[Federal Register Volume 63, Number 173 (Tuesday, September 8, 1998)]
[Proposed Rules]
[Pages 47552-48036]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-23383]



[[Page 47551]]

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Part II





Department of Health and Human Services





_______________________________________________________________________



Health Care Financing Administration



Office of Inspector General



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42 CFR Part 409, et al.



Medicare Program; Prospective Payment System for Hospital Outpatient 
Services; Proposed Rules

Federal Register / Vol. 63, No. 173 / Tuesday, September 8, 1998 / 
Proposed Rules

[[Page 47552]]



DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration
Office of Inspector General

42 CFR Parts 409, 410, 411, 412, 413, 419, 489, 498, and 1003

[HCFA-1005-P]
RIN 0938-AI56


Medicare Program; Prospective Payment System for Hospital 
Outpatient Services

AGENCY: Health Care Financing Administration (HCFA), HHS, and Office of 
Inspector General (OIG), HHS.

ACTION: Proposed rule.

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

SUMMARY: As required by sections 4521, 4522, and 4523 of the Balanced 
Budget Act of 1997, this proposed rule would eliminate the formula-
driven overpayment for certain outpatient hospital services, extend 
reductions in payment for costs of hospital outpatient services, and 
establish in regulations a prospective payment system for hospital 
outpatient services (and for Medicare Part B services furnished to 
inpatients who have no Part A coverage). The prospective payment system 
would simplify our current payment system and apply to all hospitals, 
including those that are excluded from the inpatient prospective 
payment system. The Balanced Budget Act provides for implementation of 
the prospective payment system effective January 1, 1999, but delays 
application of the system to cancer hospitals until January 1, 2000. 
The hospital outpatient prospective payment system would also apply to 
partial hospitalization services furnished by community mental health 
centers.
    Although the statutory effective date for the outpatient 
prospective payment system is January 1, 1999, implementation of the 
new system will have to be delayed because of year 2000 systems 
concerns. The demands on intermediary bill processing systems and HCFA 
internal systems to become compliant for the year 2000 preclude making 
the major systems changes that are required to implement the 
prospective payment system. The outpatient prospective payment system 
will be implemented for all hospitals and community mental health 
centers as soon as possible after January 1, 2000, and a notice of the 
anticipated implementation date will be published in the Federal 
Register at least 90 days in advance.
    This document also proposes new requirements for provider 
departments and provider-based entities. These proposed changes, as 
revised based on our consideration of public comments, will be 
effective 30 days after publication of a final rule.
    This proposed rule would also implement section 9343(c) of the 
Omnibus Budget Reconciliation Act of 1986, which prohibits Medicare 
payment for nonphysician services furnished to a hospital outpatient by 
a provider or supplier other than a hospital, unless the services are 
furnished under an arrangement with the hospital. This section also 
authorizes the Department of Health and Human Services' Office of 
Inspector General to impose a civil money penalty, not to exceed 
$10,000, against any individual or entity who knowingly and willfully 
presents a bill for non-physician or other bundled services not 
provided directly or under such an arrangement.
    This proposed rule also addresses the requirements for designating 
certain entities as provider-based or as a department of a hospital.

DATES: Comments will be considered if we receive them at the 
appropriate address, as provided below, no later than 5 p.m. on 
November 9, 1998.

ADDRESSES: Mail written comments (1 original and 3 copies) to the 
following address: Health Care Financing Administration, Department of 
Health and Human Services, Attention: HCFA-1005-P, 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 HCFA-1005-P. Comments received timely will be available 
for public inspection as they are received, generally beginning 
approximately 3 weeks after publication of a document, in Room 309-G of 
the Department's offices at 200 Independence Avenue, SW., Washington, 
DC, on Monday through Friday of each week from 8:30 a.m. to 5 p.m. 
(phone: (202) 690-7890).
    Copies: To order copies of the Federal Register containing this 
document, send your request to: New Orders, Superintendent of 
Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date 
of the issue requested and enclose a check or money order payable to 
the Superintendent of Documents, or enclose your Visa or Master Card 
number and expiration date. Credit card orders can also be placed by 
calling the order desk at (202) 512-1800 or by faxing to (202) 512-
2250. The cost for each copy is $8. As an alternative, you can view and 
photocopy the Federal Register document at most libraries designated as 
Federal Depository Libraries and at many other public and academic 
libraries throughout the country that receive the Federal Register.
    This Federal Register document is also available from the Federal 
Register online database through GPO Access, a service of the U.S. 
Government Printing Office. Free public access is available on a Wide 
Area Information Server (WAIS) through the Internet and via 
asynchronous dial-in. Internet users can access the database by using 
the World Wide Web; the Superintendent of Documents home page address 
is
http://www.access.gpo.gov/nara/index.html, by using local WAIS client 
software, or by telnet to swais.access.gpo.gov, then login as guest (no 
password required). Dial-in users should use communications software 
and modem to call 202-512-1661; type swais, then login as guest (no 
password required).

FOR FURTHER INFORMATION CONTACT:
Janet Wellham, (410) 786-4510 (for general information). Joel Schaer 
(OIG), (202) 619-0089 (for information concerning civil money 
penalties).
Kitty Ahern, (410) 786-4515 (for information related to the 
classification of services into ambulatory payment classification (APC) 
groups).
Suzanne Letsch (410) 786-4558 (for information related to volume 
control measures and updates).
George Morey (410) 786-4653 (for information related to the 
determination of provider-based status).
Janet Samen (410) 786-9161 (for information on the application of APCs 
to community mental health centers).

SUPPLEMENTARY INFORMATION: To assist readers in referencing sections 
contained in this document, we are providing the following table of 
contents.

Table of Contents

I. Background

[[Page 47553]]

II. Elimination of Formula-Driven Overpayment
III. Extension of Cost Reductions
IV. Prohibition Against Unbundling of Hospital Outpatient Services
    A. Background
    B. Previous Medicare Regulations Affecting Bundling
    C. Office of Inspector General (OIG) Civil Money Penalty 
Authority
    D. Proposed Regulations Published August 5, 1988
    1. Bundling of Hospital Outpatient Services
    2. Civil Money Penalties for Unbundling Hospital Outpatient 
Services
    E. Revised Proposed Regulations on Bundling of Hospital Services
V. Hospital Outpatient Prospective Payment System (PPS)
    A. Scope of Services Within the Outpatient PPS
    1. Services Excluded from the Hospital Outpatient PPS
    2. Services Included Within the Scope of the Hospital Outpatient 
PPS
    a. Services for Patients Who Have Exhausted Their Part A 
Benefits
    b. Partial Hospitalization Services
    c. Services Designated by the Secretary
    3. Hospital Outpatient PPS Payment Indicators
    B. Description of the Ambulatory Payment Classification (APC) 
Groups
    1. Setting Payment Rates Based on Groups of Services Rather than 
on Individual Services
    2. How the Groups Were Constructed
    3. Packaging Under the Groups
    4. Treatment of Clinic and Emergency Visits
    5. Treatment of Partial Hospitalization Services
    6. Comments on Specific APCs
    7. Discounting of Surgical Procedures
    a. Reduced Payment for Multiple Procedures
    b. Discounted Payment for Terminated Procedures
    8. Inpatient Care
    C. Calculation of Group Weights and Rates
    1. Group Weights
    2. Conversion Factor
    a. Calculating Aggregate Calendar Year 1996 Medicare and 
Beneficiary Payments for Hospital Outpatient Services (Current Law)
    b. Sum of the Relative Weights
    D. Calculation of Medicare Payment Amount and Copayment Amount
    1. Introduction
    2. Determination of Unadjusted Copayment Amount, Program Payment 
Percentage, and Copayment Percentage
    3. Calculation of Medicare Payment Amount and Beneficiary 
Copayment Amount
    4. Hospital Election to Offer Reduced Copayment
    E. Adjustment for Area Wage Differences
    1. Proposed Wage Index
    2. Labor-Related Portion of Hospital Outpatient Department PPS 
Payment Rates
    3. Adjustment of Hospital Outpatient Department PPS Payment and 
Copayment Amounts for Geographic Wage Variations
    F. Claims Submission and Processing
    G. Updates
    1. Revisions to Weights and the Wage and Other Adjustments
    2. Revisions to APC Groups
    3. Annual Update to Conversion Factor
    H. Outlier Payments
    I. Adjustments for Specific Classes of Hospitals
    J. Volume Control Measures
    K. Prohibition Against Administrative or Judicial Review
VI. Hospital Outpatient Departments and Provider-Based Entities
    A. Background
    B. Effects on Medicare
    C. Relationship of the ``Provider-Based'' Proposals to 
Prospective Payment for Outpatient Hospital Services and Effective 
Date of ``Provider-Based'' Proposals
    D. Basis for Current Provider-Based Policy
    E. Provisions of this Proposed Rule
    F. Requirements for Payment
    1. Prerequisites for Payment for Outpatient Hospital Services 
and Supplies Incident to Physician Services
    2. Prerequisites for Payment for Hospital or Critical Access 
Hospital Diagnostic Services Furnished to Outpatients
    3. Payment for Ambulatory Surgical Services
VII. MedPAC Recommendations
VIII. Collection of Information Requirements
IX. Response to Comments
X. Regulatory Impact Analysis
    A. Introduction
    B. Estimated Impact on Medicare Program
    C. Objectives
    D. Limitations of Our Analysis
    E. Hospitals Included In and Excluded From the Prospective 
Payment System
    F. Quantitative Impact Analysis of the Proposed Policy Changes 
Under the Prospective Payment System for Operating Costs and Capital 
Costs
    G. Estimated Impact of the New APC System
XI. Delay in Implementation
Regulations Text
Addenda
Addendum A--List of Proposed Hospital Outpatient Ambulatory Payment 
Classes with Status Indicators, Relative Weights, Payment Rates, and 
Coinsurance Amounts
Addendum B--Proposed Hospital Outpatient Department (HOPD) Payment 
Status by HCPCS and Related Information
Addendum C--Proposed Hospital Outpatient Payment for Procedures by 
APC
Addendum D--Summary of Medical APCs
Addendum E--Major Diagnostic Categories
Addendum F--ICD-9 Codes with Major Diagnostic Categories (MDCs) for 
Payment of Medical Visits under the Hospital Outpatient PPS
Addendum G--CPT Codes Which Will Be Paid Only As Inpatient 
Procedures
Addendum H--Status Indicators
Addendum I--Service Mix Indices by Hospital
Addendum J--Wage Index for Urban Areas
Addendum K--Wage Index for Rural Areas
Addendum L--Wage Index for Hospitals That Are Reclassified

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

APC  Ambulatory payment classification
APG  Ambulatory patient group
ASC  Ambulatory surgical center
BBA  Balanced Budget Act of 1997
CAH  Critical access hospital
CCI  [HCFA's] Correct Coding Initiative
CCR  Cost center specific cost-to-charge ratio
CHAMPUS  Civilian Health and Medical Program of the Uniformed 
Services
CMHC  Community mental health center
CMP  Civil money penalty
CORF  Comprehensive outpatient rehabilitation facility
CPT  [Physicians'] Current Procedural Terminology, 4th Edition, 
1998, copyrighted by the American Medical Association
DME  Durable medical equipment
DMEPOS  DME, orthotics, prosthetics, prosthetic devices, prosthetic 
implants and supplies
DRG  Diagnosis-related group
EACH  Essential access community hospital
ESRD  End-stage renal disease
FDO  Formula-driven overpayment
FQHC  Federally qualified health center
HCPCS  HCFA Common Procedure Coding System
HHA  Home health agency
ICD-9-CM  International Classification of Diseases, Ninth Edition, 
Clinical Modification
IME  Indirect medical education
IOL  Intraocular lens
MDC  Major diagnostic category
MDH  Medicare dependent hospital
MedPAC  Medicare Payment Advisory Commission
MSA  Metropolitan statistical area
NECMA  New England County Metropolitan Area
OBRA  Omnibus Budget Reconciliation Act
PPS  Prospective payment system
RHC  Rural health clinic
RPCH  Rural primary care hospital
RRC  Rural referral center
SCH  Sole community hospital
SGR  Sustainable growth rate
SNF  Skilled nursing facility
TEFRA  Tax Equity and Fiscal Responsibility Act of 1982

I. Background

    As the Medicare statute was originally enacted, Medicare payment 
for hospital services (inpatient and outpatient) was based on hospital-
specific reasonable costs attributable to serving Medicare 
beneficiaries. Later, the law was amended to limit payment to the 
lesser of a hospital's reasonable costs or to its customary charges. In 
1983, section 601 of the Social Security Amendments of 1983 (Public Law 
98-21) completely revised the cost-based payment system for most 
hospital inpatient services by enacting section 1886(d) of the Social

[[Page 47554]]

Security Act (the Act). This section provided for a prospective payment 
system (PPS) for acute inpatient hospital stays, effective with 
hospital cost reporting periods beginning on or after October 1, 1983.
    Although payment for most inpatient services became subject to a 
PPS, hospital outpatient services continued to be paid based on 
hospital-specific costs, which provided little incentive for hospital 
efficiency for outpatient services. At the same time, advances in 
medical technology and changes in practice patterns were bringing about 
a shift in the site of medical care from the inpatient to the 
outpatient setting. During the 1980s, the Congress took steps to 
control the escalating costs of providing outpatient care. The Congress 
amended the statute to implement across-the-board reductions of 5.8 
percent and 10 percent to the amounts otherwise payable for hospital 
operating costs and capital costs, respectively, and legislated a 
number of different payment methods for specific types of hospital 
outpatient services. These methods included fee schedules for clinical 
diagnostic laboratory tests, orthotics, prosthetics, and durable 
medical equipment (DME); composite rate payment for dialysis for 
persons with end-stage renal disease (ESRD); and payments based on 
blends of hospital costs and the rates paid in other ambulatory 
settings such as separately certified ambulatory surgical centers 
(ASCs) or physician offices for certain surgery, radiology, and other 
diagnostic procedures. Nevertheless, Medicare payment for services 
performed in the hospital outpatient setting remains largely cost-
based.
    In section 9343(f) of the Omnibus Budget Reconciliation Act of 1986 
(OBRA 1986) (Public Law 99-509) and in section 4151(b)(2) of the 
Omnibus Budget Reconciliation Act of 1990 (Public Law 101-508), the 
Congress required the Secretary to develop a proposal to replace the 
current hospital outpatient payment system with a PPS and to submit a 
report to the Congress on the proposed system. In OBRA 1986, the 
Congress paved the way for development of a PPS, under section 9343(g), 
by requiring fiscal intermediaries to require hospitals to report 
claims for services under the HCFA Common Procedure Coding System 
(HCPCS), and, under section 9343(c), by extending the prohibition 
against unbundling of hospital services under section 1862(a)(14) of 
the Act to include outpatient services as well as inpatient services. 
HCPCS coding enabled us to determine what specific procedures and 
services were being billed, while the extension of the prohibition 
against unbundling ensured that all nonpractitioner services provided 
to hospital outpatients would be billed only by the hospital, not by an 
outside supplier, and, therefore, would be reported on hospital bills 
and captured in the hospital outpatient data that could be used to 
develop an outpatient PPS.
    Section 1866(g) of the Act, as added by section 9343(c) of OBRA 
1986, and amended by section 4085(i)(17) of the Omnibus Budget 
Reconciliation Act of 1987 (OBRA 1987) (Public Law 100-203), also 
authorizes the Department of Health and Human Services' Office of 
Inspector General to impose a civil money penalty (CMP), not to exceed 
$2,000, against any individual or entity who knowingly and willfully 
presents a bill in violation of an arrangement (as defined in section 
1861(w)(1) of the Act).
    A proposed rule to implement section 9343(c) was published in the 
Federal Register on August 5, 1988. However, those regulations were 
never published as a final rule, so we are including them in this 
regulation and will implement them as part of the final regulation 
implementing the hospital outpatient PPS.
    The Secretary submitted a Report to Congress on March 17, 1995. The 
report summarized the research HCFA conducted in searching for a way to 
classify outpatient services for purposes of developing an outpatient 
PPS. The report cited Ambulatory Patient Groups (APGs), developed by 
3M-Health Information Systems under a cooperative grant with HCFA, as 
the most promising classification system for grouping outpatient 
services and recommended that APG-like groups be used in designing a 
hospital outpatient PPS.
    The report also presented a number of options that could be used, 
once a PPS was in place, for addressing the issue of rapidly growing 
beneficiary copayment. As a separate issue, we recommended that the 
Congress amend the provisions of the law pertaining to the blended 
payment methods for ASC surgery, radiology, and other diagnostic 
services to correct an anomaly that resulted in a less than full 
recognition of the amount paid by the beneficiary in calculating 
program payment (referred to as the formula-driven overpayment).
    The Balanced Budget Act of 1997 (BBA) (Public Law 105-33), enacted 
on August 5, 1997, contains a number of provisions that affect Medicare 
payment for hospital outpatient services. The purpose of this proposed 
rule is to implement sections 4521, 4522, and 4523 of the BBA and 
section 9343(c) of OBRA 1986. Section 4521 of the BBA eliminates the 
formula-driven overpayment effective for services furnished on or after 
October 1, 1997. Because of the October 1, 1997 effective date, HCFA 
has already taken action to implement this provision. Section 4522 
extends the current cost reductions of 5.8 percent and 10 percent 
(applicable to hospital outpatient operating costs and hospital capital 
costs, respectively) through and including December 31, 1999.
    Section 4523 of the BBA amends section 1833 of the Act by adding 
subsection (t), which provides for implementation of a PPS for most 
hospitals for outpatient services furnished on or after January 1, 1999 
and for cancer hospitals that are excluded from inpatient PPS for 
services furnished on or after January 1, 2000. We note that while the 
statutory effective date for the outpatient PPS is January 1, 1999, 
implementation of the new payment system will have to be delayed 
because of year 2000 systems concerns. The demands on intermediary bill 
processing systems and HCFA internal systems to become compliant for 
the year 2000 preclude making the major systems changes that are 
required to implement the PPS. See Section XI of this preamble (``Delay 
in Implementation'') for a more detailed explanation of the reasons for 
delay. The outpatient PPS will be implemented as soon as possible after 
January 1, 2000. A notice of the anticipated implementation date will 
be published in the Federal Register at least 90 days in advance. The 
rates that will go into effect on the implementation date will apply to 
all hospitals including cancer hospitals described in section 
1886(d)(1)(B)(v) of the Act. The rates will be based on the rates that 
would have been in effect January 1, 1999 updated by the rate of 
increase in the hospital market basket minus one percentage point.
    Section 1833(t)(1)(B) of the Act authorizes the Secretary to 
designate the hospital outpatient services that would be paid under the 
PPS. Section 1833(t)(1)(B) also requires that the outpatient PPS 
include inpatient services covered under Part B for beneficiaries who 
are entitled to Part A benefits but who have exhausted their Part A 
benefits or otherwise are not in a covered Part A stay. However, 
section 1833(t)(1)(B) specifically excludes as covered services under 
the outpatient PPS ambulance services and physical and occupational 
therapy, and speech-language pathology services, for which separate fee 
schedules are required by

[[Page 47555]]

statute. (See section 4531 of the BBA for amendments pertaining to 
ambulance services and section 4541 for amendments pertaining to 
outpatient rehabilitation services.)
    Section 1833(t)(2) of the Act stipulates certain requirements for 
the hospital outpatient PPS. The Secretary is required to develop a 
classification system for covered outpatient services which may consist 
of groups arranged so that the services within each group are 
comparable clinically and with respect to the use of resources. In 
addition, this section specifies data requirements for establishing 
relative payment weights, which are to be based on median hospital 
costs determined by data from the most recent available cost reports; 
requires that the portion of the Medicare payment and the beneficiary 
copayment that are attributable to labor and labor-related costs be 
adjusted for geographic wage differences; and authorizes the 
establishment of other adjustments, such as outlier adjustments or 
adjustments for certain classes of hospitals, that are necessary to 
ensure equitable payments. All adjustments are required to be made in a 
budget neutral manner. This section concludes with the requirement that 
a control on unnecessary increases in the volume of covered services be 
established.
    Section 1833(t)(3) provides for a new method of calculating 
beneficiary copayment. It freezes beneficiary copayment at 20 percent 
of the national median charges for covered services (or group of 
covered services) furnished during 1996 and updated to 1999 using the 
Secretary's estimated charge growth from 1996 to 1999. This section 
specifies how beneficiary deductibles are to be treated in calculating 
the Medicare payment and beneficiary copayment amounts and requires 
that rules be established regarding determination of copayment amounts 
for covered services that were not furnished in 1996. Further, it 
prescribes the formula for calculating the initial conversion factor 
used to determine Medicare payment amounts for 1999 and the method for 
updating the conversion factor in subsequent years.
    Sections 1833(t)(4) and (t)(5) describe the basis for determining 
the Medicare payment amount and the beneficiary copayment amount for 
services covered under the outpatient PPS. The latter section requires 
the Secretary to establish a procedure whereby hospitals may 
voluntarily elect to reduce beneficiary copayment for some or all 
covered services to an amount not less than 20 percent of the Medicare 
payment amount. Hospitals are further allowed to advertise any such 
reductions of copayment amounts. Section 4451 of the BBA added section 
1861(v)(1)(T) to the Act, which stipulates that bad debts will not be 
recognized on any copayment the hospital elects to reduce.
    Section 1833(t)(6) authorizes periodic review and revision of the 
payment groups, relative payment weights, wage index, and conversion 
factor.
    Section 1833(t)(7) describes how payment is to be made for 
ambulance services, which are specifically excluded from the outpatient 
PPS under section 1833(t)(1)(B).
    Section 1833(t)(8) provides that the Secretary may establish a 
separate conversion factor for determining services furnished by cancer 
hospitals excluded from inpatient PPS under this PPS.
    Section 1833(t)(9) prohibits administrative or judicial review of 
the PPS classification system, the groups, relative payment weights, 
adjustment factors, other adjustments, calculation of base amounts, 
periodic adjustments, and the establishment of a separate conversion 
factor for those cancer hospitals excluded from inpatient PPS.
    Section 4523(d) of the BBA amends section 1833(a)(2)(B) of the Act 
to require payment under the PPS for some services described in section 
1832(a)(2) that are currently paid on a cost basis and furnished by 
providers of services such as comprehensive outpatient rehabilitation 
facilities (CORFs), home health agencies (HHAs), hospices, and 
community mental health centers (CMHCs). This amendment requires that 
partial hospitalization services furnished by CMHCs beginning January 
1, 1999 be paid under the PPS. As noted earlier, implementation of the 
PPS will be delayed. Implementation will occur as soon as possible 
after January 1, 2000.

II. Elimination of Formula-Driven Overpayment

    Before enactment of section 4521 of the BBA, under the blended 
payment formulas for ASC procedures, radiology, and other diagnostic 
services, the ASC or physician fee schedule portion of the blends was 
calculated as if the beneficiary paid 20 percent of the ASC rate or 
physician fee schedule amount instead of the actual amount paid, which 
was 20 percent of the hospital's billed charges. Section 4521 corrects 
this anomaly by changing the blended calculations so that all amounts 
paid by the beneficiary are subtracted from the total payment in 
determining the amount due from the program. Effective for services 
furnished on or after October 1, 1997, payment for surgery, radiology, 
and other diagnostic services under blended payment methods will be 
calculated by subtracting the full amount of copayment due from the 
beneficiary (based on 20 percent of the hospital's billed charges).

 III. Extension of Cost Reductions

    Section 1861(v)(1)(S)(ii) of the Act requires that the amounts 
otherwise payable for hospital outpatient operating costs and capital 
costs be reduced by 5.8 percent and 10 percent, respectively. These 
reductions were scheduled to sunset at the end of fiscal year 1998, but 
section 4522 of the BBA extended the reductions through December 31, 
1999.

IV. Prohibition Against Unbundling of Hospital Outpatient Services

A. Background

    The Social Security Amendments of 1965 (Public Law 89-97), enacted 
on July 30, 1965, established title XVIII of the Act, which authorized 
the establishment of the Medicare program to pay part of the costs of 
health care services furnished to eligible beneficiaries. Part A of the 
program (Hospital Insurance) provides basic health insurance protection 
against the costs of inpatient or home health care. Part B of the 
program (Supplementary Medical Insurance) provides voluntary 
supplementary insurance covering most physician services and certain 
other items and services not covered under Part A, including hospital 
outpatient services.
    Before the enactment of Public Law 98-21 on April 7, 1983, which 
established the Medicare PPS for inpatient hospital services, 
nonphysician services furnished to Medicare beneficiaries who were 
hospital patients were generally billed by the hospitals. Under certain 
circumstances, however, Part B of the Medicare statute permitted 
payments to be made to an outside supplier or another provider for 
certain nonphysician services otherwise covered by Medicare Part B that 
were furnished to a hospital patient. When payments were made under 
these circumstances, some nonphysician services were billed as hospital 
services in one hospital and billed by an outside supplier in another. 
The practice of billing by suppliers outside the hospital for these 
services has been referred to in the legislative history as the 
``unbundling'' of hospital services.
    Since the enactment of Public Law 98-21 and the publication of 
implementing regulations on September 1, 1983 (48 FR 39752), the 
Medicare program has required that nonphysician

[[Page 47556]]

services furnished to hospital inpatients be covered and paid for under 
Medicare as hospital services. This practice of covering nonphysician 
services furnished to hospital inpatients by an outside supplier as 
hospital services is referred to as ``bundling.'' Under the PPS for 
inpatient hospital services, a single predetermined payment is made for 
a case based on the diagnosis-related group (DRG) to which the case is 
assigned. Bundling ensures that the DRG payments to all hospitals cover 
a comparable ``bundle'' of services related to the hospital stay.
    Specifically, Public Law 98-21 added section 1862(a)(14) to the Act 
to prohibit payment for services (other than physician services) 
furnished to an inpatient of a hospital by an entity other than the 
hospital, unless the services are furnished under an arrangement (as 
defined in section 1861(w)(1) of the Act). (Section 1861(w)(1) of the 
Act specifies that the term ``arrangements'' is limited to arrangements 
under which receipt of payment by the hospital or other provider for 
Medicare-covered services to an individual discharges the liability of 
the individual or any other person to pay for the services.) Public Law 
98-21 also added section 1866(a)(1)(H) to the Act to provide that a 
hospital is eligible to participate in the Medicare program only if the 
hospital agrees to furnish to inpatients either directly or under an 
arrangement all Medicare-covered items and services, other than 
physician services.
    Regardless of whether the hospital furnishes the services directly 
or arranges for furnishing the services, the hospital assumes financial 
responsibility for the services. The Medicare program makes payment 
only to hospitals and not to other providers or suppliers that furnish 
inpatient services on behalf of the hospitals.
    In Public Law 98-21, the Congress addressed only nonphysician 
services furnished to Medicare beneficiaries who are hospital 
inpatients. The Congress did not address at that time nonphysician 
services furnished to Medicare beneficiaries who are hospital 
outpatients, for which payment is made, usually on a cost basis, under 
Part B of Medicare. Thus, services to hospital outpatients continued to 
be unbundled in some hospitals. Subsequently, in section 9343(c) of 
OBRA 1986, the Congress extended the bundling provision to all 
nonphysician services furnished to hospital ``patients,'' thus also 
including nonphysician services furnished to Medicare beneficiaries who 
are hospital outpatients.
    Sections 9343(c)(1) and (c)(2) of OBRA 1986 amended sections 
1862(a)(14) and 1866(a)(1)(H) of the Act, respectively. As revised, 
section 1862(a)(14) of the Act prohibits payment for nonphysician 
services furnished to hospital patients (inpatients and outpatients), 
unless the services are furnished by the hospital, either directly or 
under an arrangement (as defined in section 1861(w)(1) of the Act). As 
revised, section 1866(a)(1)(H) of the Act requires each Medicare-
participating hospital to agree to furnish directly all covered 
nonphysician services required by its patients (inpatients and 
outpatients) or to have the services furnished under an arrangement (as 
defined in section 1861(w)(1) of the Act). Section 9338(a)(3) of OBRA 
1986 affected implementation of the bundling mandate by amending 
section 1861(s)(2)(K) of the Act to permit services of physician 
assistants to be covered and billed separately.
    Bundling of outpatient hospital services was required in order to 
provide a basis for implementing another provision of OBRA 1986, which 
required the development of a prospective payment methodology for 
outpatient hospital services. Section 9343(f) of OBRA 1986 amended 
section 1135 of the Act to require the Secretary to submit to the 
Congress by April 1, 1988, an interim report concerning development of 
a fully prospective payment system for ambulatory surgery. The 
legislation also specified that a final report was due to the Congress 
no later than April 1, 1989, with recommendations concerning 
implementation of a fully prospective payment mechanism for ambulatory 
surgery services by October 1, 1989. We released an interim report in 
June of 1988 and the final report in September of 1990. The final 
report summarized our research findings relating to hospital outpatient 
prospective payment and did not contain specific recommendations 
regarding a PPS for ambulatory surgical services. Later, in section 
4151(b)(2) of OBRA 1990, the Congress expanded its earlier request and 
required HCFA to develop a PPS that included all hospital outpatient 
services. That legislation also directed us to submit a report to the 
Congress concerning this proposal. We submitted a report to the 
Congress on March 17, 1995.
    In order for us to be able to develop a PPS for hospital outpatient 
services, it was necessary to have available clear and consistent rules 
about the range of services that would be included in this payment 
system. Previous policies on coverage of hospital outpatient services 
permitted services to be unbundled and thus allowed providers to vary 
their practices concerning the furnishing of services. The Congress 
recognized the inconsistencies of the current payment system and 
required bundling as a first step toward payment reform.

B. Previous Medicare Regulations Affecting Bundling

    Previous regulations set forth at 42 CFR 405.310(m) concerning 
noncoverage of certain services furnished to hospital inpatients 
(redesignated as Sec. 411.15(m)) implemented the statutory requirement 
for bundling of inpatient hospital services. They excluded from 
coverage nonphysician services furnished to hospital inpatients by an 
entity other than the hospital, unless the services were furnished 
under an arrangement. The exclusion from coverage in effect at that 
time did not apply to physician services that met the conditions for 
payment for physician services to provider patients in Sec. 405.550(b) 
(redesignated as Sec. 415.102(a)), or services of anesthetists employed 
by physicians that met the conditions for payment in Sec. 405.553(b)(4) 
concerning reasonable charges for anesthesiology services furnished by 
the anesthesiologist or by an anesthetist employed by the 
anesthesiologist. (The regulation is now deleted as the payment 
structure for anesthesiologists has changed.) The exception for 
physician services is required by section 1862(a)(14) of the Act. 
Services of physician-employed anesthetists were exempted from bundling 
as an administrative measure to prevent disruption of long-standing 
physician-anesthetist team relationships. However, in a final rule 
published on May 26, 1993 (58 FR 30630), the regulations set forth at 
Sec. 411.15(m) and Sec. 489.20(d) were revised to reflect the statutory 
exclusion of certified registered nurse anesthetist (CRNA) services 
(including services of anesthesiologist assistants), physician 
assistant services, certified nurse midwife services, and qualified 
psychologist services from the inpatient bundling requirement. Section 
411.15(m) concerns services to hospital inpatients excluded from 
coverage, and Sec. 489.20(d) concerns a provider agreement in the case 
of a hospital or critical access hospital (CAH) to furnish directly or 
make arrangements for Medicare-covered services to inpatients of a 
hospital or a CAH.

C. Office of Inspector General (OIG) Civil Money Penalty Authority

    In order to prevent the unbundling of nonphysician hospital 
services, section 9343(c)(3) of OBRA 1986 amended section 1866 of the 
Act by adding a new paragraph (g). Specifically, this

[[Page 47557]]

authority provided for the imposition of a civil money penalty (CMP), 
not to exceed $2,000, against any person who knowingly and willfully 
presents, or causes to be presented, a bill or request for payment for 
a hospital outpatient service under Part B of Medicare that violates 
the requirement for billing under arrangements specified in section 
1866(a)(1)(H) of the Act. Section 1866(g) was further amended by 
section 4085(i)(17) of OBRA 1987. Section 4085(i)(17) of OBRA 1987 
deleted all references to hospital outpatient services under Part B of 
Medicare and authorized imposition of a CMP when arrangements should 
have been made but were not. Section 1866(g) of the Act authorizes 
imposition of a CMP against any person who knowingly and willfully 
presents, or causes to be presented, a bill or request for payment 
inconsistent with an arrangement under section 1866(a)(1)(H) or in 
violation of the requirement for an arrangement. The result of this 
amendment is that the CMP is now applicable for all services furnished 
to hospital patients, whether paid for under Medicare Part A or B. The 
statute also requires that a CMP be imposed in the same manner as other 
CMPs are imposed under section 1128A of the Act. Section 231(c) of the 
Health Insurance Portability and Accountability Act of 1996 (Public Law 
104-191) revised section 1128A of the Act to increase the CMP maximum 
amount for each false claim or prohibited practice from $2,000 to 
$10,000. Implementing regulations for this authority are set forth in 
42 CFR parts 1003 and 1005.
    To implement the provisions of section 9343(c) of OBRA 1986, we 
published a proposed rule in the Federal Register on August 5, 1988 (53 
FR 29486). Those regulations have not been published in final, but we 
are proposing revised implementing regulations as part of this 
regulation.

D. Proposed Regulations Published August 5, 1988

1. Bundling of Hospital Outpatient Services
    We proposed to implement the requirement for bundling of outpatient 
hospital services by amending then existing Medicare regulations 
(Sec. 405.310 concerning particular services excluded from coverage, 
and part 410 concerning supplementary medical insurance benefits) to 
exclude coverage of any services that are furnished in a hospital to an 
outpatient of the hospital by an entity other than the hospital during 
or as a result of an encounter in the hospital, unless the services are 
furnished under an arrangement. In addition, we proposed to require 
bundling of those diagnostic procedures or tests (for example, magnetic 
resonance imaging procedures) that are furnished outside the hospital 
by an entity other than the hospital but are ordered during an 
encounter in the hospital with the patient or as a result of such an 
encounter.
    In the proposed rule, in Sec. 405.310(n)(1) concerning definitions 
of services to hospital outpatients excluded from coverage (now 
redesignated as Sec. 411.15(m)), we defined a hospital outpatient as an 
individual who is not an inpatient of the hospital but who is 
registered as an outpatient.
    We proposed to define, in Sec. 410.2 (``Definitions''), the term 
``encounter'' as a direct personal contact between a patient and a 
physician, or other person who is authorized by State licensure law 
and, where applicable, by hospital staff bylaws, to order or furnish 
services for the patient for the purpose of diagnosis or treatment of 
the patient. The use of the ``encounter'' as a basis for identifying 
the services to be bundled is not specifically required by OBRA 1986 
but is needed in order to implement the bundling requirement in a 
uniform and equitable manner, as explained further in section III. of 
the preamble of the August 5, 1988 proposed rule (53 FR 29489).
    As in the case of services to hospital inpatients, physician 
services that meet the conditions for payment for services of 
physicians to provider patients in Sec. 415.102(a) would not be bundled 
under our proposal. (The exception for physician services is required 
by section 1862(a)(14) of the Act.) We also proposed, as an 
administrative measure, to exempt from outpatient bundling the services 
of physician-employed anesthetists that meet the conditions for payment 
for services furnished by an anesthesiologist or by an anesthetist 
employed by the anesthesiologist in Sec. 405.553(b)(4). These services 
were exempted from bundling to prevent disruption of long-standing 
physician-anesthetist team relationships. We also proposed to exempt 
physician assistant services as defined in section 1861(s)(2)(K)(i) of 
the Act from inpatient and outpatient bundling. We proposed this change 
to help accomplish the objective of section 1861(s)(2)(K)(i) of the 
Act, as amended by section 9338(a)(3) of OBRA 1986, which permits 
physician assistant services to be covered and to be billed separately. 
As noted earlier, we have made the changes in the types of services 
excluded from bundling of inpatient services in the May 1993 final rule 
(58 FR 30630).
    We also proposed to revise the regulations set forth at 
Sec. 489.20, which describe the basic commitments included in the 
provider agreement. They would require a hospital that furnishes 
services to a beneficiary who is not currently an inpatient of a 
hospital but who is registered by the hospital as an outpatient to 
agree either to furnish directly or to make arrangements (in accordance 
with section 1861(w)(1) of the Act) for all items and services for 
which bundling is required under the proposed revision described above, 
and for which the beneficiary is entitled to have payment made under 
Medicare.
    We proposed in the August 5, 1988 proposed rule that if a Medicare 
outpatient is referred to another provider or supplier for further 
diagnostic testing or other diagnostic services as a result of an 
encounter that occurs in the hospital, the hospital would be 
responsible for arranging with the other entity for the furnishing of 
services. (We have now changed our view on bundling of these services 
as discussed in the following section IV.E.) Also, the hospital would 
be responsible for furnishing or arranging for the furnishing of 
prostheses and prosthetic devices (other than dental) that replace all 
or part of an internal body organ (for example, intraocular lenses 
(IOLs)) and are implanted or fitted during an encounter. For example, 
in the absence of a bundling provision, the physician who implants an 
IOL during surgery performed on an outpatient of a hospital also could 
be the supplier of the IOL and could bill Medicare under Part B for it. 
As proposed in our August 1988 rule, this practice would be prohibited, 
and the hospital would have to furnish the IOL, either directly or 
under an arrangement (that is, would have to pay for the lens). The 
same policies would apply to other items and services, such as 
artificial limbs, knees, and hips; orthotics; equipment and supplies 
covered under the prosthetic device benefit; and services incident to 
physician services. Thus, hospitals would be required to assume 
financial liability for prostheses and prosthetic devices (which are 
regarded as ``services'' for Medicare coverage purposes) and for other 
services furnished by an outside entity to their outpatients, and the 
practice of unbundling these services would be prohibited.
    Sometimes a hospital may furnish an item or service for which a 
patient will have a continuing need. For example, a hospital may 
furnish a DME item such as a wheelchair. When this situation occurs, 
the proposed rule required that

[[Page 47558]]

the hospital would be responsible for bundling the items and services 
it furnishes on-site. In adopting the view that these types of items 
are subject to bundling, we did not discount the patient's continuing 
need for them after leaving the hospital. However, the bundling 
provisions in sections 1862(a)(14) and 1866(a)(1)(H) of the Act 
prohibit unbundling of services to an individual who is a patient of a 
hospital and do not provide any specific exception to these provisions 
for DME. Therefore, we did not believe it would be appropriate to 
exclude DME from bundling when it was furnished to a hospital patient. 
(We have now changed our previous position on bundling of DME as 
discussed in section IV.E.)
2. Civil Money Penalties for Unbundling Hospital Outpatient Services
    In order to implement section 1866(g) of the Act, in our August 5, 
1988 proposed rule, we proposed that the OIG would impose a CMP against 
any person who knowingly and willfully presents, or causes to be 
presented, a bill or request for payment for a hospital outpatient 
service under Part B of Medicare that violates the billing arrangement 
under section 1866(a)(1)(H) of the Act or the requirement for an 
arrangement. The amount of the CMP was to be limited to $2,000 for each 
improper bill or request, even if the bill or request included more 
than one item or service. However, in accordance with the Health 
Insurance Portability and Accountability Act of 1996, which increased 
the minimum penalty amount to $10,000, the increased amount will now be 
reflected in the regulations.

E. Revised Proposed Regulations on Bundling of Hospital Services

    This proposed rule incorporates most of the provisions of the 
August 5, 1988 proposed rule. The following describes how the 
regulations published in this proposed rule to implement the rebundling 
of outpatient hospital services differ from the regulations we proposed 
and published on August 5, 1988:
     We are not including any of the changes in the regulations 
relating to payment for physician laboratory services (Secs. 405.555(a) 
through (c), and 405.556(c) of the August 5, 1988 proposed rule), 
because these regulations were deleted as a result of publication of 
regulations to implement the Medicare physician fee schedule published 
on November 25, 1991 (56 FR 59502).
     We are revising Sec. 409.10(b), which describes services 
that are not included in the definition of ``hospital inpatient or 
inpatient CAH services'' to include all of the services that are now 
exceptions from the bundling rule under section 1862(a)(14) of the Act. 
Section 4511 of the BBA revised sections 1862(a)(14) and 1866(a)(1)(H) 
of the Act to exclude services of nurse practitioners and clinical 
nurse specialists described in section 1861(s)(2)(K) of the Act from 
the bundling requirement.
     As previously indicated, proposed Sec. 410.2 had been 
revised in the earlier proposed rule to include a definition of an 
``encounter.'' The definition of an encounter is expanded to include 
encounters in a CAH. That section is further amended to include a 
definition of an ``outpatient'' as a person who has not been admitted 
as an inpatient but who is registered on the hospital or CAH records as 
an outpatient and receives services (rather than supplies alone) 
directly from the hospital or CAH. The revision to include CAHs in 
these definitions is made to comply with sections 1862(a)(14) and 
1866(a)(1)(H) of the Act, which require that CAHs be treated as 
hospitals for purposes of the bundling provisions. (The BBA eliminated 
rural primary care hospitals (RPCHs) and created CAHs. The Congress 
intended, under section 4201(c) of the BBA, that CAHs be subject to the 
same Medicare requirements to which RPCHs were subject.)
     The revision to Sec. 410.27 is the same as in the earlier 
proposed rule except that the revision is now designated as paragraph 
(e) instead of paragraph (c).
     We are removing paragraph (a)(4) of Sec. 410.28 
(``Hospital or CAH diagnostic services furnished to outpatients: 
Conditions'') to reflect a change made by section 4085(i)(11) of OBRA 
1987 regarding provisions of diagnostic services furnished to 
outpatients.
     Proposed Sec. 410.30 (redesignated as Sec. 416.39 in this 
proposed rule) is being significantly revised. In Sec. 410.30(a) and 
(b) (now Sec. 410.39 (a) and (b) of regulations published on August 5, 
1988, we proposed to require the hospital to furnish directly or under 
arrangements all services furnished to its outpatients during an 
encounter as well as any diagnostic services furnished outside the 
hospital that were ordered during or as a result of an encounter in the 
hospital. In this rule, we are not extending the bundling requirements 
to include diagnostic services ordered during an encounter in the 
hospital that are furnished outside the hospital. Thus, the hospital 
will not be required to furnish such diagnostic services directly or 
under arrangements. We are proposing a more limited approach to 
bundling because the PPS we are proposing involves less ``packaging'' 
than we anticipated when we published the August 1988 proposed 
regulations. At that time, we believed that a PPS payment for a 
surgical procedure was likely to include preoperative tests and that 
payment for a clinic visit was likely to include the ancillary services 
(for example, laboratory tests and x-rays) that were needed to make a 
diagnosis. Therefore, by requiring bundling of off-site diagnostic 
tests that were ordered during an outpatient encounter at the hospital, 
we believed we could ensure that: (1) We had sufficient data to set 
payment rates that included the ancillary tests, and (2) once the 
system was implemented, the bundling rules would prevent any 
duplication of program payments. That is, a service packaged into a PPS 
payment to the hospital could not also be billed to the program as an 
ancillary test by an outside entity.
    As noted above, the PPS we are proposing now does not include 
extensive packaging; therefore, the payment for related diagnostic 
tests is not included in the payments under the ambulatory payment 
classification (APC) groups for surgical procedures, clinic visits, 
emergency room visits, etc. Any diagnostic tests that are furnished 
will result in a separate payment. The program will pay the entity that 
actually furnishes the service--the hospital, if the service is 
provided directly or under arrangements made by the hospital; or 
another Medicare recognized entity, if the patient leaves the hospital 
and obtains the service elsewhere. Because diagnostic tests are not 
being packaged into another hospital service, we no longer need to 
require that a hospital furnish directly or under arrangements the 
services ordered during, or as a result of, an encounter, but furnished 
outside the hospital. If the PPS is changed in future years to require 
a more packaged approach to payment, the bundling regulations will be 
revised. Proposed Sec. 410.30 (now Sec. 410.39) is also revised to 
require that the bundling rules apply to CAHs, and the list of services 
that are excepted from the bundling requirements, in Sec. 410.30(b) 
(now Sec. 410.39(b)) (previously designated in the August 5, 1988, 
proposed rule as Sec. 410.30(c)), is expanded to include all of the 
services that are currently excepted under section 1862(a)(14) of the 
Act.
     We are revising Sec. 411.15(m) (previously designated as 
Sec. 405.310(m)) significantly. We are eliminating proposed 
Sec. 405.310(n). That section, which had described the hospital

[[Page 47559]]

outpatient services that were excluded from coverage if not furnished 
directly or under arrangements, has been revised so that we will not 
require that hospitals bundle diagnostic services ordered during or as 
a result of an encounter in the hospital if furnished outside the 
hospital. The requirements of that section have been incorporated into 
Sec. 411.15(m)(1). We are revising Sec. 411.15(m)(2), which describes 
the services that are exceptions to the bundling rule, to include all 
of the services that are now exceptions under section 1862(a)(14) of 
the Act. We are further revising Sec. 411.15(m)(3), ``Scope of 
exclusion,'' to delete the reference to DME as a service that must be 
bundled. DME is defined under section 1861(n) of the Act as equipment 
used in the patient's home or in another institution used as his home 
other than a hospital or skilled nursing facility (SNF). By definition, 
DME is not something that is provided for use in the hospital setting. 
Therefore, we do not believe that the DME benefit provides for any item 
or service that is expected to be used by the patient while in the 
hospital as an inpatient or outpatient. Section 1862(a)(14) of the Act 
requires the hospital to provide directly or under arrangements 
services furnished to the patients of a hospital or CAH. We did not 
provide an exception for DME in our earlier proposed rule, because the 
bundling requirements under sections 1862(a)(14) and 1866(a)(1)(H) of 
the Act did not provide an exception for DME. However, we now believe 
that a statutory exception is not required because the bundling 
requirements apply to the services a hospital furnishes to its 
patients, and DME is not a hospital service. The covered Part B benefit 
for DME as described under section 1861(n) of the Act is intended for 
equipment used in the home, so a hospital that furnishes DME to its 
patients is not providing a hospital service to its patients, but is 
acting in the capacity of a supplier of DME, not a provider of hospital 
services. For these reasons, we will not require bundling of DME for 
hospital patients.
     Section 412.50 was not amended in the earlier proposed 
rule, but we are revising it in this rule to specify that hospital 
inpatient services do not include the services that are exceptions to 
the bundling requirements under section 1862(a)(14) of the Act.
     We are revising proposed Sec. 489.20(d) to incorporate as 
exceptions to the bundling requirements all of the services that are 
now exceptions under section 1866(a)(1)(H) of the Act.
     In addition to minor wording changes in introductory 
paragraph (b), proposed Sec. 1003.102 remains the same as in the August 
5, 1988 proposed rule, with the exception that the revision is now 
designated as paragraph (b)(14) rather than as paragraph (b)(4), as 
originally indicated in the August 5, 1988 proposed rule. Paragraphs 
(b)(11) through (b)(13) of Sec. 1003.102 are being reserved. We are 
also amending Sec. 1003.103(a) to indicate, in accordance with section 
231(c) of the Health Insurance Portability and Accountability Act, that 
the maximum CMP for each improper bill or request has been increased to 
$10,000.
     We are also amending Sec. 1003.105 (Exclusion from 
participation in Medicare and State health care programs) by revising 
paragraph (a)(1)(i) to reflect that this basis for imposition of a CMP 
is also a basis for an exclusion from participation in Medicare and the 
State health care programs.

V. Hospital Outpatient Prospective Payment System (PPS)

    In this proposed rule, we delineate the services that are covered 
under the hospital outpatient prospective payment system (PPS) that we 
are required to establish under section 1833(t) of the Act. We also 
propose Medicare payment rates when those services are ordered or 
furnished for diagnosis or treatment of a Medicare beneficiary who is 
registered on hospital records as an outpatient, and who receives 
services directly from the hospital.
    In this section, we explain the framework for the hospital 
outpatient PPS. This framework rests on Medicare's definition of an 
outpatient, which we discuss in section IV.E, above, and on Medicare's 
definition of what constitutes a hospital outpatient department or 
clinic. In section VI., below, we address requirements to define and 
distinguish among the various sites where services that are covered 
under the hospital outpatient PPS could be furnished. For example, a 
service furnished at an outpatient department or clinic located within 
a hospital can also be furnished at a ``provider-based'' entity, at a 
site away from a hospital that functions as though it were a department 
within the hospital, at an ASC, and at a physician office. Under the 
statute as it is currently written, in order to determine whether 
Medicare makes payment for a service under the hospital outpatient PPS 
that is the subject of this proposed rule or under another provision of 
Medicare Part B, such as the ASC benefit or the physician fee schedule, 
it is essential to clarify exactly where and under what conditions the 
service was furnished.
    This PPS will apply to covered hospital outpatient services 
furnished by any hospital participating in the Medicare program, except 
for those hospitals discussed below. Partial hospitalization services 
in community mental health centers (CMHCs) will also be paid under this 
PPS.
    The cancer hospitals that are excluded from inpatient PPS will be 
paid under hospital outpatient PPS. Although the BBA provides for a 
separate conversion factor if necessary, we intend to pay cancer 
hospitals using the same conversion factor and rates as all other 
hospitals. Certain hospitals in Maryland furnish services that are 
exempt from this system because they qualify under section 1814(b)(3) 
of the Act for payment under the State's payment system. Such excluded 
services are limited to the services paid under the State's payment 
system as described in section 1814(b)(3) of the Act. Any other 
outpatient services furnished by the hospital will be paid under the 
outpatient PPS. Critical access hospitals are excluded from the 
outpatient PPS because they are paid under a reasonable cost based 
system, as required under section 1834(g) of the Act. All other 
participating hospitals will be paid under hospital outpatient PPS.
    Distinct parts of hospitals that are excluded under inpatient PPS 
will be included in the outpatient PPS, to the extent that outpatient 
services are furnished by the hospital. For example, a hospital with an 
excluded inpatient psychiatric unit will have payment made under this 
PPS for outpatient psychiatric services including to inpatients who are 
not in a covered Part A stay.

A. Scope of Services Within the Outpatient PPS

    Section 1833(t)(1)(B)(i) of the Act gives the Secretary the 
authority to designate which services are to be covered under the 
hospital outpatient PPS. In this section, we indicate the types of 
services for which we are proposing to make payment under the hospital 
outpatient PPS and the types of services we are proposing to exclude 
from the scope of the hospital outpatient PPS.
    Section 1833(t)(2)(A) of the Act requires the Secretary to develop 
a classification system for the services that she designates are 
covered under the hospital outpatient PPS. Section 1833(t)(2)(B) of the 
Act allows the Secretary to classify covered outpatient services by 
groups so that the services within each are comparable clinically and 
with respect to the use of resources.

[[Page 47560]]

We refer to the hospital outpatient PPS classification system that we 
have developed as the Ambulatory Payment Classification (APC) system. 
The APC system consists of 346 groups of services that are covered 
under the hospital outpatient PPS.
    In section V.B., below, we explain how we assigned services and 
procedures to APC groups and in sections V.C. and V.D., below, we 
explain how we used the APC groups to determine hospital outpatient PPS 
payment rates.
1. Services Excluded From the Hospital Outpatient PPS
    Section 1833(t)(1)(B)(iii) of the Act excludes the following from 
payment under the hospital outpatient PPS: ambulance services, physical 
and occupational therapy, and speech-language pathology services. These 
services will be paid under fee schedules in all settings.
    Section 1833(t)(1)(B)(i) of the Act gives the Secretary the 
authority to designate which hospital outpatient services are covered 
under the outpatient PPS. In considering which services to include 
under the outpatient PPS, we wanted to ensure that all hospital 
outpatient services are paid under a prospectively determined amount. 
Some hospital outpatient services (for example, clinical diagnostic 
laboratory services, orthotics and prosthetics, ESRD dialysis services) 
are currently paid based on fee schedules or other prospective rates. 
Payments under these fee schedules apply not only to hospital 
outpatient services, but the same or very similar payment rates apply 
across a number of sites of ambulatory care. Such similar payments 
across various settings creates a level playing field where HCFA pays 
virtually the same payment for the same service, without regard to 
where the service is furnished. So that we do not disrupt an existing 
level playing field, we propose to exclude from our PPS, hospital 
outpatient services that are currently paid prospectively determined 
rates that are the same rates paid in other settings.
    We are proposing to exclude from the hospital outpatient PPS the 
following:
    a. Certain services already paid for under fee schedules or other 
payment systems including, but not limited to, services for patients 
with ESRD that are paid for under the ESRD composite rate; laboratory 
services paid under the clinical diagnostic laboratory fee schedule; 
and DME, orthotics, prosthetics, prosthetic devices, prosthetic 
implants and supplies (DMEPOS) paid for under the DMEPOS fee schedule 
when the hospital is acting as a supplier of these items. An item such 
as crutches or a walker that is given to the patient to take home, but 
that may also be used while the patient is at the hospital, would be 
billed to the DME regional carrier rather than being paid for under the 
hospital outpatient PPS.
    b. Hospital outpatient services furnished to inpatients of an SNF 
regardless of whether the person is in a Part A covered stay and 
furnished pursuant to the resident assessment or comprehensive care 
plan and that are covered under the SNF PPS, furnished ``under 
arrangements'' and billable only by the SNF.
    c. Services and procedures that require inpatient care.
    MedPAC Recommendation: In its March 1998 report to the Congress, 
the Medicare Payment Advisory Commission (MedPAC) recommends that costs 
associated with allied health professions training, such as nursing 
schools and paramedical education, be excluded from the calculation of 
the relative weights and the conversion factor used to set outpatient 
PPS payment rates. MedPAC further recommends that Medicare make 
separate payment for these costs, consistent with the manner in which 
Medicare pays for allied health professions training costs under the 
inpatient PPS.
    Response: We agree with MedPAC's recommendation. We did not include 
costs associated with allied health professions training in the 
calculation of outpatient PPS relative weights and conversion factors. 
We propose to pay hospitals that have allied health professions 
training programs on a cost-pass-through basis similar to the way we 
treat these costs under the hospital inpatient PPS.
2. Services Included Within the Scope of the Hospital Outpatient PPS

a. Services for Patients Who Have Exhausted Their Part A Benefits

    Section 1833(t)(1)(B)(ii) of the Act provides for Medicare payment 
under the hospital outpatient PPS for certain services furnished to 
inpatients who have exhausted Part A benefits or otherwise are not in a 
covered Part A stay. Examples of services covered under this provision 
include diagnostic x-rays and certain other diagnostic services and 
radiation therapy covered under section 1832 of the Act.

b. Partial Hospitalization Services

    Section 1833(a)(2)(B) of the Act provides that partial 
hospitalization services furnished in CMHCs be paid for under the 
hospital outpatient PPS. Partial hospitalization is a distinct and 
organized intensive psychiatric outpatient day treatment program, 
designed to provide patients with profound and disabling mental health 
conditions an individualized, coordinated, comprehensive, and 
multidisciplinary treatment program.

c. Services Designated by the Secretary

    Under the authority established by the statute at section 
1833(t)(1)(B)(i), we further are proposing to include within the scope 
of services for which payment is made under the hospital outpatient PPS 
the following:
     Services that are included within the outpatient PPS 
system are all hospital outpatient services that have not been 
identified for exclusion as described in section V.A.1., above. Among 
the types of services that we have classified into APC groups for 
payment under the hospital outpatient PPS are the following: surgical 
procedures; radiology, including radiation therapy; clinic visits; 
emergency department visits; diagnostic services and other diagnostic 
tests; partial hospitalization for the mentally ill; surgical 
pathology; cancer chemotherapy.
     Services furnished to SNF inpatients that are not packaged 
into SNF consolidated billing precisely because they are services that 
are commonly furnished by hospital outpatient departments and that SNFs 
would not be able to provide, such as CT scans, magnetic resonance 
imaging, or ambulatory surgery requiring the use of an operating room.
     Supplies such as surgical dressings that can be used 
during surgery or other treatments in the hospital outpatient setting 
that are also on the DMEPOS fee schedule. Payment for such supplies, 
when they are used in the hospital, is packaged into the APC payment 
rate for the procedure or service with which the items are associated.
     Certain preventive services furnished to healthy persons, 
such as colorectal cancer screening.
    Section 4523(d)(3) of the BBA provides that we will make Part B 
payment for certain medical and other health services, when furnished 
by a provider of services or by others under arrangement with a 
provider of services, under the outpatient PPS, if we would otherwise 
pay those providers on a reasonable cost basis for those services. 
Specifically, we are proposing that we would pay for the following 
medical and other health services under the

[[Page 47561]]

outpatient PPS when furnished by a provider of services:
     Antigens (as defined in 1861(s)(2)(G) of the Act);
     Splints and casts (1861(s)(5));
     Pneumococcal vaccine, influenza vaccine, hepatitis B 
vaccine (1861(s)(10)).
    We make Part B payment for the above services under the outpatient 
PPS when those services are provided by a CORF, HHA, or hospice 
program. However, this provision does not apply to services, furnished 
by a CORF, that fall within the definition of CORF services at section 
1861(cc)(1) of the Act. It also does not apply to services furnished by 
a hospice within the scope of the hospice benefit. Nor does it apply to 
services furnished by HHAs to individuals under an HHA plan of 
treatment within the scope of the home health benefit.
3. Hospital Outpatient PPS Payment Indicators
    Column B in Addendum B indicates the payment status of each HCPCS 
code. Addendum B displays all HCPCS codes, including those incidental 
services that are packaged into APC payment rates. Addendum G 
identifies inpatient services not payable under outpatient PPS.
     We use ``A'' to indicate services that are paid under some 
other method such as the DMEPOS fee schedule or the physician fee 
schedule.
     We use ``E'' to indicate services for which payment is not 
allowed under the hospital outpatient PPS or is not covered by 
Medicare.
     We use ``C'' to indicate inpatient services that are not 
payable under the outpatient PPS.
     We use ``N'' to indicate services that are incidental, 
with payment packaged into another service or APC group.
     We use ``P'' to indicate services that are paid only in 
partial hospitalization programs.
     We use ``S'' to indicate significant procedures for which 
payment is allowed under the hospital outpatient PPS but to which the 
multiple procedure reduction does not apply.
     We use ``T'' to indicate surgical services for which 
payment is allowed under the hospital outpatient PPS. Services with a 
payment indicator ``T'' are the only services to which the multiple 
procedure payment reduction applies.
     We use ``V'' to indicate medical visits for which payment 
is allowed under the hospital outpatient PPS. Providers must use ICD-9-
CM (International Classification of Diseases, Ninth Edition, Clinical 
Modification) codes to determine the level of payment for services with 
a payment indicator ``V''.
     We use ``X'' to indicate ancillary services for which 
payment is allowed under the hospital outpatient PPS.
    The table below lists all of the outpatient PPS indicators and what 
they designate.

                                                                    Status Indicators
                                 [How Medicare Pays for Various Services When They Are Billed for Hospital Outpatients]
--------------------------------------------------------------------------------------------------------------------------------------------------------
               Indicator                             Service                                                  Status
--------------------------------------------------------------------------------------------------------------------------------------------------------
A.....................................  Pulmonary Rehabilitation;         Non-paid.
                                         Clinical Trial.
C.....................................  Inpatient Procedures............  Bill as Inpatient.
A.....................................  Durable Medical Equipment,        DMEPOS Fee Schedule.
                                         Prosthetics and Orthotics.
E.....................................  Non-covered Items and Services..  Non-paid.
A.....................................  Physical, Occupational and        Rehab Fee Schedule.
                                         Speech Therapy.
A.....................................  Ambulance.......................  Ambulance Fee Schedule.
A.....................................  EPO for ESRD patients...........  National Rate.
A.....................................  Clinical Diagnostic Laboratory    Lab Fee Schedule.
                                         Services.
A.....................................  Physician Services for ESRD       Bill to carrier.
                                         patients.
A.....................................  Screening Mammography...........  Lower of Charge or National Rate.
N.....................................  Incidental Services, packaged     Packaged; no additional payment allowed.
                                         into APC Rate.
P.....................................  Partial Hospitalization Services  Paid per diem.
S.....................................  Significant Procedure, not        Paid under hospital outpatient PPS (APC rate).
                                         reduced when multiple.
T.....................................  Significant Procedure, multiple   Paid under hospital outpatient PPS (APC rate).
                                         procedure reduction applies.
V.....................................  Visit to Clinic or Emergency      Paid under hospital outpatient PPS (APC rate).
                                         Department.
X.....................................  Ancillary Service...............  Paid under hospital outpatient PPS (APC rate).
--------------------------------------------------------------------------------------------------------------------------------------------------------

B. Description of the Ambulatory Payment Classification (APC) Groups

    In response to OBRA 1986 and OBRA 1990 requirements to develop a 
hospital outpatient PPS, we examined systems that were in place or 
under development, and we entered into a cooperative agreement with 3M-
Health Information Systems to develop a classification system for 
outpatient services. The results of our review of existing systems are 
outlined in a Report to Congress dated March 17, 1995. The report 
identified the Ambulatory Patient Groups (APGs), which were developed 
by 3M-Health Information Systems, as the most promising classification 
system, and we recommended that APG-like groups be used as the basis 
for the hospital outpatient PPS. Soon after the report was submitted to 
the Congress, 3M-Health Information Systems released an updated version 
(known as Version 2.0) of the APGs. Since the release of Version 2.0, 
HCFA has revised the APGs based on more recent Medicare data. These 
revisions constitute what we are calling the Ambulatory Payment 
Classification (APC) system or groups that are proposed in this rule. 
Services within the APC system are identified by HCPCS codes and 
descriptions.
1. Setting Payment Rates Based on Groups of Services Rather Than on 
Individual Services
    MedPAC Recommendation: In its March 1998 report to the Congress 
entitled ``Report to the Congress: Medicare Payment Policy,'' MedPAC 
recommends that payment rates under the hospital outpatient PPS be 
based upon relative weights for each individual service rather than 
upon groups of similar services to help ensure consistent payments 
across ambulatory settings. MedPAC gives several reasons to support 
this recommendation:
     If services in a group are not homogeneous, a single 
payment rate for

[[Page 47562]]

all services in the group would not be accurate.
     Hospitals whose case mix includes a greater than average 
volume of higher-cost procedures in a group with a payment rate based 
on median costs for all procedures in the group could face losses and 
would have a financial incentive to provide only the lower-cost 
procedures within a group and to avoid the higher-cost procedures.
     Grouping services creates considerable administrative 
burdens and problems related to data consistency, provider education, 
the need for extensive technical assistance, and modification of claims 
processing systems.
     If costs for services in a group change at different 
rates, the price for the group may become distorted over time, 
necessitating periodic rebasing of group weights.
     Using groups to set rates for services under the hospital 
outpatient PPS moves away from standardizing payment systems across 
ambulatory settings.
    Response: We have carefully reviewed MedPAC's concerns about using 
groups of services rather than individual services as the basis for 
setting weights under the hospital outpatient PPS, and we believe that 
we have addressed most of these concerns in our approach to ratesetting 
using APC groups.
    Section 1833(t)(2)(A) of the Act requires the Secretary to develop 
a classification system for covered outpatient services. Section 
1833(t)(2)(B) provides that this classification system may be composed 
of groups, so that services within each group are comparable clinically 
and with respect to the use of resources. The statute refers to ``each 
such service (or group of services),'' implying that we may choose or 
not choose to group services. We have chosen to set rates for groups of 
similar services rather than setting rates for individual services for 
several reasons:
     The composition of the APC groups is based on two 
premises: the procedures within each group must be similar clinically, 
and the procedures must be similar in terms of resource costs. As we 
explain below, we used 3M's APGs as a starting point, but we have 
subsequently made changes to most of the 3M groups, taking into account 
1996 outpatient claims data; data collected in a 1994 survey of ASC 
costs and charges; data collected in 1995 and 1996 to establish 
resource-based practice expense relative values under the Medicare 
physician fee schedule; comments on surgical groupings following an ASC 
town meeting held at HCFA in July 1996 at which participants reviewed 
3M's Version 2.0 surgical APGs for consistency in terms of clinical 
characteristics and resource costs; and the medical judgment of HCFA's 
medical advisors. Further, we invite comments on the composition of all 
the APC groups that are presented in this proposed rule and whether 
readers believe that further refinements are needed. We request that 
commenters support their recommendations for changes in the APC groups 
with data regarding resource costs (time, supplies, equipment, labor 
requirements) as well as clinical arguments.
    We have also solicited comments on the same surgical APC groups 
that are proposed in this rule as part of a proposed rule entitled 
``Update of Ratesetting Methodology, Payment Rates, Payment Policies, 
and the List of Covered Surgical Procedures for Ambulatory Surgical 
Centers Effective October 1, 1998'' (HCFA-1885-P), published in the 
Federal Register June 12, 1998 (63 FR 32290). We intend to coordinate 
our review of all comments submitted timely during the comment period 
for the hospital outpatient PPS proposed rule and the ASC proposed 
rule. Any subsequent changes to the APC groups will be used by both 
payment systems when we set their respective final rates. We have a 
high level of confidence in the homogeneity of the APC groups that will 
emerge from this exhaustive review process.
     We have found that, in this context, setting weights at a 
single code level suggests a level of precision that is often not 
warranted due either to low procedure volume or questionable cost data.
     Of the 10,500 codes in the HCPCS, over 5,000 describe 
services that are covered under the hospital outpatient PPS. However, 
an examination of outpatient claims data for 1997 reveals that as few 
as 100 HCPCS codes account for more than a third of all coded services 
billed during that year. MedPAC states in its report to the Congress 
that its analysis of physician claims for 1996 revealed that more than 
90 percent of hospital outpatient volume was accounted for by 300 high 
volume services. Because so many codes were billed infrequently or not 
at all, we found ratesetting to be facilitated by grouping together the 
data that were available for codes that are similar clinically. We 
disagree with MedPAC's suggestion that we establish payment groups 
composed only of low-volume procedures. If we were to establish such 
groups, we would either have to except these groups from the principle 
of clinical consistency that applies to other APC groups or greatly 
increase the number of APC groups within the outpatient PPS. And, this 
approach does not solve the problem of how to establish weights for 
procedures, whether they are taken individually or in groups, for which 
we have inadequate cost data. Placing low Medicare volume procedures in 
APC groups with which they are similar clinically and in terms of 
resource consumption does not affect the weight established for the 
group to any appreciable extent because the weight derives from the 
higher volume procedures within the group.
     Grouping closely related services, and paying the median 
cost of the group, discourages the upcoding that occurs when individual 
services that are similar have disparate median costs.
     Using APC groups to set outpatient weights is consistent 
with the ratesetting method we are proposing for ASCs. In a proposed 
rule entitled ``Update of Ratesetting Methodology, Payment Rates, 
Payment Policies, and the List of Covered Surgical Procedures for 
Ambulatory Surgical Centers Effective October 1, 1998'' (HCFA-1885-P), 
published in the Federal Register June 12, 1998 (63 FR 32290), we 
propose payment rates for surgical procedures performed in Medicare-
approved ASCs using APC surgical groups proposed in this rule.
     Payment rates for new or redefined services can be more 
reliably established by assigning codes for these services to an 
existing group of several codes that share characteristics with the new 
code rather than trying to match it to an equivalent single procedure 
for which we may or may not have reliable cost data.
     Our experience basing ASC payment rates on groups of codes 
has proved to be no more burdensome administratively than has our 
experience with setting weights on a single code basis under the 
Medicare physician fee schedule. Under the outpatient PPS, with weights 
set by APC groups, hospitals will continue to use the same HCPCS coding 
and the same claims forms that they use currently. Any burdens on HCFA 
or on hospitals necessitating additional technical assistance or 
systems changes are more a function of implementing an entirely new 
payment system than of our setting weights on the basis of groups of 
services instead of on the basis of single procedures or services.
    We invite comments on our setting rates on the basis of groups of 
services rather than on individual codes.

[[Page 47563]]

2. How the Groups Were Constructed
    3M created APGs by combining procedure codes and diagnosis codes 
into groups that were clinically related (such as all codes for repair 
of fractured legs) and analyzing claims data to determine if the codes 
that were clinically similar also used resources in similar ways (for 
example, surgical repair would likely be more resource intensive than 
closed manipulation and casting). The resources that were examined were 
based on a 3-month sample of all Medicare claims for outpatient 
services. The sample of nearly 15 million claims was selected from 
claims paid in 1992 with the charges on each claim matched to 
departmental cost-to-charge ratios from the hospital that provided the 
services. The costs that were calculated using billed charges and 
department cost-to-charge ratios included direct costs, as well as the 
overhead for performing the services. The APGs were clustered into 
significant procedures (both surgical and nonsurgical), medical visits 
(in both clinics and emergency departments), and ancillary services. 
Other groups captured incidental services (those that would not be paid 
separately) and procedures for which no payment is made, such as 
services specifically excluded from Medicare payment by statute.
    Our Report to Congress recommended the use of APG-like groups for a 
hospital outpatient prospective payment system. When the time came to 
update payment groups for ASCs, which already were paid under a PPS, we 
decided to propose the use of APG-like groups. The ASC industry was 
accustomed to eight payment groups, with rates ranging from about $300 
to about $900 in roughly $75 increments, without clinical coherence. 
While interested in our proposal, the ASCs were concerned about 
perceived misclassifications, with groups containing codes they 
believed represented divergent resources. To accommodate these 
concerns, we regrouped many surgical codes, creating more levels within 
some ranges of groups and otherwise changing 3M's system. We also found 
it necessary to change the medical APGs. The medical visit groups, 
which under the APGs were grouped based on the patient's diagnosis, 
were clearly distinct when laboratory services and plain film x-rays 
were packaged in, but were much less distinct when those ancillary 
services related to the visit were not packaged, as will be the case 
initially under our system. We therefore investigated other approaches 
to categorizing medical visits that would result in clearly defined 
payment groups without extensive packaging. We discuss these approaches 
in section V.B.4., below.
    This process of revising 3M's APGs resulted in the development of 
the set of 346 mutually-exclusive and exhaustive service categories 
called ambulatory payment classification groups or APCs. The weights of 
the groups proposed in this rule are based on new data, as required by 
the BBA. We matched the database of 98 million hospital outpatient 
claims paid in 1996 to the most recent available cost reports for each 
hospital, and constructed the groups using these cost data. We defined 
each outpatient service under the PPS by a HCPCS code and classified it 
either into one of the APC groups for which an outpatient PPS payment 
rate is established or into a non-payment category of services that are 
excluded from the outpatient PPS. A weight is associated with each APC 
group. See section V.C. of this rule for details on how we calculated 
the weights. Procedures and services assigned a non-payment 
classification include services that can be provided only on an 
inpatient basis; codes or services that are not covered by Medicare; 
and procedures and services paid under fee schedules or other payment 
method.
3. Packaging Under the Groups
    Packaged services are those that are recognized as contributing to 
the cost of the services in an APC, but that we do not pay for 
separately. Under the APC system, packaged services include the 
operating room, recovery room, anesthesia, medical/surgical supplies, 
pharmaceuticals, observation, blood, intraocular lenses, casts and 
splints, donor tissue, and various incidental services such as 
venipuncture. We ``packaged'' the services (and their costs) within the 
APC group of procedures with which they were delivered in the base 
year. Below is a list of the hospital revenue centers from which we 
derived costs that were packaged within the APC groups. For example, a 
given surgical procedure would have a cost for the use of the operating 
and recovery rooms in every case. However, supply costs might vary, 
with some patients requiring special drains and dressings and others 
needing minimal dressings. The average packaged cost for supplies might 
represent, for example, $200 for the former group 40 percent of the 
time, and $150 for the rest. Thus, the APC would include $170 for 
supplies. Similarly, only a few cases would have included observation 
in the base year, but each case in the group would include a small 
amount for the times we associated observation with the cases in the 
group.
    We have packaged the cost of pharmaceuticals and biologicals within 
APC groups. We did this because we believe drugs are usually provided 
in connection with some other treatment or procedure. We have captured 
aggregate cost data on all drugs that were billed with HCPCS codes and 
those billed with revenue center codes, whether or not a HCPCS was 
entered. Thus, historical patterns of drug use are captured within the 
APC groups with which the drugs were billed during the base year. The 
only separate drug groups we have created are for chemotherapeutic 
agents, because those were separately identified in 3M's APG system. 
Because we intended to use an APG-like system, we required detailed 
coding of chemotherapeutic agents in order to be able to capture the 
costs of the specific drugs. We did not require HCPCS coding of other 
drugs, so we cannot specifically identify costs of non-chemotherapy 
drugs. We understand, however, that some rarely-used drugs are both 
expensive and used in only a few hospitals. In those instances, APC 
payment rates may not adequately represent costs for hospitals that 
treat patients who require infusions of very costly drugs or 
biologicals. Because we do not have bills that were coded to identify 
these high-cost drugs individually, we cannot evaluate the impact of 
paying separately for high-cost drugs. We could require HCPCS coding of 
all drugs or certain categories of drugs in order to gather the data, 
but we know hospitals could find such a requirement burdensome. We 
solicit comments on this issue.
    Currently, drugs that can be self-administered are not covered 
under Part B of Medicare (with certain specific exemptions for blood-
clotting factors, immunosuppresives, erythropoietin for dialysis 
patients, and certain oral chemotherapeutic agents and antiemetics). 
This presents problems in the outpatient hospital setting because even 
a pain killer given to a groggy patient postoperatively would not be 
covered. The only way such drugs can be paid for is for the hospital to 
bill the beneficiary. In many cases, the hospital does not, both 
because keeping track of such small charges for billing purposes is 
burdensome and because beneficiaries would not understand why they are 
being asked to pay for, for example, pain medication that was clearly 
related to the procedure they had undergone.
    We propose to allow hospitals to provide drugs to patients without 
requiring that the hospital bill the

[[Page 47564]]

patient, and without Medicare's paying the hospital. Normally, 
hospitals are not allowed to waive such billing, since not charging a 
patient could be seen as an inducement to the patient to use other 
services at the hospital, for which the hospital would be paid. 
However, if the benefit is not advertised, we believe that provision of 
the self-administered drugs at no charge to the beneficiary need not 
constitute an inducement in violation of the anti-kickback rules. The 
hospital may not advertise this to the public or in any other way 
induce patients to use the hospital's service in return for forgoing 
payment.
    Recommendation: MedPAC recommends that the unit of payment under 
the outpatient PPS be the individual service or procedure that is 
furnished and that payment for services and supplies integral to the 
individual service or procedure be bundled within that single unit of 
payment.
    Response: We agree both with MedPAC's recommendation regarding what 
should constitute the unit of payment under the outpatient PPS, and 
with MedPAC's recommendation regarding the ``bundling'' of payment, 
which we call ``packaging,'' for supplies and services that are 
integral to the individual service or procedure that constitutes the 
unit of payment. All services and procedures for which payment is to be 
made under the outpatient PPS are identified by HCPCS codes and 
descriptions. This approach of identifying individual services by HCPCS 
as the unit for payment parallels the unit for payment under both the 
Medicare physician fee schedule and the ASC facility services benefit. 
In addition, as we explain above, the payment amount for each HCPCS 
code is a packaged payment that takes into account the costs associated 
with services and supplies that are integral to the primary HCPCS-coded 
service or procedure and that are furnished at the same time and in the 
same place as the primary service or procedure. Because we modeled the 
outpatient PPS package of services for surgical procedures on the 
package of services that is the basis for payments for facility 
services furnished by Medicare approved ASCs, the definition of 
packaging will become standardized across both settings upon 
implementation of the outpatient PPS.
    MedPAC cites as a disadvantage of using individual services or 
procedures as the unit for payment the limited options that are 
available to control the volume of unnecessary ancillary services. We 
discuss in section V.J. how we intend to address volume control under 
the outpatient PPS. While a broader definition of packaging that 
includes related ancillaries such as diagnostic x-rays and other 
diagnostic tests that are furnished in other settings or at a different 
time than the primary service or procedures may have potential benefits 
not realized by the more limited packaging that we are using, we are 
concerned that applying different definitions of packaging to payments 
for the same primary service furnished in different settings would 
defeat the goal of establishing a unified payment structure across 
sites. One component of achieving this goal is to employ a consistent 
definition of packaging across all sites of ambulatory services. We 
solicit comments on the packaging options and the implications for 
ratesetting and volume control of using the same or different 
definitions of packaging across different settings.
    The following table identifies by revenue code the services and 
items that are packaged into the various categories of APC groups 
(surgery, radiology, other diagnostic, medical visits, and all other 
APC groups).

                   Packaged Services by Revenue Center
------------------------------------------------------------------------
                                 SURGERY
------------------------------------------------------------------------
250....................................  PHARMACY.
251....................................  GENERIC.
252....................................  NONGENERIC.
257....................................  NONPRESCRIPTION DRUGS.
258....................................  IV SOLUTIONS.
259....................................  OTHER.
270....................................  M&S SUPPLIES.
271....................................  NONSTERILE SUPPLIES.
272....................................  STERILE SUPPLIES.
360....................................  OPERATING ROOM.
361....................................  MINOR SURGERY.
369....................................  OTHER.
370....................................  ANESTHESIA.
379....................................  OTHER.
380....................................  ``BLOOD, GENERAL CLASS''.
381....................................  PACKED RED CELLS.
382....................................  WHOLE BLOOD.
383....................................  PLASMA.
384....................................  PLATELETS.
385....................................  LEUCOCYTES.
386....................................  OTHER COMPONENTS.
387....................................  OTHER DERIVATIVES.
389....................................  OTHER BLOOD.
390....................................  BLOOD STORAGE AND PROCESSING.
391....................................  BLOOD ADMINISTRATION.
399....................................  OTHER BLOOD PROC/STORAGE.
490....................................  ``AMBULATORY SURGERY, GENERAL
                                          CLASS''.
491....................................  OTHER AMBULATORY SURGICAL CARE.
630....................................  DRUGS REQUIRING ID.
631....................................  SINGLE SOURCE DRUG.
632....................................  MULTIPLE SOURCE DRUG.
636....................................  DRUGS REQUIRING DETAILED
                                          CODING.
700....................................  CAST ROOM.
709....................................  OTHER.
710....................................  RECOVERY ROOM.
719....................................  OTHER.
720....................................  LABOR ROOM.
721....................................  LABOR.
722....................................  DELIVERY.
723....................................  CIRCUMCISION.
724....................................  BIRTHING CENTER.
729....................................  OTHER.
750....................................  GASTROINTESTINAL.
759....................................  OTHER.
760....................................  OBSERVATION ROOM.
761....................................  TREATMENT ROOM.
762....................................  OBSERVATION ROOM.
769....................................  OTHER TREATMENT ROOM.
890....................................  OTHER DONOR BANK.
891....................................  BONE.
892....................................  ORGAN.
893....................................  SKIN.
899....................................  OTHER.
920....................................  ``OTHER DIAGNOSTIC SERVICES,
                                          GENERAL CLASS''.
929....................................  OTHER DIAGNOSTIC SERVICES.
940....................................  ``OTHER THERAPEUTIC SERVICES,
                                          GENERAL CLASS''.
949....................................  OTHER THERAPEUTIC SERVICES.
------------------------------------------------------------------------
                              MEDICAL VISIT
------------------------------------------------------------------------
250....................................  PHARMACY.
251....................................  GENERIC.
252....................................  NONGENERIC.
257....................................  NONPRESCRIPTION DRUGS.
258....................................  IV SOLUTIONS.
259....................................  OTHER.
270....................................  M&S SUPPLIES.
271....................................  NONSTERILE SUPPLIES.
272....................................  STERILE SUPPLIES.
279....................................  OTHER.
380....................................  ``BLOOD, GENERAL CLASS''.
381....................................  PACKED RED CELLS.
382....................................  WHOLE BLOOD.
383....................................  PLASMA.
384....................................  PLATELETS.
385....................................  LEUCOCYTES.
386....................................  OTHER COMPONENTS.
387....................................  OTHER DERIVATIVES.
389....................................  OTHER BLOOD.
390....................................  BLOOD STORAGE AND PROCESSING.
391....................................  BLOOD ADMINISTRATION.
399....................................  OTHER BLOOD PROC/STORAGE.
630....................................  DRUGS REQUIRING ID.
631....................................  SINGLE SOURCE DRUG.
632....................................  MULTIPLE SOURCE DRUG.
636....................................  DRUGS REQUIRING DETAILED
                                          CODING.
762....................................  OBSERVATION ROOM.
------------------------------------------------------------------------
                               DIAGNOSTIC
------------------------------------------------------------------------
250....................................  PHARMACY.
251....................................  GENERIC.
252....................................  NONGENERIC.
254....................................  INCIDENT TO OTHER DIAGNOSTIC.
257....................................  NONPRESCRIPTION DRUGS.
258....................................  IV SOLUTIONS.
259....................................  OTHER.
270....................................  M&S SUPPLIES.
271....................................  NONSTERILE SUPPLIES.
272....................................  STERILE SUPPLIES.
360....................................  OPERATING ROOM.
361....................................  MINOR SURGERY.
369....................................  OTHER.
370....................................  ANESTHESIA.
372....................................  INCIDENT TO OTHER DIAGNOSTIC.
379....................................  OTHER.
380....................................  ``BLOOD, GENERAL CLASS''.
381....................................  PACKED RED CELLS.
382....................................  WHOLE BLOOD.
383....................................  PLASMA.
384....................................  PLATELETS.
385....................................  LEUCOCYTES.
386....................................  OTHER COMPONENTS.
387....................................  OTHER DERIVATIVES.
389....................................  OTHER BLOOD.
390....................................  BLOOD STORAGE AND PROCESSING.
391....................................  BLOOD ADMINISTRATION.
399....................................  OTHER BLOOD PROC/STORAGE.

[[Page 47565]]

450....................................  ER.
459....................................  OTHER.
622....................................  INCIDENT TO OTHER DIAGNOSTIC.
630....................................  DRUGS REQUIRING ID.
631....................................  SINGLE SOURCE DRUG.
632....................................  MULTIPLE SOURCE DRUG.
636....................................  DRUGS REQUIRING DETAILED
                                          CODING.
710....................................  RECOVERY ROOM.
719....................................  OTHER.
762....................................  OBSERVATION ROOM.
------------------------------------------------------------------------
                                RADIOLOGY
------------------------------------------------------------------------
250....................................  PHARMACY.
251....................................  GENERIC.
252....................................  NONGENERIC.
255....................................  INCIDENT TO RADIOLOGY.
257....................................  NON-PRESCRIPTION DRUGS.
258....................................  IV SOLUTIONS.
259....................................  OTHER.
270....................................  M&S SUPPLIES.
271....................................  NONSTERILE SUPPLIES.
272....................................  STERILE SUPPLIES.
360....................................  OPERATING ROOM.
361....................................  MINOR SURGERY.
369....................................  OTHER.
370....................................  ANESTHESIA.
371....................................  ANESTHESIA INCIDENT TO
                                          RADIOLOGY.
379....................................  OTHER.
380....................................  ``BLOOD, GENERAL CLASS''.
381....................................  PACKED RED CELLS.
382....................................  WHOLE BLOOD.
383....................................  PLASMA.
384....................................  PLATELETS.
385....................................  LEUCOCYTES.
386....................................  OTHER COMPONENTS.
387....................................  OTHER DERIVATIVES.
389....................................  OTHER BLOOD.
390....................................  BLOOD STORAGE AND PROCESSING.
391....................................  BLOOD ADMINISTRATION.
399....................................  OTHER BLOOD PROC/STORAGE.
621....................................  SUPPLIES INCIDENT TO RADIOLOGY.
630....................................  DRUGS REQUIRING ID.
631....................................  SINGLE SOURCE DRUG.
632....................................  MULTIPLE SOURCE DRUG.
636....................................  DRUGS REQUIRING DETAILED
                                          CODING.
710....................................  RECOVERY ROOM.
719....................................  OTHER.
762....................................  OBSERVATION ROOM.
------------------------------------------------------------------------
                           ALL OTHER APC GROUPS
------------------------------------------------------------------------
250....................................  PHARMACY.
251....................................  GENERIC.
252....................................  NONGENERIC.
257....................................  NONPRESCRIPTION DRUGS.
258....................................  IV SOLUTIONS.
259....................................  OTHER.
270....................................  M&S SUPPLIES.
271....................................  NONSTERILE SUPPLIES.
272....................................  STERILE SUPPLIES.
279....................................  OTHER.
380....................................  ``BLOOD, GENERAL CLASS''.
381....................................  PACKED RED CELLS.
382....................................  WHOLE BLOOD.
383....................................  PLASMA.
384....................................  PLATELETS.
385....................................  LEUCOCYTES.
386....................................  OTHER COMPONENTS.
387....................................  OTHER DERIVATIVES.
389....................................  OTHER BLOOD.
390....................................  BLOOD STORAGE AND PROCESSING.
391....................................  BLOOD ADMINISTRATION.
399....................................  OTHER BLOOD PROC/STORAGE.
630....................................  DRUGS REQUIRING ID.
631....................................  SINGLE SOURCE DRUG.
632....................................  MULTIPLE SOURCE DRUG.
636....................................  DRUGS REQUIRING DETAILED
                                          CODING.
762....................................  OBSERVATION ROOM.
------------------------------------------------------------------------

4. Treatment of Clinic and Emergency Visits
    The major issue we face in determining payment for clinic and 
emergency room visits is whether to include diagnosis as well as 
Physicians' Current Procedural Terminology (CPT) codes in setting 
payment rates. We solicit comments on the approaches that we discuss 
below and on other possible alternatives.
    Determining payment for clinic and emergency room visits requires a 
variety of considerations and trade-offs. These include:
     The impact of packaging on setting payment rates (for 
example, the more packaging, the greater the difference among APC 
payments; however, we are not proposing a fully packaged system 
initially, which reduces payment differences and may necessitate 
additional policies to increase differences across payment groups);
     How to code visits in a manner that recognizes variations 
in service intensity and levels of resource consumption (for example, 
how to pay more for visits that cost more);
     How to keep the system administratively manageable (for 
payment purposes, we assign 31 CPT codes that describe different levels 
of evaluation and management services to 7 APC groups);
     How to define critical care in terms of facility as 
opposed to physician inputs (for example, what is an appropriate 
facility payment for critical care when critical care CPT codes are 
currently determined to reflect physician inputs);
     Data problems associated with identifying costs from 
claims that list multiple services (for example, the data analysis we 
have conducted so far reflects only data from claims for single visits; 
we are analyzing data from multiple visit claims to glean additional 
information relevant to these policies);
     How to move toward greater uniformity of payments across 
ambulatory settings so as to remove payment as an incentive for 
determining site of service (for example, the trade-off that could 
result if, by enhancing differentiation of payments for services within 
the hospital outpatient setting, we were to increase payment 
differences across settings for services that are provided in both 
hospital outpatient departments and physician offices).
    Given the range of issues surrounding payments for clinic and 
emergency room visits, we are continuing to weigh different options. We 
are concerned that using diagnosis coding to set rates for hospital 
outpatient clinic visits could increase disparities in payment 
methodology between outpatient departments and physician offices, for 
which a new system of resource based practice costs is just now being 
proposed. (These concerns do not extend as much to emergent and 
critical care, which are not routinely furnished in physician office 
settings.) Diagnostic coding has not been used in the past to adjust 
payments in the physician office setting and there is no general 
evidence that practice expense (or work) in physician office settings 
varies by the patient's diagnosis. Moreover, because patients in the 
hospital outpatient department can be shifted easily to alternative 
outpatient settings, adjustment of facility costs to take diagnosis 
into account in one setting but not others may create incentives to 
shift patients among ambulatory settings in unknown ways.

Coding Visits

    We have considered several approaches to setting prospective 
payment rates for hospital clinic and emergency visits. We reviewed the 
medical visit groups in 3M's version 2.0 of APGs that are based solely 
on ICD-9 diagnosis codes, with 80 APGs providing several groups for 
each body system; we analyzed the effect on ratesetting of defining 
clinic and emergency visits solely by CPT code; and, we analyzed the 
effect of using a matrix that combines patient diagnosis with a CPT 
code to describe the nature of the outpatient encounter. We discuss 
these various approaches in more detail here and some of the advantages 
and disadvantages of each. Again, we solicit comments on these 
approaches to setting payment rates for clinic and emergency room 
visits as well as comments on alternative approaches that are not 
mentioned here.

Approach 1: Using Diagnosis Codes Only

    3M's approach of using only ICD-9 diagnosis codes with extensive 
packaging results in a wide range of group payment rates. The group 
that pays the most is almost 13 times as costly as the lowest-paid 
group. However, when we removed minor laboratory tests, x-rays, and 
certain other minor procedures that had been packaged into 3M's medical 
visit APGs in order to conform with the packaging that we propose in 
this proposed rule,

[[Page 47566]]

the difference between the highest and the lowest paid group dropped to 
not quite five times. (Fully packaged APGs are sufficiently 
differentiated for payment purposes, while partially packaged APGs are 
not; therefore, if we were to move to a fully packaged system, we would 
re-evaluate approaches using diagnosis.)
    We also found that grouping clinic and emergency visits solely on 
the basis of diagnoses tends to result in visits that require major 
resources for critical cases clustering together with less resource-
intensive follow-up visits after the crisis has passed.

Approach 2: Using CPT Codes Only

    The APC groups that we propose in this proposed rule as the basis 
for setting rates for surgical services consist solely of CPT codes. We 
looked at using only CPT codes to establish payment groups for 
outpatient clinic and emergency room visits, but we found that the 
variation between the most costly and the least costly encounter was 
quite flat, with the former only 4.5 times greater than the latter. 
When basing payment on CPT codes alone, the range reflects hospitals' 
billing patterns in increasing level of intensity, but cases at the 
margin are overwhelmed by the numbers of visits billed so that 
individual cases with low or high costs are not discernible. Also, 
billing patterns reflect standard bills, not the resources used in any 
particular case.

Approach 3: CPT and Diagnosis Hybrid

    We looked at another approach that bases payment rates on a hybrid 
of CPT codes and patient diagnoses. We first assigned 31 CPT codes that 
describe physician encounters with patients in the outpatient setting 
to seven APC groups: three for clinic visits, three for emergency 
department visits, and one for critical care. We also collapsed 
approximately 12,000 ICD-9 codes into 20 major diagnostic categories 
(MDCs), arranged generally by body system. Classifying services in this 
fashion produces a more manageable number of groups, and results in a 
matrix of 121 CPT/diagnosis combinations, in which the most costly 
combination is more than 10 times as costly as the least.
    Our grouping of evaluation and management CPT codes was based on 
several factors. As we note above, we grouped 31 CPT codes that 
represent different levels of physician ``evaluation and management'' 
of patients into seven APC groups. (For a more complete discussion, 
refer to the evaluation and management services guidelines in 
Physicians' Current Procedural Terminology 1998 edition (CPT '98) 
published by the American Medical Association.) CPT codes are more 
descriptive of physician effort than of facility use, and our cost data 
showed little difference between level 1 and level 2 visits or between 
level 4 and level 5 visits. Therefore, we elected to combine some of 
the CPT codes into a single group, for example, the two least intensive 
outpatient visit codes, 99201 and 99202, are both in APC 911, which is 
the lowest level of clinic visits, etc. Grouping CPT codes together in 
this fashion reduces administrative burden, and our data analysis shows 
only small additional cost differences among the complete set of CPT 
medical visit codes. Moreover, we found that grouping CPT codes in this 
fashion evens out certain anomalies that arise when an emergency 
department furnishes services that would not typically be thought of as 
emergency care, such as suture removal, or treatment of a skin disease. 
Even though suture removal or treatment of conditions such as impetigo, 
conjunctivitis, etc. is performed in emergency departments, these types 
of services are more appropriately furnished at a clinic because they 
do not require the more elaborate resources of the emergency 
department. Assigning codes to APC groups would allow us to set payment 
for care of patients with minor problems in the emergency department at 
a level equivalent to payment for the same care when it is furnished at 
a clinic. We welcome comments on payment for services that do not 
require emergency room use.
    Using a matrix of evaluation and management codes with patient 
diagnosis would offset the disadvantages noted above of grouping solely 
by CPT code (too little payment variation) or solely by patient 
diagnosis (reduced payment variation and commingling of resource 
intensive and non-resource intensive visits). Defining a clinic or 
emergency visit APC in terms of both CPT code and diagnosis, even when 
grouping codes to provide a manageable number of groups, would better 
recognize the facility resources consumed in providing emergency and 
critical care visits. Many such visits, of course, cluster around the 
same dollar amount, but this is expected because many visits involve 
typical care and standard resources. The cases that represent care at 
higher or lower levels of intensity appear to represent real 
differences in resource consumption. We used the CPT/patient diagnosis 
hybrid to model impacts. We do not believe that payment to individual 
hospitals would be significantly affected, whether we base payment 
rates on groups of CPT codes only or on groups that combine CPT codes 
and patient diagnosis.
    Using a matrix that combines CPT codes with patient diagnosis to 
set payment rates for clinic and emergency department visits would also 
improve the coding of diagnoses in the hospital outpatient setting 
generally. Such improved diagnosis coding is critical to evaluating 
future degrees of packaging in the APC system, and we have already 
noted that more packaging tends to increase the measured cost 
differences across APC groups.
    However, as we discussed earlier, there are also problems with 
using a matrix that includes diagnosis codes for hospital outpatient 
visits. We are concerned about the effect of using a method to pay for 
clinic visits in the hospital outpatient setting that is at variance 
with the method we use to pay for the same service in a physician 
office. A possible alternative to using diagnosis codes as an indicator 
of resource consumption in connection with medical visits in hospital 
outpatient departments is to create a uniform fee schedule for 
physician visits across all ambulatory settings, paying the site at 
which the service is furnished the physician practice expense component 
as a ``facility fee.'' However, the latter option would require 
legislation and a possible reallocation of the overhead currently 
associated with medical visits in the outpatient department to other 
outpatient services. Given the complexity of these issues, it may not 
be desirable to introduce additional differences, such as diagnosis, 
among payments in medical visits at this time. We invite public comment 
on all of the issues raised in the discussion in this section. In 
addition, after this rule is published, we will be reexamining our 
outpatient database and extending our analysis to multiple visit data. 
We will incorporate the findings of these additional analyses into our 
final decision.

