[Federal Register Volume 64, Number 211 (Tuesday, November 2, 1999)]
[Rules and Regulations]
[Pages 59380-59590]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-28367]
[[Page 59379]]
_______________________________________________________________________
Part III
Department of Health and Human Services
_______________________________________________________________________
Health Care Financing Administration
_______________________________________________________________________
42 CFR Parts 410, 411, 414, etc.
Medicare Program; Revisions to Payment Policies Under the Physician Fee
Schedule for Calendar Year 2000; Final Rule
Federal Register / Vol. 64, No. 211 / Tuesday, November 2, 1999 /
Rules and Regulations
[[Page 59380]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
42 CFR Parts 410, 411, 414, 415, and 485
[HCFA-1065-FC]
RIN 0938-AJ61
Medicare Program; Revisions to Payment Policies Under the
Physician Fee Schedule for Calendar Year 2000
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Final rule with comment period.
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SUMMARY: This final rule makes several changes affecting Medicare Part
B payment. The changes include: implementation of resource-based
malpractice insurance relative value units (RVUs); refinement of
resource-based practice expense RVUs; payment for physician pathology
and independent laboratory services; discontinuous anesthesia time;
diagnostic tests; prostate screening; use of CPT modifier -25;
qualifications for nurse practitioners; an increase in the work RVUs
for pediatric services; adjustments to the practice expense RVUs for
physician interpretation of Pap smears; and revisions to the work RVUs
for new and revised CPT codes for calendar year 1999 and a number of
other changes relating to coding and payment. Furthermore, we are
finalizing the 1999 interim physician work RVUs and are issuing interim
RVUs for new and revised codes for 2000. This final rule solicits
public comments on the second 5-year refinement of work RVUs for
services furnished beginning January 1, 2002 and requests public
comments on potentially misvalued work RVUs for all services in the CY
2000 physician fee schedule. This final rule also conforms the
regulations to existing law and policy regarding: removal of the x-ray
as a prerequisite for chiropractic manipulation; the exclusion of
payment for assisted suicide; and optometrist services. This final rule
also announces the calendar year 2000 Medicare physician fee schedule
conversion factor under the Medicare Supplementary Medical Insurance
(Part B) program as required by section 1848(d) of the Social Security
Act. The 2000 Medicare physician fee schedule conversion factor is
$36.6137.
DATES: Effective date: This rule is effective January 1, 2000. This
rule is a major rule as defined in Title 5, United States Code, section
804(2). In accordance with 5 U.S.C. section 801(a)(1)(A), we are
submitting a report to the Congress on this final rule on October 29,
1999.
Comment date: Comments on interim RVUs for selected procedure codes
identified in Addendum C and on interim practice expense RVUs and
malpractice RVUs for all codes as shown in Addendum B will be
considered if we receive them at the appropriate address, as provided
in the ADDRESSES section, no later than 5 p.m. on January 3, 2000.
Comments on all RVUs considered under the 5-year refinement process
as discussed in section IV of the preamble will be considered if we
receive them at the appropriate address, as provided below, no later
than 5 p.m. on March 1, 2000.
ADDRESSES: Mail written comments related to the 5-year refinement
process (1 original and 3 copies) to the following address: Health Care
Financing Administration, Department of Health and Human Services,
Attention: HCFA-1065-FC (5-Year Refinement), P.O. Box 8013, Baltimore,
MD 21244-8013.
Mail written comments related to interim RVUs for new and revised
procedure codes, interim practice expense RVUs, and interim malpractice
RVUs (1 original and 3 copies) to the following address: Health Care
Financing Administration, Department of Health and Human Services,
Attention: HCFA-1065-FC, P.O. Box 8013, Baltimore, MD 21244-8013.
If you prefer, you may deliver your written comments to one of the
following addresses:
Room 443-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201, or
Room C5-16-03, 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-1065-FC. Comments received timely will be available
for public inspection as they are received, generally beginning
approximately 3 weeks after publication of a document, in Room 443-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) 690-7061).
FOR FURTHER INFORMATION CONTACT:
Benjamin Long, (410) 786-0007 (for issues related to accessing the
physician fee schedule information on the HCFA homepage).
Bob Ulikowski, (410) 786-5721 (for issues related to the resource-based
malpractice relative value units).
Carolyn Mullen, (410) 786-4589 (for issues related to resource-based
practice expense relative value units).
Jim Menas, (410) 786-4507 (for issues related to physician pathology
services and independent labs and discontinuous anesthesia time).
Ken Marsalek, (410) 786-4502 (for issues related to optometrist
services).
Bill Larson, (410) 786-4639 (for issues related to the coverage of
prostate screening).
Paul W. Kim, (410) 786-7410 (for issues related to nurse practitioner
qualifications).
Dorothy Honemann, (410) 786-5702 (for issues related to the X-ray
requirement for chiropractic services).
Bill Morse, (410) 786-4520 (for issues related to diagnostic tests).
Marc Hartstein, (410) 786-4539 (for issues related to the conversion
factor and physician fee schedule update and the regulatory impact
analysis).
Diane Milstead, (410) 786-3355 (for all other issues).
SUPPLEMENTARY INFORMATION: 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. Please specify the date of the issue requested, and enclose a
check or money order payable to the Superintendent of Documents, or
enclose your Visa, Discover, or Master Card number and expiration date.
Credit card orders can also be placed by calling the order desk at
(202) 512-1800 (or toll free at 1-888-293-6498) 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.
To order the disks containing this document, send your request to:
Superintendent of Documents, Attention: Electronic Products, P.O. Box
37082, Washington, DC 20013-7082. Please specify, ``Medicare Program;
Revisions to Payment Policies Under the Physicians Fee Schedule for
Calendar Year 2000,'' and enclose a check or money order payable to the
Superintendent of Documents, or enclose your VISA, Discover, or
MasterCard number and expiration date. Credit card orders can be placed
by calling the order clerk at (202) 512-1530 (or toll free at 1-888-
293-6498) or by
[[Page 59381]]
faxing to (202) 512-1262. The cost of the two disks is $19.
Information on the Physician Fee Schedule can be found on our HCFA
homepage. This data can be accessed by using the following directions:
1. Go to the HCFA homepage (http://www.hcfa.gov).
2. Click on ``Medicare.''
3. Click on ``Professional/Technical Information.''
4. Select Medicare Payment Systems.
5. Select Physician Fee Schedule.
You will find information on the Physician Fee Schedule Regulation
on this page, as well as other documents (for example, Lewin Group
Report, Health Economics Research Report) that are referenced in the
preamble. Or, you can go directly to the Physician Fee Schedule page by
typing the following: http://www.hcfa.gov/medicare/pfsmain.htm.
To assist readers in referencing sections contained in this
preamble, we are providing the following table of contents. Some of the
issues discussed in this preamble affect the payment policies but do
not require changes to the regulations in the Code of Federal
Regulations. Information on the regulation's impact appears throughout
the preamble and not exclusively in section IX.
Table of Contents
I. Background
A. Legislative History
B. Published Changes to the Fee Schedule
C. Components of the Fee Schedule Payment Amounts
D. Development of the Relative Value Units
II. Specific Proposals for Calendar Year 2000 and Responses to
Public Comments
A. Resource-Based Malpractice Relative Value Units
1. Current Malpractice Relative Value Unit System
2. Methodology for Developing Resource-Based Malpractice
Relative Value Units
B. Resource-Based Practice Expense Relative Value Units
1. Resource-Based Practice Expense Legislation
2. Current Methodology for Computing Practice Expense Relative
Value Units
3. Refinement
C. Adjustment to the Practice Expense Relative Value Units for a
Physician's Interpretation of Abnormal Papanicolaou Smears
D. Physician Pathology Services and Independent Laboratories
E. Discontinuous Anesthesia Time
F. Optometrist Services
G. Assisted Suicide
H. CPT Modifier -25
I. Nurse Practitioner Qualifications
J. Relative Value Units for Pediatric Services
K. Percutaneous Thrombectomy of an Arteriovenous Fistula
L. Pulse Oximetry, Temperature Gradient Studies, and Venous
Pressure Determinations
M. Removal of Requirement for X-ray Before Chiropractic
Manipulation
N. Coverage of Prostate Cancer Screening Tests
O. Diagnostic Tests
1. Supervision of Diagnostic Test
2. Independent Diagnostic Testing Facilities
P. Other Issues
III. Refinement of Relative Value Units for Calendar Year 2000 and
Response to Public Comments on Interim Relative Value Units for 1999
(Including the Interim Relative Value Units Contained in the July
22, 1999 Proposed Rule)
A. Summary of Issues Discussed Related to the Adjustment of
Relative Value Units
B. Process for Establishing Work Relative Value Units for the
2000 Physician Fee Schedule
C. Other Changes to the 2000 Physician Fee Schedule and
Clarification of CPT Definitions
IV. Five Year Refinement of Relative Value Units
A. Background
B. Scope of the Five Year Review
C. Refinement of Work Relative Value Units
D. Nature and Format of Comments on Work Relative Value Units
E. New Initiatives
V. Physician Fee Schedule Update and Conversion Factor for Calendar
Year 2000
VI. Provisions of the Final Rule
VII. Collection of Information Requirements
VIII. Response to Comments
IX. Regulatory Impact Analysis
A. Resource-Based Malpractice Relative Value Units
B. Resource-Based Practice Expense Relative Value Units
C. Adjustment to the Practice Expense Relative Value Units for a
Physician's Interpretation of Abnormal Papanicolaou Smears
D. Physician Pathology Services and Independent Laboratories
E. Discontinuous Anesthesia Time
F. Optometrist Services
G. Assisted Suicide
H. CPT Modifier -25
I. Nurse Practitioner Qualifications
J. Relative Value Units for Pediatric Services
K. Percutaneous Thrombectomy of an Arteriovenous Fistula
L. Pulse Oximetry, Temperature Gradient Studies, and Venous
Pressure Determinations
M. Removal of Requirement for X-ray Before Chiropractic
Manipulation
N. Coverage of Prostate Cancer Screening Tests
O. Diagnostic Tests
1. Supervision of Diagnostic Test
2. Independent Diagnostic Testing Facilities
P. Budget Neutrality
Q. Impact on Beneficiaries
Addendum A--Explanation and Use of Addenda B
Addendum B--Relative Value Units and Related Information Used in
Determining Medicare Payments for Calendar Year 2000
Addendum C--Codes with Interim RVUs
Addendum D--GPCI File
Addendum E--Reference Set with 2000 Work RVUs
In addition, because of the many organizations and terms to
which we refer by acronym in this rule, we are listing these
acronyms and their corresponding terms in alphabetical order below:
AANA American Association of Nurse Anesthetists
AMA American Medical Association
APSA American Pediatric Surgical Association
ASA American Society of Anesthesiologists
BBA Balanced Budget Act of 1997
CF Conversion factor
CFR Code of Federal Regulations
CMDs Carrier Medical Directors
CPEPs Clinical Practice Expert Panels
CPT [Physicians'] Current Procedural Terminology [4th Edition,
1999, copyrighted by the AMA]
CRNA Certified Registered Nurse Anesthetist
DRE Digital rectal examination
DRG Diagnostic Related Group
E/M Evaluation and management
GAF Geographic adjustment factor
GPCI Geographic practice cost index
HCFA Health Care Financing Administration
HCPAC Health Care Professionals Advisory Committee
HCPCS HCFA Common Procedure Coding System
HHS [Department of] Health and Human Services
IDTFs Independent Diagnostic Testing Facilities
JUAs Joint Underwriting Associations
MEDPAC Medicare Payment Advisory Commission
MEI Medicare Economic Index
MGMA Medical Group Management Association
OBRA Omnibus Budget Reconciliation Act
OIG Office of the Inspector General
PSA Prostate-specific antigen
PC Professional component
PCF Patient Compensation Fund
PEAC Practice Expense Advisory Committee
PPS Prospective payment system
ROS Risk-of-Service
RUC [AMA's Specialty Society] Relative [Value] Update Committee
RVU Relative value unit
SMS Socioeconomic Monitoring Survey
STS The Society of Thoracic Surgeons
TC Technical component
I. Background
A. Legislative History
Since January 1, 1992, Medicare has paid for physician services
under section 1848 of the Social Security Act (the Act), ``Payment for
Physicians''
[[Page 59382]]
Services.'' This section contains three major elements: (1) A fee
schedule for the payment of physicians' services; (2) a sustainable
growth rate for the rates of increase in Medicare expenditures for
physicians' services; and (3) limits on the amounts that
nonparticipating physicians can charge beneficiaries. The Act requires
that payments under the fee schedule be based on national uniform
relative value units (RVUs) based on the resources used in furnishing a
service. Section 1848(c) of the Act requires that national RVUs be
established for physician work, practice expense, and malpractice
expense.
Section 1848(c)(2)(B)(ii)(II) of the Act provides that adjustments
in RVUs because of changes resulting from a review of those RVUs may
not cause total physician fee schedule payments to differ by more than
$20 million from what they would have been had the adjustments not been
made. If this tolerance is exceeded, we must make adjustments to the
conversion factors (CFs) to preserve budget neutrality.
B. Published Changes to the Fee Schedule
In the July 22, 1999, proposed rule (64 FR 39609), we listed all of
the final rules published through November 2, 1998, relating to the
updates to the RVUs and revisions to payment policies under the
physician fee schedule. In the July 22, 1999, proposed rule (64 FR
39608), we discussed several policy issues affecting Medicare payment
for physicians' services including implementation of resource-based
malpractice insurance relative value units (RVUs); refinement of
resource-based practice expense RVUs; payment for physician pathology
and independent laboratory services; discontinuous anesthesia time;
prostate screening; diagnostic tests; qualifications for nurse
practitioners; an increase in the work RVUs for pediatric services;
adjustments to the practice expense RVUs for physician interpretation
of Pap smears; revisions to the work RVUs for new and revised CPT codes
for calendar year 1999; and a number of other issues relating to coding
and payment. In the proposed rule, we also indicated that we would
conform the regulations to existing law and policy regarding removal of
the x-ray as a prerequisite for chiropractic manipulation, the
exclusion of payment for assisted suicide, and optometrist services.
This final rule affects the regulations set forth at--
Part 410, Supplementary medical insurance benefits;
Part 411, Exclusions from Medicare and limitations on
Medicare payment;
Part 414, Payment for Part B medical and other services;
Part 415, Services furnished by physicians in providers,
supervising physicians in teaching settings, and residents in certain
settings; and
Part 485, Conditions of participation; specialized
providers.
The information in this final rule updates information in the July
22, 1999 proposed rule (64 FR 39608).
C. Components of the Fee Schedule Payment Amounts
Under the formula set forth in section 1848(b)(1) of the Act, the
payment amount for each service paid for under the physician fee
schedule is the product of three factors: (1) A nationally uniform
relative value for the service; (2) a geographic adjustment factor
(GAF) for each physician fee schedule area; and (3) a nationally
uniform conversion factor (CF) for the service. The CF converts the
relative values into payment amounts.
For each physician fee schedule service, there are three relative
values: (1) An RVU for physician work; (2) an RVU for practice expense;
and (3) an RVU for malpractice expense. For each of these components of
the fee schedule there is a geographic practice cost index (GPCI) for
each fee schedule area. The GPCIs reflect the relative costs of
practice expenses, malpractice insurance, and physician work in an area
compared to the national average for each component.
The general formula for calculating the Medicare fee schedule
amount for a given service in a given fee schedule area can be
expressed as:
Payment = [(RVU work x GPCI work) + (RVU practice expense x GPCI
practice expense) + (RVU malpractice x GPCI malpractice) x CF]
The CF for calendar year 2000 appears in section V. The RVUs for
calendar year 2000 are in Addendum B. The GPCIs for calendar year 2000
can be found in Addendum D.
Section 1848(e) of the Act requires the Secretary to develop GAFs
for all physician fee schedule areas. The total GAF for a fee schedule
area is equal to a weighted average of the individual GPCIs for each of
the three components of the service. Thus, the GPCIs reflect the
relative practice expenses, malpractice insurance, and physicians' work
in an area compared to the national average. In accordance with the
law, however, the GAF for the physician's work reflects one-quarter of
the relative cost of physician's work compared to the national average.
D. Development of the Relative Value Units
1. Work Relative Value Units
Approximately 7,500 codes represent services included in the
physician fee schedule. The work RVUs established for the
implementation of the fee schedule in January 1992 were developed with
extensive input from the physician community. The original work RVUs
for most codes were developed by a research team at the Harvard School
of Public Health in a cooperative agreement with us. In constructing
the vignettes for the original RVUs, Harvard worked with panels of
expert physicians and obtained input from physicians from numerous
specialties.
The RVUs for radiology services are based on the American College
of Radiology relative value scale, which we integrated into the overall
physician fee schedule. The RVUs for anesthesia services are based on
RVUs from a uniform relative value guide. We established a separate CF
for anesthesia services while we continue to recognize time as a factor
in determining payment for these services. As a result, there is a
separate payment system for anesthesia services.
2. Practice Expense and Malpractice Expense Relative Value Units
Section 1848(c)(2)(C) of the Act requires that the practice expense
and malpractice expense RVUs equal the product of the base allowed
charges and the practice expense and malpractice percentages for the
service. Base allowed charges are defined as the national average
allowed charges for the service furnished during 1991, as estimated
using the most recent data available. For most services, we used 1989
charge data ``aged'' to reflect the 1991 payment rules, since those
were the most recent data available for the 1992 fee schedule.
Section 121 of the Social Security Act Amendments of 1994 (Public
Law 103-432), enacted on October 31, 1994, required us to develop a
methodology for a resource-based system for determining practice
expense RVUs for each physician service. As amended by the BBA, section
1848(c) required the new payment methodology to be phased in over 4
years, effective for services furnished in 1999, with resource-based
practice expense RVUs becoming fully effective in 2002. The BBA also
requires us to implement resource-based malpractice RVUs for services
furnished beginning in 2000.
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II. Specific Proposals for Calendar Year 2000 and Responses to
Public Comments
In response to the publication of the July 22, 1999 proposed rule,
we received approximately 2,050 comments. We received comments from
individual physicians, health care workers, and professional
associations and societies. The majority of comments addressed the
proposals related to resource-based malpractice RVUs, resource-based
practice expense RVUs, and supervision of diagnostic tests.
The proposed rule discussed policies that affect the number of RVUs
on which payment for certain services would be based. Certain changes
implemented through this final rule are subject to the $20 million
limitation on annual adjustments contained in section
1848(c)(2)(B)(ii)(II) of the Act.
After reviewing the comments and determining the policies we will
implement, we have estimated the costs and savings of these policies
and added those costs and savings to the estimated costs associated
with any other changes in RVUs for 2000. We discuss in detail the
effects of these changes in the Regulatory Impact Analysis (section
IX.)
For the convenience of the reader, the headings for the policy
issues correspond to the headings used in the July 22, 1999 proposed
rule. More detailed background information for each issue can be found
in the July 22, 1999 proposed rule.
A. Resource-Based Malpractice Relative Value Units
1. Current Relative Value Unit System
Malpractice RVUs are currently charge-based, using the same
statutory formula discussed above for practice expense RVUs but using
weighted specialty-specific malpractice expense percentages and 1991
average allowed charges. As with practice expense RVUs, malpractice
RVUs for new codes after 1991 were extrapolated from similar existing
codes or from work RVUs. Section 4505(f) of the BBA requires us to
implement resource-based malpractice RVUs for services furnished
beginning in 2000. With the implementation of resource-based
malpractice RVUs and full implementation of resource-based practice
expense RVUs in 2002, all physician fee schedule RVUs will be resource-
based, thus eliminating the last vestiges of payment inequities that
resulted from charges that did not accurately reflect the relative
resources involved in providing a service.
2. Methodology for Developing Resource-based Malpractice RVUs
The resource-based malpractice RVU methodology is data-driven based
on malpractice insurance premium data. Malpractice premium data were
used because they represent the actual malpractice expense to the
physician and are widely available. Actual malpractice premium data
were collected for the top 20 Medicare payment physician specialties.
Data were collected from all 50 States, Washington D.C., and Puerto
Rico. Data were collected from commercial and physician-owned insurers
and from joint underwriting associations (JUAs), typically State
government administered risk pooling insurance arrangements in areas
where commercial insurers left the market. Adjustments were made to
reflect mandatory patient compensation fund or PCF (a fund to pay for
any claim beyond the statutory amount thereby limiting an individual
physician's liability in cases of a large suit) surcharges in States
where PCF participation is mandatory. Premium data reflect at least a
50 percent market share in each State, with the average market share
being 77 percent. Adjustments were made to reflect a standard $1
million/$3 million mature claims made policy (a policy covering claims
made rather than services provided during the policy term).
Medicare physician specialties were mapped to malpractice insurance
rating risk classes. A national average premium was computed for each
specialty by weighting area geographic premiums by fee schedule RVUs.
Specialty risk factors or indexes were then calculated by dividing the
national average premium for each specialty by the national average
premium for the specialty with the lowest premium, psychiatry. The risk
factors describe the relative malpractice costs among specialties.
Specialty-weighted resource-based malpractice RVUs were calculated
for each procedure by summing, for all specialties providing the
procedure, the product of each specialty's risk factor times the
proportion of total service count for that procedure provided by the
specialty. This number was then multiplied by the procedure's work RVUs
to account for differences in risk-of-service (ROS) among procedures.
If ROS differences were not recognized, all services performed
exclusively by a given specialty would have the same resource-based
malpractice RVUs, even though they might vary considerably in effort,
difficulty, total payment, and their contribution to that specialty's
malpractice liability. Since work RVUs reflect differences in time,
intensity, and difficulty among procedures and are generally accepted
as accurate, we proposed them as the best available proxy for
determining ROS. To attain budget neutrality as required by law, the
total new fee schedule resource-based malpractice RVUs were compared to
the total current charge-based malpractice RVUs, and the appropriate
adjustment was made to retain the same total malpractice RVUs.
We proposed to add a new Sec. 414.22(c)(3) (Relative value units
(RVUs)) to specify that, for services furnished in the year 2000 and
subsequent years, the malpractice RVUs are based on the relative
malpractice insurance resources for each service.
A more detailed explanation of our methodology can be found in the
July 22, 1999 proposed rule (64 FR 39610).
We received the following comments on our proposed resource-based
malpractice RVUs:
Comment: Many commenters agreed that our methodology was generally
reasonable and that malpractice risk-of-service (ROS) differences among
procedures must be taken into account. While understanding that we used
work RVUs to reflect the malpractice ROS differences because we could
not find a better proxy, they commented that work RVUs may not be the
best proxy to use for ROS and suggested that we work with the medical
community to find a better alternative.
Response: As we stated in the July 1999 proposed rule, we realize
that work RVUs may not be the perfect proxy to reflect malpractice ROS
differences. It is the best proxy available at this time. We will be
happy to work with the medical community to find a better alternative
and welcome any suggestions.
Comment: The most frequently recurring comment was that, while the
law requires that we use the most recent available data, the data used
(1993 through 1995 malpractice premiums) is outdated and does not
accurately reflect current malpractice premiums. Commenters suggested
that we delay implementation of the resource-based malpractice RVUs
until more recent data can be collected. If delay is not an option, the
commenters requested that the resource-based malpractice RVUs be
considered interim subject to change, when more recent data are
collected and verified.
Response: We used the 1993 through 1995 data because they were
readily available. Moreover, we believe the use of these data are
reasonable because it is our understanding that malpractice
[[Page 59384]]
insurance premiums have been relatively stable in the 1990s. The law
requires us to implement the new malpractice RVUs in 2000. However, we
do agree that the RVUs should be considered interim until they can be
verified by more recent data.
Comment: Some commenters stated that using two risk factors,
surgical and nonsurgical, and applying the surgical risk factor to
surgical services performed by a specialty, and the lower nonsurgical
risk factor to the nonsurgical services performed by the specialty,
does not recognize that physicians typically perform a wide range of
services and that their malpractice costs are spread across the whole
range. Since a physician's malpractice premium is usually determined by
the higher risk services performed, the commenters state that the
higher risk factor should be applied to the whole range of services.
OBGYN specialties felt particularly strongly about this issue, stating
that over 80 percent of OBGYNs do both obstetrics and gynecology, and
that even if a physician only does a very minimal number of deliveries
a year he or she will pay the much higher obstetric premium.
Response: It is true that, for an individual physician in a
specialty with different risk factors depending upon whether or not the
physician performs surgery, the physician's malpractice premium will
probably be based upon the higher risk services, depending upon the
policies of the individual insurer. (For obvious surgical specialties,
for example, general surgeon and thoracic surgeon, there is only one
risk factor and this is applied to all services performed by that
specialty.) The purpose of the resource based malpractice RVUs is not
to guarantee each physician an absolute return of his or her
malpractice costs. It is rather to construct malpractice RVUs based on
the relative malpractice costs among services. We believe it is
reasonable to use the lower risk factor for the values of the lower
risk non-surgical services and to allocate the higher relative values
to the higher risk services that cause them. In the case of OBGYN
services, the higher obstetric premiums and risk factor were used for
services that were clearly obstetrical services which drive these
premiums, while the lower gynecology risk factor was used for all other
services. This also seems consistent with support from many commenters
that we use a risk of service adjuster for each service, as discussed
earlier.
Comment: Several commenters generally agreed with our policy of
retaining the existing malpractice RVUs for codes with zero work RVUs
(generally the technical component (TC) of diagnostic tests) rather
than making them zero (as they would have been if we multiplied the
premium-based RVUs by the work RVUs as our risk-of-service methodology
provides). Some commenters pointed out that retaining the existing
values leaves them charge based, however, and suggested that we work
with the physician community to find an alternative proxy to work RVUs
to use to adjust for risk-of-service. Some commenters suggested that we
merely leave the work multiplication step out of the calculation. One
commenter suggested that we use the non-physician clinical labor from
the practice expense Clinical Practice Expert Panels (CPEPs). It was
also pointed out that by retaining the present malpractice values for
the TCs and applying our methodology to the professional component (PC)
and the global fee, we created anomalies when the value of one of the
parts, the TC, was greater than the value of the whole, the global fee.
Response: As stated in the proposed rule, we welcome suggestions
concerning a different proxy than work to use to reflect ROS
differences among services with no work RVUs. We considered eliminating
the work multiplication step, but did not accept this for the reason
mentioned in the proposed rule: that without adjusting for ROS all
services performed solely or almost solely by a specialty would have
the same malpractice RVUs without regard to the different risks they
may entail. We will consider all suggestions including using the CPEP
data and may propose additional refinements in a future proposed rule.
In addition, we have corrected the global PC and TC anomaly. Instead of
separately calculating global values using our methodology, we have
added the PC and TC to obtain the global value, because that value by
definition is the sum of its TC and PC parts.
Comment: Cardiologists commented that the two-tiered surgical
breakdown was inadequate to reflect cardiologists' malpractice costs
because some of their services (for example, angioplasties and cardiac
catherization) do not neatly fall into either category, and that more
categories than just surgery or nonsurgery are required. They also
stated that we did not clearly define what are surgical and nonsurgical
services.
Response: As mentioned in the proposed rule we acknowledge that
insurers vary as to categories of physician risk classifications.
However, we believe that the major determinants of malpractice premiums
are physician specialty and whether or not the physician performs
surgery. We believe that our two risk factor methodology is generally
adequate. Our proposed methodology was based on the CPT definition of
surgery as a way to identify specific codes to be considered surgery or
nonsurgery. We applied the surgical risk factors to services in the
surgery section of CPT, codes 10000 through 69999, and the nonsurgical
risk factors to all other services. After considering this comment, we
acknowledge that the cardiological procedures they mentioned are quite
invasive and more akin to surgery than most non-surgical services. We
are, therefore, applying the higher cardiology surgical risk factor to
the following cardiology catheterization and angioplasty codes: 92980
to 92998 and 93501 to 93536. Since all malpractice RVUs are considered
to be interim, we welcome additional comments concerning other codes
which should be considered as surgery for these purposes.
Comment: Some commenters objected to our basing the resource-based
malpractice RVUs on premium data for 20 specialties with other
specialties being crosswalked to these 20 specialties. They stated that
the RVUs should be based on actual data for all specialties. Some
believed that it was particularly inappropriate to crosswalk non-
physician specialties to the ``all physician'' category.
Response: There are about 100 recognized specialties in our payment
records. We do not believe it is practical, possible, or necessary to
collect actual malpractice premium data on all these specialties. The
20 specialties most prominent in the data represent over 80 percent of
physician fee schedule payments. The shares of payments of many of the
other specialties for a specific service are extremely small and thus
have virtually no effect on the specialty share-weighted calculation.
As discussed in the proposed rule, insurers create their own risk
classes generally using ISO codes. We mapped all specialties to the
risk classes of St. Paul Companies, one of the oldest and largest
malpractice insurers. These risk classes include multiple specialties
that represent similar malpractice risk. To our knowledge, no insurer
has established risk classes for each of the almost 100 Medicare
specialties.
Comment: Some commenters objected to our computing the malpractice
RVUs for a service by weight-averaging the risk factors for all
specialties providing the service. They state that this rewards the
specialties with the lowest risk
[[Page 59385]]
factors and punishes the specialties with the highest risk factors.
Response: The basic principle underlying the physician fee schedule
is that the relative value for a service represents the resources
required to provide the typical service for all physicians providing
the service. Indeed, the law specifically prohibits any specialty
payment differential. The RVUs are intended to reflect the relative
resources required to provide the service compared to other services.
Computing resource-based malpractice RVUs for a service by weight-
averaging the relative costs of all specialties providing the service
is not intended to reward or punish a particular specialty but to
reflect average costs across all specialties providing the service and
is entirely in keeping with the basic principles underlying the fee
schedule.
Comment: Radiology groups commented that, while both the TC and PC
of radiology diagnostic tests contain malpractice RVUs, current and
proposed malpractice RVUs are generally much higher for the TC than for
the PC. They state that the radiologist supervising or interpreting the
test bears the malpractice responsibility and believe that all or the
bulk of malpractice RVUs currently in the TC should be moved to the PC.
Response: We disagree with the commenters. The total TC RVUs
(practice expense and malpractice) for the TC of radiology diagnostic
tests represent the expenses required to perform the test--equipment,
supplies, and technicians plus malpractice insurance. The total PC RVUs
(work, practice expense and malpractice) represent only the
interpretation of the test by the physician. In general, the current TC
RVUs for radiology services are significantly higher than the PC RVUs
because of the very expensive equipment, supplies and other costs. The
malpractice RVUs are generally split in similar proportion between PC
and TC as the practice expense RVUs. In cases where the physician or
group provides both the TC and PC and bills for both components, the
split is not a significant issue since the physician or group would
receive the total payment. In many cases, the TC is provided by an
entity--hospital or free standing imaging center--other than the
physician providing the interpretation. The entity providing the TC,
which includes a supervising physician who is most likely a
radiologist, assumes the risk, such as excessive irradiation of the
patient, of providing the TC. We can think of no reason to transfer any
portion of malpractice RVUs from the entity (including a supervising
physician) providing the majority of the service, the TC, to a
physician who is providing only the interpretation. The malpractice
liability associated with interpreting the test is reflected in the PC
malpractice RVUs.
Comment: One commenter stated that certain allergy and
immunotherapy codes (95145 through 95170, 95010, and 95015) should not
have zero malpractice RVUs as these codes contain work RVUs.
Response: We agree that all services with physician work RVUs
contain some potential malpractice liability and expense. This error
occurred because we rounded to zero in our computation. We have given
them a malpractice value of 0.01 RVU.
Comment: Some commenters stated that we should base the resource-
based malpractice RVUs on actual closed claims data as recommended by
MEDPAC and discussed in the proposed July 1999 proposed rule. MEDPAC
again recommended this approach in its comments and stated that some
insurers maintain a data base relating malpractice claims to ICD-9
codes and that software is available to crosswalk ICD-9 to CPT codes.
MEDPAC also commented that in using only the costs of malpractice
premiums that we failed to factor into the malpractice RVUs the ``* * *
loss of reputation* * *'' that a physician incurs from malpractice
claims. MEDPAC also indicated that ``* * * psychological costs of
professional liability are very important to physicians.''
Response: As stated in the proposed rule, we do not believe that
closed claims data linking malpractice claims to CPT codes are widely
available across the country for all or even a significant portion of
the 7000 plus CPT codes paid under the physician fee schedule. If any
such data are available, we expect they are for a very few codes on a
limited geographical basis. Our coding experts tell us it is not
possible to crosswalk ICD-9 codes to an individual CPT code with any
degree of accuracy. The statute requires that the new malpractice
system be based on the malpractice expense resources involved in
furnishing the service. We believe that the physician's malpractice
premium best reflects the malpractice expense. We do not believe that
any loss of a physician's reputation from a malpractice claim would be
related to the statutory requirement to base malpractice RVUs on the
malpractice resources involved in furnishing the service; we do not
believe that this intangible ``loss'' represents a resource used in
furnishing a service. Indeed, we do not see how loss of reputation and
psychological costs can be quantified. We encourage MEDPAC to further
develop their idea, particularly as it relates to the statutory
requirement, and submit their further analysis in comments to future
physician fee schedule notices.
Comment: Some neurologists listed five codes (95829, 95920, 95955,
95961, and 95962) assigned the neurology non-surgical risk factor that
they believe are surgical services and should be assigned the higher
neurology surgical risk factor.
Response: Our medical consultants believe that these are not
surgical services and no evidence was presented that these services
result in higher malpractice premiums for neurologists. At this time,
we will continue to apply the non-surgical risk factor to these
services. We will reconsider this decision should evidence be presented
that performance of these services results in higher malpractice
premiums.
Comment: Some neurosurgeons commented that the real effect of
malpractice changes on neurosurgeons is masked by comparing estimated
year 2000 allowed charges to 1999 allowed charges, thereby ignoring the
effect on the malpractice RVU pool of the rebasing of the MEI from 1998
to 1999. They further commented that, while comparing 2000 to 1999
malpractice RVUs for neurosurgical procedures shows significant
increases, comparing 2000 to 1998 malpractice RVUs will substantially
reduce or eliminate these increases. They also stated that, while the
updated MEI showed that the average malpractice expense represented 3.2
percent of gross income across all physician specialties, neurosurgeons
have much higher malpractice expenses of about 7 percent of gross
income. Neurosurgeons submitted a detailed methodology that they
suggested might be used as an alternative to our proposed methodology.
Response: The MEI was rebased in 1999 to reflect more recent (1997
as compared to 1989) data from the AMA's Socioeconomic Monitoring
Survey (SMS) on physician income and expenses. The more recent data
indicated that malpractice expenses across all physician specialties as
a percentage of gross income had shrunk from 4.8 to 3.2 percent. In
order to reflect these more recent data in the physician fee schedule,
the pool of malpractice RVUs was reduced from 4.8 to 3.2 percent of
total RVUs. We made this change on a budget-neutral basis: the 1.6
percentage points were redistributed among the work and practice
expense RVUs. We always show impacts relative to current law,
[[Page 59386]]
regulations and policies; therefore, comparing 2000 to 1999 changes was
not done to mask the effects of previous changes but was consistent
with past practices. The effects of proposed 2000 malpractice RVUs were
thus compared to existing 1999 levels. We agree that malpractice
expenses of neurosurgeons are generally higher than the overall average
3.2 percent of gross income for all physicians. An examination of high
volume codes performed primarily by neurosurgeons shows that the new
resource-based malpractice RVUs range from about 6 percent of the total
1999 transition RVUs to about 9 percent of fully implemented total 2002
RVUs for a given service. We are examining the alternative methodology
suggested by the neurosurgeons and will consider it along with other
alternatives during future refinement of malpractice RVUs.
Comment: Several surgical specialties commented that many of the
``winners'' under our proposal are relatively low-risk specialties (for
example, nephrology, general practice, and family practice) with
relatively low malpractice premiums, while many of the ``losers'' are
high-risk specialties (for example, cardiac surgery and thoracic
surgery) with relatively high malpractice premiums. While acknowledging
that the gains or losses are minor, usually less than 1 percent, they
state that the results are counter-intuitive and do not match clinical
practice experience. Some believe that this is a continuation of a HCFA
bias in favor of primary care specialties at the expense of surgical
specialties.
Response: We do not agree that the results are counter-intuitive or
reflect any intentional bias. The impacts compare a new resource-based
system with an existing charge-based system. The systems are on totally
different bases. All the results show is what provided the Congress
with the impetus to create the resource-based physician fee schedule in
the OBRA 1989 and expand it in subsequent legislation: charges for
physicians' services did not accurately reflect the relative resources
required to provide the services. While over the course of the
development of the fee schedule, the changes to a resource-based system
did generally increase payments for primary care services relative to
surgical services, it was because this was indicated by the resource
input data and not as a result of any intentional HCFA bias.
Result of Evaluation of Comments: After careful examination of
comments, we are adopting our proposal that new resource-based
malpractice RVUs calculated using the methodology described in the July
1999 proposed rule will become effective in 2000. We have modified our
proposal to identify certain services as surgery for purposes of
applying specialty risk factors to individual services. These RVUs can
be found in Addendum B.
B. Resource-Based Practice Expense Relative Value Units
1. Resource-Based Practice Expense Legislation
Section 121 of the Social Security Act Amendments of 1994 (Public
Law 103-432), enacted on October 31, 1994, required us to develop a
methodology for a resource-based system for determining practice
expense RVUs for each physician's service beginning in 1998. The
legislation specifically required that, in implementing the new system
of practice expense RVUs, we must apply the same budget-neutrality
provisions that we apply to other adjustments under the physician fee
schedule.
The BBA was enacted on August 5, 1997, before publication of the
October 1997 final rule (62 FR 59103). Section 4505(a) of the BBA
delayed the effective date of the resource-based practice expense RVUs
until January 1, 1999. In addition, the BBA provided for the following
revisions in the requirements to change from charge-based practice
expense RVUs to resource-based RVUs.
Instead of paying for all services entirely under a resource-based
RVU system in 1999, section 4505(b) of the BBA provided for a 4-year
transition period. The practice expense RVUs for the year 1999 will be
the sum of 75 percent of charge-based RVUs and 25 percent of the
resource-based RVUs. For the year 2000, the percentages will be 50
percent charge-based RVUs and 50 percent resource-based RVUs. For the
year 2001, the percentages will be 25 percent charge-based RVUs and 75
percent resource-based RVUs. For subsequent years, the RVUs will be
totally resource-based.
Section 4505(e) of the BBA provided that, in 1998, the practice
expense RVUs would be adjusted for certain services in anticipation of
the implementation of resource-based practice expenses beginning in
1999. Thus, practice expense RVUs for office visits were increased. For
other services whose practice expense RVUs exceeded 110 percent of the
work RVUs and which were furnished less than 75 percent of the time in
an office setting, the 1998 practice expense RVUs were reduced to a
number equal to 110 percent of the work RVUs. This limitation did not
apply to services that had proposed resource-based practice expense
RVUs in the June 18, 1997 proposed rule (62 FR 33196) that increased
from their 1997 practice expense RVUs. The procedure codes affected and
the final RVUs for 1998 were published in the October 31, 1997 final
rule (62 FR 59103).
Section 4505(d)(3) also required that a proposed rule be published
by May 1, 1998, with a 90-day comment period. A final rule was
published on November 2, 1998, (63 FR 58816) and the transition began
on January 1, 1999.
The BBA also required that we develop new resource-based practice
expense RVUs. In developing these new practice expense RVUs, section
4505(d)(1) required us to--(1) use, to the maximum extent practicable,
generally accepted accounting principles that recognize all staff,
equipment, supplies, and expenses, not just those that can be tied to
specific procedures, and use actual data on equipment use and other key
assumptions; (2) consult with organizations representing physicians
regarding the methodology and data to be used; and (3) develop a
refinement process to be used during each of the four years of the
transition period.
2. Current Methodology for Computing Practice Expense Relative Value
Units
Effective with services furnished after January 1, 1999, we
established a new methodology for computing resource-based practice
expense RVU that uses the two significant sources of actual practice
expense data we have available--the Clinical Practice Expert Panel
(CPEP) data and the American Medical Association's (AMA's)
Socioeconomic Monitoring System (SMS) data. This methodology is based
on an assumption that current aggregate specialty practice costs are a
reasonable basis for establishing initial estimates of relative
resource costs of physicians' services across specialties. It then
allocates these aggregate specialty practice costs to specific
procedures and, thus, can be seen as a ``top-down'' approach. The
following summarizes the general methodology used. (For more specific
information refer to the June 5, 1998 proposed rule (63 FR 30826) and
the November 1998 final rule with comment (63 FR 58816).)
Practice Expense Cost Pools
We used actual practice expense data by specialty, derived from the
1995 through 1997 SMS survey data, to create six cost pools:
administrative labor, clinical labor, medical supplies, medical
equipment, office supplies, and all other expenses. There were three
steps in the creation of the cost pools. They are as follows:
[[Page 59387]]
(Step 1) We used the AMA's SMS survey of actual cost data to
determine practice expenses per hour by cost category. The practice
expense per hour for each physician respondent's practice was
calculated as the practice expenses for the practice divided by the
total number of hours spent in patient care activities by the
physicians in the practice.
(Step 2) We determined the total number of physician hours, by
specialty, spent treating Medicare patients. This was calculated from
physician time data for each procedure code and the Medicare claims
data.
(Step 3) We then calculated the practice expense pools by specialty
and by cost category by multiplying the practice expenses per hour for
each category by the total physician hours.
For services with work RVUs equal to zero (including the TC of
services with PC and TC), we created a separate practice expense pool
using the average clinical staff time from the CPEP data (since these
codes by definition do not have physician time), and the ``all
physicians'' practice expense per hour.
Cost Allocation Methodology
For each specialty, we separated the six practice expense pools
into two groups, direct costs and indirect costs, and used a different
allocation basis for each group.
For direct costs, which include clinical labor, medical
supplies, and medical equipment, we used the CPEP data as the
allocation basis.
For the separate practice expense pool for services with work RVUs
equal to zero, we are using, as an interim measure, 1998 practice
expense RVUs to allocate the direct cost pools (clinical labor, medical
supplies and medical equipment).
Also, for all radiology services that are assigned work RVUs, we
used the 1998 practice expense RVUs as an interim measure to allocate
the direct practice expense cost pool for the specialty of radiology.
For all other specialties that perform radiology services that are
assigned work RVUs, we used the CPEP data for radiology services in the
allocation of that specialty's direct practice expense cost pools.
For indirect costs, which include administrative labor,
office expenses, and all other expenses, we used the total direct costs
or the 1998 practice expense RVUs, as described above, in combination
with the physician fee schedule work RVUs, to allocate the cost pools.
We converted the work RVUs to dollars using the Medicare CF (expressed
in 1995 dollars for consistency with the SMS survey years).
For procedures performed by more than one specialty, the
final procedure code allocation was a weighted average of allocations
for the specialties that perform the procedure, with the weights being
the frequency with which each specialty performs the procedure on
Medicare patients.
Other Methodological Issues
Global Practice Expense Relative Value Units
For services with the PC and TC paid under the physician fee
schedule, the global practice expense RVUs are set equal to the sum of
the PC and TC.
Practice Expenses per Hour Adjustments and Specialty
Crosswalks
Since many specialties identified in our claims data did not
correspond exactly to the specialties included in the practice expenses
tables from the SMS survey data, it was necessary to crosswalk these
specialties to the most appropriate SMS specialty category. We also
made the following adjustments to the practice expense per hour data
(the rationale for these adjustments is explained in the November 1998
proposed rule (63 FR 58817):
+ For the specialty of ``oncology'' we set the medical materials
and supplies practice expense per hour equal to the ``all physician''
medical materials and supplies practice expenses per hour.
+ We based the administrative payroll, office, and other practice
expenses per hour for the specialties of ``physical therapy'' and
``occupational therapy'' on data used to develop the salary equivalency
guidelines for these specialties. We set the practice expense per hour
for the direct cost categories equal to the ``all physicians'' practice
expense per hour from the SMS survey data.
+ We derived the resource-based practice expense RVUs for codes
performed by audiologists from the practice expenses per hour of the
other specialties that perform these codes.
+ For the specialty ``emergency medicine'' we used the ``all
physician'' practice expense per hour to create practice expense cost
pools for the categories ``clerical payroll'' and ``other expenses.''
+ For the specialty ``podiatry'' and the specialty of
``maxillofacial prosthetics'' we used the ``all physician'' practice
expenses per hour to create the practice expense pool.
+ For the specialty ``pathology'' we removed the supervision and
autopsy hours reimbursed through Part A of the Medicare program from
the practice expense per hour calculation.
Time Associated with the Work Relative Value Units
The time data resulting from the more current RUC refinement of the
work RVUs have been, on the average, 25 percent greater than the time
data obtained by the original Harvard research team for the same
services in 1992. We adjusted the Harvard research team's time data by
comparisons within families of CPT codes in order to ensure consistency
between these data sources and fairness to those services not yet
valued by the RUC.
For services with no assigned physician times, such as dialysis,
physical therapy, psychology and many radiology and other diagnostic
services, we calculated estimated total physician times based on work
RVUs, maximum clinical staff time for each service as shown in the CPEP
data, or the judgment of our clinical staff.
We calculated the time for the anesthesia CPT codes 00100 through
01996 using the base and time units from the anesthesia fee schedule
and the Medicare allowed claims data.
3. Refinement
Background
Section 4505(d)(1)(C) of the BBA requires us to develop a
refinement process to be used during each of the four years of the
transition period. In the June 1998 proposed rule (63 FR 30822) and the
November 2, 1998 final rule (63 FR 58818) we set out the parameters for
a refinement process and indicated that RVUs for all codes would be
considered interim for 1999 and for future years during the transition
period.
As part of the initial refinement process, in the November 1998
final rule, we outlined the steps we are undertaking to resolve the
outstanding general methodological issues. These steps include the
establishment of a mechanism to receive additional technical advice for
dealing with these broad practice expense RVU methodological issues;
evaluation of any additional recommendations from the GAO, MEDPAC, and
the Practicing Physicians Advisory Council; and consultation with
physicians' and other groups about these issues. In addition, we
solicited comments and suggestions about methodology from organizations
that have a broad range of interest and expertise in practice expense
and survey issues.
We also discussed a proposal submitted by the Relative Update
Committee (RUC), which was supported by almost every medical specialty
society, for the establishment of a Practice Expense Advisory Committee
(PEAC), to review comments and make recommendations on the code-
specific
[[Page 59388]]
CPEP data (that is, the clinical staff types and times, medical
supplies, and medical equipment needed for each procedure) during this
refinement period. This committee would make recommendations to the
RUC, which would make final recommendations to us.
Current Status of Refinement Activities
Top-Down Methodology
Comment: Several physician specialty societies expressed concern
about what they perceive as a lack of progress in the refinement
process. One surgical society noted the final report of the contractor
we chose to evaluate methodological issues is not due until May 2000.
Other commenters requested that we identify our plans for refinement,
provide guidance to specialty societies for refining key data sources
and inform the medical community of our progress. Several commenters
recommended that we lengthen the time period for transition, while
another requested that we consider all practice expense RVUs as interim
until all refinements are complete, even beyond 2002. Two surgical
specialty societies stated their concern that many of the
methodological issues on which they previously commented have not yet
been resolved, such as averaging of the CPEP inputs for services valued
by more than one CPEP panel, the negative effect of high patient care
hours on certain specialties, the effects of rounding on the physician
time for evaluation and management (E/M) services, and the impact of
errors in the Medicare claims data.
Response: We can understand the frustration expressed by many of
the commenters about the lack of many immediate revisions to our top-
down methodology. However, this methodology is complex and is also
dependent on the accuracy and interrelationship among five separate
data sources: the SMS survey, the CPEP inputs, Harvard and RUC
physician times, the Medicare claims data, and the work RVUs. In
addition, because the RVUs must be budget neutral, any change we make
that advantages one group could disadvantage another. Therefore, we
must ensure that all refinements we make are methodologically sound,
are consistent with Medicare policy, and, to the greatest degree
possible, are based on objective information.
We believe that we are now in a position to begin addressing many
of the methodological issues that are of concern to those commenting on
our refinement efforts. As indicated in the July 22, 1999 proposed rule
(64 FR 39608), one of our main strategies for resolving the outstanding
practice expense methodological issues was to establish a mechanism for
obtaining expert advice and technical support. We awarded a one-year
contract, beginning May 24, 1999, to The Lewin Group to provide
technical assistance in evaluating the following aspects of the
practice expense methodology:
Evaluate the validity and reliability of the SMS data for
specialty and subspecialty groups and academic and hospital-based
specialties to determine which groups may not be adequately represented
in the SMS survey.
Assist us in our consultations with the AMA and the
medical community on considering possible ways to improve the
representativeness of the aggregate specialty-specific data so that
sampling error is decreased and to eliminate as many sources of non-
response and measurement error as possible.
Evaluate the appropriateness of crosswalking unrepresented
specialties to a specialty included in the AMA survey and develop
alternative options to crosswalking.
Determine which specialties' SMS data may be affected by
inclusion of mid-level practitioners in specialty survey cost data and
develop alternative methodologies to address the issue.
Determine whether the impact on AMA SMS of non-billable
hours is significant and, if so, develop methodologies for adjusting
AMA/SMS to account for non-billable hours.
Determine whether the impact of uncompensated care is
significant and, if so, develop methodologies for adjusting the SMS
data to account for uncompensated care.
Identify and evaluate alternative and supplementary data
from sources such as specialty and multi-speciality societies and
future SMS surveys.
Determine under what circumstances, if any, we should
consider use of survey data other than AMA SMS data and, if this data
could be used, develop criteria for accepting other surveys and
determine the appropriate form of these surveys.
Consider ways that specialty data that significantly
change in a future survey can be selectively validated by AMA SMS
through an independent auditor or other appropriate entity.
Develop options for validating the Harvard/RUC physician
procedure time data.
Determine whether the effect of rounding time data for
high volume/low time services is significant and, if so, develop
methodologies to address it.
Review options supplied by us for allocating indirect
costs, including substituting physician time for physician work.
Provide advice on developing a process for the 5-year
review of practice expense RVUs.
Our contractor has accomplished the following to date:
Met with us and the AMA to discuss our future use of the
AMA SMS survey and to discuss the design and structure of the AMA's new
practice-level survey. The AMA plans to conduct its survey of practices
in alternating years with the SMS survey. Our contractor has completed
an evaluation of the 1998 SMS questionnaire and has completed an
initial review of the methodology of the practice expense per hour
values derived from the SMS data. Our contractor is developing
recommendations regarding the practice survey design and methodology
and is considering how we can use the practice-level survey and how we
can cross-walk the information to the SMS survey. We hope to present
the details of the final recommendations and our proposals regarding
them in next year's physician fee schedule proposed rule.
Met with the Society of Thoracic Surgeons (STS) to review
the methodology used in their survey to make a specific recommendation
concerning the use of this survey to calculate the practice expense per
hour for cardiothoracic surgery.
Hosted a meeting on September 15, 1999 with 37
representatives of physician specialty societies, 11 representatives of
nonphysician practitioners and a number of representatives of the AMA.
Our contractor held the meeting at our urging to allow an
opportunity for representatives of physicians and other practitioners
to raise issues and concerns regarding methodological issues which
effect Medicare payment for practice expenses. Among other issues, our
contractor discussed:
+ Improving collection reliability of practice expense data from
the SMS survey including data on practitioners not represented in the
SMS survey.
+ Developing and evaluating criteria for use of supplemental data
collection efforts.
+ Defining and validating the number of hours physicians spend in
patient care activities.
+ Appropriateness of crosswalk between HCFA and AMA specialty
designations.
Our contractor discussed concerns related to these and other issues
and facilitated a discussion among the
[[Page 59389]]
participants of potential ways of improving the top down methodology.
Submitted their first draft report, Practice Expense
Methodology, dated September 24, 1999, containing an analysis and
recommendations concerning SMS and other practice expense data. This
report has been placed on HCFA's homepage under the title ``Lewin Group
Report'' for anyone interested in reviewing it. (Access to our homepage
was discussed under the ``Address'' section earlier.)
Comment: We have received several comments regarding the effect of
the step in our methodology that weight-averages all scaled specialty-
specific dollar inputs for each CPT code to arrive at a single value
for each service. Commenters claim that this step can cause
redistributions in the specialty-specific practice expense pools and,
in some cases, can cause anomalies in the payment for certain services.
Several commenters indicate that payments for some nerve block
injections will rise by several hundred percent in the office. The
American Society of Anesthesiologists commented that the values for
some of the nerve block injections make no sense in the real world and
urged us to allow the refinement process to work before taking action
with respect to in-facility practice expense values. Some commenters
objected to the proposed increase in payments for outpatient E/M. A
number of commenters noted that office-based E/M services will increase
substantially under the proposed policy. The Society for Vascular
Surgery objected to the proposed 4 to 7 percent increase in total RVUs
for outpatient E/M. They indicated that the additional payments for an
intermediate office visit (CPT code 99213) alone will increase
$312,000,000 which will require further adjustments to the CF. The
American College of Cardiology recommended that we should implement a
way to reduce or eliminate the ``pool leakage'' for specialties such as
cardiology that have a high practice expense per hour. Such high
practice expense specialties can lose a portion of their pool to
specialties with lower expenses when the costs are averaged. Other
commenters also suggested that we should eliminate ``pool leakage.''
The American Association of Neurological Surgeons (AANS) made a similar
comment regarding ``pool leakage.'' AANS asserted that pool leakage is
unfair and violates that BBA mandate to develop a system that reflects
physicians' actual practice expenses.
The Society of Thoracic Surgeons (STS) commented that, because of
the dropping of clinical staff time in the facility setting from the
CPEP data, the values for cardiac and thoracic surgical procedures are
reduced while values for cardiac and thoracic office visits are
increased. The commenter asserted that the effect of this
``misallocation and subsequent weighted-averaging of E/M services
across specialties is a virtual draining and redistribution of cardiac
and thoracic surgery practice expenses to other specialties.'' The
commenter further stated that other anomalies demonstrate the
fallibility of this approach. For example, the scaling factors for
clinical staff for thoracic and cardiac surgery become 1.75 and 2.2
respectively, which are far from the norm for other specialties. As a
result of these high scaling factors, the values in the cardiac and
thoracic surgery practice expense pools for E/M services are increased
while the values for these same services are decreased in the internal
medicine practice expense pool. Cardiac and thoracic surgery have a
value for an E/M service which is about six times the values for these
services in the internal medicine practice expense pool. Finally, these
changes in the direct cost values for E/M services also cause the
indirect practice expense for these services to increase in a distorted
fashion.
Response: We are required by statute to have a single payment for
each service, regardless of the specialty performing that service. It
is for this reason that we adopted the weight averaging of services.
Under the top-down methodology, we calculate an ``SMS'' pool using the
practice expense per hour from the AMA's SMS as follows:
SMS Pool=Practice expense per hour * time per procedure * allowed
services.
This is summed by specialty across all procedures a specialty
performs.
We then calculate a ``CPEP'' pool using the estimates of direct
expenses for specific procedures by the CPEP:
CPEP Pool=Practice Expense for a procedure (as estimated by the CPEP) *
allowed services.
This is summed across all services a specialty does.
There is a separate pool for each category of direct costs
(clinical labor, supplies and equipment). The SMS pool is divided by
the CPEP pool for each specialty to produce a scaling factor which is
applied to the CPEP direct cost inputs. This process is intended to
match costs counted as practice expenses in the SMS survey with items
counted as a practice expense in the CPEP process. Ideally, all of the
scaling factors would equal 1.0, which would suggest that practice
expenses are being identified consistently within each pool. If the
scaling factor is more than 1.0, the CPEP inputs for each specialty are
increased prior to the weight-averaging step. If the scaling factor is
less than 1.0, the CPEP inputs for each specialty are decreased prior
to the weight-averaging step. If the scaling factors all equaled 1.0 or
alternatively were within a narrow range of each other, the weight
averaging step will have little impact on the final value for a
procedure relative to the original CPEP estimates. Thus, the ideal is
that the scaling factor equals 1.0.
Alternatively, if the scaling factors among different specialties
are equal to each other, each specialty specific value that goes into
the weight-averaging step would be the same. Since the scaling factors
tend to be less than one for the direct inputs, most specialties
overestimated practice expenses in the CPEP relative to how the costs
were estimated in the SMS survey. In the refinement process, one of our
key interests is ensuring that there is consistency between costs
counted as practice expenses in the SMS survey and costs which were
counted as practice expenses in the CPEP process. To the extent this
occurs and we can obtain reliable information on physician time related
to performing individual procedures, we believe that scaling factors
should approach 1.0 and these refinements would be an improvement in
the top-down methodology. In the interim, we believe the policies in
this final rule are an improvement in the top-down methodology.
The scaling factors for clinical labor costs for most specialties
move closer to 1.0 in this final rule. The scaling factor for all
physicians increased from 0.54 to 0.72 in this final rule relative to
last year's final rule. For a few specialties, the scaling factor
deviates sharply from 1.0 as a result of these new policies. For
instance, the scaling factor increased from 0.40 to 2.42 for thoracic
surgery, 0.36 to 3.07 for cardiac surgery, and 0.51 to 5.72 for
anesthesiology. Since the scaling factors for most specialties and for
all physician pools move closer to 1.0, we do not believe that
significant changes in policy related to the top-down methodology such
as the ones suggested by commenters are necessary. We continue to
believe the refinement process should be used to obtain better
information on physician practice expenses to further improve the top-
down methodology. We do not believe that results for a few specialties
that deviate from the general trend indicate a significant problem with
the top-down methodology. In fact, it is possible that the increase in
the scaling factor that
[[Page 59390]]
results from changes in this final rule is due to an overstatement of
SMS costs on practice expense per hour rather than an understatement of
the CPEP pool. For instance, if a physician brings nonphysician
practitioners to the hospital, whose services are charged for
separately, the expenses associated with these practitioners generate
physician revenue and should be considered as a part of the physician
work RVU. Indeed, the STS indicated in its comments that thoracic
surgeons frequently bring physician assistants to the operating room to
perform duties typical of ``the first assistant-at-surgery.'' In this
situation, the service of the assistant-at-surgery would be separately
billable and would generate additional revenue to the physician. If it
is commonplace for thoracic surgeons to bring physician assistants to
the hospital for whose services Medicare may make an additional
payment, it would be appropriate to examine whether expenses for
physician assistants are included as a practice expense in the SMS and
thus whether the practice expense per hour is overstated.
Similarly, we believe it is possible that anesthesiologists
responding to the SMS survey may have counted certified registered
nurse anesthetists as a clinical practice expense even though they may
receive an additional payment for the service of a CRNA providing
anesthesia services during a surgical procedure. We do not know that
this is the case but are instead indicating that this is an avenue for
further research to explain the very high scaling factor for
anesthesiology.
We acknowledge that payments under our rule will largely decline
for services which are predominantly performed in a facility and which
had substantial inputs for clinical staff. However, we do not believe
that this is illustrative of a problem with the top-down methodology.
Indeed, as we explained above, we believe our policies are an
improvement in the top-down methodology with a few exceptions.
With respect to some of the code level results that were pointed
out by commenters, we are concerned that there are a few instances
where the scaling and weight-averaging methodology could cause changes
in payment or redistributions that do not reflect the relative costs of
performing certain services. These occur for a few services that are
performed predominantly by a specialty whose scaling factor deviates
sharply from 1.0. For instance, as indicated by some commenters,
practice expense RVUs for pain management injection services would have
increased substantially for reasons unrelated to the relative resources
used in providing the service. This occurs because of the very high
scaling factor for anesthesia that is applied to these services. As
some commenters have noted, including anesthesiologists themselves,
these values ``make absolutely no sense in the real world.'' For this
reason, as an interim measure until refinement is completed, we will
use the average scaling factor in place of the specialty specific
scaling factor if the specialty specific scaling factor exceeds the
average scaling factor by more than 3 standard deviations. This change
will largely result in a reduction in the enormous increase in some of
the pain management services from the proposed rule as a result of a
different scaling factor being used for anesthesiology. Although these
services still appear to have higher RVUs, the changes do not seem so
extreme. We believe this change is warranted as an interim measure in
situations where there is an extreme deviation in specialty scaling
factor relative to the average scaling factor. As we have indicated,
this interim measure is being taken to avoid extremely anomalous
payments for certain services until we can further identify the reason
for aberrant scaling factors.
SMS Data
As we explained in the July 1999 proposed rule we have received
comments from a large number of medical specialty societies concerning
the SMS data and the parameters under which we would accept
supplementary data or new data. We identified as the top priority of
the technical contractor the determination of (1) the circumstances, if
any, under which we should consider use of survey data other than the
SMS data; (2) the appropriate form of these other surveys; and (3) how
these surveys or future SMS surveys can be appropriately validated for
our use.
Comment: Many organizations reiterated the concerns expressed in
previous comments that their services or their actual costs are not
adequately represented in the SMS data or, in the case of non-physician
specialties, are not represented at all. Organizations representing
emergency medicine, vascular surgery, podiatry, and optometry requested
that we use supplementary data already collected for their specialties.
Two organizations representing cardiology recommended that we use the
most current SMS data in developing practice expense values for the
year 2000. One of the comments states that a review of the most recent
data indicates that no ``gaming'' took place in the responses to this
new SMS survey, once reported practice expenses have only grown at
about the rate of medical inflation.
Two primary care specialty societies support our decision not to
use supplementary data at this time and instead to use our outside
contractor to develop reliable and standardized criteria for accepting
and validating additional specialty-specific data.
Response: We are still in the process of developing the general
criteria for the use of supplementary practice expense surveys and more
recent SMS survey data that could be used in the calculation of the
specialty-specific practice expense per hour. We have made this issue
the top priority for our methodological contractor. As stated above,
our contractor has already met with AMA staff on several occasions to
discuss the future use of the SMS survey, in particular the design,
structure and potential use of the new practice-level SMS survey. Our
contractor also held a meeting on this issue to which all major
national specialty societies were invited in order to obtain input on
concerns relating to the AMA SMS survey and other supplementary survey
data. As mentioned earlier, we have just received the first draft
report with our contractor's findings and recommendations on the
criteria for acceptance of future data. We have not yet had the
opportunity to review closely this report and its recommendations.
Therefore, we are not yet ready to determine which already submitted or
potential additional survey data would be acceptable, although we have
previously stated our preference for future surveys to be carried out
on a multi-specialty level, as is the SMS. We are pleased that,
according to the comment mentioned above, the results in general from
the latest SMS survey may not have differed significantly from the data
that are used for this rule.
Comment: The Society of Thoracic Surgeons (STS) had commented on
last year's proposed rule (63 FR 30817) that the sample size in the SMS
surveys used by us for cardiac, thoracic and vascular surgery was
insufficient for use calculating accurate practice expenses for these
specialties. The STS submitted a supplementary survey with these
earlier comments that had a larger sample size and that showed a higher
practice expense for cardiac and thoracic surgery. The comments stated
that STS contracted with the AMA in April 1998, before it was known
that the SMS data would be used in the determination of practice
expense, to conduct an SMS-clone oversample. This survey showed a
practice expense per
[[Page 59391]]
hour of $75.90, rather than the $63.80 from the 1994 through 1996 data.
The STS requests that we use this later SMS data in the calculation of
cardiac and thoracic surgery's practice expense per hour.
Response: We believe that the STS survey is unique among all
specialty surveys that we have received in that it both appears to be a
clone of the SMS surveys already used in our calculations and was
undertaken before our top-down methodology was proposed. Therefore, we
asked our contractor to evaluate and advise us on the utility of
considering the STS survey at this time. Our contractor met with the
STS, discussed the issue with SMS technical staff and submitted a
detailed questionnaire to STS about the methodology used in the survey.
In the draft report on practice expense methodology mentioned
above, our contractor discusses the standards that could be applied to
supplementary data provided by specialty groups. The draft report
suggests that supplemental data collection efforts: draw the sample
from the AMA Physician Masterfile, when possible; survey a large enough
number of individuals to assure an adequate number of useable
responses; are based on SMS survey instruments and protocols, including
administration and follow-up efforts; use the same contractors as SMS
and be fielded during the same time-frame; consistently define, through
the SMS and all additional surveys, practice expense and hours spent in
patient care; give responsibility for data editing and analysis to the
AMA's SMS project team.
In a memo to us accompanying the above mentioned draft report, our
contractor stated: ``We believe that the survey conducted by the
Society of Thoracic Surgeons meets the standards we have set forth in
the paper. Therefore, it is our recommendation that HCFA incorporate
their supplemental survey data into its calculation of practice expense
RVUs.'' We agree with this recommendation and will use the survey
submitted by STS in the calculation of thoracic and cardiac surgery's
practice expense per hour.
Result of Evaluation of Comments
We will use the survey submitted by STS in the calculation of
thoracic and cardiac surgery's practice expense per hour. We
recalculated the practice expense per hour for cardiac and thoracic
surgery by weight-averaging the new survey information with practice
expense SMS survey data from 1995 and 1996. Consistent with other
specialty information we deflated values to reflect 1995 costs. We used
the number of survey responses adjusted for non-response as the
weights. In addition, we did not include the responses from vascular
surgeons in the calculations for thoracic and cardiac surgery because
we are now crosswalking vascular surgery to all physician practice
expense per hour. This produced the following practice expense per
hour:
----------------------------------------------------------------------------------------------------------------
Clinical Labor Supplies Equipment Clerical, Office & Other
----------------------------------------------------------------------------------------------------------------
$19.50 $1.93 $2.34 $48.20
----------------------------------------------------------------------------------------------------------------
Adjustment to Direct Patient Care Hours for Pathology
In the November 1998 final rule, we made adjustments to the direct
patient care hours for pathologists to account for the fact that time
spent performing autopsies and supervising technicians are Part A
services. The pathologists had also requested that we eliminate some of
the time for ``personally performing nonsurgical laboratory procedures
including reports'' because this time also includes some part A
services. We did not make this adjustment at the time because we did
not have appropriate data. We now have the necessary information and in
the July 1999 rule we proposed to remove three hours from the total
patient care hours for pathologists.
Comment: The College of American Pathologists, as well as
individual commenters, supported the proposal to eliminate three of the
6.77 hours of pathology SMS time for performing nonsurgical laboratory
procedures. The AMA also supports this proposal because the SMS survey
shows that 45 percent of the 6.77 weekly hours spent on performing
these procedures is non-reimbursable under the physician fee schedule.
One surgical organization expressed concern that this adjustment
will be made at the expense of all other specialty pools. Other
commenters contended that many other physicians, besides pathologists,
spend time in direct patient care activities for patients which is not
separately billable including phone calls, waiting time, ``hallway''
patient consultations and ``stand-by'' time, or uncompensated care. Two
commenters argued that specialties with high patient care hours are not
treated fairly in the calculation of practice expense RVUs and ask that
we consider removing such time from the SMS data for surgical
specialties as well. In a similar comment, an anesthesiology society,
though not opposed to the proposed pathology adjustment, urged its
extension to other specialties as part of an across-the-board
refinement of SMS-generated values.
Response: We believe that the data presented by the College of
American Pathologists, in conjunction with the AMA, is persuasive that
three hours should be eliminated from the SMS direct patient care
weekly hours for pathology. Therefore, we will make the adjustment at
this time. However, though we do believe that pathology may differ from
most specialties with regard to their split between Part A and Part B
payments, we also agree that the other commenters raised a valid point
concerning other specialties' non-billable hours that may be
inadvertently captured in the SMS direct patient care hours data. It is
because of this concern that we included the issue of the SMS patient
care hours in the scope of work for our contractor. Over three pages in
the draft report from our contractor, which is referenced above and
which is available on our home page, are dedicated to this issue. The
report points out that, if there is a discrepancy between the
activities captured in the code-specific physician time values in the
Harvard and RUC database and the activities that physicians considered
in responding to the patient care hour question in the SMS survey, the
practice expense pools could be biased in either direction. We hope to
discuss recommendations on improving the accuracy of the patient care
hours data in our next proposed rule.
Result of Evaluation of Comments: We will eliminate 3 hours from
pathology's direct patient care hours for ``personally performing
nonsurgical laboratory procedures including reports'' because this time
includes some part A services.
CPEP Data
Response to Comments on Egregious CPEP Errors and Anomalies/RUC
Recommendations
As we stated in last year's final rule, comments were submitted on
the CPEP inputs for about 3000 CPT codes. In response to the July 1999
proposed rule,
[[Page 59392]]
a few additional comments on CPEP inputs have been received, most of
them reiterations of comments previously submitted. In this year's
proposed rule we stated that we plan to wait until we receive
recommendations from the RUC before making significant changes to most
code-specific inputs. The PEAC held its organizing meeting in February
1999 and met again in April to begin the task of refining the code-
specific CPEP data. The PEAC and RUC then met at the end of September
to further develop the approach to the refinement of the CPEP data and
as a result of this meeting the RUC has forwarded recommendations to us
on 65 CPT codes. The November 1998 final rule also pointed out that we
had received comments on a number of egregious errors and anomalies
that we would address in future rulemaking. Our responses to the
comments on the errors and anomalies and to the RUC recommendations are
discussed further below.
Comment: One organization representing pediatric services supports
our decision to wait for RUC recommendations on code-specific direct
practice expense inputs, while an ophthalmology subspecialty society
strongly recommends adopting the CPEP input changes suggested by
ophthalmology groups now, without waiting for RUC recommendations. A
primary care group recommended that we publish the CPEP errors and
anomalies for review before we correct them in this final rule. A few
other organizations suggested further changes to the RUC recommended
inputs or changes in inputs for codes not yet reviewed or not agreed to
by the PEAC and RUC.
Response: We believe that, particularly at these first steps in
refining the CPEP inputs, it is preferable to have a multi-specialty
agreement on changing these data, rather than accepting the
recommendations of a single group without the level of peer input that
a group like the PEAC and RUC can afford. That is the major reason we
have chosen to wait for the RUC recommendations before refining most of
the CPEP data and why, at this point, we are not addressing the few
additional changes suggested by commenters to the July 1999 proposed
rule. The commenters pointed out at the same time that there are some
obvious errors or anomalies when the corrective action is of a more
technical nature. Therefore, we believe that it will be helpful to the
refinement process to make these corrections at this time.
Comments on Egregious Errors and Anomalies
Outlined below are comments and our responses concerning those
anomalies and errors for which corrections could easily be determined.
It is important to note that while we are making some revisions now,
all practice expense inputs for these codes are still subject to
further comment, our refinement and potential PEAC and RUC review and
action. In addition, we have made minor adjustments to the CPEP supply
list by deleting a few supplies either because of the difficulty in
measuring their use, or because the supplies were not fully used up
during a single procedure and do not fit the definition that we use for
direct supply costs. Therefore, the costs for tissues, biohazard bags
and Lysol spray will be treated as indirect costs. This change should
not affect the practice expense RVUs for any service, but it will help
simplify the refinement of the supply inputs.
Comment: The American Academy of Orthopaedic Surgeons and the
American College of Surgeons both commented that we should delete
separately billable casting materials from the CPEP inputs.
Response: Casting materials are bundled into the payment for the
initial fracture management procedures and separate billing for the
supplies is not allowed under Medicare billing rules. Therefore, for
these procedures, the casting supplies should remain as inputs.
However, for casting and strapping codes CPT codes 29000 through 29750,
casting supplies can be billed for separately, and including the
supplies in the CPEP data would lead to double counting. Therefore, we
have deleted the fiberglass roll, cast padding and cast shoe from the
list of supplies for these procedures.
Comment: The American College of Surgeons commented that we should
delete Romazicon (used to reverse conscious sedation) from supplies
wherever it appears since it is not typically used.
Response: This comment brought to our attention that many drugs in
addition to Romazicon are included in the supply lists of many
procedures. Most drugs are separately billable and are not paid under
the physician fee schedule. Therefore, in keeping with our general
policy to retain in the CPEP data only those inputs that would be paid
as practice expense under the physician fee schedule, we have deleted
from the supply lists all those drugs that would be billed separately,
which would include Romazicon. We have also deleted self-administrable
drugs that are not payable under Medicare. The drugs that have been
removed are: fentanyl, demerol injection, versed injection, valium
injection, ativan syringe, bacitracin ointment, neosporin, benadryl,
steroid kenalog, IV fluids, such as saline in various quantities, D5W,
droperidol, romazicon, narcan, ancef, nubain, sodium chloride
injection, lasix, brevital, decadron, esmolol IV, metopropol IV, sodium
amobarbital, tylenol and ibuprofen.
Comment: The American College of Surgeons commented that the supply
lists for the insertion of bile duct catheters (CPT code 47510) and
stents (CPT code 47511) include an extensive and costly list of
supplies used to perform the procedure in the out-of-office setting.
However, these supply costs are covered by the facility and therefore
should be removed from the list of supplies for these codes.
Response: We agree and note that the supplies listed in the
facility setting appear to be connected with the performance of the
procedure and will be included in the payment to the facility.
Therefore, we have removed these supply costs from the data. However,
since this is a 90-day global code and would be expected to have post-
procedure visits in the office, we would welcome comments about
appropriate supplies for the office visits during the global period. In
addition, one CPEP panel listed 210 minutes of angio technician time in
the post-procedure period. Because the services of an angio tech would
only be needed during the procedure itself and not during the post-
procedure office visits, we are deleting this time.
Comment: The American College of Surgeons commented that the supply
costs for the procto-sigmoidoscopies and flexible sigmoidoscopies are
significantly higher than the supply costs for colonoscopy codes. They
attributed this rank order problem partially to the inappropriate
inclusion in the supply list of an expensive lumen tube for the
sigmoidoscopy codes. They asserted that a lumen tube is not a typical
supply for sigmoidoscopy codes and recommended the removal of this
supply from these codes.
Response: We are in agreement with the College of Surgeons that the
lumen tube is not a typical supply for these procedures and are
therefore deleting this supply from the sigmoidoscopy codes
(specifically: CPT codes 45300, 45303, 45305, 45307, 45308, 45309,
45315, 45317, 45320, 45330, 45331, 45332, 45333, 45338 and 45339).
Comment: The American Academy of Ophthalmology and the Macula,
Retina and Vitreous Societies questioned the
[[Page 59393]]
prices identified in the CPEP data for the superblade. They indicated
the price for the superblade should be $1.00 instead of the $30 listed
in the Abt pricing file.
Response: We have verified this lower price and will make the price
change to the CPEP database.
Comment: The American Academy of Ophthalmology, the American
Optometric Association and the American Society of Cataract and
Refractive Surgery stated that the CPEP data included a discrepancy in
the supply costs for CPT code 92012 (eye exam, established patient,
intermediate). The supply costs reflected were much higher than supply
costs for the other eye exam codes. They felt the supplies for the eye
exam codes are essentially the same and recommended that the supply
values for CPT code 92012 should be changed to be consistent with the
value used for the other codes in the series.
Response: We have reviewed the CPEP data and made revisions to the
supplies used for CPT code 92012 so that these supplies are consistent
with those for other eye exam codes. (We removed as suggested: patient
education booklet; fox shield; patch, eye; bleach; gonisol; contact
lens solution; tape, VHS).
Comment: The Macula, Retina and Vitreous Societies believed the
price allocated for an 18 gauge filter needle, (listed at $46) was in
error. They recommended a price of $1 for this supply. They initially
also questioned the cost allocated for color film, but in later
discussion agreed that the list price of $.85 is reasonable.
Response: We agree that the price allocated for the 18 gauge filter
needle is in error and after reviewing supply catalogs believe that the
price suggested by the commenter ($1.00) is reasonable. We will revise
the CPEP data accordingly.
Comment: The American College of Cardiology pointed out that a cast
cutter is listed in the supply list for two cardiovascular
rehabilitation procedures (CPT codes 93797 and 93798) and should be
removed.
Response: The cast cutter has been deleted from the supply list for
these codes.
Comment: The American Academy of Neurology commented that CPT code
62270, spinal fluid tap, diagnostic and CPT code 62272, drainage of
spinal fluid, are erroneously listed as having no supplies. A short
list of suggested routine supplies was included with the comment.
Response: We believe that the list is appropriate and have included
these supplies in the CPEP inputs for these services.
Comment: The Joint Council of Allergy, Asthma and Immunology
(JCAAI) pointed out that no supplies were allotted to CPT 95070,
bronchial allergy tests, though other codes in the family did have
supplies listed.
Response: We agree that the CPEP panel left out the supplies that
should have been assigned to CPT 95070, and we found that this is also
true for CPT 95071. Therefore, until the inputs for these bronchial
allergy test codes can be refined, we are assigning to them the same
supplies that are listed for the other codes in the family, such as CPT
code 95065, nose allergy test, except that, because CPT codes 95070 and
95071 are inhalation tests, we are omitting the band aid, swab, gauze,
tape and syringe included in other codes in the family.
Comment: JCAAI also commented that there were rank order anomalies
for the venom immunotherapy codes (CPT codes 95145 through 95149),
because the needed antigens were not included in the supplies. The
comment lists the antigens (adjusted for a single 1 cc dose) that are
necessary for each service: CPT code 95145 requires a single venom; CPT
code 95146 requires two venoms; CPT code 95147 requires three venoms;
CPT code 95148 requires a three vespid mix plus a single venom; CPT
code 95149 requires a three vespid mix, a single venom and a honey bee
venom.
Response: We agree that these venom antigens should be added to the
supply lists for these codes and have made the necessary adjustments.
Comment: The American College of Obstetrics and Gynecology (ACOG)
commented that the CPEP inputs for CPT code 58350, reopen fallopian
tube, show time for angiography supplies although this is not an
angiography procedure.
Response: Although the comment stated that the angiography supplies
are in CPT code 58350, they actually are present in CPT code 58340,
catheter for hysterography,(which ACOG states is overvalued in
comparison to CPT code 58350). Consistent with the comment, we are
deleting the angiographic vessel dilator and the vascular sheath. We
also noticed that CPT code 58340 shows 63 minutes of angio technician,
which we are deleting as this is not an angiography procedure. In
addition, CPT code 58340 has 175 minutes of RN time in the intra-period
in the non-facility setting, while CPT code 58350 shows only 63 minutes
RN/MA in this period. In line with ACOG's comment that CPT code 58340
is overvalued, we are changing the intra time for CPT code 58340 to 63
minutes of RN/MA clinical time to match the input for CPT code 58350.
Comment: Raytel Cardiac Services were concerned that data on
supplies and clinical staff for arrhythmia monitoring services were
based on only one monitored event during a 30-day period. The comment
requested that we check for the appropriateness of the CPEP supplies
and staff time for these services.
Response: The CPEP panel stated that there were no clinical
supplies associated with these monitoring services, and the commenter
did not supply any information regarding the clinical staff duties
required for these codes. Therefore, we have no basis for making any
changes to the inputs for these monitoring services at this time, but
would welcome further information on this issue from additional
comments or from the PEAC and RUC.
Comment: The American Academy of Dermatology commented that the
actinotherapy and photochemotherapy CPT codes 96900, 96910, 96912 and
96913 were grossly undervalued because the CPEP equipment data do not
include the costs of a photochemotherapy unit. The comment stated that
these units also use almost 200 lamps a year.
Response: It is clear that a photochemotherapy unit was omitted
from the CPEP data in error, because these procedures could not be
performed without this equipment. We will add the photochemotherapy
unit and lamps to the CPEP database.
Comment: The American College of Radiology pointed out that many of
the cardiovascular nuclear medicine codes had two types of cameras
assigned in the CPEP files, but that only one camera is needed.
Response: We found that almost all of the nuclear medicine codes
(CPT codes 78000 through 78999) had two or three cameras listed. We
have included only one camera for each of these codes as suggested by
the commenter.
Comment: The American Urological Association commented that the
cost of a lithotriptor is not included in the equipment in the in-
office setting for CPT code 50590, extracorporeal shock wave
lithotripsy.
Response: The CPEP panel only evaluated inputs for this procedure
in the facility setting. However, we assigned practice expense RVUs to
both settings; the in-office inputs were crosswalked from the facility
setting. As a result, there is no procedure-specific equipment listed
in the office setting. We are adding a lithotriptor as requested by the
commenter.
[[Page 59394]]
Comment: The College of American Pathologists (CAP) commented that
the price of $1,481 in the CPEP data for a compound microscope was
insufficient to cover the cost of the microscope used for pathology
services. CAP submitted a quotation from a pathology equipment supplier
which listed the cost of a pathologist's professional microscope at
$11,600.
Response: The price submitted by CAP appears more reasonable to us
than the original CPEP price, and we will use the new price for the
final rule, subject to later review.
Comment: The American Association of Neurological Surgeons
recommended that all receptionist time listed in the clinical
activities field in the CPEP database be deleted from the labor file,
since this should be indirect expense.
Response: We agree and have deleted all administrative staff types
from our current CPEP database since all administrative staff costs are
included in our indirect expense pool.
Comment: The American Academy of Orthopaedic Surgeons pointed out
that the CPEP panel did not assign direct inputs to CPT code 27740,
thus creating an anomaly in the family of codes 27730 through 27742.
Response: The CPEP panel only included inputs for CPT code 27740 in
the facility setting. We are adding the same clinical staff, supplies
and equipment inputs to CPT code 27740, repair of leg epiphyses, in the
office setting as are assigned to CPT code 27730, repair of tibia
epiphyses. This should help eliminate this anomaly.
Comment: The American Academy of Dermatology (AAD) commented that
there are rank order anomalies in the family of excision of malignant
lesions, CPT codes 11600 through 11606.
Response: We examined these CPT codes and noted that 11601, 11603
and 11604 were missing routine supplies in the office setting and 11601
had no supply inputs in the facility setting. We are including the same
supply inputs as are assigned to 11600, which should bring this code
family back in line.
Comment: AAD commented that there is a lack of logical progression
in the values for lesions of different sizes in the CPT code series
11400, excision of benign lesions, and 17260, destruction of malignant
lesions.
Response: We determined that the 17260 series appeared to have a
logical progression in the proposed rule. However, CPT codes 11403,
11404, 11423, 11424, 11444 have supplies missing in the office setting.
These services should have at least the same supplies as their
``parent'' CPT codes, i.e., CPT codes 11403 and 11404 should have the
same supplies as CPT codes 11400; CPT codes 11423 and 11424 the same as
11420; and CPT code 11444 the same as 11440. We are including these
missing supplies.
Comment: The American College of Chest Physicians and the National
Association for Medical Direction of Respiratory Care commented that
the practice expense RVUs for complex pulmonary stress testing, CPT
code 94621, are lower than those for simple pulmonary stress testing,
CPT code 94620. The commenter requested that this anomaly be corrected.
Response: We agree that this anomaly should be corrected. As an
interim correction until actual practice expense direct inputs can be
developed for these services, which were not evaluated by the CPEP
panels, we have crosswalked the supply and equipment inputs for CPT
code 94621 from CPT code 94620, but have crosswalked the clinical staff
time from the higher of the two CPEP panels' assigned clinical staff
time for CPT code 93015, cardiovascular stress test.
Comment: The American College of Nuclear Physicians/Society of
Nuclear Medicine commented that CPT code 78494, heart image spect,
should be referenced to CPT code 78464, heart image,(3D) single, and
CPT code 78588, perfusion lung image, should be referenced to CPT code
78585, Lung V/Q imaging.
Response: We agree that these crosswalks are appropriate, and we
have made the changes.
Comment: The American College of Obstetrics and Gynecology
recommended the following crosswalk changes: CPT code 57308, fistula
repair transperineal, should be crosswalked to either CPT code 57305,
repair rectum-vagina fistula, or CPT code 57307, fistula repair and
colostomy; CPT 57531, removal of cervix radical, should be crosswalked
to CPT code 58210, extensive hysterectomy; CPT code 59866, abortion
should be crosswalked to CPT code 59000, amniocentesis or CPT code
59015, chorion biopsy. The values for the CPT vaginectomy codes 57107,
57109, 57111 and 57112 are too low in comparison to other gynecologic
oncology procedures. The commenter recommends that we use CPT code
58210, radical abdominal hysterectomy, as a crosswalk for these four
codes, since the clinical staff time, supplies and equipment are
similar.
Response: We will crosswalk CPT codes 57308 to 57305, 57531 to
58210, and 59866 to 59000 as requested. Due to the clinical similarity
of the procedures and the comparable follow up care, we are
crosswalking the CPEP inputs from CPT code 57110 to CPT codes 57107 and
57111. For similar reasons we are crosswalking the CPEP inputs from
58200 to CPT codes 57109 and 57112.
RUC Recommendations on CPEP Inputs
The AMA forwarded for our consideration the direct input
recommendations for 65 codes originally reviewed by the PEAC and
subsequently approved by the RUC. The RUC states that in the majority
of cases, the PEAC examined all of the direct inputs for a particular
code, but that in several instances, the PEAC examined only a subset of
the direct practice expenses. The comment also explains that, in those
instances where the RUC approved crosswalking direct impact data to
multiple codes, those crosswalked codes are listed. Several
organizations representing neurology, ophthalmology, urology,
dermatology and other specialties requested that we use these PEAC/RUC
recommended refined inputs to calculate the practice expense RVUs for
the year 2000 physician fee schedule.
Response: We have reviewed the submitted codes and discuss our
specific responses to each of them below. We appreciate the work of the
PEAC and RUC in developing the recommendations on these 65 codes. From
all of our previous experience in both the CPEP and validation panels,
it is a very difficult, time-consuming and complex process to deal with
the amount of detail required to arrive at reasonable inputs for a
specific procedure. In addition, it takes time for all participants to
achieve a level of comfort with our methodology.
We are accepting most of the recommendations with the exceptions
noted below, but some of the inputs may still need further review. It
does appear that in reviewing the inputs more attention was
understandably paid to the changes proposed by the presenting groups
than to the original CPEP data that we believe could still need
refining. For example, the quantity of supplies associated with many
procedures would appear to need further discussion with a view to
ensuring appropriate standardization among different services. Another
problem lies in the inconsistent assignment in the CPEP data of
equipment to either the procedure-specific or overhead equipment
categories. This process, we acknowledge, has been hampered by the lack
of clear definitions which we hope to correct in the near future.
We would also appreciate more comments and discussion about what
constitutes appropriate clinical staff
[[Page 59395]]
duties and times during the pre-service period. As most of the 65 codes
are related to other codes that have not yet been reviewed by the PEAC
and RUC, we are recommending that, as the group gains more experience
and reviews related codes, this group of codes be reassessed to see if
any further adjustments in inputs are warranted. As an alternative, we
could propose our own changes to these codes in a future proposed rule.
As discussed above, we have deleted a few minor supplies from the
overall CPEP supply list either because of the difficulty in measuring
their use or because the supplies were not fully used up during a
single procedure. Therefore, tissues, biohazard bags, and Lysol spray
have also been deleted from the supplies of these 65 procedures, when
applicable. We also have deleted all separately billable and self-
administrable drugs and casting supplies as described earlier. In
addition, consistent with our policy excluding the CPEP inputs for
clinical staff services for a facility patient, all clinical staff time
in the out of office intra-service period has been eliminated.
Other adjustments that we have applied to these 65 codes, when
relevant, are as follows: We standardized all exam table paper to a
quantity of 7 feet per visit, as that appears to be the most common
quantity reported. We adjusted the quantity of patient gowns and pillow
cases and other supplies to be consistent with the number of visits. We
deleted items that could be considered office supplies or office
equipment. We did not add any suggested equipment that was costed at
less than $500, in order to fit the equipment definition used by Abt.
Because we believe that betadine is only used on the day of a
procedure, we deleted it from post-procedure visits.
Listed below are the 65 codes on which we received RUC
recommendations. We have noted any revisions, other than those
specified above, that we have made to these recommendations. The RUC
recommendations are available on our home page, as discussed earlier.
Access to the homepage is discussed in the introductory section of this
regulation under ADDRESS.
CPT code 17000, Destruction by any method, including laser with or
without surgical curettement, all benign or premalignant lesions other
than skin tags or cutaneous vascular proliferate lesions, including
local anesthesia; first lesion
The RUC forwarded a recommendation for supplies only. We accepted
their recommendation but deleted what appeared to be duplicated gauze
supplies.
CPT code 17003, Destruction by any method, including laser with or
without surgical curettement, all benign or premalignant lesions other
than skin tags or cutaneous vascular proliferate lesions, including
local anesthesia; second through 14 lesions
The RUC forwarded a recommendation only on the supplies for this
service. This is an add-on code, for which there would be few added
supplies since most are contained in the base code. We adjusted the
supply list accordingly. In comments, the society representing
dermatologists had indicated that this CPT code appeared to be over-
valued in comparison with other CPT codes in the family.
