.43      28.43        090
25393...  ..................  A                   Lengthen radius & ulna..      *15.87      14.21      14.21       2.32      32.40      32.40        090
25400...  ..................  A                   Repair radius or ulna...      *10.92      10.78      10.78       1.75      23.45      23.45        090
25405...  ..................  A                   Repair/graft radius or        *14.38      12.42      12.42       2.02      28.82      28.82        090
                                                   ulna.                                                                                                
25415...  ..................  A                   Repair radius & ulna....      *13.35      11.42      11.42       1.92      26.69      26.69        090
25420...  ..................  A                   Repair/graft radius &         *16.33      14.70      14.70       2.28      33.31      33.31        090
                                                   ulna.                                                                                                
25425...  ..................  A                   Repair/graft radius or        *13.21      12.02      12.02       1.87      27.10      27.10        090
                                                   ulna.                                                                                                
25426...  ..................  A                   Repair/graft radius &         *15.82      11.72      11.72       2.13      29.67      29.67        090
                                                   ulna.                                                                                                
25440...  ..................  A                   Repair/graft wrist bone.      *10.44       9.05       9.05       1.50      20.99      20.99        090
25441...  ..................  A                   Reconstruct wrist joint.      *12.90      11.36      11.36       1.89      26.15      26.15        090
25442...  ..................  A                   Reconstruct wrist joint.      *10.85       7.06       7.06       1.22      19.13      19.13        090
25443...  ..................  A                   Reconstruct wrist joint.      *10.39       9.38       9.38       1.52      21.29      21.29        090
25444...  ..................  A                   Reconstruct wrist joint.      *11.15      10.14      10.14       1.66      22.95      22.95        090
25445...  ..................  A                   Reconstruct wrist joint.       *9.69      10.36      10.36       1.72      21.77      21.77        090
25446...  ..................  A                   Wrist replacement.......      *16.55     #18.21     #18.21       3.49      38.25      38.25        090
25447...  ..................  A                   Repair wrist joint(s)...      *10.37       9.65       9.65       1.56      21.58      21.58        090
25449...  ..................  A                   Remove wrist joint            *14.49       7.84       7.84       1.16      23.49      23.49        090
                                                   implant.                                                                                             
25450...  ..................  A                   Revision of wrist joint.       *7.87       7.31       7.31       1.19      16.37      16.37        090
25455...  ..................  A                   Revision of wrist joint.       *9.49       8.71       8.71       1.42      19.62      19.62        090
25490...  ..................  A                   Reinforce radius........       *9.54       8.69       8.69       1.42      19.65      19.65        090
25491...  ..................  A                   Reinforce ulna..........       *9.96       9.10       9.10       1.49      20.55      20.55        090
25492...  ..................  A                   Reinforce radius and          *12.33      11.20      11.20       1.84      25.37      25.37        090
                                                   ulna.                                                                                                

[[Page 59117]]

                                                                                                                                                        
25500...  ..................  A                   Treat fracture of radius       *2.45       2.33       2.33       0.29       5.07       5.07        090
25505...  ..................  A                   Treat fracture of radius       *5.21       3.57       3.57       0.51       9.29       9.29        090
25515...  ..................  A                   Repair fracture of             *9.18       7.63       7.63       1.22      18.03      18.03        090
                                                   radius.                                                                                              
25520...  ..................  A                   Repair fracture of             *6.26       5.74       5.74       0.94      12.94      12.94        090
                                                   radius.                                                                                              
25525...  ..................  A                   Repair fracture of            *12.24      11.15      11.15       1.83      25.22      25.22        090
                                                   radius.                                                                                              
25526...  ..................  A                   Repair fracture of            *12.98      11.85      11.85       1.94      26.77      26.77        090
                                                   radius.                                                                                              
25530...  ..................  A                   Treat fracture of ulna..       *2.09       2.44      #2.30       0.35       4.88       4.74        090
25535...  ..................  A                   Treat fracture of ulna..       *5.14       3.57       3.57       0.54       9.25       9.25        090
25545...  ..................  A                   Repair fracture of ulna.       *8.90       7.58       7.58       1.20      17.68      17.68        090
25560...  ..................  A                   Treat fracture radius &        *2.44       2.27       2.27       0.27       4.98       4.98        090
                                                   ulna.                                                                                                
25565...  ..................  A                   Treat fracture radius &        *5.63       4.66       4.66       0.70      10.99      10.99        090
                                                   ulna.                                                                                                
25574...  ..................  A                   Treat fracture radius &        *7.01      #7.71      #7.71       1.73      16.45      16.45        090
                                                   ulna.                                                                                                
25575...  ..................  A                   Repair fracture radius/       *10.45      10.70      10.70       1.73      22.88      22.88        090
                                                   ulna.                                                                                                
25600...  ..................  A                   Treat fracture radius/         *2.63       2.84       2.84       0.42       5.89       5.89        090
                                                   ulna.                                                                                                
25605...  ..................  A                   Treat fracture radius/         *5.81       3.95       3.95       0.61      10.37      10.37        090
                                                   ulna.                                                                                                
25611...  ..................  A                   Repair fracture radius/        *7.77       6.01       6.01       0.97      14.75      14.75        090
                                                   ulna.                                                                                                
25620...  ..................  A                   Repair fracture radius/        *8.55       7.13       7.13       1.14      16.82      16.82        090
                                                   ulna.                                                                                                
25622...  ..................  A                   Treat wrist bone               *2.61       2.28       2.28       0.33       5.22       5.22        090
                                                   fracture.                                                                                            
25624...  ..................  A                   Treat wrist bone               *4.53       3.67       3.67       0.57       8.77       8.77        090
                                                   fracture.                                                                                            
25628...  ..................  A                   Repair wrist bone              *8.43       7.13       7.13       1.16      16.72      16.72        090
                                                   fracture.                                                                                            
25630...  ..................  A                   Treat wrist bone               *2.88       2.19       2.19       0.30       5.37       5.37        090
                                                   fracture.                                                                                            
25635...  ..................  A                   Treat wrist bone               *4.39       3.36       3.36       0.50       8.25       8.25        090
                                                   fracture.                                                                                            
25645...  ..................  A                   Repair wrist bone              *7.25       6.68       6.68       0.95      14.88      14.88        090
                                                   fracture.                                                                                            
25650...  ..................  A                   Repair wrist bone              *3.05       2.66       2.66       0.36       6.07       6.07        090
                                                   fracture.                                                                                            
25660...  ..................  A                   Treat wrist dislocation.       *4.76       1.82       1.82       0.26       6.84       6.84        090
25670...  ..................  A                   Repair wrist dislocation       *7.92       7.08       7.08       1.12      16.12      16.12        090
25675...  ..................  A                   Treat wrist dislocation.       *4.67       2.28       2.28       0.34       7.29       7.29        090
25676...  ..................  A                   Repair wrist dislocation       *8.04       7.32       7.32       1.11      16.47      16.47        090
25680...  ..................  A                   Treat wrist fracture....       *5.99       2.44       2.44       0.36       8.79       8.79        090
25685...  ..................  A                   Repair wrist fracture...       *9.78       8.79       8.79       1.44      20.01      20.01        090
25690...  ..................  A                   Treat wrist dislocation.       *5.50       4.89       4.89       0.73      11.12      11.12        090
25695...  ..................  A                   Repair wrist dislocation       *8.34       7.04       7.04       1.17      16.55      16.55        090
25800...  ..................  A                   Fusion of wrist joint...       *9.76     #10.74     #10.74       1.80      22.30      22.30        090
25805...  ..................  A                   Fusion/graft of wrist         *11.28     #12.41     #12.41       2.09      25.78      25.78        090
                                                   joint.                                                                                               
25810...  ..................  A                   Fusion/graft of wrist         *10.57     #11.63     #11.63       2.06      24.26      24.26        090
                                                   joint.                                                                                               
25820...  ..................  A                   Fusion of hand bones....       *7.45      #8.20      #8.20       1.48      17.13      17.13        090
25825...  ..................  A                   Fusion hand bones with         *9.27     #10.20     #10.20       1.99      21.46      21.46        090
                                                   graft.                                                                                               
25830...  ..................  A                   Fusion radioulnar jnt/        *10.06       8.60       8.60       1.45      20.11      20.11        090
                                                   ulna.                                                                                                
25900...  ..................  A                   Amputation of forearm...       *9.01       7.08       7.08       1.31      17.40      17.40        090
25905...  ..................  A                   Amputation of forearm...       *9.12       7.11       7.11       1.15      17.38      17.38        090
25907...  ..................  A                   Amputation follow-up           *7.80       5.74       5.74       1.00      14.54      14.54        090
                                                   surgery.                                                                                             
25909...  ..................  A                   Amputation follow-up           *8.96       5.55       5.55       1.06      15.57      15.57        090
                                                   surgery.                                                                                             
25915...  ..................  A                   Amputation of forearm...      *17.08      15.83      15.83       2.59      35.50      35.50        090
25920...  ..................  A                   Amputate hand at wrist..       *8.68       7.00       7.00       1.20      16.88      16.88        090
25922...  ..................  A                   Amputate hand at wrist..       *7.42       5.55       5.55       1.02      13.99      13.99        090
25924...  ..................  A                   Amputation follow-up           *8.46       7.50       7.50       1.22      17.18      17.18        090
                                                   surgery.                                                                                             
25927...  ..................  A                   Amputation of hand......       *8.80       6.29       6.29       1.22      16.31      16.31        090
25929...  ..................  A                   Amputation follow-up           *7.59       4.74       4.74       0.96      13.29      13.29        090
                                                   surgery.                                                                                             
25931...  ..................  A                   Amputation follow-up           *7.81       4.54       4.54       0.90      13.25      13.25        090
                                                   surgery.                                                                                             
25999...  ..................  C                   Forearm or wrist surgery        0.00       0.00       0.00       0.00       0.00       0.00        YYY
26010...  ..................  A                   Drainage of finger             *1.54       0.48       0.48       0.05       2.07       2.07        010
                                                   abscess.                                                                                             
26011...  ..................  A                   Drainage of finger             *2.19       1.54       1.54       0.24       3.97       3.97        010
                                                   abscess.                                                                                             
26020...  ..................  A                   Drain hand tendon sheath       *4.67       3.72       3.72       0.63       9.02       9.02        090
26025...  ..................  A                   Drainage of palm bursa..       *4.82       4.51       4.51       0.76      10.09      10.09        090
26030...  ..................  A                   Drainage of palm               *5.93       5.73       5.73       0.98      12.64      12.64        090
                                                   bursa(s).                                                                                            
26034...  ..................  A                   Treat hand bone lesion..       *6.23       4.23       4.23       0.71      11.17      11.17        090
26035...  ..................  A                   Decompress fingers/hand.       *9.51       5.17       5.17       0.86      15.54      15.54        090
26037...  ..................  A                   Decompress fingers/hand.       *7.25       6.37       6.37       1.05      14.67      14.67        090
26040...  ..................  A                   Release palm contracture       *3.33       2.86       2.86       0.49       6.68       6.68        090
26045...  ..................  A                   Release palm contracture       *5.56       4.83       4.83       0.81      11.20      11.20        090
26055...  ..................  A                   Incise finger tendon           *2.69       3.28       3.28       0.56       6.53       6.53        090
                                                   sheath.                                                                                              
26060...  ..................  A                   Incision of finger             *2.81       1.13       1.13       0.17       4.11       4.11        090
                                                   tendon.                                                                                              
26070...  ..................  A                   Explore/treat hand joint       *3.69       2.76       2.76       0.42       6.87       6.87        090
26075...  ..................  A                   Explore/treat finger           *3.79       3.78       3.78       0.62       8.19       8.19        090
                                                   joint.                                                                                               
26080...  ..................  A                   Explore/treat finger           *4.24       3.14       3.14       0.51       7.89       7.89        090
                                                   joint.                                                                                               
26100...  ..................  A                   Biopsy hand joint lining       *3.67       2.99       2.99       0.45       7.11       7.11        090
26105...  ..................  A                   Biopsy finger joint            *3.71       4.17       4.17       0.67       8.55       8.55        090
                                                   lining.                                                                                              
26110...  ..................  A                   Biopsy finger joint            *3.53       2.93       2.93       0.50       6.96       6.96        090
                                                   lining.                                                                                              
26115...  ..................  A                   Removal of hand lesion..       *3.86       2.01       2.01       0.34       6.21       6.21        090
26116...  ..................  A                   Removal of hand lesion..       *5.53       3.71       3.71       0.62       9.86       9.86        090
26117...  ..................  A                   Remove tumor, hand/            *8.55       5.07       5.07       0.91      14.53      14.53        090
                                                   finger.                                                                                              
26121...  ..................  A                   Release palm contracture       *7.54      #8.29      #8.29       1.61      17.44      17.44        090
26123...  ..................  A                   Release palm contracture       *9.29       9.10       9.10       1.53      19.92      19.92        090
26125...  ..................  A                   Release palm contracture        4.61       2.62       2.62       0.45       7.68       7.68        ZZZ

[[Page 59118]]

                                                                                                                                                        
26130...  ..................  A                   Remove wrist joint             *5.42       5.01       5.01       0.86      11.29      11.29        090
                                                   lining.                                                                                              
26135...  ..................  A                   Revise finger joint,           *6.96       4.86       4.86       0.82      12.64      12.64        090
                                                   each.                                                                                                
26140...  ..................  A                   Revise finger joint,           *6.17       4.40       4.40       0.75      11.32      11.32        090
                                                   each.                                                                                                
26145...  ..................  A                   Tendon excision, palm/         *6.32       4.71       4.71       0.80      11.83      11.83        090
                                                   finger.                                                                                              
26160...  ..................  A                   Remove tendon sheath           *3.15       2.32       2.32       0.40       5.87       5.87        090
                                                   lesion.                                                                                              
26170...  ..................  A                   Removal of palm tendon,        *4.77       2.83       2.83       0.45       8.05       8.05        090
                                                   each.                                                                                                
26180...  ..................  A                   Removal of finger tendon       *5.18       4.01       4.01       0.71       9.90       9.90        090
26185...  ..................  A                   Remove finger bone......       *5.25       4.24       4.24       0.41       9.90       9.90        090
26200...  ..................  A                   Remove hand bone lesion.       *5.51       4.48       4.48       0.72      10.71      10.71        090
26205...  ..................  A                   Remove/graft bone lesion       *7.70       6.40       6.40       1.03      15.13      15.13        090
26210...  ..................  A                   Removal of finger lesion       *5.15       3.90       3.90       0.64       9.69       9.69        090
26215...  ..................  A                   Remove/graft finger            *7.10       5.55       5.55       0.94      13.59      13.59        090
                                                   lesion.                                                                                              
26230...  ..................  A                   Partial removal of hand        *6.33       4.26       4.26       0.69      11.28      11.28        090
                                                   bone.                                                                                                
26235...  ..................  A                   Partial removal, finger        *6.19       4.17       4.17       0.71      11.07      11.07        090
                                                   bone.                                                                                                
26236...  ..................  A                   Partial removal, finger        *5.32       3.86       3.86       0.66       9.84       9.84        090
                                                   bone.                                                                                                
26250...  ..................  A                   Extensive hand surgery..       *7.55       6.00       6.00       1.07      14.62      14.62        090
26255...  ..................  A                   Extensive hand surgery..      *12.43       8.94       8.94       1.54      22.91      22.91        090
26260...  ..................  A                   Extensive finger surgery       *7.03       5.73       5.73       0.97      13.73      13.73        090
26261...  ..................  A                   Extensive finger surgery       *9.09       7.70       7.70       1.31      18.10      18.10        090
26262...  ..................  A                   Partial removal of             *5.67       4.75       4.75       0.76      11.18      11.18        090
                                                   finger.                                                                                              
26320...  ..................  A                   Removal of implant from        *3.98       3.54       3.54       0.57       8.09       8.09        090
                                                   hand.                                                                                                
26350...  ..................  A                   Repair finger/hand             *5.99       5.74       5.74       0.99      12.72      12.72        090
                                                   tendon.                                                                                              
26352...  ..................  A                   Repair/graft hand tendon       *7.68       6.60       6.60       1.10      15.38      15.38        090
26356...  ..................  A                   Repair finger/hand             *8.07       7.21       7.21       1.24      16.52      16.52        090
                                                   tendon.                                                                                              
26357...  ..................  A                   Repair finger/hand             *8.58       6.58       6.58       1.19      16.35      16.35        090
                                                   tendon.                                                                                              
26358...  ..................  A                   Repair/graft hand tendon       *9.14       7.40       7.40       1.27      17.81      17.81        090
26370...  ..................  A                   Repair finger/hand             *7.11       6.71       6.71       1.13      14.95      14.95        090
                                                   tendon.                                                                                              
26372...  ..................  A                   Repair/graft hand tendon       *8.76       6.39       6.39       1.15      16.30      16.30        090
26373...  ..................  A                   Repair finger/hand             *8.16       6.85       6.85       1.11      16.12      16.12        090
                                                   tendon.                                                                                              
26390...  ..................  A                   Revise hand/finger             *9.19       7.95       7.95       1.23      18.37      18.37        090
                                                   tendon.                                                                                              
26392...  ..................  A                   Repair/graft hand tendon      *10.26       8.61       8.61       1.26      20.13      20.13        090
26410...  ..................  A                   Repair hand tendon......       *4.63       3.29       3.29       0.51       8.43       8.43        090
26412...  ..................  A                   Repair/graft hand tendon       *6.31       6.01       6.01       0.97      13.29      13.29        090
26415...  ..................  A                   Excision, hand/finger          *8.34       6.75       6.75       0.90      15.99      15.99        090
                                                   tendon.                                                                                              
26416...  ..................  A                   Graft hand or finger           *9.37       8.64       8.64       1.41      19.42      19.42        090
                                                   tendon.                                                                                              
26418...  ..................  A                   Repair finger tendon....       *4.25       3.58       3.58       0.59       8.42       8.42        090
26420...  ..................  A                   Repair/graft finger            *6.77       5.68       5.68       0.96      13.41      13.41        090
                                                   tendon.                                                                                              
26426...  ..................  A                   Repair finger/hand             *6.15       6.31       6.31       1.07      13.53      13.53        090
                                                   tendon.                                                                                              
26428...  ..................  A                   Repair/graft finger            *7.21       5.50       5.50       1.00      13.71      13.71        090
                                                   tendon.                                                                                              
26432...  ..................  A                   Repair finger tendon....       *4.02       3.15       3.15       0.51       7.68       7.68        090
26433...  ..................  A                   Repair finger tendon....       *4.56       3.94       3.94       0.66       9.16       9.16        090
26434...  ..................  A                   Repair/graft finger            *6.09       4.95       4.95       0.84      11.88      11.88        090
                                                   tendon.                                                                                              
26437...  ..................  A                   Realignment of tendons..       *5.82       4.05       4.05       0.68      10.55      10.55        090
26440...  ..................  A                   Release palm/finger            *5.02       3.57       3.57       0.59       9.18       9.18        090
                                                   tendon.                                                                                              
26442...  ..................  A                   Release palm & finger          *8.16       3.37       3.37       0.59      12.12      12.12        090
                                                   tendon.                                                                                              
26445...  ..................  A                   Release hand/finger            *4.31       3.25       3.25       0.54       8.10       8.10        090
                                                   tendon.                                                                                              
26449...  ..................  A                   Release forearm/hand           *7.00       5.57       5.57       0.96      13.53      13.53        090
                                                   tendon.                                                                                              
26450...  ..................  A                   Incision of palm tendon.       *3.67       2.28       2.28       0.36       6.31       6.31        090
26455...  ..................  A                   Incision of finger             *3.64       1.89       1.89       0.33       5.86       5.86        090
                                                   tendon.                                                                                              
26460...  ..................  A                   Incise hand/finger             *3.46       1.72       1.72       0.30       5.48       5.48        090
                                                   tendon.                                                                                              
26471...  ..................  A                   Fusion of finger tendons       *5.73       4.15       4.15       0.67      10.55      10.55        090
26474...  ..................  A                   Fusion of finger tendons       *5.32       4.61       4.61       0.75      10.68      10.68        090
26476...  ..................  A                   Tendon lengthening......       *5.18       2.89       2.89       0.27       8.34       8.34        090
26477...  ..................  A                   Tendon shortening.......       *5.15       3.99       3.99       0.73       9.87       9.87        090
26478...  ..................  A                   Lengthening of hand            *5.80       4.30       4.30       0.72      10.82      10.82        090
                                                   tendon.                                                                                              
26479...  ..................  A                   Shortening of hand             *5.74       5.29       5.29       0.86      11.89      11.89        090
                                                   tendon.                                                                                              
26480...  ..................  A                   Transplant hand tendon..       *6.69       6.53       6.53       1.11      14.33      14.33        090
26483...  ..................  A                   Transplant/graft hand          *8.29       8.50       8.50       1.40      18.19      18.19        090
                                                   tendon.                                                                                              
26485...  ..................  A                   Transplant palm tendon..       *7.70       6.50       6.50       1.08      15.28      15.28        090
26489...  ..................  A                   Transplant/graft palm          *9.55       3.40       3.40       0.51      13.46      13.46        090
                                                   tendon.                                                                                              
26490...  ..................  A                   Revise thumb tendon.....       *8.41       7.80       7.80       1.28      17.49      17.49        090
26492...  ..................  A                   Tendon transfer with           *9.62       8.75       8.75       1.21      19.58      19.58        090
                                                   graft.                                                                                               
26494...  ..................  A                   Hand tendon/muscle             *8.47       7.28       7.28       1.23      16.98      16.98        090
                                                   transfer.                                                                                            
26496...  ..................  A                   Revise thumb tendon.....       *9.59       8.73       8.73       1.53      19.85      19.85        090
26497...  ..................  A                   Finger tendon transfer..       *9.57       8.02       8.02       1.38      18.97      18.97        090
26498...  ..................  A                   Finger tendon transfer..      *14.00      11.78      11.78       2.04      27.82      27.82        090
26499...  ..................  A                   Revision of finger......       *8.98       7.75       7.75       1.25      17.98      17.98        090
26500...  ..................  A                   Hand tendon                    *5.96       3.49       3.49       0.60      10.05      10.05        090
                                                   reconstruction.                                                                                      
26502...  ..................  A                   Hand tendon                    *7.14       5.27       5.27       0.95      13.36      13.36        090
                                                   reconstruction.                                                                                      
26504...  ..................  A                   Hand tendon                    *7.47       6.72       6.72       1.11      15.30      15.30        090
                                                   reconstruction.                                                                                      
26508...  ..................  A                   Release thumb                  *6.01       4.15       4.15       0.72      10.88      10.88        090
                                                   contracture.                                                                                         
26510...  ..................  A                   Thumb tendon transfer...       *5.43       4.15       4.15       0.68      10.26      10.26        090
26516...  ..................  A                   Fusion of knuckle joint.       *7.15       4.16       4.16       0.67      11.98      11.98        090
26517...  ..................  A                   Fusion of knuckle joints       *8.83       7.07       7.07       1.23      17.13      17.13        090

[[Page 59119]]