Hypothetical Case Using the Hybrid

    The following is a hypothetical case presented to illustrate how 
payment would be determined using the CPT code/diagnosis code hybrid. A 
new patient, an elderly woman who has recently come to live with her 
family in the area, presents to the primary care clinic complaining of 
fatigue, shortness of breath, swollen ankles, and loss of vision. The 
physician spends 45 minutes eliciting the patient's medical, family, 
and social history and performing an extensive physical examination. 
Suspecting cataracts as the

[[Page 47567]]

cause of her loss of vision, the physician suggests she make an 
appointment in the eye clinic. Suspecting congestive heart failure as 
the cause of her other symptoms, but also suspicious of coexisting 
diabetes and hypertension, the physician orders laboratory tests and an 
electrocardiogram (ECG) to be performed that day, and schedules an 
appointment in the cardiovascular clinic for a later date. If payment 
to the hospital were to be made on the basis of a CPT code/ICD-9 code 
matrix, the hospital's claim for services furnished in connection with 
this visit would identify the following information: CPT code 99204, 
comprehensive outpatient visit, new patient, and ICD-9 diagnosis code 
401.1, benign hypertension. Payment would be determined by mapping CPT 
code 99204 to APC group 915, levels 4 and 5 clinic visit, and ICD-9 
code 4011 to MDC 36, cardiovascular system diseases. Payment would be 
the rate established for the resulting hybrid group identifier, 91536. 
Addendum A lists the payment rates for the proposed hospital clinic and 
emergency room payment groups. Separate payment would be made under the 
clinical diagnostic laboratory fee schedule for the laboratory work; 
the ECG would be paid for separately on the basis of the payment rate 
established for APC 950.
    Several months later, the same patient, who now is known to have 
congestive heart failure, returns to the primary care clinic 
complaining of a cough and runny nose. The physician, having determined 
that the symptoms are due to a virus, recommends using a humidifier and 
drinking extra fluids. The hospital would code this visit with CPT code 
99212 (problem-focused outpatient visit, established patient) and with 
ICD-9 diagnosis code 460 (acute nasopharyngitis, or common cold). This 
combination, in turn, would map to APC 911, levels 1 and 2 clinic 
visit, plus MDC 31, ear, nose, mouth and throat diseases, and payment 
for this patient's second visit to the hospital clinic would be based 
on the rate established for hybrid group 91131.

Payment for Screening Services

    Every patient who presents to an emergency department and requests 
(or has requested on his or her behalf) a screening must be screened in 
accordance with section 1867(a) of the Act. If the physician or other 
hospital staff who performs the screening determines that no medical 
emergency exists, the patient can be referred to one of the hospital's 
clinics or to another provider such as a physician office for further 
treatment, or the emergency department personnel can decide to treat 
the patient in the emergency department. We propose to create a HCPCS 
code to be used to bill the screening. Payment for this new code will 
be low because no treatment is included in the screening. Payment for 
the screening APC is made only when no additional services are 
furnished by the emergency department. If non-emergency treatment is 
furnished, the appropriate emergency room visit should be billed, and 
not the screening. Similarly, if the screening reveals that an 
emergency does exist and treatment is instituted immediately, the 
screening should not be billed; the screening is subsumed into the 
further treatment. If an emergency room physician feels the need to 
consult with another physician before deciding whether the patient 
needs emergency treatment, the consultation is part of the original 
screening, and the hospital should bill for only one screening visit, 
if a bill for screening is appropriate, as described above.

Payment for Critical Care

    We propose to have hospitals use CPT code 99291 to bill for 
outpatient encounters in which critical care services are furnished. We 
use the CPT definition of ``critical care,'' which is the evaluation 
and management of the unstable critically ill or injured patient who 
requires the constant attendance of a physician. Under the outpatient 
PPS, we would allow the hospital to use CPT 99291 in place of, but not 
in addition to, a code for a medical visit or for an emergency 
department service. However, the entire duration of the hospital 
outpatient department's critical care services for an individual 
patient is represented by CPT 99291, and we would not allow the 
facility to use CPT 99292 to bill for critical care services extended 
in 30-minute increments, as would the attending physician. (We have 
packaged the costs associated with subsequent hours of critical care 
billing into the APG group of services with which the critical care 
hours were billed in the base year.) If other services, such as 
surgery, x-rays, or cardiopulmonary resuscitation, are furnished on the 
same day as the critical care services, we would allow the hospital to 
bill for them separately.
    We expect that the numbering scheme proposed in this rule to 
distinguish clinic and emergency room visits would be changed in the 
final rule. Although we believe the 5-digit identifier used in this 
proposal makes it easier to see the relationship between the CPT code 
for the level of the visit and the ICD-9-CM code for the diagnosis, for 
claims processing purposes, we would have to replace 5-digit 
identifiers with 3-digit ones.
5. Treatment of Partial Hospitalization Services
    In accordance with section 1861(ff) of the Act, partial 
hospitalization services may be furnished only by a hospital to its 
outpatients or by a community mental health center (CMHC). We published 
an interim final rule on February 11, 1994 (59 FR 6570) to establish 
coverage criteria and payment requirements for partial hospitalization 
programs. In that rule, we indicated that physician services and 
certain nonphysician practitioner services are not considered to be 
partial hospitalization services. Payment for these services is outside 
the scope of this proposed rule.
    The partial hospitalization program of services is organized and 
furnished similarly, whether the program is administered by a hospital 
or by a CMHC. Section 1833(a)(2)(B) of the Act requires that payment 
for CMHC partial hospitalization services be based on the hospital 
outpatient PPS. Thus, the methodology we are proposing would apply to 
hospital outpatient and to CMHC partial hospitalization programs. The 
current rules governing CMHC payment appear in 42 CFR part 413. This 
proposed rule would amend Sec. 413.1 to indicate that payment for 
partial hospitalization services furnished by CMHCs is made in 
accordance with the hospital outpatient prospective payment system 
described in part 419 of this chapter.
    Patients eligible for the Medicare partial hospitalization benefit 
comprise two groups: patients who have been discharged from a 
psychiatric hospital for whom partial hospitalization services are 
provided in lieu of continued inpatient treatment; and patients who 
exhibit disabling psychiatric/psychological symptoms as a result of an 
acute exacerbation of a severe and persistent mental illness for whom 
the partial hospitalization services are provided in lieu of admission 
to an inpatient psychiatric hospital.
    As required by section 1835(a)(2) of the Act, admission to a 
partial hospitalization program is limited to patients whose physicians 
certify that: (1) the individual would require inpatient psychiatric 
care in the absence of partial hospitalization services; (2) an 
individualized, written plan of care has been established by a 
physician and is reviewed periodically by a physician; and (3) the 
patient is or was under the care of a physician. This certification 
would be made when the physician

[[Page 47568]]

believes that the course of the patient's current episode of illness 
would result in psychiatric hospitalization if the partial 
hospitalization services are not substituted.
    The acute psychiatric condition being treated by a partial 
hospitalization program must require intensive active treatment, 
including a combination of medical and nursing interventions, 
individual and group psychotherapy, occupational therapy, family 
counseling, and various adjunctive therapeutic activities that are not 
primarily recreational or diversionary. The patient's degree of 
impairment must be severe enough to require a multidisciplinary 
structured day program, but not so severe that patients are incapable 
of participating in and benefitting from an active treatment program. 
Patients must require partial hospitalization services at levels of 
intensity and frequency comparable to patients in an inpatient setting 
for similar psychiatric illnesses. In addition, the patient must have 
an adequate community-based network to support the patient outside the 
partial hospitalization program.
    Typically, patients admitted to a partial hospitalization program 
initially require full-time participation in order to provide crisis 
stabilization, that is, 6 hours of programming for 5 days per week. In 
some cases, the patient may ultimately require inpatient psychiatric 
care despite the partial hospitalization services. However, in most 
cases, as the patient's symptoms diminish and functional goals are 
achieved, the frequency of attendance is reduced to 4 days and, later, 
to 3 days. Once the patient's participation drops to this level, the 
need for partial hospitalization services in lieu of inpatient 
psychiatric care is not generally indicated and the patient would be 
discharged to a lower level of outpatient psychiatric care.
    Under the current reasonable cost payment system, providers report 
the total number of units for each partial hospitalization service 
furnished during the billing period. As noted earlier, hospitals are 
also required to report claims for services using HCPCS codes. Payment 
for the additional overhead cost of supportive staff and recordkeeping 
for a comprehensive day program of services would be built into the 
provider's charge structure for covered partial hospitalization 
services and paid through the cost report settlement process.
    Because a day of care is the unit that defines the structure and 
scheduling of partial hospitalization services, we believe that a per 
diem payment for partial hospitalization services is a more appropriate 
methodology than billing for each component of a partial 
hospitalization program. A packaged, per diem approach is used by other 
governmental and private payers when paying for partial hospitalization 
services. In order to determine the median cost for the partial 
hospitalization APC group, we analyzed the components reported for each 
partial hospitalization service over the course of a billing period and 
established a per diem payment rate. This analysis resulted in an APC 
payment rate of $208.25 per day, of which $46.78 is the beneficiary's 
copayment.
    As noted above, partial hospitalization providers currently report 
the total number of units for each service billed. We have revised the 
billing instructions to require CMHCs to report HCPCS codes and to 
require hospitals and CMHCs to report the date of each service, 
effective October 1, 1998. We welcome information from the public to 
assist us in refining the median cost for a day of partial 
hospitalization. We are particularly interested in information 
concerning the mix of services that constitute a typical partial 
hospitalization day.
    We have not established a group to represent a half-day of partial 
hospitalization, although we are aware that other governmental and 
private payers have adopted both a full and half-day rate for partial 
hospitalization. For example, CHAMPUS (Civilian Health and Medical 
Program of the Uniformed Services) recognizes a day with at least 6 
hours of programming as a full day, while days with at least 3 
programmed hours, but less than 6, are paid a per diem rate equal to 75 
percent of the full day rate. However, the CHAMPUS per diem is not tied 
to the cost of certain covered services, but rather to the number of 
programmed hours the patient attends. As noted above, we will begin to 
collect information October 1, 1998, regarding which services are 
furnished each day. Once we have analyzed this information, we will be 
able to determine the extent to which half-days are used typically in 
partial hospitalization treatment planning. We are interested in public 
comments regarding whether we should establish a half-day partial 
hospitalization group.
    We have also decided not to propose a minimum number of hours or 
units of covered services that constitute a partial hospitalization day 
at this time. However, we are concerned that a low frequency of 
participation, either very few days per week or few covered services 
per day, indicate that the partial hospitalization program is no longer 
reasonable and necessary and the patient could be managed in a less 
intensive level of outpatient treatment or periodic office visits. 
Fiscal intermediaries in performing medical review of claims will 
continue to make decisions regarding whether the services furnished a 
patient are covered and payable as partial hospitalization services. As 
noted above, CHAMPUS has established a minimum of 3 hours of service 
for payment of their partial hospitalization per diem amount. We are 
specifically requesting public comment on adopting a minimum number of 
services for Medicare payment purposes.
    We note that many other payers have established an annual limit on 
the number of covered partial hospitalization days. There is currently 
no duration limit on the Medicare partial hospitalization benefit. 
Rather, in order to be covered by Medicare, partial hospitalization 
services must be reasonably expected to improve or maintain the 
patient's condition and to prevent relapse or hospitalization. For most 
psychiatric patients, particularly those with long term, chronic 
conditions, control of symptoms and maintenance of a functional level 
to avoid hospitalization is an acceptable expectation of improvement. 
It is not necessary for a course of partial hospitalization services to 
have, as its goal, restoration of the patient to the level of 
functioning exhibited prior to the onset of the illness. Some patients 
may undergo a course of treatment that increases their level of 
functioning but then reach a point where further significant 
improvement is not expected. Continued coverage after this point may be 
dependent upon evidence that the patient is not able to maintain 
stability with less intensive treatment. Although we are not proposing 
a duration standard for partial hospitalization at this time, we are 
concerned that there is significant variation in duration of treatment. 
We solicit data that show treatment duration from providers of partial 
hospitalization services. We are also considering specifying a 
timeframe for periodic physician recertification of need for partial 
hospitalization services as a method to ensure that a patient's 
individual needs continue to require the intensity of a partial 
hospitalization program.
    Finally, we are concerned about the impact of establishing a per 
diem payment for partial hospitalization on the provision of other 
outpatient mental health services. Patients should be

[[Page 47569]]

referred to the outpatient mental health treatment program that best 
suits their individual needs. Partial hospitalization programs differ 
from other outpatient mental health treatment programs in the intensity 
of the program, the frequency of participation, and the patient's need 
for a comprehensive structured program of services. Upon discharge from 
a partial hospitalization program, a patient's symptoms and level of 
functioning will have stabilized to the point that the intensity of a 
partial hospitalization program is no longer necessary. We are 
concerned that providing a per diem payment for partial hospitalization 
services may discourage timely discharge. For this reason, medical 
review by fiscal intermediaries will continue to focus on patients' 
initial and continued eligibility for partial hospitalization services.
    As noted previously, once we have complete encounter data on which 
to base the per diem partial hospitalization rate, the per diem will 
represent the median cost of services furnished on a typical day. As 
such, it will not be based on the cost of each service furnished on a 
particular day. Since partial hospitalization represents the most 
intensive outpatient program and we will have established the median 
cost of furnishing a day of partial hospitalization services, it does 
not seem appropriate to pay more for other, less intensive outpatient 
psychiatric programs. For this reason, we are specifically requesting 
public comment on establishing a limit on routine outpatient mental 
health services furnished on a given day to equal the partial 
hospitalization per diem amount.
6. Comments on Specific APCs
    APCs 061-064. We created separate (that is, unpackaged) groups for 
various chemotherapeutic agents because we believed that some agents 
had high costs that would not be recognized if those drugs were 
packaged into the median cost for the chemotherapy administration. We 
solicit comment on whether to package these costs into the chemotherapy 
delivery codes in the final rule. We request that commenters identify 
high-cost chemotherapeutic agents that would not be adequately 
recognized if packaged or that may require a separate payment or higher 
payment grouping.
    APC 226: This group represents the facility costs for making custom 
maxillofacial prosthetics. There are few claims, and the median cost is 
very low compared to the practice expenses associated with these claims 
on the Medicare physician fee schedule. We assume poor coding accounts 
for the anomalous cost. However, it may be that these services are not 
performed in hospital outpatient departments; they may actually be 
performed by maxillofacial surgeons in their offices or by dental 
laboratories. We welcome comments on whether these services are 
actually provided in the outpatient hospital setting and the resources 
involved.
    APC 317 (Cochlear device implantation): The few claims in our 
database for this procedure have such disparate costs that we are 
uncertain of the appropriate assignment of the surgery. The device is 
paid for from the DMEPOS fee schedule. We solicit comments on whether 
the implant procedure itself resembles procedures in another APC group 
to which it could be appropriately assigned.
    APCs with a status indicator of ``V'': The groups that represent 
medical visits in clinics and emergency departments are based on a 
matrix, with intensity represented by six levels of CPT codes combined 
with 20 categories of ICD-9 codes indicating diagnosis or condition. 
Although current instructions require hospitals to use a CPT code to 
bill for medical visits, we permit hospitals to bill for all medical 
visits under a single code (99201) unless a hospital chooses to be more 
specific. In 1997, our data show code 99201 accounting for 22 percent 
of all medical visits billed, which we surmise is an overstatement of 
the incidence of the lowest level clinic visit. With the implementation 
of the hospital outpatient PPS, we will require hospitals to begin 
coding medical visits with greater specificity. As a result, we expect 
to see an increase in the relative incidence of higher level medical 
visits and emergency visits and a proportional decrease in the relative 
incidence of the lowest level clinic visit. We will monitor claims by 
provider for unexplained increases in the total number of visits or in 
the proportion of visits billed at the highest levels. Use of HCPCS 
codes should conform with the CPT clinical examples of cases in each 
code level.
    Because the layout of the outpatient claim form does not allow a 
HCPCS code to be linked to more than one ICD-9-CM code, the form 
properly accounts for only one medical visit per claim. When two or 
more medical visits occur on the same day for different diagnoses, a 
separate claim would be created for each visit, showing the appropriate 
level of CPT code and the related diagnosis. We would expect this to 
occur only in those hospitals that operate many outpatient clinics 
dedicated to various conditions, such as a diabetes clinic, arthritis 
clinic, etc. Clinics in which a patient is seen for one or a number of 
conditions by one health care professional, such as in a primary care 
clinic, would bill for only one clinic visit for that encounter.
    A medical visit would not be billed simply because a patient has 
presented to a hospital for a service such as chemotherapy, cardiac 
rehabilitation, an x-ray, etc.
    We propose not to pay for a medical visit that takes place on the 
same date of service as a scheduled outpatient surgery. Registration of 
the patient, taking of vital signs, insertion of an IV, preparation for 
surgery, etc., are packaged into and paid for as part of the APC group 
to which the surgical procedure or service is classified.
    In cases where a surgical procedure or service is performed as the 
immediate result of an outpatient visit (such as the removal of skin 
lesions following a visit to a dermatology clinic) or from an emergency 
department visit, the visit would be billed with a modifier -25, 
indicating that a separately identifiable evaluation and management 
service was furnished.
    APCs 667 and 668: These groups, for cataract surgery without and 
with insertion of an IOL, should require different resources, because 
667 should not include the cost of an IOL. Because the median costs of 
the two groups are identical, we assume that hospitals were not 
correctly coding some cases. Therefore, we have reduced the median cost 
of 667 by $200 to reflect the resources associated with an IOL. We 
arrived at this figure by allowing the $150 that was allowed for an IOL 
as the ASC portion of the blended amount formerly paid, and by assuming 
that the recognition of hospitals' costs under the blend would result 
in the hospital IOL ``allowance'' being higher than the ASC's. This 
reduction will have a very small overall effect, because the services 
in APC 668 were billed more than 225 times as often as those in APC 
667. This also leads us to believe that the data we have for the 
services in APC 668 are more likely to represent accurate information.
    APC 670: This group packages payment for the acquisition costs of 
corneal tissue with the payment for the corneal transplant surgery. It 
has been brought to our attention that the costs of acquiring corneal 
tissue vary widely from one locality to another, so that packaging may 
not be a reasonable way to handle these costs. We are specifically 
soliciting comments on the issue of packaging corneal tissue costs. We 
are also soliciting suggestions for alternate ways to pay for corneal 
tissue, if the comments and supporting data we

[[Page 47570]]

receive indicate that packaging is not an appropriate way to treat 
these costs.
    APCs 761 and 762, and 791 and 792: These groups are anomalous, 
because the group entitled ``Complex'' in each case has a lower weight 
than the one entitled ``Standard.'' This has to do with the cost of the 
procedure itself compared to the cost of the radionuclide involved. We 
are working with the Society for Nuclear Medicine to correct these 
anomalies.
    APCs 902 and 903: We had very few bills for the vaccines in these 
groups (902 includes polio vaccine and DPT; 903 includes vaccines for 
rabies and plague). We are considering combining the two groups. We 
solicit comments on vaccine costs to supplement our data.
    APCs 091 and 91191: Brief psychotherapy encounters can be 
identified by either a CPT code (as in APC 091) or a low- or mid-level 
visit with a psychiatric diagnosis (APC 91191). We determined the 
median costs for these bills taken together, because we believe that 
there are no differences in the facility resources used in these 
instances. In the case of other psychiatric encounters, we believe that 
clinic services at the highest level should be the equivalent of an 
extended psychotherapy encounter. Mid- and high-level emergency room 
encounters should be billed by evaluation and management CPT codes and 
psychiatric diagnoses.
    APC 921: Although the addenda refer to this APC, in fact diabetic 
education services will be paid under the physician fee schedule, which 
will establish rates for one-on-one sessions and group sessions. The 
addenda will be corrected in the final rule. (A proposed rule titled 
``Medicare Program; Expanded Coverage for Diabetes Outpatient Self-
Management Training Services'' is under development.)
    APCs 981 and 982: These groups represent nerve and muscle tests. We 
are continuing to evaluate whether these two groups should be combined 
in the final rule, because there is very little distinction between 
them in our cost data.
    We are still examining ways to pay for drugs outside the composite 
rate for ESRD patients, and the services to be paid under our system in 
CORFs, HHAs, and hospices. These will be APCs, based on services that 
are packaged in our system.
7. Discounting of Surgical Procedures
    Under hospital outpatient PPS, we will discount payment amounts 
when more than one procedure is performed during a single operative 
session or when a surgical procedure is terminated prior to completion. 
The discount policy explained below is consistent with Medicare policy 
and regulations governing payment for physician and ASC surgical 
services.

a. Reduced Payment for Multiple Procedures

    When more than one surgical procedure (defined as those HCPCS codes 
in APC groups with status ``T'') is performed during a single operative 
session, we propose that the full Medicare payment amount and 
beneficiary copayment amount would be paid for the procedure having the 
highest APC payment rate. Fifty percent of the normal Medicare payment 
amount and beneficiary copayment amount would be paid for all other 
procedures performed during the same operative session to reflect the 
savings associated with having to prepare the patient only once and the 
incremental costs associated with anesthesia, operating and recovery 
room use, and other services required for the second and subsequent 
procedures.

b. Discounted Payment for Terminated Procedures

    Under outpatient PPS, the hospital will use modifiers to indicate 
procedures that are terminated prior to completion. Modifier-52 
(Reduced Services) is used to identify a procedure that is terminated 
after the patient has been prepared for surgery, including sedation 
when provided, and taken to the room where the procedure is to be 
performed, but before anesthesia is induced (for example, local, 
regional block(s), or general anesthesia). Fifty percent of the normal 
Medicare payment amount and beneficiary copayment amount would be paid 
for a procedure terminated before anesthesia is induced.
    Modifier-53 (Discontinued Procedure) is used to indicate that a 
surgical procedure was started but discontinued after the induction of 
anesthesia (for example, local, regional block, or general anesthesia), 
or after the procedure was started (incision made, intubation begun, 
scope inserted) due to extenuating circumstances or circumstances that 
threatened the well-being of the patient. To recognize the costs 
incurred by the hospital to prepare the patient for surgery and the 
resources expended in the operating room and recovery room, the full 
Medicare payment amount and beneficiary copayment amount would be paid 
for a procedure that was started but discontinued after the induction 
of anesthesia or after the procedure was started, as indicated by a 
modifier-53.
    The elective cancellation of procedures would not be reported. If 
multiple procedures were planned, only the procedure actually initiated 
would be billed. A pattern of canceled procedures will prompt medical 
review of the reasons for cancellation and may trigger review of the 
appropriateness of patient selection for outpatient surgery.
8. Inpatient Care
    In recent years, the distinction between inpatient and outpatient 
care has been blurred by the retention of outpatients in the hospital 
overnight, sometimes for many days in a row. Medicare paid for 
observation services while the hospital determined whether an 
outpatient needed admission for further treatment. Frequently, the 
patients did not understand that they were not inpatients until they 
were billed for 20 percent of outpatient charges as copayment. In 
November 1996, we put in place a policy limiting outpatient observation 
services to a maximum of 48 hours. We made clear at that time that 
observation was not a means to make it possible to perform inpatient 
surgery on an outpatient basis, nor was it appropriate to retain 
chemotherapy patients in long-term observation. Because observation is 
not provided as the sole service a patient receives, we packaged costs 
associated with observation into the median costs for the services, for 
example, surgery or chemotherapy, with which they were furnished in 
1996.
    There are procedures that, by their nature, require inpatient care. 
Open abdominal surgery requires a postoperative recovery period, for 
example, to ensure that bowel function resumes. Certain major surgeries 
require monitoring in an intensive care unit until the patient's 
neurological or other function returns. Yet other surgeries involve 
large or delicate surgical wounds that require monitoring, skilled 
dressing changes, and fluid replacement. These procedures obviously 
require inpatient care, and performing them on an outpatient basis 
would clearly jeopardize patient health and safety. Other procedures 
are not as clearly defined as inpatient, but we have classified them as 
inpatient because they are performed on an inpatient basis virtually 
all the time for the Medicare population, either because of the 
invasive nature of the procedures, the need for postoperative care, or 
the underlying physical condition of the patient who would require such 
surgery. These procedures are not classified in an outpatient APC 
group, and no payment is provided for these procedures under the 
hospital

[[Page 47571]]

outpatient PPS. We will deny payment for claims that are submitted for 
these procedures furnished as outpatient services because performing 
these procedures on an outpatient basis is not safe or appropriate, and 
therefore not reasonable and necessary under Medicare rules. Because we 
base these denials on the exclusion in section 1862(a)(1)(A) of the Act 
and in Sec. 411.15(k)(1), beneficiaries may be protected from liability 
by the limitation on liability provision of section 1879 of the Act.
    The procedures that we consider appropriate and safe only in an 
inpatient setting and for which we are excluding payment under the 
hospital outpatient PPS are listed in Addendum H to enable hospitals to 
make appropriate site of care decisions. This list represents national 
Medicare policy and is binding on fiscal intermediaries and peer review 
organizations, as well as on hospitals and Medicare participating ASCs.
    We acknowledge that we have classified in outpatient APC groups 
some procedures that may seem closely related to procedures that we are 
excluding from the outpatient PPS on the basis of their status as 
inpatient procedures. We expect that when the former are performed in 
the outpatient setting, they will be only the simplest, least intense 
cases. The fact that a service is included in an APC group under the 
hospital outpatient PPS should not be construed to mean that the 
procedure may only be performed in an outpatient setting. In every 
case, we expect the surgeon and the hospital to assess the risk to the 
individual patient and to act in that patient's best interests.

C. Calculation of Group Weights and Rates

1. Group Weights
    Section 1833(t)(2)(C) of the Act requires the Secretary to develop 
relative payment weights for covered groups of hospital outpatient 
services. The statute requires that such weights be developed using 
1996 hospital outpatient claims and the most recent available hospital 
cost reports. We are required to base these weights on median hospital 
costs. In constructing the database to model the outpatient PPS 
proposal, we used a universe of approximately 98 million calendar year 
1996 final action claims for hospital outpatient department services 
received through June 1997 to match to the most recent hospital cost 
reports available.
    To derive weights based on median hospital costs for services in 
the hospital outpatient APC groups, we needed to convert billed charges 
to costs and aggregate them to the procedure or visit level. To do 
this, we first identified the cost-to-charge ratio that was specific to 
each hospital's cost centers (``cost center specific cost-to-charge 
ratios'' or CCRs). We then developed a crosswalk to match the 
hospital's CCRs to revenue centers used on the hospital's 1996 
outpatient bills. The CCRs included operating and capital costs but 
excluded costs associated with direct graduate medical education and 
allied health education. (Medicare payment for direct graduate medical 
education is made as a pass-through under the inpatient PPS and 
includes the costs associated with approved educational activities for 
residents assigned to the hospital's outpatient department. We discuss 
in elsewhere in this proposed rule how we would make payment for allied 
health education.)
    Our next task was to identify each hospital's most recent available 
cost report from which to determine the hospital's CCRs. Because there 
is generally a 2-year lag between claims adjudication and cost report 
filing, the most recent cost reports that we could expect to be 
available to associate with calendar year 1996 claims were those from 
PPS-12 (cost reporting periods beginning on or after October 1, 1994 
and before October 1, 1995). We searched the PPS-12 period first to 
match the 1996 final action claims to a cost report. If we achieved a 
match, no other action was needed. However, if no match was found, we 
next searched for a cost report in the PPS-11 period and subsequently 
in the PPS-10 period, if necessary.
    If the most recent available cost report that we used for a 
provider was one that had been submitted but not settled, we calculated 
an adjustment factor to adjust for the differences that exist between 
settled and ``as submitted'' cost reports. We determined the adjustment 
factor by dividing the outpatient department cost-to-charge ratio from 
the hospital's most recent settled cost report by the outpatient 
department cost-to-charge ratio from the hospital's ``as submitted'' 
cost report for the same period. We used the resulting ratio to adjust 
each of the CCRs in the hospital's most recent ``as submitted'' cost 
report. We repeated this process for every hospital for which the most 
recent available cost report was a cost report that had not been 
settled.
    The Office of Inspector General (OIG) is concerned that the cost 
reports we are using may reflect some unallowable costs. Therefore, the 
OIG, in conjunction with HCFA, is proposing to examine the extent to 
which the cost reports used reflect costs that were inappropriately 
allowed. If this examination reveals excessive inappropriate costs, we 
would address this issue in a future proposed rule, or perhaps seek 
legislation to adjust future payment rates downward.
    When this process was completed, we were able to match revenue 
centers from approximately 83 million claims to CCRs of approximately 
5,600 hospitals. We excluded from the crosswalk approximately 15 
million claims in which the bill type denoted services that would not 
be covered under the PPS, for example, bill type 72X for dialysis 
services for patients with ESRD. The table below shows the three cost 
reporting periods we used and the percentage of the cost reports within 
each PPS period with which we were able to match 1996 claims. The most 
recent cost reports available to us were from the hospital inpatient 
PPS-12 period, and 95.8 percent of the most recent cost reports 
available to us matched the 1996 claims that we are required to use as 
the basis for establishing relative payment weights for the APC groups 
in the outpatient PPS.

------------------------------------------------------------------------
                                                              Percentage
                                                                of cost
                      Reporting period                          reports
                                                                matched
------------------------------------------------------------------------
PPS-12 (cost reporting period beginning on or after 10/1/94
 and before 10/1/95)........................................        95.8
PPS-11 (cost reporting period beginning on or after 10/1/93
 and before 10/1/94)........................................         3.7
PPS-10 (cost reporting period beginning on or after 10/1/92
 and before 10/1/93)........................................         0.5
                                                             -----------
                                                                   100.0
------------------------------------------------------------------------

    We next separated the estimated 83 million claims that we had 
matched with a cost report into two distinct groups: single-procedure 
claims and multiple-procedure claims. Single-procedure claims are those 
for which the HCPCS to be grouped to an APC is the only code that 
appears on the bill, other than laboratory and incidentals such as 
venipuncture. Multi-procedure claims included more than one HCPCS code 
that could be mapped to an APC. There were approximately 37 million 
single-procedure claims and 46 million multiple-procedure claims.
    To calculate median costs for services within an APC, we used only 
the single-procedure bills. (Of the roughly 37 million single-procedure 
claims, about 11 million were excluded from the conversion process 
largely because the only HCPCS codes reported on the claims were for 
laboratory procedures.)

[[Page 47572]]

This approach was taken because of our inability to specifically 
allocate charges or costs for packaged items and services such as 
anesthesia, recovery room, drugs, or supplies to a particular procedure 
when more than one significant procedure or medical visit was billed on 
a claim. Use of the single-procedure bills minimizes the risk of 
improperly assigning costs to the wrong procedure or visit. Although 
single-procedure/visit bills were used for determining APC relative 
payment weights, the multiple-procedure bills were used in the service 
mix calculations, regressions, and impact analyses.
    For each single-procedure claim, we calculated a cost for every 
billed line item charge by multiplying each revenue center charge by 
the appropriate hospital-specific CCR. If the appropriate cost center 
did not exist for a given hospital, we crosswalked the revenue center 
to a secondary cost center when possible, or to the hospital's overall 
cost-to-charge ratio for outpatient department services. We excluded 
from this calculation all charges associated with HCPCS codes 
previously defined as noncovered under this PPS, for example, 
laboratory, ambulance, and therapy services.
    To calculate the per-procedure or per-visit costs, we used the 
charges shown in the revenue centers that contained items integral to 
performing the procedure or visit. These included those items that we 
previously discussed as being subject to our proposed packaging 
provision. For example, in calculating the surgical procedure cost, we 
included charges for the operating room, treatment rooms, recovery, 
observation, medical and surgical supplies, blood, pharmacy, 
anesthesia, cast and splints, and donor tissue, bone, and organ. For 
medical visit cost estimates, we included charges for items such as 
medical and surgical supplies, drugs, observation, and blood. A 
complete listing of the revenue centers we used is included elsewhere 
in this preamble.
    To standardize costs for geographic wage variation, we divided the 
labor-related portion of the operating and capital costs for each 
billed item by the hospital inpatient prospective payment system wage 
index published in the Federal Register on May 8, 1998 (63 FR 25575). 
We used 60 percent to represent our estimate of that portion of costs 
attributable, on average, to labor, but this factor is sensitive to 
other payment adjustments. Therefore, we will restandardize costs in 
the final rule using FY 1999 hospital inpatient PPS wage index values 
and the final labor market share value. A more detailed discussion of 
wage index adjustments is found below (section V.E. of this document).
    We then added the standardized labor-related cost to the non-labor-
related cost component for each billed item to derive the total 
standardized cost for each procedure or medical visit. We trimmed 
standardized procedure and visit costs to remove extremely unusual 
costs that appeared to be errors in the data. The trimming methodology 
is analogous to that used in calculating the DRG weights for the 
inpatient PPS: any bills with costs outside of 3 standard deviations 
from the geometric mean were eliminated. The geometric mean and the 
associated standard deviation are used because the distribution of 
costs more closely resembles a lognormal distribution than a normal 
distribution: there are no negative costs, and the average cost is 
greater than the median cost. Using the geometric mean has the effect 
of minimizing the impact of the most unusual bills in the determination 
of the mean. The geometric mean is calculated by taking the mean of the 
natural logarithm cost. Since the distribution of the natural 
logarithms of a set of numbers is more compact than the distribution of 
the numbers themselves, bills with extreme costs do not appear as 
extreme as they would if non-logged costs were examined. This ensures 
that only the most unusual data will be removed from the calculation.
    After we trimmed the procedure and visit level costs, we mapped 
each procedure or visit cost to its assigned APC. We calculated the 
median cost for each APC weighted by procedure volume.
    Using these median APC costs, we then calculated the relative 
payment weights for each APC. We decided to scale all the relative 
payment weights to APC 91336, a mid-level clinic visit for 
cardiovascular services because it is one of the most frequently 
performed services. This approach is consistent with that used in 
developing relative value units for the Medicare physician fee 
schedule. By assigning APC 91336 a relative payment weight of ``1.0,'' 
hospitals can easily compare the relative relationship of one APC to 
another. Next, we divided the median cost for each APC by the median 
cost for APC 91336 to derive the relative payment weight for each APC.
2. Conversion Factor
    Section 1833(t)(3)(C)(i) of the Act requires that we establish a 
conversion factor for 1999 to determine the Medicare amounts for each 
covered group of services. The statute mandates that the conversion 
factor be established on the basis of the weights and aggregate 
projected utilization for 1999 and based on the base amount of payments 
described in section 1833(t)(3)(A) of the Act. Such base amount is 
calculated for the services included in the outpatient PPS, as an 
estimate of the sum of (1) total payments that would be payable from 
the Trust Fund under the current (non-PPS) payment system in 1999 plus 
(2) the beneficiary copayments that would have been made under the new 
(PPS) system in 1999. Section 1833(t)(3)(C)(ii) of the Act further 
requires that the Medicare amount take into account all appropriate 
adjustments.
    Although section 1833(t)(2)(C) of the Act requires us to project 
utilization for hospital outpatient services, we were unable to project 
precisely increases in the volume and intensity of services because we 
were not able to quantify some of the factors that affect utilization. 
For instance, we would anticipate that Medicare beneficiaries that 
choose to migrate to managed care plans may be healthier than those who 
choose to stay in fee-for-service plans. Thus, we could assume a 
decrease in the volume of services but an increase in the intensity of 
services furnished for Medicare beneficiaries enrolled in fee-for-
service plans. Another factor that we believe will affect future 
utilization is the incentive to code HCPCS accurately to receive 
payment. Currently, hospitals are paid for the majority of the 
outpatient services they furnish on a cost basis. Claims without a 
HCPCS or an invalid HCPCS are not always rejected. In contrast, under 
the new PPS, hospitals would be required to use HCPCS codes and, for 
medical visits and emergency room services, ICD-9 codes, in order to 
receive payment. We expect that frequencies may increase as a result of 
the coding requirements. All in all, these are factors we believe will 
affect the reporting of volume and intensity of services, but we were 
not able to quantify these assumptions individually to project 1999 
utilization. Therefore, we used what we believe to be a more reliable 
and valid approach to computing the conversion factor under the 
methodology described below.

Setting the Rates

    In order to convert the relative weights determined for each APC 
(see previous section) into payment rates, we calculated a conversion 
factor that would result in payments to hospitals under the PPS in 1999 
equaling the total projected payment specified in section 1833(t)(3)(A) 
of the Act. The prospective payment rate set for each APC is

[[Page 47573]]

calculated by multiplying the APC's relative weight by a conversion 
factor. We computed the conversion factor by first adding together for 
calendar year 1996 the aggregate Medicare hospital outpatient payments 
paid under the current cost-based payment system (referred to in this 
section as current law payments) plus the estimated beneficiary 
copayment amounts that would be paid under the outpatient PPS for the 
same services. We then divided that amount by the sum of the relative 
weights for all APCs under the hospital outpatient PPS. The methodology 
we followed to determine current law Medicare hospital outpatient 
payments and beneficiary copayments is discussed in section V.C.2.a., 
below, which is followed in section V.C.2.b. by a discussion of the sum 
of the relative weights.

a. Calculating Aggregate Calendar Year 1996 Medicare and Beneficiary 
Payments for Hospital Outpatient Services (Current Law)

    First, to calculate Medicare hospital outpatient payment amounts 
under current law (that is, before PPS), we identified calendar year 
1996 single and multiple procedure bills for all the services that we 
will recognize under the outpatient PPS. As we identified services that 
will be paid under the outpatient PPS, we eliminated invalid or 
noncovered HCPCS codes.
    Hospital payments include both operating and capital costs for the 
HCPCS coded services for which payment is to be made under the 
outpatient PPS. We summed both of these types of costs by HCPCS at the 
provider level. Summarizing the data in this manner allows us to 
simulate provider payment on an aggregate basis. We then applied the 
legislated capital cost reductions of 10 percent and operating cost 
reductions of 5.8 percent, as required by section 4522 of the BBA.
    We determined for each HCPCS code the applicable payment 
methodology under current law. We then calculated current law payment 
for procedures in the baseline using one of the following equations, as 
appropriate:
     For radiology procedures paid for under the radiology fee 
schedule, payment is determined in the aggregate for each provider as 
the lower of cost, charge, or blended amount. The radiology blended 
amount is determined by the following equation:

(0.42  x  lower of cost or charge minus beneficiary copayment) + (0.58 
x  ((0.62  x  global physician fee schedule amount)-beneficiary 
copayment))

     For surgical procedures for which Medicare pays an ASC 
facility fee, payment is determined in the aggregate for each provider 
as the lower of the cost, charge, or blended amount. The ASC blended 
amount is determined by the following equation:

(0.42  x  lower of cost or charge minus beneficiary copayment) + (0.58 
x  (ASC payment rate-beneficiary copayment))

     For diagnostic procedures paid under the diagnostic fee 
schedule, payment is determined in the aggregate for each provider as 
the lower of cost, charge, or blended amount. The blended amount is 
determined by the following equation:

(0.50  x  lower of cost or charge minus beneficiary copayment) + (0.50 
x  ((0.42  x  global physician fee schedule amount)-beneficiary 
copayment))

    For all other covered services not subject to one of the blended 
payment method categories, payment is determined to be the lower of 
costs or charges less beneficiary copayment. Because the formula-driven 
overpayment (FDO) was corrected beginning October 1, 1997, the blended 
equations eliminate FDO.
    We then determined each provider payment. We summed the aggregate 
amounts computed for each of the four types of payment methodologies 
discussed above to determine the Medicare payment amount for each 
provider. In addition, we also determined the amount of the beneficiary 
copayment for each provider using the beneficiary copayment amounts 
that would be paid under the PPS. Summing both the Medicare payment and 
the beneficiary copayment amounts at the provider level is necessary in 
order to determine the impact of the outpatient PPS on individual 
hospitals. In addition to calculating provider payments under the 
current law and PPS payment systems, we calculated the aggregate 
Medicare payments under the current system and beneficiary copayments 
under the PPS for all hospitals for services that are within the scope 
of the outpatient PPS. The total amount reflects the amount hospitals 
would be paid under the PPS in accordance with section 1833(t)(3)(A) of 
the Act and is the numerator in the equation for calculating the 
unadjusted conversion factor.

b. Sum of the Relative Weights

    Next we summed the relative weights. Specifically, we multiplied 
the volume of procedures or visits (excluding the volume of packaged 
services) for each group by the relative weights for each group. We 
then calculated the conversion factor by dividing the sum of the volume 
multiplied by the relative weights for each APC into the total payment 
explained above, including both Medicare payment and beneficiary 
copayment. The calendar year 1996 conversion factor is $46.32. To trend 
forward the 1996 conversion factor to 1999, HCFA's Office of the 
Actuary estimated an update factor of 1.0939. The update factor 
represents the estimated per service increase in outpatient Medicare 
payments and beneficiary copayment between 1996 and 1999 net of changes 
in the volume and intensity of services. Medicare payments per service 
were increased by projected CPI-medical items for cost-based services 
and for blend services mandated updates. Beneficiary copayments were 
increased by projected increases in CPI-outpatient charges. In 
estimating the update factor, HCFA's Office of the Actuary assumed that 
using the national median of the charges for PPS services to establish 
the unadjusted copayment amount would result in beneficiaries paying 
6.9 percent less in coinsurance payments in 1999 than what they would 
have been expected to pay otherwise, which would create an incentive 
for a behavioral offset by hospitals of 10 percent of the coinsurance 
reduction. It was assumed that 45 percent of this offset would apply to 
the services subject to the PPS and, therefore, would be included in 
setting the 1999 conversion factor. The remaining 55 percent of the 
offset would be reflected in expenditures for non-PPS services with 
both the beneficiary and Medicare absorbing this impact. The adjusted 
1999 conversion factor is $50.67.

D. Calculation of Medicare Payment Amount and Copayment Amount

1. Introduction
    In the previous section, section V.C, we explain how we determined 
national prospective payment rates, standardized for area wage 
variations, for the APC groups. In this section, we explain how we are 
proposing to calculate Medicare program payment amounts and beneficiary 
copayment amounts for each APC group.
    Under the statutory provision currently in effect, copayment for 
hospital outpatient department services is based on 20 percent of the 
hospital's billed charges. Because most hospital outpatient services 
have been paid, at least in part, on the basis of retrospectively 
calculated cost, Medicare payment amounts for most

[[Page 47574]]

hospital outpatient services are not known at the time the services are 
furnished. For that reason, coinsurance could not be based on 20 
percent of the payment amount. Accordingly, the statute required that 
copayment be based on 20 percent of charges. Because charges for 
hospital outpatient services have increased faster than costs for those 
services, beneficiaries' copayments of 20 percent of charges have, for 
some services, accounted for 50 percent or more of the total (Medicare 
program plus beneficiary) payments to the hospitals. Because of 
extensive secondary insurance coverage, a large share of the copayments 
made to hospitals is not direct out-of-pocket expenditures by the 
beneficiaries. There has, however, been concern that premiums for 
Medigap policies may be affected by the growing copayment liability. In 
addition, copayments most directly affect those beneficiaries who do 
not have supplemental insurance. This group of beneficiaries cannot 
afford to purchase supplemental insurance, and high copayment rates can 
be a hardship for those needing services. The outpatient PPS created by 
section 4523 of the BBA, which added section 1833(t) to the Act, 
includes a mechanism that is designed to eventually achieve a 
beneficiary copayment level equal to 20 percent of the prospectively 
determined payment rate that has been established for the service.
    MedPAC Comment: In its March 1998 report to the Congress, MedPAC 
expresses concern about the inequity represented by the current level 
of beneficiary copayment liability, which generally exceeds 20 percent 
of the total payment to hospitals for outpatient services. MedPAC, 
recognizing that immediate beneficiary copayment reductions to 20 
percent of payments made to hospitals would result either in 
unacceptable increases in program outlays and/or unacceptable 
reductions in payments to hospitals, agrees with the need for a phased-
in approach to the copayment reductions. However, MedPAC recommends 
that the Congress specify a shorter timeframe than that which results 
from the provisions of the BBA to phase in fully the appropriate 
beneficiary copayment contribution of 20 percent for hospital 
outpatient services paid for under the outpatient PPS.
    Response: While we do not disagree with MedPAC's recommendation 
with respect to beneficiary copayment, because of the budgetary 
implications and the existing statutory requirements resulting from the 
BBA, implementation of this recommendation would ultimately require 
action by the Congress.
    The next sections describe the steps that we followed in accordance 
with statutory requirements to determine the beneficiary copayment 
amount and the Medicare program payment amount for services paid for 
under the hospital outpatient PPS.
2. Determination of Unadjusted Copayment Amount, Program Payment 
Percentage, and Copayment Percentage
    In order to calculate program payment amounts and beneficiary 
copayment amounts, we first determined for each APC group two base 
amounts, in accordance with statutory provisions:
     An unadjusted copayment amount, described in section 
1833(t)(3)(B) of the Act.
     The ``pre-deductible payment percentage,'' which we call 
the program payment percentage, described in section 1833(t)(3)(E).
    The steps that we followed to calculate these two base amounts for 
each APC group are explained below.
    (a) Calculate the unadjusted copayment amount for each APC group.
    (i) Determine the national median of the charges billed in 1996 for 
the services that constitute the APC group after standardizing charges 
for geographic variations attributable to labor costs. (To make the 
labor adjustment, we divided the portion of each charge that we 
estimated was attributable to labor costs (60 percent) by the 
provider's hospital inpatient wage index value, and we added the result 
to the non-labor portion of the charge (40 percent). Section V.F. 
provides a detailed discussion of the adjustments made within the 
outpatient PPS to offset regional differences in labor costs.)
    (ii) Update charge values to projected 1999 levels by multiplying 
the 1996 median charge for the APC group by 29.2 percent, which the 
HCFA Office of the Actuary estimates to be the rate of growth of 
charges between 1996 and 1999.
    (iii) Multiply the estimated 1999 national median charge for the 
APC group by 20 percent, which becomes the unadjusted copayment amount 
for the APC group. The unadjusted copayment amount is frozen at the 
1999 level until such time as the program payment percentage (see 
below) equals or exceeds 80 percent (section 1833(t)(3)(B)(ii) of the 
Act).
    (b) Calculate the program payment percentage (pre-deductible 
payment percentage). In this proposed rule, we use the term program 
payment percentage to replace the term ``pre-deductible payment 
percentage,'' which is referred to in section 1833(t)(3)(E) of the Act. 
The program payment percentage is calculated annually for each APC 
group, until the value of the program payment percentage equals 80 
percent. To determine the program payment percentage for each APC 
group, we followed these steps:
    (i) Subtract the APC group's unadjusted copayment amount from the 
payment rate set for the APC group;
    (ii) Divide the difference [(APC payment rate) minus (unadjusted 
copayment amount)] by the APC payment rate, and multiply by 100. The 
resulting percentage is the program payment percentage.
    Calculation of the program payment percentage allows us to 
determine a ``copayment percentage,'' which equals the difference 
between the program payment percentage and 100 percent. As the program 
payment percentage for an APC group approaches 80 percent due to annual 
market basket increases of the APC payment rates, the copayment 
percentage, conversely, approaches 20 percent, which is ultimately the 
target copayment percentage for all services paid for under the 
hospital outpatient PPS. When the copayment percentage equals 20 
percent of the APC payment rate, we consider the copayment amount for 
that APC to be fully phased in at the standard Medicare copayment 
level, as we explain in the next section.
3. Calculation of Medicare Payment Amount and Beneficiary Copayment 
Amount
    a. Calculate the Medicare payment amount. A Medicare payment amount 
is calculated for every APC group. The Medicare payment amount takes 
into account wage index and other applicable adjustments and applicable 
beneficiary deductible amounts. The Medicare payment amount calculated 
for an APC group applies to all the services that are classified within 
that APC group. The Medicare payment amount for a specific service 
classified to an APC group under the outpatient PPS is calculated as 
follows:
    (i) Apply to the national payment rate that is set annually for 
each APC group the appropriate wage index adjustment (see section V.E. 
for a discussion of how national APC rates are to be adjusted for 
geographic wage differences) and any other adjustments applicable to 
the provider;
    (ii) Subtract from the adjusted APC group payment rate the amount 
of any applicable deductible as provided under Sec. 410.160; and
    (iii) Multiply the adjusted APC group payment rate, from which the 
applicable

[[Page 47575]]

deductible has been subtracted, by the program payment percentage 
determined for the APC group or 80 percent, whichever is lower. The 
result is the Medicare payment amount.
    b. Calculate the copayment amount.
    A copayment amount is calculated annually for each APC group. The 
copayment amount calculated for an APC group applies to all the 
services that are classified within the APC group. The copayment amount 
for an APC is calculated as follows:

    Subtract the APC group's Medicare payment amount from the 
adjusted APC group payment rate less deductible, for example, 
COPAYMENT AMOUNT equals [(adjusted APC group payment rate less 
deductible) minus (APC group Medicare payment amount). The resulting 
difference is the beneficiary copayment amount.

    Again, as soon as the Medicare program payment percentage of an 
adjusted APC payment rate less deductible equals or exceeds 80 percent, 
we set the copayment amount at 20 percent of the adjusted APC group 
payment rate, and we consider the standard Medicare 20 percent 
copayment level to be fully phased in for that APC group (section 
1833(t)(3)(B)(ii) of the Act). Thereafter, for those APC groups whose 
program payment percentage has become 80 percent of the APC payment 
rate (and whose copayment percentage is 20 percent), the unadjusted 
copayment amount for the APC ceases to be frozen at the 1999 level. The 
copayment amount for the APC group is permanently established at 20 
percent of the adjusted APC group payment rate. Because the copayment 
amount is now tied directly to the APC payment rate, the copayment 
dollar amount increases as annual updates increase the APC group 
payment rate.
    For example, assume that the wage-adjusted payment rate for an APC 
is $300; the program payment percentage for the APC group is 60 
percent; the wage-adjusted copayment amount for the APC group is $120; 
and the beneficiary has not yet satisfied any portion of his or her 
annual $100 deductible.

(A) Adjusted APC payment rate: $300
(B) Subtract the applicable deductible: $300 - $100 = $200
(C) Multiply the remainder by the program payment percentage to 
determine the Medicare payment amount: 0.6  x  $200 = $120
(D) Subtract the Medicare payment amount from the adjusted APC payment 
rate less deductible to determine the copayment amount: $200 - $120 = 
$80

    In this case, the beneficiary pays a deductible of $100 and an $80 
copayment. The program also pays $120, for a total payment to the 
hospital of $300. Applying the program payment percentage ensures that 
the program and the beneficiary pay the same proportion of payment that 
they would have paid if no deductible were taken.
    In the event that the annual deductible has already been satisfied, 
the calculation runs as follows:

(A) Adjusted APC payment rate: $300
(B) Subtract the applicable deductible: N/A
(C) Multiply by the program payment percentage to determine the 
Medicare payment amount: 0.6  x  $300 = $180
(D) Subtract the Medicare payment amount from the adjusted APC payment 
rate less deductible to determine the copayment amount: $300 - $180 = 
$120

    In this case, the beneficiary makes a $120 copayment. The program 
also pays $180, for a total payment to the hospital of $300.
4. Hospital Election To Offer Reduced Copayment
    The transition to the standard Medicare copayment rate (20 percent 
of the wage-adjusted APC payment rate) will obviously be gradual. For 
those APC groups for which copayment is currently a relatively high 
proportion of the total payment, the process will be correspondingly 
lengthy. Therefore, the Act offers hospitals the option of electing to 
reduce copayment amounts and allows the hospital to advertise these 
reduced rates. In this section, we discuss the procedure by which 
hospitals can elect to offer a reduced copayment amount, and the effect 
of such election on calculation of the program payment and beneficiary 
copayment.
    Section 1833(t)(5)(B) of the Act requires the Secretary to 
establish a procedure under which a hospital, before the beginning of a 
year, may elect to reduce the copayment amount otherwise established 
for some or all hospital outpatient department services to an amount 
that is not less than 20 percent of the hospital outpatient prospective 
payment amount. The statute further provides that the election of a 
reduced copayment amount will apply without change for the entire year, 
and that the hospital may advertise its reduced copayment levels. 
Section 1833(t)(5)(C) of the Act provides that deductibles cannot be 
waived. Finally, section 1861(v)(1)(T) of the Act (as established by 
section 4451 of the BBA) provides that no reduction in copayment 
elected by the hospital under section 1833(t)(5)(B) may be treated as a 
bad debt.
    In this rule, we are proposing that a hospital may make the 
election to reduce copayments on a calendar year basis. The hospital 
must notify its fiscal intermediary of its election to reduce 
copayments no later than 90 days prior to the start of the calendar 
year. This 90-day notification requirement is necessary in order to 
give the intermediaries sufficient time to make the systems changes 
required to implement the hospital's election. The hospital's 
notification must be in writing. It must specifically identify the APC 
groups to which the hospital's election will apply and the copayment 
level (within the limits identified below) that the hospital has 
selected for each group. The election of reduced copayment must remain 
in effect unchanged during the year for which the election was made. 
The hospital may advertise and otherwise disseminate information 
concerning the reduced level of copayment that it has elected.
    We also are proposing that a hospital may elect to reduce the 
copayment amount for any or all APC groups. A hospital may not elect to 
reduce the copayment amount for some, but not all, services within the 
same APC group.
    A hospital may not elect for an APC group a copayment amount that 
is less than 20 percent of the adjusted APC payment rate for that 
hospital. In determining whether to make such an election, hospitals 
should note that the national copayment amount under this system, based 
on 20 percent of national median charges for each APC, may yield 
copayment amounts that are significantly higher or lower than the 
copayment that the hospital has previously collected. This is because 
the median of the national charges for an APC group, from which the 
copayment amount is ultimately derived, may be higher or lower than the 
hospital's historic charges. We, therefore, advise that hospitals, in 
determining whether to exercise the option of electing lower copayment 
and the level at which to make the election, carefully study the annual 
copayment amounts for each APC group in relation to the copayment 
amount that the hospital has previously collected.
    Calculation of copayment amounts on the basis of a hospital's 
election of reduced copayment for the most part follows the formula 
described previously. For example, assume that the adjusted APC payment 
rate is $300; the program payment percentage for the

[[Page 47576]]

APC group is 60 percent; the hospital has elected a $60 adjusted 
reduced copayment amount for the APC group; and the beneficiary has not 
satisfied the annual deductible.

(A) Adjusted APC payment rate: $300
(B) Subtract the applicable deductible: $300 - $100 = $200
(C) Multiply by the program payment percentage to determine the 
Medicare payment amount: 0.6  x  $200 = $120
(D) Beneficiary's copayment is the difference between the APC payment 
rate reduced by any deductible amount and the Medicare payment amount, 
but not to exceed the adjusted reduced copayment amount: $200 - $120 = 
$80 (limited to $60 because of the hospital-elected reduced copayment 
amount)

    In this case, Medicare makes its regular payment of $120, but the 
beneficiary pays a $100 deductible and a reduced copayment amount of 
$60, for a total payment to the hospital of $280 instead of the $300 
that the hospital would have received if it had not made its election.

E. Adjustment for Area Wage Differences

1. Proposed Wage Index
    Section 1833(t)(2)(D) of the Act requires that, as part of the 
methodology for determining prospective payments to hospitals for 
outpatient services, the Secretary must determine a wage adjustment 
factor to adjust the portion of payment and copayment attributable to 
labor-related costs for relative differences in labor and labor-related 
costs across geographic regions in a budget-neutral manner.
    To determine which wage adjustment factor to incorporate into the 
hospital outpatient department PPS, we considered several options. One 
choice would be to use a wage index specific to hospital outpatient 
department labor costs. However, the Congress did not require us to nor 
did we have either the time or resources necessary to construct a 
hospital-outpatient-department-specific wage index.
    We next considered the hospital inpatient PPS wage index that HCFA 
maintains under the Medicare program. The hospital inpatient PPS wage 
index is well established, and it is constructed specifically for the 
purpose of ``reflecting the relative hospital wage level in the 
geographic area of the hospital compared to the national average 
hospital wage level'' (section 1886(d)(3)(E) of the Act), a requirement 
that is analogous to that set forth under the hospital outpatient 
department PPS in section 1833(t)(2)(D) of the Act. The data upon which 
the hospital inpatient PPS wage index is based are collected from 
Medicare cost reports, and the wage index is updated annually. Any 
changes in hospital inpatient PPS wage index values must be made in 
such a manner as to assure budget neutrality (section 1886(d)(3)(E) of 
the Act). The hospital inpatient PPS wage index for fiscal year 1998 
reflects the following:
     Total salaries and hours from short-term, acute care 
hospitals.
     Home office costs and hours.
     Fringe benefits associated with hospital and home office 
salaries.
     Direct patient care contract labor costs and hours.
     The exclusion of salaries and hours for nonhospital type 
services such as SNF services, home health services, or other 
subprovider components that are not subject to the PPS.
    A detailed description of the fiscal year 1999 hospital inpatient 
PPS wage index is contained in the proposed rule entitled ``Changes to 
the Hospital Inpatient Prospective Payment Systems and Fiscal Year 1999 
Rates (HCFA-1003-P)'' published in the Federal Register on May 8, 1998 
(63 FR 25575).
    We decided that using the hospital inpatient PPS wage index as the 
source of an adjustment factor for geographic wage differences for the 
hospital outpatient department PPS was both reasonable and logical, 
given the inseparable, subordinate status of the outpatient department 
within the hospital overall. We then had to determine which version of 
the hospital inpatient PPS wage index to use. There are several 
possible wage indices that can be developed from the basic wage and 
salary data taken from hospital cost reports, depending on changes that 
are applied to the data. One modification takes into account the effect 
of hospital redesignation under 1886(d)(8)(B) of the Act and hospital 
reclassification under 1886(d)(10). A second modification results from 
assigning to an urban hospital the statewide rural wage index value for 
the State in which that hospital is located when the wage index of the 
urban hospital would otherwise be lower than the statewide rural wage 
index value (the ``floor''). (In fiscal year 1998, this particular 
``hold harmless'' provision affected 128 hospitals in 32 metropolitan 
statistical areas (MSAs).) Given the choice between the wage index that 
we use under the hospital inpatient PPS, which reflects 
reclassification and other changes, and a wage index that does not 
incorporate these changes, we are proposing to adopt the wage index 
that is used to determine payments to hospitals under the hospital 
inpatient PPS to adjust for relative differences in labor and labor-
related costs across geographic areas under the hospital outpatient 
department PPS. We note that hospital outpatient department services do 
not fall under the category of either ``nonhospital type services'' or 
of ``other subprovider components,'' which are excluded from 
consideration in developing the hospital inpatient PPS wage index. We 
also note that because hospital staff frequently provide services in 
both the inpatient and outpatient departments, labor costs associated 
with hospital outpatient department services are generally reflected in 
the hospital wage and salary data that are the basis of the hospital 
inpatient PPS wage index.
    By statute, we implement the annual updates of the hospital 
inpatient PPS on a fiscal year basis. However, updates to the hospital 
outpatient department PPS will be made on a calendar year basis. We are 
proposing to update the wage index values used to calculate hospital 
outpatient department PPS Medicare payment and beneficiary copayment 
amounts on a calendar year basis. In other words, the hospital 
inpatient PPS wage index values that are updated annually on October 1 
will be implemented for the hospital outpatient department PPS on the 
January 1 immediately following. We are proposing this schedule so that 
wage index changes are implemented concurrently with any other 
revisions, such as changes in the APC groups resulting from new or 
deleted CPT codes, that are implemented on a calendar year basis.
2. Labor-Related Portion of Hospital Outpatient Department PPS Payment 
Rates
    In calculating payments to hospitals under the hospital inpatient 
PPS, the labor-related portion of expenses within the standardized 
amounts used to establish the prospective payment rates is multiplied 
by the hospital wage index value to offset regional wage differences. 
The fiscal year 1998 labor-related portion under the hospital inpatient 
PPS is 71.1 percent. The manner in which this portion was calculated is 
explained in detail in the August 29, 1997 Federal Register (62 FR 
45993). We note that compensation for wages, salaries, and employee 
benefits accounts for 61.4 percent of expenses, with the other 9.7 
percent attributable to professional fees, postal services, and all 
other labor-intensive services, as explained in the August 29, 1997 
Federal Register (62 FR 45995).

[[Page 47577]]

    Current ASC payment rates are standardized for regional wage 
differences, and carriers adjust the base rates to calculate payments 
to individual facilities by multiplying the labor-related portion of 
the base rate by the appropriate hospital inpatient PPS wage index 
factor. The labor-related portion of current ASC payment rates is 34.45 
percent based on 1986 ASC survey data.
    Because of the sequence of steps that we followed to construct the 
hospital outpatient department services PPS database, we had to 
estimate the percentage of hospital outpatient department costs 
attributable to labor in order to standardize hospital outpatient 
department costs for geographic wage differences. We decided that 60 
percent represented a reasonable estimate of outpatient costs 
attributable to labor, as it falls between the hospital inpatient PPS 
operating cost labor factor of 71.1 percent and the ASC labor factor of 
34.45 percent and is within a percentage point of the labor-related 
costs under the hospital inpatient operating cost PPS attributed 
directly to wages, salaries, and employee benefits (61.4 percent) under 
the rebased 1992 hospital market basket that was used to develop the 
fiscal year 1997 update factor for inpatient PPS rates (published 
August 30, 1996 at 61 FR 46187). In addition to considering what 
percentage of costs is attributed to labor by other payment systems, we 
considered health care market factors such as the shift of more complex 
services from the inpatient to the outpatient setting, which could 
influence labor intensity and costs, and 60 percent seemed appropriate. 
(As we explain in section V.I. below, regression analysis confirmed the 
labor percentage to be 60 percent.) We calculated 60 percent of each 
hospital's total operating and capital costs. We then divided that 
amount by the provider's 1996 hospital inpatient PPS wage index value 
to standardize differences in costs that are attributable to geographic 
wage differences. The total cost of performing a procedure/visit, 
therefore, includes wage-standardized operating and capital costs, as 
well as bundled ancillary costs (that is, operating room time, medical/
surgical supplies, pharmaceuticals, anesthesia, recovery room, 
observation, biologicals, etc.) and minor ancillary procedures (for 
example, venipuncture), as explained in greater detail in section V.C.
    The final hospital outpatient department PPS payment rates that 
would have been effective January 1, 1999 may differ slightly from 
those proposed in this rule because we intend to adjust APC payment 
rates using the fiscal year 1999 hospital inpatient PPS wage index 
values that are implemented October 1, 1998. The hospital inpatient PPS 
wage index values proposed for fiscal year 1999 are in the Federal 
Register proposed rule published May 8, 1998 entitled ``Changes to the 
Hospital Inpatient Prospective Payment Systems and Fiscal Year 1999 
Rates (HCFA-1003-P)'' (63 FR 25575).
    We are proposing to use the annually updated hospital inpatient PPS 
wage index values to adjust both program payment and copayment amounts 
for area wage variations, as we explain below.
3. Adjustment of Hospital Outpatient Department PPS Payment and 
Copayment Amounts for Geographic Wage Variations
    To adjust the APC payment rates and beneficiary copayment rates for 
outpatient services for geographic wage variations, we are proposing to 
use the same labor-related percentage (60 percent) that we used 
initially to standardize costs for geographic wage differences. When 
intermediaries calculate actual payment amounts, they will multiply the 
prospectively determined APC payment rate and copayment amount by that 
labor-related percentage to determine the labor-related portion of the 
base payment and copayment rates that is to be adjusted using the 
appropriate wage index factor. That labor-related portion will then be 
multiplied by the hospital's inpatient PPS wage index factor, and the 
resulting wage-adjusted labor-related portion will be added to the non-
labor-related portion, resulting in wage-adjusted payment and copayment 
rates. The wage-adjusted copayment amount is then subtracted from the 
wage-adjusted APC payment rate, and the result is the Medicare payment 
amount for the service or procedure. Note that even if a hospital 
elects to discount the copayment, the full copayment amount is assumed 
for purposes of determining Medicare program payments. (See section 
V.D. for a discussion of how Medicare program payments are calculated 
when the Part B deductible applies.)
    The following is an example of how an intermediary would calculate 
the Medicare payment for a surgical procedure with a hypothetical APC 
payment rate of $300 that is performed in the outpatient department of 
a hospital located in Heartland, USA. The copayment amount for the 
procedure is $105. The hospital inpatient PPS wage index value for 
hospitals located in Heartland, USA is 1.0234. The labor-related 
portion of the base payment rate is $180 ($300  x  60 percent), and the 
non-labor-related portion of the base payment rate is $120 ($300  x  40 
percent). The labor-related portion of the base copayment rate is $72 
($120  x  60 percent), and the non-labor-related portion of the base 
copayment rate is $48 ($120  x  40 percent). It is assumed that the 
beneficiary deductible has been met.

Wage-Adjusted Base Payment Rate (rounded to nearest dollar):
    = ($180  x  1.0234) + $120
    = $184 + $120
    = $304
Wage-Adjusted Base Copayment Rate (rounded to nearest dollar):
    = ($72  x  1.0234) + $48
    = $74 + $48
    = $122
Calculate Medicare Program Payment Amount:
    $304 - $122 = $182

F. Claims Submission and Processing

    Hospitals will receive detailed instructions on claims submission 
over the coming year. This section provides a brief overview of the 
process.
    In order for APCs to properly capture services furnished, hospitals 
must assign HCPCS codes to services. Revenue center codes will capture 
only packaged services (operating and recovery room, pharmaceuticals, 
medical/surgical supplies, etc.). Correct assignment of codes requires 
an understanding of the differences among surgical procedures, a 
knowledge of the extent of effort expended in a clinic visit, etc. We 
believe that many hospitals currently have surgical records coded using 
HCPCS in the medical records department. However, many hospital coders 
are much more familiar with the ICD-9-CM system of classification than 
they are with HCPCS. Among the sources of education available to update 
skills, hospitals may want to explore in-service education from a 
credentialed coder with experience in billing for physicians' and 
surgeons' services, classes available from local hospital associations 
or medical record associations, formal classes in local colleges, etc.
    Coding conventions in the outpatient setting differ slightly from 
those in use in inpatient settings. The diagnosis identified on the 
claim need not be the ``principal'' diagnosis, as required under DRGs. 
Instead the diagnosis is the reason for the visit as identified at the 
time of the visit. It is not necessary to wait to submit the claim 
until laboratory or x-ray results are known, in an effort to more 
clearly identify the diagnosis. In billing for clinic and emergency

[[Page 47578]]

department visits, the diagnosis should relate to the reason for the 
visit. A patient who attends several different clinics in one day 
should have separate claims submitted for each clinic visit, since at 
this time only one diagnosis can be associated with each claim. We will 
seek a change to the UB-92 allowing diagnoses to be identified by 
number, so that each line item can have a diagnosis associated with it.
    Another difference from inpatient reporting is that the DRG GROUPER 
can take every procedure coded and identify the one highest in the 
surgical hierarchy applicable to the diagnosis, then ignore those that 
do not affect the DRG. The HCPCS codes, however, are both more numerous 
and very specific and should be used appropriately, since each code 
will trigger a payment.
    We propose to apply to hospital outpatient claims HCFA's Correct 
Coding Initiative (CCI). One of the purposes of the CCI is to ensure 
that the most comprehensive of a group of codes is billed instead of 
the component parts. For example, G0001 (routine venipuncture) is a 
component part of 36430 (transfusion of blood or blood components) and 
should not be separately billed. Similarly, 94760 (pulse oximetry) 
should not be billed with surgical procedures for which it is a common 
monitoring technique. In 1997, hospital outpatient claims showed it 
more than 10,000 times with 45378 (diagnostic colonoscopy). The CCI 
also checks for mutually-exclusive code pairs. For example, 93797 
(cardiac rehabilitation without ECG monitoring) should not be billed 
simultaneously with 93798 (cardiac rehabilitation with ECG monitoring), 
which happened nearly 12,000 times in 1997 hospital outpatient claims. 
We propose to use the CCI edits to ensure that only appropriate codes 
are grouped and priced.
    Carriers have used CCI as an editing tool since January 1996, and 
have discovered that the vast majority of edits are rarely triggered. 
However, as shown in the examples above, hospitals' coding patterns 
could result in inappropriate payments unless such edits are applied. 
Under the cost reimbursement system, these types of errors did not 
ultimately result in higher payments to the hospitals; nor did 
providing wrong numbers in the units field (for example, repeating the 
revenue code). Again, under this PPS, each unit billed will trigger a 
payment. Thus, we have created a second set of edits limiting the 
number of units allowed for each HCPCS code. For example, only ``1'' 
will be accepted in the units field for cataract surgery, but for most 
services the edit allows for the procedure to be performed a number of 
times in a day, with an upper limit to reduce obvious errors. Of 
course, hospitals should report only the actual number of times a 
procedure was performed, keeping in mind that CPT and HCPCS definitions 
sometimes specify the units. For example, code 11720 is for debridement 
of nail(s) by any method; one to five. This code should be reported 
only once for any number of nails debrided between one and five, 
inclusive. If more than five nails are debrided, the appropriate code 
is 11721, debridement of nail(s) by any method; six or more, billed 
only once in place of 11720.
    We propose to require that hospital outpatient and CMHC bills that 
span more than one day indicate the date of the service for each line 
item on the bill. Line item dates of service are needed in order to 
implement the CCI and the units' edits, both of which are applied based 
on services furnished on the same date.
    Further information on billing line item dates of service, using 
HCPCS to code all claims, and editing will be provided by instructions.

G. Updates

1. Revisions to Weights and the Wage and Other Adjustments
    Section 1833(t)(6)(A) of the Act gives the Secretary authority to 
periodically review and update the APC groups, the relative payment 
weights, and the wage and the other adjustments that are components of 
the outpatient PPS, to take into account changes in medical practice, 
changes in technology, the addition of new services, new cost data, and 
other relevant information and factors.
    We explained above that we intend to update the wage index values 
used to calculate program payment and copayment amounts on a calendar 
year basis, adopting effective for services furnished each January 1 
the wage index value established for a hospital under the inpatient PPS 
the previous October 1.
    Recalibration of the APC group weights is another type of revision 
provided for under the statutory review authority. We define 
recalibration as the updating of all the APC group weights based on 
more recent information. We do not intend to make this type of update 
on an annual basis. For example, we are required to rebase ASC payment 
rates using survey data that are collected every 5 years. At this time, 
we would like to solicit comments on how frequently to recalibrate the 
hospital outpatient APC weights and on the method and data that should 
be used.
    Section 1833(t)(6)(B) of the Act requires that all revisions to APC 
groupings, weights, and other adjustments be made in a budget-neutral 
manner. Adjustments made for a particular year may not cause the 
estimated amount of expenditures under the outpatient PPS to increase 
or decrease from the expenditures that we estimate would have been made 
under the outpatient PPS without any updates or revisions.
2. Revisions to APC Groups
    It is our intent to use the same APC surgical groups in the payment 
systems both for hospital outpatient services and for surgical services 
furnished by Medicare-approved ASCs. A discussion of the use of APC 
groups to set payment rates for Medicare-approved ASCs can be found in 
the proposed rule entitled ``Update of Ratesetting Methodology, Payment 
Rates, Payment Policies, and the List of Covered Surgical Procedures 
for Ambulatory Surgical Centers Effective October 1, 1998'' (HCFA-1885-
P) that was published in the Federal Register June 12, 1998 (63 FR 
32290). In order to maintain comparability of the APC groups across 
both settings, we are proposing to coordinate our review of comments on 
the composition of the APC groups that are submitted during the public 
comment period following publication of both this proposed rule and the 
ASC proposed rule. We are further proposing to coordinate any 
adjustments to the composition of the APC surgical groups that may 
result from our analysis of both sets of comments to ensure that the 
final APC surgical groups not only reflect and take into account both 
sets of comments, but also remain comparable for ASCs and hospital 
outpatient departments to the maximum extent possible within the 
constraints imposed by statutory and regulatory requirements.
    Thereafter, we expect the composition of all the APC groups to 
remain essentially intact from one year to the next with the exception 
of the few changes that may be necessary as a consequence of annual 
revisions to HCPCS and ICD-9 codes. We do not plan to routinely 
reclassify services and procedures from one APC to another. HCFA will 
make these changes based on evidence that a reassignment would improve 
the group(s) either clinically or with respect to resource consumption. 
All changes in APC groups must be budget neutral, and changes in APC 
groups will only be made through notice and comment when we implement 
the annual outpatient PPS update.

[[Page 47579]]

    We are proposing to follow certain conventions when, as a result of 
annual HCPCS and ICD-9 revisions, we add new services to the hospital 
outpatient PPS. As part of the notice and comment process accompanying 
the annual update of the outpatient PPS, we shall propose the 
assignment of a newly created code to the existing APC that, in the 
judgment of our medical advisors, is the most similar clinically and in 
terms of resource requirements to the new service. Because a new 
service will not have any charge history or cost data associated with 
it, classification of a new service to an existing APC group will not 
alter the APC payment rate, relative weight, and program payment and 
copayment amounts that have been established for that APC group. The 
new service will assume the same payment rate, relative weight, and 
program and copayment amounts that have been established for the APC 
group to which it is classified.
    If the annual revision of HCPCS or ICD-9 result in the deletion of 
a code or service that is classified in an APC group under the 
outpatient PPS, we shall remove that service from the APC group and 
discontinue paying for the service under the outpatient PPS. When a CPT 
code that contributed cost data to our 1996 database is deleted, we 
will continue to use the cost data in the APC. This in fact did occur 
in the psychotherapy set of codes. The codes that were in effect in 
1996 have been replaced. If we did not capture these data from those 
codes, we would not be able to assign a weight to brief psychotherapy 
visits. As long as the new codes belong in the same APC, in terms of 
clinical coherence and related resource use, the data are relevant. If 
the code that contributed data to the 1996 database were revised so 
that it no longer belonged in the APC to which it was originally 
assigned, the revised code would be placed in an APC that better 
matched the new description. As in the case of an entirely new code, no 
cost data would be available for the revised code, so it would be 
assigned the weight, program payment rate, and copayment rate of the 
codes in the new APC. We will not create an APC for an entirely new 
code, but will assign it for at least 2 years to an existing group 
while accumulating data on its costs relative to the other codes in the 
APC.
    When we do reclassify a service from one APC group to another, the 
reclassification will affect the payment rate, the weight, and the 
payment and copayment amounts for both of the ``donor'' APC group and 
the ``receiving'' APC group if the service that is reclassified was 
recognized in 1996 and is reflected in our database. As a result of 
reclassifying a service that was recognized in 1996 and is reflected in 
our database, we shall recalculate the payment rate, the weight, and 
the payment and copayment amounts for both the ``donor'' APC group and 
the APC group to which the service is reassigned. If the service that 
is reclassified was not recognized in 1996 and is therefore not 
reflected in our database, we shall treat it in the same manner that we 
treat the addition of altogether new services and the removal of 
services that are deleted from HCPCS and ICD-9, that is, reclassifying 
the code will have no effect on the payment rate, relative weight, and 
payment and copayment amounts for either the donor APC or the receiving 
APC, and the reclassified code will assume the payment rate, relative 
weight, and payment and copayment amounts of the APC to which the 
service is reclassified.
3. Annual Update to Conversion Factor
    Section 1833(t)(3)(C)(ii) of the Act requires us to update annually 
the conversion factor used to determine APC payment rates. Section 
1833(t)(3)(C)(iii) of the Act provides that the update be equal to the 
hospital inpatient market basket percentage increase applicable to 
hospital discharges under section 1886(b)(3)(B)(iii) of the Act, 
reduced by one percentage point for the years 2000, 2001, and 2002. We 
also have the option (under section 1833(t)(3)(C)(iii)) of developing a 
market basket that is specific to hospital outpatient services. We are 
considering this option, and we solicit comments on possible sources of 
data that are suitable for constructing a market basket specific to 
hospital outpatient services.

H. Outlier Payments

    Section 1833(t)(2)(E) of the Act requires us to establish in a 
budget-neutral manner other adjustments that we determine are necessary 
to ensure equitable payments, such as outlier adjustments or 
adjustments for certain classes of hospitals. We considered several 
factors to evaluate the necessity of an outlier adjustment policy.
    The most relevant factor is that the proposed system has minimal 
packaging. Unlike the DRG system for inpatient services, where a 
patient can be classified into only one payment group during an 
inpatient stay, payment can be made for a number of APC groups for a 
given patient on a given day. If multiple services are delivered, 
payments will be made for multiple APCs. Because a hospital will 
receive payment for each service furnished, we believe this greatly 
reduces the need for an outlier adjustment.
    Another relevant factor is that critical care services have been 
isolated into their own APC. Payment for the critical care APC is based 
on median hospital costs of critical care services. Therefore, payments 
for this group will reflect the intensity and associated higher costs 
of this type of medical care.
    Even if critical care is not delivered, higher payment will be made 
for more serious cases. Payments for medical visits to the emergency 
room will be made at three incremental levels of intensity, and 
additional payments will be made for any other laboratory work, x-rays, 
or surgical interventions resulting from the visit.
    Upon consideration of the above factors, we do not believe that an 
outlier adjustment is necessary to ensure equitable payments.

I. Adjustments for Specific Classes of Hospitals

    As part of the analysis to determine whether payment adjustments 
would be proposed for the outpatient prospective payment system, we 
conducted extensive regression analysis of the relationship between 
outpatient hospital costs (calculated as hospital outpatient operating 
and capital cost per unit) and several factors that affect costs. The 
latter included variables used in estimating similar models for the 
inpatient PPS, as well as several variables unique to hospital 
outpatient departments. We considered all costs and services for each 
hospital relevant to the proposed payment system. Ultimately, we 
decided not to propose any adjustments to the Federal payment other 
than the wage index used to adjust for local variation in labor costs 
at this time. While this reflects a difference in policy relative to 
inpatient PPS, the proposed outpatient PPS is fundamentally different. 
Specifically, the outpatient system has limited packaging, so 
variations in costs are limited to the resources used to produce a 
single procedure. Cost variations in the inpatient system, however, 
also can be attributed to variation in the intensity of services 
bundled under a single rate. Therefore, variations in outpatient cost 
per unit among hospitals are expected to be small relative to the 
variations in inpatient cost per discharge that have been estimated in 
the past.
    We began our analysis by examining the distribution of service mix 
and cost per unit (or cost per service) among various types of 
hospitals. This analysis revealed some extreme values of cost per unit 
among types of hospitals, especially major teaching hospitals,

[[Page 47580]]

hospitals with trauma centers, and eye and ear hospitals. These costs 
were 200 percent to 400 percent higher than the average cost per unit 
for all hospitals. Because costs are measured on a per unit basis, 
values of this magnitude suggested problems both with identifying 
procedure codes and properly entering the correct unit of measurement 
(times performed, minutes of treatment, etc.). Under the current 
payment system, hospitals will be fully reimbursed for their services 
even if claims do not contain all the procedure codes that would be 
associated with revenue centers billed. A consistent practice of such 
under-coding would lead to very high costs associated with a single 
unit.
    The presence of these extreme values also suggested that a few 
hospitals could unduly influence the distribution of hospital 
outpatient cost per unit in our regression analysis. Individual bills 
were not edited for extreme unit costs. However, even removing cost 
outliers at the bill-level might not have eliminated these extreme 
variations at the hospital level. A single under-coded bill might not 
meet outlier thresholds, but the combined effects of coding differences 
on all of a hospital's bills could create much higher or lower unit 
costs.
    In light of the lack of trimming for outlier/error costs at the 
bill level, the possibility of outlier hospitals skewing the 
distribution of cost per unit, and the hospital-level analysis for 
payment adjustments argued for an edit on cost per unit at the hospital 
level. The distribution of cost per unit more closely resembles a 
lognormal distribution than a normal distribution; there are no 
negative costs and the average cost is greater than the median cost. We 
identified outliers using the mean and standard deviation of the 
natural logarithm of cost per unit. Taking the natural logarithm of any 
variable compresses the distribution and minimizes the impact of the 
most unusual bills in the determination of the mean. The compressed 
distribution also makes it more difficult to identify outliers.
    We removed 83 hospitals through an edit of three standard 
deviations from the mean of the logged unit costs: 51 hospitals with a 
logged cost per unit exceeding three standard deviations above the mean 
and 32 hospitals with a logged cost per unit less than three standard 
deviations below the mean. Removing outlier hospitals greatly improved 
the distribution of unit costs among types of hospitals. The exempted 
Maryland hospitals were also excluded from the analysis. However, we 
included the 10 cancer hospitals. After we removed the 54 exempted 
Maryland hospitals, outlier hospitals, and hospitals for which we could 
not identify payment variables, we were left with 5,419 hospitals for 
analysis. Our regression analyses use this set of hospitals.
    A variety of regression models have become the standard of practice 
for examining hospital cost variation and analyzing potential payment 
adjustments. We looked at two standard models: fully specified 
explanatory models to examine the impact of all relevant factors that 
might potentially affect outpatient hospital cost per unit and payment 
models that examine the impacts of those factors used to determine 
payment rates. The payment models standardize the dependent variable, 
hospital outpatient cost per unit, by service mix to capture the 
relationship between the APC weights and payment under the PPS, rather 
than a statistical relationship between service mix and costs. Both 
unweighted regressions and regressions weighted by volume were 
examined. All regressions employed a double log or semi-log 
specification. References to logs throughout this discussion refer to 
the natural logarithm, and the geometric mean is the mean of the 
natural logarithm of values. Our dependent variable was total hospital 
outpatient cost per unit.
    We used payment variables from the inpatient prospective payment 
system, including disproportionate share patient percentage, both 
capital and operating teaching variables (resident to average daily 
census and resident to bed ratios respectively), and dummy variables to 
account for location in a rural, large urban, and other urban area. We 
also looked at a modified teaching variable that reflects outpatient 
volume, several dummy variables unique to outpatient departments, such 
as the presence of a trauma unit, and the difference in costs among 
various types of TEFRA hospitals and cancer hospitals. A discussion of 
the major payment variables and our findings appears below.

Service Mix Index

    Using APC weights and the number of services provided in each APC, 
we calculated an average APC weight, or service mix, for each hospital. 
We also calculated a ``discounted'' service mix that considers the 
reduced weight for additional surgical procedures performed at the same 
time, which is consistent with the proposed payment system. The 
national average service mix is 1.43, and the national average service 
mix discounted for multiple procedures is 1.45. The differences between 
the two are negligible due to the low volume of services subject to 
discounting, and they proved almost interchangeable in the adjustment 
regressions. We did use the discounted service mix for our regressions 
because it reflects the proposed policy.
    Since APC weights are calculated from costs, we would expect 
approximately a one to one, or proportional, relationship between 
service mix and hospital outpatient cost per unit. That is, we expect 
the coefficient of the service mix to be one in a regression of 
outpatient cost per unit on the service mix. However, initial payment 
regressions of hospital outpatient cost per unit on service mix and the 
wage index revealed a coefficient of 0.68, suggesting that the 
calculated service mix increases faster than cost per unit; a 10 
percent increase in the service mix is associated with a 6.8 percent 
increase in costs.
    This estimated relationship prompted a preliminary analysis of the 
relationship between geometric means and median cost per unit within 
each APC. If per unit cost within APCs is distributed log normally, the 
median and the geometric mean are equivalent. However, if the 
distribution of costs within APCs is skewed, then the median may differ 
from the geometric mean. Because the dependent variable in the 
regression models is the natural log of hospital outpatient cost per 
unit, a systematic difference between the geometric mean of cost per 
unit and median cost per unit could explain the lack of one to one 
relationship between hospital service mix and hospital cost per 
service. Weighting the regression equation by the volume of services, 
essentially giving greater weight to the relationship between service 
mix and unit costs for hospitals with a higher volume of services, 
increases the relationship to 7.5 percent. Higher volume hospitals tend 
to have a higher service mix and higher service costs.
    A limited analysis of unit costs for selected APCs demonstrated 
that, in general, in APCs with low relative weights, median hospital 
cost per unit is lower than the geometric mean of logged hospital cost 
per unit, and, in APCs with high relative weights, median hospital cost 
per unit is generally higher than the geometric mean. This would lead 
to a greater spread in a hospital's service mix than appears in their 
actual cost per unit, and would provide an explanation for the less 
than proportional relationship that was estimated to exist between 
service mix and cost per unit. A regression of cost per unit on a 
service mix derived from weights based on the geometric

[[Page 47581]]

mean and the wage index demonstrated better correlation; a 10 percent 
increase in service mix led to a 7.7 percent increase in cost per unit. 
Weighting this regression equation by the volume of services increases 
the relationship to 9.1 percent, suggesting that the higher service mix 
of higher volume hospitals better tracks those hospitals' cost per 
unit.

Labor Share

    The coefficient of the hospital wage index is the estimated 
percentage change in costs attributable to a 1 percent increase in the 
wage index. This coefficient provides an estimate of the share of 
outpatient hospital unit costs that are attributable to labor. 
Depending on the model specification, the coefficient ranged from 0.51 
to 0.68 reflecting a labor share between 50 and 70 percent. The 
coefficient from a fully specified payment regression of the hospital 
cost per unit standardized for the service mix on the wage index, 
disproportionate share patient percentage, modified teaching, rural, 
and urban variables is approximately 0.60, suggesting a labor share of 
60 percent. Even though we ultimately decided that we would not propose 
additional adjustments, we believe that the coefficient from this 
specification provides the best estimate of the labor share for the 
proposed system. This judgment was based on a policy to use a labor 
share that reflected the relationship between the wage index and costs, 
rather than the effects of correlated factors. The explanatory 
regression model that has a dependent variable of unstandardized 
hospital outpatient cost per unit also implies a labor share of 60 
percent across most specifications.

Teaching Intensity and Disproportionate Share Patient Percentage

    For the inpatient PPS, the intensity of teaching programs has 
typically been measured by the resident to bed ratio or resident to 
average daily census ratio. Early in our regression analysis, we used 
resident to the average daily census of inpatient days, the teaching 
variable from inpatient capital PPS. The results suggested that costs 
increase somewhat with the size of the teaching program (p<0.05). 
However, we believed that this ratio could not adequately represent 
teaching hospitals with large outpatient departments relative to the 
size of their inpatient operations. We modified the resident to average 
daily census variable to reflect the ratio of residents to combined 
inpatient and outpatient utilization. To accomplish this, we calculated 
the ratio of inpatient costs per day to outpatient costs per unit for 
each hospital, and we used this ratio to convert hospital services into 
inpatient day equivalents. We combined both inpatient days and 
outpatient day equivalents to get a ratio of residents to inpatient and 
outpatient days. Since we cannot, at this time, allocate residents to 
inpatient and outpatient settings, we could not estimate a teaching 
variable based on residents to outpatient volume alone.
    We created the disproportionate share patient percentage variable 
by adding the percentage of inpatient days attributable to Medicaid 
patients to the percentage of Medicare patients receiving Supplemental 
Security Income. In most regression specifications, the 
disproportionate share percentage was positive, small in magnitude, and 
significant (p<0.05). These coefficients imply that a hospital with a 
40 percent disproportionate share percentage would be approximately 4.5 
percent [calculated (e(DSHP*0.11-1)*100] more 
costly than hospitals without any low-income patients. Teaching 
intensity variables were not significant in un-weighted regressions 
(p>0.05). However, they were positive and significant in regressions 
weighted by number of services. The teaching coefficient implies that a 
hospital with a resident to combined inpatient and outpatient ``days'' 
ratio of 0.35 would be 2.4 percent [calculated 
((1+IME)0.08-1)*100] more costly than hospitals with no 
residents.
    We also estimated several regression specifications to determine if 
there were thresholds for the estimated impacts of teaching and 
disproportionate share patient percentage on costs. We determined that 
positive and significant estimated differences do not occur for 
hospitals whose disproportionate share percentage is less than 0.40. 
Significant effects for the teaching variable do not occur for 
hospitals whose ratio of residents to inpatient and outpatient days is 
less than 0.32. We used these results to estimate a new 
disproportionate share patient percentage based on a 0.30 threshold and 
a ratio of residents to inpatient and outpatient ``days'' based on a 
0.28 threshold. We chose these thresholds by identifying the point at 
which the relationship between the unit costs and the teaching 
intensity or disproportionate share patient percentage becomes positive 
rather than significant because of the lack of significance associated 
with the teaching variable and because the small coefficient for the 
disproportionate share variable led to intermittent significance for 
higher values. We subtracted these thresholds from the original 
variable to create new teaching and disproportionate share patient 
percentage variables. Subtracting the threshold removes the effect of 
values that are not significantly related to cost per unit and 
eliminates the sudden increase (notch effect) in the disproportionate 
share patient percentage and teaching variable at the threshold level. 
The new variables suggest that a hospital with a disproportionate share 
patient percentage 10 points higher than the 30 percent threshold is 
approximately 2.3 percent more costly [calculated 
(eDSHP*0.23-1)*100] and that a hospital with a 
ratio of residents to inpatient and outpatient utilization 0.07 higher 
than the 0.28 threshold is approximately 0.75 percent more costly 
[calculated ((1+IME)0.11-1)*100].

Urban and Rural Location

    We also estimated difference in hospital outpatient costs between 
rural, large urban, and other urban areas. In almost all of the 
regression models, both explanatory and payment, the rural dummy 
variable was positive and significant (p<0.05). Rural hospitals had 
approximately 8 percent higher standardized unit costs than urban 
hospitals. In all of the regression models, large urban hospitals were 
not significantly different from other urban hospitals.

TEFRA and Cancer Hospitals

    We also found that some types of TEFRA hospitals (long-term care, 
children's, and psychiatric) and the ten cancer hospitals have 
significantly (p<0.05) higher unit costs standardized for service mix. 
Cancer, children's, and long term care hospitals demonstrated 
standardized unit costs that were at least 20 percent higher than other 
hospitals. We believe that these significantly higher costs largely can 
be attributed to under-coding because proper coding is not required for 
the payment of many services under the current system, especially 
medical visits. Poor coding would affect calculations of both service 
mix and cost per unit.

Estimated Payments

    The appropriateness of potential payment adjustments must be based 
on both cost effects estimated by regression analysis and other factors 
including simulated payment impacts. We simulated the impact of the 
proposed system on hospitals by calculating the percentage difference 
between payments made under current law and payments

[[Page 47582]]

under the proposed system (column 3). Section X. contains a more 
complete table that considers the impact of proposed payments on 
additional classes of hospitals, including TEFRA and cancer hospitals. 
Although Column 3 represents the net effect of the new PPS on 
hospitals, we thought it was necessary to show the impacts on hospitals 
of simply changing the payment system without including the effects of 
the overall reduced payment to hospitals because the PPS system is not 
budget neutral to current payment. To reiterate, the conversion factor 
is set by summing Medicare payments under the current system and 
beneficiary copayment under the new system and dividing by the sum of 
the relative weights. Beneficiary copayments under the new system will 
reduce overall payments to most hospitals because 20 percent of the 
median group charges is less than 20 percent of actual charges. 
Therefore, we simulated the impacts as though the conversion factor 
were set as if the system were to be budget neutral. Column 4 
demonstrates the distributional impacts resulting from implementing the 
new system after eliminating the overall reduction in payment most 
hospitals will experience due to the effect of the methodology used to 
set the conversion factor. We believe the column 4 percentage 
differences are what we should examine since any adjustment we would 
consider should correct for inequities caused by moving to a PPS (not 
the legislated reduction in total payment). Therefore, we based our 
decision about adjustments on these percentage differences rather than 
percentages combining the PPS and the overall reduction in coinsurance 
amounts required by law. We also estimated payment to cost ratios 
associated with the new payment methods and the percent change in total 
Medicare payments. All simulations used a labor share of 60 percent. 
The table below shows the results of two simulations. The first 
contains only the wage index adjustment to the APC rates. The second 
also includes the threshold adjustments for disproportionate share 
patient percentage and teaching intensity discussed above.