CPT code 17004, Destruction by any method, including laser with or
without surgical curettement, all benign or premalignant lesions other
than skin tags or cutaneous vascular proliferate lesions, including
local anesthesia; 15 or more lesions
The RUC forwarded a recommendation only on the supplies for this
service. We accepted the recommendation but deleted what appeared to be
duplicated gauze supplies and the drape sheet.
CPT code 17304, Chemosurgery (Mohs micrographic technique), including
removal of all gross tumor, surgical excision of tissue specimens,
mapping, color coding of specimens, microscopic examination of
specimens by the surgeon, and complete histopathologic preparation;
first stage, fresh tissue technique, up to 5 specimens.
We reviewed and made no changes to the RUC recommendation on
clinical staff at this time. We accepted the recommended additions to
the supply list; however, we removed the Mohs kit listed in the
original CPEP data because it duplicated the pathology supplies that
have been added to the list. For equipment, we moved the doppler,
suction machine, x-ray view box and smoke evacuator from procedure-
specific to overhead equipment because this equipment is used for a
wide range of services and thus fits the definition of overhead
equipment. We deleted the ECG machine from equipment since it is not
needed for this procedure.
CPT code 17305, Chemosurgery (Mohs micrographic technique), including
removal of all gross tumor, surgical excision of tissue specimens,
mapping, color coding of specimens, microscopic examination of
specimens by the surgeon, and complete histopathologic preparation;
second stage, fixed or fresh tissue, up to 5 specimens
We made no changes to the RUC recommendation on clinical staff at
this time. We deleted the Mohs kit from the supplies (as noted in
discussion for CPT code 17304) as well as the sutures, suture kit and
patient education pamphlet because we do not believe they are needed
for each stage of this procedure. We also deleted the nerve stimulator
because it is not typically used for this service. We made the same
adjustments for equipment as we did for CPT code 17304.
CPT code 17306, Chemosurgery (Mohs micrographic technique), including
removal of all gross tumor, surgical excision of tissue specimens,
mapping, color coding of specimens, microscopic examination of
specimens by the surgeon, and complete histopathologic preparation;
third stage, fixed or fresh tissue, up to 5 specimens
We made no changes to the RUC recommendation on clinical staff at
this time. We made the same adjustments in the supply and equipment
lists as made for CPT code 17304.
CPT code 17310, Chemosurgery (Mohs micrographic technique), including
removal of all gross tumor, surgical excision of tissue specimens,
mapping, color coding of specimens, microscopic examination of
specimens by the surgeon, and complete histopathologic preparation;
more than five specimens, fixed or fresh tissue, any stage
We reviewed and made no changes to the RUC recommendation on
clinical staff at this time. We deleted the Mohs kit for the reasons
discussed for CPT code 17304 above. We also deleted gel foam, xylocain
and the syringe from the supply list and all equipment because this is
essentially an add-on code representing an increased number of
specimens and these supplies and the equipment are reflected in the
base code.
CPT code 32000, Thoracentesis, puncture of pleural cavity for
aspiration, initial or subsequent
We reviewed and made no changes to the RUC recommendations for
clinical
[[Page 59396]]
staff time or equipment. We deleted a syringe, xylocain and atropine
from the supply list since these items should be included in the
thoracentesis kit that is also on the supply list.
CPT code 43239, Upper gastrointestinal endoscopy including esophagus,
stomach, and either the duodenum and/or jejenum as appropriate; with
biopsy single or multiple
The RUC made recommendations only on supplies and we accepted them.
CPT code 45330, Sigmoidoscopy, flexible diagnostic, with or without
collection of specimen(s) by brushing or washing (separate procedure)
The RUC made recommendations for supplies only. We accepted the
recommendations with the following adjustments. We decreased the staff
gowns and surgical masks to two items each to reflect that there would
typically only be two staff, a physician and a nurse, involved in this
procedure.
CPT code 56340 Laparoscopy, surgical; cholecystectomy (any method).
Only refinements to clinical staff time were proposed by the RUC.
We reviewed the proposed changes and the original CPEP inputs. While
the RUC proposed changes to the pre-service clinical staff time, we are
not accepting these changes at this time because there was an
inadequate explanation for these changes. We will continue to use the
original CPEP time of 15 minutes for the pre-service clinical staff
time. We also noted that the post-service staff time included two RNs.
Since it is more typical for one RN to assist with patient care during
post-operative visits, we allowed 76 minutes of staff time for one RN
and deleted 25 minutes for a second RN from the original CPEP inputs.
Total staff time is now 91 minutes. This is an interim value, and the
CPT code may be subject to further refinements.
CPT code 58100, Endometrial sampling (biopsy) with or without
endocervical sampling (biopsy), without cervical dilation, any method
(separate procedure)
We reviewed and made no change to the RUC recommendation on
clinical labor or supplies. We deleted the vaginal/surgical procedure
tray from the procedure-specific equipment because it was less than
$500 and the colposcope from the overhead equipment since it is not
typically used for this procedure.
CPT code 65855, Trabeculoplasty by laser surgery, one or more sessions
We made changes based upon review of both the RUC recommendations
and the comments of the American Academy of Ophthalmology (AAO) that
described the practice expense proposals they made to the RUC. We will
continue to use the original CPEP inputs for pre-service clinical staff
time of zero minutes. We accepted the RUC's proposed refinements for
intra-service time in the office, 62 minutes, and post-service time,
82.5 minutes. We also accepted the RUC's proposal for supplies and
equipment. These values were crosswalked to CPT codes 66762, 66770 and
66761 as recommended by the RUC.
CPT code 66170, Fistulization of sclera for glaucoma; trabeculectomy ab
externo in absence of previous surgery
We accepted the RUC's recommendation to value the procedure only in
the facility setting. Based upon review of both the recommendations of
the RUC and the comments of the AAO, we retained the original CPEP
value of zero minutes for pre-service clinical staff time and decreased
the post-service clinical staff time to 247 minutes. We accepted the
recommendations for supplies and deleted the Argon Laser and Hoskins
Lens from equipment because this procedure is performed in the facility
setting only and therefore this equipment is not used in the office for
this procedure. These are interim values and the code may be subject to
further refinement. These values were crosswalked to CPT codes 66150
66155, 66160, and 66165 as recommended by the RUC.
CPT code 66172, Fistulization of sclera for glaucoma; trabeculectomy ab
externo with scarring from previous ocular surgery or trauma (included
injection of antibiotic agents).
This procedure was valued only in the facility setting. Based upon
review of both the recommendations of the RUC and comments from the
AAO, we retained the original CPEP value of zero minutes for pre-
service clinical staff time and decreased the post-service clinical
staff time to 330 minutes. We accepted the RUC's proposals for supplies
and equipment. These are interim values and the code will be subject to
further refinement.
CPT code 66821, Discission of secondary membranous cataract (opacified
posterior lens capsule and/or anterior hyaloid); laser surgery (eg YAG
laser) (one or more stages)
Based upon review of both the recommendations of the RUC and the
comments of the AAO, we retained the original CPEP value of zero
minutes for pre-service clinical staff time, we decreased the post-
service clinical staff time to 55 minutes, and we accepted the RUC
proposed refinement of 37 minutes of intra-service clinical staff time
in the office. We accepted the RUC's proposals for supplies and
equipment. These are interim values and the code may be subject to
further refinement.
CPT code 66984, Extracapsular cataract removal with insertion of
intraocular lens prosthesis (one stage procedure), manual or mechanical
technique (eg, irrigation and aspiration or phacoemulsification).
This procedure was valued only in the facility setting. Based upon
review of both the recommendations of the RUC and the comments of the
AAO, we retained the original CPEP value of zero minutes for pre-
service clinical staff time, and we decreased the post-service clinical
staff time to 110 minutes. We accepted the RUC's proposals for supplies
and equipment. These are interim values and the code will be subject to
further refinement. These adjusted values were crosswalked to CPT codes
66830, 66840, 66850, 66852, 66920, 66983, 66985, and 66986 as
recommended by the RUC.
CPT code 67036, Vitrectomy, mechanical, pars plana approach
This procedure was valued only in the facility setting. Based upon
review of both the recommendations of the RUC and the comments of AAO,
we retained the original CPEP value of zero minutes for pre-service
clinical staff time, and we decreased the post-service clinical staff
time to 124 minutes. We accepted the RUC's proposals for supplies and
equipment. These are interim values and the code will be subject to
further refinement.
CPT code 67038, Vitrectomy, mechanical, pars plana approach; with
epiretinal membrane stripping
This procedure was valued only in the facility setting. Based upon
review of both the recommendations of the RUC and the comments the AAO,
we retained the original CPEP value of zero minutes for pre-service
clinical staff time and we adjusted the post-service clinical staff
time to 220 minutes. We accepted the RUC's proposals for supplies and
equipment. These are interim values and the code will be subject to
further refinement. These adjusted values were crosswalked to CPT codes
67039 and 67040 as recommended by the RUC.
[[Page 59397]]
CPT code 67800, Excision of chalazion; single
Based upon review of both the recommendations of the RUC and the
comments of the AAO, we retained the original CPEP value of zero
minutes of pre-service clinical staff time, and we accepted the RUC's
proposed refinements of 35 minutes for intra-service clinical staff
time and 20 minutes of post-service clinical staff time. We also
accepted their recommendations for supplies and equipment but corrected
typographical errors in the quantity of betadine, irrigation fluid and
sterile towels. These are interim values and the code will be subject
to further refinement. These adjusted values were crosswalked to CPT
codes 67700, 67710, 67715, 677801, 67805, 67810, 67840, 68020, 68040,
68100, 68110, 68115, 68130, 68135, 68440, 68705, and 68760 as
recommended by the RUC.
CPT code 67820, Correction of trichiasis; epilation, by forceps only
This procedure was valued only in the office setting. We accepted
the RUC proposed refinement of 35 minutes for intra-service clinical
staff time. We also accepted the RUC's proposed refinements for
supplies and equipment, except that we decreased the number of sterile
towels and cotton tipped applicators because of typographical errors.
These are interim values and the code will be subject to further
refinement.
CPT code 71020, Radiologic examination, chest, two views, frontal and
lateral
CPT code 72100, Radiologic examination, spine, lumbosacral;
anteroposterior and lateral
CPT code 72170, Radiologic examination, pelvis; anteroposterior only
CPT code 73560, Radiologic examination, knee; one or two views
CPT code 74000, Radiologic examination, abdomen; single anteroposterior
view
CPT code 74020, Radiologic examination, abdomen; complete, including
decubitus and/or erect views
For all these radiologic services we reviewed and made no changes
in the RUC recommendation for clinical staff time. Date stickers and
insert folders were deleted from the medical supplies because these are
considered office supplies. We accepted the RUC recommendation for
equipment except for deleting dictation equipment because it is
considered office equipment and the lead shield because it does not
cost over $500.
CPT code 76519, Ophthalmic biometry by ultrasound echography, A-scan;
with intraocular lens power calculation
We reviewed and made no changes in the RUC recommendations for
clinical staff time or supplies. We moved the printer from procedure-
specific to overhead equipment because it can be used across a range of
services.
CPT code 76700, Echography, abdominal, B-scan and/or real time with
image documentation complete
The RUC made recommendations only on supplies and, after reviewing,
we made no changes to their recommendations.
CPT code 85060, Blood smear, peripheral, interpretation by physician
with written report
CPT code 85097, Bone marrow, smear interpretation only, with or without
differential cell count
Since these are professional services only, all clinical staff
time, supplies, and equipment were deleted. Practice expenses are
included for payment with other applicable CPT codes and, if practice
expense inputs were included here, would result in a duplicate payment.
CPT code 88104, Cytopathology, fluids, washings or brushings, except
cervical or vaginal; smears with interpretation
We made no changes in the clinical staff time, but made a minor
revision to the supplies listed. We deleted the marking pen from the
supplies because the cost per procedure was negligible and deleted the
metal slide storage cabinet from overhead equipment because it is
considered furniture.
CPT code 88304, Level III--Surgical pathology, gross and microscopic
examination
CPT code 88305, Level IV--Surgical pathology, gross and microscopic
examination
We made no changes in the clinical staff time, but made a minor
revision to the supply list. We deleted the marking pen from the
supplies because the cost per procedure was negligible, and deleted the
metal slide storage cabinet and the plastic block storage cabinet from
overhead equipment because these items are considered furniture. We
also deleted the Stryker saw which is not typically used with these
procedures.
CPT code 88312, Special stains; Group I for microorganisms, each
We reviewed and made no changes to the RUC recommendations for
clinical labor, equipment and supplies.
CPT code 92004, Ophthalmological services; medical examination and
evaluation with initiation of diagnostic and treatment program;
comprehensive, new patient, one or more visits
The RUC recommendation was for supplies only; we accepted the
recommendation except for deleting the betadine from the supply list
because it would not be used during an eye examination.
CPT code 92012, Ophthalmological services; medical examination and
evaluation with initiation or continuation of diagnostic and treatment
program; intermediate, established patient
CPT code 92014, Ophthalmological services; medical examination and
evaluation with initiation or continuation of diagnostic and treatment
program; comprehensive, established patient, one or more visits
The RUC recommendation was for supplies only; we accepted this
recommendation, except for deleting the betadine from the supply list
because it would not be used during an eye examination. We also deleted
the patient education pamphlet and contact lens solution to be
consistent with comments from the American Academy of Ophthalmology.
CPT code 92083, Visual field examination, unilateral or bilateral, with
interpretation and report; extended examination
We reviewed and made no changes to the RUC recommendations for
clinical staff time or equipment. We deleted the black pins from the
supply list because they are a reusable supply. These adjusted values
were crosswalked to CPT code 92081 and 92082 as recommended by the RUC.
CPT code 92235, Fluorescein angiography (includes multiframe imaging)
with interpretation and report
We reviewed and made no change to the RUC recommendations on
supplies. For equipment, we deleted the electric table because a
reclining exam chair is also included and both are not needed for this
procedure.
CPT code 92240, Indocyanine-green angiography (includes multiframe
imaging) with interpretation and report
We received RUC recommendations on equipment only. We deleted the
[[Page 59398]]
electric table because a reclining exam chair is also included and both
would not be used for a given service.
CPT code 92250, Fundus photography with interpretation and report
We received a RUC recommendation on equipment only. We deleted the
electric table because a reclining exam chair is also included and both
are not needed for a given service. These adjusted values were
crosswalked to CPT code 92230 as recommended by the RUC.
CPT code 92507, Treatment of speech, language , voice, communication,
and/or auditory processing disorder (includes aural rehabilitation);
individual
CPT code 92526, Treatment of swallowing dysfunction and/or oral
function for feeding
CPT code 92585, Auditory evoked potentials for evoked response
audiometry and/or testing of the central nervous system
We reviewed and made no change to the clinical staff time
recommended by the RUC. However, we did not increase the wage rate for
the audiologist as suggested by the RUC because we will address this
issue globally for all staff types during refinement.
CPT code 93307, Echocardiography, transthoracic, real-time with image
documentation (2D) with or without M-mode recording; complete
The RUC made recommendations only for supplies that we reviewed and
made no changes.
CPT code 93320, Doppler echocardiography, pulsed wave and/or continuous
wave with spectral display ; complete
A comment accompanying the RUC recommendation stated that this is
an add-on code and questioned whether the RUC recommended equipment
should be included. Because the cost of the equipment is reflected in
the values for the base code, we have deleted all the equipment listed
for this service.
CPT code 94010, Spirometry, including graphic record, total and timed
vital capacity, expiratory flow rate measurement(s), with or without
maximal voluntary ventilation
We reviewed and made no changes to the RUC recommendations for
clinical labor, supplies or equipment.
CPT code 95819, Electroencephalogram (EEG) including recording awake
and asleep, with hyperventilation and/or photic stimulation
We reviewed and made no changes to the RUC's clinical labor
recommendations. We deleted the following items from the list of
supplies: printer toner cartridge, since this is an office expense; the
skin marking pen because the cost per procedure is negligible; the
nasopharyngeal-electrode because it is not typically used with this
procedure; and seconal and chloral hydrate since these are drugs that
are not paid under the physician fee schedule. We moved the pulse
oximeter from procedure-specific to overhead equipment because it can
be used for a wide range of services and deleted the exam table because
an electric bed is included with the equipment and both would not be
needed for a given service.
CPT code 95860, Needle electromyography, one extremity with or without
relaxed paraspinal areas
We reviewed and made no changes to the RUC's clinical labor
recommendations. For supplies, we deleted the sharps container and
blood medical waste bag since they are not disposed of after only one
procedure. We also substituted the ENG electrode needle for the
concentric ENG needle electrode because it is more typically used for
this procedure. For equipment, we moved the hydrocollator from
procedure-specific to overhead equipment because it is used for a wide
range of services.
CPT code 95900, Nerve conduction, amplitude and latency/velocity study,
each nerve, any /all site(s) along the nerve; motor, without F-wave
study
CPT code 95904, Nerve conduction, amplitude and latency/velocity study,
each nerve, any /all site(s) along the nerve; sensory
We reviewed and made no changes to the RUC's clinical labor
recommendations. For supplies, we deleted the skin marking pen and the
stimulator bar electrode and pick-up electrodes because they are not
disposable supplies. For equipment, we moved the hydrocollator from
procedure-specific to overhead equipment because it is used for a wide
range of services.
CPT code 97022, Application of a modality to one or more areas;
whirlpool
Based on a review of the RUC recommendation and the original CPEP
data, we are using the original CPEP staff time of 31 minutes in the
intra-service period because the RUC recommended set-up time of 13
minutes is excessive. For supplies, we deleted the sterile drape,
culterette and culture media because they are rarely used for this
procedure, and we are deleting the patient education booklet because
this procedure would be performed on the same patient more than once
and a booklet would not be required at each session. We deleted the
hilo table and hoyer lift from the equipment because they are not
typically used for the service.
CPT code 97035, Application of a modality to one or more areas;
ultrasound, each 15 minutes
We reviewed and made no changes to the RUC's clinical staff time
recommendation. However, we deleted the patient education booklet from
supplies because it is not provided with every treatment. We also
deleted the utility cart from equipment because the cost was under
$500.
CPT code 97110, Therapeutic procedure, one or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range
of motion and flexibility
We made no changes to the RUC's clinical staff time recommendation.
However, from the supply list we deleted the patient education booklet,
because it would not be provided at each therapeutic session, as well
as tape and ace bandage because they are not typically used. For
equipment, the RUC recommendation suggested 50 percent utilization for
the isokinetic strengthening equipment and the therapeutic exercise
equipment set. We have instead assumed 100 percent utilization of the
therapeutic exercise equipment as it is much more typically used than
the isokinetic equipment. We also deleted the hilo table because there
is another table listed in the equipment and only one or the other
would be used for a specific procedure.
CPT code 97530, Therapeutic activities, direct (one on one) patient
contact by the provider (use of dynamic activities to improve
functional performance); each 15 minutes
We reviewed and made no changes to the RUC's clinical staff time
recommendation. However, we deleted the patient education booklet, as
well as tape and ace bandage, from supplies, because they are not
typically used. For equipment, the RUC recommendation suggested 50
percent utilization for the isokinetic strengthening equipment and the
therapeutic exercise equipment set.
[[Page 59399]]
We have instead used 100 percent utilization of the therapeutic
exercise equipment as it is much more typically used. We also deleted
the hilo table and the low mat table because the patient would
typically be standing during this service.
The RUC also forwarded to us recommendations for the CPEP inputs
for the following services:
CPT code 11100, Biopsy of skin, subcutaneous tissue and/or mucous
membrane (including simple closure), unless otherwise listed (separate
procedure); single,
CPT code 52647, Non-contact laser coagulation of prostate, including
control of postoperative bleeding, complete (vasectomy, meatotomy,
cystourethroscopy, urethral calibration and/or dilation, and internal
urethrotomy are included),
CPT code 53850, Transurethral destruction of prostate tissue; by
microwave thermotherapy,
CPT code 53852, Transurethral destruction of prostate tissue; by
radiofrequency thermotherapy,
CPT code 64721, Neuroplasty and/or transposition; median nerve at
carpal tunnel,
CPT code 96408, Chemotherapy administration, intravenous; push
technique, and
CPT code 96410, Chemotherapy administration, intravenous; infusion
technique, up to one hour.
Since many of the changes proposed for these CPT codes included
items not typically used for the procedures, duplicate inputs,
inconsistent inputs or extensive additional in-office inputs for
services currently only costed in the facility setting, we have
concluded that further review is required before the proposed changes
can be adopted or rejected. Therefore, the original CPEP inputs will
remain unchanged. We solicit comments on these CPT codes to assist us
with those refinements.
Physicians' Clinical Staff in the Facility Setting
In the ``top-down'' methodology set forth in the 1998 regulation,
we used the raw CPEP inputs without applying edits to any of the data,
and the staff time allotted to the use of clinical staff in the
facility setting was therefore included. In our July 1999 rule, we
proposed to exclude from the raw CPEP data all clinical staff time in
the facility setting. The CPEP data is used in our methodology solely
to allocate the specialty-specific practice expense pools to the
individual CPT codes. We proposed to exclude this clinical staff time
for the following reasons: (1) Medicare should not pay twice for the
same service; (2) It is not typical practice for most specialties to
use their own staff in the facility setting; (3) Inclusion of these
costs is arguably inconsistent with both the law and Medicare
regulations. We believe these reasons strongly support not including
the costs of physicians' clinical staff used in the facility setting in
the calculation of practice expense values. However, in the proposed
rule, we invited comments on this issue and particularly solicited
information about any possible instances where it would be appropriate
to include data on the use of a physician's clinical staff in the
facility setting.
Comment: Several commenters, from the American Hospital Association
(AHA) and other hospital trade groups, as well as from several
physician specialty societies, believe we have correctly determined
that it is not a typical practice for physicians to bring their own
staff to the hospital. The AHA commented that 1,459 hospitals in the
National Hospital Panel Survey were surveyed on physician practices in
their institutions. They believe the Panel Survey ensures reliable
national estimates by stratifying hospitals according to size and
randomly selecting from each stratum in each of the nine census regions
in disproportionately larger numbers as bed size increases. There were
573 responses to the survey. They stated that, though 63 percent of the
hospitals surveyed answered that at some time in the last 6 months a
physician brought his or her own staff to the hospital, only 11 percent
of all responding hospitals said this was a regular practice. Two
primary care specialty groups agreed that it is not typical for
physicians to use their own clinical staff in the facility setting. One
specialty group representing urologists acknowledged that a survey of
its physician membership showed that less than 15 percent of its
members take their clinical staff to facility settings.
We also received many comments that took issue with the argument in
the proposed rule that it is not typical practice for most specialties
to use their own staff in the facility setting. Several commenters
questioned the validity of the AHA survey. Some commenters argued that
the category ``not a regular practice'' in the AHA survey was ambiguous
because a negative answer to the question could mean either that no
physicians regularly brought staff to the hospital or that only certain
specialties, such as cardiothoracic surgeons or anesthesiologists,
regularly brought staff to the hospital. Another specialty society
commented that the AHA survey provides no basis for concluding that
cardiothoracic surgeons do not bring their staff into the hospital
because less than 25 percent of the hospitals in the U.S. provide open
heart surgery.
Many commenters merely stated, with no data to support their view,
that it is common for their particular specialty to bring nurses or
physician assistants with them to the facility to prepare the patient
for surgery, assist during the procedure, and provide post-operative
care. Other commenters referred to the results of one or more surveys
that would indicate use of physicians' clinical staff in the facility
setting, but did not include a copy of the survey or provide any
details of the survey methodology, the sample used, or the questions
asked. An organization representing neurosurgery referred to data
collected by their society that suggests that between 40 and 60 percent
of practices in the mid-West and South Central regions of the country
use their employed clinical staff in the hospital. One organization
representing a sub-specialty of cardiology cited a survey of its
members that indicated that 55 percent of its members follow the
practice of bringing staff to the hospital for purposes of patient
education when performing such procedures as electrophysiology studies,
pacing procedures and ablations. The commenter contended that hospital
nurses are not knowledgeable enough about the above procedures to talk
comprehensively with patients or families.
Two specialty societies provided more extensive information
regarding survey data on the use of clinical staff in the facility
setting. The American Society of Anesthesiologists (ASA) stated that
the ASA surveyed 220 anesthesia practice managers in August of this
year. The survey referenced the fact that our proposed rule proposed to
exclude from CPEP data the costs of clinical staff in the facility
partly because of our belief that it was not typical and asked
respondents if their practice used any of their own staff, excluding
those who can bill separately, in the facility setting. The commenter
reported that with a 65 percent response rate, 40 percent of the
managers reported that they did use clinical staff in the facility
setting. ASA further stated that a 1997 Abt survey for the ASA
suggested that many anesthesia practices employ clinical staff with a
mean of 0.32 employees per practice; this total included a mean of 0.19
[[Page 59400]]
registered nurses and 0.04 anesthesia technicians. The commenter also
argued that the typical cost criterion does not rest on any statutory
footing and that allowances for practice expenses should be based on
average cost rather than typical cost. The STS referred to surveys
undertaken by the American Association of Physician Assistants and the
Association of Physician Assistants in Cardiovascular Surgery that
report physician assistants (PAs) are involved in at least 200,000
cardiac cases a year, that almost all these PAs have responsibilities
in the operating room, and 85 percent are involved in postoperative
care in the hospital.
Response: We want to make it clear that we are not asserting that
physicians never bring their own clinical staff into the facility
setting or that this practice may not be more common among some
specialties than among others. However, as stated in the proposed rule,
we have not seen sufficient data to convince us that the use of the
physician's clinical staff in the facility setting is a typical
practice.
The search for sufficient data did not start with the proposal in
this year's proposed rule. Rather, the inclusion by most of the CPEP
panels of varying amounts of inputs for clinical staff in the facility
setting has been controversial from the start. While many medical
specialties insist that the physicians' practice of bringing staff to
the hospital is common, other specialties indicate that this is not a
typical practice.
In our Notice of Intent to Regulate published on October 31, 1997,
we stated that there seemed to be some question of whether the practice
of bringing a physician's staff to a facility was, in fact, common and
widespread. We explicitly solicited information about this practice. We
asked for comments about the extent to which the practice occurs,
procedures involved, functions performed, type of staff employed, and
staff training and credentialling. We specifically requested the name,
location and characteristics of any facility where this practice
occurred and the facility's requirements for credentialling the staff,
including any limits on duties of the staff by the facility. In
addition, we requested that where surveys had been conducted to
document this practice, we wanted to receive copies of the surveys and
results, including such details as the survey methodology and sampling
design.
The response to this request for information was sparse. We
received only 16 responses to this issue, most were anecdotal without
any specific information. Only two comments from specialty societies
included information from surveys or objective sources. The American
Academy of Ophthalmology (AAO) surveyed 300 ophthalmologists and
reported that 45 percent of the respondents said they utilized staff
out of the office. There was no information on the sample size,
composition, or response rate. In addition, the information on the
frequency of this practice was not clear. It appears from the
information provided that a large portion of those who brought their
own staff into the facility did so less than 100, and many probably
less than 50, times a year. The STS included the PA surveys that are a
part of their current comments from which they drew indirect inferences
regarding the use of physicians' staff in the facility setting.
However, neither the AAO nor the STS surveys answered the specific
questions asked in the Notice.
In December 1997, we received a copy of the AHA survey mentioned
above that indicated that only 11 percent of the hospitals that
responded to the survey said that it was a regular practice for
physicians to bring their staff into the facility. We compared the
results of the AHA survey with the AMA's 1996 SMS survey of physicians
that included responses from 153 surgeons and obstetricians and
gynecologists about the use of clinical staff in the facility setting
and found that the findings correlated closely. In answer to the
question, ``When the physician provides services in the hospital how
often is he or she assisted by non-physician personnel employed by the
physician's practice?,'' only 11 percent of the physicians answered
``always.'' In contrast, 68 percent answered ``never'' and another 9
percent ``occasionally.'' Equally important, in answer to the question,
``Are these non-physician personnel reimbursed by the hospital,
reimbursed by a third party or are they paid directly by the practice
for services provided in the hospital?,'' 38 percent of those who
brought their staff to the facility answered ``reimbursed by
hospital,'' and only 51 percent said they were paid by the practice.
Therefore, it was both the absence of requested data that could
actually demonstrate that it was typical for physicians to bring their
staff to the hospital, as well as existence of data that strongly
indicated that this indeed was not a typical practice, that has led us
to the conclusion that it is indeed not typical for physicians to bring
their staff to a facility.
The only hard data supplied to us in the comments on the proposed
rule were provided by the ASA and STS. The ASA reported the results of
two surveys. The Abt study reported a mean of 0.32 full time equivalent
(FTE) total clinical staff per practice, of which 0.19 FTE were
registered nurses and only 0.04 FTE were anesthesia technicians. These
relatively low numbers of clinical staff per practice would actually
seem to support a conclusion that it is not typical to bring these
staff to the hospital. The ASA also conducted their own study of 220
anesthesia practice managers. With a 65 percent response rate, about 40
percent of the respondents indicated that their practice employed
clinical support personnel who were not eligible for direct
reimbursement. There is, however, no indication in their comment about
what this staff is doing and where they are doing it. In addition, this
survey actually shows that 60 percent of practices do not employ
clinical staff; therefore, this is not a typical practice. Apparently
aware of this, the ASA argues that the typicality standard ``merely
derives from the original studies undertaken as part of the development
of physician work values when the Fee Schedule was initiated.'' The ASA
then contends that we should base our practice expense on the cost of
the average patient, not the typical patient. The ASA is correct that
all of the RVUs, both work and practice expense, have been based on the
services provided to the typical patient. Though we would be willing to
discuss in the future the merits of using the typical versus the
average patient for certain practice expense categories, we do not
believe that the costs of an average patient would be meaningful
regarding the use of clinical staff in the facility setting when there
is such obvious inconsistency in practice patterns. All the use of the
cost of an average patient would accomplish would be to consistently
underpay some, while consistently overpaying others.
As stated above, while STS submitted surveys compiled by two PA
organizations, no information was included regarding the use of nurses
in the facility setting. From the submitted surveys, it would appear
that cardiovascular PAs are very active in the hospital setting. For
example, the surveys showed that almost all cardiovascular PAs assist
in the operating room. The problem with the submitted data is that,
because PAs are eligible for direct reimbursement from Medicare, the
physicians' costs associated with PAs cannot, in general, be considered
practice expense. The same would be true of nurse practitioners.
[[Page 59401]]
After reviewing all the available data, we remain convinced that
our position in the proposed rule was correct: it is not a typical
practice for physicians to bring their own staff into the facility
setting.
Comment: We received only a few comments in response to our
statement in the proposed rule that Medicare should not pay twice for
the same service and that this was a major reason to exclude the
clinical staff time for physicians' staff used in the facility setting
from the CPEP data. Two groups contended that, to the extent that Part
A is paying for the cost of clinical staff brought to the hospital by
the physician, we should take measures to see that Part A monies are
shifted to Part B. Two other organizations took issue with our
statement that, because the hospital is already paid for providing all
nursing care to its patients, the inclusion of the costs of physicians'
clinical staff in calculating the practice expense RVUs would amount to
paying twice for the same service. These commenters claimed that
because hospital payments are reweighted annually to reflect changes in
costs and charges, these facilities are not being reimbursed for the
costs of clinical staff that physicians now bring themselves to the
facilities.
The STS argued that, though our observation in the proposed rule
that there is separate Part B reimbursement for a PA acting as an
assistant-at-surgery is generally true, this is not true in the
academic setting where a resident is available, nor in California where
state law requires that two physicians be present for every case. The
commenters also raised the more general point that PAs are also used in
the office setting and point out that 15,000 PAs are employed in family
practice, either billing directly or being included as ``incident to''
physicians' services. The commenters asked why we have not raised this
issue more broadly across all specialties and suggested that we could
better eliminate duplicate payment for these clinical services by
reducing the SMS specialty pools by the amount of income received for
staff who can bill directly to Medicare.
In response to our statement that much of the time claimed for
clinical staff in the facility for making patient rounds is really a
substitute for physician work, the STS states that the Congress and the
government have explicitly encouraged the use of such physician
extenders. The commenter conceded that it is possible that the work
RVUs may need to be adjusted for all specialties, but added that it is
not clear what activities are a substitute for physician work and which
are added services. Finally, STS argued that excluding hospital-related
clinical staff costs from CPEP data because they are not otherwise
covered services or because they are separately reimbursable without
taking similar action for all other CPEP inputs with similar
characteristics is discriminatory.
Response: In the proposed rule we stated our belief that the duties
that were being attributed by many specialties to physicians' clinical
staff in the facility setting were already paid for by Medicare through
a mechanism other than physician expense. For example, an assistant at
surgery can be paid separately. In addition, we already pay the
facility to provide all nursing care to the facility patient whether
that nurse is acting as a scrub nurse or monitoring a patient
undergoing conscious sedation. We also pointed out that reviewing
charts, making patient rounds or pulling chest tubes are physicians'
services that are paid for through the physician work RVUs.
In response to the comment that we should shift Part A monies to
Part B so that a double payment would not be made, we believe this
implies that we should adjust inpatient hospital PPS rates to remove
costs associated with clinical staff brought to the hospital by
physicians. We do not believe that such an adjustment is consistent
with section 1886(d)(2)(C) of the Act which prescribes the methodology
for standardizing PPS base year costs and calculating PPS rates for
each fiscal year. We disagree with the comment that annual reweighting
of hospital costs and charges means that hospitals are not being
reimbursed for staff allegedly replaced by the clinic staff physicians
bring to hospitals. The relative weights which determine payment for a
diagnostic related group (DRG) are reweighted annually based on
hospital charges. However, this only affects the relative payment for
each DRG. Payment would continue to be included in the PPS rates unless
a specific adjustment were made to remove these costs. As stated above,
we do not believe such an adjustment is consistent with section
1886(d)(2)(C) of the Act.
The STS made several interesting points in their comments, and we
will respond to each. STS conceded that a PA acting as an assistant-at-
surgery can be separately paid, but not when another doctor is there to
assist. The STS did not clarify why the use of a PA would be necessary
in such a situation or why, if a PA is used, Medicare should recognize
any such extra costs. We believe that the STS has raised a valid issue
about the general use of physician extenders across all specialties. It
is true that in our proposed rule we only addressed the possible
substitution of nonphysician practitioners' work for physician work in
the facility setting for all specialties. It is not possible in the
CPEP data to readily identify in office setting what clinical staff
time might be a substitute for physician work or what staff is eligible
for separate payment. It was relatively rare for the CPEP panels to
identify a PA or nurse practitioner as the clinical staff type in the
office setting. However, this is clearly an issue that we intend to
address during the refinement process. In addition, as specific in-
office codes are refined, either by us or by the PEAC and RUC, the
question of possible duplication of physician work should be raised for
all services.
The STS also suggests adjustment of the SMS data to account for
staff that may bill directly. As we noted above, we have asked our
contractor to determine which specialties' SMS data may be affected by
inclusion of mid-level practitioners in specialty survey cost data and
to develop alternative methodologies to address it. It should also be
noted that the practice-level SMS survey that is in development breaks
out the costs for clinical staff who are eligible for direct payment.
Regarding the commenter's argument that we are acting in a
discriminatory manner unless we exclude from the CPEP data all inputs
that are separately billable or not covered, we are attempting to do
just that. In last year's final rule, we used the raw CPEP data and
made no modifications for any separately billable or non-covered CPEP
inputs. However, we have in this final rule identified separately
billable supplies, such as drugs and casting materials, and have
excluded these from the CPEP data. We have also excluded self-
administered drugs from the supply list because they are not covered by
Medicare. We invite comments about any other inputs currently in our
CPEP database that fall into either category.
After reviewing the comments on this issue, we continue to believe
that including in CPEP data the costs of physicians' clinical staff in
the facility setting would represent a duplicate payment that Medicare
should not make.
Comment: We also stated in the proposed rule that inclusion in CPEP
data of the costs of clinical staff brought into the facility is
arguably inconsistent with both the law and Medicare regulations. No
commenter directly challenged this contention. However, several groups
stated the general concern that the elimination of clinical staff costs
from the CPEP data
[[Page 59402]]
contradicts the intent of section 4505(d) of the BBA that specifically
states that, in developing such units, the Secretary shall utilize to
the maximum extent practicable, generally accepted cost accounting
principles which recognize all staff, equipment, supplies, and
expenses, not just those which can be tied to specific procedures. The
STS submitted an extensive comment on this point which stated that even
if it were true that the clinical staff costs would be excluded from
coverage under Medicare if physicians sought to bill separately for
those services, the point is irrelevant and inconsistent with the
statutory language and the history of the practice expense provisions.
The comment stated that the Congress defined the term practice expense
as ``all expenses for furnishing physicians'' services, excluding
malpractice expenses, physician compensation, and other physician
fringe benefits.'' The STS concluded that nothing in these definitions
requires or even permits the agency to carve out from practice expenses
RVU costs that would not be covered services on their own or that are
separately reimbursable under Medicare. The commenter added that, to
the contrary, the agency's mandate is to identify all practice expenses
incurred by physicians in their practice and then to allocate all of
those costs to particular procedures.
Response: We believe that a reading of both the law and Medicare
regulations leads to the conclusion that no payment should be made
under the physician fee schedule that is attributable to the costs of
physicians' clinical staff used in the facility setting.
Section 1862(a)(14) of the Act which discusses exclusions
from coverage states that,
``Notwithstanding any other provision of this title, no payment may
be made under part A or part B * * * for any expenses incurred for
items or services which are other than physicians' services (as defined
in regulations promulgated specifically for purposes of this paragraph)
* * * and which are furnished to an individual who is a patient of a
hospital * * * by an entity other than the hospital * * * unless the
services are furnished under arrangements. * * *''
(This section also exempts services of physician assistants, nurse
practitioners, clinical nurse specialists, certified nurse-midwife
services, qualified psychologist services, and services of certified
registered nurse anesthetists from the above exclusion.)
In Sec. 411.15 (Particular Services Excluded from
Coverage) subparagraph (m)(1), the text paraphrases the above provision
for hospital inpatients and adds that ``services subject to exclusion
under this paragraph include * * * services incident to physicians'
services.'' Section 411.15(m)(2) implements the exceptions to this
exclusion, among them ``physician services that meet the criteria of
Sec. 415.102(a) of this chapter for payment on a reasonable charge or
fee schedule basis.''
Section 415.102(a) contains the definition of physicians'
services required by section 1862(a)(14) of the Act and the criteria
referred to in Sec. 411.15(m) above: ``If the physician furnishes
services to beneficiaries in providers, the carrier pays on a fee
schedule basis provided the following requirements are met: (1) The
services are personally furnished for an individual beneficiary by a
physician. (2) The services contribute directly to the diagnosis or
treatment of an individual beneficiary. (3) The services ordinarily
require performance by a physician.''
On September 8, 1998, we published a proposed rule on a
prospective payment system for hospital outpatient services (63 FR
47552). This rule proposed to add Sec. 410.39 which embodies in
regulation for the hospital outpatient setting the exclusion in
Sec. 411.15 described above. Section 410.39(c) would exempt from the
exclusion physicians' services that meet the requirements of
Sec. 415.102(a) as described above, physician assistant, nurse
practitioner, clinical nurse specialist, certified nurse midwife, and
qualified psychologist services, as well as services of an anesthetist.
A reading of all of the above suggests that no payment should be
made under the physician fee schedule that reflects the costs of
physicians' clinical staff used in the hospital setting. Services
performed by nonphysician clinical staff do not fulfill the definition
of services personally furnished by a physician, and, therefore, the
exception to the exclusion for the physicians' services created by
section 1862(a)(14) of the Act does not apply. In addition, nursing
services, such as those performed by a scrub nurse working for a
physician, do not ordinarily require performance by a physician and,
thus, are not physicians' services for the purpose of section
1862(a)(14) of the Act. Finally, services ``incident to a physician's
service'' are explicitly excluded from coverage in the hospital setting
by Sec. 411.15(m)(1).
As stated above, we received no comments that directly addressed
our reading of the statute and regulations. The commenters merely cited
the requirement of the BBA that we should utilize generally accepted
cost accounting principles which recognize all staff, equipment,
supplies, and expenses, not just those which can be tied to specific
procedures. We believe that this section of the BBA, with its reference
to the recognition of costs that are not tied to specific procedures,
is primarily directed at our prior methodology of computing indirect
costs; this section of the law does not supersede other provisions of
the law or regulations governing Medicare payment. Nor is there any
indication that the BBA was intended to prevent us from excluding
noncovered or otherwise paid for services as allocators of direct
practice expense. We are still convinced that the inclusion of the
costs of clinical staff brought into the facility setting is
inconsistent with the law and Medicare regulations.
Comment: Several groups commented that there are appropriate
services that clinical staff in the physician's office do perform for
facility patients that are typical, are not paid for by Medicare under
any other mechanism, and that would be permitted by our regulations.
For example, clinical staff may help with arranging a psychiatric
admission to the hospital, may make follow-up telephone calls to
patients to give post-surgical instruction on drugs or pain management,
or may give other clinical guidance to the patient or patient's family.
The comments recommended that these clinical staff services be included
as direct inputs in the facility setting.
Response: We agree that there may be some clinical tasks that
clinical staff in the office can appropriately perform for a facility
patient. There first needs to be a general discussion about what are
the appropriate clinical tasks that clinical staff might perform during
each of the different global periods. (For example, we would not
consider scheduling tests or procedures to be a clinical task but an
administrative task and most of the CPEP panels assigned time for a
scheduling secretary.) We would also like to obtain a general consensus
about what are reasonable parameters for the times it takes to perform
these clinical tasks. Once there is a general approach to this issue,
we would consider recommendations for specific services. We welcome
general comments on this issue; it would also seem to be an appropriate
topic for discussion for the PEAC and RUC.
Comment: Several commenters recommended that we delay
implementation of this proposal until further data could be collected.
Some of the commenters suggested that the PEAC or our contractors help
resolve
[[Page 59403]]
the issue of including within practice expense inputs physicians'
clinical staff time in a facility. Another group of commenters advised
HCFA to survey physicians to identify the extent to which physicians
use their own staff to provide services in facilities and their reasons
for doing so. The AMA asked us to defer action on this proposal until
the physician fee schedule final rule for 2001 because specialty groups
have been given no opportunity for meaningful review of the
reasonableness of the approach or its impacts. Other organizations
suggested that we proceed with the proposal but allow affected
specialty groups to present survey data on this issue to the PEAC to
justify whether any of these costs should be included in the CPEP data.
Response: We do not plan to delay implementation of our proposal to
exclude the costs of physicians' clinical staff used in the facility
setting from the CPEP inputs. We have reviewed and analyzed the
submitted comments and continue to believe that the policy in our
proposed rule on this issue is correct. Though the PEAC is free to
discuss the issue of clinical staff in the facility setting if they so
choose, we have the ultimate responsibility for making a decision on
this basic policy issue. We will implement this proposal and will use
the adjusted CPEP data in the calculation of the practice expense RVUs
for the year 2000 physician fee schedule.
Physician Time
Pediatric Surgery Physician Time Data
The physician time assigned to pediatric surgery codes was based on
erroneously low time data from the original Harvard study, rather than
on later data from the study of pediatric services performed by the
same Harvard study team for the American Pediatric Surgical Association
(APSA) in 1992. We proposed updating the physician times for these 48
pediatric surgical services upon receipt of the needed data.
Comment: The APSA and the American College of Surgeons have
forwarded to us the updated physician times for 48 pediatric surgical
services and have requested that we use the times for the calculation
of the practice expense pools that contain these services. Included
with the comments is a detailed report entitled, ``Pediatric Surgery
and the Medicare Fee Schedule for Physicians' Services: History,
Analysis and Correction of Data on Physician Work and Physician Time.''
This request is supported by comments from the American Urological
Association and the American Academy of Pediatrics.
Response: We have substituted the revised times for these pediatric
surgical services into our physician time database and will use them in
all of our practice expense calculations.
Physical Therapy and Occupational Therapy Times
We had received comments indicating the times for the physical
therapy codes (CPT 97001 through 97770) contained in the November 1998
final rule were too low due to the fact that only intra-service times
were used. We agreed that it was appropriate to include some preservice
and postservice times for these procedures and proposed adjusting the
total code-specific times used to create the practice expense pools as
shown in Table 6 ``Revised Times for CPT codes 97001 through 97770'' in
the July 1999 proposed rule.
Comment: Two major organizations commended us for recognizing that
it is appropriate to include pre-service and post-service time and for
adjusting the RVUs to reflect this time. However, they wanted us to use
the times identified by the expert panel established by the American
Physical Therapy Association (APTA) for CPT codes 97001 through 97770.
They considered such times to more accurately reflect the times
associated with each code.
Response: We carefully evaluated the expert panel's submitted time
for CPT codes 97001 through 97770 and used it in collaboration with our
staff physicians' medical judgment to adjust the practice expense RVUs
for these codes. The times as adjusted reflect nonduplicated pre- and
post-service times that may occur when multiple services are provided
during the same therapy session. The APTA acknowledged the potential
for such overlap in commenting on our proposed rule.
Comment: The American Occupational Therapy Association was pleased
that we agreed to revise the occupational therapy times to include some
pre- and post-service times for the physical medicine and
rehabilitation CPT codes and the RUC surveyed intra-service time for
the occupational therapy evaluation and occupational therapy re-
evaluation CPT codes (97003 and 97004, respectively).
Response: We appreciate the association's comment.
Comment: An association representing physical therapists
recommended that we include additional times for two CPT codes that
were not reflected in the proposed rule. It was recommended that we use
a 20 minute time period for new CPT code 97140. In addition, the
association stated that CPT code 97150 should be added with a typical
group session of approximately 45 minutes and pre- and post-time.
Response: We are not clear about the commenter's statement that CPT
codes 97140 and 97150 were not reflected in the proposed rule. These
codes were listed in Addendum B of the proposed rule. We cannot adopt
the recommendation to treat code 97140 as a 20 minute code. When the
AMA added 97140 to the CPT codes in 1999, it defined it as a 15 minute
code. Therefore, we cannot comply with commenter's request to increase
the code's time to 20 minutes. After reviewing the comment for CPT code
97150, we have decided to refer it for close examination during the
five year refinement process.
RUC Time Database
The primary sources for the physician time data used in creating
the specialty-specific practice expense pools are the surveys done for
the initial establishment of the work RVUs and the surveys submitted to
the AMA's RUC. Some of the times used for the November 1998 final rule
differed from the official RUC database. We indicated in the proposed
rule that we plan to use the times from the verified database, in
conjunction with the Harvard times, as the basis for determining
physician times.
Comment: The AMA has submitted a database that contains verified
physician times for those codes considered by the RUC. However,
according to a letter received September 30, 1999 from the RUC, there
are certain complications in trying to calculate total physician time
for the global surgical codes. The letter states: ``* * * it became
apparent that a key assumption would need to be made about the E/M time
for each office visit included in a global surgical period. At the most
recent RUC meeting, it became apparent that there is not an obvious
standard for this data element. * * * It is apparent that this is an
issue of real importance and we will, therefore, place this issue back
on the RUC's agenda for next year. However, we will be unable, at this
time, to provide `total time calculations' for many of the codes in the
RUC database, as we have not yet agreed on the most appropriate E/M
time to be utilized in the calculations of the codes with global
surgical periods.''
Response: We believe that it would not be appropriate to utilize
the submitted RUC database until the RUC resolves the question of the
E/M time
[[Page 59404]]
assigned to global surgical visits. The premature use of this data
could potentially have unwarranted negative impacts on the specialties
that perform these global services. Therefore, we will use the current
time database as part of the calculation of the practice expense pools.
Comment: One association commented that our adjustments to the
physician time data as described in the 1998 Physician Fee Schedule
final rule seem arbitrary and premature and decreased the time for
urologic endoscopic procedures by a factor of 0.979. The commenter
recommended that we dispense with these adjustments until the
contractor has a chance to review the time data. A surgical association
recommended that the unadjusted RUC or Harvard times be used in our
practice expense calculations because the adjustments were arbitrary;
for example the time for E/M codes was increased by 4 to 6 percent
which has a serious impact. The commenter included a lengthy technical
attachment entitled, ``Are Physician Time Data Correct?'' A primary
care organization also stated it is not convinced that our decision to
adjust the Harvard time data to ensure consistency between the RUC and
Harvard data is appropriate.
Response: The adjustment to reconcile the Harvard and RUC physician
times was proposed in the June 5, 1998 proposed rule (63 FR 30818) and
was adopted in the November 2, 1998 final rule (63 FR 58814). In this
final rule we stated, ``We still believe this adjustment is appropriate
and we will continue to use the adjusted values in our calculations for
this final rule.'' There was not a discussion or proposal on this issue
in the July 22, 1999 proposed rule. Therefore, we are not changing or
dispensing with these adjustments in this final rule. However, we agree
that the accuracy and consistency of the physician time data is vitally
important to the appropriate calculation of the specialty practice
expense pools, and we welcome further discussion on this issue from all
parties. As noted above, we have asked our contractor to develop
options for validating the Harvard and RUC time data and will share
this discussion and any recommended options with the medical community.
Comment: One organization noted that, for services with a small
amount of time, a minor error in the time allotted can result in a
relatively large difference in the practice expense allocated to such
services. The commenter also recommended that we consider using an
alternative approach for determining the time used in the calculation
of practice expense for those services not performed by physicians.
Response: We would be interested in receiving any suggestions about
improved methods of verifying time for any specialty, physician or non-
physician, and would be glad to consider any specific approaches that
the commenter might want to suggest.
Comment: The American Psychiatric Association commented that the
physician times for psychotherapy codes with E/M services are sometimes
less than those services without an E/M component. The commenter
recommended that the times assigned to the codes with E/M be increased
so that they are seven minutes more than the corresponding service
without E/M.
Response: We agree that the codes with E/M should be at least equal
to those corresponding codes without E/M and are making this
adjustment. The current discrepancy in times could be due to the
previous changes in the coding of psychiatric services. However, we
believe that any further increases in time for these codes might be
better addressed during the 5-year review of work or by the RUC
process.
Comment: The American Psychiatric Association also commented that
the physician times for CPT code 90847 (family psychotherapy with
patient present) should be increased from 76 minutes to 101 minutes, so
that it is the same as CPT code 90846 (family psychotherapy without
patient present) and that the physician time for CPT code 90857
(interactive group psychotherapy) should be increased from 123 to 134
minutes so it is the same as CPT code 90853 (group psychotherapy).
Response: The times for these codes were originally assigned by the
RUC and were not affected by the change in CPT coding for psychiatric
services. Therefore, we have decided to defer changes in these times to
either the RUC process or the 5-year review.
Crosswalk Issues
Physical and Occupational Therapy Indirect Costs
Based upon comments received on the November 2, 1998 rule and after
consultation with industry representatives, we proposed increasing the
estimated space requirements that were used as part of the calculation
of the indirect practice expense per hour for physical and occupational
therapists from 250 square feet to 500 square feet per therapist.
Comment: The APTA commended us for recognizing that 250 square feet
is not representative of the actual space needed by therapists in
private practice and for proposing to increase the space allocation to
500 square feet. However, APTA asserted that 700-850 square feet is a
more accurate measure of the square feet required for such therapists.
Response: As stated in our proposed rule of July 1999, we currently
crosswalk physical and occupational therapy services to the ``all
physician'' practice expense per hour for direct costs. However, for
indirect costs we believed that the crosswalk to ``all physicians''
would overstate the actual practice expense for therapy services.
Instead, we used the data that were used to develop the therapy salary
equivalency guidelines to create the practice expense per hour for
these costs. These guidelines, which were developed for therapists
working under contract for a facility, assumed a required space of 250
square feet per therapist. After further consideration of previous
objections received from organizations representing both physical and
occupational therapists about the insufficiency of the 250 square feet,
we agreed that the 250 square feet space requirements might not be
representative of the actual space needed by privately practicing
therapists. Based on our analysis of the available data, we increased
the space requirements to 500 feet.
We have carefully considered the treatment space necessary for a
therapist in private practice and have determined that 500 square feet
or a space 25 feet by 20 feet is more than sufficient space for a
single therapist to deliver services to a single typical patient.
Although some treatment areas are larger, they are designed for
multiple therapists to work simultaneously and serve multiple patients.
Space requirements for areas such as waiting rooms, record rooms, and
restrooms are considered in the overhead for therapists in private
practice.
Comment: Several organizations have remained strongly opposed to
the use of salary equivalency guidelines to determine the clerical,
office, and other practice expense pools for therapists. The
associations recommended the SMS data in the ``all physician'' category
as a more accurate measure of the expenses associated with operating a
therapist's office. These commenters contended that the salary
equivalency guidelines were not intended to serve as the basis for
payment for patient treatment delivered in the therapist's office but
rather to pay providers directly for these services when furnished by
contract therapists who maintained separate administrative offices.
They stated that
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the guidelines established the maximum hourly rates that Medicare will
reimburse the provider for therapy services furnished by such
therapists. Thus, they argued that the salary equivalency guidelines
should not be used to determine the clerical, office, and other
practice expense pools for therapists because the overhead costs data
used in the guidelines are associated with operating a contract
therapist's administrative office but not the setting where the
clinical services are furnished.
Response: We continue to believe the salary equivalency guidelines
better approximate the actual expenses for this cost pool than the
``all physicians'' practice expense category. As previously stated, we
believe that using the ``all physicians'' practice expense category
would considerably overstate the actual practice expense for
occupational and physical therapists. We will continue to use the
salary equivalency guidelines to calculate this portion of the practice
expense pool for occupational and physical therapists for this final
rule. However, during the refinement process, we will consider all data
submitted on any service.
Comment: An association objected to the use of salary equivalency
data to determine the indirect expense portion of the practice expense
portions of the RVUs. The association recommended that we use SMS
survey data for a specialty whose indirect cost structure is similar to
that of a therapy provider. It was suggested that the SMS survey data
on physical medicine and rehabilitation, manipulation therapy or
podiatry would be a more accurate measure of the expenses associated
with operating a physical therapy office than the salary equivalency
guidelines.
Response: There is no SMS data specifically regarding podiatry
services. The other recommended specialties are primarily hospital-
based. Therefore, we continue to believe that the salary equivalency
guidelines are the best estimate of the indirect costs for outpatient
rehabilitation services.
Vascular Surgery
Based upon comments received on last year's proposed and final
rules, we proposed to change vascular surgery's crosswalk from
cardiothoracic surgery to the ``all physician'' practice expense per
hour because this more appropriately reflects the office-based nature
of much of vascular surgery's caseload.
Comment: The International Society for Cardiovascular Surgery and
The Society for Vascular Surgery stated their appreciation for the
interim increase in vascular surgery's practice expense per hour to the
``all physician'' rate. However, the Societies are concerned that,
despite this 5.8 percent increase in the practice expense per hour, and
the overall lack of impact on vascular surgery of removing clinical
staff from the facility setting, the fully implemented resource-based
practice expense RVUs for eleven of their top fifteen services were
decreased in the proposed rule. The American College of Surgeons (ACS)
agreed that vascular surgeons have patients with more co-morbidities
who require more E/M services than certain other specialties. The ACS
thus supported the change in the crosswalk of vascular surgery from
cardiac and thoracic surgeons to the ``all physician'' practice expense
per hour.
Response: We agree with the commenters that the use of the ``all
physician'' practice expense per hour rate is an appropriate interim
crosswalk for vascular surgery, and we are implementing this change.
Concerning the decrease in the practice expense RVUs for the 11 listed
services, all of these services are facility services that were
originally assigned large amounts of clinical staff time in the
facility setting. Because vascular surgeons perform a relatively large
number of office-based services as well, the impact of the decreases in
their facility services was offset by the increases in their office-
based services, and therefore the removal of the inputs for clinical
staff in the facility had little impact on the specialty as a whole.
Calculation of Practice Expense Pools--Other Issues
Medicare Claims Data
Comment: The American College of Cardiology recommended that we use
the most current Medicare claims data available because in the older
data many cardiologists identified themselves as internists. This had
the effect of decreasing the size of cardiology's practice expense
pool.
Response: We will be using the 1998 Medicare claims data, the most
current data available, for the purposes of calculating expense RVUs
for the year 2000.
``Zero Work'' Pool
In the November 2, 1998 final rule, as an interim solution, we
created a separate practice expense pool for all services with zero
work RVUs because of the possibility that inaccuracies in the data were
causing substantial reductions for these services. We used the ``all
physicians'' category for the practice expense per hour for this pool
and instead of allocating this pool by the CPEP data, we used the 1998
RVUs as the allocator. This was of benefit to most of the services
included in this interim separate expense pool, but some specialties
such as sleep medicine, neurology, ophthalmology and pathology were
negatively affected by this methodological change. We received comments
requesting that certain services negatively impacted by the adjustment
in the 1998 final rule be taken out of this special pool and instead be
treated in the same way as the vast majority of codes (that is, treated
in the same manner as they were treated before the 1998 final rule
adjustment). In the proposed rule, we requested comments both on an
adjustment in general and on specific services that should either be
included or excluded from the adjustment.
Comment: We received many comments supporting the removal of
requested services for the ``zero'' work pool. The comment from the AMA
urged us to implement this provision with respect to any codes that
specialties have requested be removed from the ``zero work'' pool. The
AMA supported the establishment of this pool but only for true
radiology services; all other ``zero work'' services should be
developed in the same way as other services provided by the other
specialties. Another comment from an organization representing primary
care physicians supported a proposal to treat codes with zero work RVUs
more consistently with other codes in the fee schedule. This commenter
stated that the reason given for the creation of the pool was concern
about possible inaccuracies in the CPEP data for the ``zero work''
codes, but since concern was expressed regarding the data for other
codes as well, ``zero work'' codes should not be given special
treatment. Several organizations representing ophthalmology and
optometry opposed the use of the ``zero work'' pool and favored
removing the ophthalmology codes from this pool. These commenters
contended that the current approach is not resource-based and that the
creation of the ``zero work'' pool undermined the rationale of the top-
down approach. In addition, the commenters stated that ophthalmology
has a practice expense per hour that is much higher than the ``all
physician'' rate assigned to the ``zero work'' pool and that neither
optometry nor ophthalmology were among the specialties requesting a
change in methodology for their ``zero work'' services, because the
data for eye care services is relatively good. A major surgical
specialty society supported
[[Page 59406]]
plans to move services with zero work RVUs from their own pool and to
treat them like other services and opposed retaining any services in
the special pool.
Several specialty societies representing imaging services,
radiation oncology, cardiology subspecialties, and vascular surgery
objected to the removal of any services from the ``zero work'' practice
expense pool or modification of this pool. One of these commenters
stated that the ``zero work'' pool should be retained, because it was
created to approximate the costs of independently owned facilities that
are not captured in the SMS data. The commenter offered as an
alternative recommendation that the current RVUs of those services in
the pool be maintained even if other codes are extracted from the pool.
Several of the commenters stated that, because the current technical
component allowances are virtually identical to those in effect prior
to the institution of resource-based practice expense RVUs, a decision,
which the commenters support, appeared to be have been made by HCFA
that these values should remain unchanged pending further data
collection and analysis. For those services that have been
disadvantaged by their move to this ``zero work'' pool, the commenters
suggested that we change their charge-based RVUs without removing them
from the ``zero work'' pool. One commenter suggested that all ``zero''
work codes should be treated uniformly and the fact that some of these
services fared better under the original top-down methodology is not a
sufficient basis for removing them from the ``zero work'' pool.
Response: We still believe that, although we regard the ``zero
work'' pool as an interim solution, there is a need to maintain this
pool until we have greater confidence in the data for the technical
component and ``zero work'' services. However, we do not believe that
we should force specialties to keep their services in this ``zero
work'' pool if there is a stated preference to have these services
treated by the same methodology as the vast majority of services. We
also do not agree that our decision to create the ``zero work'' pool
implied that the values for the technical component (TC) codes should
necessarily be maintained in the change from a charge-based to a
resource-based practice expense methodology. In the 1998 proposed rule,
before we created the ``zero work'' pool, many of the TC services would
have received large decreases in practice expense RVUs. In response to
comments in the final rule of the same year, we stated, ``the
possibility exists that inaccuracies in the CPEP data * * * are causing
the substantial reductions * * *. Therefore * * * as an interim
solution until the CPEP data for these services have been validated, we
have created a practice expense pool for all services without work
RVUs.'' The purpose of this pool was only to protect the TC services
from the substantial decreases referred to in the above quote until
further refinement could take place; the purpose, notwithstanding the
specific outcomes of the complex practice expense calculations, was not
to guarantee that these services alone would be unaffected by any
changes in our methodology. We also stated that we were not convinced
that there was a bias in the SMS survey data against TC services,
although we agreed to examine the issue during refinement.
While the creation of the ``no work'' pool was of benefit to most
of the TC services contained in it, there was an unintended result of
the pool's creation: the values of some specialties' TC services were
severely reduced. We believe that it is appropriate to remove those
services from the ``no work'' pool if the specialties performing these
services make that request. We have no basis for increasing the charge-
based RVUs for these codes as a way to offset the negative effects of
the ``no work'' pool.
Comment: The following comments were received that requested
services be removed from the ``zero work'' pool:
The American Academy of Sleep Medicine reiterated their
request that the TC of CPT codes 95805 through 95811 be moved back into
the practice expense pools of the specialties performing these
services, allocating these pools using the CPEP data. The commenter
stated that this recommendation has the support of the major
organizations whose members provide sleep medicine services.
The American Society of Electroneurodiagnostic
Technologists supported the removal of neurology codes, CPT codes 95808
through 95956, from the ``zero work'' pool.
The National Association of Epilepsy Centers, supported by
the American Academy of Neurology, requested the removal of four of the
major epilepsy services, CPT codes 95950, 95951, 95954, and 95956 from
the ``zero work'' pool. The commenter stated that the resource-based
data for these services collected through the CPEP process is more
representative of the costs of these services than the charge-based
values.
The American Academy of Neurology commented that CPT codes
95805 through 95956 should be removed from the ``zero work'' pool
because the CPEP-derived RVUs are more accurate than the historical
charge-based values.
The American College of Chest Physicians supported the
proposal to move the sleep medicine CPT codes out of the ``zero work''
pool, and requested that any of the pulmonary CPT codes 94010 through
94799 that are contained in this pool be treated in the same way.
The American Academy of Ophthalmology requested that we
move any of the CPT codes 76511 through 76529 and 92081 through 92499
that are in the ``zero work'' pool back into the practice expense pools
of the specialties that are providing these services. For all of these
codes, ophthalmologists are the predominant specialty. This change is
also supported in comments from the American Society of Cataract and
Refractive Surgery. The American Optometric Association made the same
request and added CPT codes 92060 and 92065 to the list of codes to
remove; this same request was made by the Macula, Retina and Vitreous
Societies.
The College of American Pathologists requested that CPEP
data be used to calculate all pathology technical component RVUs for
the year 2000 rather than historical charge data. This recommendation
was also supported by comments from the American Academy of Dermatology
and individual commenters.
Response: We will remove all of the above services from the ``zero
work'' pool and return them to the practice expense pools of the
specialties performing the services.
Comment: The American College of Cardiology, the American Society
of Echocardiography, and the American Society of Nuclear Cardiology
commented that CPT codes 93307 and 93350 should not be removed from the
``zero work'' pool.
Response: We will leave these services in the ``zero work'' pool as
requested by the commenters.
Site-of-Service Differential
Clarification of Site-of-Service Policy
In the 1998 final rule, we defined hospitals, skilled nursing
facilities (SNFs) and ambulatory surgical centers (ASCs) as facilities
for practice expense purposes. For purposes of physician practice
expenses, all other sites of service are considered to be non-facility
settings. The distinction between the non-facility and facility setting
takes into account the higher expenses of the practitioner in the non-
facility setting, where the practitioner typically bears the cost of
the resources (for example,
[[Page 59407]]
clinical staff, supplies and equipment) associated with the service.
The major purpose of the site of service distinction is to ensure
that Medicare does not make a duplicate payment for any of the practice
expenses incurred in providing a service for a Medicare patient. When
the beneficiary is a hospital, SNF or ASC patient, the facility is paid
for the clinical staff, supplies and equipment needed to take care of
that patient, and the lower facility rate should be paid to the
practitioner. Therefore, if the patient is a facility patient or if a
facility bills for the service, the practitioner must bill for a
facility site-of-service so that the practice expense accurately
reflects the setting in which the service was furnished. In the
proposed rule, we clarified the circumstances under which either the
non-facility or facility RVUs are used to calculate payment for a
service. Specifically, we clarified application of the site-of-service
differential for procedures performed in an ASC that are not on the
Medicare approved list; for therapy services provided in the facility
setting; and for services provided to facilities where there is a
``mixture'' of nursing home and SNF patients. With respect to provision
of services in a ``mixed'' facility, we specifically solicited comments
on ways to examine the relative costs of treating patients in different
settings, so that we can determine whether an adjustment to certain
non-facility practice expense payments is appropriate.
Comment: One organization objected to our stated policy that, in a
mixed facility, the physician is responsible for ascertaining that
there will be no Part A bill for the service in order to use the non-
facility designation. The commenter stated that this would be a time
consuming effort.
Response: We do not believe that it would be an onerous task for
the physician to determine at the time of service whether the patient
is a SNF or a nursing home patient. This information is needed to pay
the bill correctly, and the physician is in the best position to obtain
this information quickly.
Comment: The Renal Physicians Association, supported by comments
from the American College of Physicians/The American Society of
Internal Medicine, expressed concern about the application of the site-
of-service differential to the monthly capitated payment (MCP) for end-
stage renal disease services (CPT codes 90918 through 90921). The
commenter stated that the series of E/M services that are represented
by the MCP are highly variable and unpredictable and can be provided in
a multitude of settings during the month. Therefore, the use of the
site-of-service differential is not relevant to the MCP and should not
apply.
Response: We agree that the site-of-service designations are not
meaningful for a monthly service that may be provided in different
settings for the same patient during a given month. Therefore, CPT
codes 90918 through 90921 should always be reported as a nonfacility
service.
Comment: An association representing speech-language pathologists
and audiologists sought confirmation that there are no settings where
speech-language pathology and audiology services would be classified as
facility based for purposes of the physician fee schedule.
Response: The commenter is correct. As stated in the final rule of
November 2, 1998, outpatient rehabilitation services are subject to the
non-facility based practice expense.
Comment: One specialty society reiterated their belief that the
site-of-service differential is inappropriately applied to some
pediatric subspecialty services performed in the facility setting. The
commenter maintained that the use of the facility practice expense RVUs
could sacrifice access to high quality pediatric care. Two
organizations representing gastroenterologists objected to the use of
the site-of-service differential for endoscopy services, which require
conscious sedation, because the higher rate paid for these services in
the office could provide an incentive for physicians to perform these
procedures in the inappropriate office setting. One of these commenters
argued that we should either use a threshold that would require a
procedure be performed a given percent of the time in the office before
applying the site-of-service rule, or adopt MEDPAC's recommendation to
establish a clinical consensus about the settings in which a service
should be provided. An organization representing podiatrists commented
that because they bring their own supplies into a skilled nursing
facility (SNF) when providing services in that site, the lower facility
rate should not be applied. The commenter contended that, even though
multiple patients may be seen, each patient requires individual
treatment. Another organization suggested we establish a site-of-
service differential for services performed in a SNF in order to
correct the inadequacies of payment for services performed in this
site. An individual physician commented that there should not be a
site-of-service penalty for the 67900 series of CPT codes, because
these procedures are most safely and appropriately done in the facility
setting.
Response: We believe that these commenters do not understand the
purpose or the calculation of the site-of-service differential under
our new resource-based practice expense methodology. As stated above,
the purpose of the differential is both to ensure that Medicare does
not make a duplicate payment for any of the practice expenses incurred
and to take into account the higher expenses of the practitioner in the
non-facility setting. To the extent that the appropriate practice
expense inputs--clinical staff, supplies and equipment, and indirect
costs--have been assigned to the two settings, there should be no
question of penalizing those who perform their services in a facility.
The difference in practice expense RVUs in the two settings should only
reflect the difference in the relative costs of performing that
particular procedure in the facility or office setting. For that reason
there should also be no financial incentive to perform a service in one
or the other setting. As stated in previous rules, if there is evidence
that it is not safe to perform a particular service in the office
setting, this information should be submitted to HCFA's Office of
Clinical Standards and Quality.
Limitation on Facility RVUs
As we explained in the proposed rule, non-facility RVUs would be
expected to be higher than the facility RVUs for a given service,
because the practitioner bears the costs of the necessary clinical
staff, supplies, and equipment. However, because of anomalies in our
calculations, generally due to the different mix of specialties
delivering the service in the two settings, for some codes the facility
RVUs are higher than the non-facility RVUs. We proposed to limit the
facility rate so that it cannot be higher than the non-facility rate
for any given code.
Comment: An association representing urologists commented that we
should not assume that any higher facility rate is always due to
calculation errors and that we should evaluate these codes further
before implementing the proposal. The AMA and an association
representing gastroenterologists stated their belief that the
imposition of such an across-the-board limit on facility RVUs is
inappropriate, because the higher practice expense RVUs in the facility
may be due to the different mix of specialties that care for the more
complex, more costly cases in the facility setting. The AMA recommended
[[Page 59408]]
that we either use a weighted average of the RVUs from both settings or
maintain the higher facility practice expense RVUs until each affected
code can be reviewed.
Several primary care organizations commented that they agree with
the proposal to limit the facility rate so that it cannot be higher
than the non-facility rate for any given code. One commenter agreed
that non-facility RVUs would be higher than facility RVUs for a given
service, because the practitioner bears the costs of the staff,
supplies and equipment needed. Another commenter also supported the
proposal because it addresses some of the anomalies in the practice
expense RVUs.
Response: We will implement the proposal so that the facility
practice expense RVUs can never be higher than the non-facility
practice expense RVUs. Because practice costs would always be expected
to be at least somewhat higher in the office setting, where the
practitioner is responsible for the costs of the staff, supplies and
equipment, it would be an anomaly for the facility setting to have
higher practice expense RVUs assigned. This adjustment only affects 222
facility services at this time, and the decrease in value for the
affected services is minimal. There is no impact on any specialty as a
result of this adjustment.
Comment: One commenter stated that we stated under Site-of-Service
Differential in the July 1999 proposed rule (64 FR 39622) our policy
that when a service is performed in an ASC and the service is not on
the Medicare approved list of procedures and we do not make a facility
payment to the ASC, we consider the ASC a physician's office and use
the non-facility (higher) RVUs. However, the commenter notes that in
our proposed revision in Sec. 414.22(b)(5)(I) in the July 1999 proposed
rule (62 FR 39641) we do not clearly state this point.
Response: Upon review, we agree that our revision to 42 CFR
Sec. 414.22 is not clear enough. We appreciate the commenter bringing
this oversight to our attention. We, therefore, are revising
Sec. 414.22 (b)(5)(i) to clarify that, when a physician performs a
procedure on the ASC approved procedures list in an ASC, the lower
facility practice expense RVUs apply, and that when a physician
performs a procedure in an ASC that is not on the ASC approved
procedures list, the higher non-facility practice expense RVUs apply.
C. Adjustment to the Practice Expense Relative Value Units for a
Physician's Interpretation of Abnormal Papanicolaou Smears
As explained in the July 22, 1999 proposed rule, the codes for a
physician's interpretation of an abnormal Papanicolaou (Pap) smear were
revised in the November 1998 final rule to include three HCPCS level II
codes (P3001, G0124, and G0141) in addition to the CPT code 88141. This
revision was made to accommodate differences in Pap smear technology,
and we evaluated the practice expense RVUs for each of these three
codes in a slightly different manner. We now believe that it would be
more appropriate to evaluate the work, practice expense, and
malpractice RVUs for these codes identically and comparable to the
values for CPT code 88141.
We received a comment from one organization in support of our
proposal. We are finalizing this proposal and making the practice
expense RVUs identical for HCPCS codes P3001, G0124 and G0141.
D. Physician Pathology Services and Independent Laboratories
We proposed to revise our regulations to end payments to
independent laboratories under the physician fee schedule for technical
component physician pathology services furnished to hospital
inpatients. (Some hospitals provide pathology services through hospital
laboratories, and this provision does not affect them.) Under this
proposal, independent laboratories would still be able to bill and
receive payment from their Medicare carrier for the technical component
of a physician pathology service furnished to beneficiaries who are not
hospital inpatients. For the technical component of physician pathology
services provided to a hospital inpatient, the hospital would have to
bill and the independent laboratory would have to make arrangements
with the hospital to receive payment.
Specifically, we proposed revising Sec. 415.130(c) to state that
after December 31, 1999, we would pay only hospitals for technical
components of physician pathology services furnished to their
inpatients.
We received 55 comments mainly from pathology groups. Most of these
commenters requested that the proposed regulation be withdrawn and the
current policy continued. Other commenters, mainly specialty
organizations, recommended that the implementation of the proposal be
delayed two years and that arrangements in effect as of July 22, 1999,
the date of the proposed regulation, be grandfathered and the current
payment policy continued for them.
Comment: Several commenters pointed out that if the proposal is
implemented, hospitals might not compensate the independent
laboratories for the technical component of physician pathology
services. They referred to past practices where hospitals have not
adequately compensated hospital pathologists for management functions
related to the clinical laboratory, even though this cost was
appropriately reflected in the hospital's prospective payment. The
commenters refer to the Office of the Inspector General's (OIG) 1991
``Report of Financial Relationships between Hospitals and Hospital-
Based Physicians'' as well as the OIG's 1998 ``Compliance Program
Guidance for Hospitals''. One commenter specifically asked if HCFA and
OIG would create a safe harbor that sets forth a ``bright line'', for
example 80 percent of the physician fee schedule allowance, for deeming
as reasonable the negotiated technical component between hospitals that
bill for the TC service and the independent laboratories that provide
the service to the hospitals.
Response: The anti-kickback statute, section 1128B(b) of the Act,
prohibits any person from soliciting or accepting anything of value to
induce the referral of business that is reimbursable by a Federal
health care program. If a hospital were to condition, express or
implied, the referral of physician pathology services to a clinical
laboratory on the lab's agreement to accept less than fair market value
for the technical component, it would implicate the anti-kickback
statute. Under section 1128D(b)(3) of the Act, the OIG is prohibited
from determining what constitutes fair market value in any specific
situation.
Comment: Some commenters contend that the factual information in
the proposed rule is not correct and question whether double payment
is, indeed, being made for the TC services. They believe there is
significant question about whether, when the diagnostic related groups
(DRGs) were constructed, initially priced and updated through the
years, the TC for physician pathology services were adequately captured
and incorporated in the DRGs. A few commenters remarked that it was and
is the common practice in their State for hospitals to out-source the
TC of physician pathology services to independent laboratories.
[[Page 59409]]
Response: Before the prospective payment system (PPS) system was
implemented in 1983, we advised intermediaries that hospitals could
appropriately include in their base period costs the laboratory cost of
the physician pathology services furnished directly to hospital
inpatients by that hospital laboratory. At the same time, we stated
that if an independent laboratory billed the carrier for the physician
pathology services, it could continue to do so, and these costs should
not be included in the hospital's base period costs. At that time, the
TC was incidental to the pathologist's professional service, and was
not treated as a service in itself; it was the common practice at that
time for the independent laboratory to bill a single charge that
reflected both the TC and the PC physician pathology service.
During the early, transitional years of the PPS, the prospective
payment was based on a blend of a target amount (reflecting the
hospital's specific cost) and a DRG amount. The DRG amount was a blend
of regional and national standardized amounts, with separate
standardized amounts for rural and urban areas. After the transition,
hospital specific amounts were no longer used in payment, except for
sole community hospitals. In Federal fiscal year 1995, the separate
rural rate was eliminated, and rural hospitals began receiving the same
rate as urban hospitals.
Given that urban hospitals were much more likely to have the
laboratory costs of physician pathology services included in their PPS
base period costs used to calculate the urban standardized amount, it
is our view that the DRG payment methodology compensates hospitals for
the TC of physician pathology services. Also, the elimination of the
separate rural standardized amount in Federal fiscal year 1995
similarly compensates rural hospitals for the TC of physician pathology
services. It would be improper to continue to allow hospitals to
receive Part A payments that reflect the TC of physician pathology
services and simultaneously allow an independent laboratory to bill and
be paid under the physician fee schedule for the same service.
Comment: A few commenters question the assumption in the regulatory
impact analysis that 60 percent of the allowed charges for independent
laboratories represent billings for hospital inpatients. Based on
information from its membership, the College of American Pathologists
(CAP) estimated that, on average, 20 percent of Medicare payments to
independent laboratories are for Medicare inpatient services. The
commenters requested that this estimate of savings to Medicare be
appropriately reduced.
Response: We are accepting CAP's comment and calculating the
estimate based on this information.
Result of Evaluation of Comments
We are adopting our proposal to pay only hospitals for the TC of
pathology services furnished to its inpatients, but delaying
implementation until January 1, 2001 to allow independent laboratories
and hospitals sufficient time to negotiate arrangements.
E. Discontinuous Anesthesia Time
We proposed to revise our regulations to allow anesthesiologists
and certified registered nurse anesthetists (CRNAs) to sum blocks of
time around a break in continuous anesthesia care as long as there is
continuous monitoring of the patient within the blocks of time. Payment
for anesthesia services is based on the sum of base units plus time
units multiplied by a locality-specific anesthesia CF. Under current
regulations at Sec. 414.46(a)(1) (Additional rules for payment of
anesthesia services), the base unit is the value for each anesthesia
code reflecting all activities other than anesthesia time. Anesthesia
time, as defined under Sec. 414.46(a)(2), starts when the
anesthesiologist or CRNA prepares the patient for anesthesia care and
ends when the anesthesiologist or CRNA is no longer in personal
attendance; that is, when the patient is placed under postoperative
care. While in most instances the anesthesiologist or CRNA remains
continuously with the patient from the establishment of venous access
to the conclusion of anesthesia attendance, there may be instances when
there are breaks in the continuous presence of the anesthesiologist or
CRNA. (See the July 22, 1999 proposed rule (64 FR 39624) for specific
examples.) We proposed to revise the regulations in Sec. 414.46 to
include this exception to the general requirement and to revise
Sec. 414.60 (Payment for the services of CRNAs) to clarify this issue.
Comment: Both of the national specialty groups, the American
Society of Anesthesiologists and the American Association of Nurse
Anesthetists, support the proposal to allow anesthesiologists and CRNAs
to sum blocks of anesthesia time around a break in continuous
anesthesia care as long as there is continuous monitoring of the
patient within the blocks of time. Both groups requested that we
provide guidance to anesthesiologists and CRNAs on how to report
discontinuous anesthesia time.
Response: Anesthesiologists and CRNAs should report the total
anesthesia time on the HCFA claim form as the sum of the continuous
anesthesia block times. The medical record should be documented so that
a medical record auditor can see the continuous and discontinuous
periods and that the reported total anesthesia time sums to the blocks
of continuous time.
Result of Evaluation of Comments: We are adopting the proposed
policy and are revising the regulations accordingly.
F. Optometrist Services
The provisions of OBRA 1986 expanded coverage for optometrist
services. While this statutory provision had been implemented through
manual provisions, we had not revised the regulations to reflect this
change. We proposed to revise the regulations at Sec. 410.23
(Limitations on services of an optometrist) to specify that Medicare
Part B pays for the services of a doctor of optometry, acting within
the scope of his or her license, if the services would be covered as
physicians' services if performed by a doctor of medicine or
osteopathy. The American Optometric Association supported the proposed
revision to the regulations.
Comment: The American Occupational Therapy Association (AOTA) asked
that we clarify that optometrists may certify and recertify a
beneficiary's need for occupational therapy services. According to
AOTA, conforming changes should be made to Sec. 424.11(e) (Limitation
on authorization to sign statements) and relevant manual provisions on
physician certification procedures for outpatient therapy. AOTA states
that the proposed Sec. 410.23 codifies the statutory provision that
places optometrists in the same category as other physicians.
Therefore, if a service is within the optometrists' lawful scope of
practice, they contend it is permissible for a doctor of optometry to
certify and recertify a beneficiary's need for occupational therapy
services.
Response: Section 1861(r)(4) of the law provides that an
optometrist is a physician ``only with respect to the provision of
items or services described in section 1861(s).'' Because certification
and recertification are not services described in section 1861(s), we
believe that the law does not permit optometrists to be considered
physicians for the performance of these functions. We are changing the
text of the regulation (Sec. 410.23) to more directly reflect the
language of the law.
Result of Evaluation of Comments: We are revising the regulations
at Sec. 410.23
[[Page 59410]]
to specify that Medicare Part B pays for services of a doctor of
optometry, acting within the scope of his or her license, if he or she
furnishes services described in section 1861(s) that would be covered
as physicians' services when performed by a doctor of medicine or
osteopathy.
G. Assisted Suicide
The Assisted Suicide Funding Restriction Act of 1997 prohibits the
use of Federal funds to furnish or pay for any health care service or
health benefit coverage for the purpose of causing, or assisting to
cause, the death of an individual. The prohibition does not apply to
withholding or withdrawing medical treatment, nutrition, or hydration.
In addition, the prohibition does not apply to furnishing a service to
alleviate pain, even if doing so may increase the risk of death, as
long as the purpose is not to cause or assist in causing death.
We are conforming our regulations to the provisions of this Act by
adding a new paragraph (q) to Sec. 411.15 (Particular services excluded
from coverage) to exclude from coverage any health care service for the
specific purpose of causing, or assisting to cause, the death of an
individual. Long standing Medicare policy has excluded such services
under section 1862(a)(1)(A) of the Act. This section of the Act states
that no payment may be made under Part A or Part B for any expenses for
items or services that are not necessary for the diagnosis or treatment
of illness or injury or to improve the functioning of a malformed body
member.
One physician group expressed support for this provision, and we
are including the provision in the final rule.
H. CPT Modifier -25
Currently, the global surgery payment policies described in section
4820 of the Medicare Carriers Manual apply to procedures that have
global periods of 0, 10, and 90 days as shown on the physician fee
schedule database. We proposed to apply these policies also to those
services and procedures for which the global period indicator is
``XXX.'' Currently, it is only when a significant, separately
identifiable E/M service is furnished before furnishing a procedure
with a global period of 0, 10, or 90 days that the E/M service may be
paid in addition to the procedure. The coding mechanism for indicating
that the E/M service is not related to the surgical procedure is to
append modifier -25 (significant, separately identifiable evaluation
and management service by the same physician on the same day of the
procedure or other service) to the E/M service code.
We proposed that, for selected procedures that have a global period
indicator of ``XXX,'' when a significant, separately identifiable E/M
service is furnished at the same time by the same physician, the
physician must append to the E/M service code the modifier -25.
The basis for this policy is that, because every procedure has an
inherent E/M component, for an E/M service to be paid separately, a
significant, separately identifiable service would need to be
documented in the medical record. In other words, we want to prevent
the practice of physicians reporting an E/M service code for the
inherent evaluative component of the procedure itself.
Comment: Some commenters expressed the view that rather than
implement this coding instruction, the carrier should determine if
there is a problem with a physician billing for E/M codes with surgical
codes and target the physician for review.
Response: We have received this suggestion many times in relation
to other proposed coding edits. It is only within the past few years
that the CPT Editorial Panel has begun to articulate more clarifying
guidelines pertaining to the use of CPT-4 codes. In the meantime, the
Congress has mandated that we promote uniformity in paying for
services. Establishing coding principles associated with the CPT-4
coding system helps to achieve uniformity. We believe that establishing
coding guidelines is an important adjunct to conducting reviews of
problem practitioners.
Comment: Many commenters agreed that the proposal is consistent
with CPT guidelines but strongly urged clarification of the categories
of services to which this policy would apply. For example, these
commenters were unclear whether this policy would apply to diagnostic
tests, immunizations, laboratory, and pathology services.
Response: We are not making a blanket requirement that modifier -25
be used with every code in a specific category of services. Rather, we
will implement this coding policy for specific HCPCS codes when we
believe there is abuse or the potential for abuse in the reporting of
an E/M service. Before implementing an edit for a specific code
combination, we will provide an opportunity for review by physician
groups.
Comment: One commenter suggested we clarify that modifier -25
should be used and recognized as denoting a separate E/M service
furnished in conjunction with a minor procedure bearing either the
``XXX'' or the ``000'' global period policy.
Response: Our current policy for using modifier -25 is applicable
to codes with global periods of 0, 10, and 90 days as stated in section
4822.A of the Medicare Carriers Manual. We proposed that, in furnishing
a diagnostic or therapeutic service that has a global period of ``XXX''
as well, the same policy would apply and practitioners should decide
whether the E/M component of a service having a global period of
``XXX'' is routinely furnished as part of the procedure or is a
significantly, separately identifiable service. In general, for
services with global periods of ``XXX,'' as well as those with 0, 10
and 90 days, when the E/M service is a significant, separately
identifiable service, that is, the physician work furnished meets the
criteria for the level of E/M service reported, modifier -25 should be
appended to the procedure code.
Comment: A few commenters questioned the accuracy of the statement
in the proposal, ``Since every procedure has an inherent E/M component,
in order for an E/M service to be billed, there must be a significant,
separately identifiable service documented in the medical record.''
They asserted that the only procedures that have an ``inherent'' E/M
component are those that are subject to our own global surgery policies
that have been developed with input from the specialty societies.
However, there are procedures, for example, radiation oncology services
such as treatment planning and simulation which are not subject to our
global surgery policies nor do they have an E/M component. Therefore,
our statement that ``every procedure has an inherent E/M component'' is
in error. In addition, commenters stated that since we worked with the
CPT Editorial Panel to create modifier -25 to be used in appropriate
specific instances, to propose using modifier -25 for all services is
inconsistent with our previous actions. Commenters requested that we
not implement the proposal without input from the AMA's Correct Coding
Policy Committee (CCPC) and without adequate time for physician
education.
Response: One of the factors we will take into consideration as we
identify the specific procedures for which the modifier -25 policy for
separate payment for an E/M service will apply is whether the
procedure, by definition, has an inherent E/M component.
We intend to submit correct coding edits associated with this
coding policy to the AMA's CCPC for comment with a potential
implementation date of no
[[Page 59411]]
earlier than October 2000. Assuming CCPC's comments are furnished
expeditiously, we believe there will be sufficient time for us to
notify carriers of its decisions, for the specialty societies and the
AMA to notify their members, and for carriers to publish the edits in
their bulletins.
Comment: Several commenters cited particular examples of diagnostic
and treatment situations in which the E/M service and the procedure may
be reported without the need for appending modifier -25. These examples
are services represented by ophthalmology E/M codes 92002 through 92014
that result in the decision to perform a visual field examination or a
fluorescein angioscopy and urology services ``that do not have a global
period and, therefore, an E/M service would always be performed.''
Response: We will take these comments into consideration when we
develop correct coding edits based on the coding instruction related to
the use of modifier -25.
Comment: Many commenters had reservations about the burden on
physicians and carriers if this proposal were implemented. They were
concerned that this proposal would lead to using modifier -25
routinely, which in turn would lead to more carrier audits.
Another potential result with burdensome consequences to the
practitioner and the carrier would be the number of appeals that would
be generated because of contested denials when the practitioner is
found to have adequate documentation for the services furnished but the
denial was based on inadequate information.
Response: While we agree that these scenarios are possible, our
experience with the coding instruction associated with the modifier -59
(Distinct Procedural Service) has not validated this kind of concern.
While carrier post-payment reviews of two of these scenarios, namely
abuse of modifier -59 and lack of appropriate use of modifier -59, have
not been extensive, we have no evidence that practitioners are
routinely billing modifier -59 with multiple procedures performed on
the same day by the same practitioner. The carrier claims processing
systems contain edits that identify incorrect coding combinations. When
an incorrect code combination is detected, payment for one of the codes
is denied. These denials decrease Medicare expenditures. If the use of
modifier -59 had become routine, we would expect to see an increase in
expenditures because of the increased use of the modifier. This has not
been the case. In fact, expenditure data show that billing of the same
code pairs is fairly consistent from one quarter to the next, thus
suggesting that practitioners are not routinely using modifiers.
Comment: Other commenters suggested we identify the services that
are problematic and work with the AMA to clarify CPT descriptions.
Response: We will work with the AMA at the same time that we are
implementing the modifier -25 policy.
Comment: One specialty society stated that its members rarely
furnish a service designated as one with no global period without
performing services represented by an E/M visit code.
Response: We agree that an identifiable E/M service may be
furnished with many procedures for which no global period applies.
However, we are concerned about those instances in which a minimum
amount of evaluation is an inherent component of the service or
procedure. For these instances, we do not agree that it is appropriate
to report a minimum level E/M code in addition to the service or
procedure.