                                                                                                                                                        
26518...  ..................  A                   Fusion of knuckle joints       *9.02       6.51       6.51       1.22      16.75      16.75        090
26520...  ..................  A                   Release knuckle                *5.30       4.48       4.48       0.71      10.49      10.49        090
                                                   contracture.                                                                                         
26525...  ..................  A                   Release finger                 *5.33       3.64       3.64       0.62       9.59       9.59        090
                                                   contracture.                                                                                         
26530...  ..................  A                   Revise knuckle joint....       *6.69       5.16       5.16       0.85      12.70      12.70        090
26531...  ..................  A                   Revise knuckle with            *7.91       6.65       6.65       1.11      15.67      15.67        090
                                                   implant.                                                                                             
26535...  ..................  A                   Revise finger joint.....       *5.24       4.84       4.84       0.58      10.66      10.66        090
26536...  ..................  A                   Revise/implant finger          *6.37      #7.01      #7.01       1.19      14.57      14.57        090
                                                   joint.                                                                                               
26540...  ..................  A                   Repair hand joint.......       *6.43       6.64       6.64       1.12      14.19      14.19        090
26541...  ..................  A                   Repair hand joint with         *8.62       8.94       8.94       1.47      19.03      19.03        090
                                                   graft.                                                                                               
26542...  ..................  A                   Repair hand joint with         *6.78       5.67       5.67       0.97      13.42      13.42        090
                                                   graft.                                                                                               
26545...  ..................  A                   Reconstruct finger joint       *6.92       5.27       5.27       0.94      13.13      13.13        090
26546...  ..................  A                   Repair non-union hand...       *8.92       8.11       8.11       1.33      18.36      18.36        090
26548...  ..................  A                   Reconstruct finger joint       *8.03       5.79       5.79       1.00      14.82      14.82        090
26550...  ..................  A                   Construct thumb               *21.24      19.81      19.81       3.24      44.29      44.29        090
                                                   replacement.                                                                                         
26551...  ..................  A                   Great toe-hand transfer.      *46.58      42.25      42.25       6.92      95.75      95.75        090
26553...  ..................  A                   Single toe-hand transfer      *46.27      41.96      41.96       6.87      95.10      95.10        090
26554...  ..................  A                   Double toe-hand transfer      *54.95      50.06      50.06       8.20     113.21     113.21        090
26555...  ..................  A                   Positional change of          *16.63      15.41      15.41       2.52      34.56      34.56        090
                                                   finger.                                                                                              
26556...  ..................  A                   Toe joint transfer......      *47.26      42.67      42.67       6.99      96.92      96.92        090
26560...  ..................  A                   Repair of web finger....       *5.38       4.65       4.65       0.66      10.69      10.69        090
26561...  ..................  A                   Repair of web finger....      *10.92       8.89       8.89       1.56      21.37      21.37        090
26562...  ..................  A                   Repair of web finger....       *9.68     #10.65     #10.65       0.82      21.15      21.15        090
26565...  ..................  A                   Correct metacarpal flaw.       *6.74       5.82       5.82       0.85      13.41      13.41        090
26567...  ..................  A                   Correct finger deformity       *6.82       4.28       4.28       0.67      11.77      11.77        090
26568...  ..................  A                   Lengthen metacarpal/           *9.08       8.45       8.45       1.06      18.59      18.59        090
                                                   finger.                                                                                              
26580...  ..................  A                   Repair hand deformity...      *18.18      16.89      16.89       2.76      37.83      37.83        090
26585...  ..................  A                   Repair finger deformity.      *14.05      12.95      12.95       2.12      29.12      29.12        090
26587...  ..................  C                   Reconstruct extra finger        0.00       0.00       0.00       0.00       0.00       0.00        090
26590...  ..................  A                   Repair finger deformity.      *17.96      16.63      16.63       2.72      37.31      37.31        090
26591...  ..................  A                   Repair muscles of hand..       *3.25       2.29       2.29       0.39       5.93       5.93        090
26593...  ..................  A                   Release muscles of hand.       *5.31       4.12       4.12       0.70      10.13      10.13        090
26596...  ..................  A                   Excision constricting          *8.95       8.24       8.24       1.35      18.54      18.54        090
                                                   tissue.                                                                                              
26597...  ..................  A                   Release of scar                *9.82       8.02       8.02       1.37      19.21      19.21        090
                                                   contracture.                                                                                         
26600...  ..................  A                   Treat metacarpal               *1.96       1.54       1.54       0.22       3.72       3.72        090
                                                   fracture.                                                                                            
26605...  ..................  A                   Treat metacarpal               *2.85       2.29       2.29       0.36       5.50       5.50        090
                                                   fracture.                                                                                            
26607...  ..................  A                   Treat metacarpal               *5.36       3.55       3.55       0.57       9.48       9.48        090
                                                   fracture.                                                                                            
26608...  ..................  A                   Treat metacarpal               *5.36       3.55       3.55       0.57       9.48       9.48        090
                                                   fracture.                                                                                            
26615...  ..................  A                   Repair metacarpal              *5.33       4.87       4.87       0.80      11.00      11.00        090
                                                   fracture.                                                                                            
26641...  ..................  A                   Treat thumb dislocation.       *3.94       1.11       1.11       0.14       5.19       5.19        090
26645...  ..................  A                   Treat thumb fracture....       *4.41       2.20       2.20       0.33       6.94       6.94        090
26650...  ..................  A                   Repair thumb fracture...       *5.72       4.01       4.01       0.64      10.37      10.37        090
26665...  ..................  A                   Repair thumb fracture...       *7.60       6.39       6.39       1.09      15.08      15.08        090
26670...  ..................  A                   Treat hand dislocation..       *3.69       0.96       0.96       0.10       4.75       4.75        090
26675...  ..................  A                   Treat hand dislocation..       *4.64       4.34       4.34       0.60       9.58       9.58        090
26676...  ..................  A                   Pin hand dislocation....       *5.52       4.86       4.86       0.67      11.05      11.05        090
26685...  ..................  A                   Repair hand dislocation.       *6.98       5.76       5.76       0.91      13.65      13.65        090
26686...  ..................  A                   Repair hand dislocation.       *7.94       6.31       6.31       1.04      15.29      15.29        090
26700...  ..................  A                   Treat knuckle                  *3.69       0.88       0.88       0.10       4.67       4.67        090
                                                   dislocation.                                                                                         
26705...  ..................  A                   Treat knuckle                  *4.19       1.78       1.78       0.27       6.24       6.24        090
                                                   dislocation.                                                                                         
26706...  ..................  A                   Pin knuckle dislocation.       *5.12       4.68       4.68       0.75      10.55      10.55        090
26715...  ..................  A                   Repair knuckle                 *5.74       4.13       4.13       0.66      10.53      10.53        090
                                                   dislocation.                                                                                         
26720...  ..................  A                   Treat finger fracture,         *1.66       1.10       1.10       0.15       2.91       2.91        090
                                                   each.                                                                                                
26725...  ..................  A                   Treat finger fracture,         *3.33       1.54       1.54       0.23       5.10       5.10        090
                                                   each.                                                                                                
26727...  ..................  A                   Treat finger fracture,         *5.23       2.45       2.45       0.38       8.06       8.06        090
                                                   each.                                                                                                
26735...  ..................  A                   Repair finger fracture,        *5.98       3.73       3.73       0.61      10.32      10.32        090
                                                   each.                                                                                                
26740...  ..................  A                   Treat finger fracture,         *1.94       1.16       1.16       0.16       3.26       3.26        090
                                                   each.                                                                                                
26742...  ..................  A                   Treat finger fracture,         *3.85       1.98       1.98       0.32       6.15       6.15        090
                                                   each.                                                                                                
26746...  ..................  A                   Repair finger fracture,        *5.81       4.75       4.75       0.80      11.36      11.36        090
                                                   each.                                                                                                
26750...  ..................  A                   Treat finger fracture,         *1.70       0.83       0.83       0.10       2.63       2.63        090
                                                   each.                                                                                                
26755...  ..................  A                   Treat finger fracture,         *3.10       1.08       1.08       0.15       4.33       4.33        090
                                                   each.                                                                                                
26756...  ..................  A                   Pin finger fracture,           *4.39       1.90       1.90       0.33       6.62       6.62        090
                                                   each.                                                                                                
26765...  ..................  A                   Repair finger fracture,        *4.17       2.66       2.66       0.45       7.28       7.28        090
                                                   each.                                                                                                
26770...  ..................  A                   Treat finger dislocation       *3.02       0.76       0.76       0.08       3.86       3.86        090
26775...  ..................  A                   Treat finger dislocation       *3.71       1.13       1.13       0.17       5.01       5.01        090
26776...  ..................  A                   Pin finger dislocation..       *4.80       2.08       2.08       0.35       7.23       7.23        090
26785...  ..................  A                   Repair finger                  *4.21       2.97       2.97       0.48       7.66       7.66        090
                                                   dislocation.                                                                                         
26820...  ..................  A                   Thumb fusion with graft.       *8.26       6.65       6.65       1.05      15.96      15.96        090
26841...  ..................  A                   Fusion of thumb.........       *7.13       6.17       6.17       1.00      14.30      14.30        090
26842...  ..................  A                   Thumb fusion with graft.       *8.24       8.58       8.58       1.37      18.19      18.19        090
26843...  ..................  A                   Fusion of hand joint....       *7.61       6.37       6.37       1.10      15.08      15.08        090
26844...  ..................  A                   Fusion/graft of hand           *8.73       7.35       7.35       1.19      17.27      17.27        090
                                                   joint.                                                                                               
26850...  ..................  A                   Fusion of knuckle.......       *6.97       4.63       4.63       0.76      12.36      12.36        090
26852...  ..................  A                   Fusion of knuckle with         *8.46       5.72       5.72       1.00      15.18      15.18        090
                                                   graft.                                                                                               
26860...  ..................  A                   Fusion of finger joint..       *4.69       4.30       4.30       0.68       9.67       9.67        090

[[Page 59120]]

                                                                                                                                                        
26861...  ..................  A                   Fusion of finger joint,         1.74      #1.91      #1.91       0.43       4.08       4.08        ZZZ
                                                   added.                                                                                               
26862...  ..................  A                   Fusion/graft of finger         *7.37       5.16       5.16       0.85      13.38      13.38        090
                                                   joint.                                                                                               
26863...  ..................  A                   Fuse/graft added joint..        3.90       3.37       3.37       0.57       7.84       7.84        ZZZ
26910...  ..................  A                   Amputate metacarpal bone       *7.60       5.16       5.16       0.93      13.69      13.69        090
26951...  ..................  A                   Amputation of finger/          *4.59       2.87       2.87       0.49       7.95       7.95        090
                                                   thumb.                                                                                               
26952...  ..................  A                   Amputation of finger/          *6.31       4.00       4.00       0.69      11.00      11.00        090
                                                   thumb.                                                                                               
26989...  ..................  C                   Hand/finger surgery.....        0.00       0.00       0.00       0.00       0.00       0.00        YYY
26990...  ..................  A                   Drainage of pelvis             *7.48       3.10       3.10       0.51      11.09      11.09        090
                                                   lesion.                                                                                              
26991...  ..................  A                   Drainage of pelvis bursa       *6.68       1.81       1.81       0.29       8.78       8.78        090
26992...  ..................  A                   Drainage of bone lesion.      *13.02       6.38       6.38       1.05      20.45      20.45        090
27000...  ..................  A                   Incision of hip tendon..       *5.62       1.85       1.85       0.24       7.71       7.71        090
27001...  ..................  A                   Incision of hip tendon..       *6.94       2.34       2.34       0.38       9.66       9.66        090
27003...  ..................  A                   Incision of hip tendon..       *7.34       6.77       6.77       1.08      15.19      15.19        090
27005...  ..................  A                   Incision of hip tendon..       *9.66       3.37       3.37       0.54      13.57      13.57        090
27006...  ..................  A                   Incision of hip tendons.       *9.68       4.64       4.64       0.77      15.09      15.09        090
27025...  ..................  A                   Incision of hip/thigh         *11.16       6.12       6.12       1.02      18.30      18.30        090
                                                   fascia.                                                                                              
27030...  ..................  A                   Drainage of hip joint...      *13.01      11.42      11.42       1.86      26.29      26.29        090
27033...  ..................  A                   Exploration of hip joint      *13.39      11.52      11.52       1.85      26.76      26.76        090
27035...  ..................  A                   Denervation of hip joint      *16.69      11.86      11.86       2.21      30.76      30.76        090
27036...  ..................  A                   Excision of hip joint/        *12.88      11.44      11.44       1.87      26.19      26.19        090
                                                   muscle.                                                                                              
27040...  ..................  A                   Biopsy of soft tissues..       *2.87       0.72       0.72       0.11       3.70       3.70        010
27041...  ..................  A                   Biopsy of soft tissues..       *9.89       2.67       2.67       0.44      13.00      13.00        090
27047...  ..................  A                   Remove hip/pelvis lesion       *7.45       1.89       1.89       0.32       9.66       9.66        090
27048...  ..................  A                   Remove hip/pelvis lesion       *6.25       4.33       4.33       0.82      11.40      11.40        090
27049...  ..................  A                   Remove tumor, hip/pelvis      *13.66      10.14      10.14       1.87      25.67      25.67        090
27050...  ..................  A                   Biopsy of sacroiliac           *4.36       4.78       4.78       0.90      10.04      10.04        090
                                                   joint.                                                                                               
27052...  ..................  A                   Biopsy of hip joint.....       *6.23      #6.85      #6.85       1.59      14.67      14.67        090
27054...  ..................  A                   Removal of hip joint           *8.54      #9.39      #9.39       2.26      20.19      20.19        090
                                                   lining.                                                                                              
27060...  ..................  A                   Removal of ischial bursa       *5.43       3.93       3.93       0.68      10.04      10.04        090
27062...  ..................  A                   Remove femur lesion/           *5.37       4.23       4.23       0.70      10.30      10.30        090
                                                   bursa.                                                                                               
27065...  ..................  A                   Removal of hip bone            *5.90       5.59       5.59       0.90      12.39      12.39        090
                                                   lesion.                                                                                              
27066...  ..................  A                   Removal of hip bone           *10.33       7.90       7.90       1.30      19.53      19.53        090
                                                   lesion.                                                                                              
27067...  ..................  A                   Remove/graft hip bone         *13.83      11.63      11.63       1.93      27.39      27.39        090
                                                   lesion.                                                                                              
27070...  ..................  A                   Partial removal of hip        *10.72       7.41       7.41       1.21      19.34      19.34        090
                                                   bone.                                                                                                
27071...  ..................  A                   Partial removal of hip        *11.46       8.50       8.50       1.45      21.41      21.41        090
                                                   bone.                                                                                                
27075...  ..................  A                   Extensive hip surgery...      *17.23      13.54      13.54       2.32      33.09      33.09        090
27076...  ..................  A                   Extensive hip surgery...      *22.12      16.37      16.37       2.61      41.10      41.10        090
27077...  ..................  A                   Extensive hip surgery...      *23.13      18.98      18.98       3.24      45.35      45.35        090
27078...  ..................  A                   Extensive hip surgery...      *13.44       9.20       9.20       1.67      24.31      24.31        090
27079...  ..................  A                   Extensive hip surgery...      *13.75       8.64       8.64       1.66      24.05      24.05        090
27080...  ..................  A                   Removal of tail bone....       *6.39       4.78       4.78       0.87      12.04      12.04        090
27086...  ..................  A                   Remove hip foreign body.       *1.87       0.58       0.58       0.07       2.52       2.52        010
27087...  ..................  A                   Remove hip foreign body.       *8.54       3.62       3.62       0.60      12.76      12.76        090
27090...  ..................  A                   Removal of hip                *11.15       9.09       9.09       1.46      21.70      21.70        090
                                                   prosthesis.                                                                                          
27091...  ..................  A                   Removal of hip                *22.14      19.81      19.81       3.16      45.11      45.11        090
                                                   prosthesis.                                                                                          
27093...  ..................  A                   Injection for hip x-ray.        1.30       0.82       0.82       0.11       2.23       2.23        000
27095...  ..................  A                   Injection for hip x-ray.        1.50       0.93       0.93       0.13       2.56       2.56        000
27097...  ..................  A                   Revision of hip tendon..       *8.80       7.71       7.71       1.26      17.77      17.77        090
27098...  ..................  A                   Transfer tendon to             *8.83       7.71       7.71       1.26      17.80      17.80        090
                                                   pelvis.                                                                                              
27100...  ..................  A                   Transfer of abdominal         *11.08       7.68       7.68       1.42      20.18      20.18        090
                                                   muscle.                                                                                              
27105...  ..................  A                   Transfer of spinal            *11.77       5.89       5.89       1.36      19.02      19.02        090
                                                   muscle.                                                                                              
27110...  ..................  A                   Transfer of iliopsoas         *13.26      10.61      10.61       1.86      25.73      25.73        090
                                                   muscle.                                                                                              
27111...  ..................  A                   Transfer of iliopsoas         *12.15      11.63      11.63       1.65      25.43      25.43        090
                                                   muscle.                                                                                              
27120...  ..................  A                   Reconstruction of hip         *18.01      18.10      18.10       2.95      39.06      39.06        090
                                                   socket.                                                                                              
27122...  ..................  A                   Reconstruction of hip         *14.98     #16.48     #16.48       2.94      34.40      34.40        090
                                                   socket.                                                                                              
27125...  ..................  A                   Partial hip replacement.      *14.69     #16.16     #16.16       3.01      33.86      33.86        090
27130...  ..................  A                   Total hip replacement...      *20.12     #22.13     #22.13       4.58      46.83      46.83        090
27132...  ..................  A                   Total hip replacement...      *23.30     #25.63     #25.63       5.09      54.02      54.02        090
27134...  ..................  A                   Revise hip joint              *28.52     #31.37     #31.37       5.96      65.85      65.85        090
                                                   replacement.                                                                                         
27137...  ..................  A                   Revise hip joint              *21.17     #23.29     #23.29       4.82      49.28      49.28        090
                                                   replacement.                                                                                         
27138...  ..................  A                   Revise hip joint              *22.17      24.23      24.23       4.58      50.98      50.98        090
                                                   replacement.                                                                                         
27140...  ..................  A                   Transplant of femur           *12.24      11.05      11.05       1.71      25.00      25.00        090
                                                   ridge.                                                                                               
27146...  ..................  A                   Incision of hip bone....      *17.43      10.88      10.88       1.35      29.66      29.66        090
27147...  ..................  A                   Revision of hip bone....      *20.58      16.97      16.97       2.76      40.31      40.31        090
27151...  ..................  A                   Incision of hip bones...      *22.51      17.71      17.71       2.90      43.12      43.12        090
27156...  ..................  A                   Revision of hip bones...      *24.63      18.32      18.32       3.08      46.03      46.03        090
27158...  ..................  A                   Revision of pelvis......      *19.74      14.42      14.42       2.64      36.80      36.80        090
27161...  ..................  A                   Incision of neck of           *16.71      14.31      14.31       2.31      33.33      33.33        090
                                                   femur.                                                                                               
27165...  ..................  A                   Incision/fixation of          *17.91      16.76      16.76       2.63      37.30      37.30        090
                                                   femur.                                                                                               
27170...  ..................  A                   Repair/graft femur head/      *16.07      16.41      16.41       2.65      35.13      35.13        090
                                                   neck.                                                                                                
27175...  ..................  A                   Treat slipped epiphysis.       *8.46       1.18       1.18       0.18       9.82       9.82        090
27176...  ..................  A                   Treat slipped epiphysis.      *12.05      10.39      10.39       1.70      24.14      24.14        090
27177...  ..................  A                   Repair slipped epiphysis      *15.08      12.39      12.39       2.05      29.52      29.52        090
27178...  ..................  A                   Repair slipped epiphysis      *11.99      10.46      10.46       1.55      24.00      24.00        090

[[Page 59121]]

                                                                                                                                                        
27179...  ..................  A                   Revise head/neck of           *12.98      11.15      11.15       1.83      25.96      25.96        090
                                                   femur.                                                                                               
27181...  ..................  A                   Repair slipped epiphysis      *14.68      13.14      13.14       2.16      29.98      29.98        090
27185...  ..................  A                   Revision of femur              *9.18       2.77       2.77       0.87      12.82      12.82        090
                                                   epiphysis.                                                                                           
27187...  ..................  A                   Reinforce hip bones.....      *13.54     #14.89     #14.89       2.76      31.19      31.19        090
27193...  ..................  A                   Treat pelvic ring              *5.56       2.41       2.41       0.39       8.36       8.36        090
                                                   fracture.                                                                                            
27194...  ..................  A                   Treat pelvic ring              *9.65       3.90       3.90       0.50      14.05      14.05        090
                                                   fracture.                                                                                            
27200...  ..................  A                   Treat tail bone fracture       *1.84       1.49       1.49       0.17       3.50       3.50        090
27202...  ..................  A                   Repair tail bone               *7.04       6.15       6.15       0.89      14.08      14.08        090
                                                   fracture.                                                                                            
27215...  ..................  A                   Pelvic fracture(s)            *10.05     #11.06     #11.06       2.33      23.44      23.44        090
                                                   treatment.                                                                                           
27216...  ..................  A                   Treat pelvic ring             *15.19       4.30       4.30       0.66      20.15      20.15        090
                                                   fracture.                                                                                            
27217...  ..................  A                   Treat pelvic ring             *14.11      14.55      14.55       2.33      30.99      30.99        090
                                                   fracture.                                                                                            
27218...  ..................  A                   Treat pelvic ring             *20.15      14.55      14.55       2.33      37.03      37.03        090
                                                   fracture.                                                                                            
27220...  ..................  A                   Treat hip socket               *6.18       4.26       4.26       0.64      11.08      11.08        090
                                                   fracture.                                                                                            
27222...  ..................  A                   Treat hip socket              *12.70       6.37       6.37       1.03      20.10      20.10        090
                                                   fracture.                                                                                            
27226...  ..................  A                   Treat hip wall fracture.      *14.91      15.78      15.78       2.52      33.21      33.21        090
27227...  ..................  A                   Treat hip fracture(s)...      *23.45      19.70      19.70       3.20      46.35      46.35        090
27228...  ..................  A                   Treat hip fracture(s)...      *27.16      19.95      19.95       3.20      50.31      50.31        090
27230...  ..................  A                   Treat fracture of thigh.       *5.50       3.30       3.30       0.41       9.21       9.21        090
27232...  ..................  A                   Treat fracture of thigh.      *10.68       8.98       8.98       1.46      21.12      21.12        090
27235...  ..................  A                   Repair of thigh fracture      *12.16     #13.38     #13.38       2.60      28.14      28.14        090
27236...  ..................  A                   Repair of thigh fracture      *15.60      16.91      16.91       2.71      35.22      35.22        090
27238...  ..................  A                   Treatment of thigh             *5.52       4.91       4.91       0.71      11.14      11.14        090
                                                   fracture.                                                                                            
27240...  ..................  A                   Treatment of thigh            *12.50       9.70       9.70       1.53      23.73      23.73        090
                                                   fracture.                                                                                            
27244...  ..................  A                   Repair of thigh fracture      *15.94      16.30      16.30       2.62      34.86      34.86        090
27245...  ..................  A                   Repair of thigh fracture      *20.31      16.30      16.30       2.62      39.23      39.23        090
27246...  ..................  A                   Treatment of thigh             *4.71       3.87       3.87       0.60       9.18       9.18        090
                                                   fracture.                                                                                            
27248...  ..................  A                   Repair of thigh fracture      *10.45     #11.50     #11.50       2.11      24.06      24.06        090
27250...  ..................  A                   Treat hip dislocation...       *6.95       3.19       3.19       0.45      10.59      10.59        090
27252...  ..................  A                   Treat hip dislocation...      *10.39       4.34       4.34       0.68      15.41      15.41        090
27253...  ..................  A                   Repair of hip                 *12.92      13.14      13.14       2.11      28.17      28.17        090
                                                   dislocation.                                                                                         
27254...  ..................  A                   Repair of hip                 *18.26      13.47      13.47       2.27      34.00      34.00        090
                                                   dislocation.                                                                                         
27256...  ..................  A                   Treatment of hip               *4.12       1.88       1.88       0.31       6.31       6.31        010
                                                   dislocation.                                                                                         
27257...  ..................  A                   Treatment of hip               *5.22       4.62       4.62       0.73      10.57      10.57        010
                                                   dislocation.                                                                                         
27258...  ..................  A                   Repair of hip                 *15.43      13.73      13.73       2.25      31.41      31.41        090
                                                   dislocation.                                                                                         
27259...  ..................  A                   Repair of hip                 *21.55      17.20      17.20       2.82      41.57      41.57        090
                                                   dislocation.                                                                                         
27265...  ..................  A                   Treatment of hip               *5.05       3.46       3.46       0.54       9.05       9.05        090
                                                   dislocation.                                                                                         
27266...  ..................  A                   Treatment of hip               *7.49       4.45       4.45       0.71      12.65      12.65        090
                                                   dislocation.                                                                                         
27275...  ..................  A                   Manipulation of hip            *2.27       1.88       1.88       0.30       4.45       4.45        010
                                                   joint.                                                                                               
27280...  ..................  A                   Fusion of sacroiliac          *13.39      10.06      10.06       1.77      25.22      25.22        090
                                                   joint.                                                                                               
27282...  ..................  A                   Fusion of pubic bones...      *11.34       9.01       9.01       1.69      22.04      22.04        090
27284...  ..................  A                   Fusion of hip joint.....      *16.76      14.50      14.50       2.40      33.66      33.66        090
27286...  ..................  A                   Fusion of hip joint.....      *16.79      15.20      15.20       2.26      34.25      34.25        090
27290...  ..................  A                   Amputation of leg at hip      *23.28      25.40      25.40       4.70      53.38      53.38        090
27295...  ..................  A                   Amputation of leg at hip      *18.65      16.54      16.54       2.95      38.14      38.14        090
27299...  ..................  C                   Pelvis/hip joint surgery        0.00       0.00       0.00       0.00       0.00       0.00        YYY
27301...  ..................  A                   Drain thigh/knee lesion.       *6.49       2.46       2.46       0.40       9.35       9.35        090
27303...  ..................  A                   Drainage of bone lesion.       *8.28       5.86       5.86       0.96      15.10      15.10        090
27305...  ..................  A                   Incise thigh tendon &          *5.92       3.80       3.80       0.68      10.40      10.40        090
                                                   fascia.                                                                                              
27306...  ..................  A                   Incision of thigh tendon       *4.62       1.99       1.99       0.32       6.93       6.93        090
27307...  ..................  A                   Incision of thigh              *5.80       3.01       3.01       0.48       9.29       9.29        090
                                                   tendons.                                                                                             
27310...  ..................  A                   Exploration of knee            *9.27       9.60       9.60       1.51      20.38      20.38        090
                                                   joint.                                                                                               
27315...  ..................  A                   Partial removal, thigh         *6.97       5.38       5.38       0.96      13.31      13.31        090
                                                   nerve.                                                                                               
27320...  ..................  A                   Partial removal, thigh         *6.30       5.18       5.18       0.73      12.21      12.21        090
                                                   nerve.                                                                                               
27323...  ..................  A                   Biopsy thigh soft              *2.28       0.91       0.91       0.13       3.32       3.32        010
                                                   tissues.                                                                                             
27324...  ..................  A                   Biopsy thigh soft              *4.90       2.63       2.63       0.45       7.98       7.98        090
                                                   tissues.                                                                                             
27327...  ..................  A                   Removal of thigh lesion.       *4.47       2.29       2.29       0.40       7.16       7.16        090
27328...  ..................  A                   Removal of thigh lesion.       *5.57       4.07       4.07       0.73      10.37      10.37        090
27329...  ..................  A                   Remove tumor, thigh/knee      *14.14      11.69      11.69       2.14      27.97      27.97        090
27330...  ..................  A                   Biopsy knee joint lining       *4.97      #5.47      #5.47       1.19      11.63      11.63        090
27331...  ..................  A                   Explore/treat knee joint       *5.88      #6.47      #6.47       1.49      13.84      13.84        090
27332...  ..................  A                   Removal of knee                *8.27      #9.10      #9.10       1.73      19.10      19.10        090
                                                   cartilage.                                                                                           
27333...  ..................  A                   Removal of knee                *7.30      #8.03      #8.03       2.52      17.85      17.85        090
                                                   cartilage.                                                                                           
27334...  ..................  A                   Remove knee joint lining       *8.70      #9.57      #9.57       1.77      20.04      20.04        090
27335...  ..................  A                   Remove knee joint lining      *10.00     #11.00     #11.00       2.05      23.05      23.05        090
27340...  ..................  A                   Removal of kneecap bursa       *4.18       3.85       3.85       0.62       8.65       8.65        090
27345...  ..................  A                   Removal of knee cyst....       *5.92       5.63       5.63       0.95      12.50      12.50        090
27350...  ..................  A                   Removal of kneecap......       *8.17      #8.99      #8.99       1.54      18.70      18.70        090
27355...  ..................  A                   Remove femur lesion.....       *7.65       7.58       7.58       1.23      16.46      16.46        090
27356...  ..................  A                   Remove femur lesion/           *9.48       8.20       8.20       1.34      19.02      19.02        090
                                                   graft.                                                                                               
27357...  ..................  A                   Remove femur lesion/          *10.53       8.80       8.80       1.43      20.76      20.76        090
                                                   graft.                                                                                               
27358...  ..................  A                   Remove femur lesion/            4.74       4.55       4.55       0.72      10.01      10.01        ZZZ
                                                   fixation.                                                                                            
27360...  ..................  A                   Partial removal leg           *10.50       8.56       8.56       1.40      20.46      20.46        090
                                                   bone(s).                                                                                             
27365...  ..................  A                   Extensive leg surgery...      *16.27      13.94      13.94       2.43      32.64      32.64        090
27370...  ..................  A                   Injection for knee x-ray        0.96       0.60       0.60       0.05       1.61       1.61        000

[[Page 59122]]