BILLING CODE 4120-01-P

[[Page 47583]]

[GRAPHIC] [TIFF OMITTED] TP08SE98.000



[[Page 47584]]

[GRAPHIC] [TIFF OMITTED] TP08SE98.001



BILLING CODE 4120-01-C

[[Page 47585]]

    Based on our analyses, we are not proposing to make adjustments to 
the outpatient payment rates for disproportionate share patient 
percentage and teaching intensity and rural location for the following 
reasons.
    1. Estimated effects of teaching intensity and disproportionate 
share patient percentage on costs were small and, in some cases, not 
statistically significant.
    2. Payment impacts without such adjustments do not vary 
considerably, the largest being a reduction of 5.8 percent for major 
teaching hospitals. These impacts should also be evaluated in terms of 
the overall effect on Medicare payments since on average, outpatient 
services account for 10 percent of hospitals' Medicare payments. For 
example, the associated reduction of total Medicare payments for major 
teaching hospitals would be about 1 percent.
    3. With the threshold adjustments we considered, estimated payment 
reductions for rural hospitals would be 1.9 percent under the proposed 
system, rather than 1.5 percent. These hospitals also receive a greater 
percent of their Medicare income (14.7 percent) from providing 
outpatient services. Similarly, payment reductions for low-volume rural 
hospitals would be 13.9 percent of current payments, rather than 13.7 
percent, and these hospitals also earn a greater percentage of their 
Medicare income (18.2 percent) from providing outpatient services. 
Because of these potential shifts in payments, any adjustment should be 
based on stronger analytic results than those found with the current 
data.
    4. We also believe the issue of payment adjustments should be 
reexamined using data from initial years of the implemented system 
because current cost calculations and relationships among key factors 
and costs probably are affected by variation in coding patterns.
    5. HCFA is working towards standardizing payment across all sites 
of service. Fewer adjustments to the outpatient PPS would allow HCFA to 
move ahead more quickly with this approach.
    6. We believe that we should further analyze the impact of basing 
APC weight calculations on the median rather than the geometric mean 
because better correlation between costs and service mix would impact 
the size of adjustments.
    Although the payment simulations show potentially large percentage 
losses and low payment to cost ratios for low-volume hospitals, we are 
not proposing an adjustment for volume. The low-volume hospitals get a 
much greater percent of their Medicare income from the provision of 
outpatient services than the average, and total Medicare payments would 
drop by 3.1 percent for rural low-volume hospitals and 1.8 percent for 
urban low-volume hospitals. Low-volume hospitals have higher than 
average standardized unit costs, which may be attributable to economies 
of scale, under-coding, or cost allocations to the outpatient 
departments that are not volume related. However, an adjustment to the 
rates based on volume alone might reward inefficiency and create 
adverse incentives such as a reduction in services in order to increase 
payment rates. Moreover, these hospitals do not comprise a large enough 
proportion of other hospital types to substantially benefit from other 
adjustments (for example, teaching or disproportionate share).
    We are particularly concerned about the potential impact of the 
outpatient PPS on low-volume rural hospitals that are sole community 
hospitals or Medicare-dependent hospitals. Approximately 60 percent of 
the rural hospitals furnishing fewer than 5,000 visits fall into these 
categories. We are investigating the reasons for their higher costs and 
are assessing whether a temporary adjustment is needed to moderate the 
impact of moving to an outpatient PPS. One option we are considering 
would be to phase-in the outpatient PPS for low-volume Medicare-
dependent and sole community hospitals by paying a portion of the 
payment based on PPS rates and a portion based on the current payment 
system. For example, payment could be based on 75 percent of payments 
under the current system and 25 percent on PPS rates in the first year, 
50 percent current system payments and 50 percent PPS rates in the 
second year, 25 percent current system payments and 75 percent PPS 
rates in the third year, and completely on PPS rates in subsequent 
years. Another option we are considering would phase-in outpatient PPS 
if a low-volume sole community hospital or Medicare-dependent hospital 
has a negative Medicare margin for outpatient services. For example, 
payment could be based on the amount payable under outpatient PPS plus 
a percentage of the difference between those amounts and the amounts 
payable under the current system. The percentage of the difference that 
would be payable could phase down, for example, 75 percent in year one 
of implementation, 50 percent in year 2, 25 percent in year 3, and no 
adjustment in year 4 and subsequent years. We solicit comment on this 
and other alternatives we might consider. By statute, any adjustment 
would have to be budget neutral.
    We also are not proposing adjustments for cancer or TEFRA hospitals 
at this time. We believe that claims from cancer and TEFRA hospitals 
have been under-coded for many of the services cancer hospitals provide 
due to the lack of payment incentives for proper coding of these 
services under the current system. Further analysis will be conducted 
to determine if current coding practices explain the negative impact. 
If we determine that cancer hospitals would be unduly harmed because of 
the new outpatient PPS, we will consider whether an adjustment or 
perhaps a transition period is needed to moderate the impact. By 
statute, any adjustment would have to be budget neutral.
    We do not believe that this action will restrict beneficiary access 
because other hospitals provide many of the same services provided at 
TEFRA hospitals. In addition, children's and free-standing psychiatric 
hospitals are less dependent than other hospitals on Medicare revenues. 
Finally, the remaining classes of TEFRA hospitals, rehabilitation and 
long-term care, lose a much smaller percentage of their total Medicare 
income, 3.7 and 3.5 percent respectively than the average for all 
facilities.
    We are not proposing adjustments for any eye and ear or trauma 
hospitals because payment simulations demonstrated an increase in 
payments under the proposed PPS. We will assess the need for additional 
adjustments and make any appropriate changes as data become available 
under the new system.

J. Volume Control Measures

    Section 1833(t)(2)(F) of the Act requires us to develop a method 
for controlling unnecessary increases in the volume of covered 
outpatient department services, including partial hospitalization 
services in CMHCs. If the volume of services paid for increases beyond 
amounts established through methodologies determined in section 
1833(t)(2)(F), section 1833(t)(6)(C) provides that the update to the 
conversion factor may be adjusted. MedPAC recommends in its report to 
the Congress that we implement an expenditure cap to help control 
spending for hospital outpatient services and that we monitor hospital 
outpatient volume to ensure that access to services and quality of care 
are not reduced under a cap.
    In this proposed rule, we are proposing a volume control measure 
for services furnished in CY 2000. In the

[[Page 47586]]

proposed rule for rates that would be effective in CY 2001, we plan to 
propose an appropriate method for determining expenditure targets for 
services furnished in CY 2001 and subsequent years, following 
completion of further analysis of how that target should be computed. 
Later in this section, we discuss several possible approaches for 
controlling the volume of hospital outpatient services furnished in CY 
2001 and subsequent years.
    Pursuant to section 1833(t)(2)(F) and consistent with section 
1833(t)(6)(C), we are proposing to update the target amount specified 
under section 1833(t)(3)(A) for CY 1999 as an expenditure target for 
services furnished in CY 2000. We will update the CY 1999 target for 
inflation (based on the projected change in the hospital market basket 
minus one percentage point) and estimated changes in the volume and 
intensity of hospital outpatient services and estimated Part B fee-for-
service changes in enrollment. If volume exceeds the target for CY 
2000, we are proposing to adjust the update to the conversion factor 
for CY 2002. We will compare the CY 2000 target to an estimate of CY 
2000 actual payments to hospitals. (HCFA's Office of the Actuary will 
determine the CY 2000 actual payments using the best available data.) 
If unnecessary volume increases, as reflected by expenditure levels, 
cause payments to exceed the target, we will determine the percentage 
by which the target is exceeded, and adjust the CY 2002 update to the 
conversion factor by the same percentage.
    In conjunction with the Office of Inspector General, we are 
proposing to do further work to assure that only payments made in 
accordance with existing Medicare law and regulations were used in the 
calculation of the target amount. If this work reveals that adjustments 
to the target amount and expenditure ceiling are warranted, we will 
address this issue in a future rule.
    When the inpatient PPS was implemented, the packaging of all 
services provided during an admission under a single rate was the 
primary method of volume control. This method was appropriate because 
the concern was the intensity of services per admission, rather than 
the number of admissions, which was generally stable. For outpatient 
department services, there has been rapid growth in the intensity of 
ancillary services per procedure. We believe that greater packaging of 
these services might provide volume control. However, because the 
hospital outpatient PPS will not initially include a significant degree 
of packaging, we are examining a number of mechanisms to control 
unnecessary increases, as reflected by expenditure levels, in the 
volume of covered outpatient department services. The volume of 
services is a significant concern, particularly during the first few 
years of the outpatient PPS, because of the possible incentives under 
PPS to increase utilization.
    Although the updated target amount provides a basis against which 
we can measure year 2000 actual payments, we need to develop an 
approach for establishing a volume control measure for years 2001 and 
beyond. Because of the complexities involved in developing such a 
system, we do not plan to propose a method for future years (2001 and 
beyond) until we issue our notice of proposed rulemaking for CY 2001, 
but we want to open a discussion now, so that we can obtain comments 
that we can use in developing a proposal.
    One possible mechanism to control unnecessary increases in the 
volume of outpatient services paid for under the outpatient PPS is to 
expand the sustainable growth rate (SGR) system for physician services, 
which is required under section 1848(d)(3) of the Act, as amended by 
section 4502 of the BBA, to take into account hospital outpatient 
services. Physicians typically are responsible for ordering medical 
services and are thus responsible for determining a substantial portion 
of hospital outpatient volume. Expanding the SGR system for physician 
services to include hospital outpatient services would provide added 
incentives for physicians to evaluate the necessity of orders for 
hospital outpatient services.
    A second possible mechanism would be to expand the SGR system for 
physician services to include all ambulatory services, for example, 
services in hospital outpatient departments and ASCs, and to use this 
expanded SGR system to establish updates for the ambulatory facility 
payments as well as for physician fee schedule updates. This method 
would spread volume control incentives more evenly across the 
ambulatory sector. It would more closely align physician and facility 
incentives and be less sensitive than a hospital-outpatient-department-
only SGR to shifts in site of service.
    A third approach to controlling unnecessary growth in the volume of 
hospital outpatient services is to modify the physician SGR method and 
incorporate it into the hospital outpatient department payment system. 
That is, as in the physician payment context, an SGR value for hospital 
outpatient services would be calculated and payment updates for these 
services would be reduced if volume increases result in expenditures 
above target levels.
    We believe the third option of linking updates of the outpatient 
department conversion factor to an SGR system is the most feasible 
approach to take initially. Additional study, analysis, and possible 
legislative modification would be necessary before we could consider 
implementing either of the first two options discussed above. We 
acknowledge that, to the extent that hospital outpatient volume is 
physician driven, an outpatient SGR could arguably be viewed as 
unnecessarily and unfairly penalizing facilities. Moreover, because 
sites of ambulatory care are relatively interchangeable with respect to 
the delivery of outpatient services, setting appropriate targets for 
hospital outpatient departments alone could be difficult. However, an 
outpatient SGR system would parallel the SGR system created for 
physician services under section 4502 of the BBA. Physician volume 
issues have been extensively analyzed by MedPAC, and the SGR system for 
physicians has evolved as a feasible method for volume control. Many 
outpatient PPS issues are similar to physician issues because changes 
in technology and places of service can affect expenditures for both 
hospital outpatient departments and physicians.
    The outpatient SGR system would base volume and intensity growth 
allowances for services under the outpatient PPS on the growth in the 
general economy. Other factors in determining the target rate of growth 
include medical inflation, changes in enrollment, and changes in 
spending due to changes in the law or regulations. The outpatient SGR 
would be calculated as the product of--
    (1) The annual update to the conversion factor (described in 
section V.G.3. of this preamble), which is the outpatient market basket 
percentage increase reduced by one percentage point for the years 2000, 
2001, and 2002.
    (2) The percentage increase or decrease in Part B enrollees 
(excluding those enrolled in Medicare+Choice) from one year to the 
next;
    (3) The projected growth in the real gross domestic product per 
capita (or real gross domestic product per capita plus an appropriate 
factor for recent outpatient department services growth) from the 
previous year to the year involved; and
    (4) The percentage change in spending for outpatient department 
services resulting from changes in law and regulations from one year to 
the next.

[[Page 47587]]

    This growth rate system would be used in setting annual updates to 
the conversion factor for hospital outpatient services. Pursuant to 
section 1833(t)(2)(F) of the Act, and consistent with section 
1833(t)(6)(C), we would lower the annual update to the conversion 
factor for a given year if volume increases cause expenditures to 
exceed the target amount in a previous year. While we think using an 
outpatient department SGR is the most feasible option in the short 
term, in the long term we would like to develop a more integrated 
approach that addresses physicians and ASCs, as well as outpatient 
departments. In addition to requesting comments on our proposed volume 
control measure for services furnished in CY 2000, we specifically 
solicit comments on the appropriateness of applying the SGR method 
directly to payments made under the outpatient PPS for future years. We 
also welcome comments on the development of a long-term integrated 
system that we would consider as we develop possible future proposals. 
In our final rule, we will respond to comments on our proposed volume 
control measure for services furnished in CY 2000. We do not intend to 
respond to comments concerning the development of an SGR system for 
services furnished after CY 2000, an integrated system, or any other 
approach. However, we will use any comments we receive in developing a 
proposal we will make next year for volume control measures to be 
applied to services furnished after CY 2000.

K. Prohibition Against Administrative or Judicial Review

    Section 1833(t)(9) of the Act prohibits administrative or judicial 
review of the PPS classification system, the groups, relative payment 
weights, adjustment factors, other adjustments, volume control methods, 
calculation of base amounts, periodic control methods, periodic 
adjustments, and the establishment of a separate conversion factor for 
cancer hospitals.

VI. Hospital Outpatient Clinics and Other Provider-Based Entities

A. Background

    The Medicare law (section 1861(u) of the Act) lists the types of 
facilities that are regarded as providers of services, but does not use 
or define the term ``provider-based.'' However, from the beginning of 
the Medicare program, some providers, which are referred to in this 
section as ``main providers,'' have owned and operated other 
facilities, such as SNFs or HHAs, that were administered financially 
and clinically by the main provider. The subordinate facilities may 
have been located on the main provider campus or may have been located 
away from the main provider. In order to accommodate the financial 
integration of the two facilities without creating an administrative 
burden, we have permitted the subordinate facility to be considered 
provider-based. The determination of provider-based status allowed the 
main provider to achieve certain economies of scale. To the extent that 
overhead costs of the main provider, such as administrative, general, 
housekeeping, etc. were shared by the subsidiary facility, these costs 
were allowed to flow to the subordinate facility through the cost 
allocation process in the cost report. This was considered appropriate 
because these facilities were also operationally integrated, and the 
provider-based facility was sharing the overhead costs and revenue 
producing services controlled by the main provider.
    Before implementation of the hospital inpatient PPS in 1983, there 
was little incentive for providers to affiliate with one another merely 
to increase Medicare revenues or to misrepresent themselves as being 
provider-based, since at that time each provider was paid primarily on 
a retrospective, cost-based system. At that time, it was in the best 
interest of both the Medicare program and the providers to allow the 
subordinate facilities to claim provider-based status, because the main 
providers achieved certain economies, primarily on overhead costs, due 
to the low incremental nature of the additional costs incurred. For 
example, the billing department of a main provider could usually 
accommodate the additional workload associated with a provider-based 
facility by hiring an additional billing clerk, instead of incurring 
the cost of a separate billing department for the provider-based 
facility. This economy of scale would usually extend to the other 
overhead costs incurred by the main provider, because the free-standing 
facility was generally more costly to maintain than one that was 
provider-based. This was due primarily to the savings on overhead costs 
that were accomplished by the merging of the free-standing facility 
into the main provider and having it integrated with the main provider. 
Although there were several limited guidelines outlining the conditions 
for certain provider-based situations, we devoted few resources to 
reviewing provider compliance, because there was little incentive for 
providers to use this designation inappropriately.
    Since 1983, the number of provider-based facilities has increased 
significantly. For example, in July of 1982, there were 481 provider-
based HHAs as compared with 2,577 provider-based HHAs in October of 
1996. This was an increase of 435.75 percent in the 13 years since the 
PPS was established. In addition, many hospitals now have a large 
number of outpatient clinics, often located at various sites.
    We believe the growth in the number of facilities and organizations 
claiming to be provider-based has occurred for several reasons. First, 
the PPS established payment rates using base year costs that included 
provider overhead. Health care providers, looking for ways to increase 
their Medicare revenues, realized that if they established provider-
based facilities or organizations that were still subject to the 
reasonable cost principles, they would then be able to shift some of 
the overhead from the hospital inpatient operating costs to these 
provider-based facilities or organizations. The PPS main provider would 
be paid a PPS payment that was intended to cover overhead costs, as 
well as being reimbursed on a reasonable cost basis based on Medicare's 
share of the overhead costs for the services furnished by the provider-
based facility or organization. A main provider that is excluded from 
PPS and subject to the rate-of-increase limits would also benefit from 
shifting its overhead to the subordinate provider-based facility or 
organization. This cost shifting would enable it to increase its 
payment by being paid for the Medicare share of the diverted overhead 
on a cost-based methodology, as well as bringing its costs below the 
rate-of-increase limit. The main provider could then share in the 
incentive payment by having its costs come in below the target rate.
    More recently, other factors have combined to create incentives for 
providers to affiliate with one another and to acquire control of 
nonprovider treatment settings, such as physician offices. Integrated 
delivery systems offer a wide variety of health care services and can 
assume responsibility for entire episodes of a patient's illness. These 
systems are attractive to patients, who seek continuity of care, and to 
businesses seeking a single source of health services for their 
employees. The resulting growth in the number of patients enrolled by 
these integrated delivery systems has created a powerful incentive for 
affiliations. In addition, hospitals rely on referrals from physicians 
to assure a steady stream of patients, and they have begun to purchase 
physician practices and integrate them into their outpatient 
operations. This trend also has created

[[Page 47588]]

incentives for hospitals to affiliate with physician practices.

B. Effects on Medicare

    For several reasons, it is essential that we ensure that decisions 
regarding provider-based status are made appropriately, and that 
facilities or organizations are not recognized as provider-based unless 
they are in fact integral and subordinate parts of the main provider. 
As noted earlier, in cases where main providers are paid under the PPS 
and subordinate facilities or organizations are paid under the 
reasonable cost reimbursement method (section 1861(v)(1)(A) of the Act 
and 42 CFR part 413), a provider-based determination could allow the 
main provider to shift overhead costs to cost centers that are paid on 
a cost basis and thereby increase Medicare payments with no 
commensurate benefit to the Medicare program or its beneficiaries.
    Payments for services furnished in a hospital outpatient clinic 
generally include both a facility payment and payment for the 
professional services of a physician. The combined payments are 
typically higher than the payment for comparable services furnished in 
a physician office, where a separate facility fee is not payable. In 
many cases, there is also an increase in beneficiaries' out-of-pocket 
expenses compared to services furnished in a physician office. For 
example, when a beneficiary is treated in a physician office, the only 
payment made is Part B payment to the physician for his or her 
professional services, under the physician fee schedule. The single 
payment made under the physician fee schedule pays for the physician's 
work and includes a component for practice expense. The beneficiary's 
coinsurance is based on 20 percent of the physician fee schedule 
amount. However, if the same service is furnished in a hospital 
outpatient clinic, Medicare Part B payment for a facility fee is also 
made to the hospital, in addition to the physician's payment (which may 
include a smaller practice expense component). Thus, for the same 
visit, the beneficiary is also subject to the Part B coinsurance for 
the hospital's facility fee. Beneficiaries are responsible for 
coinsurance based on 20 percent of the hospital's charges (or, the 
applicable coinsurance amounts under the hospital outpatient PPS).
    Provider-based status also raises issues of Medicare coverage. 
Generally, the services of nonphysician staff furnished in a physician 
office are covered only as services ``incident to'' the professional 
services of a physician under section 1861(s)(2)(A) of the Act. This 
means that a physician must be available on the premises when the 
service is furnished, in order to provide direct supervision of that 
service. In hospital outpatient departments, however, we presume that 
the ``incident to'' requirements are met with respect to hospital 
services incident to physician services to outpatients (section 
1861(s)(2)(B)). The policy assumed the outpatient department was co-
located on the hospital premises and staff physicians would be 
available nearby to provide necessary oversight. It is possible that a 
hospital outpatient clinic may not be in the immediate vicinity of the 
hospital and may furnish nonphysician services without actually 
providing for direct physician supervision of those services. We do not 
believe that such services should be presumed to meet applicable 
``incident to'' requirements. As explained below, it could also present 
a health and safety risk at a time when the office is staffed with 
nonphysician personnel who are furnishing medical care with no 
physician present and available to attend to any unexpected emergency 
situation that may arise.
    Provider-based status for a facility or organization can have other 
implications for the health and safety of its patients. Hospital 
outpatient facilities are subject to the Medicare conditions of 
participation in 42 CFR part 482, including specific requirements 
covering such crucial areas as adequacy of physician care (Sec. 482.22, 
``Conditions of participation: Medical staff''), and the safety of the 
physical environment, including compliance with fire safety 
requirements (Sec. 482.41, ``Conditions of participation: Physical 
environment''). Beneficiaries have the right to expect that any 
outpatient department of a hospital meets applicable conditions of 
participation and that the facility is capable of providing care 
commensurate with the general level of care furnished in a hospital 
outpatient department that is co-located with the inpatient setting. 
However, the facility claimed as an outpatient department may not have 
been surveyed for compliance with the conditions of participation and, 
in some cases, we may not even have been notified of its existence.
    The BBA includes several new provisions that can be implemented 
appropriately only if clear distinctions are made between free-standing 
and provider-based facilities. Section 4205(a)(1) of the BBA amended 
section 1833(f) of the Act to extend the per-visit payment limit for 
rural health clinics (RHCs), which previously applied only to free-
standing RHCs, to most provider-based RHCs as well. (The law provides 
that the limit does not apply to RHCs located in hospitals with less 
than 50 beds.)
    Section 4541 of the BBA amended section 1833 of the Act to 
establish a prospective system of payment for outpatient physical 
therapy services (including outpatient speech-language pathology 
services) and outpatient occupational therapy services furnished after 
1998, and to establish a $1,500 annual limit on the amount of payment 
for such services to each beneficiary. Under sections 1833(g)(1) and 
(g)(2) of the Act, however, that limit does not apply to services 
furnished in hospital outpatient departments. Moreover, as explained 
later in this section of the preamble, there are differences in payment 
for ambulatory surgical services, depending on whether the services are 
furnished in a hospital, by an approved ASC, or in a physician office. 
Further, higher composite rate payments are made to hospital-based ESRD 
facilities than to free-standing ESRD facilities. Thus, it is essential 
that we have clear rules for identifying provider-based facilities.

C. Relationship of the ``Provider-Based'' Proposals to Prospective 
Payment for Outpatient Hospital Services and Effective Date of 
``Provider-Based'' Proposals

    Although the proposed regulations set forth in new Sec. 413.65 and 
in the amendment to Sec. 413.24 relate to providers generally, their 
implementation is crucial to successful implementation of a PPS for 
outpatient hospital services. No outpatient PPS can succeed if it does 
not clearly define the services to which it applies. Experience 
suggests that under the existing policies defining provider-based 
status, many ambulatory services may be characterized either as 
physician office services or as services of hospital outpatient 
departments or clinics or an ASC, depending on the financial incentives 
involved. Thus, we are publishing these proposed rules to permit 
clearer distinctions to be made between various types of services, and 
to ensure that services paid for under the outpatient PPS are of the 
same type as those included in the data on which the system is based.
    As explained in the previous section of this preamble, it is 
essential that provider-based decisions be made appropriately in all 
cases, not just those involving outpatient hospital services paid for 
under a PPS. Therefore, the effective date of these proposals will not 
be delayed until after an outpatient PPS is in effect. On the contrary, 
we plan to

[[Page 47589]]

implement proposed Secs. 413.24(d)(6)(i) and (ii), 413.65, 489.24(b), 
and 498.3, as revised based on our consideration of public comments, 
with respect to services furnished on or after 30 days following 
publication of a final rule.

D. Basis for Current Provider-Based Policy

    Although there is no direct statutory requirement to maintain 
explicit criteria for determination as to provider-based status, there 
are statutory references acknowledging the existence of this payment 
outcome. For example, section 1881(b) of the Act provides for separate 
payment rates for hospital-based (ESRD) facilities.
    There is currently no general definition of ``provider-based 
facility'' in the CFR. However, various sections of the CFR do contain 
provisions for recognition of specific types of entities as provider-
based.
    Section 405.2462(a) authorizes payment for RHCs and Federally 
qualified health centers (FQHCs) as provider-based, if:
    (1) The clinic or center is an integral and subordinate part of a 
hospital, SNF, or HHA participating in Medicare, (that is, a provider 
of services); and
    (2) The clinic or center is operated with other departments of the 
provider under common licensure, governance, and professional 
supervision.
    Definitions of hospital-based HHAs and SNFs were published in final 
notices on cost limits for HHAs and SNFs, in the June 5, 1980 (45 FR 
38014) and September 4, 1980 (45 FR 58699) issues of the Federal 
Register, respectively. These criteria were identical to one another 
and were similar to the RHC and FQHC definition but they provided 
considerably more detail in their description of common governance.
    Further, we have provided additional detail regarding the factors 
to be considered in making determinations regarding provider-based 
status in our manuals. The Medicare Regional Office Manual at section 
6860 provides a list of criteria that should be considered in making a 
determination regarding provider-based status for clinics. Also, 
section 2186 of the State Operations Manual provides direction 
regarding provider-based designation for HHAs.
    Program Memorandum A-96-7, published on August 27, 1996, pulled 
together the instructions previously manualized for specific entity 
types into a general instruction for the designation of provider-based 
status to all facilities or organizations. In developing this Program 
Memorandum, we took information from the State Operations Manual 
(sections 2024, 2186, and 2242), the Regional Office Manual (section 
1060, 2020 and 6865), and Secs. 405.2462 and 413.170 of the CFR.
    Under the policy we set forth in Program Memorandum A-96-7, the 
following applicable requirements must be met before an entity can be 
designated as provider-based for Medicare payment purposes:
    1. The entity is physically located in close proximity of the 
provider where it is based, and both facilities serve the same patient 
population (for example, from the same service, or catchment area);
    2. The entity is an integral and subordinate part of the provider 
where it is based, and as such, is operated with other departments of 
that provider under common licensure (except in situations where the 
State separately licenses the provider-based entity);
    3. The entity is included under the accreditation of the provider 
where it is based (if the provider is accredited by a national 
accrediting body) and the accrediting body recognizes the entity as 
part of the provider;
    4. The entity is operated under common ownership and control (that 
is, common governance) by the provider where it is based, as evidenced 
by the following:
     The entity is subject to common bylaws and operating 
decisions of the governing body of the provider where it is based;
     The provider has final responsibility for administrative 
decisions, final approval for personnel actions, and final approval for 
medical staff appointments in the provider-based entity; and
     The entity functions as a department of the provider where 
it is based with significant common resource usage of buildings, 
equipment, and service personnel on a daily basis.
    5. The entity director is under the direct day-to-day supervision 
of the provider where it is located, as evidenced by the following:
     The entity director or individual responsible for day-to-
day operations at the entity maintains a daily reporting relationship 
and is accountable to the Chief Executive Officer of the provider and 
reports through that individual to the governing body of the provider 
where the entity is based; and
     Administrative functions of the entity, for example, 
records, billing, laundry, housekeeping and purchasing are integrated 
with those of the provider where the entity is based.
    6. Clinical services of the entity and the provider where it is 
located are integrated as evidenced by the following:
     Professional staff of the provider-based entity have 
clinical privileges in the provider where it is based;
     The medical director of the entity (if the entity has a 
medical director) maintains a day-to-day reporting relationship to the 
chief medical officer or other similar official of the provider where 
it is based;
     All medical staff committees or the professional 
committees at the provider where the entity is based are responsible 
for all medical activities in the provider-based entity;
     Medical records for patients treated in the provider-based 
entity are integrated into the unified records system of the provider 
where the entity is based;
     Patients treated at the provider-based entity are 
considered patients of the provider and have full access to all 
provider services; and
     Patient services provided in the entity are integrated 
into corresponding inpatient and/or outpatient services, as 
appropriate, by the provider where it is based.
    7. The entity is held out to the public as part of the provider 
where it is based (for example, patients know they are entering the 
provider and will be billed accordingly).
    8. The entity and the provider where it is based are financially 
integrated as evidenced by the following:
     The entity and the provider where it is based have an 
agreement for the sharing of income and expenses, and
     The entity reports its cost in the cost report of the 
provider where it is based using the same accounting system and the 
same cost reporting period as the provider where it is based.
    Our policy will continue to follow the principles we articulated in 
Program Memorandum A-96-7 until 30 days after this rule is published as 
final in the Federal Register. After that date, we will apply the 
policies set forth in the final regulations.

E. Provisions of This Proposed Rule

    This proposed rule would add a new Sec. 413.65, stating the 
appropriate definitions of, and the general requirements for, the 
determination of ``provider-based'' status. In paragraph (a), we are 
proposing to define the following terms for purposes of this section: 
department of a provider, free-standing facility, main provider, 
provider-based entity, and provider-based status. The definitions used 
are as follows.
    Department of a provider means a facility or organization or clinic 
that is

[[Page 47590]]

either created by, or acquired by, a main provider for the purpose of 
furnishing health care services under the name, ownership, and 
financial and administrative control of the main provider in accordance 
with the provisions of proposed Sec. 413.65. A department of a provider 
is not licensed or certified to provide services in its own right, and 
Medicare conditions of participation do not apply to the department as 
an independent entity. The term ``department of a provider'' does not 
include an RHC or FQHC; however, an RHC or FQHC could qualify as a 
provider-based entity.
    Free-standing facility means an entity that furnishes health care 
services to Medicare beneficiaries, and that is not integrated with any 
other entity as a main provider, a department of a provider, or a 
provider-based entity.
    Main provider means a provider that either creates or acquires 
ownership of another entity to deliver additional health care services 
under its name, ownership, and financial and administrative control.
    Provider-based entity means a provider, or an RHC or FQHC as 
defined in Sec. 405.2401(b), that is either created by, or acquired by, 
a main provider for the purpose of furnishing health care services 
under the name, ownership, and administrative and financial control of 
the main provider in accordance with the provisions of proposed 
Sec. 413.65. A provider-based entity is certified to provide services 
in its own right.
    Provider-based status means the relationship between a main 
provider and a provider-based entity, or a department of a provider, 
that is in compliance with the provisions of proposed Sec. 413.65.
    We are proposing to state explicitly, in new paragraph (b), that a 
facility or organization is not entitled to be treated as provider-
based simply because it or the provider believe it to be provider-
based. We also would state that, if a facility or organization seeking 
provider-based status is located off the campus of a provider, or 
inclusion of the costs of the facility or organization on the 
provider's cost report would increase the total costs on that report by 
at least 5 percent, HCFA will not treat the facility or organization as 
provider-based for purposes of billing or cost reporting unless the 
provider has contacted HCFA and obtained a determination of provider-
based status. This means that we would not accept billings from the 
facility or organization as if it were provider-based, and the provider 
will not be permitted to include costs of the facility or organization 
on its cost report, unless the acquisition or creation of the facility 
or organization has been reported to us and we have determined that it 
is either a department of a provider or a provider-based entity. 
Further, a facility not located on the campus of a hospital and used as 
a site of physician services of the kind ordinarily furnished in 
physician offices will be presumed to be a free-standing facility 
unless it is determined by HCFA to have provider-based status. For 
example, a physician office practice purchased by a main provider would 
not qualify for provider-based status unless it meets all applicable 
criteria in proposed Sec. 413.65.
    We are proposing to require, in new paragraph (c), that a main 
provider that acquires a facility or organization for which it wishes 
to claim provider-based status must report its acquisition of the 
facility or organization to HCFA and furnish all information needed for 
a determination as to whether the facility or organization meets the 
criteria in this section for provider-based status. A main provider 
that has had one or more facilities or organizations determined to have 
provider-based status also must report to HCFA any material change in 
the relationship between it and any department or provider-based 
entity, such as a change in ownership of the entity or entry into a new 
or different management contract, that could affect the provider-based 
status of the department or entity.
    In new paragraph (d), we propose the requirements for a 
determination of ``provider-based status.'' In paragraph (d)(1), we 
would set forth licensure requirements for facilities or organizations 
seeking provider-based status. Any facility or organization seeking to 
be a department of a provider would have to be operated under the same 
license as the main provider. We note that if a State's licensure laws 
establish restrictions on the type or location of facilities or 
organizations that can be licensed as part of a provider, we would 
defer to those restrictions in determining whether a particular 
facility is a department of the provider. For example, if the hospital 
licensure laws of a particular State precluded facilities located more 
than 5 miles from a hospital from being licensed as part of the 
hospital, we also would not consider those facilities to be a part of 
the hospital. Provider-based entities would not have to be operated 
under the same license as the main provider, since in most cases we 
expect that they would be separately licensed by the State. To take 
account of possible State-by-State differences in licensure, however, 
we would require only that a prospective provider-based entity be 
licensed in accordance with the law of the State in which it is 
located.
    In addition, if a State health facilities' cost review commission, 
or other agency that has authority to regulate the rates charged by 
hospitals or other providers in a State, finds that a particular 
facility or organization is not part of a provider, we also would 
determine that the facility or organization does not have provider-
based status. We believe it would be inappropriate for a facility or 
organization to be considered free-standing for State ratesetting 
purposes, but provider-based status under Medicare.
    In paragraph (d)(2), we would require that a facility or 
organization be under the ownership and control of the main provider. 
In particular, we would require that the facility or organization be 
100 percent owned by the provider, that the main provider and a 
facility or organization seeking provider-based status have the same 
governing body, and that the facility or organization be operated under 
the same organizational documents as the main provider. For example, 
the facility seeking provider-based status would have to be subject to 
the bylaws and operating decisions of the governing body of the main 
provider. In addition, we would require that the main provider have 
final responsibility for administrative decisions, final approval for 
outside contracts, final responsibility for personnel policies, and 
final approval for medical staff appointments in the department or 
entity.
    In paragraph (d)(3), with respect to administration and direct 
supervision of the main provider, we are proposing to require that a 
facility or organization seeking provider-based status have a reporting 
relationship to the main provider that is characterized by the same 
frequency, intensity, and level of accountability that exists in the 
relationship between the main provider and one of its departments. As 
evidence of this relationship, we would look to whether the facility is 
under the direct supervision of the provider where it is located, 
whether it is operated under the same monitoring and oversight as any 
other department of the provider, and is operated as any other 
department with respect to supervision and accountability. We would 
expect the director or individual responsible for daily operations at 
the facility or organization to maintain a day-to-day reporting 
relationship with a manager at the main provider and to be accountable 
to the main provider's governing body in the same manner as any 
department head of the provider. We also would require integration of 
certain

[[Page 47591]]

administrative functions, in particular, billing services, records, 
human resources, payroll, employee benefit package, salary structure, 
and purchasing services. Either the same employee or group of employees 
would have to handle these administrative functions for both the 
facility or organization and the main provider, or the administrative 
functions for the entity and the main provider would have to be 
contracted out under the same contractual agreement, or be handled 
under different contract agreements, with the entity's contract being 
managed by the main provider's billing department.
    In paragraph (d)(4), we are proposing that a facility or 
organization seeking provider-based status and the main provider share 
integrated clinical services, as evidenced by privileging of the 
professional staff of the department or entity at the main provider, 
and the main provider's maintenance of the same monitoring and 
oversight of the department or entity as of other departments. Also, 
the medical director of the department or entity must maintain a day-
to-day reporting relationship with the chief medical officer (or 
equivalent) of the main provider, and be under the same supervision as 
any other director of the main provider. We also would expect medical 
staff committees or other professional committees of the main provider 
to be responsible for medical activities in the department or entity, 
including quality assurance, utilization review, and the coordination 
and integration of services. We also would expect medical records to be 
integrated into a unified retrieval system. We would expect that 
inpatient and outpatient services of the facility or organization and 
the main provider be integrated and that patients treated at the 
facility or organization who require further care have full access to 
all services of the main provider, including all inpatient or 
outpatient services of the main provider.
    In paragraph (d)(5), we would require that the proposed department 
or entity and the main provider be fully financially integrated within 
the main provider's financial system, as evidenced by the sharing of 
income and expenses. The department's or entity's costs should be 
reported in a cost center of the provider, and the department's or 
entity's financial status should be incorporated into, and readily 
identifiable in, the main provider's trial balance.
    In paragraph (d)(6), we would require that the main provider and 
the facility seeking status as a department of the provider be held out 
to the public as a single entity, so that when patients enter the 
department they are aware that they are entering the provider and will 
be billed accordingly. (This requirement would not apply to a provider-
based entity that is itself a provider, such as a SNF.)
    In paragraph (d)(7), we would require that the department of a 
provider or provider-based entity and the main provider be located on 
the same campus. Alternatively, the main provider and facility seeking 
provider-based status must demonstrate that they serve the same patient 
population. The department or entity and the main provider would be 
required to demonstrate that they serve the same patient population by 
submitting patient lists and/or demographic data showing that a high 
percentage of the patients of both come from the same geographic area, 
or that patients of the entity also receive a preponderance of services 
from the main provider. We would specify that a facility or 
organization is not considered to be in the ``immediate vicinity'' of 
the main provider if it is located in a different State than the main 
provider. We welcome comments as to whether an exception should be made 
for areas where a single metropolitan area may include two or more 
States.
    New paragraph (e) would specifically prohibit the approval of 
provider-based status for any proposed department or entity that is 
owned by two or more providers engaged in a joint venture. Some 
hospitals, under joint venture arrangements, are jointly purchasing or 
jointly creating free-standing facilities. Although the facility or 
organization is operated by two or more hospitals, the dominant 
hospital claims the free-standing facility or organization as a 
department or provider-based entity. This is clearly unallowable, 
because the facility or organization is owned by more than one 
hospital, and in its own right must be considered as free-standing, 
subject to all of the rules and certifications that govern that type of 
operation.
    In proposed paragraph (f), we would state that facilities or 
organizations operated under management contracts will be considered 
provider-based only if specific requirements for staff employment, 
administrative functions, day-to-day control of operations, and holding 
of the management contract by the provider itself rather than by a 
parent organization are met. Generally, we believe it would be 
difficult for any facility or organization operated under a management 
contract to provide all services to be able to demonstrate the degree 
of integration with a provider that would be needed to qualify for 
provider-based status. Thus, we are proposing to adopt these 
requirements, which are designed to ensure that we treat a facility or 
organization under a management contract as provider-based only if it 
clearly is operated by the provider, not by the management company or 
by a common parent organization.
    In proposed paragraph (g), we would specify nine obligations of 
hospital outpatient departments and hospital-based entities. These 
obligations are spelled out in detail to help us ensure that facilities 
seeking recognition as hospital outpatient departments or hospital-
based entities are in fact what they represent themselves as being, and 
are not simply the private offices of individual physicians or of 
physicians in group practices. The obligations are--

--In the case of hospital outpatient departments located off the main 
provider campus, compliance with the anti-dumping requirements in 
Secs. 489.20 (l), (m), (q), and (r) and 489.24. If any individual comes 
to any hospital-based entity (including an RHC) located on the main 
hospital campus and a request is made on the individual's behalf for 
examination or treatment of a medical condition, as described in 
Sec. 489.24, the hospital must comply with the anti-dumping 
requirements in Sec. 489.24. We would also revise Sec. 489.24(b) to 
clarify that for purposes of the anti-dumping rules set forth in that 
section, hospital property means the entire main hospital campus, 
including the parking lot, sidewalk, and driveway, as well as any 
facility or organization that is located off the main hospital campus 
but has been determined under Sec. 413.65 to be a department of the 
hospital.
--Billing of physician services in hospital outpatient departments or 
hospital-based entities (other than RHCs) with the correct site-of-
service indicator, so that applicable site-of-service reductions to 
physician and practitioner payment amounts can be applied;
--In the case of hospital outpatient departments, compliance with all 
the terms of the provider agreement;
--Compliance by physician staff with the nondiscrimination provisions 
in Sec. 489.10(b) of this chapter;
--In the case of hospital outpatient departments (other than RHCs), 
representation to other payers as an outpatient department of the 
hospital, and treatment of all patients, for billing purposes, as 
hospital outpatients;

[[Page 47592]]

--In the case of hospital outpatient departments or hospital-based 
entities, compliance with the payment window provisions applicable 
under Sec. 412.2(c)(5) (for PPS hospitals) or Sec. 413.40(c)(2) (for 
PPS-excluded hospitals);
--In the case of hospital outpatient departments or hospital-based 
entities (other than RHCs), notice to each beneficiary treated that he 
or she will be liable for coinsurance for a facility visit as well as 
for the physician service; and
--In the case of hospital outpatient departments, compliance with 
applicable Medicare hospital conditions of participation for hospitals 
in part 482 of this chapter.

    We would also preclude any facility or organization that furnishes 
all services under arrangements from qualifying as provider-based. We 
believe the provision of services under arrangement was intended to be 
allowed only to a limited extent, in situations where cost-
effectiveness or clinical considerations, or both, necessitate the 
provision of services by someone other than the provider's own staff. 
The ``under arrangement'' provision in section 1861(w)(1) of the Act 
and Sec. 409.3 is not intended to allow a facility merely to act as a 
billing agent for another. We are concerned that this would be the case 
if all services at a facility or organization seeking provider-based 
status were furnished under arrangement. We believe use of arranged-for 
services could, if not limited, become a means of circumventing the 
provider-based requirements. We are proposing in paragraph (g)(10) that 
a facility or organization may not qualify for provider-based status if 
all of the services furnished at the facility are furnished under 
arrangements. We note that this approach is consistent with existing 
policy under which a hospital outpatient is expected to receive 
services, rather than supplies, directly from the hospital.
    Proposed paragraph (h) states that if we learn of a provider that 
has inappropriately treated a facility or organization as provider-
based, before obtaining our determination of provider-based status, we 
would reconsider all payments to that main provider for periods subject 
to reopening, investigate, and determine whether the designation was 
appropriate. If we find it was not provider-based, we will recover all 
payments in excess of those payments that should have been made in the 
absence of the provider-based status. As explained further below, 
however, recovery will not be made for any period prior to the 
effective date of this rule if during all of that period the management 
of the facility or organization made a good-faith effort to operate it 
as a department of a provider or provider-based entity.
    In proposed paragraph (i), we would detail the application of the 
principles in paragraph (h) to situations involving inappropriate 
billing for services furnished in a physician office or other facility 
or organization as if they had been furnished in a hospital outpatient 
or other department of a provider or in a provider-based entity. 
Generally, when such cases of inappropriate billing are found, we will 
recover any overpayments as described in the preceding paragraph. Under 
certain circumstances, however, we will determine that the management 
of a facility or organization has made a good faith effort to operate 
it as a department of a provider or a provider-based entity and will 
not recover past payments. We would take this action if we determine 
that the requirements regarding licensure and public awareness in 
paragraphs (d)(1) and (d)(6) are met, all facility services were billed 
as if they had been furnished by a department of the main provider or a 
provider-based entity of the main provider, and all professional 
services of physicians and other practitioners were billed with the 
correct site-of-service indicator, as described in paragraph (g)(4).
    We are also proposing to add a new paragraph (j) that would allow 
HCFA to review past determinations. If we find that a designation was 
in error, and the facility or organization in question does not meet 
the requirements of this section, we will notify the main provider that 
the provider-based status will cease as of the first day of the next 
cost report period following notification of the redetermination.
    In addition, we are proposing to add to Sec. 413.24(d) new 
paragraphs (6)(i) and (6)(ii) to clarify that main providers, in 
completing their Medicare cost reports, may not allocate overhead costs 
to the provider-based or other cost centers that incur similar costs 
directly through management contracts or other arrangements. These 
changes are needed to prevent mis-allocation of management costs, which 
would result in excessive payment to those types of providers paid on a 
reasonable cost basis.
    As the number of affiliation agreements among various entities has 
increased, there has been a noticeable shift in the way the HHAs and 
clinics have been managed, resulting in increased Medicare payments. 
Today, there are many management companies that enter into contracts 
with main providers to manage their provider-based entities, and the 
costs of these management services are being directly assigned to the 
department or provider-based entity receiving the service. The 
contracts typically call for the management company to provide the 
billing and accounting services, and to procure services, such as 
housekeeping, laundry and linen, to enable the department or provider-
based entity to operate away from the campus and supervision of the 
main provider, even though these management companies must report to 
the board of the main provider. In addition to directly assigning these 
costs to the department or provider-based entity, the main provider, 
through the cost report, is still allocating overhead costs to the 
department or provider-based entity, even though these services are 
being performed through the management contract and not through the 
main provider. Under these circumstances, the provider could be paid 
three times for the same overhead cost. The first payment would be made 
through the PPS payment, which reflects overhead cost. The second 
payment would come through the cost of the management contract, and the 
third would come through the allocation of a share of the main 
provider's overhead cost to the department or provider-based entity. 
Our proposed changes to Sec. 413.24 are needed to prevent this result.
    To provide an administrative appeals process for entities that have 
been denied provider-based status, we are proposing to revise the 
regulations on provider appeals at Sec. 498.3. As revised, these rules 
would specify that a provider seeking a determination that a facility 
or an organization is a department of the provider or a provider-based 
entity under proposed Sec. 413.65 will be included in the definition of 
``prospective provider'' for purposes of part 498, and will be afforded 
the same appeal rights as a prospective provider, such as a hospital or 
SNF, that has been found by HCFA not to qualify for participation as a 
provider. We believe it is in the best interest of both HCFA and health 
care organizations to have an explicit procedure for handling these 
appeals.

F. Requirements for Payment

    The following discussion sets out the requirements that must be met 
to allow us to make payment under the outpatient PPS for various 
services.

[[Page 47593]]

1. Prerequisites for Payment for Outpatient Hospital Services and 
Supplies Incident to Physician Services
    Medicare Part B benefits include payment for services and supplies 
that are furnished incident to the professional services of a 
physician. Medicare makes payment for services and supplies furnished 
in physician offices that are incident to a professional service of a 
physician under the provisions of the Medicare physician fee schedule 
(section 1848 and section 1861(s)(2)(A) of the Act; 42 CFR part 414). 
Payment for the ``incident to'' services furnished in physician offices 
is generally included within the fee for the physician services. 
Medicare also makes payment for hospital services and supplies that are 
incident to a physician service furnished to outpatients (section 
1861(s)(2)(B) of the Act). Payment for ``incident to'' services 
furnished to hospital outpatients is in addition to payment for the 
professional services of a physician. The place where ``incident to'' 
services are furnished determines how Medicare pays for them.
    We are proposing to add to the regulations certain prerequisites 
that the hospital must fulfill before it can receive Medicare payment 
under section 1861(s)(2)(B) of the Act for services and supplies 
furnished ``incident to'' physician services at a site that is off the 
premises of the main hospital complex. These prerequisites are intended 
to adapt our current policy regarding payment for ``incident to'' 
services furnished to hospital outpatients to address the special 
circumstances presented by a hospital outpatient department or clinic 
that is not co-located on the hospital campus or within a short 
distance of the hospital and that HCFA has designated is a department 
of the hospital or ``provider-based.''
    The first prerequisite is that the office/clinic meet the 
responsibilities and criteria incumbent upon a provider-based entity as 
defined in Sec. 413.65(g). We are proposing this requirement because 
the fact that a hospital owns and/or operates a clinic does not 
automatically make that clinic an integral, subordinate part of the 
hospital. If the clinic does not conform with the responsibilities and 
criteria at Sec. 413.65(g), that clinic would be paid as a physician 
office, and Medicare payment for services furnished at that site would 
be made accordingly.
    The second prerequisite is that the hospital seek an official 
determination from HCFA that the provider-based designation applies to 
the proposed off-site hospital outpatient department/clinic as required 
by Sec. 413.65(d). The authority to determine whether or not an entity 
has provider-based status rests solely with HCFA. The criteria and 
obligations that are a prerequisite of a provider-based hospital 
outpatient designation are discussed earlier in this section.
    Current regulations require that, in order to be paid for as 
``incident to'' services, outpatient hospital services and supplies are 
to be furnished as an integral though incidental part of a physician 
service (Sec. 410.27(a)(1)(ii)). In addition, as a matter of policy, we 
require that the services and supplies be furnished on a physician's 
order by hospital personnel and under a physician's supervision 
(Intermediary Manual, section 3112.4(A)). When ``incident to'' services 
are furnished on hospital premises, we assume the physician supervision 
requirement to be met because staff physicians would be present nearby 
within the hospital. We also allow staff in a department of the 
hospital other than that of the ordering physician to supervise the 
services. We equate the location of the hospital outpatient department 
or hospital clinic within the hospital's walls, or their co-location on 
the same campus, with being ``on the hospital premises,'' and we assume 
physician supervision is always at hand. In the interests of 
beneficiary health and safety, we do not believe it is reasonable, 
safe, or appropriate to extend these assumptions to a hospital 
outpatient department or hospital clinic that is located off-site and 
that is not on the hospital premises, even if that outpatient 
department or clinic is accorded provider-based status. Therefore, we 
are proposing as the third prerequisite for a hospital to receive 
payment for ``incident to'' services under section 1861(s)(2)(B) of the 
Act, when these services are furnished at a hospital outpatient 
department or clinic that HCFA designates as provider-based: that the 
``incident to'' services and supplies always be furnished under the 
direct supervision of a physician.
    Unless the three prerequisites are met, we are proposing to 
continue to regard a clinic, even if it is owned or operated by a 
hospital, as a physician office or physician clinic for Medicare 
payment purposes. Payment for services and supplies incident to 
physician services that are furnished to Medicare beneficiaries at that 
site would only be paid in accordance with section 1848 and section 
1861(s)(2)(A) of the Act, and payment would be subject to Medicare 
physician fee schedule payment policies and regulations (part 410; part 
414).
2. Prerequisites for Payment for Hospital or Critical Access Hospital 
Diagnostic Services Furnished to Outpatients
    Prerequisites for payment for diagnostic services furnished to 
hospital outpatients are addressed in Sec. 410.28. We are proposing to 
add a new paragraph to the regulation that would require, at a minimum, 
a general level of physician supervision, and in some cases, direct or 
personal physician supervision, when diagnostic x-ray tests and other 
diagnostic tests are furnished at a hospital outpatient department or 
clinic that HCFA has determined meets the criteria and obligations of a 
provider-based entity in accordance with Sec. 413.65. The definitions 
of general, direct, and personal supervision are contained in 
Sec. 410.32. Although the levels of supervision defined in Sec. 410.32 
apply specifically to diagnostic x-ray and other tests that are payable 
under the Medicare physician fee schedule, we believe the same levels 
of supervision are equally relevant and reasonable and necessary to 
ensure that beneficiary health and safety are protected and that 
diagnostic x-ray and other diagnostic tests are safe and effective when 
they are furnished at a hospital outpatient department or clinic that 
HCFA has designated to be provider-based.
    We are also proposing to exclude from the supervision requirement 
in provider-based outpatient settings the same three types of 
diagnostic tests that are excluded from the supervision requirement 
under the physician fee schedule:
     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. We exclude 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 office as currently defined in 
section 2070.2 of the Medicare Carriers Manual (HCFA Pub. 14-3). These 
services are distinguished from services of a clinical psychologist, 
which are covered under section 1861(ii) of the Act, rather than 
section 1861(s)(3).

[[Page 47594]]

    We are proposing to coordinate changes to the physician supervision 
requirements for diagnostic tests performed in outpatient settings that 
HCFA has designated to be provider-based with changes made to these 
requirements under the Medicare physician fee schedule. Refer to the 
final rule governing the 1998 physician fee schedule that was published 
in the October 31, 1997 Federal Register (``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'' (BPD-884-FC) (62 FR 59048)) for a full discussion. 
Implementing instructions for physician supervision of diagnostic tests 
are being developed. We note that these implementing instructions will 
contain revisions in the supervision levels required for many 
ultrasound services, stress tests, and some other services.
    When diagnostic x-rays and other diagnostic tests are performed at 
a hospital-owned and/or operated office or clinic that is off-site and 
that HCFA does not designate as provider-based, we are proposing to pay 
for these services under the provisions of the Medicare physician fee 
schedule and the requirements of Sec. 410.32 or under the provisions of 
Sec. 410.33, if applicable.
    3. Payment for Ambulatory Surgical Services
    Upon implementation of the hospital outpatient PPS, Medicare 
payment for resource costs incurred in connection with performing 
ambulatory surgical procedures would be made either under the 
provisions of the hospital outpatient PPS; or, under the benefit 
established at section 1832(a)(2)(F) of the Act for facility services 
furnished by an approved ASC in connection with surgical procedures 
specified by the Secretary; or, under the physician fee schedule as 
established under section 1848 of the Act.
    When ambulatory surgery is performed at the hospital on Medicare 
beneficiaries who are registered at the hospital as outpatients, 
Medicare would allow payment under the outpatient PPS, as explained in 
this proposed rule. However, Medicare would make payment under the 
outpatient PPS for surgical procedures performed at an off-site clinic 
that the hospital owns and operates and for which it submits claims 
only if the off-site clinic has been designated by HCFA as a department 
of the hospital in accordance with proposed Sec. 413.65.
    Alternatively, if the hospital-owned off-site facility is certified 
or accredited in accordance with ASC conditions of coverage and the 
requirements at part 416, Medicare would make payment for covered 
surgical procedures performed at the off-site facility under the ASC 
benefit.
    However, for Medicare payment purposes, we consider an off-site 
office, clinic, organization, or facility that is owned and operated by 
a hospital but that does not meet the requirements at proposed 
Sec. 413.65 or in part 416, to be a physician office or clinic, and 
Medicare payment for surgical procedures performed at that site would 
be limited to what Medicare allows for physician services furnished in 
connection with the surgical procedure under the Medicare physician fee 
schedule.

VII. MedPAC Recommendations

    We reviewed the March 1998 report submitted by MedPAC to the 
Congress and gave its recommendations careful consideration in 
establishing the framework for the outpatient PPS that is the subject 
of this proposed rule. We responded earlier to several MedPAC 
recommendations that pertained directly to specific features of the 
outpatient PPS. In this section, we address the more general MedPAC 
recommendations on hospital outpatient payment policies.
    Recommendation: MedPAC expresses its concern about the effects of 
inappropriate payment levels that could, if they are too low, restrict 
beneficiary access to care or prompt shifts of services for financial 
rather than clinical reasons, or that could, if they are too high, 
stimulate growth in the volume of outpatient services that is unrelated 
to patient needs. MedPAC states that the initial level of payment 
established in the BBA is a reasonable starting point for the 
outpatient PPS, but recommends that the Secretary monitor access to 
hospital outpatient services to ensure that the aggregate level of 
payment under the outpatient PPS is appropriate.
    Response: We agree with MedPAC that monitoring service patterns not 
only in hospital outpatient departments but across all ambulatory 
settings subsequent to implementation of the outpatient PPS is 
essential in order to detect sudden changes and to identify variant 
trends in where services are being furnished to Medicare beneficiaries. 
As is MedPAC, we too are aware of how vividly any differences in 
payment for services furnished in different ambulatory settings will be 
revealed once the outpatient PPS is implemented, and we expect that 
these differences will, not surprisingly, precipitate shifts in 
services from one setting to another. It is the recognition of this 
likely outcome that makes it all the more urgent that we resolve the 
dilemma posed by two conflicting policy determinations raised by 
MedPAC: whether to set Medicare payments to reflect the cost of 
providing a service regardless of where the service is furnished or 
whether to set Medicare payments to acknowledge that the site where a 
service is furnished could affect the cost of furnishing the service. 
As we discuss below, we clearly are inclined toward a position that 
Medicare should determine payment on the basis of the service that is 
furnished rather on the setting where that service is furnished, but 
there are many factors still to be considered before making such a 
determination final. In the meantime, we believe that the adjustments 
provided for under the outpatient PPS will contribute to ensuring that 
Medicare is paying adequately for services, especially in areas where a 
hospital is the only provider of services to which beneficiaries have 
access. We particularly welcome comments and suggestions regarding 
methods by which we can enhance our monitoring of service delivery 
patterns to ensure that the outpatient PPS is not adversely affecting 
beneficiary access to hospital outpatient care in accordance with 
MedPAC's recommendation. We agree with MedPAC's concern that payment 
levels under the outpatient PPS be sufficient to support the provision 
of services, especially in areas where a hospital is the only provider 
of such services, but that payment levels under the outpatient PPS not 
exceed payments for the same services at other ambulatory sites to such 
a degree as to cause shifts in where services are provided for 
financial rather than clinical reasons.
    Recommendation: MedPAC recommends that HCFA continue to investigate 
service classification systems that could be applied consistently to 
all ambulatory care settings. In its 1998 report to Congress, MedPAC 
expresses concern about the impact on service delivery of paying 
different amounts for the same service based on where the service is 
furnished. MedPAC appears to favor Medicare ambulatory care payment 
systems that are standardized across hospital outpatient, physician 
office, and ASC settings. MedPAC equates ``standardized'' with 
``policies that are comparable for the same service, regardless of 
setting,'' (p. 83) and ``* * * consistency of payment across all 
ambulatory settings'' (p. 84).
    Response: In principle, we agree that establishing Medicare payment

[[Page 47595]]

uniformity across ambulatory care settings is important. We have, to 
the extent permitted by the statute, incorporated into the outpatient 
PPS elements of Medicare payment policy for ASCs and for physician 
services.
    Upon implementation of the outpatient PPS, the same unit of payment 
(HCPCS codes and descriptors) will be used for all three settings. 
Packaging under the outpatient PPS parallels that for ASCs. At least 
initially, volume control under the outpatient PPS parallels that which 
is applied to physician services. The policy for discounting multiple 
procedures will be comparable under the outpatient PPS, the ASC 
benefit, and the physician fee schedule. APC groups will be used to set 
rates for ASC payments and for hospital outpatient surgical services, 
and we propose to pay for the same surgical procedures in both 
settings. Notwithstanding these similarities, payment rates for most 
procedures will not be the same for ASCs and under the outpatient PPS. 
We use different data and methods to set rates for ASC services, for 
physician services, and for hospital outpatient services. The latter is 
attributable primarily to the fact that the statute sets forth criteria 
that are to be considered when setting payment mechanisms that are 
specific to each site of service.
    Several fundamental issues must be addressed before we achieve the 
goal of making consistent payment for the same service across all 
ambulatory sites of service. First, consensus must be reached on what 
constitutes ``consistent payment.'' Even MedPAC equivocates on this 
point, noting that while it believes that ``Medicare's payment should 
reflect the cost of efficiently providing a service, regardless of 
where it is delivered * * * (b)ecause of access or quality concerns * * 
* it may be appropriate to continue to pay different amounts for the 
same service, depending on the setting in which it is furnished.'' Does 
``consistent'' or ``comparable'' payment mean the same payment for a 
service regardless of setting? Or would consistency be achieved by 
using the same group weights for hospital outpatient and ASC payment 
rates even though we used site-specific conversion factors, resulting 
in different payment rates? Should we use ASC groups as the basis for 
setting payments for physician services? Is there a single index that 
is appropriate to standardize variations in costs attributable solely 
to geographical differences? And which legislative changes would be 
required to standardize payment for services across ambulatory 
settings? These are but a few of the issues and options that we and 
stakeholders across the spectrum of ambulatory care must thoroughly 
examine and analyze as we move towards standardizing payments across 
ambulatory sites of service. We solicit comments on this issue, on 
options to be considered in restructuring Medicare payment provisions 
towards the goal of establishing payment uniformity across ambulatory 
sites, and on strategies for achieving consensus on the definition of 
both goals and the means of attaining them.

VIII. Collection of Information Requirements

    Under the Paperwork Reduction Act of 1995, we are required to 
provide 60-day notice in the Federal Register and solicit public 
comment before a collection of information requirement is submitted to 
the Office of Management and Budget (OMB) for review and approval. In 
order to fairly evaluate whether an information collection should be 
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act 
of 1995 requires that we solicit comment on the following issues:
     The need for the information collection and its usefulness 
in carrying out the proper functions of our agency.
     The accuracy of our estimate of the information collection 
burden.
     The quality, utility, and clarity of the information to be 
collected.
     Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
    We are soliciting public comment on each of these issues for the 
provisions summarized below that contain information collection 
requirements:

Section 413.65  Requirements for a Determination That a Facility or an 
Organization is a Department of a Provider or a Provider-Based Entity

    Section 413.65(c)(1) and (c)(2) states that a main provider that 
acquires a facility or organization for which it wishes to claim 
provider-based status, including any physician offices that a hospital 
wishes to operate as a hospital outpatient department or clinic, must 
report its acquisition of the facility or organization to HCFA and must 
furnish all information needed for a determination as to whether the 
facility or organization meets the requirements in paragraph (d) of 
this section for provider-based status. This requirement applies, 
however, only if the facility or organization is located off the campus 
of the provider, or inclusion of the costs of the facility or 
organization on the provider's cost report would increase the total 
costs on the report by at least 5 percent. Furthermore, a main provider 
that has had one or more entities considered provider-based also must 
report to HCFA any material change in the relationship between it and 
any provider-based facility or organization, such as a change in 
ownership of the facility or organization or entry into a new or 
different management contract that could affect the provider-based 
status of the facility or organization.
    The burden associated with this requirement is the time for the 
main provider to report its acquisition to HCFA, furnish all 
information needed for a determination, report to HCFA any material 
change in the relationship between it and any provider-based facility 
or organization, such as a change in ownership of the facility or 
organization or entry into a new or different management contract that 
could affect the provider-based status of the facility or organization. 
It is estimated that 105 main providers will take 10 hours for a total 
of 1,050 hours.

Section 419.42  Hospital Election To Reduce Copayment

    Section 419.42(b) and (c) states that a hospital must notify its 
fiscal intermediary of its election to reduce copayments no later than 
90 days prior to the start of the calendar year. The hospital's 
election must be properly documented. It must specifically identify the 
ambulatory payment classification to which it applies and the copayment 
level (within the limits identified below) that the hospital has 
selected for each group.
    The burden associated with these requirements is the time it takes 
a hospital to compile, review, and analyze data for both revenues and 
copayments; prepare and present the data to the hospital board; make a 
business decision as to whether the hospital would elect to reduce 
copayments; and then notify its fiscal intermediary of its election. A 
hospital would notify its fiscal intermediary of its election to reduce 
copayments only if there were other providers, in close proximity, that 
would attract a majority of the hospital's business if they did not 
reduce their copayments. Since hospitals do not want to lose money by 
absorbing copayments, we anticipate that this requirement will affect 
750 hospitals and take them 10 hours each for a total of 7,500 hours.
    Section 419.42(e) states that the hospital may advertise and 
otherwise disseminate information concerning the reduced level(s) of 
coinsurance that it has elected.

[[Page 47596]]

    The burden associated with this requirement is the time for the 
hospital to disseminate information concerning its coinsurance 
election. It is estimated that 750 hospitals will each take 10 hours 
annually to disseminate this information via newsletters and 
information sessions at senior citizen centers for a total of 7,500 
hours.
    While the information collection requirements listed below are 
subject to the Paperwork Reduction Act, the burden associated with 
these requirements is captured under Sec. 413.65(c)(1) and (c)(2).
    Section 413.65(b)(2) states that a provider or a facility or 
organization must contact HCFA and the facility or organization must be 
determined by HCFA to be provider-based before the main provider begins 
billing for services of the facility or organization as if they were 
furnished by a department of the provider-based entity, or before it 
includes costs of those services on its cost report.
    Section 413.65(d)(7)(i) requires that the facility or organization 
demonstrates a high level of integration with the main provider by 
showing that it meets all of the other provider-based criteria, and 
demonstrates that it serves the same patient population as the main 
provider, either by submitting records such as common patient lists 
and/or demographic data showing that a high percentage of patients of 
both the main provider and the applicant entity come from the same 
geographic area, or by submitting data substantiating that the patients 
served by the entity also receive services from the main provider (for 
example, the patients of an RHC receive inpatient hospital services 
from the main provider).
    While the information collection requirements listed below are 
subject to the Paperwork Reduction Act, we believe the burden 
associated with these requirements is not subject to the Act, as 
defined by 5 CFR 1320.3(b)(2), because the time, effort, and financial 
resources necessary to comply with these requirements would be incurred 
by persons in the normal course of their activities.
    Section 413.65(g)(7) states that when a Medicare beneficiary is 
treated in a hospital outpatient department or hospital-based entity, 
the hospital has a duty to notify the beneficiary, prior to the 
delivery of services, of the beneficiary's potential financial 
liability (that is, a coinsurance liability for a facility visit as 
well as for the physician service).
    We believe the information collection requirement below is exempt 
from the Paperwork Reduction Act, as defined by 5 CFR 1320.4(a)(2), 
since this activity is pursuant to the conduct of an investigation or 
audit against specific individuals or entities.
    Section 413.65(i)(1) states that if HCFA determines that a provider 
has been inappropriately billing Medicare for services furnished in a 
physician office or other facility or organization as if they had been 
furnished in a hospital outpatient department or other department of a 
provider or in a provider-based entity, HCFA stops all payments to the 
provider for outpatient services until the provider can demonstrate 
which payments are proper.
    The table below indicates the annual number of responses for each 
regulation section in this proposed rule containing information 
collection requirements, the average burden per response in minutes or 
hours, and the total annual burden hours.

                                             Estimated Annual Burden
----------------------------------------------------------------------------------------------------------------
                                                                                      Average
                                                                                    burden per     Annual burden
                           CFR section                               Responses       response          hours
                                                                                      (hours)
----------------------------------------------------------------------------------------------------------------
413.65(c)(1) and (c)(2).........................................             105              10           1,050
419.42(b) and (d)...............................................             750              10           7,500
419.42(f).......................................................             750              10           7,500
                                                                 -----------------------------------------------
    Total.......................................................                                          16,050
----------------------------------------------------------------------------------------------------------------

    We have submitted a copy of this proposed rule to OMB for its 
review of the information collection requirements. These requirements 
are not effective until they have been approved by OMB. A notice will 
be published in the Federal Register when approval is obtained.
    If you comment on any of these information collection and record 
keeping 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 HCFA-1005-P, Fax number: 
(410) 786-1415 and,
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, Fax numbers: 
(202) 395-6974 or (202) 395-5167.

IX. Response to Comments

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

X. Regulatory Impact Analysis

A. Introduction

    We have examined the impacts of this proposed rule as required by 
Executive Order 12866, the Unfunded Mandates Reform Act of 1995, and 
the Regulatory Flexibility Act (RFA) (Public Law 96-354). Executive 
Order 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). Because the projected savings 
resulting from this proposed rule are

[[Page 47597]]

expected to exceed $100 million, it is considered a major rule.
    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. This proposed rule does not mandate 
any requirements for State, local, or tribal governments. However, our 
estimations indicate that the loss of income to the private sector as a 
result of this rule should exceed $300 million total to all hospitals.
    We generally prepare a regulatory flexibility analysis that is 
consistent with the RFA (5 U.S.C. 601 through 612), unless we certify 
that a proposed rule would not have a significant economic impact on a 
substantial number of small entities. For purposes of the RFA, we 
consider all hospitals to be small entities.
    Also, section 1102(b) of the Social Security Act requires us to 
prepare a regulatory impact analysis for any proposed rule that may 
have a significant impact on the operations of a substantial number of 
small rural hospitals. Such an analysis must conform to the provisions 
of section 603 of the RFA. With the exception of hospitals located in 
certain New England counties, for purposes of section 1102(b) of the 
Act, we define a small rural hospital as a hospital with fewer than 100 
beds that is located outside of a Metropolitan Statistical Area (MSA) 
or New England County Metropolitan Area (NECMA). Section 601(g) of the 
Social Security Amendments of 1983 (Public Law 98-21) designated 
hospitals in certain New England counties as belonging to the adjacent 
NECMA. Thus, for purposes of the proposed prospective payment system, 
we classify these hospitals as urban hospitals.

B. Estimated Impact on Medicare Program

    According to HCFA's Office of the Actuary, the benefit impacts of 
the hospital outpatient PPS (including elimination of the formula-
driven overpayment (FDO) effective as of October 1, 1997, extension of 
the 10 percent reduction in payments for hospital outpatient capital 
cost and the 5.8 percent reduction for outpatient services paid on a 
cost basis through CY 1999, and the implementation of a PPS for 
hospital outpatient services on January 1, 1999 would be as follows:

------------------------------------------------------------------------
                                                            Impact  ($
                       Fiscal year                           millions)
------------------------------------------------------------------------
1998....................................................            -940
1999....................................................           -1650
2000....................................................           -1330
2001....................................................           -1070
2002....................................................            -990
2003....................................................            -680
------------------------------------------------------------------------

The use of the national median of the charges for PPS services to 
establish the unadjusted copayment amount would have resulted in the 
beneficiaries paying 6.9 percent less in coinsurance payments in 1999 
than what they would have been expected to pay otherwise. It was 
assumed that there would have been a behavioral offset by the hospitals 
of 10 percent of the coinsurance reduction. It was assumed that 45 
percent of this offset would apply to the services subject to the PPS 
and, therefore, would have been included in setting the 1999 conversion 
factor. The remaining 55 percent of the offset would be reflected in 
expenditures for non-PPS services with both the beneficiary and 
Medicare absorbing this impact. With the delay in implementation of the 
outpatient PPS, the behavioral offset will not occur in 1999, and, 
therefore, there will be slightly higher program savings.

C. Objectives

    The primary objective of the proposed prospective payment system is 
to simplify the payment system while at the same time ensuring that 
payments are sufficient to adequately compensate hospitals for their 
legitimate costs. In addition, we share national goals of deficit 
reduction and restraints on government spending in general.
    We believe the proposed changes would further each of these goals 
while maintaining the financial viability of the hospital industry and 
ensuring access to high quality health care for Medicare beneficiaries. 
We expect that these proposed changes would ensure that the outcomes of 
this payment system are reasonable and equitable while avoiding or 
minimizing unintended adverse consequences.

D. Limitations of our Analysis

    The following quantitative analysis presents the projected effects 
of our proposed policy changes, as well as statutory changes, on 
various hospital groups. We use the best data available; in addition, 
we do not make adjustments for future changes in such variables as 
volume and intensity. As we have done in previous proposed rules, we 
are soliciting comments and information about the anticipated effects 
of these changes on hospitals and our methodology for estimating them.

E. Hospitals Included in and Excluded From the Prospective Payment 
System

    The outpatient prospective payment system encompasses nearly all 
hospitals that participate in the Medicare program. However, those 
services furnished by Maryland hospitals that are paid under a cost 
containment waiver in accordance with section 1814(b)(3) of the Act are 
excluded from the PPS. Critical access hospitals (CAHs) are also 
excluded and are paid at cost under section 1834(g).

F. Quantitative Impact Analysis of the Proposed Policy Changes Under 
the Prospective Payment System for Operating Costs and Capital Costs

Basis and Methodology of Estimates
    The data used in developing the quantitative analyses presented 
below are taken from the CY 1996 cost and charge data and the most 
current provider-specific file that is used for payment purposes. Our 
analysis has several qualifications. First, we draw upon various 
sources for the data used to categorize hospitals in the tables. In 
some cases, there is a fair degree of variation in the data from 
different sources. We have attempted to construct these variables with 
the best available source overall. For individual hospitals, however, 
some miscategorizations are possible.
    Using CY 1996 cost and charge data, we simulated payments using the 
current and proposed payment methodologies. We used both single and 
multiple bills to calculate current and proposed Medicare and 
beneficiary hospital outpatient payment amounts. Both current and 
proposed payment estimates include operating and capital costs. The 
exempted Maryland hospitals were excluded from the simulations; 
however, we included the 10 cancer hospitals that will be paid under 
the proposed system.
    We also trimmed outlier hospitals from the impact analysis because 
we had indications that hospitals with extreme unit costs would not 
allow us to assess the impacts among the various classes of hospitals 
accurately. First, we identified all the outlier hospitals by using an 
edit of three standard deviations from the mean of the logged unit 
costs. Trimming the data in this manner ensures that only the hospitals 
with extremely high and low costs are eliminated from the impacts. In 
doing this, we removed 83 hospitals of which 32 hospitals had extremely 
low unit costs and 51 hospitals had extremely

[[Page 47598]]

high unit costs. We conducted a thorough analysis of these hospitals to 
ensure that we did not remove any particular type of hospital (for 
example, teaching hospitals) that would further harm the integrity of 
the data. We speculate many of these hospitals are not coding 
accurately, and we will continue to perform further analysis in this 
area after implementation of the new APC system.
    After removing the 54 exempted Maryland hospitals, outlier 
hospitals, and hospitals for which we could not identify payment 
variables, we included 5,419 hospitals in our analysis. The impact 
analysis focuses on this set of hospitals. The table below demonstrates 
the results of our analysis. The table categorizes hospitals by various 
geographic and special payment consideration groups to illustrate the 
varying impacts on different types of hospitals. The first column 
represents the number of hospitals in each category. The second column 
is the hospitals' Medicare outpatient payments as a percentage of the 
hospitals' total Medicare payment. The third column shows the 
percentage change in Medicare outpatient payments comparing the current 
and proposed payment systems. The fourth column shows the change in 
total Medicare payments, resulting from implementing the PPS for 
outpatient services.
    The top row of the table shows the overall impact on the 5,419 
hospitals included in the analysis. We included as much of the data as 
possible to the extent that we were able to capture all the provider 
information necessary to determine payment. Further, our estimates 
include the same set of services for both current and proposed APC 
payments so that we could determine the impact as accurately as 
possible. Since payment under the proposed APC system can only be 
determined if bills are accurately coded, the data upon which the 
impacts were developed do not reflect all CY 1996 hospital outpatient 
services, but only those that were coded using valid HCPCS.
    The second row identifies the hospitals in our analysis with the 
exception of psychiatric, long-term care, children, and rehabilitation 
hospitals, which account for 4,864 hospitals.
    The next four rows of the table contain hospitals categorized 
according to their geographic location (all urban, which is further 
divided into large urban and other urban, or rural). There are 2,677 
hospitals located in urban areas (MSAs or NECMAs) included in our 
analysis. Among these, there are 1,516 hospitals located in large urban 
areas (populations over 1 million), and 1,161 hospitals in other urban 
areas (populations of 1 million or fewer). In addition, there are 2,187 
hospitals in rural areas. The next two groupings are by bed-size 
categories, shown separately for urban and rural hospitals. The next 
category includes the volume of outpatient services, also shown 
separately for urban and rural hospitals. The final groupings by 
geographic location are by census divisions, also shown separately for 
urban and rural hospitals.
    The next three groupings examine the impacts of the proposed 
changes on hospitals grouped by whether or not they have residency 
programs (teaching hospitals that receive an indirect medical education 
(IME) adjustment), receive disproportionate share hospital (DSH) 
payments, or some combination of these two adjustments. There are 3,847 
non-teaching hospitals in our analysis, 766 teaching hospitals with 
fewer than 100 residents, and 250 teaching hospitals with 100 or more 
residents.
    In the DSH categories, hospitals are grouped according to their DSH 
payment status. The next category groups hospitals considered urban 
after geographic reclassification, in terms of whether they receive the 
IME adjustment, the DSH adjustment, both, or neither. The next five 
rows examine the impacts of the proposed changes on rural hospitals by 
special payment groups (rural referral centers (RRCs), sole community 
hospitals/essential access community hospitals (SCHs/EACHs), Medicare 
dependent hospitals (MDHs), and SCHs and RRCs), as well as rural 
hospitals not receiving a special payment designation. The RRCs (168), 
SCH/EACHs (625), MDHs (365), and SCH and RRCs (55) shown here were not 
reclassified for purposes of the standardized amount.
    The next grouping is based on type of ownership. These data are 
taken primarily from the FY 1995 Medicare cost report files, if 
available (otherwise, FY 1994 data are used).
    The next groupings are the specialty hospitals. The first set 
includes the categorizations of eye and ear hospitals and trauma 
hospitals (hospitals having a level one trauma center) and cancer 
hospitals. The final groupings are the TEFRA hospitals, specifically 
rehabilitation, psychiatric, long-term care, and children hospitals.

G. Estimated Impact of the New APC System

    Column 3 compares our estimate of payments, incorporating statutory 
and policy changes reflected in this proposed rule for CY 1996, to our 
estimate of payments in CY 1996 under the current payment system. 
Percent differences between current and proposed payment reflect the 
combined impact of a proportionally equal reduction in payments due to 
the calculation of the conversion factor and distributional differences 
attributable to variation in cost and charge structures among 
hospitals. The methodology described in section 1833(t)(3)(C) of the 
Act outlining the calculation of the conversion factor reduces payment 
to hospitals overall by 3.8 percent relative to current law. As noted, 
section 1833(t)(3)(C) of the Act requires us to set the conversion 
factor so that total 1999 payments to hospitals under the proposed PPS 
system equal Medicare payment amounts as calculated under the current 
payment system plus beneficiary copayments as calculated under the 
proposed system (20 percent of the APC median charge or, at minimum, 20 
percent of the APC rate). The 3.8 percent loss implies that the 
difference between the median and charges higher than the median was 
proportionally larger than the difference between the median and 
charges lower than the median. Because this reduction is incorporated 
into the conversion factor, the 3.8 percent is distributed among 
hospitals proportional to their total payments. After removing the 
effect of the conversion factor calculation on total payments, the 
remaining percent differences demonstrate the redistribution of 
payments among hospitals and can be attributed to variation in both 
costs and charge structures. Variation in costs among hospitals results 
in differences between current and proposed Medicare payments, and 
variation in charge structures results in differences between current 
and proposed beneficiary copayment.
    Redistributions may also occur as a result of current payment 
methods. Total Medicare outpatient payments are less than reported 
total costs because (in addition to the 5.8 and 10 percent reductions 
for operating and capital costs) the blended payment methods applicable 
to many surgical and diagnostic services often result in payments that 
are less than reported costs. Other services such as medical visits, 
chemotherapy services, partial hospitalization services, and non-ASC 
approved surgeries are paid based on hospital costs. The new system 
redistributes the current total Medicare payments, based in part on 
cost-based payments and in part on blended

[[Page 47599]]

payment amounts, across all services. Hospitals, in the aggregate, will 
receive proportionately less for services that are currently paid based 
on costs and more for services that had been paid under blended payment 
methods.
    The impact on TEFRA hospitals is shown separately at the end of the 
table; however, these hospitals were not included in determining the 
impact on any of the other categories (for example, geographic 
location, bed size, volume, etc.). These hospitals demonstrated a very 
low service mix, but an average unit cost that is only somewhat smaller 
than the national average. We believe that billing practices may 
account for this phenomenon. Some TEFRA hospitals appear to under-code 
HCPCS and units. This may be because correct coding is not required for 
payment or because they bill an all-inclusive rate. Undercoding or 
billing an all-inclusive rate could account for their low volume, low 
service mix, and almost average cost per unit. We expect that once 
these hospitals begin to code HCPCS according to the new payment 
system, new payments will better reflect current payments.
    In general, differences among hospital classifications for short-
term acute care hospitals were relatively small. That is, payments 
under the proposed outpatient system were within a few percentage 
points of payments made under current law. The following discussion 
highlights some of the variation in payments among hospital 
classifications.
    Based on comparing current and proposed payment estimates, minor 
teaching hospitals lose 1.8 percent, while major teaching hospitals 
experience a reduction of 9.4 percent. Non-teaching hospitals 
experience a decrease of 3.1 percent. However, major teaching hospitals 
gain less of their total Medicare income (9.2 percent) from outpatient 
services than the national average (10 percent). This results in a less 
than 1 percent loss in their total Medicare income.
    Hospitals with a high percentage of low income patients 
(disproportionate share patient percentage  0.35) appear to 
experience payment reductions of 6.8 percent relative to current law. 
These hospitals have lower than average volume, and, like major 
teaching hospitals, they receive a smaller than average percent of 
their Medicare income from outpatient services.
    Rural hospitals would lose about 5.2 percent and large urban 
hospitals would lose about 5.0 percent under the new system while other 
urban hospitals would lose 0.9 percent. These small differences 
illustrate fairly equitable payment among these geographical settings. 
However, rural hospitals get a greater percentage of their Medicare 
income (14.7 percent) from outpatient services compared to the national 
average of 10 percent.
    Low-volume hospitals appear to lose a large percentage of their 
payments under the new payment system (17 percent for rural and 15.6 
percent for urban hospitals with less than 5,000 units of service). We 
believe several factors are contributing to this outcome, including 
undercoding, lack of economies of scale, and underpayment due to the 
reliance on the median instead of the geometric mean in the calculation 
of APC weights. The majority of these hospitals (about 75 percent) are 
rural. These hospitals also have a service mix (1.03) lower than the 
national average (1.45) and higher than average hospital cost per unit 
standardized for service mix. For these small hospitals, some of the 
higher standardized unit costs could be attributed to economies of 
scale. These low-volume rural hospitals also receive a greater 
percentage of their Medicare income (18.2 percent) from outpatient 
services than the average. SCHs and MDHs comprise about 60 percent of 
these low-volume rural hospitals.
    As discussed previously in section V.I, the Adjustments section, we 
are particularly concerned about the potential impact on the 
approximately 60 percent of low-volume rural hospitals that are sole 
community hospitals or Medicare-dependent hospitals. As previously 
discussed, one option would be to phase-in the outpatient PPS for low-
volume Medicare-dependent and sole community hospitals by paying a 
portion of the payment based on PPS rates and a portion based on the 
current payment system. For example, payment could be based on 75 
percent of payments under the current system and 25 percent on PPS 
rates in the first year, 50 percent current system payments and 50 
percent PPS rates in the second year, 25 percent current system 
payments and 75 percent PPS rates in the third year, and completely on 
PPS rates in subsequent years. If such an approach were adopted, the 
impact on Medicare outpatient payment for these hospitals would be as 
follows:

     Estimated Impact of a Transition Policy on Medicare Outpatient Payments for Medicare-Dependent and Sole
                                               Community Hospitals
                                                  [In percent]
----------------------------------------------------------------------------------------------------------------
                                                      Year 1          Year 2          Year 3          Year 4
----------------------------------------------------------------------------------------------------------------
MDH.............................................            -2.1            -4.3            -6.4            -8.5
SCH.............................................            -1.7            -3.3            -5.0            -6.7
SCH/RRC.........................................            -0.5            -1.0            -1.6            -2.1
----------------------------------------------------------------------------------------------------------------

    Another option discussed earlier in the adjustments section would 
phase-in outpatient PPS if a low-volume sole community or Medicare-
dependent hospital has a negative Medicare margin for outpatient 
services. For example, payment could be based on the amount payable 
under outpatient PPS plus a percentage of the difference between those 
amounts and the amounts payable under the current system. The 
percentage of the difference that would be payable could phase down, 
for example, 75 percent in the first year, 50 percent in the second 
year, 25 percent in the third year, and no additional payment in 
subsequent years. We solicit comments on these and other alternatives 
we could consider.
    As noted above, rural hospitals lose a larger percent of their 
payments than urban hospitals. Among the census divisions, rural New 
England hospitals experience the largest negative payment impact of 
13.6 percent. This could be attributed to higher non-labor costs in New 
England. West North Central hospitals also would experience a 7.7 
percent payment loss.
    Urban census division breakouts reveal that Middle Atlantic urban 
hospitals lose 11.3 percent of payments while the other urban census 
regions gain or lose modestly.
    Hospitals located in Puerto Rico gain because of the change in the 
beneficiary copayment. Previously these hospitals received 20 percent 
of their charges from the beneficiary, whereas under the

[[Page 47600]]

new PPS they would receive 20 percent of the APC median charge or, at 
minimum, they would receive 20 percent of the payment rate. Hospitals 
in Puerto Rico gain under the new proposed system because 20 percent of 
their charges are lower than 20 percent of the APC median charges or 20 
percent of the rates.
    Among special categories of rural hospitals, MDHs and SCHs/EACHs 
would experience decreases of 8.5 and 6.7 percent, respectively. Some 
of this decrease may be attributed to the impact on low-volume rural 
hospitals.
    Cancer hospitals experience a 29.2 percent loss. Several factors 
may contribute to this loss. Under-coding could be a factor 
contributing to the percentage loss. In addition, the current 
requirements for batch billing of services such as chemotherapy and 
radiation therapy and the fact that we used only single procedure bills 
to calculate group weights may also have contributed to the impact on 
these hospitals. Further analysis will be conducted to determine if 
current coding practices explain the negative impact. We will be 
verifying the accuracy of the rates for these types of procedures. 
Specifically, the APC weights were calculated using single bill 
procedures. Using single bill procedures to compute a weight for 
services which are not typically billed as a single procedure could 
result in rates that are not accurate for these services. We will 
verify the accuracy of the rates for these types of procedures by 
analyzing the costs from the multiple bills. If further analysis 
reveals that cancer hospitals would be unduly harmed because of the new 
outpatient PPS, we will consider whether an adjustment or perhaps a 
transition period is needed to moderate the impact. By statute, any 
adjustment would have to be budget neutral. Until further analysis can 
be conducted we are not proposing an adjustment for cancer hospitals.
    In accordance with the provisions of Executive Order 12866, this 
regulation was reviewed by the Office of Management and Budget.

BILLING CODE 4120-01-P

[[Page 47601]]

[GRAPHIC] [TIFF OMITTED] TP08SE98.002



[[Page 47602]]

[GRAPHIC] [TIFF OMITTED] TP08SE98.003



[[Page 47603]]

[GRAPHIC] [TIFF OMITTED] TP08SE98.004



[[Page 47604]]

[GRAPHIC] [TIFF OMITTED] TP08SE98.005



BILLING CODE 4120-01-C

[[Page 47605]]

XI. Delay in Implementation Date

    Like other public and private organizations that depend upon the 
smooth functioning of computer systems, the Medicare program faces the 
challenge making changes to assure that computers can recognize dates 
in the year 2000 and later. Computer programming, which has commonly 
employed only two digits to record the year in the date for 
transactions and other entries, will not be able to distinguish the 
year 2000 from the year 1900 without reprogramming. Such confusion in 
the context of Medicare enrollment and claims processing could create 
massive errors, as computers could mistakenly determine that 
beneficiaries are not eligible for benefits or that services were 
rendered before the effective date of benefit provisions.
    For Medicare, achieving year 2000 (Y2K) compliance involves 
renovating all computer and information systems. The year 2000 
especially affects HCFA because of our extensive reliance on multiple 
computer systems. More than 183 systems are used in administering the 
Medicare and Medicaid programs, and 98 of these are considered 
``mission critical'' for establishing beneficiary eligibility and 
making payments to providers, plans, and states. Medicare is the most 
automated health care payer in the country. The Medicare program 
processes nearly one billion claims each year, or about 17 million 
transactions each week. Fully 98 percent of inpatient hospital and 
other Medicare Part A claims are processed electronically, as are 85 
percent of physician and other Medicare Part B claims.
    The renovation process is complicated because each piece in the 
systems used by Medicare, its 60-plus claims processing contractors, 
interfaces with state Medicaid programs, and some 1.6 million providers 
must be thoroughly reviewed and renovated by those responsible for each 
particular system. Programs must be tested, both alone and for the 
complicated interfaces among them. To fix only the Medicare systems, 49 
million lines of code must be renovated. All Medicare-specific software 
must be renovated, and tested to assure that it continues to work with 
new versions of vendor-supplied software, including operating systems 
that drive the hardware. Some hardware must be upgraded, and our 
telecommunications equipment and software must be compliant. We must 
assure that all data exchanges with thousands of partners are 
compliant. Testing of year 2000 changes presents a far greater burden 
than testing of routine system changes because we must test multiple 
times on a range of different dates. For example, February 29, 2000 and 
March 1, 2000 must both be tested because CY 2000 is a leap year.
    Because this process is necessary to keep program payments going 
out to beneficiaries and providers, year 2000 work must take precedence 
over other projects that require systems changes, including some 
Balanced Budget Act provisions. The Y2K project must be completed 
before other projects simply because activity on these other projects 
would divert resources from the Y2K project and could even compromise 
the effort to assure Y2K compliance if implemented in tandem. Many 
other private and public organizations, including most major insurance 
companies, have reached the same conclusion and are halting other 
projects involving information technology changes to clear the decks 
for the year 2000.
    HCFA's independent year 2000 verification and validation 
contractor, Intermetrics, has advised the agency to delay all projects 
that could interfere with year 2000 work. Intermetrics specifically 
advised the agency to ``seek necessary relief from Congressional 
mandates, system transitions and version releases to allow near-term, 
focused attention to achieving Y2K compliant systems.'' This includes 
projects that are complex, or which would occur during a critical 
window between October 1999 and March 2000. Otherwise, they warned, 
``many of your most critical system renovations have risk of 
significant schedule slippage.''
    Implementation of outpatient PPS is one of the projects that must 
be delayed by the year 2000 system renovations, because it requires 
massive system changes. Major contractor systems will be affected: the 
Fiscal Intermediary Standard Systems (FISS), the Arkansas Part A 
Standard System (APASS), the Common Working File (CWF), the Outpatient 
Code Editor (OCE), and the various systems operated by Fiscal 
Intermediaries and their corporate entities. Several HCFA systems will 
also be affected, including the National Claims History (NCH), the 
Provider Statistical & Reimbursement System (PS&R), and the Electronic 
Data Interchange (EDI). The scope of the required changes is also 
substantial. Among the required changes are:
     Expansion of the claim record of FISS, APASS, EDI, NCH and 
CWF to accept and retain specific information related to how a service 
is being paid or why it's denied.
     Conversion of all claims history to correspond with 
expanded format.
     Rewriting the program for FISS to process claims using 
line item dates of service.
     Rewriting the program for CWF to accept non covered 
charges by claim and line item.
     Developing, installing and testing an outpatient PRICER 
which determines payment amounts based on the HCFA Common Procedural 
Codes (HCPCS).
     Revision of interfaces with the fiscal intermediaries, 
providers, Billing Agents, EDI, OCE, PS&R and NCH and create an 
interface for PRICER.
     Developing, installing and testing a program to calculate 
the variable co-insurance per payment code grouping for each provider 
who elects to accept a reduced co-insurance.
     Revision of all claims processing output and interfaces 
including: Medicare Summary Notices (MSN), Beneficiary Denial Letters 
(BDL), Explanation of Medicare Benefits (EOMB), Notice of Utilization 
(NOU), Remittance Advice (RA).
    The consequence of all these required changes to basic systems will 
be to change the entire way Fiscal Intermediaries process and pay 
hospital outpatient and community mental health center claims. There is 
also a major impact on the many systems that are required to receive 
this revised output. Changes of this magnitude require massive testing 
by all of the systems maintainers as well as each Fiscal Intermediary. 
Additionally, the impact on the Fiscal Intermediary systems has a 
domino effect. The intermediaries are doing business for Medicare under 
the auspices of their respective corporate entities. These corporate 
systems must be modified to accept, edit and relay the new information 
necessary to process outpatient PPS claims. They are also working 
toward becoming millennium compliant and competing for the same 
resources to scope, program, test and rework these changes, as well as 
the multitude of other BBA changes and Y2K. In the light of this, HCFA 
has no choice but to suspend implementing such massive change while the 
Intermediaries, their respective corporate entities, the standard 
systems maintainers as well as the provider community are working 
diligently to become Y2K compliant. It would be irresponsible to 
continue activity that would create a real danger that basic enrollment 
and claims processing activities will be disrupted, with far worse 
consequences for providers and beneficiaries than delay in 
implementation of outpatient PPS will cause.

[[Page 47606]]

    We analyzed whether existing systems could be used to mimic 
processing of bills under the outpatient PPS. In every case, there were 
insuperable obstacles. In no case, for example, could these other 
systems compute the coinsurance correctly: the other available systems 
compute coinsurance as 20 percent of charges or 20 percent of a fee 
schedule amount. We have therefore reluctantly concluded that there is 
no alternative to a delay in implementation. As previously noted, the 
outpatient PPS will be implemented as soon as possible after January 1, 
2000. A notice of the anticipated implementation date will be published 
in the Federal Register at least 90 days in advance.
    We expect that there will be no negative impact on hospitals 
generally from the delay in implementation. The effect on individual 
hospitals will, of course, vary depending on how their current cost-
based reimbursement compares to the total payments they would receive 
under the proposed system. Hospitals altogether should receive about 
the same level of Medicare program payments under the existing payment 
system, as they would have received in program payments under the 
outpatient PPS. When beneficiary coinsurance is taken into account, we 
expect that hospitals generally will receive about 3.8 percent more in 
total payments under the existing payment system, than they would have 
received in total payments under the outpatient PPS. We should note 
that payment rates will be established at the level they would have 
been if the PPS had been implemented on January 1, 1999.
    The major impact of the delay in implementation will be on 
beneficiaries who will continue to pay coinsurance based on 20 percent 
of the hospital's charges. In the aggregate, we estimate beneficiary 
coinsurance would have been 6.9 percent lower under the outpatient 
prospective payment system in 1999 than under the current system. Under 
the prospective payment system, coinsurance will be based on our 
estimate of the median coinsurance amount for each APC under the 
current system in 1999. In the aggregate, estimated median coinsurance 
amounts are 6.9 percent lower than estimated mean coinsurance amounts 
for each APC. The actual impact will depend on the extent to which 
hospitals raise their charges in 1999. For example, the impact on 
beneficiaries would be moderated if hospitals show restraint in 
increasing charges (which have been increasing more rapidly than cost). 
We will actively encourage hospitals to voluntarily restrain from 
increasing their current charges. The actual impact on a given 
beneficiary will also depend on the hospital's charge structure 
relative to national charge levels. A beneficiary receiving services 
from a hospital with relatively low charges could be advantaged by the 
delay whereas a hospital with relatively high charges would be 
disadvantaged by the delay. We note that the impact will not be carried 
over to the prospective payment system.

List of Subjects

42 CFR Part 409

    Health facilities, Medicare.

42 CFR Part 410

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

42 CFR Part 411

    Kidney diseases, Medicare, Reporting and recordkeeping 
requirements.

42 CFR Part 412

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

42 CFR Part 413

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

42 CFR Part 419

    Health facilities, Hospitals, Medicare.

42 CFR Part 489

    Health facilities, Medicare, Reporting and recordkeeping 
requirements.

42 CFR Part 498

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

42 CFR Part 1003

    Administrative practice and procedure, Archives and records, grant 
program--social programs, Maternal and Child Health, Medicaid, 
Medicare, Penalties.

    For the reasons set forth in the preamble, 42 CFR chapters IV and V 
would be amended as follows:

PART 409--HOSPITAL INSURANCE BENEFITS

    A. Part 409 is amended as set forth below:
    1. The authority citation for part 409 continues to read as 
follows:

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

Subpart B--Inpatient Hospital Services and Inpatient Critical 
Access Hospital Services

    2. In Sec. 409.10, paragraph (b) is revised to read as follows:


Sec. 409.10  Included services.

* * * * *
    (b) Inpatient hospital services does not include the following 
types of services:
    (1) Post-hospital SNF care, as described in Sec. 409.20, furnished 
by a hospital or a critical access hospital that has a swing-bed 
approval.
    (2) Nursing facility services, described in Sec. 440.155 of this 
chapter, that may be furnished as a Medicaid service under title XIX of 
the Act in a swing-bed hospital that has an approval to furnish nursing 
facility services.
    (3) Physician services that meet the requirements of 
Sec. 415.102(a) of this chapter for payment on a fee schedule basis.
    (4) Physician assistant services, as defined in section 
1861(s)(2)(K)(i) of the Act.
    (5) Nurse practitioner and clinical nurse specialist services, as 
defined in section 1861(s)(2)(K)(ii) of the Act.
    (6) Certified nurse mid-wife services, as defined in section 
1861(gg) of the Act.
    (7) Qualified psychologist services, as defined in section 1861(ii) 
of the Act.
    (8) Services of an anesthetist, as defined in Sec. 410.69 of this 
chapter.