Comment: Pertaining to physical therapy codes, the assertion was
made that the physical therapy evaluation codes 97001 and 97002 are not
comparable to the ``E/M'' codes because they do not include the concept
of ``management'' as do the E/M service codes. Since 97001 and 97002
are not comparable to the E/M codes and since modifier -25 can be used
only with an E/M service, it would not be appropriate for it to be used
with a physical therapy evaluation code when the physical therapy
evaluation code is billed with a modality or therapeutic service.
Response: We disagree with the assertion that physical therapy
codes are not comparable to the codes usually referred to as E/M codes.
The E/M service codes are described in such a way that they may be used
to report either evaluation or management services; or evaluation and
management services. We believe that modifier -25 may accurately be
used with evaluation codes associated with occupational therapy,
ophthalmology, physical therapy, psychiatry, and radiation
consultation.
Comment: Another commenter suggested that since many private payers
do not recognize modifiers appropriately, our policy would create
inconsistencies in how physicians report Medicare and non-Medicare
services.
Response: Under the current circumstances, this comment may be
valid in relation to the use of any modifier, not just modifier -25. It
is expected, however, that when the relevant portions of the Health
Insurance Portability and Accountability Act are implemented, the
format for claims for physicians' services will be standardized. In the
meantime, the requirement to use modifier -25 in those instances when
the E/M service is distinguishable from the pre-procedure work may
actually strengthen the claim for payment. This result may persuade
other third party payers to recognize this coding guideline thereby
ensuring more consistency in payment.
Result of Evaluation of Comments: We have considered the comments
we received on the proposal and are proceeding to include procedures
with a global period indicator of ``XXX'' the application of the global
surgery payment policy in as it relates to the use of modifier -25.
We will not, however, require the routine use of modifier -25 with
all procedures having a global indicator of ``XXX.'' Instead, we will
identify specific codes with which the E/M service furnished would need
to be one that is documented as being significant and separately
identifiable, and, hence, should be reported with modifier -25.
We will seek review of these codes from physician specialty
societies as well as those nonphysician practitioners who are
authorized to bill Medicare on their own.
Specific procedure codes for which the use of modifier -25 is
required when a significant, separately identifiable E/M service is
furnished and reported by the same physician or nonphysician
practitioner will be included as edits in the Correct Coding Initiative
edits. These edits will be implemented no earlier than October 1, 2000
and will continue to be added as appropriate on an ongoing basis.
In the meantime, however, since modifiers are an inherent part of
HCPCS, we urge all practitioners to familiarize themselves with them
and to make it a practice to use them when applicable.
I. Nurse Practitioner Qualifications
As explained in the July 22, 1999, proposed rule (64 FR 39608), we
gave additional consideration to the nurse practitioner (NP)
qualifications because we realized that the qualifications would
exclude many experienced NPs from continuing to qualify as NPs under
the Medicare program. It was not our intention to establish
qualifications in the November 1998 final rule (63 FR 58874) that would
cause experienced NPs, who have been furnishing services to Medicare
patients, to be barred from
[[Page 59412]]
billing under the Medicare program because they do not posses a
master's degree or national certification. Therefore, we proposed NP
qualifications that are less restrictive but that still ensure quality
services are furnished to Medicare patients. We proposed progressively
enhanced qualifications, including providing lead time for NPs to
obtain a Medicare billing number under Section 2158 of the Medicare
Carriers Manual, national certification, or (ultimately) a master's
degree in nursing. Specifically, we proposed to revise Sec. 410.75(b)
so that for Medicare Part B coverage of his or her services, a nurse
practitioner must:
(1)(i) Be a registered professional nurse who is authorized by the
State in which services are furnished to practice as a nurse
practitioner in accordance with State law; and
(ii) Be certified as a nurse practitioner by a recognized national
certifying body that has established standards for nurse practitioners;
or
(2) Be a registered professional nurse who is authorized by the
State in which the services are furnished to practice as a nurse
practitioner in accordance with State law and has been granted a
Medicare billing number as a nurse practitioner by December 31, 2000;
or
(3) Be a nurse practitioner who, on or after January 1, 2001,
applies for a Medicare billing number for the first time and meets the
standards for nurse practitioners in paragraphs (b)(1)(i) and
(b)(1)(ii) of this section; or
(4) Be a nurse practitioner who, on or after January 1, 2003,
applies for a Medicare billing number for the first time and possesses
a master's degree in nursing and meets the standards for nurse
practitioners in paragraphs (b)(1)(i) and (b)(1)(ii) of this section.
Comment: Several individuals and some organizations, including the
American College of Nurse Practitioners, American Nurses Association,
and the National Association of Pediatric Nurse Associates &
Practitioners, submitted comments in support of the proposal. However,
a couple of the commenters expressed concern that an NP whose Medicare
number expires in the future may encounter new and more stringent
qualification requirements depending on the year he or she reapplies
for a new Medicare number. One commenter was also concerned that
certain NPs, who qualify to receive Medicare billing numbers under
current requirements, would be unfairly disadvantaged if they do not
need to apply for Medicare numbers before January 1, 2001.
Response: As specified in the rule, the new qualifications
beginning January 1, 2001, would apply only to those NPs applying for
Medicare numbers for the very first time. Therefore, an NP would be
subject only to the qualification requirements under which he or she
received the initial Medicare number.
As for those NPs who qualify for the Medicare program under current
rules but have not billed Medicare, we do not share their concern. This
proposal was specifically intended to (1) avoid barring veteran NPs
from continuing to furnish services to Medicare beneficiaries and, (2)
provide a lead time for the new NPs to obtain the master's degree.
These revised qualification requirements do not detract from our goal
to ultimately require all Medicare NPs to have a master's degree.
Comment: Of the physicians and physician organizations that
submitted comments, all but the American Academy of Family Physicians
(AAFP) opposed the proposal. They stated that it would lessen the
qualification requirements of NPs and endanger the safety of Medicare
patients. A few individual doctors commented that they were appalled
because the proposed rule would allow NPs to perform and bill Medicare
directly for physicians' services. They believed that the proposal
would not only raise issues regarding quality of care but also
jeopardize the Medicare Trust Fund.
Response: It is the Social Security Act (as amended by the BBA),
and not this proposed rule, that authorizes NPs to directly bill
Medicare for performing physicians' services. Moreover, we do not agree
with these conclusions because the proposed qualification requirements
are clearly stricter than those that exist currently. We note that the
November 1998, final rule regarding NP qualifications was scheduled to
become effective January 1, 2000 (see 64 FR 25456). Thus, the new rule
merely permits the veteran NPs who have been serving the Medicare
beneficiaries to continue to do so.
Comment: The comments from most of the physician groups, such as
the American Medical Association, and many of the individual doctors
suggested that we emphasize and elaborate upon the provision requiring
NPs to collaborate with physicians. Even AAFP requested that we address
the definition of ``collaboration'' in a rule. In addition, some
commenters asked that we specify in a rule that NPs should perform only
those services specifically authorized by State law.
Response: ``Collaboration'' was not a subject of the proposed rule,
and we have no plans at this time to change the current definition.
Comment: The women's health care NPs requested that we begin
requiring the master's degree in 2007 to coincide with their plan to
require master's degree of all women's health care NPs.
Response: We believe that the lead time provided under our proposal
is sufficient for all new NPs to obtain the master's degree in nursing.
We recognize that even some states do not require the master's degree.
Nevertheless, we note that we are not precluded from establishing our
own qualification requirements for NPs who furnish services to Medicare
patients.
Result of Evaluation of Comments
The rule concerning NP qualifications is adopted as proposed. In
addition to revising Sec. 410.75(b), we are also making conforming
changes to Sec. 485.705(c)(8).
J. Relative Value Units for Pediatric Services
During the 5-year review, we did not appropriately adjust work RVUs
for certain pediatric surgical services. The present values reflect E/M
services of the postoperative period as determined in the original
study conducted by the Harvard research team and not the subsequent
study of pediatric surgical services performed in 1992 by the Harvard
research team for the American Pediatric Surgical Association (APSA).
We proposed changing the RVUs for E/M services during the global
surgical period for pediatric surgical services to reflect the findings
of the 1992 Harvard study.
Comment: The American Urological Association and the American
Academy of Pediatrics supported this proposal. The American College of
Surgeons and the APSA forwarded information from the 1992 Harvard study
on work RVUs for pediatric surgical services and requested we use this
data.
Response: We have accepted the RVUs from the 1992 Harvard study and
have substituted them in our database.
Result of Evaluation of Comments: We are changing the RVUs to
reflect the 1992 data.
K. Percutaneous Thrombectomy of an Arteriovenous Fistula
We proposed to implement a HCPCS code, defined as ``percutaneous
thrombectomy and/or revision, arteriovenous fistula, autogenous or
nonautogenous dialysis graft'' to be used until the AMA creates a
permanent CPT code. We defined it analogously to open surgical
procedures, CPT codes 36831 to 36833 and proposed a 90-day global
period for this service to be consistent with the open surgical
procedure codes and to facilitate comparisons with them.
[[Page 59413]]
We proposed individual local carrier pricing for the new HCPCS code.
Comment: The International Society for Cardiovascular Surgery and
the Society for Vascular Surgery expressed support for our proposal,
and while the American College of Radiology was also in agreement with
our proposal, they recommended a ``000'' global period rather than a 90
day global, as proposed.
Response: We continue to believe that a 90-day global period is
appropriate for this procedure because the effectiveness has been
compared to open thrombectomies, for which 90-day global periods are
used.
Comment: The American Medical Association commented that adding the
codes to HCPCS Level II , rather than through CPT, adds to the
potential for confusion and incorrect coding.
Response: We have defined a HCPCS Level II code because no
appropriate CPT code exists. These procedures are currently being
performed, so we believe that it is necessary to have a code for
billing even though no CPT code has yet been developed. As we have
stated, we also plan to collect data in conjunction with the reporting
of the new code so that we, or the CPT Editorial Panel, may refine its
definition.
Comment: The Society for Cardiovascular and Interventional
Radiology expressed support for our proposal; however, they recommended
that the ``revision'' be dropped from the code description since a
graft revision and declotting usually occur at separate sessions and a
revision typically involves another physician. They also recommended
that the interim HCPCS have a global period of ``000'' like other
percutaneous therapies rather than the 90 day period proposed and that
RVUs should be assigned for this interim code rather than allowing the
procedure to be carrier priced.
A manufacturer also expressed concern about the 90 day global
period and that this code would be carrier priced.
Response: We have specified carrier-pricing for this procedure for
the reasons outlined by the commenters. If this is a heterogenous
procedure with variations in how the thrombectomy is performed or
whether a revision is done simultaneously, the carrier will be able to
adjust the payment appropriately. We plan to collect data regarding the
procedure variations, and we will consider revisions of the code
definition, global period, and alternate codes after we have reviewed
the data.
Result of Evaluation of Comments
We will implement this code as proposed with a 90 day global period
and will review the collected data to determine if revisions to the
code definition, global period and alternate codes should be made.
L. Pulse Oximetry, Temperature Gradient Studies and Venous Pressure
Determinations
We proposed to discontinue separate payment for CPT codes 94760,
94761, 94762, 93740, and 93770 (pulse oximetry, temperature gradient
studies and venous pressure determinations) and to list them in the
physician fee schedule with a status code of ``B'' for ``payment always
bundled into payment for other services.'' We stated that continuing to
pay separately for these codes duplicates amounts included in both
facility payments and practice expense RVUs.
Comment: Several professional societies commented that we should
not consider these services to be bundled with E/M service payments.
One commenter noted that the CPT specifies that diagnostic studies may
be reported separately. Another commenter stated that if we would not
pay separately for pulse oximetry, physicians would not perform pulse
oximetry but would refer patients for arterial blood gas
determinations. Another commenter observed that the interpretation of
pulse oximetry results can be complex. The American College of Chest
Physicians and the American Academy of Sleep Medicine commented
specifically that CPT code 94762, pulse oximetry by continuous
overnight monitoring, is not performed in conjunction with an E/M. All
commenters noted that pulse oximetry is a valuable procedure.
Response: We agree that pulse oximetry is a valuable procedure.
Because the technology has progressed and been simplified and reduced
in cost, pulse oximetry is a routine inclusion in many procedures and
visits. Pulse oximetry is no more invasive and arguably less invasive
than recording the patient's temperature, another example of a
diagnostic service for which we do not make separate payment. If
interpretation of pulse oximetry or temperature data is complex, then
that interpretation is clearly part of the medical decision making
included in the E/M services. We believe that payment for pulse
oximetry equipment is included in our facility and practice expense
payments just as the costs of electronic thermometers are included.
While we believe that pulse oximetry with continuous overnight
monitoring is always performed in conjunction with an E/M service, we
agree that the patient's use of the oximeter is separate from the
typical use of equipment during the E/M service.
Medicare coverage policy or some type of utilization standards to guide
Medicare carrier review.
Response: As required by the BBA, we are developing utilization
guidelines for manual manipulation to treat subluxation of the spine
when an x-ray is not required.
Result of Evaluation of Comments: We are revising Sec. 410.22(b)(1)
to delete the x-ray requirement. Thus, this section will state that
Medicare Part B pays only for a chiropractor's manual manipulation of
the spine to correct a subluxation if the subluxation has resulted in a
neuromusculoskeletal condition for which manipulation is appropriate
treatment.
N. Coverage of Prostate Cancer Screening Tests
Effective January 1, 2000, section 4103 of the BBA provides for
Medicare coverage of certain prostate cancer screening tests for all
male Medicare beneficiaries subject to certain frequency and other
limitations. The BBA defines a prostate cancer screening test to mean a
test (among other things) that is ``provided for the purpose of early
detection of prostate cancer to a man over 50 years of age who has not
had such a test during the preceding year.'' We interpreted this
language to mean that payment may be made for a male beneficiary over
50 years of age or older (that is, starting at least one day after he
has attained age 50) for both an annual screening digital rectal
examination (DRE) and an annual screening prostate-specific antigen
(PSA) test.
We proposed to add a new Sec. 410.39 to provide coverage for two
types of prostate cancer screening. To ensure that the screening DRE is
performed as safely and accurately as possible, we proposed to require,
in Sec. 410.39(b), that the examination be performed by the patient's
attending physician who is either a doctor of medicine or osteopathy
(as defined in section 1861(r)(1) of the Act), or by the beneficiary's
attending physician assistant, nurse practitioner, clinical nurse
specialist, or certified nurse midwife (as defined in section 1861(aa)
and section 1861(gg) of the Act) who is authorized under State law to
perform the examinations. In Sec. 410.39(c), we proposed that payment
may not be made for a screening DRE performed for
[[Page 59414]]
a man age 50 or younger. For a patient over 50 years of age, payment
would be made for a screening DRE only if the beneficiary has not had
such an examination paid for by Medicare during the preceding 11 months
following the month in which his last Medicare-covered screening DRE
was performed. In Sec. 410.39(d), we specified that coverage is
available for screening PSA tests only if they are ordered by the
beneficiary's attending physician, or by the beneficiary's attending
physician assistant, nurse practitioner, clinical nurse specialist, or
certified nurse midwife who is authorized to order this test under
State law. We included this coverage requirement to assure that
beneficiaries receive appropriate information about the potential
implications of screening tests. In Sec. 410.39(e), we proposed that
payment may not be made for a screening PSA test performed for a man
age 50 or younger. For an individual over 50 years of age, payment may
be made for a screening PSA test only if he has not had such an
examination paid for by Medicare during the preceding 11 months
following the month in which his last Medicare-covered screening PSA
test was performed.
We also created a new HCPCS code, G0102, prostate cancer screening
DRE, to be used for the screening DRE. A DRE is a relatively quick and
simple procedure, and we have assigned it the same value as CPT code
99211, the lowest level E/M service. A DRE is usually furnished as part
of an E/M service. We believe that it would be extremely rare for a DRE
to be the only service provided during a patient encounter. For this
reason, we proposed to bundle the DRE into the payment for an E/M
service when a covered E/M service is furnished on the same day as a
DRE. If the DRE is the only service furnished or is provided as part of
an otherwise noncovered service, such as CPT code 99397 (preventive
services visit), HCPCS code G0102 would be payable separately if all
the aforementioned coverage requirements are met.
We also created a new HCPCS code, G0103, prostate screening;
prostate specific antigen (PSA), to be used for the screening PSA test.
The screening PSA test is priced at the same payment rate as CPT code
84153 (PSA; total) and would be paid under the clinical diagnostic
laboratory fee schedule.
Comment: All the comments we received on this subject supported
implementation of the prostate cancer screening provisions created by
the BBA. One commenter indicated that the proposed requirements are
consistent with current professional medical standards and generally in
accord with the views of practicing physicians and various national
medical societies.
However, one commenter expressed concern that the BBA was silent
with respect to the need for the ``attending'' requirement and
suggested that we needed to furnish additional rationale for adopting
the requirements in the final rule. Specifically, it was suggested that
physicians other than the beneficiary's attending physician, such as a
physician partner, might be qualified to substitute for the attending
physician in his or her absence from the office or clinic.
Response: Although the BBA is silent about who should perform DREs
or order PSA tests for Medicare patients, section 1862(a)(1)(A) of the
Act prohibits payment for services that are not reasonable and
necessary for the diagnosis or treatment of illness or injury.
Reasonable and appropriate qualification requirements help ensure that
quality screening services are delivered to Medicare patients and that
they are furnished with sufficient information about the implications
and possible results of having a PSA blood test completed. It is true
that an appropriately trained physician or other practitioner can
perform this service safely and it does not have to be limited to the
patient's attending physician. Based on the comments received from
various medical societies, we believe that we can best help ensure that
these new Medicare screening services are furnished safely and
effectively to patients by requiring that they be done by the physician
or other recognized practitioner (as stated elsewhere in this section)
who is fully knowledgeable about the patient and would be responsible
for explaining the results of the screening examination or test. We
believe that under this formulation, a physician other than the
patient's attending physician in a group practice can easily meet the
requirement.
Result of Evaluation of Comments: We are modifying our proposal to
delete the word ``attending''. The revised requirement will be that the
screening DREs and the screening PSA tests must be performed and
ordered, respectively, by the beneficiary's physician, physician
assistant, nurse practitioner, clinical nurse specialist, or certified
nurse midwife who is fully knowledgeable about the patient and would be
responsible for explaining the results of the screening examination
(test). This revision is reflected in the new Sec. 410.39.
Comment: One commenter indicated that Secs. 410.39(c)(1) and
410.39(e)(1) relating to the limitation on coverage of screening DREs
and screening PSA tests are in conflict, and need to be clarified to
make them consistent with the law and our interpretation of the law as
explained in the preamble to the proposed rule.
Response: We agree with the commenter. There is an inaccuracy in
proposed Sec. 410.39(e)(1) that needs to be corrected. As we discussed
in the preamble to the proposed rule, the BBA defines a prostate cancer
screening test to mean a test (among other things) that is ``provided
for the purpose of early detection of prostate cancer to a man over 50
years of age who has not had such a test during the preceding year.''
We have interpreted this to mean that payment may be made for a male
beneficiary over 50 years of age or older (that is, starting at least
one day after he has attained age 50) for both an annual screening DRE
and an annual screening PSA test. This means, however, that payment may
not be made for a male beneficiary on or before the day he attains age
50.
Result of Evaluation of Comments: We are revising Sec. 410.39(e)(1)
to provide that payment ``may not be made for a screening PSA blood
test performed for a man on or before the day he attains age 50.'' We
are leaving Sec. 410.39(c)(1) unchanged.
Comment: Commenters agreed with our proposal to create a new code,
G0102, for a DRE and pay for it at the same level as the lowest level
E/M code, 99211. Two commenters agreed with our proposal to bundle the
payment for a DRE into the payment for a covered E/M service furnished
on the same day. Two other commenters stated that since the DRE is a
separate covered benefit that it should always be paid separately.
Response: As stated in the July 1999 proposed rule (64 FR 39627), a
DRE is a very quick and simple examination taking only a few seconds.
We believe it is rarely the sole reason for a physician encounter and
is usually part of an E/M encounter. In those instances when it is the
only service furnished or it is furnished as part of an otherwise non-
covered service, we will pay separately for code G0102. In those
instances when it is furnished on the same day as a covered E/M
service, we believe it is appropriate to bundle it into the payment for
the covered E/M encounter.
Result of Evaluation of Comments: We are adopting our proposal to
pay for a DRE (G0102) at the same level as the lowest level E/M service
(99211) and to bundle the payment for the DRE into the payment for a
covered E/M service
[[Page 59415]]
when the two services are furnished to the patient on the same day.
O. Diagnostic Tests
1. Supervision of Diagnostic Tests
Sections 4511 and 4512 of the BBA removed the restrictions on the
areas and settings in which nurse practitioners (NPs), clinical nurse
specialists (CNSs) and physician assistants (PAs) may be paid under the
physician fee schedule for services that would be physicians' services
if furnished by a physician. We proposed to revise Sec. 410.32(b)
concerning diagnostic x-ray and other diagnostic tests and add an
exception at Sec. 410.32(b)(2) to specify that no physician supervision
of NPs and CNSs is required for diagnostic tests performed by NPs and
CNSs when they are authorized by the State to perform these tests. In
addition, we proposed to modify Sec. 410.32(b)(3) by means of a
parenthetical to state that diagnostic tests that a PA is legally
authorized to perform under State law require only a general level of
physician supervision of the PA.
We also proposed to add an exception criterion at Sec. 410.32(b)(2)
so that physician supervision rules would not apply to pathology and
laboratory codes in the 80000 series of the CPT payable under the
physician fee schedule. These codes are within the scope of the
Clinical Laboratory Improvement Amendments of 1988 (CLIA) regulations
(Part 493), and we determined it would be unnecessarily confusing to
apply another separate set of supervision rules to the performance of
these procedures. The CLIA regulations should determine the level of
supervision necessary, if any, for these procedures.
We received many comments opposing the proposal to modify
Sec. 410.32 to permit NPs and CNSs to order, interpret, and perform
radiological procedures without physician supervision when they are
authorized by the State to perform these services. Our proposal
addressed only the last activity. The legal authority for NPs and CNSs
to order and to interpret tests (and for PAs to perform these
activities under physician supervision) is not at issue. Section
410.10(a)(3) already provides that nonphysician practitioners
(including PAs, NPs, and CNSs) who are operating within the scope of
their authority under State law may order diagnostic tests. With regard
to the interpretation of diagnostic tests, Congress has specifically
recognized the ability of PAs, NPs, and CNSs to furnish services that
would be physician services, if furnished by a physician, subject to
the provisions of State law.
Several commenters expressed their approval of the proposal
regarding PAs, NPs, and CNSs.
Comment: Several commenters indicated that the proposal to change
the regulation to permit NPs and CNSs to perform diagnostic tests
without physician supervision did not explain why this change was being
proposed.
Response: As indicated in the July 1999 proposed rule (64 FR
39638), the proposal would conform the requirements of the physician
supervision policy in Sec. 410.32(b) to the BBA provisions relating to
PAs, NPs, and CNSs. Those provisions generally permitted these
practitioners to bill directly for services that would be physicians'
services if they were furnished by a physician.
Comment: Many commenters expressed concern about the qualifications
of NPs and CNSs to perform radiology procedures without physician
supervision. The commenters pointed out that--
Radiologists undergo 4 to 5 years of residency training
after medical school;
NPs and CNSs do not have the training, education, or
experience to be qualified to furnish radiology services;
The lack of training undergone by NPs and CNSs in x-ray
physics as well as nuclear medicine, magnetic resonance physics, and
ultrasound physics, places the patient in a life-threatening position;
and
The policy on this matter should be a national policy,
rather than a policy debated in each State legislature.
Response: As indicated in the July 1999 proposed rule, we made the
proposals to remove the requirement for physician supervision of NPs
and CNSs for diagnostic tests for services NPs and CNSs are authorized
to perform under State law and to establish a level of general
supervision by a physician for diagnostic tests that PAs are authorized
to perform under State law. Further, since we have not imposed
requirements regarding specific training requirements for physician
specialties to be able to perform and bill for these diagnostic tests,
we believe that it is inappropriate to apply these requirements to
practitioners whom the Congress has specifically recognized as having
the ability to furnish services that would be physician services if
furnished by a physician, subject to the provisions of State law. The
Medicare law generally leaves the scope of practice of NPs, CNSs, and
PAs to be determined by the individual States. Finally, we have no
indication that NPs and CNSs will abuse their benefit by trying to
perform diagnostic tests they are not qualified to do.
Comment: A national organization of radiologic technologists
questioned the reliance on the statutory language in section 4511 of
the BBA for policy on the issue of supervision of NPs or CNSs for
diagnostic testing and suggested that we are incorrectly interpreting
this section by proposing to allow these practitioners to perform
diagnostic testing without a supervising physician. The commenter went
on to indicate that the proposed rule creates a practice opportunity
for nurses that is not justified by the cited legislation, that it
ignores existing law, and that we are in violation of the
Administrative Procedure Act by making law that exceeds its
congressional authority.
Response: We believe that our proposal is within the law and
reflects the intent of the Congress with regard to services of NPs and
CNSs.
Comment: One commenter said that it should be made clear in the
final rule that the technical component which is the issue at hand, is
not subject to the payment reduction applicable to services of
nonphysician practitioners.
Response: We agree with the commenter. Since May 1992, Section
16000 of the Medicare Carriers Manual has stated: ``For those services
that have both a technical component and a professional component (such
as a radiology service or a diagnostic test) or if the nonphysician
practitioner provides an incident to service that is routinely
separately billed, the percentage payment limitations do not apply to
the technical component or to the incident to part of the service that
is separately billed.''
Comment: Some commenters expressed concern about the effect of this
proposal, if adopted, on the mammography certification program.
Response: Mammography certification programs are regulated by the
FDA (21 CFR Part 900), and entities performing mammography must comply
with those regulations in order to be certified. Our regulations would
not affect that process.
Comment: Some commenters indicated that the proposed revision would
be contrary to Stark I and II that was formulated to reduce self-
referral and its potential for abuse. It was pointed out that self-
referral has been shown to be an incentive for overutilization of
imaging services.
Response: The Stark provisions do not apply to the services of
nonphysician practitioners.
Comment: The American Medical Association suggested that the
proposal not to require physician supervision for
[[Page 59416]]
tests NPs and CNSs are authorized to perform under State law be delayed
until the controversy surrounding the requirement for NPS and CNSs to
be working in collaboration is better resolved.
Response: The collaboration requirement is not an issue upon which
comments were sought under this year's proposed rule, and we do not
believe that issue should delay implementation of this proposal.
Comment: Several commenters expressed their opinions on issues
relating to the levels of physician supervision that should be required
for individual diagnostic tests.
Response: No proposals on the levels of physician supervision
required for individual diagnostic tests were included in the proposed
rule, and we will not discuss them here. We plan to issue a program
memorandum setting forth revised levels of supervision.
Comment: One commenter indicated that the proposed rule cites
section 4511 of the BBA as one of the reasons for eliminating the
physician supervision requirements for NPs and CNSs and pointed out
that section 4511 could be interpreted to mean that the provision only
applies to ``incident to'' services. The commenter went on to say that,
since ``incident to'' (as set forth in section 1861(s)(2)(A)) does not
apply to diagnostic tests that have technical components, that
provision of the BBA does not mandate the elimination of the physician
supervision requirement for diagnostic tests performed by NPs and CNSs.
Response: The technical components of diagnostic tests are covered
under section 1861(s)(3) of the Act. Section 1848(j) of the Act
specifies that services covered under that section are ``physicians'
services'' for purposes of payment under the Medicare physician fee
schedule. Section 4511 of the BBA provides that NPs and CNSs may bill
directly for services that would be physician services if they were
furnished by a physician, so long as the practitioners are authorized
under State law to perform the services. This provision is not limited
to ``incident to'' services. (In fact, the very definition of
``incident to'' services is that they are services which are included
in a physician's bill and not separately billed; thus it would be
difficult to read section 4511 as applying only to those services.)
Comment: One commenter characterized the language used in our
proposal to exclude pathology and laboratory codes in the 80000 series
of the CPT from the physician supervision requirements of
Sec. 410.32(b) as ``inflammatory, patronizing, and gratuitous.'' The
language related to our statement that the decision as to the necessity
of physician supervision in connection with these services should be
made solely under the CLIA regulations and not under both the CLIA
regulations and the physician fee schedule regulations.
Response: Obviously, there was no intent to offend pathologists. We
made the proposal to remove confusion with regard to the physician
supervision requirements that apply to a class of codes.
Result of Evaluation of Comments
We are adopting our proposal to provide that--
Diagnostic tests payable under the physician fee schedule
and performed by a nurse practitioner or clinical nurse specialist
authorized to perform such tests under applicable State laws are
excluded from the physician supervision requirement set forth in 42 CFR
410.32(b);
Pathology and laboratory procedures listed in the 80000
series of the CPT and payable under the physician fee schedule are
excluded from the physician supervision requirements of Sec. 410.32(b);
and
Diagnostic tests payable under the physician fee schedule
and performed by a physician assistant authorized to perform tests
under applicable State laws require only a general level of physician
supervision.
2. Independent Diagnostic Testing Facilities
In keeping with the BBA provisions concerning services furnished by
NPs, CNSs and PAs as discussed in paragraph 1. above, we proposed to
revise Sec. 410.33(a), which establishes criteria for the operation of
independent diagnostic testing facilities (IDTFs), to include NPs and
CNSs who perform diagnostic tests that the State authorizes them to
perform in the list of entities that may be paid directly by the
carrier. We also proposed to modify the implementation date for IDTFs
from July 1, 1998 to March 15, 1999 to reflect the actual
implementation date.
Comment: Several commenters expressed concern that the proposal to
add NPs and CNSs to the list of entities that may be paid directly by
the carrier for diagnostic tests under the physician fee schedule would
enable these practitioners to open their own imaging facilities and
independently perform diagnostic imaging tests.
Response: The Congress has specifically recognized the ability of
NPs and CNSs to furnish physician services subject to the requirements
of State law. The law evidences the intent of the Congress that the
determination of the scope of services of NPs and CNSs may be
determined by the individual States. We have no reason to believe that
NPs and CNSs will abuse their benefit by trying to perform diagnostic
tests they are not qualified to do. NPs and CNSs are not precluded from
opening an IDTF. However, IDTFs that are owned and/or operated by NPs
and CNSs must meet IDTF physician supervision requirements; that is,
the IDTFs must employ or contract with a physician (MD or DO) to
provide the required levels of supervision of technicians and
equipment.
Result of Evaluation of Comments
We are adopting our proposal to amend Sec. 410.33(a) to change the
effective date and to add NPs and CNSs to the list of entities that may
be paid directly by the carrier for diagnostic tests under the
physician fee schedule.
P. Other Issues
Orthopedic Physician Assistants
OPAs are not recognized as PAs under Medicare. We received many
comments concerning the recognition of orthopedic physician assistants
(OPAs) as PAs for Medicare coverage purposes. We proposed including
OPAs as PAs as part of last year's proposed rule, but we chose not to
include the proposal in the final rule. For the reasons stated in the
1998 final rule (63 FR 58876 through 58878) we have no current plans to
address the issue again.
Image-Guided Biopsy
We received comments concerning the current image-guided biopsy
code, CPT code 19101. The commenters stated that currently two
different procedures, open incisional biopsy and image-guided breast
biopsy with the equipment that integrates imaging and biopsy are
assigned this code and it cannot be fairly valued as it does not
adequately reflect the skills, work or practice expense for the image
guided stereotaxic breast biopsy procedure. The commenters recommended
that a new separate code for image-guided vacuum assisted breast biopsy
be established. Since this issue is under consideration for a change in
coverage criteria, we will consider coding changes needed to implement
any change in coverage. No changes will be made at this time.
Portable X-ray Transportation
We received comments concerning the payment rate for portable x-ray
transportation codes R0070 and R0075. The commenters suggested that new
[[Page 59417]]
regional rates, independent of the physician fee schedule, be proposed
for portable x-ray transportation codes R0070 and R0075. Until such
regional rates are finalized, the commenters believed it would be
appropriate to continue carrier pricing based on current year rates
plus an annual adjustment for inflation. We continue to believe that
the physician fee schedule is the appropriate vehicle for portable x-
ray transportation payments because these services are payable only by
virtue of section 1861(s)(3) of the Act. Also, we did not propose new
RVUs for these services in this year's proposed rule. We will continue
to require that these codes be carrier priced at least through the end
of 2000. It is within the carrier's discretion to raise or lower
payment levels, after appropriate notification, for reasons of
inflation or other considerations.
Supervision Requirements for Therapy Assistants
An association representing physical therapists and another
association representing occupational therapists, commented that the
level of supervision required for therapy assistants in the private
practice setting should be direct supervision rather than the personal
supervision stipulated in the November 1998 final rule. They indicated
that the personal supervision requirement changed the long-standing
direct supervision requirement that was applicable to therapy
assistants in private practice prior to January 1, 1999 (then known as
therapy assistants in independent practice). The commenters further
stated that the personal supervision requirement imposed a level of
supervision higher than that required for therapy assistants furnishing
such services in other Medicare settings and that the requirement is
contrary to state law.
While we acknowledge that we have been urged to revisit this issue,
we did not include it in our proposed rule and we will not address the
issue in this final rule. We believe that supervision issues raise
concerns about quality of care, and we would prefer that any changes be
the subject of public discussion. Therefore, before we would make
changes in supervision requirements, we would include them in a future
proposed rule.
III. Refinement of Relative Value Units for Calendar Year 2000 and
Response to Public Comments on Interim Relative Value Units for
1999 (Including the Relative Value Units Contained in the July 22,
1999 Proposed Rule)
A. Summary of Issues Discussed Related to the Adjustment of Relative
Value Units
Section III. B. of this final rule describes the methodology used
to review the comments received on the RVUs for physician work and the
RVUs for new and revised CPT codes. Changes to CPT codes on the
physician fee schedule reflected in Addendum B are effective for
services furnished beginning January 1, 2000.
B. Process of Establishing Work Relative Value Units for 2000 Physician
Fee Schedule
Our November 2, 1998 final rule (63 FR 58814) announced the final
RVUs for Medicare payment for existing procedure codes under the
physician fee schedule and interim RVUs for new and revised procedure
codes. The RVUs contained in the rule applied to physician services
furnished beginning January 1, 1999. We announced that we considered
the RVUs for the interim procedure codes would be subject to public
comment under the annual refinement process. We also included an
additional 16 new and revised CPT codes in the July 22, 1999 proposed
rule and requested comments on these CPT codes. We had received the
RUC's recommendations for these CPT codes too late for them to be
included in the November 1998 final rule.
In this section, we summarize the refinements to the interim work
RVUs that have occurred since publication of the November 1998 final
rule and our establishment of the work and practice expense, and
malpractice RVUs for new and revised procedure codes for the 2000
physician fee schedule.
Work Relative Value Unit Refinements of Interim and Related Relative
Value Units (Includes Table 1--Work RVU Refinement of 1999 Interim and
Related Relative Value Units)
Although the work RVUs in the November 1998 final rule were used to
calculate 1999 payment amounts, we considered the work RVUs for the new
or revised procedure codes to be interim. We accepted comments for a
period of 60 days. We also included additional RUC work RVU
recommendations in the July 22, 1999 proposed rule. We accepted
comments on these work RVU recommendations for a period of 60 days. We
received comments from four specialty societies on four CPT codes with
interim work RVUs. Only comments received on codes listed in Addendum C
of the November 1998 final rule or codes listed in section P. of the
July 1999 proposed rule were considered. Due to the limited number of
comments received, we did not convene multispecialty refinement panels.
Rather, determinations were made by our medical staff. In reaching
their conclusions they analyzed written comments of the specialty
societies that commented.
Table 1 lists the interim and related codes reviewed during the
1999 refinement process described in this section. This table includes
the following information:
CPT Code. This is the CPT code for a service.
Description. This is an abbreviated version of the
narrative description of the code.
1999 Work RVU. The work RVUs that appeared in the November
1998 or July 1999 rule are shown for each reviewed code.
Requested Work RVU. This column identifies the work RVUs
requested by the commenters.
2000 Work RVU. This column contains the final RVUs for
physician work.
The final work RVUs emerged from analysis of the specialty
societies written comments on the 1999 interim valued CPT codes.
Table 1.--Work RVU Refinement of 1999 Interim and Related RVUs
----------------------------------------------------------------------------------------------------------------
1999 Work Requested 2000 Work
CPT Code MOD Description RVU Work RVU RVU
----------------------------------------------------------------------------------------------------------------
33975................ ................. Ventricular access device...... 21.00 21.00 21.00
33976................ ................. Ventricular access device...... 23.00 23.00 23.00
69990................ ................. Microsurgery add-on............ 3.47 3.47 3.47
78020................ 26............... Thyroid met uptake............. 0.60 0.67 0.60
----------------------------------------------------------------------------------------------------------------
* All CPT codes and descriptors copyright 1998 American Medical Association.
[[Page 59418]]
Implantation of ventricular assist device (CPT codes 33975 and 33976)
Comment: One speciality society commented that they concur with our
proposed work RVUs for the intraoperative work associated with the
implantation of a ventricular assist device. It should be noted that
the concurrence was contingent upon the global period of ``XXX'' days
that we assigned to CPT codes 33975 and 33976.
Response: We believe that the substitution of an ``XXX'' global
period for the original global period of 90 days, and the resulting
reduction in the work RVUs for the implantation of ventricular assist
devices, has resulted in equitable work RVUs for the implantation of
ventricular assist devices. We appreciate the opportunity to work with
specialty societies to accomplish equitable work RVUs.
Microsurgery add-on (CPT code 69990)
Comment: Many surgical groups commented that we should always pay
separately for the use of the operating microscope unless its use is
explicitly stated in the definition of the procedure. They claim that
increasing use of the operating microscope has led to increased work.
Response: We are sympathetic to the idea that increasing use of the
operating microscope has led to increased work. However, the current
evaluation of CPT code 69990 was not based on an evaluation of the
increased work for the myriad of procedures for which an operating
microscope may be used. We believe that it is unlikely that one add-on
code can correctly reimburse for work done on procedures varying from
cranial neurosurgery to foot surgery. Our 5-year review of work RVUs
will be active in the coming year. We believe that the 5-year review
process is the appropriate mechanism for reviewing appropriate payment
for microsurgery.
Comment: Two specialty groups recommended that we increase the
physician work RVU of CPT code 78020, Thyroid carcinoma metastases,
from 0.60 work RVUs to the AMA RUC recommended value of 0.67 work RVUs.
Response: The specialty society reported that this procedure was
previously reported with unlisted CPT code 78099. The specialty survey
also estimated that this code will be billed approximately 15 percent
of the time that CPT code 78018 is billed. According to Medicare
frequency data, CPT code 78099 was only billed 61 times in 1997 while
the projected utilization for CPT code 78020 for 1999 is approximately
575 claims annually. In order to keep budget neutrality within this
family of codes we will retain its proposed recommendation of 0.60 work
RVUs for CPT code 78020.
Establishment of Interim Work Relative Value Units for New and Revised
Physicians' Current Procedural Terminology Codes and New HCFA Common
Procedure Coding System Codes for 2000 Methodology (Includes Table 2--
American Medical Association Specialty Society Relative Value Update
Committee and Health Care Professionals Advisory Committee
Recommendations and HCFA's Decisions for New and Revised 2000 CPT
Codes)
One aspect of establishing work RVUs for 2000 was related to the
assignment of interim work RVUs for all new and revised CPT codes. As
described in our November 25, 1992 notice on the 1993 fee schedule (57
FR 55938) and in section III.B of our November 22, 1996 final rule (61
FR 59505 through 59506) we established a process, based on
recommendations received from the AMA's RUC, for establishing interim
work RVUs for new and revised codes.
This year we received work RVU recommendations for approximately 61
new and revised CPT codes from the RUC. Our staff and medical officers
reviewed the RUC recommendations by comparing them to our reference set
or to other comparable services for which work RVUs that had been
established previously, or to both of these criteria. We also
considered the relationships among the new and revised codes for which
we received RUC recommendations. We agreed with the majority of those
relationships reflected in the RUC values. In some cases, when we
agreed with the RUC relationships, we revised the work RVUs recommended
by the RUC to achieve work neutrality within families of codes. That
is, the work RVUs have been adjusted so that the sum of the new or
revised work RVUs (weighted by projected frequency of use) for a family
of codes will be the same as the sum of the current work RVUs (weighted
by their current frequency of use). For approximately 69 percent of the
RUC recommendations, proposed work RVUs were accepted, and for
approximately 31 percent, the work RVUs were decreased.
There were also 7 CPT codes for which we did not receive a RUC
recommendation. After review of these CPT codes by our staff and
medical officers, we established interim work RVUs for all 7 CPT codes.
Table 2 lists the new or revised CPT codes, and their associated
work RVUs, that will be interim in 2000. This table includes the
following information:
A ``#'' identifies a new code for 2000.
CPT code. This is the CPT code for a service.
Modifier. A ``26'' in this column indicates that the work
RVUs are for the professional component of the code.
Description. This is an abbreviated version of the
narrative description of the code.
RUC recommendations. This column identifies the work RVUs
recommended by the RUC.
HCPAC recommendations. This column identifies work RVUs
recommended by the HCPAC.
HCFA decision. This column indicates whether we agreed
with the RUC recommendation (``agree''); we established work RVUs that
are higher than the RUC recommendation (``increase''); or we
established work RVUs that were less than the RUC recommendation
(``decrease''). Codes for which we did not accept the RUC
recommendation are discussed in greater detail following Table 2. An
``(a)'' indicates that no RUC recommendation was provided. A discussion
follows the table.
HCFA Work RVUs. This column contains the RVUs for
physician work based on our reviews of the RUC recommendations.
2000 Work RVUs. This column establishes the 2000 RVUs for
physician work.
Table 2.--AMA RUC and HCPAC Recommendations and HCFA Decisions for New and Revised 2000 CPT Codes
----------------------------------------------------------------------------------------------------------------
RUC HCPAC HCFA Work 2000 Work
CPT* code MOD Description recommendation recommendation HCFA decision RVU RVU
----------------------------------------------------------------------------------------------------------------
11980#..... ....... Hormone pellet .............. .............. (a)........... 1.48 1.48
implanation.
13102#..... ....... Repair wound/ 1.24 .............. Agree......... 1.24 1.24
lesion add-on.
13122#..... ....... Repair wound/ 1.44 .............. Agree......... 1.44 1.44
lesion add-on.
[[Page 59419]]
13133#..... ....... Repair wound/ 2.19 .............. Agree......... 2.19 2.19
lesion add-on.
13153#..... ....... Repair wound/ 2.38 .............. Agree......... 2.38 2.38
lesion add-on.
20979#..... ....... US bone .............. .............. (a)........... 0.17 0.17
stimulation.
22318#..... ....... Treat odontoid 21.50 .............. Agree......... 21.50 21.50
fx w/o graft.
22319#..... ....... Treat odontoid 24.00 .............. Agree......... 24.00 24.00
fx w/ graft.
27096#..... ....... Inject 1.40 .............. Decrease...... 1.10 1.10
sacroiliac
joint.
33140#..... ....... Heart 20.00 .............. Agree......... 20.00 20.00
Revascularize
(TMR).
33244...... ....... Remove eltrd, 13.76 .............. Agree......... 13.76 13.76
Transven.
33249...... ....... Eltrd/insert 14.23 .............. Agree......... 14.23 14.23
pace-defib.
33282#..... ....... Implant pat- 4.17 .............. Agree......... 4.17 4.17
active ht
record.
33284#..... ....... Remove pat- 2.50 .............. Agree......... 2.50 2.50
active ht
record.
33405...... ....... Replacement of 30.61 .............. Agree......... 30.61 30.61
aortic valve.
33410#..... ....... Replacement of 32.46 .............. Agree......... 32.46 32.46
aortic valve.
33968#..... ....... Remove aortic 2.00 .............. Decrease...... 0.64 0.64
assist device.
35879#..... ....... Revise graft w/ 16.00 .............. Agree......... 16.00 16.00
vein.
35881#..... ....... Revise graft w/ 18.00 .............. Agree......... 18.00 18.00
vein.
36521#..... ....... Apheresis w/ .............. .............. (a)........... 1.74 1.74
adsorp/reinfuse.
36550#..... ....... Declot vascular .............. .............. (a)........... 0.00 0.00
device.
36819#..... ....... AV fusion by 14.00 .............. Agree......... 14.00 14.00
basilic vein.
39560#..... ....... Resect 12.00 .............. Agree......... 12.00 12.00
diaphragm,
simple.
39561#..... ....... Resect 17.50 .............. Agree......... 17.50 17.50
diaphragm,
complex.
50541#..... ....... Laparo ablate 16.00 .............. Agree......... 16.00 16.00
renal cyst.
50544#..... ....... Laparoscopy, 22.40 .............. Agree......... 22.40 22.40
pyeloplasty.
50546#..... ....... Laparoscopic 20.48 .............. Agree......... 20.48 20.48
nephrectomy.
50547#..... ....... Laparo removal 25.50 .............. Agree......... 25.50 25.50
donor kidney.
50548#..... ....... Laparo-asst 24.40 .............. Agree......... 24.40 24.40
remove k/ureter.
50945#..... ....... Laparo 17.00 .............. Agree......... 17.00 17.00
ureterolithotom
y.
51990#..... ....... Laparo urethral 12.50 .............. Agree......... 12.50 12.50
suspension.
51992#..... ....... Laparo sling 14.01 .............. Agree......... 14.01 14.01
operation.
54692#..... ....... Laparoscopy, 12.88 .............. Agree......... 12.88 12.88
orchiopexy.
61751...... ....... Brain biopsy w/ 17.62 .............. Agree......... 17.62 17.62
CT/MR guide.
61862#..... ....... Implant 27.34 .............. Decrease...... 19.34 19.34
neurostim,
subcort.
61885...... ....... Implant 8.00 .............. Decrease...... 5.85 5.85
neurostim one
array.
61886#..... ....... Implant 8.00 .............. Agree......... 8.00 8.00
neurostim
arrays.
62263#..... ....... Lysis epidural 7.20 .............. Decrease...... 6.02 6.02
adhesions.
62310#..... ....... Inject spine C/T 2.20 .............. Decrease...... 1.91 1.91
62311#..... ....... Inject spine L/S 1.78 .............. Decrease...... 1.54 1.54
(CD).
62318#..... ....... Inject spine w/ 2.35 .............. Decrease...... 2.04 2.04
cath, C/T.
62319#..... ....... Inject spine w/ 2.15 .............. Decrease...... 1.87 1.87
cath L/S (CD).
64470#..... ....... Inj 1.85 .............. Agree......... 1.85 1.85
paravertebral C/
T.
64472#..... ....... Inj 1.29 .............. Agree......... 1.29 1.29
paravertebral C/
T Add-on.
64479#..... ....... Inj foramen 2.20 .............. Agree......... 2.20 2.20
epidural C/T.
64480#..... ....... Inj foramen 1.54 .............. Agree......... 1.54 1.54
epidural add-on.
64483#..... ....... Inj foramen 1.90 .............. Agree......... 1.90 1.90
epidural L/S.
64484#..... ....... Inj foramen 1.33 .............. Agree......... 1.33 1.33
epidural add-on.
64573#..... ....... Implant 7.50 .............. Agree......... 7.50 7.50
neuroelectrodes.
64626#..... ....... Destr 3.28 .............. Agree......... 3.28 3.28
paravertebri
nerve C/T.
64627#..... ....... Destr 1.16 .............. Agree......... 1.16 1.16
paravertebral N
add-on.
72275#..... 26..... Epidurography... 0.83 .............. Decrease...... 0.54 0.54
72285...... 26..... X-ray C/T spine 1.16 .............. Agree......... 1.16 1.16
disk.
73542#..... 26..... X-ray exam, 0.64 .............. Decrease...... 0.54 0.54
sacroiliac
joint.
76005#..... 26..... Fluoroguide for 0.60 .............. Decrease...... 0.54 0.54
spine inject.
76873#..... 26..... Echograph trans 1.92 .............. Decrease...... 0.99 0.99
R, pros study.
77427#..... ....... Radiation TX 3.31 .............. Agree......... 3.31 3.31
management, x5.
78267...... ....... Breath test 0.00 .............. Agree......... 0.00 0.00
attain/anal, C-
14.
78268...... ....... Breath test 0.19 .............. Decrease...... 0.00 0.00
analysis, C-14.
78456#..... 26..... Acute venous 1.00 .............. Agree......... 1.00 1.00
thrombus image.
92961#..... ....... Cardioversion, 4.60 .............. Agree......... 4.60 4.60
electric, int.
93727#..... 26..... Analyze ILR 0.52 .............. Agree......... 0.52 0.52
system.
93741#..... 26..... Analyze ht pace 0.90 .............. Decrease...... 0.64 0.64
device sngl.
93742#..... 26..... Analyze ht pace 1.03 .............. Decrease...... 0.73 0.73
device sngl.
93743#..... 26..... Analyze ht pace 1.17 .............. Decrease...... 0.83 0.83
device doub.
93744#..... 26..... Analyze ht pace 1.33 .............. Decrease...... 0.95 0.95
device doub.
96570#..... ....... Photodynamic tx, .............. .............. (a)........... 1.10 1.10
30 min.
96571#..... ....... Photodynamic tx, .............. .............. (a)........... 0.55 0.55
addl 15 min.
99170#..... ....... Anogenital exam, 1.75 .............. Agree......... 1.75 1.75
child.
99173#..... ....... Visual screening .............. .............. (a)........... 0.00 0.00
test.
99291...... ....... Critical care, 4.00 .............. Decrease...... 3.60 3.60
first hour.
99292...... ....... Critical care, 2.00 .............. Decrease...... 1.80 1.80
addl 30 min.
----------------------------------------------------------------------------------------------------------------
a No RUC recommendation provided.
[[Page 59420]]
# New Codes.
* All numeric HCPCS CPT Copyright 1997 American Medical Association.
Discussion of Codes for Which There Were No RUC Recommendations or for
Which the RUC Recommendations Were Not Accepted
The following is a summary of our rationale for not accepting
particular RUC work RVU recommendations. It is arranged by type of
service in CPT order. Additionally, we also discuss those CPT codes for
which we received no RUC recommendations for physician work RVUs. This
summary refers only to work RVUs.
Subcutaneous hormone pellet implantation (CPT code 11980)
We did not receive a work RVU recommendation from the RUC for CPT
code 11980. Our clinical staff estimate that the work associated with
CPT code 11980 is similar to that for insertion of implantable
contraceptive capsules, CPT code 11975. For the 2000 fee schedule we
will use the work RVUs from CPT code 11975 for CPT code 11980. The work
RVU for CPT code 11980 will be considered interim for 2000.
Low intensity ultrasound stimulation to aid bone healing,
noninvasive (CPT code 20979)
We did not receive a work RVU recommendation from the RUC for CPT
code 20979. Our clinical staff estimate that the work associated with
CPT code 20979 is comparable to a level 1 office visit for an
established patient, CPT code 99211. The work RVU for CPT code 20979
will be considered interim for 2000.
Injection procedure for sacroiliac joint arthrography and/or
anesthetic/steroid (CPT code 27096)
The RUC evaluated the work for this procedure based on a survey of
radiologists and a clinical description of the service including the
injection of both contrast and therapeutic substances. The RUC assigned
a work RVU of 1.4, comparable to other contrast injection procedures.
However, the RUC description also notes that this procedure is
performed without contrast in which case it is reported as CPT code
20610 for a large joint injection. The work RVU for CPT code 20610 is
0.79. Our medical staff has confirmed that CPT 27096 is also commonly
done without contrast. We estimate that CPT code 27096 will be
performed half of the time without contrast. To maintain work
neutrality, we assigned a work RVU of 1.10 based on the weighted
average of procedures with contrast (CPT codes 27093 and 27095) valued
at 1.40 work RVUs and a procedure without contrast (CPT code 20610)
valued at 0.79 work RVUs.
Removal of a percutaneous intra-aortic balloon assist device or
pump (IABP) (CPT code 33968)
The RUC evaluated the removal of a percutaneous IABP as equivalent
to 30 minutes of critical care time and assigned a value of 2.00 work
RVUs. Our medical staff wishes to emphasize that the time involved with
weaning and observation of the patient prior to removal of the IABP
should be billed under the appropriate E/M service. Furthermore, since
weaning and observation prior to removal of the IABP ensures that the
patient is hemodynamically able to tolerate removal of the IABP, we
disagree with the RUC's conclusion that the work of removing an IABP is
equivalent to the work of providing critical care services.
Our medical staff estimate that the physician work involved is
considerably less than 30 minutes. While compression of the removal
site may be required for up to 30 minutes, the compression and
observation is frequently delegated to hospital staff after a shorter
physician observation period immediately following removal. The work
has also decreased recently due to the use of smaller, 8 French IABPs
and the availability of special compression devices. We have estimated
the typical work as comparable to a level 1 subsequent hospital visit,
CPT code 99231, and have assigned work RVUs of 0.64 to this procedure.
We advise that this procedure must be performed personally by the
billing physician in order to be considered a covered physician
service. If the procedure is performed by nursing staff or a hospital
catheterization lab technician, then the physician may not claim
payment. When a claim is submitted for CPT code 33968, the time
involved in removing the IABP may not be counted towards critical care
time.
Therapeutic apheresis with extracorporeal column adsorption and
plasma reinfusion (CPT code 36521)
We did not receive a recommendation from the RUC for CPT code
36521. Our clinical staff estimate that the work for this procedure is
comparable to therapeutic apheresis involving plasma or cell exchange,
CPT code 36520.
Declotting by thrombolytic agent of implanted reservoir vascular
access device or catheter (CPT code 36550)
This is a new CPT code for which no work recommendation was made by
the RUC. Our medical staff reviewed the submission to the AMA CPT panel
and the RUC survey and determined that the skill level required for
this procedure was that of a registered nurse with some specialized
training. Furthermore, the procedure is generally performed by a
registered nurse with physician assistance upon request. In the past,
this procedure has been billed under CPT code 99211 (level 1 visit for
an established patient), which is frequently used for services provided
by ancillary staff under physician supervision. Therefore, we have
assigned 0.00 physician work RVUs for this procedure. An E/M service
may be billed separately if the physician participates in this
procedure, or provides another, separately identifiable medically
necessary E/M service. Therefore, inclusion of physician work RVUs for
CPT code 36550 would lead to duplicate payments.
Subcortical neurostimulator array implantation (CPT code 61862)
The RUC evaluated this code with a building block approach that
included the work of stereotactic localization, the device
implantation, and 140 minutes of intraoperative testing contributing
8.00 work RVUs. The RUC recommendation for the entire procedure is
27.34 work RVUs. Because the time for intraoperative testing is
variable, we are subtracting 8.00 work RVUs and assigning a value for
the procedure of 19.34. We are advising using CPT codes 95961 (work
RVUs of 2.97) and 95962 (work RVUs of 3.21), functional cortical and
subcortical mapping, to report the work of intraoperative testing. We
also note that since the work of stereotactic localization is included
in 61862, we will deny payment for other stereotactic localization
codes billed in conjunction with this code.
[[Page 59421]]
Incision and subcutaneous placement of cranial neurostimulator
pulse generator or receiver, direct or inductive coupling; with
connection to a single electrode array (CPT code 61885) and
Incision and subcutaneous placement of cranial neurostimulator
pulse generator or receiver, direct or inductive coupling; with
connection to two or more electrode arrays (CPT code 61886)
CPT code 61885 was revised to describe the placement of a cranial
neurostimulator connected to a single electrode array while CPT code
61886 is a new code that describes the same procedure with connection
to two or more electrode arrays.
Currently most cranial neurostimulator placement is reported under
CPT code 61885, whether connected to one, two, or more electrode
arrays. In the future 100 percent of old CPT code 61885 will be billed
as either CPT code 61885 or CPT code 61886. The RUC recommended an
increase in work RVUs from 5.85 to 8.00 for CPT code 61885 and
recommended a work RVU of 8.00 for CPT code 61886. Our medical staff
does not think an increase in work for CPT code 61885 is justified. The
work RVU for CPT code 61885 was increased during the last 5-year review
of physician work, and the review of the material submitted by the RUC
did not include evidence that the physician work for CPT code 61885 has
changed in the last two years. Therefore, we will continue to assign
5.85 work RVUs to CPT code 61885. Our medical staff agrees that the
physician work for CPT code 61886 is greater than the work for CPT code
61885 and will assign 8.00 work RVUs, as recommended by the RUC, to CPT
code 61886. Additionally, we will monitor the utilization pattern for
these codes to determine if a work neutrality adjustment is required in
the future.
Percutaneous lysis of epidural adhesions using solution injection
(for example, hypertonic saline, enzyme) or mechanical means (for
example, spring-wound catheter) including radiologic localization
(includes contrast when administered) (CPT code 62263)
This is a new CPT code for which the RUC recommended a work value
of 7.20 work RVUs using a building block approach. We found flaws in
the RUC construction of the building blocks. One building block, CPT
code 62279 (Injection of diagnostic or therapeutic anesthetic or
antispasmodic substance (including narcotics); epidural, lumbar, or
caudal, continuous) was counted twice. This is incorrect since the
catheter is only placed once. To correct this, we adopted the RUC's
estimate that the injection portion of an injection code (which
includes catheter placement) is \1/3\ of the total work of the code,
and we assumed a total of two injections. This resulted in counting CPT
code 62270 1.33 times instead of twice.
Our medical staff also determined that the building block for
fluoroscopic guidance was incorrectly crosswalked to new CPT code 76005
(see below) and that the appropriate crosswalk for fluoroscopic
guidance was CPT code 76003 (Fluoroscopic localization for needle
biopsy or fine needle aspiration) which requires comparable work. These
corrections result in a work RVU of 6.02 for CPT code 62263.
Epidural or subarachnoid spine injection procedures (CPT codes
62310, 62311, 62318, and 62319)
New CPT codes 62310 through 62319 were developed to organize
different routes (subarachnoid, epidural) at different levels
(cervical, thoracic, lumber, caudal), for different substances
(narcotic, anesthetic, steroid, antispasmodic). Nine CPT codes,
previously used to report these services, were deleted and crosswalked
into these four new CPT codes. Although we agree with the relativity
established by the RUC, in order to retain budget neutrality within
this family of codes the RUC recommendations had to be uniformly
reduced. The work RVUs for these four new CPT codes will be: 62310
(work RVU=1.91), 62311 (work RVU=1.54), 62318 (work RVU=2.04), and
62319 (work RVU=1.87).
Epidurography (CPT code 72275)
The RUC compared this procedure to myelography, CPT code 72265, and
assigned identical work RVUs of 0.83. While the RUC survey and
discussion state that the work of epidurography is comparable, or even
greater, than the work of myelography, the RUC notes also state that
this service was previously reported as 72265-52, myelography with
reduced service. The RUC discussion also notes that this procedure will
be done as an adjunct procedure to epidural injections. Our medical
staff has also determined that the work of epidurography is comparable
to CPT codes 73525 (Hip Arthrography), 76003 (Fluoroscopic localization
for needle biopsy and fine needle aspiration), and 73542 (Sacroiliac
joint arthrography, see below). In view of the conflicting information
received from the RUC, the comparability of work to the CPT codes
above, and because use of epidurography as an adjunct procedure to
epidural injections is very similar to the adjunctive use of sacroiliac
joint arthrography for sacroiliac joint injections, we are assigning a
work RVU of 0.54 to CPT code 72275.
Sacroiliac joint arthrography (CPT code 73542)
The RUC recommended a work RVU of 0.64 based on an evaluation that
this procedure requires more work than the similar reference procedure,
hip arthrography, CPT code 73525. However, the survey time estimates
are virtually identical and the RUC description also notes that this
procedure was previously reported as CPT code 73525. Our medical staff
does not believe there is enough difference in the physician work
components of CPT codes 73542 and 73525 to justify a higher work RVU
for 73542. Therefore, we are assigning a work RVU of 0.54 to CPT code
73542.
Fluoroscopic guidance and localization of needle or catheter tip
for spine or paraspinous diagnostic or therapeutic injection
procedures (epidural, transforaminal epidural, subarachnoid,
paravertebral facet joint nerve or sacroiliac joint) including
neurolytic agent destruction (CPT code 76005)
The RUC recommended a work RVU of 0.60 for CPT code 76005 based on
its estimate that more work was required than the similar referenced
procedure, Fluoroscopic localization for needle biopsy or fine needle
aspiration, CPT 76003, that is valued at 0.54 work RVUs. However,
survey time estimates were almost identical and this procedure was
previously reported as CPT code 76003. Based on the RUC survey, our
medical staff does not believe there is enough difference in the
physician work components of 76005 and 76003 to justify a higher work
RVU for 76005. Therefore, we are assigning a work RVU of 0.54 to CPT
code 76005.
Prostate Volume Study (CPT code 76873)
This procedure takes place weeks before interstitial radioactive
seed placement for prostate cancer. Our medical staff are aware of two
approaches to map the prostate for this purpose. The first involves
measuring prostate volume by transrectal sonography, making 5 mm cuts
of the prostate, and mapping prostate anatomy to a grid that is then
used to implant the radioactive seeds accurately several weeks later.
This approach does not involve the use of general anesthesia. The
second approach takes place after the patient has been placed under
[[Page 59422]]
general anesthesia for seed implantation and involves positioning the
patient, performing the volume study (with 5mm cuts of the prostate),
calculating the treatment dose (by the radiation physicist), and
immediately implanting the seeds. Even though this new CPT code was
developed to describe the first approach, the RUC recommendation of
1.92 work RVUs was based on the use of general anesthesia for
performance of the prostate volume study. Our medical staff estimates
that the average time to perform the procedure is 30 minutes and that
the work is comparable to performance of CPT code 76805, Echography,
pregnant uterus, B-scan and/or real time with image documentation;
complete. Therefore, we have assigned it a work RVU of 0.99.
CPT code 76873 should not be used on the same day as seed
implantation and, therefore, we will not allow payment for this service
on the same day as seed implantation or other services that are part of
seed implantation.
Urea breath test, C-14; acquisition for analysis (CPT code 78267),
and Breath test analysis, C-14 (CPT code 78268)
The RUC recommended a work RVU of 0.00 for CPT code 78267 and 0.19
work RVUs for CPT code 78268. These CPT codes describe procedures
currently paid under the lab fee schedule under CPT codes 83013 and
83014 respectively. Our medical staff have reviewed these codes and do
not believe any physician work is required for the performance of
either service. Moreover, the work required for performance of these
services is practically identical to those services still described
under CPT codes 83013 and 83014 which are urea breath tests using the
C-13 isotope. Therefore, these codes will continue to be paid under the
lab fee schedule with CPT code 78267 crosswalked to CPT code 83014 and
CPT code 78268 crosswalked to CPT code 83013. Payment rates will be
identical to the crosswalk codes.
Electronic Analysis of pacing cardioverter-defibrillator * * *
without reprogramming (CPT code 93741)
The RUC recommended a work RVU of 0.90 for CPT code 93741. This
recommendation was inconsistent with both the RUC survey data and with
the building block approach that the RUC offered as an alternative. The
reference procedure used in the RUC survey was CPT code 93737,
Electronic analysis of cardioverter-defibrillator only * * * without
reprogramming, that has a work RVU of 0.45. Our medical staff believes
that the physician work for CPT code 93741 is greater than that of CPT
code 93737, and notwithstanding the conflicting information received
from the RUC, has assigned 0.64 work RVUs to CPT code 93741. This value
is based on a building block approach combining 100 percent of CPT code
93737 and 50 percent of CPT code 93734, Electronic analysis of single
chamber pacemaker system * * * without reprogramming which has a work
RVU of 0.38.
Electronic analysis of pacing cardioverter-defibrillator * * *
single chamber, with reprogramming (CPT code 93742)
The RUC recommended a work RVU of 1.03 based on their estimate that
CPT code 93742 required 14 percent more work than CPT code 93741. This
recommendation was inconsistent with both the results of the RUC survey
and with their building block approach that combined 100 percent of CPT
code 93738 (Electronic analysis of cardioverter/defibrillator only * *
* with reprogramming, work RVU of 0.92) plus 50 percent of CPT code
93735 (Electronic analysis of single chamber pacemaker system * * *
with reprogramming, work RVUs of 0.74). Our medical staff agrees that
CPT code 93742 requires more physician work than CPT code 93741 because
it includes reprogramming. After analysis of the conflicting
information received from the RUC, we agree that CPT code 93742
requires 14 percent more work than CPT code 93741. Therefore, we have
assigned 0.73 work RVUs to CPT code 93742.
Electronic analysis of pacing cardioverter-defibrillator * * * dual
chamber, without reprogramming (CPT code 93743)
The RUC recommended 1.17 work RVUs for CPT code 93743 because of
its estimate that CPT code 93743 required 30 percent more work than CPT
code 93741. This recommendation was inconsistent with both the RUC
survey data and its building block approach that combined 100 percent
of CPT code 93738 with 50 percent of CPT code 93735. Our medical staff
agrees that CPT code 93743 requires more work than CPT code 93741.
After analysis of the conflicting information received from the RUC, we
agree that CPT code 93743 requires 30 percent more work than CPT code
93741. Therefore, we have assigned 0.83 work RVUs to CPT code 93743.
Electronic analysis of pacing cardioverter-defibrillator * * * dual
chamber, with reprogramming (CPT code 93744)
The RUC recommended 1.33 work RVUs for CPT code 93744 based on its
estimate that CPT code 93744 required 14 percent more work than CPT
code 93743. This recommendation was inconsistent with both the RUC
survey data and its building block approach. After analysis of the
information received from the RUC, our medical staff agrees that CPT
code 93744 requires 14 percent more work than CPT code 93743.
Therefore, we have assigned 0.95 work RVUs to CPT code 93744.
Photodynamic therapy by endoscopic application of light to ablate
abnormal tissue via activation of photosensitive drug(s); first 30
minutes (CPT code 96570), and Photodynamic therapy by endoscopic
application of light to ablate abnormal tissue via activation of
photosensitive drug(s); each additional 15 minutes (CPT code 96571)
These CPT codes describe a procedure that is performed to ablate
abnormal tissue during a bronchoscopy or upper gastrointestinal
endoscopy. These procedures have been billed using CPT codes for
ablation or destruction of tumors not amenable to other described
methods of destruction during endoscopy. Our medical staff reviewed the
work RVUs for the base endoscopic procedure codes and the procedure
codes used for billing photodynamic therapy (CPT 31641, 43228, and
43258) and valued the work for the new CPT codes as the difference
between the work RVU of the CPT code billed and the CPT value of the
endo base. We also assumed a procedure time of 60 minutes and are
valuing CPT code 96570 at 1.10 work RVUs and CPT 96571 at 0.55 work
RVUs. We will not allow payment for other endoscopy procedures on the
same date unless it is for a significant, separately identifiable
service (for example, ablation of a separate lesion) and the claim
contains the appropriate modifier.
Screening test of visual acuity (CPT code 99173)
We consider this procedure to be a screening procedure for which
Medicare payment is not authorized. There are no work RVUs associated
with CPT code 99173.
[[Page 59423]]
Critical Care, 1st hour (CPT code 99291), and Critical Care, each
additional thirty minutes (CPT code 99292)
The definition of critical care in CPT 2000 has been revised and
the RUC has forwarded a recommendation that the revised definition of
critical care was editorial and did not warrant a change in work RVUs,
which are 4.0 RVUs for code 99291 and 2.0 RVUs for CPT code 99292. Our
medical staff disagrees. Therefore, in accordance with our policy of
making work neutrality adjustments at the time a new or revised CPT
code is published, we have made a work neutrality adjustment to these
codes. We have assigned work values of 3.6 RVUs to CPT code 99291 and
1.8 RVUs to CPT code 99292 for the reasons set forth below.
We compared the work intensity (RVUs per hour) of critical care to
other E/M services. The work intensity for each E/M service was
calculated from the ``typical'' performance time in the CPT code
descriptor. Initial and subsequent hospital visits have a work
intensity of 2.56 RVUs per hour, initial inpatient consultations have a
work intensity of 1.98 RVUs per hour, and initial/established office
visits have a work intensity of 2.67 RVUs per hour. Similar E/M
services have similar work intensities to ensure that the assigned RVU
is not anomalous. This facilitates appropriate utilization, coding, and
payment. The work intensity of critical care, 4.0 RVUs per hour, is
considerably higher than the work intensity of other E/M services. This
higher work intensity has been justified on the basis that critical
care is significantly different from care described by other E/M
services. These differences have been said to include the following:
Critical care is provided to critically ill patients who,
by definition, are more severely ill than other patients.
The analysis of multiple and complex databases needed to
care for critically ill patients is a highly work intensive process,
clearly greater than that required to care for non-critically ill
patients.
The frequent application of advanced technology essential
to the care of critically ill patients clearly requires more intense
work than is needed for the care of other patients.
CPT 2000 includes significant and substantive changes in
the definition of critical care that directly affect the work intensity
of critical care. Among these changes are:
Deletion of the word ``unstable'' to describe critically
ill or injured patients.
Redefinition of a critical illness to say, ``A critical
illness or injury acutely impairs one or more vital organ systems such
that the patient's survival is jeopardized.''
A change in the frequency for which the work of
``extensive interpretation of multiple databases and the application of
advanced technology'' is required to meet the standards for critical
care. CPT 1999 says that such work is ``often required'' while CPT 2000
says that such work ``may be required.''
As discussed below, the result of these new work requirements for
critical care is to make it somewhat more comparable to the work
requirements of E/M services with lower work intensities. In some
situations this could allow E/M services with lower work intensities to
be coded as critical care.
The new definition of critical illness or injury does not
sufficiently distinguish critically ill patients from other patients
whose care is appropriately described by other E/M services with less
work intensity. For example, many patients with an acute exacerbation
of congestive heart failure, regardless of severity, could meet the new
definition of critical illness. The problem is compounded by the
elimination of the requirement for ``extensive interpretation of
multiple databases and the application of advanced technology'' as a
typical component of critical care. This will make it more difficult to
distinguish between the work of critical care and the work of care
appropriately coded under other E/M services. For example, the
physician work required to manage patients with congestive heart
failure varies significantly depending on the severity of illness. The
care provided to many of these patients would, appropriately, be coded
as a non-critical care E/M service because of the lower intensity of
physician work required.
In making the work neutrality adjustment we considered the work
intensity of other E/M services as described above, and we modeled
probable changes in the utilization pattern of critical care services.
Our modeling included projections of the number of E/M services
currently, and appropriately, coded as non-critical care that will be
coded as critical care next year. Based upon this analysis, we estimate
that the appropriate work neutrality adjustment for critical care
services is 3.6 RVUs for code 99291 and 1.8 RVUs for code 99292.
We will analyze the utilization data for codes 99291 and 99292 and
other appropriate E/M services starting in January 2000 to determine
whether actual utilization patterns match our projections. Based on
this analysis, we will consider making further work neutrality
adjustments, either increasing or decreasing the work RVUs, as
appropriate.
Note : Codes 99295 through 99298 were revised in CPT 2000.
However, due to the different payment methodology for CPT codes
99295 through 99298, we are not proposing a work neutrality
adjustment for these codes.
Establishment of Interim Practice Expense Relative Value Units for New
and Revised Physicians' Current Procedural Terminology (CPT) Codes and
New HCFA Common Procedure Coding System Codes for 2000 Methodology
We have developed a process for establishing interim practice
expense RVUs (PERVUs) for new and revised codes that is similar to that
used for work RVUs. Under this process, the RUC will recommend the
practice expense direct inputs, that is, the staff time, supplies, and
equipment associated with each new code. We will then review the
recommendations in a manner similar to our evaluation of the
recommended work RVUs. Because this is the first year that the RUC has
been asked to develop the practice expense inputs for new CPT codes,
and developing the practice expense inputs for new procedures is a
complicated and time-consuming endeavor, the RUC recommended actual
direct inputs for a minority of the new CPT codes. For the other
procedures, the RUC either recommended a crosswalk to the inputs of an
existing CPT code or made no recommendation at this time. For a few of
the codes without a RUC recommendation, the interested specialty
society sent us recommendations for possible crosswalks of the direct
inputs. We will consider all direct cost input crosswalks to be a
temporary proxy for the values for these crosswalked services until
procedure-specific actual inputs can be developed.
The table below lists the new CPT codes for which we agree with the
RUC recommended crosswalk to the practice expense inputs of an existing
CPT code:
[[Page 59424]]
------------------------------------------------------------------------
New CPT Code Existing CPT Code
------------------------------------------------------------------------
22318 Treat odontoid FX w/o graft..... 63075 Neck spine disk surgery.
22319 Treat odontoid FX w/ graft...... 22548 Neck spine Fusion.
27096 Inject sacroiliac joint......... 27093 Injection for hip X-ray.
35879 Revise graft w/ vein............ 35301 Rechanneling of artery.
35881 Revise graft w/ vein............ 35301 Rechanneling of artery.
50547 Lapro removal donor kidney...... 36830 Artery-vein graft.
62310 Inject spine C/T................ 56349 Esophagogastric
fundoplasty.
62311 Inject spine L/S (CD)........... 62298 Injection into spinal
canal.
62318 Inject spine w/ cath, C/T....... 62289 Injection into spinal
canal.
62319 Inject spine w/ cath, L/S (CD).. 62277 Inject spinal
anesthetic.
64470 Injection paravertebral C/T..... 64442 Injection for nerve
block.
64479 Injection foramen epidural C/T.. 64442 Injection for nerve
block.
64483 Injection foramen epidural L/S.. 64442 Injection for nerve
block.
64626 Destroy paravertebral nerve C/T. 64622 Destroy paravertebral
nerve L/S.
72275 Epidurography................... 72265 Contrast X-ray, lower
spine.
73542 X-ray exam, sacroiliac joint.... 73525 Contrast X-ray of hip.
76005 Fluoroguide for spine injection. 76003 Needle localization by X-
ray.
77427 Radiation TX management, X5..... 77430 Weekly radiation
therapy.
------------------------------------------------------------------------
The following table shows the CPT codes for which the RUC provided
no practice expense recommendations. Therefore, we crosswalked these
new CPT codes to what we believe to be the most appropriate existing
CPT codes.
------------------------------------------------------------------------
New CPT Code Existing CPT Code
------------------------------------------------------------------------
11980 Implant hormone pellet(s)....... 11975 Insert contraceptive
cap.
20979 US bone stimulation............. 20974 Electrical bone
stimulation.
33140 Heart revascularize (TMR)....... 33020 Incision of heart sac.
33282 Implant pat-active HT record.... 33212 Insertion of pulse
generator.
33284 Remove pat-active HT record..... 33233 Removal of pacemaker
system.
33968 Remove aortic assist device..... No direct costs.
36521 Apheresis w/ adsorp/reinfuse.... 36520 Plasma and/or cell
exchange.
36550 Declot vascular device.......... 99211 Office/outpatient visit,
est.
61862 Implant neurostimu, subcort..... 61855 Implant neuroreceiver.
61886 Implant neurostim arrays........ 61855 Implant neuroreceiver.
92961 Cardioversion, electric, int.... 93610 Intra-atrial pacing.
93727 Analyze IRL system.............. 93272 ECG/review, interpret
only.
93741 Analyze HT pace device single... 93737 Analyze cardio/
defibrillator.
93742 Analyze HT pace device single... 93738 Analyze cardio/
defibrillator.
93743 Analyze HT pace device dual..... 93738 Analyze cardio/
defibrillator.
93744 Analyze HT pace device dual..... 93738 Analyze cardio/
defibrillator.
99170 Anogenital exam, child.......... 57452 Examination of vagina.
------------------------------------------------------------------------
For the following CPT codes we received practice expense
recommendations, from either the RUC or a specialty society, that
require a short discussion. If we have made any modifications to the
recommendations as a result of our review process, the specific changes
are discussed.
CPT Code 13102, Repair, complex, trunk; each additional 5 cm or less
CPT Code 13122, Repair, complex, scalp, arms and/or legs; each
additional 5 cm or less
CPT Code 13133, Repair, complex, forehead, cheeks, chin, mouth, neck,
axillae, genitalia, hands and or feet; each additional 5 cm or less
CPT Code 13153, Repair, complex, eyelids, nose, ears and/or lips; each
additional 5 cm or less
The RUC made no practice expense recommendations for these above
four CPT codes. However, the American Society of Plastic and
Reconstructive Surgeons recommended to us that we reference these CPT
codes to the practice expense inputs for the respective parent codes
(CPT codes 13101, 13121, 13132 and 13152, respectively) and that we
make the appropriate adjustments to account for the fact that these are
add-on codes. We have accepted this recommendation.
CPT Code 33410, Replacement, aortic valve, with cardiopulmonary bypass,
with stentless tissue valve
The RUC made no recommendation on this CPT code. However, the
Society of Thoracic Surgeons recommended that we crosswalk the direct
inputs for this procedure to the direct inputs of CPT code 33406,
Repacement, aortic valve, with cardiopulmonary bypass, with homograft
valve (freehand). We agree that this is an appropriate crosswalk.
CPT Code 36819, Arteriovenous anastomosis, open; by basilic vein
transposition
The RUC approved a list of inputs that had been developed with
reference to the inputs for existing CPT code 36830 and recommended
their acceptance. We agree with the list of inputs, but have adjusted
the supplies and staff times to reflect that there are only two post-
visits assigned to CPT code 36819.
CPT 39560, Resection, diaphragm; with simple repair
CPT 39561, Resection, diaphragm; with complex repair
The RUC made no recommendations on these CPT codes. However, the
Society of Thoracic Surgeons recommended that we crosswalk the direct
inputs for these procedures to the direct inputs of CPT codes 39501,
Repair diaphragmatic laceration and 39502, Repair paraesophageal hiatus
hernia, transabdominal, with or without
[[Page 59425]]
fundoplasty, vagotomy, and/or phyloroplasty, except neonatal,
respectively. We agree that these are appropriate crosswalks.
CPT Code 50541, Laparoscopy, surgical; ablation of renal cysts
CPT Code 50544, Laparoscopy, surgical; pyeloplasty
CPT Code 50546, Laparoscopy, surgical; nephrectomy
CPT Code 50548, Laparoscopically assisted nephrourereterectomy
CPT Code 50945, Laparoscopy, surgical; ureterolithotomy
CPT Code 51990, Laparoscopy, surgical; urethral suspension for stress
incontinence
CPT Code 51992, Laparoscopy, surgical; sling operation for stress
incontinence
CPT Code 54692, Laparoscopy, surgical; ochiopexy for intra-abdominal
testis
The RUC recommended direct practice expense inputs for each of the
above CPT codes. We accepted these recommendations with only minor
modification. We removed the autoclave from the overhead equipment
because it is not needed for the post-procedure visits for these
services and adjusted the supplies for CPT code 50544 to reflect that
the service is assigned two rather than three office visits. We did not
add the female catheter at this time to the list of supplies for CPT
codes 51990 and 51992 because we had no information on this supply.
CPT Code 64472, Injection anesthetic agent and/or steroid,
paravertebral facet joint or facet joint nerve; cervical or thoracic,
each addition level
CPT Code 64480, Injection, anesthetic agent and/or steroid,
transforaminal epidural; cervical or thoracic, each additional level
CPT Code 64484, Injection, anesthetic agent and/or steroid,
transforaminal epidural; lumbar or sacral, each additional level
CPT Code 64627, Destruction by neurolytic agent, paravertebral facet
joint nerve; cervical or thoracic, each additional level
The RUC sent us only suggested clinical staff intra-service times
for these four add-on codes. These clinical staff times were derived by
comparison to the RUC physician intra-service times. Because the
clinical staff times and physician times are not always the same for a
given service, we are, in the interim, crosswalking the practice
expense inputs for CPT codes 64472, 64480, and 64484 to the direct
inputs for a similar add-on code, CPT code 64443, Injection, anesthetic
agent; paravertebral facet joint nerve, lumbar, each additional level.
We are crosswalking the practice expense inputs for CPT code 64627 to
another appropriate add-on code, CPT code 64623, Destruction by
neurolytic agent; paravertebral facet joint nerve, lumbar, each
additional level.
CPT Code 76873, Echography, transrectal; prostate volume study for
brachytherapy treatment planning
The RUC recommended a list of direct cost inputs for this CPT code.
However, because these practice expense recommendations differed
greatly from the CPEP inputs for other CPT codes in the same family,
we, as an interim measure, crosswalked the practice expense inputs for
this code to CPT code 76872, Echography, transrectal, which was used by
the RUC as the reference CPT code for this service and was also the CPT
code used formerly to report this procedure.
CPT Code 78456, Acute venous thrombosis imaging, peptide
We accepted the RUC recommended direct practice expense inputs
except that we deleted forms and labels (considered office supplies
from the medical supply list) and the dictation machine (considered
office equipment). We have not included the bar phantom at this time
because the data provided with the recommendation was insufficient to
develop a cost for this equipment.
CPT Code 90471, Immunization administration; one vaccine
We accepted the RUC's practice expense recommendations concerning
clinical labor, supplies, and equipment inputs with the following
adjustments: office supplies, which included the record sheet, school
record form and Xerox copy, were deleted from the medical supply list;
the APAP elixir was also removed since Medicare does not include
coverage of self-administered drugs. We deleted the examination table
from the overhead equipment, because it is not needed for the procedure
and, in keeping with the CPEP definitions of the equipment categories,
moved the refrigerator from the procedure-specific to the overhead
medical equipment category.
CPT Code 90472, Immunization administration; each additional vaccine
We accepted the RUC recommendation for clinical staff time and made
the same adjustments to the RUC recommendation for supplies as we did
for CPT code 90471. In addition, we deleted all equipment because this
is an add-on CPT code and all equipment costs are captured in the base
CPT code.
For the following CPT codes we did not receive practice expense
recommendations from either the RUC or a specialty society and we were
unable to do a direct crosswalk to existing CPT codes.
CPT Code 62263, Percutaneous lysis of eipidural adhesions, with or
without endoscopic guidance, using solution injection or mechanical
means including x-ray localization with or without contrast
We are crosswalking this service to CPT code 62282, Injection of
neurolytic substance; epidural, lumbar or caudal, which is a service
assigned three post-procedure visits. We are adjusting the inputs of
CPT code 62263 to reflect the two post-procedure visits assigned to
this procedure.
CPT Code 96570, Photodynamic therapy by endoscopic application of light
to ablate abnormal tissue via activation of photsensitive drug(s);
first 30 minutes, and CPT code 96571 Photodynamic therapy by endoscopic
application of light to ablate abnormal tissue via activation of
photsensitive drug(s); each additional 15 minutes.
These codes are add-on codes. That is, they will always be billed
along with another procedure. Most of the direct practice expense
inputs will be assigned to the base procedure. The inputs for 96570 and
96571 only reflect the additional inputs that are required. We have
included an argon laser under equipment and 30 minutes of clinical
staff intra-service time for CPT code 96570. For CPT code 95671, we
included 15 minutes of clinical staff intra-service time. This is
consistent with the discussion for these codes contained in the
evaluation of the work RVUs.
C. Other Changes to the 2000 Physician Fee Schedule and Clarification
of CPT Definitions
For the 2000 physician fee schedule, we are establishing or
revising several alpha-numeric HCPCS codes for the reporting of certain
services that are not clearly described by existing CPT codes. We view
these codes as temporary since we will be referring them to the CPT
Editorial Panel for possible inclusion in future editions of the CPT.
Additionally, included in this section are some clarifications of
proper usages of some new or revised codes.
[[Page 59426]]
External Counterpulsation (G0166)
A new level 2 HCPCS code has been created to describe this
technology. External counterpulsation (ECP) consists of sequential
compression and decompression of a series of leg and lower trunk air-
filled cuffs, coordinated with the cardiac cycle. ECP has been approved
for patients with severe stable angina pectoris refractory to medical
and/or surgical treatment. An average course of treatment consists of
35, one-hour treatments over seven weeks. We determined that the
procedure is performed by non-physician personnel, but requires a
physician to be available for emergencies and intermittent physician
supervision. Because of the minimal physician involvement we have
assigned .07 work RVU to HCPCS code G0166.
We will not allow payment for the following services on the same
day as ECP unless they are medically necessary and delivered in a
clinical setting not involving ECP treatment:
CPT code 97016 (vasopneumatic devices).
CPT codes 93720, 93721, 93722 (total body
plethysmography).
CPT codes 93000, 93005, 93010 (electrocardiogram).
CPT code 92971 (external cardioassist).
CPT code 93922 (noninvasive physiologic studies of
extremity arteries). If patients undergoing ECP require significant E/M
services in the same period, those services should be billed using the
appropriate E/M code with modifier -25 to indicate a significant
separately identifiable service.
Interim practice expense direct cost inputs were established based
on the information available to us concerning the cost of the machine,
hours per week of use, registered nurse/technical time per use,
disposable supplies, and overhead. Because this is a new procedure,
information on practice expense was limited. Therefore, we expect to
refine these inputs as more information becomes available.
Hyperbaric oxygen treatment not requiring physician attendance, per
treatment session (G0167)
This code was created because the only current code for hyperbaric
oxygen treatment is CPT code 99183. Because many providers have stated
that physician attendance may not be needed for hyperbaric oxygen
treatment, the new HCPCS code G0167 was created to allow coding of
these services. The creation of a code does not change current coverage
policy.
The physician work of this code is zero. The practice expense
inputs were crosswalked to CPT code 99183, though we will consider a
lower value in the future if we find that the practice expenses are
lower in situations in which there is no physician attendance.
Wound closure utilizing tissue adhesives only (G0168)
This new code should only be used when a wound is closed solely
with the use of this new product. Wounds closed with a combination of
wound closure adhesives and other traditional methods of wound closure
(staples or sutures) should still be coded using the appropriate CPT
code (12001-12007). FDA data shows that the time needed to close a
wound with wound adhesive is, on average, one quarter of the time
needed to close a wound with traditional methods (including use of
wound closure tapes). We estimate that the work of HCPCS code G0168 is
comparable to the work of a level two E/M service and have assigned a
work RVU of .45.
We established interim practice expense inputs for this service by
crosswalking inputs from CPT code 12001. We then adjusted the inputs by
adding the cost of the wound adhesive and removing the supplies that
would not be needed for this type of wound closure. We also reduced the
clinical staff time to reflect that the wound size is less complex and
treatment method less time consuming.
Removal of devitalized tissue, without use of anesthesia (G0169)
This code was created because the CPT codes 11040 through 11044 for
debridement were created to describe complex surgical services
requiring the use of general anesthesia. Many practitioners, including
physical therapists, occupational therapists, and nurses, do active
wound care under physicians' orders. Active care involves the use of
high pressure water jets, scissors, or scalpels. Wound care involving
use of dressings, gauze, or medications, but not active tissue removal,
should not be coded using HCPCS code G0169. The service to be coded
with HCPCS code G0169 typically involves regular removal of devitalized
tissues in ulcers or non-healing wounds. We have created this code to
eliminate the confusion involved in using debridement codes, some of
which have 10 day global periods. This code will be recognized as a
therapy service for purposes of the outpatient rehabilitation payment
system and will replace the CPT codes 11040 and 11044 for use by
physical and occupational therapists.
We estimate that the work of HCPCS code G0169 is comparable to the
work of CPT code 11040; therefore, we have assigned 0.5 work RVUs to
this new code. For the practice expense component, we crosswalked the
inputs for this code to the inputs for CPT code 97022, whirlpool
therapy.
Application of tissue cultured skin grafts, including bilaminate
skin substitutes or neodermis, including site preparation, initial
25 sq cm; and G0171 Application of tissue cultured skin grafts,
including bilaminate skin substitutes or neodermis, including site
preparation, each additional 25 sq cm (G0170)
CPT 1999 recommended that CPT codes 15100 to 15121, for split-
thickness skin grafting, be used for tissue cultured or bilaminate skin
substitutes or neodermis. Instead, we have decided that effective
January 1, 2000, these services should be reported with the new HCPCS
codes G0170 and G0171 on Medicare claims. The CPT codes for split-
thickness skin grafts may no longer be used to describe tissue cultured
or bilaminate skin substitutes or neodermis. Because the tissue
cultured and ``bioengineered'' products are available for use on small
skin ulcers, and because there is no need to harvest a graft and care
for the donor site, we estimate that the physician work in using these
cultures and ``bioengineered'' products is considerably less than the
work in performing split-thickness skin grafts. The work value for the
new codes was calculated with a building block approach using CPT code
15000 (skin graft with work value of 4.00) and either CPT code 15350
(skin homograft with work value of 4.00) or CPT code 15400 (skin
heterograft with work value of 4.00).