                                                                                                                                                        
27372...  ..................  A                   Removal of foreign body.       *5.07       3.42       3.42       0.54       9.03       9.03        090
27380...  ..................  A                   Repair of kneecap tendon       *7.16      #7.88      #7.88       1.29      16.33      16.33        090
27381...  ..................  A                   Repair/graft kneecap          *10.34      11.27      11.27       1.82      23.43      23.43        090
                                                   tendon.                                                                                              
27385...  ..................  A                   Repair of thigh muscle..       *7.76      #8.54      #8.54       1.42      17.72      17.72        090
27386...  ..................  A                   Repair/graft of thigh         *10.56     #11.62     #11.62       2.02      24.20      24.20        090
                                                   muscle.                                                                                              
27390...  ..................  A                   Incision of thigh tendon       *5.33       4.36       4.36       0.71      10.40      10.40        090
27391...  ..................  A                   Incision of thigh              *7.20       5.42       5.42       0.90      13.52      13.52        090
                                                   tendons.                                                                                             
27392...  ..................  A                   Incision of thigh              *9.20       7.67       7.67       1.28      18.15      18.15        090
                                                   tendons.                                                                                             
27393...  ..................  A                   Lengthening of thigh           *6.39       5.67       5.67       0.93      12.99      12.99        090
                                                   tendon.                                                                                              
27394...  ..................  A                   Lengthening of thigh           *8.50       5.73       5.73       0.94      15.17      15.17        090
                                                   tendons.                                                                                             
27395...  ..................  A                   Lengthening of thigh          *11.73      10.48      10.48       1.65      23.86      23.86        090
                                                   tendons.                                                                                             
27396...  ..................  A                   Transplant of thigh            *7.86       7.06       7.06       1.11      16.03      16.03        090
                                                   tendon.                                                                                              
27397...  ..................  A                   Transplants of thigh          *11.28       8.88       8.88       1.45      21.61      21.61        090
                                                   tendons.                                                                                             
27400...  ..................  A                   Revise thigh muscles/          *9.02       7.89       7.89       1.24      18.15      18.15        090
                                                   tendons.                                                                                             
27403...  ..................  A                   Repair of knee cartilage       *8.33       8.79       8.79       1.44      18.56      18.56        090
27405...  ..................  A                   Repair of knee ligament.       *8.65      #9.52      #9.52       1.67      19.84      19.84        090
27407...  ..................  A                   Repair of knee ligament.      *10.28       8.87       8.87       1.42      20.57      20.57        090
27409...  ..................  A                   Repair of knee ligaments      *12.90     #14.19     #14.19       2.48      29.57      29.57        090
27418...  ..................  A                   Repair degenerated            *10.85     #11.94     #11.94       1.85      24.64      24.64        090
                                                   kneecap.                                                                                             
27420...  ..................  A                   Revision of unstable           *9.83     #10.81     #10.81       1.74      22.38      22.38        090
                                                   kneecap.                                                                                             
27422...  ..................  A                   Revision of unstable           *9.78     #10.76     #10.76       1.83      22.37      22.37        090
                                                   kneecap.                                                                                             
27424...  ..................  A                   Revision/removal of            *9.81     #10.79     #10.79       1.89      22.49      22.49        090
                                                   kneecap.                                                                                             
27425...  ..................  A                   Lateral retinacular            *5.22      #5.74      #5.74       1.08      12.04      12.04        090
                                                   release.                                                                                             
27427...  ..................  A                   Reconstruction, knee....       *9.36     #10.30     #10.30       2.25      21.91      21.91        090
27428...  ..................  A                   Reconstruction, knee....      *14.00      13.67      13.67       2.71      30.38      30.38        090
27429...  ..................  A                   Reconstruction, knee....      *15.52      11.27      11.27       1.83      28.62      28.62        090
27430...  ..................  A                   Revision of thigh              *9.67       9.36       9.36       1.50      20.53      20.53        090
                                                   muscles.                                                                                             
27435...  ..................  A                   Incision of knee joint..       *9.49       7.03       7.03       1.13      17.65      17.65        090
27437...  ..................  A                   Revise kneecap..........       *8.46      #9.31      #9.31       1.55      19.32      19.32        090
27438...  ..................  A                   Revise kneecap with           *11.23     #12.35     #12.35       2.14      25.72      25.72        090
                                                   implant.                                                                                             
27440...  ..................  A                   Revision of knee joint..      *10.43     #11.47     #11.47       2.10      24.00      24.00        090
27441...  ..................  A                   Revision of knee joint..      *10.82       9.14       9.14       1.51      21.47      21.47        090
27442...  ..................  A                   Revision of knee joint..      *11.89     #13.08     #13.08       3.05      28.02      28.02        090
27443...  ..................  A                   Revision of knee joint..      *10.93     #12.02     #12.02       3.34      26.29      26.29        090
27445...  ..................  A                   Revision of knee joint..      *17.68     #19.45     #19.45       4.21      41.34      41.34        090
27446...  ..................  A                   Revision of knee joint..      *15.84     #17.42     #17.42       3.87      37.13      37.13        090
27447...  ..................  A                   Total knee replacement..      *21.48     #23.63     #23.63       4.95      50.06      50.06        090
27448...  ..................  A                   Incision of thigh.......      *11.06     #12.17     #12.17       2.09      25.32      25.32        090
27450...  ..................  A                   Incision of thigh.......      *13.98      14.84      14.84       2.36      31.18      31.18        090
27454...  ..................  A                   Realignment of thigh          *17.56      15.70      15.70       2.82      36.08      36.08        090
                                                   bone.                                                                                                
27455...  ..................  A                   Realignment of knee.....      *12.82      12.01      12.01       1.95      26.78      26.78        090
27457...  ..................  A                   Realignment of knee.....      *13.45      13.30      13.30       2.14      28.89      28.89        090
27465...  ..................  A                   Shortening of thigh bone      *13.87      12.24      12.24       2.00      28.11      28.11        090
27466...  ..................  A                   Lengthening of thigh          *16.33      13.43      13.43       2.27      32.03      32.03        090
                                                   bone.                                                                                                
27468...  ..................  A                   Shorten/lengthen thighs.      *18.97      16.84      16.84       2.75      38.56      38.56        090
27470...  ..................  A                   Repair of thigh.........      *16.07      16.67      16.67       2.60      35.34      35.34        090
27472...  ..................  A                   Repair/graft of thigh...      *17.72     #19.49     #19.49       3.16      40.37      40.37        090
27475...  ..................  A                   Surgery to stop leg            *8.64       7.74       7.74       1.27      17.65      17.65        090
                                                   growth.                                                                                              
27477...  ..................  A                   Surgery to stop leg            *9.85     #10.84     #10.84       2.57      23.26      23.26        090
                                                   growth.                                                                                              
27479...  ..................  A                   Surgery to stop leg           *12.80      11.63      11.63       1.89      26.32      26.32        090
                                                   growth.                                                                                              
27485...  ..................  A                   Surgery to stop leg            *8.84       7.91       7.91       1.30      18.05      18.05        090
                                                   growth.                                                                                              
27486...  ..................  A                   Revise knee joint             *19.27     #21.20     #21.20       4.26      44.73      44.73        090
                                                   replace.                                                                                             
27487...  ..................  A                   Revise knee joint             *25.27      27.76      27.76       5.97      59.00      59.00        090
                                                   replace.                                                                                             
27488...  ..................  A                   Removal of knee               *15.74      16.16      16.16       2.58      34.48      34.48        090
                                                   prosthesis.                                                                                          
27495...  ..................  A                   Reinforce thigh.........      *15.55     #17.11     #17.11       2.82      35.48      35.48        090
27496...  ..................  A                   Decompression of thigh/        *6.11       4.53       4.53       0.74      11.38      11.38        090
                                                   knee.                                                                                                
27497...  ..................  A                   Decompression of thigh/        *7.17       5.55       5.55       0.91      13.63      13.63        090
                                                   knee.                                                                                                
27498...  ..................  A                   Decompression of thigh/        *7.99       6.32       6.32       1.04      15.35      15.35        090
                                                   knee.                                                                                                
27499...  ..................  A                   Decompression of thigh/        *9.00       7.28       7.28       1.19      17.47      17.47        090
                                                   knee.                                                                                                
27500...  ..................  A                   Treatment of thigh             *5.92       5.41       5.41       0.82      12.15      12.15        090
                                                   fracture.                                                                                            
27501...  ..................  A                   Treatment of thigh             *5.92       5.41       5.41       0.82      12.15      12.15        090
                                                   fracture.                                                                                            
27502...  ..................  A                   Treatment of thigh            *10.58       7.67       7.67       1.21      19.46      19.46        090
                                                   fracture.                                                                                            
27503...  ..................  A                   Treatment of thigh            *10.58       7.67       7.67       1.21      19.46      19.46        090
                                                   fracture.                                                                                            
27506...  ..................  A                   Repair of thigh fracture      *17.45      16.02      16.02       2.56      36.03      36.03        090
27507...  ..................  A                   Treatment of thigh            *13.99     #15.39     #15.39       2.56      31.94      31.94        090
                                                   fracture.                                                                                            
27508...  ..................  A                   Treatment of thigh             *5.83       4.22       4.22       0.65      10.70      10.70        090
                                                   fracture.                                                                                            
27509...  ..................  A                   Treatment of thigh             *7.71       4.22       4.22       0.65      12.58      12.58        090
                                                   fracture.                                                                                            
27510...  ..................  A                   Treatment of thigh             *9.13       6.82       6.82       1.09      17.04      17.04        090
                                                   fracture.                                                                                            
27511...  ..................  A                   Treatment of thigh            *13.64     #15.00     #15.00       2.56      31.20      31.20        090
                                                   fracture.                                                                                            
27513...  ..................  A                   Treatment of thigh            *17.92      16.02      16.02       2.56      36.50      36.50        090
                                                   fracture.                                                                                            
27514...  ..................  A                   Repair of thigh fracture      *17.30      15.76      15.76       2.53      35.59      35.59        090
27516...  ..................  A                   Repair of thigh growth         *5.37       4.82       4.82       0.71      10.90      10.90        090
                                                   plate.                                                                                               
27517...  ..................  A                   Repair of thigh growth         *8.78       7.82       7.82       1.28      17.88      17.88        090
                                                   plate.                                                                                               
27519...  ..................  A                   Repair of thigh growth        *15.02      12.68      12.68       2.05      29.75      29.75        090
                                                   plate.                                                                                               

[[Page 59123]]

                                                                                                                                                        
27520...  ..................  A                   Treat kneecap fracture..       *2.86       3.04       3.04       0.45       6.35       6.35        090
27524...  ..................  A                   Repair of kneecap             *10.00      10.34      10.34       1.65      21.99      21.99        090
                                                   fracture.                                                                                            
27530...  ..................  A                   Treatment of knee              *3.78       3.40       3.40       0.51       7.69       7.69        090
                                                   fracture.                                                                                            
27532...  ..................  A                   Treatment of knee              *7.30       5.68       5.68       0.91      13.89      13.89        090
                                                   fracture.                                                                                            
27535...  ..................  A                   Treatment of knee             *11.50      11.69      11.69       1.88      25.07      25.07        090
                                                   fracture.                                                                                            
27536...  ..................  A                   Repair of knee fracture.      *15.65      11.69      11.69       1.88      29.22      29.22        090
27538...  ..................  A                   Treat knee fracture(s)..       *4.87       3.37       3.37       0.51       8.75       8.75        090
27540...  ..................  A                   Repair of knee fracture.      *13.10      10.95      10.95       1.74      25.79      25.79        090
27550...  ..................  A                   Treat knee dislocation..       *5.76       2.57       2.57       0.36       8.69       8.69        090
27552...  ..................  A                   Treat knee dislocation..       *7.90       3.43       3.43       0.53      11.86      11.86        090
27556...  ..................  A                   Repair of knee                *14.41      12.48      12.48       1.95      28.84      28.84        090
                                                   dislocation.                                                                                         
27557...  ..................  A                   Repair of knee                *16.77      14.60      14.60       2.43      33.80      33.80        090
                                                   dislocation.                                                                                         
27558...  ..................  A                   Repair of knee                *17.72      14.60      14.60       2.43      34.75      34.75        090
                                                   dislocation.                                                                                         
27560...  ..................  A                   Treat kneecap                  *3.82       1.43       1.43       0.16       5.41       5.41        090
                                                   dislocation.                                                                                         
27562...  ..................  A                   Treat kneecap                  *5.79       5.18       5.18       0.76      11.73      11.73        090
                                                   dislocation.                                                                                         
27566...  ..................  A                   Repair kneecap                *12.23      10.58      10.58       1.67      24.48      24.48        090
                                                   dislocation.                                                                                         
27570...  ..................  A                   Fixation of knee joint..       *1.74       1.72       1.72       0.28       3.74       3.74        010
27580...  ..................  A                   Fusion of knee..........      *19.37      15.70      15.70       2.56      37.63      37.63        090
27590...  ..................  A                   Amputate leg at thigh...      *12.03       9.11       9.11       1.80      22.94      22.94        090
27591...  ..................  A                   Amputate leg at thigh...      *12.68      11.77      11.77       2.11      26.56      26.56        090
27592...  ..................  A                   Amputate leg at thigh...      *10.02       8.11       8.11       1.61      19.74      19.74        090
27594...  ..................  A                   Amputation follow-up           *6.92       3.65       3.65       0.68      11.25      11.25        090
                                                   surgery.                                                                                             
27596...  ..................  A                   Amputation follow-up          *10.60       7.37       7.37       1.42      19.39      19.39        090
                                                   surgery.                                                                                             
27598...  ..................  A                   Amputate lower leg at         *10.53      10.04      10.04       1.78      22.35      22.35        090
                                                   knee.                                                                                                
27599...  ..................  C                   Leg surgery procedure...        0.00       0.00       0.00       0.00       0.00       0.00        YYY
27600...  ..................  A                   Decompression of lower         *5.65       3.39       3.39       0.64       9.68       9.68        090
                                                   leg.                                                                                                 
27601...  ..................  A                   Decompression of lower         *5.64       3.38       3.38       0.67       9.69       9.69        090
                                                   leg.                                                                                                 
27602...  ..................  A                   Decompression of lower         *7.35       4.05       4.05       0.77      12.17      12.17        090
                                                   leg.                                                                                                 
27603...  ..................  A                   Drain lower leg lesion..       *4.94       2.38       2.38       0.41       7.73       7.73        090
27604...  ..................  A                   Drain lower leg bursa...       *4.47       1.02       1.02       0.14       5.63       5.63        090
27605...  ..................  A                   Incision of achilles           *2.87       1.18       1.18       0.14       4.19       4.19        010
                                                   tendon.                                                                                              
27606...  ..................  A                   Incision of achilles           *4.14       2.12       2.12       0.35       6.61       6.61        010
                                                   tendon.                                                                                              
27607...  ..................  A                   Treat lower leg bone           *7.97       6.01       6.01       0.98      14.96      14.96        090
                                                   lesion.                                                                                              
27610...  ..................  A                   Explore/treat ankle            *8.34       7.43       7.43       1.13      16.90      16.90        090
                                                   joint.                                                                                               
27612...  ..................  A                   Exploration of ankle           *7.33       7.97       7.97       1.30      16.60      16.60        090
                                                   joint.                                                                                               
27613...  ..................  A                   Biopsy lower leg soft          *2.17       0.67       0.67       0.10       2.94       2.94        010
                                                   tissue.                                                                                              
27614...  ..................  A                   Biopsy lower leg soft          *5.66       2.26       2.26       0.38       8.30       8.30        090
                                                   tissue.                                                                                              
27615...  ..................  A                   Remove tumor, lower leg.      *12.56       8.23       8.23       1.42      22.21      22.21        090
27618...  ..................  A                   Remove lower leg lesion.       *5.09       2.10       2.10       0.32       7.51       7.51        090
27619...  ..................  A                   Remove lower leg lesion.       *8.40       4.13       4.13       0.67      13.20      13.20        090
27620...  ..................  A                   Explore, treat ankle           *5.98       6.03       6.03       0.96      12.97      12.97        090
                                                   joint.                                                                                               
27625...  ..................  A                   Remove ankle joint             *8.30       8.71       8.71       1.27      18.28      18.28        090
                                                   lining.                                                                                              
27626...  ..................  A                   Remove ankle joint             *8.91      #9.80      #9.80       1.25      19.96      19.96        090
                                                   lining.                                                                                              
27630...  ..................  A                   Removal of tendon lesion       *4.80       3.10       3.10       0.46       8.36       8.36        090
27635...  ..................  A                   Remove lower leg bone          *7.78       8.04       8.04       1.27      17.09      17.09        090
                                                   lesion.                                                                                              
27637...  ..................  A                   Remove/graft leg bone          *9.85       8.47       8.47       1.40      19.72      19.72        090
                                                   lesion.                                                                                              
27638...  ..................  A                   Remove/graft leg bone         *10.57       9.15       9.15       1.52      21.24      21.24        090
                                                   lesion.                                                                                              
27640...  ..................  A                   Partial removal of tibia      *11.37       9.81       9.81       1.57      22.75      22.75        090
27641...  ..................  A                   Partial removal of             *9.24       7.13       7.13       1.18      17.55      17.55        090
                                                   fibula.                                                                                              
27645...  ..................  A                   Extensive lower leg           *14.17      11.64      11.64       1.98      27.79      27.79        090
                                                   surgery.                                                                                             
27646...  ..................  A                   Extensive lower leg           *12.66      10.75      10.75       1.71      25.12      25.12        090
                                                   surgery.                                                                                             
27647...  ..................  A                   Extensive ankle/heel          *12.24       9.95       9.95       1.35      23.54      23.54        090
                                                   surgery.                                                                                             
27648...  ..................  A                   Injection for ankle x-          0.96       0.52       0.52       0.05       1.53       1.53        000
                                                   ray.                                                                                                 
27650...  ..................  A                   Repair achilles tendon..       *9.69       8.98       8.98       1.41      20.08      20.08        090
27652...  ..................  A                   Repair/graft achilles         *10.33      10.41      10.41       1.56      22.30      22.30        090
                                                   tendon.                                                                                              
27654...  ..................  A                   Repair of achilles            *10.02      10.93      10.93       1.65      22.60      22.60        090
                                                   tendon.                                                                                              
27656...  ..................  A                   Repair leg fascia defect       *4.57       3.18       3.18       0.54       8.29       8.29        090
27658...  ..................  A                   Repair of leg tendon,          *4.98       4.02       4.02       0.60       9.60       9.60        090
                                                   each.                                                                                                
27659...  ..................  A                   Repair of leg tendon,          *6.81       5.87       5.87       0.86      13.54      13.54        090
                                                   each.                                                                                                
27664...  ..................  A                   Repair of leg tendon,          *4.59       3.41       3.41       0.52       8.52       8.52        090
                                                   each.                                                                                                
27665...  ..................  A                   Repair of leg tendon,          *5.40       4.95       4.95       0.76      11.11      11.11        090
                                                   each.                                                                                                
27675...  ..................  A                   Repair lower leg tendons       *7.18       6.40       6.40       0.94      14.52      14.52        090
27676...  ..................  A                   Repair lower leg tendons       *8.42       7.56       7.56       1.14      17.12      17.12        090
27680...  ..................  A                   Release of lower leg           *5.74       4.12       4.12       0.61      10.47      10.47        090
                                                   tendon.                                                                                              
27681...  ..................  A                   Release of lower leg           *6.82       5.97       5.97       0.86      13.65      13.65        090
                                                   tendons.                                                                                             
27685...  ..................  A                   Revision of lower leg          *6.50       3.83       3.83       0.41      10.74      10.74        090
                                                   tendon.                                                                                              
27686...  ..................  A                   Revise lower leg tendons       *7.46       6.56       6.56       0.90      14.92      14.92        090
27687...  ..................  A                   Revision of calf tendon.       *6.24       5.45       5.45       0.76      12.45      12.45        090
27690...  ..................  A                   Revise lower leg tendon.       *8.71       6.74       6.74       0.88      16.33      16.33        090
27691...  ..................  A                   Revise lower leg tendon.       *9.96       7.89       7.89       1.23      19.08      19.08        090
27692...  ..................  A                   Revise additional leg           1.87       2.03       2.03       0.29       4.19       4.19        ZZZ
                                                   tendon.                                                                                              
27695...  ..................  A                   Repair of ankle ligament       *6.51      #7.16      #7.16       1.32      14.99      14.99        090
27696...  ..................  A                   Repair of ankle                *8.27       7.06       7.06       1.16      16.49      16.49        090
                                                   ligaments.                                                                                           
27698...  ..................  A                   Repair of ankle ligament       *9.36     #10.30     #10.30       1.86      21.52      21.52        090

[[Page 59124]]

                                                                                                                                                        
27700...  ..................  A                   Revision of ankle joint.       *9.29     #10.22     #10.22       1.51      21.02      21.02        090
27702...  ..................  A                   Reconstruct ankle joint.      *13.67     #15.04     #15.04       3.99      32.70      32.70        090
27703...  ..................  A                   Reconstruction, ankle         *15.87      13.82      13.82       2.25      31.94      31.94        090
                                                   joint.                                                                                               
27704...  ..................  A                   Removal of ankle implant       *7.62       5.84       5.84       0.98      14.44      14.44        090
27705...  ..................  A                   Incision of tibia.......      *10.38      10.74      10.74       1.76      22.88      22.88        090
27707...  ..................  A                   Incision of fibula......       *4.37       4.75       4.75       0.79       9.91       9.91        090
27709...  ..................  A                   Incision of tibia &            *9.95     #10.95     #10.95       2.14      23.04      23.04        090
                                                   fibula.                                                                                              
27712...  ..................  A                   Realignment of lower leg      *14.25      10.99      10.99       1.63      26.87      26.87        090
27715...  ..................  A                   Revision of lower leg...      *14.39      12.61      12.61       1.88      28.88      28.88        090
27720...  ..................  A                   Repair of tibia.........      *11.79     #12.97     #12.97       2.25      27.01      27.01        090
27722...  ..................  A                   Repair/graft of tibia...      *11.82      10.50      10.50       1.64      23.96      23.96        090
27724...  ..................  A                   Repair/graft of tibia...      *14.99      15.50      15.50       2.87      33.36      33.36        090
27725...  ..................  A                   Repair of lower leg.....      *15.59      10.43      10.43       1.53      27.55      27.55        090
27727...  ..................  A                   Repair of lower leg.....      *14.01       9.38       9.38       1.84      25.23      25.23        090
27730...  ..................  A                   Repair of tibia                *7.41       3.59       3.59       0.84      11.84      11.84        090
                                                   epiphysis.                                                                                           
27732...  ..................  A                   Repair of fibula               *5.32       4.84       4.84       0.79      10.95      10.95        090
                                                   epiphysis.                                                                                           
27734...  ..................  A                   Repair lower leg               *8.48       7.54       7.54       1.23      17.25      17.25        090
                                                   epiphyses.                                                                                           
27740...  ..................  A                   Repair of leg epiphyses.       *9.30       8.36       8.36       1.36      19.02      19.02        090
27742...  ..................  A                   Repair of leg epiphyses.      *10.30       9.29       9.29       1.52      21.11      21.11        090
27745...  ..................  A                   Reinforce tibia.........      *10.07       8.97       8.97       1.39      20.43      20.43        090
27750...  ..................  A                   Treatment of tibia             *3.19       3.45       3.45       0.50       7.14       7.14        090
                                                   fracture.                                                                                            
27752...  ..................  A                   Treatment of tibia             *5.84       5.09       5.09       0.81      11.74      11.74        090
                                                   fracture.                                                                                            
27756...  ..................  A                   Repair of tibia fracture       *6.78      #7.46      #7.46       1.70      15.94      15.94        090
27758...  ..................  A                   Repair of tibia fracture      *11.67     #12.84     #12.84       2.22      26.73      26.73        090
27759...  ..................  A                   Repair of tibia fracture      *13.76      13.74      13.74       2.22      29.72      29.72        090
27760...  ..................  A                   Treatment of ankle             *3.01       2.58       2.58       0.37       5.96       5.96        090
                                                   fracture.                                                                                            
27762...  ..................  A                   Treatment of ankle             *5.25       3.36       3.36       0.50       9.11       9.11        090
                                                   fracture.                                                                                            
27766...  ..................  A                   Repair of ankle fracture       *8.36       7.87       7.87       1.26      17.49      17.49        090
27780...  ..................  A                   Treatment of fibula            *2.65       1.97       1.97       0.26       4.88       4.88        090
                                                   fracture.                                                                                            
27781...  ..................  A                   Treatment of fibula            *4.40       3.29       3.29       0.49       8.18       8.18        090
                                                   fracture.                                                                                            
27784...  ..................  A                   Repair of fibula               *7.11       5.59       5.59       0.87      13.57      13.57        090
                                                   fracture.                                                                                            
27786...  ..................  A                   Treatment of ankle             *2.84       2.52       2.52       0.38       5.74       5.74        090
                                                   fracture.                                                                                            
27788...  ..................  A                   Treatment of ankle             *4.45       3.27       3.27       0.50       8.22       8.22        090
                                                   fracture.                                                                                            
27792...  ..................  A                   Repair of ankle fracture       *7.66       7.38       7.38       1.17      16.21      16.21        090
27808...  ..................  A                   Treatment of ankle             *2.83       2.79       2.79       0.39       6.01       6.01        090
                                                   fracture.                                                                                            
27810...  ..................  A                   Treatment of ankle             *5.13       5.05       5.05       0.80      10.98      10.98        090
                                                   fracture.                                                                                            
27814...  ..................  A                   Repair of ankle fracture      *10.68      10.00      10.00       1.60      22.28      22.28        090
27816...  ..................  A                   Treatment of ankle             *2.89       3.47      #3.18       0.55       6.91       6.62        090
                                                   fracture.                                                                                            
27818...  ..................  A                   Treatment of ankle             *5.50      #6.05      #6.05       1.06      12.61      12.61        090
                                                   fracture.                                                                                            
27822...  ..................  A                   Repair of ankle fracture       *9.20     #10.12     #10.12       1.88      21.20      21.20        090
27823...  ..................  A                   Repair of ankle fracture      *11.80      12.79      12.79       2.05      26.64      26.64        090
27824...  ..................  A                   Treat lower leg fracture       *2.89       3.47      #3.18       0.55       6.91       6.62        090
27825...  ..................  A                   Treat lower leg fracture       *6.19       6.51       6.51       1.06      13.76      13.76        090
27826...  ..................  A                   Treat lower leg fracture       *8.54      #9.39      #9.39       1.88      19.81      19.81        090
27827...  ..................  A                   Treat lower leg fracture      *14.06      11.71      11.71       1.88      27.65      27.65        090
27828...  ..................  A                   Treat lower leg fracture      *16.23      12.79      12.79       2.05      31.07      31.07        090
27829...  ..................  A                   Treat lower leg joint...       *5.49      #6.04      #6.04       1.37      12.90      12.90        090
27830...  ..................  A                   Treat lower leg                *3.79       3.25       3.25       0.46       7.50       7.50        090
                                                   dislocation.                                                                                         
27831...  ..................  A                   Treat lower leg                *4.56       3.98       3.98       0.59       9.13       9.13        090
                                                   dislocation.                                                                                         
27832...  ..................  A                   Repair lower leg               *6.49       5.70       5.70       0.89      13.08      13.08        090
                                                   dislocation.                                                                                         
27840...  ..................  A                   Treat ankle dislocation.       *4.58       1.87       1.87       0.21       6.66       6.66        090
27842...  ..................  A                   Treat ankle dislocation.       *6.21       2.22       2.22       0.34       8.77       8.77        090
27846...  ..................  A                   Repair ankle dislocation       *9.79       8.59       8.59       1.37      19.75      19.75        090
27848...  ..................  A                   Repair ankle dislocation      *11.20       8.36       8.36       1.32      20.88      20.88        090
27860...  ..................  A                   Fixation of ankle joint.       *2.34       1.39       1.39       0.23       3.96       3.96        010
27870...  ..................  A                   Fusion of ankle joint...      *13.91      13.34      13.34       2.22      29.47      29.47        090
27871...  ..................  A                   Fusion of tibiofibular         *9.17       7.79       7.79       1.21      18.17      18.17        090
                                                   joint.                                                                                               
27880...  ..................  A                   Amputation of lower leg.      *11.85       8.36       8.36       1.60      21.81      21.81        090
27881...  ..................  A                   Amputation of lower leg.      *12.34      10.82      10.82       1.87      25.03      25.03        090
27882...  ..................  A                   Amputation of lower leg.       *8.94       7.36       7.36       1.42      17.72      17.72        090
27884...  ..................  A                   Amputation follow-up           *8.21       3.37       3.37       0.61      12.19      12.19        090
                                                   surgery.                                                                                             
27886...  ..................  A                   Amputation follow-up           *9.32       7.17       7.17       1.34      17.83      17.83        090
                                                   surgery.                                                                                             
27888...  ..................  A                   Amputation of foot at          *9.67       9.49       9.49       1.65      20.81      20.81        090
                                                   ankle.                                                                                               
27889...  ..................  A                   Amputation of foot at          *9.98       8.43       8.43       1.55      19.96      19.96        090
                                                   ankle.                                                                                               
27892...  ..................  A                   Decompression of leg....       *7.39       3.39       3.39       0.64      11.42      11.42        090
27893...  ..................  A                   Decompression of leg....       *7.35       3.38       3.38       0.67      11.40      11.40        090
27894...  ..................  A                   Decompression of leg....      *10.49       4.05       4.05       0.77      15.31      15.31        090
27899...  ..................  C                   Leg/ankle surgery               0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                   procedure.                                                                                           
28001...  ..................  A                   Drainage of bursa of           *2.73       0.52       0.52       0.05       3.30       3.30        010
                                                   foot.                                                                                                
28002...  ..................  A                   Treatment of foot              *4.62       2.25       2.25       0.33       7.20       7.20        010
                                                   infection.                                                                                           
28003...  ..................  A                   Treatment of foot              *8.41       3.50       3.50       0.59      12.50      12.50        090
                                                   infection.                                                                                           
28005...  ..................  A                   Treat foot bone lesion..       *8.68       4.08       4.08       0.61      13.37      13.37        090
28008...  ..................  A                   Incision of foot fascia.       *4.45       2.68       2.68       0.29       7.42       7.42        090
28010...  ..................  A                   Incision of toe tendon..       *2.84       3.62       3.62       0.33       6.79       6.79        090