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS

    B. 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 1395(hh)), unless otherwise indicated.

Subpart A--General Provisions

    2. In Sec. 410.2, the following definitions are added in 
alphabetical order to read as follows:


Sec. 410.2  Definitions.

    As used in this part--
* * * * *
    Encounter means a direct personal contact between a patient and a 
physician, or other person who is authorized by State licensure law 
and, if applicable, by hospital or CAH staff bylaws, to order or 
furnish hospital services for diagnosis or treatment of the patient.
* * * * *

[[Page 47607]]

    Outpatient means a person who has not been admitted as an inpatient 
but who is registered on the hospital or CAH records as an outpatient 
and receives services (rather than supplies alone) directly from the 
hospital or CAH.
* * * * *

Subpart B--Medical and Other Health Services

    3. In Sec. 410.27, the section heading is revised, the introductory 
text to paragraph (a) is revised, the introductory text to paragraph 
(a)(1) is republished, and new paragraphs (a)(1)(iii), (e), and (f) are 
added to read as follows:


Sec. 410.27  Outpatient hospital services and supplies incident to a 
physician service: Conditions.

    (a) Medicare Part B pays for hospital services and supplies 
furnished incident to a physician service to outpatients, including 
drugs and biologicals that cannot be self-administered, if--
    (1) They are furnished--
* * * * *
    (iii) In the hospital or at a location (other than an RHC or an 
FQHC) that HCFA designates as qualifying as a department of a provider 
under Sec. 413.65 of this chapter; and
* * * * *
    (e) Services furnished by an entity other than the hospital are 
subject to the limitations specified in Sec. 410.39(a).
    (f) Services furnished at a location (other than an RHC or an FQHC) 
that HCFA designates as having provider-based status under Sec. 413.65 
of this chapter must be under the direct supervision of a physician as 
defined in Sec. 410.32(b)(3)(ii).
    4. In Sec. 410.28, paragraph (a)(4) is removed, paragraph (c) is 
redesignated as paragraph (d), and new paragraphs (c) and (e) are added 
to read as follows:


Sec. 410.28  Hospital or CAH diagnostic services furnished to 
outpatients: Conditions.

* * * * *
    (c) Diagnostic services furnished by an entity other than the 
hospital or CAH are subject to the limitations specified in 
Sec. 410.39(a).
* * * * *
    (e) Medicare Part B makes payment under section 1833(t) of the Act 
for diagnostic tests performed at a facility (other than an RHC or an 
FQHC) that HCFA designates as having provider-based status only when 
the diagnostic tests are furnished under the appropriate level of 
physician supervision specified by HCFA in accordance with the 
definitions in Sec. 410.32(b)(3)(i), (b)(3)(ii), and (b)(3)(iii).
    5. A new Sec. 410.39 is added to read as follows:


Sec. 410.39  Limitations on coverage of certain services furnished to 
hospital outpatients.

    (a) Except as provided in paragraph (c) of this section, Medicare 
Part B does not pay for any item or service that is furnished to a 
hospital outpatient (as defined in Sec. 410.2) during an encounter (as 
defined in Sec. 410.2) by an entity other than the hospital unless the 
hospital has an arrangement (as defined in Sec. 409.3 of this chapter) 
with that entity to furnish that particular service to its patients.
    (b) As used in paragraph (a) of this section, the term ``hospital'' 
includes a CAH.
    (c) The limitations stated in paragraphs (a) and (b) of this 
section do not apply to the following services:
    (1) Physician services that meet the requirements of 
Sec. 415.102(a) of this chapter for payment on a fee schedule basis.
    (2) Physician assistant services, as defined in section 
1861(s)(2)(K)(i) of the Act.
    (3) Nurse practitioner and clinical nurse specialist services, as 
defined in section 1861(s)(2)(K)(ii) of the Act.
    (4) Certified nurse mid-wife services, as defined in section 
1861(gg) of the Act.
    (5) Qualified psychologist services, as defined in section 1861(ii) 
of the Act.
    (6) Services of an anesthetist, as defined in Sec. 410.69.

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

    C. 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 1395(hh)).

Subpart A--General Exclusions and Exclusion of Particular Services

    2. In Sec. 411.15, the introductory text is republished; the 
section heading to paragraph (m) is revised; paragraph (m)(1) is 
revised; the introductory text to paragraph (m)(2) is republished; 
paragraphs (m)(2)(iii), (m)(2)(iv), and (m)(2)(v) are redesignated as 
paragraphs (m)(2)(iv), (m)(2)(v), and (m)(2)(vi), respectively; and new 
paragraphs (m)(2)(iii) and (m)(3) are added to read as follows:


Sec. 411.15  Particular services excluded from coverage.

    The following services are excluded from coverage.
* * * * *
    (m) Services to hospital patients--(1) Basic rule. Except as 
provided in paragraph (m)(2) of this section, any service furnished to 
an inpatient of a hospital or to a hospital outpatient (as defined in 
Sec. 410.2 of this chapter) during an encounter (as defined in 
Sec. 410.2 of this chapter) by an entity other than the hospital, 
unless the hospital has an arrangement (as defined in Sec. 409.3 of 
this chapter) with that entity to furnish that particular service to 
the hospital's patients. (As used in this paragraph (m)(1), the term 
``hospital'' includes a CAH.)
    (2) Exceptions. The following services are not excluded from 
coverage:
* * * * *
    (iii) Nurse practitioner and clinical nurse specialist services, as 
defined in section 1861(s)(2)(K)(ii) of the Act.
* * * * *
    (3) Scope of exclusion. Services subject to exclusion under the 
provisions of this paragraph (m) include, but are not limited to, 
clinical laboratory services; pacemakers and other prostheses and 
prosthetic devices (other than dental) that replace all or part of an 
internal body organ (for example, intraocular lenses); artificial 
limbs, knees, and hips; equipment and supplies covered under the 
prosthetic device benefits; and services incident to a physician 
service.
* * * * *

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

    D. Part 412 is amended as set forth below:
    1. The authority citation for part 412 continues to read as 
follows:

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

Subpart C--Conditions for Payment Under the Prospective Payment 
Systems for Inpatient Operating Costs and Inpatient Capital-Related 
Costs

    2. In Sec. 412.50, paragraphs (a) and (b) are revised to read as 
follows:


Sec. 412.50  Furnishing of inpatient hospital services directly or 
under arrangements.

    (a) The applicable payments made under the prospective payment 
systems, as described in subparts H and M of this part, are payment in 
full for all inpatient hospital services, as defined in Sec. 409.10

[[Page 47608]]

of this chapter. Inpatient hospital services do not include the 
following types of services:
    (1) Physician services that meet the requirements of 
Sec. 415.102(a) of this chapter for payment on a fee schedule basis.
    (2) Physician assistant services, as defined in section 
1861(s)(2)(K)(i) of the Act.
    (3) Nurse practitioner and clinical nurse specialist services, as 
defined in section 1861(s)(2)(K)(ii) of the Act.
    (4) Certified nurse mid-wife services, as defined in section 
1861(gg) of the Act.
    (5) Qualified psychologist services, as defined in section 1861(ii) 
of the Act.
    (6) Services of an anesthetist, as defined in Sec. 410.69 of this 
chapter.
    (b) HCFA does not pay any provider or supplier other than the 
hospital for services furnished to a beneficiary who is an inpatient, 
except for the services described in paragraphs (a)(1) through (a)(6) 
of this section.
* * * * *

PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR 
END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED 
PAYMENT RATES FOR SKILLED NURSING FACILITIES

    E. Part 413 is amended as set forth below:
    1. The authority citation for part 413 continues to read as 
follows:

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

Subpart A--Introduction and General Rules


Sec. 413.1  [Amended]

    2. In Sec. 413.1, paragraph (a)(2)(viii) is removed.

Subpart B--Accounting Records and Reports

    3. In Sec. 413.24, the heading to paragraph (d) is published, and a 
new paragraph (d)(6) is added to read as follows:


Sec. 413.24  Adequate cost data and cost finding.

* * * * *
    (d) Cost finding methods. * * *
    (6) Management contracts. (i) If the main provider purchases 
services for a department of the provider or a provider-based entity 
through a management contract or otherwise directly assigns costs to 
the department or entity, the like costs of the main provider must be 
carved out to ensure that they are not allocated to the department of 
the provider or provider-based entity. However, if the like costs of 
the main provider cannot be separately identified, the costs of the 
services purchased through a management contract must be included in 
the main provider's administrative and general costs and allocated 
among the provider's overall statistics.
    (ii) Costs of free-standing entities may not be shown in the 
provider's trial balance for purposes of stepping down overhead costs 
to such entities. The provider must develop detailed work papers 
showing the exact cost of the services (including overhead) provided to 
or by the free-standing entity and show those carved out costs as non-
reimbursable cost centers in the provider's trial balance.
* * * * *

Subpart E--Payments to Providers

    4. A new Sec. 413.65 is added to read as follows:


Sec. 413.65  Requirements for a determination that a facility or an 
organization is a department of a provider or a provider-based entity.

    (a) Definitions. In this subpart E, unless the context indicates 
otherwise--
    Department of a provider means a facility or organization or a 
physician office that is either created by, or acquired by, a main 
provider for the purpose of furnishing health care services under the 
name, ownership, and financial and administrative control of the main 
provider, in accordance with the provisions of this section. A 
department of a provider may not be licensed to provide health care 
services in its own right, and Medicare conditions of participation do 
not apply to a department as an independent entity. For purposes of 
this part, the term ``department of a provider'' does not include an 
RHC or an FQHC.
    Free-standing facility means an entity that furnishes health care 
services to Medicare beneficiaries and that is not integrated with any 
other entity as a main provider, a department of a provider, or a 
provider-based entity.
    Main provider means a provider that either creates, or acquires 
ownership of, another entity to deliver additional health care services 
under its name, ownership, and financial and administrative control.
    Provider-based entity means a provider of health care services, or 
an RHC or an FQHC as defined in Sec. 405.2401(b) of this chapter, that 
is either created by, or acquired by, a main provider for the purpose 
of furnishing health care services under the name, ownership, and 
administrative and financial control of the main provider, in 
accordance with the provisions of this section.
    Provider-based status means the relationship between a main 
provider and a provider-based entity or a department of a provider, 
that complies with the provisions of this section.
    (b) Responsibility for obtaining provider-based determinations. (1) 
A facility or organization is not entitled to be treated as provider-
based simply because it or the main provider believe it is provider-
based.
    (2) A provider or a facility or organization must contact HCFA and 
the facility or organization must be determined by HCFA to be provider-
based before the main provider begins billing for services of the 
facility or organization as if they were furnished by a department of 
the provider or provider-based entity, or before it includes costs of 
those services on its cost report.
    (3) A facility that is not located on the campus of a hospital and 
is used as a site of physician services of the kind ordinarily 
furnished in physician offices will be presumed to be a free-standing 
facility, unless it is determined by HCFA to have provider-based 
status.
    (c) Reporting. (1) A main provider that acquires a facility or 
organization for which it wishes to claim provider-based status, 
including any physician offices that a hospital wishes to operate as a 
hospital outpatient department or clinic, must report its acquisition 
of the facility or organization to HCFA and must furnish all 
information needed for a determination as to whether the facility or 
organization meets the requirements in paragraph (d) of this section 
for provider-based status.
    (2) A main provider that has had one or more facilities or 
organizations considered provider-based also must report to HCFA any 
material change in the relationship between it and any provider-based 
facility or organization, such as a change in ownership of the facility 
or organization or entry into a new or different management contract 
that could affect the provider-based status of the facility or 
organization.
    (d) Requirements. An entity must meet the following requirements to 
be determined by HCFA to be a provider-based entity or a department of 
a provider:
    (1) Licensure. The department of the provider and the main provider 
are operated under the same license, except in areas where the State 
requires a separate license for the department of

[[Page 47609]]

the provider. If a State health facilities' cost review commission or 
other agency that has authority to regulate the rates charged by 
hospitals or other providers in a State finds that a particular 
facility or organization is not part of a provider, HCFA will determine 
that the facility or organization does not have provider-based status.
    (2) Operation under the ownership and control of the main provider. 
The facility or organization seeking provider-based status is operated 
under the ownership and control of the main provider, as evidenced by 
the following:
    (i) The facility or organization is 100 percent owned by the 
provider.
    (ii) The main provider and the facility or organization seeking 
status as a department of the provider have the same governing body.
    (iii) The facility or organization is operated under the same 
organizational documents as the main provider. For example, the 
facility or organization seeking provider-based status must be subject 
to common bylaws and operating decisions of the governing body of the 
provider where it is based.
    (iv) The main provider has final responsibility for administrative 
decisions, final approval for contracts with outside parties, final 
approval for personnel actions, final responsibility for personnel 
policies (such as fringe benefits/code of conduct), and final approval 
for medical staff appointments in the facility or organization.
    (3) Administration and supervision. The reporting relationship 
between the facility or organization seeking provider-based status and 
the main provider must have the same frequency, intensity, and level of 
accountability that exists in the relationship between the main 
provider and one of its departments, as evidenced by compliance with 
all of the following requirements:
    (i) The facility or organization is under the direct supervision of 
the provider where it is located.
    (ii) The facility or organization is operated under the same 
monitoring and oversight by the provider as any other department of the 
provider, and is operated just as any other department of the provider 
with regard to supervision and accountability. The facility or 
organization director or individual responsible for daily operations at 
the entity--
    (A) Maintains a day-to-day reporting relationship with a manager at 
the main provider; and
    (B) Is accountable to the governing body of the main provider, in 
the same manner as any department head of the provider.
    (iii) The following administrative functions of the facility or 
organization are integrated with those of the provider where the 
facility or organization is based: billing services, records, human 
resources, payroll, employee benefit package, salary structure, and 
purchasing services. Either the same employees or group of employees 
handle these administrative functions for the facility or organization 
and the main provider, or the administrative functions for both the 
facility or organization and the entity are--
    (A) Contracted out under the same contract agreement; or
    (B) Handled under different contract agreements, with the contract 
of the facility or organization being managed by the main provider's 
billing department.
    (4) Clinical services. The clinical services of the facility or 
organization seeking provider-based status and the main provider are 
integrated as evidenced by the following:
    (i) Professional staff of the facility or organization have 
clinical privileges at the main provider.
    (ii) The main provider maintains the same monitoring and oversight 
of the facility or organization as it does for any other department of 
the provider.
    (iii) The medical director of the facility or organization seeking 
provider-based status maintains a day-to-day reporting relationship 
with the Chief Medical Officer or other similar official of the main 
provider, and is under the same type of supervision and accountability 
as any other director, medical or otherwise, of the main provider.
    (iv) Medical staff committees or other professional committees at 
the main provider are responsible for medical activities in the 
facility or organization including quality assurance, utilization 
review, and the coordination and integration of services, to the extent 
practicable, between the facility or organization seeking provider-
based status and the main provider.
    (v) Medical records for patients treated in the facility or 
organization are integrated into a unified retrieval system (or cross 
reference) of the main provider.
    (vi) Inpatient and outpatient services of the facility or 
organization and the main provider are integrated, and patients treated 
at the facility or organization who require further care have full 
access to all services of the main provider and are referred where 
appropriate to the corresponding inpatient or outpatient department or 
service of the main provider.
    (5) Financial integration. The financial operations of the facility 
or organization are fully integrated within the financial system of the 
main provider, as evidenced by shared income and expenses between the 
main provider and the facility or organization. The costs of the 
facility or organization are reported in a cost center of the provider, 
and the financial status of the facility or organization is 
incorporated and readily identified in the main provider's trial 
balance.
    (6) Public awareness. The facility or organization seeking status 
as a department of a provider is held out to the public and other 
payers as part of the main provider. When patients enter the provider-
based facility or organization, they are aware that they are entering 
the main provider and are billed accordingly.
    (7) Location in immediate vicinity. The facility or organization 
and the main provider are located on the same campus, except where the 
following requirements are met:
    (i) The facility or organization demonstrates a high level of 
integration with the main provider by showing that it meets all of the 
other provider-based criteria, and demonstrates that it serves the same 
patient population as the main provider, either by submitting records 
such as common patient lists and/or demographic data showing that a 
high percentage of patients of both the main provider and the applicant 
entity come from the same geographic area, or by submitting data 
substantiating that the patients served by the entity also receive 
services from the main provider (for example, the patients of an RHC 
receive inpatient hospital services from the main provider).
    (ii) A facility or organization is not considered to be in the 
``immediate vicinity'' of the main provider if the facility or 
organization and the main provider are located in different States.
    (e) Provider-based status not applicable to joint ventures. A 
facility or organization cannot be considered provider-based if the 
entity is owned by two or more providers engaged in a joint venture. 
For example, where a hospital has jointly purchased or jointly created 
free-standing facilities under joint venture arrangements, neither 
party to the joint venture arrangement can claim the free-standing 
facility as a provider-based entity.
    (f) Management contracts. Facilities and organizations operated 
under management contracts are considered provider-based if all of the 
following criteria are met:
    (1) The staff of the facility or organization are employed by the

[[Page 47610]]

provider or by another organization other than the management company.
    (2) The administrative functions of the facility or organization 
are integrated with those of the main provider, as determined under 
criteria in paragraph (b)(3)(iii) of this section.
    (3) The main provider has significant day-to-day control over the 
operations of the facility or organization as determined under criteria 
in paragraph (b)(3)(ii) of this section.
    (4) The management contract is held by the main provider itself, 
not by a parent organization that has control over both the main 
provider and the facility or organization.
    (g) Obligations of hospital outpatient departments and hospital-
based entities. (1) Hospital outpatient departments located either on 
or off the main premises of the hospital must comply with the anti-
dumping rules in Secs. 489.20(l), (m), (q), and (r) and 489.24 of this 
chapter. If any individual comes to any hospital-based entity 
(including an RHC) located on the main hospital campus, and a request 
is made on the individual's behalf for examination or treatment of a 
medical condition, as described in Sec. 489.24, the hospital must 
comply with the anti-dumping rules in Sec. 489.24.
    (2) Physician services furnished in hospital outpatient departments 
or hospital-based entities (other than RHCs) must be billed with the 
correct site-of-service indicator, so that applicable site-of-service 
reductions to physician and practitioner payment amounts can be 
applied.
    (3) Hospital outpatient departments must comply with all the terms 
of the hospital's provider agreement.
    (4) Physicians who work in hospital outpatient departments or 
hospital-based entities are obligated to comply with the non-
discrimination provisions in Sec. 489.10(b) of this chapter.
    (5) Hospital outpatient departments (other than RHCs) must hold 
themselves out to other payers as outpatient departments of that 
hospital, and must treat all patients, for billing purposes, as 
hospital outpatients. The department must not treat some patients as 
hospital outpatients and others as physician office patients.
    (6) In the case of a patient admitted to the hospital as an 
inpatient after receiving treatment in the hospital outpatient 
department or hospital-based entity, payments for services in the 
hospital outpatient department or hospital-based entity are subject to 
the payment window provisions applicable to PPS hospitals and to 
hospitals and units excluded from PPS set forth at Sec. 412.2(c)(5) of 
this chapter and at Sec. 413.40(c)(2), respectively.
    (7) When a Medicare beneficiary is treated in a hospital outpatient 
department or hospital-based entity (other than an RHC), the hospital 
has a duty to notify the beneficiary, prior to the delivery of 
services, of the beneficiary's potential financial liability (that is, 
a coinsurance liability for an outpatient visit to the hospital as well 
as for the physician service).
    (8) Hospital outpatient departments must meet applicable hospital 
health and safety rules for Medicare-participating hospitals in part 
482 of this chapter.
    (9) A facility or organization may not qualify for provider-based 
status if all services furnished at the facility are furnished under 
arrangement.
    (h) Inappropriate treatment of a facility or organization as 
provider-based. If HCFA learns of a provider treating a facility or 
organization as provider-based without notifying HCFA to obtain a 
determination of provider-based status, HCFA reconsiders all payments 
to that provider for all cost reporting periods subject to re-opening 
in accordance with Secs. 405.1885 and 405.1889 of this chapter. HCFA 
then investigates and determines whether the requirements in paragraph 
(d) of this section were met. If the facility or organization did not 
qualify for a provider-based determination, HCFA recovers the 
difference between the amount of payments that actually were made and 
the amount of payments that should have been made in the absence of a 
determination of provider-based status, except that recovery will not 
be made for any period prior to [insert the effective date of final 
rule] if during all of that period the management of the entity made a 
good faith effort to operate it as a provider-based facility or 
organization, as described in paragraph (i)(2) of this section.
    (i) Inappropriate billing. (1) If HCFA determines that a provider 
has been inappropriately billing Medicare for services furnished in a 
physician office or other facility or organization as if they had been 
furnished in a hospital outpatient department or other department of a 
provider or in a provider-based entity, HCFA stops all payments to the 
provider for outpatient services until the provider can demonstrate 
which payments are proper. If overpayments have been made, HCFA 
recovers the difference between the amount of payments that actually 
were made and the amount of the payments that should have been made in 
the absence of the determination of provider-based status. However, 
past payments attributable to treatment as a department of a provider 
or a provider-based entity for any period prior to [insert effective 
date of final rule] are not recovered if during all of that period the 
management of a facility or an organization made a good faith effort to 
operate it as a department of a provider or a provider-based entity, as 
described in paragraph (i)(2) of this section, prior to [insert 
effective date of final rule].
    (2) HCFA determines that the management of a facility has made a 
good faith effort to operate it as a provider-based entity if--
    (i) The requirements regarding licensure and public awareness in 
paragraphs (d)(1) and (d)(6) of this section are met;
    (ii) All facility services were billed as if they had been 
furnished by a department of a provider or a provider-based entity of 
the main provider; and
    (iii) All professional services of physicians and other 
practitioners were billed with the correct site-of-service indicator, 
as described in paragraph (g)(7) of this section.
    (j) Correction of errors. HCFA may review a past determination of 
provider-based status if it believes that the determination may be 
inappropriate, based on the provisions of this section. If HCFA 
determines that a previous determination was in error, and the entity 
should not be considered provider-based, HCFA notifies the main 
provider. Treatment of the facility or organization as provider-based 
ceases with the first day of the next cost report period following 
notification of the redetermination.

Subpart F--Specific Categories of Costs

    5. In Sec. 413.118, the heading to paragraph (d) is republished, 
and a new paragraph (d)(5) is added to read as follows:


Sec. 413.118  Payment for facility services related to covered ASC 
surgical procedures performed in hospitals on an outpatient basis.

* * * * *
    (d) Blended payment amount. * * *
    (5) For portions of cost reporting periods beginning on or after 
October 1, 1997, for purposes of calculating the blended payment amount 
under paragraph (d)(4) of this section, the ASC payment amount is the 
sum of the standard overhead amounts reduced by deductibles and 
coinsurance as defined in section 1866(a)(2)(ii) of the Act.
* * * * *
    6. In Sec. 413.122, the heading to paragraph (b) is republished, a 
new

[[Page 47611]]

paragraph (b)(5) is added, the heading to paragraph (c) is republished, 
and a new paragraph (c)(4) is added to read as follows:


413.122  Payment for hospital outpatient radiology services and other 
diagnostic procedures.

* * * * *
    (b) Payment for hospital outpatient radiology services. * * *
    (5) For hospital outpatient radiology services furnished on or 
after October 1, 1997, the blended payment amount is equal to the sum 
of--
    (i) 42 percent of the hospital-specific amount; and
    (ii) 58 percent of the fee schedule amount calculated as 62 percent 
of the sum of the fee schedule amounts payable for the same services 
when furnished by participating physicians in their offices in the same 
locality, less deductible and coinsurance as defined in section 
1866(a)(2)(A)(ii) of the Act.
    (c) Payment for other diagnostic procedures. * * *
    (4) For other diagnostic services furnished on or after October 1, 
1997, the blended payment amount is equal to the sum of--
    (i) 50 percent of the hospital-specific amount; and
    (ii) 50 percent of the fee schedule amount calculated as 42 percent 
of the sum of the fee schedule amounts payable for the same services 
when furnished by participating physicians in their offices in the same 
locality, less deductible and coinsurance as defined in section 
1866(a)(2)(A)(ii) of the Act.
    7. In Sec. 413.124, paragraph (a) is revised to read as follows:


Sec. 413.124  Reduction to hospital outpatient operating costs.

    (a) Except for sole community hospitals, as defined in Sec. 412.92 
of this chapter, and critical access hospitals, the reasonable costs of 
outpatient hospital services (other than capital-related costs of such 
services) are reduced by 5.8 percent for services furnished during 
portions of cost reporting periods occurring on or after October 1, 
1990 and before January 1, 2000.
* * * * *

Subpart G--Capital-Related Costs

    8. In Sec. 413.130, the heading to paragraph (j) and the 
introductory text to paragraph (j)(1) are republished, and paragraph 
(j)(1)(ii) is revised to read as follows:


Sec. 413.130  Introduction to capital-related costs.

* * * * *
    (j) Reduction to capital-related costs. (1) Except for sole 
community hospitals and critical access hospitals, the amount of 
capital-related costs of all hospital outpatient services is reduced 
by--
* * * * *
    (ii) 10 percent for portions of cost reporting periods occurring on 
or after October 1, 1991 through December 31, 1999 and before January 
1, 2000.
* * * * *
    F. A new part 419, consisting of Secs. 419.1, 419.2, 419.20, 
419.21, 419.22, 419.30, 419.31, 419.32, 419.40, 419.41, 419.42, 419.43, 
419.44, 419.50, 419.51, and 419.60, is added to read as follows:

PART 419--PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT 
DEPARTMENT SERVICES

Subpart A--General Provisions

Sec.
419.1  Scope of part.
419.2  Basis of payment.

Subpart B--Services Subject to and Excluded From the Hospital 
Outpatient Prospective Payment System

419.20  Hospitals subject to the hospital outpatient prospective 
payment system.
419.21  Hospital outpatient services subject to the outpatient 
prospective payment system.
419.22  Hospital outpatient services excluded from payment under the 
hospital outpatient prospective payment system.

Subpart C--Basic Methodology for Determining Prospective Payment Rates 
for Hospital Outpatient Services

419.30  Base expenditure target for calendar year 1999.
419.31  Ambulatory Payment Classification (APC) system and payment 
weights.
419.32  Calculation of prospective payment rates for hospital 
outpatient services.

Subpart D--Payments to Hospitals

419.40  Payment concepts.
419.41  Calculation of national beneficiary copayment amounts and 
national Medicare program payment amounts.
419.42  Hospital election to reduce copayment.
419.43  Adjustments to national program payment and beneficiary 
copayment amounts.
419.44  Payment reductions for surgical procedures.

Subpart E--Updates

419.50  Revisions to groups, weights, and other adjustments.
419.51  Volume control measures for services furnished in CY 2000.

Subpart F--Limitations on Review

419.60  Limitations on administrative and judicial review.

    Authority: Secs. 1102, 1833(t), and 1871 of the Social Security 
Act (42 U.S.C. 1302, 1395l(t), and 1395(hh)).

PART 419--PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL OUTPATIENT 
DEPARTMENT SERVICES

Subpart A--General Provisions


Sec. 419.1  Scope of part.

    (a) Purpose. This part implements section 1833(t) of the Act by 
establishing a prospective payment system for services furnished by 
hospital outpatient departments to Medicare beneficiaries who are 
registered on hospital records as outpatients, effective for services 
furnished on or after the implementation date.
    (b) Summary of content. This subpart describes the basis of payment 
for outpatient hospital services under the prospective payment system. 
Subpart B sets forth the categories of hospitals and services that are 
subject to the outpatient hospital prospective payment system and those 
categories of hospitals and services that are excluded from the 
outpatient hospital prospective payment system. Subpart C sets forth 
requirements and the basic methodology by which prospective payment 
rates for hospital outpatient services are determined. Subpart D 
describes Medicare payment amounts, beneficiary copayment amounts, and 
methods of payment to hospitals under the hospital outpatient 
prospective payment system. Subpart E describes how the hospital 
outpatient prospective payment system may be revised to take into 
account changes in medical practice and technology, the addition or 
deletion of services, new cost data, and other relevant information and 
factors.


Sec. 419.2  Basis of payment.

    (a) Unit of payment. Under the hospital outpatient prospective 
payment system, hospitals are paid a predetermined amount for 
designated services, which are identified by codes established under 
the Health Care Financing Administration Common Procedure Coding System 
(HCPCS), furnished to Medicare beneficiaries. The prospective payment 
rate for each service or procedure for which payment is allowed under 
the hospital outpatient prospective payment system is determined 
according to the methodology described in subpart C of this part. The 
manner in which the Medicare payment amount and the beneficiary 
copayment amount for each service or procedure are determined is 
described in subpart D of this part.
    (b) Costs included in determination of hospital outpatient 
department payment rates. The prospective payment system establishes a 
national payment rate,

[[Page 47612]]

standardized for geographic wage differences, for operating and 
capital-related costs that are directly related and integral to 
performing a procedure or furnishing a service on an outpatient basis, 
including, but not limited to--
    (1) Use of an operating suite, procedure room, or treatment room;
    (2) Use of recovery room;
    (3) Use of an observation bed;
    (4) Anesthesia, drugs, biologicals, other pharmaceuticals, and 
blood; medical and surgical supplies and equipment; surgical dressings; 
splints, casts, and other devices used for reduction of fractures and 
dislocations;
    (5) Supplies and equipment for administering and monitoring 
anesthesia or sedation;
    (6) Intra-ocular lenses (IOLs);
    (7) Incidental services such as venipuncture;
    (8) Capital-related costs.
    (c) Costs excluded from determination of hospital outpatient 
prospective payment rates. The following costs are excluded from the 
hospital outpatient prospective payment rates:
    (1) Medical education costs for approved nursing and allied health 
education programs.
    (2) Costs for services listed in Sec. 419.22.

Subpart B--Services Subject to and Excluded From the Hospital 
Outpatient Prospective Payment System


Sec. 419.20  Hospitals subject to the hospital outpatient prospective 
payment system.

    (a) Applicability. The hospital outpatient prospective payment 
system is applicable to any hospital participating in the Medicare 
program, except those specified in paragraph (b) of this section, for 
services furnished on or after the implementation date.
    (b) Hospitals excluded from the outpatient prospective payment 
system. (1) Those services furnished by Maryland hospitals that are 
paid under a cost containment waiver in accordance with section 
1814(b)(3) of the Act are excluded from the hospital outpatient 
prospective payment system.
    (2) Critical access hospitals (CAHs) are excluded from the hospital 
outpatient prospective payment system.


Sec. 419.21  Hospital outpatient services subject to the outpatient 
prospective payment system.

     Beginning on the implementation date, except for services 
described in Sec. 419.22, payment is made under the hospital outpatient 
prospective payment system for--
    (a) Medicare Part B services furnished to hospital outpatients 
designated by HCFA under this part that are not otherwise excluded 
under Sec. 419.22;
    (b) Services that are covered under Medicare Part B when furnished 
to hospital inpatients who are either not entitled to benefits under 
Part A or who have exhausted their Part A benefits, but are entitled to 
benefits under Part B of the program;
    (c) Partial hospitalization services furnished by community mental 
health centers (CMHCs);
    (d) The following medical and other health services furnished by a 
comprehensive outpatient rehabilitation facility (CORF) when they fall 
outside the definition of CORF services at section 1861(cc)(1) of the 
Act; or by a home health agency (HHA) to patients who are not under an 
HHA plan or treatment; or, by a hospice program furnishing services to 
patients outside the hospice benefit:
    (1) Antigens.
    (2) Splints and casts.
    (3) Pneumococcal vaccine, influenza vaccine, hepatitis B vaccine.


Sec. 419.22  Hospital outpatient services excluded from payment under 
the hospital outpatient prospective payment system.

    The following services are not paid for under the hospital 
outpatient prospective payment system:
    (a) Physician services.
    (b) Nurse practitioner services.
    (c) Physician assistant services.
    (d) Certified nurse-midwife services.
    (e) Services of qualified psychologists.
    (f) Services of an anesthetist as defined in Sec. 410.69 of this 
chapter.
    (g) Clinical social worker services as defined in section 
1861(hh)(2) of the Act.
    (h) Rehabilitation services described in section 1833(a)(8) of the 
Act.
    (i) Ambulance services.
    (j) Prosthetics and prosthetic supplies, prosthetic devices, 
prosthetic implants (except IOLs), and orthotic devices.
    (k) Durable medical equipment supplied by the hospital for the 
patient to take home.
    (l) Clinical diagnostic laboratory services.
    (m) Dialysis services furnished to ESRD patients.
    (n) Services and procedures that are not safely furnished in an 
outpatient setting or that require inpatient care.
    (o) Services specific to other sites such as nursing homes.
    (p) Services furnished to persons who are inpatients of a SNF and 
furnished pursuant to the resident assessment or comprehensive care 
plan but that are covered under the SNF prospective payment system, 
furnished ``under arrangement,'' and billable only by the SNF.
    (q) Services that are not covered by Medicare by statute.
    (r) Services that are not reasonable or necessary for the diagnosis 
or treatment of an illness or disease.

Subpart C--Basic Methodology for Determining Prospective Payment 
Rates for Hospital Outpatient Services


Sec. 419.30  Base expenditure target for calendar year 1999.

    (a) HCFA estimates the aggregate amount that would be payable for 
hospital outpatient services in calendar year 1999 by summing--
    (1) The total amounts that would be payable from the Trust Fund for 
covered hospital outpatient services without regard to the outpatient 
prospective payment system described in this part; and
    (2) The total amounts of copayments estimated to be paid by 
beneficiaries, under the prospective payment system described in this 
part, to hospitals for covered hospital outpatient services.
    (b) The aggregate amount under paragraph (a) of this section is 
determined as though the deductible required under section 1833(b) of 
the Act did not apply.


Sec. 419.31  Ambulatory Payment Classification (APC) system and payment 
weights.

    (a) APC groups. (1) HCFA classifies hospital outpatient services 
and procedures that are comparable clinically and similar in terms of 
resource use into APC groups.
    (2) The payment rate determined for an APC group in accordance with 
Sec. 419.32 and the copayment amount and program payment amount 
determined for an APC group in accordance with subpart D of this part 
apply to every individual service or procedure within the APC group.
    (b) APC weighting factors. (1) Using hospital claims data from 
calendar year 1996 and data from the most recent available hospital 
cost reports, HCFA determines the median costs for the services and 
procedures within each APC group.
    (2) HCFA assigns to each APC group an appropriate weighting factor 
to reflect the relative median costs for the services within the APC 
group compared to the median costs for the services in all APC groups.
    (c) Standardizing amounts. (1) HCFA determines the portion of costs 
determined in paragraph (b)(1) of this section that is labor-related. 
This is known as the ``labor-related portion'' of hospital outpatient 
costs.
    (2) HCFA standardizes the median costs determined in paragraph 
(b)(1) of

[[Page 47613]]

this section by adjusting for variations in hospital labor costs across 
geographic areas.


Sec. 419.32  Calculation of prospective payment rates for hospital 
outpatient services.

    (a) Conversion factor for 1999. HCFA calculates a conversion factor 
in such a manner as to ensure that payment for hospital outpatient 
services furnished in 1999 would have equalled the base expenditure 
target calculated in Sec. 419.30, taking APC group weights and 
estimated service volume into account.
    (b) Conversion factor for calendar years 2000, 2001, and 2002. (1) 
Subject to paragraph (c)(2) of this section, the conversion factor for 
each of the calendar years 2000, 2001, and 2002 is equal to the 
conversion factor calculated under paragraph (a) of this section for 
the previous year adjusted by the hospital inpatient market basket 
percentage increase applicable under section 1886(b)(3)(B)(iii) of the 
Act for fiscal years 2000, 2001, and 2002, respectively, reduced by one 
percentage point.
    (2) Beginning in calendar year 2000, HCFA may substitute for the 
hospital inpatient market basket percentage in paragraph (c)(1) of this 
section a market basket percentage increase that is determined and 
applied to hospital outpatient services in the same manner that the 
hospital inpatient market basket percentage increase is determined and 
applied to inpatient hospital services.
    (c) Payment rates. The payment rate for services and procedures for 
which payment is made under the hospital outpatient prospective payment 
system is the product of the conversion factor calculated under 
paragraph (a) or paragraph (b) of this section and the relative weight 
determined under Sec. 419.31(b).

Subpart D--Payments to Hospitals


Sec. 419.40  Payment concepts.

    In addition to the payment rate described in Sec. 419.32, for each 
APC group there is a predetermined beneficiary copayment amount as 
described in Sec. 419.41(a). The Medicare payment for each APC is 
calculated by applying the program payment percentage as described in 
Sec. 419.41(b).
    (b) For purposes of this section--
    Copayment percentage is calculated as the difference between the 
program payment percentage and 100 percent. The copayment percentage in 
any year is thus defined for each APC group as the greater of the 
following: the ratio of the APC group unadjusted copayment amount to 
the annual APC group payment rate, or 20 percent.
    Program payment percentage is calculated as the lower of the 
following: the ratio of the APC group payment rate minus the APC group 
unadjusted copayment amount, to the APC group payment rate, or 80 
percent.
    Unadjusted copayment amount is calculated as 20 percent of the 
wage-adjusted national median of charges for services within an APC 
group furnished during 1996, updated to 1999 using an actuarial 
projection of charge increases for hospital outpatient department 
services during the period 1996 to 1999.


Sec. 419.41  Calculation of national beneficiary copayment amounts and 
national Medicare program payment amounts.

    (a) Calculation of the national beneficiary copayment amount. To 
calculate the unadjusted copayment amount for each APC group, HCFA--
    (1) Standardizes 1996 hospital charges for the services within each 
APC group to offset variations in hospital labor costs across 
geographic areas;
    (2) Identifies the median of the wage-neutralized 1996 charges for 
each APC group; and,
    (3) Determines the value equal to 20 percent of the wage-
neutralized 1996 median charge for each APC group and multiplies that 
value by an actuarial projection of increases in charges for hospital 
outpatient department services during the period 1996 to 1999. The 
result is the unadjusted beneficiary copayment amount for the APC 
group.
    (b) Calculation of the program payment amount for each APC group. 
(1) HCFA calculates annually the program payment percentage for every 
APC group on the basis of each group's unadjusted copayment amount and 
its payment rate after the payment rate is adjusted in accordance with 
Sec. 419.32.
    (2) The Medicare program payment amounts are calculated annually by 
multiplying the updated APC group payment rates by the program payment 
percentage.
    (c) To determine payment amounts due for a service paid for under 
the hospital outpatient prospective payment system, HCFA makes the 
following calculations:
    (1) Makes the wage index adjustment and any other adjustments that 
are appropriate in accordance with Sec. 419.43.
    (2) Subtracts the amount of the applicable Part B deductible 
provided under Sec. 410.160 of this chapter.
    (3) Multiplies the remainder by the program payment percentage for 
the group to determine the program payment amount.
    (4) Subtracts the program payment amount from the amount determined 
in paragraph (c)(2) of this section to determine the copayment amount.


Sec. 419.42  Hospital election to reduce copayment.

    (a) A hospital may elect to reduce copayments for any or all APC 
groups on a calendar year basis. A hospital may not elect to reduce 
copayment for some, but not all, services within the same group.
    (b) A hospital must notify its fiscal intermediary of its election 
to reduce copayments no later than 90 days prior to the start of the 
calendar year.
    (c) The hospital's election must be properly documented. It must 
specifically identify the APCs to which it applies and the copayment 
level (within the limits identified below) that the hospital has 
selected for each group.
    (d) The election of reduced copayment must remain in effect 
unchanged during the year for which the election was made.
    (e) The hospital may advertise and otherwise disseminate 
information concerning the reduced level(s) of copayment that it has 
elected.
    (f) In electing reduced copayment, a hospital may elect a level 
that is less than that year's national copayment amount for the group, 
but not less than 20 percent of the APC payment rate as determined in 
Sec. 419.32.


Sec. 419.43  Adjustments to national program payment and beneficiary 
copayment amounts.

    (a) General rule. HCFA determines national prospective payment 
rates for hospital outpatient department services and determines a wage 
adjustment factor to adjust the portion of the APC payment and national 
beneficiary copayment amount attributable to labor-related costs for 
relative differences in labor and labor-related costs across geographic 
regions in a budget neutral manner.
    (b) Labor-related portion of payment and copayment rates for 
hospital outpatient services. HCFA determines the portion of hospital 
outpatient costs attributable to labor and labor-related costs (known 
as the ``labor-related portion'' of hospital outpatient costs) in 
accordance with Sec. 419.31(c)(1).
    (c) Wage index factor. HCFA uses the hospital inpatient prospective 
payment system wage index established in accordance with section 
1886(d)(3)(E) of the Act and part 412 of this chapter to make the 
adjustment referred to in paragraph (a) of this section.
    (d) Other adjustments. Any other adjustments to payment amounts 
made by HCFA to ensure equitable payments are made in a budget neutral 
manner.

[[Page 47614]]

Sec. 419.44  Payment reductions for surgical procedures.

    (a) Multiple surgical procedures. When more than one surgical 
procedure for which payment is made under the hospital outpatient 
prospective payment system is performed during a single surgical 
encounter, the Medicare program payment amount and the beneficiary 
copayment amount are based on--
    (1) The full amounts for the procedure with the highest APC payment 
rate; and
    (2) One half of the full program and beneficiary payment amounts 
for all other covered procedures.
    (b) Terminated procedures. When a surgical procedure is terminated 
prior to completion due to extenuating circumstances or circumstances 
that threaten the well-being of the patient, the Medicare program 
payment amount and the beneficiary copayment amount are based on--
    (1) The full amounts if the procedure is discontinued after the 
induction of anesthesia or after the procedure is started; and
    (2) One-half of the full program and beneficiary payment amounts if 
the procedure is discontinued after the patient is prepared for surgery 
and taken to the room where the procedure is to be performed, but 
before anesthesia is induced.

Subpart E--Updates


Sec. 419.50  Revisions to groups, weights, and other adjustments.

    (a) HCFA periodically reviews and updates groups, relative payment 
weights, and the wage and other adjustments to take into account 
changes in medical practice, changes in technology, the addition of new 
services, new cost data, and other relevant information and factors.
    (1) Changes in the APC system. HCFA may make a change in the group 
composition of the APC system or recalibrate any APC weight, as needed, 
but not more frequently than once a year. HCFA makes these changes 
based on evidence that a reassignment would improve the consistency of 
the group(s) either clinically or with respect to resource consumption.
    (2) New services. HCFA assigns a new service to the APC group that 
is most similar clinically and with respect to resource consumption.
    (3) Budget neutrality. HCFA adjusts the conversion factor so that 
any adjustments determined under paragraphs (a)(1) through (a)(3) of 
this section do not increase or decrease the amount of expenditures 
that would have been made under this section if the adjustments had not 
been made.
    (b) Annual update to conversion factor. HCFA updates the conversion 
factor annually as specified in Sec. 419.32.


Sec. 419.51  Volume control measures for services furnished in CY 2000.

    HCFA uses the target amount specified under section 1833(t)(3)(A) 
of the Act as an expenditure target for services furnished in CY 1999. 
HCFA updates the target amount to CY 2000 based on the adjustment to 
the conversion factor in Sec. 419.32(b), estimated changes in the 
volume and intensity of hospital outpatient services, and estimated 
changes in beneficiary enrollment. HCFA compares the CY 2000 target to 
an estimate of CY 2000 actual payments to hospitals. If unnecessary 
volume increases cause payments to exceed the target, HCFA determines 
the percentage by which the target is exceeded, and adjusts the CY 2002 
update to the conversion factor by the same percentage.

Subpart F--Limitations on Review


Sec. 419.60  Limitations on administrative and judicial review.

    There can be no administrative or judicial review under sections 
1869 and 1878 of the Act, or otherwise of--
    (a) The development of the APC system, including--
    (1) Establishment of the groups and relative payment weights;
    (2) Wage adjustment factors;
    (3) Other adjustments; and
    (4) Methods for controlling unnecessary increases in volume.
    (b) The calculation of base amounts described in section 1833(t)(3) 
of the Act;
    (c) Periodic adjustments described in section 1833(t)(6) of the 
Act; and
    (d) The establishment of a separate conversion factor for hospitals 
described in section 1886(d)(1)(B)(v) of the Act.

PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL

    G. Part 489 is amended as set forth below:
    1. The authority citation to part 489 continues to read as follows:

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

Subpart B--Essentials of Provider Agreements

    2. In Sec. 489.20, the introductory text to the section is 
republished; the introductory text to paragraph (d) is revised; 
paragraphs (d)(3), (d)(4), and (d)(5) are redesignated as paragraphs 
(d)(4), (d)(5), and (d)(6), respectively; and a new paragraph (d)(3) is 
added to read as follows:


Sec. 489.20  Basic commitments.

    The provider agrees to the following:
* * * * *
    (d) In the case of a hospital or a CAH that furnishes services to 
Medicare beneficiaries, either to furnish directly or to make 
arrangements (as defined in Sec. 409.3 of this chapter) for all 
Medicare-covered services to inpatients and outpatients of a hospital 
or a CAH except the following:
* * * * *
    (3) Nurse practitioner and clinical nurse specialist services, as 
defined in section 1861(s)(2)(K)(ii) of the Act.
* * * * *
    3. In Sec. 489.24(b), the definition for ``Comes to the emergency 
department'' is revised to read as follows:


Sec. 489.24  Special responsibilities of Medicare hospitals in 
emergency cases.

* * * * *
    (b) * * *
    Comes to the emergency department means, with respect to an 
individual requesting examination or treatment, that the individual is 
on the hospital property. For purposes of this section, ``property'' 
means the entire main hospital campus, including the parking lot, 
sidewalk, and driveway, as well as any facility or organization that is 
located off the main hospital campus but has been determined under 
Sec. 416.35 of this chapter to be a department of the hospital. 
Property also includes ambulances owned and operated by the hospital, 
even if the ambulance is not on hospital grounds. An individual in a 
nonhospital-owned ambulance on hospital property is considered to have 
come to the hospital's emergency department. An individual in a 
nonhospital-owned ambulance off hospital property is not considered to 
have come to the hospital's emergency department, even if a member of 
the ambulance staff contacts the hospital by telephone or telemetry 
communications and informs the hospital that they want to transport the 
individual to the hospital for examination and treatment. In such 
situations, the hospital may deny access if it is in ``diversionary 
status,'' that is, it does not have the staff or facilities to accept 
any additional emergency patients. If, however, the ambulance staff 
disregards the hospital's instructions and transports the individual on 
to hospital property, the individual is considered to have come to the 
emergency department.
* * * * *

[[Page 47615]]

PART 498--APPEALS PROCEDURES FOR DETERMINATIONS THAT AFFECT 
PARTICIPATION IN THE MEDICARE PROGRAM AND FOR DETERMINATIONS THAT 
AFFECT THE PARTICIPATION OF ICFs/MR AND CERTAIN NFs IN THE MEDICAID 
PROGRAM

    H. Part 498 is amended as set forth below:
    1. The authority citation for part 498 continues to read as 
follows:

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

    2. In Sec. 498.2, the introductory text is republished, and the 
definition of ``Provider'' is revised to read as follows:


Sec. 498.2  Definitions.

As used in this part --

* * * * *
    Provider means a hospital, critical access hospital (CAH), skilled 
nursing facility (SNF), comprehensive outpatient rehabilitation 
facility (CORF), home health agency (HHA), or hospice, that has in 
effect an agreement to participate in Medicare, that has in effect an 
agreement to participate in Medicaid, or a clinic, rehabilitation 
agency, or public health agency that has a similar agreement but only 
to furnish outpatient physical therapy or outpatient speech pathology 
services, and prospective provider means any of the listed entities 
that seeks to participate in Medicare as a provider or to have any 
facility or organization determined to be a department of the provider 
or provider-based entity under Sec. 412.65 of this chapter.
* * * * *
    3. In Sec. 498.3, the introductory text to paragraph (b) is 
republished; paragraphs (b)(2) through (b)(14) are redesignated as 
paragraphs (b)(3) through (b)(15), respectively; and a new paragraph 
(b)(2) is added to read as follows:


Sec. 498.3  Scope and applicability.

* * * * *
    (b) Initial determinations by HCFA. HCFA makes initial 
determinations with respect to the following matters:
* * * * *
    (2) Whether a prospective department of a provider or provider-
based entity qualifies as a department of a provider or provider-based 
entity under Sec. 413.65 of this chapter.
* * * * *

PART 1003--CIVIL MONEY PENALTIES, ASSESSMENTS AND EXCLUSIONS

    I. Part 1003 is amended as set forth below:
    1. The authority citation for part 1003 is revised to read as 
follows:

    Authority: 42 U.S.C. 1302, 1320-7, 1320a-7a, 1320b-10, 1395u(j), 
1395u(k), 1395cc(g), 1395dd(d)(1), 1395mm, 1395nn(g), 1395ss(d), 
1396b(m), 11131(c) and 11137(b)(2).

    2. Section 1003.100 is amended by revising paragraph (a) to read as 
follows:


Sec. 1003.100  Basis and purpose.

    (a) Basis. This part implements sections 1102, 1128(c), 1128A, 
1140, 1842(j), 1842(k), 1866(g), 1876(i)(6), 1877(g), 1882(d) and 
1903(m)(5) of the Social Security Act, and sections 421(c) and 
427(b)(2) of Pub. L. 99-660 (42 U.S.C. 1302, 1320a-7, 1320a-7a, 1320b-
10, 1395u(j), 1395u(k), 1395cc(g), 1395mm(i)(6), 1395nn(g), 1395ss(d), 
1396d(m)(5), 11131(c) and 11137(b)(2)).
* * * * *
    3. Section 1003.102 is amended by republishing the introductory 
text to paragraph (b), by reserving paragraphs (b)(11) through (b)(13), 
and by adding a new paragraph (b)(14) to read as follows:


Sec. 1003.102  Basis for civil money penalties and assessments.

* * * * *
    (b) The OIG may impose a penalty, and where authorized, an 
assessment against any person (including an insurance company in the 
case of paragraphs (b)(5) and (b)(6) of this section) whom it 
determines in accordance with this part--
* * * * *
    (11) [Reserved]
    (12) [Reserved]
    (13) [Reserved]
    (14) Has knowingly and willfully presented, or caused to be 
presented, a bill or request for payment for an item or service 
furnished to a hospital patient for which payment may be made under the 
Medicare or another Federal health care program, if that bill or 
request is inconsistent with an arrangement under section 1866(a)(1)(H) 
of the Act, or violates the requirements for such an arrangement.
* * * * *
    4. Section 1003.103 is amended by revising paragraph (a) to read as 
follows:


Sec. 1003.103  Amount of penalty.

    (a) Except as provided in paragraphs (b) through (f) of this 
section, the OIG may impose a penalty of not more than $10,000 for each 
item or service that is subject to a determination under Sec. 1003.102.
* * * * *
    5. Section 1003.105 is amended by revising paragraph (a)(1)(i) to 
read as follows:


Sec. 1003.105  Exclusion from participation in Medicare and State 
health care programs.

    (a)(1) * * *
    (i) Any person who is subject to a penalty or assessment under 
Sec. 1003.102(a), (b)(1) through (b)(4), or (b)(14).
* * * * *
(Catalog of Federal Domestic Assistance 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: June 29, 1998.
Nancy-Ann Min DeParle,
Administrator, Health Care Financing Administration.

    Dated: June 29, 1998.
June G. Brown,
Inspector General, Department of Health and Human Services.

    Approved: August 15, 1998.
Donna E. Shalala,
Secretary.

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

  

  


  

[[Page 47615]]



  Addendum A.--List of Proposed Hospital Outpatient Ambulatory Payment Classes With Status Indicators, Relative
                                 Weights, Payment Rates, and Coinsurance Amounts
----------------------------------------------------------------------------------------------------------------
                                                                                          National     Minimum
 APC \1\       Group title                             Status      Relative   Payment    unadjusted   unadjusted
   \2\                                               indicator      weight      rate    coinsurance  coinsurance
----------------------------------------------------------------------------------------------------------------
020......  Partial             ..................  S                   4.11    $208.01       $46.78       $41.60
            Hospitalization
            per diem.
031......  Dental procedures.  ..................  S                   1.34     $67.90       $13.58       $13.58
061......  Level I             ..................  X                   1.04     $52.70       $36.61       $10.54
            Chemotherapeutic
            agents.
062......  Level II            ..................  X                   1.69     $85.63       $36.61       $17.13
            Chemotherapeutic
            agents.

[[Page 47616]]

063......  Level III           ..................  X                   2.89    $146.43      $110.97       $29.29
            Chemotherapeutic
            agents.
064......  Level IV            ..................  X                   4.17    $211.29      $140.12       $42.26
            Chemotherapeutic
            agents.
089......  Neuropsychological  ..................  X                   2.54    $128.70       $37.29       $25.74
            Testing.
090......  Monitoring          ..................  X                   0.85     $43.07       $12.43        $8.61
            psychiatric drugs.
091......  Brief Individual    ..................  S                   1.09     $55.23       $14.01       $11.05
            Psychotherapy.
092......  Extended            ..................  S                   1.57     $79.55       $21.92       $15.91
            Individual
            Psychotherapy.
093......  Family              ..................  S                   1.54     $78.03       $20.11       $15.61
            Psychotherapy.
094......  Group               ..................  S                   1.24     $62.83       $20.11       $12.57
            Psychotherapy.
121......  Level I needle      ..................  T                   0.67     $33.95       $20.91        $6.79
            biopsy/aspiration.
122......  Level II needle     ..................  T                   4.87    $246.76      $115.03       $49.35
            biopsy/aspiration.
131......  Level I incision &  ..................  T                   1.94     $98.30       $36.61       $19.66
            drainage.
132......  Level II incision   ..................  T                   6.04    $306.04      $134.13       $61.21
            & drainage.
137......  Nail procedures...  ..................  T                   0.46     $23.31        $4.66        $4.66
141......  Level I             ..................  T                   0.59     $29.90        $9.49        $5.98
            Destruction of
            lesion.
142......  Level II            ..................  T                   3.77    $191.02       $73.00       $38.20
            Destruction of
            lesion.
151......  Level I             ..................  T                   1.74     $88.16       $35.71       $17.63
            debridement/
            destruction.
152......  Level II            ..................  T                  10.43    $528.48      $261.71      $105.70
            debridement/
            destruction.
161......  Level I excision/   ..................  T                   3.50    $177.34       $75.48       $35.47
            biopsy.
162......  Level II excision/  ..................  T                   5.67    $287.30      $125.43       $57.46
            biopsy.
163......  Level III excision/ ..................  T                  10.69    $541.66      $264.65      $108.33
            biopsy.
181......  Level I skin        ..................  T                   2.19    $110.97       $43.84       $22.19
            repair.
182......  Level II skin       ..................  T                   4.00    $202.68       $84.98       $40.54
            repair.
183......  Level III skin      ..................  T                  11.17    $565.98      $286.46      $113.20
            repair.
184......  Level IV skin       ..................  T                  15.17    $768.66      $396.40      $153.73
            repair.
197......  Incision/excision   ..................  T                  12.13    $614.62      $310.75      $122.92
            breast.
198......  Breast              ..................  T                  19.17    $971.33      $530.20      $194.27
            reconstruction/
            mastectomy.
200......  Arthrocentesis &    ..................  T                   1.89     $95.77       $39.10       $19.15
            Ligament/Tendon
            Injection.
207......  Closed treatment    ..................  T                   1.70     $86.14       $31.64       $17.23
            fracture finger/
            toe/trunk.
209......  Closed treatment    ..................  T                   1.94     $98.30       $37.29       $19.66
            fracture/
            dislocation/
            except finger/toe/
            trunk.
210......  Bone/joint          ..................  T                  10.46    $530.00      $283.40      $106.00
            manipulation
            under anesthesia.
216......  Open/percutaneous   ..................  T                  20.13  $1,019.98      $520.82      $204.00
            treatment
            fracture or
            dislocation.
217......  Arthroplasty......  ..................  T                  20.48  $1,037.71      $526.81      $207.54
218......  Arthroplasty with   ..................  T                  27.49  $1,392.90      $715.52      $278.58
            prosthesis.
*226.....  Maxillofacial       ..................  T                   1.59     $80.56       $21.92       $16.11
            prostheses.
231......  Level I skull and   ..................  T                  12.02    $609.05      $299.90      $121.81
            facial bone
            procedures.
232......  Level II skull and  ..................  T                  23.93  $1,212.52      $639.35      $242.50
            facial bone
            procedures.
251......  Level I             ..................  T                  14.26    $722.55      $366.12      $144.51
            Musculoskeletal
            Procedures.
252......  Level II            ..................  T                  19.39    $982.48      $509.18      $196.50
            Musculoskeletal
            Procedures.
253......  Level III           ..................  T                  26.33  $1,334.13      $699.24      $266.83
            Musculoskeletal
            Procedures.
254......  Level IV            ..................  T                  34.37  $1,741.51      $937.11      $348.30
            Musculoskeletal
            Procedures.
261......  Level I Hand        ..................  T                  10.54    $534.06      $261.48      $106.81
            Musculoskeletal
            Procedures.
262......  Level II Hand       ..................  T                  18.35    $929.78      $480.82      $185.96
            Musculoskeletal
            Procedures.
271......  Level I Foot        ..................  T                  14.41    $730.15      $368.38      $146.03
            Musculoskeletal
            Procedures.
272......  Level II Foot       ..................  T                  16.56    $839.09      $409.74      $167.82
            Musculoskeletal
            Procedures.
276......  Bunion Procedures.  ..................  T                  19.19    $972.35      $500.14      $194.47
280......  Diagnostic          ..................  T                  22.20  $1,124.86      $581.72      $224.97
            Arthroscopy.
281......  Level I Surgical    ..................  T                  22.65  $1,147.66      $590.20      $229.53
            Arthroscopy.
282......  Level II Surgical   ..................  T                  23.94  $1,213.03      $614.04      $242.61
            Arthroscopy.
286......  Arthroscopically-   ..................  T                  26.76  $1,355.91      $802.41      $271.18
            Aided Procedures.
311......  Level I ENT         ..................  T                   1.43     $72.46       $20.57       $14.49
            Procedures.
312......  Level II ENT        ..................  T                   7.26    $367.86      $178.31       $73.57
            Procedures.
313......  Level III ENT       ..................  T                  15.81    $801.08      $411.09      $160.22
            Procedures.
314......  Level IV ENT        ..................  T                  25.65  $1,299.67      $693.37      $259.93
            Procedures.
*317.....  Implantation of     ..................  T              .........  .........  ...........  ...........
            Cochlear Device.
318......  Nasal               ..................  T                   2.07    $104.89       $38.65       $20.98
            Cauterization/
            Packing.
319......  Tonsil/Adenoid      ..................  T                  17.30    $876.58      $480.02      $175.32
            Procedures.
320......  Thoracentesis/      ..................  T                   3.17    $160.62       $79.33       $32.12
            Lavage Procedures.
331......  Level I Endoscopy   ..................  T                   0.69     $34.96       $14.01        $6.99
            Upper Airway.
332......  Level II Endoscopy  ..................  T                   9.74    $493.52      $244.98       $98.70
            Upper Airway.
333......  Level III           ..................  T                  17.24    $873.54      $464.20      $174.71
            Endoscopy Upper
            Airway.
336......  Endoscopy Lower     ..................  T                   7.44    $376.98      $197.98       $75.40
            Airway.
339......  Injection of        ..................  T                   1.02     $51.68       $19.66       $10.34
            Sclerosing
            Solution.
341......  Level I Needle and  ..................  T                   0.13      $6.59        $2.94        $1.32
            Catheter
            Placement.
342......  Level II Needle     ..................  T                   3.20    $162.14       $80.23       $32.43
            and Catheter
            Placement.
343......  Level III Needle    ..................  T                   9.52    $482.37      $224.87       $96.47
            and Catheter
            Placement.
346......  Placement           ..................  T                   4.83    $244.73      $120.23       $48.95
            Transvenous Caths/
            Cutdown.
347......  Injection           ..................  T                   2.93    $148.46       $62.15       $29.69
            Procedures for
            Interventional
            Radiology.
360......  Removal/Revision,   ..................  T                   6.09    $308.58      $140.12       $61.72
            Pacemaker/
            Vascular Device.
367......  Vascular Ligation.  ..................  T                  17.59    $891.28      $449.06      $178.26
368......   Vascular Repair/   ..................  T                  22.83  $1,156.78      $648.85      $231.36
            Fistula
            Construction.
369......  Blood and Blood     ..................  T                   4.33    $219.40       $97.18       $43.88
            Product Exchange.

[[Page 47617]]

396......  Lymph Node          ..................  T                  13.28    $672.89      $338.77      $134.58
            Excisions.
397......  Thyroid/            ..................  T                  18.36    $930.29      $496.86      $186.06
            Lymphadenectomy
            Procedures.
406......  Esophageal          ..................  T                   4.31    $218.39      $108.48       $43.68
            Dilation without
            Endoscopy.
407......  Esophagoscopy.....  ..................  T                   7.06    $357.73      $189.84       $71.55
417......  Diagnostic Upper    ..................  T                   6.44    $326.31      $181.70       $65.26
            GI Endoscopy.
418......  Therapeutic Upper   ..................  T                   7.59    $384.58      $214.25       $76.92
            GI Endoscopy.
419......  Small Intestine     ..................  T                   7.13    $361.27      $164.08       $72.25
            Endoscopy.
426......  Diagnostic Lower    ..................  T                   6.85    $347.09      $187.81       $69.42
            GI Endoscopy.
427......  Therapeutic Lower   ..................  T                   8.22    $416.50      $224.19       $83.30
            GI Endoscopy.
437......  Therapeutic         ..................  T                   2.91    $147.45       $76.61       $29.49
            Anoscopy.
446......  Diagnostic          ..................  T                   2.59    $131.23       $65.09       $26.25
            Sigmoidoscopy.
447......  Therapeutic         ..................  T                   6.87    $348.10      $184.76       $69.62
            Proctosigmoidosco
            py.
448......  Therapeutic         ..................  T                   5.37    $272.09      $141.25       $54.42
            Flexible
            Sigmoidoscopy.
449......  Complex GI          ..................  T                   7.80    $395.22      $215.38       $79.04
            Endoscopy.
451......  Level I Anal/       ..................  T                   2.56    $129.71       $54.24       $25.94
            Rectal Procedures.
452......  Level II Anal/      ..................  T                   4.82    $244.23      $109.61       $48.85
            Rectal Procedures.
453......  Level III Anal/     ..................  T                  16.87    $854.79      $445.22      $170.96
            Rectal Procedures.
456......  Endoscopic          ..................  T                   9.78    $495.55      $257.19       $99.11
            Retrograde
            Cholangio-
            Pancreatography
            (ERCP).
458......  Percutaneous        ..................  T                   7.23    $366.34      $181.59       $73.27
            Biliary
            Endoscopic
            Procedures.
459......  Peritoneal and      ..................  T                  18.06    $915.09      $496.52      $183.02
            Abdominal
            Procedures.
466......  Hernia/Hydrocele    ..................  T                  21.43  $1,085.85      $562.97      $217.17
            Procedures.
470......  Tube Procedures...  ..................  T                   2.22    $112.49       $54.92       $22.50
521......  Level I             ..................  T                   5.06    $256.39      $112.10       $51.28
            Cystourethroscopy
            and other
            Genitourinary
            Procedures.
522......  Level II            ..................  T                  10.46    $530.00      $262.39      $106.00
            Cystourethroscopy
            and other
            Genitourinary
            Procedures.
523......  Level III           ..................  T                  16.87    $854.79      $447.03      $170.96
            Cystourethroscopy
            and other
            Genitourinary
            Procedures.
524......  Level IV            ..................  T                  28.89  $1,463.84      $833.38      $292.77
            Cystourethroscopy
            and other
            Genitourinary
            Procedures.
527......  Lithotripsy.......  ..................  T                  51.56  $2,612.52    $1,372.95      $522.50
529......  Simple Urinary      ..................  T                   2.50    $126.67       $63.05       $25.33
            Studies and
            Procedures.
530......  Genitourinary       ..................  T                   2.52    $127.69       $54.69       $25.54
            Procedures.
531......  Level I Urethral    ..................  T                  18.94    $959.68      $527.26      $191.94
            Procedures.
532......  Level II Urethral   ..................  T                  25.50  $1,292.07      $602.18      $258.41
            Procedures.
536......  Circumcision......  ..................  T                  13.17    $667.32      $326.57      $133.46
537......  Penile Procedures.  ..................  T                  28.72  $1,455.23      $864.34      $291.05
538......  Insertion of        ..................  T                  45.59  $2,310.02    $1,540.64      $462.00
            Penile Prosthesis.
546......  Testes/Epididymis   ..................  T                  17.14    $868.47      $453.81      $173.69
            Procedures.
547......  Prostate Biopsy...  ..................  T                   4.39    $222.44      $125.20       $44.49
550......  Surgical            ..................  T                  16.89    $855.81      $447.93      $171.16
            Hysteroscopy.
551......  Level I             ..................  T                  24.78  $1,255.59      $711.67      $251.12
            Laparoscopy.
552......  Level II            ..................  T                  37.71  $1,910.75    $1,053.16      $382.15
            Laparoscopy.
561......  Level I Female      ..................  T                   1.52     $77.02       $24.63       $15.40
            Reproductive
            Procedures.
562......  Level II Female     ..................  T                  12.76    $646.54      $330.75      $129.31
            Reproductive
            Procedures.
563......  Level III Female    ..................  T                  16.90    $856.31      $464.88      $171.26
            Reproductive
            Procedures.
567......  D & C.............  ..................  T                  13.61    $689.61      $364.09      $137.92
568......  Infertility         ..................  T                   2.49    $126.17       $49.49       $25.23
            Procedures.
578......  Pregnancy and       ..................  T                   1.26     $63.84       $33.90       $12.77
            Neonatal Care
            Procedures.
580......  Vaginal Delivery..  ..................  T                   4.59    $232.57      $146.34       $46.51
586......  Therapeutic         ..................  T                  12.50    $633.37      $431.89      $126.67
            Abortion.
587......  Spontaneous         ..................  T                  13.25    $671.37      $347.02      $134.27
            Abortion.
600......  Spinal Tap........  ..................  T                   2.63    $133.26       $61.47       $26.65
601......  Level I Nervous     ..................  T                   3.11    $157.58       $74.13       $31.52
            System Injections.
602......  Level II Nervous    ..................  T                   3.33    $168.73       $87.69       $33.75
            System Injections.
616......  Implantation of     ..................  T                  14.43    $731.16      $366.57      $146.23
            Neurostimulator
            Electrodes.
617......  Revision/Removal    ..................  T                  11.56    $585.74      $287.59      $117.15
            Neurological
            Device.
618......  Implantation of     ..................  T                  25.56  $1,295.11      $780.49      $259.02
            Neurological
            Device.
631......  Level I Nerve       ..................  T                  12.98    $657.69      $333.80      $131.54
            Procedures.
632......  Level II Nerve      ..................  T                  18.13    $918.64      $461.04      $183.73
            Procedures.
648......  Laser Retinal       ..................  T                   3.94    $199.64       $95.15       $39.93
            Procedures.
649......  Laser Eye           ..................  T                   4.44    $224.97      $111.64       $44.99
            Procedures except
            Retinal.
651......  Level I Anterior    ..................  T                   7.24    $366.85      $174.70       $73.37
            Segment Eye
            Procedures.
652......  Level II Anterior   ..................  T                  16.48    $835.03      $433.69      $167.01
            Segment Eye
            Procedures.
667......  Cataract            ..................  T                  15.33    $776.40      $521.72      $155.28
            Procedures.
668......  Cataract            ..................  T                  19.28    $976.91      $530.87      $195.38
            Procedures with
            IOL Insert.
670......  Corneal Transplant  ..................  T                  29.23  $1,481.07      $847.50      $296.21
676......  Posterior Segment   ..................  T                   6.30    $319.22      $140.35       $63.84
            Eye Procedures.
677......  Strabismus/Muscle   ..................  T                  16.26    $823.89      $436.63      $164.78
            Procedures.
681......  Level I Eye         ..................  T                   1.67     $84.62       $30.51       $16.92
            Procedures.
682......  Level II Eye        ..................  T                   3.54    $179.37       $81.36       $35.87
            Procedures.
683......  Level III Eye       ..................  T                  10.19    $516.32      $257.87      $103.26
            Procedures.
684......  Level IV Eye        ..................  T                  13.48    $683.02      $348.94      $136.60
            Procedures.

[[Page 47618]]

690......  Vitrectomy........  ..................  T                  30.54  $1,547.45      $852.02      $309.49
700......  Plain Film........  ..................  X                   0.78     $39.52       $22.37        $7.90
706......  Miscellaneous       ..................  X                   1.96     $99.31       $57.63       $19.86
            Radiological
            Procedures.
710......  Computerized Axial  ..................  S                   5.06    $256.39      $176.28       $51.28
            Tomography.
716......  Fluoroscopy.......  ..................  X                   1.59     $80.56       $47.91       $16.11
720......  Magnetic Resonance  ..................  S                   6.34    $321.24      $206.11       $64.25
            Angiography.
726......  Magnetic Resonance  ..................  S                   7.96    $403.33      $258.09       $80.67
            Imaging.
728......  Myelography.......  ..................  S                   4.07    $206.22      $113.23       $41.24
730......  Arthography.......  ..................  S                   2.48    $125.66       $72.09       $25.13
736......  Digestive           ..................  S                   1.85     $93.74       $54.24       $18.75
            Radiology.
737......  Diagnostic          ..................  S                   2.81    $142.38       $86.56       $28.48
            Urography.
738......  Therapeutic         ..................  S                   4.48    $227.00      $133.23       $45.40
            Radiologic
            Procedures.
739......  Diagnostic          ..................  S                   5.83    $295.40      $168.71       $59.08
            Angiography and
            Venography.
746......  Mammography.......  ..................  S                   0.69     $34.96       $19.44        $6.99
747......  Diagnostic          ..................  S                   1.65     $83.60       $54.69       $16.72
            Ultrasound Except
            Vascular.
749......  Guidance under      ..................  X                   2.44    $123.63       $76.16       $24.73
            Ultrasound.
750......  Therapeutic         ..................  X                   0.91     $46.11       $25.54        $9.22
            Radiation
            Treatment
            Planning.
751......  Level I             ..................  X                   1.15     $58.27       $33.22       $11.65
            Therapeutic
            Radiation
            Treatment
            Preparation.
752......  Level II            ..................  X                   3.54    $179.37       $88.82       $35.87
            Therapeutic
            Radiation
            Treatment
            Preparation.
757......  Radiation Therapy.  ..................  S                   2.30    $116.54       $52.43       $23.31
758......  Hyperthermic        ..................  S                   3.41    $172.78       $76.84       $34.56
            Therapies.
759......  Brachytherapy and   ..................  S                   7.98    $404.34      $160.01       $80.87
            Complex
            Radioelement
            Applications.
760......  PET Scans.........  ..................  S                  17.26    $874.55      $419.46      $174.91
*761.....  Standard Non-       ..................  S                   2.04    $103.37       $61.47       $20.67
            Imaging Nuclear
            Medicine.
*762.....  Complex Non-        ..................  S                   1.78     $90.19       $51.53       $18.04
            Imaging Nuclear
            Medicine.
771......  Standard Planar     ..................  S                   3.78    $191.53      $116.84       $38.31
            Nuclear Medicine.
772......  Complex Planar      ..................  S                   4.22    $213.83      $127.92       $42.77
            Nuclear Medicine.
781......  Standard SPECT      ..................  S                   5.26    $266.52      $145.77       $53.30
            Nuclear Medicine.
782......  Complex SPECT       ..................  S                   9.28    $470.21      $275.04       $94.04
            Nuclear Medicine.
*791.....  Standard            ..................  S                  15.83    $802.10      $562.06      $160.42
            Therapeutic
            Nuclear Medicine.
*792.....  Complex             ..................  S                   4.80    $243.21      $144.19       $48.64
            Therapeutic
            Nuclear Medicine.
861......  Immunology Tests..  ..................  X                   0.13      $6.59        $3.62        $1.32
881......  Level I Pathology.  ..................  X                   0.20     $10.13        $6.78        $2.03
882......  Level II Pathology  ..................  X                   0.39     $19.76       $11.75        $3.95
883......  Level III           ..................  X                   0.65     $32.94       $20.34        $6.59
            Pathology.
900......  Critical Care.....  ..................  V                   7.44    $376.98      $144.87       $75.40
901......  Level I             ..................  X                   0.07      $3.55        $2.49        $0.71
            Immunization.
*902.....  Level II            ..................  X                   1.78     $90.19       $41.47       $18.04
            Immunization.
*903.....  Level III           ..................  X                   1.16     $58.78       $25.65       $11.76
            Immunization.
906......  Infusion Therapy    ..................  X                   1.46     $73.98       $42.49       $14.80
            except
            Chemotherapy.
907......  Intramuscular       ..................  X                   0.85     $43.07       $11.98        $8.61
            Injections.
+91111...  Low Level Clinic    Well care and       V                   1.06     $53.71       $12.66       $10.74
            Visits.             administrative.
91118....  Low Level Clinic    Skin and breast     V                   0.83     $42.06        $9.27        $8.41
            Visits.             diseases.
91124....  Low Level Clinic    Musculoskeletal     V                   0.87     $44.08        $9.49        $8.82
            Visits.             diseases.
91131....  Low Level Clinic    Ear, nose, mouth    V                   0.81     $41.04        $9.04        $8.21
            Visits.             and throat
                                diseases.
91133....  Low Level Clinic    Respiratory system  V                   0.80     $40.54        $8.59        $8.11
            Visits.             diseases.
91136....  Low Level Clinic    Cardiovascular      V                   0.85     $43.07        $8.61        $8.61
            Visits.             system diseases.
91141....  Low Level Clinic    Digestive system    V                   0.98     $49.66       $10.40        $9.93
            Visits.             diseases.
91153....  Low Level Clinic    Kidney, urinary     V                   0.91     $46.11        $9.27        $9.22
            Visits.             tract and male
                                genital diseases.
91156....  Low Level Clinic    Female genital      V                   0.93     $47.12        $9.42        $9.42
            Visits.             system diseases.
*91157...  Low Level Clinic    Pregnancy and       V                   1.33     $67.39       $14.46       $13.48
            Visits.             neonatal care.
91163....  Low Level Clinic    Nervous system      V                   0.98     $49.66       $10.17        $9.93
            Visits.             diseases.
*91168...  Low Level Clinic    Eye diseases......  V                   0.98     $49.66       $10.62        $9.93
            Visits.
*91172...  Low Level Clinic    Trauma and          V                   1.06     $53.71       $14.24       $10.74
            Visits.             poisoning.
*91178...  Low Level Clinic    Major signs,        V                   1.52     $77.02       $21.58       $15.40
            Visits.             symptoms and
                                findings.
91182....  Low Level Clinic    Endocrine,          V                   0.87     $44.08        $9.04        $8.82
            Visits.             nutritional and
                                metabolic
                                diseases.
*91186...  Low Level Clinic    Immunologic and     V                   1.09     $55.23       $11.30       $11.05
            Visits.             hematologic
                                diseases.
91188....  Low Level Clinic    Malignancy........  V                   0.72     $36.48        $8.14        $7.30
            Visits.
+91191...  Low Level Clinic    Psychiatric         V                   1.09     $55.23       $14.01       $11.05
            Visits.             disorders.
91197....  Low Level Clinic    Infectious disease  V                   1.02     $51.68       $11.53       $10.34
            Visits.
+91199...  Low Level Clinic    Unknown cause of    V                   1.31     $66.38       $20.79       $13.28
            Visits.             mortality.
+91311...  Mid Level Clinic    Well care and       V                   1.06     $53.71       $12.66       $10.74
            Visits.             administrative.
91318....  Mid Level Clinic    Skin and breast     V                   0.98     $49.66        $9.93        $9.93
            Visits.             diseases.
91324....  Mid Level Clinic    Musculoskeletal     V                   0.98     $49.66        $9.93        $9.93
            Visits.             diseases.
91331....  Mid Level Clinic    Ear, nose, mouth    V                   0.94     $47.63        $9.53        $9.53
            Visits.             and throat
                                diseases.
91333....  Mid Level Clinic    Respiratory system  V                   0.93     $47.12        $9.42        $9.42
            Visits.             diseases.
91336....  Mid Level Clinic    Cardiovascular      V                   1.00     $50.67       $10.13       $10.13
            Visits.             system diseases.
91341....  Mid Level Clinic    Digestive system    V                   1.00     $50.67       $10.13       $10.13
            Visits.             diseases.
91353....  Mid Level Clinic    Kidney, urinary     V                   1.04     $52.70       $10.54       $10.54
            Visits.             tract and male
                                genital diseases.

[[Page 47619]]

91356....  Mid Level Clinic    Female genital      V                   1.06     $53.71       $10.74       $10.74
            Visits.             system diseases.
*91357...  Mid Level Clinic    Pregnancy and       V                   1.22     $61.82       $12.66       $12.36
            Visits.             neonatal care.
91363....  Mid Level Clinic    Nervous system      V                   1.04     $52.70       $10.54       $10.54
            Visits.             diseases.
*91368...  Mid Level Clinic    Eye diseases......  V                   0.87     $44.08        $8.82        $8.82
            Visits.
*91372...  Mid Level Clinic    Trauma and          V                   1.06     $53.71       $10.85       $10.74
            Visits.             poisoning.
*91378...  Mid Level Clinic    Major signs,        V                   1.13     $57.26       $11.45       $11.45
            Visits.             symptoms and
                                findings.
91382....  Mid Level Clinic    Endocrine,          V                   1.00     $50.67       $10.13       $10.13
            Visits.             nutritional and
                                metabolic
                                diseases.
*91386...  Mid Level Clinic    Immunologic and     V                   1.04     $52.70       $10.54       $10.54
            Visits.             hematologic
                                diseases.
91388....  Mid Level Clinic    Malignancy........  V                   0.83     $42.06        $8.41        $8.41
            Visits.
+91391...  Mid Level Clinic    Psychiatric         V                   1.09     $55.23       $14.01       $11.05
            Visits.             disorders.
91397....  Mid Level Clinic    Infectious disease  V                   1.06     $53.71       $10.74       $10.74
            Visits.
+91399...  Mid Level Clinic    Unknown cause of    V                   1.31     $66.38       $20.79       $13.28
            Visits.             mortality.
+91511...  High Level Clinic   Well care and       V                   1.06     $53.71       $12.66       $10.74
            Visits.             administrative.
91518....  High Level Clinic   Skin and breast     V                   1.69     $85.63       $19.21       $17.13
            Visits.             diseases.
91524....  High Level Clinic   Musculoskeletal     V                   1.37     $69.42       $15.37       $13.88
            Visits.             diseases.
91531....  High Level Clinic   Ear, nose, mouth    V                   1.31     $66.38       $14.92       $13.28
            Visits.             and throat
                                diseases.
91533....  High Level Clinic   Respiratory system  V                   1.33     $67.39       $13.79       $13.48
            Visits.             diseases.
91536....  High Level Clinic   Cardiovascular      V                   1.43     $72.46       $15.37       $14.49
            Visits.             system diseases.
91541....  High Level Clinic   Digestive system    V                   1.50     $76.00       $16.05       $15.20
            Visits.             diseases.
91553....  High Level Clinic   Kidney, urinary     V                   1.30     $65.87       $14.01       $13.17
            Visits.             tract and male
                                genital diseases.
91556....  High Level Clinic   Female genital      V                   1.43     $72.46       $14.49       $14.49
            Visits.             system diseases.
91557....  High Level Clinic   Pregnancy and       V                   1.81     $91.71       $22.15       $18.34
            Visits.             neonatal care.
91563....  High Level Clinic   Nervous system      V                   1.50     $76.00       $16.72       $15.20
            Visits.             diseases.
91568....  High Level Clinic   Eye diseases......  V                   1.31     $66.38       $13.79       $13.28
            Visits.
91572....  High Level Clinic   Trauma and          V                   1.69     $85.63       $22.15       $17.13
            Visits.             poisoning.
91578....  High Level Clinic   Major signs,        V                   1.89     $95.77       $29.15       $19.15
            Visits.             symptoms and
                                findings.
91582....  High Level Clinic   Endocrine,          V                   1.41     $71.44       $15.14       $14.29
            Visits.             nutritional and
                                metabolic
                                diseases.
91586....  High Level Clinic   Immunologic and     V                   1.65     $83.60       $18.98       $16.72
            Visits.             hematologic
                                diseases.
91588....  High Level Clinic   Malignancy........  V                   1.09     $55.23       $12.43       $11.05
            Visits.
91591....  High Level Clinic   Psychiatric         V                   1.57     $79.55       $21.92       $15.91
            Visits.             disorders.
91597....  High Level Clinic   Infectious disease  V                   1.76     $89.18       $19.66       $17.84
            Visits.
+91599...  High Level Clinic   Unknown cause of    V                   1.31     $66.38       $20.79       $13.28
            Visits.             mortality.
919......  Electroconvulsive   ..................  S                   3.17    $160.62       $80.00       $32.12
            Therapy.
920......  Biofeedback and     ..................  S                   1.17     $59.28       $29.61       $11.86
            other Training.
*921.....  Diabetes Education  ..................  S              .........  .........  ...........  ...........
926......  Dialysis for other  ..................  S                   4.28    $216.87       $69.83       $43.37
            than ESRD
            patients.
928......  Alimentary Tests..  ..................  X                   3.11    $157.58       $83.85       $31.52
930......  Minor Eye           ..................  X                   1.02     $51.68       $22.83       $10.34
            Examinations.
931......  Level I Eye Tests.  ..................  X                   0.74     $37.50       $21.47        $7.50
932......  Level II Eye Tests  ..................  X                   2.52    $127.69       $65.09       $25.54
936......  Fitting of Vision   ..................  X                   0.52     $26.35        $9.49        $5.27
            Aids.
940......  Otorhinolaryngolog  ..................  X                   3.04    $154.04       $51.98       $30.81
            ic Function Tests.
941......  Level I Audiometry  ..................  X                   0.74     $37.50       $13.56        $7.50
942......  Level II            ..................  X                   1.48     $74.99       $22.15       $15.00
            Audiometry.
947......  Resuscitation and   ..................  S                   4.07    $206.22      $109.61       $41.24
            Cardioversion.
948......  Cardiac             ..................  X                   0.81     $41.04       $16.95        $8.21
            Rehabilitation.
949......  Cardiovascular      ..................  X                   1.46     $73.98       $62.83       $14.80
            Stress Test.
950......  Electrocardiogram   ..................  X                   0.35     $17.73       $15.82        $3.55
            (ECG).
+95111...  Low Level ER        Well care and       V                   1.06     $53.71       $12.66       $10.74
            Visits.             administrative.
95118....  Low Level ER        Skin and breast     V                   1.17     $59.28       $19.21       $11.86
            Visits.             diseases.
95124....  Low Level ER        Musculoskeletal     V                   1.17     $59.28       $19.89       $11.86
            Visits.             diseases.
95131....  Low Level ER        Ear, nose, mouth    V                   1.11     $56.24       $17.63       $11.25
            Visits.             and throat
                                diseases.
95133....  Low Level ER        Respiratory system  V                   1.15     $58.27       $18.31       $11.65
            Visits.             diseases.
95136....  Low Level ER        Cardiovascular      V                   1.24     $62.83       $19.89       $12.57
            Visits.             system diseases.
95141....  Low Level ER        Digestive system    V                   1.30     $65.87       $21.02       $13.17
            Visits.             diseases.
95153....  Low Level ER        Kidney, urinary     V                   1.43     $72.46       $24.41       $14.49
            Visits.             tract and male
                                genital diseases.
95156....  Low Level ER        Female genital      V                   1.41     $71.44       $23.73       $14.29
            Visits.             system diseases.
95157....  Low Level ER        Pregnancy and       V                   1.44     $72.96       $24.18       $14.59
            Visits.             neonatal care.
95163....  Low Level ER        Nervous system      V                   1.31     $66.38       $22.83       $13.28
            Visits.             diseases.
95168....  Low Level ER        Eye diseases......  V                   1.20     $60.80       $20.79       $12.16
            Visits.
95172....  Low Level ER        Trauma and          V                   1.28     $64.86       $22.15       $12.97
            Visits.             poisoning.
95178....  Low Level ER        Major signs,        V                   2.02    $102.35       $37.97       $20.47
            Visits.             symptoms and
                                findings.
95182....  Low Level ER        Endocrine,          V                   1.50     $76.00       $24.63       $15.20
            Visits.             nutritional and
                                metabolic
                                diseases.
95186....  Low Level ER        Immunologic and     V                   1.43     $72.46       $25.76       $14.49
            Visits.             hematologic
                                diseases.
95188....  Low Level ER        Malignancy........  V                   1.52     $77.02       $26.44       $15.40
            Visits.
95191....  Low Level ER        Psychiatric         V                   1.09     $55.23       $14.01       $11.05
            Visits.             Disorders.
95197....  Low Level ER        Infectious disease  V                   1.24     $62.83       $20.57       $12.57
            Visits.
+95199...  Low Level ER        Unknown cause of    V                   1.31     $66.38       $20.79       $13.28
            Visits.             mortality.
+95311...  Mid Level ER        Well care and       V                   1.06     $53.71       $12.66       $10.74
            Visits.             administrative.
95318....  Mid Level ER        Skin and breast     V                   1.89     $95.77       $34.80       $19.15
            Visits.             diseases.

[[Page 47620]]

95324....  Mid Level ER        Musculoskeletal     V                   1.78     $90.19       $32.32       $18.04
            Visits.             diseases.
95331....  Mid Level ER        Ear, nose, mouth    V                   1.81     $91.71       $31.64       $18.34
            Visits.             and throat
                                diseases.
95333....  Mid Level ER        Respiratory system  V                   1.91     $96.78       $33.67       $19.36
            Visits.             diseases.
95336....  Mid Level ER        Cardiovascular      V                   2.02    $102.35       $36.16       $20.47
            Visits.             system diseases.
95341....  Mid Level ER        Digestive system    V                   2.02    $102.35       $36.61       $20.47
            Visits.             diseases.
95353....  Mid Level ER        Kidney, urinary     V                   2.06    $104.38       $38.19       $20.88
            Visits.             tract and male
                                genital diseases.
95356....  Mid Level ER        Female genital      V                   2.04    $103.37       $36.61       $20.67
            Visits.             system diseases.
95357....  Mid Level ER        Pregnancy and       V                   2.06    $104.38       $39.78       $20.88
            Visits.             neonatal care.
95363....  Mid Level ER        Nervous system      V                   2.00    $101.34       $37.29       $20.27
            Visits.             diseases.
95368....  Mid Level ER        Eye diseases......  V                   1.69     $85.63       $33.00       $17.13
            Visits.
95372....  Mid Level ER        Trauma and          V                   2.02    $102.35       $38.87       $20.47
            Visits.             poisoning.
95378....  Mid Level ER        Major signs,        V                   3.07    $155.56       $58.76       $31.11
            Visits.             symptoms and
                                findings.
95382....  Mid Level ER        Endocrine,          V                   2.30    $116.54       $43.62       $23.31
            Visits.             nutritional and
                                metabolic
                                diseases.
95386....  Mid Level ER        Immunologic and     V                   2.39    $121.10       $47.01       $24.22
            Visits.             hematologic
                                diseases.
95388....  Mid Level ER        Malignancy........  V                   2.15    $108.94       $41.13       $21.79
            Visits.
95391....  Mid Level ER        Psychiatric         V                   2.00    $101.34       $35.93       $20.27
            Visits.             Disorders.
95397....  Mid Level ER        Infectious disease  V                   1.98    $100.33       $36.61       $20.07
            Visits.
+95399...  Mid Level ER        Unknown cause of    V                   1.31     $66.38       $20.79       $13.28
            Visits.             mortality.
+95511...  High Level ER       Well care and       V                   1.06     $53.71       $12.66       $10.74
            Visits.             administrative.
95518....  High Level ER       Skin and breast     V                   2.61    $132.25       $46.56       $26.45
            Visits.             diseases.
95524....  High Level ER       Musculoskeletal     V                   2.44    $123.63       $41.36       $24.73
            Visits.             diseases.
95531....  High Level ER       Ear, nose, mouth    V                   2.56    $129.71       $44.07       $25.94
            Visits.             and throat
                                diseases.
95533....  High Level ER       Respiratory system  V                   3.19    $161.64       $54.69       $32.33
            Visits.             diseases.
95536....  High Level ER       Cardiovascular      V                   3.17    $160.62       $54.69       $32.12
            Visits.             system diseases.
95541....  High Level ER       Digestive system    V                   2.89    $146.43       $54.69       $29.29
            Visits.             diseases.
95553....  High Level ER       Kidney, urinary     V                   2.89    $146.43       $54.69       $29.29
            Visits.             tract and male
                                genital diseases.
95556....  High Level ER       Female genital      V                   2.73    $138.33       $50.85       $27.67
            Visits.             system diseases.
95557....  High Level ER       Pregnancy and       V                   2.93    $148.46       $54.92       $29.69
            Visits.             neonatal care.
95563....  High Level ER       Nervous system      V                   3.04    $154.04       $58.08       $30.81
            Visits.             diseases.
95568....  High Level ER       Eye diseases......  V                   2.31    $117.05       $40.00       $23.41
            Visits.
95572....  High Level ER       Trauma and          V                   2.74    $138.83       $50.17       $27.77
            Visits.             poisoning.
95578....  High Level ER       Major signs,        V                   6.85    $347.09      $148.48       $69.42
            Visits.             symptoms and
                                findings.
95582....  High Level ER       Endocrine,          V                   3.28    $166.20       $64.64       $33.24
            Visits.             nutritional and
                                metabolic
                                diseases.
95586....  High Level ER       Immunologic and     V                   3.70    $187.48       $74.35       $37.50
            Visits.             hematologic
                                diseases.
95588....  High Level ER       Malignancy........  V                   3.67    $185.96       $61.70       $37.19
            Visits.
95591....  High Level ER       Psychiatric         V                   3.48    $176.33       $62.38       $35.27
            Visits.             Disorders.
95597....  High Level ER       Infectious disease  V                   2.81    $142.38       $53.34       $28.48
            Visits.
+95599...  High Level ER       Unknown cause of    V                   1.31     $66.38       $20.79       $13.28
            Visits.             mortality.
956......  Continuous ECG and  ..................  X                   1.11     $56.24       $55.82       $11.25
            Blood Pressure
            Monitoring.
957......  Echocardiography..  ..................  S                   2.83    $143.39      $117.07       $28.68
958......  Diagnostic Cardiac  ..................  T                  26.11  $1,322.98      $659.47      $264.60
            Catheterization.
960......  Cardiac             ..................  S                   4.24    $214.84      $144.41       $42.97
            Electrophysiologi
            c Tests/
            Procedures.
966......  Electronic          ..................  X                   0.39     $19.76       $12.43        $3.95
            Analysis of
            Pacemakers/other
            Devices.
967......  Non-Invasive        ..................  X                   1.70     $86.14       $57.40       $17.23
            Vascular Studies.
968......  Vascular            ..................  X                   2.37    $120.09       $79.55       $24.02
            Ultrasound.
969......  Hyperbaric Oxygen.  ..................  S                   2.65    $134.27      $141.70       $26.85
971......  Level I Pulmonary   ..................  X                   0.78     $39.52       $21.47        $7.90
            Tests.
972......  Level II Pulmonary  ..................  X                   1.02     $51.68       $29.38       $10.34
            Tests.
973......  Level III           ..................  S                   1.89     $95.77       $55.82       $19.15
            Pulmonary Tests.
976......  Pulmonary Therapy.  ..................  S                   0.44     $22.29       $14.92        $4.46
977......  Allergy Tests.....  ..................  X                   0.63     $31.92       $12.66        $6.38
978......  Allergy Injections  ..................  X                   0.31     $15.71        $3.39        $3.14
979......  Extended EEG        ..................  S                  10.17    $515.31      $288.83      $103.06
            Studies and Sleep
            Studies.
980......  Electroencephalogr  ..................  S                   2.15    $108.94       $57.86       $21.79
            am.
*981.....  Level I Nerve and   ..................  X                   1.46     $73.98       $41.81       $14.80
            Muscle Tests.
*982.....  Level II Nerve and  ..................  X                   1.39     $70.43       $38.87       $14.09
            Muscle Tests.
987......  Subcutaneous or     ..................  S                   0.65     $32.94       $13.33        $6.59
            Intramuscular
            Chemotherapy.
988......  Chemotherapy        ..................  S                   4.15    $210.28       $97.52       $42.06
            except by
            Extended Infusion.
989......  Chemotherapy by     ..................  S                   1.72     $87.15       $40.68       $17.43
            Extended Infusion.
990......  Photochemotherapy.  ..................  S                   0.43     $21.79        $8.14        $4.36
997......  Manipulation        ..................  S                   0.69     $34.96        $7.23        $6.99
            Therapy.
999......  Therapeutic         ..................  X                   0.43     $21.79       $10.85        $4.36
            Phlebotomy.
----------------------------------------------------------------------------------------------------------------

          

  

  


[[Page 47621]]



Addendum B.--Proposed Hospital Outpatient Department (HOPD) Payment Status by HCPCS Code and Related Information
----------------------------------------------------------------------------------------------------------------
                                                                              Proposed    National     Minimum
CPT \1\/      HOPD status           Description         Proposed   Relative   payment    unadjusted   unadjusted
  HCPCS        indicator                                  APC       weight      rate    coinsurance  coinsurance
---\2\----------------------------------------------------------------------------------------------------------
00100...  N                   Anesth, skin surgery...  .........  .........  .........  ...........  ...........
00102...  N                   Anesth, repair of cleft  .........  .........  .........  ...........  ...........
                               lip.
00103...  N                   Anesth, blepharoplasty.  .........  .........  .........  ...........  ...........
00104...  N                   Anesth for electroshock  .........  .........  .........  ...........  ...........
00120...  N                   Anesthesia for ear       .........  .........  .........  ...........  ...........
                               surgery.
00124...  N                   Anesthesia for ear exam  .........  .........  .........  ...........  ...........
00126...  N                   Anesth, tympanotomy....  .........  .........  .........  ...........  ...........
00140...  N                   Anesth, procedures on    .........  .........  .........  ...........  ...........
                               eye.
00142...  N                   Anesthesia for lens      .........  .........  .........  ...........  ...........
                               surgery.
00144...  N                   Anesth, corneal          .........  .........  .........  ...........  ...........
                               transplant.
00145...  N                   Anesth, vitrectomy.....  .........  .........  .........  ...........  ...........
00147...  N                   Anesth, iridectomy.....  .........  .........  .........  ...........  ...........
00148...  N                   Anesthesia for eye exam  .........  .........  .........  ...........  ...........
00160...  N                   Anesth, nose, sinus      .........  .........  .........  ...........  ...........
                               surgery.
00162...  N                   Anesth, nose, sinus      .........  .........  .........  ...........  ...........
                               surgery.
00164...  N                   Anesth, biopsy of nose.  .........  .........  .........  ...........  ...........
00170...  N                   Anesth, procedure on     .........  .........  .........  ...........  ...........
                               mouth.
00172...  N                   Anesth, cleft palate     .........  .........  .........  ...........  ...........
                               repair.
00174...  C                   Anesth, pharyngeal       .........  .........  .........  ...........  ...........
                               surgery.
00176...  C                   Anesth, pharyngeal       .........  .........  .........  ...........  ...........
                               surgery.
00190...  N                   Anesth, facial bone      .........  .........  .........  ...........  ...........
                               surgery.
00192...  C                   Anesth, facial bone      .........  .........  .........  ...........  ...........
                               surgery.
00210...  N                   Anesth, open head        .........  .........  .........  ...........  ...........
                               surgery.
00212...  N                   Anesth, skull drainage.  .........  .........  .........  ...........  ...........
00214...  C                   Anesth, skull drainage.  .........  .........  .........  ...........  ...........
00215...  C                   Anesth, skull fracture.  .........  .........  .........  ...........  ...........
00216...  N                   Anesth, head vessel      .........  .........  .........  ...........  ...........
                               surgery.
00218...  N                   Anesth, special head     .........  .........  .........  ...........  ...........
                               surgery.
00220...  N                   Anesth, spinal fluid     .........  .........  .........  ...........  ...........
                               shunt.
00222...  N                   Anesth, head nerve       .........  .........  .........  ...........  ...........
                               surgery.
00300...  N                   Anesth, skin surgery,    .........  .........  .........  ...........  ...........
                               neck.
00320...  N                   Anesth, neck organ       .........  .........  .........  ...........  ...........
                               surgery.
00322...  N                   Anesth, biopsy of        .........  .........  .........  ...........  ...........
                               thyroid.
00350...  N                   Anesth, neck vessel      .........  .........  .........  ...........  ...........
                               surgery.
00352...  N                   Anesth, neck vessel      .........  .........  .........  ...........  ...........
                               surgery.
00400...  N                   Anesth, chest skin       .........  .........  .........  ...........  ...........
                               surgery.
00402...  N                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               breast.
00404...  C                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               breast.
00406...  C                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               breast.
00410...  N                   Anesth, correct heart    .........  .........  .........  ...........  ...........
                               rhythm.
00420...  N                   Anesth, skin surgery,    .........  .........  .........  ...........  ...........
                               back.
00450...  N                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               shoulder.
00452...  C                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               shoulder.
00454...  N                   Anesth, collarbone       .........  .........  .........  ...........  ...........
                               biopsy.
00470...  N                   Anesth, removal of rib.  .........  .........  .........  ...........  ...........
00472...  N                   Anesth, chest wall       .........  .........  .........  ...........  ...........
                               repair.
00474...  C                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               rib(s).
00500...  N                   Anesth, esophageal       .........  .........  .........  ...........  ...........
                               surgery.
00520...  N                   Anesth, chest procedure  .........  .........  .........  ...........  ...........
00522...  N                   Anesth, chest lining     .........  .........  .........  ...........  ...........
                               biopsy.
00524...  C                   Anesth, chest drainage.  .........  .........  .........  ...........  ...........
00528...  N                   Anesth, chest partition  .........  .........  .........  ...........  ...........
                               view.
00530...  C                   Anesth, pacemaker        .........  .........  .........  ...........  ...........
                               insertion.
00532...  N                   Anesth, vascular access  .........  .........  .........  ...........  ...........
00534...  N                   Anesth, cardioverter/    .........  .........  .........  ...........  ...........
                               defib.
00540...  C                   Anesth, chest surgery..  .........  .........  .........  ...........  ...........
00542...  C                   Anesth, release of lung  .........  .........  .........  ...........  ...........
00544...  C                   Anesth, chest lining     .........  .........  .........  ...........  ...........
                               removal.
00546...  C                   Anesth, lung,chest wall  .........  .........  .........  ...........  ...........
                               surg.
00548...  N                   Anesth, trachea,bronchi  .........  .........  .........  ...........  ...........
                               surg.
00560...  C                   Anesth, open heart       .........  .........  .........  ...........  ...........
                               surgery.
00562...  C                   Anesth, open heart       .........  .........  .........  ...........  ...........
                               surgery.
00580...  C                   Anesth,heart/lung        .........  .........  .........  ...........  ...........
                               transplant.
00600...  N                   Anesth, spine, cord      .........  .........  .........  ...........  ...........
                               surgery.
00604...  C                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               vertebra.
00620...  N                   Anesth, spine, cord      .........  .........  .........  ...........  ...........
                               surgery.
00622...  C                   Anesth, removal of       .........  .........  .........  ...........  ...........
                               nerves.
00630...  N                   Anesth, spine, cord      .........  .........  .........  ...........  ...........
                               surgery.
00632...  C                   Anesth, removal of       .........  .........  .........  ...........  ...........
                               nerves.
00634...  C                   Anesth for               .........  .........  .........  ...........  ...........
                               chemonucleolysis.
00670...  C                   Anesth, spine, cord      .........  .........  .........  ...........  ...........
                               surgery.
00700...  N                   Anesth, abdominal wall   .........  .........  .........  ...........  ...........
                               surg.
00702...  N                   Anesth, for liver        .........  .........  .........  ...........  ...........
                               biopsy.
00730...  N                   Anesth, abdominal wall   .........  .........  .........  ...........  ...........
                               surg.
00740...  N                   Anesth, gi               .........  .........  .........  ...........  ...........
                               visualization.