The work in preparing a graft site and placing a graft equals the
work of CPT code 15000 plus 50 percent of the work of either CPT code
15350 or 15400, due to the multiple procedure reduction rule. Since the
work values for CPT codes 15000, 15350, and 15400 are based upon graft
site preparation and placement of a 100 sq. cm. graft or less, and
HCPCS G0170 describes a graft size of 25 cm or less, the work value for
HCPCS code G0170 is 25 percent of the work value of CPT code 15000
(4.00) plus 50 percent of CPT code 15350 or 15400 (2.00). This results
in a work RVU of 1.5 (25 percent of 6.00). The work RVU for HCPCS code
G0171 was calculated similarly using CPT codes 15001 (skin graft add-on
with work
[[Page 59427]]
value of 1.00) and 15351 (skin homograft add-on with a work value of
1.00) resulting in a work RVU of .38 for HCPCS code G0171.
We calculated the practice expense inputs for HCPCS code G0170 by
crosswalking the supply and overhead equipment inputs from CPT 15350.
We added a power table and soft tissue tray as the procedure-specific
equipment inputs and added 80 minutes of RN/MA clinical time in the
intra service period. For HCPCS code G0171 we added 20 minutes of RN/MA
clinical time in the intra service period.
IV. Five Year Refinement of Relative Value Units
A. Background
Section 1848(c)(2)(B)(i) of the Act requires that we review all
RVUs no less often than every five years. As part of the final rule
published December 8, 1994 (59 FR 63410), we solicited public comment
on all work RVUs for approximately 7,000 CPT and HCPCS codes. The scope
of the 5-year review was limited to work values, since at that time,
the law required practice expense and malpractice RVUs be calculated
based on 1991 allowed charges and practice expense and malpractice
expense shares for the specialties performing the services. We applied
the specialty practice cost shares from the AMA's Socioeconomic Survey
to 1989 actual charges ``aged'' forward to approximate 1991 charges. In
addition, we were aware of the move to replace the charge-based
practice expense system by a resource-based methodology. The December
8, 1994 final rules also outlined the proposed process for refinement
of the work RVUs and provided a suggested format for submission of
comments.
As a result of the December 8, 1994 final rule, we received more
than 500 comments on approximately 1,100 codes. Subsequent to review of
the comments by our medical staff, comments on approximately 700 codes
were forwarded to the RUC for review. An additional 300 codes
identified by our staff as potentially misvalued were also forwarded to
the RUC. A process similar to that used for the annual physician fee
schedule update was used for evaluating the proposed changes to the
work RVUs and a notice discussing these proposed changes was published
in the Federal Register May 3, 1996 (61 FR 19992). As outlined in the
notice, for 28 percent of the codes we proposed to increase the work
RVUs; for 61 percent of the codes we proposed to maintain the work RVUs
and for 11 percent of the codes we proposed to decrease the work RVUs.
(Our proposed work RVUs agreed with the RUC recommendations for 93
percent of the codes.)
In response to the May 3, 1996 proposed notice, we received more
than 2,900 comments on approximately 133 codes plus all anesthesia
services. In order to address these comments, we convened
multispecialty panels of physicians. A detailed discussion of this
process, as well as the final results of the 5-year review, were
included in the final rule with comment period published November 22,
1996 (61 FR 59490).
B. Scope of the Five Year Refinement
We have made several preliminary decisions about the scope of the
5-year refinement and issues for which we are requesting public
comment. All work RVUs are subject to comment. Practice expense and
malpractice expense RVUs will not be subject to comment and will not be
recalculated as part of the 5-year refinement.
Section 4505(f) of the BBA requires us to implement malpractice
resource-based RVUs for services furnished beginning in CY 2000. The
BBA at section 4505 also provides for a gradual 4-year transition for
resource-based practice expenses, with resource-based practice expenses
becoming fully effective in CY 2002. Since resource-based malpractice
RVUs will have only just been implemented in CY 2000, and resource-
based practice expenses will be in the middle of transitioning to a
fully resource-based system, it would be premature to include these
components in this 5-year review. While these components of the fee
schedule will also eventually be subject to review, we will be
evaluating how to best approach this task.
C. Refinement of Work Relative Value Units
During the first 5-year review, we relied on public commenters to
identify services that were misvalued. For the second 5-year refinement
of work RVUs for services furnished beginning January 1, 2002, we are
requesting public comments on potentially misvalued work RVUs for all
services in the CY 2000 physician fee schedule. These comments will be
an important source of information that we will consider in developing
further plans for the 5-year review which we will propose in 2001.
However, since this process generally elicits comments focusing on
undervalued codes, we will supplement the information we receive
through these comments with other data and analyses we are initiating,
as described in section IV.E.
Comments will be considered if we receive them at the appropriate
address as provided below, no later than 5 p.m., March 1, 2000. Mail
written comments related to the 5-year refinement process (1 original
and 3 copies) to the following address: Health Care Financing
Administration, Department of Health and Human Services, Attention:
HCFA-1065-FC (5-Year Refinement), P.O. Box 8013, Baltimore, MD 21244-
8013. Comments must include the appropriate CPT code (for example CPT
code 90918) and the suggested RVUs (for example, 11.00 RVUs). Unless
otherwise specified, we will assume that all suggested RVUs are on the
2000 scale. Failure to provide this information may result in our
inability to evaluate the comments adequately. We will consider all
comments on all work RVUs in the development of a proposed rule that we
intend to publish in 2001. In that rule, we will propose the revisions
to work RVUs that we believe need to be made. Finalization of that rule
will be based on review and analysis of comments received in response
to the proposed rule.
In addition to internal review and analysis, we propose to share
comments we receive on all CY 2000 RVUs with the RUC, which currently
makes recommendations to us on the assignment of RVUs to new and
revised CPT codes. This process was used during the first 5-year review
and we believe that it was beneficial. The RUC's perspective will be
helpful because of its experience in recommending RVUs for the codes
that have been added to, or revised by, the CPT panel since we
implemented the physician fee schedule in 1992. Furthermore, the RUC,
by virtue of its multispecialty membership and consultation with
approximately 65 specialty societies, involves the medical community in
the refinement process. We emphasize, however, as we reiterated for the
first 5-year review, that we retain the responsibility for analyzing
the comments in the 2000 physician fee schedule, developing the
proposed rule for 2001, evaluating the comments on the proposed rule,
and deciding whether to revise RVUs. We are not delegating this
responsibility to the RUC or any other organization.
D. Nature and Format of Comments on Work Relative Value Units
While all written public comments are welcomed, based on our past
experience we have found it particularly beneficial if the comments
include information in a particular format. This includes the CPT code,
a clinical description of the service, and a discussion of how the work
of that
[[Page 59428]]
service is analogous to one or more reference services. The use of one
or more reference services is of fundamental importance because the
relative value of the work in a physicians' service exists only in
comparison with the physician work in another service.
The reference services cited should be commonly performed services
with established work RVUs and also fairly well understood outside of
their specialty. We have included a list of suggested reference
services in Addendum E. The RVUs assigned to these services represent
benchmarks to serve as a basis for comparison with the work represented
by other codes. However, the inclusion of these services in the
reference set does not mean that they are exempted from public comment
on the RVUs assigned to them. If none of the services in the reference
set are suitable for reference, we recommend choosing another service
from the physician fee schedule and explaining why it is a better
reference procedure.
Physician work has two components; time and intensity. The clinical
analogy for many services can be strengthened by dividing the service
into the following three time segments and comparing them with the
respective segments of the reference services:
Preservice work--Work performed before the actual
procedure such as review of records, solicitation of informed consent,
and preparation of equipment. Time spent by the physician dressing,
scrubbing, and waiting for the patient should be identified. Preservice
work also includes the time spent scrubbing, positioning, or otherwise
preparing the patient. For surgical procedures with global periods,
commenters should include estimates of the number, time, and type of
visits from the day before surgery until the patient enters the
operating room. The visit when the physician decides to operate and the
visits preceding it should not be included in the estimate of
preservice work since these services are not included in the Medicare
definition of global period.
Intraservice work--The actual performance of the
procedure. For evaluation and management services, this would be
described as ``face to face'' time in the inpatient setting. For
surgical procedures, the customary term would be ``skin-to-skin'' or
its equivalent for those procedures not beginning with incisions.
Postservice work--Analysis of data collected from the
encounter, preparation of a report, and communication of the results.
For procedures with global periods, commenters should identify the time
spent by the physician with the patient after the procedure on the same
day and whether the patient typically goes home to an ordinary hospital
bed or to the intensive care unit. Commenters should describe the
number, time, and type of physician visits from the day after the
procedure until the end of the global period. They should also
distinguish inpatient from outpatient visits.
In making these estimations, we encourage detailed clinical
information such as data derived from operating logs, operative
reports, medical charts concerning the length of service, the amount of
work performed before and after the service, and the length of stay in
the hospital. The usefulness of these data is greatly increased if the
data are presented with comparable data for reference services and
evidence that justifies that the data presented are nationally
representative of the average work involved in furnishing the service.
One common mistake commenters make is to provide data that are not
representative of national practices. Another common mistake is to
present a lengthy and elaborate description of the work in the service,
but to omit, or to provide an incomplete description of, the
comparability of the work in the service to the work in the reference
procedure or procedures identified.
Intensity of the work in the service is best compared by breaking
the intensity into the following elements:
Mental effort and judgment--Commenters should compare the
service in question with a reference service as to the amount of
clinical data that needs to be considered, the fund of knowledge
required, the range of possible decisions, the number of factors
considered in making a decision, and the degree of complexity of the
interaction of these factors.
Technical skill and physical effort--One useful measure of
skill is the point in training when a resident is expected to be able
to perform the procedure. Physical effort can be compared by dividing
services into tasks and making the direct comparisons of tasks. In
making the comparison, it is necessary to show that the differences in
physician effort are not reflected accurately by differences in the
time involved; if they are, considerations of physician effort amount
to double counting of physician work in the service.
Psychological stress--Two kinds of psychological stress
are usually associated with physician work. The first is the pressure
involved when the outcome is heavily dependent upon skill and judgment
and a mistake has serious consequences. The second is related to
unpleasant conditions connected with the work that are not affected by
skill or judgment. These circumstances would include situations with
high rates of mortality or morbidity regardless of the physician's
skill or judgment, difficult patients or families, or physician
physical discomfort. Of the two forms of stress, only the former is
fully accepted as an aspect of work; many consider the latter to be a
highly variable function of physician personality.
Intensity often varies significantly in the course of furnishing a
service. One common mistake commenters make is to ``anchor'' the value
of the service to a point of maximum intensity during the service as
the basis for comparing services. It is unlikely that the maximum
intensity is an accurate reflection of the average intensity of a
service; a lengthy procedure that is simple except for a few moments of
extreme intensity is probably less work than one of equal length during
which a fairly high level of intensity is maintained throughout.
E. New Initiatives
While we intend to continue the process used during the first 5-
year review, we realize there were limitations to that process,
particularly with respect to identifying overvalued codes.
In preparation for the second 5-year review of work RVUs, we
awarded a contract to Health Economic Research (HER) to obtain
technical assistance to establish a framework for the second 5-year
review. We were interested in identifying methods by which we could
identify CPT codes in the physician fee schedule that may have been
assigned inappropriate work RVUs and also identify services whose work
RVUs may have changed since they were originally developed or last
revised.
HER identified seven methods that we could potentially use to
identify misvalued services. These methods focus upon different
components of the work RVU: Total work; time components of total work;
that is, total service time, pre- and intra-service time, and post-
operative visits; and work per unit of time. They include:
1. Clinical Panels. The use of clinical panels to evaluate total
physician work. The panels could identify within clinical family rank
order anomalies and cross-specialty anomalies in similar services and
recalibrate reference set procedures.
2. Rasch Paired Comparison Method. This method identifies misvalued
CPT codes in terms of either total or intra-
[[Page 59429]]
service work based on a small-group panel comparison of codes within
clinical families. This method could be used to identify statistical
outliers that appear to be either misaligned or compressed in terms of
overall physician work effort employing a simpler approach than
magnitude estimation.
3. Clinical Profile. Use a physician-level-clinical profile
database that includes estimates of total available clinical time, as
well as estimates of total volume of services provided during that time
period at the CPT code level. This method would use objectively
collected volume of service estimates and current work RVU time
estimates to evaluate the reasonableness of total service time
estimates relative to estimates of available service time.
4. Alternative Data Sources. Four alternative objective data
sources could be used in the direct identification of services whose
intra-service times may be misvalued: Anesthesia time estimates from
Medicare claims data, operative times obtained from a data vendor,
operative times collected from a panel of hospitals, and intra-service
times collected through direct observation.
5. Claims Data: Focused Review. Use Medicare claims data to
identify services whose number of pre- and post-operative hospital
visits provided during the global surgical period may be misvalued
given current lengths of stay and proportion of same day surgery cases.
6. Claims Data: Over Time. Use Medicare claims data to identify
services with potentially misvalued work RVUs by analyzing changes over
time in site of service, frequency, and specialty mix.
7. Direct Comparison. Identify services with potentially misvalued
work RVUs through a direct comparison of work per unit of time (WPUT).
This method would use statistical analysis to identify those services
with a WPUT estimate that differs significantly from the typical value
for a group of services expected to have similar levels of WPUT.
In their report, HER also suggested that we: establish a set of
standard data collection methods and review procedures and review and
correct flaws in the annual review process.
(Note: The contents of this report can be accessed through our
homepage, as discussed earlier.)
We are incorporating some of the approaches identified by our
contractor, and are also considering other means of identifying
misvalued services.
We recently awarded a contract to HER to examine in more detail
secondary databases that will enable us to validate RUC and Harvard
physician time data. Three databases will be examined: D.J. Sullivan
intraoperative time data, outpatient and ambulatory care survey data
obtained by the National Center for Health Statistics, and MGMA group
practice data on total clinical time and services.
We are also attempting to identify other primary and secondary
databases that have the potential for identifying misvalued services.
We would welcome any comments on the existence and usefulness of such
databases, as well as comments on other methodologies that might assist
us in determining how to identify misvalued services.
V. Physician Fee Schedule Update and Conversion Factor for Calendar
Year 2000
The 2000 physician fee schedule conversion factor is $36.6137. The
2000 anesthesia conversion factor is $17.77.
The specific calculations to determine the conversion factor for
physicians' services for calendar year 2000 are explained below.
Detail on Calculation of the Calendar Year 2000 Physician Fee
Schedule Update and the 2000 Conversion Factor
Physician Fee Schedule Update and Conversion Factor
The conversion factor is affected by section 1848(c)(2)(B)(ii)(II)
of the Act, which requires that changes to the relative value units of
the Medicare physician fee schedule not cause expenditures to increase
or decrease by more than $20 million from the amount of expenditures
that would have been made if such adjustments had not been made. We
implement this requirement through a uniform budget-neutrality
adjustment to the conversion factor.
Taking this factor into account, as well as the percent change in
the MEI and Sustainable Growth Rate (SGR) adjustments described below,
the 2000 conversion factor is calculated as follows:
1999 Conversion Factor....................................... 34.7315
2000 Update.................................................. 1.05472
Volume and Intensity Adjustment.............................. 0.9988
Other Factors................................................ 1.0007
2000 Conversion Factor....................................... 36.6137
The 5.5 (1.05472) percent 2000 update is calculated as follows:
MEI.......................................................... 2.4%
SGR adjustment............................................... 3.0%
2000 Update.................................................. 5.5%
Under section 1848(d)(3) of the Act, the update is equal to the
product of the MEI and the performance adjustment factor (or SGR
adjustment). Thus, the MEI of 2.4 percent (or 1.024) and the SGR
adjustment of 3.0 percent (1.03) are multiplied together to produce the
2000 update of 5.5 percent (1.05472).
There is another adjustment of 1.0007 to the conversion factor to
reflect that Medicare will no longer provide separate payment for pulse
oximetry, temperature gradient studies and venous pressure
determinations. Payment for these codes is bundled into payment for
other services. Consistent with our proposed rule (64 FR 39638),
savings from this provision are recognized in the budget neutrality
calculation on the physician fee schedule conversion factor.
The MEI and the SGR adjustments are described below.
The Percentage Change in the Medicare Economic Index
The MEI measures the weighted-average annual price change for
various inputs needed to produce physicians' services. The MEI is a
fixed-weight input price index, with an adjustment for the change in
economy-wide labor productivity. This index, which has 1996 base
weights, is comprised of two broad categories: physician's own time and
physician's practice expense.
The physician's own time component represents the net income
portion of business receipts and primarily reflects the input of the
physician's own time into the production of physicians' services in
physicians' offices. This category consists of two subcomponents: wages
and salaries and fringe benefits. These components are adjusted by the
10-year moving average annual percent change in output per man-hour for
the nonfarm business sector to eliminate double counting for
productivity growth in physicians' offices and the general economy.
The physician's practice expense category represents the rate of
price growth in nonphysician inputs to the production of services in
physicians' offices. This category consists of wages and salaries and
fringe benefits for nonphysician staff and other nonlabor inputs. Like
physician's own time, the nonphysician staff categories are adjusted
for productivity using the 10-year moving average annual percent change
in output per man-hour for the nonfarm business sector. The physician's
practice expense component also includes the following categories of
nonlabor inputs: office expense, medical materials and supplies,
professional liability insurance, medical equipment, professional car,
and other expense. The table below presents a listing of the MEI
[[Page 59430]]
cost categories with associated weights and percent changes for price
proxies for the 2000 update. The calendar year 2000 MEI is 2.4 percent.
Increase in the Medicare Economic Index Update for Calendar Year 2000
\1\
------------------------------------------------------------------------
CY 2000
Cost Categories and Price Measures 1996 Percent
Weights \2\ Changes
------------------------------------------------------------------------
Medicare Economic Index Total................. 100.0 2.4
1. Physician's Own Time 3 4............... 54.5 2.3
a. Wages and Salaries: Average hourly 44.2 2.5
earnings private nonfarm, net of
productivity.........................
b. Fringe Benefits: Employment Cost 10.3 1.2
Index, benefits, private nonfarm, net
of productivity......................
2. Physician's Practice Expense \3\....... 45.5 2.5
a. Nonphysician Employee Compensation. 16.8 2.2
1. Wages and Salaries: Employment 12.4 2.5
Cost Index, wages and salaries,
weighted by occupation, net of
productivity.....................
2. Fringe Benefits: Employment 4.4 1.5
Cost Index, fringe benefits,
white collar, net of productivity
b. Office Expense: Consumer Price 11.6 2.3
Index for Urban Consumers (CPI-U),
housing..............................
c. Medical Materials and Supplies: 4.5 5.5
Producer Price Index (PPI), ethical
drugs/PPI, surgical appliances and
supplies/CPI-U, medical equipment and
supplies (equally weighted)..........
d. Professional Liability Insurance: 3.2 3.9
HCFA professional liability insurance
survey \5\...........................
e. Medical Equipment: PPI, medical 1.9 -0.5
instruments and equipment............
f. Other Professional Expense......... 7.6 1.7
1. Professional Car: CPI-U, 1.3 -1.1
private transportation...........
2. Other: CPI-U, all items less 6.3 2.3
food and energy..................
Addendum:
Productivity: 10-year moving average of n/a 1.2
output per man-hour, nonfarm business
sector...................................
Physician's Own Time, not productivity 54.5 3.5
adjusted.................................
Wages and salaries, not productivity 44.2 3.8
adjusted.............................
Fringe benefits, not productivity 10.3 2.4
adjusted.............................
Nonphysician Employee Compensation, not 16.8 3.5
productivity adjusted....................
Wages and salaries, not productivity 12.4 3.7
adjusted.............................
Fringe benefits, not productivity 4.4 2.7
adjusted.............................
------------------------------------------------------------------------
\1\ The rates of historical change are for the 12-month period ending
June 30, 1999, which is the period used for computing the calendar
year 2000 update. The price proxy values are based upon the latest
available Bureau of Labor Statistics data as of September 21, 1999.
\2\ The weights shown for the MEI components are the 1996 base-year
weights, which may not sum to subtotals or totals because of rounding.
The MEI is a fixed-weight, Laspeyres-type input price index whose
category weights indicate the distribution of expenditures among the
inputs to physicians' services for calendar year 1996. To determine
the MEI level for a given year, the price proxy level for each
component is multiplied by its 1996 weight. The sum of these products
(weights multiplied by the price index levels) over all cost
categories yields the composite MEI level for a given year. The annual
percent change in the MEI levels is an estimate of price change over
time for a fixed market basket of inputs to physicians' services.
\3\ The Physician's Own Time and Nonphysician Employee Compensation
category price measures include an adjustment for productivity. The
price measure for each category is divided by the 10-year moving
average of output per man-hour in the nonfarm business sector. For
example, the fringe benefit component of Physician's Own Time is
calculated by dividing the rate of growth in the employment cost index
for benefits of private nonfarm workers by the 10-year moving average
rate of growth of output per man-hour for the nonfarm business sector.
Dividing one plus the decimal form of the percent change in the
average hourly earnings (1+.024=1.024) by one plus the decimal form of
the percent change in the 10-year moving average of labor productivity
(1+.012=1.012) equals one plus the change in average hourly earnings
net of the change in output per man hour (1.024/1.012=1.012). All
Physician's Own Time and Nonphysician Employee Compensation categories
are adjusted in this way. Due to a higher level of precision the
computer calculated quotient may differ from the quotient calculated
from rounded individual percent changes.
\4\ The average hourly earnings proxy, the Employment Cost Index
proxies, as well as the CPI-U, housing and CPI-U, private
transportation are published in the Current Labor Statistics Section
of the Bureau of Labor Statistics' Monthly Labor Review. The remaining
CPIs and PPIs in the revised index can be obtained from the Bureau of
Labor Statistics' CPI Detailed Report or Producer Price Indexes.
\5\ Derived from a HCFA survey of several major insurers (the latest
available historical percent change data are for the period ending
second quarter of 1999).
n/a Productivity is factored into the MEI compensation categories as an
adjustment to the price variables; therefore, no explicit weight
exists for productivity in the MEI.
Medicare Performance Relative to the SGR
Medicare Sustainable Growth Rate
Section 1848(f) of the Act, as amended by section 4503 of the BBA,
replaces the volume performance standard with a sustainable growth rate
(SGR) standard. It specifies the formula for establishing yearly SGR
targets for physicians' services under Medicare. The use of SGR targets
is intended to control the actual growth in Medicare expenditures for
physicians' services.
The SGR targets are not limits on expenditures. Payments for
services are not withheld if the SGR target is exceeded. Rather, the
appropriate fee schedule update, as specified in section 1848(d)(3)(A)
of the Act, is adjusted to reflect the success or failure in meeting
the SGR target.
As provided in section 4502 of the BBA, the update to the
conversion factor is adjusted based on a comparison of actual
expenditure to the SGR. The law refers to this update as the update
adjustment factor. The amended section 1848(d)(3) of the Act now states
that ``the `update adjustment factor' for a year is equal (as estimated
by the Secretary) to--
(i) the difference between (I) the sum of the allowed expenditures
for physicians' services (as determined under subparagraph (C)) for the
period beginning April 1, 1997, and ending on March 31 of the year
involved, and (II) the amount of actual expenditures for physicians'
services furnished during the period beginning April 1, 1997, and
ending on March 31 of the preceding year; divided by
(ii) the actual expenditures for physicians' services for the 12-
month period ending on March 31 of the preceding year, increased by the
sustainable growth rate under
[[Page 59431]]
subsection (f) for the fiscal year which begins during such 12-month
period.''
The result is a 3.0 percent adjustment for 2000.
VI. Provisions of the Final Rule
The provisions of this final rule restate the provisions of the
July 22, 1999, proposed rule except as noted elsewhere in this
preamble. Following is a highlight of the changes made:
For our proposal relating to physician pathology services and
independent laboratories (Sec. 415.130(c)), we have decided to adopt
our proposal to pay only hospitals for the TC services furnished to its
inpatients, but delay implementation until January 1, 2001, to allow
independent laboratories and hospitals sufficient time to negotiate
arrangements.
For our proposal relating to optometrist services, we are revising
the regulations at Sec. 410.23 (Limitations on services of an
optometrist) to specify that Medicare Part B pays for services of a
doctor of optometry, acting within the scope of his or her license,
with respect to the provision of items or services described in section
1861(s) of the Act.
For our proposal relating to CPT modifier -25, we are making the
following changes:
We are proceeding to include procedures with a global
period indicator of ``XXX'' in the application of the global surgery
payment policy relating to the use of modifier -25.
We will not, however, require the routine use of modifier
-25 with all procedures having a global indicator of ``XXX''. Instead,
we will identify specific codes if an E/M service is furnished with a
specified code. To be billed for, it would need to be documented as
being significant and separately identifiable and be reported with
modifier -25.
We will seek review of these codes from physician
specialty societies, as well as those nonphysician practitioners who
are authorized to bill Medicare on their own.
Specific procedure codes for which the use of modifier -25
is required when a significant, separately identifiable E/M service is
furnished and reported by the same physician or nonphysician
practitioner will be included as edits in the Correct Coding Initiative
edits.
These edits will be implemented no earlier than October 1,
2000, and will continue to be added as appropriate on an ongoing basis.
In the meantime, however, since modifiers are an inherent
part of HCPCS, we urge all practitioners to familiarize themselves with
them and to make it a practice to use them when applicable.
For our proposal relating to coverage of prostate cancer screening
tests (Sec. 410.39) we are implementing the requirements as stated in
the proposed rule. However, we are revising Sec. 410.39(e)(1) to
provide that payment ``may not be made for a screening PSA blood test
performed for a man age 50 or younger''.
For our proposal to discontinue separate payment for pulse
oximetry, temperature gradient studies, venous pressure determinations,
and to list them in the physician fee schedule with a status code of
``B'' for ``payment always bundled into payment for other services,''
we will bundle payment for these services starting in 2000 with the
exception of 94762, which we will continue to pay separately when
continuous overnight monitoring is medically necessary as a separate
procedure.
VII. Collection of Information Requirements
This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1980 (44 U.S.C. 3501 et seq.).
VIII. Response to Comments
Because of the large number of items of correspondence we normally
receive on Federal Register documents published for comment, we are not
able to acknowledge or respond to them individually. We will consider
all comments we receive by the date and time specified in the DATES
section of this preamble, and, if we proceed with a subsequent
document, we will respond to the comments in the preamble to that
document.
IX. Regulatory Impact Analysis
We have examined the impacts of this final rule as required by
Executive Order (EO) 12866, the Unfunded Mandates Reform Act (UMRA)
(Public Law 104-4), the Regulatory Flexibility Act (RFA) (Public Law
96-354), and the Federalism Executive Order (EO) 13132.
Executive Order 12866 directs agencies to assess costs and benefits
of available regulatory alternatives and, when regulation is necessary,
to select regulatory approaches that maximize net benefits (including
potential economic, environmental, public health and safety effects,
distributive impacts, and equity). A regulatory impact analysis (RIA)
must be prepared for major rules with economically significant effects
($100 million or more annually). The changes in the Medicare physician
fee schedule are, for the most part, budget neutral. This final rule
conforms the regulations to new statutory benefits that exceed $100
million in Medicare spending. (See the estimated costs tables in
sections IX. M. and IX. N.) Therefore, this final rule is considered to
be a major rule as defined in Title 5, United States Code, Section
804(2).
The UMRA also requires (in section 202) that agencies prepare an
assessment of anticipated costs and benefits before developing any rule
that may result in an expenditure by State, local, or tribal
governments, in the aggregate, or by the private sector, of $100
million or more in any given year. This final rule will have no
consequential effect on State, local, or tribal governments. We believe
the private sector cost of this rule falls below these thresholds as
well.
The RFA requires that we analyze regulatory options for small
businesses and other small entities. We prepare a Regulatory
Flexibility Analysis unless we certify that a rule would not have a
significant economic impact on a substantial number of small entities.
The analysis must include a justification of why action is being taken,
the kinds and number of small entities the rule affects, and an
explanation of any meaningful options that achieve the objectives and
lessen significant adverse economic impact on the small entities.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis if a rule may have a significant impact on
the operations of a substantial number of small rural hospitals. This
analysis must conform to the provisions of section 604 of the RFA. For
purposes of section 1102(b) of the Act, we define a small rural
hospital as a hospital that is located outside of a Metropolitan
Statistical Area and has fewer than 50 beds.
For purposes of the RFA, all physicians are considered to be small
entities. There are about 700,000 physicians and other practitioners
who receive Medicare payment under the physician fee schedule. We have
prepared the following analysis which, together with the rest of this
preamble, meets all four assessment requirements. It explains the
rationale for and purpose of the rule, details the costs and benefits
of the rule, analyzes alternatives, and presents the measures we
considered to minimize the burden on small entities.
[[Page 59432]]
A. Resource-Based Malpractice Relative Value Units
As explained earlier in this preamble, the resource-based
malpractice RVUs must be implemented in a budget-neutral manner. That
is, the total fee schedule malpractice RVUs must be the same under the
resource-based method as would have existed had the prior charge-based
malpractice RVUs been retained. This means that increases in RVUs for
some services will necessarily be offset by corresponding decreases in
values for other services. Table 3 shows, by specialty, the estimated
percentage changes in allowed charges for our proposed resource-based
malpractice RVUs.
As Table 3 shows, the effects on payments are very modest and, in
most cases, negligible. Of the 35 major payment specialties, 15 are
estimated to experience payment increases, 19 are estimated to
experience payment decreases, and 1 experiences no change. Only two
specialties are estimated to experience increases of more than 1
percent, emergency medicine (2.6 percent) and nephrology (1.1 percent),
with an estimated median payment increase of 0.3 percent among the
specialties that receive an increase. Only three specialties are
estimated to experience payment decreases of 1 percent or more cardiac
surgery (-1.2 percent), orthopedic surgery (-1.1 percent), and thoracic
surgery (-1.0 percent) with an estimated median payment decrease of -
0.5 percent among the specialties which receive a decrease. These
impacts are slightly different than those shown in the July 22 proposed
rule because they reflect different case mix using 1998 rather than
1997 service frequencies; incorporate RVU changes made as a result of
comments received on the NPRM; and reflect the final budget-neutrality
adjustment calculated by our actuaries.
The impact of the changes on the total revenue (Medicare and non-
Medicare) for a given specialty is less than the impact displayed in
Table 3 since physicians furnish services to both Medicare and non-
Medicare patients. The magnitude of the impact on Medicare payment for
a specialty depends generally on the mix of services a physician in the
specialty furnishes.
Table 3.--Impact on Total Allowed Charges by Specialty of the Resource
Based Malpractice Expense Relative Value Units
[Percent change]
------------------------------------------------------------------------
Allowed Impact by
Specialty charges (in specialty
billions) (percent)
------------------------------------------------------------------------
ANESTHESIOLOGY.......................... 0.2 -0.6
CARDIAC SURGERY......................... 0.3 -1.2
CARDIOLOGY.............................. 3.7 -0.1
CLINICS................................. 1.4 0.2
DERMATOLOGY............................. 1.2 0.0
EMERGENCY MEDICINE...................... 0.8 2.6
FAMILY PRACTICE......................... 3.0 0.3
GASTROENTEROLOGY........................ 1.1 -0.4
GENERAL PRACTICE........................ 1.0 0.4
GENERAL SURGERY......................... 1.7 -0.2
HEMATOLOGY ONCOLOGY..................... 0.6 0.2
INTERNAL MEDICINE....................... 6.3 0.3
NEPHROLOGY.............................. 0.9 1.1
NEUROLOGY............................... 0.8 0.3
NEUROSURGERY............................ 0.3 0.5
OBSTETRICS/GYNECOLOGY................... 0.4 -0.6
OPHTHALMOLOGY........................... 3.5 -0.5
ORTHOPEDIC SURGERY...................... 2.0 -1.1
OTOLARYNGOLOGY.......................... 0.6 -0.3
PATHOLOGY............................... 0.5 -0.6
PLASTIC SURGERY......................... 0.2 -0.3
PSYCHIATRY.............................. 1.1 -0.2
PULMONARY............................... 1.0 0.2
RADIATION ONCOLOGY...................... 0.4 -0.5
RADIOLOGY............................... 2.7 -0.6
RHEUMATOLOGY............................ 0.3 0.3
THORACIC SURGERY........................ 0.5 -1.0
UROLOGY................................. 1.2 -0.1
VASCULAR SURGERY........................ 0.3 -0.5
ALL OTHER PHYSICIAN..................... 1.2 0.1
OTHERS:
CHIROPRACTOR........................ 0.4 0.6
NONPHYSICIAN PRACTITIONER........... 0.9 -0.4
OPTOMETRIST......................... 0.4 0.4
PODIATRY............................ 1.0 0.4
SUPPLIERS........................... 0.4 -0.4
------------------------------------------------------------------------
B. Resource-Based Practice Expense Relative Value Units
Revisions in resource-based practice expense RVUs for physicians'
services are calculated to be budget neutral, that is, the total
practice expense RVUs for calendar year 2000 are calculated to be the
same as the total practice expense RVUs that we estimate would have
occurred without the changes proposed in this regulation. This means
that increases in practice expense RVUs for
[[Page 59433]]
some services will necessarily be offset by corresponding decreases in
values for other services.
Table 4, ``Impact on Total Allowed Charges by Specialty of the
Final Rule Practice Expense Changes'' shows, by specialty, the
estimated percent changes in allowed charges resulting from the
practice expense proposals discussed earlier in this rule. This table
shows the impact of changes in the year 2000, as well as 3-year impact
from 2000 to 2002 on the fully implemented practice expense RVUs. In
the year 2000, the practice expense RVUs are a blend of 50 percent of
the charged-based RVU and 50 percent of the resource-based RVU. The
year 2000 impact column shows the impact of changes in this rule
relative to what payments would have been in 2000 had there been no
changes from this rule. The column labeled 2000-2002 impact compares
payments using the fully implemented RVUs published in the November 2,
1998 final rule (63 FR 58816) to the fully implemented RVUs reflecting
changes included in this rule.
Table 4.--Impact on Total Allowed Charges by Specialty of Final Rule Practice Expense Changes
[Percent change]
----------------------------------------------------------------------------------------------------------------
Allowed Year 2000 2000-2002
Specialty charges (in impact impact
billions) (percent) (percent)
----------------------------------------------------------------------------------------------------------------
ANESTHESIOLOGY.................................................. 1.6 -3 -9
CARDIAC SURGERY................................................. 0.3 -2 -6
CARDIOLOGY...................................................... 3.7 -1 -3
CLINICS......................................................... 1.4 0 -1
DERMATOLOGY..................................................... 1.2 0 0
EMERGENCY MEDICINE.............................................. 0.8 -1 -2
FAMILY PRACTICE................................................. 3.0 0 1
GASTROENTEROLOGY................................................ 1.1 -1 -4
GENERAL PRACTICE................................................ 1.0 0 1
GENERAL SURGERY................................................. 1.8 0 -1
HEMATOLOGY ONCOLOGY............................................. 0.6 0 0
INTERNAL MEDICINE............................................... 6.3 0 0
NEPHROLOGY...................................................... 0.9 0 1
NEUROLOGY....................................................... 0.8 0 0
NEUROSURGERY.................................................... 0.3 0 -1
OBSTETRICS/GYNECOLOGY........................................... 0.4 1 2
OPHTHALMOLOGY................................................... 3.5 1 2
ORTHOPEDIC SURGERY.............................................. 2.0 0 1
OTHER PHYSICIAN................................................. 1.2 -1 -2
OTOLARYNGOLOGY.................................................. 0.6 1 2
PATHOLOGY....................................................... 0.5 3 9
PLASTIC SURGERY................................................. 0.2 1 2
PSYCHIATRY...................................................... 1.1 0 -1
PULMONARY....................................................... 1.0 -1 -2
RADIATION ONCOLOGY.............................................. 0.6 0 0
RADIOLOGY....................................................... 2.8 -1 -2
RHEUMATOLOGY.................................................... 0.3 1 4
THORACIC SURGERY................................................ 0.5 -2 -5
UROLOGY......................................................... 1.2 0 1
VASCULAR SURGERY................................................ 0.3 0 -1
OTHERS: .............. 0 0
CHIROPRACTOR................................................ 0.4 0 0
NONPHYSICIAN PRACTITIONER................................... 0.9 0 0
OPTOMETRIST................................................. 0.4 2 5
PODIATRY.................................................... 1.0 1 2
SUPPLIERS................................................... 0.4 6 18
----------------------------------------------------------------------------------------------------------------
Table 5 shows the impacts we displayed in the proposed rule
published on July 22, 1999 for practice expense only and the
corresponding impacts which result from this final rule. This table
shows only the fully implemented fee schedule impact, not the year 2000
impact incorporating the transition. There are two factors that explain
the difference between the proposed rule and final rule impact
statements. In the proposed rule, we indicated that we were considering
removing some services from the zero physician work RVU pool. We did
not include the effect of that policy change in the proposed rule
impact statement. That change is now included in the ``Final Rule''
column. The zero work RVU change affects specialties which perform the
technical portion of diagnostic tests. We are also using a higher
practice expense per hour for thoracic and cardiac surgery in order to
establish the SMS specialty practice expense pools. This change affects
only these two specialties. Both of these changes are discussed in more
detail earlier in the preamble to this final rule.
[[Page 59434]]
Table 5.--Impact on Total Allowed Charges by Specialty of Practice Expense Changes Only 7/22/1999 Proposed Rule
and This Final Rule
----------------------------------------------------------------------------------------------------------------
Allowed Proposed rule Final rule
Specialty charges impact impact
(billions) (percent) (percent)
----------------------------------------------------------------------------------------------------------------
ANESTHESIOLOGY.................................................. 1.6 -8 -9
CARDIAC SURGERY................................................. 0.3 -8 -6
CARDIOLOGY...................................................... 3.7 -2 -3
CLINICS......................................................... 1.4 -1 -1
DERMATOLOGY..................................................... 1.2 2 0
EMERGENCY MEDICINE.............................................. 0.8 -1 -2
FAMILY PRACTICE................................................. 3.0 2 1
GASTROENTEROLOGY................................................ 1.1 -2 -4
GENERAL PRACTICE................................................ 1.0 2 1
GENERAL SURGERY................................................. 1.8 0 -1
HEMATOLOGY ONCOLOGY............................................. 0.6 1 0
INTERNAL MEDICINE............................................... 6.3 0 0
NEPHROLOGY...................................................... 0.9 0 1
NEUROLOGY....................................................... 0.8 1 0
NEUROSURGERY.................................................... 0.3 1 -1
OBSTETRICS/GYNECOLOGY........................................... 0.4 3 2
OPHTHALMOLOGY................................................... 3.5 1 2
ORTHOPEDIC SURGERY.............................................. 2.0 3 1
OTHER PHYSICIAN................................................. 1.2 0 -2
OTOLARYNGOLOGY.................................................. 0.6 2 2
PATHOLOGY....................................................... 0.5 2 9
PLASTIC SURGERY................................................. 0.2 1 2
PSYCHIATRY...................................................... 1.1 -1 -1
PULMONARY....................................................... 1.0 -2 -2
RADIATION ONCOLOGY.............................................. 0.6 0 0
RADIOLOGY....................................................... 2.8 0 -2
RHEUMATOLOGY.................................................... 0.3 5 4
THORACIC SURGERY................................................ 0.5 -6 -5
UROLOGY......................................................... 1.2 2 1
VASCULAR SURGERY................................................ 0.3 0 -1
OTHERS:
CHIROPRACTOR................................................ 0.4 0 0
NONPHYSICIAN PRACTITIONER................................... 0.9 2 0
OPTOMETRIST................................................. 0.4 2 5
PODIATRY.................................................... 1.0 2 2
SUPPLIERS................................................... 0.4 1 18
----------------------------------------------------------------------------------------------------------------
Table 6 shows the percentage change in total payment (in 2000
physician fee schedule dollars) for selected high-volume procedures
that result from the change in payment related to the changes in
practice expense and malpractice RVUs contained in this final rule.
These tables reflect the impact of this final rule only on the fully
implemented fee schedule amount. The payments in these columns are
determined using a conversion factor of $36.6137. The RVUs used for
calculating payments in the ``old'' columns are from the Federal
Register published on November 2, 1998. The RVUs used in calculating
payments in the ``new'' columns are from this final rule. By using the
conversion factor of $36.6137 to calculate payments in both the ``old''
and ``new'' columns, the impact of changes in practice expense and
malpractice expense RVU are illustrated. These tables do not show the
actual impact on payment from 1999 to 2000 because they do not
incorporate the effect of the transition or physician fee schedule
update. In general, payments for services in the facility setting,
including evaluation and management services, are declining due to our
policy to exclude costs associated with bringing clinical staff to the
facility setting. Payment for a tissue exam by a pathologist (CPT
88305) is increasing due to our proposal to remove the service from the
zero work pool. The increase in value for the technical portion of the
services causes a corresponding increase in the global service.
Table 6.--Total Payment For Selected Procedures
----------------------------------------------------------------------------------------------------------------
Old non- New non- Percent Old New Percent
Code Mod Description facility facility change facility facility change
----------------------------------------------------------------------------------------------------------------
11721.... ...... Debride nail, 6 $ 39.18 $ 39.18 0% 34.43 $ 28.56 -17
or more.
17000.... ...... Destroy benign/ 49.43 60.41 22 32.24 32.95 2
premal lesion.
27130.... ...... Total hip NA NA NA 1,435.23 1,395.71 -3
replacement.
27236.... ...... Treat thigh NA NA NA 1,118.73 1,065.82 -5
fracture.
27244.... ...... Treat thigh NA NA NA 1,133.38 1,085.96 -4
fracture.
27447.... ...... Total knee NA NA NA 1,500.43 1,460.52 -3
replacement.
33533.... ...... CABG, arterial, NA NA NA 1,940.01 1,829.59 -6
single.
35301.... ...... Rechanneling of NA NA NA 1,124.23 1,133.93 1
artery.
43239.... ...... Upper GI 272.41 247.14 -9 147.63 139.13 -6
endoscopy,
biopsy.
45385.... ...... Lesion removal 413.00 462.80 12 292.69 275.70 -6
colonoscopy.
[[Page 59435]]
66821.... ...... After cataract 201.74 196.98 -2 191.58 170.99 -11
laser surgery.
66984.... ...... Remove cataract/ NA NA NA 700.03 654.65 -6
insert lens.
67210.... ...... Treatment of 593.87 602.66 1 545.08 550.67 1
retinal lesion.
71010.... 26.... Chest x-ray.... 8.79 8.79 0 8.79 8.79 0
71020.... ...... Chest x-ray.... 35.15 34.42 -2 35.17 34.42 -2
71020.... 26.... Chest x-ray.... 10.62 10.62 0 10.62 10.62 0
77430.... ...... Weekly 180.14 187.83 4 180.23 187.83 4
radiation
therapy.
78465.... ...... Heart image 542.25 527.24 -3 542.52 527.24 -3
(3d), multiple.
88305.... ...... Tissue exam by 61.51 82.01 33 61.54 82.01 33
pathologist.
88305.... 26.... Tissue exam by 40.28 40.64 1 40.29 40.64 1
pathologist.
90801.... ...... Psy dx 143.53 146.09 2 142.86 138.77 -3
interview.
90806.... ...... Psytx, off, 45- 97.76 97.76 0 95.98 93.73 -2
50 min.
90807.... ...... Psytx, off, 45- 101.79 103.62 2 102.94 99.22 -4
50 min w/e&m.
90862.... ...... Medication 49.79 50.89 2 49.09 46.50 -5
management.
90921.... ...... ESRD related 245.31 263.25 7 245.43 237.26 -3
services,
month.
90935.... ...... Hemodialysis, NA NA NA 69.97 61.51 -12
one evaluation.
92004.... ...... Eye exam, new 120.83 124.49 3 86.82 88.61 2
patient.
92012.... ...... Eye exam 75.79 63.71 -16 36.27 36.61 1
established
pat.
92014.... ...... Eye exam & 87.87 91.53 4 58.98 59.68 1
treatment.
92980.... ...... Insert NA NA NA 949.13 851.63 -10
intracoronary
stent.
92982.... ...... Coronary artery NA NA NA 716.15 630.12 -12
dilation.
93000.... ...... Electrocardiogr 26.36 26.36 0 26.37 26.36 0
am, complete.
93010.... ...... Electrocardiogr 8.79 8.79 0 8.79 8.79 0
am report.
93015.... ...... Cardiovascular 106.55 104.35 -2 106.60 104.35 -2
stress test.
93307.... ...... Echo exam of 204.30 198.08 -3 204.40 198.08 -3
heart.
93307.... 26.... Echo exam of 49.79 48.70 -2 49.82 48.70 -2
heart.
93510.... 26.... Left heart 231.03 247.87 7 231.15 247.87 7
catheterizatio
n.
98941.... ...... Chiropractic 34.78 35.15 1 30.40 30.76 1
manipulation.
99202.... ...... Office/ 68.47 72.50 6 53.48 45.40 -15
outpatient
visit, new.
99203.... ...... Office/ 97.03 102.52 6 78.03 69.57 -11
outpatient
visit, new.
99204.... ...... Office/ 136.94 145.36 6 112.09 102.88 -8
outpatient
visit, new.
99205.... ...... Office/ 169.89 179.41 6 145.43 135.84 -7
outpatient
visit, new.
99211.... ...... Office/ 23.07 25.63 11 14.29 8.79 -38
outpatient
visit, est.
99212.... ...... Office/ 36.61 39.18 7 28.21 23.07 -18
outpatient
visit, est.
99213.... ...... Office/ 48.33 51.63 7 38.46 33.68 -12
outpatient
visit, est.
99214.... ...... Office/ 76.16 80.92 6 62.27 56.02 -10
outpatient
visit, est.
99215.... ...... Office/ 110.94 116.07 5 96.71 90.44 -6
outpatient
visit, est.
99221.... ...... Initial NA NA NA 72.53 65.17 -10
hospital care.
99222.... ...... Initial NA NA NA 115.02 108.38 -6
hospital care.
99223.... ...... Initial NA NA NA 157.52 151.21 -4
hospital care.
99231.... ...... Subsequent NA NA NA 34.07 32.59 -4
hospital care.
99232.... ...... Subsequent NA NA NA 54.95 53.82 -2
hospital care.
99233.... ...... Subsequent NA NA NA 78.39 76.16 -3
hospital care.
99236.... ...... Observ/hosp NA NA NA 220.52 215.29 -2
same date.
99238.... ...... Hospital NA NA NA 68.87 64.44 -6
discharge day.
99239.... ...... Hospital NA NA NA 91.58 88.24 -4
discharge day.
99241.... ...... Office 57.12 61.14 7 40.66 32.95 -19
consultation.
99242.... ...... Office 95.93 101.79 6 74.36 67.37 -9
consultation.
99243.... ...... Office 121.92 128.51 5 98.54 89.70 -9
consultation.
99244.... ...... Office 168.06 176.48 5 142.13 132.54 -7
consultation.
99245.... ...... Office 213.09 222.25 4 186.09 176.11 -5
consultation.
99251.... ...... Initial NA NA NA 42.13 36.61 -13
inpatient
consult.
99252.... ...... Initial NA NA NA 77.29 71.76 -7
inpatient
consult.
99253.... ...... Initial NA NA NA 104.40 97.39 -7
inpatient
consult.
99254.... ...... Initial NA NA NA 146.16 138.77 -5
inpatient
consult.
99255.... ...... Initial NA NA NA 198.18 191.12 -4
inpatient
consult.
99261.... ...... Follow-up NA NA NA 28.21 23.80 -16
inpatient
consult.
99262.... ...... Follow-up NA NA NA 50.92 45.77 -10
inpatient
consult.
99263.... ...... Follow-up NA NA NA 72.16 67.37 -7
inpatient
consult.
99282.... ...... Emergency dept NA NA NA 27.84 26.73 -4
visit.
99283.... ...... Emergency dept NA NA NA 59.34 60.05 1
visit.
99284.... ...... Emergency dept NA NA NA 92.31 94.10 2
visit.
99285.... ...... Emergency dept NA NA NA 142.50 146.09 3
visit.
99291.... ...... Critical care, 187.10 187.83 0 185.72 179.41 -3
first hour.
99292.... ...... Critical care, 94.46 96.66 2 93.41 89.70 -4
addl 30 min.
99301.... ...... Nursing NA NA NA 65.57 60.41 -8
facility care.
99302.... ...... Nursing NA NA NA 86.82 80.92 -7
facility care.
99303.... ...... Nursing NA NA NA 107.70 100.32 -7
facility care.
99311.... ...... Nursing fac NA NA NA 33.70 30.02 -11
care, subseq.
99312.... ...... Nursing fac NA NA NA 53.12 49.79 -6
care, subseq.
99313.... ...... Nursing fac NA NA NA 74.73 71.03 -5
care, subseq.
99348.... ...... Home visit, est 70.30 72.50 3 70.70 66.64 -6
patient.
99350.... ...... Home visit, est 158.17 164.40 4 154.95 154.88 0
patient.
----------------------------------------------------------------------------------------------------------------
Table 7 shows the combined impact of the proposed changes in the
malpractice RVUs and the fully implemented practice expense RVUs.
Comment: One commenter indicated that specialty level impacts
displayed in the proposed rule were misleading and
[[Page 59436]]
caused a great deal of confusion in the physician community. Although
the commenter indicated that it is appropriate for us to display
specialty level impacts that result from the new rule relative to prior
policy, the commenter also requested that we show the total impact of
adopting resource-based methodologies.
Response: In general, we show the impact of changes that result
from a new rule, not the cumulative impact of changes in policy
contained in prior rules as well as the new one. However, we
acknowledge that it can be difficult to understand changes that result
from adoption of the resource-based practice expense methodology
because those changes may result from policy changes contained in the
final rule published on November 2, 1998 (63 FR 58814), from changes
due to this final rule, and because all of these changes are occurring
over the 4-year transition period. Impacts of the final rule published
on November 2, 1998 are shown on page 58895 of the physician fee
schedule final rule published on November 2, 1998. The percentage
increase for a particular specialty can be combined with the impacts
shown in table 7 (which shows the impacts in addition to those
presented in the November 2, 1998 final rule) to determine the impact
of moving to resource based methodologies for practice expense and
malpractice expense.
The impact of the changes on the total revenue (Medicare and non-
Medicare) for a given specialty is less than the impact displayed in
these tables since physicians furnish services to both Medicare and
non-Medicare patients. The magnitude of the impact that Medicare
payment has on a specialty depends generally on the mix of services a
physician in the specialty provides and the sites in which the services
are performed. As we indicated in the proposed rule, each year since
the fee schedule has been implemented, our actuaries have determined
any adjustments needed to meet the requirements of budget neutrality. A
key component of the actuarial determination of budget neutrality
involves estimating any impact of changes in the volume and intensity
of physicians' services furnished to Medicare beneficiaries as a result
of the proposed changes.
In estimating the impacts of proposed changes under the physician
fee schedule on the volume and intensity of services, the actuaries
have historically used a model that assumes that 50 percent of the
change in net revenue for a procedure would be recouped. This does not
mean that the payments are reduced by 50 percent. In fact, payments
have typically been reduced only by a few percent or less. In 1999, the
actuary revised the assumption about response to payment changes and
will use a model that assumes a 30 percent volume-and-intensity
response to price reductions. The actuary is continuing to assume no
reduction in volume and intensity response to a price increase. Our
actuary's analysis of the volume-and-intensity response is available on
our homepage (www.hcfa.gov).
Comment: We again received comments in response to our assumption
that physicians respond to payment reductions so as to offset revenue
reductions. One commenter indicated that a 30 percent volume-and-
intensity response seems extreme.
Response: We provide a response to this and similar comments in the
final rule published November 2, 1998 (63 FR 588894). We reiterate that
our assumption that physicians respond to payment reductions so as to
offset 30 percent of revenue reduction in physician fees. Most
physicians, even those in specialties with a negative payment impact
shown in table 7, will experience an increase in physician fees in
2000. This is largely due to an update of 5.4 percent. Since there are
few specialties that will actually experience a decline in payment in
2000, the adjustment to the conversion factor for behavioral responses
to fee reductions will be only 0.12 percent (or approximately $0.04).
To the extent that the volume-and-intensity response does not occur,
the SGR system enacted as part of the BBA will return the volume-and-
intensity adjustment in the form of higher future updates to the
Medicare physician fee schedule CF. The volume-and-intensity adjustment
should not affect aggregate payments because our actuaries assume an
offsetting increase in the volume and intensity of services provided in
2000.
Table 7.--Impact on Total Allowed Charges by Specialty of Fully
Implemented Practice Expense and Malpractice Expense Relative Value
Units
------------------------------------------------------------------------
Changes
Allowed Resulting from
Specialty Charges (in this Final
billions) Rule (percent)
------------------------------------------------------------------------
ANESTHESIOLOGY.......................... 1.6 -9
CARDIAC SURGERY......................... 0.3 -8
CARDIOLOGY.............................. 3.7 -3
CLINICS................................. 1.4 -1
DERMATOLOGY............................. 1.2 0
EMERGENCY MEDICINE...................... 0.8 1
FAMILY PRACTICE......................... 3.0 1
GASTROENTEROLOGY........................ 1.1 -4
GENERAL PRACTICE........................ 1.0 2
GENERAL SURGERY......................... 1.8 -1
HEMATOLOGY ONCOLOGY..................... 0.6 0
INTERNAL MEDICINE....................... 6.3 0
NEPHROLOGY.............................. 0.9 2
NEUROLOGY............................... 0.8 0
NEUROSURGERY............................ 0.3 -1
OBSTETRICS/GYNECOLOGY................... 0.4 1
OPHTHALMOLOGY........................... 3.5 2
ORTHOPEDIC SURGERY...................... 2.0 0
OTHER PHYSICIAN......................... 1.2 -2
OTOLARYNGOLOGY.......................... 0.6 1
PATHOLOGY............................... 0.5 8
PLASTIC SURGERY......................... 0.2 1
[[Page 59437]]
PSYCHIATRY.............................. 1.1 -1
PULMONARY............................... 1.0 -2
RADIATION ONCOLOGY...................... 0.6 0
RADIOLOGY............................... 2.8 -3
RHEUMATOLOGY............................ 0.3 4
THORACIC SURGERY........................ 0.5 -6
UROLOGY................................. 1.2 1
VASCULAR SURGERY........................ 0.3 -1
OTHERS:
CHIROPRACTOR........................ 0.4 1
NONPHYSICIAN PRACTITIONER........... 0.9 0
OPTOMETRIST......................... 0.4 5
PODIATRY............................ 1.0 2
SUPPLIERS........................... 0.4 17
------------------------------------------------------------------------
Comment: A few commenters indicated that HCFA has not fulfilled its
statutory obligation to provide impacts on the practice expense RVUs in
different geographical areas or compare Medicare payments under the new
practice expense RVUS with actual practice costs for physicians in each
specialty.
Response: Section 4505(d)(3) of the BBA required the Secretary to
provide the impacts suggested by this commenter as part of a notice of
proposed rule making in the Spring of 1998. We provided impacts of the
newly adopted resource-based practice expense by specialty and
geographic area in the proposed rule published June 5, 1998 (63 FR
58895). Unlike adoption of the physician fee schedule published on
January 1, 1992, the adoption of the practice expense methodology has a
negligible impact on payments by geographical area. For this reason we
are not continuing to display those impacts. With respect to comparing
the new practice expense RVUs to actual practice expenses for
physicians in each specialty, we do not believe that the data are
available to make reliable comparisons. Although we do have aggregate,
specialty level data on practice expense from the SMS, these data are
used to establish relative payment amounts for the more than 7,000
physician services paid for by Medicare and are intended to represent
the relative resources used by physicians in providing services to
Medicare patients. The SMS data do not allow us to directly compare
these practice expense relative values to ``actual'' practice expenses.
Table 7 shows the combined impact of the changes in the malpractice
RVUs and the fully implemented practice expense RVUs. The impact of the
changes on the total revenue (Medicare and non-Medicare) for a given
specialty is less than the impact displayed in these tables since
physicians furnish services to both Medicare and non-Medicare patients.
The magnitude of the impact that Medicare payment has on a specialty
depends generally on the mix of services a physician in the specialty
provides and the sites in which the services are performed.
C. Adjustment to the Practice Expense Relative Value Units for a
Physician's Interpretation of Abnormal Papanicolaou Smears
Currently, there are several codes for a physician's interpretation
of an abnormal pap smear (three HCPCS codes and one CPT code). We
evaluated the practice expense RVUs for each of these codes in a
slightly different manner, and the practice expense RVUs assigned to
HCPCS code G0141 were much lower than those for the other codes. We
believe it is more appropriate to have the RVUs for all of these codes
identical to those for CPT code 88141. The impact of this provision has
been incorporated into the physician fee schedule budget-neutrality
calculation.
D. Physician Pathology Services and Independent Laboratories
Independent laboratories usually bill for a combined service that
is the sum of the PC and TC services. These services can be furnished
to both hospital and nonhospital patients.
The claims processing instructions require the independent
laboratory to use the hospital as the place of service (POS) for TC
billing of hospital patients. However, our analysis of national claims
data indicates that independent laboratories are likely to use the
independent laboratory as the POS. Thus, we cannot directly calculate
the independent laboratory's billings for the combined service to
hospital inpatients.
Based on our knowledge of laboratory practice arrangements, we have
assumed that 20 percent of the allowed charges for independent
laboratories represent billings for hospital inpatients. We adjusted
this amount to remove PC billings because they are billable
notwithstanding the provisions of this final rule. We estimated the PC
amount by multiplying the total allowed charges for each code by the
ratio of the PC RVUs to total RVUs for that code. The remaining amount
represents the total allowed charges for TC services for hospital
inpatients.
We estimated that payment under the physician fee schedule for TC
billings by independent laboratories will decrease by $6 million.
However, we are delaying implementation for 1 year so hospitals can
make the necessary arrangements
The hospital is paid under the prospective payment system for the
TC of a physician pathology service to hospital inpatients. If the
independent laboratory furnishes the TC, it must enter into an
arrangement with a hospital to be paid appropriately for this service.
E. Discontinuous Anesthesia Time
This final rule clarifies that if an anesthesia practitioner has
not been billing for a block of time before an interruption in
services, he or she would be able to bill for that block of time and
receive payment. It is our understanding that, in most instances, a
block of time before an interruption is generally about 15 minutes, or
one time
[[Page 59438]]
unit. However, some anesthesia practitioners may have interpreted our
regulations as allowing them to bill for the block of time before an
interruption. If an anesthesia practitioner has billed in this manner,
then our revision to the regulations will not have any economic effect.
We estimate that overall there are no costs or savings to the Medicare
program.
F. Optometrist Services
The provisions of the OBRA 1986 expanded coverage of optometrist
services. While this statutory provision had been implemented through
manual provisions, we had not revised the regulations to reflect this
change. We proposed to revise the regulations at Sec. 410.23 to specify
that Medicare Part B pays for the services of a doctor of optometry,
acting within the scope of his or her license, if the services are
those described in section 1861(s) of the Act and 42 CFR 410.10.
We received comments from the American Optometric Association
supporting the proposed revision to the regulations. We are revising
the regulations at Sec. 410.23 to specify that Medicare Part B pays for
services of a doctor of optometry, acting within the scope of his or
her license, if the services are those described in section 1861(s) of
the Act and 42 CFR 410.10.
G. Assisted Suicide
This final rule conforms the regulations to a provision in the
Assisted Suicide Funding Act of 1997. This statute prohibits the use of
Federal funds to furnish or pay for any health care service or health
benefit coverage for the purpose of causing, or assisting to cause, the
death of any individual. We believe that this change will have no
program costs or savings given the exclusion from Medicare payment of
expenses for these services under section 1862(a)(1)(A) of the Act.
This section states that no payment may be made under Part A or Part B
for any expenses incurred for items or services that are not reasonable
or necessary for the diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body member.
H. CPT Modifier -25
For selected procedures for which current global surgery rules do
not apply (for example, those for which the global indicator is ``XXX''
in the database), this rule provides that a practitioner may bill for
an E/M service only if it is a significant separately identifiable
service. This situation will be reported by appending modifier -25 to
the E/M service code. This policy will assist carriers in claims
adjudication and eliminate unnecessary denials when practitioners
append modifier -25 to the E/M service to signify that the E/M service
reported is appropriate because it was a significant and separately
identifiable service from the procedure performed. We expect the
savings to be minimal because the specific procedures to which this
policy is to be applied have still to be identified and edits for these
procedures will not begin to be implemented until October 2000 at the
earliest.
I. Nurse Practitioner Qualifications
The NP qualifications stated in this final rule provide a mechanism
that permits those individuals who have a Medicare NP billing number
before January 1, 2001, to continue to bill as NPs. Therefore, an
individual who may not have been nationally certified as an NP, or who
does not have a master's degree in nursing, is permitted to continue to
bill under the Medicare program. However, after January 1, 2003, to
obtain a Medicare NP billing number, a new applicant is required to
possess a master's degree in nursing, State authorization to practice
as an NP, and national certification as an NP. By this time, nursing
professionals will have had ample notification and time to acquire
these credentials. There are no Medicare program costs or savings
associated with this provision. Furthermore, these requirements are
consistent with our understanding of certification and training
requirements being implemented by NP professional groups.
J. Relative Value Units for Pediatric Services
This final rule corrects our use of the wrong data in establishing
the work RVUs for certain pediatric surgical services. Since pediatric
services are a small portion of services under Medicare, this change
has a negligible cost or saving impact on the Medicare program
K. Percutaneous Thrombectomy of an Arteriovenous Fistula
We have established payment for a new HCPCS code that more
accurately describes the activities regarding percutaneous thrombectomy
of a dialysis graft or fistula. Since this is basically a coding change
we do not anticipate any costs or savings to the Medicare program.
L. Pulse Oximetry, Temperature Gradient Studies, and Venous Pressure
Determinations
We discontinued separate payment for CPT codes 94760 (noninvasive
ear or pulse oximetry for oxygen saturation; single determination);
94761 (non-invasive ear or pulse oximetry for oxygen saturation;
multiple determinations); 93740 (temperature gradient studies); and
93770 (determination of venous pressure). Payment for these codes is
bundled into payment for other services. Any savings from this
provision are incorporated into the physician fee schedule budget-
neutrality calculation.
M. Removal of Requirement for X-ray Before Chiropractic Manipulation
This final rule conforms the regulations to section 4513(a) of the
BBA. We expect that removal of the requirement will encourage increased
billing for chiropractic manipulation. The impact of this BBA provision
is shown in the table below.
Estimated Costs
[$ millions]
------------------------------------------------------------------------
------------------------------------------------------------------------
FY 2000.......................................................... 20
FY 2001.......................................................... 40
FY 2002.......................................................... 50
FY 2003.......................................................... 70
FY 2004.......................................................... 80
------
Total.......................................................... 260
------------------------------------------------------------------------
N. Coverage of Prostate Cancer Screening Tests
Section 4103 of the BBA authorizes coverage of certain prostate
cancer screening tests, effective January 1, 2000, subject to certain
frequency and payment limitations. The new tests include: (1) screening
DREs and (2) screening prostate-specific antigen tests. Based on the
projected utilization of these screening services and related medically
necessary follow-up tests and treatment that may be required for the
beneficiaries screened, we estimate that this BBA provision will result
in an increase in Medicare payments as described in the table below for
FYs 2000 through 2002. These payments will be made to many urologists,
primary care physicians, and other practitioners (involved in screening
DREs), and to clinical laboratories (involved in screening prostate-
specific antigen tests) nationally.
[[Page 59439]]
Estimated Medicare Costs
[$ million]
------------------------------------------------------------------------
Part A Part B Total
------------------------------------------------------------------------
FY 2000...................................... 170 590 760
FY 2001...................................... 300 1,100 1,400
FY 2002...................................... 400 1,270 1,670
FY 2003...................................... 500 1,470 1,970
FY 2004...................................... 620 1,710 2,330
--------------------------
Total...................................... 1,990 6,140 8,130
------------------------------------------------------------------------
We believe that the effect of the rule will be positive. Prostate
cancer is the most commonly diagnosed cancer in men and the second
leading cause of cancer death for American men. The American Cancer
Society estimates that in 1999 about 179,000 new cases of prostate
cancer will be diagnosed in the United States, and about 37,000 people
will die directly from the disease. According to the American
Urological Association, the use of a screening prostate-specific
antigen blood test, in combination with a screening DRE, is the best
method for detecting prostate cancer when the disease is localized and
potentially curable. Although coverage of prostate cancer screening
should improve access to this service for Medicare beneficiaries, the
benefits of such screening, based on the available medical literature,
are not entirely clear. The literature on the benefits of cancer
detection, especially among men over 70, indicates that screening for
prostate cancer does not necessarily lead to the prolongation of life
or improvement in the quality of life. However, when prostate cancer is
found early, there is evidence that it can often be treated
successfully. Through early detection of prostate cancer made possible
under the new benefit and the use of appropriate treatment measures,
our expectation is that the harmful effects of this serious disease
among the Medicare population will be reduced in the future.
O. Diagnostic Tests
1. Supervision of Diagnostic Test
The requirements of the physician supervision policy in
Sec. 410.32(b) conform to the BBA provisions relating to PAs, NPs, and
CNSs. We clarified that the level of physician supervision for
diagnostic tests performed by PAs, when they are authorized by the
State to perform these tests, is general. This means that we will not
require that the supervising physician for the diagnostic test be on
the premises when the test is performed. No level of physician
supervision is required for diagnostic tests performed by NPs and CNSs
when they are authorized by the State to perform these tests. The scope
of services for which PAs, NPs, or CNSs can bill will not be affected;
therefore, we do not expect any significant costs or savings.
2. Independent Diagnostic Testing Facilities (IDTF)
The IDTF provision at Sec. 410.33 states that NPs and CNSs are
included among the entities that may bill carriers directly for
diagnostic tests. This final rule is a technical one and will not have
a significant effect on costs or savings.
P. Budget-Neutrality
Each year since the fee schedule has been implemented, our
actuaries have determined any adjustments needed to meet the budget-
neutrality requirement of the statute. A component of the actuarial
determination of budget-neutrality involves estimating the impact of
changes in the volume-and-intensity of physicians' services provided to
Medicare beneficiaries as a result of the proposed changes. Consistent
with the provision in the November 2, 1998 final rule, the actuaries
used a model that assumes a 30 percent volume-and-intensity response to
price reductions.
Q. Impact on Beneficiaries
Although changes in payments to physicians when the physician fee
schedule was implemented in 1992 were large, we detected no problems
with beneficiary access to care. Furthermore, because there is a 4-year
transition to the resource-based practice expense system, we expect
minimal impact on beneficiary access to care.
We are currently conducting substantial research to evaluate
beneficiary access to physicians. This research includes, but is not
limited to, augmenting the beneficiary survey questionnaire to further
clarify access problems, conducting a survey of Medicare physicians to
identify physician specialties and procedures by geographic areas, and
tracking claims data in ``vulnerable populations.''
In accordance with the provisions of Executive Order 12866, this
regulation was reviewed by the Office of Management and Budget.
Federalism
We have examined this rule in accordance with Executive Order 13132
and have determined that this final rule will not have any negative
impact on the rights, roles, or responsibilities of State, local, or
Tribal governments.
List of Subjects
42 CFR Part 410
Health facilities, Health professions, Kidney diseases,
Laboratories, Medicare, Rural areas, X-rays.
42 CFR Part 411
Kidney diseases, Medicare, Reporting and recordkeeping
requirements.
42 CFR Part 414
Administrative practice and procedure, Health facilities, Health
professions, Kidney diseases, Medicare, Reporting and recordkeeping
requirements, Rural areas, X-rays.
42 CFR Part 415
Health facilities, Health professions, Medicare and Reporting and
recordkeeping requirements.
42 CFR Part 485
Grant programs--health, Health facilities, Medicaid, Medicare,
Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, 42 CFR chapter IV is
amended as follows:
PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS
A. Part 410 is amended as set forth below:
1. The authority citation for part 410 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. In Sec. 410.22, paragraph (b)(1) is revised to read as follows:
Sec. 410.22. Limitations on services of a chiropractor.
* * * * *
(b) Limitations on services. (1) Medicare Part B pays only for a
chiropractor's manual manipulation of the spine to correct a
subluxation if the subluxation has resulted in a neuromusculoskeletal
condition for which manual manipulation is appropriate treatment.
* * * * *
3. Section 410.23 is revised to read as follows:
Sec. 410.23 Limitations on services of an optometrist.
Medicare Part B pays for the services of a doctor of optometry,
which he or she is legally authorized to perform in the State in which
he or she performs them, if the services are among those described in
section 1861(s) of the Act and Sec. 410.10 of this part.
[[Page 59440]]
4. In Sec. 410.32, the introductory text to paragraph (b)(2) is
republished for the convenience of the reader, paragraph (b)(2) is
amended by adding new paragraphs (b)(2)(v) and (b)(2)(vi), and the
introductory text to paragraph (b)(3) is revised to read as follows:
Sec. 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and
other diagnostic tests: Conditions.
* * * * *
(b) Diagnostic x-ray and other diagnostic tests. * * *
(2) Exceptions. The following diagnostic tests payable under the
physician fee schedule are excluded from the basic rule set forth in
paragraph (b)(1) of this section:
* * * * *
(v) Diagnostic tests performed by a nurse practitioner or clinical
nurse specialist authorized to perform the tests under applicable State
laws.
(vi) Pathology and laboratory procedures listed in the 80000 series
of the Current Procedural Terminology published by the American Medical
Association.
(3) Levels of supervision. Except where otherwise indicated, all
diagnostic x-ray and other diagnostic tests subject to this provision
and payable under the physician fee schedule must be furnished under at
least a general level of physician supervision as defined in paragraph
(b)(3)(i) of this section. In addition, some of these tests also
require either direct or personal supervision as defined in paragraphs
(b)(3)(ii) or (b)(3)(iii) of this section, respectively. (However,
diagnostic tests performed by a physician assistant (PA) that the PA is
legally authorized to perform under State law require only a general
level of physician supervision.) When direct or personal supervision is
required, physician supervision at the specified level is required
throughout the performance of the test.
* * * * *
5. In Sec. 410.33, paragraph (a)(1) is revised to read as follows:
Sec. 410.33 Independent diagnostic testing facility.
(a) General rule. (1) Effective for diagnostic procedures performed
on or after March 15, 1999, carriers will pay for diagnostic procedures
under the physician fee schedule only when performed by a physician, a
group practice of physicians, an approved supplier of portable x-ray
services, a nurse practitioner, or a clinical nurse specialist when he
or she performs a test he or she is authorized by the State to perform,
or an independent diagnostic testing facility (IDTF). An IDTF may be a
fixed location, a mobile entity, or an individual nonphysician
practitioner. It is independent of a physician's office or hospital;
however, these rules apply when an IDTF furnishes diagnostic procedures
in a physician's office.
* * * * *
6. A new section 410.39 is added to read as follows:
Sec. 410.39 Prostate cancer screening tests: Conditions for and
limitations on coverage.
(a) Definitions. As used in this section, the following definitions
apply:
(1) Prostate cancer screening tests means any of the following
procedures furnished to an individual for the purpose of early
detection of prostate cancer:
(i) A screening digital rectal examination.
(ii) A screening prostate-specific antigen blood test.
(iii) For years beginning after 2002, other procedures HCFA finds
appropriate for the purpose of early detection of prostate cancer,
taking into account changes in technology and standards of medical
practice, availability, effectiveness, costs, and other factors HCFA
considers appropriate.
(2) A screening digital rectal examination means a clinical
examination of an individual's prostate for nodules or other
abnormalities of the prostate.
(3) A screening prostate-specific antigen blood test means a test
that measures the level of prostate-specific antigen in an individual's
blood.
(b) Condition for coverage of screening digital rectal
examinations. Medicare Part B pays for a screening digital rectal
examination if it is performed by the beneficiary's physician, or by
the beneficiary's physician assistant, nurse practitioner, clinical
nurse specialist, or certified nurse midwife who is authorized to
perform this service under State law.
(c) Limitation on coverage of screening digital rectal
examinations. (1) Payment may not be made for a screening digital
rectal examination performed for a man age 50 or younger.
(2) For an individual over 50 years of age, payment may be made for
a screening digital rectal examination only if the man has not had such
an examination paid for by Medicare during the preceding 11 months
following the month in which his last Medicare-covered screening
digital rectal examination was performed.
(d) Condition for coverage of screening prostate-specific antigen
blood tests. Medicare Part B pays for a screening prostate-specific
antigen blood test if it is ordered by the beneficiary's physician, or
by the beneficiary's physician assistant, nurse practitioner, clinical
nurse specialist, or certified nurse midwife who is authorized to order
this test under State law.
(e) Limitation on coverage of screening prostate-specific antigen
blood test. (1) Payment may not be made for a screening prostate-
specific antigen blood test performed for a man age 50 or younger.
(2) For an individual over 50 years of age, payment may be made for
a screening prostate-specific antigen blood test only if the man has
not had such an examination paid for by Medicare during the preceding
11 months following the month in which his last Medicare-covered
screening prostate-specific antigen blood test was performed.
7. In Sec. 410.75, paragraph (b) is revised to read as follows:
Sec. 410.75 Nurse practitioner's services.
* * * * *
(b) Qualifications. For Medicare Part B coverage of his or her
services, a nurse practitioner must--(1)(i) Be a registered
professional nurse who is authorized by the State in which the services
are furnished to practice as a nurse practitioner in accordance with
State law; and
(ii) Be certified as a nurse practitioner by a recognized national
certifying body that has established standards for nurse practitioners;
or
(2) Be a registered professional nurse who is authorized by the
State in which the services are furnished to practice as a nurse
practitioner in accordance with State law and have been granted a
Medicare billing number as a nurse practitioner by December 31, 2000;
or
(3) Be a nurse practitioner who on or after January 1, 2001,
applies for a Medicare billing number for the first time and meets the
standards for nurse practitioners in paragraphs (b)(1)(i) and
(b)(1)(ii) of this section; or
(4) Be a nurse practitioner who on or after January 1, 2003,
applies for a Medicare billing number for the first time and possesses
a master's degree in nursing and meets the standards for nurse
practitioners in paragraphs (b)(1)(i) and (b)(1)(ii) of this section.
* * * * *
PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE
PAYMENT
B. Part 411 is amended as set forth below:
[[Page 59441]]
1. The authority citation for Part 411 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. In Sec. 411.15, the introductory text in the section is revised,
the introductory text to paragraph (a) is republished, paragraph (a)(1)
is revised, the introductory text to paragraph (k) is republished, and
new paragraphs (k)(9) and (q) are added to read as follows:
Sec. 411.15 Particular services excluded from coverage.
The following services are excluded from coverage:
(a) Routine physical checkups such as:
(1) Examinations performed for a purpose other than treatment or
diagnosis of a specific illness, symptoms, complaint, or injury, except
for screening mammography, colorectal cancer screening tests, screening
pelvic examinations, or prostate cancer screening tests that meet the
criteria specified in paragraphs (k)(6) through (k)(9) of this section.
* * * * *
(k) Any services that are not reasonable and necessary for one of
the following purposes:
* * * * *
(9) In the case of prostate cancer screening tests, for the purpose
of early detection of prostate cancer, subject to the conditions and
limitations specified in Sec. 410.39 of this chapter.
* * * * *
(q) Assisted suicide. Any health care service used for the purpose
of causing, or assisting to cause, the death of any individual. This
does not pertain to the withholding or withdrawing of medical treatment
or care, nutrition or hydration or to the provision of a service for
the purpose of alleviating pain or discomfort, even if the use may
increase the risk of death, so long as the service is not furnished for
the specific purpose of causing death.
PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES
C. Part 414 is amended as set forth below:
1. The authority citation for part 414 continues to read as
follows:
Authority: Secs. 1102, 1871, and 1881(b)(1) of the Social
Security Act (42 U.S.C. 1302, 1395(hh), and 1395rr(b)(1)).
2. In Sec. 414.22, the introductory text is republished, paragraph
(b)(5)(i) is revised, and a new paragraph (c)(3) is added to read as
follows:
Sec. 414.22 Relative value units (RVUs).
HCFA establishes RVUs for physicians' work, practice expense, and
malpractice insurance.
* * * * *
(b) Practice expense RVUs. * * *
(5) * * *
(i) Usually one of two levels of practice expense RVUs can be
applied to each code. The lower facility practice expense RVUs apply to
services furnished to patients in the hospital, skilled nursing
facility, or ambulatory surgical center when the physician performs
procedures on the ASC approved procedures list. The higher non-facility
practice expense RVUs apply to services performed in a physician's
office or in an ASC if the physician is performing a procedure not on
the ASC approved procedures list, services furnished to patients in a
nursing facility, in a facility or institution other than a hospital,
skilled nursing facility, or in the home. The facility practice expense
RVUs for a particular code may not be greater than the non-facility
RVUs for that code.
* * * * *
(c) Malpractice insurance RVUs. * * *
(3) For services furnished in the year 2000 and subsequent years,
the malpractice RVUs are based on the relative malpractice insurance
resources.
3. In Sec. 414.46, the introductory texts to paragraphs (a) and (b)
are republished, paragraphs (a)(1) and (a)(2) are revised, paragraph
(a)(3) is added, and paragraphs (b)(1) and (b)(2) are revised to read
as follows:
Sec. 414.46 Additional rules for payment of anesthesia services.
(a) Definitions. For purposes of this section, the following
definitions apply:
(1) Base unit means the value for each anesthesia code that
reflects all activities other than anesthesia time. These activities
include usual preoperative and postoperative visits, the administration
of fluids and blood incident to anesthesia care, and monitoring
services.
(2) Anesthesia practitioner, for the purpose of anesthesia time,
means a physician who performs the anesthesia service alone, a CRNA who
is not medically directed who performs the anesthesia service alone, or
a medically directed CRNA.
(3) Anesthesia time means the time during which an anesthesia
practitioner is present with the patient. It starts when the anesthesia
practitioner begins to prepare the patient for anesthesia services and
ends when the anesthesia practitioner is no longer furnishing
anesthesia services to the beneficiary, that is, when the beneficiary
may be placed safely under postoperative care. Anesthesia time is a
continuous time period from the start of anesthesia to the end of an
anesthesia service. In counting anesthesia time, the anesthesia
practitioner can add blocks of anesthesia time around an interruption
in anesthesia time as long as the anesthesia practitioner is furnishing
continuous anesthesia care within the time periods around the
interruption.
(b) Determinations of payment amount--Basic rule. For anesthesia
services performed, medically directed, or medically supervised by a
physician, the carrier pays the lesser of the actual charge or the
anesthesia fee schedule amount.
(1) The carrier bases the fee schedule amount for an anesthesia
service on the product of the sum of allowable base and time units and
an anesthesia-specific CF. The carrier calculates the time units from
the anesthesia time reported by the anesthesia practitioner for the
anesthesia procedure. The physician who fulfills the conditions for
medical direction in Sec. 415.110 (Conditions for payment:
Anesthesiology services) reports the same anesthesia time as the
medically-directed CRNA.
(2) HCFA furnishes the carrier with the base units for each
anesthesia procedure code. The base units are derived from the 1988
American Society of Anesthesiologists' Relative Value Guide except that
the number of base units recognized for anesthesia services furnished
during cataract or iridectomy surgery is four units.
* * * * *
4. In Sec. 414.60, the introductory text of paragraph (a) is
revised to read as follows:
Sec. 414.60 Payment for the services of CRNAs.
(a) Basis for payment. The allowance for the anesthesia service
furnished by a CRNA, medically directed or not medically directed, is
based on allowable base and time units as defined in Sec. 414.46(a).
Beginning with CY 1994--
* * * * *
PART 415--SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS,
SUPERVISING PHYSICIANS IN TEACHING SETTINGS, AND RESIDENTS IN
CERTAIN SETTINGS
D. Part 415 is amended as set forth below:
[[Page 59442]]
1. The authority citation for part 415 continues to read as
follows:
Authority: Secs. 1102 and 1871 of the Social Security Act (42
U.S.C. 1302 and 1395hh).
2. Section 415.130(c) is revised to read as follows:
Sec. 415.130 Conditions for payment; Physician pathology services.
* * * * *
(c) Physician pathology services furnished by an independent
laboratory. The technical component of physician pathology services
furnished by an independent laboratory to a hospital inpatient before
January 1, 2001, or to an outpatient are paid on a fee schedule basis
under this subpart. On or after January 1, 2001, payment is made only
to the hospital for the technical component of physician pathology
services furnished to a hospital inpatient.
PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS
E. Part 485 is amended as set forth below:
1. The authority citation for part 485 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. 485.705, paragraph(c)(8) is revised to read as follows:
Sec. 485.705 Personnel qualifications.
* * * * *
(8) A nurse practitioner is a person who must:
(i) Be a registered professional nurse who is authorized by the
State in which the services are furnished to practice as a nurse
practitioner in accordance with State law; and
(ii) Be certified as a nurse practitioner by a recognized national
certifying body that has established standards for nurse practitioners;
or
(iii) Be a registered professional nurse who is authorized by the
State in which the services are furnished to practice as a nurse
practitioner in accordance with State law and have been granted a
Medicare billing number as a nurse practitioner by December 31, 2000;
or
(iv) Be a nurse practitioner who on or after January 1, 2001,
applies for a Medicare billing number for the first time and meets the
standards for nurse practitioners in paragraphs (c)(8)(i) and
(c)(8)(ii) of this section; or
(v) Be a nurse practitioner who on or after January 1, 2003,
applies for a Medicare billing number for the first time and possesses
a master's degree in nursing and meets the standards for nurse
practitioners in paragraphs (b)(1)(i) and (b)(1)(ii) of this section.
(Catalog of Federal Domestic Assistance Program No. 93.778, Medical
Assistance Program)
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)
Dated: October 21, 1999.
Michael M. Hash,
Deputy Administrator, Health Care Financing Administration.
Dated: October 22, 1999.
Donna E. Shalala,
Secretary.
Note: These addenda will not appear in the Code of Federal
Regulations.
Addendum A--Explanation and Use of Addendum B
The addenda on the following pages provide various data pertaining
to the Medicare fee schedule for physicians' services furnished in
2000. Addendum B contains the RVUs for work, non-facility practice
expense, facility practice expense, and malpractice expense, and other
information for all services included in the physician fee schedule.
Addendum B--2000 Relative Value Units and Related Information Used
in Determining Medicare Payments for 2000
This addendum contains the following information for each CPT code
and alphanumeric HCPCS code, except for alphanumeric codes beginning
with B (enteral and parenteral therapy), E (durable medical equipment),
K (temporary codes for nonphysicians' services or items), or L
(orthotics), and codes for anesthesiology.
1. CPT/HCPCS code. This is the CPT or alphanumeric HCPCS number for
the service. Alphanumeric HCPCS codes are included at the end of this
addendum.
2. Modifier. A modifier is shown if there is a technical component
(modifier TC) and a professional component (PC) (modifier -26) for the
service. If there is a PC and a TC for the service, Addendum B contains
three entries for the code: One for the global values (both
professional and technical); one for modifier -26 (PC); and one for
modifier TC. The global service is not designated by a modifier, and
physicians must bill using the code without a modifier if the physician
furnishes both the PC and the TC of the service.
Modifier -53 is shown for a discontinued procedure. There will be
RVUs for the code (CPT code 45378) with this modifier.
3. Status indicator. This indicator shows whether the CPT/HCPCS
code is in the physician fee schedule and whether it is separately
payable if the service is covered.
A = Active code. These codes are separately payable under the fee
schedule if covered. There will be RVUs for codes with this status. The
presence of an ``A'' indicator does not mean that Medicare has made a
national decision regarding the coverage of the service. Carriers
remain responsible for coverage decisions in the absence of a national
Medicare policy.
B = Bundled code. Payment for covered services is always bundled
into payment for other services not specified. If RVUs are shown, they
are not used for Medicare payment. If these services are covered,
payment for them is subsumed by the payment for the services to which
they are incident. (An example is a telephone call from a hospital
nurse regarding care of a patient.)
C = Carrier-priced code. Carriers will establish RVUs and payment
amounts for these services, generally on a case-by-case basis following
review of documentation, such as an operative report.
D = Deleted code. These codes are deleted effective with the
beginning of the calendar year.
E = Excluded from physician fee schedule by regulation. These codes
are for items or services that we chose to exclude from the physician
fee schedule payment by regulation. No RVUs are shown, and no payment
may be made under the physician fee schedule for these codes. Payment
for them, if they are covered, continues under reasonable charge or
other payment procedures.
G = Code not valid for Medicare purposes. Medicare does not
recognize codes assigned this status. Medicare uses another code for
reporting of, and payment for, these services.
N = Noncovered service. These codes are noncovered services.
Medicare payment may not be made for these codes. If RVUs are shown,
they are not used for Medicare payment.
P = Bundled or excluded code. There are no RVUs for these services.
No separate payment should be made for them under the physician fee
schedule.
--If the item or service is covered as incident to a physician's
service and is furnished on the same day as a physician's service,
payment for it is bundled into the payment for the physician's service
to which it is incident (an example is an elastic bandage furnished by
a physician incident to a physician's service).
[[Page 59443]]
--If the item or service is covered as other than incident to a
physician's service, it is excluded from the physician fee schedule
(for example, colostomy supplies) and is paid under the other payment
provisions of the Act.
R = Restricted coverage. Special coverage instructions apply. If
the service is covered and no RVUs are shown, it is carrier-priced.
T = Injections. There are RVUs for these services, but they are
only paid if there are no other services payable under the physician
fee schedule billed on the same date by the same provider. If any other
services payable under the physician fee schedule are billed on the
same date by the same provider, these services are bundled into the
service(s) for which payment is made.
X = Exclusion by law. These codes represent an item or service that
is not within the definition of ``physicians' services'' for physician
fee schedule payment purposes. No RVUs are shown for these codes, and
no payment may be made under the physician fee schedule. (Examples are
ambulance services and clinical diagnostic laboratory services.)
4. Description of code. This is an abbreviated version of the
narrative description of the code.
5. Physician work RVUs. These are the RVUs for the physician work
for this service in 2000. Codes that are not used for Medicare payment
are identified with a ``+.''
6. Fully implemented non-facility practice expense RVUs. These are
the fully implemented resource-based practice expense RVUs for non-
facility settings.
7. Year 2000 Transition non-facility practice expense RVUs. Blended
non-facility practice expense RVUs for use in 2000.
8. Fully implemented facility practice expense RVUs. These are the
fully implemented resource-based practice expense RVUs for facility
settings.
9. Year 2000 transition facility practice expense RVUs. Blended
facility practice expense RVUs for use in 2000.
10. Malpractice expense RVUs. These are the RVUs for the
malpractice expense for the service for 2000.
11. Fully implemented non-facility total. This is the sum of the
work, fully implemented non-facility practice expense, and malpractice
expense RVUs.
12. Year 2000 transition non-facility total. This is the sum of the
work, transition non-facility practice expense, and malpractice expense
RVUs for use in 2000.
13. Fully implemented facility total. This is the sum of the work,
fully implemented facility practice expense, and malpractice expense
RVUs.
14. Year 2000 transition facility total. This is the sum of the
work, transition facility practice expense, and malpractice expense
RVUs for use in 2000.
15. Global period. This indicator shows the number of days in the
global period for the code (0, 10, or 90 days). An explanation of the
alpha codes follows:
MMM = The code describes a service furnished in uncomplicated
maternity cases including antepartum care, delivery, and postpartum
care. The usual global surgical concept does not apply. See the 1999
Physicians' Current Procedural Terminology for specific definitions.
XXX = The global concept does not apply.
YYY = The global period is to be set by the carrier (for example,
unlisted surgery codes).
ZZZ = The code is part of another service and falls within the
global period for the other service.
\4\ PE RVUs = Practice Expense Relative Value
Units.
[[Page 59443]]
Addendum B.--Relative Value Units (RVUs) and Related Information Used in Determining Medicare Payments for 2000
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Year Year
Fully 2000 Year Fully 2000 Year
Physician Implemented Transi- Fully 2000 Mal- Implemented Transi- Fully 2000
CPT \1\/ HCPCS MOD Status Description Work RVUs Non- tional Implemented Transi- Practice Non- tional Implemented Transi- Global
\2\ \3\ Facility PE Non- Facility PE tional RVUs Facility Non- Facility tional
RVUs Facility RVUs Facility Total Facility Total Facility
PE RVUs PE RVUs Total Total
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
10040.......... ............. A Acne surgery of skin 1.18 1.57 0.96 0.52 0.35 0.05 2.80 2.19 1.75 1.58 010
abscess.
10060.......... ............. A Drainage of skin 1.17 1.26 0.87 0.62 0.43 0.08 2.51 2.12 1.87 1.68 010
abscess.
10061.......... ............. A Drainage of skin 2.40 1.95 1.32 1.12 0.74 0.15 4.50 3.87 3.67 3.29 010
abscess.
10080.......... ............. A Drainage of pilonidal 1.17 1.95 1.25 0.68 0.48 0.09 3.21 2.51 1.94 1.74 010
cyst.