[[Page 59125]]

                                                                                                                                                        
28011...  ..................  A                   Incision of toe tendons.       *4.14       1.77       1.77       0.19       6.10       6.10        090
28020...  ..................  A                   Exploration of a foot          *5.01       4.40       4.40       0.56       9.97       9.97        090
                                                   joint.                                                                                               
28022...  ..................  A                   Exploration of a foot          *4.67       2.74       2.74       0.31       7.72       7.72        090
                                                   joint.                                                                                               
28024...  ..................  A                   Exploration of a toe           *4.38       2.39       2.39       0.24       7.01       7.01        090
                                                   joint.                                                                                               
28030...  ..................  A                   Removal of foot nerve...       *6.15       3.93       3.93       0.42      10.50      10.50        090
28035...  ..................  A                   Decompression of tibia         *5.09       6.18      #5.60       0.90      12.17      11.59        090
                                                   nerve.                                                                                               
28043...  ..................  A                   Excision of foot lesion.       *3.54       1.73       1.73       0.20       5.47       5.47        090
28045...  ..................  A                   Excision of foot lesion.       *4.72       3.99       3.99       0.46       9.17       9.17        090
28046...  ..................  A                   Resection of tumor, foot      *10.18       5.35       5.35       0.79      16.32      16.32        090
28050...  ..................  A                   Biopsy of foot joint           *4.25       3.84       3.84       0.53       8.62       8.62        090
                                                   lining.                                                                                              
28052...  ..................  A                   Biopsy of foot joint           *3.94       3.82       3.82       0.43       8.19       8.19        090
                                                   lining.                                                                                              
28054...  ..................  A                   Biopsy of toe joint            *3.45       2.24       2.24       0.28       5.97       5.97        090
                                                   lining.                                                                                              
28060...  ..................  A                   Partial removal foot           *5.23       4.22       4.22       0.53       9.98       9.98        090
                                                   fascia.                                                                                              
28062...  ..................  A                   Removal of foot fascia..       *6.52       7.06       7.06       0.86      14.44      14.44        090
28070...  ..................  A                   Removal of foot joint          *5.10       4.48       4.48       0.48      10.06      10.06        090
                                                   lining.                                                                                              
28072...  ..................  A                   Removal of foot joint          *4.58       3.21       3.21       0.42       8.21       8.21        090
                                                   lining.                                                                                              
28080...  ..................  A                   Removal of foot lesion..       *3.58       4.07       4.07       0.45       8.10       8.10        090
28086...  ..................  A                   Excise foot tendon             *4.78       3.12       3.12       0.46       8.36       8.36        090
                                                   sheath.                                                                                              
28088...  ..................  A                   Excise foot tendon             *3.86       3.62       3.62       0.40       7.88       7.88        090
                                                   sheath.                                                                                              
28090...  ..................  A                   Removal of foot lesion..       *4.41       3.02       3.02       0.29       7.72       7.72        090
28092...  ..................  A                   Removal of toe lesions..       *3.64       2.03       2.03       0.25       5.92       5.92        090
28100...  ..................  A                   Removal of ankle/heel          *5.66       4.58       4.58       0.56      10.80      10.80        090
                                                   lesion.                                                                                              
28102...  ..................  A                   Remove/graft foot lesion       *7.73       6.84       6.84       0.85      15.42      15.42        090
28103...  ..................  A                   Remove/graft foot lesion       *6.50       5.61       5.61       0.69      12.80      12.80        090
28104...  ..................  A                   Removal of foot lesion..       *5.12       4.33       4.33       0.49       9.94       9.94        090
28106...  ..................  A                   Remove/graft foot lesion       *7.16       6.42       6.42       0.79      14.37      14.37        090
28107...  ..................  A                   Remove/graft foot lesion       *5.56       4.86       4.86       0.48      10.90      10.90        090
28108...  ..................  A                   Removal of toe lesions..       *4.16       4.20       4.20       0.38       8.74       8.74        090
28110...  ..................  A                   Part removal of                *4.08       3.48       3.48       0.39       7.95       7.95        090
                                                   metatarsal.                                                                                          
28111...  ..................  A                   Part removal of                *5.01       5.04       5.04       0.65      10.70      10.70        090
                                                   metatarsal.                                                                                          
28112...  ..................  A                   Part removal of                *4.49       3.96       3.96       0.45       8.90       8.90        090
                                                   metatarsal.                                                                                          
28113...  ..................  A                   Part removal of                *4.79       4.44       4.44       0.48       9.71       9.71        090
                                                   metatarsal.                                                                                          
28114...  ..................  A                   Removal of metatarsal          *9.79       9.17       9.17       1.42      20.38      20.38        090
                                                   heads.                                                                                               
28116...  ..................  A                   Revision of foot........       *7.75       5.48       5.48       0.57      13.80      13.80        090
28118...  ..................  A                   Removal of heel bone....       *5.96       5.71       5.71       0.66      12.33      12.33        090
28119...  ..................  A                   Removal of heel spur....       *5.39       5.44       5.44       0.57      11.40      11.40        090
28120...  ..................  A                   Part removal of ankle/         *5.40       5.04       5.04       0.67      11.11      11.11        090
                                                   heel.                                                                                                
28122...  ..................  A                   Partial removal of foot        *7.29       4.48       4.48       0.54      12.31      12.31        090
                                                   bone.                                                                                                
28124...  ..................  A                   Partial removal of toe..       *4.81       4.11       4.11       0.37       9.29       9.29        090
28126...  ..................  A                   Partial removal of toe..       *3.52       3.98       3.98       0.36       7.86       7.86        090
28130...  ..................  A                   Removal of ankle bone...       *8.11       7.03       7.03       0.88      16.02      16.02        090
28140...  ..................  A                   Removal of metatarsal...       *6.91       4.93       4.93       0.62      12.46      12.46        090
28150...  ..................  A                   Removal of toe..........       *4.09       3.29       3.29       0.38       7.76       7.76        090
28153...  ..................  A                   Partial removal of toe..       *3.66       3.99       3.99       0.36       8.01       8.01        090
28160...  ..................  A                   Partial removal of toe..       *3.74       4.12       4.12       0.38       8.24       8.24        090
28171...  ..................  A                   Extensive foot surgery..       *9.60       7.99       7.99       0.88      18.47      18.47        090
28173...  ..................  A                   Extensive foot surgery..       *8.80       5.74       5.74       0.74      15.28      15.28        090
28175...  ..................  A                   Extensive foot surgery..       *6.05       5.38       5.38       0.58      12.01      12.01        090
28190...  ..................  A                   Removal of foot foreign        *1.96       0.52       0.52       0.05       2.53       2.53        010
                                                   body.                                                                                                
28192...  ..................  A                   Removal of foot foreign        *4.64       1.95       1.95       0.24       6.83       6.83        090
                                                   body.                                                                                                
28193...  ..................  A                   Removal of foot foreign        *5.73       2.38       2.38       0.30       8.41       8.41        090
                                                   body.                                                                                                
28200...  ..................  A                   Repair of foot tendon...       *4.60       5.06       5.06       0.50      10.16      10.16        090
28202...  ..................  A                   Repair/graft of foot           *6.84       5.82       5.82       0.77      13.43      13.43        090
                                                   tendon.                                                                                              
28208...  ..................  A                   Repair of foot tendon...       *4.37       2.81       2.81       0.28       7.46       7.46        090
28210...  ..................  A                   Repair/graft of foot           *6.35       5.60       5.60       0.60      12.55      12.55        090
                                                   tendon.                                                                                              
28220...  ..................  A                   Release of foot tendon..       *4.53       3.87       3.87       0.43       8.83       8.83        090
28222...  ..................  A                   Release of foot tendons.       *5.62       6.40       6.40       0.63      12.65      12.65        090
28225...  ..................  A                   Release of foot tendon..       *3.66       2.37       2.37       0.25       6.28       6.28        090
28226...  ..................  A                   Release of foot tendons.       *4.53       3.38       3.38       0.40       8.31       8.31        090
28230...  ..................  A                   Incision of foot               *4.24       2.43       2.43       0.22       6.89       6.89        090
                                                   tendon(s).                                                                                           
28232...  ..................  A                   Incision of toe tendon..       *3.39       1.60       1.60       0.15       5.14       5.14        090
28234...  ..................  A                   Incision of foot tendon.       *3.37       1.53       1.53       0.14       5.04       5.04        090
28238...  ..................  A                   Revision of foot tendon.       *7.73       7.23       7.23       0.85      15.81      15.81        090
28240...  ..................  A                   Release of big toe......       *4.36       2.13       2.13       0.23       6.72       6.72        090
28250...  ..................  A                   Revision of foot fascia.       *5.92       4.46       4.46       0.50      10.88      10.88        090
28260...  ..................  A                   Release of midfoot joint       *7.96       4.43       4.43       0.48      12.87      12.87        090
28261...  ..................  A                   Revision of foot tendon.      *11.73       5.91       5.91       0.58      18.22      18.22        090
28262...  ..................  A                   Revision of foot and          *15.83      11.91      11.91       1.44      29.18      29.18        090
                                                   ankle.                                                                                               
28264...  ..................  A                   Release of midfoot joint      *10.35       9.56       9.56       1.17      21.08      21.08        090
28270...  ..................  A                   Release of foot                *4.76       2.63       2.63       0.23       7.62       7.62        090
                                                   contracture.                                                                                         
28272...  ..................  A                   Release of toe joint,          *3.80       2.04       2.04       0.18       6.02       6.02        090
                                                   each.                                                                                                
28280...  ..................  A                   Fusion of toes..........       *5.19       2.22       2.22       0.30       7.71       7.71        090
28285...  ..................  A                   Repair of hammertoe.....       *4.59       4.37       4.37       0.39       9.35       9.35        090
28286...  ..................  A                   Repair of hammertoe.....       *4.56       3.58       3.58       0.38       8.52       8.52        090

[[Page 59126]]

                                                                                                                                                        
28288...  ..................  A                   Partial removal of foot        *4.74       3.75       3.75       0.43       8.92       8.92        090
                                                   bone.                                                                                                
28290...  ..................  A                   Correction of bunion....       *5.66       5.36       5.36       0.63      11.65      11.65        090
28292...  ..................  A                   Correction of bunion....       *7.04       7.05       7.05       0.74      14.83      14.83        090
28293...  ..................  A                   Correction of bunion....       *9.15       9.55       9.55       0.98      19.68      19.68        090
28294...  ..................  A                   Correction of bunion....       *8.56       9.16       9.16       0.86      18.58      18.58        090
28296...  ..................  A                   Correction of bunion....       *9.18       8.81       8.81       0.98      18.97      18.97        090
28297...  ..................  A                   Correction of bunion....       *9.18       9.02       9.02       1.05      19.25      19.25        090
28298...  ..................  A                   Correction of bunion....       *7.94      #8.73      #8.73       0.79      17.46      17.46        090
28299...  ..................  A                   Correction of bunion....       *8.88      #9.77      #9.77       1.08      19.73      19.73        090
28300...  ..................  A                   Incision of heel bone...       *9.54       6.52       6.52       0.79      16.85      16.85        090
28302...  ..................  A                   Incision of ankle bone..       *9.55       8.89       8.89       1.12      19.56      19.56        090
28304...  ..................  A                   Incision of midfoot            *9.16       6.44       6.44       0.70      16.30      16.30        090
                                                   bones.                                                                                               
28305...  ..................  A                   Incise/graft midfoot          *10.50       9.85       9.85       1.03      21.38      21.38        090
                                                   bones.                                                                                               
28306...  ..................  A                   Incision of metatarsal..       *5.86       4.57       4.57       0.47      10.90      10.90        090
28307...  ..................  A                   Incision of metatarsal..       *6.33       5.87       5.87       0.76      12.96      12.96        090
28308...  ..................  A                   Incision of metatarsal..       *5.29       5.71       5.71       0.50      11.50      11.50        090
28309...  ..................  A                   Incision of metatarsals.      *12.78       6.87       6.87       1.00      20.65      20.65        090
28310...  ..................  A                   Revision of big toe.....       *5.43       4.17       4.17       0.42      10.02      10.02        090
28312...  ..................  A                   Revision of toe.........       *4.55       4.56       4.56       0.45       9.56       9.56        090
28313...  ..................  A                   Repair deformity of toe.       *5.01       2.57       2.57       0.31       7.89       7.89        090
28315...  ..................  A                   Removal of sesamoid bone       *4.86       4.24       4.24       0.41       9.51       9.51        090
28320...  ..................  A                   Repair of foot bones....       *9.18       8.69       8.69       1.03      18.90      18.90        090
28322...  ..................  A                   Repair of metatarsals...       *8.34       4.67       4.67       0.52      13.53      13.53        090
28340...  ..................  A                   Resect enlarged toe            *6.98       6.34       6.34       0.91      14.23      14.23        090
                                                   tissue.                                                                                              
28341...  ..................  A                   Resect enlarged toe.....       *8.41       7.66       7.66       0.96      17.03      17.03        090
28344...  ..................  A                   Repair extra toe(s).....       *4.26       3.70       3.70       0.60       8.56       8.56        090
28345...  ..................  A                   Repair webbed toe(s)....       *5.92       5.34       5.34       0.73      11.99      11.99        090
28360...  ..................  A                   Reconstruct cleft foot..      *13.34      11.91      11.91       1.95      27.20      27.20        090
28400...  ..................  A                   Treatment of heel              *2.16       2.57       2.57       0.40       5.13       5.13        090
                                                   fracture.                                                                                            
28405...  ..................  A                   Treatment of heel              *4.57       3.90       3.90       0.58       9.05       9.05        090
                                                   fracture.                                                                                            
28406...  ..................  A                   Treatment of heel              *6.31       6.09       6.09       0.93      13.33      13.33        090
                                                   fracture.                                                                                            
28415...  ..................  A                   Repair of heel fracture.      *15.97       9.02       9.02       1.39      26.38      26.38        090
28420...  ..................  A                   Repair/graft heel             *16.64      10.89      10.89       1.63      29.16      29.16        090
                                                   fracture.                                                                                            
28430...  ..................  A                   Treatment of ankle             *2.09       2.45       2.45       0.35       4.89       4.89        090
                                                   fracture.                                                                                            
28435...  ..................  A                   Treatment of ankle             *3.40       3.36       3.36       0.50       7.26       7.26        090
                                                   fracture.                                                                                            
28436...  ..................  A                   Treatment of ankle             *4.71       4.19       4.19       0.68       9.58       9.58        090
                                                   fracture.                                                                                            
28445...  ..................  A                   Repair of ankle fracture       *9.33       8.80       8.80       1.40      19.53      19.53        090
28450...  ..................  A                   Treat midfoot fracture,        *1.90       1.87       1.87       0.25       4.02       4.02        090
                                                   each.                                                                                                
28455...  ..................  A                   Treat midfoot fracture,        *3.09       2.54       2.54       0.34       5.97       5.97        090
                                                   each.                                                                                                
28456...  ..................  A                   Repair midfoot fracture.       *2.68       2.27       2.27       0.38       5.33       5.33        090
28465...  ..................  A                   Repair midfoot fracture,       *7.01       5.54       5.54       0.81      13.36      13.36        090
                                                   each.                                                                                                
28470...  ..................  A                   Treat metatarsal               *1.99       1.80       1.80       0.23       4.02       4.02        090
                                                   fracture.                                                                                            
28475...  ..................  A                   Treat metatarsal               *2.97       2.34       2.34       0.30       5.61       5.61        090
                                                   fracture.                                                                                            
28476...  ..................  A                   Repair metatarsal              *3.38       3.37       3.37       0.45       7.20       7.20        090
                                                   fracture.                                                                                            
28485...  ..................  A                   Repair metatarsal              *5.71       4.68       4.68       0.60      10.99      10.99        090
                                                   fracture.                                                                                            
28490...  ..................  A                   Treat big toe fracture..       *1.09       0.90       0.90       0.10       2.09       2.09        090
28495...  ..................  A                   Treat big toe fracture..       *1.58       1.12       1.12       0.13       2.83       2.83        090
28496...  ..................  A                   Repair big toe fracture.       *2.33       2.07       2.07       0.31       4.71       4.71        090
28505...  ..................  A                   Repair big toe fracture.       *3.81       2.99       2.99       0.43       7.23       7.23        090
28510...  ..................  A                   Treatment of toe               *1.09       0.89       0.89       0.09       2.07       2.07        090
                                                   fracture.                                                                                            
28515...  ..................  A                   Treatment of toe               *1.46       1.12       1.12       0.11       2.69       2.69        090
                                                   fracture.                                                                                            
28525...  ..................  A                   Repair of toe fracture..       *3.32       2.06       2.06       0.29       5.67       5.67        090
28530...  ..................  A                   Treat sesamoid bone            *1.06       1.00       1.00       0.10       2.16       2.16        090
                                                   fracture.                                                                                            
28531...  ..................  A                   Treat sesamoid bone            *2.35       1.91       1.91       0.32       4.58       4.58        090
                                                   fracture.                                                                                            
28540...  ..................  A                   Treat foot dislocation..       *2.04       0.60       0.60       0.06       2.70       2.70        090
28545...  ..................  A                   Treat foot dislocation..       *2.45       1.31       1.31       0.14       3.90       3.90        090
28546...  ..................  A                   Treat foot dislocation..       *3.20       2.74       2.74       0.45       6.39       6.39        090
28555...  ..................  A                   Repair foot dislocation.       *6.30       5.58       5.58       0.73      12.61      12.61        090
28570...  ..................  A                   Treat foot dislocation..       *1.66       1.59       1.59       0.17       3.42       3.42        090
28575...  ..................  A                   Treat foot dislocation..       *3.31       2.77       2.77       0.42       6.50       6.50        090
28576...  ..................  A                   Treat foot dislocation..       *4.17       2.77       2.77       0.42       7.36       7.36        090
28585...  ..................  A                   Repair foot dislocation.       *7.99       4.96       4.96       0.55      13.50      13.50        090
28600...  ..................  A                   Treat foot dislocation..       *1.89       0.68       0.68       0.08       2.65       2.65        090
28605...  ..................  A                   Treat foot dislocation..       *2.71       2.26       2.26       0.34       5.31       5.31        090
28606...  ..................  A                   Treat foot dislocation..       *4.90       3.49       3.49       0.55       8.94       8.94        090
28615...  ..................  A                   Repair foot dislocation.       *7.77       4.96       4.96       0.78      13.51      13.51        090
28630...  ..................  A                   Treat toe dislocation...       *1.70       1.03       1.03       0.11       2.84       2.84        010
28635...  ..................  A                   Treat toe dislocation...       *1.91       1.45       1.45       0.18       3.54       3.54        010
28636...  ..................  A                   Treat toe dislocation...       *2.77       2.56       2.56       0.42       5.75       5.75        010
28645...  ..................  A                   Repair toe dislocation..       *4.22       3.24       3.24       0.38       7.84       7.84        090
28660...  ..................  A                   Treat toe dislocation...       *1.23       0.63       0.63       0.06       1.92       1.92        010
28665...  ..................  A                   Treat toe dislocation...       *1.92       0.98       0.98       0.11       3.01       3.01        010
28666...  ..................  A                   Treat toe dislocation...       *2.66       2.44       2.44       0.40       5.50       5.50        010
28675...  ..................  A                   Repair of toe                  *2.92       3.00       3.00       0.41       6.33       6.33        090
                                                   dislocation.                                                                                         

[[Page 59127]]

                                                                                                                                                        
28705...  ..................  A                   Fusion of foot bones....      *15.21      15.11      15.11       2.35      32.67      32.67        090
28715...  ..................  A                   Fusion of foot bones....      *13.10      12.33      12.33       1.89      27.32      27.32        090
28725...  ..................  A                   Fusion of foot bones....      *11.61       9.44       9.44       1.44      22.49      22.49        090
28730...  ..................  A                   Fusion of foot bones....      *10.76       9.00       9.00       1.33      21.09      21.09        090
28735...  ..................  A                   Fusion of foot bones....      *10.85       9.76       9.76       1.37      21.98      21.98        090
28737...  ..................  A                   Revision of foot bones..       *9.64       8.87       8.87       1.13      19.64      19.64        090
28740...  ..................  A                   Fusion of foot bones....       *8.02       5.14       5.14       0.72      13.88      13.88        090
28750...  ..................  A                   Fusion of big toe joint.       *7.30       5.32       5.32       0.82      13.44      13.44        090
28755...  ..................  A                   Fusion of big toe joint.       *4.74       3.69       3.69       0.45       8.88       8.88        090
28760...  ..................  A                   Fusion of big toe joint.       *7.75       5.40       5.40       0.65      13.80      13.80        090
28800...  ..................  A                   Amputation of midfoot...       *8.21       6.65       6.65       1.19      16.05      16.05        090
28805...  ..................  A                   Amputation thru                *8.39       6.32       6.32       1.21      15.92      15.92        090
                                                   metatarsal.                                                                                          
28810...  ..................  A                   Amputation toe &               *6.21       3.91       3.91       0.75      10.87      10.87        090
                                                   metatarsal.                                                                                          
28820...  ..................  A                   Amputation of toe.......       *4.41       2.58       2.58       0.46       7.45       7.45        090
28825...  ..................  A                   Partial amputation of          *3.59       2.40       2.40       0.41       6.40       6.40        090
                                                   toe.                                                                                                 
28899...  ..................  C                   Foot/toes surgery               0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                   procedure.                                                                                           
29000...  ..................  A                   Application of body cast        2.25       1.85       1.85       0.21       4.31       4.31        000
29010...  ..................  A                   Application of body cast        2.06       2.33      #2.27       0.34       4.73       4.67        000
29015...  ..................  A                   Application of body cast        2.41       2.33       2.33       0.33       5.07       5.07        000
29020...  ..................  A                   Application of body cast        2.11       1.82       1.82       0.23       4.16       4.16        000
29025...  ..................  A                   Application of body cast        2.40       0.75       0.75       0.14       3.29       3.29        000
29035...  ..................  A                   Application of body cast        1.77       1.95       1.95       0.32       4.04       4.04        000
29040...  ..................  A                   Application of body cast        2.22       2.02       2.02       0.30       4.54       4.54        000
29044...  ..................  A                   Application of body cast        2.12       2.09       2.09       0.34       4.55       4.55        000
29046...  ..................  A                   Application of body cast        2.41       2.23       2.23       0.36       5.00       5.00        000
29049...  ..................  A                   Application of figure           0.89       0.42       0.42       0.06       1.37       1.37        000
                                                   eight.                                                                                               
29055...  ..................  A                   Application of shoulder         1.78       1.20       1.20       0.17       3.15       3.15        000
                                                   cast.                                                                                                
29058...  ..................  A                   Application of shoulder         1.31       0.65       0.65       0.09       2.05       2.05        000
                                                   cast.                                                                                                
29065...  ..................  A                   Application of long arm         0.87       0.80       0.80       0.13       1.80       1.80        000
                                                   cast.                                                                                                
29075...  ..................  A                   Application of forearm          0.77       0.61       0.61       0.10       1.48       1.48        000
                                                   cast.                                                                                                
29085...  ..................  A                   Apply hand/wrist cast...        0.87       0.50       0.50       0.08       1.45       1.45        000
29105...  ..................  A                   Apply long arm splint...        0.87       0.50       0.50       0.08       1.45       1.45        000
29125...  ..................  A                   Apply forearm splint....        0.59       0.37       0.37       0.05       1.01       1.01        000
29126...  ..................  A                   Apply forearm splint....        0.77       0.40       0.40       0.06       1.23       1.23        000
29130...  ..................  A                   Application of finger           0.50       0.17       0.17       0.02       0.69       0.69        000
                                                   splint.                                                                                              
29131...  ..................  A                   Application of finger           0.55       0.39       0.39       0.06       1.00       1.00        000
                                                   splint.                                                                                              
29200...  ..................  A                   Strapping of chest......        0.65       0.27       0.27       0.03       0.95       0.95        000
29220...  ..................  A                   Strapping of low back...        0.64       0.38       0.38       0.05       1.07       1.07        000
29240...  ..................  A                   Strapping of shoulder...        0.71       0.27       0.27       0.03       1.01       1.01        000
29260...  ..................  A                   Strapping of elbow or           0.55       0.23       0.23       0.03       0.81       0.81        000
                                                   wrist.                                                                                               
29280...  ..................  A                   Strapping of hand or            0.51       0.21       0.21       0.02       0.74       0.74        000
                                                   finger.                                                                                              
29305...  ..................  A                   Application of hip cast.        2.03       1.88       1.88       0.31       4.22       4.22        000
29325...  ..................  A                   Application of hip casts        2.32       1.94       1.94       0.28       4.54       4.54        000
29345...  ..................  A                   Application of long leg         1.40       1.02       1.02       0.16       2.58       2.58        000
                                                   cast.                                                                                                
29355...  ..................  A                   Application of long leg         1.53       1.10       1.10       0.17       2.80       2.80        000
                                                   cast.                                                                                                
29358...  ..................  A                   Apply long leg cast             1.43      #1.57      #1.57       0.33       3.33       3.33        000
                                                   brace.                                                                                               
29365...  ..................  A                   Application of long leg         1.18       0.86       0.86       0.14       2.18       2.18        000
                                                   cast.                                                                                                
29405...  ..................  A                   Apply short leg cast....        0.86       0.79       0.79       0.12       1.77       1.77        000
29425...  ..................  A                   Apply short leg cast....        1.01       0.97       0.97       0.14       2.12       2.12        000
29435...  ..................  A                   Apply short leg cast....        1.18       1.18       1.18       0.18       2.54       2.54        000
29440...  ..................  A                   Addition of walker to           0.57       0.23       0.23       0.03       0.83       0.83        000
                                                   cast.                                                                                                
29445...  ..................  A                   Apply rigid leg cast....        1.78       1.70       1.70       0.28       3.76       3.76        000
29450...  ..................  A                   Application of leg cast.        1.02       0.39       0.39       0.04       1.45       1.45        000
29505...  ..................  A                   Application long leg            0.69       0.57       0.57       0.07       1.33       1.33        000
                                                   splint.                                                                                              
29515...  ..................  A                   Application lower leg           0.73       0.47       0.47       0.06       1.26       1.26        000
                                                   splint.                                                                                              
29520...  ..................  A                   Strapping of hip........        0.54       0.36       0.36       0.03       0.93       0.93        000
29530...  ..................  A                   Strapping of knee.......        0.57       0.35       0.35       0.05       0.97       0.97        000
29540...  ..................  A                   Strapping of ankle......        0.51       0.30       0.30       0.03       0.84       0.84        000
29550...  ..................  A                   Strapping of toes.......        0.47       0.28       0.28       0.03       0.78       0.78        000
29580...  ..................  A                   Application of paste            0.57       0.79       0.79       0.04       1.40       1.40        000
                                                   boot.                                                                                                
29590...  ..................  A                   Application of foot             0.76       0.28       0.28       0.03       1.07       1.07        000
                                                   splint.                                                                                              
29700...  ..................  A                   Removal/revision of cast        0.57       0.32       0.32       0.05       0.94       0.94        000
29705...  ..................  A                   Removal/revision of cast        0.76       0.35       0.35       0.05       1.16       1.16        000
29710...  ..................  A                   Removal/revision of cast        1.34       0.45       0.45       0.07       1.86       1.86        000
29715...  ..................  A                   Removal/revision of cast        0.94       0.86       0.86       0.12       1.92       1.92        000
29720...  ..................  A                   Repair of body cast.....        0.68       0.23       0.23       0.04       0.95       0.95        000
29730...  ..................  A                   Windowing of cast.......        0.75       0.26       0.26       0.04       1.05       1.05        000
29740...  ..................  A                   Wedging of cast.........        1.12       0.38       0.38       0.06       1.56       1.56        000
29750...  ..................  A                   Wedging of clubfoot cast        1.26       0.50       0.50       0.07       1.83       1.83        000
29799...  ..................  C                   Casting/strapping               0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                   procedure.                                                                                           
29800...  ..................  A                   Jaw arthroscopy/surgery.       *6.43       4.01       4.01       0.46      10.90      10.90        090
29804...  ..................  A                   Jaw arthroscopy/surgery.       *8.14      #8.95      #8.95       1.46      18.55      18.55        090
29815...  ..................  A                   Shoulder arthroscopy....       *5.89       4.84       4.84       0.76      11.49      11.49        090
29819...  ..................  A                   Shoulder arthroscopy/          *7.62      #8.38      #8.38       1.73      17.73      17.73        090
                                                   surgery.                                                                                             