[[Page 47622]]

00750...  N                   Anesth, repair of        .........  .........  .........  ...........  ...........
                               hernia.
00752...  N                   Anesth, repair of        .........  .........  .........  ...........  ...........
                               hernia.
00754...  N                   Anesth, repair of        .........  .........  .........  ...........  ...........
                               hernia.
00756...  N                   Anesth, repair of        .........  .........  .........  ...........  ...........
                               hernia.
00770...  N                   Anesth, blood vessel     .........  .........  .........  ...........  ...........
                               repair.
00790...  N                   Anesth, surg upper       .........  .........  .........  ...........  ...........
                               abdomen.
00792...  C                   Anesth, part liver       .........  .........  .........  ...........  ...........
                               removal.
00794...  C                   Anesth, pancreas         .........  .........  .........  ...........  ...........
                               removal.
00796...  C                   Anesth, for liver        .........  .........  .........  ...........  ...........
                               transplant.
00800...  N                   Anesth, abdominal wall   .........  .........  .........  ...........  ...........
                               surg.
00802...  C                   Anesth, fat layer        .........  .........  .........  ...........  ...........
                               removal.
00810...  N                   Anesth, intestine        .........  .........  .........  ...........  ...........
                               endoscopy.
00820...  N                   Anesth, abdominal wall   .........  .........  .........  ...........  ...........
                               surg.
00830...  N                   Anesth, repair of        .........  .........  .........  ...........  ...........
                               hernia.
00832...  N                   Anesth, repair of        .........  .........  .........  ...........  ...........
                               hernia.
00840...  N                   Anesth, surg lower       .........  .........  .........  ...........  ...........
                               abdomen.
00842...  N                   Anesth, amniocentesis..  .........  .........  .........  ...........  ...........
00844...  C                   Anesth, pelvis surgery.  .........  .........  .........  ...........  ...........
00846...  C                   Anesth, hysterectomy...  .........  .........  .........  ...........  ...........
00848...  C                   Anesth, pelvic organ     .........  .........  .........  ...........  ...........
                               surg.
00850...  C                   Anesth, cesarean         .........  .........  .........  ...........  ...........
                               section.
00855...  C                   Anesth, hysterectomy...  .........  .........  .........  ...........  ...........
00857...  C                   Analgesia, labor & c-    .........  .........  .........  ...........  ...........
                               section.
00860...  N                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               abdomen.
00862...  N                   Anesth, kidney, ureter   .........  .........  .........  ...........  ...........
                               surg.
00864...  C                   Anesth, removal of       .........  .........  .........  ...........  ...........
                               bladder.
00865...  C                   Anesth, removal of       .........  .........  .........  ...........  ...........
                               prostate.
00866...  C                   Anesth, removal of       .........  .........  .........  ...........  ...........
                               adrenal.
00868...  C                   Anesth, kidney           .........  .........  .........  ...........  ...........
                               transplant.
00870...  N                   Anesth, bladder stone    .........  .........  .........  ...........  ...........
                               surg.
00872...  N                   Anesth,kidney stone      .........  .........  .........  ...........  ...........
                               destruct.
00873...  N                   Anesth,kidney stone      .........  .........  .........  ...........  ...........
                               destruct.
00880...  N                   Anesth, abdomen vessel   .........  .........  .........  ...........  ...........
                               surg.
00882...  C                   Anesth, major vein       .........  .........  .........  ...........  ...........
                               ligation.
00884...  C                   Anesth, major vein       .........  .........  .........  ...........  ...........
                               revision.
00900...  N                   Anesth, perineal         .........  .........  .........  ...........  ...........
                               procedure.
00902...  N                   Anesth, anorectal        .........  .........  .........  ...........  ...........
                               surgery.
00904...  C                   Anesth, perineal         .........  .........  .........  ...........  ...........
                               surgery.
00906...  N                   Anesth, removal of       .........  .........  .........  ...........  ...........
                               vulva.
00908...  C                   Anesth, removal of       .........  .........  .........  ...........  ...........
                               prostate.
00910...  N                   Anesth, bladder surgery  .........  .........  .........  ...........  ...........
00912...  N                   Anesth, bladder tumor    .........  .........  .........  ...........  ...........
                               surg.
00914...  N                   Anesth, removal of       .........  .........  .........  ...........  ...........
                               prostate.
00916...  N                   Anesth, bleeding         .........  .........  .........  ...........  ...........
                               control.
00918...  N                   Anesth, stone removal..  .........  .........  .........  ...........  ...........
00920...  N                   Anesth, genitalia        .........  .........  .........  ...........  ...........
                               surgery.
00922...  N                   Anesth, sperm duct       .........  .........  .........  ...........  ...........
                               surgery.
00924...  N                   Anesth, testis           .........  .........  .........  ...........  ...........
                               exploration.
00926...  N                   Anesth, removal of       .........  .........  .........  ...........  ...........
                               testis.
00928...  C                   Anesth, removal of       .........  .........  .........  ...........  ...........
                               testis.
00930...  N                   Anesth, testis           .........  .........  .........  ...........  ...........
                               suspension.
00932...  C                   Anesth, amputation of    .........  .........  .........  ...........  ...........
                               penis.
00934...  C                   Anesth, penis, nodes     .........  .........  .........  ...........  ...........
                               removal.
00936...  C                   Anesth, penis, nodes     .........  .........  .........  ...........  ...........
                               removal.
00938...  N                   Anesth, insert penis     .........  .........  .........  ...........  ...........
                               device.
00940...  N                   Anesth, vaginal          .........  .........  .........  ...........  ...........
                               procedures.
00942...  N                   Anesth, surgery on       .........  .........  .........  ...........  ...........
                               vagina.
00944...  C                   Anesth, vaginal          .........  .........  .........  ...........  ...........
                               hysterectomy.
00946...  N                   Anesth, vaginal          .........  .........  .........  ...........  ...........
                               delivery.
00948...  N                   Anesth, repair of        .........  .........  .........  ...........  ...........
                               cervix.
00950...  N                   Anesth, vaginal          .........  .........  .........  ...........  ...........
                               endoscopy.
00952...  N                   Anesth, uterine          .........  .........  .........  ...........  ...........
                               endoscopy.
00955...  C                   Analgesia, vaginal       .........  .........  .........  ...........  ...........
                               delivery.
01000...  N                   Anesth, skin surgery,    .........  .........  .........  ...........  ...........
                               pelvis.
01110...  N                   Anesth, skin surgery,    .........  .........  .........  ...........  ...........
                               pelvis.
01120...  N                   Anesth, pelvis surgery.  .........  .........  .........  ...........  ...........
01130...  N                   Anesth, body cast        .........  .........  .........  ...........  ...........
                               procedure.
01140...  C                   Anesth, amputation at    .........  .........  .........  ...........  ...........
                               pelvis.
01150...  C                   Anesth, pelvic tumor     .........  .........  .........  ...........  ...........
                               surgery.
01160...  N                   Anesth, pelvis           .........  .........  .........  ...........  ...........
                               procedure.
01170...  N                   Anesth, pelvis surgery.  .........  .........  .........  ...........  ...........
01180...  N                   Anesth, pelvis nerve     .........  .........  .........  ...........  ...........
                               removal.
01190...  C                   Anesth, pelvis nerve     .........  .........  .........  ...........  ...........
                               removal.
01200...  N                   Anesth, hip joint        .........  .........  .........  ...........  ...........
                               procedure.
01202...  N                   Anesth, arthroscopy of   .........  .........  .........  ...........  ...........
                               hip.

[[Page 47623]]

01210...  N                   Anesth, hip joint        .........  .........  .........  ...........  ...........
                               surgery.
01212...  C                   Anesth, hip              .........  .........  .........  ...........  ...........
                               disarticulation.
01214...  C                   Anesth, replacement of   .........  .........  .........  ...........  ...........
                               hip.
01220...  N                   Anesth, procedure on     .........  .........  .........  ...........  ...........
                               femur.
01230...  N                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               femur.
01232...  C                   Anesth, amputation of    .........  .........  .........  ...........  ...........
                               femur.
01234...  C                   Anesth, radical femur    .........  .........  .........  ...........  ...........
                               surg.
01240...  N                   Anesth, upper leg skin   .........  .........  .........  ...........  ...........
                               surg.
01250...  N                   Anesth, upper leg        .........  .........  .........  ...........  ...........
                               surgery.
01260...  N                   Anesth, upper leg veins  .........  .........  .........  ...........  ...........
                               surg.
01270...  N                   Anesth, thigh arteries   .........  .........  .........  ...........  ...........
                               surg.
01272...  C                   Anesth, femoral artery   .........  .........  .........  ...........  ...........
                               surg.
01274...  C                   Anesth, femoral          .........  .........  .........  ...........  ...........
                               embolectomy.
01300...  N                   Anesth, skin surgery,    .........  .........  .........  ...........  ...........
                               knee.
01320...  N                   Anesth, knee area        .........  .........  .........  ...........  ...........
                               surgery.
01340...  N                   Anesth, knee area        .........  .........  .........  ...........  ...........
                               procedure.
01360...  N                   Anesth, knee area        .........  .........  .........  ...........  ...........
                               surgery.
01380...  N                   Anesth, knee joint       .........  .........  .........  ...........  ...........
                               procedure.
01382...  N                   Anesth, knee             .........  .........  .........  ...........  ...........
                               arthroscopy.
01390...  N                   Anesth, knee area        .........  .........  .........  ...........  ...........
                               procedure.
01392...  N                   Anesth, knee area        .........  .........  .........  ...........  ...........
                               surgery.
01400...  N                   Anesth, knee joint       .........  .........  .........  ...........  ...........
                               surgery.
01402...  C                   Anesth, replacement of   .........  .........  .........  ...........  ...........
                               knee.
01404...  C                   Anesth, amputation at    .........  .........  .........  ...........  ...........
                               knee.
01420...  N                   Anesth, knee joint       .........  .........  .........  ...........  ...........
                               casting.
01430...  N                   Anesth, knee veins       .........  .........  .........  ...........  ...........
                               surgery.
01432...  N                   Anesth, knee vessel      .........  .........  .........  ...........  ...........
                               surg.
01440...  N                   Anesth, knee arteries    .........  .........  .........  ...........  ...........
                               surg.
01442...  C                   Anesth, knee artery      .........  .........  .........  ...........  ...........
                               surg.
01444...  C                   Anesth, knee artery      .........  .........  .........  ...........  ...........
                               repair.
01460...  N                   Anesth, lower leg skin   .........  .........  .........  ...........  ...........
                               surg.
01462...  N                   Anesth, lower leg        .........  .........  .........  ...........  ...........
                               procedure.
01464...  N                   Anesth, ankle            .........  .........  .........  ...........  ...........
                               arthroscopy.
01470...  N                   Anesth, lower leg        .........  .........  .........  ...........  ...........
                               surgery.
01472...  N                   Anesth, achilles tendon  .........  .........  .........  ...........  ...........
                               surg.
01474...  N                   Anesth, lower leg        .........  .........  .........  ...........  ...........
                               surgery.
01480...  N                   Anesth, lower leg bone   .........  .........  .........  ...........  ...........
                               surg.
01482...  N                   Anesth, radical leg      .........  .........  .........  ...........  ...........
                               surgery.
01484...  N                   Anesth, lower leg        .........  .........  .........  ...........  ...........
                               revision.
01486...  C                   Anesth, ankle            .........  .........  .........  ...........  ...........
                               replacement.
01490...  N                   Anesth, lower leg        .........  .........  .........  ...........  ...........
                               casting.
01500...  N                   Anesth, leg arteries     .........  .........  .........  ...........  ...........
                               surg.
01502...  C                   Anesth, lowerleg         .........  .........  .........  ...........  ...........
                               embolectomy.
01520...  N                   Anesth, lower leg vein   .........  .........  .........  ...........  ...........
                               surg.
01522...  N                   Anesth, lower leg vein   .........  .........  .........  ...........  ...........
                               surg.
01600...  N                   Anesth, shoulder skin    .........  .........  .........  ...........  ...........
                               surg.
01610...  N                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               shoulder.
01620...  N                   Anesth, shoulder         .........  .........  .........  ...........  ...........
                               procedure.
01622...  N                   Anesth, shoulder         .........  .........  .........  ...........  ...........
                               arthroscopy.
01630...  N                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               shoulder.
01632...  C                   Anesth, surgery of       .........  .........  .........  ...........  ...........
                               shoulder.
01634...  C                   Anesth, shoulder joint   .........  .........  .........  ...........  ...........
                               amput.
01636...  C                   Anesth, forequarter      .........  .........  .........  ...........  ...........
                               amput.
01638...  C                   Anesth, shoulder         .........  .........  .........  ...........  ...........
                               replacement.
01650...  N                   Anesth, shoulder artery  .........  .........  .........  ...........  ...........
                               surg.
01652...  C                   Anesth, shoulder vessel  .........  .........  .........  ...........  ...........
                               surg.
01654...  C                   Anesth, shoulder vessel  .........  .........  .........  ...........  ...........
                               surg.
01656...  C                   Anesth, arm-leg vessel   .........  .........  .........  ...........  ...........
                               surg.
01670...  N                   Anesth, shoulder vein    .........  .........  .........  ...........  ...........
                               surg.
01680...  N                   Anesth, shoulder         .........  .........  .........  ...........  ...........
                               casting.
01682...  N                   Anesth, airplane cast..  .........  .........  .........  ...........  ...........
01700...  N                   Anesth, elbow area skin  .........  .........  .........  ...........  ...........
                               surg.
01710...  N                   Anesth, elbow area       .........  .........  .........  ...........  ...........
                               surgery.
01712...  N                   Anesth, upperarm tendon  .........  .........  .........  ...........  ...........
                               surg.
01714...  N                   Anesth, upperarm tendon  .........  .........  .........  ...........  ...........
                               surg.
01716...  N                   Anesth, biceps tendon    .........  .........  .........  ...........  ...........
                               repair.
01730...  N                   Anesth, upperarm         .........  .........  .........  ...........  ...........
                               procedure.
01732...  N                   Anesth, elbow            .........  .........  .........  ...........  ...........
                               arthroscopy.
01740...  N                   Anesth, upper arm        .........  .........  .........  ...........  ...........
                               surgery.
01742...  N                   Anesth, humerus surgery  .........  .........  .........  ...........  ...........
01744...  N                   Anesth, humerus repair.  .........  .........  .........  ...........  ...........
01756...  C                   Anesth, radical humerus  .........  .........  .........  ...........  ...........
                               surg.
01758...  N                   Anesth, humeral lesion   .........  .........  .........  ...........  ...........
                               surg.
01760...  N                   Anesth, elbow            .........  .........  .........  ...........  ...........
                               replacement.
01770...  N                   Anesth, upperarm artery  .........  .........  .........  ...........  ...........
                               surg.

[[Page 47624]]

01772...  C                   Anesth, upperarm         .........  .........  .........  ...........  ...........
                               embolectomy.
01780...  N                   Anesth, upper arm vein   .........  .........  .........  ...........  ...........
                               surg.
01782...  C                   Anesth, upperarm vein    .........  .........  .........  ...........  ...........
                               repair.
01784...  N                   Anesth, av fistula       .........  .........  .........  ...........  ...........
                               repair.
01800...  N                   Anesth, lower arm skin   .........  .........  .........  ...........  ...........
                               surg.
01810...  N                   Anesth, lower arm        .........  .........  .........  ...........  ...........
                               surgery.
01820...  N                   Anesth, lower arm        .........  .........  .........  ...........  ...........
                               procedure.
01830...  N                   Anesth, lower arm        .........  .........  .........  ...........  ...........
                               surgery.
01832...  N                   Anesth, wrist            .........  .........  .........  ...........  ...........
                               replacement.
01840...  N                   Anesth, lowerarm artery  .........  .........  .........  ...........  ...........
                               surg.
01842...  C                   Anesth, lowerarm         .........  .........  .........  ...........  ...........
                               embolectomy.
01844...  N                   Anesth, vascular shunt   .........  .........  .........  ...........  ...........
                               surg.
01850...  N                   Anesth, lower arm vein   .........  .........  .........  ...........  ...........
                               surg.
01852...  C                   Anesth, lowerarm vein    .........  .........  .........  ...........  ...........
                               repair.
01860...  N                   Anesth, lower arm        .........  .........  .........  ...........  ...........
                               casting.
01900...  N                   Anesth, uterus/tube      .........  .........  .........  ...........  ...........
                               inject.
01902...  C                   Anesth, burr holes,      .........  .........  .........  ...........  ...........
                               skull.
01904...  C                   Anesth, skull x-ray      .........  .........  .........  ...........  ...........
                               inject.
01906...  N                   Anesth, lumbar           .........  .........  .........  ...........  ...........
                               myelography.
01908...  N                   Anesth, cervical         .........  .........  .........  ...........  ...........
                               myelography.
01910...  N                   Anesth, skull            .........  .........  .........  ...........  ...........
                               myelography.
01912...  N                   Anesth, lumbar           .........  .........  .........  ...........  ...........
                               discography.
01914...  N                   Anesth, cervical         .........  .........  .........  ...........  ...........
                               discography.
01916...  C                   Anesth, head             .........  .........  .........  ...........  ...........
                               arteriogram.
01918...  C                   Anesth, limb             .........  .........  .........  ...........  ...........
                               arteriogram.
01920...  N                   Anesth, catheterize      .........  .........  .........  ...........  ...........
                               heart.
01921...  C                   Anesth, vessel surgery.  .........  .........  .........  ...........  ...........
01922...  N                   Anesth, cat or MRI scan  .........  .........  .........  ...........  ...........
01990...  C                   Support for organ donor  .........  .........  .........  ...........  ...........
01995...  N                   Regional anesthesia,     .........  .........  .........  ...........  ...........
                               limb.
01996...  N                   Manage daily drug        .........  .........  .........  ...........  ...........
                               therapy.
01999...  N                   Unlisted anesth          .........  .........  .........  ...........  ...........
                               procedure.
10040...  T                   Acne surgery of skin           131       1.94    $102.84       $36.61       $20.57
                               abscess.
10060...  T                   Drainage of skin               131       1.94    $102.84       $36.61       $20.57
                               abscess.
10061...  T                   Drainage of skin               131       1.94    $102.84       $36.61       $20.57
                               abscess.
10080...  T                   Drainage of pilonidal          131       1.94    $102.84       $36.61       $20.57
                               cyst.
10081...  T                   Drainage of pilonidal          131       1.94    $102.84       $36.61       $20.57
                               cyst.
10120...  T                   Remove foreign body....        131       1.94    $102.84       $36.61       $20.57
10121...  T                   Remove foreign body....        163      10.69    $565.14      $264.65      $113.03
10140...  T                   Drainage of hematoma/          131       1.94    $102.84       $36.61       $20.57
                               fluid.
10160...  T                   Puncture drainage of           131       1.94    $102.84       $36.61       $20.57
                               lesion.
10180...  T                   Complex drainage, wound        131       1.94    $102.84       $36.61       $20.57
11000...  T                   Debride infected skin..        151       1.74     $92.07       $35.71       $18.41
11001...  T                   Debride infect skin add        151       1.74     $92.07       $35.71       $18.41
11010...  T                   Debride skin, fx.......        163      10.69    $565.14      $264.65      $113.03
11011...  T                   Debride skin/muscle, fx        163      10.69    $565.14      $264.65      $113.03
11012...  T                   Debride skin/muscle/           163      10.69    $565.14      $264.65      $113.03
                               bone, fx.
11040...  T                   Debride skin partial...        151       1.74     $92.07       $35.71       $18.41
11041...  T                   Debride skin full......        151       1.74     $92.07       $35.71       $18.41
11042...  T                   Debride skin/tissue....        151       1.74     $92.07       $35.71       $18.41
11043...  T                   Debride tissue/muscle..        162       5.67    $299.71      $125.43       $59.94
11044...  T                   Debride tissue/muscle/         162       5.67    $299.71      $125.43       $59.94
                               bone.
11055...  T                   Trim skin lesion.......        151       1.74     $92.07       $35.71       $18.41
11056...  T                   Trim 2 to 4 skin               151       1.74     $92.07       $35.71       $18.41
                               lesions.
11057...  T                   Trim over 4 skin               151       1.74     $92.07       $35.71       $18.41
                               lesions.
11100...  T                   Biopsy of skin lesion..        161       3.50    $185.12       $75.48       $37.02
11101...  T                   Biopsy, each added             161       3.50    $185.12       $75.48       $37.02
                               lesion.
11200...  T                   Removal of skin tags...        151       1.74     $92.07       $35.71       $18.41
11201...  T                   Removal of added skin          151       1.74     $92.07       $35.71       $18.41
                               tags.
11300...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11301...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11302...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11303...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11305...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11306...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11307...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11308...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11310...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11311...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11312...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11313...  T                   Shave skin lesion......        151       1.74     $92.07       $35.71       $18.41
11400...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11401...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11402...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11403...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02

[[Page 47625]]

11404...  T                   Removal of skin lesion.        162       5.67    $299.71      $125.43       $59.94
11406...  T                   Removal of skin lesion.        163      10.69    $565.14      $264.65      $113.03
11420...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11421...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11422...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11423...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11424...  T                   Removal of skin lesion.        162       5.67    $299.71      $125.43       $59.94
11426...  T                   Removal of skin lesion.        163      10.69    $565.14      $264.65      $113.03
11440...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11441...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11442...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11443...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11444...  T                   Removal of skin lesion.        162       5.67    $299.71      $125.43       $59.94
11446...  T                   Removal of skin lesion.        163      10.69    $565.14      $264.65      $113.03
11450...  T                   Removal, sweat gland           163      10.69    $565.14      $264.65      $113.03
                               lesion.
11451...  T                   Removal, sweat gland           163      10.69    $565.14      $264.65      $113.03
                               lesion.
11462...  T                   Removal, sweat gland           163      10.69    $565.14      $264.65      $113.03
                               lesion.
11463...  T                   Removal, sweat gland           163      10.69    $565.14      $264.65      $113.03
                               lesion.
11470...  T                   Removal, sweat gland           163      10.69    $565.14      $264.65      $113.03
                               lesion.
11471...  T                   Removal, sweat gland           163      10.69    $565.14      $264.65      $113.03
                               lesion.
11600...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11601...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11602...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11603...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11604...  T                   Removal of skin lesion.        162       5.67    $299.71      $125.43       $59.94
11606...  T                   Removal of skin lesion.        163      10.69    $565.14      $264.65      $113.03
11620...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11621...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11622...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11623...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11624...  T                   Removal of skin lesion.        163      10.69    $565.14      $264.65      $113.03
11626...  T                   Removal of skin lesion.        163      10.69    $565.14      $264.65      $113.03
11640...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11641...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11642...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11643...  T                   Removal of skin lesion.        161       3.50    $185.12       $75.48       $37.02
11644...  T                   Removal of skin lesion.        163      10.69    $565.14      $264.65      $113.03
11646...  T                   Removal of skin lesion.        163      10.69    $565.14      $264.65      $113.03
11719...  T                   Trim nail(s)...........        137       0.46     $24.49        $4.90        $4.90
11720...  T                   Debride nail, 1-5......        137       0.46     $24.49        $4.90        $4.90
11721...  T                   Debride nail, 6 or more        137       0.46     $24.49        $4.90        $4.90
11730...  T                   Removal of nail plate..        151       1.74     $92.07       $35.71       $18.41
11731...  T                   Removal of second nail         151       1.74     $92.07       $35.71       $18.41
                               plate.
11732...  T                   Remove additional nail         151       1.74     $92.07       $35.71       $18.41
                               plate.
11740...  T                   Drain blood from under         137       0.46     $24.49        $4.90        $4.90
                               nail.
11750...  T                   Removal of nail bed....        161       3.50    $185.12       $75.48       $37.02
11752...  T                   Remove nail bed/finger         163      10.69    $565.14      $264.65      $113.03
                               tip.
11755...  T                   Biopsy, nail unit......        137       0.46     $24.49        $4.90        $4.90
11760...  T                   Reconstruction of nail         181       2.19    $115.58       $43.84       $23.12
                               bed.
11762...  T                   Reconstruction of nail         181       2.19    $115.58       $43.84       $23.12
                               bed.
11765...  T                   Excision of nail fold,         151       1.74     $92.07       $35.71       $18.41
                               toe.
11770...  T                   Removal of pilonidal           162       5.67    $299.71      $125.43       $59.94
                               lesion.
11771...  T                   Removal of pilonidal           163      10.69    $565.14      $264.65      $113.03
                               lesion.
11772...  T                   Removal of pilonidal           163      10.69    $565.14      $264.65      $113.03
                               lesion.
11900...  T                   Injection into skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
11901...  T                   Added skin lesions             151       1.74     $92.07       $35.71       $18.41
                               injection.
11920...  T                   Correct skin color             181       2.19    $115.58       $43.84       $23.12
                               defects.
11921...  T                   Correct skin color             181       2.19    $115.58       $43.84       $23.12
                               defects.
11922...  T                   Correct skin color             181       2.19    $115.58       $43.84       $23.12
                               defects.
11950...  T                   Therapy for contour            181       2.19    $115.58       $43.84       $23.12
                               defects.
11951...  T                   Therapy for contour            181       2.19    $115.58       $43.84       $23.12
                               defects.
11952...  T                   Therapy for contour            181       2.19    $115.58       $43.84       $23.12
                               defects.
11954...  T                   Therapy for contour            181       2.19    $115.58       $43.84       $23.12
                               defects.
11960...  T                   Insert tissue                  183      11.17    $590.61      $286.57      $118.12
                               expander(s).
11970...  T                   Replace tissue expander        183      11.17    $590.61      $286.57      $118.12
11971...  T                   Remove tissue                  163      10.69    $565.14      $264.65      $113.03
                               expander(s).
11975...  E                   Insert contraceptive     .........  .........  .........  ...........  ...........
                               cap.
11976...  T                   Removal of                     131       1.94    $102.84       $36.61       $20.57
                               contraceptive cap.
11977...  E                   Removal/reinsert contra  .........  .........  .........  ...........  ...........
                               cap.
12001...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12002...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12004...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12005...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12006...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12007...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).

[[Page 47626]]

12011...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12013...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12014...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12015...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12016...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12017...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12018...  T                   Repair superficial             181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12020...  T                   Closure of split wound.        181       2.19    $115.58       $43.84       $23.12
12021...  T                   Closure of split wound.        181       2.19    $115.58       $43.84       $23.12
12031...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12032...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12034...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12035...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12036...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12037...  T                   Layer closure of               183      11.17    $590.61      $286.57      $118.12
                               wound(s).
12041...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12042...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12044...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12045...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12046...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12047...  T                   Layer closure of               183      11.17    $590.61      $286.57      $118.12
                               wound(s).
12051...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12052...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12053...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12054...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12055...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12056...  T                   Layer closure of               181       2.19    $115.58       $43.84       $23.12
                               wound(s).
12057...  T                   Layer closure of               183      11.17    $590.61      $286.57      $118.12
                               wound(s).
13100...  T                   Repair of wound or             182       4.00    $211.56       $84.98       $42.31
                               lesion.
13101...  T                   Repair of wound or             182       4.00    $211.56       $84.98       $42.31
                               lesion.
13120...  T                   Repair of wound or             182       4.00    $211.56       $84.98       $42.31
                               lesion.
13121...  T                   Repair of wound or             182       4.00    $211.56       $84.98       $42.31
                               lesion.
13131...  T                   Repair of wound or             182       4.00    $211.56       $84.98       $42.31
                               lesion.
13132...  T                   Repair of wound or             182       4.00    $211.56       $84.98       $42.31
                               lesion.
13150...  T                   Repair of wound or             182       4.00    $211.56       $84.98       $42.31
                               lesion.
13151...  T                   Repair of wound or             182       4.00    $211.56       $84.98       $42.31
                               lesion.
13152...  T                   Repair of wound or             182       4.00    $211.56       $84.98       $42.31
                               lesion.
13160...  T                   Late closure of wound..        182       4.00    $211.56       $84.98       $42.31
13300...  T                   Repair of wound or             182       4.00    $211.56       $84.98       $42.31
                               lesion.
14000...  T                   Skin tissue                    183      11.17    $590.61      $286.57      $118.12
                               rearrangement.
14001...  T                   Skin tissue                    183      11.17    $590.61      $286.57      $118.12
                               rearrangement.
14020...  T                   Skin tissue                    183      11.17    $590.61      $286.57      $118.12
                               rearrangement.
14021...  T                   Skin tissue                    183      11.17    $590.61      $286.57      $118.12
                               rearrangement.
14040...  T                   Skin tissue                    183      11.17    $590.61      $286.57      $118.12
                               rearrangement.
14041...  T                   Skin tissue                    183      11.17    $590.61      $286.57      $118.12
                               rearrangement.
14060...  T                   Skin tissue                    183      11.17    $590.61      $286.57      $118.12
                               rearrangement.
14061...  T                   Skin tissue                    183      11.17    $590.61      $286.57      $118.12
                               rearrangement.
14300...  T                   Skin tissue                    183      11.17    $590.61      $286.57      $118.12
                               rearrangement.
14350...  T                   Skin tissue                    183      11.17    $590.61      $286.57      $118.12
                               rearrangement.
15000...  T                   Skin graft procedure...        183      11.17    $590.61      $286.57      $118.12
15050...  T                   Skin pinch graft               183      11.17    $590.61      $286.57      $118.12
                               procedure.
15100...  T                   Skin split graft               183      11.17    $590.61      $286.57      $118.12
                               procedure.
15101...  T                   Skin split graft               183      11.17    $590.61      $286.57      $118.12
                               procedure.
15120...  T                   Skin split graft               183      11.17    $590.61      $286.57      $118.12
                               procedure.
15121...  T                   Skin split graft               183      11.17    $590.61      $286.57      $118.12
                               procedure.
15200...  T                   Skin full graft                183      11.17    $590.61      $286.57      $118.12
                               procedure.
15201...  T                   Skin full graft                183      11.17    $590.61      $286.57      $118.12
                               procedure.
15220...  T                   Skin full graft                183      11.17    $590.61      $286.57      $118.12
                               procedure.
15221...  T                   Skin full graft                183      11.17    $590.61      $286.57      $118.12
                               procedure.
15240...  T                   Skin full graft                183      11.17    $590.61      $286.57      $118.12
                               procedure.
15241...  T                   Skin full graft                183      11.17    $590.61      $286.57      $118.12
                               procedure.
15260...  T                   Skin full graft                183      11.17    $590.61      $286.57      $118.12
                               procedure.
15261...  T                   Skin full graft                183      11.17    $590.61      $286.57      $118.12
                               procedure.
15350...  T                   Skin homograft                 183      11.17    $590.61      $286.57      $118.12
                               procedure.
15400...  T                   Skin heterograft               183      11.17    $590.61      $286.57      $118.12
                               procedure.
15570...  T                   Form skin pedicle flap.        183      11.17    $590.61      $286.57      $118.12
15572...  T                   Form skin pedicle flap.        183      11.17    $590.61      $286.57      $118.12
15574...  T                   Form skin pedicle flap.        183      11.17    $590.61      $286.57      $118.12
15576...  T                   Form skin pedicle flap.        183      11.17    $590.61      $286.57      $118.12
15580...  T                   Attach skin pedicle            183      11.17    $590.61      $286.57      $118.12
                               graft.
15600...  T                   Skin graft procedure...        183      11.17    $590.61      $286.57      $118.12
15610...  T                   Skin graft procedure...        183      11.17    $590.61      $286.57      $118.12
15620...  T                   Skin graft procedure...        183      11.17    $590.61      $286.57      $118.12
15625...  T                   Skin graft procedure...        183      11.17    $590.61      $286.57      $118.12
15630...  T                   Skin graft procedure...        183      11.17    $590.61      $286.57      $118.12

[[Page 47627]]

15650...  T                   Transfer skin pedicle          183      11.17    $590.61      $286.57      $118.12
                               flap.
15732...  T                   Muscle-skin graft, head/       184      15.17    $802.17      $396.40      $160.43
                               neck.
15734...  T                   Muscle-skin graft,             184      15.17    $802.17      $396.40      $160.43
                               trunk.
15736...  T                   Muscle-skin graft, arm.        184      15.17    $802.17      $396.40      $160.43
15738...  T                   Muscle-skin graft, leg.        184      15.17    $802.17      $396.40      $160.43
15740...  T                   Island pedicle flap            184      15.17    $802.17      $396.40      $160.43
                               graft.
15750...  T                   Neurovascular pedicle          184      15.17    $802.17      $396.40      $160.43
                               graft.
15756...  C                   Free muscle flap,        .........  .........  .........  ...........  ...........
                               microvasc.
15757...  C                   Free skin flap,          .........  .........  .........  ...........  ...........
                               microvasc.
15758...  C                   Free fascial flap,       .........  .........  .........  ...........  ...........
                               microvasc.
15760...  T                   Composite skin graft...        184      15.17    $802.17      $396.40      $160.43
15770...  T                   Derma-fat-fascia graft.        184      15.17    $802.17      $396.40      $160.43
15775...  T                   Hair transplant punch          183      11.17    $590.61      $286.57      $118.12
                               grafts.
15776...  T                   Hair transplant punch          183      11.17    $590.61      $286.57      $118.12
                               grafts.
15780...  T                   Abrasion treatment of          163      10.69    $565.14      $264.65      $113.03
                               skin.
15781...  T                   Abrasion treatment of          163      10.69    $565.14      $264.65      $113.03
                               skin.
15782...  T                   Abrasion treatment of          163      10.69    $565.14      $264.65      $113.03
                               skin.
15783...  T                   Abrasion treatment of          151       1.74     $92.07       $35.71       $18.41
                               skin.
15786...  T                   Abrasion treatment of          151       1.74     $92.07       $35.71       $18.41
                               lesion.
15787...  T                   Abrasion, added skin           151       1.74     $92.07       $35.71       $18.41
                               lesions.
15788...  T                   Chemical peel, face,           151       1.74     $92.07       $35.71       $18.41
                               epiderm.
15789...  T                   Chemical peel, face,           151       1.74     $92.07       $35.71       $18.41
                               dermal.
15792...  T                   Chemical peel,                 151       1.74     $92.07       $35.71       $18.41
                               nonfacial.
15793...  T                   Chemical peel,                 151       1.74     $92.07       $35.71       $18.41
                               nonfacial.
15810...  T                   Salabrasion............        151       1.74     $92.07       $35.71       $18.41
15811...  T                   Salabrasion............        163      10.69    $565.14      $264.65      $113.03
15819...  T                   Plastic surgery, neck..        183      11.17    $590.61      $286.57      $118.12
15820...  T                   Revision of lower              183      11.17    $590.61      $286.57      $118.12
                               eyelid.
15821...  T                   Revision of lower              183      11.17    $590.61      $286.57      $118.12
                               eyelid.
15822...  T                   Revision of upper              183      11.17    $590.61      $286.57      $118.12
                               eyelid.
15823...  T                   Revision of upper              183      11.17    $590.61      $286.57      $118.12
                               eyelid.
15824...  T                   Removal of forehead            184      15.17    $802.17      $396.40      $160.43
                               wrinkles.
15825...  T                   Removal of neck                183      11.17    $590.61      $286.57      $118.12
                               wrinkles.
15826...  T                   Removal of brow                184      15.17    $802.17      $396.40      $160.43
                               wrinkles.
15828...  T                   Removal of face                184      15.17    $802.17      $396.40      $160.43
                               wrinkles.
15829...  T                   Removal of skin                183      11.17    $590.61      $286.57      $118.12
                               wrinkles.
15831...  T                   Excise excessive skin          184      15.17    $802.17      $396.40      $160.43
                               tissue.
15832...  T                   Excise excessive skin          184      15.17    $802.17      $396.40      $160.43
                               tissue.
15833...  T                   Excise excessive skin          184      15.17    $802.17      $396.40      $160.43
                               tissue.
15834...  T                   Excise excessive skin          184      15.17    $802.17      $396.40      $160.43
                               tissue.
15835...  T                   Excise excessive skin          183      11.17    $590.61      $286.57      $118.12
                               tissue.
15836...  T                   Excise excessive skin          184      15.17    $802.17      $396.40      $160.43
                               tissue.
15837...  T                   Excise excessive skin          184      15.17    $802.17      $396.40      $160.43
                               tissue.
15838...  T                   Excise excessive skin          163      10.69    $565.14      $264.65      $113.03
                               tissue.
15839...  T                   Excise excessive skin          184      15.17    $802.17      $396.40      $160.43
                               tissue.
15840...  T                   Graft for face nerve           184      15.17    $802.17      $396.40      $160.43
                               palsy.
15841...  T                   Graft for face nerve           184      15.17    $802.17      $396.40      $160.43
                               palsy.
15842...  T                   Graft for face nerve           184      15.17    $802.17      $396.40      $160.43
                               palsy.
15845...  T                   Skin and muscle repair,        184      15.17    $802.17      $396.40      $160.43
                               face.
15850...  T                   Removal of sutures.....        151       1.74     $92.07       $35.71       $18.41
15851...  T                   Removal of sutures.....        151       1.74     $92.07       $35.71       $18.41
15852...  T                   Dressing change, not           151       1.74     $92.07       $35.71       $18.41
                               for burn.
15860...  N                   Test for blood flow in   .........  .........  .........  ...........  ...........
                               graft.
15876...  T                   Suction assisted               184      15.17    $802.17      $396.40      $160.43
                               lipectomy.
15877...  T                   Suction assisted               184      15.17    $802.17      $396.40      $160.43
                               lipectomy.
15878...  T                   Suction assisted               184      15.17    $802.17      $396.40      $160.43
                               lipectomy.
15879...  T                   Suction assisted               184      15.17    $802.17      $396.40      $160.43
                               lipectomy.
15920...  T                   Removal of tail bone           163      10.69    $565.14      $264.65      $113.03
                               ulcer.
15922...  T                   Removal of tail bone           184      15.17    $802.17      $396.40      $160.43
                               ulcer.
15931...  T                   Remove sacrum pressure         163      10.69    $565.14      $264.65      $113.03
                               sore.
15933...  T                   Remove sacrum pressure         163      10.69    $565.14      $264.65      $113.03
                               sore.
15934...  T                   Remove sacrum pressure         184      15.17    $802.17      $396.40      $160.43
                               sore.
15935...  T                   Remove sacrum pressure         184      15.17    $802.17      $396.40      $160.43
                               sore.
15936...  T                   Remove sacrum pressure         184      15.17    $802.17      $396.40      $160.43
                               sore.
15937...  T                   Remove sacrum pressure         184      15.17    $802.17      $396.40      $160.43
                               sore.
15940...  T                   Removal of pressure            163      10.69    $565.14      $264.65      $113.03
                               sore.
15941...  T                   Removal of pressure            163      10.69    $565.14      $264.65      $113.03
                               sore.
15944...  T                   Removal of pressure            184      15.17    $802.17      $396.40      $160.43
                               sore.
15945...  T                   Removal of pressure            184      15.17    $802.17      $396.40      $160.43
                               sore.
15946...  T                   Removal of pressure            184      15.17    $802.17      $396.40      $160.43
                               sore.
15950...  T                   Remove thigh pressure          163      10.69    $565.14      $264.65      $113.03
                               sore.
15951...  T                   Remove thigh pressure          163      10.69    $565.14      $264.65      $113.03
                               sore.
15952...  T                   Remove thigh pressure          184      15.17    $802.17      $396.40      $160.43
                               sore.
15953...  T                   Remove thigh pressure          184      15.17    $802.17      $396.40      $160.43
                               sore.
15956...  T                   Remove thigh pressure          184      15.17    $802.17      $396.40      $160.43
                               sore.

[[Page 47628]]

15958...  T                   Remove thigh pressure          184      15.17    $802.17      $396.40      $160.43
                               sore.
15999...  T                   Removal of pressure            163      10.69    $565.14      $264.65      $113.03
                               sore.
16000...  T                   Initial treatment of           151       1.74     $92.07       $35.71       $18.41
                               burn(s).
16010...  T                   Treatment of burn(s)...        152      10.43    $551.43      $261.71      $110.29
16015...  T                   Treatment of burn(s)...        152      10.43    $551.43      $261.71      $110.29
16020...  T                   Treatment of burn(s)...        151       1.74     $92.07       $35.71       $18.41
16025...  T                   Treatment of burn(s)...        151       1.74     $92.07       $35.71       $18.41
16030...  T                   Treatment of burn(s)...        151       1.74     $92.07       $35.71       $18.41
16035...  T                   Incision of burn scab..        162       5.67    $299.71      $125.43       $59.94
16040...  T                   Burn wound excision....        162       5.67    $299.71      $125.43       $59.94
16041...  T                   Burn wound excision....        162       5.67    $299.71      $125.43       $59.94
16042...  T                   Burn wound excision....        162       5.67    $299.71      $125.43       $59.94
17000...  T                   Destroy benign/premal          141       0.59     $31.34        $9.49        $6.27
                               lesion.
17003...  T                   Destroy 2-14 lesions...        141       0.59     $31.34        $9.49        $6.27
17004...  T                   Destroy 15 & more              142       3.78    $199.81       $73.00       $39.96
                               lesions.
17106...  T                   Destruction of skin            141       0.59     $31.34        $9.49        $6.27
                               lesions.
17107...  T                   Destruction of skin            142       3.78    $199.81       $73.00       $39.96
                               lesions.
17108...  T                   Destruction of skin            142       3.78    $199.81       $73.00       $39.96
                               lesions.
17110...  T                   Destruct lesion, 1-14..        141       0.59     $31.34        $9.49        $6.27
17111...  T                   Destruct lesion, 15 or         142       3.78    $199.81       $73.00       $39.96
                               more.
17250...  T                   Chemical cautery,              151       1.74     $92.07       $35.71       $18.41
                               tissue.
17260...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17261...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17262...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17263...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17264...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17266...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17270...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17271...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17272...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17273...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17274...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17276...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17280...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17281...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17282...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17283...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17284...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17286...  T                   Destruction of skin            151       1.74     $92.07       $35.71       $18.41
                               lesions.
17304...  T                   Chemosurgery of skin           162       5.67    $299.71      $125.43       $59.94
                               lesion.
17305...  T                   2nd stage chemosurgery.        162       5.67    $299.71      $125.43       $59.94
17306...  T                   3rd stage chemosurgery.        162       5.67    $299.71      $125.43       $59.94
17307...  T                   Followup skin lesion           162       5.67    $299.71      $125.43       $59.94
                               therapy.
17310...  T                   Extensive skin                 162       5.67    $299.71      $125.43       $59.94
                               chemosurgery.
17340...  T                   Cryotherapy of skin....        151       1.74     $92.07       $35.71       $18.41
17360...  T                   Skin peel therapy......        151       1.74     $92.07       $35.71       $18.41
17380...  T                   Hair removal by                151       1.74     $92.07       $35.71       $18.41
                               electrolysis.
17999...  T                   Skin tissue procedure..        121       0.67     $35.26       $21.02        $7.05
19000...  T                   Drainage of breast             121       0.67     $35.26       $21.02        $7.05
                               lesion.
19001...  T                   Drain added breast             121       0.67     $35.26       $21.02        $7.05
                               lesion.
19020...  T                   Incision of breast             132       6.04    $319.30      $134.24       $63.86
                               lesion.
19030...  T                   Injection for breast x-        347       2.93    $154.75       $62.15       $30.95
                               ray.
19100...  T                   Biopsy of breast.......        122       4.87    $257.60      $115.03       $51.52
19101...  T                   Biopsy of breast.......        197      12.13    $641.54      $310.75      $128.31
19110...  T                   Nipple exploration.....        197      12.13    $641.54      $310.75      $128.31
19112...  T                   Excise breast duct             197      12.13    $641.54      $310.75      $128.31
                               fistula.
19120...  T                   Removal of breast              197      12.13    $641.54      $310.75      $128.31
                               lesion.
19125...  T                   Excision, breast lesion        197      12.13    $641.54      $310.75      $128.31
19126...  T                   Excision, add'l breast         197      12.13    $641.54      $310.75      $128.31
                               lesion.
19140...  T                   Removal of breast              197      12.13    $641.54      $310.75      $128.31
                               tissue.
19160...  T                   Removal of breast              198      19.17  $1,013.73      $530.20      $202.75
                               tissue.
19162...  T                   Remove breast tissue,          198      19.17  $1,013.73      $530.20      $202.75
                               nodes.
19180...  T                   Removal of breast......        198      19.17  $1,013.73      $530.20      $202.75
19182...  T                   Removal of breast......        198      19.17  $1,013.73      $530.20      $202.75
19200...  C                   Removal of breast......  .........  .........  .........  ...........  ...........
19220...  C                   Removal of breast......  .........  .........  .........  ...........  ...........
19240...  C                   Removal of breast......  .........  .........  .........  ...........  ...........
19260...  C                   Removal of chest wall    .........  .........  .........  ...........  ...........
                               lesion.
19271...  C                   Revision of chest wall.  .........  .........  .........  ...........  ...........
19272...  C                   Extensive chest wall     .........  .........  .........  ...........  ...........
                               surgery.
19290...  T                   Place needle wire,             197      12.13    $641.54      $310.75      $128.31
                               breast.
19291...  T                   Place needle wire,             197      12.13    $641.54      $310.75      $128.31
                               breast.
19316...  T                   Suspension of breast...        198      19.17  $1,013.73      $530.20      $202.75
19318...  T                   Reduction of large             198      19.17  $1,013.73      $530.20      $202.75
                               breast.
19324...  T                   Enlarge breast.........        198      19.17  $1,013.73      $530.20      $202.75

[[Page 47629]]

19325...  T                   Enlarge breast with            198      19.17  $1,013.73      $530.20      $202.75
                               implant.
19328...  T                   Removal of breast              198      19.17  $1,013.73      $530.20      $202.75
                               implant.
19330...  T                   Removal of implant             198      19.17  $1,013.73      $530.20      $202.75
                               material.
19340...  T                   Immediate breast               198      19.17  $1,013.73      $530.20      $202.75
                               prosthesis.
19342...  T                   Delayed breast                 198      19.17  $1,013.73      $530.20      $202.75
                               prosthesis.
19350...  T                   Breast reconstruction..        198      19.17  $1,013.73      $530.20      $202.75
19355...  T                   Correct inverted               198      19.17  $1,013.73      $530.20      $202.75
                               nipple(s).
19357...  T                   Breast reconstruction..        198      19.17  $1,013.73      $530.20      $202.75
19361...  C                   Breast reconstruction..  .........  .........  .........  ...........  ...........
19364...  C                   Breast reconstruction..  .........  .........  .........  ...........  ...........
19366...  T                   Breast reconstruction..        198      19.17  $1,013.73      $530.20      $202.75
19367...  C                   Breast reconstruction..  .........  .........  .........  ...........  ...........
19368...  C                   Breast reconstruction..  .........  .........  .........  ...........  ...........
19369...  C                   Breast reconstruction..  .........  .........  .........  ...........  ...........
19370...  T                   Surgery of breast              198      19.17  $1,013.73      $530.20      $202.75
                               capsule.
19371...  T                   Removal of breast              198      19.17  $1,013.73      $530.20      $202.75
                               capsule.
19380...  T                   Revise breast                  198      19.17  $1,013.73      $530.20      $202.75
                               reconstruction.
19396...  T                   Design custom breast           197      12.13    $641.54      $310.75      $128.31
                               implant.
19499...  T                   Breast surgery                 197      12.13    $641.54      $310.75      $128.31
                               procedure.
20000...  T                   Incision of abscess....        131       1.94    $102.84       $36.61       $20.57
20005...  T                   Incision of deep               251      14.26    $754.18      $366.12      $150.84
                               abscess.
20100...  C                   Explore wound, neck....  .........  .........  .........  ...........  ...........
20101...  C                   Explore wound, chest...  .........  .........  .........  ...........  ...........
20102...  C                   Explore wound, abdomen.  .........  .........  .........  ...........  ...........
20103...  C                   Explore wound,           .........  .........  .........  ...........  ...........
                               extremity.
20150...  C                   Excise epiphyseal bar..  .........  .........  .........  ...........  ...........
20200...  T                   Muscle biopsy..........        162       5.67    $299.71      $125.43       $59.94
20205...  T                   Deep muscle biopsy.....        162       5.67    $299.71      $125.43       $59.94
20206...  T                   Needle biopsy, muscle..        122       4.87     $257.6      $115.03       $51.52
20220...  T                   Bone biopsy, trocar/           162       5.67    $299.71      $125.43       $59.94
                               needle.
20225...  T                   Bone biopsy, trocar/           162       5.67    $299.71      $125.43       $59.94
                               needle.
20240...  T                   Bone biopsy, excisional        163      10.69    $565.14      $264.65      $113.03
20245...  T                   Bone biopsy, excisional        163      10.69    $565.14      $264.65      $113.03
20250...  T                   Open bone biopsy.......        251      14.26    $754.18      $366.12      $150.84
20251...  T                   Open bone biopsy.......        251      14.26    $754.18      $366.12      $150.84
20500...  T                   Injection of sinus             181       2.19    $115.58       $43.84       $23.12
                               tract.
20501...  T                   Inject sinus tract for         347       2.93    $154.75       $62.15       $30.95
                               x-ray.
20520...  T                   Removal of foreign body        161       3.50    $185.12       $75.48       $37.02
20525...  T                   Removal of foreign body        163      10.69    $565.14      $264.65      $113.03
20550...  T                   Inj tendon/ligament/           200       1.89     $99.90       $39.10       $19.98
                               cyst.
20600...  T                   Drain/inject joint/            200       1.89     $99.90       $39.10       $19.98
                               bursa.
20605...  T                   Drain/inject joint/            200       1.89     $99.90       $39.10       $19.98
                               bursa.
20610...  T                   Drain/inject joint/            200       1.89     $99.90       $39.10       $19.98
                               bursa.
20615...  T                   Treatment of bone cyst.        121       0.67     $35.26       $21.02        $7.05
20650...  T                   Insert and remove bone         251      14.26    $754.18      $366.12      $150.84
                               pin.
20660...  C                   Apply,remove fixation    .........  .........  .........  ...........  ...........
                               device.
20661...  C                   Application of head      .........  .........  .........  ...........  ...........
                               brace.
20662...  C                   Application of pelvis    .........  .........  .........  ...........  ...........
                               brace.
20663...  C                   Application of thigh     .........  .........  .........  ...........  ...........
                               brace.
20664...  C                   Halo brace application.  .........  .........  .........  ...........  ...........
20665...  N                   Removal of fixation      .........  .........  .........  ...........  ...........
                               device.
20670...  T                   Removal of support             162       5.67    $299.71      $125.43       $59.94
                               implant.
20680...  T                   Removal of support             163      10.69    $565.14      $264.65      $113.03
                               implant.
20690...  T                   Apply bone fixation            252      19.39  $1,025.49      $509.18      $205.10
                               device.
20692...  T                   Apply bone fixation            252      19.39  $1,025.49      $509.18      $205.10
                               device.
20693...  T                   Adjust bone fixation           251      14.26    $754.18      $366.12      $150.84
                               device.
20694...  T                   Remove bone fixation           251      14.26    $754.18      $366.12      $150.84
                               device.
20802...  C                   Replantation, arm,       .........  .........  .........  ...........  ...........
                               complete.
20805...  C                   Replant forearm,         .........  .........  .........  ...........  ...........
                               complete.
20808...  C                   Replantation, hand,      .........  .........  .........  ...........  ...........
                               complete.
20816...  C                   Replantation digit,      .........  .........  .........  ...........  ...........
                               complete.
20822...  C                   Replantation digit,      .........  .........  .........  ...........  ...........
                               complete.
20824...  C                   Replantation thumb,      .........  .........  .........  ...........  ...........
                               complete.
20827...  C                   Replantation thumb,      .........  .........  .........  ...........  ...........
                               complete.
20838...  C                   Replantation, foot,      .........  .........  .........  ...........  ...........
                               complete.
20900...  T                   Removal of bone for            252      19.39  $1,025.49      $509.18      $205.10
                               graft.
20902...  T                   Removal of bone for            252      19.39  $1,025.49      $509.18      $205.10
                               graft.
20910...  T                   Remove cartilage for           183      11.17    $590.61      $286.57      $118.12
                               graft.
20912...  T                   Remove cartilage for           183      11.17    $590.61      $286.57      $118.12
                               graft.
20920...  T                   Removal of fascia for          183      11.17    $590.61      $286.57      $118.12
                               graft.
20922...  T                   Removal of fascia for          183      11.17    $590.61      $286.57      $118.12
                               graft.
20924...  T                   Removal of tendon for          252      19.39  $1,025.49      $509.18      $205.10
                               graft.
20926...  T                   Removal of tissue for          183      11.17    $590.61      $286.57      $118.12
                               graft.
20930...  C                   Spinal bone allograft..  .........  .........  .........  ...........  ...........
20931...  C                   Spinal bone allograft..  .........  .........  .........  ...........  ...........

[[Page 47630]]

20936...  C                   Spinal bone autograft..  .........  .........  .........  ...........  ...........
20937...  C                   Spinal bone autograft..  .........  .........  .........  ...........  ...........
20938...  C                   Spinal bone autograft..  .........  .........  .........  ...........  ...........
20950...  T                   Record fluid                   132       6.04    $319.30      $134.24       $63.86
                               pressure,muscle.
20955...  C                   Fibula bone graft,       .........  .........  .........  ...........  ...........
                               microvasc.
20956...  C                   Iliac bone graft,        .........  .........  .........  ...........  ...........
                               microvasc.
20957...  C                   Mt bone graft,           .........  .........  .........  ...........  ...........
                               microvasc.
20962...  C                   Other bone graft,        .........  .........  .........  ...........  ...........
                               microvasc.
20969...  C                   Bone/skin graft,         .........  .........  .........  ...........  ...........
                               microvasc.
20970...  C                   Bone/skin graft, iliac   .........  .........  .........  ...........  ...........
                               crest.
20972...  C                   Bone-skin graft,         .........  .........  .........  ...........  ...........
                               metatarsal.
20973...  C                   Bone-skin graft, great   .........  .........  .........  ...........  ...........
                               toe.
20974...  A                   Electrical bone          .........  .........  .........  ...........  ...........
                               stimulation.
20975...  T                   Electrical bone                251      14.26    $754.18      $366.12      $150.84
                               stimulation.
20999...  N                   Musculoskeletal surgery  .........  .........  .........  ...........  ...........
21010...  T                   Incision of jaw joint..        232      23.93  $1,265.45      $639.35      $253.09
21015...  T                   Resection of facial            231      12.02    $635.66       299.90      $127.13
                               tumor.
21025...  T                   Excision of bone, lower        231      12.02    $635.66       299.90      $127.13
                               jaw.
21026...  T                   Excision of facial             231      12.02    $635.66       299.90      $127.13
                               bone(s).
21029...  T                   Contour of face bone           231      12.02    $635.66       299.90      $127.13
                               lesion.
21030...  T                   Removal of face bone           231      12.02    $635.66       299.90      $127.13
                               lesion.
21031...  T                   Remove exostosis,              231      12.02    $635.66       299.90      $127.13
                               mandible.
21032...  T                   Remove exostosis,              231      12.02    $635.66       299.90      $127.13
                               maxilla.
21034...  T                   Removal of face bone           232      23.93  $1,265.45      $639.35      $253.09
                               lesion.
21040...  T                   Removal of jaw bone            231      12.02    $635.66       299.90      $127.13
                               lesion.
21041...  T                   Removal of jaw bone            231      12.02    $635.66       299.90      $127.13
                               lesion.
21044...  T                   Removal of jaw bone            232      23.93  $1,265.45      $639.35      $253.09
                               lesion.
21045...  C                   Extensive jaw surgery..  .........  .........  .........  ...........  ...........
21050...  T                   Removal of jaw joint...        232      23.93  $1,265.45      $639.35      $253.09
21060...  T                   Remove jaw joint               232      23.93  $1,265.45      $639.35      $253.09
                               cartilage.
21070...  T                   Remove coronoid process        232      23.93  $1,265.45      $639.35      $253.09
21076...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21077...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21079...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21080...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21081...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21082...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21083...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21084...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21085...  N                   Prepare face/oral        .........  .........  .........  ...........  ...........
                               prosthesis.
21086...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21087...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21088...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21089...  T                   Prepare face/oral              226       1.59     $84.23       $21.92       $16.85
                               prosthesis.
21100...  T                   Maxillofacial fixation.        231      12.02    $635.66       299.90      $127.13
21110...  T                   Interdental fixation...        231      12.02    $635.66       299.90      $127.13
21116...  T                   Injection, jaw joint x-        347       2.93    $154.75       $62.15       $30.95
                               ray.
21120...  T                   Reconstruction of chin.        231      12.02    $635.66       299.90      $127.13
21121...  T                   Reconstruction of chin.        232      23.93  $1,265.45      $639.35      $253.09
21122...  T                   Reconstruction of chin.        232      23.93  $1,265.45      $639.35      $253.09
21123...  T                   Reconstruction of chin.        232      23.93  $1,265.45      $639.35      $253.09
21125...  T                   Augmentation lower jaw         231      12.02    $635.66       299.90      $127.13
                               bone.
21127...  T                   Augmentation lower jaw         232      23.93  $1,265.45      $639.35      $253.09
                               bone.
21137...  C                   Reduction of forehead..  .........  .........  .........  ...........  ...........
21138...  C                   Reduction of forehead..  .........  .........  .........  ...........  ...........
21139...  C                   Reduction of forehead..  .........  .........  .........  ...........  ...........
21141...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21142...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21143...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21145...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21146...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21147...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21150...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21151...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21154...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21155...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21159...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21160...  C                   Reconstruct midface,     .........  .........  .........  ...........  ...........
                               lefort.
21172...  C                   Reconstruct orbit/       .........  .........  .........  ...........  ...........
                               forehead.
21175...  C                   Reconstruct orbit/       .........  .........  .........  ...........  ...........
                               forehead.
21179...  C                   Reconstruct entire       .........  .........  .........  ...........  ...........
                               forehead.
21180...  C                   Reconstruct entire       .........  .........  .........  ...........  ...........
                               forehead.
21181...  T                   Contour cranial bone           232      23.93  $1,265.45      $639.35      $253.09
                               lesion.
21182...  C                   Reconstruct cranial      .........  .........  .........  ...........  ...........
                               bone.
21183...  C                   Reconstruct cranial      .........  .........  .........  ...........  ...........
                               bone.

[[Page 47631]]

21184...  C                   Reconstruct cranial      .........  .........  .........  ...........  ...........
                               bone.
21188...  C                   Reconstruction of        .........  .........  .........  ...........  ...........
                               midface.
21193...  C                   Reconstruct lower jaw    .........  .........  .........  ...........  ...........
                               bone.
21194...  C                   Reconstruct lower jaw    .........  .........  .........  ...........  ...........
                               bone.
21195...  C                   Reconstruct lower jaw    .........  .........  .........  ...........  ...........
                               bone.
21196...  C                   Reconstruct lower jaw    .........  .........  .........  ...........  ...........
                               bone.
21198...  C                   Reconstruct lower jaw    .........  .........  .........  ...........  ...........
                               bone.
21206...  T                   Reconstruct upper jaw          232      23.93  $1,265.45      $639.35      $253.09
                               bone.
21208...  T                   Augmentation of facial         232      23.93  $1,265.45      $639.35      $253.09
                               bones.
21209...  T                   Reduction of facial            232      23.93  $1,265.45      $639.35      $253.09
                               bones.
21210...  T                   Face bone graft........        232      23.93  $1,265.45      $639.35      $253.09
21215...  T                   Lower jaw bone graft...        232      23.93  $1,265.45      $639.35      $253.09
21230...  T                   Rib cartilage graft....        232      23.93  $1,265.45      $639.35      $253.09
21235...  T                   Ear cartilage graft....        232      23.93  $1,265.45      $639.35      $253.09
21240...  T                   Reconstruction of jaw          232      23.93  $1,265.45      $639.35      $253.09
                               joint.
21242...  T                   Reconstruction of jaw          232      23.93  $1,265.45      $639.35      $253.09
                               joint.
21243...  T                   Reconstruction of jaw          218      27.50  $1,454.49      $715.52      $290.90
                               joint.
21244...  T                   Reconstruction of lower        232      23.93  $1,265.45      $639.35      $253.09
                               jaw.
21245...  T                   Reconstruction of jaw..        232      23.93  $1,265.45      $639.35      $253.09
21246...  T                   Reconstruction of jaw..        232      23.93  $1,265.45      $639.35      $253.09
21247...  C                   Reconstruct lower jaw    .........  .........  .........  ...........  ...........
                               bone.
21248...  T                   Reconstruction of jaw..        232      23.93  $1,265.45      $639.35      $253.09
21249...  T                   Reconstruction of jaw..        232      23.93  $1,265.45      $639.35      $253.09
21255...  C                   Reconstruct lower jaw    .........  .........  .........  ...........  ...........
                               bone.
21256...  C                   Reconstruction of orbit  .........  .........  .........  ...........  ...........
21260...  T                   Revise eye sockets.....        232      23.93  $1,265.45      $639.35      $253.09
21261...  C                   Revise eye sockets.....  .........  .........  .........  ...........  ...........
21263...  C                   Revise eye sockets.....  .........  .........  .........  ...........  ...........
21267...  T                   Revise eye sockets.....        232      23.93  $1,265.45      $639.35      $253.09
21268...  C                   Revise eye sockets.....  .........  .........  .........  ...........  ...........
21270...  T                   Augmentation cheek bone        232      23.93  $1,265.45      $639.35      $253.09
21275...  T                   Revision orbitofacial          232      23.93  $1,265.45      $639.35      $253.09
                               bones.
21280...  T                   Revision of eyelid.....        231      12.02    $635.66      $299.90      $127.13
21282...  T                   Revision of eyelid.....        231      12.02    $635.66      $299.90      $127.13
21295...  T                   Revision of jaw muscle/        231      12.02    $635.66      $299.90      $127.13
                               bone.
21296...  T                   Revision of jaw muscle/        231      12.02    $635.66      $299.90      $127.13
                               bone.
21299...  T                   Cranio/maxillofacial           231      12.02    $635.66      $299.90      $127.13
                               surgery.
21300...  T                   Treatment of skull             231      12.02    $635.66      $299.90      $127.13
                               fracture.
21310...  T                   Treatment of nose              231      12.02    $635.66      $299.90      $127.13
                               fracture.
21315...  T                   Treatment of nose              231      12.02    $635.66      $299.90      $127.13
                               fracture.
21320...  T                   Treatment of nose              231      12.02    $635.66      $299.90      $127.13
                               fracture.
21325...  T                   Repair of nose fracture        231      12.02    $635.66      $299.90      $127.13
21330...  T                   Repair of nose fracture        232      23.93  $1,265.45      $639.35      $253.09
21335...  T                   Repair of nose fracture        232      23.93  $1,265.45      $639.35      $253.09
21336...  T                   Repair nasal septal            216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
21337...  T                   Repair nasal septal            231      12.02    $635.66      $299.90      $127.13
                               fracture.
21338...  T                   Repair nasoethmoid             232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21339...  T                   Repair nasoethmoid             232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21340...  T                   Repair of nose fracture        232      23.93  $1,265.45      $639.35      $253.09
21343...  T                   Repair of sinus                232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21344...  C                   Repair of sinus          .........  .........  .........  ...........  ...........
                               fracture.
21345...  T                   Repair of nose/jaw             232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21346...  C                   Repair of nose/jaw       .........  .........  .........  ...........  ...........
                               fracture.
21347...  C                   Repair of nose/jaw       .........  .........  .........  ...........  ...........
                               fracture.
21348...  C                   Repair of nose/jaw       .........  .........  .........  ...........  ...........
                               fracture.
21355...  T                   Repair cheek bone              231      12.02    $635.66      $299.90      $127.13
                               fracture.
21356...  C                   Repair cheek bone        .........  .........  .........  ...........  ...........
                               fracture.
21360...  C                   Repair cheek bone        .........  .........  .........  ...........  ...........
                               fracture.
21365...  C                   Repair cheek bone        .........  .........  .........  ...........  ...........
                               fracture.
21366...  C                   Repair cheek bone        .........  .........  .........  ...........  ...........
                               fracture.
21385...  C                   Repair eye socket        .........  .........  .........  ...........  ...........
                               fracture.
21386...  C                   Repair eye socket        .........  .........  .........  ...........  ...........
                               fracture.
21387...  C                   Repair eye socket        .........  .........  .........  ...........  ...........
                               fracture.
21390...  C                   Repair eye socket        .........  .........  .........  ...........  ...........
                               fracture.
21395...  C                   Repair eye socket        .........  .........  .........  ...........  ...........
                               fracture.
21400...  T                   Treat eye socket               231      12.02    $635.66      $299.90      $127.13
                               fracture.
21401...  T                   Repair eye socket              231      12.02    $635.66      $299.90      $127.13
                               fracture.
21406...  C                   Repair eye socket        .........  .........  .........  ...........  ...........
                               fracture.
21407...  C                   Repair eye socket        .........  .........  .........  ...........  ...........
                               fracture.
21408...  C                   Repair eye socket        .........  .........  .........  ...........  ...........
                               fracture.
21421...  T                   Treat mouth roof               232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21422...  C                   Repair mouth roof        .........  .........  .........  ...........  ...........
                               fracture.
21423...  C                   Repair mouth roof        .........  .........  .........  ...........  ...........
                               fracture.
21431...  C                   Treat craniofacial       .........  .........  .........  ...........  ...........
                               fracture.
21432...  C                   Repair craniofacial      .........  .........  .........  ...........  ...........
                               fracture.

[[Page 47632]]

21433...  C                   Repair craniofacial      .........  .........  .........  ...........  ...........
                               fracture.
21435...  C                   Repair craniofacial      .........  .........  .........  ...........  ...........
                               fracture.
21436...  C                   Repair craniofacial      .........  .........  .........  ...........  ...........
                               fracture.
21440...  T                   Repair dental ridge            231      12.02    $635.66      $299.90      $127.13
                               fracture.
21445...  T                   Repair dental ridge            232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21450...  T                   Treat lower jaw                232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21451...  T                   Treat lower jaw                231      12.02    $635.66      $299.90      $127.13
                               fracture.
21452...  T                   Treat lower jaw                232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21453...  T                   Treat lower jaw                232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21454...  T                   Treat lower jaw                232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21461...  T                   Repair lower jaw               232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21462...  T                   Repair lower jaw               232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21465...  T                   Repair lower jaw               232      23.93  $1,265.45      $639.35      $253.09
                               fracture.
21470...  C                   Repair lower jaw         .........  .........  .........  ...........  ...........
                               fracture.
21480...  T                   Reset dislocated jaw...        231      12.02    $635.66      $299.90      $127.13
21485...  T                   Reset dislocated jaw...        231      12.02    $635.66      $299.90      $127.13
21490...  T                   Repair dislocated jaw..        232      23.93  $1,265.45      $639.35      $253.09
21493...  T                   Treat hyoid bone               231      12.02    $635.66      $299.90      $127.13
                               fracture.
21494...  T                   Repair hyoid bone              231      12.02    $635.66      $299.90      $127.13
                               fracture.
21495...  C                   Repair hyoid bone        .........  .........  .........  ...........  ...........
                               fracture.
21497...  T                   Interdental wiring.....        231      12.02    $635.66      $299.90      $127.13
21499...  T                   Head surgery procedure.        231      12.02    $635.66      $299.90      $127.13
21501...  T                   Drain neck/chest lesion        132       6.04    $319.30      $134.24       $63.86
21502...  T                   Drain chest lesion.....        252      19.39  $1,025.49      $509.18      $205.10
21510...  C                   Drainage of bone lesion  .........  .........  .........  ...........  ...........
21550...  T                   Biopsy of neck/chest...        161       3.50    $185.12       $75.48       $37.02
21555...  T                   Remove lesion neck/            163      10.69    $565.14      $264.65      $113.03
                               chest.
21556...  T                   Remove lesion neck/            163      10.69    $565.14      $264.65      $113.03
                               chest.
21557...  C                   Remove tumor, neck or    .........  .........  .........  ...........  ...........
                               chest.
21600...  T                   Partial removal of rib.        252      19.39  $1,025.49      $509.18      $205.10
21610...  T                   Partial removal of rib.        252      19.39  $1,025.49      $509.18      $205.10
21615...  C                   Removal of rib.........  .........  .........  .........  ...........  ...........
21616...  C                   Removal of rib and       .........  .........  .........  ...........  ...........
                               nerves.
21620...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               sternum.
21627...  C                   Sternal debridement....  .........  .........  .........  ...........  ...........
21630...  C                   Extensive sternum        .........  .........  .........  ...........  ...........
                               surgery.
21632...  C                   Extensive sternum        .........  .........  .........  ...........  ...........
                               surgery.
21700...  T                   Revision of neck muscle        132       6.04    $319.30      $134.24       $63.86
21705...  C                   Revision of neck muscle/ .........  .........  .........  ...........  ...........
                               rib.
21720...  T                   Revision of neck muscle        132       6.04    $319.30      $134.24       $63.86
21725...  T                   Revision of neck muscle        132       6.04    $319.30      $134.24       $63.86
21740...  C                   Reconstruction of        .........  .........  .........  ...........  ...........
                               sternum.
21750...  C                   Repair of sternum        .........  .........  .........  ...........  ...........
                               separation.
21800...  T                   Treatment of rib               207       1.70     $90.11       $31.64       $18.02
                               fracture.
21805...  T                   Treatment of rib               216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
21810...  C                   Treatment of rib         .........  .........  .........  ...........  ...........
                               fracture(s).
21820...  T                   Treat sternum fracture.        207       1.70     $90.11       $31.64       $18.02
21825...  C                   Repair sternum fracture  .........  .........  .........  ...........  ...........
21899...  T                   Neck/chest surgery             207       1.70     $90.11       $31.64       $18.02
                               procedure.
21920...  T                   Biopsy soft tissue of          161       3.50    $185.12       $75.48       $37.02
                               back.
21925...  T                   Biopsy soft tissue of          163      10.69    $565.14      $264.65      $113.03
                               back.
21930...  T                   Remove lesion, back or         163      10.69    $565.14      $264.65      $113.03
                               flank.
21935...  T                   Remove tumor of back...        163      10.69    $565.14      $264.65      $113.03
22100...  C                   Remove part of neck      .........  .........  .........  ...........  ...........
                               vertebra.
22101...  C                   Remove part, thorax      .........  .........  .........  ...........  ...........
                               vertebra.
22102...  C                   Remove part, lumbar      .........  .........  .........  ...........  ...........
                               vertebra.
22103...  C                   Remove extra spine       .........  .........  .........  ...........  ...........
                               segment.
22110...  C                   Remove part of neck      .........  .........  .........  ...........  ...........
                               vertebra.
22112...  C                   Remove part, thorax      .........  .........  .........  ...........  ...........
                               vertebra.
22114...  C                   Remove part, lumbar      .........  .........  .........  ...........  ...........
                               vertebra.
22116...  C                   Remove extra spine       .........  .........  .........  ...........  ...........
                               segment.
22210...  C                   Revision of neck spine.  .........  .........  .........  ...........  ...........
22212...  C                   Revision of thorax       .........  .........  .........  ...........  ...........
                               spine.
22214...  C                   Revision of lumbar       .........  .........  .........  ...........  ...........
                               spine.
22216...  C                   Revise, extra spine      .........  .........  .........  ...........  ...........
                               segment.
22220...  C                   Revision of neck spine.  .........  .........  .........  ...........  ...........
22222...  C                   Revision of thorax       .........  .........  .........  ...........  ...........
                               spine.
22224...  C                   Revision of lumbar       .........  .........  .........  ...........  ...........
                               spine.
22226...  C                   Revise, extra spine      .........  .........  .........  ...........  ...........
                               segment.
22305...  T                   Treat spine process            207       1.70     $90.11       $31.64       $18.02
                               fracture.
22310...  T                   Treat spine fracture...        207       1.70     $90.11       $31.64       $18.02
22315...  T                   Treat spine fracture...        207       1.70     $90.11       $31.64       $18.02
22325...  C                   Repair of spine          .........  .........  .........  ...........  ...........
                               fracture.
22326...  C                   Repair neck spine        .........  .........  .........  ...........  ...........
                               fracture.
22327...  C                   Repair thorax spine      .........  .........  .........  ...........  ...........
                               fracture.

[[Page 47633]]

22328...  C                   Repair each add spine    .........  .........  .........  ...........  ...........
                               fx.
22505...  T                   Manipulation of spine..        210      10.46    $553.39       $283.4      $110.68
22548...  C                   Neck spine fusion......  .........  .........  .........  ...........  ...........
22554...  C                   Neck spine fusion......  .........  .........  .........  ...........  ...........
22556...  C                   Thorax spine fusion....  .........  .........  .........  ...........  ...........
22558...  C                   Lumbar spine fusion....  .........  .........  .........  ...........  ...........
22585...  C                   Additional spinal        .........  .........  .........  ...........  ...........
                               fusion.
22590...  C                   Spine & skull spinal     .........  .........  .........  ...........  ...........
                               fusion.
22595...  C                   Neck spinal fusion.....  .........  .........  .........  ...........  ...........
22600...  C                   Neck spine fusion......  .........  .........  .........  ...........  ...........
22610...  C                   Thorax spine fusion....  .........  .........  .........  ...........  ...........
22612...  C                   Lumbar spine fusion....  .........  .........  .........  ...........  ...........
22614...  C                   Spine fusion, extra      .........  .........  .........  ...........  ...........
                               segment.
22630...  C                   Lumbar spine fusion....  .........  .........  .........  ...........  ...........
22632...  C                   Spine fusion, extra      .........  .........  .........  ...........  ...........
                               segment.
22800...  C                   Fusion of spine........  .........  .........  .........  ...........  ...........
22802...  C                   Fusion of spine........  .........  .........  .........  ...........  ...........
22804...  C                   Fusion of spine........  .........  .........  .........  ...........  ...........
22808...  C                   Fusion of spine........  .........  .........  .........  ...........  ...........
22810...  C                   Fusion of spine........  .........  .........  .........  ...........  ...........
22812...  C                   Fusion of spine........  .........  .........  .........  ...........  ...........
22818...  C                   Kyphectomy, 1-2          .........  .........  .........  ...........  ...........
                               segments.
22819...  C                   Kyphectomy, 3 & more     .........  .........  .........  ...........  ...........
                               segment.
22830...  C                   Exploration of spinal    .........  .........  .........  ...........  ...........
                               fusion.
22840...  C                   Insert spine fixation    .........  .........  .........  ...........  ...........
                               device.
22841...  C                   Insert spine fixation    .........  .........  .........  ...........  ...........
                               device.
22842...  C                   Insert spine fixation    .........  .........  .........  ...........  ...........
                               device.
22843...  C                   Insert spine fixation    .........  .........  .........  ...........  ...........
                               device.
22844...  C                   Insert spine fixation    .........  .........  .........  ...........  ...........
                               device.
22845...  C                   Insert spine fixation    .........  .........  .........  ...........  ...........
                               device.
22846...  C                   Insert spine fixation    .........  .........  .........  ...........  ...........
                               device.
22847...  C                   Insert spine fixation    .........  .........  .........  ...........  ...........
                               device.
22848...  C                   Insert pelvic fixation   .........  .........  .........  ...........  ...........
                               device.
22849...  C                   Reinsert spinal          .........  .........  .........  ...........  ...........
                               fixation.
22850...  C                   Remove spine fixation    .........  .........  .........  ...........  ...........
                               device.
22851...  C                   Apply spine prosth       .........  .........  .........  ...........  ...........
                               device.
22852...  C                   Remove spine fixation    .........  .........  .........  ...........  ...........
                               device.
22855...  C                   Remove spine fixation    .........  .........  .........  ...........  ...........
                               device.
22899...  T                   Spine surgery procedure        207       1.70     $90.11       $31.64       $18.02
22900...  T                   Remove abdominal wall          163      10.69    $565.14      $264.65      $113.03
                               lesion.
22999...  T                   Abdomen surgery                163      10.69    $565.14      $264.65      $113.03
                               procedure.
23000...  T                   Removal of calcium             162       5.67    $299.71      $125.43       $59.94
                               deposits.
23020...  T                   Release shoulder joint.        253      26.33  $1,392.78      $699.24      $278.56
23030...  T                   Drain shoulder lesion..        132       6.04    $319.30      $134.24       $63.86
23031...  T                   Drain shoulder bursa...        132       6.04    $319.30      $134.24       $63.86
23035...  C                   Drain shoulderbone       .........  .........  .........  ...........  ...........
                               lesion.
23040...  T                   Exploratory shoulder           252      19.39  $1,025.49      $509.18      $205.10
                               surgery.
23044...  T                   Exploratory shoulder           252      19.39  $1,025.49      $509.18      $205.10
                               surgery.
23065...  T                   Biopsy shoulder tissues        161       3.50    $185.12       $75.48       $37.02
23066...  T                   Biopsy shoulder tissues        163      10.69    $565.14      $264.65      $113.03
23075...  T                   Removal of shoulder            162       5.67    $299.71      $125.43       $59.94
                               lesion.
23076...  T                   Removal of shoulder            163      10.69    $565.14      $264.65      $113.03
                               lesion.
23077...  T                   Remove tumor of                163      10.69    $565.14      $264.65      $113.03
                               shoulder.
23100...  T                   Biopsy of shoulder             251      14.26    $754.18      $366.12      $150.84
                               joint.
23101...  T                   Shoulder joint surgery.        252      19.39  $1,025.49      $509.18      $205.10
23105...  T                   Remove shoulder joint          252      19.39  $1,025.49      $509.18      $205.10
                               lining.
23106...  T                   Incision of collarbone         252      19.39  $1,025.49      $509.18      $205.10
                               joint.
23107...  T                   Explore, treat shoulder        252      19.39  $1,025.49      $509.18      $205.10
                               joint.
23120...  T                   Partial removal,               253      26.33  $1,392.78      $699.24      $278.56
                               collarbone.
23125...  C                   Removal of collarbone..  .........  .........  .........  ...........  ...........
23130...  T                   Partial removal,               253      26.33  $1,392.78      $699.24      $278.56
                               shoulderbone.
23140...  T                   Removal of bone lesion.        251      14.26    $754.18      $366.12      $150.84
23145...  T                   Removal of bone lesion.        252      19.39  $1,025.49      $509.18      $205.10
23146...  T                   Removal of bone lesion.        252      19.39  $1,025.49      $509.18      $205.10
23150...  T                   Removal of humerus             252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
23155...  T                   Removal of humerus             252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
23156...  T                   Removal of humerus             252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
23170...  T                   Remove collarbone              252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
23172...  T                   Remove shoulder blade          252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
23174...  T                   Remove humerus lesion..        252      19.39  $1,025.49      $509.18      $205.10
23180...  T                   Remove collarbone              252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
23182...  T                   Remove shoulderblade           252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
23184...  T                   Remove humerus lesion..        252      19.39  $1,025.49      $509.18      $205.10
23190...  T                   Partial removal of             252      19.39  $1,025.49      $509.18      $205.10
                               scapula.
23195...  C                   Removal of head of       .........  .........  .........  ...........  ...........
                               humerus.