10081.......... ............. A Drainage of pilonidal 2.45 2.71 1.96 1.57 1.09 0.20 5.36 4.61 4.22 3.74 010
cyst.
10120.......... ............. A Remove foreign body... 1.22 1.72 1.11 0.69 0.47 0.10 3.04 2.43 2.01 1.79 010
10121.......... ............. A Remove foreign body... 2.69 2.64 1.87 1.74 1.15 0.24 5.57 4.80 4.67 4.08 010
10140.......... ............. A Drainage of hematoma/ 1.53 1.32 0.92 0.82 0.54 0.11 2.96 2.56 2.46 2.18 010
fluid.
10160.......... ............. A Puncture drainage of 1.20 1.46 0.94 0.72 0.47 0.09 2.75 2.23 2.01 1.76 010
lesion.
10180.......... ............. A Complex drainage, 2.25 1.33 1.24 1.24 1.19 0.23 3.81 3.72 3.72 3.67 010
wound.
11000.......... ............. A Debride infected skin. 0.60 0.52 0.48 0.23 0.23 0.04 1.16 1.12 0.87 0.87 000
11001.......... ............. A Debride infected skin 0.30 0.29 0.29 0.12 0.13 0.02 0.61 0.61 0.44 0.45 ZZZ
add-on.
11010.......... ............. A Debride skin, fx...... 4.20 2.42 3.36 2.08 3.19 0.36 6.98 7.92 6.64 7.75 010
11011.......... ............. A Debride skin/muscle, 4.95 3.66 4.39 2.58 3.85 0.48 9.09 9.82 8.01 9.28 000
fx.
11012.......... ............. A Debride skin/muscle/ 6.88 4.83 5.98 4.06 5.59 0.71 12.42 13.57 11.65 13.18 000
bone, fx.
11040.......... ............. A Debride skin, partial. 0.50 0.45 0.44 0.19 0.21 0.03 0.98 0.97 0.72 0.74 000
11041.......... ............. A Debride skin, full.... 0.82 0.61 0.61 0.32 0.32 0.06 1.49 1.49 1.20 1.20 000
11042.......... ............. A Debride skin/tissue... 1.12 0.85 0.78 0.44 0.40 0.09 2.06 1.99 1.65 1.61 000
11043.......... ............. A Debride tissue/muscle. 2.38 2.40 2.18 1.37 1.67 0.22 5.00 4.78 3.97 4.27 010
11044.......... ............. A Debride tissue/muscle/ 3.06 3.10 3.08 1.79 2.43 0.30 6.46 6.44 5.15 5.79 010
bone.
11055.......... ............. R Trim skin lesion...... 0.27 0.34 0.31 0.11 0.13 0.02 0.63 0.60 0.40 0.42 000
11056.......... ............. R Trim skin lesions, 2 0.39 0.38 0.38 0.15 0.17 0.03 0.80 0.80 0.57 0.59 000
to 4.
11057.......... ............. R Trim skin lesions, 0.50 0.42 0.36 0.20 0.18 0.03 0.95 0.89 0.73 0.71 000
over 4.
11100.......... ............. A Biopsy of skin lesion. 0.81 1.53 1.04 0.37 0.33 0.04 2.38 1.89 1.22 1.18 000
11101.......... ............. A Biopsy, skin add-on... 0.41 0.68 0.50 0.19 0.18 0.02 1.11 0.93 0.62 0.61 ZZZ
11200.......... ............. A Removal of skin tags.. 0.77 1.05 0.76 0.31 0.28 0.04 1.86 1.57 1.12 1.09 010
11201.......... ............. A Remove skin tags add- 0.29 0.42 0.30 0.12 0.11 0.02 0.73 0.61 0.43 0.42 ZZZ
on.
11300.......... ............. A Shave skin lesion..... 0.51 1.00 0.79 0.22 0.26 0.03 1.54 1.33 0.76 0.80 000
11301.......... ............. A Shave skin lesion..... 0.85 1.10 0.92 0.40 0.39 0.04 1.99 1.81 1.29 1.28 000
11302.......... ............. A Shave skin lesion..... 1.05 1.20 1.09 0.48 0.49 0.05 2.30 2.19 1.58 1.59 000
11303.......... ............. A Shave skin lesion..... 1.24 1.31 1.40 0.56 0.65 0.06 2.61 2.70 1.86 1.95 000
11305.......... ............. A Shave skin lesion..... 0.67 0.79 0.68 0.28 0.28 0.04 1.50 1.39 0.99 0.99 000
11306.......... ............. A Shave skin lesion..... 0.99 1.05 0.91 0.43 0.41 0.05 2.09 1.95 1.47 1.45 000
[[Page 59444]]
11307.......... ............. A Shave skin lesion..... 1.14 1.15 1.09 0.51 0.51 0.05 2.34 2.28 1.70 1.70 000
11308.......... ............. A Shave skin lesion..... 1.41 1.22 1.37 0.61 0.69 0.07 2.70 2.85 2.09 2.17 000
11310.......... ............. A Shave skin lesion..... 0.73 1.10 0.93 0.34 0.36 0.04 1.87 1.70 1.11 1.13 000
11311.......... ............. A Shave skin lesion..... 1.05 1.21 1.07 0.51 0.49 0.05 2.31 2.17 1.61 1.59 000
11312.......... ............. A Shave skin lesion..... 1.20 1.28 1.25 0.58 0.60 0.05 2.53 2.50 1.83 1.85 000
11313.......... ............. A Shave skin lesion..... 1.62 1.52 1.57 0.76 0.79 0.08 3.22 3.27 2.46 2.49 000
11400.......... ............. A Removal of skin lesion 0.91 2.37 1.48 0.71 0.50 0.07 3.35 2.46 1.69 1.48 010
11401.......... ............. A Removal of skin lesion 1.32 2.39 1.56 0.86 0.62 0.10 3.81 2.98 2.28 2.04 010
11402.......... ............. A Removal of skin lesion 1.61 2.48 1.73 0.95 0.72 0.11 4.20 3.45 2.67 2.44 010
11403.......... ............. A Removal of skin lesion 1.92 2.69 1.98 1.08 0.86 0.15 4.76 4.05 3.15 2.93 010
11404.......... ............. A Removal of skin lesion 2.20 2.83 2.17 1.17 0.96 0.18 5.21 4.55 3.55 3.34 010
11406.......... ............. A Removal of skin lesion 2.76 3.13 2.59 1.40 1.72 0.25 6.14 5.60 4.41 4.73 010
11420.......... ............. A Removal of skin lesion 1.06 1.96 1.26 0.75 0.52 0.08 3.10 2.40 1.89 1.66 010
11421.......... ............. A Removal of skin lesion 1.53 2.28 1.53 0.96 0.68 0.11 3.92 3.17 2.60 2.32 010
11422.......... ............. A Removal of skin lesion 1.76 2.46 1.74 1.03 0.77 0.12 4.34 3.62 2.91 2.65 010
11423.......... ............. A Removal of skin lesion 2.17 2.75 2.09 1.22 0.97 0.17 5.09 4.43 3.56 3.31 010
11424.......... ............. A Removal of skin lesion 2.62 2.90 2.21 1.39 1.08 0.20 5.72 5.03 4.21 3.90 010
11426.......... ............. A Removal of skin lesion 3.78 3.56 2.78 1.86 1.93 0.32 7.66 6.88 5.96 6.03 010
11440.......... ............. A Removal of skin lesion 1.15 2.50 1.63 0.91 0.65 0.08 3.73 2.86 2.14 1.88 010
11441.......... ............. A Removal of skin lesion 1.61 2.62 1.77 1.12 0.79 0.11 4.34 3.49 2.84 2.51 010
11442.......... ............. A Removal of skin lesion 1.87 2.68 1.95 1.22 0.92 0.13 4.68 3.95 3.22 2.92 010
11443.......... ............. A Removal of skin lesion 2.49 3.14 2.36 1.53 1.16 0.18 5.81 5.03 4.20 3.83 010
11444.......... ............. A Removal of skin lesion 3.42 3.59 2.60 1.94 1.37 0.25 7.26 6.27 5.61 5.04 010
11446.......... ............. A Removal of skin lesion 4.49 4.07 3.00 2.47 1.72 0.32 8.88 7.81 7.28 6.53 010
11450.......... ............. A Removal, sweat gland 2.73 3.94 3.43 1.08 2.00 0.24 6.91 6.40 4.05 4.97 090
lesion.
11451.......... ............. A Removal, sweat gland 3.95 4.85 4.00 1.56 2.36 0.37 9.17 8.32 5.88 6.68 090
lesion.
11462.......... ............. A Removal, sweat gland 2.51 3.89 3.26 1.01 1.82 0.23 6.63 6.00 3.75 4.56 090
lesion.
11463.......... ............. A Removal, sweat gland 3.95 5.20 3.69 1.63 1.90 0.39 9.54 8.03 5.97 6.24 090
lesion.
11470.......... ............. A Removal, sweat gland 3.25 4.41 3.72 1.30 2.16 0.31 7.97 7.28 4.86 5.72 090
lesion.
11471.......... ............. A Removal, sweat gland 4.41 5.44 4.06 1.81 2.24 0.42 10.27 8.89 6.64 7.07 090
lesion.
11600.......... ............. A Removal of skin lesion 1.41 2.53 1.88 0.96 0.79 0.09 4.03 3.38 2.46 2.29 010
11601.......... ............. A Removal of skin lesion 1.93 2.61 2.06 1.08 0.92 0.11 4.65 4.10 3.12 2.96 010
11602.......... ............. A Removal of skin lesion 2.09 2.66 2.32 1.27 1.13 0.12 4.87 4.53 3.48 3.34 010
11603.......... ............. A Removal of skin lesion 2.35 2.82 2.63 1.35 1.29 0.15 5.32 5.13 3.85 3.79 010
11604.......... ............. A Removal of skin lesion 2.58 2.99 2.90 1.43 1.42 0.18 5.75 5.66 4.19 4.18 010
11606.......... ............. A Removal of skin lesion 3.43 3.51 3.45 1.74 2.56 0.28 7.22 7.16 5.45 6.27 010
11620.......... ............. A Removal of skin lesion 1.34 2.49 1.97 0.98 0.86 0.09 3.92 3.40 2.41 2.29 010
11621.......... ............. A Removal of skin lesion 1.97 2.63 2.27 1.22 1.09 0.11 4.71 4.35 3.30 3.17 010
11622.......... ............. A Removal of skin lesion 2.34 2.79 2.59 1.43 1.32 0.14 5.27 5.07 3.91 3.80 010
11623.......... ............. A Removal of skin lesion 2.93 2.71 2.76 1.67 1.54 0.20 5.84 5.89 4.80 4.67 010
11624.......... ............. A Removal of skin lesion 3.43 3.01 3.25 1.90 1.82 0.25 6.69 6.93 5.58 5.50 010
11626.......... ............. A Removal of skin lesion 4.30 3.96 3.83 2.29 3.00 0.34 8.60 8.47 6.93 7.64 010
11640.......... ............. A Removal of skin lesion 1.53 2.56 2.18 1.13 1.02 0.10 4.19 3.81 2.76 2.65 010
11641.......... ............. A Removal of skin lesion 2.44 2.90 2.59 1.58 1.36 0.14 5.48 5.17 4.16 3.94 010
11642.......... ............. A Removal of skin lesion 2.93 2.80 2.80 1.80 1.60 0.18 5.91 5.91 4.91 4.71 010
11643.......... ............. A Removal of skin lesion 3.50 3.12 3.20 2.09 1.87 0.24 6.86 6.94 5.83 5.61 010
11644.......... ............. A Removal of skin lesion 4.55 3.72 3.77 2.60 2.26 0.32 8.59 8.64 7.47 7.13 010
11646.......... ............. A Removal of skin lesion 5.95 4.92 4.81 3.32 4.01 0.46 11.33 11.22 9.73 10.42 010
11719.......... ............. R Trim nail(s).......... 0.11 0.47 0.37 0.04 0.09 0.01 0.59 0.49 0.16 0.21 000
11720.......... ............. A Debride nail, 1-5..... 0.32 0.40 0.38 0.13 0.16 0.02 0.74 0.72 0.47 0.50 000
11721.......... ............. A Debride nail, 6 or 0.54 0.50 0.55 0.21 0.26 0.04 1.08 1.13 0.79 0.84 000
more.
11730.......... ............. A Removal of nail plate. 1.13 0.71 0.60 0.44 0.35 0.07 1.91 1.80 1.64 1.55 000
11732.......... ............. A Remove nail plate, add- 0.57 0.28 0.28 0.23 0.19 0.04 0.89 0.89 0.84 0.80 ZZZ
on.
11740.......... ............. A Drain blood from under 0.37 0.64 0.53 0.14 0.18 0.03 1.04 0.93 0.54 0.58 000
nail.
11750.......... ............. A Removal of nail bed... 1.86 1.48 1.88 0.77 0.96 0.12 3.46 3.86 2.75 2.94 010
11752.......... ............. A Remove nail bed/finger 2.67 1.82 2.44 1.61 1.57 0.20 4.69 5.31 4.48 4.44 010
tip.
11755.......... ............. A Biopsy, nail unit..... 1.31 0.96 1.02 0.57 0.82 0.08 2.35 2.41 1.96 2.21 000
11760.......... ............. A Repair of nail bed.... 1.58 1.50 1.26 1.10 0.81 0.13 3.21 2.97 2.81 2.52 010
11762.......... ............. A Reconstruction of nail 2.89 1.93 2.36 1.70 1.55 0.20 5.02 5.45 4.79 4.64 010
bed.
11765.......... ............. A Excision of nail fold, 0.69 0.93 0.74 0.42 0.35 0.05 1.67 1.48 1.16 1.09 010
toe.
11770.......... ............. A Removal of pilonidal 2.61 2.89 2.90 1.28 2.09 0.24 5.74 5.75 4.13 4.94 010
lesion.
11771.......... ............. A Removal of pilonidal 5.74 5.06 4.99 4.01 4.46 0.55 11.35 11.28 10.30 10.75 090
lesion.
11772.......... ............. A Removal of pilonidal 6.98 6.01 5.62 4.49 4.86 0.70 13.69 13.30 12.17 12.54 090
lesion.
11900.......... ............. A Injection into skin 0.52 0.70 0.49 0.21 0.18 0.02 1.24 1.03 0.75 0.72 000
lesions.
11901.......... ............. A Added skin lesions 0.80 0.83 0.64 0.36 0.29 0.03 1.66 1.47 1.19 1.12 000
injection.
11920.......... ............. R Correct skin color 1.61 1.82 1.55 0.77 1.03 0.17 3.60 3.33 2.55 2.81 000
defects.
11921.......... ............. R Correct skin color 1.93 2.01 1.77 0.98 1.25 0.20 4.14 3.90 3.11 3.38 000
defects.
11922.......... ............. R Correct skin color 0.49 0.34 0.37 0.26 0.33 0.05 0.88 0.91 0.80 0.87 ZZZ
defects.
11950.......... ............. R Therapy for contour 0.84 1.02 1.16 0.36 0.83 0.06 1.92 2.06 1.26 1.73 000
defects.
11951.......... ............. R Therapy for contour 1.19 1.34 1.32 0.53 0.91 0.09 2.62 2.60 1.81 2.19 000
defects.
11952.......... ............. R Therapy for contour 1.69 2.17 1.73 0.79 1.04 0.11 3.97 3.53 2.59 2.84 000
defects.
11954.......... ............. R Therapy for contour 1.85 2.11 1.70 0.71 1.00 0.20 4.16 3.75 2.76 3.05 000
defects.
11960.......... ............. A Insert tissue 9.08 NA NA 9.32 8.86 0.89 NA NA 19.29 18.83 090
expander(s).
11970.......... ............. A Replace tissue 7.06 NA NA 4.67 6.55 0.75 NA NA 12.48 14.36 090
expander.
11971.......... ............. A Remove tissue 2.13 5.53 4.02 3.23 2.87 0.22 7.88 6.37 5.58 5.22 090
expander(s).
11975.......... ............. N Insert contraceptive +1.48 1.48 1.32 0.57 0.86 0.11 3.07 2.91 2.16 2.45 XXX
cap.
11976.......... ............. R Removal of 1.78 1.52 1.46 0.64 1.02 0.13 3.43 3.37 2.55 2.93 XXX
contraceptive cap.
11977.......... ............. N Removal/reinsert +3.30 2.19 2.38 1.28 1.92 0.25 5.74 5.93 4.83 5.47 XXX
contra cap.
11980.......... ............. A Implant hormone 1.48 1.48 1.48 0.57 0.57 0.11 3.07 3.07 2.16 2.16 000
pellet(s).
12001.......... ............. A Repair superficial 1.70 2.27 1.45 0.82 0.72 0.15 4.12 3.30 2.67 2.57 010
wound(s).
12002.......... ............. A Repair superficial 1.86 2.36 1.61 0.85 0.86 0.16 4.38 3.63 2.87 2.88 010
wound(s).
[[Page 59445]]
12004.......... ............. A Repair superficial 2.24 2.54 1.89 0.97 1.11 0.20 4.98 4.33 3.41 3.55 010
wound(s).
12005.......... ............. A Repair superficial 2.86 2.92 2.26 1.21 1.41 0.26 6.04 5.38 4.33 4.53 010
wound(s).
12006.......... ............. A Repair superficial 3.67 4.13 3.03 1.88 1.91 0.34 8.14 7.04 5.89 5.92 010
wound(s).
12007.......... ............. A Repair superficial 4.12 4.45 3.20 2.12 2.04 0.38 8.95 7.70 6.62 6.54 010
wound(s).
12011.......... ............. A Repair superficial 1.76 2.37 1.59 0.82 0.81 0.16 4.29 3.51 2.74 2.73 010
wound(s).
12013.......... ............. A Repair superficial 1.99 2.50 1.81 0.87 1.00 0.18 4.67 3.98 3.04 3.17 010
wound(s).
12014.......... ............. A Repair superficial 2.46 2.79 2.04 1.05 1.17 0.22 5.47 4.72 3.73 3.85 010
wound(s).
12015.......... ............. A Repair superficial 3.19 3.21 2.49 1.24 1.50 0.29 6.69 5.97 4.72 4.98 010
wound(s).
12016.......... ............. A Repair superficial 3.93 3.44 2.95 1.56 2.01 0.36 7.73 7.24 5.85 6.30 010
wound(s).
12017.......... ............. A Repair superficial 4.71 5.20 4.43 2.29 2.97 0.44 10.35 9.58 7.44 8.12 010
wound(s).
12018.......... ............. A Repair superficial 5.53 5.84 5.72 2.63 4.11 0.46 11.83 11.71 8.62 10.10 010
wound(s).
12020.......... ............. A Closure of split wound 2.62 2.61 1.95 1.52 1.41 0.23 5.46 4.80 4.37 4.26 010
12021.......... ............. A Closure of split wound 1.84 2.00 1.34 1.10 0.72 0.15 3.99 3.33 3.09 2.71 010
12031.......... ............. A Layer closure of 2.15 2.68 1.73 1.16 0.78 0.14 4.97 4.02 3.45 3.07 010
wound(s).
12032.......... ............. A Layer closure of 2.47 2.78 1.96 1.24 0.91 0.15 5.40 4.58 3.86 3.53 010
wound(s).
12034.......... ............. A Layer closure of 2.92 2.99 2.30 1.41 1.51 0.24 6.15 5.46 4.57 4.67 010
wound(s).
12035.......... ............. A Layer closure of 3.43 2.99 2.54 1.62 1.85 0.32 6.74 6.29 5.37 5.60 010
wound(s).
12036.......... ............. A Layer closure of 4.05 4.88 3.70 2.34 2.43 0.40 9.33 8.15 6.79 6.88 010
wound(s).
12037.......... ............. A Layer closure of 4.67 5.10 4.23 2.78 3.07 0.44 10.21 9.34 7.89 8.18 010
wound(s).
12041.......... ............. A Layer closure of 2.37 2.97 1.94 1.20 0.83 0.17 5.51 4.48 3.74 3.37 010
wound(s).
12042.......... ............. A Layer closure of 2.74 2.97 2.12 1.36 1.00 0.18 5.89 5.04 4.28 3.92 010
wound(s).
12044.......... ............. A Layer closure of 3.14 3.02 2.39 1.54 1.65 0.26 6.42 5.79 4.94 5.05 010
wound(s).
12045.......... ............. A Layer closure of 3.64 3.34 2.83 1.80 2.06 0.32 7.30 6.79 5.76 6.02 010
wound(s).
12046.......... ............. A Layer closure of 4.25 4.91 3.99 2.41 2.74 0.37 9.53 8.61 7.03 7.36 010
wound(s).
12047.......... ............. A Layer closure of 4.65 5.10 4.73 2.84 3.60 0.44 10.19 9.82 7.93 8.69 010
wound(s).
12051.......... ............. A Layer closure of 2.47 2.90 2.00 1.34 0.95 0.17 5.54 4.64 3.98 3.59 010
wound(s).
12052.......... ............. A Layer closure of 2.77 2.91 2.26 1.31 1.06 0.17 5.85 5.20 4.25 4.00 010
wound(s).
12053.......... ............. A Layer closure of 3.12 3.02 2.47 1.47 1.69 0.23 6.37 5.82 4.82 5.04 010
wound(s).
12054.......... ............. A Layer closure of 3.46 3.34 3.08 1.58 2.20 0.29 7.09 6.83 5.33 5.95 010
wound(s).
12055.......... ............. A Layer closure of 4.43 4.10 3.81 2.11 2.82 0.39 8.92 8.63 6.93 7.64 010
wound(s).
12056.......... ............. A Layer closure of 5.24 5.64 5.39 2.94 4.04 0.43 11.31 11.06 8.61 9.71 010
wound(s).
12057.......... ............. A Layer closure of 5.96 5.54 5.79 3.51 4.78 0.49 11.99 12.24 9.96 11.23 010
wound(s).
13100.......... ............. A Repair of wound or 3.12 3.19 2.22 1.78 1.20 0.22 6.53 5.56 5.12 4.54 010
lesion.
13101.......... ............. A Repair of wound or 3.92 3.52 2.89 2.23 1.68 0.23 7.67 7.04 6.38 5.83 010
lesion.
13102.......... ............. A Repair wound/lesion 1.24 0.71 0.71 0.57 0.57 0.08 2.03 2.03 1.89 1.89 ZZZ
add-on.
13120.......... ............. A Repair of wound or 3.30 3.32 2.40 1.79 1.27 0.25 6.87 5.95 5.34 4.82 010
lesion.
13121.......... ............. A Repair of wound or 4.33 3.75 3.32 2.29 1.87 0.27 8.35 7.92 6.89 6.47 010
lesion.
13122.......... ............. A Repair wound/lesion 1.44 0.83 0.83 0.66 0.66 0.09 2.36 2.36 2.19 2.19 ZZZ
add-on.
13131.......... ............. A Repair of wound or 3.79 3.59 2.87 2.13 1.61 0.26 7.64 6.92 6.18 5.66 010
lesion.
13132.......... ............. A Repair of wound or 5.95 4.48 4.72 3.14 2.81 0.34 10.77 11.01 9.43 9.10 010
lesion.
13133.......... ............. A Repair wound/lesion 2.19 1.18 1.18 1.01 1.01 0.12 3.49 3.49 3.32 3.32 ZZZ
add-on.
13150.......... ............. A Repair of wound or 3.81 4.79 3.35 2.48 2.20 0.29 8.89 7.45 6.58 6.30 010
lesion.
13151.......... ............. A Repair of wound or 4.45 4.88 3.77 2.88 2.11 0.30 9.63 8.52 7.63 6.86 010
lesion.
13152.......... ............. A Repair of wound or 6.33 5.61 5.59 3.80 3.30 0.40 12.34 12.32 10.53 10.03 010
lesion.
13153.......... ............. A Repair wound/lesion 2.38 1.31 1.31 1.09 1.09 0.15 3.84 3.84 3.62 3.62 ZZZ
add-on.
13160.......... ............. A Late closure of wound. 10.48 NA NA 6.22 4.92 1.08 NA NA 17.78 16.48 090
13300.......... ............. D Repair of wound or 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 010
lesion.
14000.......... ............. A Skin tissue 5.89 6.86 5.28 4.35 3.10 0.46 13.21 11.63 10.70 9.45 090
rearrangement.
14001.......... ............. A Skin tissue 8.47 8.15 6.65 5.62 5.39 0.67 17.29 15.79 14.76 14.53 090
rearrangement.
14020.......... ............. A Skin tissue 6.59 7.27 6.30 4.90 5.11 0.51 14.37 13.40 12.00 12.21 090
rearrangement.
14021.......... ............. A Skin tissue 10.06 8.86 7.80 6.65 6.70 0.73 19.65 18.59 17.44 17.49 090
rearrangement.
14040.......... ............. A Skin tissue 7.87 7.72 7.54 5.62 4.65 0.53 16.12 15.94 14.02 13.05 090
rearrangement.
14041.......... ............. A Skin tissue 11.49 9.63 9.09 7.50 5.89 0.69 21.81 21.27 19.68 18.07 090
rearrangement.
14060.......... ............. A Skin tissue 8.50 8.21 8.31 6.41 7.41 0.60 17.31 17.41 15.51 16.51 090
rearrangement.
14061.......... ............. A Skin tissue 12.29 10.57 10.98 8.40 7.05 0.75 23.61 24.02 21.44 20.09 090
rearrangement.
14300.......... ............. A Skin tissue 11.76 9.64 10.96 7.84 10.06 0.92 22.32 23.64 20.52 22.74 090
rearrangement.
14350.......... ............. A Skin tissue 9.61 NA NA 5.76 6.18 0.90 NA NA 16.27 16.69 090
rearrangement.
15000.......... ............. A Skin graft............ 4.00 2.37 2.35 1.93 2.13 0.36 6.73 6.71 6.29 6.49 000
15001.......... ............. A Skin graft add-on..... 1.00 0.49 0.49 0.48 0.48 0.09 1.58 1.58 1.57 1.57 ZZZ
15050.......... ............. A Skin pinch graft...... 4.30 4.68 3.31 3.53 2.74 0.41 9.39 8.02 8.24 7.45 090
15100.......... ............. A Skin split graft...... 9.05 5.97 5.45 5.80 5.37 0.94 15.96 15.44 15.79 15.36 090
15101.......... ............. A Skin split graft add- 1.72 1.10 1.42 0.76 1.25 0.18 3.00 3.32 2.66 3.15 ZZZ
on.
15120.......... ............. A Skin split graft...... 9.83 7.96 7.27 6.56 6.57 0.80 18.59 17.90 17.19 17.20 090
15121.......... ............. A Skin split graft add- 2.67 1.63 2.40 1.30 2.23 0.26 4.56 5.33 4.23 5.16 ZZZ
on.
15200.......... ............. A Skin full graft....... 8.03 8.64 6.56 5.32 4.90 0.72 17.39 15.31 14.07 13.65 090
15201.......... ............. A Skin full graft add-on 1.32 1.02 1.42 0.65 1.11 0.13 2.47 2.87 2.10 2.56 ZZZ
15220.......... ............. A Skin full graft....... 7.87 8.87 7.06 5.70 5.48 0.68 17.42 15.61 14.25 14.03 090
15221.......... ............. A Skin full graft add-on 1.19 0.84 1.29 0.58 1.00 0.11 2.14 2.59 1.88 2.30 ZZZ
15240.......... ............. A Skin full graft....... 9.04 8.45 7.54 6.44 6.53 0.77 18.26 17.35 16.25 16.34 090
15241.......... ............. A Skin full graft add-on 1.86 1.36 1.97 0.95 1.59 0.17 3.39 4.00 2.98 3.62 ZZZ
15260.......... ............. A Skin full graft....... 10.06 8.69 8.40 7.17 7.64 0.65 19.40 19.11 17.88 18.35 090
15261.......... ............. A Skin full graft add-on 2.23 1.50 2.30 1.16 1.91 0.17 3.90 4.70 3.56 4.31 ZZZ
15350.......... ............. A Skin homograft........ 4.00 6.87 4.60 3.93 3.13 0.40 11.27 9.00 8.33 7.53 090
15351.......... ............. A Skin homograft add-on. 1.00 0.42 0.42 0.42 0.42 0.09 1.51 1.51 1.51 1.51 ZZZ
15400.......... ............. A Skin heterograft...... 4.00 4.18 2.67 4.18 2.67 0.34 8.52 7.01 8.52 7.01 090
15401.......... ............. A Skin heterograft add- 1.00 0.42 0.42 0.42 0.42 0.09 1.51 1.51 1.51 1.51 ZZZ
on.
15570.......... ............. A Form skin pedicle flap 9.21 7.93 6.95 5.72 5.85 0.91 18.05 17.07 15.84 15.97 090
15572.......... ............. A Form skin pedicle flap 9.27 7.34 6.59 5.04 5.44 0.87 17.48 16.73 15.18 15.58 090
15574.......... ............. A Form skin pedicle flap 9.88 7.87 6.87 6.32 6.09 0.86 18.61 17.61 17.06 16.83 090
15576.......... ............. A Form skin pedicle flap 8.69 8.17 5.78 6.04 4.72 0.71 17.57 15.18 15.44 14.12 090
15580.......... ............. D Attach skin pedicle 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
graft.
[[Page 59446]]
15600.......... ............. A Skin graft............ 1.91 4.86 3.79 2.05 2.17 0.19 6.96 5.89 4.15 4.27 090
15610.......... ............. A Skin graft............ 2.42 2.56 2.81 2.25 2.57 0.25 5.23 5.48 4.92 5.24 090
15620.......... ............. A Skin graft............ 2.94 5.65 4.69 2.97 3.24 0.27 8.86 7.90 6.18 6.45 090
15625.......... ............. D Skin graft............ 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
15630.......... ............. A Skin graft............ 3.27 5.42 4.67 3.20 3.56 0.29 8.98 8.23 6.76 7.12 090
15650.......... ............. A Transfer skin pedicle 3.97 6.05 5.40 3.38 4.06 0.33 10.35 9.70 7.68 8.36 090
flap.
15732.......... ............. A Muscle-skin graft, 17.84 NA NA 11.16 13.98 1.47 NA NA 30.47 33.29 090
head/neck.
15734.......... ............. A Muscle-skin graft, 17.79 NA NA 10.78 15.71 1.88 NA NA 30.45 35.38 090
trunk.
15736.......... ............. A Muscle-skin graft, arm 16.27 NA NA 10.10 13.85 1.72 NA NA 28.09 31.84 090
15738.......... ............. A Muscle-skin graft, leg 17.92 NA NA 10.68 12.34 1.91 NA NA 30.51 32.17 090
15740.......... ............. A Island pedicle flap 10.25 8.43 9.86 6.70 8.99 0.64 19.32 20.75 17.59 19.88 090
graft.
15750.......... ............. A Neurovascular pedicle 11.41 NA NA 7.95 10.47 1.17 NA NA 20.53 23.05 090
graft.
15756.......... ............. A Free muscle flap, 35.23 NA NA 21.07 26.87 3.62 NA NA 59.92 65.72 090
microvasc.
15757.......... ............. A Free skin flap, 35.23 NA NA 21.60 27.13 3.37 NA NA 60.20 65.73 090
microvasc.
15758.......... ............. A Free fascial flap, 35.10 NA NA 21.42 27.04 3.40 NA NA 59.92 65.54 090
microvasc.
15760.......... ............. A Composite skin graft.. 8.74 8.00 7.96 5.98 6.95 0.72 17.46 17.42 15.44 16.41 090
15770.......... ............. A Derma-fat-fascia graft 7.52 NA NA 5.85 6.98 0.81 NA NA 14.18 15.31 090
15775.......... ............. R Hair transplant punch 3.96 2.96 3.05 1.53 2.33 0.42 7.34 7.43 5.91 6.71 000
grafts.
15776.......... ............. R Hair transplant punch 5.54 4.96 4.67 2.14 3.26 0.59 11.09 10.80 8.27 9.39 000
grafts.
15780.......... ............. A Abrasion treatment of 7.29 6.64 4.15 6.40 3.62 0.54 14.47 11.98 14.23 11.45 090
skin.
15781.......... ............. A Abrasion treatment of 4.85 4.70 4.40 4.32 3.19 0.29 9.84 9.54 9.46 8.33 090
skin.
15782.......... ............. A Abrasion treatment of 4.32 4.03 2.66 3.71 2.18 0.27 8.62 7.25 8.30 6.77 090
skin.
15783.......... ............. A Abrasion treatment of 4.29 4.35 3.18 3.11 2.06 0.26 8.90 7.73 7.66 6.61 090
skin.
15786.......... ............. A Abrasion, lesion, 2.03 1.68 1.18 1.24 0.79 0.11 3.82 3.32 3.38 2.93 010
single.
15787.......... ............. A Abrasion, lesions, add- 0.33 0.27 0.26 0.18 0.16 0.02 0.62 0.61 0.53 0.51 ZZZ
on.
15788.......... ............. R Chemical peel, face, 2.09 2.84 2.23 1.02 1.32 0.10 5.03 4.42 3.21 3.51 090
epiderm.
15789.......... ............. R Chemical peel, face, 4.92 5.54 3.58 3.41 2.51 0.30 10.76 8.80 8.63 7.73 090
dermal.
15792.......... ............. R Chemical peel, 1.86 2.70 1.62 1.64 1.09 0.11 4.67 3.59 3.61 3.06 090
nonfacial.
15793.......... ............. A Chemical peel, 3.74 NA NA 3.38 1.96 0.16 NA NA 7.28 5.86 090
nonfacial.
15810.......... ............. A Salabrasion........... 4.74 3.87 4.00 3.87 4.00 0.38 8.99 9.12 8.99 9.12 090
15811.......... ............. A Salabrasion........... 5.39 4.00 4.03 4.00 4.03 0.57 9.96 9.99 9.96 9.99 090
15819.......... ............. A Plastic surgery, neck. 9.38 NA NA 6.35 7.52 0.83 NA NA 16.56 17.73 090
15820.......... ............. A Revision of lower 5.15 8.21 7.18 5.88 6.02 0.30 13.66 12.63 11.33 11.47 090
eyelid.
15821.......... ............. A Revision of lower 5.72 8.71 7.77 6.29 6.56 0.30 14.73 13.79 12.31 12.58 090
eyelid.
15822.......... ............. A Revision of upper 4.45 7.97 6.65 5.57 5.45 0.23 12.65 11.33 10.25 10.13 090
eyelid.
15823.......... ............. A Revision of upper 7.05 9.49 8.93 6.90 7.64 0.33 16.87 16.31 14.28 15.02 090
eyelid.
15824.......... ............. R Removal of forehead 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
wrinkles.
15825.......... ............. R Removal of neck 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
wrinkles.
15826.......... ............. R Removal of brow 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
wrinkles.
15828.......... ............. R Removal of face 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
wrinkles.
15829.......... ............. R Removal of skin 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
wrinkles.
15831.......... ............. A Excise excessive skin 12.40 NA NA 7.01 8.85 1.24 NA NA 20.65 22.49 090
tissue.
15832.......... ............. A Excise excessive skin 11.59 NA NA 7.52 8.26 1.20 NA NA 20.31 21.05 090
tissue.
15833.......... ............. A Excise excessive skin 10.64 NA NA 7.22 6.99 1.31 NA NA 19.17 18.94 090
tissue.
15834.......... ............. A Excise excessive skin 10.85 NA NA 6.10 6.95 1.23 NA NA 18.18 19.03 090
tissue.
15835.......... ............. A Excise excessive skin 11.67 NA NA 5.64 6.62 1.36 NA NA 18.67 19.65 090
tissue.
15836.......... ............. A Excise excessive skin 9.34 NA NA 5.90 6.10 0.95 NA NA 16.19 16.39 090
tissue.
15837.......... ............. A Excise excessive skin 8.43 6.63 6.56 6.27 6.38 0.82 15.88 15.81 15.52 15.63 090
tissue.
15838.......... ............. A Excise excessive skin 7.13 NA NA 5.56 5.97 0.53 NA NA 13.22 13.63 090
tissue.
15839.......... ............. A Excise excessive skin 9.38 6.20 4.43 5.61 4.13 0.80 16.38 14.61 15.79 14.31 090
tissue.
15840.......... ............. A Graft for face nerve 13.26 NA NA 9.49 12.66 1.06 NA NA 23.81 26.98 090
palsy.
15841.......... ............. A Graft for face nerve 23.26 NA NA 14.65 16.48 2.51 NA NA 40.42 42.25 090
palsy.
15842.......... ............. A Graft for face nerve 37.96 NA NA 22.41 26.94 5.53 NA NA 65.90 70.43 090
palsy.
15845.......... ............. A Skin and muscle 12.57 NA NA 8.84 11.93 0.87 NA NA 22.28 25.37 090
repair, face.
15850.......... ............. B Removal of sutures.... +0.78 1.38 0.89 0.30 0.35 0.05 2.21 1.72 1.13 1.18 XXX
15851.......... ............. A Removal of sutures.... 0.86 1.53 0.93 0.32 0.25 0.06 2.45 1.85 1.24 1.17 000
15852.......... ............. A Dressing change, not 0.86 1.65 1.07 0.33 0.29 0.07 2.58 2.00 1.26 1.22 000
for burn.
15860.......... ............. A Test for blood flow in 1.95 1.11 1.29 0.86 1.17 0.19 3.25 3.43 3.00 3.31 000
graft.
15876.......... ............. R Suction assisted 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
lipectomy.
15877.......... ............. R Suction assisted 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
lipectomy.
15878.......... ............. R Suction assisted 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
lipectomy.
15879.......... ............. R Suction assisted 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
lipectomy.
15920.......... ............. A Removal of tail bone 7.95 NA NA 5.34 4.27 0.75 NA NA 14.04 12.97 090
ulcer.
15922.......... ............. A Removal of tail bone 9.90 NA NA 6.70 6.60 1.03 NA NA 17.63 17.53 090
ulcer.
15931.......... ............. A Remove sacrum pressure 9.24 NA NA 5.46 4.32 0.95 NA NA 15.65 14.51 090
sore.
15933.......... ............. A Remove sacrum pressure 10.85 NA NA 7.62 7.57 1.13 NA NA 19.60 19.55 090
sore.
15934.......... ............. A Remove sacrum pressure 12.69 NA NA 7.92 8.01 1.34 NA NA 21.95 22.04 090
sore.
15935.......... ............. A Remove sacrum pressure 14.57 NA NA 9.44 10.82 1.53 NA NA 25.54 26.92 090
sore.
15936.......... ............. A Remove sacrum pressure 12.38 NA NA 8.39 9.77 1.30 NA NA 22.07 23.45 090
sore.
15937.......... ............. A Remove sacrum pressure 14.21 NA NA 9.56 12.09 1.49 NA NA 25.26 27.79 090
sore.
15940.......... ............. A Remove hip pressure 9.34 NA NA 5.68 4.77 0.96 NA NA 15.98 15.07 090
sore.
15941.......... ............. A Remove hip pressure 11.43 NA NA 8.85 8.25 1.20 NA NA 21.48 20.88 090
sore.
15944.......... ............. A Remove hip pressure 11.46 NA NA 8.01 9.03 1.19 NA NA 20.66 21.68 090
sore.
15945.......... ............. A Remove hip pressure 12.69 NA NA 8.88 10.49 1.33 NA NA 22.90 24.51 090
sore.
15946.......... ............. A Remove hip pressure 21.57 NA NA 13.49 15.76 2.15 NA NA 37.21 39.48 090
sore.
15950.......... ............. A Remove thigh pressure 7.54 NA NA 5.07 4.17 0.77 NA NA 13.38 12.48 090
sore.
15951.......... ............. A Remove thigh pressure 10.72 NA NA 7.65 7.98 1.11 NA NA 19.48 19.81 090
sore.
15952.......... ............. A Remove thigh pressure 11.39 NA NA 6.94 7.34 1.19 NA NA 19.52 19.92 090
sore.
15953.......... ............. A Remove thigh pressure 12.63 NA NA 8.32 9.09 1.31 NA NA 22.26 23.03 090
sore.
15956.......... ............. A Remove thigh pressure 15.52 NA NA 10.04 14.29 1.61 NA NA 27.17 31.42 090
sore.
15958.......... ............. A Remove thigh pressure 15.48 NA NA 10.05 14.27 1.59 NA NA 27.12 31.34 090
sore.
[[Page 59447]]
15999.......... ............. C Removal of pressure 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
sore.
16000.......... ............. A Initial treatment of 0.89 0.94 0.66 0.24 0.22 0.07 1.90 1.62 1.20 1.18 000
burn(s).
16010.......... ............. A Treatment of burn(s).. 0.87 1.04 0.70 0.34 0.26 0.07 1.98 1.64 1.28 1.20 000
16015.......... ............. A Treatment of burn(s).. 2.35 1.64 1.93 0.98 1.60 0.21 4.20 4.49 3.54 4.16 000
16020.......... ............. A Treatment of burn(s).. 0.80 1.01 0.69 0.23 0.21 0.06 1.87 1.55 1.09 1.07 000
16025.......... ............. A Treatment of burn(s).. 1.85 1.59 1.04 0.66 0.46 0.16 3.60 3.05 2.67 2.47 000
16030.......... ............. A Treatment of burn(s).. 2.08 2.54 1.55 0.83 0.70 0.19 4.81 3.82 3.10 2.97 000
16035.......... ............. A Incision of burn scab. 4.82 2.85 2.45 2.09 2.07 0.48 8.15 7.75 7.39 7.37 090
17000.......... ............. A Destroy benign/premal 0.60 1.02 0.74 0.27 0.25 0.03 1.65 1.37 0.90 0.88 010
lesion.
17003.......... ............. A Destroy lesions, 2-14. 0.15 0.25 0.20 0.07 0.07 0.01 0.41 0.36 0.23 0.23 ZZZ
17004.......... ............. A Destroy lesions, 15 or 2.79 2.36 2.40 1.27 1.25 0.11 5.26 5.30 4.17 4.15 010
more.
17106.......... ............. A Destruction of skin 4.59 3.68 2.89 2.67 1.86 0.27 8.54 7.75 7.53 6.72 090
lesions.
17107.......... ............. A Destruction of skin 9.16 6.09 5.06 4.91 3.46 0.51 15.76 14.73 14.58 13.13 090
lesions.
17108.......... ............. A Destruction of skin 13.20 8.09 9.10 7.12 8.62 0.76 22.05 23.06 21.08 22.58 090
lesions.
17110.......... ............. A Destruct lesion, 1-14. 0.65 0.96 0.70 0.26 0.24 0.04 1.65 1.39 0.95 0.93 010
17111.......... ............. A Destruct lesion, 15 or 0.92 1.16 0.91 0.37 0.35 0.05 2.13 1.88 1.34 1.32 010
more.
17250.......... ............. A Chemical cautery, 0.50 0.64 0.51 0.19 0.19 0.04 1.18 1.05 0.73 0.73 000
tissue.
17260.......... ............. A Destruction of skin 0.91 1.24 1.24 0.41 0.52 0.04 2.19 2.19 1.36 1.47 010
lesions.
17261.......... ............. A Destruction of skin 1.17 1.36 1.44 0.54 0.65 0.05 2.58 2.66 1.76 1.87 010
lesions.
17262.......... ............. A Destruction of skin 1.58 1.56 1.77 0.74 0.87 0.06 3.20 3.41 2.38 2.51 010
lesions.
17263.......... ............. A Destruction of skin 1.79 1.66 2.05 0.83 1.03 0.07 3.52 3.91 2.69 2.89 010
lesions.
17264.......... ............. A Destruction of skin 1.94 1.74 2.28 0.89 1.15 0.08 3.76 4.30 2.91 3.17 010
lesions.
17266.......... ............. A Destruction of skin 2.34 1.93 2.66 0.99 1.34 0.11 4.38 5.11 3.44 3.79 010
lesions.
17270.......... ............. A Destruction of skin 1.32 1.44 1.45 0.60 0.67 0.06 2.82 2.83 1.98 2.05 010
lesions.
17271.......... ............. A Destruction of skin 1.49 1.51 1.71 0.71 0.83 0.06 3.06 3.26 2.26 2.38 010
lesions.
17272.......... ............. A Destruction of skin 1.77 1.65 2.02 0.84 1.02 0.07 3.49 3.86 2.68 2.86 010
lesions.
17273.......... ............. A Destruction of skin 2.05 1.79 2.30 0.97 1.19 0.08 3.92 4.43 3.10 3.32 010
lesions.
17274.......... ............. A Destruction of skin 2.59 2.04 2.76 1.24 1.49 0.11 4.74 5.46 3.94 4.19 010
lesions.
17276.......... ............. A Destruction of skin 3.20 2.35 3.03 1.61 1.73 0.15 5.70 6.38 4.96 5.08 010
lesions.
17280.......... ............. A Destruction of skin 1.17 1.36 1.58 0.54 0.72 0.05 2.58 2.80 1.76 1.94 010
lesions.
17281.......... ............. A Destruction of skin 1.72 1.63 1.95 0.82 0.98 0.07 3.42 3.74 2.61 2.77 010
lesions.
17282.......... ............. A Destruction of skin 2.04 1.79 2.29 0.97 1.19 0.08 3.91 4.41 3.09 3.31 010
lesions.
17283.......... ............. A Destruction of skin 2.64 2.08 2.68 1.25 1.45 0.11 4.83 5.43 4.00 4.20 010
lesions.
17284.......... ............. A Destruction of skin 3.21 2.35 3.08 1.52 1.72 0.13 5.69 6.42 4.86 5.06 010
lesions.
17286.......... ............. A Destruction of skin 4.44 2.96 3.83 2.52 2.44 0.21 7.61 8.48 7.17 7.09 010
lesions.
17304.......... ............. A Chemosurgery of skin 7.60 6.62 5.49 3.63 2.91 0.31 14.53 13.40 11.54 10.82 000
lesion.
17305.......... ............. A 2nd stage chemosurgery 2.85 2.87 2.66 1.37 1.30 0.11 5.83 5.62 4.33 4.26 000
17306.......... ............. A 3rd stage chemosurgery 2.85 2.88 2.20 1.38 1.07 0.11 5.84 5.16 4.34 4.03 000
17307.......... ............. A Followup skin lesion 2.85 3.02 2.31 1.39 1.10 0.11 5.98 5.27 4.35 4.06 000
therapy.
17310.......... ............. A Extensive skin 0.95 0.97 0.56 0.47 0.27 0.05 1.97 1.56 1.47 1.27 000
chemosurgery.
17340.......... ............. A Cryotherapy of skin... 0.76 1.35 0.83 0.26 0.21 0.05 2.16 1.64 1.07 1.02 010
17360.......... ............. A Skin peel therapy..... 1.43 1.50 0.90 0.78 0.47 0.06 2.99 2.39 2.27 1.96 010
17380.......... ............. R Hair removal by 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
electrolysis.
17999.......... ............. C Skin tissue procedure. 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
19000.......... ............. A Drainage of breast 0.84 1.14 0.78 0.24 0.23 0.07 2.05 1.69 1.15 1.14 000
lesion.
19001.......... ............. A Drain breast lesion 0.42 0.77 0.52 0.12 0.13 0.03 1.22 0.97 0.57 0.58 ZZZ
add-on.
19020.......... ............. A Incision of breast 3.57 6.27 3.90 3.21 2.37 0.34 10.18 7.81 7.12 6.28 090
lesion.
19030.......... ............. A Injection for breast x- 1.53 9.38 4.96 0.42 0.48 0.06 10.97 6.55 2.01 2.07 000
ray.
19100.......... ............. A Biopsy of breast...... 1.27 3.03 1.86 0.39 0.37 0.09 4.39 3.22 1.75 1.73 000
19101.......... ............. A Biopsy of breast...... 3.18 8.46 5.50 2.52 2.53 0.23 11.87 8.91 5.93 5.94 010
19110.......... ............. A Nipple exploration.... 4.30 7.34 5.01 4.22 3.45 0.42 12.06 9.73 8.94 8.17 090
19112.......... ............. A Excise breast duct 3.67 6.68 4.61 2.89 2.72 0.35 10.70 8.63 6.91 6.74 090
fistula.
19120.......... ............. A Removal of breast 5.56 4.12 3.64 3.47 3.31 0.55 10.23 9.75 9.58 9.42 090
lesion.
19125.......... ............. A Excision, breast 6.06 4.80 3.98 3.66 3.41 0.60 11.46 10.64 10.32 10.07 090
lesion.
19126.......... ............. A Excision, addl breast 2.93 NA NA 1.11 1.34 0.30 NA NA 4.34 4.57 ZZZ
lesion.
19140.......... ............. A Removal of breast 5.14 8.59 6.63 3.55 4.11 0.52 14.25 12.29 9.21 9.77 090
tissue.
19160.......... ............. A Removal of breast 5.99 NA NA 4.40 4.44 0.59 NA NA 10.98 11.02 090
tissue.
19162.......... ............. A Remove breast tissue, 13.53 NA NA 8.00 9.09 1.33 NA NA 22.86 23.95 090
nodes.
19180.......... ............. A Removal of breast..... 8.80 NA NA 5.90 6.00 0.87 NA NA 15.57 15.67 090
19182.......... ............. A Removal of breast..... 7.73 NA NA 4.94 5.77 0.77 NA NA 13.44 14.27 090
19200.......... ............. A Removal of breast..... 15.49 NA NA 9.08 10.09 1.51 NA NA 26.08 27.09 090
19220.......... ............. A Removal of breast..... 15.72 NA NA 8.98 10.31 1.49 NA NA 26.19 27.52 090
19240.......... ............. A Removal of breast..... 16.00 NA NA 8.93 9.59 1.58 NA NA 26.51 27.17 090
19260.......... ............. A Removal of chest wall 15.44 NA NA 10.33 7.91 1.68 NA NA 27.45 25.03 090
lesion.
19271.......... ............. A Revision of chest wall 18.90 NA NA 13.73 14.44 2.13 NA NA 34.76 35.47 090
19272.......... ............. A Extensive chest wall 21.55 NA NA 14.28 13.98 2.52 NA NA 38.35 38.05 090
surgery.
19290.......... ............. A Place needle wire, 1.27 4.39 2.44 0.36 0.42 0.05 5.71 3.76 1.68 1.74 000
breast.
19291.......... ............. A Place needle wire, 0.63 1.50 0.89 0.17 0.22 0.03 2.16 1.55 0.83 0.88 ZZZ
breast.
19316.......... ............. A Suspension of breast.. 10.69 NA NA 6.98 9.87 1.13 NA NA 18.80 21.69 090
19318.......... ............. A Reduction of large 15.62 NA NA 9.72 12.56 1.65 NA NA 26.99 29.83 090
breast.
19324.......... ............. A Enlarge breast........ 5.85 NA NA 3.50 3.54 0.61 NA NA 9.96 10.00 090
19325.......... ............. A Enlarge breast with 8.45 NA NA 4.75 5.56 0.90 NA NA 14.10 14.91 090
implant.
19328.......... ............. A Removal of breast 5.68 NA NA 4.13 4.11 0.60 NA NA 10.41 10.39 090
implant.
19330.......... ............. A Removal of implant 7.59 NA NA 4.88 4.55 0.80 NA NA 13.27 12.94 090
material.
19340.......... ............. A Immediate breast 6.33 NA NA 3.23 5.39 0.67 NA NA 10.23 12.39 ZZZ
prosthesis.
19342.......... ............. A Delayed breast 11.20 NA NA 7.27 9.50 1.19 NA NA 19.66 21.89 090
prosthesis.
19350.......... ............. A Breast reconstruction. 8.92 11.33 9.51 6.22 6.95 0.95 21.20 19.38 16.09 16.82 090
19355.......... ............. A Correct inverted 7.57 12.40 8.88 4.47 4.91 0.75 20.72 17.20 12.79 13.23 090
nipple(s).
19357.......... ............. A Breast reconstruction. 18.16 NA NA 12.50 12.85 1.92 NA NA 32.58 32.93 090
19361.......... ............. A Breast reconstruction. 19.26 NA NA 11.31 16.58 2.04 NA NA 32.61 37.88 090
19364.......... ............. A Breast reconstruction. 41.00 NA NA 23.84 20.97 4.22 NA NA 69.06 66.19 090
[[Page 59448]]
19366.......... ............. A Breast reconstruction. 21.28 NA NA 11.53 14.67 2.15 NA NA 34.96 38.10 090
19367.......... ............. A Breast reconstruction. 25.73 NA NA 14.70 18.28 2.72 NA NA 43.15 46.73 090
19368.......... ............. A Breast reconstruction. 32.42 NA NA 17.49 19.67 3.46 NA NA 53.37 55.55 090
19369.......... ............. A Breast reconstruction. 29.82 NA NA 17.46 19.66 3.17 NA NA 50.45 52.65 090
19370.......... ............. A Surgery of breast 8.05 NA NA 5.55 6.13 0.86 NA NA 14.46 15.04 090
capsule.
19371.......... ............. A Removal of breast 9.35 NA NA 6.53 7.56 0.99 NA NA 16.87 17.90 090
capsule.
19380.......... ............. A Revise breast 9.14 NA NA 6.42 7.61 0.97 NA NA 16.53 17.72 090
reconstruction.
19396.......... ............. A Design custom breast 2.17 4.29 3.00 1.14 1.42 0.23 6.69 5.40 3.54 3.82 000
implant.
19499.......... ............. C Breast surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
20000.......... ............. A Incision of abscess... 2.12 1.93 1.43 1.11 0.79 0.15 4.20 3.70 3.38 3.06 010
20005.......... ............. A Incision of deep 3.42 2.69 2.34 2.10 2.05 0.31 6.42 6.07 5.83 5.78 010
abscess.
20100.......... ............. A Explore wound, neck... 10.08 5.63 5.51 4.82 5.11 0.94 16.65 16.53 15.84 16.13 010
20101.......... ............. A Explore wound, chest.. 3.22 3.14 2.42 1.88 1.79 0.30 6.66 5.94 5.40 5.31 010
20102.......... ............. A Explore wound, abdomen 3.94 3.51 2.80 1.91 2.00 0.39 7.84 7.13 6.24 6.33 010
20103.......... ............. A Explore wound, 5.30 3.95 3.38 2.95 2.88 0.53 9.78 9.21 8.78 8.71 010
extremity.
20150.......... ............. A Excise epiphyseal bar. 13.69 NA NA 8.96 11.21 1.03 NA NA 23.68 25.93 090
20200.......... ............. A Muscle biopsy......... 1.46 1.59 1.41 0.61 0.92 0.17 3.22 3.04 2.24 2.55 000
20205.......... ............. A Deep muscle biopsy.... 2.35 3.76 2.90 0.97 1.51 0.28 6.39 5.53 3.60 4.14 000
20206.......... ............. A Needle biopsy, muscle. 0.99 2.74 1.89 0.30 0.67 0.06 3.79 2.94 1.35 1.72 000
20220.......... ............. A Bone biopsy, trocar/ 1.27 3.56 2.49 1.89 1.66 0.06 4.89 3.82 3.22 2.99 000
needle.
20225.......... ............. A Bone biopsy, trocar/ 1.87 0.64 1.62 0.64 1.44 0.10 2.61 3.59 2.61 3.41 000
needle.
20240.......... ............. A Bone biopsy, 3.23 NA NA 3.66 2.85 0.27 NA NA 7.16 6.35 010
excisional.
20245.......... ............. A Bone biopsy, 3.95 NA NA 4.04 3.97 0.36 NA NA 8.35 8.28 010
excisional.
20250.......... ............. A Open bone biopsy...... 5.03 NA NA 3.82 4.66 0.46 NA NA 9.31 10.15 010
20251.......... ............. A Open bone biopsy...... 5.56 NA NA 4.41 5.38 0.67 NA NA 10.64 11.61 010
20500.......... ............. A Injection of sinus 1.23 4.74 2.57 3.06 1.63 0.09 6.06 3.89 4.38 2.95 010
tract.
20501.......... ............. A Inject sinus tract for 0.76 11.77 6.05 0.21 0.27 0.03 12.56 6.84 1.00 1.06 000
x-ray.
20520.......... ............. A Removal of foreign 1.85 4.50 2.64 2.87 1.63 0.15 6.50 4.64 4.87 3.63 010
body.
20525.......... ............. A Removal of foreign 3.50 5.30 3.86 3.68 3.05 0.34 9.14 7.70 7.52 6.89 010
body.
20550.......... ............. A Inject tendon/ligament/ 0.86 1.73 1.07 0.20 0.21 0.06 2.65 1.99 1.12 1.13 000
cyst.
20600.......... ............. A Drain/inject, joint/ 0.66 1.17 0.84 0.26 0.26 0.05 1.88 1.55 0.97 0.97 000
bursa.
20605.......... ............. A Drain/inject, joint/ 0.68 1.47 0.98 0.26 0.26 0.05 2.20 1.71 0.99 0.99 000
bursa.
20610.......... ............. A Drain/inject, joint/ 0.79 1.80 1.15 0.31 0.28 0.06 2.65 2.00 1.16 1.13 000
bursa.
20615.......... ............. A Treatment of bone cyst 2.28 3.73 2.13 2.28 1.28 0.16 6.17 4.57 4.72 3.72 010
20650.......... ............. A Insert and remove bone 2.23 3.69 2.43 2.63 1.90 0.17 6.09 4.83 5.03 4.30 010
pin.
20660.......... ............. A Apply,remove fixation 2.51 NA NA 1.31 1.50 0.45 NA NA 4.27 4.46 000
device.
20661.......... ............. A Application of head 4.89 NA NA 6.04 5.10 0.83 NA NA 11.76 10.82 090
brace.
20662.......... ............. A Application of pelvis 6.07 NA NA 4.88 5.99 0.64 NA NA 11.59 12.70 090
brace.
20663.......... ............. A Application of thigh 5.43 NA NA 4.12 4.58 0.55 NA NA 10.10 10.56 090
brace.
20664.......... ............. A Halo brace application 8.06 NA NA 7.72 5.94 1.38 NA NA 17.16 15.38 090
20665.......... ............. A Removal of fixation 1.31 2.10 1.32 1.12 0.83 0.17 3.58 2.80 2.60 2.31 010
device.
20670.......... ............. A Removal of support 1.74 4.77 2.79 3.10 1.75 0.17 6.68 4.70 5.01 3.66 010
implant.
20680.......... ............. A Removal of support 3.35 4.12 3.87 4.12 3.87 0.33 7.80 7.55 7.80 7.55 090
implant.
20690.......... ............. A Apply bone fixation 3.52 NA NA 1.89 2.93 0.33 NA NA 5.74 6.78 090
device.
20692.......... ............. A Apply bone fixation 6.41 NA NA 3.37 4.68 0.64 NA NA 10.42 11.73 090
device.
20693.......... ............. A Adjust bone fixation 5.86 NA NA 9.96 6.33 0.66 NA NA 16.48 12.85 090
device.
20694.......... ............. A Remove bone fixation 4.16 7.14 4.98 5.20 4.01 0.43 11.73 9.57 9.79 8.60 090
device.
20802.......... ............. A Replantation, arm, 41.15 NA NA 22.61 31.78 3.51 NA NA 67.27 76.44 090
complete.
20805.......... ............. A Replant, forearm, 50.00 NA NA 38.99 44.55 3.56 NA NA 92.55 98.11 090
complete.
20808.......... ............. A Replantation hand, 61.65 NA NA 45.51 53.90 5.46 NA NA 112.62 121.01 090
complete.
20816.......... ............. A Replantation digit, 30.94 NA NA 40.11 35.41 3.20 NA NA 74.25 69.55 090
complete.
20822.......... ............. A Replantation digit, 25.59 NA NA 32.28 28.83 2.64 NA NA 60.51 57.06 090
complete.
20824.......... ............. A Replantation thumb, 30.94 NA NA 38.46 34.59 3.26 NA NA 72.66 68.79 090
complete.
20827.......... ............. A Replantation thumb, 26.41 NA NA 35.68 30.89 2.72 NA NA 64.81 60.02 090
complete.
20838.......... ............. A Replantation foot, 41.41 NA NA 24.63 32.79 4.99 NA NA 71.03 79.19 090
complete.
20900.......... ............. A Removal of bone for 5.58 5.34 4.19 5.34 4.19 0.55 11.47 10.32 11.47 10.32 090
graft.
20902.......... ............. A Removal of bone for 7.55 NA NA 7.87 6.62 0.78 NA NA 16.20 14.95 090
graft.
20910.......... ............. A Remove cartilage for 5.34 6.69 3.78 5.81 3.34 0.43 12.46 9.55 11.58 9.11 090
graft.
20912.......... ............. A Remove cartilage for 6.35 NA NA 6.14 5.58 0.55 NA NA 13.04 12.48 090
graft.
20920.......... ............. A Removal of fascia for 5.31 NA NA 4.99 4.63 0.51 NA NA 10.81 10.45 090
graft.
20922.......... ............. A Removal of fascia for 6.61 9.16 6.96 5.82 5.29 0.84 16.61 14.41 13.27 12.74 090
graft.
20924.......... ............. A Removal of tendon for 6.48 NA NA 6.26 6.09 0.68 NA NA 13.42 13.25 090
graft.
20926.......... ............. A Removal of tissue for 5.53 NA NA 5.52 4.17 0.73 NA NA 11.78 10.43 090
graft.
20930.......... ............. B Spinal bone allograft. 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
20931.......... ............. A Spinal bone allograft. 1.81 NA NA 0.96 1.42 0.31 NA NA 3.08 3.54 ZZZ
20936.......... ............. B Spinal bone autograft. 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
20937.......... ............. A Spinal bone autograft. 2.79 NA NA 1.48 2.19 0.34 NA NA 4.61 5.32 ZZZ
20938.......... ............. A Spinal bone autograft. 3.02 NA NA 1.60 2.37 0.44 NA NA 5.06 5.83 ZZZ
20950.......... ............. A Fluid pressure, muscle 1.26 NA NA 1.63 1.41 0.13 NA NA 3.02 2.80 000
20955.......... ............. A Fibula bone graft, 39.21 NA NA 26.38 32.64 3.88 NA NA 69.47 75.73 090
microvasc.
20956.......... ............. A Iliac bone graft, 39.27 NA NA 26.86 28.03 4.68 NA NA 70.81 71.98 090
microvasc.
20957.......... ............. A Mt bone graft, 40.65 NA NA 18.49 24.37 4.84 NA NA 63.98 69.86 090
microvasc.
20962.......... ............. A Other bone graft, 39.27 NA NA 25.63 27.41 4.28 NA NA 69.18 70.96 090
microvasc.
20969.......... ............. A Bone/skin graft, 43.92 NA NA 29.27 36.41 4.12 NA NA 77.31 84.45 090
microvasc.
20970.......... ............. A Bone/skin graft, iliac 43.06 NA NA 28.16 35.41 4.49 NA NA 75.71 82.96 090
crest.
20972.......... ............. A Bone/skin graft, 42.99 NA NA 18.71 30.85 3.89 NA NA 65.59 77.73 090
metatarsal.
20973.......... ............. A Bone/skin graft, great 45.76 NA NA 26.86 36.36 4.73 NA NA 77.35 86.85 090
toe.
20974.......... ............. A Electrical bone 0.62 0.37 2.04 0.31 1.09 0.04 1.03 2.70 0.97 1.75 000
stimulation.
20975.......... ............. A Electrical bone 2.60 NA NA 1.38 2.24 0.31 NA NA 4.29 5.15 000
stimulation.
20979.......... ............. A Us bone stimulation... 0.17 0.25 0.25 0.07 0.07 0.01 0.43 0.43 0.25 0.25 000
20999.......... ............. C Musculoskeletal 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
surgery.
[[Page 59449]]
21010.......... ............. A Incision of jaw joint. 10.14 NA NA 6.45 8.78 0.50 NA NA 17.09 19.42 090
21015.......... ............. A Resection of facial 5.29 NA NA 5.70 6.01 0.52 NA NA 11.51 11.82 090
tumor.
21025.......... ............. A Excision of bone, 10.06 6.87 5.68 6.28 4.27 0.77 17.70 16.51 17.11 15.10 090
lower jaw.
21026.......... ............. A Excision of facial 4.85 4.88 4.15 4.41 3.06 0.38 10.11 9.38 9.64 8.29 090
bone(s).
21029.......... ............. A Contour of face bone 7.71 5.94 7.57 5.43 5.02 0.62 14.27 15.90 13.76 13.35 090
lesion.
21030.......... ............. A Removal of face bone 6.46 5.06 4.35 4.27 3.05 0.47 11.99 11.28 11.20 9.98 090
lesion.
21031.......... ............. A Remove exostosis, 3.24 3.14 3.57 2.00 2.00 0.24 6.62 7.05 5.48 5.48 090
mandible.
21032.......... ............. A Remove exostosis, 3.24 3.11 3.66 2.11 2.11 0.25 6.60 7.15 5.60 5.60 090
maxilla.
21034.......... ............. A Removal of face bone 16.17 9.28 8.43 9.28 8.43 1.32 26.77 25.92 26.77 25.92 090
lesion.
21040.......... ............. A Removal of jaw bone 2.11 2.79 2.90 1.63 1.57 0.16 5.06 5.17 3.90 3.84 090
lesion.
21041.......... ............. A Removal of jaw bone 6.71 5.25 5.75 4.12 3.63 0.49 12.45 12.95 11.32 10.83 090
lesion.
21044.......... ............. A Removal of jaw bone 11.86 NA NA 7.61 8.99 0.89 NA NA 20.36 21.74 090
lesion.
21045.......... ............. A Extensive jaw surgery. 16.17 NA NA 9.85 12.43 1.25 NA NA 27.27 29.85 090
21050.......... ............. A Removal of jaw joint.. 10.77 NA NA 10.76 11.81 0.74 NA NA 22.27 23.32 090
21060.......... ............. A Remove jaw joint 10.23 NA NA 9.97 11.09 0.77 NA NA 20.97 22.09 090
cartilage.
21070.......... ............. A Remove coronoid 8.20 NA NA 5.65 6.52 0.71 NA NA 14.56 15.43 090
process.
21076.......... ............. A Prepare face/oral 13.42 9.45 12.74 7.11 7.56 0.94 23.81 27.10 21.47 21.92 010
prosthesis.
21077.......... ............. A Prepare face/oral 33.75 23.77 32.04 17.89 19.02 2.44 59.96 68.23 54.08 55.21 090
prosthesis.
21079.......... ............. A Prepare face/oral 22.34 16.79 23.55 12.37 13.77 1.51 40.64 47.40 36.22 37.62 090
prosthesis.
21080.......... ............. A Prepare face/oral 25.10 18.87 26.47 13.90 15.47 1.74 45.71 53.31 40.74 42.31 090
prosthesis.
21081.......... ............. A Prepare face/oral 22.88 17.19 24.11 12.67 14.10 1.60 41.67 48.59 37.15 38.58 090
prosthesis.
21082.......... ............. A Prepare face/oral 20.87 14.70 19.81 11.06 11.76 1.47 37.04 42.15 33.40 34.10 090
prosthesis.
21083.......... ............. A Prepare face/oral 19.30 14.51 20.35 10.69 11.90 1.31 35.12 40.96 31.30 32.51 090
prosthesis.
21084.......... ............. A Prepare face/oral 22.51 16.92 23.73 12.47 13.87 1.61 41.04 47.85 36.59 37.99 090
prosthesis.
21085.......... ............. A Prepare face/oral 9.00 6.34 8.54 4.77 5.07 0.66 16.00 18.20 14.43 14.73 010
prosthesis.
21086.......... ............. A Prepare face/oral 24.92 18.73 26.27 13.80 15.36 1.84 45.49 53.03 40.56 42.12 090
prosthesis.
21087.......... ............. A Prepare face/oral 24.92 17.55 23.65 13.21 14.05 1.81 44.28 50.38 39.94 40.78 090
prosthesis.
21088.......... ............. C Prepare face/oral 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
prosthesis.
21089.......... ............. C Prepare face/oral 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
prosthesis.
21100.......... ............. A Maxillofacial fixation 4.22 4.56 2.86 3.82 2.49 0.24 9.02 7.32 8.28 6.95 090
21110.......... ............. A Interdental fixation.. 5.21 4.98 5.49 3.79 3.40 0.34 10.53 11.04 9.34 8.95 090
21116.......... ............. A Injection, jaw joint x- 0.81 6.89 3.84 0.26 0.53 0.05 7.75 4.70 1.12 1.39 000
ray.
21120.......... ............. A Reconstruction of chin 4.93 8.74 6.32 4.97 4.44 0.40 14.07 11.65 10.30 9.77 090
21121.......... ............. A Reconstruction of chin 7.64 6.96 6.55 5.61 5.87 0.60 15.20 14.79 13.85 14.11 090
21122.......... ............. A Reconstruction of chin 8.52 NA NA 6.57 6.67 0.72 NA NA 15.81 15.91 090
21123.......... ............. A Reconstruction of chin 11.16 NA NA 8.08 8.46 0.90 NA NA 20.14 20.52 090
21125.......... ............. A Augmentation, lower 10.62 7.74 6.43 7.28 6.20 0.81 19.17 17.86 18.71 17.63 090
jaw bone.
21127.......... ............. A Augmentation, lower 11.12 8.65 8.62 6.58 7.58 0.92 20.69 20.66 18.62 19.62 090
jaw bone.
21137.......... ............. A Reduction of forehead. 9.82 NA NA 7.09 7.41 0.88 NA NA 17.79 18.11 090
21138.......... ............. A Reduction of forehead. 12.19 NA NA 7.49 8.56 1.06 NA NA 20.74 21.81 090
21139.......... ............. A Reduction of forehead. 14.61 NA NA 9.79 10.67 1.27 NA NA 25.67 26.55 090
21141.......... ............. A Reconstruct midface, 18.10 NA NA 10.76 13.16 1.42 NA NA 30.28 32.68 090
lefort.
21142.......... ............. A Reconstruct midface, 18.81 NA NA 12.13 14.12 1.77 NA NA 32.71 34.70 090
lefort.
21143.......... ............. A Reconstruct midface, 19.58 NA NA 10.36 13.54 1.21 NA NA 31.15 34.33 090
lefort.
21145.......... ............. A Reconstruct midface, 19.94 NA NA 10.42 12.99 1.46 NA NA 31.82 34.39 090
lefort.
21146.......... ............. A Reconstruct midface, 20.71 NA NA 10.62 13.37 1.61 NA NA 32.94 35.69 090
lefort.
21147.......... ............. A Reconstruct midface, 21.77 NA NA 11.20 13.96 1.53 NA NA 34.50 37.26 090
lefort.
21150.......... ............. A Reconstruct midface, 25.24 NA NA 12.77 16.40 1.85 NA NA 39.86 43.49 090
lefort.
21151.......... ............. A Reconstruct midface, 28.30 NA NA 17.35 19.90 3.25 NA NA 48.90 51.45 090
lefort.
21154.......... ............. A Reconstruct midface, 30.52 NA NA 16.07 20.06 3.14 NA NA 49.73 53.72 090
lefort.
21155.......... ............. A Reconstruct midface, 34.45 NA NA 16.74 22.00 3.54 NA NA 54.73 59.99 090
lefort.
21159.......... ............. A Reconstruct midface, 42.38 NA NA 24.12 28.89 3.77 NA NA 70.27 75.04 090
lefort.
21160.......... ............. A Reconstruct midface, 46.44 NA NA 22.31 29.59 3.51 NA NA 72.26 79.54 090
lefort.
21172.......... ............. A Reconstruct orbit/ 27.80 NA NA 14.48 18.26 1.92 NA NA 44.20 47.98 090
forehead.
21175.......... ............. A Reconstruct orbit/ 33.17 NA NA 18.07 22.26 3.75 NA NA 54.99 59.18 090
forehead.
21179.......... ............. A Reconstruct entire 22.25 NA NA 15.84 16.73 2.52 NA NA 40.61 41.50 090
forehead.
21180.......... ............. A Reconstruct entire 25.19 NA NA 17.68 18.86 2.21 NA NA 45.08 46.26 090
forehead.
21181.......... ............. A Contour cranial bone 9.90 NA NA 7.35 7.54 1.04 NA NA 18.29 18.48 090
lesion.
21182.......... ............. A Reconstruct cranial 32.19 NA NA 21.26 23.45 2.77 NA NA 56.22 58.41 090
bone.
21183.......... ............. A Reconstruct cranial 35.31 NA NA 20.94 24.50 3.14 NA NA 59.39 62.95 090
bone.
21184.......... ............. A Reconstruct cranial 38.24 NA NA 23.21 26.83 6.52 NA NA 67.97 71.59 090
bone.
21188.......... ............. A Reconstruction of 22.46 NA NA 14.91 16.27 1.87 NA NA 39.24 40.60 090
midface.
21193.......... ............. A Reconstruct lower jaw 17.15 NA NA 9.99 11.68 1.42 NA NA 28.56 30.25 090
bone.
21194.......... ............. A Reconstruct lower jaw 19.84 NA NA 11.54 13.51 1.64 NA NA 33.02 34.99 090
bone.
21195.......... ............. A Reconstruct lower jaw 17.24 NA NA 11.29 12.34 1.34 NA NA 29.87 30.92 090
bone.
21196.......... ............. A Reconstruct lower jaw 18.91 NA NA 12.30 13.54 1.50 NA NA 32.71 33.95 090
bone.
21198.......... ............. A Reconstruct lower jaw 14.16 NA NA 11.18 13.63 1.03 NA NA 26.37 28.82 090
bone.
21206.......... ............. A Reconstruct upper jaw 14.10 NA NA 9.29 10.15 1.02 NA NA 24.41 25.27 090
bone.
21208.......... ............. A Augmentation of facial 10.23 8.77 10.49 7.56 9.89 0.79 19.79 21.51 18.58 20.91 090
bones.
21209.......... ............. A Reduction of facial 6.72 6.65 5.82 5.08 5.03 0.55 13.92 13.09 12.35 12.30 090
bones.
21210.......... ............. A Face bone graft....... 10.23 8.10 10.16 7.38 6.75 0.75 19.08 21.14 18.36 17.73 090
21215.......... ............. A Lower jaw bone graft.. 10.77 8.11 10.49 6.40 6.42 0.78 19.66 22.04 17.95 17.97 090
21230.......... ............. A Rib cartilage graft... 10.77 NA NA 8.72 9.99 0.96 NA NA 20.45 21.72 090
21235.......... ............. A Ear cartilage graft... 6.72 9.59 8.81 6.80 7.41 0.53 16.84 16.06 14.05 14.66 090
21240.......... ............. A Reconstruction of jaw 14.05 NA NA 11.16 13.97 1.09 NA NA 26.30 29.11 090
joint.
21242.......... ............. A Reconstruction of jaw 12.95 NA NA 11.32 13.39 1.09 NA NA 25.36 27.43 090
joint.
21243.......... ............. A Reconstruction of jaw 20.79 NA NA 13.54 14.59 1.53 NA NA 35.86 36.91 090
joint.
21244.......... ............. A Reconstruction of 11.86 NA NA 8.48 11.32 0.95 NA NA 21.29 24.13 090
lower jaw.
21245.......... ............. A Reconstruction of jaw. 11.86 9.18 10.82 9.18 10.82 0.91 21.95 23.59 21.95 23.59 090
21246.......... ............. A Reconstruction of jaw. 12.47 9.45 9.52 9.43 9.51 0.96 22.88 22.95 22.86 22.94 090
21247.......... ............. A Reconstruct lower jaw 22.63 NA NA 15.54 21.28 1.62 NA NA 39.79 45.53 090
bone.
[[Page 59450]]
21248.......... ............. A Reconstruction of jaw. 11.48 8.15 10.93 7.14 7.00 0.85 20.48 23.26 19.47 19.33 090
21249.......... ............. A Reconstruction of jaw. 17.52 10.73 15.82 9.73 10.10 1.33 29.58 34.67 28.58 28.95 090
21255.......... ............. A Reconstruct lower jaw 16.72 NA NA 9.58 14.77 1.66 NA NA 27.96 33.15 090
bone.
21256.......... ............. A Reconstruction of 16.19 NA NA 12.33 15.83 1.38 NA NA 29.90 33.40 090
orbit.
21260.......... ............. A Revise eye sockets.... 16.52 NA NA 8.27 14.00 0.67 NA NA 25.46 31.19 090
21261.......... ............. A Revise eye sockets.... 31.49 NA NA 19.66 19.48 2.38 NA NA 53.53 53.35 090
21263.......... ............. A Revise eye sockets.... 28.42 NA NA 14.31 24.12 1.12 NA NA 43.85 53.66 090
21267.......... ............. A Revise eye sockets.... 18.90 NA NA 14.04 14.95 1.12 NA NA 34.06 34.97 090
21268.......... ............. A Revise eye sockets.... 24.48 NA NA 15.03 15.85 3.89 NA NA 43.40 44.22 090
21270.......... ............. A Augmentation, cheek 10.23 7.80 9.11 7.80 9.11 0.89 18.92 20.23 18.92 20.23 090
bone.
21275.......... ............. A Revision, orbitofacial 11.24 NA NA 9.47 9.59 1.05 NA NA 21.76 21.88 090
bones.
21280.......... ............. A Revision of eyelid.... 6.03 NA NA 6.09 6.65 0.29 NA NA 12.41 12.97 090
21282.......... ............. A Revision of eyelid.... 3.49 NA NA 4.82 4.50 0.20 NA NA 8.51 8.19 090
21295.......... ............. A Revision of jaw muscle/ 1.53 NA NA 3.69 2.37 0.11 NA NA 5.33 4.01 090
bone.
21296.......... ............. A Revision of jaw muscle/ 4.25 NA NA 4.30 4.12 0.35 NA NA 8.90 8.72 090
bone.
21299.......... ............. C Cranio/maxillofacial 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
surgery.
21300.......... ............. A Treatment of skull 0.72 2.45 1.73 0.28 0.57 0.08 3.25 2.53 1.08 1.37 000
fracture.
21310.......... ............. A Treatment of nose 0.58 2.32 1.57 0.16 0.43 0.06 2.96 2.21 0.80 1.07 000
fracture.
21315.......... ............. A Treatment of nose 1.51 2.97 2.47 1.14 1.47 0.12 4.60 4.10 2.77 3.10 010
fracture.
21320.......... ............. A Treatment of nose 1.85 4.14 3.34 1.85 2.03 0.14 6.13 5.33 3.84 4.02 010
fracture.
21325.......... ............. A Treatment of nose 3.77 NA NA 3.24 3.84 0.31 NA NA 7.32 7.92 090
fracture.
21330.......... ............. A Treatment of nose 5.38 NA NA 4.79 5.61 0.47 NA NA 10.64 11.46 090
fracture.
21335.......... ............. A Treatment of nose 8.61 NA NA 6.68 8.48 0.65 NA NA 15.94 17.74 090
fracture.
21336.......... ............. A Treat nasal septal 5.72 NA NA 4.91 4.68 0.47 NA NA 11.10 10.87 090
fracture.
21337.......... ............. A Treat nasal septal 2.70 4.69 3.88 2.76 2.91 0.23 7.62 6.81 5.69 5.84 090
fracture.
21338.......... ............. A Treat nasoethmoid 6.46 NA NA 5.57 5.51 0.53 NA NA 12.56 12.50 090
fracture.
21339.......... ............. A Treat nasoethmoid 8.09 NA NA 6.17 6.93 0.65 NA NA 14.91 15.67 090
fracture.
21340.......... ............. A Treatment of nose 10.77 NA NA 8.62 9.15 0.69 NA NA 20.08 20.61 090
fracture.
21343.......... ............. A Treatment of sinus 12.95 NA NA 9.17 9.56 1.20 NA NA 23.32 23.71 090
fracture.
21344.......... ............. A Treatment of sinus 19.72 NA NA 12.94 11.45 1.78 NA NA 34.44 32.95 090
fracture.
21345.......... ............. A Treat nose/jaw 8.16 7.38 7.98 6.94 7.76 0.64 16.18 16.78 15.74 16.56 090
fracture.
21346.......... ............. A Treat nose/jaw 10.61 NA NA 8.58 9.39 0.83 NA NA 20.02 20.83 090
fracture.
21347.......... ............. A Treat nose/jaw 12.69 NA NA 8.84 10.04 1.08 NA NA 22.61 23.81 090
fracture.
21348.......... ............. A Treat nose/jaw 16.69 NA NA 9.89 11.10 1.44 NA NA 28.02 29.23 090
fracture.
21355.......... ............. A Treat cheek bone 3.77 3.55 2.62 2.02 1.86 0.32 7.64 6.71 6.11 5.95 010
fracture.
21356.......... ............. A Treat cheek bone 4.15 NA NA 2.96 3.96 0.34 NA NA 7.45 8.45 010
fracture.
21360.......... ............. A Treat cheek bone 6.46 NA NA 5.13 6.43 0.52 NA NA 12.11 13.41 090
fracture.
21365.......... ............. A Treat cheek bone 14.95 NA NA 10.44 11.92 1.28 NA NA 26.67 28.15 090
fracture.
21366.......... ............. A Treat cheek bone 17.77 NA NA 11.32 12.22 1.52 NA NA 30.61 31.51 090
fracture.
21385.......... ............. A Treat eye socket 9.16 NA NA 6.77 8.59 0.67 NA NA 16.60 18.42 090
fracture.
21386.......... ............. A Treat eye socket 9.16 NA NA 7.25 8.55 0.75 NA NA 17.16 18.46 090
fracture.
21387.......... ............. A Treat eye socket 9.70 NA NA 7.64 7.87 0.78 NA NA 18.12 18.35 090
fracture.
21390.......... ............. A Treat eye socket 10.13 NA NA 8.00 10.05 0.74 NA NA 18.87 20.92 090
fracture.
21395.......... ............. A Treat eye socket 12.68 NA NA 9.01 9.73 1.16 NA NA 22.85 23.57 090
fracture.
21400.......... ............. A Treat eye socket 1.40 2.89 2.35 0.95 1.31 0.12 4.41 3.87 2.47 2.83 090
fracture.
21401.......... ............. A Treat eye socket 3.26 4.39 3.60 2.75 2.78 0.25 7.90 7.11 6.26 6.29 090
fracture.
21406.......... ............. A Treat eye socket 7.01 NA NA 5.77 5.71 0.60 NA NA 13.38 13.32 090
fracture.
21407.......... ............. A Treat eye socket 8.61 NA NA 7.15 7.42 0.70 NA NA 16.46 16.73 090
fracture.
21408.......... ............. A Treat eye socket 12.38 NA NA 9.36 9.29 1.21 NA NA 22.95 22.88 090
fracture.
21421.......... ............. A Treat mouth roof 5.14 6.30 6.48 5.21 5.67 0.38 11.82 12.00 10.73 11.19 090
fracture.
21422.......... ............. A Treat mouth roof 8.32 NA NA 6.64 8.29 0.69 NA NA 15.65 17.30 090
fracture.
21423.......... ............. A Treat mouth roof 10.40 NA NA 7.35 9.00 0.82 NA NA 18.57 20.22 090
fracture.
21431.......... ............. A Treat craniofacial 7.05 NA NA 5.49 6.01 0.54 NA NA 13.08 13.60 090
fracture.
21432.......... ............. A Treat craniofacial 8.61 NA NA 7.38 7.36 0.94 NA NA 16.93 16.91 090
fracture.
21433.......... ............. A Treat craniofacial 25.35 NA NA 15.62 17.56 2.11 NA NA 43.08 45.02 090
fracture.
21435.......... ............. A Treat craniofacial 17.25 NA NA 12.21 13.30 1.36 NA NA 30.82 31.91 090
fracture.
21436.......... ............. A Treat craniofacial 28.04 NA NA 17.19 16.55 1.88 NA NA 47.11 46.47 090
fracture.
21440.......... ............. A Treat dental ridge 2.70 4.84 4.09 3.09 3.16 0.20 7.74 6.99 5.99 6.06 090
fracture.
21445.......... ............. A Treat dental ridge 5.38 6.00 6.32 4.56 5.49 0.42 11.80 12.12 10.36 11.29 090
fracture.
21450.......... ............. A Treat lower jaw 2.97 5.29 4.19 2.40 2.74 0.23 8.49 7.39 5.60 5.94 090
fracture.
21451.......... ............. A Treat lower jaw 4.87 5.83 6.08 4.82 5.32 0.37 11.07 11.32 10.06 10.56 090
fracture.
21452.......... ............. A Treat lower jaw 1.98 7.22 4.37 3.63 2.57 0.15 9.35 6.50 5.76 4.70 090
fracture.
21453.......... ............. A Treat lower jaw 5.54 6.45 6.83 5.38 6.00 0.44 12.43 12.81 11.36 11.98 090
fracture.
21454.......... ............. A Treat lower jaw 6.46 NA NA 4.91 6.32 0.48 NA NA 11.85 13.26 090
fracture.
21461.......... ............. A Treat lower jaw 8.09 7.82 8.74 6.98 8.32 0.65 16.56 17.48 15.72 17.06 090
fracture.
21462.......... ............. A Treat lower jaw 9.79 8.73 10.21 7.30 9.50 0.76 19.28 20.76 17.85 20.05 090
fracture.
21465.......... ............. A Treat lower jaw 11.91 NA NA 7.08 8.12 0.95 NA NA 19.94 20.98 090
fracture.
21470.......... ............. A Treat lower jaw 15.34 NA NA 9.08 13.70 1.21 NA NA 25.63 30.25 090
fracture.
21480.......... ............. A Reset dislocated jaw.. 0.61 1.54 1.20 0.18 0.46 0.05 2.20 1.86 0.84 1.12 000
21485.......... ............. A Reset dislocated jaw.. 3.99 3.53 2.96 3.01 2.10 0.27 7.79 7.22 7.27 6.36 090
21490.......... ............. A Repair dislocated jaw. 11.86 NA NA 7.08 6.97 0.84 NA NA 19.78 19.67 090
21493.......... ............. A Treat hyoid bone 1.27 0.49 1.07 0.49 1.01 0.10 1.86 2.44 1.86 2.38 090
fracture.
21494.......... ............. A Treat hyoid bone 6.28 2.43 5.30 2.43 5.30 0.45 9.16 12.03 9.16 12.03 090
fracture.
21495.......... ............. A Treat hyoid bone 5.69 NA NA 5.29 5.26 0.41 NA NA 11.39 11.36 090
fracture.
21497.......... ............. A Interdental wiring.... 3.86 4.29 4.30 3.43 3.87 0.30 8.45 8.46 7.59 8.03 090
21499.......... ............. C Head surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
21501.......... ............. A Drain neck/chest 3.81 3.96 2.97 3.48 2.73 0.37 8.14 7.15 7.66 6.91 090
lesion.
21502.......... ............. A Drain chest lesion.... 7.12 NA NA 7.43 6.01 0.78 NA NA 15.33 13.91 090
21510.......... ............. A Drainage of bone 5.74 NA NA 7.47 5.81 0.63 NA NA 13.84 12.18 090
lesion.
21550.......... ............. A Biopsy of neck/chest.. 2.06 2.21 1.57 1.21 0.84 0.12 4.39 3.75 3.39 3.02 010
21555.......... ............. A Remove lesion, neck/ 4.35 4.12 2.93 2.52 2.13 0.39 8.86 7.67 7.26 6.87 090
chest.
[[Page 59451]]
21556.......... ............. A Remove lesion, neck/ 5.57 NA NA 3.29 3.71 0.52 NA NA 9.38 9.80 090
chest.
21557.......... ............. A Remove tumor, neck/ 8.88 NA NA 7.48 8.35 0.81 NA NA 17.17 18.04 090
chest.
21600.......... ............. A Partial removal of rib 6.89 NA NA 8.41 6.65 0.79 NA NA 16.09 14.33 090
21610.......... ............. A Partial removal of rib 14.61 NA NA 10.32 7.97 1.99 NA NA 26.92 24.57 090
21615.......... ............. A Removal of rib........ 9.87 NA NA 9.28 10.14 1.30 NA NA 20.45 21.31 090
21616.......... ............. A Removal of rib and 12.04 NA NA 12.51 10.20 1.45 NA NA 26.00 23.69 090
nerves.
21620.......... ............. A Partial removal of 6.79 NA NA 8.74 8.09 0.78 NA NA 16.31 15.66 090
sternum.
21627.......... ............. A Sternal debridement... 6.81 NA NA 15.24 10.35 0.84 NA NA 22.89 18.00 090
21630.......... ............. A Extensive sternum 17.38 NA NA 13.47 13.73 1.95 NA NA 32.80 33.06 090
surgery.
21632.......... ............. A Extensive sternum 18.14 NA NA 15.46 13.99 2.27 NA NA 35.87 34.40 090
surgery.