[[Page 59128]]

                                                                                                                                                        
29820...  ..................  A                   Shoulder arthroscopy/          *7.07      #7.78      #7.78       1.73      16.58      16.58        090
                                                   surgery.                                                                                             
29821...  ..................  A                   Shoulder arthroscopy/          *7.72      #8.49      #8.49       2.13      18.34      18.34        090
                                                   surgery.                                                                                             
29822...  ..................  A                   Shoulder arthroscopy/          *7.43      #8.17      #8.17       1.74      17.34      17.34        090
                                                   surgery.                                                                                             
29823...  ..................  A                   Shoulder arthroscopy/          *8.17      #8.99      #8.99       2.32      19.48      19.48        090
                                                   surgery.                                                                                             
29825...  ..................  A                   Shoulder arthroscopy/          *7.62      #8.38      #8.38       2.05      18.05      18.05        090
                                                   surgery.                                                                                             
29826...  ..................  A                   Shoulder arthroscopy/          *8.99      #9.89      #9.89       2.31      21.19      21.19        090
                                                   surgery.                                                                                             
29830...  ..................  A                   Elbow arthroscopy.......       *5.76       5.32       5.32       0.83      11.91      11.91        090
29834...  ..................  A                   Elbow arthroscopy/             *6.28       5.84       5.84       0.96      13.08      13.08        090
                                                   surgery.                                                                                             
29835...  ..................  A                   Elbow arthroscopy/             *6.48       6.03       6.03       0.99      13.50      13.50        090
                                                   surgery.                                                                                             
29836...  ..................  A                   Elbow arthroscopy/             *7.55       7.03       7.03       1.15      15.73      15.73        090
                                                   surgery.                                                                                             
29837...  ..................  A                   Elbow arthroscopy/             *6.87       6.40       6.40       1.06      14.33      14.33        090
                                                   surgery.                                                                                             
29838...  ..................  A                   Elbow arthroscopy/             *7.71       7.05       7.05       1.14      15.90      15.90        090
                                                   surgery.                                                                                             
29840...  ..................  A                   Wrist arthroscopy.......       *5.54       3.29       3.29       0.54       9.37       9.37        090
29843...  ..................  A                   Wrist arthroscopy/             *6.01       5.60       5.60       0.91      12.52      12.52        090
                                                   surgery.                                                                                             
29844...  ..................  A                   Wrist arthroscopy/             *6.37       5.59       5.59       0.95      12.91      12.91        090
                                                   surgery.                                                                                             
29845...  ..................  A                   Wrist arthroscopy/             *7.52       7.00       7.00       1.15      15.67      15.67        090
                                                   surgery.                                                                                             
29846...  ..................  A                   Wrist arthroscopy/             *6.75      #7.43      #7.43       2.20      16.38      16.38        090
                                                   surgery.                                                                                             
29847...  ..................  A                   Wrist arthroscopy/             *7.08       6.78       6.78       0.97      14.83      14.83        090
                                                   surgery.                                                                                             
29848...  ..................  A                   Wrist arthroscopy/             *5.44       3.85       3.85       0.62       9.91       9.91        090
                                                   surgery.                                                                                             
29850...  ..................  A                   Knee arthroscopy/surgery       *8.19      #9.01      #9.01       1.74      18.94      18.94        090
29851...  ..................  A                   Knee arthroscopy/surgery      *13.10      10.95      10.95       1.74      25.79      25.79        090
29855...  ..................  A                   Tibial arthroscopy/           *10.62     #11.68     #11.68       1.88      24.18      24.18        090
                                                   surgery.                                                                                             
29856...  ..................  A                   Tibial arthroscopy/           *14.14      11.69      11.69       1.88      27.71      27.71        090
                                                   surgery.                                                                                             
29860...  ..................  A                   Hip arthroscopy, dx.....       *8.05       4.84       4.84       0.76      13.65      13.65        090
29861...  ..................  A                   Hip arthroscopy/surgery.       *9.15       9.38       9.38       1.73      20.26      20.26        090
29862...  ..................  A                   Hip arthroscopy/surgery.       *9.90      10.07      10.07       2.32      22.29      22.29        090
29863...  ..................  A                   Hip arthroscopy/surgery.       *9.90       8.72       8.72       1.73      20.35      20.35        090
29870...  ..................  A                   Knee arthroscopy,              *5.07       4.02       4.02       0.64       9.73       9.73        090
                                                   diagnostic.                                                                                          
29871...  ..................  A                   Knee arthroscopy/              *6.55       6.77       6.77       0.96      14.28      14.28        090
                                                   drainage.                                                                                            
29874...  ..................  A                   Knee arthroscopy/surgery       *7.05      #7.76      #7.76       1.52      16.33      16.33        090
29875...  ..................  A                   Knee arthroscopy/surgery       *6.31      #6.94      #6.94       1.61      14.86      14.86        090
29876...  ..................  A                   Knee arthroscopy/surgery       *7.92      #8.71      #8.71       1.95      18.58      18.58        090
29877...  ..................  A                   Knee arthroscopy/surgery       *7.35      #8.09      #8.09       1.81      17.25      17.25        090
29879...  ..................  A                   Knee arthroscopy/surgery       *8.04      #8.84      #8.84       2.19      19.07      19.07        090
29880...  ..................  A                   Knee arthroscopy/surgery       *8.50      #9.35      #9.35       2.22      20.07      20.07        090
29881...  ..................  A                   Knee arthroscopy/surgery       *7.76      #8.54      #8.54       1.82      18.12      18.12        090
29882...  ..................  A                   Knee arthroscopy/surgery       *8.65      #9.52      #9.52       1.90      20.07      20.07        090
29883...  ..................  A                   Knee arthroscopy/surgery       *9.46     #10.41     #10.41       2.80      22.67      22.67        090
29884...  ..................  A                   Knee arthroscopy/surgery       *7.33      #8.06      #8.06       1.56      16.95      16.95        090
29885...  ..................  A                   Knee arthroscopy/surgery       *9.09       8.23       8.23       1.35      18.67      18.67        090
29886...  ..................  A                   Knee arthroscopy/surgery       *7.54       6.80       6.80       1.12      15.46      15.46        090
29887...  ..................  A                   Knee arthroscopy/surgery       *9.04      #9.94      #9.94       1.71      20.69      20.69        090
29888...  ..................  A                   Knee arthroscopy/surgery      *13.90     #15.29     #15.29       3.18      32.37      32.37        090
29889...  ..................  A                   Knee arthroscopy/surgery      *15.13      10.26      10.26       1.68      27.07      27.07        090
29891...  ..................  A                   Ankle arthroscopy/             *8.40       8.86       8.86       1.77      19.03      19.03        090
                                                   surgery.                                                                                             
29892...  ..................  A                   Ankle arthroscopy/             *9.00       8.86       8.86       1.77      19.63      19.63        090
                                                   surgery.                                                                                             
29893...  ..................  A                   Scope, plantar                 *5.22       5.20       5.20       0.46      10.88      10.88        090
                                                   fasciotomy.                                                                                          
29894...  ..................  A                   Ankle arthroscopy/             *7.21      #7.93      #7.93       1.47      16.61      16.61        090
                                                   surgery.                                                                                             
29895...  ..................  A                   Ankle arthroscopy/             *6.99      #7.69      #7.69       1.51      16.19      16.19        090
                                                   surgery.                                                                                             
29897...  ..................  A                   Ankle arthroscopy/             *7.18      #7.90      #7.90       1.77      16.85      16.85        090
                                                   surgery.                                                                                             
29898...  ..................  A                   Ankle arthroscopy/             *8.32      #9.15      #9.15       1.91      19.38      19.38        090
                                                   surgery.                                                                                             
29909...  ..................  C                   Arthroscopy of joint....        0.00       0.00       0.00       0.00       0.00       0.00        YYY
30000...  ..................  A                   Drainage of nose lesion.       *1.43       0.58       0.58       0.05       2.06       2.06        010
30020...  ..................  A                   Drainage of nose lesion.       *1.43       0.60       0.60       0.06       2.09       2.09        010
30100...  ..................  A                   Intranasal biopsy.......        0.94       0.69       0.69       0.08       1.71       1.71        000
30110...  ..................  A                   Removal of nose polyp(s)       *1.63       1.29       1.29       0.14       3.06       3.06        010
30115...  ..................  A                   Removal of nose polyp(s)       *4.35       2.81       2.81       0.30       7.46       7.46        090
30117...  ..................  A                   Removal of intranasal          *3.16       2.84       2.84       0.31       6.31       6.31        090
                                                   lesion.                                                                                              
30118...  ..................  A                   Removal of intranasal          *9.69       8.01       8.01       0.92      18.62      18.62        090
                                                   lesion.                                                                                              
30120...  ..................  A                   Revision of nose........       *5.27      #5.80      #5.80       1.00      12.07      12.07        090
30124...  ..................  A                   Removal of nose lesion..       *3.10       1.34       1.34       0.16       4.60       4.60        090
30125...  ..................  A                   Removal of nose lesion..       *7.16       5.55       5.55       0.73      13.44      13.44        090
30130...  ..................  A                   Removal of turbinate           *3.38       1.67       1.67       0.17       5.22       5.22        090
                                                   bones.                                                                                               
30140...  ..................  A                   Removal of turbinate           *3.43       3.04       3.04       0.34       6.81       6.81        090
                                                   bones.                                                                                               
30150...  ..................  A                   Partial removal of nose.       *9.14       7.92       7.92       1.07      18.13      18.13        090
30160...  ..................  A                   Removal of nose.........       *9.58     #10.54     #10.54       1.73      21.85      21.85        090
30200...  ..................  A                   Injection treatment of          0.78       0.37       0.37       0.04       1.19       1.19        000
                                                   nose.                                                                                                
30210...  ..................  A                   Nasal sinus therapy.....       *1.08       0.26       0.26       0.03       1.37       1.37        010
30220...  ..................  A                   Insert nasal septal            *1.54       1.51       1.51       0.16       3.21       3.21        010
                                                   button.                                                                                              
30300...  ..................  A                   Remove nasal foreign           *1.04       0.46       0.46       0.05       1.55       1.55        010
                                                   body.                                                                                                
30310...  ..................  A                   Remove nasal foreign           *1.96       1.62       1.62       0.18       3.76       3.76        010
                                                   body.                                                                                                
30320...  ..................  A                   Remove nasal foreign           *4.52       4.29       4.29       0.43       9.24       9.24        090
                                                   body.                                                                                                
30400...  ..................  R                   Reconstruction of nose..       *9.83       9.97       9.97       1.36      21.16      21.16        090
30410...  ..................  R                   Reconstruction of nose..      *12.98     #14.28     #14.28       2.01      29.27      29.27        090

[[Page 59129]]

                                                                                                                                                        
30420...  ..................  R                   Reconstruction of nose..      *15.88     #17.47     #17.47       2.22      35.57      35.57        090
30430...  ..................  R                   Revision of nose........       *7.21       6.09       6.09       0.66      13.96      13.96        090
30435...  ..................  R                   Revision of nose........      *11.71      10.17      10.17       1.10      22.98      22.98        090
30450...  ..................  R                   Revision of nose........      *18.65      11.24      11.24       0.91      30.80      30.80        090
30460...  ..................  A                   Revision of nose........       *9.96       8.58       8.58       0.93      19.47      19.47        090
30462...  ..................  A                   Revision of nose........      *19.57      17.16      17.16       1.87      38.60      38.60        090
30520...  ..................  A                   Repair of nasal septum..       *5.70      #6.27      #6.27       0.96      12.93      12.93        090
30540...  ..................  A                   Repair nasal defect.....       *7.75       6.63       6.63       0.70      15.08      15.08        090
30545...  ..................  A                   Repair nasal defect.....      *11.38      10.83      10.83       0.93      23.14      23.14        090
30560...  ..................  A                   Release of nasal               *1.26       0.55       0.55       0.06       1.87       1.87        010
                                                   adhesions.                                                                                           
30580...  ..................  A                   Repair upper jaw fistula       *6.69       6.24       6.24       0.57      13.50      13.50        090
30600...  ..................  A                   Repair mouth/nose              *6.02       3.77       3.77       0.36      10.15      10.15        090
                                                   fistula.                                                                                             
30620...  ..................  A                   Intranasal                     *5.97      #6.57      #6.57       1.10      13.64      13.64        090
                                                   reconstruction.                                                                                      
30630...  ..................  A                   Repair nasal septum            *7.12       6.24       6.24       0.71      14.07      14.07        090
                                                   defect.                                                                                              
30801...  ..................  A                   Cauterization inner nose       *1.09       0.47       0.47       0.05       1.61       1.61        010
30802...  ..................  A                   Cauterization inner nose       *2.03       0.94       0.94       0.11       3.08       3.08        010
30901...  ..................  A                   Control of nosebleed....        1.21       0.56       0.56       0.06       1.83       1.83        000
30903...  ..................  A                   Control of nosebleed....        1.54       0.85       0.85       0.08       2.47       2.47        000
30905...  ..................  A                   Control of nosebleed....        1.97       1.79       1.79       0.17       3.93       3.93        000
30906...  ..................  A                   Repeat control of               2.45       1.08       1.08       0.11       3.64       3.64        000
                                                   nosebleed.                                                                                           
30915...  ..................  A                   Ligation nasal sinus           *7.20       4.95       4.95       0.52      12.67      12.67        090
                                                   artery.                                                                                              
30920...  ..................  A                   Ligation upper jaw             *9.83       9.54       9.54       1.32      20.69      20.69        090
                                                   artery.                                                                                              
30930...  ..................  A                   Therapy fracture of nose       *1.26       0.71       0.71       0.08       2.05       2.05        010
30999...  ..................  C                   Nasal surgery procedure.        0.00       0.00       0.00       0.00       0.00       0.00        YYY
31000...  ..................  A                   Irrigation maxillary           *1.15       0.43       0.43       0.05       1.63       1.63        010
                                                   sinus.                                                                                               
31002...  ..................  A                   Irrigation sphenoid            *1.91       0.46       0.46       0.05       2.42       2.42        010
                                                   sinus.                                                                                               
31020...  ..................  A                   Exploration maxillary          *2.94       2.66       2.66       0.29       5.89       5.89        090
                                                   sinus.                                                                                               
31030...  ..................  A                   Exploration maxillary          *5.92      #6.51      #6.51       0.86      13.29      13.29        090
                                                   sinus.                                                                                               
31032...  ..................  A                   Explore sinus, remove          *6.57      #7.23      #7.23       0.99      14.79      14.79        090
                                                   polyps.                                                                                              
31040...  ..................  A                   Exploration behind upper       *9.42       7.98       7.98       0.86      18.26      18.26        090
                                                   jaw.                                                                                                 
31050...  ..................  A                   Exploration sphenoid           *5.28      #5.81      #5.81       0.64      11.73      11.73        090
                                                   sinus.                                                                                               
31051...  ..................  A                   Sphenoid sinus surgery..       *7.11      #7.82      #7.82       0.85      15.78      15.78        090
31070...  ..................  A                   Exploration of frontal         *4.28       4.69       4.69       0.50       9.47       9.47        090
                                                   sinus.                                                                                               
31075...  ..................  A                   Exploration of frontal         *9.16     #10.08     #10.08       1.10      20.34      20.34        090
                                                   sinus.                                                                                               
31080...  ..................  A                   Removal of frontal sinus      *11.42       9.21       9.21       1.12      21.75      21.75        090
31081...  ..................  A                   Removal of frontal sinus      *12.75      10.32      10.32       1.30      24.37      24.37        090
31084...  ..................  A                   Removal of frontal sinus      *13.51      14.79      14.79       1.62      29.92      29.92        090
31085...  ..................  A                   Removal of frontal sinus      *14.20     #15.62     #15.62       1.76      31.58      31.58        090
31086...  ..................  A                   Removal of frontal sinus      *12.86      10.87      10.87       1.15      24.88      24.88        090
31087...  ..................  A                   Removal of frontal sinus      *13.10      10.39      10.39       1.33      24.82      24.82        090
31090...  ..................  A                   Exploration of sinuses..       *9.53     #10.48     #10.48       2.12      22.13      22.13        090
31200...  ..................  A                   Removal of ethmoid sinus       *4.97       4.62       4.62       0.48      10.07      10.07        090
31201...  ..................  A                   Removal of ethmoid sinus       *8.37       7.01       7.01       0.75      16.13      16.13        090
31205...  ..................  A                   Removal of ethmoid sinus      *10.24       8.03       8.03       0.81      19.08      19.08        090
31225...  ..................  A                   Removal of upper jaw....      *19.23      19.44      19.44       2.37      41.04      41.04        090
31230...  ..................  A                   Removal of upper jaw....      *21.94      21.74      21.74       2.48      46.16      46.16        090
31231...  ..................  A                   Nasal endoscopy, dx.....        1.10       1.37       1.37       0.15       2.62       2.62        000
31233...  ..................  A                   Nasal/sinus endoscopy,          2.18       2.79       2.79       0.31       5.28       5.28        000
                                                   dx.                                                                                                  
31235...  ..................  A                   Nasal/sinus endoscopy,          2.64       2.39       2.39       0.26       5.29       5.29        000
                                                   dx.                                                                                                  
31237...  ..................  A                   Nasal/sinus endoscopy,          2.98      #3.28      #3.28       0.37       6.63       6.63        000
                                                   surg.                                                                                                
31238...  ..................  A                   Nasal/sinus endoscopy,          3.26      #3.59      #3.59       0.45       7.30       7.30        000
                                                   surg.                                                                                                
31239...  ..................  A                   Nasal/sinus endoscopy,         *8.70      #9.57      #9.57       1.18      19.45      19.45        010
                                                   surg.                                                                                                
31240...  ..................  A                   Nasal/sinus endoscopy,          2.61      #2.87      #2.87       0.37       5.85       5.85        000
                                                   surg.                                                                                                
31254...  ..................  A                   Revision of ethmoid             4.65      #5.12      #5.12       0.69      10.46      10.46        000
                                                   sinus.                                                                                               
31255...  ..................  A                   Removal of ethmoid sinus        6.96      #7.66      #7.66       1.14      15.76      15.76        000
31256...  ..................  A                   Exploration maxillary           3.29      #3.62      #3.62       0.41       7.32       7.32        000
                                                   sinus.                                                                                               
31267...  ..................  A                   Endoscopy, maxillary            5.46       5.23       5.23       0.81      11.50      11.50        000
                                                   sinus.                                                                                               
31276...  ..................  A                   Sinus surgical endoscopy        8.85       6.72       6.72       0.73      16.30      16.30        000
31287...  ..................  A                   Nasal/sinus endoscopy,          3.92      #4.31      #4.31       0.65       8.88       8.88        000
                                                   surg.                                                                                                
31288...  ..................  A                   Nasal/sinus endoscopy,          4.58      #5.04      #5.04       0.78      10.40      10.40        000
                                                   surg.                                                                                                
31290...  ..................  A                   Nasal/sinus endoscopy,        *17.24      16.47      16.47       1.80      35.51      35.51        010
                                                   surg.                                                                                                
31291...  ..................  A                   Nasal/sinus endoscopy,        *18.19      17.31      17.31       1.88      37.38      37.38        010
                                                   surg.                                                                                                
31292...  ..................  A                   Nasal/sinus endoscopy,        *14.76      13.38      13.38       1.45      29.59      29.59        010
                                                   surg.                                                                                                
31293...  ..................  A                   Nasal/sinus endoscopy,        *16.21      14.64      14.64       1.59      32.44      32.44        010
                                                   surg.                                                                                                
31294...  ..................  A                   Nasal/sinus endoscopy,        *19.06      16.72      16.72       1.83      37.61      37.61        010
                                                   surg.                                                                                                
31299...  ..................  C                   Sinus surgery procedure.        0.00       0.00       0.00       0.00       0.00       0.00        YYY
31300...  ..................  A                   Removal of larynx lesion      *14.29      11.58      11.58       1.28      27.15      27.15        090
31320...  ..................  A                   Diagnostic incision            *5.26       3.87       3.87       0.48       9.61       9.61        090
                                                   larynx.                                                                                              
31360...  ..................  A                   Removal of larynx.......      *17.08     #18.79     #18.79       2.19      38.06      38.06        090
31365...  ..................  A                   Removal of larynx.......      *24.16     #26.58     #26.58       3.10      53.84      53.84        090
31367...  ..................  A                   Partial removal of            *21.86      17.22      17.22       1.88      40.96      40.96        090
                                                   larynx.                                                                                              
31368...  ..................  A                   Partial removal of            *27.09      26.76      26.76       3.06      56.91      56.91        090
                                                   larynx.                                                                                              
31370...  ..................  A                   Partial removal of            *21.38      17.18      17.18       1.88      40.44      40.44        090
                                                   larynx.                                                                                              
31375...  ..................  A                   Partial removal of            *20.21      14.84      14.84       1.56      36.61      36.61        090
                                                   larynx.                                                                                              

[[Page 59130]]