[[Page 47634]]

23200...  C                   Removal of collarbone..  .........  .........  .........  ...........  ...........
23210...  C                   Removal of               .........  .........  .........  ...........  ...........
                               shoulderblade.
23220...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               humerus.
23221...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               humerus.
23222...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               humerus.
23330...  T                   Remove shoulder foreign        163      10.69    $565.14      $264.65      $113.03
                               body.
23331...  T                   Remove shoulder foreign        163      10.69    $565.14      $264.65      $113.03
                               body.
23332...  C                   Remove shoulder foreign  .........  .........  .........  ...........  ...........
                               body.
23350...  T                   Injection for shoulder         347       2.93    $154.75       $62.15       $30.95
                               x-ray.
23395...  C                   Muscle transfer,         .........  .........  .........  ...........  ...........
                               shoulder/arm.
23397...  C                   Muscle transfers.......  .........  .........  .........  ...........  ...........
23400...  C                   Fixation of              .........  .........  .........  ...........  ...........
                               shoulderblade.
23405...  T                   Incision of tendon &           252      19.39  $1,025.49      $509.18      $205.10
                               muscle.
23406...  T                   Incise tendon(s) &             252      19.39  $1,025.49      $509.18      $205.10
                               muscle(s).
23410...  T                   Repair of tendon(s)....        254      34.37  $1,817.86      $937.22      $363.57
23412...  T                   Repair of tendon(s)....        254      34.37  $1,817.86      $937.22      $363.57
23415...  T                   Release of shoulder            253      26.33  $1,392.78      $699.24      $278.56
                               ligament.
23420...  T                   Repair of shoulder.....        254      34.37  $1,817.86      $937.22      $363.57
23430...  T                   Repair biceps tendon...        254      34.37  $1,817.86      $937.22      $363.57
23440...  C                   Removal/transplant       .........  .........  .........  ...........  ...........
                               tendon.
23450...  T                   Repair shoulder capsule        254      34.37  $1,817.86      $937.22      $363.57
23455...  T                   Repair shoulder capsule        254      34.37  $1,817.86      $937.22      $363.57
23460...  T                   Repair shoulder capsule        254      34.37  $1,817.86      $937.22      $363.57
23462...  T                   Repair shoulder capsule        254      34.37  $1,817.86      $937.22      $363.57
23465...  T                   Repair shoulder capsule        254      34.37  $1,817.86      $937.22      $363.57
23466...  T                   Repair shoulder capsule        254      34.37  $1,817.86      $937.22      $363.57
23470...  C                   Reconstruct shoulder     .........  .........  .........  ...........  ...........
                               joint.
23472...  C                   Reconstruct shoulder     .........  .........  .........  ...........  ...........
                               joint.
23480...  T                   Revision of collarbone.        253      26.33  $1,392.78      $699.24      $278.56
23485...  T                   Revision of collarbone.        253      26.33  $1,392.78      $699.24      $278.56
23490...  T                   Reinforce clavicle.....        253      26.33  $1,392.78      $699.24      $278.56
23491...  T                   Reinforce shoulderbones        253      26.33  $1,392.78      $699.24      $278.56
23500...  T                   Treat clavicle fracture        207       1.70     $90.11       $31.64       $18.02
23505...  T                   Treat clavicle fracture        207       1.70     $90.11       $31.64       $18.02
23515...  T                   Repair clavicle                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
23520...  T                   Treat clavicle                 207       1.70     $90.11       $31.64       $18.02
                               dislocation.
23525...  T                   Treat clavicle                 207       1.70     $90.11       $31.64       $18.02
                               dislocation.
23530...  T                   Repair clavicle                216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
23532...  T                   Repair clavicle                216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
23540...  T                   Treat clavicle                 207       1.70     $90.11       $31.64       $18.02
                               dislocation.
23545...  T                   Treat clavicle                 207       1.70     $90.11       $31.64       $18.02
                               dislocation.
23550...  T                   Repair clavicle                216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
23552...  T                   Repair clavicle                216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
23570...  T                   Treat shoulderblade            207       1.70     $90.11       $31.64       $18.02
                               fracture.
23575...  T                   Treat shoulderblade            207       1.70     $90.11       $31.64       $18.02
                               fracture.
23585...  T                   Repair scapula fracture        216      20.13  $1,064.67      $520.93      $212.93
23600...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
23605...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
23615...  T                   Repair humerus fracture        216      20.13  $1,064.67      $520.93      $212.93
23616...  T                   Repair humerus fracture        216      20.13  $1,064.67      $520.93      $212.93
23620...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
23625...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
23630...  T                   Repair humerus fracture        216      20.13  $1,064.67      $520.93      $212.93
23650...  T                   Treat shoulder                 207       1.70     $90.11       $31.64       $18.02
                               dislocation.
23655...  T                   Treat shoulder                 210      10.46    $553.39      $283.40      $110.68
                               dislocation.
23660...  T                   Repair shoulder                216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
23665...  T                   Treat dislocation/             209       1.94    $102.84       $37.29       $20.57
                               fracture.
23670...  T                   Repair dislocation/            216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
23675...  T                   Treat dislocation/             209       1.94    $102.84       $37.29       $20.57
                               fracture.
23680...  T                   Repair dislocation/            216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
23700...  T                   Fixation of shoulder...        210      10.46    $553.39      $283.40      $110.68
23800...  T                   Fusion of shoulder             253      26.33  $1,392.78      $699.24      $278.56
                               joint.
23802...  T                   Fusion of shoulder             253      26.33  $1,392.78      $699.24      $278.56
                               joint.
23900...  C                   Amputation of arm &      .........  .........  .........  ...........  ...........
                               girdle.
23920...  C                   Amputation at shoulder   .........  .........  .........  ...........  ...........
                               joint.
23921...  T                   Amputation follow-up           183      11.17    $590.61      $286.57      $118.12
                               surgery.
23929...  T                   Shoulder surgery               207       1.70     $90.11       $31.64       $18.02
                               procedure.
23930...  T                   Drainage of arm lesion.        132       6.04    $319.30      $134.24       $63.86
23931...  T                   Drainage of arm bursa..        132       6.04    $319.30      $134.24       $63.86
23935...  T                   Drain arm/elbow bone           251      14.26    $754.18      $366.12      $150.84
                               lesion.
24000...  T                   Exploratory elbow              252      19.39  $1,025.49      $509.18      $205.10
                               surgery.
24006...  T                   Release elbow joint....        252      19.39  $1,025.49      $509.18      $205.10
24065...  T                   Biopsy arm/elbow soft          161       3.50    $185.12       $75.48       $37.02
                               tissue.
24066...  T                   Biopsy arm/elbow soft          163      10.69    $565.14      $264.65      $113.03
                               tissue.
24075...  T                   Remove arm/elbow lesion        162       5.67    $299.71      $125.43       $59.94

[[Page 47635]]

24076...  T                   Remove arm/elbow lesion        163      10.69    $565.14      $264.65      $113.03
24077...  T                   Remove tumor of arm/           163      10.69    $565.14      $264.65      $113.03
                               elbow.
24100...  T                   Biopsy elbow joint             251      14.26    $754.18      $366.12      $150.84
                               lining.
24101...  T                   Explore/treat elbow            252      19.39  $1,025.49      $509.18      $205.10
                               joint.
24102...  T                   Remove elbow joint             252      19.39  $1,025.49      $509.18      $205.10
                               lining.
24105...  T                   Removal of elbow bursa.        251      14.26    $754.18      $366.12      $150.84
24110...  T                   Remove humerus lesion..        251      14.26    $754.18      $366.12      $150.84
24115...  T                   Remove/graft bone              252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
24116...  T                   Remove/graft bone              252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
24120...  T                   Remove elbow lesion....        251      14.26    $754.18      $366.12      $150.84
24125...  T                   Remove/graft bone              252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
24126...  T                   Remove/graft bone              252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
24130...  T                   Removal of head of             252      19.39  $1,025.49      $509.18      $205.10
                               radius.
24134...  T                   Removal of arm bone            252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
24136...  T                   Remove radius bone             252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
24138...  T                   Remove elbow bone              252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
24140...  T                   Partial removal of arm         252      19.39  $1,025.49      $509.18      $205.10
                               bone.
24145...  T                   Partial removal of             252      19.39  $1,025.49      $509.18      $205.10
                               radius.
24147...  T                   Partial removal of             252      19.39  $1,025.49      $509.18      $205.10
                               elbow.
24149...  C                   Radical resection of     .........  .........  .........  ...........  ...........
                               elbow.
24150...  C                   Extensive humerus        .........  .........  .........  ...........  ...........
                               surgery.
24151...  C                   Extensive humerus        .........  .........  .........  ...........  ...........
                               surgery.
24152...  C                   Extensive radius         .........  .........  .........  ...........  ...........
                               surgery.
24153...  C                   Extensive radius         .........  .........  .........  ...........  ...........
                               surgery.
24155...  T                   Removal of elbow joint.        253      26.33  $1,392.78      $699.24      $278.56
24160...  T                   Remove elbow joint             252      19.39  $1,025.49      $509.18      $205.10
                               implant.
24164...  T                   Remove radius head             252      19.39  $1,025.49      $509.18      $205.10
                               implant.
24200...  T                   Removal of arm foreign         161       3.50    $185.12       $75.48       $37.02
                               body.
24201...  T                   Removal of arm foreign         163      10.69    $565.14      $264.65      $113.03
                               body.
24220...  T                   Injection for elbow x-         347       2.93    $154.75       $62.15       $30.95
                               ray.
24301...  T                   Muscle/tendon transfer.        252      19.39  $1,025.49      $509.18      $205.10
24305...  T                   Arm tendon lengthening.        252      19.39  $1,025.49      $509.18      $205.10
24310...  T                   Revision of arm tendon.        251      14.26    $754.18      $366.12      $150.84
24320...  T                   Repair of arm tendon...        253      26.33  $1,392.78      $699.24      $278.56
24330...  T                   Revision of arm muscles        253      26.33  $1,392.78      $699.24      $278.56
24331...  T                   Revision of arm muscles        253      26.33  $1,392.78      $699.24      $278.56
24340...  T                   Repair of biceps tendon        253      26.33  $1,392.78      $699.24      $278.56
24341...  T                   Repair tendon/muscle           253      26.33  $1,392.78      $699.24      $278.56
                               arm.
24342...  T                   Repair of ruptured             253      26.33  $1,392.78      $699.24      $278.56
                               tendon.
24350...  T                   Repair of tennis elbow.        252      19.39  $1,025.49      $509.18      $205.10
24351...  T                   Repair of tennis elbow.        252      19.39  $1,025.49      $509.18      $205.10
24352...  T                   Repair of tennis elbow.        252      19.39  $1,025.49      $509.18      $205.10
24354...  T                   Repair of tennis elbow.        252      19.39  $1,025.49      $509.18      $205.10
24356...  T                   Revision of tennis             252      19.39  $1,025.49      $509.18      $205.10
                               elbow.
24360...  T                   Reconstruct elbow joint        217      20.48  $1,083.27      $526.81      $216.65
24361...  T                   Reconstruct elbow joint        218      27.50  $1,454.49      $715.52      $290.90
24362...  T                   Reconstruct elbow joint        218      27.50  $1,454.49      $715.52      $290.90
24363...  T                   Replace elbow joint....        218      27.50  $1,454.49      $715.52      $290.90
24365...  T                   Reconstruct head of            217      20.48  $1,083.27      $526.81      $216.65
                               radius.
24366...  T                   Reconstruct head of            218      27.50  $1,454.49      $715.52      $290.90
                               radius.
24400...  T                   Revision of humerus....        252      19.39  $1,025.49      $509.18      $205.10
24410...  T                   Revision of humerus....        252      19.39  $1,025.49      $509.18      $205.10
24420...  T                   Revision of humerus....        253      26.33  $1,392.78      $699.24      $278.56
24430...  T                   Repair of humerus......        253      26.33  $1,392.78      $699.24      $278.56
24435...  T                   Repair humerus with            253      26.33  $1,392.78      $699.24      $278.56
                               graft.
24470...  T                   Revision of elbow joint        253      26.33  $1,392.78      $699.24      $278.56
24495...  T                   Decompression of               252      19.39  $1,025.49      $509.18      $205.10
                               forearm.
24498...  T                   Reinforce humerus......        253      26.33  $1,392.78      $699.24      $278.56
24500...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
24505...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
24515...  T                   Repair humerus fracture        216      20.13  $1,064.67      $520.93      $212.93
24516...  T                   Repair humerus fracture        216      20.13  $1,064.67      $520.93      $212.93
24530...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
24535...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
24538...  T                   Treat humerus fracture.        216      20.13  $1,064.67      $520.93      $212.93
24545...  T                   Repair humerus fracture        216      20.13  $1,064.67      $520.93      $212.93
24546...  T                   Repair humerus fracture        216      20.13  $1,064.67      $520.93      $212.93
24560...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
24565...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
24566...  T                   Treat humerus fracture.        216      20.13  $1,064.67      $520.93      $212.93
24575...  T                   Repair humerus fracture        216      20.13  $1,064.67      $520.93      $212.93
24576...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
24577...  T                   Treat humerus fracture.        209       1.94    $102.84       $37.29       $20.57
24579...  T                   Repair humerus fracture        216      20.13  $1,064.67      $520.93      $212.93
24582...  T                   Treat humerus fracture.        216      20.13  $1,064.67      $520.93      $212.93

[[Page 47636]]

24586...  T                   Repair elbow fracture..        216      20.13  $1,064.67      $520.93      $212.93
24587...  T                   Repair elbow fracture..        216      20.13  $1,064.67      $520.93      $212.93
24600...  T                   Treat elbow dislocation        209       1.94    $102.84       $37.29       $20.57
24605...  T                   Treat elbow dislocation        210      10.46    $553.39      $283.40      $110.68
24615...  T                   Repair elbow                   216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
24620...  T                   Treat elbow fracture...        209       1.94    $102.84       $37.29       $20.57
24635...  T                   Repair elbow fracture..        216      20.13  $1,064.67      $520.93      $212.93
24640...  T                   Treat elbow dislocation        209       1.94    $102.84       $37.29       $20.57
24650...  T                   Treat radius fracture..        209       1.94    $102.84       $37.29       $20.57
24655...  T                   Treat radius fracture..        209       1.94    $102.84       $37.29       $20.57
24665...  T                   Repair radius fracture.        216      20.13  $1,064.67      $520.93      $212.93
24666...  T                   Repair radius fracture.        216      20.13  $1,064.67      $520.93      $212.93
24670...  T                   Treatment of ulna              209       1.94    $102.84       $37.29       $20.57
                               fracture.
24675...  T                   Treatment of ulna              209       1.94    $102.84       $37.29       $20.57
                               fracture.
24685...  T                   Repair ulna fracture...        216      20.13  $1,064.67      $520.93      $212.93
24800...  T                   Fusion of elbow joint..        253      26.33  $1,392.78      $699.24      $278.56
24802...  T                   Fusion/graft of elbow          253      26.33  $1,392.78      $699.24      $278.56
                               joint.
24900...  C                   Amputation of upper arm  .........  .........  .........  ...........  ...........
24920...  C                   Amputation of upper arm  .........  .........  .........  ...........  ...........
24925...  T                   Amputation follow-up           251      14.26    $754.18      $366.12      $150.84
                               surgery.
24930...  C                   Amputation follow-up     .........  .........  .........  ...........  ...........
                               surgery.
24931...  C                   Amputate upper arm &     .........  .........  .........  ...........  ...........
                               implant.
24935...  C                   Revision of amputation.  .........  .........  .........  ...........  ...........
24940...  C                   Revision of upper arm..  .........  .........  .........  ...........  ...........
24999...  T                   Upper arm/elbow surgery        209       1.94    $102.84       $37.29       $20.57
25000...  T                   Incision of tendon             251      14.26    $754.18      $366.12      $150.84
                               sheath.
25020...  T                   Decompression of               251      14.26    $754.18      $366.12      $150.84
                               forearm.
25023...  T                   Decompression of               252      19.39  $1,025.49      $509.18      $205.10
                               forearm.
25028...  T                   Drainage of forearm            251      14.26    $754.18      $366.12      $150.84
                               lesion.
25031...  T                   Drainage of forearm            251      14.26    $754.18      $366.12      $150.84
                               bursa.
25035...  T                   Treat forearm bone             251      14.26    $754.18      $366.12      $150.84
                               lesion.
25040...  T                   Explore/treat wrist            252      19.39  $1,025.49      $509.18      $205.10
                               joint.
25065...  T                   Biopsy forearm soft            161       3.50    $185.12       $75.48       $37.02
                               tissues.
25066...  T                   Biopsy forearm soft            163      10.69    $565.14      $264.65      $113.03
                               tissues.
25075...  T                   Removal of forearm             162       5.67    $299.71      $125.43       $59.94
                               lesion.
25076...  T                   Removal of forearm             163      10.69    $565.14      $264.65      $113.03
                               lesion.
25077...  T                   Remove tumor, forearm/         163      10.69    $565.14      $264.65      $113.03
                               wrist.
25085...  T                   Incision of wrist              251      14.26    $754.18      $366.12      $150.84
                               capsule.
25100...  T                   Biopsy of wrist joint..        251      14.26    $754.18      $366.12      $150.84
25101...  T                   Explore/treat wrist            252      19.39  $1,025.49      $509.18      $205.10
                               joint.
25105...  T                   Remove wrist joint             252      19.39  $1,025.49      $509.18      $205.10
                               lining.
25107...  T                   Remove wrist joint             252      19.39  $1,025.49      $509.18      $205.10
                               cartilage.
25110...  T                   Remove wrist tendon            251      14.26    $754.18      $366.12      $150.84
                               lesion.
25111...  T                   Remove wrist tendon            261      10.54    $557.31      $261.48      $111.46
                               lesion.
25112...  T                   Remove wrist tendon            261      10.54    $557.31      $261.48      $111.46
                               lesion.
25115...  T                   Remove wrist/forearm           251      14.26    $754.18      $366.12      $150.84
                               lesion.
25116...  T                   Remove wrist/forearm           251      14.26    $754.18      $366.12      $150.84
                               lesion.
25118...  T                   Excise wrist tendon            252      19.39  $1,025.49      $509.18      $205.10
                               sheath.
25119...  T                   Partial removal of ulna        252      19.39  $1,025.49      $509.18      $205.10
25120...  T                   Removal of forearm             252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
25125...  T                   Remove/graft forearm           252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
25126...  T                   Remove/graft forearm           252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
25130...  T                   Removal of wrist lesion        252      19.39  $1,025.49      $509.18      $205.10
25135...  T                   Remove & graft wrist           252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
25136...  T                   Remove & graft wrist           252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
25145...  T                   Remove forearm bone            252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
25150...  T                   Partial removal of ulna        252      19.39  $1,025.49      $509.18      $205.10
25151...  T                   Partial removal of             252      19.39  $1,025.49      $509.18      $205.10
                               radius.
25170...  C                   Extensive forearm        .........  .........  .........  ...........  ...........
                               surgery.
25210...  T                   Removal of wrist bone..        262      18.35    $970.64      $480.93      $194.13
25215...  T                   Removal of wrist bones.        262      18.35    $970.64      $480.93      $194.13
25230...  T                   Partial removal of             252      19.39  $1,025.49      $509.18      $205.10
                               radius.
25240...  T                   Partial removal of ulna        252      19.39  $1,025.49      $509.18      $205.10
25246...  T                   Injection for wrist x-         347       2.93    $154.75       $62.15       $30.95
                               ray.
25248...  T                   Remove forearm foreign         251      14.26    $754.18      $366.12      $150.84
                               body.
25250...  T                   Removal of wrist               252      19.39  $1,025.49      $509.18      $205.10
                               prosthesis.
25251...  T                   Removal of wrist               252      19.39  $1,025.49      $509.18      $205.10
                               prosthesis.
25260...  T                   Repair forearm tendon/         252      19.39  $1,025.49      $509.18      $205.10
                               muscle.
25263...  T                   Repair forearm tendon/         252      19.39  $1,025.49      $509.18      $205.10
                               muscle.
25265...  T                   Repair forearm tendon/         252      19.39  $1,025.49      $509.18      $205.10
                               muscle.
25270...  T                   Repair forearm tendon/         252      19.39  $1,025.49      $509.18      $205.10
                               muscle.
25272...  T                   Repair forearm tendon/         252      19.39  $1,025.49      $509.18      $205.10
                               muscle.
25274...  T                   Repair forearm tendon/         252      19.39  $1,025.49      $509.18      $205.10
                               muscle.
25280...  T                   Revise wrist/forearm           252      19.39  $1,025.49      $509.18      $205.10
                               tendon.
25290...  T                   Incise wrist/forearm           252      19.39  $1,025.49      $509.18      $205.10
                               tendon.

[[Page 47637]]

25295...  T                   Release wrist/forearm          251      14.26    $754.18      $366.12      $150.84
                               tendon.
25300...  T                   Fusion of tendons at           252      19.39  $1,025.49      $509.18      $205.10
                               wrist.
25301...  T                   Fusion of tendons at           252      19.39  $1,025.49      $509.18      $205.10
                               wrist.
25310...  T                   Transplant forearm             253      26.33  $1,392.78      $699.24      $278.56
                               tendon.
25312...  T                   Transplant forearm             253      26.33  $1,392.78      $699.24      $278.56
                               tendon.
25315...  T                   Revise palsy hand              253      26.33  $1,392.78      $699.24      $278.56
                               tendon(s).
25316...  T                   Revise palsy hand              253      26.33  $1,392.78      $699.24      $278.56
                               tendon(s).
25320...  T                   Repair/revise wrist            253      26.33  $1,392.78      $699.24      $278.56
                               joint.
25332...  T                   Revise wrist joint.....        217      20.48  $1,083.27      $526.81      $216.65
25335...  T                   Realignment of hand....        253      26.33  $1,392.78      $699.24      $278.56
25337...  T                   Reconstruct ulna/              253      26.33  $1,392.78      $699.24      $278.56
                               radioulnar.
25350...  T                   Revision of radius.....        253      26.33  $1,392.78      $699.24      $278.56
25355...  T                   Revision of radius.....        253      26.33  $1,392.78      $699.24      $278.56
25360...  T                   Revision of ulna.......        252      19.39  $1,025.49      $509.18      $205.10
25365...  T                   Revise radius & ulna...        252      19.39  $1,025.49      $509.18      $205.10
25370...  T                   Revise radius or ulna..        253      26.33  $1,392.78      $699.24      $278.56
25375...  T                   Revise radius & ulna...        253      26.33  $1,392.78      $699.24      $278.56
25390...  C                   Shorten radius/ulna....  .........  .........  .........  ...........  ...........
25391...  C                   Lengthen radius/ulna...  .........  .........  .........  ...........  ...........
25392...  C                   Shorten radius & ulna..  .........  .........  .........  ...........  ...........
25393...  C                   Lengthen radius & ulna.  .........  .........  .........  ...........  ...........
25400...  T                   Repair radius or ulna..        252      19.39  $1,025.49      $509.18      $205.10
25405...  C                   Repair/graft radius or   .........  .........  .........  ...........  ...........
                               ulna.
25415...  T                   Repair radius & ulna...        252      19.39  $1,025.49      $509.18      $205.10
25420...  C                   Repair/graft radius &    .........  .........  .........  ...........  ...........
                               ulna.
25425...  T                   Repair/graft radius or         253      26.33  $1,392.78      $699.24      $278.56
                               ulna.
25426...  T                   Repair/graft radius &          253      26.33  $1,392.78      $699.24      $278.56
                               ulna.
25440...  T                   Repair/graft wrist bone        253      26.33  $1,392.78      $699.24      $278.56
25441...  T                   Reconstruct wrist joint        218      27.50  $1,454.49      $715.52      $290.90
25442...  T                   Reconstruct wrist joint        218      27.50  $1,454.49      $715.52      $290.90
25443...  T                   Reconstruct wrist joint        218      27.50  $1,454.49      $715.52      $290.90
25444...  T                   Reconstruct wrist joint        218      27.50  $1,454.49      $715.52      $290.90
25445...  T                   Reconstruct wrist joint        218      27.50  $1,454.49      $715.52      $290.90
25446...  T                   Wrist replacement......        218      27.50  $1,454.49      $715.52      $290.90
25447...  T                   Repair wrist joint(s)..        217      20.48  $1,083.27      $526.81      $216.65
25449...  T                   Remove wrist joint             217      20.48  $1,083.27      $526.81      $216.65
                               implant.
25450...  T                   Revision of wrist joint        253      26.33  $1,392.78      $699.24      $278.56
25455...  T                   Revision of wrist joint        253      26.33  $1,392.78      $699.24      $278.56
25490...  T                   Reinforce radius.......        253      26.33  $1,392.78      $699.24      $278.56
25491...  T                   Reinforce ulna.........        253      26.33  $1,392.78      $699.24      $278.56
25492...  T                   Reinforce radius and           253      26.33  $1,392.78      $699.24      $278.56
                               ulna.
25500...  T                   Treat fracture of              209       1.94    $102.84       $37.29       $20.57
                               radius.
25505...  T                   Treat fracture of              209       1.94    $102.84       $37.29       $20.57
                               radius.
25515...  T                   Repair fracture of             216      20.13  $1,064.67      $520.93      $212.93
                               radius.
25520...  T                   Repair fracture of             209       1.94    $102.84       $37.29       $20.57
                               radius.
25525...  T                   Repair fracture of             216      20.13  $1,064.67      $520.93      $212.93
                               radius.
25526...  T                   Repair fracture of             216      20.13  $1,064.67      $520.93      $212.93
                               radius.
25530...  T                   Treat fracture of ulna.        209       1.94    $102.84       $37.29       $20.57
25535...  T                   Treat fracture of ulna.        209       1.94    $102.84       $37.29       $20.57
25545...  T                   Repair fracture of ulna        216      20.13  $1,064.67      $520.93      $212.93
25560...  T                   Treat fracture radius &        209       1.94    $102.84       $37.29       $20.57
                               ulna.
25565...  T                   Treat fracture radius &        209       1.94    $102.84       $37.29       $20.57
                               ulna.
25574...  T                   Treat fracture radius &        216      20.13  $1,064.67      $520.93      $212.93
                               ulna.
25575...  T                   Repair fracture radius/        216      20.13  $1,064.67      $520.93      $212.93
                               ulna.
25600...  T                   Treat fracture radius/         209       1.94    $102.84       $37.29       $20.57
                               ulna.
25605...  T                   Treat fracture radius/         209       1.94    $102.84       $37.29       $20.57
                               ulna.
25611...  T                   Repair fracture radius/        216      20.13  $1,064.67      $520.93      $212.93
                               ulna.
25620...  T                   Repair fracture radius/        216      20.13  $1,064.67      $520.93      $212.93
                               ulna.
25622...  T                   Treat wrist bone               209       1.94    $102.84       $37.29       $20.57
                               fracture.
25624...  T                   Treat wrist bone               209       1.94    $102.84       $37.29       $20.57
                               fracture.
25628...  T                   Repair wrist bone              216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
25630...  T                   Treat wrist bone               209       1.94    $102.84       $37.29       $20.57
                               fracture.
25635...  T                   Treat wrist bone               209       1.94    $102.84       $37.29       $20.57
                               fracture.
25645...  T                   Repair wrist bone              216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
25650...  T                   Repair wrist bone              209       1.94    $102.84       $37.29       $20.57
                               fracture.
25660...  T                   Treat wrist dislocation        209       1.94    $102.84       $37.29       $20.57
25670...  T                   Repair wrist                   216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
25675...  T                   Treat wrist dislocation        209       1.94    $102.84       $37.29       $20.57
25676...  T                   Repair wrist                   216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
25680...  T                   Treat wrist fracture...        209       1.94    $102.84       $37.29       $20.57
25685...  T                   Repair wrist fracture..        216      20.13  $1,064.67      $520.93      $212.93
25690...  T                   Treat wrist dislocation        209       1.94     102.84       $37.29       $20.57
25695...  T                   Repair wrist                   216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
25800...  T                   Fusion of wrist joint..        253      26.33  $1,392.78      $699.24      $278.56
25805...  T                   Fusion/graft of wrist          253      26.33  $1,392.78      $699.24      $278.56
                               joint.

[[Page 47638]]

25810...  T                   Fusion/graft of wrist          253      26.33  $1,392.78      $699.24      $278.56
                               joint.
25820...  T                   Fusion of hand bones...        261      10.54    $557.31      $261.48      $111.46
25825...  T                   Fusion hand bones with         262      18.35    $970.64      $480.93      $194.13
                               graft.
25830...  T                   Fusion radioulnar jnt/         253      26.33  $1,392.78      $699.24      $278.56
                               ulna.
25900...  C                   Amputation of forearm..  .........  .........  .........  ...........  ...........
25905...  C                   Amputation of forearm..  .........  .........  .........  ...........  ...........
25907...  T                   Amputation follow-up           251      14.26    $754.18      $366.12      $150.84
                               surgery.
25909...  C                   Amputation follow-up     .........  .........  .........  ...........  ...........
                               surgery.
25915...  C                   Amputation of forearm..  .........  .........  .........  ...........  ...........
25920...  C                   Amputate hand at wrist.  .........  .........  .........  ...........  ...........
25922...  T                   Amputate hand at wrist.        251      14.26    $754.18      $366.12      $150.84
25924...  C                   Amputation follow-up     .........  .........  .........  ...........  ...........
                               surgery.
25927...  C                   Amputation of hand.....  .........  .........  .........  ...........  ...........
25929...  T                   Amputation follow-up           183      11.17    $590.61      $286.57      $118.12
                               surgery.
25931...  C                   Amputation follow-up     .........  .........  .........  ...........  ...........
                               surgery.
25999...  T                   Forearm or wrist               209       1.94    $102.84       $37.29       $20.57
                               surgery.
26010...  T                   Drainage of finger             131       1.94    $102.84       $36.61       $20.57
                               abscess.
26011...  T                   Drainage of finger             131       1.94    $102.84       $36.61       $20.57
                               abscess.
26020...  T                   Drain hand tendon              261      10.54    $557.31      $261.48      $111.46
                               sheath.
26025...  T                   Drainage of palm bursa.        261      10.54    $557.31      $261.48      $111.46
26030...  T                   Drainage of palm               261      10.54    $557.31      $261.48      $111.46
                               bursa(s).
26034...  T                   Treat hand bone lesion.        261      10.54    $557.31      $261.48      $111.46
26035...  T                   Decompress fingers/hand        261      10.54    $557.31      $261.48      $111.46
26037...  T                   Decompress fingers/hand        261      10.54    $557.31      $261.48      $111.46
26040...  T                   Release palm                   262      18.35    $970.64      $480.93      $194.13
                               contracture.
26045...  T                   Release palm                   262      18.35    $970.64      $480.93      $194.13
                               contracture.
26055...  T                   Incise finger tendon           261      10.54    $557.31      $261.48      $111.46
                               sheath.
26060...  T                   Incision of finger             261      10.54    $557.31      $261.48      $111.46
                               tendon.
26070...  T                   Explore/treat hand             261      10.54    $557.31      $261.48      $111.46
                               joint.
26075...  T                   Explore/treat finger           261      10.54    $557.31      $261.48      $111.46
                               joint.
26080...  T                   Explore/treat finger           261      10.54    $557.31      $261.48      $111.46
                               joint.
26100...  T                   Biopsy hand joint              261      10.54    $557.31      $261.48      $111.46
                               lining.
26105...  T                   Biopsy finger joint            261      10.54    $557.31      $261.48      $111.46
                               lining.
26110...  T                   Biopsy finger joint            261      10.54    $557.31      $261.48      $111.46
                               lining.
26115...  T                   Removal of hand lesion.        163      10.69    $565.14      $264.65      $113.03
26116...  T                   Removal of hand lesion.        163      10.69    $565.14      $264.65      $113.03
26117...  T                   Remove tumor, hand/            163      10.69    $565.14      $264.65      $113.03
                               finger.
26121...  T                   Release palm                   262      18.35    $970.64      $480.93      $194.13
                               contracture.
26123...  T                   Release palm                   262      18.35    $970.64      $480.93      $194.13
                               contracture.
26125...  T                   Release palm                   262      18.35    $970.64      $480.93      $194.13
                               contracture.
26130...  T                   Remove wrist joint             261      10.54    $557.31      $261.48      $111.46
                               lining.
26135...  T                   Revise finger joint,           262      18.35    $970.64      $480.93      $194.13
                               each.
26140...  T                   Revise finger joint,           261      10.54    $557.31      $261.48      $111.46
                               each.
26145...  T                   Tendon excision, palm/         261      10.54    $557.31      $261.48      $111.46
                               finger.
26160...  T                   Remove tendon sheath           261      10.54    $557.31      $261.48      $111.46
                               lesion.
26170...  T                   Removal of palm tendon,        261      10.54    $557.31      $261.48      $111.46
                               each.
26180...  T                   Removal of finger              261      10.54    $557.31      $261.48      $111.46
                               tendon.
26185...  T                   Remove finger bone.....        261      10.54    $557.31      $261.48      $111.46
26200...  T                   Remove hand bone lesion        261      10.54    $557.31      $261.48      $111.46
26205...  T                   Remove/graft bone              262      18.35    $970.64      $480.93      $194.13
                               lesion.
26210...  T                   Removal of finger              261      10.54    $557.31      $261.48      $111.46
                               lesion.
26215...  T                   Remove/graft finger            261      10.54    $557.31      $261.48      $111.46
                               lesion.
26230...  T                   Partial removal of hand        261      10.54    $557.31      $261.48      $111.46
                               bone.
26235...  T                   Partial removal, finger        261      10.54    $557.31      $261.48      $111.46
                               bone.
26236...  T                   Partial removal, finger        261      10.54    $557.31      $261.48      $111.46
                               bone.
26250...  T                   Extensive hand surgery.        261      10.54    $557.31      $261.48      $111.46
26255...  T                   Extensive hand surgery.        262      18.35    $970.64      $480.93      $194.13
26260...  T                   Extensive finger               261      10.54    $557.31      $261.48      $111.46
                               surgery.
26261...  T                   Extensive finger               261      10.54    $557.31      $261.48      $111.46
                               surgery.
26262...  T                   Partial removal of             261      10.54    $557.31      $261.48      $111.46
                               finger.
26320...  T                   Removal of implant from        163      10.69    $565.14      $264.65      $113.03
                               hand.
26350...  T                   Repair finger/hand             262      18.35    $970.64      $480.93      $194.13
                               tendon.
26352...  T                   Repair/graft hand              262      18.35    $970.64      $480.93      $194.13
                               tendon.
26356...  T                   Repair finger/hand             262      18.35    $970.64      $480.93      $194.13
                               tendon.
26357...  T                   Repair finger/hand             262      18.35    $970.64      $480.93      $194.13
                               tendon.
26358...  T                   Repair/graft hand              262      18.35    $970.64      $480.93      $194.13
                               tendon.
26370...  T                   Repair finger/hand             262      18.35    $970.64      $480.93      $194.13
                               tendon.
26372...  T                   Repair/graft hand              262      18.35    $970.64      $480.93      $194.13
                               tendon.
26373...  T                   Repair finger/hand             262      18.35    $970.64      $480.93      $194.13
                               tendon.
26390...  T                   Revise hand/finger             262      18.35    $970.64      $480.93      $194.13
                               tendon.
26392...  T                   Repair/graft hand              262      18.35    $970.64      $480.93      $194.13
                               tendon.
26410...  T                   Repair hand tendon.....        261      10.54    $557.31      $261.48      $111.46
26412...  T                   Repair/graft hand              262      18.35    $970.64      $480.93      $194.13
                               tendon.
26415...  T                   Excision, hand/finger          262      18.35    $970.64      $480.93      $194.13
                               tendon.
26416...  T                   Graft hand or finger           262      18.35    $970.64      $480.93      $194.13
                               tendon.

[[Page 47639]]

26418...  T                   Repair finger tendon...        261      10.54    $557.31      $261.48      $111.46
26420...  T                   Repair/graft finger            262      18.35    $970.64      $480.93      $194.13
                               tendon.
26426...  T                   Repair finger/hand             262      18.35    $970.64      $480.93      $194.13
                               tendon.
26428...  T                   Repair/graft finger            262      18.35    $970.64      $480.93      $194.13
                               tendon.
26432...  T                   Repair finger tendon...        261      10.54    $557.31      $261.48      $111.46
26433...  T                   Repair finger tendon...        261      10.54    $557.31      $261.48      $111.46
26434...  T                   Repair/graft finger            262      18.35    $970.64      $480.93      $194.13
                               tendon.
26437...  T                   Realignment of tendons.        261      10.54    $557.31      $261.48      $111.46
26440...  T                   Release palm/finger            261      10.54    $557.31      $261.48      $111.46
                               tendon.
26442...  T                   Release palm & finger          262      18.35    $970.64      $480.93      $194.13
                               tendon.
26445...  T                   Release hand/finger            261      10.54    $557.31      $261.48      $111.46
                               tendon.
26449...  T                   Release forearm/hand           262      18.35    $970.64      $480.93      $194.13
                               tendon.
26450...  T                   Incision of palm tendon        261      10.54    $557.31      $261.48      $111.46
26455...  T                   Incision of finger             261      10.54    $557.31      $261.48      $111.46
                               tendon.
26460...  T                   Incise hand/finger             261      10.54    $557.31      $261.48      $111.46
                               tendon.
26471...  T                   Fusion of finger               261      10.54    $557.31      $261.48      $111.46
                               tendons.
26474...  T                   Fusion of finger               261      10.54    $557.31      $261.48      $111.46
                               tendons.
26476...  T                   Tendon lengthening.....        261      10.54    $557.31      $261.48      $111.46
26477...  T                   Tendon shortening......        261      10.54    $557.31      $261.48      $111.46
26478...  T                   Lengthening of hand            261      10.54    $557.31      $261.48      $111.46
                               tendon.
26479...  T                   Shortening of hand             261      10.54    $557.31      $261.48      $111.46
                               tendon.
26480...  T                   Transplant hand tendon.        262      18.35    $970.64      $480.93      $194.13
26483...  T                   Transplant/graft hand          262      18.35    $970.64      $480.93      $194.13
                               tendon.
26485...  T                   Transplant palm tendon.        262      18.35    $970.64      $480.93      $194.13
26489...  T                   Transplant/graft palm          262      18.35    $970.64      $480.93      $194.13
                               tendon.
26490...  T                   Revise thumb tendon....        262      18.35    $970.64      $480.93      $194.13
26492...  T                   Tendon transfer with           262      18.35    $970.64      $480.93      $194.13
                               graft.
26494...  T                   Hand tendon/muscle             262      18.35    $970.64      $480.93      $194.13
                               transfer.
26496...  T                   Revise thumb tendon....        262      18.35    $970.64      $480.93      $194.13
26497...  T                   Finger tendon transfer.        262      18.35    $970.64      $480.93      $194.13
26498...  T                   Finger tendon transfer.        262      18.35    $970.64      $480.93      $194.13
26499...  T                   Revision of finger.....        262      18.35    $970.64      $480.93      $194.13
26500...  T                   Hand tendon                    261      10.54    $557.31      $261.48      $111.46
                               reconstruction.
26502...  T                   Hand tendon                    262      18.35    $970.64      $480.93      $194.13
                               reconstruction.
26504...  T                   Hand tendon                    262      18.35    $970.64      $480.93      $194.13
                               reconstruction.
26508...  T                   Release thumb                  261      10.54    $557.31      $261.48      $111.46
                               contracture.
26510...  T                   Thumb tendon transfer..        262      18.35    $970.64      $480.93      $194.13
26516...  T                   Fusion of knuckle joint        262      18.35    $970.64      $480.93      $194.13
26517...  T                   Fusion of knuckle              262      18.35    $970.64      $480.93      $194.13
                               joints.
26518...  T                   Fusion of knuckle              262      18.35    $970.64      $480.93      $194.13
                               joints.
26520...  T                   Release knuckle                261      10.54    $557.31      $261.48      $111.46
                               contracture.
26525...  T                   Release finger                 261      10.54    $557.31      $261.48      $111.46
                               contracture.
26530...  T                   Revise knuckle joint...        217      20.48  $1,083.27      $526.81      $216.65
26531...  T                   Revise knuckle with            218      27.50  $1,454.49      $715.52      $290.90
                               implant.
26535...  T                   Revise finger joint....        217      20.48  $1,083.27      $526.81      $216.65
26536...  T                   Revise/implant finger          218      27.50  $1,454.49      $715.52      $290.90
                               joint.
26540...  T                   Repair hand joint......        261      10.54    $557.31      $261.48      $111.46
26541...  T                   Repair hand joint with         262      18.35    $970.64      $480.93      $194.13
                               graft.
26542...  T                   Repair hand joint with         261      10.54    $557.31      $261.48      $111.46
                               graft.
26545...  T                   Reconstruct finger             262      18.35    $970.64      $480.93      $194.13
                               joint.
26546...  T                   Repair non-union hand..        262      18.35    $970.64      $480.93      $194.13
26548...  T                   Reconstruct finger             262      18.35    $970.64      $480.93      $194.13
                               joint.
26550...  T                   Construct thumb                262      18.35    $970.64      $480.93      $194.13
                               replacement.
26551...  C                   Great toe-hand transfer  .........  .........  .........  ...........  ...........
26553...  C                   Single toe-hand          .........  .........  .........  ...........  ...........
                               transfer.
26554...  C                   Double toe-hand          .........  .........  .........  ...........  ...........
                               transfer.
26555...  T                   Positional change of           262      18.35    $970.64      $480.93      $194.13
                               finger.
26556...  C                   Toe joint transfer.....  .........  .........  .........  ...........  ...........
26560...  T                   Repair of web finger...        261      10.54    $557.31      $261.48      $111.46
26561...  T                   Repair of web finger...        262      18.35    $970.64      $480.93      $194.13
26562...  T                   Repair of web finger...        262      18.35    $970.64      $480.93      $194.13
26565...  T                   Correct metacarpal flaw        262      18.35    $970.64      $480.93      $194.13
26567...  T                   Correct finger                 262      18.35    $970.64      $480.93      $194.13
                               deformity.
26568...  T                   Lengthen metacarpal/           262      18.35    $970.64      $480.93      $194.13
                               finger.
26580...  T                   Repair hand deformity..        262      18.35    $970.64      $480.93      $194.13
26585...  T                   Repair finger deformity        262      18.35    $970.64      $480.93      $194.13
26587...  T                   Reconstruct extra              261      10.54    $557.31      $261.48      $111.46
                               finger.
26590...  T                   Repair finger deformity        262      18.35    $970.64      $480.93      $194.13
26591...  T                   Repair muscles of hand.        262      18.35    $970.64      $480.93      $194.13
26593...  T                   Release muscles of hand        261      10.54    $557.31      $261.48      $111.46
26596...  T                   Excision constricting          262      18.35    $970.64      $480.93      $194.13
                               tissue.
26597...  T                   Release of scar                262      18.35    $970.64      $480.93      $194.13
                               contracture.
26600...  T                   Treat metacarpal               209       1.94    $102.84       $37.29       $20.57
                               fracture.
26605...  T                   Treat metacarpal               209       1.94    $102.84       $37.29       $20.57
                               fracture.
26607...  T                   Treat metacarpal               209       1.94    $102.84       $37.29       $20.57
                               fracture.

[[Page 47640]]

26608...  T                   Treat metacarpal               216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
26615...  T                   Repair metacarpal              216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
26641...  T                   Treat thumb dislocation        209       1.94    $102.84       $37.29       $20.57
26645...  T                   Treat thumb fracture...        209       1.94    $102.84       $37.29       $20.57
26650...  T                   Repair thumb fracture..        216      20.13  $1,064.67      $520.93      $212.93
26665...  T                   Repair thumb fracture..        216      20.13  $1,064.67      $520.93      $212.93
26670...  T                   Treat hand dislocation.        209       1.94    $102.84       $37.29       $20.57
26675...  T                   Treat hand dislocation.        210      10.46    $553.39       $283.4      $110.68
26676...  T                   Pin hand dislocation...        216      20.13  $1,064.67      $520.93      $212.93
26685...  T                   Repair hand dislocation        216      20.13  $1,064.67      $520.93      $212.93
26686...  T                   Repair hand dislocation        216      20.13  $1,064.67      $520.93      $212.93
26700...  T                   Treat knuckle                  207       1.70     $90.11       $31.64       $18.02
                               dislocation.
26705...  T                   Treat knuckle                  210      10.46    $553.39       $283.4      $110.68
                               dislocation.
26706...  T                   Pin knuckle dislocation        209       1.94    $102.84       $37.29       $20.57
26715...  T                   Repair knuckle                 216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
26720...  T                   Treat finger fracture,         207       1.70     $90.11       $31.64       $18.02
                               each.
26725...  T                   Treat finger fracture,         207       1.70     $90.11       $31.64       $18.02
                               each.
26727...  T                   Treat finger fracture,         216      20.13  $1,064.67      $520.93      $212.93
                               each.
26735...  T                   Repair finger fracture,        216      20.13  $1,064.67      $520.93      $212.93
                               each.
26740...  T                   Treat finger fracture,         207       1.70     $90.11       $31.64       $18.02
                               each.
26742...  T                   Treat finger fracture,         209       1.94    $102.84       $37.29       $20.57
                               each.
26746...  T                   Repair finger fracture,        216      20.13  $1,064.67      $520.93      $212.93
                               each.
26750...  T                   Treat finger fracture,         207       1.70     $90.11       $31.64       $18.02
                               each.
26755...  T                   Treat finger fracture,         207       1.70     $90.11       $31.64       $18.02
                               each.
26756...  T                   Pin finger fracture,           216      20.13  $1,064.67      $520.93      $212.93
                               each.
26765...  T                   Repair finger fracture,        216      20.13  $1,064.67      $520.93      $212.93
                               each.
26770...  T                   Treat finger                   207       1.70     $90.11       $31.64       $18.02
                               dislocation.
26775...  T                   Treat finger                   210      10.46    $553.39       $283.4      $110.68
                               dislocation.
26776...  T                   Pin finger dislocation.        216      20.13  $1,064.67      $520.93      $212.93
26785...  T                   Repair finger                  216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
26820...  T                   Thumb fusion with graft        262      18.35    $970.64      $480.93      $194.13
26841...  T                   Fusion of thumb........        262      18.35    $970.64      $480.93      $194.13
26842...  T                   Thumb fusion with graft        262      18.35    $970.64      $480.93      $194.13
26843...  T                   Fusion of hand joint...        262      18.35    $970.64      $480.93      $194.13
26844...  T                   Fusion/graft of hand           262      18.35    $970.64      $480.93      $194.13
                               joint.
26850...  T                   Fusion of knuckle......        262      18.35    $970.64      $480.93      $194.13
26852...  T                   Fusion of knuckle with         262      18.35    $970.64      $480.93      $194.13
                               graft.
26860...  T                   Fusion of finger joint.        262      18.35    $970.64      $480.93      $194.13
26861...  T                   Fusion of finger joint,        262      18.35    $970.64      $480.93      $194.13
                               added.
26862...  T                   Fusion/graft of finger         262      18.35    $970.64      $480.93      $194.13
                               joint.
26863...  T                   Fuse/graft added joint.        262      18.35    $970.64      $480.93      $194.13
26910...  T                   Amputate metacarpal            262      18.35    $970.64      $480.93      $194.13
                               bone.
26951...  T                   Amputation of finger/          261      10.54    $557.31      $261.48      $111.46
                               thumb.
26952...  T                   Amputation of finger/          261      10.54    $557.31      $261.48      $111.46
                               thumb.
26989...  T                   Hand/finger surgery....        207       1.70     $90.11       $31.64       $18.02
26990...  T                   Drainage of pelvis             251      14.26    $754.18      $366.12      $150.84
                               lesion.
26991...  T                   Drainage of pelvis             251      14.26    $754.18      $366.12      $150.84
                               bursa.
26992...  C                   Drainage of bone lesion  .........  .........  .........  ...........  ...........
27000...  T                   Incision of hip tendon.        251      14.26    $754.18      $366.12      $150.84
27001...  T                   Incision of hip tendon.        252      19.39  $1,025.49      $509.18      $205.10
27003...  T                   Incision of hip tendon.        252      19.39  $1,025.49      $509.18      $205.10
27005...  C                   Incision of hip tendon.  .........  .........  .........  ...........  ...........
27006...  C                   Incision of hip tendons  .........  .........  .........  ...........  ...........
27025...  C                   Incision of hip/thigh    .........  .........  .........  ...........  ...........
                               fascia.
27030...  C                   Drainage of hip joint..  .........  .........  .........  ...........  ...........
27033...  T                   Exploration of hip             253      26.33  $1,392.78      $699.24      $278.56
                               joint.
27035...  C                   Denervation of hip       .........  .........  .........  ...........  ...........
                               joint.
27036...  C                   Excision of hip joint/   .........  .........  .........  ...........  ...........
                               muscle.
27040...  T                   Biopsy of soft tissues.        162       5.67    $299.71      $125.43       $59.94
27041...  T                   Biopsy of soft tissues.        163      10.69    $565.14      $264.65      $113.03
27047...  T                   Remove hip/pelvis              163      10.69    $565.14      $264.65      $113.03
                               lesion.
27048...  T                   Remove hip/pelvis              163      10.69    $565.14      $264.65      $113.03
                               lesion.
27049...  T                   Remove tumor, hip/             163      10.69    $565.14      $264.65      $113.03
                               pelvis.
27050...  T                   Biopsy of sacroiliac           251      14.26    $754.18      $366.12      $150.84
                               joint.
27052...  T                   Biopsy of hip joint....        251      14.26    $754.18      $366.12      $150.84
27054...  C                   Removal of hip joint     .........  .........  .........  ...........  ...........
                               lining.
27060...  T                   Removal of ischial             251      14.26    $754.18      $366.12      $150.84
                               bursa.
27062...  T                   Remove femur lesion/           251      14.26    $754.18      $366.12      $150.84
                               bursa.
27065...  T                   Removal of hip bone            251      14.26    $754.18      $366.12      $150.84
                               lesion.
27066...  T                   Removal of hip bone            252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
27067...  T                   Remove/graft hip bone          252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
27070...  C                   Partial removal of hip   .........  .........  .........  ...........  ...........
                               bone.
27071...  C                   Partial removal of hip   .........  .........  .........  ...........  ...........
                               bone.
27075...  C                   Extensive hip surgery..  .........  .........  .........  ...........  ...........
27076...  C                   Extensive hip surgery..  .........  .........  .........  ...........  ...........

[[Page 47641]]

27077...  C                   Extensive hip surgery..  .........  .........  .........  ...........  ...........
27078...  C                   Extensive hip surgery..  .........  .........  .........  ...........  ...........
27079...  C                   Extensive hip surgery..  .........  .........  .........  ...........  ...........
27080...  T                   Removal of tail bone...        252      19.39  $1,025.49      $509.18      $205.10
27086...  T                   Remove hip foreign body        251      14.26    $754.18      $366.12      $150.84
27087...  T                   Remove hip foreign body        251      14.26    $754.18      $366.12      $150.84
27090...  C                   Removal of hip           .........  .........  .........  ...........  ...........
                               prosthesis.
27091...  C                   Removal of hip           .........  .........  .........  ...........  ...........
                               prosthesis.
27093...  T                   Injection for hip x-ray        347       2.93    $154.75       $62.15       $30.95
27095...  T                   Injection for hip x-ray        347       2.93    $154.75       $62.15       $30.95
27097...  T                   Revision of hip tendon.        252      19.39  $1,025.49      $509.18      $205.10
27098...  T                   Transfer tendon to             252      19.39  $1,025.49      $509.18      $205.10
                               pelvis.
27100...  T                   Transfer of abdominal          253      26.33  $1,392.78      $699.24      $278.56
                               muscle.
27105...  T                   Transfer of spinal             253      26.33  $1,392.78      $699.24      $278.56
                               muscle.
27110...  T                   Transfer of iliopsoas          253      26.33  $1,392.78      $699.24      $278.56
                               muscle.
27111...  T                   Transfer of iliopsoas          253      26.33  $1,392.78      $699.24      $278.56
                               muscle.
27120...  C                   Reconstruction of hip    .........  .........  .........  ...........  ...........
                               socket.
27122...  C                   Reconstruction of hip    .........  .........  .........  ...........  ...........
                               socket.
27125...  C                   Partial hip replacement  .........  .........  .........  ...........  ...........
27130...  C                   Total hip replacement..  .........  .........  .........  ...........  ...........
27132...  C                   Total hip replacement..  .........  .........  .........  ...........  ...........
27134...  C                   Revise hip joint         .........  .........  .........  ...........  ...........
                               replacement.
27137...  C                   Revise hip joint         .........  .........  .........  ...........  ...........
                               replacement.
27138...  C                   Revise hip joint         .........  .........  .........  ...........  ...........
                               replacement.
27140...  C                   Transplant of femur      .........  .........  .........  ...........  ...........
                               ridge.
27146...  C                   Incision of hip bone...  .........  .........  .........  ...........  ...........
27147...  C                   Revision of hip bone...  .........  .........  .........  ...........  ...........
27151...  C                   Incision of hip bones..  .........  .........  .........  ...........  ...........
27156...  C                   Revision of hip bones..  .........  .........  .........  ...........  ...........
27158...  C                   Revision of pelvis.....  .........  .........  .........  ...........  ...........
27161...  C                   Incision of neck of      .........  .........  .........  ...........  ...........
                               femur.
27165...  C                   Incision/fixation of     .........  .........  .........  ...........  ...........
                               femur.
27170...  C                   Repair/graft femur head/ .........  .........  .........  ...........  ...........
                               neck.
27175...  C                   Treat slipped epiphysis  .........  .........  .........  ...........  ...........
27176...  C                   Treat slipped epiphysis  .........  .........  .........  ...........  ...........
27177...  C                   Repair slipped           .........  .........  .........  ...........  ...........
                               epiphysis.
27178...  C                   Repair slipped           .........  .........  .........  ...........  ...........
                               epiphysis.
27179...  C                   Revise head/neck of      .........  .........  .........  ...........  ...........
                               femur.
27181...  C                   Repair slipped           .........  .........  .........  ...........  ...........
                               epiphysis.
27185...  C                   Revision of femur        .........  .........  .........  ...........  ...........
                               epiphysis.
27187...  C                   Reinforce hip bones....  .........  .........  .........  ...........  ...........
27193...  T                   Treat pelvic ring              209       1.94    $102.84       $37.29       $20.57
                               fracture.
27194...  T                   Treat pelvic ring              210      10.46    $553.39       $283.4      $110.68
                               fracture.
27200...  T                   Treat tail bone                207       1.70     $90.11       $31.64       $18.02
                               fracture.
27202...  T                   Repair tail bone               216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27215...  C                   Pelvic fracture(s)       .........  .........  .........  ...........  ...........
                               treatment.
27216...  C                   Treat pelvic ring        .........  .........  .........  ...........  ...........
                               fracture.
27217...  C                   Treat pelvic ring        .........  .........  .........  ...........  ...........
                               fracture.
27218...  C                   Treat pelvic ring        .........  .........  .........  ...........  ...........
                               fracture.
27220...  T                   Treat hip socket               209       1.94    $102.84       $37.29       $20.57
                               fracture.
27222...  C                   Treat hip socket         .........  .........  .........  ...........  ...........
                               fracture.
27226...  C                   Treat hip wall fracture  .........  .........  .........  ...........  ...........
27227...  C                   Treat hip fracture(s)..  .........  .........  .........  ...........  ...........
27228...  C                   Treat hip fracture(s)..  .........  .........  .........  ...........  ...........
27230...  T                   Treat fracture of thigh        209       1.94    $102.84       $37.29       $20.57
27232...  C                   Treat fracture of thigh  .........  .........  .........  ...........  ...........
27235...  C                   Repair of thigh          .........  .........  .........  ...........  ...........
                               fracture.
27236...  C                   Repair of thigh          .........  .........  .........  ...........  ...........
                               fracture.
27238...  T                   Treatment of thigh             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27240...  C                   Treatment of thigh       .........  .........  .........  ...........  ...........
                               fracture.
27244...  C                   Repair of thigh          .........  .........  .........  ...........  ...........
                               fracture.
27245...  C                   Repair of thigh          .........  .........  .........  ...........  ...........
                               fracture.
27246...  T                   Treatment of thigh             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27248...  C                   Repair of thigh          .........  .........  .........  ...........  ...........
                               fracture.
27250...  T                   Treat hip dislocation..        209       1.94    $102.84       $37.29       $20.57
27252...  T                   Treat hip dislocation..        210      10.46    $553.39       $283.4      $110.68
27253...  C                   Repair of hip            .........  .........  .........  ...........  ...........
                               dislocation.
27254...  C                   Repair of hip            .........  .........  .........  ...........  ...........
                               dislocation.
27256...  T                   Treatment of hip               209       1.94    $102.84       $37.29       $20.57
                               dislocation.
27257...  T                   Treatment of hip               210      10.46    $553.39       $283.4      $110.68
                               dislocation.
27258...  C                   Repair of hip            .........  .........  .........  ...........  ...........
                               dislocation.
27259...  C                   Repair of hip            .........  .........  .........  ...........  ...........
                               dislocation.
27265...  T                   Treatment of hip               209       1.94    $102.84       $37.29       $20.57
                               dislocation.
27266...  T                   Treatment of hip               217      20.48  $1,083.27      $526.81      $216.65
                               dislocation.
27275...  T                   Manipulation of hip            210      10.46    $553.39       $283.4      $110.68
                               joint.

[[Page 47642]]

27280...  C                   Fusion of sacroiliac     .........  .........  .........  ...........  ...........
                               joint.
27282...  C                   Fusion of pubic bones..  .........  .........  .........  ...........  ...........
27284...  C                   Fusion of hip joint....  .........  .........  .........  ...........  ...........
27286...  C                   Fusion of hip joint....  .........  .........  .........  ...........  ...........
27290...  C                   Amputation of leg at     .........  .........  .........  ...........  ...........
                               hip.
27295...  C                   Amputation of leg at     .........  .........  .........  ...........  ...........
                               hip.
27299...  T                   Pelvis/hip joint               207       1.70     $90.11       $31.64       $18.02
                               surgery.
27301...  T                   Drain thigh/knee lesion        132       6.04     $319.3      $134.24       $63.86
27303...  C                   Drainage of bone lesion  .........  .........  .........  ...........  ...........
27305...  T                   Incise thigh tendon &          251      14.26    $754.18      $366.12      $150.84
                               fascia.
27306...  T                   Incision of thigh              251      14.26    $754.18      $366.12      $150.84
                               tendon.
27307...  T                   Incision of thigh              251      14.26    $754.18      $366.12      $150.84
                               tendons.
27310...  T                   Exploration of knee            252      19.39  $1,025.49      $509.18      $205.10
                               joint.
27315...  T                   Partial removal, thigh         631      12.98     $686.6       $333.8      $137.32
                               nerve.
27320...  T                   Partial removal, thigh         631      12.98     $686.6       $333.8      $137.32
                               nerve.
27323...  T                   Biopsy thigh soft              162       5.67    $299.71      $125.43       $59.94
                               tissues.
27324...  T                   Biopsy thigh soft              163      10.69    $565.14      $264.65      $113.03
                               tissues.
27327...  T                   Removal of thigh lesion        163      10.69    $565.14      $264.65      $113.03
27328...  T                   Removal of thigh lesion        163      10.69    $565.14      $264.65      $113.03
27329...  T                   Remove tumor, thigh/           163      10.69    $565.14      $264.65      $113.03
                               knee.
27330...  T                   Biopsy knee joint              252      19.39  $1,025.49      $509.18      $205.10
                               lining.
27331...  T                   Explore/treat knee             252      19.39  $1,025.49      $509.18      $205.10
                               joint.
27332...  T                   Removal of knee                252      19.39  $1,025.49      $509.18      $205.10
                               cartilage.
27333...  T                   Removal of knee                252      19.39  $1,025.49      $509.18      $205.10
                               cartilage.
27334...  T                   Remove knee joint              252      19.39  $1,025.49      $509.18      $205.10
                               lining.
27335...  T                   Remove knee joint              252      19.39  $1,025.49      $509.18      $205.10
                               lining.
27340...  T                   Removal of kneecap             251      14.26    $754.18      $366.12      $150.84
                               bursa.
27345...  T                   Removal of knee cyst...        251      14.26    $754.18      $366.12      $150.84
27350...  T                   Removal of kneecap.....        252      19.39  $1,025.49      $509.18      $205.10
27355...  T                   Remove femur lesion....        252      19.39  $1,025.49      $509.18      $205.10
27356...  T                   Remove femur lesion/           252      19.39  $1,025.49      $509.18      $205.10
                               graft.
27357...  T                   Remove femur lesion/           252      19.39  $1,025.49      $509.18      $205.10
                               graft.
27358...  T                   Remove femur lesion/           252      19.39  $1,025.49      $509.18      $205.10
                               fixation.
27360...  T                   Partial removal leg            252      19.39  $1,025.49      $509.18      $205.10
                               bone(s).
27365...  C                   Extensive leg surgery..  .........  .........  .........  ...........  ...........
27370...  T                   Injection for knee x-          347       2.93    $154.75       $62.15       $30.95
                               ray.
27372...  T                   Removal of foreign body        163      10.69    $565.14      $264.65      $113.03
27380...  T                   Repair of kneecap              251      14.26    $754.18      $366.12      $150.84
                               tendon.
27381...  T                   Repair/graft kneecap           251      14.26    $754.18      $366.12      $150.84
                               tendon.
27385...  T                   Repair of thigh muscle.        251      14.26    $754.18      $366.12      $150.84
27386...  T                   Repair/graft of thigh          251      14.26    $754.18      $366.12      $150.84
                               muscle.
27390...  T                   Incision of thigh              251      14.26    $754.18      $366.12      $150.84
                               tendon.
27391...  T                   Incision of thigh              251      14.26    $754.18      $366.12      $150.84
                               tendons.
27392...  T                   Incision of thigh              251      14.26    $754.18      $366.12      $150.84
                               tendons.
27393...  T                   Lengthening of thigh           252      19.39  $1,025.49      $509.18      $205.10
                               tendon.
27394...  T                   Lengthening of thigh           252      19.39  $1,025.49      $509.18      $205.10
                               tendons.
27395...  T                   Lengthening of thigh           253      26.33  $1,392.78      $699.24      $278.56
                               tendons.
27396...  T                   Transplant of thigh            252      19.39  $1,025.49      $509.18      $205.10
                               tendon.
27397...  T                   Transplants of thigh           253      26.33  $1,392.78      $699.24      $278.56
                               tendons.
27400...  T                   Revise thigh muscles/          253      26.33  $1,392.78      $699.24      $278.56
                               tendons.
27403...  T                   Repair of knee                 252      19.39  $1,025.49      $509.18      $205.10
                               cartilage.
27405...  T                   Repair of knee ligament        253      26.33  $1,392.78      $699.24      $278.56
27407...  T                   Repair of knee ligament        253      26.33  $1,392.78      $699.24      $278.56
27409...  T                   Repair of knee                 253      26.33  $1,392.78      $699.24      $278.56
                               ligaments.
27418...  T                   Repair degenerated             253      26.33  $1,392.78      $699.24      $278.56
                               kneecap.
27420...  T                   Revision of unstable           253      26.33  $1,392.78      $699.24      $278.56
                               kneecap.
27422...  T                   Revision of unstable           253      26.33  $1,392.78      $699.24      $278.56
                               kneecap.
27424...  T                   Revision/removal of            253      26.33  $1,392.78      $699.24      $278.56
                               kneecap.
27425...  T                   Lateral retinacular            252      19.39  $1,025.49      $509.18      $205.10
                               release.
27427...  T                   Reconstruction, knee...        254      34.37  $1,817.86      $937.22      $363.57
27428...  T                   Reconstruction, knee...        254      34.37  $1,817.86      $937.22      $363.57
27429...  T                   Reconstruction, knee...        254      34.37  $1,817.86      $937.22      $363.57
27430...  T                   Revision of thigh              253      26.33  $1,392.78      $699.24      $278.56
                               muscles.
27435...  T                   Incision of knee joint.        253      26.33  $1,392.78      $699.24      $278.56
27437...  T                   Revise kneecap.........        217      20.48  $1,083.27      $526.81      $216.65
27438...  T                   Revise kneecap with            218      27.50  $1,454.49      $715.52      $290.90
                               implant.
27440...  T                   Revision of knee joint.        217      20.48  $1,083.27      $526.81      $216.65
27441...  T                   Revision of knee joint.        217      20.48  $1,083.27      $526.81      $216.65
27442...  T                   Revision of knee joint.        217      20.48  $1,083.27      $526.81      $216.65
27443...  T                   Revision of knee joint.        217      20.48  $1,083.27      $526.81      $216.65
27445...  C                   Revision of knee joint.  .........  .........  .........  ...........  ...........
27446...  C                   Revision of knee joint.  .........  .........  .........  ...........  ...........
27447...  C                   Total knee replacement.  .........  .........  .........  ...........  ...........
27448...  C                   Incision of thigh......  .........  .........  .........  ...........  ...........
27450...  C                   Incision of thigh......  .........  .........  .........  ...........  ...........

[[Page 47643]]

27454...  C                   Realignment of thigh     .........  .........  .........  ...........  ...........
                               bone.
27455...  C                   Realignment of knee....  .........  .........  .........  ...........  ...........
27457...  C                   Realignment of knee....  .........  .........  .........  ...........  ...........
27465...  C                   Shortening of thigh      .........  .........  .........  ...........  ...........
                               bone.
27466...  C                   Lengthening of thigh     .........  .........  .........  ...........  ...........
                               bone.
27468...  C                   Shorten/lengthen thighs  .........  .........  .........  ...........  ...........
27470...  C                   Repair of thigh........  .........  .........  .........  ...........  ...........
27472...  C                   Repair/graft of thigh..  .........  .........  .........  ...........  ...........
27475...  C                   Surgery to stop leg      .........  .........  .........  ...........  ...........
                               growth.
27477...  C                   Surgery to stop leg      .........  .........  .........  ...........  ...........
                               growth.
27479...  C                   Surgery to stop leg      .........  .........  .........  ...........  ...........
                               growth.
27485...  C                   Surgery to stop leg      .........  .........  .........  ...........  ...........
                               growth.
27486...  C                   Revise knee joint        .........  .........  .........  ...........  ...........
                               replace.
27487...  C                   Revise knee joint        .........  .........  .........  ...........  ...........
                               replace.
27488...  C                   Removal of knee          .........  .........  .........  ...........  ...........
                               prosthesis.
27495...  C                   Reinforce thigh........  .........  .........  .........  ...........  ...........
27496...  T                   Decompression of thigh/        251      14.26    $754.18      $366.12      $150.84
                               knee.
27497...  T                   Decompression of thigh/        251      14.26    $754.18      $366.12      $150.84
                               knee.
27498...  T                   Decompression of thigh/        251      14.26    $754.18      $366.12      $150.84
                               knee.
27499...  T                   Decompression of thigh/        251      14.26    $754.18      $366.12      $150.84
                               knee.
27500...  T                   Treatment of thigh             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27501...  T                   Treatment of thigh             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27502...  T                   Treatment of thigh             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27503...  T                   Treatment of thigh             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27506...  C                   Repair of thigh          .........  .........  .........  ...........  ...........
                               fracture.
27507...  C                   Treatment of thigh       .........  .........  .........  ...........  ...........
                               fracture.
27508...  T                   Treatment of thigh             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27509...  T                   Treatment of thigh             216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27510...  T                   Treatment of thigh             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27511...  C                   Treatment of thigh       .........  .........  .........  ...........  ...........
                               fracture.
27513...  C                   Treatment of thigh       .........  .........  .........  ...........  ...........
                               fracture.
27514...  C                   Repair of thigh          .........  .........  .........  ...........  ...........
                               fracture.
27516...  T                   Repair of thigh growth         209       1.94    $102.84       $37.29       $20.57
                               plate.
27517...  T                   Repair of thigh growth         209       1.94    $102.84       $37.29       $20.57
                               plate.
27519...  C                   Repair of thigh growth   .........  .........  .........  ...........  ...........
                               plate.
27520...  T                   Treat kneecap fracture.        209       1.94    $102.84       $37.29       $20.57
27524...  C                   Repair of kneecap        .........  .........  .........  ...........  ...........
                               fracture.
27530...  T                   Treatment of knee              209       1.94    $102.84       $37.29       $20.57
                               fracture.
27532...  T                   Treatment of knee              209       1.94    $102.84       $37.29       $20.57
                               fracture.
27535...  C                   Treatment of knee        .........  .........  .........  ...........  ...........
                               fracture.
27536...  C                   Repair of knee fracture  .........  .........  .........  ...........  ...........
27538...  T                   Treat knee fracture(s).        209       1.94    $102.84       $37.29       $20.57
27540...  C                   Repair of knee fracture  .........  .........  .........  ...........  ...........
27550...  T                   Treat knee dislocation.        209       1.94    $102.84       $37.29       $20.57
27552...  T                   Treat knee dislocation.        210      10.46    $553.39      $283.40      $110.68
27556...  T                   Repair of knee                 216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
27557...  C                   Repair of knee           .........  .........  .........  ...........  ...........
                               dislocation.
27558...  C                   Repair of knee           .........  .........  .........  ...........  ...........
                               dislocation.
27560...  T                   Treat kneecap                  209       1.94    $102.84       $37.29       $20.57
                               dislocation.
27562...  T                   Treat kneecap                  210      10.46    $553.39      $283.40      $110.68
                               dislocation.
27566...  T                   Repair kneecap                 216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
27570...  T                   Fixation of knee joint.        210      10.46    $553.39      $283.40      $110.68
27580...  C                   Fusion of knee.........  .........  .........  .........  ...........  ...........
27590...  C                   Amputate leg at thigh..  .........  .........  .........  ...........  ...........
27591...  C                   Amputate leg at thigh..  .........  .........  .........  ...........  ...........
27592...  C                   Amputate leg at thigh..  .........  .........  .........  ...........  ...........
27594...  T                   Amputation follow-up           251      14.26    $754.18      $366.12      $150.84
                               surgery.
27596...  C                   Amputation follow-up     .........  .........  .........  ...........  ...........
                               surgery.
27598...  C                   Amputate lower leg at    .........  .........  .........  ...........  ...........
                               knee.
27599...  T                   Leg surgery procedure..        209       1.94    $102.84       $37.29       $20.57
27600...  T                   Decompression of lower         251      14.26    $754.18      $366.12      $150.84
                               leg.
27601...  T                   Decompression of lower         251      14.26    $754.18      $366.12      $150.84
                               leg.
27602...  T                   Decompression of lower         251      14.26    $754.18      $366.12      $150.84
                               leg.
27603...  T                   Drain lower leg lesion.        132       6.04     $319.3      $134.24       $63.86
27604...  T                   Drain lower leg bursa..        251      14.26    $754.18      $366.12      $150.84
27605...  T                   Incision of achilles           271      14.41    $762.01      $368.38      $152.40
                               tendon.
27606...  T                   Incision of achilles           251      14.26    $754.18      $366.12      $150.84
                               tendon.
27607...  T                   Treat lower leg bone           251      14.26    $754.18      $366.12      $150.84
                               lesion.
27610...  T                   Explore/treat ankle            252      19.39  $1,025.49      $509.18      $205.10
                               joint.
27612...  T                   Exploration of ankle           252      19.39  $1,025.49      $509.18      $205.10
                               joint.
27613...  T                   Biopsy lower leg soft          161       3.50    $185.12       $75.48       $37.02
                               tissue.
27614...  T                   Biopsy lower leg soft          163      10.69    $565.14      $264.65      $113.03
                               tissue.
27615...  T                   Remove tumor, lower leg        216      20.13  $1,064.67      $520.93      $212.93
27618...  T                   Remove lower leg lesion        163      10.69    $565.14      $264.65      $113.03
27619...  T                   Remove lower leg lesion        163      10.69    $565.14      $264.65      $113.03

[[Page 47644]]

27620...  T                   Explore, treat ankle           252      19.39  $1,025.49      $509.18      $205.10
                               joint.
27625...  T                   Remove ankle joint             252      19.39  $1,025.49      $509.18      $205.10
                               lining.
27626...  T                   Remove ankle joint             252      19.39  $1,025.49      $509.18      $205.10
                               lining.
27630...  T                   Removal of tendon              251      14.26    $754.18      $366.12      $150.84
                               lesion.
27635...  T                   Remove lower leg bone          252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
27637...  T                   Remove/graft leg bone          252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
27638...  T                   Remove/graft leg bone          252      19.39  $1,025.49      $509.18      $205.10
                               lesion.
27640...  T                   Partial removal of             253      26.33  $1,392.78      $699.24      $278.56
                               tibia.
27641...  T                   Partial removal of             252      19.39  $1,025.49      $509.18      $205.10
                               fibula.
27645...  C                   Extensive lower leg      .........  .........  .........  ...........  ...........
                               surgery.
27646...  C                   Extensive lower leg      .........  .........  .........  ...........  ...........
                               surgery.
27647...  T                   Extensive ankle/heel           253      26.33  $1,392.78      $699.24      $278.56
                               surgery.
27648...  T                   Injection for ankle x-         347       2.93    $154.75       $62.15       $30.95
                               ray.
27650...  T                   Repair achilles tendon.        253      26.33  $1,392.78      $699.24      $278.56
27652...  T                   Repair/graft achilles          253      26.33  $1,392.78      $699.24      $278.56
                               tendon.
27654...  T                   Repair of achilles             253      26.33  $1,392.78      $699.24      $278.56
                               tendon.
27656...  T                   Repair leg fascia              251      14.26    $754.18      $366.12      $150.84
                               defect.
27658...  T                   Repair of leg tendon,          251      14.26    $754.18      $366.12      $150.84
                               each.
27659...  T                   Repair of leg tendon,          251      14.26    $754.18      $366.12      $150.84
                               each.
27664...  T                   Repair of leg tendon,          251      14.26    $754.18      $366.12      $150.84
                               each.
27665...  T                   Repair of leg tendon,          252      19.39  $1,025.49      $509.18      $205.10
                               each.
27675...  T                   Repair lower leg               251      14.26    $754.18      $366.12      $150.84
                               tendons.
27676...  T                   Repair lower leg               252      19.39  $1,025.49      $509.18      $205.10
                               tendons.
27680...  T                   Release of lower leg           252      19.39  $1,025.49      $509.18      $205.10
                               tendon.
27681...  T                   Release of lower leg           252      19.39  $1,025.49      $509.18      $205.10
                               tendons.
27685...  T                   Revision of lower leg          252      19.39  $1,025.49      $509.18      $205.10
                               tendon.
27686...  T                   Revise lower leg               252      19.39  $1,025.49      $509.18      $205.10
                               tendons.
27687...  T                   Revision of calf tendon        252      19.39  $1,025.49      $509.18      $205.10
27690...  T                   Revise lower leg tendon        253      26.33  $1,392.78      $699.24      $278.56
27691...  T                   Revise lower leg tendon        253      26.33  $1,392.78      $699.24      $278.56
27692...  T                   Revise additional leg          253      26.33  $1,392.78      $699.24      $278.56
                               tendon.
27695...  T                   Repair of ankle                252      19.39  $1,025.49      $509.18      $205.10
                               ligament.
27696...  T                   Repair of ankle                252      19.39  $1,025.49      $509.18      $205.10
                               ligaments.
27698...  T                   Repair of ankle                252      19.39  $1,025.49      $509.18      $205.10
                               ligament.
27700...  T                   Revision of ankle joint        217      20.48  $1,083.27      $526.81      $216.65
27702...  C                   Reconstruct ankle joint  .........  .........  .........  ...........  ...........
27703...  C                   Reconstruction, ankle    .........  .........  .........  ...........  ...........
                               joint.
27704...  T                   Removal of ankle               251      14.26    $754.18      $366.12      $150.84
                               implant.
27705...  T                   Incision of tibia......        253      26.33  $1,392.78      $699.24      $278.56
27707...  T                   Incision of fibula.....        251      14.26    $754.18      $366.12      $150.84
27709...  T                   Incision of tibia &            252      19.39  $1,025.49      $509.18      $205.10
                               fibula.
27712...  C                   Realignment of lower     .........  .........  .........  ...........  ...........
                               leg.
27715...  C                   Revision of lower leg..  .........  .........  .........  ...........  ...........
27720...  C                   Repair of tibia........  .........  .........  .........  ...........  ...........
27722...  C                   Repair/graft of tibia..  .........  .........  .........  ...........  ...........
27724...  C                   Repair/graft of tibia..  .........  .........  .........  ...........  ...........
27725...  C                   Repair of lower leg....  .........  .........  .........  ...........  ...........
27727...  C                   Repair of lower leg....  .........  .........  .........  ...........  ...........
27730...  T                   Repair of tibia                252      19.39  $1,025.49      $509.18      $205.10
                               epiphysis.
27732...  T                   Repair of fibula               252      19.39  $1,025.49      $509.18      $205.10
                               epiphysis.
27734...  T                   Repair lower leg               252      19.39  $1,025.49      $509.18      $205.10
                               epiphyses.
27740...  T                   Repair of leg epiphyses        252      19.39  $1,025.49      $509.18      $205.10
27742...  T                   Repair of leg epiphyses        253      26.33  $1,392.78      $699.24      $278.56
27745...  T                   Reinforce tibia........        253      26.33  $1,392.78      $699.24      $278.56
27750...  T                   Treatment of tibia             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27752...  T                   Treatment of tibia             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27756...  T                   Repair of tibia                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27758...  T                   Repair of tibia                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27759...  T                   Repair of tibia                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27760...  T                   Treatment of ankle             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27762...  T                   Treatment of ankle             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27766...  T                   Repair of ankle                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27780...  T                   Treatment of fibula            209       1.94    $102.84       $37.29       $20.57
                               fracture.
27781...  T                   Treatment of fibula            209       1.94    $102.84       $37.29       $20.57
                               fracture.
27784...  T                   Repair of fibula               216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27786...  T                   Treatment of ankle             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27788...  T                   Treatment of ankle             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27792...  T                   Repair of ankle                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27808...  T                   Treatment of ankle             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27810...  T                   Treatment of ankle             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27814...  T                   Repair of ankle                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27816...  T                   Treatment of ankle             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27818...  T                   Treatment of ankle             209       1.94    $102.84       $37.29       $20.57
                               fracture.
27822...  T                   Repair of ankle                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27823...  T                   Repair of ankle                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.

[[Page 47645]]

27824...  T                   Treat lower leg                209       1.94    $102.84       $37.29       $20.57
                               fracture.
27825...  T                   Treat lower leg                209       1.94    $102.84       $37.29       $20.57
                               fracture.
27826...  T                   Treat lower leg                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27827...  T                   Treat lower leg                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27828...  T                   Treat lower leg                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
27829...  T                   Treat lower leg joint..        216      20.13  $1,064.67      $520.93      $212.93
27830...  T                   Treat lower leg                209       1.94    $102.84       $37.29       $20.57
                               dislocation.
27831...  T                   Treat lower leg                210      10.46    $553.39      $283.40      $110.68
                               dislocation.
27832...  T                   Repair lower leg               216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
27840...  T                   Treat ankle dislocation        209       1.94    $102.84       $37.29       $20.57
27842...  T                   Treat ankle dislocation        210      10.46    $553.39      $283.40      $110.68
27846...  T                   Repair ankle                   216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
27848...  T                   Repair ankle                   216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
27860...  T                   Fixation of ankle joint        210      10.46    $553.39      $283.40      $110.68
27870...  T                   Fusion of ankle joint..        253      26.33  $1,392.78      $699.24      $278.56
27871...  T                   Fusion of tibiofibular         253      26.33  $1,392.78      $699.24      $278.56
                               joint.
27880...  C                   Amputation of lower leg  .........  .........  .........  ...........  ...........
27881...  C                   Amputation of lower leg  .........  .........  .........  ...........  ...........
27882...  C                   Amputation of lower leg  .........  .........  .........  ...........  ...........
27884...  T                   Amputation follow-up           251      14.26    $754.18      $366.12      $150.84
                               surgery.
27886...  C                   Amputation follow-up     .........  .........  .........  ...........  ...........
                               surgery.
27888...  C                   Amputation of foot at    .........  .........  .........  ...........  ...........
                               ankle.
27889...  T                   Amputation of foot at          252      19.39  $1,025.49      $509.18      $205.10
                               ankle.
27892...  T                   Decompression of leg...        251      14.26    $754.18      $366.12      $150.84
27893...  T                   Decompression of leg...        251      14.26    $754.18      $366.12      $150.84
27894...  T                   Decompression of leg...        251      14.26    $754.18      $366.12      $150.84
27899...  T                   Leg/ankle surgery              209       1.94    $102.84       $37.29       $20.57
                               procedure.
28001...  T                   Drainage of bursa of           132       6.04     $319.3      $134.24       $63.86
                               foot.
28002...  T                   Treatment of foot              251      14.26    $754.18      $366.12      $150.84
                               infection.
28003...  T                   Treatment of foot              251      14.26    $754.18      $366.12      $150.84
                               infection.
28005...  T                   Treat foot bone lesion.        271      14.41    $762.01      $368.38      $152.40
28008...  T                   Incision of foot fascia        271      14.41    $762.01      $368.38      $152.40
28010...  T                   Incision of toe tendon.        271      14.41    $762.01      $368.38      $152.40
28011...  T                   Incision of toe tendons        271      14.41    $762.01      $368.38      $152.40
28020...  T                   Exploration of a foot          271      14.41    $762.01      $368.38      $152.40
                               joint.
28022...  T                   Exploration of a foot          271      14.41    $762.01      $368.38      $152.40
                               joint.
28024...  T                   Exploration of a toe           271      14.41    $762.01      $368.38      $152.40
                               joint.
28030...  T                   Removal of foot nerve..        631      12.98    $686.60      $333.80      $137.32
28035...  T                   Decompression of tibia         631      12.98    $686.60      $333.80      $137.32
                               nerve.
28043...  T                   Excision of foot lesion        162       5.67    $299.71      $125.43       $59.94
28045...  T                   Excision of foot lesion        271      14.41    $762.01      $368.38      $152.40
28046...  T                   Resection of tumor,            271      14.41    $762.01      $368.38      $152.40
                               foot.
28050...  T                   Biopsy of foot joint           271      14.41    $762.01      $368.38      $152.40
                               lining.
28052...  T                   Biopsy of foot joint           271      14.41    $762.01      $368.38      $152.40
                               lining.
28054...  T                   Biopsy of toe joint            271      14.41    $762.01      $368.38      $152.40
                               lining.
28060...  T                   Partial removal foot           272      16.56    $875.63      $409.74      $175.13
                               fascia.
28062...  T                   Removal of foot fascia.        272      16.56    $875.63      $409.74      $175.13
28070...  T                   Removal of foot joint          272      16.56    $875.63      $409.74      $175.13
                               lining.
28072...  T                   Removal of foot joint          272      16.56    $875.63      $409.74      $175.13
                               lining.
28080...  T                   Removal of foot lesion.        271      14.41    $762.01      $368.38      $152.40
28086...  T                   Excise foot tendon             271      14.41    $762.01      $368.38      $152.40
                               sheath.
28088...  T                   Excise foot tendon             271      14.41    $762.01      $368.38      $152.40
                               sheath.
28090...  T                   Removal of foot lesion.        271      14.41    $762.01      $368.38      $152.40
28092...  T                   Removal of toe lesions.        271      14.41    $762.01      $368.38      $152.40
28100...  T                   Removal of ankle/heel          271      14.41    $762.01      $368.38      $152.40
                               lesion.
28102...  T                   Remove/graft foot              272      16.56    $875.63      $409.74      $175.13
                               lesion.
28103...  T                   Remove/graft foot              272      16.56    $875.63      $409.74      $175.13
                               lesion.
28104...  T                   Removal of foot lesion.        271      14.41    $762.01      $368.38      $152.40
28106...  T                   Remove/graft foot              272      16.56    $875.63      $409.74      $175.13
                               lesion.
28107...  T                   Remove/graft foot              272      16.56    $875.63      $409.74      $175.13
                               lesion.
28108...  T                   Removal of toe lesions.        271      14.41    $762.01      $368.38      $152.40
28110...  T                   Part removal of                276      19.19  $1,014.71      $500.14      $202.94
                               metatarsal.
28111...  T                   Part removal of                271      14.41    $762.01      $368.38      $152.40
                               metatarsal.
28112...  T                   Part removal of                271      14.41    $762.01      $368.38      $152.40
                               metatarsal.
28113...  T                   Part removal of                271      14.41    $762.01      $368.38      $152.40
                               metatarsal.
28114...  T                   Removal of metatarsal          271      14.41    $762.01      $368.38      $152.40
                               heads.
28116...  T                   Revision of foot.......        271      14.41    $762.01      $368.38      $152.40
28118...  T                   Removal of heel bone...        271      14.41    $762.01      $368.38      $152.40
28119...  T                   Removal of heel spur...        271      14.41    $762.01      $368.38      $152.40
28120...  T                   Part removal of ankle/         271      14.41    $762.01      $368.38      $152.40
                               heel.
28122...  T                   Partial removal of foot        271      14.41    $762.01      $368.38      $152.40
                               bone.
28124...  T                   Partial removal of toe.        271      14.41    $762.01      $368.38      $152.40
28126...  T                   Partial removal of toe.        271      14.41    $762.01      $368.38      $152.40
28130...  T                   Removal of ankle bone..        271      14.41    $762.01      $368.38      $152.40
28140...  T                   Removal of metatarsal..        271      14.41    $762.01      $368.38      $152.40

[[Page 47646]]

28150...  T                   Removal of toe.........        271      14.41    $762.01      $368.38      $152.40
28153...  T                   Partial removal of toe.        271      14.41    $762.01      $368.38      $152.40
28160...  T                   Partial removal of toe.        271      14.41    $762.01      $368.38      $152.40
28171...  T                   Extensive foot surgery.        271      14.41    $762.01      $368.38      $152.40
28173...  T                   Extensive foot surgery.        271      14.41    $762.01      $368.38      $152.40
28175...  T                   Extensive foot surgery.        271      14.41    $762.01      $368.38      $152.40
28190...  T                   Removal of foot foreign        161       3.50    $185.12       $75.48       $37.02
                               body.
28192...  T                   Removal of foot foreign        163      10.69    $565.14      $264.65      $113.03
                               body.
28193...  T                   Removal of foot foreign        163      10.69    $565.14      $264.65      $113.03
                               body.
28200...  T                   Repair of foot tendon..        271      14.41    $762.01      $368.38      $152.40
28202...  T                   Repair/graft of foot           272      16.56    $875.63      $409.74      $175.13
                               tendon.
28208...  T                   Repair of foot tendon..        271      14.41    $762.01      $368.38      $152.40
28210...  T                   Repair/graft of foot           271      14.41    $762.01      $368.38      $152.40
                               tendon.
28220...  T                   Release of foot tendon.        271      14.41    $762.01      $368.38      $152.40
28222...  T                   Release of foot tendons        271      14.41    $762.01      $368.38      $152.40
28225...  T                   Release of foot tendon.        271      14.41    $762.01      $368.38      $152.40
28226...  T                   Release of foot tendons        271      14.41    $762.01      $368.38      $152.40
28230...  T                   Incision of foot               271      14.41    $762.01      $368.38      $152.40
                               tendon(s).
28232...  T                   Incision of toe tendon.        271      14.41    $762.01      $368.38      $152.40
28234...  T                   Incision of foot tendon        271      14.41    $762.01      $368.38      $152.40
28238...  T                   Revision of foot tendon        272      16.56    $875.63      $409.74      $175.13
28240...  T                   Release of big toe.....        271      14.41    $762.01      $368.38      $152.40
28250...  T                   Revision of foot fascia        272      16.56    $875.63      $409.74      $175.13
28260...  T                   Release of midfoot             272      16.56    $875.63      $409.74      $175.13
                               joint.
28261...  T                   Revision of foot tendon        272      16.56    $875.63      $409.74      $175.13
28262...  T                   Revision of foot and           272      16.56    $875.63      $409.74      $175.13
                               ankle.
28264...  T                   Release of midfoot             272      16.56    $875.63      $409.74      $175.13
                               joint.
28270...  T                   Release of foot                271      14.41    $762.01      $368.38      $152.40
                               contracture.
28272...  T                   Release of toe joint,          271      14.41    $762.01      $368.38      $152.40
                               each.
28280...  T                   Fusion of toes.........        271      14.41    $762.01      $368.38      $152.40
28285...  T                   Repair of hammertoe....        271      14.41    $762.01      $368.38      $152.40
28286...  T                   Repair of hammertoe....        271      14.41    $762.01      $368.38      $152.40
28288...  T                   Partial removal of foot        272      16.56    $875.63      $409.74      $175.13
                               bone.
28290...  T                   Correction of bunion...        276      19.19  $1,014.71      $500.14      $202.94
28292...  T                   Correction of bunion...        276      19.19  $1,014.71      $500.14      $202.94
28293...  T                   Correction of bunion...        276      19.19  $1,014.71      $500.14      $202.94
28294...  T                   Correction of bunion...        276      19.19  $1,014.71      $500.14      $202.94
28296...  T                   Correction of bunion...        276      19.19  $1,014.71      $500.14      $202.94
28297...  T                   Correction of bunion...        276      19.19  $1,014.71      $500.14      $202.94
28298...  T                   Correction of bunion...        276      19.19  $1,014.71      $500.14      $202.94
28299...  T                   Correction of bunion...        276      19.19  $1,014.71      $500.14      $202.94
28300...  T                   Incision of heel bone..        272      16.56    $875.63      $409.74      $175.13
28302...  T                   Incision of ankle bone.        272      16.56    $875.63      $409.74      $175.13
28304...  T                   Incision of midfoot            272      16.56    $875.63      $409.74      $175.13
                               bones.
28305...  T                   Incise/graft midfoot           272      16.56    $875.63      $409.74      $175.13
                               bones.
28306...  T                   Incision of metatarsal.        272      16.56    $875.63      $409.74      $175.13
28307...  T                   Incision of metatarsal.        272      16.56    $875.63      $409.74      $175.13
28308...  T                   Incision of metatarsal.        272      16.56    $875.63      $409.74      $175.13
28309...  T                   Incision of metatarsals        272      16.56    $875.63      $409.74      $175.13
28310...  T                   Revision of big toe....        271      14.41    $762.01      $368.38      $152.40
28312...  T                   Revision of toe........        271      14.41    $762.01      $368.38      $152.40
28313...  T                   Repair deformity of toe        271      14.41    $762.01      $368.38      $152.40
28315...  T                   Removal of sesamoid            271      14.41    $762.01      $368.38      $152.40
                               bone.
28320...  T                   Repair of foot bones...        272      16.56    $875.63      $409.74      $175.13
28322...  T                   Repair of metatarsals..        272      16.56    $875.63      $409.74      $175.13
28340...  T                   Resect enlarged toe            271      14.41    $762.01      $368.38      $152.40
                               tissue.
28341...  T                   Resect enlarged toe....        271      14.41    $762.01      $368.38      $152.40
28344...  T                   Repair extra toe(s)....        272      16.56    $875.63      $409.74      $175.13
28345...  T                   Repair webbed toe(s)...        272      16.56    $875.63      $409.74      $175.13
28360...  T                   Reconstruct cleft foot.        272      16.56    $875.63      $409.74      $175.13
28400...  T                   Treatment of heel              209       1.94    $102.84       $37.29       $20.57
                               fracture.
28405...  T                   Treatment of heel              209       1.94    $102.84       $37.29       $20.57
                               fracture.
28406...  T                   Treatment of heel              216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
28415...  T                   Repair of heel fracture        216      20.13  $1,064.67      $520.93      $212.93
28420...  T                   Repair/graft heel              216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
28430...  T                   Treatment of ankle             209       1.94    $102.84       $37.29       $20.57
                               fracture.
28435...  T                   Treatment of ankle             209       1.94    $102.84       $37.29       $20.57
                               fracture.
28436...  T                   Treatment of ankle             216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
28445...  T                   Repair of ankle                216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
28450...  T                   Treat midfoot fracture,        209       1.94    $102.84       $37.29       $20.57
                               each.
28455...  T                   Treat midfoot fracture,        209       1.94    $102.84       $37.29       $20.57
                               each.
28456...  T                   Repair midfoot fracture        216      20.13  $1,064.67      $520.93      $212.93
28465...  T                   Repair midfoot                 216      20.13  $1,064.67      $520.93      $212.93
                               fracture, each.
28470...  T                   Treat metatarsal               209       1.94    $102.84       $37.29       $20.57
                               fracture.
28475...  T                   Treat metatarsal               209       1.94    $102.84       $37.29       $20.57
                               fracture.

[[Page 47647]]

28476...  T                   Repair metatarsal              216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
28485...  T                   Repair metatarsal              216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
28490...  T                   Treat big toe fracture.        207       1.70     $90.11       $31.64       $18.02
28495...  T                   Treat big toe fracture.        207       1.70     $90.11       $31.64       $18.02
28496...  T                   Repair big toe fracture        216      20.13  $1,064.67      $520.93      $212.93
28505...  T                   Repair big toe fracture        216      20.13  $1,064.67      $520.93      $212.93
28510...  T                   Treatment of toe               207       1.70     $90.11       $31.64       $18.02
                               fracture.
28515...  T                   Treatment of toe               207       1.70     $90.11       $31.64       $18.02
                               fracture.
28525...  T                   Repair of toe fracture.        216      20.13  $1,064.67      $520.93      $212.93
28530...  T                   Treat sesamoid bone            209       1.94    $102.84       $37.29       $20.57
                               fracture.
28531...  T                   Treat sesamoid bone            216      20.13  $1,064.67      $520.93      $212.93
                               fracture.
28540...  T                   Treat foot dislocation.        209       1.94    $102.84       $37.29       $20.57
28545...  T                   Treat foot dislocation.        210      10.46    $553.39      $283.40      $110.68
28546...  T                   Treat foot dislocation.        216      20.13  $1,064.67      $520.93      $212.93
28555...  T                   Repair foot dislocation        216      20.13  $1,064.67      $520.93      $212.93
28570...  T                   Treat foot dislocation.        209       1.94    $102.84       $37.29       $20.57
28575...  T                   Treat foot dislocation.        210      10.46    $553.39      $283.40      $110.68
28576...  T                   Treat foot dislocation.        216      20.13  $1,064.67      $520.93      $212.93
28585...  T                   Repair foot dislocation        216      20.13  $1,064.67      $520.93      $212.93
28600...  T                   Treat foot dislocation.        209       1.94    $102.84       $37.29       $20.57
28605...  T                   Treat foot dislocation.        210      10.46    $553.39      $283.40      $110.68
28606...  T                   Treat foot dislocation.        216      20.13  $1,064.67      $520.93      $212.93
28615...  T                   Repair foot dislocation        216      20.13  $1,064.67      $520.93      $212.93
28630...  T                   Treat toe dislocation..        207       1.70     $90.11       $31.64       $18.02
28635...  T                   Treat toe dislocation..        210      10.46    $553.39      $283.40      $110.68
28636...  T                   Treat toe dislocation..        216      20.13  $1,064.67      $520.93      $212.93
28645...  T                   Repair toe dislocation.        216      20.13  $1,064.67      $520.93      $212.93
28660...  T                   Treat toe dislocation..        207       1.70     $90.11       $31.64       $18.02
28665...  T                   Treat toe dislocation..        210      10.46    $553.39      $283.40      $110.68
28666...  T                   Treat toe dislocation..        216      20.13  $1,064.67      $520.93      $212.93
28675...  T                   Repair of toe                  216      20.13  $1,064.67      $520.93      $212.93
                               dislocation.
28705...  T                   Fusion of foot bones...        272      16.56    $875.63      $409.74      $175.13
28715...  T                   Fusion of foot bones...        272      16.56    $875.63      $409.74      $175.13
28725...  T                   Fusion of foot bones...        272      16.56    $875.63      $409.74      $175.13
28730...  T                   Fusion of foot bones...        272      16.56    $875.63      $409.74      $175.13
28735...  T                   Fusion of foot bones...        272      16.56    $875.63      $409.74      $175.13
28737...  T                   Revision of foot bones.        271      14.41    $762.01      $368.38      $152.40
28740...  T                   Fusion of foot bones...        272      16.56    $875.63      $409.74      $175.13
28750...  T                   Fusion of big toe joint        271      14.41    $762.01      $368.38      $152.40
28755...  T                   Fusion of big toe joint        271      14.41    $762.01      $368.38      $152.40
28760...  T                   Fusion of big toe joint        272      16.56    $875.63      $409.74      $175.13
28800...  C                   Amputation of midfoot..  .........  .........  .........  ...........  ...........
28805...  C                   Amputation thru          .........  .........  .........  ...........  ...........
                               metatarsal.
28810...  T                   Amputation toe &               271      14.41    $762.01      $368.38      $152.40
                               metatarsal.
28820...  T                   Amputation of toe......        271      14.41    $762.01      $368.38      $152.40
28825...  T                   Partial amputation of          271      14.41    $762.01      $368.38      $152.40
                               toe.
28899...  T                   Foot/toes surgery              207       1.70     $90.11       $31.64       $18.02
                               procedure.
29000...  N                   Application of body      .........  .........  .........  ...........  ...........
                               cast.
29010...  N                   Application of body      .........  .........  .........  ...........  ...........
                               cast.
29015...  N                   Application of body      .........  .........  .........  ...........  ...........
                               cast.
29020...  N                   Application of body      .........  .........  .........  ...........  ...........
                               cast.
29025...  N                   Application of body      .........  .........  .........  ...........  ...........
                               cast.
29035...  N                   Application of body      .........  .........  .........  ...........  ...........
                               cast.
29040...  N                   Application of body      .........  .........  .........  ...........  ...........
                               cast.
29044...  N                   Application of body      .........  .........  .........  ...........  ...........
                               cast.
29046...  N                   Application of body      .........  .........  .........  ...........  ...........
                               cast.
29049...  N                   Application of figure    .........  .........  .........  ...........  ...........
                               eight.
29055...  N                   Application of shoulder  .........  .........  .........  ...........  ...........
                               cast.
29058...  N                   Application of shoulder  .........  .........  .........  ...........  ...........
                               cast.
29065...  N                   Application of long arm  .........  .........  .........  ...........  ...........
                               cast.
29075...  N                   Application of forearm   .........  .........  .........  ...........  ...........
                               cast.
29085...  N                   Apply hand/wrist cast..  .........  .........  .........  ...........  ...........
29105...  N                   Apply long arm splint..  .........  .........  .........  ...........  ...........
29125...  N                   Apply forearm splint...  .........  .........  .........  ...........  ...........
29126...  N                   Apply forearm splint...  .........  .........  .........  ...........  ...........
29130...  N                   Application of finger    .........  .........  .........  ...........  ...........
                               splint.
29131...  N                   Application of finger    .........  .........  .........  ...........  ...........
                               splint.
29200...  N                   Strapping of chest.....  .........  .........  .........  ...........  ...........
29220...  N                   Strapping of low back..  .........  .........  .........  ...........  ...........
29240...  N                   Strapping of shoulder..  .........  .........  .........  ...........  ...........
29260...  N                   Strapping of elbow or    .........  .........  .........  ...........  ...........
                               wrist.
29280...  N                   Strapping of hand or     .........  .........  .........  ...........  ...........
                               finger.
29305...  N                   Application of hip cast  .........  .........  .........  ...........  ...........
29325...  N                   Application of hip       .........  .........  .........  ...........  ...........
                               casts.
29345...  N                   Application of long leg  .........  .........  .........  ...........  ...........
                               cast.