21700.......... ............. A Revision of neck 6.19 7.79 6.15 7.44 5.98 0.74 14.72 13.08 14.37 12.91 090
muscle.
21705.......... ............. A Revision of neck 9.60 NA NA 6.91 6.09 1.27 NA NA 17.78 16.96 090
muscle/rib.
21720.......... ............. A Revision of neck 5.68 6.61 5.39 6.28 5.23 0.82 13.11 11.89 12.78 11.73 090
muscle.
21725.......... ............. A Revision of neck 6.99 NA NA 6.15 5.70 0.68 NA NA 13.82 13.37 090
muscle.
21740.......... ............. A Reconstruction of 16.50 NA NA 15.80 12.78 1.95 NA NA 34.25 31.23 090
sternum.
21750.......... ............. A Repair of sternum 10.77 NA NA 13.66 10.81 1.35 NA NA 25.78 22.93 090
separation.
21800.......... ............. A Treatment of rib 0.96 1.85 1.35 0.92 0.88 0.09 2.90 2.40 1.97 1.93 090
fracture.
21805.......... ............. A Treatment of rib 2.75 NA NA 6.38 3.93 0.29 NA NA 9.42 6.97 090
fracture.
21810.......... ............. A Treatment of rib 6.86 NA NA 7.52 7.74 0.56 NA NA 14.94 15.16 090
fracture(s).
21820.......... ............. A Treat sternum fracture 1.28 2.23 1.86 1.29 1.39 0.12 3.63 3.26 2.69 2.79 090
21825.......... ............. A Treat sternum fracture 7.41 NA NA 12.61 10.05 0.95 NA NA 20.97 18.41 090
21899.......... ............. C Neck/chest surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
21920.......... ............. A Biopsy soft tissue of 2.06 2.34 1.60 0.78 0.61 0.10 4.50 3.76 2.94 2.77 010
back.
21925.......... ............. A Biopsy soft tissue of 4.49 10.67 6.40 4.21 3.17 0.43 15.59 11.32 9.13 8.09 090
back.
21930.......... ............. A Remove lesion, back or 5.00 4.44 3.70 2.67 2.81 0.47 9.91 9.17 8.14 8.28 090
flank.
21935.......... ............. A Remove tumor, back.... 17.96 NA NA 11.50 9.33 1.79 NA NA 31.25 29.08 090
22100.......... ............. A Remove part of neck 9.73 NA NA 8.21 8.25 1.34 NA NA 19.28 19.32 090
vertebra.
22101.......... ............. A Remove part, thorax 9.81 NA NA 8.40 8.55 1.23 NA NA 19.44 19.59 090
vertebra.
22102.......... ............. A Remove part, lumbar 9.81 NA NA 8.27 6.58 1.37 NA NA 19.45 17.76 090
vertebra.
22103.......... ............. A Remove extra spine 2.34 NA NA 1.22 1.82 0.33 NA NA 3.89 4.49 ZZZ
segment.
22110.......... ............. A Remove part of neck 12.74 NA NA 10.38 10.47 1.88 NA NA 25.00 25.09 090
vertebra.
22112.......... ............. A Remove part, thorax 12.81 NA NA 10.04 10.39 1.57 NA NA 24.42 24.77 090
vertebra.
22114.......... ............. A Remove part, lumbar 12.81 NA NA 12.03 9.95 1.37 NA NA 26.21 24.13 090
vertebra.
22116.......... ............. A Remove extra spine 2.32 NA NA 1.19 1.80 0.32 NA NA 3.83 4.44 ZZZ
segment.
22210.......... ............. A Revision of neck spine 23.82 NA NA 16.42 15.72 3.46 NA NA 43.70 43.00 090
22212.......... ............. A Revision of thorax 19.42 NA NA 14.26 16.51 1.99 NA NA 35.67 37.92 090
spine.
22214.......... ............. A Revision of lumbar 19.45 NA NA 14.84 15.62 2.35 NA NA 36.64 37.42 090
spine.
22216.......... ............. A Revise, extra spine 6.04 NA NA 3.18 4.34 0.81 NA NA 10.03 11.19 ZZZ
segment.
22220.......... ............. A Revision of neck spine 21.37 NA NA 14.77 16.42 3.15 NA NA 39.29 40.94 090
22222.......... ............. A Revision of thorax 21.52 NA NA 13.09 13.93 1.01 NA NA 35.62 36.46 090
spine.
22224.......... ............. A Revision of lumbar 21.52 NA NA 14.83 15.38 2.43 NA NA 38.78 39.33 090
spine.
22226.......... ............. A Revise, extra spine 6.04 NA NA 3.16 4.33 0.73 NA NA 9.93 11.10 ZZZ
segment.
22305.......... ............. A Treat spine process 2.05 2.69 2.57 1.72 2.09 0.21 4.95 4.83 3.98 4.35 090
fracture.
22310.......... ............. A Treat spine fracture.. 2.61 3.88 3.31 2.97 2.85 0.27 6.76 6.19 5.85 5.73 090
22315.......... ............. A Treat spine fracture.. 8.84 NA NA 8.29 7.14 1.14 NA NA 18.27 17.12 090
22318.......... ............. A Treat odontoid fx w/o 21.50 NA NA 14.50 14.50 3.89 NA NA 39.89 39.89 090
graft.
22319.......... ............. A Treat odontoid fx w/ 24.00 NA NA 16.72 16.72 4.34 NA NA 45.06 45.06 090
graft.
22325.......... ............. A Treat spine fracture.. 18.30 NA NA 13.73 11.38 2.29 NA NA 34.32 31.97 090
22326.......... ............. A Treat neck spine 19.59 NA NA 14.88 16.09 3.18 NA NA 37.65 38.86 090
fracture.
22327.......... ............. A Treat thorax spine 19.20 NA NA 14.47 15.89 2.64 NA NA 36.31 37.73 090
fracture.
22328.......... ............. A Treat each add spine 4.61 NA NA 2.41 3.60 0.68 NA NA 7.70 8.89 ZZZ
fx.
22505.......... ............. A Manipulation of spine. 1.87 4.03 2.73 2.69 2.06 0.13 6.03 4.73 4.69 4.06 010
22548.......... ............. A Neck spine fusion..... 25.82 NA NA 17.59 21.14 4.66 NA NA 48.07 51.62 090
22554.......... ............. A Neck spine fusion..... 18.62 NA NA 13.50 17.50 3.14 NA NA 35.26 39.26 090
22556.......... ............. A Thorax spine fusion... 23.46 NA NA 16.52 20.03 3.20 NA NA 43.18 46.69 090
22558.......... ............. A Lumbar spine fusion... 22.28 NA NA 14.96 18.43 2.62 NA NA 39.86 43.33 090
22585.......... ............. A Additional spinal 5.53 NA NA 2.90 4.38 0.85 NA NA 9.28 10.76 ZZZ
fusion.
22590.......... ............. A Spine & skull spinal 20.51 NA NA 14.94 19.18 3.38 NA NA 38.83 43.07 090
fusion.
22595.......... ............. A Neck spinal fusion.... 19.39 NA NA 13.99 18.57 3.23 NA NA 36.61 41.19 090
22600.......... ............. A Neck spine fusion..... 16.14 NA NA 12.34 15.80 2.53 NA NA 31.01 34.47 090
22610.......... ............. A Thorax spine fusion... 16.02 NA NA 12.29 15.71 2.22 NA NA 30.53 33.95 090
22612.......... ............. A Lumbar spine fusion... 21.00 NA NA 15.00 18.68 2.62 NA NA 38.62 42.30 090
22614.......... ............. A Spine fusion, extra 6.44 NA NA 3.43 4.78 0.82 NA NA 10.69 12.04 ZZZ
segment.
22630.......... ............. A Lumbar spine fusion... 20.84 NA NA 15.55 17.78 3.05 NA NA 39.44 41.67 090
22632.......... ............. A Spine fusion, extra 5.23 NA NA 2.76 4.09 0.72 NA NA 8.71 10.04 ZZZ
segment.
22800.......... ............. A Fusion of spine....... 18.25 NA NA 13.08 17.44 2.09 NA NA 33.42 37.78 090
22802.......... ............. A Fusion of spine....... 30.88 NA NA 20.41 25.57 3.38 NA NA 54.67 59.83 090
22804.......... ............. A Fusion of spine....... 36.27 NA NA 23.20 26.97 3.82 NA NA 63.29 67.06 090
22808.......... ............. A Fusion of spine....... 26.27 NA NA 17.93 18.96 3.79 NA NA 47.99 49.02 090
22810.......... ............. A Fusion of spine....... 30.27 NA NA 19.54 19.76 3.51 NA NA 53.32 53.54 090
22812.......... ............. A Fusion of spine....... 32.70 NA NA 20.85 24.50 3.60 NA NA 57.15 60.80 090
22818.......... ............. A Kyphectomy, 1-2 31.83 NA NA 19.82 25.24 4.31 NA NA 55.96 61.38 090
segments.
22819.......... ............. A Kyphectomy, 3 or more. 36.44 NA NA 21.49 26.08 4.93 NA NA 62.86 67.45 090
22830.......... ............. A Exploration of spinal 10.85 NA NA 9.34 11.15 1.31 NA NA 21.50 23.31 090
fusion.
22840.......... ............. A Insert spine fixation 12.54 NA NA 8.07 7.28 1.61 NA NA 22.22 21.43 ZZZ
device.
22841.......... ............. B Insert spine fixation 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
device.
22842.......... ............. A Insert spine fixation 12.58 NA NA 6.67 7.06 1.63 NA NA 20.88 21.27 ZZZ
device.
22843.......... ............. A Insert spine fixation 13.46 NA NA 7.24 8.26 1.64 NA NA 22.34 23.36 ZZZ
device.
22844.......... ............. A Insert spine fixation 16.44 NA NA 10.32 10.83 1.76 NA NA 28.52 29.03 ZZZ
device.
22845.......... ............. A Insert spine fixation 11.96 NA NA 7.81 7.00 1.95 NA NA 21.72 20.91 ZZZ
device.
22846.......... ............. A Insert spine fixation 12.42 NA NA 8.08 8.33 2.00 NA NA 22.50 22.75 ZZZ
device.
[[Page 59452]]
22847.......... ............. A Insert spine fixation 13.80 NA NA 8.56 9.04 1.63 NA NA 23.99 24.47 ZZZ
device.
22848.......... ............. A Insert pelv fixation 6.00 NA NA 4.55 5.38 0.64 NA NA 11.19 12.02 ZZZ
device.
22849.......... ............. A Reinsert spinal 18.51 NA NA 13.27 13.02 2.25 NA NA 34.03 33.78 090
fixation.
22850.......... ............. A Remove spine fixation 9.52 NA NA 8.26 9.11 1.19 NA NA 18.97 19.82 090
device.
22851.......... ............. A Apply spine prosth 6.71 NA NA 5.02 5.99 0.93 NA NA 12.66 13.63 ZZZ
device.
22852.......... ............. A Remove spine fixation 9.01 NA NA 7.99 9.32 1.09 NA NA 18.09 19.42 090
device.
22855.......... ............. A Remove spine fixation 15.13 NA NA 11.16 9.63 2.35 NA NA 28.64 27.11 090
device.
22899.......... ............. C Spine surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
22900.......... ............. A Remove abdominal wall 5.80 NA NA 4.25 3.77 0.57 NA NA 10.62 10.14 090
lesion.
22999.......... ............. C Abdomen surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
23000.......... ............. A Removal of calcium 4.36 7.26 5.39 6.86 5.19 0.40 12.02 10.15 11.62 9.95 090
deposits.
23020.......... ............. A Release shoulder joint 8.93 NA NA 9.07 8.48 0.93 NA NA 18.93 18.34 090
23030.......... ............. A Drain shoulder lesion. 3.43 5.09 3.72 3.75 3.05 0.33 8.85 7.48 7.51 6.81 010
23031.......... ............. A Drain shoulder bursa.. 2.74 5.07 2.81 3.46 1.87 0.26 8.07 5.81 6.46 4.87 010
23035.......... ............. A Drain shoulder bone 8.61 NA NA 13.99 10.37 0.88 NA NA 23.48 19.86 090
lesion.
23040.......... ............. A Exploratory shoulder 9.20 NA NA 10.47 10.27 0.95 NA NA 20.62 20.42 090
surgery.
23044.......... ............. A Exploratory shoulder 7.12 NA NA 8.98 8.24 0.74 NA NA 16.84 16.10 090
surgery.
23065.......... ............. A Biopsy shoulder 2.27 2.56 1.64 1.32 1.02 0.11 4.94 4.02 3.70 3.40 010
tissues.
23066.......... ............. A Biopsy shoulder 4.16 6.36 3.82 5.36 3.32 0.41 10.93 8.39 9.93 7.89 090
tissues.
23075.......... ............. A Removal of shoulder 2.39 4.44 3.13 2.76 2.29 0.23 7.06 5.75 5.38 4.91 010
lesion.
23076.......... ............. A Removal of shoulder 7.63 NA NA 7.22 5.53 0.78 NA NA 15.63 13.94 090
lesion.
23077.......... ............. A Remove tumor of 16.09 NA NA 12.44 10.23 1.58 NA NA 30.11 27.90 090
shoulder.
23100.......... ............. A Biopsy of shoulder 6.03 NA NA 7.52 7.36 0.60 NA NA 14.15 13.99 090
joint.
23101.......... ............. A Shoulder joint surgery 5.58 NA NA 7.51 7.09 0.57 NA NA 13.66 13.24 090
23105.......... ............. A Remove shoulder joint 8.23 NA NA 9.01 9.42 0.85 NA NA 18.09 18.50 090
lining.
23106.......... ............. A Incision of collarbone 5.96 NA NA 8.05 6.60 0.64 NA NA 14.65 13.20 090
joint.
23107.......... ............. A Explore treat shoulder 8.62 NA NA 9.41 9.85 0.88 NA NA 18.91 19.35 090
joint.
23120.......... ............. A Partial removal, 7.11 NA NA 8.65 6.83 0.73 NA NA 16.49 14.67 090
collar bone.
23125.......... ............. A Removal of collar bone 9.39 NA NA 9.39 9.30 0.97 NA NA 19.75 19.66 090
23130.......... ............. A Remove shoulder bone, 7.55 NA NA 8.53 8.09 0.77 NA NA 16.85 16.41 090
part.
23140.......... ............. A Removal of bone lesion 6.89 NA NA 7.46 5.99 0.68 NA NA 15.03 13.56 090
23145.......... ............. A Removal of bone lesion 9.09 NA NA 11.74 10.28 0.84 NA NA 21.67 20.21 090
23146.......... ............. A Removal of bone lesion 7.83 NA NA 9.01 7.35 0.82 NA NA 17.66 16.00 090
23150.......... ............. A Removal of humerus 8.48 NA NA 8.44 7.83 0.85 NA NA 17.77 17.16 090
lesion.
23155.......... ............. A Removal of humerus 10.35 NA NA 10.54 10.05 1.08 NA NA 21.97 21.48 090
lesion.
23156.......... ............. A Removal of humerus 8.68 NA NA 8.67 8.48 0.89 NA NA 18.24 18.05 090
lesion.
23170.......... ............. A Remove collar bone 6.86 NA NA 8.94 7.08 0.72 NA NA 16.52 14.66 090
lesion.
23172.......... ............. A Remove shoulder blade 6.90 NA NA 8.18 6.89 0.72 NA NA 15.80 14.51 090
lesion.
23174.......... ............. A Remove humerus lesion. 9.51 NA NA 9.90 9.59 0.94 NA NA 20.35 20.04 090
23180.......... ............. A Remove collar bone 8.53 NA NA 13.35 9.01 0.88 NA NA 22.76 18.42 090
lesion.
23182.......... ............. A Remove shoulder blade 8.15 NA NA 15.09 11.11 0.84 NA NA 24.08 20.10 090
lesion.
23184.......... ............. A Remove humerus lesion. 9.38 NA NA 13.49 11.54 0.95 NA NA 23.82 21.87 090
23190.......... ............. A Partial removal of 7.24 NA NA 7.28 6.94 0.74 NA NA 15.26 14.92 090
scapula.
23195.......... ............. A Removal of head of 9.81 NA NA 9.64 9.66 1.02 NA NA 20.47 20.49 090
humerus.
23200.......... ............. A Removal of collar bone 12.08 NA NA 13.22 11.59 1.22 NA NA 26.52 24.89 090
23210.......... ............. A Removal of shoulder 12.49 NA NA 12.52 11.15 1.25 NA NA 26.26 24.89 090
blade.
23220.......... ............. A Partial removal of 14.56 NA NA 14.26 13.67 1.47 NA NA 30.29 29.70 090
humerus.
23221.......... ............. A Partial removal of 17.74 NA NA 13.19 16.44 1.26 NA NA 32.19 35.44 090
humerus.
23222.......... ............. A Partial removal of 23.92 NA NA 18.33 17.32 2.43 NA NA 44.68 43.67 090
humerus.
23330.......... ............. A Remove shoulder 1.85 4.44 2.52 3.20 1.75 0.18 6.47 4.55 5.23 3.78 010
foreign body.
23331.......... ............. A Remove shoulder 7.38 NA NA 8.31 5.38 0.76 NA NA 16.45 13.52 090
foreign body.
23332.......... ............. A Remove shoulder 11.62 NA NA 10.61 10.58 1.19 NA NA 23.42 23.39 090
foreign body.
23350.......... ............. A Injection for shoulder 1.00 8.70 4.63 0.28 0.42 0.04 9.74 5.67 1.32 1.46 000
x-ray.
23395.......... ............. A Muscle transfer, 16.85 NA NA 12.83 12.46 1.74 NA NA 31.42 31.05 090
shoulder/arm.
23397.......... ............. A Muscle transfers...... 16.13 NA NA 12.97 14.07 1.68 NA NA 30.78 31.88 090
23400.......... ............. A Fixation of shoulder 13.54 NA NA 13.77 12.23 1.42 NA NA 28.73 27.19 090
blade.
23405.......... ............. A Incision of tendon & 8.37 NA NA 9.72 8.93 0.86 NA NA 18.95 18.16 090
muscle.
23406.......... ............. A Incise tendon(s) & 10.79 NA NA 10.34 10.28 1.13 NA NA 22.26 22.20 090
muscle(s).
23410.......... ............. A Repair of tendon(s)... 12.45 NA NA 11.54 11.71 1.27 NA NA 25.26 25.43 090
23412.......... ............. A Repair of tendon(s)... 13.31 NA NA 12.03 13.27 1.36 NA NA 26.70 27.94 090
23415.......... ............. A Release of shoulder 9.97 NA NA 9.05 7.34 1.02 NA NA 20.04 18.33 090
ligament.
23420.......... ............. A Repair of shoulder.... 13.30 NA NA 12.78 14.33 1.36 NA NA 27.44 28.99 090
23430.......... ............. A Repair biceps tendon.. 9.98 NA NA 10.23 9.10 1.02 NA NA 21.23 20.10 090
23440.......... ............. A Remove/transplant 10.48 NA NA 10.30 9.04 1.08 NA NA 21.86 20.60 090
tendon.
23450.......... ............. A Repair shoulder 13.40 NA NA 11.63 12.74 1.37 NA NA 26.40 27.51 090
capsule.
23455.......... ............. A Repair shoulder 14.37 NA NA 12.34 14.62 1.47 NA NA 28.18 30.46 090
capsule.
23460.......... ............. A Repair shoulder 15.37 NA NA 12.88 14.08 1.56 NA NA 29.81 31.01 090
capsule.
23462.......... ............. A Repair shoulder 15.30 NA NA 12.83 14.63 1.50 NA NA 29.63 31.43 090
capsule.
23465.......... ............. A Repair shoulder 15.85 NA NA 13.21 14.29 1.63 NA NA 30.69 31.77 090
capsule.
23466.......... ............. A Repair shoulder 14.22 NA NA 12.21 14.59 1.47 NA NA 27.90 30.28 090
capsule.
23470.......... ............. A Reconstruct shoulder 17.15 NA NA 13.98 16.09 1.76 NA NA 32.89 35.00 090
joint.
23472.......... ............. A Reconstruct shoulder 16.92 NA NA 13.86 17.03 1.74 NA NA 32.52 35.69 090
joint.
23480.......... ............. A Revision of collar 11.18 NA NA 10.27 8.71 1.16 NA NA 22.61 21.05 090
bone.
23485.......... ............. A Revision of collar 13.43 NA NA 11.78 12.05 1.37 NA NA 26.58 26.85 090
bone.
23490.......... ............. A Reinforce clavicle.... 11.86 NA NA 10.12 10.48 1.24 NA NA 23.22 23.58 090
23491.......... ............. A Reinforce shoulder 14.21 NA NA 11.72 12.75 1.48 NA NA 27.41 28.44 090
bones.
23500.......... ............. A Treat clavicle 2.08 3.16 2.48 2.16 1.98 0.21 5.45 4.77 4.45 4.27 090
fracture.
23505.......... ............. A Treat clavicle 3.69 4.84 3.82 3.43 3.11 0.37 8.90 7.88 7.49 7.17 090
fracture.
23515.......... ............. A Treat clavicle 7.41 NA NA 7.40 7.46 0.76 NA NA 15.57 15.63 090
fracture.
23520.......... ............. A Treat clavicle 2.16 3.26 2.38 2.20 1.85 0.21 5.63 4.75 4.57 4.22 090
dislocation.
23525.......... ............. A Treat clavicle 3.60 4.45 3.30 3.32 2.74 0.37 8.42 7.27 7.29 6.71 090
dislocation.
[[Page 59453]]
23530.......... ............. A Treat clavicle 7.31 NA NA 6.69 6.92 0.74 NA NA 14.74 14.97 090
dislocation.
23532.......... ............. A Treat clavicle 8.01 NA NA 6.86 7.36 0.84 NA NA 15.71 16.21 090
dislocation.
23540.......... ............. A Treat clavicle 2.23 3.60 2.64 2.20 1.94 0.21 6.04 5.08 4.64 4.38 090
dislocation.
23545.......... ............. A Treat clavicle 3.25 4.19 3.17 3.10 2.63 0.32 7.76 6.74 6.67 6.20 090
dislocation.
23550.......... ............. A Treat clavicle 7.24 NA NA 7.28 7.96 0.73 NA NA 15.25 15.93 090
dislocation.
23552.......... ............. A Treat clavicle 8.45 NA NA 7.74 7.83 0.84 NA NA 17.03 17.12 090
dislocation.
23570.......... ............. A Treat shoulder blade 2.23 3.17 2.51 2.28 2.06 0.23 5.63 4.97 4.74 4.52 090
fx.
23575.......... ............. A Treat shoulder blade 4.06 5.10 4.04 3.84 3.41 0.41 9.57 8.51 8.31 7.88 090
fx.
23585.......... ............. A Treat scapula fracture 8.96 NA NA 8.66 8.51 0.92 NA NA 18.54 18.39 090
23600.......... ............. A Treat humerus fracture 2.93 4.83 3.99 3.21 3.18 0.30 8.06 7.22 6.44 6.41 090
23605.......... ............. A Treat humerus fracture 4.87 7.30 6.24 5.81 5.49 0.51 12.68 11.62 11.19 10.87 090
23615.......... ............. A Treat humerus fracture 9.35 NA NA 9.10 10.14 0.96 NA NA 19.41 20.45 090
23616.......... ............. A Treat humerus fracture 21.27 NA NA 14.98 19.60 2.19 NA NA 38.44 43.06 090
23620.......... ............. A Treat humerus fracture 2.40 4.54 3.84 3.00 2.22 0.25 7.19 6.49 5.65 4.87 090
23625.......... ............. A Treat humerus fracture 3.93 6.35 5.25 4.82 4.49 0.41 10.69 9.59 9.16 8.83 090
23630.......... ............. A Treat humerus fracture 7.35 NA NA 7.37 8.08 0.75 NA NA 15.47 16.18 090
23650.......... ............. A Treat shoulder 3.39 4.54 3.41 3.05 2.67 0.32 8.25 7.12 6.76 6.38 090
dislocation.
23655.......... ............. A Treat shoulder 4.57 NA NA 3.73 3.46 0.46 NA NA 8.76 8.49 090
dislocation.
23660.......... ............. A Treat shoulder 7.49 NA NA 7.08 8.01 0.69 NA NA 15.26 16.19 090
dislocation.
23665.......... ............. A Treat dislocation/ 4.47 6.51 5.08 5.10 4.37 0.46 11.44 10.01 10.03 9.30 090
fracture.
23670.......... ............. A Treat dislocation/ 7.90 NA NA 7.63 8.53 0.81 NA NA 16.34 17.24 090
fracture.
23675.......... ............. A Treat dislocation/ 6.05 7.38 5.83 5.93 5.10 0.62 14.05 12.50 12.60 11.77 090
fracture.
23680.......... ............. A Treat dislocation/ 10.06 NA NA 8.74 10.38 1.03 NA NA 19.83 21.47 090
fracture.
23700.......... ............. A Fixation of shoulder.. 2.52 NA NA 2.93 2.60 0.26 NA NA 5.71 5.38 010
23800.......... ............. A Fusion of shoulder 14.16 NA NA 13.11 15.01 1.41 NA NA 28.68 30.58 090
joint.
23802.......... ............. A Fusion of shoulder 16.60 NA NA 10.33 12.80 1.70 NA NA 28.63 31.10 090
joint.
23900.......... ............. A Amputation of arm & 19.72 NA NA 14.14 13.89 1.86 NA NA 35.72 35.47 090
girdle.
23920.......... ............. A Amputation at shoulder 14.61 NA NA 11.81 13.42 1.52 NA NA 27.94 29.55 090
joint.
23921.......... ............. A Amputation follow-up 5.49 5.99 5.31 5.96 5.30 0.50 11.98 11.30 11.95 11.29 090
surgery.
23929.......... ............. C Shoulder surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
23930.......... ............. A Drainage of arm lesion 2.94 4.96 3.36 3.46 2.61 0.29 8.19 6.59 6.69 5.84 010
23931.......... ............. A Drainage of arm bursa. 1.79 4.62 2.72 2.99 1.70 0.17 6.58 4.68 4.95 3.66 010
23935.......... ............. A Drain arm/elbow bone 6.09 NA NA 10.32 7.71 0.62 NA NA 17.03 14.42 090
lesion.
24000.......... ............. A Exploratory elbow 5.82 NA NA 5.23 6.09 0.58 NA NA 11.63 12.49 090
surgery.
24006.......... ............. A Release elbow joint... 9.31 NA NA 7.76 7.76 0.96 NA NA 18.03 18.03 090
24065.......... ............. A Biopsy arm/elbow soft 2.08 4.83 2.85 2.77 1.60 0.11 7.02 5.04 4.96 3.79 010
tissue.
24066.......... ............. A Biopsy arm/elbow soft 5.21 7.18 5.06 5.75 4.35 0.55 12.94 10.82 11.51 10.11 090
tissue.
24075.......... ............. A Remove arm/elbow 3.92 6.71 4.43 5.08 3.62 0.38 11.01 8.73 9.38 7.92 090
lesion.
24076.......... ............. A Remove arm/elbow 6.30 NA NA 6.16 5.08 0.64 NA NA 13.10 12.02 090
lesion.
24077.......... ............. A Remove tumor of arm/ 11.76 NA NA 11.59 11.11 1.17 NA NA 24.52 24.04 090
elbow.
24100.......... ............. A Biopsy elbow joint 4.93 NA NA 5.86 5.23 0.46 NA NA 11.25 10.62 090
lining.
24101.......... ............. A Explore/treat elbow 6.13 NA NA 6.05 6.68 0.63 NA NA 12.81 13.44 090
joint.
24102.......... ............. A Remove elbow joint 8.03 NA NA 7.02 8.30 0.83 NA NA 15.88 17.16 090
lining.
24105.......... ............. A Removal of elbow bursa 3.61 NA NA 4.30 4.20 0.37 NA NA 8.28 8.18 090
24110.......... ............. A Remove humerus lesion. 7.39 NA NA 8.21 8.28 0.78 NA NA 16.38 16.45 090
24115.......... ............. A Remove/graft bone 9.63 NA NA 11.53 9.93 0.85 NA NA 22.01 20.41 090
lesion.
24116.......... ............. A Remove/graft bone 11.81 NA NA 10.57 10.56 1.20 NA NA 23.58 23.57 090
lesion.
24120.......... ............. A Remove elbow lesion... 6.65 NA NA 5.85 6.19 0.68 NA NA 13.18 13.52 090
24125.......... ............. A Remove/graft bone 7.89 NA NA 6.55 6.42 0.76 NA NA 15.20 15.07 090
lesion.
24126.......... ............. A Remove/graft bone 8.31 NA NA 6.84 7.44 0.87 NA NA 16.02 16.62 090
lesion.
24130.......... ............. A Removal of head of 6.25 NA NA 5.97 6.63 0.65 NA NA 12.87 13.53 090
radius.
24134.......... ............. A Removal of arm bone 9.73 NA NA 13.12 11.28 0.94 NA NA 23.79 21.95 090
lesion.
24136.......... ............. A Remove radius bone 7.99 NA NA 5.60 7.57 0.80 NA NA 14.39 16.36 090
lesion.
24138.......... ............. A Remove elbow bone 8.05 NA NA 6.95 6.94 0.84 NA NA 15.84 15.83 090
lesion.
24140.......... ............. A Partial removal of arm 9.18 NA NA 13.98 11.75 0.95 NA NA 24.11 21.88 090
bone.
24145.......... ............. A Partial removal of 7.58 NA NA 9.58 8.25 0.77 NA NA 17.93 16.60 090
radius.
24147.......... ............. A Partial removal of 7.54 NA NA 9.24 8.21 0.80 NA NA 17.58 16.55 090
elbow.
24149.......... ............. A Radical resection of 14.20 NA NA 10.60 12.16 1.46 NA NA 26.26 27.82 090
elbow.
24150.......... ............. A Extensive humerus 13.27 NA NA 12.97 14.13 1.34 NA NA 27.58 28.74 090
surgery.
24151.......... ............. A Extensive humerus 15.58 NA NA 13.68 14.35 1.50 NA NA 30.76 31.43 090
surgery.
24152.......... ............. A Extensive radius 10.06 NA NA 8.25 7.82 0.95 NA NA 19.26 18.83 090
surgery.
24153.......... ............. A Extensive radius 11.54 NA NA 6.78 9.06 0.67 NA NA 18.99 21.27 090
surgery.
24155.......... ............. A Removal of elbow joint 11.73 NA NA 8.82 10.25 1.18 NA NA 21.73 23.16 090
24160.......... ............. A Remove elbow joint 7.83 NA NA 6.79 6.02 0.78 NA NA 15.40 14.63 090
implant.
24164.......... ............. A Remove radius head 6.23 NA NA 5.85 5.93 0.65 NA NA 12.73 12.81 090
implant.
24200.......... ............. A Removal of arm foreign 1.76 4.49 2.55 2.69 1.50 0.14 6.39 4.45 4.59 3.40 010
body.
24201.......... ............. A Removal of arm foreign 4.56 7.05 5.19 5.77 4.55 0.48 12.09 10.23 10.81 9.59 090
body.
24220.......... ............. A Injection for elbow x- 1.31 10.17 5.36 0.37 0.46 0.07 11.55 6.74 1.75 1.84 000
ray.
24301.......... ............. A Muscle/tendon transfer 10.20 NA NA 8.44 8.51 1.04 NA NA 19.68 19.75 090
24305.......... ............. A Arm tendon lengthening 7.45 NA NA 6.57 4.96 0.75 NA NA 14.77 13.16 090
24310.......... ............. A Revision of arm tendon 5.98 NA NA 6.79 5.00 0.63 NA NA 13.40 11.61 090
24320.......... ............. A Repair of arm tendon.. 10.56 NA NA 9.85 9.92 0.98 NA NA 21.39 21.46 090
24330.......... ............. A Revision of arm 9.60 NA NA 7.65 8.57 1.03 NA NA 18.28 19.20 090
muscles.
24331.......... ............. A Revision of arm 10.65 NA NA 8.18 9.31 1.11 NA NA 19.94 21.07 090
muscles.
24340.......... ............. A Repair of biceps 7.89 NA NA 6.70 7.15 0.81 NA NA 15.40 15.85 090
tendon.
24341.......... ............. A Repair arm tendon/ 7.90 NA NA 6.86 7.23 0.82 NA NA 15.58 15.95 090
muscle.
24342.......... ............. A Repair of ruptured 10.62 NA NA 8.46 9.86 1.10 NA NA 20.18 21.58 090
tendon.
24350.......... ............. A Repair of tennis elbow 5.25 NA NA 5.24 4.92 0.54 NA NA 11.03 10.71 090
24351.......... ............. A Repair of tennis elbow 5.91 NA NA 5.71 5.34 0.62 NA NA 12.24 11.87 090
24352.......... ............. A Repair of tennis elbow 6.43 NA NA 6.23 6.21 0.66 NA NA 13.32 13.30 090
24354.......... ............. A Repair of tennis elbow 6.48 NA NA 6.15 6.12 0.68 NA NA 13.31 13.28 090
[[Page 59454]]
24356.......... ............. A Revision of tennis 6.68 NA NA 6.14 7.02 0.70 NA NA 13.52 14.40 090
elbow.
24360.......... ............. A Reconstruct elbow 12.34 NA NA 9.17 11.95 1.27 NA NA 22.78 25.56 090
joint.
24361.......... ............. A Reconstruct elbow 14.08 NA NA 9.90 12.08 1.46 NA NA 25.44 27.62 090
joint.
24362.......... ............. A Reconstruct elbow 14.99 NA NA 10.74 8.94 1.34 NA NA 27.07 25.27 090
joint.
24363.......... ............. A Replace elbow joint... 18.49 NA NA 12.73 17.40 1.91 NA NA 33.13 37.80 090
24365.......... ............. A Reconstruct head of 8.39 NA NA 7.27 7.72 0.87 NA NA 16.53 16.98 090
radius.
24366.......... ............. A Reconstruct head of 9.13 NA NA 7.57 9.24 0.95 NA NA 17.65 19.32 090
radius.
24400.......... ............. A Revision of humerus... 11.06 NA NA 11.50 10.33 1.13 NA NA 23.69 22.52 090
24410.......... ............. A Revision of humerus... 14.82 NA NA 12.33 13.79 1.37 NA NA 28.52 29.98 090
24420.......... ............. A Revision of humerus... 13.44 NA NA 14.52 13.94 1.36 NA NA 29.32 28.74 090
24430.......... ............. A Repair of humerus..... 12.81 NA NA 11.38 13.34 1.32 NA NA 25.51 27.47 090
24435.......... ............. A Repair humerus with 13.17 NA NA 12.48 14.11 1.36 NA NA 27.01 28.64 090
graft.
24470.......... ............. A Revision of elbow 8.74 NA NA 7.28 7.94 0.92 NA NA 16.94 17.60 090
joint.
24495.......... ............. A Decompression of 8.12 NA NA 9.44 7.84 0.91 NA NA 18.47 16.87 090
forearm.
24498.......... ............. A Reinforce humerus..... 11.92 NA NA 11.35 11.30 1.23 NA NA 24.50 24.45 090
24500.......... ............. A Treat humerus fracture 3.21 6.75 4.76 2.97 2.87 0.32 10.28 8.29 6.50 6.40 090
24505.......... ............. A Treat humerus fracture 5.17 9.99 7.44 6.03 5.46 0.53 15.69 13.14 11.73 11.16 090
24515.......... ............. A Treat humerus fracture 11.65 NA NA 10.18 10.33 1.16 NA NA 22.99 23.14 090
24516.......... ............. A Treat humerus fracture 11.65 NA NA 10.61 10.54 1.20 NA NA 23.46 23.39 090
24530.......... ............. A Treat humerus fracture 3.50 7.70 5.33 4.28 3.62 0.35 11.55 9.18 8.13 7.47 090
24535.......... ............. A Treat humerus fracture 6.87 10.08 7.67 6.07 5.67 0.72 17.67 15.26 13.66 13.26 090
24538.......... ............. A Treat humerus fracture 9.43 NA NA 9.20 8.93 0.96 NA NA 19.59 19.32 090
24545.......... ............. A Treat humerus fracture 10.46 NA NA 9.08 9.95 1.08 NA NA 20.62 21.49 090
24546.......... ............. A Treat humerus fracture 15.69 NA NA 12.41 11.62 1.62 NA NA 29.72 28.93 090
24560.......... ............. A Treat humerus fracture 2.80 6.54 4.44 2.77 2.56 0.28 9.62 7.52 5.85 5.64 090
24565.......... ............. A Treat humerus fracture 5.56 9.08 6.41 5.22 4.48 0.57 15.21 12.54 11.35 10.61 090
24566.......... ............. A Treat humerus fracture 7.79 NA NA 8.31 7.45 0.78 NA NA 16.88 16.02 090
24575.......... ............. A Treat humerus fracture 10.66 NA NA 7.66 8.06 1.10 NA NA 19.42 19.82 090
24576.......... ............. A Treat humerus fracture 2.86 6.31 4.33 2.86 2.60 0.29 9.46 7.48 6.01 5.75 090
24577.......... ............. A Treat humerus fracture 5.79 9.38 6.86 5.48 4.91 0.60 15.77 13.25 11.87 11.30 090
24579.......... ............. A Treat humerus fracture 11.60 NA NA 9.13 9.11 1.19 NA NA 21.92 21.90 090
24582.......... ............. A Treat humerus fracture 8.55 NA NA 9.10 8.14 0.88 NA NA 18.53 17.57 090
24586.......... ............. A Treat elbow fracture.. 15.21 NA NA 10.20 13.09 1.56 NA NA 26.97 29.86 090
24587.......... ............. A Treat elbow fracture.. 15.16 NA NA 9.96 12.43 1.46 NA NA 26.58 29.05 090
24600.......... ............. A Treat elbow 4.23 8.26 5.19 4.52 3.32 0.42 12.91 9.84 9.17 7.97 090
dislocation.
24605.......... ............. A Treat elbow 5.42 NA NA 4.36 3.43 0.56 NA NA 10.34 9.41 090
dislocation.
24615.......... ............. A Treat elbow 9.42 NA NA 7.13 8.61 0.98 NA NA 17.53 19.01 090
dislocation.
24620.......... ............. A Treat elbow fracture.. 6.98 NA NA 5.98 5.04 0.70 NA NA 13.66 12.72 090
24635.......... ............. A Treat elbow fracture.. 13.19 NA NA 19.27 15.64 1.37 NA NA 33.83 30.20 090
24640.......... ............. A Treat elbow 1.20 5.18 3.14 1.61 1.36 0.11 6.49 4.45 2.92 2.67 010
dislocation.
24650.......... ............. A Treat radius fracture. 2.16 6.23 4.34 2.55 1.89 0.22 8.61 6.72 4.93 4.27 090
24655.......... ............. A Treat radius fracture. 4.40 8.62 5.95 4.66 3.97 0.45 13.47 10.80 9.51 8.82 090
24665.......... ............. A Treat radius fracture. 8.14 NA NA 8.36 8.05 0.84 NA NA 17.34 17.03 090
24666.......... ............. A Treat radius fracture. 9.49 NA NA 9.02 10.09 0.98 NA NA 19.49 20.56 090
24670.......... ............. A Treat ulnar fracture.. 2.54 6.15 4.14 2.73 2.43 0.26 8.95 6.94 5.53 5.23 090
24675.......... ............. A Treat ulnar fracture.. 4.72 8.77 6.29 4.91 4.36 0.49 13.98 11.50 10.12 9.57 090
24685.......... ............. A Treat ulnar fracture.. 8.80 NA NA 8.69 8.91 0.91 NA NA 18.40 18.62 090
24800.......... ............. A Fusion of elbow joint. 11.20 NA NA 8.56 10.03 1.13 NA NA 20.89 22.36 090
24802.......... ............. A Fusion/graft of elbow 13.69 NA NA 10.33 11.78 1.37 NA NA 25.39 26.84 090
joint.
24900.......... ............. A Amputation of upper 9.60 NA NA 9.49 8.91 1.00 NA NA 20.09 19.51 090
arm.
24920.......... ............. A Amputation of upper 9.54 NA NA 10.32 8.84 0.95 NA NA 20.81 19.33 090
arm.
24925.......... ............. A Amputation follow-up 7.07 NA NA 7.69 7.25 0.71 NA NA 15.47 15.03 090
surgery.
24930.......... ............. A Amputation follow-up 10.25 NA NA 10.82 9.84 0.99 NA NA 22.06 21.08 090
surgery.
24931.......... ............. A Amputate upper arm & 12.72 NA NA 8.15 10.14 1.29 NA NA 22.16 24.15 090
implant.
24935.......... ............. A Revision of amputation 15.56 NA NA 11.18 13.03 1.58 NA NA 28.32 30.17 090
24940.......... ............. C Revision of upper arm. 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
24999.......... ............. C Upper arm/elbow 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
surgery.
25000.......... ............. A Incision of tendon 3.38 NA NA 5.80 4.92 0.35 NA NA 9.53 8.65 090
sheath.
25020.......... ............. A Decompression of 5.92 NA NA 9.13 6.93 0.66 NA NA 15.71 13.51 090
forearm.
25023.......... ............. A Decompression of 12.96 NA NA 14.45 10.18 1.34 NA NA 28.75 24.48 090
forearm.
25028.......... ............. A Drainage of forearm 5.25 NA NA 8.56 5.40 0.53 NA NA 14.34 11.18 090
lesion.
25031.......... ............. A Drainage of forearm 4.14 NA NA 8.30 4.51 0.36 NA NA 12.80 9.01 090
bursa.
25035.......... ............. A Treat forearm bone 7.36 NA NA 13.04 9.94 0.74 NA NA 21.14 18.04 090
lesion.
25040.......... ............. A Explore/treat wrist 7.18 NA NA 7.72 6.95 0.74 NA NA 15.64 14.87 090
joint.
25065.......... ............. A Biopsy forearm soft 1.99 2.44 1.63 2.44 1.43 0.10 4.53 3.72 4.53 3.52 010
tissues.
25066.......... ............. A Biopsy forearm soft 4.13 NA NA 6.57 4.12 0.42 NA NA 11.12 8.67 090
tissues.
25075.......... ............. A Removal of forearm 3.74 NA NA 6.22 4.30 0.36 NA NA 10.32 8.40 090
lesion.
25076.......... ............. A Removal of forearm 4.92 NA NA 10.22 7.16 0.51 NA NA 15.65 12.59 090
lesion.
25077.......... ............. A Remove tumor, forearm/ 9.76 NA NA 12.85 11.03 0.97 NA NA 23.58 21.76 090
wrist.
25085.......... ............. A Incision of wrist 5.50 NA NA 8.41 6.71 0.57 NA NA 14.48 12.78 090
capsule.
25100.......... ............. A Biopsy of wrist joint. 3.90 NA NA 5.81 5.24 0.41 NA NA 10.12 9.55 090
25101.......... ............. A Explore/treat wrist 4.69 NA NA 6.40 6.00 0.49 NA NA 11.58 11.18 090
joint.
25105.......... ............. A Remove wrist joint 5.85 NA NA 8.97 7.98 0.60 NA NA 15.42 14.43 090
lining.
25107.......... ............. A Remove wrist joint 6.43 NA NA 9.07 7.40 0.67 NA NA 16.17 14.50 090
cartilage.
25110.......... ............. A Remove wrist tendon 3.92 NA NA 6.81 4.93 0.39 NA NA 11.12 9.24 090
lesion.
25111.......... ............. A Remove wrist tendon 3.39 NA NA 5.23 4.36 0.34 NA NA 8.96 8.09 090
lesion.
25112.......... ............. A Reremove wrist tendon 4.53 NA NA 6.02 5.03 0.47 NA NA 11.02 10.03 090
lesion.
25115.......... ............. A Remove wrist/forearm 8.82 NA NA 13.51 10.63 0.92 NA NA 23.25 20.37 090
lesion.
25116.......... ............. A Remove wrist/forearm 7.11 NA NA 12.46 10.48 0.74 NA NA 20.31 18.33 090
lesion.
25118.......... ............. A Excise wrist tendon 4.37 NA NA 6.29 5.76 0.46 NA NA 11.12 10.59 090
sheath.
25119.......... ............. A Partial removal of 6.04 NA NA 9.12 8.17 0.62 NA NA 15.78 14.83 090
ulna.
[[Page 59455]]
25120.......... ............. A Removal of forearm 6.10 NA NA 11.79 9.44 0.64 NA NA 18.53 16.18 090
lesion.
25125.......... ............. A Remove/graft forearm 7.48 NA NA 12.59 10.01 0.77 NA NA 20.84 18.26 090
lesion.
25126.......... ............. A Remove/graft forearm 7.55 NA NA 11.49 9.44 0.77 NA NA 19.81 17.76 090
lesion.
25130.......... ............. A Removal of wrist 5.26 NA NA 6.62 5.60 0.54 NA NA 12.42 11.40 090
lesion.
25135.......... ............. A Remove & graft wrist 6.89 NA NA 7.48 6.71 0.73 NA NA 15.10 14.33 090
lesion.
25136.......... ............. A Remove & graft wrist 5.97 NA NA 6.48 5.81 0.62 NA NA 13.07 12.40 090
lesion.
25145.......... ............. A Remove forearm bone 6.37 NA NA 11.88 9.17 0.66 NA NA 18.91 16.20 090
lesion.
25150.......... ............. A Partial removal of 7.09 NA NA 9.85 8.55 0.72 NA NA 17.66 16.36 090
ulna.
25151.......... ............. A Partial removal of 7.39 NA NA 12.50 9.37 0.77 NA NA 20.66 17.53 090
radius.
25170.......... ............. A Extensive forearm 11.09 NA NA 14.22 12.42 1.16 NA NA 26.47 24.67 090
surgery.
25210.......... ............. A Removal of wrist bone. 5.95 NA NA 7.05 6.18 0.62 NA NA 13.62 12.75 090
25215.......... ............. A Removal of wrist bones 7.89 NA NA 10.32 9.87 0.81 NA NA 19.02 18.57 090
25230.......... ............. A Partial removal of 5.23 NA NA 6.56 6.30 0.53 NA NA 12.32 12.06 090
radius.
25240.......... ............. A Partial removal of 5.17 NA NA 8.60 7.18 0.53 NA NA 14.30 12.88 090
ulna.
25246.......... ............. A Injection for wrist x- 1.45 8.81 4.68 0.40 0.47 0.06 10.32 6.19 1.91 1.98 000
ray.
25248.......... ............. A Remove forearm foreign 5.14 NA NA 8.97 5.67 0.51 NA NA 14.62 11.32 090
body.
25250.......... ............. A Removal of wrist 6.60 NA NA 7.34 6.73 0.68 NA NA 14.62 14.01 090
prosthesis.
25251.......... ............. A Removal of wrist 9.57 NA NA 12.36 10.66 0.98 NA NA 22.91 21.21 090
prosthesis.
25260.......... ............. A Repair forearm tendon/ 7.80 NA NA 13.24 9.12 0.81 NA NA 21.85 17.73 090
muscle.
25263.......... ............. A Repair forearm tendon/ 7.82 NA NA 14.42 10.34 0.81 NA NA 23.05 18.97 090
muscle.
25265.......... ............. A Repair forearm tendon/ 9.88 NA NA 14.96 11.79 1.02 NA NA 25.86 22.69 090
muscle.
25270.......... ............. A Repair forearm tendon/ 6.00 NA NA 12.30 7.98 0.62 NA NA 18.92 14.60 090
muscle.
25272.......... ............. A Repair forearm tendon/ 7.04 NA NA 12.82 8.28 0.74 NA NA 20.60 16.06 090
muscle.
25274.......... ............. A Repair forearm tendon/ 8.75 NA NA 13.79 10.49 0.91 NA NA 23.45 20.15 090
muscle.
25280.......... ............. A Revise wrist/forearm 7.22 NA NA 12.43 8.51 0.74 NA NA 20.39 16.47 090
tendon.
25290.......... ............. A Incise wrist/forearm 5.29 NA NA 13.83 8.26 0.55 NA NA 19.67 14.10 090
tendon.
25295.......... ............. A Release wrist/forearm 6.55 NA NA 12.25 7.78 0.68 NA NA 19.48 15.01 090
tendon.
25300.......... ............. A Fusion of tendons at 8.80 NA NA 9.37 8.68 0.87 NA NA 19.04 18.35 090
wrist.
25301.......... ............. A Fusion of tendons at 8.40 NA NA 8.58 7.97 0.83 NA NA 17.81 17.20 090
wrist.
25310.......... ............. A Transplant forearm 8.14 NA NA 13.62 10.69 0.84 NA NA 22.60 19.67 090
tendon.
25312.......... ............. A Transplant forearm 9.57 NA NA 14.64 11.46 0.98 NA NA 25.19 22.01 090
tendon.
25315.......... ............. A Revise palsy hand 10.20 NA NA 14.29 11.52 1.10 NA NA 25.59 22.82 090
tendon(s).
25316.......... ............. A Revise palsy hand 12.33 NA NA 16.10 13.79 1.23 NA NA 29.66 27.35 090
tendon(s).
25320.......... ............. A Repair/revise wrist 10.77 NA NA 10.24 9.79 1.11 NA NA 22.12 21.67 090
joint.
25332.......... ............. A Revise wrist joint.... 11.41 NA NA 10.48 10.66 1.16 NA NA 23.05 23.23 090
25335.......... ............. A Realignment of hand... 12.88 NA NA 12.16 12.27 1.36 NA NA 26.40 26.51 090
25337.......... ............. A Reconstruct ulna/ 10.17 NA NA 11.18 10.26 1.06 NA NA 22.41 21.49 090
radioulnar.
25350.......... ............. A Revision of radius.... 8.78 NA NA 13.85 11.06 0.91 NA NA 23.54 20.75 090
25355.......... ............. A Revision of radius.... 10.17 NA NA 13.76 11.83 1.05 NA NA 24.98 23.05 090
25360.......... ............. A Revision of ulna...... 8.43 NA NA 13.95 10.46 0.90 NA NA 23.28 19.79 090
25365.......... ............. A Revise radius & ulna.. 12.40 NA NA 16.87 14.03 1.20 NA NA 30.47 27.63 090
25370.......... ............. A Revise radius or ulna. 13.36 NA NA 13.09 12.93 1.30 NA NA 27.75 27.59 090
25375.......... ............. A Revise radius & ulna.. 13.04 NA NA 15.05 14.79 1.27 NA NA 29.36 29.10 090
25390.......... ............. A Shorten radius or ulna 10.40 NA NA 14.88 12.23 1.07 NA NA 26.35 23.70 090
25391.......... ............. A Lengthen radius or 13.65 NA NA 18.97 15.59 1.42 NA NA 34.04 30.66 090
ulna.
25392.......... ............. A Shorten radius & ulna. 13.95 NA NA 14.47 13.99 1.46 NA NA 29.88 29.40 090
25393.......... ............. A Lengthen radius & ulna 15.87 NA NA 16.54 15.98 1.62 NA NA 34.03 33.47 090
25400.......... ............. A Repair radius or ulna. 10.92 NA NA 14.74 13.22 1.13 NA NA 26.79 25.27 090
25405.......... ............. A Repair/graft radius or 14.38 NA NA 17.88 15.68 1.48 NA NA 33.74 31.54 090
ulna.
25415.......... ............. A Repair radius & ulna.. 13.35 NA NA 19.16 15.78 1.39 NA NA 33.90 30.52 090
25420.......... ............. A Repair/graft radius & 16.33 NA NA 18.64 17.30 1.69 NA NA 36.66 35.32 090
ulna.
25425.......... ............. A Repair/graft radius or 13.21 NA NA 21.63 17.34 1.33 NA NA 36.17 31.88 090
ulna.
25426.......... ............. A Repair/graft radius & 15.82 NA NA 16.66 14.69 1.33 NA NA 33.81 31.84 090
ulna.
25440.......... ............. A Repair/graft wrist 10.44 NA NA 9.46 9.64 1.09 NA NA 20.99 21.17 090
bone.
25441.......... ............. A Reconstruct wrist 12.90 NA NA 11.28 11.81 1.35 NA NA 25.53 26.06 090
joint.
25442.......... ............. A Reconstruct wrist 10.85 NA NA 10.92 9.29 1.13 NA NA 22.90 21.27 090
joint.
25443.......... ............. A Reconstruct wrist 10.39 NA NA 10.94 10.56 1.09 NA NA 22.42 22.04 090
joint.
25444.......... ............. A Reconstruct wrist 11.15 NA NA 11.23 11.12 1.16 NA NA 23.54 23.43 090
joint.
25445.......... ............. A Reconstruct wrist 9.69 NA NA 10.96 11.10 1.00 NA NA 21.65 21.79 090
joint.
25446.......... ............. A Wrist replacement..... 16.55 NA NA 13.82 16.79 1.70 NA NA 32.07 35.04 090
25447.......... ............. A Repair wrist joint(s). 10.37 NA NA 9.91 10.19 1.07 NA NA 21.35 21.63 090
25449.......... ............. A Remove wrist joint 14.49 NA NA 13.47 10.99 1.50 NA NA 29.46 26.98 090
implant.
25450.......... ............. A Revision of wrist 7.87 NA NA 11.63 9.78 0.65 NA NA 20.15 18.30 090
joint.
25455.......... ............. A Revision of wrist 9.49 NA NA 10.99 10.22 0.72 NA NA 21.20 20.43 090
joint.
25490.......... ............. A Reinforce radius...... 9.54 NA NA 12.91 11.17 0.99 NA NA 23.44 21.70 090
25491.......... ............. A Reinforce ulna........ 9.96 NA NA 13.86 11.87 1.04 NA NA 24.86 22.87 090
25492.......... ............. A Reinforce radius and 12.33 NA NA 13.76 12.96 1.29 NA NA 27.38 26.58 090
ulna.
25500.......... ............. A Treat fracture of 2.45 5.89 4.21 2.56 1.92 0.23 8.57 6.89 5.24 4.60 090
radius.
25505.......... ............. A Treat fracture of 5.21 8.97 6.42 5.02 4.45 0.53 14.71 12.16 10.76 10.19 090
radius.
25515.......... ............. A Treat fracture of 9.18 NA NA 8.92 8.60 0.86 NA NA 18.96 18.64 090
radius.
25520.......... ............. A Treat fracture of 6.26 9.24 7.74 5.65 5.94 0.64 16.14 14.64 12.55 12.84 090
radius.
25525.......... ............. A Treat fracture of 12.24 NA NA 10.74 11.42 1.28 NA NA 24.26 24.94 090
radius.
25526.......... ............. A Treat fracture of 12.98 NA NA 17.25 15.06 1.34 NA NA 31.57 29.38 090
radius.
25530.......... ............. A Treat fracture of ulna 2.09 5.92 4.29 2.51 1.88 0.21 8.22 6.59 4.81 4.18 090
25535.......... ............. A Treat fracture of ulna 5.14 8.80 6.34 5.11 4.49 0.51 14.45 11.99 10.76 10.14 090
25545.......... ............. A Treat fracture of ulna 8.90 NA NA 8.64 8.44 0.92 NA NA 18.46 18.26 090
25560.......... ............. A Treat fracture radius 2.44 5.95 4.21 2.59 2.53 0.23 8.62 6.88 5.26 5.20 090
& ulna.
25565.......... ............. A Treat fracture radius 5.63 9.36 7.21 5.19 5.13 0.57 15.56 13.41 11.39 11.33 090
& ulna.
25574.......... ............. A Treat fracture radius 7.01 NA NA 7.62 8.00 0.73 NA NA 15.36 15.74 090
& ulna.
25575.......... ............. A Treat fracture radius/ 10.45 NA NA 9.59 10.60 1.08 NA NA 21.12 22.13 090
ulna.
25600.......... ............. A Treat fracture radius/ 2.63 6.22 4.65 2.74 2.14 0.27 9.12 7.55 5.64 5.04 090
ulna.
[[Page 59456]]
25605.......... ............. A Treat fracture radius/ 5.81 9.47 6.88 5.48 4.89 0.60 15.88 13.29 11.89 11.30 090
ulna.
25611.......... ............. A Treat fracture radius/ 7.77 NA NA 8.46 7.49 0.80 NA NA 17.03 16.06 090
ulna.
25620.......... ............. A Treat fracture radius/ 8.55 NA NA 8.34 8.04 0.88 NA NA 17.77 17.47 090
ulna.
25622.......... ............. A Treat wrist bone 2.61 6.19 4.33 2.72 1.98 0.27 9.07 7.21 5.60 4.86 090
fracture.
25624.......... ............. A Treat wrist bone 4.53 8.75 6.37 4.70 3.35 0.47 13.75 11.37 9.70 8.35 090
fracture.
25628.......... ............. A Treat wrist bone 8.43 NA NA 8.39 8.07 0.89 NA NA 17.71 17.39 090
fracture.
25630.......... ............. A Treat wrist bone 2.88 6.33 4.36 2.71 1.95 0.29 9.50 7.53 5.88 5.12 090
fracture.
25635.......... ............. A Treat wrist bone 4.39 8.59 6.12 4.51 3.17 0.45 13.43 10.96 9.35 8.01 090
fracture.
25645.......... ............. A Treat wrist bone 7.25 NA NA 7.71 7.48 0.75 NA NA 15.71 15.48 090
fracture.
25650.......... ............. A Treat wrist bone 3.05 6.35 4.62 2.94 2.20 0.31 9.71 7.98 6.30 5.56 090
fracture.
25660.......... ............. A Treat wrist 4.76 NA NA 4.74 3.36 0.48 NA NA 9.98 8.60 090
dislocation.
25670.......... ............. A Treat wrist 7.92 NA NA 8.07 7.88 0.82 NA NA 16.81 16.62 090
dislocation.
25675.......... ............. A Treat wrist 4.67 8.28 5.38 4.77 3.62 0.47 13.42 10.52 9.91 8.76 090
dislocation.
25676.......... ............. A Treat wrist 8.04 NA NA 8.06 8.00 0.81 NA NA 16.91 16.85 090
dislocation.
25680.......... ............. A Treat wrist fracture.. 5.99 NA NA 5.71 4.18 0.53 NA NA 12.23 10.70 090
25685.......... ............. A Treat wrist fracture.. 9.78 NA NA 9.27 9.41 0.98 NA NA 20.03 20.17 090
25690.......... ............. A Treat wrist 5.50 NA NA 6.10 5.71 0.56 NA NA 12.16 11.77 090
dislocation.
25695.......... ............. A Treat wrist 8.34 NA NA 8.37 8.01 0.87 NA NA 17.58 17.22 090
dislocation.
25800.......... ............. A Fusion of wrist joint. 9.76 NA NA 9.53 10.60 1.00 NA NA 20.29 21.36 090
25805.......... ............. A Fusion/graft of wrist 11.28 NA NA 10.60 12.04 1.17 NA NA 23.05 24.49 090
joint.
25810.......... ............. A Fusion/graft of wrist 10.57 NA NA 9.88 11.25 1.08 NA NA 21.53 22.90 090
joint.
25820.......... ............. A Fusion of hand bones.. 7.45 NA NA 8.22 8.56 0.74 NA NA 16.41 16.75 090
25825.......... ............. A Fuse hand bones with 9.27 NA NA 9.18 10.13 0.95 NA NA 19.40 20.35 090
graft.
25830.......... ............. A Fusion, radioulnar jnt/ 10.06 NA NA 13.53 11.43 1.03 NA NA 24.62 22.52 090
ulna.
25900.......... ............. A Amputation of forearm. 9.01 NA NA 11.99 9.84 0.95 NA NA 21.95 19.80 090
25905.......... ............. A Amputation of forearm. 9.12 NA NA 13.04 10.38 0.95 NA NA 23.11 20.45 090
25907.......... ............. A Amputation follow-up 7.80 NA NA 12.86 9.55 0.82 NA NA 21.48 18.17 090
surgery.
25909.......... ............. A Amputation follow-up 8.96 NA NA 12.73 9.38 0.96 NA NA 22.65 19.30 090
surgery.
25915.......... ............. A Amputation of forearm. 17.08 NA NA 14.24 15.71 1.83 NA NA 33.15 34.62 090
25920.......... ............. A Amputate hand at wrist 8.68 NA NA 8.24 7.92 0.92 NA NA 17.84 17.52 090
25922.......... ............. A Amputate hand at wrist 7.42 NA NA 8.04 7.03 0.77 NA NA 16.23 15.22 090
25924.......... ............. A Amputation follow-up 8.46 NA NA 8.61 8.38 0.61 NA NA 17.68 17.45 090
surgery.
25927.......... ............. A Amputation of hand.... 8.80 NA NA 11.44 9.14 0.93 NA NA 21.17 18.87 090
25929.......... ............. A Amputation follow-up 7.59 NA NA 7.50 6.32 0.76 NA NA 15.85 14.67 090
surgery.
25931.......... ............. A Amputation follow-up 7.81 NA NA 13.63 9.28 0.79 NA NA 22.23 17.88 090
surgery.
25999.......... ............. C Forearm or wrist 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
surgery.
26010.......... ............. A Drainage of finger 1.54 4.36 2.44 3.16 1.71 0.12 6.02 4.10 4.82 3.37 010
abscess.
26011.......... ............. A Drainage of finger 2.19 5.79 3.73 4.88 3.28 0.22 8.20 6.14 7.29 5.69 010
abscess.
26020.......... ............. A Drain hand tendon 4.67 NA NA 9.73 6.89 0.49 NA NA 14.89 12.05 090
sheath.
26025.......... ............. A Drainage of palm bursa 4.82 NA NA 9.83 7.36 0.50 NA NA 15.15 12.68 090
26030.......... ............. A Drainage of palm 5.93 NA NA 10.46 8.34 0.62 NA NA 17.01 14.89 090
bursa(s).
26034.......... ............. A Treat hand bone lesion 6.23 NA NA 11.65 8.12 0.64 NA NA 18.52 14.99 090
26035.......... ............. A Decompress fingers/ 9.51 NA NA 13.52 9.57 0.97 NA NA 24.00 20.05 090
hand.
26037.......... ............. A Decompress fingers/ 7.25 NA NA 10.26 8.59 0.75 NA NA 18.26 16.59 090
hand.
26040.......... ............. A Release palm 3.33 NA NA 9.42 6.26 0.34 NA NA 13.09 9.93 090
contracture.
26045.......... ............. A Release palm 5.56 NA NA 10.72 7.98 0.57 NA NA 16.85 14.11 090
contracture.
26055.......... ............. A Incise finger tendon 2.69 6.10 4.83 5.85 4.71 0.28 9.07 7.80 8.82 7.68 090
sheath.
26060.......... ............. A Incision of finger 2.81 NA NA 6.07 3.65 0.30 NA NA 9.18 6.76 090
tendon.
26070.......... ............. A Explore/treat hand 3.69 NA NA 8.97 5.24 0.32 NA NA 12.98 9.25 090
joint.
26075.......... ............. A Explore/treat finger 3.79 NA NA 9.44 6.77 0.35 NA NA 13.58 10.91 090
joint.
26080.......... ............. A Explore/treat finger 4.24 NA NA 9.96 6.69 0.43 NA NA 14.63 11.36 090
joint.
26100.......... ............. A Biopsy hand joint 3.67 NA NA 6.79 5.02 0.36 NA NA 10.82 9.05 090
lining.
26105.......... ............. A Biopsy finger joint 3.71 NA NA 9.88 7.21 0.38 NA NA 13.97 11.30 090
lining.
26110.......... ............. A Biopsy finger joint 3.53 NA NA 9.29 6.24 0.36 NA NA 13.18 10.13 090
lining.
26115.......... ............. A Removal of hand lesion 3.86 6.17 4.18 6.17 4.18 0.39 10.42 8.43 10.42 8.43 090
26116.......... ............. A Removal of hand lesion 5.53 NA NA 10.62 7.33 0.57 NA NA 16.72 13.43 090
26117.......... ............. A Remove tumor, hand/ 8.55 NA NA 12.26 8.88 0.88 NA NA 21.69 18.31 090
finger.
26121.......... ............. A Release palm 7.54 NA NA 12.24 10.62 0.78 NA NA 20.56 18.94 090
contracture.
26123.......... ............. A Release palm 9.29 NA NA 13.19 11.54 0.97 NA NA 23.45 21.80 090
contracture.
26125.......... ............. A Release palm 4.61 NA NA 2.50 2.67 0.49 NA NA 7.60 7.77 ZZZ
contracture.
26130.......... ............. A Remove wrist joint 5.42 NA NA 11.89 8.67 0.56 NA NA 17.87 14.65 090
lining.
26135.......... ............. A Revise finger joint, 6.96 NA NA 13.28 9.28 0.73 NA NA 20.97 16.97 090
each.
26140.......... ............. A Revise finger joint, 6.17 NA NA 12.39 8.59 0.64 NA NA 19.20 15.40 090
each.
26145.......... ............. A Tendon excision, palm/ 6.32 NA NA 12.67 8.89 0.66 NA NA 19.65 15.87 090
finger.
26160.......... ............. A Remove tendon sheath 3.15 6.10 4.31 6.03 4.28 0.32 9.57 7.78 9.50 7.75 090
lesion.
26170.......... ............. A Removal of palm 4.77 NA NA 6.99 5.03 0.53 NA NA 12.29 10.33 090
tendon, each.
26180.......... ............. A Removal of finger 5.18 NA NA 7.27 5.81 0.55 NA NA 13.00 11.54 090
tendon.
26185.......... ............. A Remove finger bone.... 5.25 NA NA 7.06 5.83 0.54 NA NA 12.85 11.62 090
26200.......... ............. A Remove hand bone 5.51 NA NA 10.76 7.81 0.56 NA NA 16.83 13.88 090
lesion.
26205.......... ............. A Remove/graft bone 7.70 NA NA 11.85 9.40 0.81 NA NA 20.36 17.91 090
lesion.
26210.......... ............. A Removal of finger 5.15 NA NA 10.94 7.59 0.53 NA NA 16.62 13.27 090
lesion.
26215.......... ............. A Remove/graft finger 7.10 NA NA 11.70 8.86 0.66 NA NA 19.46 16.62 090
lesion.
26230.......... ............. A Partial removal of 6.33 NA NA 10.45 7.54 0.66 NA NA 17.44 14.53 090
hand bone.
26235.......... ............. A Partial removal, 6.19 NA NA 9.86 7.20 0.65 NA NA 16.70 14.04 090
finger bone.
26236.......... ............. A Partial removal, 5.32 NA NA 9.65 6.92 0.55 NA NA 15.52 12.79 090
finger bone.
26250.......... ............. A Extensive hand surgery 7.55 NA NA 13.89 10.20 0.75 NA NA 22.19 18.50 090
26255.......... ............. A Extensive hand surgery 12.43 NA NA 16.86 13.28 1.19 NA NA 30.48 26.90 090
26260.......... ............. A Extensive finger 7.03 NA NA 12.72 9.47 0.72 NA NA 20.47 17.22 090
surgery.
26261.......... ............. A Extensive finger 9.09 NA NA 15.25 11.81 0.66 NA NA 25.00 21.56 090
surgery.
26262.......... ............. A Partial removal of 5.67 NA NA 11.30 8.23 0.59 NA NA 17.56 14.49 090
finger.
26320.......... ............. A Removal of implant 3.98 NA NA 9.96 6.90 0.41 NA NA 14.35 11.29 090
from hand.
[[Page 59457]]
26350.......... ............. A Repair finger/hand 5.99 NA NA 15.17 10.70 0.62 NA NA 21.78 17.31 090
tendon.
26352.......... ............. A Repair/graft hand 7.68 NA NA 16.81 11.99 0.80 NA NA 25.29 20.47 090
tendon.
26356.......... ............. A Repair finger/hand 8.07 NA NA 16.30 12.06 0.85 NA NA 25.22 20.98 090
tendon.
26357.......... ............. A Repair finger/hand 8.58 NA NA 16.28 11.71 0.89 NA NA 25.75 21.18 090
tendon.
26358.......... ............. A Repair/graft hand 9.14 NA NA 16.29 12.16 0.95 NA NA 26.38 22.25 090
tendon.
26370.......... ............. A Repair finger/hand 7.11 NA NA 15.70 11.49 0.74 NA NA 23.55 19.34 090
tendon.
26372.......... ............. A Repair/graft hand 8.76 NA NA 16.71 11.82 0.90 NA NA 26.37 21.48 090
tendon.
26373.......... ............. A Repair finger/hand 8.16 NA NA 15.64 11.54 0.84 NA NA 24.64 20.54 090
tendon.
26390.......... ............. A Revise hand/finger 9.19 NA NA 13.18 10.91 0.95 NA NA 23.32 21.05 090
tendon.
26392.......... ............. A Repair/graft hand 10.26 NA NA 20.11 14.73 1.07 NA NA 31.44 26.06 090
tendon.
26410.......... ............. A Repair hand tendon.... 4.63 NA NA 12.14 7.86 0.48 NA NA 17.25 12.97 090
26412.......... ............. A Repair/graft hand 6.31 NA NA 13.47 10.00 0.66 NA NA 20.44 16.97 090
tendon.
26415.......... ............. A Excision, hand/finger 8.34 NA NA 12.95 10.14 0.74 NA NA 22.03 19.22 090
tendon.
26416.......... ............. A Graft hand or finger 9.37 NA NA 22.26 15.82 0.96 NA NA 32.59 26.15 090
tendon.
26418.......... ............. A Repair finger tendon.. 4.25 NA NA 12.21 8.05 0.44 NA NA 16.90 12.74 090
26420.......... ............. A Repair/graft finger 6.77 NA NA 15.68 10.92 0.70 NA NA 23.15 18.39 090
tendon.
26426.......... ............. A Repair finger/hand 6.15 NA NA 12.86 9.86 0.64 NA NA 19.65 16.65 090
tendon.
26428.......... ............. A Repair/graft finger 7.21 NA NA 14.86 10.42 0.74 NA NA 22.81 18.37 090
tendon.
26432.......... ............. A Repair finger tendon.. 4.02 NA NA 10.07 5.89 0.42 NA NA 14.51 10.33 090
26433.......... ............. A Repair finger tendon.. 4.56 NA NA 10.76 7.52 0.48 NA NA 15.80 12.56 090
26434.......... ............. A Repair/graft finger 6.09 NA NA 11.03 8.20 0.61 NA NA 17.73 14.90 090
tendon.
26437.......... ............. A Realignment of tendons 5.82 NA NA 10.95 7.68 0.61 NA NA 17.38 14.11 090
26440.......... ............. A Release palm/finger 5.02 NA NA 14.09 8.98 0.53 NA NA 19.64 14.53 090
tendon.
26442.......... ............. A Release palm & finger 8.16 NA NA 15.68 9.67 0.85 NA NA 24.69 18.68 090
tendon.
26445.......... ............. A Release hand/finger 4.31 NA NA 13.87 8.70 0.45 NA NA 18.63 13.46 090
tendon.
26449.......... ............. A Release forearm/hand 7.00 NA NA 14.65 10.35 0.74 NA NA 22.39 18.09 090
tendon.
26450.......... ............. A Incision of palm 3.67 NA NA 6.58 4.53 0.38 NA NA 10.63 8.58 090
tendon.
26455.......... ............. A Incision of finger 3.64 NA NA 6.47 4.26 0.38 NA NA 10.49 8.28 090
tendon.
26460.......... ............. A Incise hand/finger 3.46 NA NA 6.22 4.05 0.36 NA NA 10.04 7.87 090
tendon.
26471.......... ............. A Fusion of finger 5.73 NA NA 10.55 7.53 0.59 NA NA 16.87 13.85 090
tendons.
26474.......... ............. A Fusion of finger 5.32 NA NA 10.81 7.91 0.55 NA NA 16.68 13.78 090
tendons.
26476.......... ............. A Tendon lengthening.... 5.18 NA NA 10.62 6.88 0.52 NA NA 16.32 12.58 090
26477.......... ............. A Tendon shortening..... 5.15 NA NA 10.65 7.49 0.53 NA NA 16.33 13.17 090
26478.......... ............. A Lengthening of hand 5.80 NA NA 11.23 7.95 0.60 NA NA 17.63 14.35 090
tendon.
26479.......... ............. A Shortening of hand 5.74 NA NA 11.23 8.49 0.60 NA NA 17.57 14.83 090
tendon.
26480.......... ............. A Transplant hand tendon 6.69 NA NA 14.87 10.98 0.70 NA NA 22.26 18.37 090
26483.......... ............. A Transplant/graft hand 8.29 NA NA 17.30 13.26 0.86 NA NA 26.45 22.41 090
tendon.
26485.......... ............. A Transplant palm tendon 7.70 NA NA 16.49 11.77 0.79 NA NA 24.98 20.26 090
26489.......... ............. A Transplant/graft palm 9.55 NA NA 13.45 8.57 0.86 NA NA 23.86 18.98 090
tendon.
26490.......... ............. A Revise thumb tendon... 8.41 NA NA 12.40 10.44 0.88 NA NA 21.69 19.73 090
26492.......... ............. A Tendon transfer with 9.62 NA NA 13.48 11.49 0.95 NA NA 24.05 22.06 090
graft.
26494.......... ............. A Hand tendon/muscle 8.47 NA NA 16.33 12.12 0.90 NA NA 25.70 21.49 090
transfer.
26496.......... ............. A Revise thumb tendon... 9.59 NA NA 12.49 10.98 1.00 NA NA 23.08 21.57 090
26497.......... ............. A Finger tendon transfer 9.57 NA NA 13.21 10.96 0.96 NA NA 23.74 21.49 090
26498.......... ............. A Finger tendon transfer 14.00 NA NA 16.17 14.48 1.45 NA NA 31.62 29.93 090
26499.......... ............. A Revision of finger.... 8.98 NA NA 14.46 11.44 0.81 NA NA 24.25 21.23 090
26500.......... ............. A Hand tendon 5.96 NA NA 11.42 7.61 0.62 NA NA 18.00 14.19 090
reconstruction.
26502.......... ............. A Hand tendon 7.14 NA NA 11.07 8.40 0.71 NA NA 18.92 16.25 090
reconstruction.
26504.......... ............. A Hand tendon 7.47 NA NA 10.89 9.09 0.74 NA NA 19.10 17.30 090
reconstruction.
26508.......... ............. A Release thumb 6.01 NA NA 11.40 7.95 0.62 NA NA 18.03 14.58 090
contracture.
26510.......... ............. A Thumb tendon transfer. 5.43 NA NA 10.83 7.67 0.56 NA NA 16.82 13.66 090
26516.......... ............. A Fusion of knuckle 7.15 NA NA 11.57 8.04 0.74 NA NA 19.46 15.93 090
joint.
26517.......... ............. A Fusion of knuckle 8.83 NA NA 13.32 10.50 0.90 NA NA 23.05 20.23 090
joints.
26518.......... ............. A Fusion of knuckle 9.02 NA NA 12.86 9.97 0.94 NA NA 22.82 19.93 090
joints.
26520.......... ............. A Release knuckle 5.30 NA NA 14.10 9.48 0.55 NA NA 19.95 15.33 090
contracture.
26525.......... ............. A Release finger 5.33 NA NA 14.22 9.09 0.55 NA NA 20.10 14.97 090
contracture.
26530.......... ............. A Revise knuckle joint.. 6.69 NA NA 16.09 10.85 0.68 NA NA 23.46 18.22 090
26531.......... ............. A Revise knuckle with 7.91 NA NA 15.97 11.60 0.82 NA NA 24.70 20.33 090
implant.
26535.......... ............. A Revise finger joint... 5.24 NA NA 8.30 6.78 0.39 NA NA 13.93 12.41 090
26536.......... ............. A Revise/implant finger 6.37 NA NA 13.37 10.49 0.64 NA NA 20.38 17.50 090
joint.
26540.......... ............. A Repair hand joint..... 6.43 NA NA 11.58 9.40 0.67 NA NA 18.68 16.50 090
26541.......... ............. A Repair hand joint with 8.62 NA NA 13.40 11.55 0.88 NA NA 22.90 21.05 090
graft.
26542.......... ............. A Repair hand joint with 6.78 NA NA 11.42 8.79 0.71 NA NA 18.91 16.28 090
graft.
26545.......... ............. A Reconstruct finger 6.92 NA NA 11.82 8.77 0.73 NA NA 19.47 16.42 090
joint.
26546.......... ............. A Repair nonunion hand.. 8.92 NA NA 13.21 11.01 0.93 NA NA 23.06 20.86 090
26548.......... ............. A Reconstruct finger 8.03 NA NA 12.84 9.56 0.84 NA NA 21.71 18.43 090
joint.
26550.......... ............. A Construct thumb 21.24 NA NA 16.14 18.82 2.24 NA NA 39.62 42.30 090
replacement.
26551.......... ............. A Great toe-hand 46.58 NA NA 28.30 37.08 4.99 NA NA 79.87 88.65 090
transfer.
26553.......... ............. A Single transfer, toe- 46.27 NA NA 27.81 36.68 4.95 NA NA 79.03 87.90 090
hand.
26554.......... ............. A Double transfer, toe- 54.95 NA NA 31.16 42.75 5.74 NA NA 91.85 103.44 090
hand.
26555.......... ............. A Positional change of 16.63 NA NA 17.80 17.26 1.73 NA NA 36.16 35.62 090
finger.
26556.......... ............. A Toe joint transfer.... 47.26 NA NA 31.11 38.71 5.06 NA NA 83.43 91.03 090
26560.......... ............. A Repair of web finger.. 5.38 NA NA 9.32 7.19 0.53 NA NA 15.23 13.10 090
26561.......... ............. A Repair of web finger.. 10.92 NA NA 14.72 12.19 1.13 NA NA 26.77 24.24 090
26562.......... ............. A Repair of web finger.. 9.68 NA NA 13.27 12.42 1.02 NA NA 23.97 23.12 090
26565.......... ............. A Correct metacarpal 6.74 NA NA 12.00 9.16 0.70 NA NA 19.44 16.60 090
flaw.
26567.......... ............. A Correct finger 6.82 NA NA 11.38 8.01 0.71 NA NA 18.91 15.54 090
deformity.
26568.......... ............. A Lengthen metacarpal/ 9.08 NA NA 16.44 12.81 0.91 NA NA 26.43 22.80 090
finger.
26580.......... ............. A Repair hand deformity. 18.18 NA NA 14.34 16.34 1.51 NA NA 34.03 36.03 090
26585.......... ............. A Repair finger 14.05 NA NA 11.86 12.96 0.84 NA NA 26.75 27.85 090
deformity.
26587.......... ............. C Reconstruct extra 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
finger.
[[Page 59458]]
26590.......... ............. A Repair finger 17.96 NA NA 15.57 16.81 1.79 NA NA 35.32 36.56 090
deformity.
26591.......... ............. A Repair muscles of hand 3.25 NA NA 9.92 6.21 0.34 NA NA 13.51 9.80 090
26593.......... ............. A Release muscles of 5.31 NA NA 10.46 7.47 0.55 NA NA 16.32 13.33 090
hand.
26596.......... ............. A Excision constricting 8.95 NA NA 8.17 8.56 0.87 NA NA 17.99 18.38 090
tissue.
26597.......... ............. A Release of scar 9.82 NA NA 13.61 11.16 1.03 NA NA 24.46 22.01 090
contracture.
26600.......... ............. A Treat metacarpal 1.96 5.84 3.76 2.48 1.66 0.20 8.00 5.92 4.64 3.82 090
fracture.
26605.......... ............. A Treat metacarpal 2.85 7.44 4.97 3.73 2.49 0.30 10.59 8.12 6.88 5.64 090
fracture.
26607.......... ............. A Treat metacarpal 5.36 NA NA 6.97 5.41 0.55 NA NA 12.88 11.32 090
fracture.
26608.......... ............. A Treat metacarpal 5.36 NA NA 6.90 5.38 0.56 NA NA 12.82 11.30 090
fracture.
26615.......... ............. A Treat metacarpal 5.33 NA NA 6.60 5.95 0.55 NA NA 12.48 11.83 090
fracture.
26641.......... ............. A Treat thumb 3.94 7.74 4.47 4.35 2.78 0.37 12.05 8.78 8.66 7.09 090
dislocation.
26645.......... ............. A Treat thumb fracture.. 4.41 8.57 5.48 4.60 3.50 0.42 13.40 10.31 9.43 8.33 090
26650.......... ............. A Treat thumb fracture.. 5.72 NA NA 7.24 5.80 0.59 NA NA 13.55 12.11 090
26665.......... ............. A Treat thumb fracture.. 7.60 NA NA 7.78 7.36 0.78 NA NA 16.16 15.74 090
26670.......... ............. A Treat hand dislocation 3.69 7.67 4.36 4.22 2.63 0.35 11.71 8.40 8.26 6.67 090
26675.......... ............. A Treat hand dislocation 4.64 7.84 6.28 3.77 4.24 0.47 12.95 11.39 8.88 9.35 090
26676.......... ............. A Pin hand dislocation.. 5.52 NA NA 7.52 6.40 0.57 NA NA 13.61 12.49 090
26685.......... ............. A Treat hand dislocation 6.98 NA NA 7.41 6.83 0.72 NA NA 15.11 14.53 090
26686.......... ............. A Treat hand dislocation 7.94 NA NA 7.91 7.38 0.81 NA NA 16.66 16.13 090
26700.......... ............. A Treat knuckle 3.69 4.20 2.58 2.56 1.76 0.35 8.24 6.62 6.60 5.80 090
dislocation.
26705.......... ............. A Treat knuckle 4.19 7.30 4.62 3.80 2.87 0.41 11.90 9.22 8.40 7.47 090
dislocation.
26706.......... ............. A Pin knuckle 5.12 NA NA 4.95 5.02 0.53 NA NA 10.60 10.67 090
dislocation.
26715.......... ............. A Treat knuckle 5.74 NA NA 6.73 5.61 0.60 NA NA 13.07 11.95 090
dislocation.
26720.......... ............. A Treat finger fracture, 1.66 2.50 1.85 1.44 1.02 0.16 4.32 3.67 3.26 2.84 090
each.
26725.......... ............. A Treat finger fracture, 3.33 4.31 2.99 2.80 1.82 0.34 7.98 6.66 6.47 5.49 090
each.
26727.......... ............. A Treat finger fracture, 5.23 NA NA 7.08 4.87 0.54 NA NA 12.85 10.64 090
each.
26735.......... ............. A Treat finger fracture, 5.98 NA NA 6.97 5.51 0.61 NA NA 13.56 12.10 090
each.
26740.......... ............. A Treat finger fracture, 1.94 3.06 2.16 2.15 1.39 0.19 5.19 4.29 4.28 3.52 090
each.
26742.......... ............. A Treat finger fracture, 3.85 8.25 5.20 4.44 3.30 0.39 12.49 9.44 8.68 7.54 090
each.
26746.......... ............. A Treat finger fracture, 5.81 NA NA 6.92 6.04 0.61 NA NA 13.34 12.46 090
each.
26750.......... ............. A Treat finger fracture, 1.70 2.92 1.91 2.01 1.46 0.16 4.78 3.77 3.87 3.32 090
each.
26755.......... ............. A Treat finger fracture, 3.10 4.12 2.65 2.58 1.88 0.31 7.53 6.06 5.99 5.29 090
each.
26756.......... ............. A Pin finger fracture, 4.39 NA NA 6.67 4.37 0.46 NA NA 11.52 9.22 090
each.
26765.......... ............. A Treat finger fracture, 4.17 NA NA 6.00 4.45 0.43 NA NA 10.60 9.05 090
each.
26770.......... ............. A Treat finger 3.02 4.03 2.43 2.35 1.59 0.29 7.34 5.74 5.66 4.90 090
dislocation.
26775.......... ............. A Treat finger 3.71 7.16 4.20 3.40 2.32 0.37 11.24 8.28 7.48 6.40 090
dislocation.
26776.......... ............. A Pin finger dislocation 4.80 NA NA 6.85 4.56 0.51 NA NA 12.16 9.87 090
26785.......... ............. A Treat finger 4.21 NA NA 6.03 4.63 0.44 NA NA 10.68 9.28 090
dislocation.
26820.......... ............. A Thumb fusion with 8.26 NA NA 13.37 10.30 0.86 NA NA 22.49 19.42 090
graft.
26841.......... ............. A Fusion of thumb....... 7.13 NA NA 11.93 9.32 0.74 NA NA 19.80 17.19 090
26842.......... ............. A Thumb fusion with 8.24 NA NA 13.45 11.38 0.85 NA NA 22.54 20.47 090
graft.
26843.......... ............. A Fusion of hand joint.. 7.61 NA NA 12.71 9.81 0.76 NA NA 21.08 18.18 090
26844.......... ............. A Fusion/graft of hand 8.73 NA NA 12.58 10.28 0.88 NA NA 22.19 19.89 090
joint.
26850.......... ............. A Fusion of knuckle..... 6.97 NA NA 11.57 8.30 0.73 NA NA 19.27 16.00 090
26852.......... ............. A Fusion of knuckle with 8.46 NA NA 12.81 9.51 0.88 NA NA 22.15 18.85 090
graft.
26860.......... ............. A Fusion of finger joint 4.69 NA NA 10.23 7.45 0.49 NA NA 15.41 12.63 090
26861.......... ............. A Fusion of finger jnt, 1.74 NA NA 0.94 1.51 0.18 NA NA 2.86 3.43 ZZZ
add-on.
26862.......... ............. A Fusion/graft of finger 7.37 NA NA 12.51 9.06 0.76 NA NA 20.64 17.19 090
joint.
26863.......... ............. A Fuse/graft added joint 3.90 NA NA 2.13 2.90 0.40 NA NA 6.43 7.20 ZZZ
26910.......... ............. A Amputate metacarpal 7.60 NA NA 11.56 8.58 0.79 NA NA 19.95 16.97 090
bone.
26951.......... ............. A Amputation of finger/ 4.59 NA NA 10.10 6.61 0.48 NA NA 15.17 11.68 090
thumb.
26952.......... ............. A Amputation of finger/ 6.31 NA NA 11.19 7.77 0.66 NA NA 18.16 14.74 090
thumb.
26989.......... ............. C Hand/finger surgery... 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
26990.......... ............. A Drainage of pelvis 7.48 NA NA 12.99 8.18 0.73 NA NA 21.20 16.39 090
lesion.
26991.......... ............. A Drainage of pelvis 6.68 10.23 6.10 7.86 4.91 0.65 17.56 13.43 15.19 12.24 090
bursa.
26992.......... ............. A Drainage of bone 13.02 NA NA 16.40 11.66 1.36 NA NA 30.78 26.04 090
lesion.
27000.......... ............. A Incision of hip tendon 5.62 NA NA 6.41 4.21 0.58 NA NA 12.61 10.41 090
27001.......... ............. A Incision of hip tendon 6.94 NA NA 7.17 4.86 0.71 NA NA 14.82 12.51 090
27003.......... ............. A Incision of hip tendon 7.34 NA NA 8.16 7.76 0.76 NA NA 16.26 15.86 090
27005.......... ............. A Incision of hip tendon 9.66 NA NA 9.00 6.33 0.98 NA NA 19.64 16.97 090
27006.......... ............. A Incision of hip 9.68 NA NA 9.39 7.22 1.01 NA NA 20.08 17.91 090
tendons.
27025.......... ............. A Incision of hip/thigh 11.16 NA NA 9.43 8.04 1.17 NA NA 21.76 20.37 090
fascia.
27030.......... ............. A Drainage of hip joint. 13.01 NA NA 11.09 11.74 1.34 NA NA 25.44 26.09 090
27033.......... ............. A Exploration of hip 13.39 NA NA 11.32 11.91 1.37 NA NA 26.08 26.67 090
joint.
27035.......... ............. A Denervation of hip 16.69 NA NA 14.60 13.74 1.69 NA NA 32.98 32.12 090
joint.
27036.......... ............. A Excision of hip joint/ 12.88 NA NA 12.60 12.51 1.33 NA NA 26.81 26.72 090
muscle.
27040.......... ............. A Biopsy of soft tissues 2.87 4.90 2.84 3.25 2.02 0.17 7.94 5.88 6.29 5.06 010
27041.......... ............. A Biopsy of soft tissues 9.89 NA NA 7.41 5.16 0.84 NA NA 18.14 15.89 090
27047.......... ............. A Remove hip/pelvis 7.45 8.16 5.11 6.39 4.22 0.74 16.35 13.30 14.58 12.41 090
lesion.
27048.......... ............. A Remove hip/pelvis 6.25 NA NA 7.07 5.89 0.63 NA NA 13.95 12.77 090
lesion.
27049.......... ............. A Remove tumor, hip/ 13.66 NA NA 11.83 11.42 1.33 NA NA 26.82 26.41 090
pelvis.