                                                                                                                                                        
31380...  ..................  A                   Partial removal of            *20.21      17.27      17.27       1.88      39.36      39.36        090
                                                   larynx.                                                                                              
31382...  ..................  A                   Partial removal of            *20.52      16.06      16.06       1.78      38.36      38.36        090
                                                   larynx.                                                                                              
31390...  ..................  A                   Removal of larynx &           *27.53      27.08      27.08       4.05      58.66      58.66        090
                                                   pharynx.                                                                                             
31395...  ..................  A                   Reconstruct larynx &          *31.09      33.52      33.52       4.42      69.03      69.03        090
                                                   pharynx.                                                                                             
31400...  ..................  A                   Revision of larynx......      *10.31       7.81       7.81       0.91      19.03      19.03        090
31420...  ..................  A                   Removal of epiglottis...      *10.22       8.08       8.08       0.84      19.14      19.14        090
31500...  ..................  A                   Insert emergency airway.        2.33       1.14       1.14       0.14       3.61       3.61        000
31502...  ..................  A                   Change of windpipe              0.65       0.58       0.58       0.07       1.30       1.30        000
                                                   airway.                                                                                              
31505...  ..................  A                   Diagnostic laryngoscopy.        0.61       0.43       0.43       0.05       1.09       1.09        000
31510...  ..................  A                   Laryngoscopy with biopsy        1.92       0.55       0.55       0.07       2.54       2.54        000
31511...  ..................  A                   Remove foreign body,            2.16       0.96       0.96       0.10       3.22       3.22        000
                                                   larynx.                                                                                              
31512...  ..................  A                   Removal of larynx lesion        2.07       1.79       1.79       0.20       4.06       4.06        000
31513...  ..................  A                   Injection into vocal            2.10      #2.31      #2.31       0.38       4.79       4.79        000
                                                   cord.                                                                                                
31515...  ..................  A                   Laryngoscopy for                1.80       1.13       1.13       0.14       3.07       3.07        000
                                                   aspiration.                                                                                          
31520...  ..................  A                   Diagnostic laryngoscopy.        2.56       1.64       1.64       0.18       4.38       4.38        000
31525...  ..................  A                   Diagnostic laryngoscopy.        2.63       2.20       2.20       0.23       5.06       5.06        000
31526...  ..................  A                   Diagnostic laryngoscopy.        2.57      #2.83      #2.83       0.38       5.78       5.78        000
31527...  ..................  A                   Laryngoscopy for                3.27       2.99       2.99       0.30       6.56       6.56        000
                                                   treatment.                                                                                           
31528...  ..................  A                   Laryngoscopy and                2.37      #2.61      #2.61       0.30       5.28       5.28        000
                                                   dilatation.                                                                                          
31529...  ..................  A                   Laryngoscopy and                2.68       2.46       2.46       0.25       5.39       5.39        000
                                                   dilatation.                                                                                          
31530...  ..................  A                   Operative laryngoscopy..        3.39       3.63       3.63       0.39       7.41       7.41        000
31531...  ..................  A                   Operative laryngoscopy..        3.59      #3.95      #3.95       0.60       8.14       8.14        000
31535...  ..................  A                   Operative laryngoscopy..        3.16      #3.48      #3.48       0.45       7.09       7.09        000
31536...  ..................  A                   Operative laryngoscopy..        3.56      #3.92      #3.92       0.59       8.07       8.07        000
31540...  ..................  A                   Operative laryngoscopy..        4.13      #4.54      #4.54       0.61       9.28       9.28        000
31541...  ..................  A                   Operative laryngoscopy..        4.53       4.56       4.56       0.75       9.84       9.84        000
31560...  ..................  A                   Operative laryngoscopy..        5.46       4.99       4.99       0.51      10.96      10.96        000
31561...  ..................  A                   Operative laryngoscopy..        6.00       6.27       6.27       1.08      13.35      13.35        000
31570...  ..................  A                   Laryngoscopy with               3.87      #4.26      #4.26       0.60       8.73       8.73        000
                                                   injection.                                                                                           
31571...  ..................  A                   Laryngoscopy with               4.27       4.51       4.51       0.69       9.47       9.47        000
                                                   injection.                                                                                           
31575...  ..................  A                   Diagnostic laryngoscopy.        1.10       1.56       1.56       0.17       2.83       2.83        000
31576...  ..................  A                   Laryngoscopy with biopsy        1.97      #2.17      #2.17       0.33       4.47       4.47        000
31577...  ..................  A                   Remove foreign body,            2.47      #2.72      #2.72       0.37       5.56       5.56        000
                                                   larynx.                                                                                              
31578...  ..................  A                   Removal of larynx lesion        2.84      #3.12      #3.12       0.48       6.44       6.44        000
31579...  ..................  A                   Diagnostic laryngoscopy.        2.26       2.33       2.33       0.26       4.85       4.85        000
31580...  ..................  A                   Revision of larynx......      *12.38     #13.62     #13.62       1.63      27.63      27.63        090
31582...  ..................  A                   Revision of larynx......      *21.62      17.87      17.87       1.94      41.43      41.43        090
31584...  ..................  A                   Repair of larynx              *19.64      12.72      12.72       1.34      33.70      33.70        090
                                                   fracture.                                                                                            
31585...  ..................  A                   Repair of larynx               *4.64       3.77       3.77       0.40       8.81       8.81        090
                                                   fracture.                                                                                            
31586...  ..................  A                   Repair of larynx               *8.03       6.55       6.55       0.71      15.29      15.29        090
                                                   fracture.                                                                                            
31587...  ..................  A                   Revision of larynx......      *11.99       7.21       7.21       0.79      19.99      19.99        090
31588...  ..................  A                   Revision of larynx......      *13.11      10.70      10.70       1.16      24.97      24.97        090
31590...  ..................  A                   Reinnervate larynx......       *6.97       5.76       5.76       0.62      13.35      13.35        090
31595...  ..................  A                   Larynx nerve surgery....       *8.34       6.84       6.84       0.74      15.92      15.92        090
31599...  ..................  C                   Larynx surgery procedure        0.00       0.00       0.00       0.00       0.00       0.00        YYY
31600...  ..................  A                   Incision of windpipe....        3.62      #3.98      #3.98       0.65       8.25       8.25        000
31601...  ..................  A                   Incision of windpipe....        4.45      #4.90      #4.90       0.66      10.01      10.01        000
31603...  ..................  A                   Incision of windpipe....        4.15       4.23       4.23       0.66       9.04       9.04        000
31605...  ..................  A                   Incision of windpipe....        3.58      #3.94      #3.94       0.50       8.02       8.02        000
31610...  ..................  A                   Incision of windpipe....       *8.76       6.67       6.67       0.92      16.35      16.35        090
31611...  ..................  A                   Surgery/speech                 *5.64       6.45       6.45       1.04      13.13      13.13        090
                                                   prosthesis.                                                                                          
31612...  ..................  A                   Puncture/clear windpipe.        0.91       1.17      #1.00       0.12       2.20       2.03        000
31613...  ..................  A                   Repair windpipe opening.       *4.59       2.21       2.21       0.28       7.08       7.08        090
31614...  ..................  A                   Repair windpipe opening.       *7.12       6.74       6.74       0.73      14.59      14.59        090
31615...  ..................  A                   Visualization of                2.09       1.95       1.95       0.22       4.26       4.26        000
                                                   windpipe.                                                                                            
31622...  ..................  A                   Diagnostic bronchoscopy.        2.80      #3.08      #3.08       0.34       6.22       6.22        000
31625...  ..................  A                   Bronchoscopy with biopsy        3.37      #3.71      #3.71       0.35       7.43       7.43        000
31628...  ..................  A                   Bronchoscopy with biopsy        3.81      #4.19      #4.19       0.38       8.38       8.38        000
31629...  ..................  A                   Bronchoscopy with biopsy        3.37      #3.71      #3.71       0.34       7.42       7.42        000
31630...  ..................  A                   Bronchoscopy with repair        3.82       3.72       3.72       0.50       8.04       8.04        000
31631...  ..................  A                   Bronchoscopy with               4.37       3.94       3.94       0.48       8.79       8.79        000
                                                   dilation.                                                                                            
31635...  ..................  A                   Remove foreign body,            3.68      #4.05      #4.05       0.53       8.26       8.26        000
                                                   airway.                                                                                              
31640...  ..................  A                   Bronchoscopy & remove           4.94       5.02       5.02       0.67      10.63      10.63        000
                                                   lesion.                                                                                              
31641...  ..................  A                   Bronchoscopy, treat             5.03      #5.53      #5.53       0.85      11.41      11.41        000
                                                   blockage.                                                                                            
31645...  ..................  A                   Bronchoscopy, clear             3.16      #3.48      #3.48       0.30       6.94       6.94        000
                                                   airways.                                                                                             
31646...  ..................  A                   Bronchoscopy, reclear           2.72      #2.99      #2.99       0.27       5.98       5.98        000
                                                   airways.                                                                                             
31656...  ..................  A                   Bronchoscopy, inject for        2.17      #2.39      #2.39       0.31       4.87       4.87        000
                                                   x-ray.                                                                                               
31700...  ..................  A                   Insertion of airway             1.34       1.38       1.38       0.17       2.89       2.89        000
                                                   catheter.                                                                                            
31708...  ..................  A                   Instill airway contrast         1.41       0.77       0.77       0.09       2.27       2.27        000
                                                   dye.                                                                                                 
31710...  ..................  A                   Insertion of airway             1.30       0.90       0.90       0.12       2.32       2.32        000
                                                   catheter.                                                                                            
31715...  ..................  A                   Injection for bronchus x-       1.11       0.48       0.48       0.04       1.63       1.63        000
                                                   ray.                                                                                                 
31717...  ..................  A                   Bronchial brush biopsy..        2.12       0.73       0.73       0.06       2.91       2.91        000
31720...  ..................  A                   Clearance of airways....        1.06       0.74       0.74       0.09       1.89       1.89        000
31725...  ..................  A                   Clearance of airways....        1.96       1.41       1.41       0.15       3.52       3.52        000

[[Page 59131]]

                                                                                                                                                        
31730...  ..................  A                   Intro windpipe wire/tube        2.85       2.47       2.47       0.23       5.55       5.55        000
31750...  ..................  A                   Repair of windpipe......      *13.02       8.88       8.88       1.09      22.99      22.99        090
31755...  ..................  A                   Repair of windpipe......      *15.93      13.30      13.30       1.44      30.67      30.67        090
31760...  ..................  A                   Repair of windpipe......      *22.35      10.92      10.92       2.55      35.82      35.82        090
31766...  ..................  A                   Reconstruction of             *30.43      18.40      18.40       1.12      49.95      49.95        090
                                                   windpipe.                                                                                            
31770...  ..................  A                   Repair/graft of bronchus      *22.51      15.07      15.07       2.08      39.66      39.66        090
31775...  ..................  A                   Reconstruct bronchus....      *23.54      16.37      16.37       1.92      41.83      41.83        090
31780...  ..................  A                   Reconstruct windpipe....      *17.72      17.33      17.33       2.08      37.13      37.13        090
31781...  ..................  A                   Reconstruct windpipe....      *23.53      16.86      16.86       1.96      42.35      42.35        090
31785...  ..................  A                   Remove windpipe lesion..      *17.23       8.92       8.92       1.17      27.32      27.32        090
31786...  ..................  A                   Remove windpipe lesion..      *23.98      13.30      13.30       2.24      39.52      39.52        090
31800...  ..................  A                   Repair of windpipe             *7.43       4.90       4.90       0.76      13.09      13.09        090
                                                   injury.                                                                                              
31805...  ..................  A                   Repair of windpipe            *13.13       9.82       9.82       1.41      24.36      24.36        090
                                                   injury.                                                                                              
31820...  ..................  A                   Closure of windpipe            *4.49       3.58       3.58       0.46       8.53       8.53        090
                                                   lesion.                                                                                              
31825...  ..................  A                   Repair of windpipe             *6.81       5.00       5.00       0.58      12.39      12.39        090
                                                   defect.                                                                                              
31830...  ..................  A                   Revise windpipe scar....       *4.50       3.66       3.66       0.42       8.58       8.58        090
31899...  ..................  C                   Airways surgical                0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                   procedure.                                                                                           
32000...  ..................  A                   Drainage of chest.......        1.54       0.90       0.90       0.08       2.52       2.52        000
32002...  ..................  A                   Treatment of collapsed          2.19       1.34       1.34       0.22       3.75       3.75        000
                                                   lung.                                                                                                
32005...  ..................  A                   Treat lung lining               2.19       1.09       1.09       0.15       3.43       3.43        000
                                                   chemically.                                                                                          
32020...  ..................  A                   Insertion of chest tube.        3.98       2.63       2.63       0.43       7.04       7.04        000
32035...  ..................  A                   Exploration of chest....       *8.67       6.76       6.76       1.25      16.68      16.68        090
32036...  ..................  A                   Exploration of chest....       *9.68       7.13       7.13       1.32      18.13      18.13        090
32095...  ..................  A                   Biopsy through chest           *8.36       8.25       8.25       1.45      18.06      18.06        090
                                                   wall.                                                                                                
32100...  ..................  A                   Exploration/biopsy of         *11.84      11.24      11.24       2.10      25.18      25.18        090
                                                   chest.                                                                                               
32110...  ..................  A                   Explore/repair chest....      *13.62      11.51      11.51       2.01      27.14      27.14        090
32120...  ..................  A                   Re-exploration of chest.      *11.54       9.45       9.45       1.72      22.71      22.71        090
32124...  ..................  A                   Explore chest, free           *12.72      10.94      10.94       2.21      25.87      25.87        090
                                                   adhesions.                                                                                           
32140...  ..................  A                   Removal of lung               *13.93      12.37      12.37       2.42      28.72      28.72        090
                                                   lesion(s).                                                                                           
32141...  ..................  A                   Remove/treat lung             *14.00      13.42      13.42       2.53      29.95      29.95        090
                                                   lesions.                                                                                             
32150...  ..................  A                   Removal of lung               *14.15      10.34      10.34       2.01      26.50      26.50        090
                                                   lesion(s).                                                                                           
32151...  ..................  A                   Remove lung foreign body      *14.21       9.15       9.15       1.37      24.73      24.73        090
32160...  ..................  A                   Open chest heart massage       *9.30       9.13       9.13       1.52      19.95      19.95        090
32200...  ..................  A                   Open drainage, lung           *15.29       6.89       6.89       0.93      23.11      23.11        090
                                                   lesion.                                                                                              
32201...  ..................  A                   Percut drainage, lung           4.00       3.03       3.03       0.35       7.38       7.38        000
                                                   lesion.                                                                                              
32215...  ..................  A                   Treat chest lining......      *11.33       7.62       7.62       1.28      20.23      20.23        090
32220...  ..................  A                   Release of lung.........      *19.27      15.81      15.81       3.01      38.09      38.09        090
32225...  ..................  A                   Partial release of lung.      *13.96      11.84      11.84       2.28      28.08      28.08        090
32310...  ..................  A                   Removal of chest lining.      *13.44      11.64      11.64       2.10      27.18      27.18        090
32320...  ..................  A                   Free/remove chest lining      *20.54      18.10      18.10       3.40      42.04      42.04        090
32400...  ..................  A                   Needle biopsy chest             1.76       1.48       1.48       0.12       3.36       3.36        000
                                                   lining.                                                                                              
32402...  ..................  A                   Open biopsy chest lining       *7.56       7.58       7.58       1.34      16.48      16.48        090
32405...  ..................  A                   Biopsy, lung or                 1.93       2.12       2.12       0.18       4.23       4.23        000
                                                   mediastinum.                                                                                         
32420...  ..................  A                   Puncture/clear lung.....        2.18       1.50       1.50       0.13       3.81       3.81        000
32440...  ..................  A                   Removal of lung.........      *21.02      18.56      18.56       3.55      43.13      43.13        090
32442...  ..................  A                   Sleeve pneumonectomy....      *26.24      17.94      17.94       3.50      47.68      47.68        090
32445...  ..................  A                   Removal of lung.........      *25.09      20.46      20.46       3.88      49.43      49.43        090
32480...  ..................  A                   Partial removal of lung.      *18.32      17.15      17.15       3.23      38.70      38.70        090
32482...  ..................  A                   Bilobectomy.............      *19.71      17.15      17.15       3.23      40.09      40.09        090
32484...  ..................  A                   Segmentectomy...........      *20.69      17.15      17.15       3.23      41.07      41.07        090
32486...  ..................  A                   Sleeve lobectomy........      *23.92      16.54      16.54       3.23      43.69      43.69        090
32488...  ..................  A                   Completion pneumonectomy      *25.71      17.74      17.74       3.46      46.91      46.91        090
32491...  ..................  R                   Lung volume reduction...       21.25      15.45      15.45       3.02      39.72      39.72        090
32500...  ..................  A                   Partial removal of lung.      *14.30      13.47      13.47       2.56      30.33      30.33        090
32501...  ..................  A                   Repair bronchus (add-on)        4.69       4.31       4.31       0.70       9.70       9.70        ZZZ
32520...  ..................  A                   Remove lung & revise          *21.68      20.67      20.67       3.93      46.28      46.28        090
                                                   chest.                                                                                               
32522...  ..................  A                   Remove lung & revise          *24.20      21.90      21.90       4.19      50.29      50.29        090
                                                   chest.                                                                                               
32525...  ..................  A                   Remove lung & revise          *26.50      23.50      23.50       4.61      54.61      54.61        090
                                                   chest.                                                                                               
32540...  ..................  A                   Removal of lung lesion..      *14.64      11.67      11.67       2.05      28.36      28.36        090
32601...  ..................  A                   Thoracoscopy, diagnostic        5.46       3.47       3.47       0.57       9.50       9.50        000
32602...  ..................  A                   Thoracoscopy, diagnostic        5.96       3.87       3.87       0.64      10.47      10.47        000
32603...  ..................  A                   Thoracoscopy, diagnostic        7.81       3.47       3.47       0.57      11.85      11.85        000
32604...  ..................  A                   Thoracoscopy, diagnostic        8.78       3.87       3.87       0.64      13.29      13.29        000
32605...  ..................  A                   Thoracoscopy, diagnostic        6.93       3.47       3.47       0.57      10.97      10.97        000
32606...  ..................  A                   Thoracoscopy, diagnostic        8.40       3.87       3.87       0.64      12.91      12.91        000
32650...  ..................  A                   Thoracoscopy, surgical..      *10.75       7.62       7.62       1.28      19.65      19.65        090
32651...  ..................  A                   Thoracoscopy, surgical..      *12.91      11.84      11.84       2.28      27.03      27.03        090
32652...  ..................  A                   Thoracoscopy, surgical..      *18.66      15.81      15.81       3.01      37.48      37.48        090
32653...  ..................  A                   Thoracoscopy, surgical..      *12.87      10.34      10.34       2.01      25.22      25.22        090
32654...  ..................  A                   Thoracoscopy, surgical..      *12.44      11.51      11.51       2.01      25.96      25.96        090
32655...  ..................  A                   Thoracoscopy, surgical..      *13.10      13.42      13.42       2.53      29.05      29.05        090
32656...  ..................  A                   Thoracoscopy, surgical..      *12.91      13.36      13.36       2.36      28.63      28.63        090
32657...  ..................  A                   Thoracoscopy, surgical..      *13.65      13.47      13.47       2.56      29.68      29.68        090
32658...  ..................  A                   Thoracoscopy, surgical..      *11.63     #12.79     #12.79       2.52      26.94      26.94        090

[[Page 59132]]

                                                                                                                                                        
32659...  ..................  A                   Thoracoscopy, surgical..      *11.59     #12.75     #12.75       2.61      26.95      26.95        090
32660...  ..................  A                   Thoracoscopy, surgical..      *17.43     #19.17     #19.17       3.56      40.16      40.16        090
32661...  ..................  A                   Thoracoscopy, surgical..      *13.25       9.25       9.25       1.47      23.97      23.97        090
32662...  ..................  A                   Thoracoscopy, surgical..      *16.44      14.55      14.55       2.74      33.73      33.73        090
32663...  ..................  A                   Thoracoscopy, surgical..      *18.47      17.15      17.15       3.23      38.85      38.85        090
32664...  ..................  A                   Thoracoscopy, surgical..      *14.20      10.55      10.55       2.04      26.79      26.79        090
32665...  ..................  A                   Thoracoscopy, surgical..      *15.54      14.33      14.33       2.64      32.51      32.51        090
32800...  ..................  A                   Repair lung hernia......      *13.69       8.28       8.28       1.58      23.55      23.55        090
32810...  ..................  A                   Close chest after             *13.05       6.50       6.50       1.19      20.74      20.74        090
                                                   drainage.                                                                                            
32815...  ..................  A                   Close bronchial fistula.      *23.15      15.22      15.22       2.62      40.99      40.99        090
32820...  ..................  A                   Reconstruct injured           *21.48      19.01      19.01       3.24      43.73      43.73        090
                                                   chest.                                                                                               
32850...  ..................  X                   Donor pneumonectomy.....        0.00       0.00       0.00       0.00       0.00       0.00        XXX
32851...  ..................  A                   Lung transplant, single.      *38.63      25.55      25.55       4.99      69.17      69.17        090
32852...  ..................  A                   Lung transplant w/bypass      *41.80      27.71      27.71       5.41      74.92      74.92        090
32853...  ..................  A                   Lung transplant, double.      *47.81      31.94      31.94       6.24      85.99      85.99        090
32854...  ..................  A                   Lung transplant w/bypass      *50.98      34.10      34.10       6.67      91.75      91.75        090
32900...  ..................  A                   Removal of rib(s).......      *20.27       8.47       8.47       1.63      30.37      30.37        090
32905...  ..................  A                   Revise & repair chest         *20.75      12.74      12.74       2.60      36.09      36.09        090
                                                   wall.                                                                                                
32906...  ..................  A                   Revise & repair chest         *26.77      15.42      15.42       2.92      45.11      45.11        090
                                                   wall.                                                                                                
32940...  ..................  A                   Revision of lung........      *19.43      11.37      11.37       1.75      32.55      32.55        090
32960...  ..................  A                   Therapeutic pneumothorax        1.84       0.93       0.93       0.13       2.90       2.90        000
32999...  ..................  C                   Chest surgery procedure.        0.00       0.00       0.00       0.00       0.00       0.00        YYY
33010...  ..................  A                   Drainage of heart sac...        2.24       1.54       1.54       0.14       3.92       3.92        000
33011...  ..................  A                   Repeat drainage of heart        2.24       1.11       1.11       0.12       3.47       3.47        000
                                                   sac.                                                                                                 
33015...  ..................  A                   Incision of heart sac...       *6.80       4.26       4.26       0.62      11.68      11.68        090
33020...  ..................  A                   Incision of heart sac...      *12.61      13.26      13.26       2.52      28.39      28.39        090
33025...  ..................  A                   Incision of heart sac...      *12.09     #13.30     #13.30       2.61      28.00      28.00        090
33030...  ..................  A                   Partial removal of heart      *18.71     #20.58     #20.58       3.92      43.21      43.21        090
                                                   sac.                                                                                                 
33031...  ..................  A                   Partial removal of heart      *21.79      13.25      13.25       2.50      37.54      37.54        090
                                                   sac.                                                                                                 
33050...  ..................  A                   Removal of heart sac          *14.36       9.25       9.25       1.47      25.08      25.08        090
                                                   lesion.                                                                                              
33120...  ..................  A                   Removal of heart lesion.      *24.56     #27.02     #27.02       5.17      56.75      56.75        090
33130...  ..................  A                   Removal of heart lesion.      *21.39      13.50      13.50       2.22      37.11      37.11        090
33200...  ..................  A                   Insertion of heart            *12.48      12.27      12.27       1.90      26.65      26.65        090
                                                   pacemaker.                                                                                           
33201...  ..................  A                   Insertion of heart            *10.18      11.19      11.19       1.67      23.04      23.04        090
                                                   pacemaker.                                                                                           
33206...  ..................  A                   Insertion of heart             *6.67      #7.34      #7.34       1.34      15.35      15.35        090
                                                   pacemaker.                                                                                           
33207...  ..................  A                   Insertion of heart             *8.04      #8.84      #8.84       1.33      18.21      18.21        090
                                                   pacemaker.                                                                                           
33208...  ..................  A                   Insertion of heart             *8.13      #8.94      #8.94       1.54      18.61      18.61        090
                                                   pacemaker.                                                                                           
33210...  ..................  A                   Insertion of heart              3.30       3.30       3.30       0.27       6.87       6.87        000
                                                   electrode.                                                                                           
33211...  ..................  A                   Insertion of heart              3.40       3.30       3.30       0.27       6.97       6.97        000
                                                   electrode.                                                                                           
33212...  ..................  A                   Insertion of pulse             *5.52       5.38       5.38       0.88      11.78      11.78        090
                                                   generator.                                                                                           
33213...  ..................  A                   Insertion of pulse             *6.37       5.38       5.38       0.88      12.63      12.63        090
                                                   generator.                                                                                           
33214...  ..................  A                   Upgrade of pacemaker           *7.75       5.40       5.40       1.06      14.21      14.21        090
                                                   system.                                                                                              
33216...  ..................  A                   Revision implanted             *5.39       5.02       5.02       0.55      10.96      10.96        090
                                                   electrode.                                                                                           
33217...  ..................  A                   Insert/revise electrode.       *5.75       5.02       5.02       0.55      11.32      11.32        090
33218...  ..................  A                   Repair pacemaker               *5.44       4.59       4.59       0.62      10.65      10.65        090
                                                   electrodes.                                                                                          
33220...  ..................  A                   Repair pacemaker               *5.52       4.59       4.59       0.62      10.73      10.73        090
                                                   electrode.                                                                                           
33222...  ..................  A                   Pacemaker aicd pocket...       *4.96      #5.46      #5.46       1.01      11.43      11.43        090
33223...  ..................  A                   Pacemaker aicd pocket...       *6.46       5.70       5.70       1.01      13.17      13.17        090
33233...  ..................  A                   Removal of pacemaker           *3.29       2.64       2.64       0.05       5.98       5.98        090
                                                   system.                                                                                              
33234...  ..................  A                   Removal of pacemaker           *7.82       2.84       2.84       0.23      10.89      10.89        090
                                                   system.                                                                                              
33235...  ..................  A                   Removal pacemaker              *9.40       3.14       3.14       0.33      12.87      12.87        090
                                                   electrode.                                                                                           
33236...  ..................  A                   Remove electrode/             *12.60       3.98       3.98       0.62      17.20      17.20        090
                                                   thoracotomy.                                                                                         
33237...  ..................  A                   Remove electrode/             *13.71       9.60       9.60       1.13      24.44      24.44        090
                                                   thoracotomy.                                                                                         
33238...  ..................  A                   Remove electrode/             *15.22      10.29      10.29       2.01      27.52      27.52        090
                                                   thoracotomy.                                                                                         
33240...  ..................  A                   Insert/replace pulse           *7.60       5.38       5.38       0.88      13.86      13.86        090
                                                   gener.                                                                                               
33241...  ..................  A                   Remove pulse generator         *3.24       2.16       2.16       0.43       5.83       5.83        090
                                                   only.                                                                                                
33242...  ..................  A                   Repair pulse generator/        *6.17      #6.79      #6.79       1.54      14.50      14.50        090
                                                   leads.                                                                                               
33243...  ..................  A                   Remove generator/             *22.64       9.02       9.02       1.54      33.20      33.20        090
                                                   thoracotomy.                                                                                         
33244...  ..................  A                   Remove generator........       *8.97       9.02       9.02       1.54      19.53      19.53        090
33245...  ..................  A                   Implant heart                 *14.30     #15.73     #15.73       2.36      32.39      32.39        090
                                                   defibrillator.                                                                                       
33246...  ..................  A                   Implant heart                 *20.71      20.79      20.79       3.19      44.69      44.69        090
                                                   defibrillator.                                                                                       
33247...  ..................  A                   Insert/replace leads....      *10.21     #11.23     #11.23       2.36      23.80      23.80        090
33249...  ..................  A                   Insert/replace leads/         *13.28     #14.61     #14.61       3.19      31.08      31.08        090
                                                   gener.                                                                                               
33250...  ..................  A                   Ablate heart dysrhythm        *21.85      11.56      11.56       0.86      34.27      34.27        090
                                                   focus.                                                                                               
33251...  ..................  A                   Ablate heart dysrhythm        *24.88      16.41      16.41       3.21      44.50      44.50        090
                                                   focus.                                                                                               
33253...  ..................  A                   Reconstruct atria.......      *31.06      21.81      21.81       4.26      57.13      57.13        090
33261...  ..................  A                   Ablate heart dysrhythm        *24.88      13.96      13.96       2.73      41.57      41.57        090
                                                   focus.                                                                                               
33300...  ..................  A                   Repair of heart wound...      *17.92      14.36      14.36       2.60      34.88      34.88        090
33305...  ..................  A                   Repair of heart wound...      *21.44      17.40      17.40       3.07      41.91      41.91        090
33310...  ..................  A                   Exploratory heart             *18.51      11.28      11.28       1.93      31.72      31.72        090
                                                   surgery.                                                                                             
33315...  ..................  A                   Exploratory heart             *22.37      14.48      14.48       2.57      39.42      39.42        090
                                                   surgery.                                                                                             
33320...  ..................  A                   Repair major blood            *16.79      14.14      14.14       2.51      33.44      33.44        090
                                                   vessel(s).                                                                                           
33321...  ..................  A                   Repair major vessel.....      *20.20      21.75      21.75       3.61      45.56      45.56        090
33322...  ..................  A                   Repair major blood            *20.62      21.75      21.75       3.61      45.98      45.98        090
                                                   vessel(s).                                                                                           

[[Page 59133]]