[[Page 47648]]

29355...  N                   Application of long leg  .........  .........  .........  ...........  ...........
                               cast.
29358...  N                   Apply long leg cast      .........  .........  .........  ...........  ...........
                               brace.
29365...  N                   Application of long leg  .........  .........  .........  ...........  ...........
                               cast.
29405...  N                   Apply short leg cast...  .........  .........  .........  ...........  ...........
29425...  N                   Apply short leg cast...  .........  .........  .........  ...........  ...........
29435...  N                   Apply short leg cast...  .........  .........  .........  ...........  ...........
29440...  N                   Addition of walker to    .........  .........  .........  ...........  ...........
                               cast.
29445...  N                   Apply rigid leg cast...  .........  .........  .........  ...........  ...........
29450...  N                   Application of leg cast  .........  .........  .........  ...........  ...........
29505...  N                   Application long leg     .........  .........  .........  ...........  ...........
                               splint.
29515...  N                   Application lower leg    .........  .........  .........  ...........  ...........
                               splint.
29520...  N                   Strapping of hip.......  .........  .........  .........  ...........  ...........
29530...  N                   Strapping of knee......  .........  .........  .........  ...........  ...........
29540...  N                   Strapping of ankle.....  .........  .........  .........  ...........  ...........
29550...  N                   Strapping of toes......  .........  .........  .........  ...........  ...........
29580...  N                   Application of paste     .........  .........  .........  ...........  ...........
                               boot.
29590...  N                   Application of foot      .........  .........  .........  ...........  ...........
                               splint.
29700...  N                   Removal/revision of      .........  .........  .........  ...........  ...........
                               cast.
29705...  N                   Removal/revision of      .........  .........  .........  ...........  ...........
                               cast.
29710...  N                   Removal/revision of      .........  .........  .........  ...........  ...........
                               cast.
29715...  N                   Removal/revision of      .........  .........  .........  ...........  ...........
                               cast.
29720...  N                   Repair of body cast....  .........  .........  .........  ...........  ...........
29730...  N                   Windowing of cast......  .........  .........  .........  ...........  ...........
29740...  N                   Wedging of cast........  .........  .........  .........  ...........  ...........
29750...  N                   Wedging of clubfoot      .........  .........  .........  ...........  ...........
                               cast.
29799...  N                   Casting/strapping        .........  .........  .........  ...........  ...........
                               procedure.
29800...  T                   Jaw arthroscopy/surgery        280      22.20  $1,174.36      $581.72      $234.87
29804...  T                   Jaw arthroscopy/surgery        281      22.65  $1,197.87      $590.31      $239.57
29815...  T                   Shoulder arthroscopy...        280      22.20  $1,174.36      $581.72      $234.87
29819...  T                   Shoulder arthroscopy/          281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29820...  T                   Shoulder arthroscopy/          281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29821...  T                   Shoulder arthroscopy/          281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29822...  T                   Shoulder arthroscopy/          281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29823...  T                   Shoulder arthroscopy/          281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29825...  T                   Shoulder arthroscopy/          281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29826...  T                   Shoulder arthroscopy/          281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29830...  T                   Elbow arthroscopy......        280      22.20  $1,174.36      $581.72      $234.87
29834...  T                   Elbow arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29835...  T                   Elbow arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29836...  T                   Elbow arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29837...  T                   Elbow arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29838...  T                   Elbow arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29840...  T                   Wrist arthroscopy......        280      22.20  $1,174.36      $581.72      $234.87
29843...  T                   Wrist arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29844...  T                   Wrist arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29845...  T                   Wrist arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29846...  T                   Wrist arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29847...  T                   Wrist arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29848...  T                   Wrist arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29850...  T                   Knee arthroscopy/              286      26.76  $1,415.31      $802.53      $283.06
                               surgery.
29851...  T                   Knee arthroscopy/              286      26.76  $1,415.31      $802.53      $283.06
                               surgery.
29855...  T                   Tibial arthroscopy/            286      26.76  $1,415.31      $802.53      $283.06
                               surgery.
29856...  T                   Tibial arthroscopy/            286      26.76  $1,415.31      $802.53      $283.06
                               surgery.
29860...  T                   Hip arthroscopy, dx....        281      22.65  $1,197.87      $590.31      $239.57
29861...  T                   Hip arthroscopy/surgery        281      22.65  $1,197.87      $590.31      $239.57
29862...  T                   Hip arthroscopy/surgery        281      22.65  $1,197.87      $590.31      $239.57
29863...  T                   Hip arthroscopy/surgery        281      22.65  $1,197.87      $590.31      $239.57
29870...  T                   Knee arthroscopy,              280      22.20  $1,174.36      $581.72      $234.87
                               diagnostic.
29871...  T                   Knee arthroscopy/              282      23.94  $1,266.43      $614.04      $253.29
                               drainage.
29874...  T                   Knee arthroscopy/              281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29875...  T                   Knee arthroscopy/              281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29876...  T                   Knee arthroscopy/              282      23.94  $1,266.43      $614.04      $253.29
                               surgery.
29877...  T                   Knee arthroscopy/              281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29879...  T                   Knee arthroscopy/              281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29880...  T                   Knee arthroscopy/              281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29881...  T                   Knee arthroscopy/              281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29882...  T                   Knee arthroscopy/              282      23.94  $1,266.43      $614.04      $253.29
                               surgery.
29883...  T                   Knee arthroscopy/              282      23.94  $1,266.43      $614.04      $253.29
                               surgery.
29884...  T                   Knee arthroscopy/              281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29885...  T                   Knee arthroscopy/              282      23.94  $1,266.43      $614.04      $253.29
                               surgery.
29886...  T                   Knee arthroscopy/              281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29887...  T                   Knee arthroscopy/              282      23.94  $1,266.43      $614.04      $253.29
                               surgery.
29888...  T                   Knee arthroscopy/              286      26.76  $1,415.31      $802.53      $283.06
                               surgery.
29889...  T                   Knee arthroscopy/              286      26.76  $1,415.31      $802.53      $283.06
                               surgery.
29891...  T                   Ankle arthroscopy/             282      23.94  $1,266.43      $614.04      $253.29
                               surgery.

[[Page 47649]]

29892...  T                   Ankle arthroscopy/             286      26.76  $1,415.31      $802.53      $283.06
                               surgery.
29893...  T                   Scope, plantar                 271      14.41    $762.01      $368.38      $152.40
                               fasciotomy.
29894...  T                   Ankle arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29895...  T                   Ankle arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29897...  T                   Ankle arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29898...  T                   Ankle arthroscopy/             281      22.65  $1,197.87      $590.31      $239.57
                               surgery.
29909...  T                   Arthroscopy of joint...        280      22.20  $1,174.36      $581.72      $234.87
30000...  T                   Drainage of nose lesion        311       1.43     $75.42       $20.57       $15.08
30020...  T                   Drainage of nose lesion        311       1.43     $75.42       $20.57       $15.08
30100...  T                   Intranasal biopsy......        311       1.43     $75.42       $20.57       $15.08
30110...  T                   Removal of nose                311       1.43     $75.42       $20.57       $15.08
                               polyp(s).
30115...  T                   Removal of nose                313      15.81    $836.45      $411.09      $167.29
                               polyp(s).
30117...  T                   Removal of intranasal          311       1.43     $75.42       $20.57       $15.08
                               lesion.
30118...  T                   Removal of intranasal          313      15.81    $836.45      $411.09      $167.29
                               lesion.
30120...  T                   Revision of nose.......        313      15.81    $836.45      $411.09      $167.29
30124...  T                   Removal of nose lesion.        311       1.43     $75.42       $20.57       $15.08
30125...  T                   Removal of nose lesion.        313      15.81    $836.45      $411.09      $167.29
30130...  T                   Removal of turbinate           313      15.81    $836.45      $411.09      $167.29
                               bones.
30140...  T                   Removal of turbinate           313      15.81    $836.45      $411.09      $167.29
                               bones.
30150...  T                   Partial removal of nose        313      15.81    $836.45      $411.09      $167.29
30160...  T                   Removal of nose........        313      15.81    $836.45      $411.09      $167.29
30200...  T                   Injection treatment of         347       2.93    $154.75       $62.15       $30.95
                               nose.
30210...  T                   Nasal sinus therapy....        311       1.43     $75.42       $20.57       $15.08
30220...  T                   Insert nasal septal            311       1.43     $75.42       $20.57       $15.08
                               button.
30300...  T                   Remove nasal foreign           311       1.43     $75.42       $20.57       $15.08
                               body.
30310...  T                   Remove nasal foreign           313      15.81    $836.45      $411.09      $167.29
                               body.
30320...  T                   Remove nasal foreign           313      15.81    $836.45      $411.09      $167.29
                               body.
30400...  T                   Reconstruction of nose.        314      25.65  $1,356.54      $693.37      $271.31
30410...  T                   Reconstruction of nose.        314      25.65  $1,356.54      $693.37      $271.31
30420...  T                   Reconstruction of nose.        314      25.65  $1,356.54      $693.37      $271.31
30430...  T                   Revision of nose.......        313      15.81    $836.45      $411.09      $167.29
30435...  T                   Revision of nose.......        314      25.65  $1,356.54      $693.37      $271.31
30450...  T                   Revision of nose.......        314      25.65  $1,356.54      $693.37      $271.31
30460...  T                   Revision of nose.......        314      25.65  $1,356.54      $693.37      $271.31
30462...  T                   Revision of nose.......        314      25.65  $1,356.54      $693.37      $271.31
30520...  T                   Repair of nasal septum.        313      15.81    $836.45      $411.09      $167.29
30540...  T                   Repair nasal defect....        313      15.81    $836.45      $411.09      $167.29
30545...  T                   Repair nasal defect....        314      25.65  $1,356.54      $693.37      $271.31
30560...  T                   Release of nasal               311       1.43     $75.42       $20.57       $15.08
                               adhesions.
30580...  T                   Repair upper jaw               313      15.81    $836.45      $411.09      $167.29
                               fistula.
30600...  T                   Repair mouth/nose              313      15.81    $836.45      $411.09      $167.29
                               fistula.
30620...  T                   Intranasal                     313      15.81    $836.45      $411.09      $167.29
                               reconstruction.
30630...  T                   Repair nasal septum            313      15.81    $836.45      $411.09      $167.29
                               defect.
30801...  T                   Cauterization inner            312       7.26    $383.95      $178.31       $76.79
                               nose.
30802...  T                   Cauterization inner            312       7.26    $383.95      $178.31       $76.79
                               nose.
30901...  T                   Control of nosebleed...        318       2.07    $109.70       $38.65       $21.94
30903...  T                   Control of nosebleed...        318       2.07     109.70       $38.65       $21.94
30905...  T                   Control of nosebleed...        318       2.07    $109.70       $38.65       $21.94
30906...  T                   Repeat control of              318       2.07    $109.70       $38.65       $21.94
                               nosebleed.
30915...  T                   Ligation nasal sinus           367      17.59    $930.48      $449.06      $186.10
                               artery.
30920...  T                   Ligation upper jaw             367      17.59    $930.48      $449.06      $186.10
                               artery.
30930...  T                   Therapy fracture of            312       7.26    $383.95      $178.31       $76.79
                               nose.
30999...  T                   Nasal surgery procedure        318       2.07    $109.70       $38.65       $21.94
31000...  T                   Irrigation maxillary           311       1.43     $75.42       $20.57       $15.08
                               sinus.
31002...  T                   Irrigation sphenoid            311       1.43     $75.42       $20.57       $15.08
                               sinus.
31020...  T                   Exploration maxillary          313      15.81    $836.45      $411.09      $167.29
                               sinus.
31030...  T                   Exploration maxillary          313      15.81    $836.45      $411.09      $167.29
                               sinus.
31032...  T                   Explore sinus, remove          313      15.81    $836.45      $411.09      $167.29
                               polyps.
31040...  T                   Exploration behind             314      25.65  $1,356.54      $693.37      $271.31
                               upper jaw.
31050...  T                   Exploration sphenoid           313      15.81    $836.45      $411.09      $167.29
                               sinus.
31051...  T                   Sphenoid sinus surgery.        313      15.81    $836.45      $411.09      $167.29
31070...  T                   Exploration of frontal         313      15.81    $836.45      $411.09      $167.29
                               sinus.
31075...  T                   Exploration of frontal         314      25.65  $1,356.54      $693.37      $271.31
                               sinus.
31080...  T                   Removal of frontal             314      25.65  $1,356.54      $693.37      $271.31
                               sinus.
31081...  T                   Removal of frontal             314      25.65  $1,356.54      $693.37      $271.31
                               sinus.
31084...  T                   Removal of frontal             314      25.65  $1,356.54      $693.37      $271.31
                               sinus.
31085...  T                   Removal of frontal             314      25.65  $1,356.54      $693.37      $271.31
                               sinus.
31086...  T                   Removal of frontal             314      25.65  $1,356.54      $693.37      $271.31
                               sinus.
31087...  T                   Removal of frontal             314      25.65  $1,356.54      $693.37      $271.31
                               sinus.
31090...  T                   Exploration of sinuses.        314      25.65  $1,356.54      $693.37      $271.31
31200...  T                   Removal of ethmoid             313      15.81    $836.45      $411.09      $167.29
                               sinus.
31201...  T                   Removal of ethmoid             314      25.65  $1,356.54      $693.37      $271.31
                               sinus.
31205...  T                   Removal of ethmoid             314      25.65  $1,356.54      $693.37      $271.31
                               sinus.
31225...  C                   Removal of upper jaw...  .........  .........  .........  ...........  ...........
31230...  C                   Removal of upper jaw...  .........  .........  .........  ...........  ...........

[[Page 47650]]

31231...  T                   Nasal endoscopy, dx....        331       0.69     $36.24       $14.01        $7.25
31233...  T                   Nasal/sinus endoscopy,         332       9.74    $515.19      $244.98      $103.04
                               dx.
31235...  T                   Nasal/sinus endoscopy,         332       9.74    $515.19      $244.98      $103.04
                               dx.
31237...  T                   Nasal/sinus endoscopy,         332       9.74    $515.19      $244.98      $103.04
                               surg.
31238...  T                   Nasal/sinus endoscopy,         332       9.74    $515.19      $244.98      $103.04
                               surg.
31239...  T                   Nasal/sinus endoscopy,         333      17.24    $911.87      $464.20      $182.37
                               surg.
31240...  T                   Nasal/sinus endoscopy,         332       9.74    $515.19      $244.98      $103.04
                               surg.
31254...  T                   Revision of ethmoid            333      17.24    $911.87      $464.20      $182.37
                               sinus.
31255...  T                   Removal of ethmoid             333      17.24    $911.87      $464.20      $182.37
                               sinus.
31256...  T                   Exploration maxillary          333      17.24    $911.87      $464.20      $182.37
                               sinus.
31267...  T                   Endoscopy, maxillary           333      17.24    $911.87      $464.20      $182.37
                               sinus.
31276...  T                   Sinus surgical                 333      17.24    $911.87      $464.20      $182.37
                               endoscopy.
31287...  T                   Nasal/sinus endoscopy,         333      17.24    $911.87      $464.20      $182.37
                               surg.
31288...  T                   Nasal/sinus endoscopy,         333      17.24    $911.87      $464.20      $182.37
                               surg.
31290...  C                   Nasal/sinus endoscopy,   .........  .........  .........  ...........  ...........
                               surg.
31291...  C                   Nasal/sinus endoscopy,   .........  .........  .........  ...........  ...........
                               surg.
31292...  C                   Nasal/sinus endoscopy,   .........  .........  .........  ...........  ...........
                               surg.
31293...  C                   Nasal/sinus endoscopy,   .........  .........  .........  ...........  ...........
                               surg.
31294...  C                   Nasal/sinus endoscopy,   .........  .........  .........  ...........  ...........
                               surg.
31299...  T                   Sinus surgery procedure        331       0.69     $36.24       $14.01        $7.25
31300...  T                   Removal of larynx              314      25.65  $1,356.54      $693.37      $271.31
                               lesion.
31320...  T                   Diagnostic incision            313      15.81    $836.45      $411.09      $167.29
                               larynx.
31360...  C                   Removal of larynx......  .........  .........  .........  ...........  ...........
31365...  C                   Removal of larynx......  .........  .........  .........  ...........  ...........
31367...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               larynx.
31368...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               larynx.
31370...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               larynx.
31375...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               larynx.
31380...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               larynx.
31382...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               larynx.
31390...  C                   Removal of larynx &      .........  .........  .........  ...........  ...........
                               pharynx.
31395...  C                   Reconstruct larynx &     .........  .........  .........  ...........  ...........
                               pharynx.
31400...  T                   Revision of larynx.....        314      25.65  $1,356.54      $693.37      $271.31
31420...  T                   Removal of epiglottis..        314      25.65  $1,356.54      $693.37      $271.31
31500...  S                   Insert emergency airway        947       4.07    $215.48      $109.61       $43.10
31502...  T                   Change of windpipe             470       2.22    $117.53       $54.92       $23.51
                               airway.
31505...  T                   Diagnostic laryngoscopy        331       0.69     $36.24       $14.01        $7.25
31510...  T                   Laryngoscopy with              332       9.74    $515.19      $244.98      $103.04
                               biopsy.
31511...  T                   Remove foreign body,           332       9.74    $515.19      $244.98      $103.04
                               larynx.
31512...  T                   Removal of larynx              332       9.74    $515.19      $244.98      $103.04
                               lesion.
31513...  T                   Injection into vocal           332       9.74    $515.19      $244.98      $103.04
                               cord.
31515...  T                   Laryngoscopy for               332       9.74    $515.19      $244.98      $103.04
                               aspiration.
31520...  T                   Diagnostic laryngoscopy        332       9.74    $515.19      $244.98      $103.04
31525...  T                   Diagnostic laryngoscopy        332       9.74    $515.19      $244.98      $103.04
31526...  T                   Diagnostic laryngoscopy        332       9.74    $515.19      $244.98      $103.04
31527...  T                   Laryngoscopy for               333      17.24    $911.87      $464.20      $182.37
                               treatment.
31528...  T                   Laryngoscopy and               332       9.74    $515.19      $244.98      $103.04
                               dilatation.
31529...  T                   Laryngoscopy and               332       9.74    $515.19      $244.98      $103.04
                               dilatation.
31530...  T                   Operative laryngoscopy.        333      17.24    $911.87      $464.20      $182.37
31531...  T                   Operative laryngoscopy.        333      17.24    $911.87      $464.20      $182.37
31535...  T                   Operative laryngoscopy.        333      17.24    $911.87      $464.20      $182.37
31536...  T                   Operative laryngoscopy.        333      17.24    $911.87      $464.20      $182.37
31540...  T                   Operative laryngoscopy.        333      17.24    $911.87      $464.20      $182.37
31541...  T                   Operative laryngoscopy.        333      17.24    $911.87      $464.20      $182.37
31560...  T                   Operative laryngoscopy.        333      17.24    $911.87      $464.20      $182.37
31561...  T                   Operative laryngoscopy.        333      17.24    $911.87      $464.20      $182.37
31570...  T                   Laryngoscopy with              333      17.24    $911.87      $464.20      $182.37
                               injection.
31571...  T                   Laryngoscopy with              333      17.24    $911.87      $464.20      $182.37
                               injection.
31575...  T                   Diagnostic laryngoscopy        331       0.69     $36.24       $14.01        $7.25
31576...  T                   Laryngoscopy with              332       9.74    $515.19      $244.98      $103.04
                               biopsy.
31577...  T                   Remove foreign body,           332       9.74    $515.19      $244.98      $103.04
                               larynx.
31578...  T                   Removal of larynx              332       9.74    $515.19      $244.98      $103.04
                               lesion.
31579...  T                   Diagnostic laryngoscopy        331       0.69     $36.24       $14.01        $7.25
31580...  C                   Revision of larynx.....  .........  .........  .........  ...........  ...........
31582...  C                   Revision of larynx.....  .........  .........  .........  ...........  ...........
31584...  C                   Repair of larynx         .........  .........  .........  ...........  ...........
                               fracture.
31585...  T                   Repair of larynx               207       1.70     $90.11       $31.64       $18.02
                               fracture.
31586...  T                   Repair of larynx               209       1.94    $102.84       $37.29       $20.57
                               fracture.
31587...  C                   Revision of larynx.....  .........  .........  .........  ...........  ...........
31588...  T                   Revision of larynx.....        314      25.65  $1,356.54      $693.37      $271.31
31590...  T                   Reinnervate larynx.....        314      25.65  $1,356.54      $693.37      $271.31
31595...  T                   Larynx nerve surgery...        313      15.81    $836.45      $411.09      $167.29
31599...  T                   Larynx surgery                 207       1.70     $90.11       $31.64       $18.02
                               procedure.
31600...  C                   Incision of windpipe...  .........  .........  .........  ...........  ...........
31601...  C                   Incision of windpipe...  .........  .........  .........  ...........  ...........

[[Page 47651]]

31603...  T                   Incision of windpipe...        311       1.43     $75.42       $20.57       $15.08
31605...  T                   Incision of windpipe...        311       1.43     $75.42       $20.57       $15.08
31610...  C                   Incision of windpipe...  .........  .........  .........  ...........  ...........
31611...  T                   Surgery/speech                 313      15.81    $836.45      $411.09      $167.29
                               prosthesis.
31612...  T                   Puncture/clear windpipe        312       7.26    $383.95      $178.31       $76.79
31613...  T                   Repair windpipe opening        313      15.81    $836.45      $411.09      $167.29
31614...  T                   Repair windpipe opening        313      15.81    $836.45      $411.09      $167.29
31615...  T                   Visualization of               336       7.44    $393.74      $197.98       $78.75
                               windpipe.
31622...  T                   Diagnostic bronchoscopy        336       7.44    $393.74      $197.98       $78.75
31625...  T                   Bronchoscopy with              336       7.44    $393.74      $197.98       $78.75
                               biopsy.
31628...  T                   Bronchoscopy with              336       7.44    $393.74      $197.98       $78.75
                               biopsy.
31629...  T                   Bronchoscopy with              336       7.44    $393.74      $197.98       $78.75
                               biopsy.
31630...  T                   Bronchoscopy with              336       7.44    $393.74      $197.98       $78.75
                               repair.
31631...  T                   Bronchoscopy with              336       7.44    $393.74      $197.98       $78.75
                               dilation.
31635...  T                   Remove foreign body,           336       7.44    $393.74      $197.98       $78.75
                               airway.
31640...  T                   Bronchoscopy & remove          336       7.44    $393.74      $197.98       $78.75
                               lesion.
31641...  T                   Bronchoscopy, treat            336       7.44    $393.74      $197.98       $78.75
                               blockage.
31645...  T                   Bronchoscopy, clear            336       7.44    $393.74      $197.98       $78.75
                               airways.
31646...  T                   Bronchoscopy, reclear          336       7.44    $393.74      $197.98       $78.75
                               airways.
31656...  T                   Bronchoscopy, inject           336       7.44    $393.74      $197.98       $78.75
                               for xray.
31700...  T                   Insertion of airway            332       9.74    $515.19      $244.98      $103.04
                               catheter.
31708...  T                   Instill airway contrast        347       2.93    $154.75       $62.15       $30.95
                               dye.
31710...  T                   Insertion of airway            347       2.93    $154.75       $62.15       $30.95
                               catheter.
31715...  T                   Injection for bronchus         347       2.93    $154.75       $62.15       $30.95
                               x-ray.
31717...  T                   Bronchial brush biopsy.        332       9.74    $515.19      $244.98      $103.04
31720...  T                   Clearance of airways...        332       9.74    $515.19      $244.98      $103.04
31725...  C                   Clearance of airways...  .........  .........  .........  ...........  ...........
31730...  T                   Intro windpipe wire/           332       9.74    $515.19      $244.98      $103.04
                               tube.
31750...  T                   Repair of windpipe.....        314      25.65  $1,356.54      $693.37      $271.31
31755...  T                   Repair of windpipe.....        314      25.65  $1,356.54      $693.37      $271.31
31760...  C                   Repair of windpipe.....  .........  .........  .........  ...........  ...........
31766...  C                   Reconstruction of        .........  .........  .........  ...........  ...........
                               windpipe.
31770...  C                   Repair/graft of          .........  .........  .........  ...........  ...........
                               bronchus.
31775...  C                   Reconstruct bronchus...  .........  .........  .........  ...........  ...........
31780...  C                   Reconstruct windpipe...  .........  .........  .........  ...........  ...........
31781...  C                   Reconstruct windpipe...  .........  .........  .........  ...........  ...........
31785...  C                   Remove windpipe lesion.  .........  .........  .........  ...........  ...........
31786...  C                   Remove windpipe lesion.  .........  .........  .........  ...........  ...........
31800...  C                   Repair of windpipe       .........  .........  .........  ...........  ...........
                               injury.
31805...  C                   Repair of windpipe       .........  .........  .........  ...........  ...........
                               injury.
31820...  T                   Closure of windpipe            313      15.81    $836.45      $411.09      $167.29
                               lesion.
31825...  T                   Repair of windpipe             313      15.81    $836.45      $411.09      $167.29
                               defect.
31830...  T                   Revise windpipe scar...        313      15.81    $836.45      $411.09      $167.29
31899...  T                   Airways surgical               336       7.44    $393.74      $197.98       $78.75
                               procedure.
32000...  T                   Drainage of chest......        320       3.17    $167.49       $79.33       $33.50
32002...  T                   Treatment of collapsed         320       3.17    $167.49       $79.33       $33.50
                               lung.
32005...  C                   Treat lung lining        .........  .........  .........  ...........  ...........
                               chemically.
32020...  T                   Insertion of chest tube        320       3.17    $167.49       $79.33       $33.50
32035...  C                   Exploration of chest...  .........  .........  .........  ...........  ...........
32036...  C                   Exploration of chest...  .........  .........  .........  ...........  ...........
32095...  C                   Biopsy through chest     .........  .........  .........  ...........  ...........
                               wall.
32100...  C                   Exploration/biopsy of    .........  .........  .........  ...........  ...........
                               chest.
32110...  C                   Explore/repair chest...  .........  .........  .........  ...........  ...........
32120...  C                   Re-exploration of chest  .........  .........  .........  ...........  ...........
32124...  C                   Explore chest, free      .........  .........  .........  ...........  ...........
                               adhesions.
32140...  C                   Removal of lung          .........  .........  .........  ...........  ...........
                               lesion(s).
32141...  C                   Remove/treat lung        .........  .........  .........  ...........  ...........
                               lesions.
32150...  C                   Removal of lung          .........  .........  .........  ...........  ...........
                               lesion(s).
32151...  C                   Remove lung foreign      .........  .........  .........  ...........  ...........
                               body.
32160...  C                   Open chest heart         .........  .........  .........  ...........  ...........
                               massage.
32200...  C                   Open drainage, lung      .........  .........  .........  ...........  ...........
                               lesion.
32201...  C                   Percut drainage, lung    .........  .........  .........  ...........  ...........
                               lesion.
32215...  C                   Treat chest lining.....  .........  .........  .........  ...........  ...........
32220...  C                   Release of lung........  .........  .........  .........  ...........  ...........
32225...  C                   Partial release of lung  .........  .........  .........  ...........  ...........
32310...  C                   Removal of chest lining  .........  .........  .........  ...........  ...........
32320...  C                   Free/remove chest        .........  .........  .........  ...........  ...........
                               lining.
32400...  T                   Needle biopsy chest            122       4.87    $257.60      $115.03       $51.52
                               lining.
32402...  C                   Open biopsy chest        .........  .........  .........  ...........  ...........
                               lining.
32405...  T                   Biopsy, lung or                122       4.87    $257.60      $115.03       $51.52
                               mediastinum.
32420...  T                   Puncture/clear lung....        320       3.17    $167.49       $79.33       $33.50
32440...  C                   Removal of lung........  .........  .........  .........  ...........  ...........
32442...  C                   Sleeve pneumonectomy...  .........  .........  .........  ...........  ...........
32445...  C                   Removal of lung........  .........  .........  .........  ...........  ...........
32480...  C                   Partial removal of lung  .........  .........  .........  ...........  ...........

[[Page 47652]]

32482...  C                   Bilobectomy............  .........  .........  .........  ...........  ...........
32484...  C                   Segmentectomy..........  .........  .........  .........  ...........  ...........
32486...  C                   Sleeve lobectomy.......  .........  .........  .........  ...........  ...........
32488...  C                   Completion               .........  .........  .........  ...........  ...........
                               pneumonectomy.
32491...  C                   Lung volume reduction..  .........  .........  .........  ...........  ...........
32500...  C                   Partial removal of lung  .........  .........  .........  ...........  ...........
32501...  C                   Repair bronchus (add-    .........  .........  .........  ...........  ...........
                               on).
32520...  C                   Remove lung & revise     .........  .........  .........  ...........  ...........
                               chest.
32522...  C                   Remove lung & revise     .........  .........  .........  ...........  ...........
                               chest.
32525...  C                   Remove lung & revise     .........  .........  .........  ...........  ...........
                               chest.
32540...  C                   Removal of lung lesion.  .........  .........  .........  ...........  ...........
32601...  C                   Thoracoscopy,            .........  .........  .........  ...........  ...........
                               diagnostic.
32602...  C                   Thoracoscopy,            .........  .........  .........  ...........  ...........
                               diagnostic.
32603...  C                   Thoracoscopy,            .........  .........  .........  ...........  ...........
                               diagnostic.
32604...  C                   Thoracoscopy,            .........  .........  .........  ...........  ...........
                               diagnostic.
32605...  C                   Thoracoscopy,            .........  .........  .........  ...........  ...........
                               diagnostic.
32606...  C                   Thoracoscopy,            .........  .........  .........  ...........  ...........
                               diagnostic.
32650...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32651...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32652...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32653...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32654...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32655...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32656...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32657...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32658...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32659...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32660...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32661...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32662...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32663...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32664...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32665...  C                   Thoracoscopy, surgical.  .........  .........  .........  ...........  ...........
32800...  C                   Repair lung hernia.....  .........  .........  .........  ...........  ...........
32810...  C                   Close chest after        .........  .........  .........  ...........  ...........
                               drainage.
32815...  C                   Close bronchial fistula  .........  .........  .........  ...........  ...........
32820...  C                   Reconstruct injured      .........  .........  .........  ...........  ...........
                               chest.
32850...  C                   Donor pneumonectomy....  .........  .........  .........  ...........  ...........
32851...  C                   Lung transplant, single  .........  .........  .........  ...........  ...........
32852...  C                   Lung transplant w/       .........  .........  .........  ...........  ...........
                               bypass.
32853...  C                   Lung transplant, double  .........  .........  .........  ...........  ...........
32854...  C                   Lung transplant w/       .........  .........  .........  ...........  ...........
                               bypass.
32900...  C                   Removal of rib(s)......  .........  .........  .........  ...........  ...........
32905...  C                   Revise & repair chest    .........  .........  .........  ...........  ...........
                               wall.
32906...  C                   Revise & repair chest    .........  .........  .........  ...........  ...........
                               wall.
32940...  C                   Revision of lung.......  .........  .........  .........  ...........  ...........
32960...  T                   Therapeutic                    320       3.17    $167.49       $79.33       $33.50
                               pneumothorax.
32999...  T                   Chest surgery procedure        320       3.17    $167.49       $79.33       $33.50
33010...  T                   Drainage of heart sac..        320       3.17    $167.49       $79.33       $33.50
33011...  T                   Repeat drainage of             320       3.17    $167.49       $79.33       $33.50
                               heart sac.
33015...  C                   Incision of heart sac..  .........  .........  .........  ...........  ...........
33020...  C                   Incision of heart sac..  .........  .........  .........  ...........  ...........
33025...  C                   Incision of heart sac..  .........  .........  .........  ...........  ...........
33030...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               heart sac.
33031...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               heart sac.
33050...  C                   Removal of heart sac     .........  .........  .........  ...........  ...........
                               lesion.
33120...  C                   Removal of heart lesion  .........  .........  .........  ...........  ...........
33130...  C                   Removal of heart lesion  .........  .........  .........  ...........  ...........
33200...  C                   Insertion of heart       .........  .........  .........  ...........  ...........
                               pacemaker.
33201...  C                   Insertion of heart       .........  .........  .........  ...........  ...........
                               pacemaker.
33206...  C                   Insertion of heart       .........  .........  .........  ...........  ...........
                               pacemaker.
33207...  C                   Insertion of heart       .........  .........  .........  ...........  ...........
                               pacemaker.
33208...  C                   Insertion of heart       .........  .........  .........  ...........  ...........
                               pacemaker.
33210...  C                   Insertion of heart       .........  .........  .........  ...........  ...........
                               electrode.
33211...  C                   Insertion of heart       .........  .........  .........  ...........  ...........
                               electrode.
33212...  C                   Insertion of pulse       .........  .........  .........  ...........  ...........
                               generator.
33213...  C                   Insertion of pulse       .........  .........  .........  ...........  ...........
                               generator.
33214...  C                   Upgrade of pacemaker     .........  .........  .........  ...........  ...........
                               system.
33216...  C                   Revision implanted       .........  .........  .........  ...........  ...........
                               electrode.
33217...  C                   Insert/revise electrode  .........  .........  .........  ...........  ...........
33218...  C                   Repair pacemaker         .........  .........  .........  ...........  ...........
                               electrodes.
33220...  C                   Repair pacemaker         .........  .........  .........  ...........  ...........
                               electrode.
33222...  T                   Pacemaker AICD pocket..        360       6.09    $322.24      $140.12       $64.45
33223...  T                   Pacemaker AICD pocket..        360       6.09    $322.24      $140.12       $64.45
33233...  C                   Removal of pacemaker     .........  .........  .........  ...........  ...........
                               system.

[[Page 47653]]

33234...  C                   Removal of pacemaker     .........  .........  .........  ...........  ...........
                               system.
33235...  C                   Removal pacemaker        .........  .........  .........  ...........  ...........
                               electrode.
33236...  C                   Remove electrode/        .........  .........  .........  ...........  ...........
                               thoracotomy.
33237...  C                   Remove electrode/        .........  .........  .........  ...........  ...........
                               thoracotomy.
33238...  C                   Remove electrode/        .........  .........  .........  ...........  ...........
                               thoracotomy.
33240...  C                   Insert/replace pulse     .........  .........  .........  ...........  ...........
                               gener.
33241...  C                   Remove pulse generator   .........  .........  .........  ...........  ...........
                               only.
33242...  C                   Repair pulse generator/  .........  .........  .........  ...........  ...........
                               leads.
33243...  C                   Remove generator/        .........  .........  .........  ...........  ...........
                               thoracotomy.
33244...  C                   Remove generator.......  .........  .........  .........  ...........  ...........
33245...  C                   Implant heart            .........  .........  .........  ...........  ...........
                               defibrillator.
33246...  C                   Implant heart            .........  .........  .........  ...........  ...........
                               defibrillator.
33247...  C                   Insert/replace leads...  .........  .........  .........  ...........  ...........
33249...  C                   Insert/replace leads/    .........  .........  .........  ...........  ...........
                               gener.
33250...  C                   Ablate heart dysrhythm   .........  .........  .........  ...........  ...........
                               focus.
33251...  C                   Ablate heart dysrhythm   .........  .........  .........  ...........  ...........
                               focus.
33253...  C                   Reconstruct atria......  .........  .........  .........  ...........  ...........
33261...  C                   Ablate heart dysrhythm   .........  .........  .........  ...........  ...........
                               focus.
33300...  C                   Repair of heart wound..  .........  .........  .........  ...........  ...........
33305...  C                   Repair of heart wound..  .........  .........  .........  ...........  ...........
33310...  C                   Exploratory heart        .........  .........  .........  ...........  ...........
                               surgery.
33315...  C                   Exploratory heart        .........  .........  .........  ...........  ...........
                               surgery.
33320...  C                   Repair major blood       .........  .........  .........  ...........  ...........
                               vessel(s).
33321...  C                   Repair major vessel....  .........  .........  .........  ...........  ...........
33322...  C                   Repair major blood       .........  .........  .........  ...........  ...........
                               vessel(s).
33330...  C                   Insert major vessel      .........  .........  .........  ...........  ...........
                               graft.
33332...  C                   Insert major vessel      .........  .........  .........  ...........  ...........
                               graft.
33335...  C                   Insert major vessel      .........  .........  .........  ...........  ...........
                               graft.
33400...  C                   Repair of aortic valve.  .........  .........  .........  ...........  ...........
33401...  C                   Valvuloplasty, open....  .........  .........  .........  ...........  ...........
33403...  C                   Valvuloplasty, w/cp      .........  .........  .........  ...........  ...........
                               bypass.
33404...  C                   Prepare heart-aorta      .........  .........  .........  ...........  ...........
                               conduit.
33405...  C                   Replacement of aortic    .........  .........  .........  ...........  ...........
                               valve.
33406...  C                   Replacement, aortic      .........  .........  .........  ...........  ...........
                               valve.
33411...  C                   Replacement of aortic    .........  .........  .........  ...........  ...........
                               valve.
33412...  C                   Replacement of aortic    .........  .........  .........  ...........  ...........
                               valve.
33413...  C                   Replacement, aortic      .........  .........  .........  ...........  ...........
                               valve.
33414...  C                   Repair, aortic valve...  .........  .........  .........  ...........  ...........
33415...  C                   Revision, subvalvular    .........  .........  .........  ...........  ...........
                               tissue.
33416...  C                   Revise ventricle muscle  .........  .........  .........  ...........  ...........
33417...  C                   Repair of aortic valve.  .........  .........  .........  ...........  ...........
33420...  C                   Revision of mitral       .........  .........  .........  ...........  ...........
                               valve.
33422...  C                   Revision of mitral       .........  .........  .........  ...........  ...........
                               valve.
33425...  C                   Repair of mitral valve.  .........  .........  .........  ...........  ...........
33426...  C                   Repair of mitral valve.  .........  .........  .........  ...........  ...........
33427...  C                   Repair of mitral valve.  .........  .........  .........  ...........  ...........
33430...  C                   Replacement of mitral    .........  .........  .........  ...........  ...........
                               valve.
33460...  C                   Revision of tricuspid    .........  .........  .........  ...........  ...........
                               valve.
33463...  C                   Valvuloplasty,           .........  .........  .........  ...........  ...........
                               tricuspid.
33464...  C                   Valvuloplasty,           .........  .........  .........  ...........  ...........
                               tricuspid.
33465...  C                   Replace tricuspid valve  .........  .........  .........  ...........  ...........
33468...  C                   Revision of tricuspid    .........  .........  .........  ...........  ...........
                               valve.
33470...  C                   Revision of pulmonary    .........  .........  .........  ...........  ...........
                               valve.
33471...  C                   Valvotomy, pulmonary     .........  .........  .........  ...........  ...........
                               valve.
33472...  C                   Revision of pulmonary    .........  .........  .........  ...........  ...........
                               valve.
33474...  C                   Revision of pulmonary    .........  .........  .........  ...........  ...........
                               valve.
33475...  C                   Replacement, pulmonary   .........  .........  .........  ...........  ...........
                               valve.
33476...  C                   Revision of heart        .........  .........  .........  ...........  ...........
                               chamber.
33478...  C                   Revision of heart        .........  .........  .........  ...........  ...........
                               chamber.
33496...  C                   Repair, prosth valve     .........  .........  .........  ...........  ...........
                               clot.
33500...  C                   Repair heart vessel      .........  .........  .........  ...........  ...........
                               fistula.
33501...  C                   Repair heart vessel      .........  .........  .........  ...........  ...........
                               fistula.
33502...  C                   Coronary artery          .........  .........  .........  ...........  ...........
                               correction.
33503...  C                   Coronary artery graft..  .........  .........  .........  ...........  ...........
33504...  C                   Coronary artery graft..  .........  .........  .........  ...........  ...........
33505...  C                   Repair artery w/tunnel.  .........  .........  .........  ...........  ...........
33506...  C                   Repair artery,           .........  .........  .........  ...........  ...........
                               translocation.
33510...  C                   CABG, vein, single.....  .........  .........  .........  ...........  ...........
33511...  C                   CABG, vein, two........  .........  .........  .........  ...........  ...........
33512...  C                   CABG, vein, three......  .........  .........  .........  ...........  ...........
33513...  C                   CABG, vein, four.......  .........  .........  .........  ...........  ...........
33514...  C                   CABG, vein, five.......  .........  .........  .........  ...........  ...........
33516...  C                   CABG, vein, six+.......  .........  .........  .........  ...........  ...........
33517...  C                   CABG, artery-vein,       .........  .........  .........  ...........  ...........
                               single.
33518...  C                   CABG, artery-vein, two.  .........  .........  .........  ...........  ...........

[[Page 47654]]

33519...  C                   CABG, artery-vein,       .........  .........  .........  ...........  ...........
                               three.
33521...  C                   CABG, artery-vein, four  .........  .........  .........  ...........  ...........
33522...  C                   CABG, artery-vein, five  .........  .........  .........  ...........  ...........
33523...  C                   CABG, artery-vein, six+  .........  .........  .........  ...........  ...........
33530...  C                   Coronary artery, bypass/ .........  .........  .........  ...........  ...........
                               reop.
33533...  C                   CABG, arterial, single.  .........  .........  .........  ...........  ...........
33534...  C                   CABG, arterial, two....  .........  .........  .........  ...........  ...........
33535...  C                   CABG, arterial, three..  .........  .........  .........  ...........  ...........
33536...  C                   CABG, arterial, four+..  .........  .........  .........  ...........  ...........
33542...  C                   Removal of heart lesion  .........  .........  .........  ...........  ...........
33545...  C                   Repair of heart damage.  .........  .........  .........  ...........  ...........
33572...  C                   Open coronary            .........  .........  .........  ...........  ...........
                               endarterectomy.
33600...  C                   Closure of valve.......  .........  .........  .........  ...........  ...........
33602...  C                   Closure of valve.......  .........  .........  .........  ...........  ...........
33606...  C                   Anastomosis/artery-      .........  .........  .........  ...........  ...........
                               aorta.
33608...  C                   Repair anomaly w/        .........  .........  .........  ...........  ...........
                               conduit.
33610...  C                   Repair by enlargement..  .........  .........  .........  ...........  ...........
33611...  C                   Repair double ventricle  .........  .........  .........  ...........  ...........
33612...  C                   Repair double ventricle  .........  .........  .........  ...........  ...........
33615...  C                   Repair (simple fontan).  .........  .........  .........  ...........  ...........
33617...  C                   Repair by modified       .........  .........  .........  ...........  ...........
                               fontan.
33619...  C                   Repair single ventricle  .........  .........  .........  ...........  ...........
33641...  C                   Repair heart septum      .........  .........  .........  ...........  ...........
                               defect.
33645...  C                   Revision of heart veins  .........  .........  .........  ...........  ...........
33647...  C                   Repair heart septum      .........  .........  .........  ...........  ...........
                               defects.
33660...  C                   Repair of heart defects  .........  .........  .........  ...........  ...........
33665...  C                   Repair of heart defects  .........  .........  .........  ...........  ...........
33670...  C                   Repair of heart          .........  .........  .........  ...........  ...........
                               chambers.
33681...  C                   Repair heart septum      .........  .........  .........  ...........  ...........
                               defect.
33684...  C                   Repair heart septum      .........  .........  .........  ...........  ...........
                               defect.
33688...  C                   Repair heart septum      .........  .........  .........  ...........  ...........
                               defect.
33690...  C                   Reinforce pulmonary      .........  .........  .........  ...........  ...........
                               artery.
33692...  C                   Repair of heart defects  .........  .........  .........  ...........  ...........
33694...  C                   Repair of heart defects  .........  .........  .........  ...........  ...........
33697...  C                   Repair of heart defects  .........  .........  .........  ...........  ...........
33702...  C                   Repair of heart defects  .........  .........  .........  ...........  ...........
33710...  C                   Repair of heart defects  .........  .........  .........  ...........  ...........
33720...  C                   Repair of heart defect.  .........  .........  .........  ...........  ...........
33722...  C                   Repair of heart defect.  .........  .........  .........  ...........  ...........
33730...  C                   Repair heart-vein        .........  .........  .........  ...........  ...........
                               defect(s).
33732...  C                   Repair heart-vein        .........  .........  .........  ...........  ...........
                               defect.
33735...  C                   Revision of heart        .........  .........  .........  ...........  ...........
                               chamber.
33736...  C                   Revision of heart        .........  .........  .........  ...........  ...........
                               chamber.
33737...  C                   Revision of heart        .........  .........  .........  ...........  ...........
                               chamber.
33750...  C                   Major vessel shunt.....  .........  .........  .........  ...........  ...........
33755...  C                   Major vessel shunt.....  .........  .........  .........  ...........  ...........
33762...  C                   Major vessel shunt.....  .........  .........  .........  ...........  ...........
33764...  C                   Major vessel shunt &     .........  .........  .........  ...........  ...........
                               graft.
33766...  C                   Major vessel shunt.....  .........  .........  .........  ...........  ...........
33767...  C                   Atrial septectomy/       .........  .........  .........  ...........  ...........
                               septostomy.
33770...  C                   Repair great vessels     .........  .........  .........  ...........  ...........
                               defect.
33771...  C                   Repair great vessels     .........  .........  .........  ...........  ...........
                               defect.
33774...  C                   Repair great vessels     .........  .........  .........  ...........  ...........
                               defect.
33775...  C                   Repair great vessels     .........  .........  .........  ...........  ...........
                               defect.
33776...  C                   Repair great vessels     .........  .........  .........  ...........  ...........
                               defect.
33777...  C                   Repair great vessels     .........  .........  .........  ...........  ...........
                               defect.
33778...  C                   Repair great vessels     .........  .........  .........  ...........  ...........
                               defect.
33779...  C                   Repair great vessels     .........  .........  .........  ...........  ...........
                               defect.
33780...  C                   Repair great vessels     .........  .........  .........  ...........  ...........
                               defect.
33781...  C                   Repair great vessels     .........  .........  .........  ...........  ...........
                               defect.
33786...  C                   Repair arterial trunk..  .........  .........  .........  ...........  ...........
33788...  C                   Revision of pulmonary    .........  .........  .........  ...........  ...........
                               artery.
33800...  C                   Aortic suspension......  .........  .........  .........  ...........  ...........
33802...  C                   Repair vessel defect...  .........  .........  .........  ...........  ...........
33803...  C                   Repair vessel defect...  .........  .........  .........  ...........  ...........
33813...  C                   Repair septal defect...  .........  .........  .........  ...........  ...........
33814...  C                   Repair septal defect...  .........  .........  .........  ...........  ...........
33820...  C                   Revise major vessel....  .........  .........  .........  ...........  ...........
33822...  C                   Revise major vessel....  .........  .........  .........  ...........  ...........
33824...  C                   Revise major vessel....  .........  .........  .........  ...........  ...........
33840...  C                   Remove aorta             .........  .........  .........  ...........  ...........
                               constriction.
33845...  C                   Remove aorta             .........  .........  .........  ...........  ...........
                               constriction.
33851...  C                   Remove aorta             .........  .........  .........  ...........  ...........
                               constriction.
33852...  C                   Repair septal defect...  .........  .........  .........  ...........  ...........
33853...  C                   Repair septal defect...  .........  .........  .........  ...........  ...........

[[Page 47655]]

33860...  C                   Ascending aorta graft..  .........  .........  .........  ...........  ...........
33861...  C                   Ascending aorta graft..  .........  .........  .........  ...........  ...........
33863...  C                   Ascending aorta graft..  .........  .........  .........  ...........  ...........
33870...  C                   Transverse aortic arch   .........  .........  .........  ...........  ...........
                               graft.
33875...  C                   Thoracic aorta graft...  .........  .........  .........  ...........  ...........
33877...  C                   Thoracoabdominal graft.  .........  .........  .........  ...........  ...........
33910...  C                   Remove lung artery       .........  .........  .........  ...........  ...........
                               emboli.
33915...  C                   Remove lung artery       .........  .........  .........  ...........  ...........
                               emboli.
33916...  C                   Surgery of great vessel  .........  .........  .........  ...........  ...........
33917...  C                   Repair pulmonary artery  .........  .........  .........  ...........  ...........
33918...  C                   Repair pulmonary         .........  .........  .........  ...........  ...........
                               atresia.
33919...  C                   Repair pulmonary         .........  .........  .........  ...........  ...........
                               atresia.
33920...  C                   Repair pulmonary         .........  .........  .........  ...........  ...........
                               atresia.
33922...  C                   Transect pulmonary       .........  .........  .........  ...........  ...........
                               artery.
33924...  C                   Remove pulmonary shunt.  .........  .........  .........  ...........  ...........
33930...  C                   Removal of donor heart/  .........  .........  .........  ...........  ...........
                               lung.
33935...  C                   Transplantation, heart/  .........  .........  .........  ...........  ...........
                               lung.
33940...  C                   Removal of donor heart.  .........  .........  .........  ...........  ...........
33945...  C                   Transplantation of       .........  .........  .........  ...........  ...........
                               heart.
33960...  C                   External circulation     .........  .........  .........  ...........  ...........
                               assist.
33961...  C                   External circulation     .........  .........  .........  ...........  ...........
                               assist.
33970...  C                   Aortic circulation       .........  .........  .........  ...........  ...........
                               assist.
33971...  C                   Aortic circulation       .........  .........  .........  ...........  ...........
                               assist.
33973...  C                   Insert balloon device..  .........  .........  .........  ...........  ...........
33974...  C                   Remove intra-aortic      .........  .........  .........  ...........  ...........
                               balloon.
33975...  C                   Implant ventricular      .........  .........  .........  ...........  ...........
                               device.
33976...  C                   Implant ventricular      .........  .........  .........  ...........  ...........
                               device.
33977...  C                   Remove ventricular       .........  .........  .........  ...........  ...........
                               device.
33978...  C                   Remove ventricular       .........  .........  .........  ...........  ...........
                               device.
33999...  T                   Cardiac surgery                320       3.17    $167.49       $79.33       $33.50
                               procedure.
34001...  C                   Removal of artery clot.  .........  .........  .........  ...........  ...........
34051...  C                   Removal of artery clot.  .........  .........  .........  ...........  ...........
34101...  C                   Removal of artery clot.  .........  .........  .........  ...........  ...........
34111...  C                   Removal of arm artery    .........  .........  .........  ...........  ...........
                               clot.
34151...  C                   Removal of artery clot.  .........  .........  .........  ...........  ...........
34201...  C                   Removal of artery clot.  .........  .........  .........  ...........  ...........
34203...  C                   Removal of leg artery    .........  .........  .........  ...........  ...........
                               clot.
34401...  C                   Removal of vein clot...  .........  .........  .........  ...........  ...........
34421...  C                   Removal of vein clot...  .........  .........  .........  ...........  ...........
34451...  C                   Removal of vein clot...  .........  .........  .........  ...........  ...........
34471...  C                   Removal of vein clot...  .........  .........  .........  ...........  ...........
34490...  C                   Removal of vein clot...  .........  .........  .........  ...........  ...........
34501...  C                   Repair valve, femoral    .........  .........  .........  ...........  ...........
                               vein.
34502...  C                   Reconstruct, vena cava.  .........  .........  .........  ...........  ...........
34510...  C                   Transposition of vein    .........  .........  .........  ...........  ...........
                               valve.
34520...  C                   Cross-over vein graft..  .........  .........  .........  ...........  ...........
34530...  C                   Leg vein fusion........  .........  .........  .........  ...........  ...........
35001...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35002...  C                   Repair artery rupture,   .........  .........  .........  ...........  ...........
                               neck.
35005...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35011...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35013...  C                   Repair artery rupture,   .........  .........  .........  ...........  ...........
                               arm.
35021...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35022...  C                   Repair artery rupture,   .........  .........  .........  ...........  ...........
                               chest.
35045...  C                   Repair defect of arm     .........  .........  .........  ...........  ...........
                               artery.
35081...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35082...  C                   Repair artery rupture,   .........  .........  .........  ...........  ...........
                               aorta.
35091...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35092...  C                   Repair artery rupture,   .........  .........  .........  ...........  ...........
                               aorta.
35102...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35103...  C                   Repair artery rupture,   .........  .........  .........  ...........  ...........
                               groin.
35111...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35112...  C                   Repair artery rupture,   .........  .........  .........  ...........  ...........
                               spleen.
35121...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35122...  C                   Repair artery rupture,   .........  .........  .........  ...........  ...........
                               belly.
35131...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35132...  C                   Repair artery rupture,   .........  .........  .........  ...........  ...........
                               groin.
35141...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35142...  C                   Repair artery rupture,   .........  .........  .........  ...........  ...........
                               thigh.
35151...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35152...  C                   Repair artery rupture,   .........  .........  .........  ...........  ...........
                               knee.
35161...  C                   Repair defect of artery  .........  .........  .........  ...........  ...........
35162...  C                   Repair artery rupture..  .........  .........  .........  ...........  ...........
35180...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35182...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.

[[Page 47656]]

35184...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35188...  T                   Repair blood vessel            368      22.83  $1,207.67      $648.85      $241.53
                               lesion.
35189...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35190...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35201...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35206...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35207...  T                   Repair blood vessel            368      22.83  $1,207.67      $648.85      $241.53
                               lesion.
35211...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35216...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35221...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35226...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35231...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35236...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35241...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35246...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35251...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35256...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35261...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35266...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35271...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35276...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35281...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35286...  C                   Repair blood vessel      .........  .........  .........  ...........  ...........
                               lesion.
35301...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35311...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35321...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35331...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35341...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35351...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35355...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35361...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35363...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35371...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35372...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35381...  C                   Rechanneling of artery.  .........  .........  .........  ...........  ...........
35390...  C                   Reoperation, carotid...  .........  .........  .........  ...........  ...........
35400...  C                   Angioscopy.............  .........  .........  .........  ...........  ...........
35450...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35452...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35454...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35456...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35458...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35459...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35460...  C                   Repair venous blockage.  .........  .........  .........  ...........  ...........
35470...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35471...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35472...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35473...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35474...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35475...  C                   Repair arterial          .........  .........  .........  ...........  ...........
                               blockage.
35476...  C                   Repair venous blockage.  .........  .........  .........  ...........  ...........
35480...  C                   Atherectomy, open......  .........  .........  .........  ...........  ...........
35481...  C                   Atherectomy, open......  .........  .........  .........  ...........  ...........
35482...  C                   Atherectomy, open......  .........  .........  .........  ...........  ...........
35483...  C                   Atherectomy, open......  .........  .........  .........  ...........  ...........
35484...  C                   Atherectomy, open......  .........  .........  .........  ...........  ...........
35485...  C                   Atherectomy, open......  .........  .........  .........  ...........  ...........
35490...  C                   Atherectomy,             .........  .........  .........  ...........  ...........
                               percutaneous.
35491...  C                   Atherectomy,             .........  .........  .........  ...........  ...........
                               percutaneous.
35492...  C                   Atherectomy,             .........  .........  .........  ...........  ...........
                               percutaneous.
35493...  C                   Atherectomy,             .........  .........  .........  ...........  ...........
                               percutaneous.
35494...  C                   Atherectomy,             .........  .........  .........  ...........  ...........
                               percutaneous.
35495...  C                   Atherectomy,             .........  .........  .........  ...........  ...........
                               percutaneous.
35501...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35506...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35507...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35508...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35509...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35511...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35515...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35516...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35518...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35521...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35526...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35531...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........

[[Page 47657]]

35533...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35536...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35541...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35546...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35548...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35549...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35551...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35556...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35558...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35560...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35563...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35565...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35566...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35571...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35582...  C                   Vein bypass graft......  .........  .........  .........  ...........  ...........
35583...  C                   Vein bypass graft......  .........  .........  .........  ...........  ...........
35585...  C                   Vein bypass graft......  .........  .........  .........  ...........  ...........
35587...  C                   Vein bypass graft......  .........  .........  .........  ...........  ...........
35601...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35606...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35612...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35616...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35621...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35623...  C                   Bypass graft, not vein.  .........  .........  .........  ...........  ...........
35626...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35631...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35636...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35641...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35642...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35645...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35646...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35650...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35651...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35654...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35656...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35661...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35663...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35665...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35666...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35671...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35681...  C                   Artery bypass graft....  .........  .........  .........  ...........  ...........
35691...  C                   Arterial transposition.  .........  .........  .........  ...........  ...........
35693...  C                   Arterial transposition.  .........  .........  .........  ...........  ...........
35694...  C                   Arterial transposition.  .........  .........  .........  ...........  ...........
35695...  C                   Arterial transposition.  .........  .........  .........  ...........  ...........
35700...  C                   Reoperation, bypass      .........  .........  .........  ...........  ...........
                               graft.
35701...  C                   Exploration, carotid     .........  .........  .........  ...........  ...........
                               artery.
35721...  C                   Exploration, femoral     .........  .........  .........  ...........  ...........
                               artery.
35741...  C                   Exploration popliteal    .........  .........  .........  ...........  ...........
                               artery.
35761...  C                   Exploration of artery/   .........  .........  .........  ...........  ...........
                               vein.
35800...  C                   Explore neck vessels...  .........  .........  .........  ...........  ...........
35820...  C                   Explore chest vessels..  .........  .........  .........  ...........  ...........
35840...  C                   Explore abdominal        .........  .........  .........  ...........  ...........
                               vessels.
35860...  C                   Explore limb vessels...  .........  .........  .........  ...........  ...........
35870...  C                   Repair vessel graft      .........  .........  .........  ...........  ...........
                               defect.
35875...  T                   Removal of clot in             368      22.83  $1,207.67      $648.85      $241.53
                               graft.
35876...  T                   Removal of clot in             368      22.83  $1,207.67      $648.85      $241.53
                               graft.
35901...  C                   Excision, graft, neck..  .........  .........  .........  ...........  ...........
35903...  C                   Excision, graft,         .........  .........  .........  ...........  ...........
                               extremity.
35905...  C                   Excision, graft, thorax  .........  .........  .........  ...........  ...........
35907...  C                   Excision, graft,         .........  .........  .........  ...........  ...........
                               abdomen.
36000...  N                   Place needle in vein...  .........  .........  .........  ...........  ...........
36005...  T                   Injection, venography..        347       2.93    $154.75       $62.15       $30.95
36010...  T                   Place catheter in vein.        342       3.20    $169.45       $80.23       $33.89
36011...  T                   Place catheter in vein.        342       3.20    $169.45       $80.23       $33.89
36012...  T                   Place catheter in vein.        342       3.20    $169.45       $80.23       $33.89
36013...  T                   Place catheter in              342       3.20    $169.45       $80.23       $33.89
                               artery.
36014...  T                   Place catheter in              342       3.20    $169.45       $80.23       $33.89
                               artery.
36015...  T                   Place catheter in              342       3.20    $169.45       $80.23       $33.89
                               artery.
36100...  T                   Establish access to            342       3.20    $169.45       $80.23       $33.89
                               artery.
36120...  T                   Establish access to            342       3.20    $169.45       $80.23       $33.89
                               artery.
36140...  T                   Establish access to            342       3.20    $169.45       $80.23       $33.89
                               artery.
36145...  N                   Artery to vein shunt...  .........  .........  .........  ...........  ...........
36160...  T                   Establish access to            342       3.20    $169.45       $80.23       $33.89
                               aorta.
36200...  T                   Place catheter in aorta        342       3.20    $169.45       $80.23       $33.89

[[Page 47658]]

36215...  T                   Place catheter in              343       9.52    $503.44      $224.87      $100.69
                               artery.
36216...  T                   Place catheter in              343       9.52    $503.44      $224.87      $100.69
                               artery.
36217...  T                   Place catheter in              343       9.52    $503.44      $224.87      $100.69
                               artery.
36218...  T                   Place catheter in              343       9.52    $503.44      $224.87      $100.69
                               artery.
36245...  T                   Place catheter in              343       9.52    $503.44      $224.87      $100.69
                               artery.
36246...  T                   Place catheter in              343       9.52    $503.44      $224.87      $100.69
                               artery.
36247...  T                   Place catheter in              343       9.52    $503.44      $224.87      $100.69
                               artery.
36248...  T                   Place catheter in              343       9.52    $503.44      $224.87      $100.69
                               artery.
36260...  T                   Insertion of infusion          368      22.83  $1,207.67      $648.85      $241.53
                               pump.
36261...  T                   Revision of infusion           360       6.09    $322.24      $140.12       $64.45
                               pump.
36262...  T                   Removal of infusion            360       6.09    $322.24      $140.12       $64.45
                               pump.
36299...  T                   Vessel injection               360       6.09    $322.24      $140.12       $64.45
                               procedure.
36400...  N                   Drawing blood..........  .........  .........  .........  ...........  ...........
36405...  N                   Drawing blood..........  .........  .........  .........  ...........  ...........
36406...  N                   Drawing blood..........  .........  .........  .........  ...........  ...........
36410...  T                   Drawing blood..........        341       0.13      $6.86        $2.94        $1.37
36415...  E                   Drawing blood..........  .........  .........  .........  ...........  ...........
36420...  T                   Establish access to            341       0.13      $6.86        $2.94        $1.37
                               vein.
36425...  T                   Establish access to            341       0.13      $6.86        $2.94        $1.37
                               vein.
36430...  T                   Blood transfusion              369       4.33    $229.19       $97.18       $45.84
                               service.
36440...  T                   Blood transfusion              369       4.33    $229.19       $97.18       $45.84
                               service.
36450...  T                   Exchange transfusion           369       4.33    $229.19       $97.18       $45.84
                               service.
36455...  T                   Exchange transfusion           369       4.33    $229.19       $97.18       $45.84
                               service.
36460...  T                   Transfusion service,           369       4.33    $229.19       $97.18       $45.84
                               fetal.
36468...  T                   Injection(s); spider           339       1.02     $53.87       $19.66       $10.77
                               veins.
36469...  T                   Injection(s); spider           339       1.02     $53.87       $19.66       $10.77
                               veins.
36470...  T                   Injection therapy of           339       1.02     $53.87       $19.66       $10.77
                               vein.
36471...  T                   Injection therapy of           339       1.02     $53.87       $19.66       $10.77
                               veins.
36481...  T                   Insertion of catheter,         343       9.52    $503.44      $224.87      $100.69
                               vein.
36488...  S                   Insertion of catheter,         346       4.83    $255.64      $120.23       $51.13
                               vein.
36489...  S                   Insertion of catheter,         346       4.83    $255.64      $120.23       $51.13
                               vein.
36490...  S                   Insertion of catheter,         346       4.83    $255.64      $120.23       $51.13
                               vein.
36491...  S                   Insertion of catheter,         346       4.83    $255.64      $120.23       $51.13
                               vein.
36493...  S                   Repositioning of cvc...        346       4.83    $255.64      $120.23       $51.13
36500...  T                   Insertion of catheter,         342       3.20    $169.45       $80.23       $33.89
                               vein.
36510...  C                   Insertion of catheter,   .........  .........  .........  ...........  ...........
                               vein.
36520...  T                   Plasma and/or cell             369       4.33    $229.19       $97.18       $45.84
                               exchange.
36522...  T                   Photopheresis..........        369       4.33    $229.19       $97.18       $45.84
36530...  T                   Insertion of infusion          368      22.83  $1,207.67      $648.85      $241.53
                               pump.
36531...  T                   Revision of infusion           360       6.09    $322.24      $140.12       $64.45
                               pump.
36532...  T                   Removal of infusion            360       6.09    $322.24      $140.12       $64.45
                               pump.
36533...  T                   Insertion of access            368      22.83  $1,207.67      $648.85      $241.53
                               port.
36534...  T                   Revision of access port        360       6.09    $322.24      $140.12       $64.45
36535...  T                   Removal of access port.        360       6.09    $322.24      $140.12       $64.45
36600...  N                   Withdrawal of arterial   .........  .........  .........  ...........  ...........
                               blood.
36620...  T                   Insertion catheter,            342       3.20    $169.45       $80.23       $33.89
                               artery.
36625...  T                   Insertion catheter,            342       3.20    $169.45       $80.23       $33.89
                               artery.
36640...  S                   Insertion catheter,            346       4.83    $255.64      $120.23       $51.13
                               artery.
36660...  C                   Insertion catheter,      .........  .........  .........  ...........  ...........
                               artery.
36680...  X                   Insert needle, bone            906       1.46     $77.38       $42.49       $15.48
                               cavity.
36800...  T                   Insertion of cannula...        368      22.83  $1,207.67      $648.85      $241.53
36810...  T                   Insertion of cannula...        368      22.83  $1,207.67      $648.85      $241.53
36815...  T                   Insertion of cannula...        368      22.83  $1,207.67      $648.85      $241.53
36821...  T                   Artery-vein fusion.....        368      22.83  $1,207.67      $648.85      $241.53
36822...  C                   Insertion of cannula(s)  .........  .........  .........  ...........  ...........
36825...  T                   Artery-vein graft......        368      22.83  $1,207.67      $648.85      $241.53
36830...  T                   Artery-vein graft......        368      22.83  $1,207.67      $648.85      $241.53
36832...  T                   Revise artery-vein             368      22.83  $1,207.67      $648.85      $241.53
                               fistula.
36834...  C                   Repair A-V aneurysm....  .........  .........  .........  ...........  ...........
36835...  T                   Artery to vein shunt...        368      22.83  $1,207.67      $648.85      $241.53
36860...  T                   Cannula declotting.....        368      22.83  $1,207.67      $648.85      $241.53
36861...  T                   Cannula declotting.....        368      22.83  $1,207.67      $648.85      $241.53
37140...  C                   Revision of circulation  .........  .........  .........  ...........  ...........
37145...  C                   Revision of circulation  .........  .........  .........  ...........  ...........
37160...  C                   Revision of circulation  .........  .........  .........  ...........  ...........
37180...  C                   Revision of circulation  .........  .........  .........  ...........  ...........
37181...  C                   Splice spleen/kidney     .........  .........  .........  ...........  ...........
                               veins.
37195...  C                   Thrombolytic therapy,    .........  .........  .........  ...........  ...........
                               stroke.
37200...  C                   Transcatheter biopsy...  .........  .........  .........  ...........  ...........
37201...  C                   Transcatheter therapy    .........  .........  .........  ...........  ...........
                               infuse.
37202...  C                   Transcatheter therapy    .........  .........  .........  ...........  ...........
                               infuse.
37203...  T                   Transcatheter retrieval        360       6.09    $322.24      $140.12       $64.45
37204...  C                   Transcatheter occlusion  .........  .........  .........  ...........  ...........
37205...  C                   Transcatheter stent....  .........  .........  .........  ...........  ...........
37206...  C                   Transcatheter stent....  .........  .........  .........  ...........  ...........

[[Page 47659]]

37207...  C                   Transcatheter stent....  .........  .........  .........  ...........  ...........
37208...  C                   Transcatheter stent....  .........  .........  .........  ...........  ...........
37209...  C                   Exchange arterial        .........  .........  .........  ...........  ...........
                               catheter.
37250...  C                   Intravascular us.......  .........  .........  .........  ...........  ...........
37251...  C                   Intravascular us.......  .........  .........  .........  ...........  ...........
37565...  C                   Ligation of neck vein..  .........  .........  .........  ...........  ...........
37600...  C                   Ligation of neck artery  .........  .........  .........  ...........  ...........
37605...  C                   Ligation of neck artery  .........  .........  .........  ...........  ...........
37606...  C                   Ligation of neck artery  .........  .........  .........  ...........  ...........
37607...  T                   Ligation of fistula....        368      22.83  $1,207.67      $648.85      $241.53
37609...  T                   Temporal artery                162       5.67    $299.71      $125.43       $59.94
                               procedure.
37615...  C                   Ligation of neck artery  .........  .........  .........  ...........  ...........
37616...  C                   Ligation of chest        .........  .........  .........  ...........  ...........
                               artery.
37617...  C                   Ligation of abdomen      .........  .........  .........  ...........  ...........
                               artery.
37618...  T                   Ligation of extremity          367      17.59    $930.48      $449.06      $186.10
                               artery.
37620...  C                   Revision of major vein.  .........  .........  .........  ...........  ...........
37650...  T                   Revision of major vein.        367      17.59    $930.48      $449.06      $186.10
37660...  C                   Revision of major vein.  .........  .........  .........  ...........  ...........
37700...  T                   Revise leg vein........        367      17.59    $930.48      $449.06      $186.10
37720...  T                   Removal of leg vein....        367      17.59    $930.48      $449.06      $186.10
37730...  T                   Removal of leg veins...        367      17.59    $930.48      $449.06      $186.10
37735...  T                   Removal of leg veins/          367      17.59    $930.48      $449.06      $186.10
                               lesion.
37760...  T                   Revision of leg veins..        367      17.59    $930.48      $449.06      $186.10
37780...  T                   Revision of leg vein...        367      17.59    $930.48      $449.06      $186.10
37785...  T                   Revise secondary               367      17.59    $930.48      $449.06      $186.10
                               varicosity.
37788...  C                   Revascularization,       .........  .........  .........  ...........  ...........
                               penis.
37790...  T                   Penile venous occlusion        537      28.72  $1,519.13      $864.45      $303.83
37799...  T                   Vascular surgery               162       5.67    $299.71      $125.43       $59.94
                               procedure.
38100...  C                   Removal of spleen,       .........  .........  .........  ...........  ...........
                               total.
38101...  C                   Removal of spleen,       .........  .........  .........  ...........  ...........
                               partial.
38102...  C                   Removal of spleen,       .........  .........  .........  ...........  ...........
                               total.
38115...  C                   Repair of ruptured       .........  .........  .........  ...........  ...........
                               spleen.
38200...  T                   Injection for spleen x-        347       2.93    $154.75       $62.15       $30.95
                               ray.
38230...  T                   Bone marrow collection.        369       4.33    $229.19       $97.18       $45.84
38231...  T                   Stem cell collection...        369       4.33    $229.19       $97.18       $45.84
38240...  C                   Bone marrow/stem         .........  .........  .........  ...........  ...........
                               transplant.
38241...  C                   Bone marrow/stem         .........  .........  .........  ...........  ...........
                               transplant.
38300...  T                   Drainage lymph node            132       6.04     $319.3      $134.24       $63.86
                               lesion.
38305...  T                   Drainage lymph node            132       6.04     $319.3      $134.24       $63.86
                               lesion.
38308...  T                   Incision of lymph              396      13.28    $702.27      $338.77      $140.45
                               channels.
38380...  C                   Thoracic duct procedure  .........  .........  .........  ...........  ...........
38381...  C                   Thoracic duct procedure  .........  .........  .........  ...........  ...........
38382...  C                   Thoracic duct procedure  .........  .........  .........  ...........  ...........
38500...  T                   Biopsy/removal, lymph          396      13.28    $702.27      $338.77      $140.45
                               node(s).
38505...  T                   Needle biopsy, lymph           122       4.87     $257.6      $115.03       $51.52
                               node(s).
38510...  T                   Biopsy/removal, lymph          396      13.28    $702.27      $338.77      $140.45
                               node(s).
38520...  T                   Biopsy/removal, lymph          396      13.28    $702.27      $338.77      $140.45
                               node(s).
38525...  T                   Biopsy/removal, lymph          396      13.28    $702.27      $338.77      $140.45
                               node(s).
38530...  T                   Biopsy/removal, lymph          396      13.28    $702.27      $338.77      $140.45
                               node(s).
38542...  T                   Explore deep node(s),          397      18.37    $971.62      $496.97      $194.32
                               neck.
38550...  T                   Removal neck/armpit            396      13.28    $702.27      $338.77      $140.45
                               lesion.
38555...  T                   Removal neck/armpit            397      18.37    $971.62      $496.97      $194.32
                               lesion.
38562...  C                   Removal, pelvic lymph    .........  .........  .........  ...........  ...........
                               nodes.
38564...  C                   Removal, abdomen lymph   .........  .........  .........  ...........  ...........
                               nodes.
38700...  C                   Removal of lymph nodes,  .........  .........  .........  ...........  ...........
                               neck.
38720...  C                   Removal of lymph nodes,  .........  .........  .........  ...........  ...........
                               neck.
38724...  C                   Removal of lymph nodes,  .........  .........  .........  ...........  ...........
                               neck.
38740...  T                   Remove armpit lymph            397      18.37    $971.62      $496.97      $194.32
                               nodes.
38745...  T                   Remove armpits lymph           397      18.37    $971.62      $496.97      $194.32
                               nodes.
38746...  C                   Remove thoracic lymph    .........  .........  .........  ...........  ...........
                               nodes.
38747...  C                   Remove abdominal lymph   .........  .........  .........  ...........  ...........
                               nodes.
38760...  T                   Remove groin lymph             397      18.37    $971.62      $496.97      $194.32
                               nodes.
38765...  C                   Remove groin lymph       .........  .........  .........  ...........  ...........
                               nodes.
38770...  C                   Remove pelvis lymph      .........  .........  .........  ...........  ...........
                               nodes.
38780...  C                   Remove abdomen lymph     .........  .........  .........  ...........  ...........
                               nodes.
38790...  T                   Injection for lymphatic        347       2.93    $154.75       $62.15       $30.95
                               xray.
38794...  T                   Access thoracic lymph          342       3.20    $169.45       $80.23       $33.89
                               duct.
38999...  T                   Blood/lymph system             132       6.04    $319.30      $134.24       $63.86
                               procedure.
39000...  C                   Exploration of chest...  .........  .........  .........  ...........  ...........
39010...  C                   Exploration of chest...  .........  .........  .........  ...........  ...........
39200...  C                   Removal chest lesion...  .........  .........  .........  ...........  ...........
39220...  C                   Removal chest lesion...  .........  .........  .........  ...........  ...........
39400...  C                   Visualization of chest.  .........  .........  .........  ...........  ...........
39499...  C                   Chest procedure........  .........  .........  .........  ...........  ...........
39501...  C                   Repair diaphragm         .........  .........  .........  ...........  ...........
                               laceration.

[[Page 47660]]

39502...  C                   Repair paraesophageal    .........  .........  .........  ...........  ...........
                               hernia.
39503...  C                   Repair of diaphragm      .........  .........  .........  ...........  ...........
                               hernia.
39520...  C                   Repair of diaphragm      .........  .........  .........  ...........  ...........
                               hernia.
39530...  C                   Repair of diaphragm      .........  .........  .........  ...........  ...........
                               hernia.
39531...  C                   Repair of diaphragm      .........  .........  .........  ...........  ...........
                               hernia.
39540...  C                   Repair of diaphragm      .........  .........  .........  ...........  ...........
                               hernia.
39541...  C                   Repair of diaphragm      .........  .........  .........  ...........  ...........
                               hernia.
39545...  C                   Revision of diaphragm..  .........  .........  .........  ...........  ...........
39599...  C                   Diaphragm surgery        .........  .........  .........  ...........  ...........
                               procedure.
40490...  T                   Biopsy of lip..........        311       1.43     $75.42       $20.57       $15.08
40500...  T                   Partial excision of lip        313      15.81    $836.45      $411.09      $167.29
40510...  T                   Partial excision of lip        313      15.81    $836.45      $411.09      $167.29
40520...  T                   Partial excision of lip        313      15.81    $836.45      $411.09      $167.29
40525...  T                   Reconstruct lip with           313      15.81    $836.45      $411.09      $167.29
                               flap.
40527...  T                   Reconstruct lip with           313      15.81    $836.45      $411.09      $167.29
                               flap.
40530...  T                   Partial removal of lip.        313      15.81    $836.45      $411.09      $167.29
40650...  T                   Repair lip.............        313      15.81    $836.45      $411.09      $167.29
40652...  T                   Repair lip.............        313      15.81    $836.45      $411.09      $167.29
40654...  T                   Repair lip.............        313      15.81    $836.45      $411.09      $167.29
40700...  T                   Repair cleft lip/nasal.        314      25.65  $1,356.54      $693.37      $271.31
40701...  T                   Repair cleft lip/nasal.        314      25.65  $1,356.54      $693.37      $271.31
40702...  T                   Repair cleft lip/nasal.        314      25.65  $1,356.54      $693.37      $271.31
40720...  T                   Repair cleft lip/nasal.        314      25.65  $1,356.54      $693.37      $271.31
40761...  T                   Repair cleft lip/nasal.        314      25.65  $1,356.54      $693.37      $271.31
40799...  T                   Lip surgery procedure..        311       1.43     $75.42       $20.57       $15.08
40800...  T                   Drainage of mouth              311       1.43     $75.42       $20.57       $15.08
                               lesion.
40801...  T                   Drainage of mouth              311       1.43     $75.42       $20.57       $15.08
                               lesion.
40804...  T                   Removal foreign body,          311       1.43     $75.42       $20.57       $15.08
                               mouth.
40805...  T                   Removal foreign body,          311       1.43     $75.42       $20.57       $15.08
                               mouth.
40806...  T                   Incision of lip fold...        311       1.43     $75.42       $20.57       $15.08
40808...  T                   Biopsy of mouth lesion.        311       1.43     $75.42       $20.57       $15.08
40810...  T                   Excision of mouth              311       1.43     $75.42       $20.57       $15.08
                               lesion.
40812...  T                   Excise/repair mouth            311       1.43     $75.42       $20.57       $15.08
                               lesion.
40814...  T                   Excise/repair mouth            313      15.81    $836.45      $411.09      $167.29
                               lesion.
40816...  T                   Excision of mouth              313      15.81    $836.45      $411.09      $167.29
                               lesion.
40818...  T                   Excise oral mucosa for         313      15.81    $836.45      $411.09      $167.29
                               graft.
40819...  T                   Excise lip or cheek            313      15.81    $836.45      $411.09      $167.29
                               fold.
40820...  T                   Treatment of mouth             311       1.43     $75.42       $20.57       $15.08
                               lesion.
40830...  T                   Repair mouth laceration        312       7.26    $383.95      $178.31       $76.79
40831...  T                   Repair mouth laceration        312       7.26    $383.95      $178.31       $76.79
40840...  T                   Reconstruction of mouth        313      15.81    $836.45      $411.09      $167.29
40842...  T                   Reconstruction of mouth        313      15.81    $836.45      $411.09      $167.29
40843...  T                   Reconstruction of mouth        314      25.65  $1,356.54      $693.37      $271.31
40844...  T                   Reconstruction of mouth        314      25.65  $1,356.54      $693.37      $271.31
40845...  T                   Reconstruction of mouth        314      25.65  $1,356.54      $693.37      $271.31
40899...  T                   Mouth surgery procedure        311       1.43     $75.42       $20.57       $15.08
41000...  T                   Drainage of mouth              311       1.43     $75.42       $20.57       $15.08
                               lesion.
41005...  T                   Drainage of mouth              311       1.43     $75.42       $20.57       $15.08
                               lesion.
41006...  T                   Drainage of mouth              313      15.81    $836.45      $411.09      $167.29
                               lesion.
41007...  T                   Drainage of mouth              313      15.81    $836.45      $411.09      $167.29
                               lesion.
41008...  T                   Drainage of mouth              313      15.81    $836.45      $411.09      $167.29
                               lesion.
41009...  T                   Drainage of mouth              313      15.81    $836.45      $411.09      $167.29
                               lesion.
41010...  T                   Incision of tongue fold        313      15.81    $836.45      $411.09      $167.29
41015...  T                   Drainage of mouth              313      15.81    $836.45      $411.09      $167.29
                               lesion.
41016...  T                   Drainage of mouth              313      15.81    $836.45      $411.09      $167.29
                               lesion.
41017...  T                   Drainage of mouth              313      15.81    $836.45      $411.09      $167.29
                               lesion.
41018...  T                   Drainage of mouth              313      15.81    $836.45      $411.09      $167.29
                               lesion.
41100...  T                   Biopsy of tongue.......        311       1.43     $75.42       $20.57       $15.08
41105...  T                   Biopsy of tongue.......        311       1.43     $75.42       $20.57       $15.08
41108...  T                   Biopsy of floor of             311       1.43     $75.42       $20.57       $15.08
                               mouth.
41110...  T                   Excision of tongue             311       1.43     $75.42       $20.57       $15.08
                               lesion.
41112...  T                   Excision of tongue             313      15.81    $836.45      $411.09      $167.29
                               lesion.
41113...  T                   Excision of tongue             313      15.81    $836.45      $411.09      $167.29
                               lesion.
41114...  T                   Excision of tongue             313      15.81    $836.45      $411.09      $167.29
                               lesion.
41115...  T                   Excision of tongue fold        311       1.43     $75.42       $20.57       $15.08
41116...  T                   Excision of mouth              313      15.81    $836.45      $411.09      $167.29
                               lesion.
41120...  T                   Partial removal of             313      15.81    $836.45      $411.09      $167.29
                               tongue.
41130...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               tongue.
41135...  C                   Tongue and neck surgery  .........  .........  .........  ...........  ...........
41140...  C                   Removal of tongue......  .........  .........  .........  ...........  ...........
41145...  C                   Tongue removal; neck     .........  .........  .........  ...........  ...........
                               surgery.
41150...  C                   Tongue, mouth, jaw       .........  .........  .........  ...........  ...........
                               surgery.
41153...  C                   Tongue, mouth, neck      .........  .........  .........  ...........  ...........
                               surgery.
41155...  C                   Tongue, jaw, & neck      .........  .........  .........  ...........  ...........
                               surgery.
41250...  T                   Repair tongue                  312       7.26    $383.95      $178.31       $76.79
                               laceration.

[[Page 47661]]

41251...  T                   Repair tongue                  312       7.26    $383.95      $178.31       $76.79
                               laceration.
41252...  T                   Repair tongue                  312       7.26    $383.95      $178.31       $76.79
                               laceration.
41500...  T                   Fixation of tongue.....        312       7.26    $383.95      $178.31       $76.79
41510...  T                   Tongue to lip surgery..        312       7.26    $383.95      $178.31       $76.79
41520...  T                   Reconstruction, tongue         313      15.81    $836.45      $411.09      $167.29
                               fold.
41599...  T                   Tongue and mouth               311       1.43     $75.42       $20.57       $15.08
                               surgery.
41800...  T                   Drainage of gum lesion.        312       7.26    $383.95      $178.31       $76.79
41805...  T                   Removal foreign body,          311       1.43     $75.42       $20.57       $15.08
                               gum.
41806...  T                   Removal foreign body,          311       1.43     $75.42       $20.57       $15.08
                               jawbone.
41820...  T                   Excision, gum, each            311       1.43     $75.42       $20.57       $15.08
                               quadrant.
41821...  T                   Excision of gum flap...        311       1.43     $75.42       $20.57       $15.08
41822...  T                   Excision of gum lesion.        231      12.02    $635.66       $299.9      $127.13
41823...  T                   Excision of gum lesion.        231      12.02    $635.66       $299.9      $127.13
41825...  T                   Excision of gum lesion.        311       1.43     $75.42       $20.57       $15.08
41826...  T                   Excision of gum lesion.        311       1.43     $75.42       $20.57       $15.08
41827...  T                   Excision of gum lesion.        313      15.81    $836.45      $411.09      $167.29
41828...  T                   Excision of gum lesion.        311       1.43     $75.42       $20.57       $15.08
41830...  T                   Removal of gum tissue..        311       1.43     $75.42       $20.57       $15.08
41850...  T                   Treatment of gum lesion        311       1.43     $75.42       $20.57       $15.08
41870...  T                   Gum graft..............        311       1.43     $75.42       $20.57       $15.08
41872...  T                   Repair gum.............        311       1.43     $75.42       $20.57       $15.08
41874...  T                   Repair tooth socket....        311       1.43     $75.42       $20.57       $15.08
41899...  T                   Dental surgery                 311       1.43     $75.42       $20.57       $15.08
                               procedure.
42000...  T                   Drainage mouth roof            311       1.43     $75.42       $20.57       $15.08
                               lesion.
42100...  T                   Biopsy roof of mouth...        311       1.43     $75.42       $20.57       $15.08
42104...  T                   Excision lesion, mouth         311       1.43     $75.42       $20.57       $15.08
                               roof.
42106...  T                   Excision lesion, mouth         311       1.43     $75.42       $20.57       $15.08
                               roof.
42107...  T                   Excision lesion, mouth         313      15.81    $836.45      $411.09      $167.29
                               roof.
42120...  T                   Remove palate/lesion...        313      15.81    $836.45      $411.09      $167.29
42140...  T                   Excision of uvula......        311       1.43     $75.42       $20.57       $15.08
42145...  C                   Repair, palate,pharynx/  .........  .........  .........  ...........  ...........
                               uvula.
42160...  T                   Treatment mouth roof           311       1.43     $75.42       $20.57       $15.08
                               lesion.
42180...  T                   Repair palate..........        313      15.81    $836.45      $411.09      $167.29
42182...  T                   Repair palate..........        313      15.81    $836.45      $411.09      $167.29
42200...  T                   Reconstruct cleft              313      15.81    $836.45      $411.09      $167.29
                               palate.
42205...  T                   Reconstruct cleft              313      15.81    $836.45      $411.09      $167.29
                               palate.
42210...  T                   Reconstruct cleft              314      25.65  $1,356.54      $693.37      $271.31
                               palate.
42215...  T                   Reconstruct cleft              313      15.81    $836.45      $411.09      $167.29
                               palate.
42220...  T                   Reconstruct cleft              313      15.81    $836.45      $411.09      $167.29
                               palate.
42225...  T                   Reconstruct cleft              314      25.65  $1,356.54      $693.37      $271.31
                               palate.
42226...  T                   Lengthening of palate..        314      25.65  $1,356.54      $693.37      $271.31
42227...  T                   Lengthening of palate..        314      25.65  $1,356.54      $693.37      $271.31
42235...  T                   Repair palate..........        313      15.81    $836.45      $411.09      $167.29
42260...  T                   Repair nose to lip             313      15.81    $836.45      $411.09      $167.29
                               fistula.
42280...  T                   Preparation, palate            311       1.43     $75.42       $20.57       $15.08
                               mold.
42281...  T                   Insertion, palate              311       1.43     $75.42       $20.57       $15.08
                               prosthesis.
42299...  T                   Palate/uvula surgery...        311       1.43     $75.42       $20.57       $15.08
42300...  T                   Drainage of salivary           312       7.26    $383.95      $178.31       $76.79
                               gland.
42305...  T                   Drainage of salivary           312       7.26    $383.95      $178.31       $76.79
                               gland.
42310...  T                   Drainage of salivary           312       7.26    $383.95      $178.31       $76.79
                               gland.
42320...  T                   Drainage of salivary           312       7.26    $383.95      $178.31       $76.79
                               gland.
42325...  T                   Create salivary cyst           313      15.81    $836.45      $411.09      $167.29
                               drain.
42326...  T                   Create salivary cyst           313      15.81    $836.45      $411.09      $167.29
                               drain.
42330...  T                   Removal of salivary            311       1.43     $75.42       $20.57       $15.08
                               stone.
42335...  T                   Removal of salivary            311       1.43     $75.42       $20.57       $15.08
                               stone.
42340...  T                   Removal of salivary            313      15.81    $836.45      $411.09      $167.29
                               stone.
42400...  T                   Biopsy of salivary             122       4.87     $257.6      $115.03       $51.52
                               gland.
42405...  T                   Biopsy of salivary             312       7.26    $383.95      $178.31       $76.79
                               gland.
42408...  T                   Excision of salivary           313      15.81    $836.45      $411.09      $167.29
                               cyst.
42409...  T                   Drainage of salivary           313      15.81    $836.45      $411.09      $167.29
                               cyst.
42410...  T                   Excise parotid gland/          313      15.81    $836.45      $411.09      $167.29
                               lesion.
42415...  T                   Excise parotid gland/          314      25.65  $1,356.54      $693.37      $271.31
                               lesion.
42420...  T                   Excise parotid gland/          314      25.65  $1,356.54      $693.37      $271.31
                               lesion.
42425...  T                   Excise parotid gland/          314      25.65  $1,356.54      $693.37      $271.31
                               lesion.
42426...  C                   Excise parotid gland/    .........  .........  .........  ...........  ...........
                               lesion.
42440...  T                   Excision submaxillary          313      15.81    $836.45      $411.09      $167.29
                               gland.
42450...  T                   Excision sublingual            313      15.81    $836.45      $411.09      $167.29
                               gland.
42500...  T                   Repair salivary duct...        313      15.81    $836.45      $411.09      $167.29
42505...  T                   Repair salivary duct...        313      15.81    $836.45      $411.09      $167.29
42507...  T                   Parotid duct diversion.        313      15.81    $836.45      $411.09      $167.29
42508...  T                   Parotid duct diversion.        313      15.81    $836.45      $411.09      $167.29
42509...  T                   Parotid duct diversion.        314      25.65  $1,356.54      $693.37      $271.31
42510...  T                   Parotid duct diversion.        313      15.81    $836.45      $411.09      $167.29
42550...  T                   Injection for salivary         347       2.93    $154.75       $62.15       $30.95
                               x-ray.
42600...  T                   Closure of salivary            313      15.81    $836.45      $411.09      $167.29
                               fistula.

[[Page 47662]]

42650...  T                   Dilation of salivary           311       1.43     $75.42       $20.57       $15.08
                               duct.
42660...  T                   Dilation of salivary           311       1.43     $75.42       $20.57       $15.08
                               duct.
42665...  T                   Ligation of salivary           311       1.43     $75.42       $20.57       $15.08
                               duct.
42699...  T                   Salivary surgery               311       1.43     $75.42       $20.57       $15.08
                               procedure.
42700...  T                   Drainage of tonsil             312       7.26    $383.95      $178.31       $76.79
                               abscess.
42720...  T                   Drainage of throat             312       7.26    $383.95      $178.31       $76.79
                               abscess.
42725...  T                   Drainage of throat             313      15.81    $836.45      $411.09      $167.29
                               abscess.
42800...  T                   Biopsy of throat.......        312       7.26    $383.95      $178.31       $76.79
42802...  T                   Biopsy of throat.......        312       7.26    $383.95      $178.31       $76.79
42804...  T                   Biopsy of upper nose/          312       7.26    $383.95      $178.31       $76.79
                               throat.
42806...  T                   Biopsy of upper nose/          312       7.26    $383.95      $178.31       $76.79
                               throat.
42808...  T                   Excise pharynx lesion..        312       7.26    $383.95      $178.31       $76.79
42809...  T                   Remove pharynx foreign         151       1.74     $92.07       $35.71       $18.41
                               body.
42810...  T                   Excision of neck cyst..        313      15.81    $836.45      $411.09      $167.29
42815...  T                   Excision of neck cyst..        313      15.81    $836.45      $411.09      $167.29
42820...  T                   Remove tonsils and             319      17.30    $914.81      $480.02      $182.96
                               adenoids.
42821...  T                   Remove tonsils and             319      17.30    $914.81      $480.02      $182.96
                               adenoids.
42825...  T                   Removal of tonsils.....        319      17.30    $914.81      $480.02      $182.96
42826...  T                   Removal of tonsils.....        319      17.30    $914.81      $480.02      $182.96
42830...  T                   Removal of adenoids....        319      17.30    $914.81      $480.02      $182.96
42831...  T                   Removal of adenoids....        319      17.30    $914.81      $480.02      $182.96
42835...  T                   Removal of adenoids....        319      17.30    $914.81      $480.02      $182.96
42836...  T                   Removal of adenoids....        319      17.30    $914.81      $480.02      $182.96
42842...  T                   Extensive surgery of           314      25.65  $1,356.54      $693.37      $271.31
                               throat.
42844...  T                   Extensive surgery of           314      25.65  $1,356.54      $693.37      $271.31
                               throat.
42845...  C                   Extensive surgery of     .........  .........  .........  ...........  ...........
                               throat.
42860...  T                   Excision of tonsil tags        319      17.30    $914.81      $480.02      $182.96
42870...  T                   Excision of lingual            319      17.30    $914.81      $480.02      $182.96
                               tonsil.
42890...  T                   Partial removal of             314      25.65  $1,356.54      $693.37      $271.31
                               pharynx.
42892...  T                   Revision of pharyngeal         314      25.65  $1,356.54      $693.37      $271.31
                               walls.
42894...  C                   Revision of pharyngeal   .........  .........  .........  ...........  ...........
                               walls.
42900...  T                   Repair throat wound....        313      15.81    $836.45      $411.09      $167.29
42950...  T                   Reconstruction of              313      15.81    $836.45      $411.09      $167.29
                               throat.
42953...  C                   Repair throat,           .........  .........  .........  ...........  ...........
                               esophagus.
42955...  T                   Surgical opening of            313      15.81    $836.45      $411.09      $167.29
                               throat.
42960...  T                   Control throat bleeding        318       2.07     $109.7       $38.65       $21.94
42961...  C                   Control throat bleeding  .........  .........  .........  ...........  ...........
42962...  T                   Control throat bleeding        313      15.81    $836.45      $411.09      $167.29
42970...  T                   Control nose/throat            318       2.07     $109.7       $38.65       $21.94
                               bleeding.
42971...  C                   Control nose/throat      .........  .........  .........  ...........  ...........
                               bleeding.
42972...  T                   Control nose/throat            313      15.81    $836.45      $411.09      $167.29
                               bleeding.
42999...  T                   Throat surgery                 318       2.07     $109.7       $38.65       $21.94
                               procedure.
43020...  T                   Incision of esophagus..        313      15.81    $836.45      $411.09      $167.29
43030...  T                   Throat muscle surgery..        313      15.81    $836.45      $411.09      $167.29
43045...  C                   Incision of esophagus..  .........  .........  .........  ...........  ...........
43100...  C                   Excision of esophagus    .........  .........  .........  ...........  ...........
                               lesion.
43101...  C                   Excision of esophagus    .........  .........  .........  ...........  ...........
                               lesion.
43107...  C                   Removal of esophagus...  .........  .........  .........  ...........  ...........
43108...  C                   Removal of esophagus...  .........  .........  .........  ...........  ...........
43112...  C                   Removal of esophagus...  .........  .........  .........  ...........  ...........
43113...  C                   Removal of esophagus...  .........  .........  .........  ...........  ...........
43116...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               esophagus.
43117...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               esophagus.
43118...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               esophagus.
43121...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               esophagus.
43122...  C                   Parital removal of       .........  .........  .........  ...........  ...........
                               esophagus.
43123...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               esophagus.
43124...  C                   Removal of esophagus...  .........  .........  .........  ...........  ...........
43130...  C                   Removal of esophagus     .........  .........  .........  ...........  ...........
                               pouch.
43135...  C                   Removal of esophagus     .........  .........  .........  ...........  ...........
                               pouch.
43200...  T                   Esophagus endoscopy....        417       6.44    $340.85      $181.70       $68.17
43202...  T                   Esophagus endoscopy,           417       6.44    $340.85      $181.70       $68.17
                               biopsy.
43204...  T                   Esophagus endoscopy &          407       7.06    $373.17      $189.84       $74.63
                               inject.
43205...  T                   Esophagus endoscopy/           407       7.06    $373.17      $189.84       $74.63
                               ligation.
43215...  T                   Esophagus endoscopy....        407       7.06    $373.17      $189.84       $74.63
43216...  T                   Esophagus endoscopy/           407       7.06    $373.17      $189.84       $74.63
                               lesion.
43217...  T                   Esophagus endoscopy....        407       7.06    $373.17      $189.84       $74.63
43219...  T                   Esophagus endoscopy....        449       7.80    $412.35      $215.38       $82.47
43220...  T                   Esophagus                      407       7.06    $373.17      $189.84       $74.63
                               endoscopy,dilation.
43226...  T                   Esophagus                      407       7.06    $373.17      $189.84       $74.63
                               endoscopy,dilation.
43227...  T                   Esophagus endoscopy,           407       7.06    $373.17      $189.84       $74.63
                               repair.
43228...  T                   Esophagus                      449       7.80    $412.35      $215.38       $82.47
                               endoscopy,ablation.
43234...  T                   Upper GI endoscopy,            417       6.44    $340.85      $181.70       $68.17
                               exam.
43235...  T                   Upper gi                       417       6.44    $340.85      $181.70       $68.17
                               endoscopy,diagnosis.
43239...  T                   Upper GI endoscopy,            417       6.44    $340.85      $181.70       $68.17
                               biopsy.