27050.......... ............. A Biopsy of sacroiliac 4.36 NA NA 5.63 5.41 0.44 NA NA 10.43 10.21 090
joint.
27052.......... ............. A Biopsy of hip joint... 6.23 NA NA 7.19 7.31 0.64 NA NA 14.06 14.18 090
27054.......... ............. A Removal of hip joint 8.54 NA NA 9.32 9.76 0.87 NA NA 18.73 19.17 090
lining.
27060.......... ............. A Removal of ischial 5.43 NA NA 6.07 5.17 0.55 NA NA 12.05 11.15 090
bursa.
27062.......... ............. A Remove femur lesion/ 5.37 NA NA 6.23 5.41 0.55 NA NA 12.15 11.33 090
bursa.
27065.......... ............. A Removal of hip bone 5.90 NA NA 7.45 6.76 0.60 NA NA 13.95 13.26 090
lesion.
27066.......... ............. A Removal of hip bone 10.33 NA NA 11.03 9.80 1.04 NA NA 22.40 21.17 090
lesion.
27067.......... ............. A Remove/graft hip bone 13.83 NA NA 12.98 12.80 1.42 NA NA 28.23 28.05 090
lesion.
27070.......... ............. A Partial removal of hip 10.72 NA NA 15.60 11.82 1.10 NA NA 27.42 23.64 090
bone.
27071.......... ............. A Partial removal of hip 11.46 NA NA 16.05 12.64 1.17 NA NA 28.68 25.27 090
bone.
[[Page 59459]]
27075.......... ............. A Extensive hip surgery. 17.23 NA NA 14.84 14.77 1.76 NA NA 33.83 33.76 090
27076.......... ............. A Extensive hip surgery. 22.12 NA NA 18.03 17.90 2.24 NA NA 42.39 42.26 090
27077.......... ............. A Extensive hip surgery. 23.13 NA NA 18.09 19.35 2.42 NA NA 43.64 44.90 090
27078.......... ............. A Extensive hip surgery. 13.44 NA NA 13.26 11.62 1.39 NA NA 28.09 26.45 090
27079.......... ............. A Extensive hip surgery. 13.75 NA NA 13.49 11.44 1.40 NA NA 28.64 26.59 090
27080.......... ............. A Removal of tail bone.. 6.39 NA NA 6.51 5.85 0.67 NA NA 13.57 12.91 090
27086.......... ............. A Remove hip foreign 1.87 4.24 2.44 3.21 1.77 0.15 6.26 4.46 5.23 3.79 010
body.
27087.......... ............. A Remove hip foreign 8.54 NA NA 7.87 5.90 0.85 NA NA 17.26 15.29 090
body.
27090.......... ............. A Removal of hip 11.15 NA NA 10.12 9.99 1.15 NA NA 22.42 22.29 090
prosthesis.
27091.......... ............. A Removal of hip 22.14 NA NA 16.16 18.83 2.17 NA NA 40.47 43.14 090
prosthesis.
27093.......... ............. A Injection for hip x- 1.30 10.02 5.46 0.44 0.67 0.08 11.40 6.84 1.82 2.05 000
ray.
27095.......... ............. A Injection for hip x- 1.50 10.11 5.56 0.48 0.75 0.09 11.70 7.15 2.07 2.34 000
ray.
27096.......... ............. A Inject sacroiliac 1.10 9.96 9.96 0.36 0.36 0.09 11.15 11.15 1.55 1.55 000
joint.
27097.......... ............. A Revision of hip tendon 8.80 NA NA 8.33 8.35 0.92 NA NA 18.05 18.07 090
27098.......... ............. A Transfer tendon to 8.83 NA NA 8.42 8.40 0.92 NA NA 18.17 18.15 090
pelvis.
27100.......... ............. A Transfer of abdominal 11.08 NA NA 12.18 10.26 1.10 NA NA 24.36 22.44 090
muscle.
27105.......... ............. A Transfer of spinal 11.77 NA NA 10.63 8.51 1.23 NA NA 23.63 21.51 090
muscle.
27110.......... ............. A Transfer of iliopsoas 13.26 NA NA 12.97 12.24 1.18 NA NA 27.41 26.68 090
muscle.
27111.......... ............. A Transfer of iliopsoas 12.15 NA NA 10.50 11.56 1.27 NA NA 23.92 24.98 090
muscle.
27120.......... ............. A Reconstruction of hip 18.01 NA NA 13.53 16.59 1.84 NA NA 33.38 36.44 090
socket.
27122.......... ............. A Reconstruction of hip 14.98 NA NA 12.96 15.43 1.54 NA NA 29.48 31.95 090
socket.
27125.......... ............. A Partial hip 14.69 NA NA 12.42 14.98 1.50 NA NA 28.61 31.17 090
replacement.
27130.......... ............. A Total hip replacement. 20.12 NA NA 15.85 19.94 2.05 NA NA 38.02 42.11 090
27132.......... ............. A Total hip replacement. 23.30 NA NA 17.55 22.69 2.38 NA NA 43.23 48.37 090
27134.......... ............. A Revise hip joint 28.52 NA NA 20.16 27.10 2.92 NA NA 51.60 58.54 090
replacement.
27137.......... ............. A Revise hip joint 21.17 NA NA 16.47 20.88 2.17 NA NA 39.81 44.22 090
replacement.
27138.......... ............. A Revise hip joint 22.17 NA NA 16.86 21.58 2.28 NA NA 41.31 46.03 090
replacement.
27140.......... ............. A Transplant femur ridge 12.24 NA NA 10.64 11.32 1.26 NA NA 24.14 24.82 090
27146.......... ............. A Incision of hip bone.. 17.43 NA NA 14.80 13.31 1.80 NA NA 34.03 32.54 090
27147.......... ............. A Revision of hip bone.. 20.58 NA NA 15.53 16.98 2.08 NA NA 38.19 39.64 090
27151.......... ............. A Incision of hip bones. 22.51 NA NA 9.75 14.49 2.36 NA NA 34.62 39.36 090
27156.......... ............. A Revision of hip bones. 24.63 NA NA 17.40 18.64 2.57 NA NA 44.60 45.84 090
27158.......... ............. A Revision of pelvis.... 19.74 NA NA 12.92 14.29 2.06 NA NA 34.72 36.09 090
27161.......... ............. A Incision of neck of 16.71 NA NA 13.20 14.37 1.71 NA NA 31.62 32.79 090
femur.
27165.......... ............. A Incision/fixation of 17.91 NA NA 13.79 15.99 1.82 NA NA 33.52 35.72 090
femur.
27170.......... ............. A Repair/graft femur 16.07 NA NA 12.80 15.31 1.65 NA NA 30.52 33.03 090
head/neck.
27175.......... ............. A Treat slipped 8.46 NA NA 6.43 3.86 0.89 NA NA 15.78 13.21 090
epiphysis.
27176.......... ............. A Treat slipped 12.05 NA NA 8.79 10.04 1.19 NA NA 22.03 23.28 090
epiphysis.
27177.......... ............. A Treat slipped 15.08 NA NA 10.38 11.92 1.57 NA NA 27.03 28.57 090
epiphysis.
27178.......... ............. A Treat slipped 11.99 NA NA 8.96 10.16 1.03 NA NA 21.98 23.18 090
epiphysis.
27179.......... ............. A Revise head/neck of 12.98 NA NA 9.56 10.83 1.35 NA NA 23.89 25.16 090
femur.
27181.......... ............. A Treat slipped 14.68 NA NA 8.48 11.37 1.37 NA NA 24.53 27.42 090
epiphysis.
27185.......... ............. A Revision of femur 9.18 NA NA 7.75 5.38 0.80 NA NA 17.73 15.36 090
epiphysis.
27187.......... ............. A Reinforce hip bones... 13.54 NA NA 12.20 14.18 1.38 NA NA 27.12 29.10 090
27193.......... ............. A Treat pelvic ring 5.56 6.31 4.47 4.84 3.73 0.57 12.44 10.60 10.97 9.86 090
fracture.
27194.......... ............. A Treat pelvic ring 9.65 8.08 6.16 7.01 5.62 1.01 18.74 16.82 17.67 16.28 090
fracture.
27200.......... ............. A Treat tail bone 1.84 2.52 2.07 1.54 1.58 0.18 4.54 4.09 3.56 3.60 090
fracture.
27202.......... ............. A Treat tail bone 7.04 NA NA 13.51 10.09 0.89 NA NA 21.44 18.02 090
fracture.
27215.......... ............. A Treat pelvic 10.05 NA NA 9.28 10.64 1.00 NA NA 20.33 21.69 090
fracture(s).
27216.......... ............. A Treat pelvic ring 15.19 NA NA 11.12 7.90 1.56 NA NA 27.87 24.65 090
fracture.
27217.......... ............. A Treat pelvic ring 14.11 NA NA 11.51 13.65 1.44 NA NA 27.06 29.20 090
fracture.
27218.......... ............. A Treat pelvic ring 20.15 NA NA 11.37 13.58 1.96 NA NA 33.48 35.69 090
fracture.
27220.......... ............. A Treat hip socket 6.18 6.69 5.66 5.18 4.90 0.64 13.51 12.48 12.00 11.72 090
fracture.
27222.......... ............. A Treat hip socket 12.70 NA NA 9.27 8.09 1.32 NA NA 23.29 22.11 090
fracture.
27226.......... ............. A Treat hip wall 14.91 NA NA 12.19 14.66 1.11 NA NA 28.21 30.68 090
fracture.
27227.......... ............. A Treat hip fracture(s). 23.45 NA NA 16.06 18.72 2.53 NA NA 42.04 44.70 090
27228.......... ............. A Treat hip fracture(s). 27.16 NA NA 18.21 19.93 2.79 NA NA 48.16 49.88 090
27230.......... ............. A Treat thigh fracture.. 5.50 6.61 5.10 5.35 4.47 0.55 12.66 11.15 11.40 10.52 090
27232.......... ............. A Treat thigh fracture.. 10.68 NA NA 8.28 9.02 1.11 NA NA 20.07 20.81 090
27235.......... ............. A Treat thigh fracture.. 12.16 NA NA 9.92 12.22 1.25 NA NA 23.33 25.63 090
27236.......... ............. A Treat thigh fracture.. 15.60 NA NA 11.85 15.10 1.59 NA NA 29.04 32.29 090
27238.......... ............. A Treat thigh fracture.. 5.52 NA NA 5.40 5.37 0.56 NA NA 11.48 11.45 090
27240.......... ............. A Treat thigh fracture.. 12.50 NA NA 9.26 9.90 1.30 NA NA 23.06 23.70 090
27244.......... ............. A Treat thigh fracture.. 15.94 NA NA 12.01 14.85 1.63 NA NA 29.58 32.42 090
27245.......... ............. A Treat thigh fracture.. 20.31 NA NA 14.39 16.04 2.09 NA NA 36.79 38.44 090
27246.......... ............. A Treat thigh fracture.. 4.71 6.25 5.23 5.03 4.62 0.49 11.45 10.43 10.23 9.82 090
27248.......... ............. A Treat thigh fracture.. 10.45 NA NA 9.05 10.77 1.06 NA NA 20.56 22.28 090
27250.......... ............. A Treat hip dislocation. 6.95 NA NA 5.57 4.52 0.68 NA NA 13.20 12.15 090
27252.......... ............. A Treat hip dislocation. 10.39 NA NA 7.47 6.09 1.08 NA NA 18.94 17.56 090
27253.......... ............. A Treat hip dislocation. 12.92 NA NA 10.05 12.16 1.33 NA NA 24.30 26.41 090
27254.......... ............. A Treat hip dislocation. 18.26 NA NA 12.35 13.49 1.83 NA NA 32.44 33.58 090
27256.......... ............. A Treat hip dislocation. 4.12 NA NA 4.36 3.20 0.39 NA NA 8.87 7.71 010
27257.......... ............. A Treat hip dislocation. 5.22 NA NA 4.17 4.59 0.53 NA NA 9.92 10.34 010
27258.......... ............. A Treat hip dislocation. 15.43 NA NA 12.67 13.79 1.58 NA NA 29.68 30.80 090
27259.......... ............. A Treat hip dislocation. 21.55 NA NA 15.89 17.28 2.14 NA NA 39.58 40.97 090
27265.......... ............. A Treat hip dislocation. 5.05 NA NA 5.16 4.46 0.53 NA NA 10.74 10.04 090
27266.......... ............. A Treat hip dislocation. 7.49 NA NA 6.52 5.68 0.78 NA NA 14.79 13.95 090
27275.......... ............. A Manipulation of hip 2.27 NA NA 2.93 2.49 0.24 NA NA 5.44 5.00 010
joint.
27280.......... ............. A Fusion of sacroiliac 13.39 NA NA 13.14 12.03 1.38 NA NA 27.91 26.80 090
joint.
27282.......... ............. A Fusion of pubic bones. 11.34 NA NA 10.85 10.32 0.84 NA NA 23.03 22.50 090
27284.......... ............. A Fusion of hip joint... 16.76 NA NA 12.67 14.21 1.65 NA NA 31.08 32.62 090
[[Page 59460]]
27286.......... ............. A Fusion of hip joint... 16.79 NA NA 14.71 15.61 1.76 NA NA 33.26 34.16 090
27290.......... ............. A Amputation of leg at 23.28 NA NA 15.53 21.55 2.28 NA NA 41.09 47.11 090
hip.
27295.......... ............. A Amputation of leg at 18.65 NA NA 13.27 15.61 1.97 NA NA 33.89 36.23 090
hip.
27299.......... ............. C Pelvis/hip joint 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
surgery.
27301.......... ............. A Drain thigh/knee 6.49 13.32 8.00 11.90 7.29 0.67 20.48 15.16 19.06 14.45 090
lesion.
27303.......... ............. A Drainage of bone 8.28 NA NA 12.65 9.51 0.85 NA NA 21.78 18.64 090
lesion.
27305.......... ............. A Incise thigh tendon & 5.92 NA NA 8.01 6.07 0.63 NA NA 14.56 12.62 090
fascia.
27306.......... ............. A Incision of thigh 4.62 NA NA 6.47 4.32 0.48 NA NA 11.57 9.42 090
tendon.
27307.......... ............. A Incision of thigh 5.80 NA NA 6.83 5.05 0.60 NA NA 13.23 11.45 090
tendons.
27310.......... ............. A Exploration of knee 9.27 NA NA 9.00 9.71 0.95 NA NA 19.22 19.93 090
joint.
27315.......... ............. A Partial removal, thigh 6.97 NA NA 4.69 5.27 0.72 NA NA 12.38 12.96 090
nerve.
27320.......... ............. A Partial removal, thigh 6.30 NA NA 4.28 4.95 0.62 NA NA 11.20 11.87 090
nerve.
27323.......... ............. A Biopsy, thigh soft 2.28 4.86 2.93 3.04 1.77 0.14 7.28 5.35 5.46 4.19 010
tissues.
27324.......... ............. A Biopsy, thigh soft 4.90 NA NA 5.98 4.42 0.53 NA NA 11.41 9.85 090
tissues.
27327.......... ............. A Removal of thigh 4.47 7.18 4.84 5.50 4.00 0.45 12.10 9.76 10.42 8.92 090
lesion.
27328.......... ............. A Removal of thigh 5.57 NA NA 6.17 5.30 0.56 NA NA 12.30 11.43 090
lesion.
27329.......... ............. A Remove tumor, thigh/ 14.14 NA NA 13.00 12.85 1.40 NA NA 28.54 28.39 090
knee.
27330.......... ............. A Biopsy, knee joint 4.97 NA NA 5.46 5.70 0.51 NA NA 10.94 11.18 090
lining.
27331.......... ............. A Explore/treat knee 5.88 NA NA 6.59 6.81 0.60 NA NA 13.07 13.29 090
joint.
27332.......... ............. A Removal of knee 8.27 NA NA 7.66 8.77 0.83 NA NA 16.76 17.87 090
cartilage.
27333.......... ............. A Removal of knee 7.30 NA NA 7.10 7.91 0.74 NA NA 15.14 15.95 090
cartilage.
27334.......... ............. A Remove knee joint 8.70 NA NA 8.61 9.50 0.90 NA NA 18.21 19.10 090
lining.
27335.......... ............. A Remove knee joint 10.00 NA NA 9.62 10.78 1.02 NA NA 20.64 21.80 090
lining.
27340.......... ............. A Removal of kneecap 4.18 NA NA 4.99 4.59 0.43 NA NA 9.60 9.20 090
bursa.
27345.......... ............. A Removal of knee cyst.. 5.92 NA NA 6.52 6.32 0.61 NA NA 13.05 12.85 090
27347.......... ............. A Remove knee cyst...... 5.78 2.58 2.58 2.58 2.58 0.59 8.95 8.95 8.95 8.95 090
27350.......... ............. A Removal of kneecap.... 8.17 NA NA 7.96 8.86 0.84 NA NA 16.97 17.87 090
27355.......... ............. A Remove femur lesion... 7.65 NA NA 9.59 8.91 0.78 NA NA 18.02 17.34 090
27356.......... ............. A Remove femur lesion/ 9.48 NA NA 10.28 9.59 0.97 NA NA 20.73 20.04 090
graft.
27357.......... ............. A Remove femur lesion/ 10.53 NA NA 10.41 9.98 1.08 NA NA 22.02 21.59 090
graft.
27358.......... ............. A Remove femur lesion/ 4.74 NA NA 2.50 3.72 0.49 NA NA 7.73 8.95 ZZZ
fixation.
27360.......... ............. A Partial removal, leg 10.50 NA NA 15.68 12.49 1.09 NA NA 27.27 24.08 090
bone(s).
27365.......... ............. A Extensive leg surgery. 16.27 NA NA 13.63 14.38 1.64 NA NA 31.54 32.29 090
27370.......... ............. A Injection for knee x- 0.96 10.37 5.51 0.27 0.46 0.04 11.37 6.51 1.27 1.46 000
ray.
27372.......... ............. A Removal of foreign 5.07 6.85 5.28 5.80 4.76 0.51 12.43 10.86 11.38 10.34 090
body.
27380.......... ............. A Repair of kneecap 7.16 NA NA 7.38 7.97 0.74 NA NA 15.28 15.87 090
tendon.
27381.......... ............. A Repair/graft kneecap 10.34 NA NA 9.17 10.70 1.07 NA NA 20.58 22.11 090
tendon.
27385.......... ............. A Repair of thigh muscle 7.76 NA NA 7.87 8.57 0.79 NA NA 16.42 17.12 090
27386.......... ............. A Repair/graft of thigh 10.56 NA NA 9.97 11.29 1.08 NA NA 21.61 22.93 090
muscle.
27390.......... ............. A Incision of thigh 5.33 NA NA 6.50 5.62 0.54 NA NA 12.37 11.49 090
tendon.
27391.......... ............. A Incision of thigh 7.20 NA NA 7.62 6.75 0.75 NA NA 15.57 14.70 090
tendons.
27392.......... ............. A Incision of thigh 9.20 NA NA 9.32 8.82 0.93 NA NA 19.45 18.95 090
tendons.
27393.......... ............. A Lengthening of thigh 6.39 NA NA 7.41 6.78 0.64 NA NA 14.44 13.81 090
tendon.
27394.......... ............. A Lengthening of thigh 8.50 NA NA 9.05 7.64 0.87 NA NA 18.42 17.01 090
tendons.
27395.......... ............. A Lengthening of thigh 11.73 NA NA 12.41 11.89 1.21 NA NA 25.35 24.83 090
tendons.
27396.......... ............. A Transplant of thigh 7.86 NA NA 8.75 8.21 0.80 NA NA 17.41 16.87 090
tendon.
27397.......... ............. A Transplants of thigh 11.28 NA NA 10.42 10.03 1.17 NA NA 22.87 22.48 090
tendons.
27400.......... ............. A Revise thigh muscles/ 9.02 NA NA 9.38 8.97 0.92 NA NA 19.32 18.91 090
tendons.
27403.......... ............. A Repair of knee 8.33 NA NA 8.07 8.81 0.86 NA NA 17.26 18.00 090
cartilage.
27405.......... ............. A Repair of knee 8.65 NA NA 8.85 9.59 0.89 NA NA 18.39 19.13 090
ligament.
27407.......... ............. A Repair of knee 10.28 NA NA 9.51 9.57 1.02 NA NA 20.81 20.87 090
ligament.
27409.......... ............. A Repair of knee 12.90 NA NA 11.22 13.31 1.34 NA NA 25.46 27.55 090
ligaments.
27418.......... ............. A Repair degenerated 10.85 NA NA 9.78 11.37 1.12 NA NA 21.75 23.34 090
kneecap.
27420.......... ............. A Revision of unstable 9.83 NA NA 8.75 10.24 0.99 NA NA 19.57 21.06 090
kneecap.
27422.......... ............. A Revision of unstable 9.78 NA NA 9.01 10.35 1.00 NA NA 19.79 21.13 090
kneecap.
27424.......... ............. A Revision/removal of 9.81 NA NA 8.77 10.24 1.02 NA NA 19.60 21.07 090
kneecap.
27425.......... ............. A Lateral retinacular 5.22 NA NA 6.23 6.23 0.53 NA NA 11.98 11.98 090
release.
27427.......... ............. A Reconstruction, knee.. 9.36 NA NA 8.73 9.96 0.94 NA NA 19.03 20.26 090
27428.......... ............. A Reconstruction, knee.. 14.00 NA NA 11.89 13.37 1.40 NA NA 27.29 28.77 090
27429.......... ............. A Reconstruction, knee.. 15.52 NA NA 11.48 11.86 1.56 NA NA 28.56 28.94 090
27430.......... ............. A Revision of thigh 9.67 NA NA 8.74 9.45 0.97 NA NA 19.38 20.09 090
muscles.
27435.......... ............. A Incision of knee joint 9.49 NA NA 8.58 8.11 0.98 NA NA 19.05 18.58 090
27437.......... ............. A Revise kneecap........ 8.46 NA NA 8.51 9.31 0.85 NA NA 17.82 18.62 090
27438.......... ............. A Revise kneecap with 11.23 NA NA 10.23 11.82 1.15 NA NA 22.61 24.20 090
implant.
27440.......... ............. A Revision of knee joint 10.43 NA NA 9.78 11.12 0.73 NA NA 20.94 22.28 090
27441.......... ............. A Revision of knee joint 10.82 NA NA 9.65 9.79 0.78 NA NA 21.25 21.39 090
27442.......... ............. A Revision of knee joint 11.89 NA NA 10.33 12.27 1.22 NA NA 23.44 25.38 090
27443.......... ............. A Revision of knee joint 10.93 NA NA 9.98 11.51 1.12 NA NA 22.03 23.56 090
27445.......... ............. A Revision of knee joint 17.68 NA NA 13.43 17.27 1.83 NA NA 32.94 36.78 090
27446.......... ............. A Revision of knee joint 15.84 NA NA 13.34 16.13 1.60 NA NA 30.78 33.57 090
27447.......... ............. A Total knee replacement 21.48 NA NA 16.12 20.88 2.19 NA NA 39.79 44.55 090
27448.......... ............. A Incision of thigh..... 11.06 NA NA 10.55 11.88 1.14 NA NA 22.75 24.08 090
27450.......... ............. A Incision of thigh..... 13.98 NA NA 12.66 14.39 1.43 NA NA 28.07 29.80 090
27454.......... ............. A Realignment of thigh 17.56 NA NA 13.57 15.31 1.76 NA NA 32.89 34.63 090
bone.
27455.......... ............. A Realignment of knee... 12.82 NA NA 11.39 12.21 1.27 NA NA 25.48 26.30 090
27457.......... ............. A Realignment of knee... 13.45 NA NA 10.87 12.65 1.37 NA NA 25.69 27.47 090
27465.......... ............. A Shortening of thigh 13.87 NA NA 13.06 13.17 1.43 NA NA 28.36 28.47 090
bone.
27466.......... ............. A Lengthening of thigh 16.33 NA NA 14.92 14.75 1.67 NA NA 32.92 32.75 090
bone.
27468.......... ............. A Shorten/lengthen 18.97 NA NA 13.23 15.76 1.94 NA NA 34.14 36.67 090
thighs.
27470.......... ............. A Repair of thigh....... 16.07 NA NA 14.73 16.41 1.64 NA NA 32.44 34.12 090
27472.......... ............. A Repair/graft of thigh. 17.72 NA NA 15.45 18.30 1.83 NA NA 35.00 37.85 090
[[Page 59461]]
27475.......... ............. A Surgery to stop leg 8.64 NA NA 8.15 8.28 0.86 NA NA 17.65 17.78 090
growth.
27477.......... ............. A Surgery to stop leg 9.85 NA NA 9.26 10.51 0.96 NA NA 20.07 21.32 090
growth.
27479.......... ............. A Surgery to stop leg 12.80 NA NA 10.12 11.37 1.35 NA NA 24.27 25.52 090
growth.
27485.......... ............. A Surgery to stop leg 8.84 NA NA 8.17 8.38 0.89 NA NA 17.90 18.11 090
growth.
27486.......... ............. A Revise/replace knee 19.27 NA NA 14.99 19.00 1.97 NA NA 36.23 40.24 090
joint.
27487.......... ............. A Revise/replace knee 25.27 NA NA 18.20 24.17 2.57 NA NA 46.04 52.01 090
joint.
27488.......... ............. A Removal of knee 15.74 NA NA 13.12 15.33 1.61 NA NA 30.47 32.68 090
prosthesis.
27495.......... ............. A Reinforce thigh....... 15.55 NA NA 14.29 16.43 1.59 NA NA 31.43 33.57 090
27496.......... ............. A Decompression of thigh/ 6.11 NA NA 7.14 6.03 0.66 NA NA 13.91 12.80 090
knee.
27497.......... ............. A Decompression of thigh/ 7.17 NA NA 7.77 6.90 0.75 NA NA 15.69 14.82 090
knee.
27498.......... ............. A Decompression of thigh/ 7.99 NA NA 7.28 7.07 0.87 NA NA 16.14 15.93 090
knee.
27499.......... ............. A Decompression of thigh/ 9.00 NA NA 7.78 7.84 0.93 NA NA 17.71 17.77 090
knee.
27500.......... ............. A Treatment of thigh 5.92 13.49 9.68 6.36 6.12 0.61 20.02 16.21 12.89 12.65 090
fracture.
27501.......... ............. A Treatment of thigh 5.92 14.23 10.05 7.23 6.55 0.62 20.77 16.59 13.77 13.09 090
fracture.
27502.......... ............. A Treatment of thigh 10.58 NA NA 9.64 8.98 1.10 NA NA 21.32 20.66 090
fracture.
27503.......... ............. A Treatment of thigh 10.58 NA NA 9.73 9.03 1.10 NA NA 21.41 20.71 090
fracture.
27506.......... ............. A Treatment of thigh 17.45 NA NA 13.28 15.34 1.79 NA NA 32.52 34.58 090
fracture.
27507.......... ............. A Treatment of thigh 13.99 NA NA 11.41 14.06 1.43 NA NA 26.83 29.48 090
fracture.
27508.......... ............. A Treatment of thigh 5.83 8.67 6.63 4.90 4.74 0.60 15.10 13.06 11.33 11.17 090
fracture.
27509.......... ............. A Treatment of thigh 7.71 NA NA 7.88 6.23 0.80 NA NA 16.39 14.74 090
fracture.
27510.......... ............. A Treatment of thigh 9.13 NA NA 6.73 7.07 0.95 NA NA 16.81 17.15 090
fracture.
27511.......... ............. A Treatment of thigh 13.64 NA NA 11.87 14.08 1.40 NA NA 26.91 29.12 090
fracture.
27513.......... ............. A Treatment of thigh 17.92 NA NA 14.12 15.76 1.83 NA NA 33.87 35.51 090
fracture.
27514.......... ............. A Treatment of thigh 17.30 NA NA 13.27 15.19 1.78 NA NA 32.35 34.27 090
fracture.
27516.......... ............. A Treat thigh fx growth 5.37 9.25 7.24 5.23 5.23 0.56 15.18 13.17 11.16 11.16 090
plate.
27517.......... ............. A Treat thigh fx growth 8.78 9.41 8.95 7.02 7.76 0.90 19.09 18.63 16.70 17.44 090
plate.
27519.......... ............. A Treat thigh fx growth 15.02 NA NA 12.76 13.26 1.51 NA NA 29.29 29.79 090
plate.
27520.......... ............. A Treat kneecap fracture 2.86 7.06 5.18 3.39 2.52 0.30 10.22 8.34 6.55 5.68 090
27524.......... ............. A Treat kneecap fracture 10.00 NA NA 8.08 9.65 1.03 NA NA 19.11 20.68 090
27530.......... ............. A Treat knee fracture... 3.78 7.55 5.62 3.86 3.78 0.39 11.72 9.79 8.03 7.95 090
27532.......... ............. A Treat knee fracture... 7.30 6.83 6.50 5.34 5.75 0.76 14.89 14.56 13.40 13.81 090
27535.......... ............. A Treat knee fracture... 11.50 NA NA 10.80 11.75 1.18 NA NA 23.48 24.43 090
27536.......... ............. A Treat knee fracture... 15.65 NA NA 11.05 11.87 1.61 NA NA 28.31 29.13 090
27538.......... ............. A Treat knee fracture(s) 4.87 8.86 6.26 4.92 4.29 0.51 14.24 11.64 10.30 9.67 090
27540.......... ............. A Treat knee fracture... 13.10 NA NA 9.51 10.70 1.33 NA NA 23.94 25.13 090
27550.......... ............. A Treat knee dislocation 5.76 8.76 5.78 5.20 4.00 0.57 15.09 12.11 11.53 10.33 090
27552.......... ............. A Treat knee dislocation 7.90 NA NA 6.95 5.34 0.82 NA NA 15.67 14.06 090
27556.......... ............. A Treat knee dislocation 14.41 NA NA 12.97 13.26 1.51 NA NA 28.89 29.18 090
27557.......... ............. A Treat knee dislocation 16.77 NA NA 14.42 15.13 1.72 NA NA 32.91 33.62 090
27558.......... ............. A Treat knee dislocation 17.72 NA NA 14.59 15.22 1.80 NA NA 34.11 34.74 090
27560.......... ............. A Treat kneecap 3.82 7.55 4.55 3.64 2.60 0.36 11.73 8.73 7.82 6.78 090
dislocation.
27562.......... ............. A Treat kneecap 5.79 NA NA 4.98 5.30 0.59 NA NA 11.36 11.68 090
dislocation.
27566.......... ............. A Treat kneecap 12.23 NA NA 9.14 10.31 1.26 NA NA 22.63 23.80 090
dislocation.
27570.......... ............. A Fixation of knee joint 1.74 NA NA 2.65 2.26 0.18 NA NA 4.57 4.18 010
27580.......... ............. A Fusion of knee........ 19.37 NA NA 15.00 16.02 1.98 NA NA 36.35 37.37 090
27590.......... ............. A Amputate leg at thigh. 12.03 NA NA 11.59 10.74 1.30 NA NA 24.92 24.07 090
27591.......... ............. A Amputate leg at thigh. 12.68 NA NA 12.90 12.84 1.34 NA NA 26.92 26.86 090
27592.......... ............. A Amputate leg at thigh. 10.02 NA NA 10.43 9.62 1.07 NA NA 21.52 20.71 090
27594.......... ............. A Amputation follow-up 6.92 NA NA 7.95 5.96 0.75 NA NA 15.62 13.63 090
surgery.
27596.......... ............. A Amputation follow-up 10.60 NA NA 10.81 9.41 1.15 NA NA 22.56 21.16 090
surgery.
27598.......... ............. A Amputate lower leg at 10.53 NA NA 10.20 10.55 1.10 NA NA 21.83 22.18 090
knee.
27599.......... ............. C Leg surgery procedure. 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
27600.......... ............. A Decompression of lower 5.65 NA NA 7.35 5.52 0.65 NA NA 13.65 11.82 090
leg.
27601.......... ............. A Decompression of lower 5.64 NA NA 7.47 5.57 0.64 NA NA 13.75 11.85 090
leg.
27602.......... ............. A Decompression of lower 7.35 NA NA 7.41 5.91 0.86 NA NA 15.62 14.12 090
leg.
27603.......... ............. A Drain lower leg lesion 4.94 13.17 7.88 8.84 5.71 0.50 18.61 13.32 14.28 11.15 090
27604.......... ............. A Drain lower leg bursa. 4.47 8.77 4.94 7.10 3.83 0.37 13.61 9.78 11.94 8.67 090
27605.......... ............. A Incision of achilles 2.87 7.07 4.18 3.48 2.38 0.28 10.22 7.33 6.63 5.53 010
tendon.
27606.......... ............. A Incision of achilles 4.14 8.16 5.23 4.43 3.37 0.42 12.72 9.79 8.99 7.93 010
tendon.
27607.......... ............. A Treat lower leg bone 7.97 NA NA 12.52 9.52 0.80 NA NA 21.29 18.29 090
lesion.
27610.......... ............. A Explore/treat ankle 8.34 NA NA 8.90 8.48 0.84 NA NA 18.08 17.66 090
joint.
27612.......... ............. A Exploration of ankle 7.33 NA NA 7.19 7.92 0.68 NA NA 15.20 15.93 090
joint.
27613.......... ............. A Biopsy lower leg soft 2.17 5.38 3.06 2.63 1.50 0.13 7.68 5.36 4.93 3.80 010
tissue.
27614.......... ............. A Biopsy lower leg soft 5.66 9.15 5.80 6.20 4.33 0.55 15.36 12.01 12.41 10.54 090
tissue.
27615.......... ............. A Remove tumor, lower 12.56 NA NA 13.71 11.32 1.26 NA NA 27.53 25.14 090
leg.
27618.......... ............. A Remove lower leg 5.09 9.98 6.13 5.68 3.98 0.48 15.55 11.70 11.25 9.55 090
lesion.
27619.......... ............. A Remove lower leg 8.40 10.50 7.49 7.85 6.17 0.80 19.70 16.69 17.05 15.37 090
lesion.
27620.......... ............. A Explore/treat ankle 5.98 NA NA 7.02 6.78 0.58 NA NA 13.58 13.34 090
joint.
27625.......... ............. A Remove ankle joint 8.30 NA NA 8.55 9.00 0.78 NA NA 17.63 18.08 090
lining.
27626.......... ............. A Remove ankle joint 8.91 NA NA 9.00 9.82 0.88 NA NA 18.79 19.61 090
lining.
27630.......... ............. A Removal of tendon 4.80 9.81 6.59 5.84 4.60 0.45 15.06 11.84 11.09 9.85 090
lesion.
27635.......... ............. A Remove lower leg bone 7.78 NA NA 9.63 9.18 0.78 NA NA 18.19 17.74 090
lesion.
27637.......... ............. A Remove/graft leg bone 9.85 NA NA 10.94 10.07 1.01 NA NA 21.80 20.93 090
lesion.
27638.......... ............. A Remove/graft leg bone 10.57 NA NA 11.27 10.60 1.06 NA NA 22.90 22.23 090
lesion.
27640.......... ............. A Partial removal of 11.37 NA NA 15.30 12.98 1.14 NA NA 27.81 25.49 090
tibia.
27641.......... ............. A Partial removal of 9.24 NA NA 13.84 10.79 0.92 NA NA 24.00 20.95 090
fibula.
27645.......... ............. A Extensive lower leg 14.17 NA NA 15.28 13.96 1.46 NA NA 30.91 29.59 090
surgery.
27646.......... ............. A Extensive lower leg 12.66 NA NA 15.63 13.65 1.24 NA NA 29.53 27.55 090
surgery.
27647.......... ............. A Extensive ankle/heel 12.24 NA NA 10.11 10.46 1.02 NA NA 23.37 23.72 090
surgery.
27648.......... ............. A Injection for ankle x- 0.96 8.03 4.30 0.29 0.43 0.05 9.04 5.31 1.30 1.44 000
ray.
27650.......... ............. A Repair achilles tendon 9.69 NA NA 8.48 9.12 0.95 NA NA 19.12 19.76 090
[[Page 59462]]
27652.......... ............. A Repair/graft achilles 10.33 NA NA 8.56 9.93 0.98 NA NA 19.87 21.24 090
tendon.
27654.......... ............. A Repair of achilles 10.02 NA NA 8.89 10.38 0.90 NA NA 19.81 21.30 090
tendon.
27656.......... ............. A Repair leg fascia 4.57 11.57 7.51 6.19 4.82 0.44 16.58 12.52 11.20 9.83 090
defect.
27658.......... ............. A Repair of leg tendon, 4.98 11.28 7.82 7.64 6.00 0.46 16.72 13.26 13.08 11.44 090
each.
27659.......... ............. A Repair of leg tendon, 6.81 11.75 9.06 8.24 7.31 0.61 19.17 16.48 15.66 14.73 090
each.
27664.......... ............. A Repair of leg tendon, 4.59 9.13 6.42 7.53 5.62 0.45 14.17 11.46 12.57 10.66 090
each.
27665.......... ............. A Repair of leg tendon, 5.40 12.40 8.89 8.13 6.75 0.53 18.33 14.82 14.06 12.68 090
each.
27675.......... ............. A Repair lower leg 7.18 NA NA 7.12 7.04 0.69 NA NA 14.99 14.91 090
tendons.
27676.......... ............. A Repair lower leg 8.42 NA NA 8.11 8.16 0.74 NA NA 17.27 17.32 090
tendons.
27680.......... ............. A Release of lower leg 5.74 NA NA 6.74 5.61 0.54 NA NA 13.02 11.89 090
tendon.
27681.......... ............. A Release of lower leg 6.82 NA NA 7.32 6.90 0.68 NA NA 14.82 14.40 090
tendons.
27685.......... ............. A Revision of lower leg 6.50 7.41 5.79 7.41 5.79 0.56 14.47 12.85 14.47 12.85 090
tendon.
27686.......... ............. A Revise lower leg 7.46 8.56 7.84 8.31 7.72 0.74 16.76 16.04 16.51 15.92 090
tendons.
27687.......... ............. A Revision of calf 6.24 NA NA 7.25 6.58 0.56 NA NA 14.05 13.38 090
tendon.
27690.......... ............. A Revise lower leg 8.71 NA NA 8.14 7.73 0.76 NA NA 17.61 17.20 090
tendon.
27691.......... ............. A Revise lower leg 9.96 NA NA 10.02 9.29 0.95 NA NA 20.93 20.20 090
tendon.
27692.......... ............. A Revise additional leg 1.87 NA NA 0.90 1.55 0.19 NA NA 2.96 3.61 ZZZ
tendon.
27695.......... ............. A Repair of ankle 6.51 NA NA 7.87 7.82 0.63 NA NA 15.01 14.96 090
ligament.
27696.......... ............. A Repair of ankle 8.27 NA NA 8.71 8.19 0.76 NA NA 17.74 17.22 090
ligaments.
27698.......... ............. A Repair of ankle 9.36 NA NA 8.48 9.83 0.84 NA NA 18.68 20.03 090
ligament.
27700.......... ............. A Revision of ankle 9.29 NA NA 6.90 9.00 0.68 NA NA 16.87 18.97 090
joint.
27702.......... ............. A Reconstruct ankle 13.67 NA NA 11.60 13.96 1.41 NA NA 26.68 29.04 090
joint.
27703.......... ............. A Reconstruction, ankle 15.87 NA NA 11.39 13.20 1.32 NA NA 28.58 30.39 090
joint.
27704.......... ............. A Removal of ankle 7.62 NA NA 8.14 7.24 0.67 NA NA 16.43 15.53 090
implant.
27705.......... ............. A Incision of tibia..... 10.38 NA NA 10.22 10.94 1.06 NA NA 21.66 22.38 090
27707.......... ............. A Incision of fibula.... 4.37 NA NA 7.19 6.17 0.45 NA NA 12.01 10.99 090
27709.......... ............. A Incision of tibia & 9.95 NA NA 9.98 10.93 1.02 NA NA 20.95 21.90 090
fibula.
27712.......... ............. A Realignment of lower 14.25 NA NA 12.42 12.18 1.46 NA NA 28.13 27.89 090
leg.
27715.......... ............. A Revision of lower leg. 14.39 NA NA 13.00 13.35 1.47 NA NA 28.86 29.21 090
27720.......... ............. A Repair of tibia....... 11.79 NA NA 12.04 13.06 1.21 NA NA 25.04 26.06 090
27722.......... ............. A Repair/graft of tibia. 11.82 NA NA 11.45 11.43 1.21 NA NA 24.48 24.46 090
27724.......... ............. A Repair/graft of tibia. 14.99 NA NA 13.86 15.34 1.54 NA NA 30.39 31.87 090
27725.......... ............. A Repair of lower leg... 15.59 NA NA 13.98 12.65 1.58 NA NA 31.15 29.82 090
27727.......... ............. A Repair of lower leg... 14.01 NA NA 12.39 11.29 1.41 NA NA 27.81 26.71 090
27730.......... ............. A Repair of tibia 7.41 13.83 8.87 8.57 6.24 0.74 21.98 17.02 16.72 14.39 090
epiphysis.
27732.......... ............. A Repair of fibula 5.32 13.02 9.14 6.78 6.02 0.53 18.87 14.99 12.63 11.87 090
epiphysis.
27734.......... ............. A Repair lower leg 8.48 NA NA 8.16 8.17 0.76 NA NA 17.40 17.41 090
epiphyses.
27740.......... ............. A Repair of leg 9.30 17.83 13.45 8.59 8.83 0.97 28.10 23.72 18.86 19.10 090
epiphyses.
27742.......... ............. A Repair of leg 10.30 14.94 12.51 8.98 9.53 0.93 26.17 23.74 20.21 20.76 090
epiphyses.
27745.......... ............. A Reinforce tibia....... 10.07 NA NA 10.81 10.27 1.02 NA NA 21.90 21.36 090
27750.......... ............. A Treatment of tibia 3.19 7.22 5.48 3.53 3.64 0.32 10.73 8.99 7.04 7.15 090
fracture.
27752.......... ............. A Treatment of tibia 5.84 9.50 7.51 5.54 5.53 0.61 15.95 13.96 11.99 11.98 090
fracture.
27756.......... ............. A Treatment of tibia 6.78 NA NA 9.12 8.61 0.70 NA NA 16.60 16.09 090
fracture.
27758.......... ............. A Treatment of tibia 11.67 NA NA 11.03 12.48 1.19 NA NA 23.89 25.34 090
fracture.
27759.......... ............. A Treatment of tibia 13.76 NA NA 12.13 13.52 1.41 NA NA 27.30 28.69 090
fracture.
27760.......... ............. A Treatment of ankle 3.01 6.94 4.87 3.46 2.43 0.31 10.26 8.19 6.78 5.75 090
fracture.
27762.......... ............. A Treatment of ankle 5.25 8.95 6.30 5.12 4.39 0.53 14.73 12.08 10.90 10.17 090
fracture.
27766.......... ............. A Treatment of ankle 8.36 NA NA 7.52 8.03 0.86 NA NA 16.74 17.25 090
fracture.
27780.......... ............. A Treatment of fibula 2.65 4.70 3.42 3.23 2.15 0.26 7.61 6.33 6.14 5.06 090
fracture.
27781.......... ............. A Treatment of fibula 4.40 8.05 5.81 4.20 3.89 0.45 12.90 10.66 9.05 8.74 090
fracture.
27784.......... ............. A Treatment of fibula 7.11 NA NA 7.47 6.77 0.73 NA NA 15.31 14.61 090
fracture.
27786.......... ............. A Treatment of ankle 2.84 6.94 4.84 3.37 2.37 0.29 10.07 7.97 6.50 5.50 090
fracture.
27788.......... ............. A Treatment of ankle 4.45 7.97 5.76 4.16 2.97 0.46 12.88 10.67 9.07 7.88 090
fracture.
27792.......... ............. A Treatment of ankle 7.66 NA NA 7.21 7.61 0.78 NA NA 15.65 16.05 090
fracture.
27808.......... ............. A Treatment of ankle 2.83 7.80 5.42 3.94 3.49 0.29 10.92 8.54 7.06 6.61 090
fracture.
27810.......... ............. A Treatment of ankle 5.13 8.97 7.23 5.11 5.30 0.53 14.63 12.89 10.77 10.96 090
fracture.
27814.......... ............. A Treatment of ankle 10.68 NA NA 9.75 10.30 1.10 NA NA 21.53 22.08 090
fracture.
27816.......... ............. A Treatment of ankle 2.89 7.40 5.59 3.98 3.72 0.29 10.58 8.77 7.16 6.90 090
fracture.
27818.......... ............. A Treatment of ankle 5.50 9.18 7.88 5.29 5.93 0.56 15.24 13.94 11.35 11.99 090
fracture.
27822.......... ............. A Treatment of ankle 9.20 NA NA 34.89 22.94 0.95 NA NA 45.04 33.09 090
fracture.
27823.......... ............. A Treatment of ankle 11.80 NA NA 35.41 24.65 1.21 NA NA 48.42 37.66 090
fracture.
27824.......... ............. A Treat lower leg 2.89 7.79 5.78 3.90 3.68 0.29 10.97 8.96 7.08 6.86 090
fracture.
27825.......... ............. A Treat lower leg 6.19 9.70 8.39 5.71 6.39 0.64 16.53 15.22 12.54 13.22 090
fracture.
27826.......... ............. A Treat lower leg 8.54 NA NA 33.17 21.68 0.88 NA NA 42.59 31.10 090
fracture.
27827.......... ............. A Treat lower leg 14.06 NA NA 36.76 24.74 1.44 NA NA 52.26 40.24 090
fracture.
27828.......... ............. A Treat lower leg 16.23 NA NA 38.05 25.97 1.67 NA NA 55.95 43.87 090
fracture.
27829.......... ............. A Treat lower leg joint. 5.49 NA NA 25.16 15.86 0.56 NA NA 31.21 21.91 090
27830.......... ............. A Treat lower leg 3.79 7.44 5.49 3.48 3.51 0.38 11.61 9.66 7.65 7.68 090
dislocation.
27831.......... ............. A Treat lower leg 4.56 NA NA 4.50 4.41 0.46 NA NA 9.52 9.43 090
dislocation.
27832.......... ............. A Treat lower leg 6.49 NA NA 7.50 6.85 0.68 NA NA 14.67 14.02 090
dislocation.
27840.......... ............. A Treat ankle 4.58 NA NA 5.05 3.54 0.45 NA NA 10.08 8.57 090
dislocation.
27842.......... ............. A Treat ankle 6.21 NA NA 4.62 3.52 0.64 NA NA 11.47 10.37 090
dislocation.
27846.......... ............. A Treat ankle 9.79 NA NA 9.03 9.18 0.96 NA NA 19.78 19.93 090
dislocation.
27848.......... ............. A Treat ankle 11.20 NA NA 26.90 17.99 1.15 NA NA 39.25 30.34 090
dislocation.
27860.......... ............. A Fixation of ankle 2.34 NA NA 2.95 2.23 0.23 NA NA 5.52 4.80 010
joint.
27870.......... ............. A Fusion of ankle joint. 13.91 NA NA 12.58 13.53 1.40 NA NA 27.89 28.84 090
27871.......... ............. A Fusion of tibiofibular 9.17 NA NA 9.70 9.08 0.92 NA NA 19.79 19.17 090
joint.
27880.......... ............. A Amputation of lower 11.85 NA NA 10.82 9.95 1.27 NA NA 23.94 23.07 090
leg.
27881.......... ............. A Amputation of lower 12.34 NA NA 11.88 11.81 1.31 NA NA 25.53 25.46 090
leg.
27882.......... ............. A Amputation of lower 8.94 NA NA 10.97 9.48 0.98 NA NA 20.89 19.40 090
leg.
27884.......... ............. A Amputation follow-up 8.21 NA NA 9.47 6.57 0.89 NA NA 18.57 15.67 090
surgery.
[[Page 59463]]
27886.......... ............. A Amputation follow-up 9.32 NA NA 9.50 8.64 1.01 NA NA 19.83 18.97 090
surgery.
27888.......... ............. A Amputation of foot at 9.67 NA NA 9.74 10.02 1.01 NA NA 20.42 20.70 090
ankle.
27889.......... ............. A Amputation of foot at 9.98 NA NA 8.62 8.89 1.10 NA NA 19.70 19.97 090
ankle.
27892.......... ............. A Decompression of leg.. 7.39 NA NA 7.23 5.46 0.80 NA NA 15.42 13.65 090
27893.......... ............. A Decompression of leg.. 7.35 NA NA 6.59 5.13 0.69 NA NA 14.63 13.17 090
27894.......... ............. A Decompression of leg.. 10.49 NA NA 8.55 6.48 1.12 NA NA 20.16 18.09 090
27899.......... ............. C Leg/ankle surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
28001.......... ............. A Drainage of bursa of 2.73 4.29 2.43 2.72 1.50 0.18 7.20 5.34 5.63 4.41 010
foot.
28002.......... ............. A Treatment of foot 4.62 5.47 3.96 3.77 3.11 0.37 10.46 8.95 8.76 8.10 010
infection.
28003.......... ............. A Treatment of foot 8.41 8.65 6.23 8.65 5.28 0.66 17.72 15.30 17.72 14.35 090
infection.
28005.......... ............. A Treat foot bone lesion 8.68 NA NA 8.74 6.59 0.74 NA NA 18.16 16.01 090
28008.......... ............. A Incision of foot 4.45 6.03 4.47 5.13 4.02 0.31 10.79 9.23 9.89 8.78 090
fascia.
28010.......... ............. A Incision of toe tendon 2.84 5.56 4.75 3.93 2.95 0.19 8.59 7.78 6.96 5.98 090
28011.......... ............. A Incision of toe 4.14 6.81 4.37 5.68 3.32 0.33 11.28 8.84 10.15 7.79 090
tendons.
28020.......... ............. A Exploration of foot 5.01 7.49 6.14 5.44 5.11 0.41 12.91 11.56 10.86 10.53 090
joint.
28022.......... ............. A Exploration of foot 4.67 6.14 4.56 4.92 3.21 0.35 11.16 9.58 9.94 8.23 090
joint.
28024.......... ............. A Exploration of toe 4.38 6.24 4.42 4.94 3.12 0.32 10.94 9.12 9.64 7.82 090
joint.
28030.......... ............. A Removal of foot nerve. 6.15 NA NA 3.19 3.73 0.42 NA NA 9.76 10.30 090
28035.......... ............. A Decompression of tibia 5.09 6.42 6.57 4.67 5.38 0.42 11.93 12.08 10.18 10.89 090
nerve.
28043.......... ............. A Excision of foot 3.54 5.67 3.78 4.11 3.00 0.27 9.48 7.59 7.92 6.81 090
lesion.
28045.......... ............. A Excision of foot 4.72 6.25 5.29 4.71 4.52 0.36 11.33 10.37 9.79 9.60 090
lesion.
28046.......... ............. A Resection of tumor, 10.18 9.19 7.50 8.94 7.38 0.82 20.19 18.50 19.94 18.38 090
foot.
28050.......... ............. A Biopsy of foot joint 4.25 5.48 4.83 4.55 4.36 0.33 10.06 9.41 9.13 8.94 090
lining.
28052.......... ............. A Biopsy of foot joint 3.94 5.60 4.88 4.86 3.47 0.32 9.86 9.14 9.12 7.73 090
lining.
28054.......... ............. A Biopsy of toe joint 3.45 5.61 4.02 5.38 3.91 0.29 9.35 7.76 9.12 7.65 090
lining.
28060.......... ............. A Partial removal, foot 5.23 6.68 5.63 5.39 4.99 0.38 12.29 11.24 11.00 10.60 090
fascia.
28062.......... ............. A Removal of foot fascia 6.52 8.28 7.97 5.26 6.46 0.45 15.25 14.94 12.23 13.43 090
28070.......... ............. A Removal of foot joint 5.10 5.82 5.34 5.12 4.99 0.37 11.29 10.81 10.59 10.46 090
lining.
28072.......... ............. A Removal of foot joint 4.58 6.77 5.13 5.79 4.64 0.41 11.76 10.12 10.78 9.63 090
lining.
28080.......... ............. A Removal of foot lesion 3.58 5.74 5.08 4.36 4.39 0.26 9.58 8.92 8.20 8.23 090
28086.......... ............. A Excise foot tendon 4.78 8.36 5.88 6.81 5.10 0.47 13.61 11.13 12.06 10.35 090
sheath.
28088.......... ............. A Excise foot tendon 3.86 6.48 5.21 5.56 4.75 0.35 10.69 9.42 9.77 8.96 090
sheath.
28090.......... ............. A Removal of foot lesion 4.41 6.05 4.67 4.50 3.89 0.32 10.78 9.40 9.23 8.62 090
28092.......... ............. A Removal of toe lesions 3.64 6.70 4.45 4.84 3.52 0.28 10.62 8.37 8.76 7.44 090
28100.......... ............. A Removal of ankle/heel 5.66 8.69 6.83 6.40 5.69 0.49 14.84 12.98 12.55 11.84 090
lesion.
28102.......... ............. A Remove/graft foot 7.73 NA NA 7.47 7.45 0.72 NA NA 15.92 15.90 090
lesion.
28103.......... ............. A Remove/graft foot 6.50 13.37 9.73 5.53 5.81 0.52 20.39 16.75 12.55 12.83 090
lesion.
28104.......... ............. A Removal of foot lesion 5.12 6.59 5.65 5.78 5.24 0.38 12.09 11.15 11.28 10.74 090
28106.......... ............. A Remove/graft foot 7.16 NA NA 6.39 6.68 0.53 NA NA 14.08 14.37 090
lesion.
28107.......... ............. A Remove/graft foot 5.56 6.30 5.79 5.98 5.63 0.40 12.26 11.75 11.94 11.59 090
lesion.
28108.......... ............. A Removal of toe lesions 4.16 5.54 5.05 4.26 3.27 0.28 9.98 9.49 8.70 7.71 090
28110.......... ............. A Part removal of 4.08 6.57 5.18 5.63 4.71 0.31 10.96 9.57 10.02 9.10 090
metatarsal.
28111.......... ............. A Part removal of 5.01 8.06 6.77 6.19 5.83 0.42 13.49 12.20 11.62 11.26 090
metatarsal.
28112.......... ............. A Part removal of 4.49 6.79 5.55 5.98 5.14 0.35 11.63 10.39 10.82 9.98 090
metatarsal.
28113.......... ............. A Part removal of 4.79 6.76 5.79 5.69 5.26 0.36 11.91 10.94 10.84 10.41 090
metatarsal.
28114.......... ............. A Removal of metatarsal 9.79 9.29 9.62 9.29 9.62 0.82 19.90 20.23 19.90 20.23 090
heads.
28116.......... ............. A Revision of foot...... 7.75 6.87 6.41 5.72 5.84 0.56 15.18 14.72 14.03 14.15 090
28118.......... ............. A Removal of heel bone.. 5.96 6.71 6.46 5.92 6.06 0.48 13.15 12.90 12.36 12.50 090
28119.......... ............. A Removal of heel spur.. 5.39 6.38 6.14 4.99 5.45 0.37 12.14 11.90 10.75 11.21 090
28120.......... ............. A Part removal of ankle/ 5.40 10.25 7.86 7.60 6.54 0.47 16.12 13.73 13.47 12.41 090
heel.
28122.......... ............. A Partial removal of 7.29 8.45 6.66 7.79 6.33 0.56 16.30 14.51 15.64 14.18 090
foot bone.
28124.......... ............. A Partial removal of toe 4.81 7.08 5.77 6.06 4.15 0.32 12.21 10.90 11.19 9.28 090
28126.......... ............. A Partial removal of toe 3.52 6.03 5.18 5.45 3.81 0.24 9.79 8.94 9.21 7.57 090
28130.......... ............. A Removal of ankle bone. 8.11 NA NA 7.68 7.66 0.75 NA NA 16.54 16.52 090
28140.......... ............. A Removal of metatarsal. 6.91 7.40 6.38 6.50 5.93 0.59 14.90 13.88 14.00 13.43 090
28150.......... ............. A Removal of toe........ 4.09 6.52 5.05 5.65 4.61 0.32 10.93 9.46 10.06 9.02 090
28153.......... ............. A Partial removal of toe 3.66 6.07 5.20 4.36 3.27 0.24 9.97 9.10 8.26 7.17 090
28160.......... ............. A Partial removal of toe 3.74 6.22 5.35 5.69 3.97 0.27 10.23 9.36 9.70 7.98 090
28171.......... ............. A Extensive foot surgery 9.60 NA NA 6.75 7.71 0.62 NA NA 16.97 17.93 090
28173.......... ............. A Extensive foot surgery 8.80 8.71 7.47 7.49 6.86 0.71 18.22 16.98 17.00 16.37 090
28175.......... ............. A Extensive foot surgery 6.05 7.17 6.51 5.67 5.76 0.41 13.63 12.97 12.13 12.22 090
28190.......... ............. A Removal of foot 1.96 5.06 2.81 2.93 1.61 0.13 7.15 4.90 5.02 3.70 010
foreign body.
28192.......... ............. A Removal of foot 4.64 6.55 4.34 4.58 3.35 0.36 11.55 9.34 9.58 8.35 090
foreign body.
28193.......... ............. A Removal of foot 5.73 6.71 4.65 5.35 3.97 0.42 12.86 10.80 11.50 10.12 090
foreign body.
28200.......... ............. A Repair of foot tendon. 4.60 6.36 5.93 5.25 5.37 0.33 11.29 10.86 10.18 10.30 090
28202.......... ............. A Repair/graft of foot 6.84 6.81 6.57 5.74 6.03 0.53 14.18 13.94 13.11 13.40 090
tendon.
28208.......... ............. A Repair of foot tendon. 4.37 6.05 4.55 4.77 3.91 0.31 10.73 9.23 9.45 8.59 090
28210.......... ............. A Repair/graft of foot 6.35 7.96 7.02 5.72 5.90 0.46 14.77 13.83 12.53 12.71 090
tendon.
28220.......... ............. A Release of foot tendon 4.53 5.92 5.06 4.94 3.52 0.30 10.75 9.89 9.77 8.35 090
28222.......... ............. A Release of foot 5.62 6.33 6.64 5.86 4.67 0.36 12.31 12.62 11.84 10.65 090
tendons.
28225.......... ............. A Release of foot tendon 3.66 5.68 4.13 4.54 3.56 0.25 9.59 8.04 8.45 7.47 090
28226.......... ............. A Release of foot 4.53 5.90 4.79 5.11 4.39 0.33 10.76 9.65 9.97 9.25 090
tendons.
28230.......... ............. A Incision of foot 4.24 6.00 4.32 5.45 3.39 0.31 10.55 8.87 10.00 7.94 090
tendon(s).
28232.......... ............. A Incision of toe tendon 3.39 6.13 3.94 5.18 3.03 0.25 9.77 7.58 8.82 6.67 090
28234.......... ............. A Incision of foot 3.37 6.28 3.97 4.60 2.72 0.24 9.89 7.58 8.21 6.33 090
tendon.
28238.......... ............. A Revision of foot 7.73 7.16 7.51 6.43 7.14 0.56 15.45 15.80 14.72 15.43 090
tendon.
28240.......... ............. A Release of big toe.... 4.36 5.87 4.09 5.11 3.71 0.32 10.55 8.77 9.79 8.39 090
28250.......... ............. A Revision of foot 5.92 6.77 5.81 6.08 5.46 0.42 13.11 12.15 12.42 11.80 090
fascia.
28260.......... ............. A Release of midfoot 7.96 7.25 6.03 6.19 5.50 0.57 15.78 14.56 14.72 14.03 090
joint.
28261.......... ............. A Revision of foot 11.73 9.10 7.76 8.32 7.37 0.84 21.67 20.33 20.89 19.94 090
tendon.
28262.......... ............. A Revision of foot and 15.83 14.39 13.66 12.98 12.96 1.48 31.70 30.97 30.29 30.27 090
ankle.
[[Page 59464]]
28264.......... ............. A Release of midfoot 10.35 8.63 9.51 8.63 9.51 0.86 19.84 20.72 19.84 20.72 090
joint.
28270.......... ............. A Release of foot 4.76 6.49 4.67 5.77 3.60 0.32 11.57 9.75 10.85 8.68 090
contracture.
28272.......... ............. A Release of toe joint, 3.80 5.63 3.92 4.32 2.72 0.24 9.67 7.96 8.36 6.76 090
each.
28280.......... ............. A Fusion of toes........ 5.19 6.49 4.45 5.75 4.08 0.45 12.13 10.09 11.39 9.72 090
28285.......... ............. A Repair of hammertoe... 4.59 6.48 5.61 5.33 5.04 0.32 11.39 10.52 10.24 9.95 090
28286.......... ............. A Repair of hammertoe... 4.56 6.41 5.15 5.09 4.49 0.32 11.29 10.03 9.97 9.37 090
28288.......... ............. A Partial removal of 4.74 6.67 5.37 6.53 5.30 0.38 11.79 10.49 11.65 10.42 090
foot bone.
28289.......... ............. A Repair hallux rigidus. 7.04 2.82 2.82 2.82 2.82 0.55 10.41 10.41 10.41 10.41 090
28290.......... ............. A Correction of bunion.. 5.66 7.28 6.55 7.18 6.50 0.46 13.40 12.67 13.30 12.62 090
28292.......... ............. A Correction of bunion.. 7.04 7.53 7.59 6.30 6.98 0.50 15.07 15.13 13.84 14.52 090
28293.......... ............. A Correction of bunion.. 9.15 8.54 9.45 6.71 8.54 0.61 18.30 19.21 16.47 18.30 090
28294.......... ............. A Correction of bunion.. 8.56 8.06 9.00 6.55 8.25 0.55 17.17 18.11 15.66 17.36 090
28296.......... ............. A Correction of bunion.. 9.18 8.59 9.08 7.34 8.45 0.66 18.43 18.92 17.18 18.29 090
28297.......... ............. A Correction of bunion.. 9.18 8.47 9.13 8.47 9.13 0.74 18.39 19.05 18.39 19.05 090
28298.......... ............. A Correction of bunion.. 7.94 7.89 8.68 6.92 8.20 0.54 16.37 17.16 15.40 16.68 090
28299.......... ............. A Correction of bunion.. 8.88 8.11 9.36 6.93 8.77 0.61 17.60 18.85 16.42 18.26 090
28300.......... ............. A Incision of heel bone. 9.54 11.65 9.37 8.35 7.72 0.87 22.06 19.78 18.76 18.13 090
28302.......... ............. A Incision of ankle bone 9.55 11.95 10.80 8.50 9.08 0.78 22.28 21.13 18.83 19.41 090
28304.......... ............. A Incision of midfoot 9.16 8.59 7.79 6.97 6.98 0.68 18.43 17.63 16.81 16.82 090
bones.
28305.......... ............. A Incise/graft midfoot 10.50 13.89 12.29 9.66 10.18 0.61 25.00 23.40 20.77 21.29 090
bones.
28306.......... ............. A Incision of metatarsal 5.86 6.50 5.73 5.36 5.16 0.45 12.81 12.04 11.67 11.47 090
28307.......... ............. A Incision of metatarsal 6.33 7.85 7.11 7.44 6.91 0.51 14.69 13.95 14.28 13.75 090
28308.......... ............. A Incision of metatarsal 5.29 5.96 6.08 4.39 5.30 0.35 11.60 11.72 10.03 10.94 090
28309.......... ............. A Incision of 12.78 NA NA 9.28 8.37 0.99 NA NA 23.05 22.14 090
metatarsals.
28310.......... ............. A Revision of big toe... 5.43 6.83 5.68 5.50 5.02 0.37 12.63 11.48 11.30 10.82 090
28312.......... ............. A Revision of toe....... 4.55 6.59 5.77 6.01 5.48 0.33 11.47 10.65 10.89 10.36 090
28313.......... ............. A Repair deformity of 5.01 7.12 4.96 7.12 4.26 0.45 12.58 10.42 12.58 9.72 090
toe.
28315.......... ............. A Removal of sesamoid 4.86 6.02 5.31 4.58 4.59 0.33 11.21 10.50 9.77 9.78 090
bone.
28320.......... ............. A Repair of foot bones.. 9.18 NA NA 8.45 8.94 0.82 NA NA 18.45 18.94 090
28322.......... ............. A Repair of metatarsals. 8.34 7.10 6.09 7.10 6.09 0.74 16.18 15.17 16.18 15.17 090
28340.......... ............. A Resect enlarged toe 6.98 7.60 7.24 5.59 6.24 0.52 15.10 14.74 13.09 13.74 090
tissue.
28341.......... ............. A Resect enlarged toe... 8.41 8.00 8.16 6.02 7.17 0.55 16.96 17.12 14.98 16.13 090
28344.......... ............. A Repair extra toe(s)... 4.26 5.49 4.76 4.97 4.50 0.38 10.13 9.40 9.61 9.14 090
28345.......... ............. A Repair webbed toe(s).. 5.92 6.73 6.27 6.25 6.03 0.48 13.13 12.67 12.65 12.43 090
28360.......... ............. A Reconstruct cleft foot 13.34 NA NA 12.03 12.48 1.39 NA NA 26.76 27.21 090
28400.......... ............. A Treatment of heel 2.16 6.94 4.87 4.09 2.75 0.21 9.31 7.24 6.46 5.12 090
fracture.
28405.......... ............. A Treatment of heel 4.57 7.25 5.74 5.18 4.71 0.44 12.26 10.75 10.19 9.72 090
fracture.
28406.......... ............. A Treatment of heel 6.31 NA NA 7.48 7.05 0.65 NA NA 14.44 14.01 090
fracture.
28415.......... ............. A Treat heel fracture... 15.97 NA NA 35.81 22.80 1.58 NA NA 53.36 40.35 090
28420.......... ............. A Treat/graft heel 16.64 NA NA 35.95 23.89 1.67 NA NA 54.26 42.20 090
fracture.
28430.......... ............. A Treatment of ankle 2.09 6.58 4.62 3.68 2.51 0.20 8.87 6.91 5.97 4.80 090
fracture.
28435.......... ............. A Treatment of ankle 3.40 6.81 5.23 4.20 3.93 0.31 10.52 8.94 7.91 7.64 090
fracture.
28436.......... ............. A Treatment of ankle 4.71 NA NA 6.09 5.32 0.50 NA NA 11.30 10.53 090
fracture.
28445.......... ............. A Treat ankle fracture.. 9.33 NA NA 9.73 9.64 0.90 NA NA 19.96 19.87 090
28450.......... ............. A Treat midfoot 1.90 6.22 4.13 3.59 2.31 0.18 8.30 6.21 5.67 4.39 090
fracture, each.
28455.......... ............. A Treat midfoot 3.09 5.15 3.96 3.99 2.69 0.25 8.49 7.30 7.33 6.03 090
fracture, each.
28456.......... ............. A Treat midfoot fracture 2.68 NA NA 4.89 3.68 0.26 NA NA 7.83 6.62 090
28465.......... ............. A Treat midfoot 7.01 NA NA 20.63 13.32 0.65 NA NA 28.29 20.98 090
fracture, each.
28470.......... ............. A Treat metatarsal 1.99 5.81 3.88 3.02 2.00 0.19 7.99 6.06 5.20 4.18 090
fracture.
28475.......... ............. A Treat metatarsal 2.97 5.78 4.16 3.87 2.57 0.26 9.01 7.39 7.10 5.80 090
fracture.
28476.......... ............. A Treat metatarsal 3.38 NA NA 5.49 4.58 0.32 NA NA 9.19 8.28 090
fracture.
28485.......... ............. A Treat metatarsal 5.71 NA NA 20.72 12.90 0.48 NA NA 26.91 19.09 090
fracture.
28490.......... ............. A Treat big toe fracture 1.09 2.13 1.56 1.78 1.14 0.10 3.32 2.75 2.97 2.33 090
28495.......... ............. A Treat big toe fracture 1.58 2.17 1.70 1.89 1.25 0.12 3.87 3.40 3.59 2.95 090
28496.......... ............. A Treat big toe fracture 2.33 6.61 4.43 4.31 3.28 0.23 9.17 6.99 6.87 5.84 090
28505.......... ............. A Treat big toe fracture 3.81 17.83 10.54 17.83 10.54 0.34 21.98 14.69 21.98 14.69 090
28510.......... ............. A Treatment of toe 1.09 1.88 1.43 1.80 1.15 0.09 3.06 2.61 2.98 2.33 090
fracture.
28515.......... ............. A Treatment of toe 1.46 2.06 1.64 1.89 1.25 0.11 3.63 3.21 3.46 2.82 090
fracture.
28525.......... ............. A Treat toe fracture.... 3.32 16.35 9.30 16.35 9.30 0.30 19.97 12.92 19.97 12.92 090
28530.......... ............. A Treat sesamoid bone 1.06 3.90 2.50 2.22 1.39 0.08 5.04 3.64 3.36 2.53 090
fracture.
28531.......... ............. A Treat sesamoid bone 2.35 13.22 7.65 8.81 5.44 0.17 15.74 10.17 11.33 7.96 090
fracture.
28540.......... ............. A Treat foot dislocation 2.04 4.21 2.43 3.38 1.86 0.15 6.40 4.62 5.57 4.05 090
28545.......... ............. A Treat foot dislocation 2.45 3.60 2.51 3.60 2.51 0.22 6.27 5.18 6.27 5.18 090
28546.......... ............. A Treat foot dislocation 3.20 4.79 3.88 4.79 3.88 0.30 8.29 7.38 8.29 7.38 090
28555.......... ............. A Repair foot 6.30 9.83 7.95 9.83 7.95 0.59 16.72 14.84 16.72 14.84 090
dislocation.
28570.......... ............. A Treat foot dislocation 1.66 5.01 3.37 3.36 2.12 0.14 6.81 5.17 5.16 3.92 090
28575.......... ............. A Treat foot dislocation 3.31 3.72 3.37 3.72 3.37 0.32 7.35 7.00 7.35 7.00 090
28576.......... ............. A Treat foot dislocation 4.17 5.18 4.10 5.18 4.10 0.41 9.76 8.68 9.76 8.68 090
28585.......... ............. A Repair foot 7.99 13.84 9.61 13.84 9.61 0.71 22.54 18.31 22.54 18.31 090
dislocation.
28600.......... ............. A Treat foot dislocation 1.89 5.50 3.12 3.63 2.00 0.16 7.55 5.17 5.68 4.05 090
28605.......... ............. A Treat foot dislocation 2.71 6.00 4.23 3.85 3.15 0.26 8.97 7.20 6.82 6.12 090
28606.......... ............. A Treat foot dislocation 4.90 13.40 8.60 6.01 4.90 0.50 18.80 14.00 11.41 10.30 090
28615.......... ............. A Repair foot 7.77 NA NA 24.09 14.74 0.77 NA NA 32.63 23.28 090
dislocation.
28630.......... ............. A Treat toe dislocation. 1.70 1.78 1.45 1.78 1.17 0.14 3.62 3.29 3.62 3.01 010
28635.......... ............. A Treat toe dislocation. 1.91 2.88 2.23 2.24 1.52 0.15 4.94 4.29 4.30 3.58 010
28636.......... ............. A Treat toe dislocation. 2.77 5.61 4.20 2.65 2.72 0.26 8.64 7.23 5.68 5.75 010
28645.......... ............. A Repair toe dislocation 4.22 7.74 5.63 7.74 5.63 0.31 12.27 10.16 12.27 10.16 090
28660.......... ............. A Treat toe dislocation. 1.23 3.83 2.26 2.03 1.36 0.11 5.17 3.60 3.37 2.70 010
28665.......... ............. A Treat toe dislocation. 1.92 3.17 2.12 2.60 1.57 0.14 5.23 4.18 4.66 3.63 010
28666.......... ............. A Treat toe dislocation. 2.66 8.39 5.52 2.53 2.59 0.26 11.31 8.44 5.45 5.51 010
28675.......... ............. A Repair of toe 2.92 11.17 7.22 11.17 7.22 0.28 14.37 10.42 14.37 10.42 090
dislocation.
[[Page 59465]]
28705.......... ............. A Fusion of foot bones.. 15.21 NA NA 11.89 14.15 1.40 NA NA 28.50 30.76 090
28715.......... ............. A Fusion of foot bones.. 13.10 NA NA 11.44 12.41 1.28 NA NA 25.82 26.79 090
28725.......... ............. A Fusion of foot bones.. 11.61 NA NA 10.53 10.39 1.06 NA NA 23.20 23.06 090
28730.......... ............. A Fusion of foot bones.. 10.76 NA NA 9.64 9.71 1.00 NA NA 21.40 21.47 090
28735.......... ............. A Fusion of foot bones.. 10.85 NA NA 9.48 10.04 0.96 NA NA 21.29 21.85 090
28737.......... ............. A Revision of foot bones 9.64 NA NA 9.05 9.34 0.86 NA NA 19.55 19.84 090
28740.......... ............. A Fusion of foot bones.. 8.02 9.65 7.62 7.98 6.78 0.70 18.37 16.34 16.70 15.50 090
28750.......... ............. A Fusion of big toe 7.30 9.61 7.69 7.82 6.80 0.70 17.61 15.69 15.82 14.80 090
joint.
28755.......... ............. A Fusion of big toe 4.74 6.92 5.46 5.42 4.71 0.38 12.04 10.58 10.54 9.83 090
joint.
28760.......... ............. A Fusion of big toe 7.75 7.17 6.52 6.63 6.25 0.59 15.51 14.86 14.97 14.59 090
joint.
28800.......... ............. A Amputation of midfoot. 8.21 NA NA 7.96 7.59 0.82 NA NA 16.99 16.62 090
28805.......... ............. A Amputation thru 8.39 NA NA 7.82 7.34 0.89 NA NA 17.10 16.62 090
metatarsal.
28810.......... ............. A Amputation toe & 6.21 NA NA 6.70 5.47 0.65 NA NA 13.56 12.33 090
metatarsal.
28820.......... ............. A Amputation of toe..... 4.41 8.44 5.62 5.97 4.39 0.44 13.29 10.47 10.82 9.24 090
28825.......... ............. A Partial amputation of 3.59 7.81 5.21 5.58 4.09 0.35 11.75 9.15 9.52 8.03 090
toe.
28899.......... ............. C Foot/toes surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
29000.......... ............. A Application of body 2.25 9.84 5.93 1.15 1.58 0.34 12.43 8.52 3.74 4.17 000
cast.
29010.......... ............. A Application of body 2.06 9.88 6.21 1.11 1.79 0.26 12.20 8.53 3.43 4.11 000
cast.
29015.......... ............. A Application of body 2.41 8.96 5.75 1.03 1.15 0.14 11.51 8.30 3.58 3.70 000
cast.
29020.......... ............. A Application of body 2.11 8.90 5.44 0.91 0.95 0.12 11.13 7.67 3.14 3.18 000
cast.
29025.......... ............. A Application of body 2.40 11.77 6.29 1.23 0.82 0.27 14.44 8.96 3.90 3.49 000
cast.
29035.......... ............. A Application of body 1.77 11.95 7.04 0.81 0.94 0.19 13.91 9.00 2.77 2.90 000
cast.
29040.......... ............. A Application of body 2.22 8.60 5.40 0.76 1.48 0.18 11.00 7.80 3.16 3.88 000
cast.
29044.......... ............. A Application of body 2.12 14.95 8.61 1.16 1.72 0.23 17.30 10.96 3.51 4.07 000
cast.
29046.......... ............. A Application of body 2.41 14.97 8.70 1.31 1.87 0.25 17.63 11.36 3.97 4.53 000
cast.
29049.......... ............. A Application of figure 0.89 5.90 3.18 0.24 0.24 0.09 6.88 4.16 1.22 1.22 000
eight.
29055.......... ............. A Application of 1.78 9.53 5.42 0.90 1.10 0.18 11.49 7.38 2.86 3.06 000
shoulder cast.
29058.......... ............. A Application of 1.31 6.44 3.58 0.53 0.62 0.12 7.87 5.01 1.96 2.05 000
shoulder cast.
29065.......... ............. A Application of long 0.87 4.32 2.60 0.44 0.44 0.09 5.28 3.56 1.40 1.40 000
arm cast.
29075.......... ............. A Application of forearm 0.77 3.87 2.27 0.37 0.35 0.08 4.72 3.12 1.22 1.20 000
cast.
29085.......... ............. A Apply hand/wrist cast. 0.87 3.80 2.17 0.38 0.33 0.09 4.76 3.13 1.34 1.29 000
29105.......... ............. A Apply long arm splint. 0.87 2.86 1.70 0.29 0.28 0.09 3.82 2.66 1.25 1.24 000
29125.......... ............. A Apply forearm splint.. 0.59 2.37 1.39 0.17 0.19 0.06 3.02 2.04 0.82 0.84 000
29126.......... ............. A Apply forearm splint.. 0.77 2.86 1.65 0.24 0.23 0.07 3.70 2.49 1.08 1.07 000
29130.......... ............. A Application of finger 0.50 0.77 0.48 0.14 0.12 0.05 1.32 1.03 0.69 0.67 000
splint.
29131.......... ............. A Application of finger 0.55 1.33 0.88 0.21 0.21 0.05 1.93 1.48 0.81 0.81 000
splint.
29200.......... ............. A Strapping of chest.... 0.65 1.33 0.81 0.17 0.16 0.06 2.04 1.52 0.88 0.87 000
29220.......... ............. A Strapping of low back. 0.64 1.09 0.75 0.26 0.24 0.05 1.78 1.44 0.95 0.93 000
29240.......... ............. A Strapping of shoulder. 0.71 1.30 0.80 0.19 0.24 0.07 2.08 1.58 0.97 1.02 000
29260.......... ............. A Strapping of elbow or 0.55 1.04 0.65 0.15 0.14 0.05 1.64 1.25 0.75 0.74 000
wrist.
29280.......... ............. A Strapping of hand or 0.51 1.07 0.65 0.14 0.13 0.05 1.63 1.21 0.70 0.69 000
finger.
29305.......... ............. A Application of hip 2.03 11.84 6.94 1.10 1.57 0.21 14.08 9.18 3.34 3.81 000
cast.
29325.......... ............. A Application of hip 2.32 9.18 5.65 1.19 1.65 0.24 11.74 8.21 3.75 4.21 000
casts.
29345.......... ............. A Application of long 1.40 5.41 3.26 0.71 0.64 0.14 6.95 4.80 2.25 2.18 000
leg cast.
29355.......... ............. A Application of long 1.53 5.67 3.43 0.77 0.69 0.15 7.35 5.11 2.45 2.37 000
leg cast.
29358.......... ............. A Apply long leg cast 1.43 6.31 4.01 0.76 0.81 0.14 7.88 5.58 2.33 2.38 000
brace.
29365.......... ............. A Application of long 1.18 4.61 2.77 0.61 0.54 0.12 5.91 4.07 1.91 1.84 000
leg cast.
29405.......... ............. A Apply short leg cast.. 0.86 3.92 2.39 0.41 0.42 0.09 4.87 3.34 1.36 1.37 000
29425.......... ............. A Apply short leg cast.. 1.01 3.69 2.37 0.48 0.51 0.10 4.80 3.48 1.59 1.62 000
29435.......... ............. A Apply short leg cast.. 1.18 6.16 3.72 0.62 0.63 0.11 7.45 5.01 1.91 1.92 000
29440.......... ............. A Addition of walker to 0.57 2.26 1.26 0.24 0.19 0.06 2.89 1.89 0.87 0.82 000
cast.
29445.......... ............. A Apply rigid leg cast.. 1.78 5.90 3.87 0.74 1.29 0.16 7.84 5.81 2.68 3.23 000
29450.......... ............. A Application of leg 1.02 2.85 1.64 0.44 0.33 0.08 3.95 2.74 1.54 1.43 000
cast.
29505.......... ............. A Application, long leg 0.69 3.18 1.90 0.21 0.42 0.07 3.94 2.66 0.97 1.18 000
splint.
29515.......... ............. A Application lower leg 0.73 2.45 1.48 0.22 0.24 0.06 3.24 2.27 1.01 1.03 000
splint.
29520.......... ............. A Strapping of hip...... 0.54 1.17 0.78 0.28 0.24 0.03 1.74 1.35 0.85 0.81 000
29530.......... ............. A Strapping of knee..... 0.57 1.12 0.75 0.16 0.27 0.05 1.74 1.37 0.78 0.89 000
29540.......... ............. A Strapping of ankle.... 0.51 0.50 0.42 0.17 0.17 0.03 1.04 0.96 0.71 0.71 000
29550.......... ............. A Strapping of toes..... 0.47 0.46 0.38 0.18 0.17 0.03 0.96 0.88 0.68 0.67 000
29580.......... ............. A Application of paste 0.57 0.97 0.92 0.22 0.21 0.05 1.59 1.54 0.84 0.83 000
boot.
29590.......... ............. A Application of foot 0.76 0.68 0.49 0.26 0.21 0.05 1.49 1.30 1.07 1.02 000
splint.
29700.......... ............. A Removal/revision of 0.57 0.72 0.54 0.21 0.20 0.06 1.35 1.17 0.84 0.83 000
cast.
29705.......... ............. A Removal/revision of 0.76 0.88 0.63 0.31 0.25 0.08 1.72 1.47 1.15 1.09 000
cast.
29710.......... ............. A Removal/revision of 1.34 1.47 0.98 0.63 0.44 0.12 2.93 2.44 2.09 1.90 000
cast.
29715.......... ............. A Removal/revision of 0.94 4.58 2.76 0.29 0.38 0.10 5.62 3.80 1.33 1.42 000
cast.
29720.......... ............. A Repair of body cast... 0.68 4.36 2.31 0.35 0.24 0.07 5.11 3.06 1.10 0.99 000
29730.......... ............. A Windowing of cast..... 0.75 0.85 0.57 0.29 0.22 0.08 1.68 1.40 1.12 1.05 000
29740.......... ............. A Wedging of cast....... 1.12 2.99 1.70 0.43 0.32 0.11 4.22 2.93 1.66 1.55 000
29750.......... ............. A Wedging of clubfoot 1.26 2.25 1.40 0.58 0.43 0.11 3.62 2.77 1.95 1.80 000
cast.
29799.......... ............. C Casting/strapping 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
29800.......... ............. A Jaw arthroscopy/ 6.43 NA NA 7.25 5.80 0.59 NA NA 14.27 12.82 090
surgery.
29804.......... ............. A Jaw arthroscopy/ 8.14 NA NA 8.32 9.02 0.62 NA NA 17.08 17.78 090
surgery.
29815.......... ............. A Shoulder arthroscopy.. 5.89 NA NA 6.63 5.94 0.58 NA NA 13.10 12.41 090
29819.......... ............. A Shoulder arthroscopy/ 7.62 NA NA 8.46 8.78 0.78 NA NA 16.86 17.18 090
surgery.
29820.......... ............. A Shoulder arthroscopy/ 7.07 NA NA 8.58 8.51 0.73 NA NA 16.38 16.31 090
surgery.
29821.......... ............. A Shoulder arthroscopy/ 7.72 NA NA 8.42 8.82 0.78 NA NA 16.92 17.32 090
surgery.
29822.......... ............. A Shoulder arthroscopy/ 7.43 NA NA 8.79 8.83 0.76 NA NA 16.98 17.02 090
surgery.
29823.......... ............. A Shoulder arthroscopy/ 8.17 NA NA 9.01 9.39 0.83 NA NA 18.01 18.39 090
surgery.
29825.......... ............. A Shoulder arthroscopy/ 7.62 NA NA 8.55 8.82 0.78 NA NA 16.95 17.22 090
surgery.
29826.......... ............. A Shoulder arthroscopy/ 8.99 NA NA 9.52 10.13 0.93 NA NA 19.44 20.05 090
surgery.
29830.......... ............. A Elbow arthroscopy..... 5.76 NA NA 5.26 5.52 0.62 NA NA 11.64 11.90 090
[[Page 59466]]
29834.......... ............. A Elbow arthroscopy/ 6.28 NA NA 6.20 6.27 0.64 NA NA 13.12 13.19 090
surgery.
29835.......... ............. A Elbow arthroscopy/ 6.48 NA NA 6.44 6.49 0.66 NA NA 13.58 13.63 090
surgery.
29836.......... ............. A Elbow arthroscopy/ 7.55 NA NA 6.63 7.13 0.77 NA NA 14.95 15.45 090
surgery.
29837.......... ............. A Elbow arthroscopy/ 6.87 NA NA 6.38 6.67 0.71 NA NA 13.96 14.25 090
surgery.
29838.......... ............. A Elbow arthroscopy/ 7.71 NA NA 6.70 7.18 0.80 NA NA 15.21 15.69 090
surgery.
29840.......... ............. A Wrist arthroscopy..... 5.54 NA NA 6.82 5.20 0.57 NA NA 12.93 11.31 090
29843.......... ............. A Wrist arthroscopy/ 6.01 NA NA 6.96 6.52 0.66 NA NA 13.63 13.19 090
surgery.
29844.......... ............. A Wrist arthroscopy/ 6.37 NA NA 7.64 6.86 0.67 NA NA 14.68 13.90 090
surgery.
29845.......... ............. A Wrist arthroscopy/ 7.52 NA NA 7.46 7.53 0.77 NA NA 15.75 15.82 090
surgery.
29846.......... ............. A Wrist arthroscopy/ 6.75 NA NA 9.53 8.80 0.71 NA NA 16.99 16.26 090
surgery.
29847.......... ............. A Wrist arthroscopy/ 7.08 NA NA 10.52 8.94 0.74 NA NA 18.34 16.76 090
surgery.
29848.......... ............. A Wrist endoscopy/ 5.44 NA NA 6.81 5.50 0.58 NA NA 12.83 11.52 090
surgery.
29850.......... ............. A Knee arthroscopy/ 8.19 NA NA 6.57 5.73 0.71 NA NA 15.47 14.63 090
surgery.
29851.......... ............. A Knee arthroscopy/ 13.10 NA NA 10.84 11.36 1.37 NA NA 25.31 25.83 090
surgery.
29855.......... ............. A Tibial arthroscopy/ 10.62 NA NA 9.65 11.17 1.09 NA NA 21.36 22.88 090
surgery.
29856.......... ............. A Tibial arthroscopy/ 14.14 NA NA 12.03 12.36 1.47 NA NA 27.64 27.97 090
surgery.
29860.......... ............. A Hip arthroscopy, dx... 8.05 NA NA 7.01 6.13 0.77 NA NA 15.83 14.95 090
29861.......... ............. A Hip arthroscopy/ 9.15 NA NA 8.17 9.18 0.88 NA NA 18.20 19.21 090
surgery.
29862.......... ............. A Hip arthroscopy/ 9.90 NA NA 8.58 9.76 0.95 NA NA 19.43 20.61 090
surgery.
29863.......... ............. A Hip arthroscopy/ 9.90 NA NA 8.86 9.16 0.95 NA NA 19.71 20.01 090
surgery.
29870.......... ............. A Knee arthroscopy, dx.. 5.07 NA NA 5.36 4.86 0.52 NA NA 10.95 10.45 090
29871.......... ............. A Knee arthroscopy/ 6.55 NA NA 7.03 7.19 0.59 NA NA 14.17 14.33 090
drainage.
29874.......... ............. A Knee arthroscopy/ 7.05 NA NA 6.83 7.63 0.68 NA NA 14.56 15.36 090
surgery.
29875.......... ............. A Knee arthroscopy/ 6.31 NA NA 6.55 7.04 0.66 NA NA 13.52 14.01 090
surgery.
29876.......... ............. A Knee arthroscopy/ 7.92 NA NA 7.86 8.66 0.80 NA NA 16.58 17.38 090
surgery.
29877.......... ............. A Knee arthroscopy/ 7.35 NA NA 7.14 7.96 0.76 NA NA 15.25 16.07 090
surgery.
29879.......... ............. A Knee arthroscopy/ 8.04 NA NA 7.49 8.54 0.84 NA NA 16.37 17.42 090
surgery.
29880.......... ............. A Knee arthroscopy/ 8.50 NA NA 7.77 8.96 0.89 NA NA 17.16 18.35 090
surgery.
29881.......... ............. A Knee arthroscopy/ 7.76 NA NA 7.36 8.32 0.80 NA NA 15.92 16.88 090
surgery.
29882.......... ............. A Knee arthroscopy/ 8.65 NA NA 7.79 9.06 0.90 NA NA 17.34 18.61 090
surgery.
29883.......... ............. A Knee arthroscopy/ 9.46 NA NA 8.26 9.78 0.98 NA NA 18.70 20.22 090
surgery.
29884.......... ............. A Knee arthroscopy/ 7.33 NA NA 7.86 8.31 0.75 NA NA 15.94 16.39 090
surgery.
29885.......... ............. A Knee arthroscopy/ 9.09 NA NA 8.79 8.86 0.95 NA NA 18.83 18.90 090
surgery.