                                                                                                                                                        
33330...  ..................  A                   Insert major vessel           *21.43      12.67      12.67       1.93      36.03      36.03        090
                                                   graft.                                                                                               
33332...  ..................  A                   Insert major vessel           *23.96      15.07      15.07       2.39      41.42      41.42        090
                                                   graft.                                                                                               
33335...  ..................  A                   Insert major vessel           *30.01      15.07      15.07       2.39      47.47      47.47        090
                                                   graft.                                                                                               
33400...  ..................  A                   Repair of aortic valve..      *25.34      26.21      26.21       2.83      54.38      54.38        090
33401...  ..................  A                   Valvuloplasty, open.....      *23.91      26.21      26.21       2.83      52.95      52.95        090
33403...  ..................  A                   Valvuloplasty, w/cp           *24.89      26.21      26.21       2.83      53.93      53.93        090
                                                   bypass.                                                                                              
33404...  ..................  A                   Prepare heart-aorta           *28.54      31.25      31.25       5.59      65.38      65.38        090
                                                   conduit.                                                                                             
33405...  ..................  A                   Replacement of aortic         *30.61      30.48      30.48       5.33      66.42      66.42        090
                                                   valve.                                                                                               
33406...  ..................  A                   Replacement, aortic           *32.30     #35.53     #35.53       7.45      75.28      75.28        090
                                                   valve.                                                                                               
33411...  ..................  A                   Replacement of aortic         *32.47     #35.72     #35.72       7.45      75.64      75.64        090
                                                   valve.                                                                                               
33412...  ..................  A                   Replacement of aortic         *34.79     #38.27     #38.27       7.45      80.51      80.51        090
                                                   valve.                                                                                               
33413...  ..................  A                   Replacement, aortic           *35.24     #38.76     #38.76       7.23      81.23      81.23        090
                                                   valve.                                                                                               
33414...  ..................  A                   Repair, aortic valve....      *30.35     #33.39     #33.39       7.45      71.19      71.19        090
33415...  ..................  A                   Revision, subvalvular         *27.15     #29.87     #29.87       5.33      62.35      62.35        090
                                                   tissue.                                                                                              
33416...  ..................  A                   Revise ventricle muscle.      *30.35      28.14      28.14       4.99      63.48      63.48        090
33417...  ..................  A                   Repair of aortic valve..      *28.53     #31.38     #31.38       6.18      66.09      66.09        090
33420...  ..................  A                   Revision of mitral valve      *22.70      19.82      19.82       2.45      44.97      44.97        090
33422...  ..................  A                   Revision of mitral valve      *25.94     #28.53     #28.53       6.45      60.92      60.92        090
33425...  ..................  A                   Repair of mitral valve..      *27.00     #29.70     #29.70       5.42      62.12      62.12        090
33426...  ..................  A                   Repair of mitral valve..      *31.03      31.96      31.96       5.80      68.79      68.79        090
33427...  ..................  A                   Repair of mitral valve..      *33.72      34.71      34.71       6.30      74.73      74.73        090
33430...  ..................  A                   Replacement of mitral         *31.43     #34.57     #34.57       6.11      72.11      72.11        090
                                                   valve.                                                                                               
33460...  ..................  A                   Revision of tricuspid         *23.60     #25.96     #25.96       4.73      54.29      54.29        090
                                                   valve.                                                                                               
33463...  ..................  A                   Valvuloplasty, tricuspid      *25.62     #28.18     #28.18       5.95      59.75      59.75        090
33464...  ..................  A                   Valvuloplasty, tricuspid      *27.33     #30.06     #30.06       5.95      63.34      63.34        090
33465...  ..................  A                   Replace tricuspid valve.      *28.79     #31.67     #31.67       5.95      66.41      66.41        090
33468...  ..................  A                   Revision of tricuspid         *30.12     #33.13     #33.13       6.30      69.55      69.55        090
                                                   valve.                                                                                               
33470...  ..................  A                   Revision of pulmonary         *20.81      19.82      19.82       2.45      43.08      43.08        090
                                                   valve.                                                                                               
33471...  ..................  A                   Valvotomy, pulmonary          *22.25     #24.48     #24.48       2.83      49.56      49.56        090
                                                   valve.                                                                                               
33472...  ..................  A                   Revision of pulmonary         *22.25     #24.48     #24.48       2.83      49.56      49.56        090
                                                   valve.                                                                                               
33474...  ..................  A                   Revision of pulmonary         *23.04     #25.34     #25.34       2.83      51.21      51.21        090
                                                   valve.                                                                                               
33475...  ..................  A                   Replacement, pulmonary        *28.41     #31.25     #31.25       6.11      65.77      65.77        090
                                                   valve.                                                                                               
33476...  ..................  A                   Revision of heart             *25.77      28.14      28.14       4.99      58.90      58.90        090
                                                   chamber.                                                                                             
33478...  ..................  A                   Revision of heart             *26.74     #29.41     #29.41       5.42      61.57      61.57        090
                                                   chamber.                                                                                             
33496...  ..................  A                   Repair, prosth valve          *27.25     #29.98     #29.98       5.33      62.56      62.56        090
                                                   clot.                                                                                                
33500...  ..................  A                   Repair heart vessel           *25.55     #28.11     #28.11       5.20      58.86      58.86        090
                                                   fistula.                                                                                             
33501...  ..................  A                   Repair heart vessel           *17.78      14.14      14.14       2.51      34.43      34.43        090
                                                   fistula.                                                                                             
33502...  ..................  A                   Coronary artery               *21.04      14.14      14.14       2.51      37.69      37.69        090
                                                   correction.                                                                                          
33503...  ..................  A                   Coronary artery graft...      *21.78     #23.96     #23.96       5.20      50.94      50.94        090
33504...  ..................  A                   Coronary artery graft...      *24.66     #27.13     #27.13       5.20      56.99      56.99        090
33505...  ..................  A                   Repair artery w/tunnel..      *26.84     #29.52     #29.52       6.03      62.39      62.39        090
33506...  ..................  A                   Repair artery,                *26.71     #29.38     #29.38       6.03      62.12      62.12        090
                                                   translocation.                                                                                       
33510...  ..................  A                   CABG, vein, single......      *25.12     #27.63     #27.63       5.20      57.95      57.95        090
33511...  ..................  A                   CABG, vein, two.........      *27.40     #30.14     #30.14       5.71      63.25      63.25        090
33512...  ..................  A                   CABG, vein, three.......      *29.67     #32.64     #32.64       6.22      68.53      68.53        090
33513...  ..................  A                   CABG, vein, four........      *31.95     #35.15     #35.15       6.73      73.83      73.83        090
33514...  ..................  A                   CABG, vein, five........      *35.00     #38.50     #38.50       7.23      80.73      80.73        090
33516...  ..................  A                   CABG, vein, six+........      *37.40     #41.14     #41.14       7.74      86.28      86.28        090
33517...  ..................  A                   CABG, artery-vein,             *2.57      #2.83      #2.83       0.50       5.90       5.90        090
                                                   single.                                                                                              
33518...  ..................  A                   CABG, artery-vein, two..       *4.85      #5.34      #5.34       1.02      11.21      11.21        090
33519...  ..................  A                   CABG, artery-vein, three       *7.12      #7.83      #7.83       1.52      16.47      16.47        090
33521...  ..................  A                   CABG, artery-vein, four.       *9.40     #10.34     #10.34       2.03      21.77      21.77        090
33522...  ..................  A                   CABG, artery-vein, five.      *11.67     #12.84     #12.84       2.54      27.05      27.05        090
33523...  ..................  A                   CABG, artery-vein, six+.      *13.95     #15.35     #15.35       3.05      32.35      32.35        090
33530...  ..................  A                   Coronary artery, bypass/        5.86      #6.45      #6.45       2.18      14.49      14.49        ZZZ
                                                   reop.                                                                                                
33533...  ..................  A                   CABG, arterial, single..      *25.83     #28.41     #28.41       5.36      59.60      59.60        090
33534...  ..................  A                   CABG, arterial, two.....      *28.82     #31.70     #31.70       6.03      66.55      66.55        090
33535...  ..................  A                   CABG, arterial, three...      *31.81     #34.99     #34.99       6.70      73.50      73.50        090
33536...  ..................  A                   CABG, arterial, four+...      *34.79     #38.27     #38.27       7.37      80.43      80.43        090
33542...  ..................  A                   Removal of heart lesion.      *28.85      30.73      30.73       5.53      65.11      65.11        090
33545...  ..................  A                   Repair of heart damage..      *36.78      34.92      34.92       6.28      77.98      77.98        090
33572...  ..................  A                   Open coronary                   4.45       3.23       3.23       0.63       8.31       8.31        ZZZ
                                                   endarterectomy.                                                                                      
33600...  ..................  A                   Closure of valve........      *29.51     #32.46     #32.46       6.11      68.08      68.08        090
33602...  ..................  A                   Closure of valve........      *28.54      30.48      30.48       5.33      64.35      64.35        090
33606...  ..................  A                   Anastomosis/artery-aorta      *30.74     #33.81     #33.81       7.45      72.00      72.00        090
33608...  ..................  A                   Repair anomaly w/conduit      *31.09     #34.20     #34.20       7.45      72.74      72.74        090
33610...  ..................  A                   Repair by enlargement...      *30.61     #33.67     #33.67       7.45      71.73      71.73        090
33611...  ..................  A                   Repair double ventricle.      *32.30     #35.53     #35.53       7.45      75.28      75.28        090
33612...  ..................  A                   Repair double ventricle.      *33.26     #36.59     #36.59       7.45      77.30      77.30        090
33615...  ..................  A                   Repair (simple fontan)..      *32.06     #35.27     #35.27       7.45      74.78      74.78        090
33617...  ..................  A                   Repair by modified            *34.03     #37.43     #37.43       7.45      78.91      78.91        090
                                                   fontan.                                                                                              
33619...  ..................  A                   Repair single ventricle.      *37.57     #41.33     #41.33       8.04      86.94      86.94        090
33641...  ..................  A                   Repair heart septum           *21.39     #23.53     #23.53       4.87      49.79      49.79        090
                                                   defect.                                                                                              
33645...  ..................  A                   Revision of heart veins.      *24.82     #27.30     #27.30       4.87      56.99      56.99        090

[[Page 59134]]

                                                                                                                                                        
33647...  ..................  A                   Repair heart septum           *28.73     #31.60     #31.60       6.28      66.61      66.61        090
                                                   defects.                                                                                             
33660...  ..................  A                   Repair of heart defects.      *25.54     #28.09     #28.09       5.42      59.05      59.05        090
33665...  ..................  A                   Repair of heart defects.      *28.60      31.27      31.27       5.42      65.29      65.29        090
33670...  ..................  A                   Repair of heart chambers      *32.73     #36.00     #36.00       7.45      76.18      76.18        090
33681...  ..................  A                   Repair heart septum           *27.67     #30.44     #30.44       6.28      64.39      64.39        090
                                                   defect.                                                                                              
33684...  ..................  A                   Repair heart septum           *29.65     #32.62     #32.62       6.28      68.55      68.55        090
                                                   defect.                                                                                              
33688...  ..................  A                   Repair heart septum           *30.62     #33.68     #33.68       6.28      70.58      70.58        090
                                                   defect.                                                                                              
33690...  ..................  A                   Reinforce pulmonary           *19.55     #21.51     #21.51       4.29      45.35      45.35        090
                                                   artery.                                                                                              
33692...  ..................  A                   Repair of heart defects.      *30.75     #33.83     #33.83       7.45      72.03      72.03        090
33694...  ..................  A                   Repair of heart defects.      *31.73     #34.90     #34.90       7.45      74.08      74.08        090
33697...  ..................  A                   Repair of heart defects.      *33.71     #37.08     #37.08       7.45      78.24      78.24        090
33702...  ..................  A                   Repair of heart defects.      *26.54     #29.19     #29.19       5.33      61.06      61.06        090
33710...  ..................  A                   Repair of heart defects.      *29.71     #32.68     #32.68       6.28      68.67      68.67        090
33720...  ..................  A                   Repair of heart defect..      *26.56     #29.22     #29.22       5.33      61.11      61.11        090
33722...  ..................  A                   Repair of heart defect..      *28.41      30.48      30.48       5.33      64.22      64.22        090
33730...  ..................  A                   Repair heart-vein             *31.67     #34.84     #34.84       7.45      73.96      73.96        090
                                                   defect(s).                                                                                           
33732...  ..................  A                   Repair heart-vein defect      *28.16     #30.98     #30.98       5.42      64.56      64.56        090
33735...  ..................  A                   Revision of heart             *21.39      25.69      25.69       4.87      51.95      51.95        090
                                                   chamber.                                                                                             
33736...  ..................  A                   Revision of heart             *23.52      25.69      25.69       4.87      54.08      54.08        090
                                                   chamber.                                                                                             
33737...  ..................  A                   Revision of heart             *21.76     #23.94     #23.94       4.87      50.57      50.57        090
                                                   chamber.                                                                                             
33750...  ..................  A                   Major vessel shunt......      *21.41      22.10      22.10       4.29      47.80      47.80        090
33755...  ..................  A                   Major vessel shunt......      *21.79      22.10      22.10       4.29      48.18      48.18        090
33762...  ..................  A                   Major vessel shunt......      *21.79      22.10      22.10       4.29      48.18      48.18        090
33764...  ..................  A                   Major vessel shunt &          *21.79      22.10      22.10       4.29      48.18      48.18        090
                                                   graft.                                                                                               
33766...  ..................  A                   Major vessel shunt......      *22.76      22.10      22.10       4.29      49.15      49.15        090
33767...  ..................  A                   Atrial septectomy/            *24.50      25.69      25.69       4.87      55.06      55.06        090
                                                   septostomy.                                                                                          
33770...  ..................  A                   Repair great vessels          *33.29     #36.62     #36.62       7.45      77.36      77.36        090
                                                   defect.                                                                                              
33771...  ..................  A                   Repair great vessels          *34.65     #38.12     #38.12       7.45      80.22      80.22        090
                                                   defect.                                                                                              
33774...  ..................  A                   Repair great vessels          *30.98      31.27      31.27       5.42      67.67      67.67        090
                                                   defect.                                                                                              
33775...  ..................  A                   Repair great vessels          *32.20      31.27      31.27       5.42      68.89      68.89        090
                                                   defect.                                                                                              
33776...  ..................  A                   Repair great vessels          *34.04      34.92      34.92       6.28      75.24      75.24        090
                                                   defect.                                                                                              
33777...  ..................  A                   Repair great vessels          *33.46      31.27      31.27       5.42      70.15      70.15        090
                                                   defect.                                                                                              
33778...  ..................  A                   Repair great vessels          *35.82     #39.40     #39.40       7.37      82.59      82.59        090
                                                   defect.                                                                                              
33779...  ..................  A                   Repair great vessels          *36.21     #39.83     #39.83       7.37      83.41      83.41        090
                                                   defect.                                                                                              
33780...  ..................  A                   Repair great vessels          *36.94     #40.63     #40.63       7.37      84.94      84.94        090
                                                   defect.                                                                                              
33781...  ..................  A                   Repair great vessels          *36.45     #40.10     #40.10       7.37      83.92      83.92        090
                                                   defect.                                                                                              
33786...  ..................  A                   Repair arterial trunk...      *34.84     #38.32     #38.32       7.45      80.61      80.61        090
33788...  ..................  A                   Revision of pulmonary         *26.62     #29.28     #29.28       5.20      61.10      61.10        090
                                                   artery.                                                                                              
33800...  ..................  A                   Aortic suspension.......      *16.24      14.14      14.14       2.51      32.89      32.89        090
33802...  ..................  A                   Repair vessel defect....      *17.66     #19.43     #19.43       4.29      41.38      41.38        090
33803...  ..................  A                   Repair vessel defect....      *19.60     #21.56     #21.56       4.29      45.45      45.45        090
33813...  ..................  A                   Repair septal defect....      *20.65      22.10      22.10       4.29      47.04      47.04        090
33814...  ..................  A                   Repair septal defect....      *25.77     #28.35     #28.35       5.33      59.45      59.45        090
33820...  ..................  A                   Revise major vessel.....      *16.29     #17.92     #17.92       4.29      38.50      38.50        090
33822...  ..................  A                   Revise major vessel.....      *17.32     #19.05     #19.05       4.29      40.66      40.66        090
33824...  ..................  A                   Revise major vessel.....      *19.52     #21.47     #21.47       4.29      45.28      45.28        090
33840...  ..................  A                   Remove aorta                  *20.63     #22.69     #22.69       5.59      48.91      48.91        090
                                                   constriction.                                                                                        
33845...  ..................  A                   Remove aorta                  *22.12     #24.33     #24.33       5.59      52.04      52.04        090
                                                   constriction.                                                                                        
33851...  ..................  A                   Remove aorta                  *21.27     #23.40     #23.40       5.59      50.26      50.26        090
                                                   constriction.                                                                                        
33852...  ..................  A                   Repair septal defect....      *23.71     #26.08     #26.08       5.59      55.38      55.38        090
33853...  ..................  A                   Repair septal defect....      *31.72     #34.89     #34.89       7.45      74.06      74.06        090
33860...  ..................  A                   Ascending aorta graft...      *33.96      34.71      34.71       6.18      74.85      74.85        090
33861...  ..................  A                   Ascending aorta graft...      *34.52      34.71      34.71       6.18      75.41      75.41        090
33863...  ..................  A                   Ascending aorta graft...      *36.47      34.71      34.71       6.18      77.36      77.36        090
33870...  ..................  A                   Transverse aortic arch        *40.31      44.30      44.30       8.04      92.65      92.65        090
                                                   graft.                                                                                               
33875...  ..................  A                   Thoracic aorta graft....      *33.06      31.25      31.25       5.59      69.90      69.90        090
33877...  ..................  A                   Thoracoabdominal graft..      *42.60      44.11      44.11       8.38      95.09      95.09        090
33910...  ..................  A                   Remove lung artery            *24.59      14.65      14.65       2.77      42.01      42.01        090
                                                   emboli.                                                                                              
33915...  ..................  A                   Remove lung artery            *21.02      12.02      12.02       2.22      35.26      35.26        090
                                                   emboli.                                                                                              
33916...  ..................  A                   Surgery of great vessel.      *25.83      17.57      17.57       3.43      46.83      46.83        090
33917...  ..................  A                   Repair pulmonary artery.      *24.50     #26.95     #26.95       6.30      57.75      57.75        090
33918...  ..................  A                   Repair pulmonary atresia      *26.45     #29.10     #29.10       5.20      60.75      60.75        090
33919...  ..................  A                   Repair pulmonary atresia      *32.67     #35.94     #35.94       7.45      76.06      76.06        090
33920...  ..................  A                   Repair pulmonary atresia      *31.95     #35.15     #35.15       7.45      74.55      74.55        090
33922...  ..................  A                   Transect pulmonary            *23.52     #25.87     #25.87       2.83      52.22      52.22        090
                                                   artery.                                                                                              
33924...  ..................  A                   Remove pulmonary shunt..        5.50       4.00       4.00       0.78      10.28      10.28        ZZZ
33930...  ..................  X                   Removal of donor heart/         0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                   lung.                                                                                                
33935...  ..................  R                   Transplantation, heart/       *60.96     #67.06     #67.06      13.54     141.56     141.56        090
                                                   lung.                                                                                                
33940...  ..................  X                   Removal of donor heart..        0.00       0.00       0.00       0.00       0.00       0.00        XXX
33945...  ..................  R                   Transplantation of heart      *42.10     #46.31     #46.31      11.05      99.46      99.46        090
33960...  ..................  A                   External circulation           19.36       7.01       7.01       0.94      27.31      27.31        XXX
                                                   assist.                                                                                              
33961...  ..................  A                   External circulation           10.93       7.01       7.01       0.94      18.88      18.88        XXX
                                                   assist.                                                                                              
33970...  ..................  A                   Aortic circulation              6.75      #7.43      #7.43       1.00      15.18      15.18        000
                                                   assist.                                                                                              
33971...  ..................  A                   Aortic circulation             *9.69       5.16       5.16       0.91      15.76      15.76        090
                                                   assist.                                                                                              

[[Page 59135]]

                                                                                                                                                        
33973...  ..................  A                   Insert balloon device...        9.76       7.54       7.54       1.00      18.30      18.30        000
33974...  ..................  A                   Remove intra-aortic           *14.41       5.56       5.56       0.91      20.88      20.88        090
                                                   balloon.                                                                                             
33975...  ..................  A                   Implant ventricular           *21.60      14.19      14.19       2.77      38.56      38.56        090
                                                   device.                                                                                              
33976...  ..................  A                   Implant ventricular           *29.10      19.33      19.33       3.78      52.21      52.21        090
                                                   device.                                                                                              
33977...  ..................  A                   Remove ventricular            *19.29      12.41      12.41       2.43      34.13      34.13        090
                                                   device.                                                                                              
33978...  ..................  A                   Remove ventricular            *21.73      14.19      14.19       2.77      38.69      38.69        090
                                                   device.                                                                                              
33999...  ..................  C                   Cardiac surgery                 0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                   procedure.                                                                                           
34001...  ..................  A                   Removal of artery clot..      *12.91       9.58       9.58       1.87      24.36      24.36        090
34051...  ..................  A                   Removal of artery clot..      *15.21       8.81       8.81       1.59      25.61      25.61        090
34101...  ..................  A                   Removal of artery clot..       *9.97       8.34       8.34       1.71      20.02      20.02        090
34111...  ..................  A                   Removal of arm artery          *8.07       7.59       7.59       1.59      17.25      17.25        090
                                                   clot.                                                                                                
34151...  ..................  A                   Removal of artery clot..      *16.86      11.96      11.96       2.39      31.21      31.21        090
34201...  ..................  A                   Removal of artery clot..       *9.13       8.90       8.90       1.78      19.81      19.81        090
34203...  ..................  A                   Removal of leg artery         *12.21       8.63       8.63       1.72      22.56      22.56        090
                                                   clot.                                                                                                
34401...  ..................  A                   Removal of vein clot....      *12.86       8.07       8.07       1.39      22.32      22.32        090
34421...  ..................  A                   Removal of vein clot....       *9.93       7.45       7.45       1.51      18.89      18.89        090
34451...  ..................  A                   Removal of vein clot....      *14.44      10.69      10.69       2.14      27.27      27.27        090
34471...  ..................  A                   Removal of vein clot....      *10.18       3.51       3.51       0.55      14.24      14.24        090
34490...  ..................  A                   Removal of vein clot....       *7.60       7.27       7.27       1.54      16.41      16.41        090
34501...  ..................  A                   Repair valve, femoral         *10.93       7.35       7.35       0.86      19.14      19.14        090
                                                   vein.                                                                                                
34502...  ..................  A                   Reconstruct, vena cava..      *26.95      18.65      18.65       3.64      49.24      49.24        090
34510...  ..................  A                   Transposition of vein         *13.25       8.89       8.89       1.04      23.18      23.18        090
                                                   valve.                                                                                               
34520...  ..................  A                   Cross-over vein graft...      *13.74       9.33       9.33       1.09      24.16      24.16        090
34530...  ..................  A                   Leg vein fusion.........      *17.61      12.35      12.35       1.44      31.40      31.40        090
35001...  ..................  A                   Repair defect of artery.      *19.64      15.90      15.90       3.18      38.72      38.72        090
35002...  ..................  A                   Repair artery rupture,        *21.00      12.64      12.64       2.41      36.05      36.05        090
                                                   neck.                                                                                                
35005...  ..................  A                   Repair defect of artery.      *18.12      10.28      10.28       2.19      30.59      30.59        090
35011...  ..................  A                   Repair defect of artery.      *11.65     #12.82     #12.82       2.76      27.23      27.23        090
35013...  ..................  A                   Repair artery rupture,        *17.40      14.70      14.70       3.03      35.13      35.13        090
                                                   arm.                                                                                                 
35021...  ..................  A                   Repair defect of artery.      *19.65      18.13      18.13       3.06      40.84      40.84        090
35022...  ..................  A                   Repair artery rupture,        *23.18      14.78      14.78       2.80      40.76      40.76        090
                                                   chest.                                                                                               
35045...  ..................  A                   Repair defect of arm          *11.26      12.35      12.35       2.50      26.11      26.11        090
                                                   artery.                                                                                              
35081...  ..................  A                   Repair defect of artery.      *28.01      21.45      21.45       4.18      53.64      53.64        090
35082...  ..................  A                   Repair artery rupture,        *36.35      22.91      22.91       4.59      63.85      63.85        090
                                                   aorta.                                                                                               
35091...  ..................  A                   Repair defect of artery.      *35.40      22.67      22.67       4.25      62.32      62.32        090
35092...  ..................  A                   Repair artery rupture,        *38.39      26.27      26.27       5.21      69.87      69.87        090
                                                   aorta.                                                                                               
35102...  ..................  A                   Repair defect of artery.      *30.76      22.15      22.15       4.32      57.23      57.23        090
35103...  ..................  A                   Repair artery rupture,        *33.57      26.16      26.16       5.21      64.94      64.94        090
                                                   groin.                                                                                               
35111...  ..................  A                   Repair defect of artery.      *16.43      17.60      17.60       3.70      37.73      37.73        090
35112...  ..................  A                   Repair artery rupture,        *18.69      10.45      10.45       2.22      31.36      31.36        090
                                                   spleen.                                                                                              
35121...  ..................  A                   Repair defect of artery.      *25.99      19.12      19.12       3.66      48.77      48.77        090
35122...  ..................  A                   Repair artery rupture,        *33.45      17.92      17.92       3.96      55.33      55.33        090
                                                   belly.                                                                                               
35131...  ..................  A                   Repair defect of artery.      *18.55      15.88      15.88       3.15      37.58      37.58        090
35132...  ..................  A                   Repair artery rupture,        *21.95      18.68      18.68       3.58      44.21      44.21        090
                                                   groin.                                                                                               
35141...  ..................  A                   Repair defect of artery.      *14.46      14.70      14.70       2.88      32.04      32.04        090
35142...  ..................  A                   Repair artery rupture,        *15.86      16.10      16.10       3.24      35.20      35.20        090
                                                   thigh.                                                                                               
35151...  ..................  A                   Repair defect of artery.      *17.00      15.36      15.36       2.94      35.30      35.30        090
35152...  ..................  A                   Repair artery rupture,        *16.70       9.27       9.27       1.95      27.92      27.92        090
                                                   knee.                                                                                                
35161...  ..................  A                   Repair defect of artery.      *18.76      15.88      15.88       3.15      37.79      37.79        090
35162...  ..................  A                   Repair artery rupture...      *19.78      18.68      18.68       3.58      42.04      42.04        090
35180...  ..................  A                   Repair blood vessel           *13.62       7.37       7.37       1.48      22.47      22.47        090
                                                   lesion.                                                                                              
35182...  ..................  A                   Repair blood vessel           *17.74      10.65      10.65       1.61      30.00      30.00        090
                                                   lesion.                                                                                              
35184...  ..................  A                   Repair blood vessel           *12.25       9.73       9.73       1.96      23.94      23.94        090
                                                   lesion.                                                                                              
35188...  ..................  A                   Repair blood vessel           *14.28       8.11       8.11       1.59      23.98      23.98        090
                                                   lesion.                                                                                              
35189...  ..................  A                   Repair blood vessel           *18.43      11.33      11.33       2.21      31.97      31.97        090
                                                   lesion.                                                                                              
35190...  ..................  A                   Repair blood vessel           *12.75      10.34      10.34       2.14      25.23      25.23        090
                                                   lesion.                                                                                              
35201...  ..................  A                   Repair blood vessel            *9.99      10.07      10.07       1.94      22.00      22.00        090
                                                   lesion.                                                                                              
35206...  ..................  A                   Repair blood vessel            *9.25      10.15      10.15       2.03      21.43      21.43        090
                                                   lesion.                                                                                              
35207...  ..................  A                   Repair blood vessel           *10.15      10.80      10.80       1.93      22.88      22.88        090
                                                   lesion.                                                                                              
35211...  ..................  A                   Repair blood vessel           *22.12      13.38      13.38       2.59      38.09      38.09        090
                                                   lesion.                                                                                              
35216...  ..................  A                   Repair blood vessel           *18.75      10.68      10.68       2.08      31.51      31.51        090
                                                   lesion.                                                                                              
35221...  ..................  A                   Repair blood vessel           *16.42      11.09      11.09       2.20      29.71      29.71        090
                                                   lesion.                                                                                              
35226...  ..................  A                   Repair blood vessel            *9.06      #9.97      #9.97       1.95      20.98      20.98        090
                                                   lesion.                                                                                              
35231...  ..................  A                   Repair blood vessel           *12.00     #13.20     #13.20       2.91      28.11      28.11        090
                                                   lesion.                                                                                              
35236...  ..................  A                   Repair blood vessel           *10.54     #11.59     #11.59       2.56      24.69      24.69        090
                                                   lesion.                                                                                              
35241...  ..................  A                   Repair blood vessel           *23.12      13.49      13.49       2.60      39.21      39.21        090
                                                   lesion.                                                                                              
35246...  ..................  A                   Repair blood vessel           *19.84      16.95      16.95       2.15      38.94      38.94        090
                                                   lesion.                                                                                              
35251...  ..................  A                   Repair blood vessel           *17.49       9.59       9.59       1.88      28.96      28.96        090
                                                   lesion.                                                                                              
35256...  ..................  A                   Repair blood vessel           *11.38      12.40      12.40       2.39      26.17      26.17        090
                                                   lesion.                                                                                              
35261...  ..................  A                   Repair blood vessel           *11.63     #12.79     #12.79       2.66      27.08      27.08        090
                                                   lesion.                                                                                              
35266...  ..................  A                   Repair blood vessel           *10.30     #11.33     #11.33       2.41      24.04      24.04        090
                                                   lesion.                                                                                              
35271...  ..................  A                   Repair blood vessel           *22.12      12.53      12.53       2.56      37.21      37.21        090
                                                   lesion.                                                                                              
35276...  ..................  A                   Repair blood vessel           *18.75      10.85      10.85       2.26      31.86      31.86        090
                                                   lesion.                                                                                              
35281...  ..................  A                   Repair blood vessel           *16.48      17.28      17.28       3.37      37.13      37.13        090
                                                   lesion.                                                                                              

[[Page 59136]]