[[Page 47663]]

43241...  T                   Upper GI endoscopy with        418       7.59    $401.58      $214.25       $80.32
                               tube.
43243...  T                   Upper GI endoscopy &           418       7.59    $401.58      $214.25       $80.32
                               inject..
43244...  T                   Upper GI endoscopy/            418       7.59    $401.58      $214.25       $80.32
                               ligation.
43245...  T                   Operative upper GI             418       7.59    $401.58      $214.25       $80.32
                               endoscopy.
43246...  T                   Place gastrostomy tube.        418       7.59    $401.58      $214.25       $80.32
43247...  T                   Operative upper GI             418       7.59    $401.58      $214.25       $80.32
                               endoscopy.
43248...  T                   Upper GI endoscopy/            418       7.59    $401.58      $214.25       $80.32
                               guidewire.
43249...  T                   Esophagus                      418       7.59    $401.58      $214.25       $80.32
                               endoscopy,dilation.
43250...  T                   Upper GI endoscopy/            418       7.59    $401.58      $214.25       $80.32
                               tumor.
43251...  T                   Operative upper GI             418       7.59    $401.58      $214.25       $80.32
                               endoscopy.
43255...  T                   Operative upper GI             418       7.59    $401.58      $214.25       $80.32
                               endoscopy.
43258...  T                   Operative upper GI             449       7.80    $412.35      $215.38       $82.47
                               endoscopy.
43259...  T                   Endoscopic ultrasound          449       7.80    $412.35      $215.38       $82.47
                               exam.
43260...  T                   Endoscopy,bile duct/           456       9.78    $517.15      $257.19      $103.43
                               pancreas.
43261...  T                   Endoscopy,bile duct/           456       9.78    $517.15      $257.19      $103.43
                               pancreas.
43262...  T                   Endoscopy,bile duct/           456       9.78    $517.15      $257.19      $103.43
                               pancreas.
43263...  T                   Endoscopy,bile duct/           456       9.78    $517.15      $257.19      $103.43
                               pancreas.
43264...  T                   Endoscopy,bile duct/           456       9.78    $517.15      $257.19      $103.43
                               pancreas.
43265...  T                   Endoscopy,bile duct/           456       9.78    $517.15      $257.19      $103.43
                               pancreas.
43267...  T                   Endoscopy,bile duct/           456       9.78    $517.15      $257.19      $103.43
                               pancreas.
43268...  T                   Endoscopy,bile duct/           456       9.78    $517.15      $257.19      $103.43
                               pancreas.
43269...  T                   Endoscopy,bile duct/           456       9.78    $517.15      $257.19      $103.43
                               pancreas.
43271...  T                   Endoscopy,bile duct/           456       9.78    $517.15      $257.19      $103.43
                               pancreas.
43272...  T                   Endoscopy,bile duct/           449       7.80    $412.35      $215.38       $82.47
                               pancreas.
43300...  C                   Repair of esophagus....  .........  .........  .........  ...........  ...........
43305...  C                   Repair esophagus and     .........  .........  .........  ...........  ...........
                               fistula.
43310...  C                   Repair of esophagus....  .........  .........  .........  ...........  ...........
43312...  C                   Repair esophagus and     .........  .........  .........  ...........  ...........
                               fistula.
43320...  C                   Fuse esophagus &         .........  .........  .........  ...........  ...........
                               stomach.
43324...  C                   Revise esophagus &       .........  .........  .........  ...........  ...........
                               stomach.
43325...  C                   Revise esophagus &       .........  .........  .........  ...........  ...........
                               stomach.
43326...  C                   Revise esophagus &       .........  .........  .........  ...........  ...........
                               stomach.
43330...  C                   Repair of esophagus....  .........  .........  .........  ...........  ...........
43331...  C                   Repair of esophagus....  .........  .........  .........  ...........  ...........
43340...  C                   Fuse esophagus &         .........  .........  .........  ...........  ...........
                               intestine.
43341...  C                   Fuse esophagus &         .........  .........  .........  ...........  ...........
                               intestine.
43350...  C                   Surgical opening,        .........  .........  .........  ...........  ...........
                               esophagus.
43351...  C                   Surgical opening,        .........  .........  .........  ...........  ...........
                               esophagus.
43352...  C                   Surgical opening,        .........  .........  .........  ...........  ...........
                               esophagus.
43360...  C                   Gastrointestinal repair  .........  .........  .........  ...........  ...........
43361...  C                   Gastrointestinal repair  .........  .........  .........  ...........  ...........
43400...  C                   Ligate esophagus veins.  .........  .........  .........  ...........  ...........
43401...  C                   Esophagus surgery for    .........  .........  .........  ...........  ...........
                               veins.
43405...  C                   Ligate/staple esophagus  .........  .........  .........  ...........  ...........
43410...  C                   Repair esophagus wound.  .........  .........  .........  ...........  ...........
43415...  C                   Repair esophagus wound.  .........  .........  .........  ...........  ...........
43420...  C                   Repair esophagus         .........  .........  .........  ...........  ...........
                               opening.
43425...  C                   Repair esophagus         .........  .........  .........  ...........  ...........
                               opening.
43450...  T                   Dilate esophagus.......        406       4.31    $228.21      $108.48       $45.64
43453...  T                   Dilate esophagus.......        406       4.31    $228.21      $108.48       $45.64
43456...  T                   Dilate esophagus.......        406       4.31    $228.21      $108.48       $45.64
43458...  T                   Dilation of esophagus..        406       4.31    $228.21      $108.48       $45.64
43460...  C                   Pressure treatment       .........  .........  .........  ...........  ...........
                               esophagus.
43496...  C                   Free jejunum flap,       .........  .........  .........  ...........  ...........
                               microvasc.
43499...  T                   Esophagus surgery              406       4.31    $228.21      $108.48       $45.64
                               procedure.
43500...  C                   Surgical opening of      .........  .........  .........  ...........  ...........
                               stomach.
43501...  C                   Surgical repair of       .........  .........  .........  ...........  ...........
                               stomach.
43502...  C                   Surgical repair of       .........  .........  .........  ...........  ...........
                               stomach.
43510...  C                   Surgical opening of      .........  .........  .........  ...........  ...........
                               stomach.
43520...  C                   Incision of pyloric      .........  .........  .........  ...........  ...........
                               muscle.
43600...  T                   Biopsy of stomach......        417       6.44    $340.85      $181.70       $68.17
43605...  C                   Biopsy of stomach......  .........  .........  .........  ...........  ...........
43610...  C                   Excision of stomach      .........  .........  .........  ...........  ...........
                               lesion.
43611...  C                   Excision of stomach      .........  .........  .........  ...........  ...........
                               lesion.
43620...  C                   Removal of stomach.....  .........  .........  .........  ...........  ...........
43621...  C                   Removal of stomach.....  .........  .........  .........  ...........  ...........
43622...  C                   Removal of stomach.....  .........  .........  .........  ...........  ...........
43631...  C                   Removal of stomach,      .........  .........  .........  ...........  ...........
                               partial.
43632...  C                   Removal stomach,         .........  .........  .........  ...........  ...........
                               partial.
43633...  C                   Removal stomach,         .........  .........  .........  ...........  ...........
                               partial.
43634...  C                   Removal stomach,         .........  .........  .........  ...........  ...........
                               partial.
43635...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               stomach.
43638...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               stomach.
43639...  C                   Removal stomach,         .........  .........  .........  ...........  ...........
                               partial.
43640...  C                   Vagotomy & pylorus       .........  .........  .........  ...........  ...........
                               repair.

[[Page 47664]]

43641...  C                   Vagotomy & pylorus       .........  .........  .........  ...........  ...........
                               repair.
43750...  T                   Place gastrostomy tube.        418       7.59    $401.58      $214.25       $80.32
43760...  T                   Change gastrostomy tube        470       2.22    $117.53       $54.92       $23.51
43761...  T                   Reposition gastrostomy         470       2.22    $117.53       $54.92       $23.51
                               tube.
43800...  C                   Reconstruction of        .........  .........  .........  ...........  ...........
                               pylorus.
43810...  C                   Fusion of stomach and    .........  .........  .........  ...........  ...........
                               bowel.
43820...  C                   Fusion of stomach and    .........  .........  .........  ...........  ...........
                               bowel.
43825...  C                   Fusion of stomach and    .........  .........  .........  ...........  ...........
                               bowel.
43830...  C                   Place gastrostomy tube.  .........  .........  .........  ...........  ...........
43831...  C                   Place gastrostomy tube.  .........  .........  .........  ...........  ...........
43832...  C                   Place gastrostomy tube.  .........  .........  .........  ...........  ...........
43840...  C                   Repair of stomach        .........  .........  .........  ...........  ...........
                               lesion.
43842...  C                   Gastroplasty for         .........  .........  .........  ...........  ...........
                               obesity.
43843...  C                   Gastroplasty for         .........  .........  .........  ...........  ...........
                               obesity.
43846...  C                   Gastric bypass for       .........  .........  .........  ...........  ...........
                               obesity.
43847...  C                   Gastric bypass for       .........  .........  .........  ...........  ...........
                               obesity.
43848...  C                   Revision gastroplasty..  .........  .........  .........  ...........  ...........
43850...  C                   Revise stomach-bowel     .........  .........  .........  ...........  ...........
                               fusion.
43855...  C                   Revise stomach-bowel     .........  .........  .........  ...........  ...........
                               fusion.
43860...  C                   Revise stomach-bowel     .........  .........  .........  ...........  ...........
                               fusion.
43865...  C                   Revise stomach-bowel     .........  .........  .........  ...........  ...........
                               fusion.
43870...  T                   Repair stomach opening.        182       4.00    $211.56       $84.98       $42.31
43880...  C                   Repair stomach-bowel     .........  .........  .........  ...........  ...........
                               fistula.
43999...  T                   Stomach surgery                470       2.22    $117.53       $54.92       $23.51
                               procedure.
44005...  C                   Freeing of bowel         .........  .........  .........  ...........  ...........
                               adhesion.
44010...  C                   Incision of small bowel  .........  .........  .........  ...........  ...........
44015...  C                   Insert needle catheter,  .........  .........  .........  ...........  ...........
                               bowel.
44020...  C                   Exploration of small     .........  .........  .........  ...........  ...........
                               bowel.
44021...  C                   Decompress small bowel.  .........  .........  .........  ...........  ...........
44025...  C                   Incision of large bowel  .........  .........  .........  ...........  ...........
44050...  C                   Reduce bowel             .........  .........  .........  ...........  ...........
                               obstruction.
44055...  C                   Correct malrotation of   .........  .........  .........  ...........  ...........
                               bowel.
44100...  T                   Biopsy of bowel........        417       6.44    $340.85      $181.70       $68.17
44110...  C                   Excision of bowel        .........  .........  .........  ...........  ...........
                               lesion(s).
44111...  C                   Excision of bowel        .........  .........  .........  ...........  ...........
                               lesion(s).
44120...  C                   Removal of small         .........  .........  .........  ...........  ...........
                               intestine.
44121...  C                   Removal of small         .........  .........  .........  ...........  ...........
                               intestine.
44125...  C                   Removal of small         .........  .........  .........  ...........  ...........
                               intestine.
44130...  C                   Bowel to bowel fusion..  .........  .........  .........  ...........  ...........
44139...  C                   Mobilization of colon..  .........  .........  .........  ...........  ...........
44140...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               colon.
44141...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               colon.
44143...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               colon.
44144...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               colon.
44145...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               colon.
44146...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               colon.
44147...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               colon.
44150...  C                   Removal of colon.......  .........  .........  .........  ...........  ...........
44151...  C                   Removal of colon/        .........  .........  .........  ...........  ...........
                               ileostomy.
44152...  C                   Removal of colon/        .........  .........  .........  ...........  ...........
                               ileostomy.
44153...  C                   Removal of colon/        .........  .........  .........  ...........  ...........
                               ileostomy.
44155...  C                   Removal of colon.......  .........  .........  .........  ...........  ...........
44156...  C                   Removal of colon/        .........  .........  .........  ...........  ...........
                               ileostomy.
44160...  C                   Removal of colon.......  .........  .........  .........  ...........  ...........
44300...  C                   Open bowel to skin.....  .........  .........  .........  ...........  ...........
44310...  C                   Ileostomy/jejunostomy..  .........  .........  .........  ...........  ...........
44312...  T                   Revision of ileostomy..        183      11.17    $590.61      $286.57      $118.12
44314...  C                   Revision of ileostomy..  .........  .........  .........  ...........  ...........
44316...  C                   Devise bowel pouch.....  .........  .........  .........  ...........  ...........
44320...  C                   Colostomy..............  .........  .........  .........  ...........  ...........
44322...  C                   Colostomy with biopsies  .........  .........  .........  ...........  ...........
44340...  T                   Revision of colostomy..        183      11.17    $590.61      $286.57      $118.12
44345...  C                   Revision of colostomy..  .........  .........  .........  ...........  ...........
44346...  C                   Revision of colostomy..  .........  .........  .........  ...........  ...........
44360...  T                   Small bowel endoscopy..        419       7.13    $377.09      $164.08       $75.42
44361...  T                   Small bowel                    419       7.13    $377.09      $164.08       $75.42
                               endoscopy,biopsy.
44363...  T                   Small bowel endoscopy..        419       7.13    $377.09      $164.08       $75.42
44364...  T                   Small bowel endoscopy..        419       7.13    $377.09      $164.08       $75.42
44365...  T                   Small bowel endoscopy..        419       7.13    $377.09      $164.08       $75.42
44366...  T                   Small bowel endoscopy..        419       7.13    $377.09      $164.08       $75.42
44369...  T                   Small bowel endoscopy..        449       7.80    $412.35      $215.38       $82.47
44372...  T                   Small bowel endoscopy..        419       7.13    $377.09      $164.08       $75.42
44373...  T                   Small bowel endoscopy..        419       7.13    $377.09      $164.08       $75.42
44376...  T                   Small bowel endoscopy..        419       7.13    $377.09      $164.08       $75.42
44377...  T                   Small bowel endoscopy..        419       7.13    $377.09      $164.08       $75.42

[[Page 47665]]

44378...  T                   Small bowel endoscopy..        419       7.13    $377.09      $164.08       $75.42
44380...  T                   Small bowel endoscopy..        426       6.85    $362.40      $187.81       $72.48
44382...  T                   Small bowel endoscopy..        426       6.85    $362.40      $187.81       $72.48
44385...  T                   Endoscopy of bowel             426       6.85    $362.40      $187.81       $72.48
                               pouch.
44386...  T                   Endoscopy, bowel pouch,        426       6.85    $362.40      $187.81       $72.48
                               biopsy.
44388...  T                   Colon endoscopy........        426       6.85    $362.40      $187.81       $72.48
44389...  T                   Colonoscopy with biopsy        426       6.85    $362.40      $187.81       $72.48
44390...  T                   Colonoscopy for foreign        427       8.22    $434.88      $224.19       $86.98
                               body.
44391...  T                   Colonoscopy for                427       8.22    $434.88      $224.19       $86.98
                               bleeding.
44392...  T                   Colonoscopy &                  427       8.22    $434.88      $224.19       $86.98
                               polypectomy.
44393...  T                   Colonoscopy, lesion            449       7.80    $412.35      $215.38       $82.47
                               removal.
44394...  T                   Colonoscopy w/snare....        427       8.22    $434.88      $224.19       $86.98
44500...  C                   Intro, gastrointestinal  .........  .........  .........  ...........  ...........
                               tube.
44602...  C                   Suture, small intestine  .........  .........  .........  ...........  ...........
44603...  C                   Suture, small intestine  .........  .........  .........  ...........  ...........
44604...  C                   Suture, large intestine  .........  .........  .........  ...........  ...........
44605...  C                   Repair of bowel lesion.  .........  .........  .........  ...........  ...........
44615...  C                   Intestinal               .........  .........  .........  ...........  ...........
                               stricturoplasty.
44620...  C                   Repair bowel opening...  .........  .........  .........  ...........  ...........
44625...  C                   Repair bowel opening...  .........  .........  .........  ...........  ...........
44626...  C                   Repair bowel opening...  .........  .........  .........  ...........  ...........
44640...  C                   Repair bowel-skin        .........  .........  .........  ...........  ...........
                               fistula.
44650...  C                   Repair bowel fistula...  .........  .........  .........  ...........  ...........
44660...  C                   Repair bowel-bladder     .........  .........  .........  ...........  ...........
                               fistula.
44661...  C                   Repair bowel-bladder     .........  .........  .........  ...........  ...........
                               fistula.
44680...  C                   Surgical revision,       .........  .........  .........  ...........  ...........
                               intestine.
44700...  C                   Suspend bowel w/         .........  .........  .........  ...........  ...........
                               prosthesis.
44799...  T                   Intestine surgery              419       7.13    $377.09      $164.08       $75.42
                               procedure.
44800...  C                   Excision of bowel pouch  .........  .........  .........  ...........  ...........
44820...  C                   Excision of mesentery    .........  .........  .........  ...........  ...........
                               lesion.
44850...  C                   Repair of mesentery....  .........  .........  .........  ...........  ...........
44899...  C                   Bowel surgery procedure  .........  .........  .........  ...........  ...........
44900...  C                   Drain, app abscess,      .........  .........  .........  ...........  ...........
                               open.
44901...  C                   Drain, app abscess,      .........  .........  .........  ...........  ...........
                               perc.
44950...  C                   Appendectomy...........  .........  .........  .........  ...........  ...........
44955...  C                   Appendectomy...........  .........  .........  .........  ...........  ...........
44960...  C                   Appendectomy...........  .........  .........  .........  ...........  ...........
45000...  T                   Drainage of pelvic             452       4.83    $255.64      $109.61       $51.13
                               abscess.
45005...  T                   Drainage of rectal             452       4.83    $255.64      $109.61       $51.13
                               abscess.
45020...  T                   Drainage of rectal             452       4.83    $255.64      $109.61       $51.13
                               abscess.
45100...  T                   Biopsy of rectum.......        452       4.83    $255.64      $109.61       $51.13
45108...  T                   Removal of anorectal           453      16.87    $892.28      $445.22      $178.46
                               lesion.
45110...  C                   Removal of rectum......  .........  .........  .........  ...........  ...........
45111...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               rectum.
45112...  C                   Removal of rectum......  .........  .........  .........  ...........  ...........
45113...  C                   Partial proctectomy....  .........  .........  .........  ...........  ...........
45114...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               rectum.
45116...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               rectum.
45119...  C                   Remove, rectum w/        .........  .........  .........  ...........  ...........
                               reservoir.
45120...  C                   Removal of rectum......  .........  .........  .........  ...........  ...........
45121...  C                   Removal of rectum and    .........  .........  .........  ...........  ...........
                               colon.
45123...  C                   Partial proctectomy....  .........  .........  .........  ...........  ...........
45130...  C                   Excision of rectal       .........  .........  .........  ...........  ...........
                               prolapse.
45135...  C                   Excision of rectal       .........  .........  .........  ...........  ...........
                               prolapse.
45150...  T                   Excision of rectal             453      16.87    $892.28      $445.22      $178.46
                               stricture.
45160...  T                   Excision of rectal             453      16.87    $892.28      $445.22      $178.46
                               lesion.
45170...  T                   Excision of rectal             453      16.87    $892.28      $445.22      $178.46
                               lesion.
45190...  T                   Destruction, rectal            453      16.87    $892.28      $445.22      $178.46
                               tumor.
45300...  T                   Proctosigmoidoscopy....        446       2.59    $137.12       $65.09       $27.42
45303...  T                   Proctosigmoidoscopy....        447       6.87    $363.38      $184.87       $72.68
45305...  T                   Proctosigmoidoscopy;           446       2.59    $137.12       $65.09       $27.42
                               biopsy.
45307...  T                   Proctosigmoidoscopy....        447       6.87    $363.38      $184.87       $72.68
45308...  T                   Proctosigmoidoscopy....        447       6.87    $363.38      $184.87       $72.68
45309...  T                   Proctosigmoidoscopy....        447       6.87    $363.38      $184.87       $72.68
45315...  T                   Proctosigmoidoscopy....        447       6.87    $363.38      $184.87       $72.68
45317...  T                   Proctosigmoidoscopy....        447       6.87    $363.38      $184.87       $72.68
45320...  T                   Proctosigmoidoscopy....        447       6.87    $363.38      $184.87       $72.68
45321...  T                   Proctosigmoidoscopy....        447       6.87    $363.38      $184.87       $72.68
45330...  T                   Sigmoidoscopy,                 446       2.59    $137.12       $65.09       $27.42
                               diagnostic.
45331...  T                   Sigmoidoscopy and              446       2.59    $137.12       $65.09       $27.42
                               biopsy.
45332...  T                   Sigmoidoscopy..........        448       5.37    $284.04      $141.25       $56.81
45333...  T                   Sigmoidoscopy &                448       5.37    $284.04      $141.25       $56.81
                               polypectomy.
45334...  T                   Sigmoidoscopy for              448       5.37    $284.04      $141.25       $56.81
                               bleeding.
45337...  T                   Sigmoidoscopy,                 448       5.37    $284.04      $141.25       $56.81
                               decompression.
45338...  T                   Sigmoidoscopy..........        448       5.37    $284.04      $141.25       $56.81

[[Page 47666]]

45339...  T                   Sigmoidoscopy..........        449       7.80    $412.35      $215.38       $82.47
45355...  T                   Surgical colonoscopy...        427       8.22    $434.88      $224.19       $86.98
45378...  T                   Diagnostic colonoscopy.        426       6.85    $362.40      $187.81       $72.48
45379...  T                   Colonoscopy............        427       8.22    $434.88      $224.19       $86.98
45380...  T                   Colonoscopy and biopsy.        426       6.85    $362.40      $187.81       $72.48
45382...  T                   Colonoscopy, control           427       8.22    $434.88      $224.19       $86.98
                               bleeding.
45383...  T                   Colonoscopy, lesion            449       7.80    $412.35      $215.38       $82.47
                               removal.
45384...  T                   Colonoscopy............        427       8.22    $434.88      $224.19       $86.98
45385...  T                   Colonoscopy, lesion            427       8.22    $434.88      $224.19       $86.98
                               removal.
45500...  T                   Repair of rectum.......        453      16.87    $892.28      $445.22      $178.46
45505...  T                   Repair of rectum.......        453      16.87    $892.28      $445.22      $178.46
45520...  T                   Treatment of rectal            339       1.02     $53.87       $19.66       $10.77
                               prolapse.
45540...  C                   Correct rectal prolapse  .........  .........  .........  ...........  ...........
45541...  C                   Correct rectal prolapse  .........  .........  .........  ...........  ...........
45550...  C                   Repair rectum; remove    .........  .........  .........  ...........  ...........
                               sigmoid.
45560...  T                   Repair of rectocele....        453      16.87    $892.28      $445.22      $178.46
45562...  C                   Exploration/repair of    .........  .........  .........  ...........  ...........
                               rectum.
45563...  C                   Exploration/repair of    .........  .........  .........  ...........  ...........
                               rectum.
45800...  C                   Repair rectumbladder     .........  .........  .........  ...........  ...........
                               fistula.
45805...  C                   Repair fistula;          .........  .........  .........  ...........  ...........
                               colostomy.
45820...  C                   Repair rectourethral     .........  .........  .........  ...........  ...........
                               fistula.
45825...  C                   Repair fistula;          .........  .........  .........  ...........  ...........
                               colostomy.
45900...  T                   Reduction of rectal            452       4.83    $255.64      $109.61       $51.13
                               prolapse.
45905...  T                   Dilation of anal               452       4.83    $255.64      $109.61       $51.13
                               sphincter.
45910...  T                   Dilation of rectal             452       4.83    $255.64      $109.61       $51.13
                               narrowing.
45915...  T                   Remove rectal                  452       4.83    $255.64      $109.61       $51.13
                               obstruction.
45999...  T                   Rectum surgery                 452       4.83    $255.64      $109.61       $51.13
                               procedure.
46030...  T                   Removal of rectal              452       4.83    $255.64      $109.61       $51.13
                               marker.
46040...  T                   Incision of rectal             452       4.83    $255.64      $109.61       $51.13
                               abscess.
46045...  T                   Incision of rectal             453      16.87    $892.28      $445.22      $178.46
                               abscess.
46050...  T                   Incision of anal               452       4.83    $255.64      $109.61       $51.13
                               abscess.
46060...  T                   Incision of rectal             453      16.87    $892.28      $445.22      $178.46
                               abscess.
46070...  T                   Incision of anal septum        451       2.56    $135.16       $54.24       $27.03
46080...  T                   Incision of anal               452       4.83    $255.64      $109.61       $51.13
                               sphincter.
46083...  T                   Incise external                451       2.56    $135.16       $54.24       $27.03
                               hemorrhoid.
46200...  T                   Removal of anal fissure        453      16.87    $892.28      $445.22      $178.46
46210...  T                   Removal of anal crypt..        452       4.83    $255.64      $109.61       $51.13
46211...  T                   Removal of anal crypts.        453      16.87    $892.28      $445.22      $178.46
46220...  T                   Removal of anal tab....        451       2.56    $135.16       $54.24       $27.03
46221...  T                   Ligation of                    451       2.56    $135.16       $54.24       $27.03
                               hemorrhoid(s).
46230...  T                   Removal of anal tabs...        451       2.56    $135.16       $54.24       $27.03
46250...  T                   Hemorrhoidectomy.......        453      16.87    $892.28      $445.22      $178.46
46255...  T                   Hemorrhoidectomy.......        453      16.87    $892.28      $445.22      $178.46
46257...  T                   Remove hemorrhoids &           453      16.87    $892.28      $445.22      $178.46
                               fissure.
46258...  T                   Remove hemorrhoids &           453      16.87    $892.28      $445.22      $178.46
                               fistula.
46260...  T                   Hemorrhoidectomy.......        453      16.87    $892.28      $445.22      $178.46
46261...  T                   Remove hemorrhoids &           453      16.87    $892.28      $445.22      $178.46
                               fissure.
46262...  T                   Remove hemorrhoids &           453      16.87    $892.28      $445.22      $178.46
                               fistula.
46270...  T                   Removal of anal fistula        453      16.87    $892.28      $445.22      $178.46
46275...  T                   Removal of anal fistula        453      16.87    $892.28      $445.22      $178.46
46280...  T                   Removal of anal fistula        453      16.87    $892.28      $445.22      $178.46
46285...  T                   Removal of anal fistula        453      16.87    $892.28      $445.22      $178.46
46288...  T                   Repair anal fistula....        453      16.87    $892.28      $445.22      $178.46
46320...  T                   Removal of hemorrhoid          451       2.56    $135.16       $54.24       $27.03
                               clot.
46500...  T                   Injection into                 451       2.56    $135.16       $54.24       $27.03
                               hemorrhoids.
46600...  N                   Diagnostic anoscopy....  .........  .........  .........  ...........  ...........
46604...  N                   Anoscopy and dilation..  .........  .........  .........  ...........  ...........
46606...  T                   Anoscopy and biopsy....        436       1.43     $75.42       $24.86       $15.08
46608...  T                   Anoscopy; remove               437       2.91    $153.77       $76.61       $30.75
                               foreign body.
46610...  T                   Anoscopy; remove lesion        437       2.91    $153.77       $76.61       $30.75
46611...  T                   Anoscopy...............        437       2.91    $153.77       $76.61       $30.75
46612...  T                   Anoscopy; remove               437       2.91    $153.77       $76.61       $30.75
                               lesions.
46614...  T                   Anoscopy; control              437       2.91    $153.77       $76.61       $30.75
                               bleeding.
46615...  T                   Anoscopy...............        437       2.91    $153.77       $76.61       $30.75
46700...  T                   Repair of anal                 453      16.87    $892.28      $445.22      $178.46
                               stricture.
46705...  C                   Repair of anal           .........  .........  .........  ...........  ...........
                               stricture.
46715...  C                   Repair of anovaginal     .........  .........  .........  ...........  ...........
                               fistula.
46716...  C                   Repair of anovaginal     .........  .........  .........  ...........  ...........
                               fistula.
46730...  C                   Construction of absent   .........  .........  .........  ...........  ...........
                               anus.
46735...  C                   Construction of absent   .........  .........  .........  ...........  ...........
                               anus.
46740...  C                   Construction of absent   .........  .........  .........  ...........  ...........
                               anus.
46742...  C                   Repair, imperforated     .........  .........  .........  ...........  ...........
                               anus.
46744...  C                   Repair, cloacal anomaly  .........  .........  .........  ...........  ...........
46746...  C                   Repair, cloacal anomaly  .........  .........  .........  ...........  ...........
46748...  C                   Repair, cloacal anomaly  .........  .........  .........  ...........  ...........

[[Page 47667]]

46750...  T                   Repair of anal                 453      16.87    $892.28      $445.22      $178.46
                               sphincter.
46751...  C                   Repair of anal           .........  .........  .........  ...........  ...........
                               sphincter.
46753...  T                   Reconstruction of anus.        453      16.87    $892.28      $445.22      $178.46
46754...  T                   Removal of suture from         452       4.83    $255.64      $109.61       $51.13
                               anus.
46760...  T                   Repair of anal                 453      16.87    $892.28      $445.22      $178.46
                               sphincter.
46761...  T                   Repair of anal                 453      16.87    $892.28      $445.22      $178.46
                               sphincter.
46762...  T                   Implant artificial             453      16.87    $892.28      $445.22      $178.46
                               sphincter.
46900...  T                   Destruction, anal              152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
46910...  T                   Destruction, anal              152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
46916...  T                   Cryosurgery, anal              152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
46917...  T                   Laser surgery, anal            152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
46922...  T                   Excision of anal               152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
46924...  T                   Destruction, anal              152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
46934...  T                   Destruction of                 451       2.56    $135.16       $54.24       $27.03
                               hemorrhoids.
46935...  T                   Destruction of                 451       2.56    $135.16       $54.24       $27.03
                               hemorrhoids.
46936...  T                   Destruction of                 451       2.56    $135.16       $54.24       $27.03
                               hemorrhoids.
46937...  T                   Cryotherapy of rectal          453      16.87    $892.28      $445.22      $178.46
                               lesion.
46938...  T                   Cryotherapy of rectal          453      16.87    $892.28      $445.22      $178.46
                               lesion.
46940...  T                   Treatment of anal              451       2.56    $135.16       $54.24       $27.03
                               fissure.
46942...  T                   Treatment of anal              451       2.56    $135.16       $54.24       $27.03
                               fissure.
46945...  T                   Ligation of hemorrhoids        451       2.56    $135.16       $54.24       $27.03
46946...  T                   Ligation of hemorrhoids        451       2.56    $135.16       $54.24       $27.03
46999...  T                   Anus surgery procedure.        452       4.83    $255.64      $109.61       $51.13
47000...  T                   Needle biopsy of liver.        122       4.87    $257.60      $115.03       $51.52
47001...  C                   Needle biopsy, liver...  .........  .........  .........  ...........  ...........
47010...  C                   Open drainage, liver     .........  .........  .........  ...........  ...........
                               lesion.
47011...  C                   Percut drain, liver      .........  .........  .........  ...........  ...........
                               lesion.
47015...  C                   Inject/aspirate liver    .........  .........  .........  ...........  ...........
                               cyst.
47100...  C                   Wedge biopsy of liver..  .........  .........  .........  ...........  ...........
47120...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               liver.
47122...  C                   Extensive removal of     .........  .........  .........  ...........  ...........
                               liver.
47125...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               liver.
47130...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               liver.
47133...  C                   Removal of donor liver.  .........  .........  .........  ...........  ...........
47134...  C                   Partial removal, donor   .........  .........  .........  ...........  ...........
                               liver.
47135...  C                   Transplantation of       .........  .........  .........  ...........  ...........
                               liver.
47136...  C                   Transplantation of       .........  .........  .........  ...........  ...........
                               liver.
47300...  C                   Surgery for liver        .........  .........  .........  ...........  ...........
                               lesion.
47350...  C                   Repair liver wound.....  .........  .........  .........  ...........  ...........
47360...  C                   Repair liver wound.....  .........  .........  .........  ...........  ...........
47361...  C                   Repair liver wound.....  .........  .........  .........  ...........  ...........
47362...  C                   Repair liver wound.....  .........  .........  .........  ...........  ...........
47399...  T                   Liver surgery procedure        122       4.87    $257.60      $115.03       $51.52
47400...  C                   Incision of liver duct.  .........  .........  .........  ...........  ...........
47420...  C                   Incision of bile duct..  .........  .........  .........  ...........  ...........
47425...  C                   Incision of bile duct..  .........  .........  .........  ...........  ...........
47460...  C                   Incise bile duct         .........  .........  .........  ...........  ...........
                               sphincter.
47480...  C                   Incision of gallbladder  .........  .........  .........  ...........  ...........
47490...  C                   Incision of gallbladder  .........  .........  .........  ...........  ...........
47500...  T                   Injection for liver x-         347       2.93    $154.75       $62.15       $30.95
                               rays.
47505...  T                   Injection for liver x-         347       2.93    $154.75       $62.15       $30.95
                               rays.
47510...  T                   Insert catheter, bile          458       7.24    $382.97      $181.70       $76.59
                               duct.
47511...  T                   Insert bile duct drain.        458       7.24    $382.97      $181.70       $76.59
47525...  T                   Change bile duct               470       2.22    $117.53       $54.92       $23.51
                               catheter.
47530...  T                   Revise, reinsert bile          470       2.22    $117.53       $54.92       $23.51
                               tube.
47550...  C                   Bile duct endoscopy....  .........  .........  .........  ...........  ...........
47552...  T                   Biliary endoscopy, thru        458       7.24    $382.97      $181.70       $76.59
                               skin.
47553...  T                   Biliary endoscopy, thru        458       7.24    $382.97      $181.70       $76.59
                               skin.
47554...  T                   Biliary endoscopy, thru        458       7.24    $382.97      $181.70       $76.59
                               skin.
47555...  T                   Biliary endoscopy, thru        458       7.24    $382.97      $181.70       $76.59
                               skin.
47556...  T                   Biliary endoscopy, thru        458       7.24    $382.97      $181.70       $76.59
                               skin.
47600...  C                   Removal of gallbladder.  .........  .........  .........  ...........  ...........
47605...  C                   Removal of gallbladder.  .........  .........  .........  ...........  ...........
47610...  C                   Removal of gallbladder.  .........  .........  .........  ...........  ...........
47612...  C                   Removal of gallbladder.  .........  .........  .........  ...........  ...........
47620...  C                   Removal of gallbladder.  .........  .........  .........  ...........  ...........
47630...  T                   Remove bile duct stone.        458       7.24    $382.97      $181.70       $76.59
47700...  C                   Exploration of bile      .........  .........  .........  ...........  ...........
                               ducts.
47701...  C                   Bile duct revision.....  .........  .........  .........  ...........  ...........
47711...  C                   Excision of bile duct    .........  .........  .........  ...........  ...........
                               tumor.
47712...  C                   Excision of bile duct    .........  .........  .........  ...........  ...........
                               tumor.
47715...  C                   Excision of bile duct    .........  .........  .........  ...........  ...........
                               cyst.
47716...  C                   Fusion of bile duct      .........  .........  .........  ...........  ...........
                               cyst.
47720...  C                   Fuse gallbladder &       .........  .........  .........  ...........  ...........
                               bowel.
47721...  C                   Fuse upper gi            .........  .........  .........  ...........  ...........
                               structures.

[[Page 47668]]

47740...  C                   Fuse gallbladder &       .........  .........  .........  ...........  ...........
                               bowel.
47741...  C                   Fuse gallbladder &       .........  .........  .........  ...........  ...........
                               bowel.
47760...  C                   Fuse bile ducts and      .........  .........  .........  ...........  ...........
                               bowel.
47765...  C                   Fuse liver ducts &       .........  .........  .........  ...........  ...........
                               bowel.
47780...  C                   Fuse bile ducts and      .........  .........  .........  ...........  ...........
                               bowel.
47785...  C                   Fuse bile ducts and      .........  .........  .........  ...........  ...........
                               bowel.
47800...  C                   Reconstruction of bile   .........  .........  .........  ...........  ...........
                               ducts.
47801...  C                   Placement, bile duct     .........  .........  .........  ...........  ...........
                               support.
47802...  C                   Fuse liver duct &        .........  .........  .........  ...........  ...........
                               intestine.
47900...  C                   Suture bile duct injury  .........  .........  .........  ...........  ...........
47999...  T                   Bile tract surgery             470       2.22    $117.53       $54.92       $23.51
                               procedure.
48000...  C                   Drainage of abdomen....  .........  .........  .........  ...........  ...........
48001...  C                   Placement of drain,      .........  .........  .........  ...........  ...........
                               pancreas.
48005...  C                   Resect/debride pancreas  .........  .........  .........  ...........  ...........
48020...  C                   Removal of pancreatic    .........  .........  .........  ...........  ...........
                               stone.
48100...  C                   Biopsy of pancreas.....  .........  .........  .........  ...........  ...........
48102...  T                   Needle biopsy, pancreas        122       4.87    $257.60      $115.03       $51.52
48120...  C                   Removal of pancreas      .........  .........  .........  ...........  ...........
                               lesion.
48140...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               pancreas.
48145...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               pancreas.
48146...  C                   Pancreatectomy.........  .........  .........  .........  ...........  ...........
48148...  C                   Removal of pancreatic    .........  .........  .........  ...........  ...........
                               duct.
48150...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               pancreas.
48152...  C                   Pancreatectomy.........  .........  .........  .........  ...........  ...........
48153...  C                   Pancreatectomy.........  .........  .........  .........  ...........  ...........
48154...  C                   Pancreatectomy.........  .........  .........  .........  ...........  ...........
48155...  C                   Removal of pancreas....  .........  .........  .........  ...........  ...........
48160...  E                   Pancreas removal,        .........  .........  .........  ...........  ...........
                               transplant.
48180...  C                   Fuse pancreas and bowel  .........  .........  .........  ...........  ...........
48400...  C                   Injection,               .........  .........  .........  ...........  ...........
                               intraoperative.
48500...  C                   Surgery of pancreas      .........  .........  .........  ...........  ...........
                               cyst.
48510...  C                   Drain pancreatic         .........  .........  .........  ...........  ...........
                               pseudocyst.
48511...  C                   Drain pancreatic         .........  .........  .........  ...........  ...........
                               pseudocyst.
48520...  C                   Fuse pancreas cyst and   .........  .........  .........  ...........  ...........
                               bowel.
48540...  C                   Fuse pancreas cyst and   .........  .........  .........  ...........  ...........
                               bowel.
48545...  C                   Pancreatorrhaphy.......  .........  .........  .........  ...........  ...........
48547...  C                   Duodenal exclusion.....  .........  .........  .........  ...........  ...........
48550...  E                   Donor pancreatectomy...  .........  .........  .........  ...........  ...........
48554...  E                   Transplantallograft      .........  .........  .........  ...........  ...........
                               pancreas.
48556...  C                   Removal, allograft       .........  .........  .........  ...........  ...........
                               pancreas.
48999...  T                   Pancreas surgery               122       4.87    $257.60      $115.03       $51.52
                               procedure.
49000...  C                   Exploration of abdomen.  .........  .........  .........  ...........  ...........
49002...  C                   Reopening of abdomen...  .........  .........  .........  ...........  ...........
49010...  C                   Exploration behind       .........  .........  .........  ...........  ...........
                               abdomen.
49020...  C                   Drain abdominal abscess  .........  .........  .........  ...........  ...........
49021...  C                   Drain abdominal abscess  .........  .........  .........  ...........  ...........
49040...  C                   Open drainage abdom      .........  .........  .........  ...........  ...........
                               abscess.
49041...  C                   Percut drain abdom       .........  .........  .........  ...........  ...........
                               abscess.
49060...  C                   Open drain retroper      .........  .........  .........  ...........  ...........
                               abscess.
49061...  C                   Percutdrain retroper     .........  .........  .........  ...........  ...........
                               abscess.
49062...  C                   Drain to peritoneal      .........  .........  .........  ...........  ...........
                               cavity.
49080...  T                   Puncture, peritoneal           320       3.17    $167.49       $79.33       $33.50
                               cavity.
49081...  T                   Removal of abdominal           320       3.17    $167.49       $79.33       $33.50
                               fluid.
49085...  T                   Remove abdomen foreign         459      18.06    $954.97      $496.52      $190.99
                               body.
49180...  T                   Biopsy, abdominal mass.        122       4.87    $257.60      $115.03       $51.52
49200...  C                   Removal of abdominal     .........  .........  .........  ...........  ...........
                               lesion.
49201...  C                   Removal of abdominal     .........  .........  .........  ...........  ...........
                               lesion.
49215...  C                   Excise sacral spine      .........  .........  .........  ...........  ...........
                               tumor.
49220...  C                   Multiple surgery,        .........  .........  .........  ...........  ...........
                               abdomen.
49250...  T                   Excision of umbilicus..        459      18.06    $954.97      $496.52      $190.99
49255...  C                   Removal of omentum.....  .........  .........  .........  ...........  ...........
49400...  T                   Air injection into             347       2.93    $154.75       $62.15       $30.95
                               abdomen.
49420...  T                   Insert abdominal drain.        459      18.06    $954.97      $496.52      $190.99
49421...  T                   Insert abdominal drain.        459      18.06    $954.97      $496.52      $190.99
49422...  T                   Remove perm cannula/           470       2.22    $117.53       $54.92       $23.51
                               catheter.
49423...  T                   Exchange drainage cath.        459      18.06    $954.97      $496.52      $190.99
49424...  T                   Assess cyst, contrast          347       2.93    $154.75       $62.15       $30.95
                               inj.
49425...  C                   Insert abdomen-venous    .........  .........  .........  ...........  ...........
                               drain.
49426...  T                   Revise abdomen-venous          459      18.06    $954.97      $496.52      $190.99
                               shunt.
49427...  T                   Injection, abdominal           347       2.93    $154.75       $62.15       $30.95
                               shunt.
49428...  C                   Ligation of shunt......  .........  .........  .........  ...........  ...........
49429...  T                   Removal of shunt.......        470       2.22    $117.53       $54.92       $23.51
49495...  T                   Repair inguinal hernia,        466      21.43  $1,133.23      $562.97      $226.65
                               init.
49496...  T                   Repair inguinal hernia,        466      21.43  $1,133.23      $562.97      $226.65
                               init.
49500...  T                   Repair inguinal hernia.        466      21.43  $1,133.23      $562.97      $226.65

[[Page 47669]]

49501...  T                   Repair inguinal hernia,        466      21.43  $1,133.23      $562.97      $226.65
                               init.
49505...  T                   Repair inguinal hernia.        466      21.43  $1,133.23      $562.97      $226.65
49507...  T                   Repair, inguinal hernia        466      21.43  $1,133.23      $562.97      $226.65
49520...  T                   Rerepair inguinal              466      21.43  $1,133.23      $562.97      $226.65
                               hernia.
49521...  T                   Repair inguinal hernia,        466      21.43  $1,133.23      $562.97      $226.65
                               rec.
49525...  T                   Repair inguinal hernia.        466      21.43  $1,133.23      $562.97      $226.65
49540...  T                   Repair lumbar hernia...        466      21.43  $1,133.23      $562.97      $226.65
49550...  T                   Repair femoral hernia..        466      21.43  $1,133.23      $562.97      $226.65
49553...  T                   Repair femoral hernia,         466      21.43  $1,133.23      $562.97      $226.65
                               init.
49555...  T                   Repair femoral hernia..        466      21.43  $1,133.23      $562.97      $226.65
49557...  T                   Repair femoral hernia,         466      21.43  $1,133.23      $562.97      $226.65
                               recur.
49560...  T                   Repair abdominal hernia        466      21.43  $1,133.23      $562.97      $226.65
49561...  T                   Repair incisional              466      21.43  $1,133.23      $562.97      $226.65
                               hernia.
49565...  T                   Rerepair abdominal             466      21.43  $1,133.23      $562.97      $226.65
                               hernia.
49566...  T                   Repair incisional              466      21.43  $1,133.23      $562.97      $226.65
                               hernia.
49568...  T                   Hernia repair w/mesh...        466      21.43  $1,133.23      $562.97      $226.65
49570...  T                   Repair epigastric              466      21.43  $1,133.23      $562.97      $226.65
                               hernia.
49572...  T                   Repair, epigastric             466      21.43  $1,133.23      $562.97      $226.65
                               hernia.
49580...  T                   Repair umbilical hernia        466      21.43  $1,133.23      $562.97      $226.65
49582...  T                   Repair umbilical hernia        466      21.43  $1,133.23      $562.97      $226.65
49585...  T                   Repair umbilical hernia        466      21.43  $1,133.23      $562.97      $226.65
49587...  T                   Repair umbilical hernia        466      21.43  $1,133.23      $562.97      $226.65
49590...  T                   Repair abdominal hernia        466      21.43  $1,133.23      $562.97      $226.65
49600...  T                   Repair umbilical lesion        466      21.43  $1,133.23      $562.97      $226.65
49605...  C                   Repair umbilical lesion  .........  .........  .........  ...........  ...........
49606...  C                   Repair umbilical lesion  .........  .........  .........  ...........  ...........
49610...  C                   Repair umbilical lesion  .........  .........  .........  ...........  ...........
49611...  C                   Repair umbilical lesion  .........  .........  .........  ...........  ...........
49900...  C                   Repair of abdominal      .........  .........  .........  ...........  ...........
                               wall.
49905...  C                   Omental flap...........  .........  .........  .........  ...........  ...........
49906...  C                   Free omental flap,       .........  .........  .........  ...........  ...........
                               microvasc.
49999...  T                   Abdomen surgery                470       2.22    $117.53       $54.92       $23.51
                               procedure.
50010...  C                   Exploration of kidney..  .........  .........  .........  ...........  ...........
50020...  C                   Open drain renal         .........  .........  .........  ...........  ...........
                               abscess.
50021...  C                   Percut drain renal       .........  .........  .........  ...........  ...........
                               abscess.
50040...  C                   Drainage of kidney.....  .........  .........  .........  ...........  ...........
50045...  C                   Exploration of kidney..  .........  .........  .........  ...........  ...........
50060...  C                   Removal of kidney stone  .........  .........  .........  ...........  ...........
50065...  C                   Incision of kidney.....  .........  .........  .........  ...........  ...........
50070...  C                   Incision of kidney.....  .........  .........  .........  ...........  ...........
50075...  C                   Removal of kidney stone  .........  .........  .........  ...........  ...........
50080...  C                   Removal of kidney stone  .........  .........  .........  ...........  ...........
50081...  C                   Removal of kidney stone  .........  .........  .........  ...........  ...........
50100...  C                   Revise kidney blood      .........  .........  .........  ...........  ...........
                               vessels.
50120...  C                   Exploration of kidney..  .........  .........  .........  ...........  ...........
50125...  C                   Explore and drain        .........  .........  .........  ...........  ...........
                               kidney.
50130...  C                   Removal of kidney stone  .........  .........  .........  ...........  ...........
50135...  C                   Exploration of kidney..  .........  .........  .........  ...........  ...........
50200...  T                   Biopsy of kidney.......        122       4.87    $257.60      $115.03       $51.52
50205...  C                   Biopsy of kidney.......  .........  .........  .........  ...........  ...........
50220...  C                   Removal of kidney......  .........  .........  .........  ...........  ...........
50225...  C                   Removal of kidney......  .........  .........  .........  ...........  ...........
50230...  C                   Removal of kidney......  .........  .........  .........  ...........  ...........
50234...  C                   Removal of kidney &      .........  .........  .........  ...........  ...........
                               ureter.
50236...  C                   Removal of kidney &      .........  .........  .........  ...........  ...........
                               ureter.
50240...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               kidney.
50280...  C                   Removal of kidney        .........  .........  .........  ...........  ...........
                               lesion.
50290...  C                   Removal of kidney        .........  .........  .........  ...........  ...........
                               lesion.
50300...  C                   Removal of donor kidney  .........  .........  .........  ...........  ...........
50320...  C                   Removal of donor kidney  .........  .........  .........  ...........  ...........
50340...  C                   Removal of kidney......  .........  .........  .........  ...........  ...........
50360...  C                   Transplantation of       .........  .........  .........  ...........  ...........
                               kidney.
50365...  C                   Transplantation of       .........  .........  .........  ...........  ...........
                               kidney.
50370...  C                   Remove transplanted      .........  .........  .........  ...........  ...........
                               kidney.
50380...  C                   Reimplantation of        .........  .........  .........  ...........  ...........
                               kidney.
50390...  T                   Drainage of kidney             122       4.87    $257.60      $115.03       $51.52
                               lesion.
50392...  T                   Insert kidney drain....        347       2.93    $154.75       $62.15       $30.95
50393...  T                   Insert ureteral tube...        347       2.93    $154.75       $62.15       $30.95
50394...  T                   Injection for kidney x-        347       2.93    $154.75       $62.15       $30.95
                               ray.
50395...  T                   Create passage to              347       2.93    $154.75       $62.15       $30.95
                               kidney.
50396...  T                   Measure kidney pressure        529       2.50    $132.23       $63.05       $26.45
50398...  T                   Change kidney tube.....        521       5.06    $267.39      $112.10       $53.48
50400...  C                   Revision of kidney/      .........  .........  .........  ...........  ...........
                               ureter.
50405...  C                   Revision of kidney/      .........  .........  .........  ...........  ...........
                               ureter.
50500...  C                   Repair of kidney wound.  .........  .........  .........  ...........  ...........

[[Page 47670]]

50520...  C                   Close kidney-skin        .........  .........  .........  ...........  ...........
                               fistula.
50525...  C                   Repair renal-abdomen     .........  .........  .........  ...........  ...........
                               fistula.
50526...  C                   Repair renal-abdomen     .........  .........  .........  ...........  ...........
                               fistula.
50540...  C                   Revision of horseshoe    .........  .........  .........  ...........  ...........
                               kidney.
50551...  T                   Kidney endoscopy.......        522      10.46    $553.39      $262.39      $110.68
50553...  T                   Kidney endoscopy.......        522      10.46    $553.39      $262.39      $110.68
50555...  T                   Kidney endoscopy &             522      10.46    $553.39      $262.39      $110.68
                               biopsy.
50557...  T                   Kidney endoscopy &             522      10.46    $553.39      $262.39      $110.68
                               treatment.
50559...  T                   Renal endoscopy;               522      10.46    $553.39      $262.39      $110.68
                               radiotracer.
50561...  T                   Kidney endoscopy &             522      10.46    $553.39      $262.39      $110.68
                               treatment.
50570...  C                   Kidney endoscopy.......  .........  .........  .........  ...........  ...........
50572...  C                   Kidney endoscopy.......  .........  .........  .........  ...........  ...........
50574...  C                   Kidney endoscopy &       .........  .........  .........  ...........  ...........
                               biopsy.
50575...  C                   Kidney endoscopy.......  .........  .........  .........  ...........  ...........
50576...  C                   Kidney endoscopy &       .........  .........  .........  ...........  ...........
                               treatment.
50578...  C                   Renal endoscopy;         .........  .........  .........  ...........  ...........
                               radiotracer.
50580...  C                   Kidney endoscopy &       .........  .........  .........  ...........  ...........
                               treatment.
50590...  T                   Fragmenting of kidney          527      51.56  $2,726.80    $1,372.95      $545.36
                               stone.
50600...  C                   Exploration of ureter..  .........  .........  .........  ...........  ...........
50605...  C                   Insert ureteral support  .........  .........  .........  ...........  ...........
50610...  C                   Removal of ureter stone  .........  .........  .........  ...........  ...........
50620...  C                   Removal of ureter stone  .........  .........  .........  ...........  ...........
50630...  C                   Removal of ureter stone  .........  .........  .........  ...........  ...........
50650...  C                   Removal of ureter......  .........  .........  .........  ...........  ...........
50660...  C                   Removal of ureter......  .........  .........  .........  ...........  ...........
50684...  T                   Injection for ureter x-        347       2.93    $154.75       $62.15       $30.95
                               ray.
50686...  T                   Measure ureter pressure        529       2.50    $132.23       $63.05       $26.45
50688...  T                   Change of ureter tube..        470       2.22    $117.53       $54.92       $23.51
50690...  T                   Injection for ureter x-        347       2.93    $154.75       $62.15       $30.95
                               ray.
50700...  C                   Revision of ureter.....  .........  .........  .........  ...........  ...........
50715...  C                   Release of ureter......  .........  .........  .........  ...........  ...........
50722...  C                   Release of ureter......  .........  .........  .........  ...........  ...........
50725...  C                   Release/revise ureter..  .........  .........  .........  ...........  ...........
50727...  C                   Revise ureter..........  .........  .........  .........  ...........  ...........
50728...  C                   Revise ureter..........  .........  .........  .........  ...........  ...........
50740...  C                   Fusion of ureter &       .........  .........  .........  ...........  ...........
                               kidney.
50750...  C                   Fusion of ureter &       .........  .........  .........  ...........  ...........
                               kidney.
50760...  C                   Fusion of ureters......  .........  .........  .........  ...........  ...........
50770...  C                   Splicing of ureters....  .........  .........  .........  ...........  ...........
50780...  C                   Reimplant ureter in      .........  .........  .........  ...........  ...........
                               bladder.
50782...  C                   Reimplant ureter in      .........  .........  .........  ...........  ...........
                               bladder.
50783...  C                   Reimplant ureter in      .........  .........  .........  ...........  ...........
                               bladder.
50785...  C                   Reimplant ureter in      .........  .........  .........  ...........  ...........
                               bladder.
50800...  C                   Implant ureter in bowel  .........  .........  .........  ...........  ...........
50810...  C                   Fusion of ureter &       .........  .........  .........  ...........  ...........
                               bowel.
50815...  C                   Urine shunt to bowel...  .........  .........  .........  ...........  ...........
50820...  C                   Construct bowel bladder  .........  .........  .........  ...........  ...........
50825...  C                   Construct bowel bladder  .........  .........  .........  ...........  ...........
50830...  C                   Revise urine flow......  .........  .........  .........  ...........  ...........
50840...  C                   Replace ureter by bowel  .........  .........  .........  ...........  ...........
50845...  C                   Appendico-vesicostomy..  .........  .........  .........  ...........  ...........
50860...  C                   Transplant ureter to     .........  .........  .........  ...........  ...........
                               skin.
50900...  C                   Repair of ureter.......  .........  .........  .........  ...........  ...........
50920...  C                   Closure ureter/skin      .........  .........  .........  ...........  ...........
                               fistula.
50930...  C                   Closure ureter/bowel     .........  .........  .........  ...........  ...........
                               fistula.
50940...  C                   Release of ureter......  .........  .........  .........  ...........  ...........
50951...  T                   Endoscopy of ureter....        523      16.87    $892.28      $447.03      $178.46
50953...  T                   Endoscopy of ureter....        523      16.87    $892.28      $447.03      $178.46
50955...  T                   Ureter endoscopy &             523      16.87    $892.28      $447.03      $178.46
                               biopsy.
50957...  T                   Ureter endoscopy &             523      16.87    $892.28      $447.03      $178.46
                               treatment.
50959...  T                   Ureter endoscopy &             523      16.87    $892.28      $447.03      $178.46
                               tracer.
50961...  T                   Ureter endoscopy &             523      16.87    $892.28      $447.03      $178.46
                               treatment.
50970...  C                   Ureter endoscopy.......  .........  .........  .........  ...........  ...........
50972...  C                   Ureter endoscopy &       .........  .........  .........  ...........  ...........
                               catheter.
50974...  C                   Ureter endoscopy &       .........  .........  .........  ...........  ...........
                               biopsy.
50976...  C                   Ureter endoscopy &       .........  .........  .........  ...........  ...........
                               treatment.
50978...  C                   Ureter endoscopy &       .........  .........  .........  ...........  ...........
                               tracer.
50980...  C                   Ureter endoscopy &       .........  .........  .........  ...........  ...........
                               treatment.
51000...  T                   Drainage of bladder....        530       2.52    $133.21       $54.69       $26.64
51005...  T                   Drainage of bladder....        530       2.52    $133.21       $54.69       $26.64
51010...  T                   Drainage of bladder....        530       2.52    $133.21       $54.69       $26.64
51020...  T                   Incise & treat bladder.        523      16.87    $892.28      $447.03      $178.46
51030...  T                   Incise & treat bladder.        523      16.87    $892.28      $447.03      $178.46
51040...  T                   Incise & drain bladder.        523      16.87    $892.28      $447.03      $178.46
51045...  T                   Incise bladder, drain          523      16.87    $892.28      $447.03      $178.46
                               ureter.

[[Page 47671]]

51050...  T                   Removal of bladder             523      16.87    $892.28      $447.03      $178.46
                               stone.
51060...  C                   Removal of ureter stone  .........  .........  .........  ...........  ...........
51065...  T                   Removal of ureter stone        523      16.87    $892.28      $447.03      $178.46
51080...  T                   Drainage of bladder            132       6.04    $319.30      $134.24       $63.86
                               abscess.
51500...  T                   Removal of bladder cyst        466      21.43  $1,133.23      $562.97      $226.65
51520...  T                   Removal of bladder             523      16.87    $892.28      $447.03      $178.46
                               lesion.
51525...  C                   Removal of bladder       .........  .........  .........  ...........  ...........
                               lesion.
51530...  C                   Removal of bladder       .........  .........  .........  ...........  ...........
                               lesion.
51535...  C                   Repair of ureter lesion  .........  .........  .........  ...........  ...........
51550...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               bladder.
51555...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               bladder.
51565...  C                   Revise bladder &         .........  .........  .........  ...........  ...........
                               ureter(s).
51570...  C                   Removal of bladder.....  .........  .........  .........  ...........  ...........
51575...  C                   Removal of bladder &     .........  .........  .........  ...........  ...........
                               nodes.
51580...  C                   Remove bladder; revise   .........  .........  .........  ...........  ...........
                               tract.
51585...  C                   Removal of bladder &     .........  .........  .........  ...........  ...........
                               nodes.
51590...  C                   Remove bladder; revise   .........  .........  .........  ...........  ...........
                               tract.
51595...  C                   Remove bladder; revise   .........  .........  .........  ...........  ...........
                               tract.
51596...  C                   Remove bladder, create   .........  .........  .........  ...........  ...........
                               pouch.
51597...  C                   Removal of pelvic        .........  .........  .........  ...........  ...........
                               structures.
51600...  T                   Injection for bladder x-       347       2.93    $154.75       $62.15       $30.95
                               ray.
51605...  T                   Preparation for bladder        347       2.93    $154.75       $62.15       $30.95
                               xray.
51610...  T                   Injection for bladder x-       347       2.93    $154.75       $62.15       $30.95
                               ray.
51700...  T                   Irrigation of bladder..        530       2.52    $133.21       $54.69       $26.64
51705...  T                   Change of bladder tube.        470       2.22    $117.53       $54.92       $23.51
51710...  T                   Change of bladder tube.        470       2.22    $117.53       $54.92       $23.51
51715...  T                   Endoscopic injection/          531      18.94  $1,001.98      $527.26      $200.40
                               implant.
51720...  T                   Treatment of bladder           530       2.52    $133.21       $54.69       $26.64
                               lesion.
51725...  T                   Simple cystometrogram..        529       2.50    $132.23       $63.05       $26.45
51726...  T                   Complex cystometrogram.        529       2.50    $132.23       $63.05       $26.45
51736...  T                   Urine flow measurement.        529       2.50    $132.23       $63.05       $26.45
51741...  T                   Electro-uroflowmetry,          529       2.50    $132.23       $63.05       $26.45
                               first.
51772...  T                   Urethra pressure               529       2.50    $132.23       $63.05       $26.45
                               profile.
51784...  T                   Anal/urinary muscle            529       2.50    $132.23       $63.05       $26.45
                               study.
51785...  T                   Anal/urinary muscle            529       2.50    $132.23       $63.05       $26.45
                               study.
51792...  T                   Urinary reflex study...        529       2.50    $132.23       $63.05       $26.45
51795...  T                   Urine voiding pressure         529       2.50    $132.23       $63.05       $26.45
                               study.
51797...  T                   Intraabdominal pressure        529       2.50    $132.23       $63.05       $26.45
                               test.
51800...  C                   Revision of bladder/     .........  .........  .........  ...........  ...........
                               urethra.
51820...  C                   Revision of urinary      .........  .........  .........  ...........  ...........
                               tract.
51840...  C                   Attach bladder/urethra.  .........  .........  .........  ...........  ...........
51841...  C                   Attach bladder/urethra.  .........  .........  .........  ...........  ...........
51845...  C                   Repair bladder neck....  .........  .........  .........  ...........  ...........
51860...  C                   Repair of bladder wound  .........  .........  .........  ...........  ...........
51865...  C                   Repair of bladder wound  .........  .........  .........  ...........  ...........
51880...  T                   Repair of bladder              523      16.87    $892.28      $447.03      $178.46
                               opening.
51900...  C                   Repair bladder/vagina    .........  .........  .........  ...........  ...........
                               lesion.
51920...  C                   Close bladder-uterus     .........  .........  .........  ...........  ...........
                               fistula.
51925...  C                   Hysterectomy/bladder     .........  .........  .........  ...........  ...........
                               repair.
51940...  C                   Correction of bladder    .........  .........  .........  ...........  ...........
                               defect.
51960...  C                   Revision of bladder &    .........  .........  .........  ...........  ...........
                               bowel.
51980...  C                   Construct bladder        .........  .........  .........  ...........  ...........
                               opening.
52000...  T                   Cystoscopy.............        521       5.06    $267.39      $112.10       $53.48
52005...  T                   Cystoscopy & ureter            522      10.46    $553.39      $262.39      $110.68
                               catheter.
52007...  T                   Cystoscopy and biopsy..        522      10.46    $553.39      $262.39      $110.68
52010...  T                   Cystoscopy & duct              522      10.46    $553.39      $262.39      $110.68
                               catheter.
52204...  T                   Cystoscopy.............        522      10.46    $553.39      $262.39      $110.68
52214...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.
52224...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.
52234...  T                   Cystoscopy and                 523      16.87    $892.28      $447.03      $178.46
                               treatment.
52235...  T                   Cystoscopy and                 523      16.87    $892.28      $447.03      $178.46
                               treatment.
52240...  T                   Cystoscopy and                 523      16.87    $892.28      $447.03      $178.46
                               treatment.
52250...  T                   Cystoscopy &                   523      16.87    $892.28      $447.03      $178.46
                               radiotracer.
52260...  T                   Cystoscopy & treatment.        522      10.46    $553.39      $262.39      $110.68
52265...  T                   Cystoscopy & treatment.        521       5.06    $267.39      $112.10       $53.48
52270...  T                   Cystoscopy & revise            522      10.46    $553.39      $262.39      $110.68
                               urethra.
52275...  T                   Cystoscopy & revise            522      10.46    $553.39      $262.39      $110.68
                               urethra.
52276...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.
52277...  T                   Cystoscopy and                 523      16.87    $892.28      $447.03      $178.46
                               treatment.
52281...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.
52282...  T                   Cystoscopy, implant            523      16.87    $892.28      $447.03      $178.46
                               stent.
52283...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.
52285...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.
52290...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.
52300...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.

[[Page 47672]]

52301...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.
52305...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.
52310...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.
52315...  T                   Cystoscopy and                 522      10.46    $553.39      $262.39      $110.68
                               treatment.
52317...  T                   Remove bladder stone...        523      16.87    $892.28      $447.03      $178.46
52318...  T                   Remove bladder stone...        523      16.87    $892.28      $447.03      $178.46
52320...  T                   Cystoscopy and                 523      16.87    $892.28      $447.03      $178.46
                               treatment.
52325...  T                   Cystoscopy, stone              523      16.87    $892.28      $447.03      $178.46
                               removal.
52327...  T                   Cystoscopy, inject             522      10.46    $553.39      $262.39      $110.68
                               material.
52330...  T                   Cystoscopy and                 523      16.87    $892.28      $447.03      $178.46
                               treatment.
52332...  T                   Cystoscopy and                 523      16.87    $892.28      $447.03      $178.46
                               treatment.
52334...  T                   Create passage to              523      16.87    $892.28      $447.03      $178.46
                               kidney.
52335...  T                   Endoscopy of urinary           523      16.87    $892.28      $447.03      $178.46
                               tract.
52336...  T                   Cystoscopy, stone              523      16.87    $892.28      $447.03      $178.46
                               removal.
52337...  T                   Cystoscopy, stone              524      28.89   1,527.95      $833.49      $305.59
                               removal.
52338...  T                   Cystoscopy and                 523      16.87    $892.28      $447.03      $178.46
                               treatment.
52339...  T                   Cystoscopy and                 523      16.87    $892.28      $447.03      $178.46
                               treatment.
52340...  T                   Cystoscopy and                 523      16.87    $892.28      $447.03      $178.46
                               treatment.
52450...  T                   Incision of prostate...        523      16.87    $892.28      $447.03      $178.46
52500...  T                   Revision of bladder            523      16.87    $892.28      $447.03      $178.46
                               neck.
52510...  T                   Dilation prostatic             522      10.46    $553.39      $262.39      $110.68
                               urethra.
52601...  T                   Prostatectomy (TURP)...        524      28.89  $1,527.95      $833.49      $305.59
52606...  T                   Control postop bleeding        523      16.87    $892.28      $447.03      $178.46
52612...  T                   Prostatectomy, first           524      28.89  $1,527.95      $833.49      $305.59
                               stage.
52614...  T                   Prostatectomy, second          524      28.89  $1,527.95      $833.49      $305.59
                               stage.
52620...  T                   Remove residual                524      28.89  $1,527.95      $833.49      $305.59
                               prostate.
52630...  T                   Remove prostate                524      28.89  $1,527.95      $833.49      $305.59
                               regrowth.
52640...  T                   Relieve bladder                523      16.87    $892.28      $447.03      $178.46
                               contracture.
52647...  T                   Laser surgery of               524      28.89  $1,527.95      $833.49      $305.59
                               prostate.
52648...  T                   Laser surgery of               524      28.89  $1,527.95      $833.49      $305.59
                               prostate.
52700...  T                   Drainage of prostate           523      16.87    $892.28      $447.03      $178.46
                               abscess.
53000...  T                   Incision of urethra....        531      18.94  $1,001.98      $527.26      $200.40
53010...  T                   Incision of urethra....        531      18.94  $1,001.98      $527.26      $200.40
53020...  T                   Incision of urethra....        531      18.94  $1,001.98      $527.26      $200.40
53025...  T                   Incision of urethra....        531      18.94  $1,001.98      $527.26      $200.40
53040...  T                   Drainage of urethra            531      18.94  $1,001.98      $527.26      $200.40
                               abscess.
53060...  T                   Drainage of urethra            531      18.94  $1,001.98      $527.26      $200.40
                               abscess.
53080...  T                   Drainage of urinary            531      18.94  $1,001.98      $527.26      $200.40
                               leakage.
53085...  C                   Drainage of urinary      .........  .........  .........  ...........  ...........
                               leakage.
53200...  T                   Biopsy of urethra......        531      18.94  $1,001.98      $527.26      $200.40
53210...  T                   Removal of urethra.....        532      25.50  $1,348.71      $602.29      $269.74
53215...  T                   Removal of urethra.....        532      25.50  $1,348.71      $602.29      $269.74
53220...  T                   Treatment of urethra           532      25.50  $1,348.71      $602.29      $269.74
                               lesion.
53230...  T                   Removal of urethra             532      25.50  $1,348.71      $602.29      $269.74
                               lesion.
53235...  T                   Removal of urethra             532      25.50  $1,348.71      $602.29      $269.74
                               lesion.
53240...  T                   Surgery for urethra            532      25.50  $1,348.71      $602.29      $269.74
                               pouch.
53250...  T                   Removal of urethra             531      18.94  $1,001.98      $527.26      $200.40
                               gland.
53260...  T                   Treatment of urethra           531      18.94  $1,001.98      $527.26      $200.40
                               lesion.
53265...  T                   Treatment of urethra           531      18.94  $1,001.98      $527.26      $200.40
                               lesion.
53270...  T                   Removal of urethra             531      18.94  $1,001.98      $527.26      $200.40
                               gland.
53275...  T                   Repair of urethra              531      18.94  $1,001.98      $527.26      $200.40
                               defect.
53400...  T                   Revise urethra, 1st            532      25.50  $1,348.71      $602.29      $269.74
                               stage.
53405...  T                   Revise urethra, 2nd            532      25.50  $1,348.71      $602.29      $269.74
                               stage.
53410...  T                   Reconstruction of              532      25.50  $1,348.71      $602.29      $269.74
                               urethra.
53415...  C                   Reconstruction of        .........  .........  .........  ...........  ...........
                               urethra.
53420...  T                   Reconstruct urethra,           532      25.50  $1,348.71      $602.29      $269.74
                               stage 1.
53425...  T                   Reconstruct urethra,           532      25.50  $1,348.71      $602.29      $269.74
                               stage 2.
53430...  T                   Reconstruction of              532      25.50  $1,348.71      $602.29      $269.74
                               urethra.
53440...  T                   Correct bladder                538      45.59  $2,411.41    $1,540.64      $482.28
                               function.
53442...  T                   Remove perineal                531      18.94  $1,001.98      $527.26      $200.40
                               prosthesis.
53443...  C                   Reconstruction of        .........  .........  .........  ...........  ...........
                               urethra.
53445...  T                   Correct urine flow             538      45.59  $2,411.41    $1,540.64      $482.28
                               control.
53447...  T                   Remove artificial              532      25.50  $1,348.71      $602.29      $269.74
                               sphincter.
53449...  T                   Correct artificial             532      25.50  $1,348.71      $602.29      $269.74
                               sphincter.
53450...  T                   Revision of urethra....        532      25.50  $1,348.71      $602.29      $269.74
53460...  T                   Revision of urethra....        532      25.50  $1,348.71      $602.29      $269.74
53502...  T                   Repair of urethra              531      18.94  $1,001.98      $527.26      $200.40
                               injury.
53505...  T                   Repair of urethra              531      18.94  $1,001.98      $527.26      $200.40
                               injury.
53510...  T                   Repair of urethra              531      18.94  $1,001.98      $527.26      $200.40
                               injury.
53515...  T                   Repair of urethra              532      25.50  $1,348.71      $602.29      $269.74
                               injury.
53520...  T                   Repair of urethra              532      25.50  $1,348.71      $602.29      $269.74
                               defect.
53600...  T                   Dilate urethra                 530       2.52    $133.21       $54.69       $26.64
                               stricture.
53601...  T                   Dilate urethra                 530       2.52    $133.21       $54.69       $26.64
                               stricture.
53605...  T                   Dilate urethra                 522      10.46    $553.39      $262.39      $110.68
                               stricture.
53620...  T                   Dilate urethra                 530       2.52    $133.21       $54.69       $26.64
                               stricture.

[[Page 47673]]

53621...  T                   Dilate urethra                 530       2.52    $133.21       $54.69       $26.64
                               stricture.
53660...  T                   Dilation of urethra....        530       2.52    $133.21       $54.69       $26.64
53661...  T                   Dilation of urethra....        530       2.52    $133.21       $54.69       $26.64
53665...  T                   Dilation of urethra....        531      18.94  $1,001.98      $527.26       $200.4
53670...  N                   Insert urinary catheter  .........  .........  .........  ...........  ...........
53675...  T                   Insert urinary catheter        530       2.52    $133.21       $54.69       $26.64
53850...  T                   Prostatic microwave            524      28.89  $1,527.95      $833.49      $305.59
                               thermotx.
53852...  T                   Prostatic rf thermotx..        524      28.89  $1,527.95      $833.49      $305.59
53899...  T                   Urology surgery                530       2.52    $133.21       $54.69       $26.64
                               procedure.
54000...  T                   Slitting of prepuce....        531      18.94  $1,001.98      $527.26       $200.4
54001...  T                   Slitting of prepuce....        531      18.94  $1,001.98      $527.26       $200.4
54015...  T                   Drain penis lesion.....        132       6.04     $319.3      $134.24       $63.86
54050...  T                   Destruction, penis             152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
54055...  T                   Destruction, penis             152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
54056...  T                   Cryosurgery, penis             152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
54057...  T                   Laser surg, penis              152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
54060...  T                   Excision of penis              152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
54065...  T                   Destruction, penis             152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
54100...  T                   Biopsy of penis........        162       5.67    $299.71      $125.43       $59.94
54105...  T                   Biopsy of penis........        162       5.67    $299.71      $125.43       $59.94
54110...  T                   Treatment of penis             537      28.72  $1,519.13      $864.45      $303.83
                               lesion.
54111...  T                   Treat penis lesion,            537      28.72  $1,519.13      $864.45      $303.83
                               graft.
54112...  T                   Treat penis lesion,            537      28.72  $1,519.13      $864.45      $303.83
                               graft.
54115...  T                   Treatment of penis             132       6.04     $319.3      $134.24       $63.86
                               lesion.
54120...  T                   Partial removal of             537      28.72  $1,519.13      $864.45      $303.83
                               penis.
54125...  C                   Removal of penis.......  .........  .........  .........  ...........  ...........
54130...  C                   Remove penis & nodes...  .........  .........  .........  ...........  ...........
54135...  C                   Remove penis & nodes...  .........  .........  .........  ...........  ...........
54150...  T                   Circumcision...........        536      13.17    $696.39      $326.57      $139.28
54152...  T                   Circumcision...........        536      13.17    $696.39      $326.57      $139.28
54160...  T                   Circumcision...........        536      13.17    $696.39      $326.57      $139.28
54161...  T                   Circumcision...........        536      13.17    $696.39      $326.57      $139.28
54200...  T                   Treatment of penis             530       2.52    $133.21       $54.69       $26.64
                               lesion.
54205...  T                   Treatment of penis             537      28.72  $1,519.13      $864.45      $303.83
                               lesion.
54220...  T                   Treatment of penis             530       2.52    $133.21       $54.69       $26.64
                               lesion.
54230...  T                   Prepare penis study....        347       2.93    $154.75       $62.15       $30.95
54231...  T                   Dynamic cavernosometry.        530       2.52    $133.21       $54.69       $26.64
54235...  T                   Penile injection.......        530       2.52    $133.21       $54.69       $26.64
54240...  T                   Penis study............        529       2.50    $132.23       $63.05       $26.45
54250...  T                   Penis study............        529       2.50    $132.23       $63.05       $26.45
54300...  T                   Revision of penis......        537      28.72  $1,519.13      $864.45      $303.83
54304...  T                   Revision of penis......        537      28.72  $1,519.13      $864.45      $303.83
54308...  T                   Reconstruction of              537      28.72  $1,519.13      $864.45      $303.83
                               urethra.
54312...  T                   Reconstruction of              537      28.72  $1,519.13      $864.45      $303.83
                               urethra.
54316...  T                   Reconstruction of              537      28.72  $1,519.13      $864.45      $303.83
                               urethra.
54318...  T                   Reconstruction of              537      28.72  $1,519.13      $864.45      $303.83
                               urethra.
54322...  T                   Reconstruction of              537      28.72  $1,519.13      $864.45      $303.83
                               urethra.
54324...  T                   Reconstruction of              537      28.72  $1,519.13      $864.45      $303.83
                               urethra.
54326...  T                   Reconstruction of              537      28.72  $1,519.13      $864.45      $303.83
                               urethra.
54328...  T                   Revise penis, urethra..        537      28.72  $1,519.13      $864.45      $303.83
54332...  C                   Revise penis, urethra..  .........  .........  .........  ...........  ...........
54336...  C                   Revise penis, urethra..  .........  .........  .........  ...........  ...........
54340...  T                   Secondary urethral             537      28.72  $1,519.13      $864.45      $303.83
                               surgery.
54344...  T                   Secondary urethral             537      28.72  $1,519.13      $864.45      $303.83
                               surgery.
54348...  T                   Secondary urethral             537      28.72  $1,519.13      $864.45      $303.83
                               surgery.
54352...  T                   Reconstruct urethra,           537      28.72  $1,519.13      $864.45      $303.83
                               penis.
54360...  T                   Penis plastic surgery..        537      28.72  $1,519.13      $864.45      $303.83
54380...  T                   Repair penis...........        537      28.72  $1,519.13      $864.45      $303.83
54385...  T                   Repair penis...........        537      28.72  $1,519.13      $864.45      $303.83
54390...  C                   Repair penis and         .........  .........  .........  ...........  ...........
                               bladder.
54400...  T                   Insert semi-rigid              538      45.59  $2,411.41    $1,540.64      $482.28
                               prosthesis.
54401...  T                   Insert self-contd              538      45.59  $2,411.41    $1,540.64      $482.28
                               prosthesis.
54402...  T                   Remove penis prosthesis        537      28.72  $1,519.13      $864.45      $303.83
54405...  T                   Insert multi-comp              538      45.59  $2,411.41    $1,540.64      $482.28
                               prosthesis.
54407...  T                   Remove multi-comp              537      28.72  $1,519.13      $864.45      $303.83
                               prosthesis.
54409...  T                   Revise penis prosthesis        537      28.72  $1,519.13      $864.45      $303.83
54420...  T                   Revision of penis......        537      28.72  $1,519.13      $864.45      $303.83
54430...  C                   Revision of penis......  .........  .........  .........  ...........  ...........
54435...  T                   Revision of penis......        537      28.72  $1,519.13      $864.45      $303.83
54440...  T                   Repair of penis........        537      28.72  $1,519.13      $864.45      $303.83
54450...  T                   Preputial stretching...        530       2.52    $133.21       $54.69       $26.64
54500...  T                   Biopsy of testis.......        122       4.87     $257.6      $115.03       $51.52
54505...  T                   Biopsy of testis.......        546      17.15    $906.97      $453.81      $181.39
54510...  T                   Removal of testis              546      17.15    $906.97      $453.81      $181.39
                               lesion.
54520...  T                   Removal of testis......        546      17.15    $906.97      $453.81      $181.39

[[Page 47674]]

54530...  T                   Removal of testis......        546      17.15    $906.97      $453.81      $181.39
54535...  C                   Extensive testis         .........  .........  .........  ...........  ...........
                               surgery.
54550...  T                   Exploration for testis.        546      17.15    $906.97      $453.81      $181.39
54560...  C                   Exploration for testis.  .........  .........  .........  ...........  ...........
54600...  T                   Reduce testis torsion..        546      17.15    $906.97      $453.81      $181.39
54620...  T                   Suspension of testis...        546      17.15    $906.97      $453.81      $181.39
54640...  T                   Suspension of testis...        546      17.15    $906.97      $453.81      $181.39
54650...  C                   Orchiopexy (Fowler-      .........  .........  .........  ...........  ...........
                               Stephens).
54660...  T                   Revision of testis.....        546      17.15    $906.97      $453.81      $181.39
54670...  T                   Repair testis injury...        546      17.15    $906.97      $453.81      $181.39
54680...  T                   Relocation of                  546      17.15    $906.97      $453.81      $181.39
                               testis(es).
54700...  T                   Drainage of scrotum....        546      17.15    $906.97      $453.81      $181.39
54800...  T                   Biopsy of epididymis...        122       4.87     $257.6      $115.03       $51.52
54820...  T                   Exploration of                 546      17.15    $906.97      $453.81      $181.39
                               epididymis.
54830...  T                   Remove epididymis              546      17.15    $906.97      $453.81      $181.39
                               lesion.
54840...  T                   Remove epididymis              546      17.15    $906.97      $453.81      $181.39
                               lesion.
54860...  T                   Removal of epididymis..        546      17.15    $906.97      $453.81      $181.39
54861...  T                   Removal of epididymis..        546      17.15    $906.97      $453.81      $181.39
54900...  T                   Fusion of spermatic            546      17.15    $906.97      $453.81      $181.39
                               ducts.
54901...  T                   Fusion of spermatic            546      17.15    $906.97      $453.81      $181.39
                               ducts.
55000...  T                   Drainage of hydrocele..        121       0.67     $35.26       $21.02        $7.05
55040...  T                   Removal of hydrocele...        466      21.43  $1,133.23      $562.97      $226.65
55041...  T                   Removal of hydroceles..        466      21.43  $1,133.23      $562.97      $226.65
55060...  T                   Repair of hydrocele....        546      17.15    $906.97      $453.81      $181.39
55100...  T                   Drainage of scrotum            132       6.04     $319.3      $134.24       $63.86
                               abscess.
55110...  T                   Explore scrotum........        546      17.15    $906.97      $453.81      $181.39
55120...  T                   Removal of scrotum             546      17.15    $906.97      $453.81      $181.39
                               lesion.
55150...  T                   Removal of scrotum.....        546      17.15    $906.97      $453.81      $181.39
55175...  T                   Revision of scrotum....        546      17.15    $906.97      $453.81      $181.39
55180...  T                   Revision of scrotum....        546      17.15    $906.97      $453.81      $181.39
55200...  T                   Incision of sperm duct.        546      17.15    $906.97      $453.81      $181.39
55250...  T                   Removal of sperm               546      17.15    $906.97      $453.81      $181.39
                               duct(s).
55300...  T                   Preparation,sperm duct         347       2.93    $154.75       $62.15       $30.95
                               x-ray.
55400...  T                   Repair of sperm duct...        546      17.15    $906.97      $453.81      $181.39
55450...  T                   Ligation of sperm duct.        546      17.15    $906.97      $453.81      $181.39
55500...  T                   Removal of hydrocele...        546      17.15    $906.97      $453.81      $181.39
55520...  T                   Removal of sperm cord          546      17.15    $906.97      $453.81      $181.39
                               lesion.
55530...  T                   Revise spermatic cord          546      17.15    $906.97      $453.81      $181.39
                               veins.
55535...  T                   Revise spermatic cord          546      17.15    $906.97      $453.81      $181.39
                               veins.
55540...  T                   Revise hernia & sperm          546      17.15    $906.97      $453.81      $181.39
                               veins.
55600...  C                   Incise sperm duct pouch  .........  .........  .........  ...........  ...........
55605...  C                   Incise sperm duct pouch  .........  .........  .........  ...........  ...........
55650...  C                   Remove sperm duct pouch  .........  .........  .........  ...........  ...........
55680...  T                   Remove sperm pouch             546      17.15    $906.97      $453.81      $181.39
                               lesion.
55700...  T                   Biopsy of prostate.....        547       4.39    $232.13       $125.2       $46.43
55705...  T                   Biopsy of prostate.....        547       4.39    $232.13       $125.2       $46.43
55720...  T                   Drainage of prostate           523      16.87    $892.28      $447.03      $178.46
                               abscess.
55725...  T                   Drainage of prostate           523      16.87    $892.28      $447.03      $178.46
                               abscess.
55801...  C                   Removal of prostate....  .........  .........  .........  ...........  ...........
55810...  C                   Extensive prostate       .........  .........  .........  ...........  ...........
                               surgery.
55812...  C                   Extensive prostate       .........  .........  .........  ...........  ...........
                               surgery.
55815...  C                   Extensive prostate       .........  .........  .........  ...........  ...........
                               surgery.
55821...  C                   Removal of prostate....  .........  .........  .........  ...........  ...........
55831...  C                   Removal of prostate....  .........  .........  .........  ...........  ...........
55840...  C                   Extensive prostate       .........  .........  .........  ...........  ...........
                               surgery.
55842...  C                   Extensive prostate       .........  .........  .........  ...........  ...........
                               surgery.
55845...  C                   Extensive prostate       .........  .........  .........  ...........  ...........
                               surgery.
55859...  T                   Percut/needle insert,          523      16.87    $892.28      $447.03      $178.46
                               pros.
55860...  C                   Surgical exposure,       .........  .........  .........  ...........  ...........
                               prostate.
55862...  C                   Extensive prostate       .........  .........  .........  ...........  ...........
                               surgery.
55865...  C                   Extensive prostate       .........  .........  .........  ...........  ...........
                               surgery.
55870...  T                   Electroejaculation.....        568       2.50    $132.23       $49.49       $26.45
55899...  T                   Genital surgery                530       2.52    $133.21       $54.69       $26.64
                               procedure.
55970...  E                   Sex transformation, M    .........  .........  .........  ...........  ...........
                               to F.
55980...  E                   Sex transformation, F    .........  .........  .........  ...........  ...........
                               to M.
56300...  T                   Laparoscopy; diagnostic        551      24.78  $1,310.51      $711.67       $262.1
56301...  T                   Laparoscopy; tubal             551      24.78  $1,310.51      $711.67       $262.1
                               cautery.
56302...  T                   Laparoscopy; tubal             551      24.78  $1,310.51      $711.67       $262.1
                               block.
56303...  T                   Laparoscopy; excise            551      24.78  $1,310.51      $711.67       $262.1
                               lesions.
56304...  T                   Laparoscopy; lysis.....        551      24.78  $1,310.51      $711.67       $262.1
56305...  T                   Laparoscopy; biopsy....        551      24.78  $1,310.51      $711.67       $262.1
56306...  T                   Laparoscopy; aspiration        551      24.78  $1,310.51      $711.67       $262.1
56307...  T                   Laparoscopy; remove            552      37.72  $1,995.15    $1,053.16      $399.03
                               adnexa.
56308...  C                   Laparoscopy;             .........  .........  .........  ...........  ...........
                               hysterectomy.
56309...  T                   Laparoscopy; remove            552      37.72  $1,995.15    $1,053.16      $399.03
                               myoma.

[[Page 47675]]

56310...  C                   Laparoscopic             .........  .........  .........  ...........  ...........
                               enterolysis.
56311...  T                   Laparoscopic lymph node        552      37.72  $1,995.15    $1,053.16      $399.03
                               biop.
56312...  T                   Laparoscopic                   552      37.72  $1,995.15    $1,053.16      $399.03
                               lymphadenectomy.
56313...  T                   Laparoscopic                   552      37.72  $1,995.15    $1,053.16      $399.03
                               lymphadenectomy.
56314...  C                   Lapar; drain lymphocele  .........  .........  .........  ...........  ...........
56315...  C                   Laparoscopic             .........  .........  .........  ...........  ...........
                               appendectomy.
56316...  T                   Laparoscopic hernia            552      37.72  $1,995.15    $1,053.16      $399.03
                               repair.
56317...  T                   Laparoscopic hernia            552      37.72  $1,995.15    $1,053.16      $399.03
                               repair.
56318...  T                   Laparoscopic                   552      37.72  $1,995.15    $1,053.16      $399.03
                               orchiectomy.
56320...  T                   Laparoscopy, spermatic         552      37.72  $1,995.15    $1,053.16      $399.03
                               veins.
56322...  C                   Laparoscopy, vagus       .........  .........  .........  ...........  ...........
                               nerves.
56323...  C                   Laparoscopy, vagus       .........  .........  .........  ...........  ...........
                               nerves.
56324...  C                   Laparoscopy,             .........  .........  .........  ...........  ...........
                               cholecystoenter.
56340...  C                   Laparoscopic             .........  .........  .........  ...........  ...........
                               cholecystectomy.
56341...  C                   Laparoscopic             .........  .........  .........  ...........  ...........
                               cholecystectomy.
56342...  C                   Laparoscopic             .........  .........  .........  ...........  ...........
                               cholecystectomy.
56343...  T                   Laparoscopic                   552      37.72  $1,995.15    $1,053.16      $399.03
                               salpingostomy.
56344...  T                   Laparoscopic                   552      37.72  $1,995.15    $1,053.16      $399.03
                               fimbrioplasty.
56345...  C                   Laparoscopic             .........  .........  .........  ...........  ...........
                               splenectomy.
56346...  T                   Laparoscopic                   551      24.78  $1,310.51      $711.67       $262.1
                               gastrostomy.
56347...  C                   Laparoscopic             .........  .........  .........  ...........  ...........
                               jejunostomy.
56348...  C                   Laparo; resect           .........  .........  .........  ...........  ...........
                               intestine.
56349...  C                   Laparoscopy;             .........  .........  .........  ...........  ...........
                               fundoplasty.
56350...  T                   Hysteroscopy;                  562      12.76    $674.84      $330.86      $134.97
                               diagnostic.
56351...  T                   Hysteroscopy; biopsy...        550      16.89    $893.26      $447.93      $178.65
56352...  T                   Hysteroscopy; lysis....        550      16.89    $893.26      $447.93      $178.65
56353...  T                   Hysteroscopy; resect           550      16.89    $893.26      $447.93      $178.65
                               septum.
56354...  T                   Hysteroscopy; remove           550      16.89    $893.26      $447.93      $178.65
                               myoma.
56355...  T                   Hysteroscopy; remove           550      16.89    $893.26      $447.93      $178.65
                               impact.
56356...  T                   Hysteroscopy; ablation.        550      16.89    $893.26      $447.93      $178.65
56362...  T                   Laparoscopy w/cholangio        552      37.72  $1,995.15    $1,053.16      $399.03
56363...  T                   Laparoscopy w/biopsy...        552      37.72  $1,995.15    $1,053.16      $399.03
56399...  T                   Laparoscopy procedure..        562      12.76    $674.84      $330.86      $134.97
56405...  T                   I & D of vulva/perineum        561       1.52     $80.32       $24.63       $16.06
56420...  T                   Drainage of gland              561       1.52     $80.32       $24.63       $16.06
                               abscess.
56440...  T                   Surgery for vulva              562      12.76    $674.84      $330.86      $134.97
                               lesion.
56441...  T                   Lysis of labial                561       1.52     $80.32       $24.63       $16.06
                               lesion(s).
56501...  T                   Destruction, vulva             152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
56515...  T                   Destruction, vulva             152      10.43    $551.43      $261.71      $110.29
                               lesion(s).
56605...  T                   Biopsy of vulva/               161       3.50    $385.12       $75.48       $37.02
                               perineum.
56606...  T                   Biopsy of vulva/               161       3.50    $185.12       $75.48       $37.02
                               perineum.
56620...  T                   Partial removal of             563      16.91    $894.24      $464.88      $178.85
                               vulva.
56625...  T                   Complete removal of            563      16.91    $894.24      $464.88      $178.85
                               vulva.
56630...  C                   Extensive vulva surgery  .........  .........  .........  ...........  ...........
56631...  C                   Extensive vulva surgery  .........  .........  .........  ...........  ...........
56632...  C                   Extensive vulva surgery  .........  .........  .........  ...........  ...........
56633...  C                   Extensive vulva surgery  .........  .........  .........  ...........  ...........
56634...  C                   Extensive vulva surgery  .........  .........  .........  ...........  ...........
56637...  C                   Extensive vulva surgery  .........  .........  .........  ...........  ...........
56640...  C                   Extensive vulva surgery  .........  .........  .........  ...........  ...........
56700...  T                   Partial removal of             562      12.76    $674.84      $330.86      $134.97
                               hymen.
56720...  T                   Incision of hymen......        562      12.76    $674.84      $330.86      $134.97
56740...  T                   Remove vagina gland            562      12.76    $674.84      $330.86      $134.97
                               lesion.
56800...  T                   Repair of vagina.......        562      12.76    $674.84      $330.86      $134.97
56805...  C                   Repair clitoris........  .........  .........  .........  ...........  ...........
56810...  T                   Repair of perineum.....        562      12.76    $674.84      $330.86      $134.97
57000...  T                   Exploration of vagina..        562      12.76    $674.84      $330.86      $134.97
57010...  T                   Drainage of pelvic             562      12.76    $674.84      $330.86      $134.97
                               abscess.
57020...  T                   Drainage of pelvic             562      12.76    $674.84      $330.86      $134.97
                               fluid.
57061...  T                   Destruction vagina             561       1.52     $80.32       $24.63       $16.06
                               lesion(s).
57065...  T                   Destruction vagina             562      12.76    $674.84      $330.86      $134.97
                               lesion(s).
57100...  T                   Biopsy of vagina.......        561       1.52     $80.32       $24.63       $16.06
57105...  T                   Biopsy of vagina.......        562      12.76    $674.84      $330.86      $134.97
57108...  C                   Partial removal of       .........  .........  .........  ...........  ...........
                               vagina.
57110...  C                   Removal of vagina......  .........  .........  .........  ...........  ...........
57120...  C                   Closure of vagina......  .........  .........  .........  ...........  ...........
57130...  T                   Remove vagina lesion...        562      12.76    $674.84      $330.86      $134.97
57135...  T                   Remove vagina lesion...        562      12.76    $674.84      $330.86      $134.97
57150...  T                   Treat vagina infection.        561       1.52     $80.32       $24.63       $16.06
57160...  T                   Insertion of pessary/          561       1.52     $80.32       $24.63       $16.06
                               device.
57170...  T                   Fitting of diaphragm/          561       1.52     $80.32       $24.63       $16.06
                               cap.
57180...  T                   Treat vaginal bleeding.        561       1.52     $80.32       $24.63       $16.06
57200...  T                   Repair of vagina.......        562      12.76    $674.84      $330.86      $134.97
57210...  T                   Repair vagina/perineum.        562      12.76    $674.84      $330.86      $134.97
57220...  T                   Revision of urethra....        563      16.91    $894.24      $464.88      $178.85

[[Page 47676]]

57230...  T                   Repair of urethral             562      12.76    $674.84      $330.86      $134.97
                               lesion.
57240...  T                   Repair bladder & vagina        563      16.91    $894.24      $464.88      $178.85
57250...  T                   Repair rectum & vagina.        563      16.91    $894.24      $464.88      $178.85
57260...  T                   Repair of vagina.......        563      16.91    $894.24      $464.88      $178.85
57265...  T                   Extensive repair of            563      16.91    $894.24      $464.88      $178.85
                               vagina.
57268...  T                   Repair of bowel bulge..        563      16.91    $894.24      $464.88      $178.85
57270...  C                   Repair of bowel pouch..  .........  .........  .........  ...........  ...........
57280...  C                   Suspension of vagina...  .........  .........  .........  ...........  ...........
57282...  C                   Repair of vaginal        .........  .........  .....