                                                                                                                                                        
35286...  ..................  A                   Repair blood vessel           *11.87      11.71      11.71       2.33      25.91      25.91        090
                                                   lesion.                                                                                              
35301...  ..................  A                   Rechanneling of artery..      *18.70      14.46      14.46       2.81      35.97      35.97        090
35311...  ..................  A                   Rechanneling of artery..      *23.85      22.06      22.06       4.61      50.52      50.52        090
35321...  ..................  A                   Rechanneling of artery..      *11.97      12.96      12.96       2.69      27.62      27.62        090
35331...  ..................  A                   Rechanneling of artery..      *23.52      13.34      13.34       2.66      39.52      39.52        090
35341...  ..................  A                   Rechanneling of artery..      *25.11      17.37      17.37       3.53      46.01      46.01        090
35351...  ..................  A                   Rechanneling of artery..      *20.11      14.95      14.95       2.97      38.03      38.03        090
35355...  ..................  A                   Rechanneling of artery..      *16.09      15.42      15.42       2.99      34.50      34.50        090
35361...  ..................  A                   Rechanneling of artery..      *23.59      19.37      19.37       3.88      46.84      46.84        090
35363...  ..................  A                   Rechanneling of artery..      *24.66      22.77      22.77       4.40      51.83      51.83        090
35371...  ..................  A                   Rechanneling of artery..      *11.64      12.51      12.51       2.50      26.65      26.65        090
35372...  ..................  A                   Rechanneling of artery..      *13.56      11.20      11.20       2.28      27.04      27.04        090
35381...  ..................  A                   Rechanneling of artery..      *15.81      13.67      13.67       2.71      32.19      32.19        090
35390...  ..................  A                   Reoperation, carotid....        3.19       1.67       1.67       0.39       5.25       5.25        ZZZ
35400...  ..................  A                   Angioscopy..............        3.00       2.27       2.27       0.27       5.54       5.54        ZZZ
35450...  ..................  A                   Repair arterial blockage       10.07     #11.08     #11.08       1.38      22.53      22.53        000
35452...  ..................  A                   Repair arterial blockage        6.91       4.35       4.35       0.61      11.87      11.87        000
35454...  ..................  A                   Repair arterial blockage        6.04      #6.64      #6.64       1.53      14.21      14.21        000
35456...  ..................  A                   Repair arterial blockage        7.35      #8.09      #8.09       1.69      17.13      17.13        000
35458...  ..................  A                   Repair arterial blockage        9.49      10.13      10.13       1.83      21.45      21.45        000
35459...  ..................  A                   Repair arterial blockage        8.63      #9.49      #9.49       1.69      19.81      19.81        000
35460...  ..................  A                   Repair venous blockage..        6.04       3.16       3.16       0.74       9.94       9.94        000
35470...  ..................  A                   Repair arterial blockage        8.63      #9.49      #9.49       1.69      19.81      19.81        000
35471...  ..................  A                   Repair arterial blockage       10.07     #11.08     #11.08       1.38      22.53      22.53        000
35472...  ..................  A                   Repair arterial blockage        6.91       3.61       3.61       0.85      11.37      11.37        000
35473...  ..................  A                   Repair arterial blockage        6.04      #6.64      #6.64       1.53      14.21      14.21        000
35474...  ..................  A                   Repair arterial blockage        7.36      #8.10      #8.10       1.69      17.15      17.15        000
35475...  ..................  R                   Repair arterial blockage        9.49      10.13      10.13       1.83      21.45      21.45        000
35476...  ..................  A                   Repair venous blockage..        6.04       3.16       3.16       0.74       9.94       9.94        000
35480...  ..................  A                   Atherectomy, open.......       11.08     #12.19     #12.19       1.38      24.65      24.65        000
35481...  ..................  A                   Atherectomy, open.......        7.61       4.35       4.35       0.61      12.57      12.57        000
35482...  ..................  A                   Atherectomy, open.......        6.65      #7.32      #7.32       1.53      15.50      15.50        000
35483...  ..................  A                   Atherectomy, open.......        8.10      #8.91      #8.91       1.69      18.70      18.70        000
35484...  ..................  A                   Atherectomy, open.......       10.44      10.13      10.13       1.83      22.40      22.40        000
35485...  ..................  A                   Atherectomy, open.......        9.49       4.52       4.52       1.06      15.07      15.07        000
35490...  ..................  A                   Atherectomy,                   11.08     #12.19     #12.19       1.38      24.65      24.65        000
                                                   percutaneous.                                                                                        
35491...  ..................  A                   Atherectomy,                    7.61       4.35       4.35       0.61      12.57      12.57        000
                                                   percutaneous.                                                                                        
35492...  ..................  A                   Atherectomy,                    6.65      #7.32      #7.32       1.53      15.50      15.50        000
                                                   percutaneous.                                                                                        
35493...  ..................  A                   Atherectomy,                    8.10      #8.91      #8.91       1.69      18.70      18.70        000
                                                   percutaneous.                                                                                        
35494...  ..................  A                   Atherectomy,                   10.44      10.13      10.13       1.83      22.40      22.40        000
                                                   percutaneous.                                                                                        
35495...  ..................  A                   Atherectomy,                    9.49       4.52       4.52       1.06      15.07      15.07        000
                                                   percutaneous.                                                                                        
35501...  ..................  A                   Artery bypass graft.....      *19.19      19.35      19.35       3.49      42.03      42.03        090
35506...  ..................  A                   Artery bypass graft.....      *19.67      19.17      19.17       3.64      42.48      42.48        090
35507...  ..................  A                   Artery bypass graft.....      *19.67      17.92      17.92       3.61      41.20      41.20        090
35508...  ..................  A                   Artery bypass graft.....      *18.65      18.11      18.11       3.43      40.19      40.19        090
35509...  ..................  A                   Artery bypass graft.....      *18.07      18.90      18.90       3.92      40.89      40.89        090
35511...  ..................  A                   Artery bypass graft.....      *16.83      10.40      10.40       1.92      29.15      29.15        090
35515...  ..................  A                   Artery bypass graft.....      *18.65      11.25      11.25       2.01      31.91      31.91        090
35516...  ..................  A                   Artery bypass graft.....      *16.32      17.37      17.37       3.54      37.23      37.23        090
35518...  ..................  A                   Artery bypass graft.....      *15.42     #16.96     #16.96       3.38      35.76      35.76        090
35521...  ..................  A                   Artery bypass graft.....      *16.17      17.53      17.53       3.34      37.04      37.04        090
35526...  ..................  A                   Artery bypass graft.....      *20.00      12.95      12.95       2.44      35.39      35.39        090
35531...  ..................  A                   Artery bypass graft.....      *25.61      20.25      20.25       3.90      49.76      49.76        090
35533...  ..................  A                   Artery bypass graft.....      *20.52      21.04      21.04       4.43      45.99      45.99        090
35536...  ..................  A                   Artery bypass graft.....      *23.11      21.37      21.37       4.17      48.65      48.65        090
35541...  ..................  A                   Artery bypass graft.....      *25.80      19.55      19.55       3.65      49.00      49.00        090
35546...  ..................  A                   Artery bypass graft.....      *25.54      21.39      21.39       4.26      51.19      51.19        090
35548...  ..................  A                   Artery bypass graft.....      *21.57      19.55      19.55       3.65      44.77      44.77        090
35549...  ..................  A                   Artery bypass graft.....      *23.35      21.39      21.39       4.26      49.00      49.00        090
35551...  ..................  A                   Artery bypass graft.....      *26.67      19.25      19.25       3.87      49.79      49.79        090
35556...  ..................  A                   Artery bypass graft.....      *21.76      18.71      18.71       3.71      44.18      44.18        090
35558...  ..................  A                   Artery bypass graft.....      *14.04     #15.44     #15.44       3.23      32.71      32.71        090
35560...  ..................  A                   Artery bypass graft.....      *23.56      20.22      20.22       3.93      47.71      47.71        090
35563...  ..................  A                   Artery bypass graft.....      *15.14       8.32       8.32       1.70      25.16      25.16        090
35565...  ..................  A                   Artery bypass graft.....      *15.14     #16.65     #16.65       3.51      35.30      35.30        090
35566...  ..................  A                   Artery bypass graft.....      *26.92      20.62      20.62       4.08      51.62      51.62        090
35571...  ..................  A                   Artery bypass graft.....      *18.58      19.36      19.36       3.87      41.81      41.81        090
35582...  ..................  A                   Vein bypass graft.......      *27.13      23.74      23.74       4.89      55.76      55.76        090
35583...  ..................  A                   Vein bypass graft.......      *22.37      20.44      20.44       4.13      46.94      46.94        090
35585...  ..................  A                   Vein bypass graft.......      *28.39      22.95      22.95       4.63      55.97      55.97        090
35587...  ..................  A                   Vein bypass graft.......      *19.05     #20.96     #20.96       4.13      44.14      44.14        090
35601...  ..................  A                   Artery bypass graft.....      *17.50      18.83      18.83       3.33      39.66      39.66        090
35606...  ..................  A                   Artery bypass graft.....      *18.71      17.55      17.55       3.51      39.77      39.77        090
35612...  ..................  A                   Artery bypass graft.....      *15.76      16.75      16.75       3.30      35.81      35.81        090

[[Page 59137]]

                                                                                                                                                        
35616...  ..................  A                   Artery bypass graft.....      *15.70      16.79      16.79       3.42      35.91      35.91        090
35621...  ..................  A                   Artery bypass graft.....      *14.54     #15.99     #15.99       3.80      34.33      34.33        090
35623...  ..................  A                   Bypass graft, not vein..      *16.62       8.06       8.06       1.88      26.56      26.56        090
35626...  ..................  A                   Artery bypass graft.....      *23.63      20.51      20.51       4.08      48.22      48.22        090
35631...  ..................  A                   Artery bypass graft.....      *24.60      17.87      17.87       3.57      46.04      46.04        090
35636...  ..................  A                   Artery bypass graft.....      *22.46      13.50      13.50       2.45      38.41      38.41        090
35641...  ..................  A                   Artery bypass graft.....      *24.57      20.56      20.56       4.08      49.21      49.21        090
35642...  ..................  A                   Artery bypass graft.....      *17.98      10.33      10.33       2.20      30.51      30.51        090
35645...  ..................  A                   Artery bypass graft.....      *17.47      11.15      11.15       2.05      30.67      30.67        090
35646...  ..................  A                   Artery bypass graft.....      *25.81      23.78      23.78       4.73      54.32      54.32        090
35650...  ..................  A                   Artery bypass graft.....      *14.36     #15.80     #15.80       3.56      33.72      33.72        090
35651...  ..................  A                   Artery bypass graft.....      *25.04      24.09      24.09       4.69      53.82      53.82        090
35654...  ..................  A                   Artery bypass graft.....      *18.61     #20.47     #20.47       4.42      43.50      43.50        090
35656...  ..................  A                   Artery bypass graft.....      *19.53      17.73      17.73       3.60      40.86      40.86        090
35661...  ..................  A                   Artery bypass graft.....      *13.18     #14.50     #14.50       3.30      30.98      30.98        090
35663...  ..................  A                   Artery bypass graft.....      *14.17     #15.59     #15.59       3.80      33.56      33.56        090
35665...  ..................  A                   Artery bypass graft.....      *15.40     #16.94     #16.94       3.57      35.91      35.91        090
35666...  ..................  A                   Artery bypass graft.....      *19.19      20.06      20.06       4.00      43.25      43.25        090
35671...  ..................  A                   Artery bypass graft.....      *14.80      15.60      15.60       4.08      34.48      34.48        090
35681...  ..................  A                   Artery bypass graft.....        8.05      #8.86      #8.86       3.52      20.43      20.43        ZZZ
35691...  ..................  A                   Arterial transposition..      *18.05      19.62      19.62       3.81      41.48      41.48        090
35693...  ..................  A                   Arterial transposition..      *15.36       9.40       9.40       1.91      26.67      26.67        090
35694...  ..................  A                   Arterial transposition..      *19.16       9.33       9.33       2.17      30.66      30.66        090
35695...  ..................  A                   Arterial transposition..      *19.16       9.33       9.33       2.17      30.66      30.66        090
35700...  ..................  A                   Reoperation, bypass             3.08       1.61       1.61       0.38       5.07       5.07        ZZZ
                                                   graft.                                                                                               
35701...  ..................  A                   Exploration, carotid           *5.55       5.82       5.82       1.25      12.62      12.62        090
                                                   artery.                                                                                              
35721...  ..................  A                   Exploration, femoral           *5.28       5.56       5.56       1.11      11.95      11.95        090
                                                   artery.                                                                                              
35741...  ..................  A                   Exploration popliteal          *5.37       5.73       5.73       1.15      12.25      12.25        090
                                                   artery.                                                                                              
35761...  ..................  A                   Exploration of artery/         *5.37       5.81       5.81       1.14      12.32      12.32        090
                                                   vein.                                                                                                
35800...  ..................  A                   Explore neck vessels....       *7.02       5.28       5.28       0.97      13.27      13.27        090
35820...  ..................  A                   Explore chest vessels...      *12.88       7.92       7.92       1.43      22.23      22.23        090
35840...  ..................  A                   Explore abdominal              *9.77       7.23       7.23       1.44      18.44      18.44        090
                                                   vessels.                                                                                             
35860...  ..................  A                   Explore limb vessels....       *5.55       5.81       5.81       1.15      12.51      12.51        090
35870...  ..................  A                   Repair vessel graft           *22.17      10.64      10.64       2.47      35.28      35.28        090
                                                   defect.                                                                                              
35875...  ..................  A                   Removal of clot in graft      *10.01       8.21       8.21       1.65      19.87      19.87        090
35876...  ..................  A                   Removal of clot in graft      *13.67       8.21       8.21       1.65      23.53      23.53        090
35901...  ..................  A                   Excision, graft, neck...       *8.19       7.18       7.18       1.46      16.83      16.83        090
35903...  ..................  A                   Excision, graft,               *9.39       7.18       7.18       1.46      18.03      18.03        090
                                                   extremity.                                                                                           
35905...  ..................  A                   Excision, graft, thorax.      *18.19       7.18       7.18       1.46      26.83      26.83        090
35907...  ..................  A                   Excision, graft, abdomen      *19.24       7.18       7.18       1.46      27.88      27.88        090
36000...  ..................  A                   Place needle in vein....        0.18       0.24      #0.20       0.04       0.46       0.42        XXX
36005...  ..................  A                   Injection, venography...        0.95       0.47       0.47       0.04       1.46       1.46        000
36010...  ..................  A                   Place catheter in vein..        2.43       2.11       2.11       0.31       4.85       4.85        XXX
36011...  ..................  A                   Place catheter in vein..        3.14       1.90       1.90       0.22       5.26       5.26        XXX
36012...  ..................  A                   Place catheter in vein..        3.52       2.67       2.67       0.32       6.51       6.51        XXX
36013...  ..................  A                   Place catheter in artery        2.52       2.11       2.11       0.31       4.94       4.94        XXX
36014...  ..................  A                   Place catheter in artery        3.02       2.28       2.28       0.27       5.57       5.57        XXX
36015...  ..................  A                   Place catheter in artery        3.52       2.67       2.67       0.32       6.51       6.51        XXX
36100...  ..................  A                   Establish access to             3.02       2.59       2.59       0.32       5.93       5.93        XXX
                                                   artery.                                                                                              
36120...  ..................  A                   Establish access to             2.01      #2.21      #2.21       0.30       4.52       4.52        XXX
                                                   artery.                                                                                              
36140...  ..................  A                   Establish access to             2.01       1.41       1.41       0.24       3.66       3.66        XXX
                                                   artery.                                                                                              
36145...  ..................  A                   Artery to vein shunt....        2.01      #2.21      #2.21       0.49       4.71       4.71        XXX
36160...  ..................  A                   Establish access to             2.52       2.32       2.32       0.35       5.19       5.19        XXX
                                                   aorta.                                                                                               
36200...  ..................  A                   Place catheter in aorta.        3.02       2.73       2.73       0.28       6.03       6.03        XXX
36215...  ..................  A                   Place catheter in artery        4.68       2.78       2.78       0.23       7.69       7.69        XXX
36216...  ..................  A                   Place catheter in artery        5.28       3.29       3.29       0.27       8.84       8.84        XXX
36217...  ..................  A                   Place catheter in artery        6.30       3.92       3.92       0.32      10.54      10.54        XXX
36218...  ..................  A                   Place catheter in artery        1.01       0.62       0.62       0.05       1.68       1.68        XXX
36245...  ..................  A                   Place catheter in artery        4.68       3.15       3.15       0.26       8.09       8.09        XXX
36246...  ..................  A                   Place catheter in artery        5.28       3.29       3.29       0.27       8.84       8.84        XXX
36247...  ..................  A                   Place catheter in artery        6.30       3.92       3.92       0.32      10.54      10.54        XXX
36248...  ..................  A                   Place catheter in artery        1.01       0.62       0.62       0.05       1.68       1.68        XXX
36260...  ..................  A                   Insertion of infusion          *9.71       6.74       6.74       1.41      17.86      17.86        090
                                                   pump.                                                                                                
36261...  ..................  A                   Revision of infusion           *5.45       2.23       2.23       0.42       8.10       8.10        090
                                                   pump.                                                                                                
36262...  ..................  A                   Removal of infusion pump       *4.02       1.93       1.93       0.40       6.35       6.35        090
36299...  ..................  C                   Vessel injection                0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                   procedure.                                                                                           
36400...  ..................  A                   Drawing blood...........        0.18       0.09       0.09       0.01       0.28       0.28        XXX
36405...  ..................  A                   Drawing blood...........        0.18       0.45       0.45       0.03       0.66       0.66        XXX
36406...  ..................  A                   Drawing blood...........        0.18       0.16       0.16       0.01       0.35       0.35        XXX
36410...  ..................  A                   Drawing blood...........        0.18       0.22      #0.20       0.02       0.42       0.40        XXX
36415...  ..................  I                   Drawing blood...........        0.00       0.00       0.00       0.00       0.00       0.00        XXX
36420...  ..................  A                   Establish access to vein        1.01       0.51       0.51       0.05       1.57       1.57        XXX
36425...  ..................  A                   Establish access to vein        0.76       0.08       0.08       0.01       0.85       0.85        XXX
36430...  ..................  A                   Blood transfusion               0.00       0.96       0.96       0.07       1.03       1.03        XXX
                                                   service.                                                                                             

[[Page 59138]]

                                                                                                                                                        
36440...  ..................  A                   Blood transfusion               1.03       0.94       0.94       0.07       2.04       2.04        XXX
                                                   service.                                                                                             
36450...  ..................  A                   Exchange transfusion            2.23       1.88       1.88       0.18       4.29       4.29        XXX
                                                   service.                                                                                             
36455...  ..................  A                   Exchange transfusion            2.43       2.27       2.27       0.22       4.92       4.92        XXX
                                                   service.                                                                                             
36460...  ..................  A                   Transfusion service,            6.59       4.71       4.71       1.09      12.39      12.39        XXX
                                                   fetal.                                                                                               
36468...  ..................  R                   Injection(s); spider            0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                   veins.                                                                                               
36469...  ..................  R                   Injection(s); spider            0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                   veins.                                                                                               
36470...  ..................  A                   Injection therapy of           *1.09       0.27       0.27       0.04       1.40       1.40        010
                                                   vein.                                                                                                
36471...  ..................  A                   Injection therapy of           *1.57       0.39       0.39       0.05       2.01       2.01        010
                                                   veins.                                                                                               
36481...  ..................  A                   Insertion of catheter,          6.99       5.30       5.30       0.61      12.90      12.90        000
                                                   vein.                                                                                                
36488...  ..................  A                   Insertion of catheter,          1.35       0.97       0.97       0.14       2.46       2.46        000
                                                   vein.                                                                                                
36489...  ..................  A                   Insertion of catheter,          1.22       1.12       1.12       0.17       2.51       2.51        000
                                                   vein.                                                                                                
36490...  ..................  A                   Insertion of catheter,          1.67       1.38       1.38       0.20       3.25       3.25        000
                                                   vein.                                                                                                
36491...  ..................  A                   Insertion of catheter,          1.43      #1.57      #1.57       0.32       3.32       3.32        000
                                                   vein.                                                                                                
36493...  ..................  A                   Repositioning of cvc....        1.21       0.63       0.63       0.16       2.00       2.00        000
36500...  ..................  A                   Insertion of catheter,          3.52       0.08       0.08       0.01       3.61       3.61        000
                                                   vein.                                                                                                
36510...  ..................  A                   Insertion of catheter,          1.09       0.34       0.34       0.02       1.45       1.45        000
                                                   vein.                                                                                                
36520...  ..................  A                   Plasma and/or cell              1.74      #1.91      #1.91       0.12       3.77       3.77        000
                                                   exchange.                                                                                            
36522...  ..................  A                   Photopheresis...........        1.67       2.48      #1.84       0.37       4.52       3.88        000
36530...  ..................  R                   Insertion of infusion          *6.20       4.82       4.82       1.02      12.04      12.04        010
                                                   pump.                                                                                                
36531...  ..................  R                   Revision of infusion           *4.87       4.37       4.37       0.27       9.51       9.51        010
                                                   pump.                                                                                                
36532...  ..................  R                   Removal of infusion pump       *3.30       1.77       1.77       0.37       5.44       5.44        010
36533...  ..................  A                   Insertion of access port       *5.32       4.29       4.29       0.85      10.46      10.46        010
36534...  ..................  A                   Revision of access port.       *2.80      #3.08      #3.08       0.21       6.09       6.09        010
36535...  ..................  A                   Removal of access port..       *2.27       1.81       1.81       0.38       4.46       4.46        010
36600...  ..................  A                   Withdrawal of arterial          0.32       0.28       0.28       0.02       0.62       0.62        XXX
                                                   blood.                                                                                               
36620...  ..................  A                   Insertion catheter,             1.15       0.66       0.66       0.14       1.95       1.95        000
                                                   artery.                                                                                              
36625...  ..................  A                   Insertion catheter,             2.11       0.86       0.86       0.18       3.15       3.15        000
                                                   artery.                                                                                              
36640...  ..................  A                   Insertion catheter,             2.10      #2.31      #2.31       0.40       4.81       4.81        000
                                                   artery.                                                                                              
36660...  ..................  A                   Insertion catheter,             1.40       0.49       0.49       0.04       1.93       1.93        000
                                                   artery.                                                                                              
36680...  ..................  A                   Insert needle, bone             1.20       1.24       1.24       0.10       2.54       2.54        000
                                                   cavity.                                                                                              
36800...  ..................  A                   Insertion of cannula....        2.43       2.22       2.22       0.28       4.93       4.93        000
36810...  ..................  A                   Insertion of cannula....        3.97      #4.37      #4.37       0.74       9.08       9.08        000
36815...  ..................  A                   Insertion of cannula....        2.62      #2.88      #2.88       0.70       6.20       6.20        000
36821...  ..................  A                   Artery-vein fusion......       *8.93       7.24       7.24       1.46      17.63      17.63        090
36822...  ..................  A                   Insertion of cannula(s).       *5.42       5.60       5.60       0.77      11.79      11.79        090
36825...  ..................  A                   Artery-vein graft.......       *9.84     #10.82     #10.82       2.21      22.87      22.87        090
36830...  ..................  A                   Artery-vein graft.......      *12.00       9.96       9.96       2.36      24.32      24.32        090
36832...  ..................  A                   Revise artery-vein             *6.45      #7.10      #7.10       2.38      15.93      15.93        090
                                                   fistula.                                                                                             
36834...  ..................  A                   Repair A-V aneurysm.....       *9.93       7.80       7.80       1.66      19.39      19.39        090
36835...  ..................  A                   Artery to vein shunt....       *7.15       3.42       3.42       0.79      11.36      11.36        090
36860...  ..................  A                   Cannula declotting......        2.01       2.57      #2.21       0.43       5.01       4.65        000
36861...  ..................  A                   Cannula declotting......        2.52      #2.77      #2.77       1.01       6.30       6.30        000
37140...  ..................  A                   Revision of circulation.      *23.60      16.29      16.29       3.34      43.23      43.23        090
37145...  ..................  A                   Revision of circulation.      *24.61      17.13      17.13       1.72      43.46      43.46        090
37160...  ..................  A                   Revision of circulation.      *21.60      17.74      17.74       3.79      43.13      43.13        090
37180...  ..................  A                   Revision of circulation.      *24.61      14.19      14.19       2.76      41.56      41.56        090
37181...  ..................  A                   Splice spleen/kidney          *26.68      16.41      16.41       3.52      46.61      46.61        090
                                                   veins.                                                                                               
37195...  ..................  A                   Thrombolytic therapy,           0.00       7.68       7.68       0.54       8.22       8.22        XXX
                                                   stroke.                                                                                              
37200...  ..................  A                   Transcatheter biopsy....        4.56       1.59       1.59       0.13       6.28       6.28        000
37201...  ..................  A                   Transcatheter therapy           5.00       5.50       5.50       0.64      11.14      11.14        000
                                                   infuse.                                                                                              
37202...  ..................  A                   Transcatheter therapy           5.68       4.30       4.30       0.50      10.48      10.48        000
                                                   infuse.                                                                                              
37203...  ..................  A                   Transcatheter retrieval.        5.03       3.82       3.82       0.45       9.30       9.30        000
37204...  ..................  A                   Transcatheter occlusion.       18.14      13.76      13.76       1.60      33.50      33.50        000
37205...  ..................  A                   Transcatheter stent.....        8.28       5.16       5.16       0.42      13.86      13.86        000
37206...  ..................  A                   Transcatheter stent.....        4.13       2.58       2.58       0.21       6.92       6.92        ZZZ
37207...  ..................  A                   Transcatheter stent.....        8.28       5.16       5.16       0.42      13.86      13.86        000
37208...  ..................  A                   Transcatheter stent.....        4.13       2.58       2.58       0.21       6.92       6.92        ZZZ
37209...  ..................  A                   Exchange arterial               2.27       1.41       1.41       0.11       3.79       3.79        000
                                                   catheter.                                                                                            
37250...  ..................  A                   Intravascular us........        2.10       1.14       1.14       0.13       3.37       3.37        ZZZ
37251...  ..................  A                   Intravascular us........        1.60       0.87       0.87       0.10       2.57       2.57        ZZZ
37565...  ..................  A                   Ligation of neck vein...       *4.44       3.79       3.79       0.74       8.97       8.97        090
37600...  ..................  A                   Ligation of neck artery.       *4.57       4.98       4.98       0.80      10.35      10.35        090
37605...  ..................  A                   Ligation of neck artery.       *6.19       5.56       5.56       1.04      12.79      12.79        090
37606...  ..................  A                   Ligation of neck artery.       *6.28       5.92       5.92       0.72      12.92      12.92        090
37607...  ..................  A                   Ligation of fistula.....       *6.16       3.06       3.06       0.71       9.93       9.93        090
37609...  ..................  A                   Temporal artery                *2.30       2.22       2.22       0.38       4.90       4.90        010
                                                   procedure.                                                                                           
37615...  ..................  A                   Ligation of neck artery.       *5.73       5.62       5.62       1.11      12.46      12.46        090
37616...  ..................  A                   Ligation of chest artery      *16.49       4.21       4.21       0.83      21.53      21.53        090
37617...  ..................  A                   Ligation of abdomen           *15.95       8.00       8.00       1.54      25.49      25.49        090
                                                   artery.                                                                                              
37618...  ..................  A                   Ligation of extremity          *4.84       4.98       4.98       1.06      10.88      10.88        090
                                                   artery.