29886.......... ............. A Knee arthroscopy/ 7.54 NA NA 7.66 7.52 0.78 NA NA 15.98 15.84 090
surgery.
29887.......... ............. A Knee arthroscopy/ 9.04 NA NA 8.59 9.69 0.94 NA NA 18.57 19.67 090
surgery.
29888.......... ............. A Knee arthroscopy/ 13.90 NA NA 11.68 14.14 1.41 NA NA 26.99 29.45 090
surgery.
29889.......... ............. A Knee arthroscopy/ 15.13 NA NA 12.54 11.84 1.56 NA NA 29.23 28.53 090
surgery.
29891.......... ............. A Ankle arthroscopy/ 8.40 NA NA 8.12 8.87 0.81 NA NA 17.33 18.08 090
surgery.
29892.......... ............. A Ankle arthroscopy/ 9.00 NA NA 8.60 9.11 0.87 NA NA 18.47 18.98 090
surgery.
29893.......... ............. A Scope, plantar 5.22 NA NA 4.62 5.13 0.37 NA NA 10.21 10.72 090
fasciotomy.
29894.......... ............. A Ankle arthroscopy/ 7.21 NA NA 7.04 7.83 0.65 NA NA 14.90 15.69 090
surgery.
29895.......... ............. A Ankle arthroscopy/ 6.99 NA NA 7.22 7.79 0.65 NA NA 14.86 15.43 090
surgery.
29897.......... ............. A Ankle arthroscopy/ 7.18 NA NA 7.56 8.07 0.68 NA NA 15.42 15.93 090
surgery.
29898.......... ............. A Ankle arthroscopy/ 8.32 NA NA 7.55 8.74 0.74 NA NA 16.61 17.80 090
surgery.
29909.......... ............. C Arthroscopy of joint.. 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
30000.......... ............. A Drainage of nose 1.43 2.10 1.37 1.33 0.83 0.11 3.64 2.91 2.87 2.37 010
lesion.
30020.......... ............. A Drainage of nose 1.43 2.33 1.49 1.37 0.85 0.07 3.83 2.99 2.87 2.35 010
lesion.
30100.......... ............. A Intranasal biopsy..... 0.94 1.12 0.94 0.54 0.46 0.07 2.13 1.95 1.55 1.47 000
30110.......... ............. A Removal of nose 1.63 2.26 1.83 0.90 0.80 0.11 4.00 3.57 2.64 2.54 010
polyp(s).
30115.......... ............. A Removal of nose 4.35 NA NA 3.98 3.52 0.31 NA NA 8.64 8.18 090
polyp(s).
30117.......... ............. A Removal of intranasal 3.16 3.79 3.44 2.85 2.97 0.23 7.18 6.83 6.24 6.36 090
lesion.
30118.......... ............. A Removal of intranasal 9.69 NA NA 7.73 8.21 0.71 NA NA 18.13 18.61 090
lesion.
30120.......... ............. A Revision of nose...... 5.27 5.10 5.70 5.10 5.70 0.40 10.77 11.37 10.77 11.37 090
30124.......... ............. A Removal of nose lesion 3.10 NA NA 2.96 1.85 0.21 NA NA 6.27 5.16 090
30125.......... ............. A Removal of nose lesion 7.16 NA NA 5.91 5.97 0.48 NA NA 13.55 13.61 090
30130.......... ............. A Removal of turbinate 3.38 NA NA 3.48 2.65 0.23 NA NA 7.09 6.26 090
bones.
30140.......... ............. A Removal of turbinate 3.43 NA NA 3.88 3.59 0.25 NA NA 7.56 7.27 090
bones.
30150.......... ............. A Partial removal of 9.14 NA NA 7.47 8.04 0.77 NA NA 17.38 17.95 090
nose.
30160.......... ............. A Removal of nose....... 9.58 NA NA 7.67 9.56 0.75 NA NA 18.00 19.89 090
30200.......... ............. A Injection treatment of 0.78 1.02 0.71 0.45 0.33 0.06 1.86 1.55 1.29 1.17 000
nose.
30210.......... ............. A Nasal sinus therapy... 1.08 1.73 1.01 0.64 0.39 0.08 2.89 2.17 1.80 1.55 010
30220.......... ............. A Insert nasal septal 1.54 2.08 1.86 0.89 0.86 0.11 3.73 3.51 2.54 2.51 010
button.
30300.......... ............. A Remove nasal foreign 1.04 2.15 1.33 0.39 0.32 0.08 3.27 2.45 1.51 1.44 010
body.
30310.......... ............. A Remove nasal foreign 1.96 NA NA 1.75 1.76 0.14 NA NA 3.85 3.86 010
body.
30320.......... ............. A Remove nasal foreign 4.52 NA NA 4.70 4.68 0.33 NA NA 9.55 9.53 090
body.
30400.......... ............. R Reconstruction of nose 9.83 NA NA 7.91 9.37 0.84 NA NA 18.58 20.04 090
30410.......... ............. R Reconstruction of nose 12.98 NA NA 9.59 12.55 1.14 NA NA 23.71 26.67 090
30420.......... ............. R Reconstruction of nose 15.88 NA NA 11.49 15.23 1.25 NA NA 28.62 32.36 090
30430.......... ............. R Revision of nose...... 7.21 NA NA 6.17 6.39 0.62 NA NA 14.00 14.22 090
30435.......... ............. R Revision of nose...... 11.71 NA NA 9.14 10.09 1.03 NA NA 21.88 22.83 090
30450.......... ............. R Revision of nose...... 18.65 NA NA 12.87 12.54 1.65 NA NA 33.17 32.84 090
30460.......... ............. A Revision of nose...... 9.96 NA NA 7.96 8.64 0.87 NA NA 18.79 19.47 090
30462.......... ............. A Revision of nose...... 19.57 NA NA 12.66 15.64 1.90 NA NA 34.13 37.11 090
30520.......... ............. A Repair of nasal septum 5.70 NA NA 5.21 6.01 0.41 NA NA 11.32 12.12 090
30540.......... ............. A Repair nasal defect... 7.75 NA NA 5.43 6.32 0.54 NA NA 13.72 14.61 090
30545.......... ............. A Repair nasal defect... 11.38 NA NA 8.33 10.04 0.88 NA NA 20.59 22.30 090
30560.......... ............. A Release of nasal 1.26 1.93 1.27 1.31 0.81 0.09 3.28 2.62 2.66 2.16 010
adhesions.
30580.......... ............. A Repair upper jaw 6.69 4.60 5.69 4.60 4.00 0.49 11.78 12.87 11.78 11.18 090
fistula.
30600.......... ............. A Repair mouth/nose 6.02 4.10 4.10 4.10 4.10 0.47 10.59 10.59 10.59 10.59 090
fistula.
30620.......... ............. A Intranasal 5.97 NA NA 5.65 6.39 0.45 NA NA 12.07 12.81 090
reconstruction.
30630.......... ............. A Repair nasal septum 7.12 NA NA 6.31 6.54 0.53 NA NA 13.96 14.19 090
defect.
[[Page 59467]]
30801.......... ............. A Cauterization, inner 1.09 2.15 1.33 1.96 1.11 0.08 3.32 2.50 3.13 2.28 010
nose.
30802.......... ............. A Cauterization, inner 2.03 2.64 1.83 2.42 1.72 0.14 4.81 4.00 4.59 3.89 010
nose.
30901.......... ............. A Control of nosebleed.. 1.21 1.89 1.25 0.33 0.32 0.10 3.20 2.56 1.64 1.63 000
30903.......... ............. A Control of nosebleed.. 1.54 2.21 1.57 0.52 0.72 0.12 3.87 3.23 2.18 2.38 000
30905.......... ............. A Control of nosebleed.. 1.97 3.97 2.96 0.81 1.38 0.15 6.09 5.08 2.93 3.50 000
30906.......... ............. A Repeat control of 2.45 4.29 2.73 1.29 1.23 0.18 6.92 5.36 3.92 3.86 000
nosebleed.
30915.......... ............. A Ligation, nasal sinus 7.20 NA NA 6.26 5.82 0.52 NA NA 13.98 13.54 090
artery.
30920.......... ............. A Ligation, upper jaw 9.83 NA NA 7.78 9.07 0.70 NA NA 18.31 19.60 090
artery.
30930.......... ............. A Therapy, fracture of 1.26 NA NA 1.75 1.26 0.09 NA NA 3.10 2.61 010
nose.
30999.......... ............. C Nasal surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
31000.......... ............. A Irrigation, maxillary 1.15 1.98 1.23 0.66 0.45 0.08 3.21 2.46 1.89 1.68 010
sinus.
31002.......... ............. A Irrigation, sphenoid 1.91 NA NA 1.78 1.02 0.13 NA NA 3.82 3.06 010
sinus.
31020.......... ............. A Exploration, maxillary 2.94 3.57 3.23 3.17 3.03 0.21 6.72 6.38 6.32 6.18 090
sinus.
31030.......... ............. A Exploration, maxillary 5.92 4.36 5.72 4.36 5.72 0.43 10.71 12.07 10.71 12.07 090
sinus.
31032.......... ............. A Explore sinus, remove 6.57 NA NA 5.50 6.68 0.48 NA NA 12.55 13.73 090
polyps.
31040.......... ............. A Exploration behind 9.42 NA NA 6.22 7.44 0.69 NA NA 16.33 17.55 090
upper jaw.
31050.......... ............. A Exploration, sphenoid 5.28 NA NA 4.56 5.44 0.39 NA NA 10.23 11.11 090
sinus.
31051.......... ............. A Sphenoid sinus surgery 7.11 NA NA 5.93 7.21 0.55 NA NA 13.59 14.87 090
31070.......... ............. A Exploration of frontal 4.28 NA NA 4.34 4.72 0.31 NA NA 8.93 9.31 090
sinus.
31075.......... ............. A Exploration of frontal 9.16 NA NA 7.61 9.28 0.63 NA NA 17.40 19.07 090
sinus.
31080.......... ............. A Removal of frontal 11.42 NA NA 8.36 9.18 0.81 NA NA 20.59 21.41 090
sinus.
31081.......... ............. A Removal of frontal 12.75 NA NA 9.08 10.14 1.86 NA NA 23.69 24.75 090
sinus.
31084.......... ............. A Removal of frontal 13.51 NA NA 9.88 12.97 1.03 NA NA 24.42 27.51 090
sinus.
31085.......... ............. A Removal of frontal 14.20 NA NA 10.17 13.56 1.35 NA NA 25.72 29.11 090
sinus.
31086.......... ............. A Removal of frontal 12.86 NA NA 9.70 10.75 0.96 NA NA 23.52 24.57 090
sinus.
31087.......... ............. A Removal of frontal 13.10 NA NA 9.51 10.40 0.93 NA NA 23.54 24.43 090
sinus.
31090.......... ............. A Exploration of sinuses 9.53 NA NA 8.08 9.73 0.68 NA NA 18.29 19.94 090
31200.......... ............. A Removal of ethmoid 4.97 NA NA 5.52 5.27 0.28 NA NA 10.77 10.52 090
sinus.
31201.......... ............. A Removal of ethmoid 8.37 NA NA 7.01 7.31 0.59 NA NA 15.97 16.27 090
sinus.
31205.......... ............. A Removal of ethmoid 10.24 NA NA 8.29 8.50 0.61 NA NA 19.14 19.35 090
sinus.
31225.......... ............. A Removal of upper jaw.. 19.23 NA NA 14.11 17.61 1.41 NA NA 34.75 38.25 090
31230.......... ............. A Removal of upper jaw.. 21.94 NA NA 15.90 19.75 1.67 NA NA 39.51 43.36 090
31231.......... ............. A Nasal endoscopy, dx... 1.10 1.70 1.60 0.61 1.05 0.08 2.88 2.78 1.79 2.23 000
31233.......... ............. A Nasal/sinus endoscopy, 2.18 2.34 2.69 1.27 1.40 0.15 4.67 5.02 3.60 3.73 000
dx.
31235.......... ............. A Nasal/sinus endoscopy, 2.64 2.61 2.60 1.55 1.43 0.18 5.43 5.42 4.37 4.25 000
dx.
31237.......... ............. A Nasal/sinus endoscopy, 2.98 2.87 3.22 1.70 1.74 0.21 6.06 6.41 4.89 4.93 000
surg.
31238.......... ............. A Nasal/sinus endoscopy, 3.26 3.26 3.58 1.91 1.93 0.23 6.75 7.07 5.40 5.42 000
surg.
31239.......... ............. A Nasal/sinus endoscopy, 8.70 NA NA 6.54 8.47 0.44 NA NA 15.68 17.61 010
surg.
31240.......... ............. A Nasal/sinus endoscopy, 2.61 NA NA 1.48 2.30 0.18 NA NA 4.27 5.09 000
surg.
31254.......... ............. A Revision of ethmoid 4.65 NA NA 2.74 4.15 0.32 NA NA 7.71 9.12 000
sinus.
31255.......... ............. A Removal of ethmoid 6.96 NA NA 4.10 6.21 0.50 NA NA 11.56 13.67 000
sinus.
31256.......... ............. A Exploration maxillary 3.29 NA NA 1.94 2.94 0.23 NA NA 5.46 6.46 000
sinus.
31267.......... ............. A Endoscopy, maxillary 5.46 NA NA 3.22 4.45 0.39 NA NA 9.07 10.30 000
sinus.
31276.......... ............. A Sinus endoscopy, 8.85 NA NA 5.12 6.21 0.63 NA NA 14.60 15.69 000
surgical.
31287.......... ............. A Nasal/sinus endoscopy, 3.92 NA NA 2.31 3.50 0.28 NA NA 6.51 7.70 000
surg.
31288.......... ............. A Nasal/sinus endoscopy, 4.58 NA NA 2.70 4.09 0.32 NA NA 7.60 8.99 000
surg.
31290.......... ............. A Nasal/sinus endoscopy, 17.24 NA NA 11.53 14.70 1.28 NA NA 30.05 33.22 010
surg.
31291.......... ............. A Nasal/sinus endoscopy, 18.19 NA NA 11.87 15.33 1.73 NA NA 31.79 35.25 010
surg.
31292.......... ............. A Nasal/sinus endoscopy, 14.76 NA NA 10.02 12.27 1.03 NA NA 25.81 28.06 010
surg.
31293.......... ............. A Nasal/sinus endoscopy, 16.21 NA NA 10.66 13.28 1.09 NA NA 27.96 30.58 010
surg.
31294.......... ............. A Nasal/sinus endoscopy, 19.06 NA NA 12.43 15.29 1.71 NA NA 33.20 36.06 010
surg.
31299.......... ............. C Sinus surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
31300.......... ............. A Removal of larynx 14.29 NA NA 15.68 14.13 1.02 NA NA 30.99 29.44 090
lesion.
31320.......... ............. A Diagnostic incision, 5.26 NA NA 10.85 7.53 0.39 NA NA 16.50 13.18 090
larynx.
31360.......... ............. A Removal of larynx..... 17.08 NA NA 17.05 18.72 1.24 NA NA 35.37 37.04 090
31365.......... ............. A Removal of larynx..... 24.16 NA NA 21.02 24.94 1.77 NA NA 46.95 50.87 090
31367.......... ............. A Partial removal of 21.86 NA NA 21.37 20.03 1.59 NA NA 44.82 43.48 090
larynx.
31368.......... ............. A Partial removal of 27.09 NA NA 25.45 27.25 1.98 NA NA 54.52 56.32 090
larynx.
31370.......... ............. A Partial removal of 21.38 NA NA 21.33 19.99 1.60 NA NA 44.31 42.97 090
larynx.
31375.......... ............. A Partial removal of 20.21 NA NA 18.85 17.48 1.41 NA NA 40.47 39.10 090
larynx.
31380.......... ............. A Partial removal of 20.21 NA NA 18.98 18.86 1.44 NA NA 40.63 40.51 090
larynx.
31382.......... ............. A Partial removal of 20.52 NA NA 21.34 19.39 1.51 NA NA 43.37 41.42 090
larynx.
31390.......... ............. A Removal of larynx & 27.53 NA NA 25.78 27.59 1.99 NA NA 55.30 57.11 090
pharynx.
31395.......... ............. A Reconstruct larynx & 31.09 NA NA 30.43 33.41 2.25 NA NA 63.77 66.75 090
pharynx.
31400.......... ............. A Revision of larynx.... 10.31 NA NA 13.45 10.97 0.74 NA NA 24.50 22.02 090
31420.......... ............. A Removal of epiglottis. 10.22 NA NA 13.35 11.06 0.74 NA NA 24.31 22.02 090
31500.......... ............. A Insert emergency 2.33 NA NA 0.56 0.90 0.17 NA NA 3.06 3.40 000
airway.
31502.......... ............. A Change of windpipe 0.65 1.58 1.11 0.27 0.45 0.04 2.27 1.80 0.96 1.14 000
airway.
31505.......... ............. A Diagnostic 0.61 1.48 0.98 0.23 0.24 0.05 2.14 1.64 0.89 0.90 000
laryngoscopy.
31510.......... ............. A Laryngoscopy with 1.92 2.37 1.49 1.01 0.81 0.14 4.43 3.55 3.07 2.87 000
biopsy.
31511.......... ............. A Remove foreign body, 2.16 2.55 1.80 0.81 0.93 0.18 4.89 4.14 3.15 3.27 000
larynx.
31512.......... ............. A Removal of larynx 2.07 2.48 2.21 1.13 1.54 0.19 4.74 4.47 3.39 3.80 000
lesion.
31513.......... ............. A Injection into vocal 2.10 NA NA 1.25 1.88 0.15 NA NA 3.50 4.13 000
cord.
31515.......... ............. A Laryngoscopy for 1.80 2.21 1.72 0.77 1.00 0.12 4.13 3.64 2.69 2.92 000
aspiration.
31520.......... ............. A Diagnostic 2.56 NA NA 1.34 1.56 0.18 NA NA 4.08 4.30 000
laryngoscopy.
31525.......... ............. A Diagnostic 2.63 2.60 2.50 1.45 1.33 0.18 5.41 5.31 4.26 4.14 000
laryngoscopy.
31526.......... ............. A Diagnostic 2.57 NA NA 1.51 2.29 0.18 NA NA 4.26 5.04 000
laryngoscopy.
31527.......... ............. A Laryngoscopy for 3.27 NA NA 1.68 2.46 0.23 NA NA 5.18 5.96 000
treatment.
31528.......... ............. A Laryngoscopy and 2.37 NA NA 1.26 2.05 0.18 NA NA 3.81 4.60 000
dilatation.
31529.......... ............. A Laryngoscopy and 2.68 NA NA 1.46 2.07 0.19 NA NA 4.33 4.94 000
dilatation.
31530.......... ............. A Operative laryngoscopy 3.39 NA NA 1.73 2.84 0.23 NA NA 5.35 6.46 000
[[Page 59468]]
31531.......... ............. A Operative laryngoscopy 3.59 NA NA 2.13 3.21 0.26 NA NA 5.98 7.06 000
31535.......... ............. A Operative laryngoscopy 3.16 NA NA 1.82 2.80 0.23 NA NA 5.21 6.19 000
31536.......... ............. A Operative laryngoscopy 3.56 NA NA 2.09 3.17 0.26 NA NA 5.91 6.99 000
31540.......... ............. A Operative laryngoscopy 4.13 NA NA 2.42 3.68 0.30 NA NA 6.85 8.11 000
31541.......... ............. A Operative laryngoscopy 4.53 NA NA 2.65 3.80 0.32 NA NA 7.50 8.65 000
31560.......... ............. A Operative laryngoscopy 5.46 NA NA 3.13 4.28 0.39 NA NA 8.98 10.13 000
31561.......... ............. A Operative laryngoscopy 6.00 NA NA 3.47 5.14 0.43 NA NA 9.90 11.57 000
31570.......... ............. A Laryngoscopy with 3.87 3.83 4.23 2.21 2.26 0.29 7.99 8.39 6.37 6.42 000
injection.
31571.......... ............. A Laryngoscopy with 4.27 NA NA 2.47 3.68 0.31 NA NA 7.05 8.26 000
injection.
31575.......... ............. A Diagnostic 1.10 1.79 1.74 0.59 0.72 0.08 2.97 2.92 1.77 1.90 000
laryngoscopy.
31576.......... ............. A Laryngoscopy with 1.97 1.89 2.13 1.09 1.73 0.13 3.99 4.23 3.19 3.83 000
biopsy.
31577.......... ............. A Remove foreign body, 2.47 2.20 2.58 1.33 2.14 0.18 4.85 5.23 3.98 4.79 000
larynx.
31578.......... ............. A Removal of larynx 2.84 2.51 2.95 0.94 2.17 0.20 5.55 5.99 3.98 5.21 000
lesion.
31579.......... ............. A Diagnostic 2.26 2.56 2.55 1.26 1.27 0.16 4.98 4.97 3.68 3.69 000
laryngoscopy.
31580.......... ............. A Revision of larynx.... 12.38 NA NA 13.82 14.30 0.88 NA NA 27.08 27.56 090
31582.......... ............. A Revision of larynx.... 21.62 NA NA 19.80 19.60 1.54 NA NA 42.96 42.76 090
31584.......... ............. A Treat larynx fracture. 19.64 NA NA 17.28 15.54 1.54 NA NA 38.46 36.72 090
31585.......... ............. A Treat larynx fracture. 4.64 NA NA 7.52 5.81 0.32 NA NA 12.48 10.77 090
31586.......... ............. A Treat larynx fracture. 8.03 NA NA 11.05 9.08 0.57 NA NA 19.65 17.68 090
31587.......... ............. A Revision of larynx.... 11.99 NA NA 12.50 10.16 0.88 NA NA 25.37 23.03 090
31588.......... ............. A Revision of larynx.... 13.11 NA NA 15.12 13.37 0.94 NA NA 29.17 27.42 090
31590.......... ............. A Reinnervate larynx.... 6.97 NA NA 10.28 8.27 0.47 NA NA 17.72 15.71 090
31595.......... ............. A Larynx nerve surgery.. 8.34 NA NA 9.81 8.62 0.61 NA NA 18.76 17.57 090
31599.......... ............. C Larynx surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
31600.......... ............. A Incision of windpipe.. 3.62 NA NA 1.66 2.99 0.34 NA NA 5.62 6.95 000
31601.......... ............. A Incision of windpipe.. 4.45 NA NA 2.28 3.80 0.36 NA NA 7.09 8.61 000
31603.......... ............. A Incision of windpipe.. 4.15 NA NA 1.93 3.26 0.38 NA NA 6.46 7.79 000
31605.......... ............. A Incision of windpipe.. 3.58 NA NA 1.33 2.81 0.36 NA NA 5.27 6.75 000
31610.......... ............. A Incision of windpipe.. 8.76 NA NA 9.92 8.58 0.70 NA NA 19.38 18.04 090
31611.......... ............. A Surgery/speech 5.64 NA NA 8.80 7.90 0.41 NA NA 14.85 13.95 090
prosthesis.
31612.......... ............. A Puncture/clear 0.91 1.26 1.27 0.36 0.73 0.06 2.23 2.24 1.33 1.70 000
windpipe.
31613.......... ............. A Repair windpipe 4.59 NA NA 8.15 5.28 0.37 NA NA 13.11 10.24 090
opening.
31614.......... ............. A Repair windpipe 7.12 NA NA 10.85 9.08 0.53 NA NA 18.50 16.73 090
opening.
31615.......... ............. A Visualization of 2.09 3.10 2.61 0.95 1.54 0.14 5.33 4.84 3.18 3.77 000
windpipe.
31622.......... ............. A Dx bronchoscope/wash.. 2.78 3.26 3.30 0.92 2.13 0.13 6.17 6.21 3.83 5.04 000
31623.......... ............. A Dx bronchoscope/brush. 2.88 3.30 3.32 0.95 2.15 0.15 6.33 6.35 3.98 5.18 000
31624.......... ............. A Dx bronchoscope/lavage 2.88 2.89 3.12 0.95 2.15 0.15 5.92 6.15 3.98 5.18 000
31625.......... ............. A Bronchoscopy with 3.37 2.88 3.46 1.07 2.55 0.16 6.41 6.99 4.60 6.08 000
biopsy.
31628.......... ............. A Bronchoscopy with 3.81 3.35 3.95 1.15 2.85 0.13 7.29 7.89 5.09 6.79 000
biopsy.
31629.......... ............. A Bronchoscopy with 3.37 NA NA 1.03 2.53 0.11 NA NA 4.51 6.01 000
biopsy.
31630.......... ............. A Bronchoscopy with 3.82 NA NA 1.62 2.83 0.34 NA NA 5.78 6.99 000
repair.
31631.......... ............. A Bronchoscopy with 4.37 NA NA 1.63 2.96 0.31 NA NA 6.31 7.64 000
dilation.
31635.......... ............. A Remove foreign body, 3.68 NA NA 1.33 2.87 0.23 NA NA 5.24 6.78 000
airway.
31640.......... ............. A Bronchoscopy & remove 4.94 NA NA 2.07 3.76 0.37 NA NA 7.38 9.07 000
lesion.
31641.......... ............. A Bronchoscopy, treat 5.03 NA NA 1.77 3.89 0.28 NA NA 7.08 9.20 000
blockage.
31643.......... ............. A Diag bronchoscope/ 3.50 1.83 2.59 1.27 2.31 0.20 5.53 6.29 4.97 6.01 000
catheter.
31645.......... ............. A Bronchoscopy, clear 3.16 NA NA 0.98 2.38 0.13 NA NA 4.27 5.67 000
airways.
31646.......... ............. A Bronchoscopy, reclear 2.72 NA NA 0.85 2.05 0.12 NA NA 3.69 4.89 000
airway.
31656.......... ............. A Bronchoscopy, inj for 2.17 NA NA 0.58 1.59 0.10 NA NA 2.85 3.86 000
xray.
31700.......... ............. A Insertion of airway 1.34 1.85 1.68 0.38 0.94 0.08 3.27 3.10 1.80 2.36 000
catheter.
31708.......... ............. A Instill airway 1.41 NA NA 0.41 0.63 0.06 NA NA 1.88 2.10 000
contrast dye.
31710.......... ............. A Insertion of airway 1.30 NA NA 0.39 0.69 0.05 NA NA 1.74 2.04 000
catheter.
31715.......... ............. A Injection for bronchus 1.11 NA NA 0.30 0.41 0.04 NA NA 1.45 1.56 000
x-ray.
31717.......... ............. A Bronchial brush biopsy 2.12 3.10 1.95 0.66 0.73 0.08 5.30 4.15 2.86 2.93 000
31720.......... ............. A Clearance of airways.. 1.06 1.82 1.31 0.33 0.57 0.06 2.94 2.43 1.45 1.69 000
31725.......... ............. A Clearance of airways.. 1.96 NA NA 0.64 1.09 0.08 NA NA 2.68 3.13 000
31730.......... ............. A Intro, windpipe wire/ 2.85 2.39 2.54 0.99 1.84 0.15 5.39 5.54 3.99 4.84 000
tube.
31750.......... ............. A Repair of windpipe.... 13.02 NA NA 14.34 11.99 1.00 NA NA 28.36 26.01 090
31755.......... ............. A Repair of windpipe.... 15.93 NA NA 17.11 15.77 1.20 NA NA 34.24 32.90 090
31760.......... ............. A Repair of windpipe.... 22.35 NA NA 14.17 13.01 2.09 NA NA 38.61 37.45 090
31766.......... ............. A Reconstruction of 30.43 NA NA 16.93 18.45 3.73 NA NA 51.09 52.61 090
windpipe.
31770.......... ............. A Repair/graft of 22.51 NA NA 17.03 16.69 2.06 NA NA 41.60 41.26 090
bronchus.
31775.......... ............. A Reconstruct bronchus.. 23.54 NA NA 19.25 18.51 2.80 NA NA 45.59 44.85 090
31780.......... ............. A Reconstruct windpipe.. 17.72 NA NA 14.00 16.41 1.70 NA NA 33.42 35.83 090
31781.......... ............. A Reconstruct windpipe.. 23.53 NA NA 16.97 17.64 2.83 NA NA 43.33 44.00 090
31785.......... ............. A Remove windpipe lesion 17.23 NA NA 13.17 11.43 1.35 NA NA 31.75 30.01 090
31786.......... ............. A Remove windpipe lesion 23.98 NA NA 18.42 16.43 1.99 NA NA 44.39 42.40 090
31800.......... ............. A Repair of windpipe 7.43 NA NA 6.89 6.11 0.74 NA NA 15.06 14.28 090
injury.
31805.......... ............. A Repair of windpipe 13.13 NA NA 13.03 11.85 1.72 NA NA 27.88 26.70 090
injury.
31820.......... ............. A Closure of windpipe 4.49 7.27 5.58 7.25 5.57 0.34 12.10 10.41 12.08 10.40 090
lesion.
31825.......... ............. A Repair of windpipe 6.81 9.86 7.65 9.86 7.65 0.52 17.19 14.98 17.19 14.98 090
defect.
31830.......... ............. A Revise windpipe scar.. 4.50 7.20 5.59 7.20 5.59 0.36 12.06 10.45 12.06 10.45 090
31899.......... ............. C Airways surgical 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
32000.......... ............. A Drainage of chest..... 1.54 3.17 2.08 0.47 0.73 0.07 4.78 3.69 2.08 2.34 000
32001.......... ............. D Total lung lavage..... 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 000
32002.......... ............. A Treatment of collapsed 2.19 NA NA 0.67 1.06 0.11 NA NA 2.97 3.36 000
lung.
32005.......... ............. A Treat lung lining 2.19 NA NA 0.77 0.98 0.18 NA NA 3.14 3.35 000
chemically.
32020.......... ............. A Insertion of chest 3.98 NA NA 1.42 2.14 0.37 NA NA 5.77 6.49 000
tube.
32035.......... ............. A Exploration of chest.. 8.67 NA NA 10.53 8.94 1.05 NA NA 20.25 18.66 090
32036.......... ............. A Exploration of chest.. 9.68 NA NA 11.78 9.76 1.19 NA NA 22.65 20.63 090
32095.......... ............. A Biopsy through chest 8.36 NA NA 10.93 9.94 0.98 NA NA 20.27 19.28 090
wall.
[[Page 59469]]
32100.......... ............. A Exploration/biopsy of 11.84 NA NA 12.11 12.16 1.45 NA NA 25.40 25.45 090
chest.
32110.......... ............. A Explore/repair chest.. 13.62 NA NA 12.52 12.51 1.67 NA NA 27.81 27.80 090
32120.......... ............. A Re-exploration of 11.54 NA NA 12.71 11.49 1.45 NA NA 25.70 24.48 090
chest.
32124.......... ............. A Explore chest free 12.72 NA NA 11.54 11.71 1.57 NA NA 25.83 26.00 090
adhesions.
32140.......... ............. A Removal of lung 13.93 NA NA 13.74 13.58 1.68 NA NA 29.35 29.19 090
lesion(s).
32141.......... ............. A Remove/treat lung 14.00 NA NA 11.53 13.05 1.74 NA NA 27.27 28.79 090
lesions.
32150.......... ............. A Removal of lung 14.15 NA NA 12.78 12.00 1.71 NA NA 28.64 27.86 090
lesion(s).
32151.......... ............. A Remove lung foreign 14.21 NA NA 14.09 12.01 1.76 NA NA 30.06 27.98 090
body.
32160.......... ............. A Open chest heart 9.30 NA NA 7.61 8.76 1.07 NA NA 17.98 19.13 090
massage.
32200.......... ............. A Drain, open, lung 15.29 NA NA 10.89 9.19 1.25 NA NA 27.43 25.73 090
lesion.
32201.......... ............. A Drain, percut, lung 4.00 NA NA 5.64 4.47 0.32 NA NA 9.96 8.79 000
lesion.
32215.......... ............. A Treat chest lining.... 11.33 NA NA 12.89 10.58 1.37 NA NA 25.59 23.28 090
32220.......... ............. A Release of lung....... 19.27 NA NA 16.10 16.63 2.28 NA NA 37.65 38.18 090
32225.......... ............. A Partial release of 13.96 NA NA 13.36 13.11 1.74 NA NA 29.06 28.81 090
lung.
32310.......... ............. A Removal of chest 13.44 NA NA 12.66 12.65 1.65 NA NA 27.75 27.74 090
lining.
32320.......... ............. A Free/remove chest 20.54 NA NA 15.49 17.57 2.50 NA NA 38.53 40.61 090
lining.
32400.......... ............. A Needle biopsy chest 1.76 1.70 1.66 0.52 1.07 0.07 3.53 3.49 2.35 2.90 000
lining.
32402.......... ............. A Open biopsy chest 7.56 NA NA 11.02 9.63 0.94 NA NA 19.52 18.13 090
lining.
32405.......... ............. A Biopsy, lung or 1.93 2.25 2.28 0.53 1.42 0.08 4.26 4.29 2.54 3.43 000
mediastinum.
32420.......... ............. A Puncture/clear lung... 2.18 NA NA 0.64 1.14 0.10 NA NA 2.92 3.42 000
32440.......... ............. A Removal of lung....... 21.02 NA NA 16.12 18.13 2.60 NA NA 39.74 41.75 090
32442.......... ............. A Sleeve pneumonectomy.. 26.24 NA NA 16.60 18.04 3.28 NA NA 46.12 47.56 090
32445.......... ............. A Removal of lung....... 25.09 NA NA 16.55 19.38 3.09 NA NA 44.73 47.56 090
32480.......... ............. A Partial removal of 18.32 NA NA 13.97 16.29 2.25 NA NA 34.54 36.86 090
lung.
32482.......... ............. A Bilobectomy........... 19.71 NA NA 15.10 16.86 2.38 NA NA 37.19 38.95 090
32484.......... ............. A Segmentectomy......... 20.69 NA NA 15.42 17.02 2.54 NA NA 38.65 40.25 090
32486.......... ............. A Sleeve lobectomy...... 23.92 NA NA 17.84 17.90 3.04 NA NA 44.80 44.86 090
32488.......... ............. A Completion 25.71 NA NA 18.14 18.70 3.19 NA NA 47.04 47.60 090
pneumonectomy.
32491.......... ............. R Lung volume reduction. 21.25 NA NA 16.12 16.45 2.84 NA NA 40.21 40.54 090
32500.......... ............. A Partial removal of 14.30 NA NA 13.67 14.15 1.79 NA NA 29.76 30.24 090
lung.
32501.......... ............. A Repair bronchus add-on 4.69 NA NA 1.87 3.28 0.53 NA NA 7.09 8.50 ZZZ
32520.......... ............. A Remove lung & revise 21.68 NA NA 16.65 19.54 2.75 NA NA 41.08 43.97 090
chest.
32522.......... ............. A Remove lung & revise 24.20 NA NA 17.31 20.54 3.03 NA NA 44.54 47.77 090
chest.
32525.......... ............. A Remove lung & revise 26.50 NA NA 17.81 21.66 3.29 NA NA 47.60 51.45 090
chest.
32540.......... ............. A Removal of lung lesion 14.64 NA NA 13.89 13.28 1.81 NA NA 30.34 29.73 090
32601.......... ............. A Thoracoscopy, 5.46 NA NA 4.66 4.22 0.68 NA NA 10.80 10.36 000
diagnostic.
32602.......... ............. A Thoracoscopy, 5.96 NA NA 4.86 4.53 0.74 NA NA 11.56 11.23 000
diagnostic.
32603.......... ............. A Thoracoscopy, 7.81 NA NA 5.62 4.70 0.78 NA NA 14.21 13.29 000
diagnostic.
32604.......... ............. A Thoracoscopy, 8.78 NA NA 6.22 5.21 1.07 NA NA 16.07 15.06 000
diagnostic.
32605.......... ............. A Thoracoscopy, 6.93 NA NA 5.67 4.72 0.86 NA NA 13.46 12.51 000
diagnostic.
32606.......... ............. A Thoracoscopy, 8.40 NA NA 5.86 5.03 1.04 NA NA 15.30 14.47 000
diagnostic.
32650.......... ............. A Thoracoscopy, surgical 10.75 NA NA 11.21 9.74 1.26 NA NA 23.22 21.75 090
32651.......... ............. A Thoracoscopy, surgical 12.91 NA NA 11.23 12.04 1.55 NA NA 25.69 26.50 090
32652.......... ............. A Thoracoscopy, surgical 18.66 NA NA 14.31 15.74 2.30 NA NA 35.27 36.70 090
32653.......... ............. A Thoracoscopy, surgical 12.87 NA NA 11.96 11.59 1.55 NA NA 26.38 26.01 090
32654.......... ............. A Thoracoscopy, surgical 12.44 NA NA 9.46 10.98 1.48 NA NA 23.38 24.90 090
32655.......... ............. A Thoracoscopy, surgical 13.10 NA NA 11.28 12.92 1.54 NA NA 25.92 27.56 090
32656.......... ............. A Thoracoscopy, surgical 12.91 NA NA 12.02 13.26 1.61 NA NA 26.54 27.78 090
32657.......... ............. A Thoracoscopy, surgical 13.65 NA NA 12.09 13.36 1.65 NA NA 27.39 28.66 090
32658.......... ............. A Thoracoscopy, surgical 11.63 NA NA 11.87 12.88 1.45 NA NA 24.95 25.96 090
32659.......... ............. A Thoracoscopy, surgical 11.59 NA NA 11.94 12.89 1.46 NA NA 24.99 25.94 090
32660.......... ............. A Thoracoscopy, surgical 17.43 NA NA 16.64 18.72 2.29 NA NA 36.36 38.44 090
32661.......... ............. A Thoracoscopy, surgical 13.25 NA NA 13.12 11.58 1.65 NA NA 28.02 26.48 090
32662.......... ............. A Thoracoscopy, surgical 16.44 NA NA 13.61 14.70 2.03 NA NA 32.08 33.17 090
32663.......... ............. A Thoracoscopy, surgical 18.47 NA NA 14.31 16.46 2.25 NA NA 35.03 37.18 090
32664.......... ............. A Thoracoscopy, surgical 14.20 NA NA 11.27 11.36 1.64 NA NA 27.11 27.20 090
32665.......... ............. A Thoracoscopy, surgical 15.54 NA NA 11.56 13.56 1.80 NA NA 28.90 30.90 090
32800.......... ............. A Repair lung hernia.... 13.69 NA NA 13.79 11.39 1.41 NA NA 28.89 26.49 090
32810.......... ............. A Close chest after 13.05 NA NA 12.87 9.96 1.66 NA NA 27.58 24.67 090
drainage.
32815.......... ............. A Close bronchial 23.15 NA NA 18.44 17.48 2.94 NA NA 44.53 43.57 090
fistula.
32820.......... ............. A Reconstruct injured 21.48 NA NA 15.61 18.12 2.40 NA NA 39.49 42.00 090
chest.
32850.......... ............. X Donor pneumonectomy... 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
32851.......... ............. A Lung transplant, 38.63 NA NA 25.49 26.61 5.21 NA NA 69.33 70.45 090
single.
32852.......... ............. A Lung transplant with 41.80 NA NA 26.49 28.28 5.81 NA NA 74.10 75.89 090
bypass.
32853.......... ............. A Lung transplant, 47.81 NA NA 29.00 31.83 6.43 NA NA 83.24 86.07 090
double.
32854.......... ............. A Lung transplant with 50.98 NA NA 31.09 34.05 6.75 NA NA 88.82 91.78 090
bypass.
32900.......... ............. A Removal of rib(s)..... 20.27 NA NA 15.10 12.15 2.40 NA NA 37.77 34.82 090
32905.......... ............. A Revise & repair chest 20.75 NA NA 15.06 14.45 2.55 NA NA 38.36 37.75 090
wall.
32906.......... ............. A Revise & repair chest 26.77 NA NA 18.49 17.61 3.34 NA NA 48.60 47.72 090
wall.
32940.......... ............. A Revision of lung...... 19.43 NA NA 14.72 13.53 2.37 NA NA 36.52 35.33 090
32960.......... ............. A Therapeutic 1.84 1.91 1.46 0.41 0.71 0.13 3.88 3.43 2.38 2.68 000
pneumothorax.
32997.......... ............. A Total lung lavage..... 6.00 2.28 2.28 2.28 2.28 0.58 8.86 8.86 8.86 8.86 000
32999.......... ............. C Chest surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
33010.......... ............. A Drainage of heart sac. 2.24 NA NA 0.84 1.26 0.27 NA NA 3.35 3.77 000
33011.......... ............. A Repeat drainage of 2.24 NA NA 0.86 0.73 0.26 NA NA 3.36 3.23 000
heart sac.
33015.......... ............. A Incision of heart sac. 6.80 NA NA 5.25 4.94 0.88 NA NA 12.93 12.62 090
33020.......... ............. A Incision of heart sac. 12.61 NA NA 10.68 12.54 1.63 NA NA 24.92 26.78 090
33025.......... ............. A Incision of heart sac. 12.09 NA NA 11.23 12.83 1.55 NA NA 24.87 26.47 090
33030.......... ............. A Partial removal of 18.71 NA NA 16.61 19.47 2.41 NA NA 37.73 40.59 090
heart sac.
33031.......... ............. A Partial removal of 21.79 NA NA 18.80 16.59 2.90 NA NA 43.49 41.28 090
heart sac.
33050.......... ............. A Removal of heart sac 14.36 NA NA 13.33 11.69 1.77 NA NA 29.46 27.82 090
lesion.
[[Page 59470]]
33120.......... ............. A Removal of heart 24.56 NA NA 22.33 25.83 3.19 NA NA 50.08 53.58 090
lesion.
33130.......... ............. A Removal of heart 21.39 NA NA 16.52 15.59 2.42 NA NA 40.33 39.40 090
lesion.
33140.......... ............. A Heart revascularize 20.00 NA NA 13.15 13.15 2.56 NA NA 35.71 35.71 090
(tmr).
33200.......... ............. A Insertion of heart 12.48 NA NA 11.99 12.66 1.45 NA NA 25.92 26.59 090
pacemaker.
33201.......... ............. A Insertion of heart 10.18 NA NA 12.63 12.39 1.34 NA NA 24.15 23.91 090
pacemaker.
33206.......... ............. A Insertion of heart 6.67 NA NA 6.17 7.07 0.84 NA NA 13.68 14.58 090
pacemaker.
33207.......... ............. A Insertion of heart 8.04 NA NA 6.50 8.05 1.03 NA NA 15.57 17.12 090
pacemaker.
33208.......... ............. A Insertion of heart 8.13 NA NA 6.64 8.17 1.07 NA NA 15.84 17.37 090
pacemaker.
33210.......... ............. A Insertion of heart 3.30 NA NA 1.34 2.46 0.42 NA NA 5.06 6.18 000
electrode.
33211.......... ............. A Insertion of heart 3.40 NA NA 1.44 2.51 0.44 NA NA 5.28 6.35 000
electrode.
33212.......... ............. A Insertion of pulse 5.52 NA NA 4.93 5.39 0.71 NA NA 11.16 11.62 090
generator.
33213.......... ............. A Insertion of pulse 6.37 NA NA 5.25 5.55 0.82 NA NA 12.44 12.74 090
generator.
33214.......... ............. A Upgrade of pacemaker 7.75 NA NA 6.29 6.08 0.99 NA NA 15.03 14.82 090
system.
33216.......... ............. A Revise eltrd pacing- 5.39 NA NA 5.43 5.44 0.70 NA NA 11.52 11.53 090
defib.
33217.......... ............. A Revise eltrd pacing- 5.75 NA NA 5.54 5.50 0.76 NA NA 12.05 12.01 090
defib.
33218.......... ............. A Revise eltrd pacing- 5.44 NA NA 4.93 4.96 0.70 NA NA 11.07 11.10 090
defib.
33220.......... ............. A Revise eltrd pacing- 5.52 NA NA 4.98 4.98 0.71 NA NA 11.21 11.21 090
defib.
33222.......... ............. A Revise pocket, 4.96 NA NA 4.31 5.12 0.62 NA NA 9.89 10.70 090
pacemaker.
33223.......... ............. A Revise pocket, pacing- 6.46 NA NA 5.70 5.95 0.88 NA NA 13.04 13.29 090
defib.
33233.......... ............. A Removal of pacemaker 3.29 NA NA 4.24 3.56 0.44 NA NA 7.97 7.29 090
system.
33234.......... ............. A Removal of pacemaker 7.82 NA NA 6.33 4.71 1.05 NA NA 15.20 13.58 090
system.
33235.......... ............. A Removal pacemaker 9.40 NA NA 6.96 5.19 1.26 NA NA 17.62 15.85 090
electrode.
33236.......... ............. A Remove electrode/ 12.60 NA NA 11.48 7.90 1.63 NA NA 25.71 22.13 090
thoracotomy.
33237.......... ............. A Remove electrode/ 13.71 NA NA 12.46 11.44 1.77 NA NA 27.94 26.92 090
thoracotomy.
33238.......... ............. A Remove electrode/ 15.22 NA NA 11.68 11.43 1.41 NA NA 28.31 28.06 090
thoracotomy.
33240.......... ............. A Insert pulse generator 7.60 NA NA 6.36 6.10 1.03 NA NA 14.99 14.73 090
33241.......... ............. A Remove pulse generator 3.24 NA NA 3.95 3.15 0.44 NA NA 7.63 6.83 090
33242.......... ............. D Repair pulse generator/ 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
leads.
33243.......... ............. A Remove eltrd/ 22.64 NA NA 13.87 11.83 3.03 NA NA 39.54 37.50 090
thoracotomy.
33244.......... ............. A Remove eltrd, transven 13.76 NA NA 9.22 9.51 1.83 NA NA 24.81 25.10 090
33245.......... ............. A Insert epic eltrd pace- 14.30 NA NA 14.30 15.69 1.83 NA NA 30.43 31.82 090
defib.
33246.......... ............. A Insert epic eltrd/ 20.71 NA NA 16.35 19.46 2.74 NA NA 39.80 42.91 090
generator.
33247.......... ............. D Insert/replace leads.. 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 090
33249.......... ............. A Eltrd/insert pace- 14.23 NA NA 9.87 12.87 1.79 NA NA 25.89 28.89 090
defib.
33250.......... ............. A Ablate heart dysrhythm 21.85 NA NA 14.51 13.53 2.97 NA NA 39.33 38.35 090
focus.
33251.......... ............. A Ablate heart dysrhythm 24.88 NA NA 20.04 18.93 3.26 NA NA 48.18 47.07 090
focus.
33253.......... ............. A Reconstruct atria..... 31.06 NA NA 22.48 23.08 4.12 NA NA 57.66 58.26 090
33261.......... ............. A Ablate heart dysrhythm 24.88 NA NA 19.80 17.48 2.94 NA NA 47.62 45.30 090
focus.
33282.......... ............. A Implant pat-active ht 4.17 NA NA 5.99 5.99 0.53 NA NA 10.69 10.69 090
record.
33284.......... ............. A Remove pat-active ht 2.50 NA NA 5.46 5.46 0.33 NA NA 8.29 8.29 090
record.
33300.......... ............. A Repair of heart wound. 17.92 NA NA 15.54 15.56 2.33 NA NA 35.79 35.81 090
33305.......... ............. A Repair of heart wound. 21.44 NA NA 18.48 18.68 2.81 NA NA 42.73 42.93 090
33310.......... ............. A Exploratory heart 18.51 NA NA 17.47 14.86 2.48 NA NA 38.46 35.85 090
surgery.
33315.......... ............. A Exploratory heart 22.37 NA NA 18.77 17.24 3.00 NA NA 44.14 42.61 090
surgery.
33320.......... ............. A Repair major blood 16.79 NA NA 14.26 14.81 2.14 NA NA 33.19 33.74 090
vessel(s).
33321.......... ............. A Repair major vessel... 20.20 NA NA 17.18 20.39 2.36 NA NA 39.74 42.95 090
33322.......... ............. A Repair major blood 20.62 NA NA 17.70 20.65 2.70 NA NA 41.02 43.97 090
vessel(s).
33330.......... ............. A Insert major vessel 21.43 NA NA 16.24 15.00 2.79 NA NA 40.46 39.22 090
graft.
33332.......... ............. A Insert major vessel 23.96 NA NA 16.19 16.27 3.29 NA NA 43.44 43.52 090
graft.
33335.......... ............. A Insert major vessel 30.01 NA NA 21.84 19.10 3.99 NA NA 55.84 53.10 090
graft.
33400.......... ............. A Repair of aortic valve 25.34 NA NA 23.32 25.88 3.34 NA NA 52.00 54.56 090
33401.......... ............. A Valvuloplasty, open... 23.91 NA NA 18.63 23.54 3.19 NA NA 45.73 50.64 090
33403.......... ............. A Valvuloplasty, w/cp 24.89 NA NA 22.49 25.47 3.47 NA NA 50.85 53.83 090
bypass.
33404.......... ............. A Prepare heart-aorta 28.54 NA NA 24.27 29.09 3.68 NA NA 56.49 61.31 090
conduit.
33405.......... ............. A Replacement of aortic 30.61 NA NA 22.51 27.80 3.97 NA NA 57.09 62.38 090
valve.
33406.......... ............. A Replacement of aortic 32.30 NA NA 23.12 30.84 4.18 NA NA 59.60 67.32 090
valve.
33410.......... ............. A Replacement of aortic 32.46 NA NA 23.27 23.27 4.21 NA NA 59.94 59.94 090
valve.
33411.......... ............. A Replacement of aortic 32.47 NA NA 23.37 31.07 4.21 NA NA 60.05 67.75 090
valve.
33412.......... ............. A Replacement of aortic 34.79 NA NA 26.56 34.05 4.18 NA NA 65.53 73.02 090
valve.
33413.......... ............. A Replacement of aortic 35.24 NA NA 27.44 34.75 4.59 NA NA 67.27 74.58 090
valve.
33414.......... ............. A Repair of aortic valve 30.35 NA NA 27.32 31.78 3.88 NA NA 61.55 66.01 090
33415.......... ............. A Revision, subvalvular 27.15 NA NA 24.07 28.25 2.84 NA NA 54.06 58.24 090
tissue.
33416.......... ............. A Revise ventricle 30.35 NA NA 22.76 26.65 4.00 NA NA 57.11 61.00 090
muscle.
33417.......... ............. A Repair of aortic valve 28.53 NA NA 26.71 30.39 3.72 NA NA 58.96 62.64 090
33420.......... ............. A Revision of mitral 22.70 NA NA 11.55 16.53 1.58 NA NA 35.83 40.81 090
valve.
33422.......... ............. A Revision of mitral 25.94 NA NA 21.00 25.98 3.34 NA NA 50.28 55.26 090
valve.
33425.......... ............. A Repair of mitral valve 27.00 NA NA 20.88 26.56 3.47 NA NA 51.35 57.03 090
33426.......... ............. A Repair of mitral valve 31.03 NA NA 22.76 28.72 4.03 NA NA 57.82 63.78 090
33427.......... ............. A Repair of mitral valve 33.72 NA NA 23.61 30.64 4.42 NA NA 61.75 68.78 090
33430.......... ............. A Replacement of mitral 31.43 NA NA 22.84 30.18 4.09 NA NA 58.36 65.70 090
valve.
33460.......... ............. A Revision of tricuspid 23.60 NA NA 19.32 23.75 3.00 NA NA 45.92 50.35 090
valve.
33463.......... ............. A Valvuloplasty, 25.62 NA NA 20.41 25.50 3.34 NA NA 49.37 54.46 090
tricuspid.
33464.......... ............. A Valvuloplasty, 27.33 NA NA 21.36 26.99 3.57 NA NA 52.26 57.89 090
tricuspid.
33465.......... ............. A Replace tricuspid 28.79 NA NA 21.88 28.13 3.65 NA NA 54.32 60.57 090
valve.
33468.......... ............. A Revision of tricuspid 30.12 NA NA 30.14 33.05 3.93 NA NA 64.19 67.10 090
valve.
33470.......... ............. A Revision of pulmonary 20.81 NA NA 11.39 16.45 2.50 NA NA 34.70 39.76 090
valve.
33471.......... ............. A Valvotomy, pulmonary 22.25 NA NA 13.10 19.84 1.75 NA NA 37.10 43.84 090
valve.
33472.......... ............. A Revision of pulmonary 22.25 NA NA 14.82 20.70 2.53 NA NA 39.60 45.48 090
valve.
33474.......... ............. A Revision of pulmonary 23.04 NA NA 19.95 23.73 2.62 NA NA 45.61 49.39 090
valve.
33475.......... ............. A Replacement, pulmonary 28.41 NA NA 23.01 28.46 3.73 NA NA 55.15 60.60 090
valve.
33476.......... ............. A Revision of heart 25.77 NA NA 16.31 23.43 2.38 NA NA 44.46 51.58 090
chamber.
[[Page 59471]]
33478.......... ............. A Revision of heart 26.74 NA NA 22.86 27.39 3.68 NA NA 53.28 57.81 090
chamber.
33496.......... ............. A Repair, prosth valve 27.25 NA NA 23.63 28.09 3.63 NA NA 54.51 58.97 090
clot.
33500.......... ............. A Repair heart vessel 25.55 NA NA 19.92 25.22 3.10 NA NA 48.57 53.87 090
fistula.
33501.......... ............. A Repair heart vessel 17.78 NA NA 15.19 15.27 2.09 NA NA 35.06 35.14 090
fistula.
33502.......... ............. A Coronary artery 21.04 NA NA 24.95 20.15 2.86 NA NA 48.85 44.05 090
correction.
33503.......... ............. A Coronary artery graft. 21.78 NA NA 15.16 20.58 2.70 NA NA 39.64 45.06 090
33504.......... ............. A Coronary artery graft. 24.66 NA NA 25.77 27.61 2.63 NA NA 53.06 54.90 090
33505.......... ............. A Repair artery w/tunnel 26.84 NA NA 18.09 25.07 3.16 NA NA 48.09 55.07 090
33506.......... ............. A Repair artery, 26.71 NA NA 20.10 25.99 2.94 NA NA 49.75 55.64 090
translocation.
33510.......... ............. A CABG, vein, single.... 25.12 NA NA 20.20 25.10 3.27 NA NA 48.59 53.49 090
33511.......... ............. A CABG, vein, two....... 27.40 NA NA 21.09 26.90 3.56 NA NA 52.05 57.86 090
33512.......... ............. A CABG, vein, three..... 29.67 NA NA 21.86 28.64 3.79 NA NA 55.32 62.10 090
33513.......... ............. A CABG, vein, four...... 31.95 NA NA 23.05 30.60 4.11 NA NA 59.11 66.66 090
33514.......... ............. A CABG, vein, five...... 35.00 NA NA 24.57 33.18 4.49 NA NA 64.06 72.67 090
33516.......... ............. A Cabg, vein, six or 37.40 NA NA 25.70 35.18 4.78 NA NA 67.88 77.36 090
more.
33517.......... ............. A CABG, artery-vein, 2.57 NA NA 1.08 2.08 0.33 NA NA 3.98 4.98 ZZZ
single.
33518.......... ............. A CABG, artery-vein, two 4.85 NA NA 2.04 3.92 0.63 NA NA 7.52 9.40 ZZZ
33519.......... ............. A CABG, artery-vein, 7.12 NA NA 2.99 5.75 0.92 NA NA 11.03 13.79 ZZZ
three.
33521.......... ............. A CABG, artery-vein, 9.40 NA NA 3.95 7.59 1.21 NA NA 14.56 18.20 ZZZ
four.
33522.......... ............. A CABG, artery-vein, 11.67 NA NA 4.92 9.43 1.49 NA NA 18.08 22.59 ZZZ
five.
33523.......... ............. A Cabg, art-vein, six or 13.95 NA NA 5.91 11.29 1.78 NA NA 21.64 27.02 ZZZ
more.
33530.......... ............. A Coronary artery, 5.86 NA NA 2.45 4.73 0.76 NA NA 9.07 11.35 ZZZ
bypass/reop.
33533.......... ............. A CABG, arterial, single 25.83 NA NA 20.61 25.72 3.33 NA NA 49.77 54.88 090
33534.......... ............. A CABG, arterial, two... 28.82 NA NA 21.24 27.82 3.68 NA NA 53.74 60.32 090
33535.......... ............. A CABG, arterial, three. 31.81 NA NA 22.27 30.12 3.96 NA NA 58.04 65.89 090
33536.......... ............. A Cabg, arterial, four 34.79 NA NA 22.99 32.26 4.39 NA NA 62.17 71.44 090
or more.
33542.......... ............. A Removal of heart 28.85 NA NA 23.85 28.60 3.76 NA NA 56.46 61.21 090
lesion.
33545.......... ............. A Repair of heart damage 36.78 NA NA 26.66 32.28 4.80 NA NA 68.24 73.86 090
33572.......... ............. A Open coronary 4.45 NA NA 1.86 2.69 0.58 NA NA 6.89 7.72 ZZZ
endarterectomy.
33600.......... ............. A Closure of valve...... 29.51 NA NA 20.75 27.99 2.58 NA NA 52.84 60.08 090
33602.......... ............. A Closure of valve...... 28.54 NA NA 20.34 26.71 2.84 NA NA 51.72 58.09 090
33606.......... ............. A Anastomosis/artery- 30.74 NA NA 22.57 29.63 3.97 NA NA 57.28 64.34 090
aorta.
33608.......... ............. A Repair anomaly w/ 31.09 NA NA 25.80 31.46 4.27 NA NA 61.16 66.82 090
conduit.
33610.......... ............. A Repair by enlargement. 30.61 NA NA 25.46 31.00 3.64 NA NA 59.71 65.25 090
33611.......... ............. A Repair double 32.30 NA NA 23.66 31.11 4.44 NA NA 60.40 67.85 090
ventricle.
33612.......... ............. A Repair double 33.26 NA NA 28.03 33.87 4.51 NA NA 65.80 71.64 090
ventricle.
33615.......... ............. A Repair, simple fontan. 32.06 NA NA 28.54 33.41 3.88 NA NA 64.48 69.35 090
33617.......... ............. A Repair, modified 34.03 NA NA 30.55 35.59 4.75 NA NA 69.33 74.37 090
fontan.
33619.......... ............. A Repair single 37.57 NA NA 37.15 41.00 5.03 NA NA 79.75 83.60 090
ventricle.
33641.......... ............. A Repair heart septum 21.39 NA NA 16.18 20.86 2.78 NA NA 40.35 45.03 090
defect.
33645.......... ............. A Revision of heart 24.82 NA NA 20.99 25.31 3.32 NA NA 49.13 53.45 090
veins.
33647.......... ............. A Repair heart septum 28.73 NA NA 24.78 29.54 3.81 NA NA 57.32 62.08 090
defects.
33660.......... ............. A Repair of heart 25.54 NA NA 23.25 26.87 3.13 NA NA 51.92 55.54 090
defects.
33665.......... ............. A Repair of heart 28.60 NA NA 23.59 28.77 4.00 NA NA 56.19 61.37 090
defects.
33670.......... ............. A Repair of heart 32.73 NA NA 16.95 28.01 3.35 NA NA 53.03 64.09 090
chambers.
33681.......... ............. A Repair heart septum 27.67 NA NA 25.17 29.11 3.60 NA NA 56.44 60.38 090
defect.
33684.......... ............. A Repair heart septum 29.65 NA NA 22.59 29.00 3.63 NA NA 55.87 62.28 090
defect.
33688.......... ............. A Repair heart septum 30.62 NA NA 13.00 24.78 3.74 NA NA 47.36 59.14 090
defect.
33690.......... ............. A Reinforce pulmonary 19.55 NA NA 18.43 20.89 2.38 NA NA 40.36 42.82 090
artery.
33692.......... ............. A Repair of heart 30.75 NA NA 21.37 29.04 4.22 NA NA 56.34 64.01 090
defects.
33694.......... ............. A Repair of heart 31.73 NA NA 21.76 29.82 3.36 NA NA 56.85 64.91 090
defects.
33697.......... ............. A Repair of heart 33.71 NA NA 22.55 31.40 4.52 NA NA 60.78 69.63 090
defects.
33702.......... ............. A Repair of heart 26.54 NA NA 23.99 27.84 3.55 NA NA 54.08 57.93 090
defects.
33710.......... ............. A Repair of heart 29.71 NA NA 20.95 28.21 4.15 NA NA 54.81 62.07 090
defects.
33720.......... ............. A Repair of heart defect 26.56 NA NA 22.02 26.87 3.56 NA NA 52.14 56.99 090
33722.......... ............. A Repair of heart defect 28.41 NA NA 25.06 29.07 3.97 NA NA 57.44 61.45 090
33730.......... ............. A Repair heart-vein 31.67 NA NA 16.96 27.39 4.24 NA NA 52.87 63.30 090
defect(s).
33732.......... ............. A Repair heart-vein 28.16 NA NA 21.40 27.51 3.93 NA NA 53.49 59.60 090
defect.
33735.......... ............. A Revision of heart 21.39 NA NA 17.48 22.68 2.21 NA NA 41.08 46.28 090
chamber.
33736.......... ............. A Revision of heart 23.52 NA NA 23.03 25.46 3.03 NA NA 49.58 52.01 090
chamber.
33737.......... ............. A Revision of heart 21.76 NA NA 18.63 22.31 0.86 NA NA 41.25 44.93 090
chamber.
33750.......... ............. A Major vessel shunt.... 21.41 NA NA 13.10 18.54 2.72 NA NA 37.23 42.67 090
33755.......... ............. A Major vessel shunt.... 21.79 NA NA 12.92 18.45 1.37 NA NA 36.08 41.61 090
33762.......... ............. A Major vessel shunt.... 21.79 NA NA 12.92 18.45 2.95 NA NA 37.66 43.19 090
33764.......... ............. A Major vessel shunt & 21.79 NA NA 14.44 19.21 2.07 NA NA 38.30 43.07 090
graft.
33766.......... ............. A Major vessel shunt.... 22.76 NA NA 20.65 22.32 3.08 NA NA 46.49 48.16 090
33767.......... ............. A Major vessel shunt.... 24.50 NA NA 14.91 21.40 3.49 NA NA 42.90 49.39 090
33770.......... ............. A Repair great vessels 33.29 NA NA 22.43 31.09 2.76 NA NA 58.48 67.14 090
defect.
33771.......... ............. A Repair great vessels 34.65 NA NA 16.50 28.94 2.87 NA NA 54.02 66.46 090
defect.
33774.......... ............. A Repair great vessels 30.98 NA NA 23.62 28.78 1.18 NA NA 55.78 60.94 090
defect.
33775.......... ............. A Repair great vessels 32.20 NA NA 16.95 25.45 2.67 NA NA 51.82 60.32 090
defect.
33776.......... ............. A Repair great vessels 34.04 NA NA 17.66 27.78 2.82 NA NA 54.52 64.64 090
defect.
33777.......... ............. A Repair great vessels 33.46 NA NA 17.44 25.69 2.77 NA NA 53.67 61.92 090
defect.
33778.......... ............. A Repair great vessels 35.82 NA NA 25.08 33.92 2.97 NA NA 63.87 72.71 090
defect.
33779.......... ............. A Repair great vessels 36.21 NA NA 16.77 30.00 4.72 NA NA 57.70 70.93 090
defect.
33780.......... ............. A Repair great vessels 36.94 NA NA 18.78 31.44 5.08 NA NA 60.80 73.46 090
defect.
33781.......... ............. A Repair great vessels 36.45 NA NA 16.47 30.00 3.02 NA NA 55.94 69.47 090
defect.
33786.......... ............. A Repair arterial trunk. 34.84 NA NA 17.97 29.78 2.88 NA NA 55.69 67.50 090
33788.......... ............. A Revision of pulmonary 26.62 NA NA 14.54 23.16 2.21 NA NA 43.37 51.99 090
artery.
33800.......... ............. A Aortic suspension..... 16.24 NA NA 18.55 16.95 1.95 NA NA 36.74 35.14 090
33802.......... ............. A Repair vessel defect.. 17.66 NA NA 18.40 19.75 2.40 NA NA 38.46 39.81 090
[[Page 59472]]
33803.......... ............. A Repair vessel defect.. 19.60 NA NA 12.08 17.74 2.35 NA NA 34.03 39.69 090
33813.......... ............. A Repair septal defect.. 20.65 NA NA 16.82 20.40 2.92 NA NA 40.39 43.97 090
33814.......... ............. A Repair septal defect.. 25.77 NA NA 22.73 26.75 3.47 NA NA 51.97 55.99 090
33820.......... ............. A Revise major vessel... 16.29 NA NA 17.44 18.45 2.05 NA NA 35.78 36.79 090
33822.......... ............. A Revise major vessel... 17.32 NA NA 11.19 15.93 2.19 NA NA 30.70 35.44 090
33824.......... ............. A Revise major vessel... 19.52 NA NA 18.40 20.85 2.45 NA NA 40.37 42.82 090
33840.......... ............. A Remove aorta 20.63 NA NA 20.55 22.59 2.89 NA NA 44.07 46.11 090
constriction.
33845.......... ............. A Remove aorta 22.12 NA NA 19.92 23.16 3.10 NA NA 45.14 48.38 090
constriction.
33851.......... ............. A Remove aorta 21.27 NA NA 23.00 24.20 2.92 NA NA 47.19 48.39 090
constriction.
33852.......... ............. A Repair septal defect.. 23.71 NA NA 23.20 25.75 3.07 NA NA 49.98 52.53 090
33853.......... ............. A Repair septal defect.. 31.72 NA NA 29.49 33.68 4.07 NA NA 65.28 69.47 090
33860.......... ............. A Ascending aortic graft 33.96 NA NA 23.85 30.76 4.46 NA NA 62.27 69.18 090
33861.......... ............. A Ascending aortic graft 34.52 NA NA 23.62 30.65 4.58 NA NA 62.72 69.75 090
33863.......... ............. A Ascending aortic graft 36.47 NA NA 24.53 31.10 4.77 NA NA 65.77 72.34 090
33870.......... ............. A Transverse aortic arch 40.31 NA NA 25.91 37.00 5.38 NA NA 71.60 82.69 090
graft.
33875.......... ............. A Thoracic aortic graft. 33.06 NA NA 22.17 28.04 4.27 NA NA 59.50 65.37 090
33877.......... ............. A Thoracoabdominal graft 42.60 NA NA 27.20 37.54 5.48 NA NA 75.28 85.62 090
33910.......... ............. A Remove lung artery 24.59 NA NA 19.00 17.45 3.12 NA NA 46.71 45.16 090
emboli.
33915.......... ............. A Remove lung artery 21.02 NA NA 12.58 12.81 2.26 NA NA 35.86 36.09 090
emboli.
33916.......... ............. A Surgery of great 25.83 NA NA 18.00 18.54 3.27 NA NA 47.10 47.64 090
vessel.
33917.......... ............. A Repair pulmonary 24.50 NA NA 21.74 25.50 3.30 NA NA 49.54 53.30 090
artery.
33918.......... ............. A Repair pulmonary 26.45 NA NA 14.73 23.16 3.77 NA NA 44.95 53.38 090
atresia.
33919.......... ............. A Repair pulmonary 32.67 NA NA 17.13 28.07 4.56 NA NA 54.36 65.30 090
atresia.
33920.......... ............. A Repair pulmonary 31.95 NA NA 24.52 31.34 4.47 NA NA 60.94 67.76 090
atresia.
33922.......... ............. A Transect pulmonary 23.52 NA NA 21.31 24.70 2.40 NA NA 47.23 50.62 090
artery.
33924.......... ............. A Remove pulmonary shunt 5.50 NA NA 2.24 3.29 0.77 NA NA 8.51 9.56 ZZZ
33930.......... ............. X Removal of donor heart/ 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
lung.
33935.......... ............. R Transplantation, heart/ 60.96 NA NA 35.30 54.04 8.06 NA NA 104.32 123.06 090
lung.
33940.......... ............. X Removal of donor heart 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 XXX
33945.......... ............. R Transplantation of 42.10 NA NA 27.65 38.96 5.60 NA NA 75.35 86.66 090
heart.
33960.......... ............. A External circulation 19.36 NA NA 5.96 6.79 1.59 NA NA 26.91 27.74 XXX
assist.
33961.......... ............. A External circulation 10.93 NA NA 4.18 5.90 1.35 NA NA 16.46 18.18 ZZZ
assist.
33968.......... ............. A Remove aortic assist 0.64 0.25 0.25 0.25 0.25 0.27 1.16 1.16 1.16 1.16 090
device.
33970.......... ............. A Aortic circulation 6.75 NA NA 2.81 5.44 0.91 NA NA 10.47 13.10 000
assist.
33971.......... ............. A Aortic circulation 9.69 NA NA 10.07 7.84 1.29 NA NA 21.05 18.82 090
assist.
33973.......... ............. A Insert balloon device. 9.76 NA NA 4.01 6.10 1.32 NA NA 15.09 17.18 000
33974.......... ............. A Remove intra-aortic 14.41 NA NA 13.03 9.53 1.94 NA NA 29.38 25.88 090
balloon.
33975.......... ............. A Implant ventricular 39.00 NA NA 22.02 18.71 2.86 NA NA 63.88 60.57 XXX
device.
33976.......... ............. A Implant ventricular 43.00 NA NA 23.99 22.49 3.91 NA NA 70.90 69.40 XXX
device.
33977.......... ............. A Remove ventricular 19.29 NA NA 13.77 13.62 2.56 NA NA 35.62 35.47 090
device.
33978.......... ............. A Remove ventricular 21.73 NA NA 15.09 15.25 2.89 NA NA 39.71 39.87 090
device.
33999.......... ............. C Cardiac surgery 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 YYY
procedure.
34001.......... ............. A Removal of artery clot 12.91 NA NA 6.63 8.52 1.56 NA NA 21.10 22.99 090
34051.......... ............. A Removal of artery clot 15.21 NA NA 7.88 8.72 1.85 NA NA 24.94 25.78 090
34101.......... ............. A Removal of artery clot 9.97 NA NA 5.10 7.08 1.13 NA NA 16.20 18.18 090
34111.......... ............. A Removal of arm artery 8.07 NA NA 4.35 6.30 0.84 NA NA 13.26 15.21 090
clot.
34151.......... ............. A Removal of artery clot 16.86 NA NA 8.09 10.54 1.87 NA NA 26.82 29.27 090
34201.......... ............. A Removal of artery clot 9.13 NA NA 5.25 7.46 1.06 NA NA 15.44 17.65 090
34203.......... ............. A Removal of leg artery 12.21 NA NA 6.47 7.92 1.43 NA NA 20.11 21.56 090
clot.
34401.......... ............. A Removal of vein clot.. 12.86 NA NA 6.32 7.54 1.25 NA NA 20.43 21.65 090
34421.......... ............. A Removal of vein clot.. 9.93 NA NA 5.53 6.81 0.97 NA NA 16.43 17.71 090
34451.......... ............. A Removal of vein clot.. 14.44 NA NA 7.10 9.35 1.60 NA NA 23.14 25.39 090
34471.......... ............. A Removal of vein clot.. 10.18 NA NA 4.97 4.39 1.00 NA NA 16.15 15.57 090
34490.......... ............. A Removal of vein clot.. 7.60 NA NA 5.38 6.64 0.76 NA NA 13.74 15.00 090
34501.......... ............. A Repair valve, femoral 10.93 NA NA 8.66 8.32 1.43 NA NA 21.02 20.68 090
vein.
34502.......... ............. A Reconstruct vena cava. 26.95 NA NA 12.81 16.53 2.97 NA NA 42.73 46.45 090
34510.......... ............. A Transposition of vein 13.25 NA NA 10.92 10.29 1.64 NA NA 25.81 25.18 090
valve.
34520.......... ............. A Cross-over vein graft. 13.74 NA NA 8.07 9.10 1.64 NA NA 23.45 24.48 090
34530.......... ............. A Leg vein fusion....... 17.61 NA NA 9.56 11.48 2.00 NA NA 29.17 31.09 090
35001.......... ............. A Repair defect of 19.64 NA NA 9.54 13.40 2.51 NA NA 31.69 35.55 090
artery.
35002.......... ............. A Repair artery rupture, 21.00 NA NA 9.75 11.74 2.43 NA NA 33.18 35.17 090
neck.
35005.......... ............. A Repair defect of 18.12 NA NA 7.42 9.29 1.40 NA NA 26.94 28.81 090
artery.
35011.......... ............. A Repair defect of 11.65 NA NA 5.84 9.88 1.36 NA NA 18.85 22.89 090
artery.
35013.......... ............. A Repair artery rupture, 17.40 NA NA 7.80 11.88 2.00 NA NA 27.20 31.28 090
arm.
35021.......... ............. A Repair defect of 19.65 NA NA 10.50 15.09 2.42 NA NA 32.57 37.16 090
artery.
35022.......... ............. A Repair artery rupture, 23.18 NA NA 9.92 12.98 2.15 NA NA 35.25 38.31 090
chest.
35045.......... ............. A Repair defect of arm 11.26 NA NA 6.77 10.09 1.26 NA NA 19.29 22.61 090
artery.
35081.......... ............. A Repair defect of 28.01 NA NA 12.98 18.13 3.30 NA NA 44.29 49.44 090
artery.
35082.......... ............. A Repair artery rupture, 36.35 NA NA 15.12 19.99 4.14 NA NA 55.61 60.48 090
aorta.
35091.......... ............. A Repair defect of 35.40 NA NA 15.78 20.19 4.28 NA NA 55.46 59.87 090
artery.
35092.......... ............. A Repair artery rupture, 38.39 NA NA 16.31 22.41 4.48 NA NA 59.18 65.28 090
aorta.
35102.......... ............. A Repair defect of 30.76 NA NA 13.76 18.90 3.65 NA NA 48.17 53.31 090
artery.
35103.......... ............. A Repair artery rupture, 33.57 NA NA 14.39 21.39 3.84 NA NA 51.80 58.80 090
groin.
35111.......... ............. A Repair defect of 16.43 NA NA 7.93 13.52 1.82 NA NA 26.18 31.77 090
artery.
35112.......... ............. A Repair artery rupture, 18.69 NA NA 8.41 9.88 2.14 NA NA 29.24 30.71 090
spleen.
35121.......... ............. A Repair defect of 25.99 NA NA 11.98 16.37 3.10 NA NA 41.07 45.46 090
artery.
35122.......... ............. A Repair artery rupture, 33.45 NA NA 14.53 16.99 3.69 NA NA 51.67 54.13 090
belly.
35131.......... ............. A Repair defect of 18.55 NA NA 9.20 13.22 2.20 NA NA 29.95 33.97 090
artery.
35132.......... ............. A Repair artery rupture, 21.95 NA NA 10.05 15.16 2.47 NA NA 34.47 39.58 090
groin.
35141.......... ............. A Repair defect of 14.46 NA NA 7.61 11.78 1.73 NA NA 23.80 27.97 090
artery.
35142.......... ............. A Repair artery rupture, 15.86 NA NA 7.83 12.65 1.92 NA NA 25.61 30.43 090
thigh.
[[Page 59473]]
35151.......... ............. A Repair defect of 17.00 NA NA 8.50 12.59 2.01 NA NA 27.51 31.60 090
artery.
35152.......... ............. A Repair artery rupture, 16.70 NA NA 8.40 9.23 2.01 NA NA 27.11 27.94 090
knee.
35161.......... ............. A Repair defect of 18.76 NA NA 9.76 13.50 2.19 NA NA 30.71 34.45 090
artery.
35162.......... ............. A Repair artery rupture. 19.78 NA NA 9.89 15.08 2.26 NA NA 31.93 37.12 090
35180.......... ............. A Repair blood vessel 13.62 NA NA 7.04 7.52 1.53 NA NA 22.19 22.67 090
lesion.
35182.......... ............. A Repair blood vessel 17.74 NA NA 9.71 10.64 2.19 NA NA 29.64 30.57 090
lesion.
35184.......... ............. A Repair blood vessel 12.25 NA NA 6.40 8.48 1.45 NA NA 20.10 22.18 090
lesion.
35188.......... ............. A Repair blood vessel 14.28 NA NA 6.86 7.83 1.70 NA NA 22.84 23.81 090
lesion.
35189.......... ............. A Repair blood vessel 18.43 NA NA 9.24 10.77 2.17 NA NA 29.84 31.37 090
lesion.
35190.......... ............. A Repair blood vessel 12.75 NA NA 6.57 8.90 1.48 NA NA 20.80 23.13 090
lesion.
35201.......... ............. A Repair blood vessel 9.99 NA NA 5.36 8.15 1.23 NA NA 16.58 19.37 090
lesion.
35206.......... ............. A Repair blood vessel 9.25 NA NA 6.29 8.66 1.06 NA NA 16.60 18.97 090
lesion.
35207.......... ............. A Repair blood vessel 10.15 NA NA 8.37 10.05 1.06 NA NA 19.58 21.26 090
lesion.
35211.......... ............. A Repair blood vessel 22.12 NA NA 18.73 16.63 2.91 NA NA 43.76 41.66 090
lesion.
35216.......... ............. A Repair blood vessel 18.75 NA NA 14.34 12.97 2.24 NA NA 35.33 33.96 090
lesion.
35221.......... ............. A Repair blood vessel 16.42 NA NA 7.99 10.02 1.81 NA NA 26.22 28.25 090
lesion.
35226.......... ............. A Repair blood vessel 9.06 NA NA 6.97 8.90 1.15 NA NA 17.18 19.11 090
lesion.
35231.......... ............. A Repair blood vessel 12.00 NA NA 6.76 10.55 1.38 NA NA 20.14 23.93 090
lesion.
35236.......... ............. A Repair blood vessel 10.54 NA NA 6.94 9.76 1.23 NA NA 18.71 21.53 090
lesion.
35241.......... ............. A Repair blood vessel 23.12 NA NA 21.00 17.82 2.84 NA NA 46.96 43.78 090
lesion.
35246.......... ............. A Repair blood vessel 19.84 NA NA 14.39 16.40 2.42 NA NA 36.65 38.66 090
lesion.
35251.......... ............. A Repair blood vessel 17.49 NA NA 8.12 9.27 1.87 NA NA 27.48 28.63 090
lesion.
35256.......... ............. A Repair blood vessel 11.38 NA NA 7.25 10.36 1.37 NA NA 20.00 23.11 090
lesion.
35261.......... ............. A Repair blood vessel 11.63 NA NA 5.93 9.91 1.38 NA NA 18.94 22.92 090
lesion.
35266.......... ............. A Repair blood vessel 10.30 NA NA 6.47 9.39 1.24 NA NA 18.01 20.93 090
lesion.
35271.......... ............. A Repair blood vessel 22.12 NA NA 18.70 16.15 2.95 NA NA 43.77 41.22 090
lesion.
35276.......... ............. A Repair blood vessel 18.75 NA NA 15.75 13.77 2.50 NA NA 37.00 35.02 090
lesion.
35281.......... ............. A Repair blood vessel 16.48 NA NA 8.06 13.41 1.84 NA NA 26.38 31.73 090
lesion.
35286.......... ............. A Repair blood vessel 11.87 NA NA 7.84 10.28 1.39 NA NA 21.10 23.54 090
lesion.
35301.......... ............. A Rechanneling of artery 18.70 NA NA 9.86 12.78 2.29 NA NA 30.85 33.77 090
35311.......... ............. A Rechanneling of artery 23.85 NA NA 12.98 18.46 3.12 NA NA 39.95 45.43 090
35321.......... ............. A Rechanneling of artery 11.97 NA NA 6.06 10.06 1.40 NA NA 19.43 23.43 090
35331.......... ............. A Rechanneling of artery 23.52 NA NA 11.10 12.79 2.88 NA NA 37.50 39.19 090
35341.......... ............. A Rechanneling of artery 25.11 NA NA 11.52 15.19 3.07 NA NA 39.70 43.37 090
35351.......... ............. A Rechanneling of artery 20.11 NA NA 9.57 12.90 2.33 NA NA 32.01 35.34 090
35355.......... ............. A Rechanneling of artery 16.09 NA NA 8.08 12.41 1.86 NA NA 26.03 30.36 090
35361.......... ............. A Rechanneling of artery 23.59 NA NA 10.84 15.93 2.74 NA NA 37.17 42.26 090
35363.......... ............. A Rechanneling of artery 24.66 NA NA 11.54 18.13 2.81 NA NA 39.01 45.60 090
35371.......... ............. A Rechanneling of artery 11.64 NA NA 6.12 9.85 1.37 NA NA 19.13 22.86 090
35372.......... ............. A Rechanneling of artery 13.56 NA NA 6.85 9.50 1.59 NA NA 22.00 24.65 090
35381.......... ............. A Rechanneling of artery 15.81 NA NA 7.94 11.39 1.85 NA NA 25.60 29.05 090
35390.......... ............. A Reoperation, carotid 3.19 NA NA 1.24 1.53 0.40 NA NA 4.83 5.12 ZZZ
add-on.
35400.......... ............. A Angioscopy............ 3.00 NA NA 1.15 1.81 0.27 NA NA 4.42 5.08 ZZZ
35450.......... ............. A Repair arterial 10.07 NA NA 4.45 8.24 1.17 NA NA 15.69 19.48 000
blockage.
35452.......... ............. A Repair arterial 6.91 NA NA 3.34 4.03 0.83 NA NA 11.08 11.77 000
blockage.
35454.......... ............. A Repair arterial 6.04 NA NA 2.93 5.07 0.71 NA NA 9.68 11.82 000
blockage.
35456.......... ............. A Repair arterial 7.35 NA NA 3.48 6.13 0.87 NA NA 11.70 14.35 000
blockage.
35458.......... ............. A Repair arterial 9.49 NA NA 4.30 7.65 1.13 NA NA 14.92 18.27 000
blockage.
35459.......... ............. A Repair arterial 8.63 NA NA 3.90 7.10 0.99 NA NA 13.52 16.72 000
blockage.
35460.......... ............. A Repair venous blockage 6.04 NA NA 2.74 3.09 0.64 NA NA 9.42 9.77 000
35470.......... ............. A Repair arterial 8.63 NA NA 3.59 6.95 0.68 NA NA 12.90 16.26 000
blockage.
35471.......... ............. A Repair arterial 10.07 NA NA 4.15 8.09 0.82 NA NA 15.04 18.98 000
blockage.
35472.......... ............. A Repair arterial 6.91 NA NA 2.97 3.45 0.55 NA NA 10.43 10.91 000
blockage.
35473.......... ............. A Repair arterial 6.04 NA NA 2.60 4.91 0.41 NA NA 9.05 11.36 000
blockage.
35474.......... ............. A Repair arterial 7.36 NA NA 3.07 5.93 0.53 NA NA 10.96 13.82 000
blockage.
35475.......... ............. R Repair arterial 9.49 NA NA 3.48 7.24 0.51 NA NA 13.48 17.24 000
blockage.
35476.......... ............. A Repair venous blockage 6.04 NA NA 2.34 2.89 0.26 NA NA 8.64 9.19 000
35480.......... ............. A Atherectomy, open..... 11.08 NA NA 4.76 9.00 1.16 NA NA 17.00 21.24 000
35481.......... ............. A Atherectomy, open..... 7.61 NA NA 3.85 4.29 0.95 NA NA 12.41 12.85 000
35482.......... ............. A Atherectomy, open..... 6.65 NA NA 3.31 5.63 0.83 NA NA 10.79 13.11 000
35483.......... ............. A Atherectomy, open..... 8.10 NA NA 3.80 6.74 0.98 NA NA 12.88 15.82 000
35484.......... ............. A Atherectomy, open..... 10.44 NA NA 4.69 7.84 1.11 NA NA 16.24 19.39 000
35485.......... ............. A Atherectomy, open..... 9.49 NA NA 4.26 4.59 1.15 NA NA 14.90 15.23 000
35490.......... ............. A Atherectomy, 11.08 NA NA 4.42 8.83 1.03 NA NA 16.53 20.94 000
percutaneous.
35491.......... ............. A Atherectomy, 7.61 NA NA 3.09 3.91 0.77 NA NA 11.47 12.29 000
percutaneous.
35492.......... ............. A Atherectomy, 6.65 NA NA 2.97 5.46 0.71 NA NA 10.33 12.82 000
percutaneous.
35493.......... ............. A Atherectomy, 8.10 NA NA 3.98 6.83 0.91 NA NA 12.99 15.84 000
percutaneous.
35494.......... ............. A Atherectomy, 10.44 NA NA 3.77 7.38 0.50 NA NA 14.71 18.32 000
percutaneous.
35495.......... ............. A Atherectomy, 9.49 NA NA 4.64 4.78 1.09 NA NA 15.22 15.36 000
percutaneous.
35500.......... ............. C Harvest vein for 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ
bypass.
35501.......... ............. A Artery bypass graft... 19.19 NA NA 7.16 14.08 2.39 NA NA 28.74 35.66 090
35506.......... ............. A Artery bypass graft... 19.67 NA NA 9.61 15.21 2.41 NA NA 31.69 37.29 090
35507.......... ............. A Artery bypass graft... 19.67 NA NA 9.34 14.40 2.43 NA NA 31.44 36.50 090
35508.......... ............. A Artery bypass graft... 18.65 NA NA 9.30 14.48 2.42 NA NA 30.37 35.55 090
35509.......... ............. A Artery bypass graft... 18.07 NA NA 8.42 14.47 2.21 NA NA 28.70 34.75 090
35511.......... ............. A Artery bypass graft... 16.83 NA NA 8.12 9.71 2.00 NA NA 26.95 28.54 090
35515.......... ............. A Artery bypass graft... 18.65 NA NA 8.74 10.48 2.39 NA NA 29.78 31.52 090
35516.......... ............. A Artery bypass graft... 16.32 NA NA 7.73 13.29 2.00 NA NA 26.05 31.61 090
35518.......... ............. A Artery bypass graft... 15.42 NA NA 6.97 12.69 1.74 NA NA 24.13 29.85 090
35521.......... ............. A Artery bypass graft... 16.17 NA NA 8.17 13.60 1.88 NA NA 26.22 31.65 090
35526.......... ............. A Artery bypass graft... 20.00 NA NA 10.39 12.22 2.48 NA NA 32.87 34.70 090
[[Page 59474]]
35531.......... ............. A Artery bypass graft... 25.61 NA NA 11.64 16.81 3.04 NA NA 40.29 45.46 090
35533.......... ............. A Artery bypass graft... 20.52 NA NA 9.61 16.22 2.27 NA NA 32.40 39.01 090
35536.......... ............. A Artery bypass graft... 23.11 NA NA 10.58 16.89 2.90 NA NA 36.59 42.90 090
35541.......... ............. A Artery bypass graft... 25.80 NA NA 12.16 16.69 3.08 NA NA 41.04 45.57 090
35546.......... ............. A Artery bypass graft... 25.54 NA NA 11.80 17.51 2.91 NA NA 40.25 45.96 090
35548.......... ............. A Artery bypass graft... 21.57 NA NA 10.54 15.88 2.34 NA NA 34.45 39.79 090
35549.......... ............. A Artery bypass graft... 23.35 NA NA 11.16 17.19 2.69 NA NA 37.20 43.23 090
35551.......... ............. A Artery bypass graft... 26.67 NA NA 12.61 16.75 2.85 NA NA 42.13 46.27 090
35556.......... ............. A Artery bypass graft... 21.76 NA NA 10.32 15.32 2.57 NA NA 34.65 39.65 090
35558.......... ............. A Artery bypass graft... 14.04 NA NA 7.36 12.06 1.61 NA NA 23.01 27.71 090
35560.......... ............. A Artery bypass graft... 23.56 NA NA 11.55 16.75 2.84 NA NA 37.95 43.15 090
35563.......... ............. A Artery bypass graft... 15.14 NA NA 7.95 8.49 1.71 NA NA 24.80 25.34 090
35565.......... ............. A Artery bypass graft... 15.14 NA NA 7.71 12.89 1.78 NA NA 24.63 29.81 090
35566.......... ............. A Artery bypass graft... 26.92 NA NA 15.55 18.97 3.22 NA NA 45.69 49.11 090
35571.......... ............. A Artery bypass graft... 18.58 NA NA 10.67 15.84 2.22 NA NA 31.47 36.64 090
35582.......... ............. A Vein bypass graft..... 27.13 NA NA 12.13 18.95 3.14 NA NA 42.40 49.22 090
35583.......... ............. A Vein bypass graft..... 22.37 NA NA 11.58 16.88 2.63 NA NA 36.58 41.88 090
35585.......... ............. A Vein bypass graft..... 28.39 NA NA 15.14 20.03 3.33 NA NA 46.86 51.75 090
35587.......... ............. A Vein bypass graft..... 19.05 NA NA 11.88 17.32 2.23 NA NA 33.16 38.60 090
35601.......... ............. A Artery bypass graft... 17.50 NA NA 8.20 14.32 2.16 NA NA 27.86 33.98 090
35606.......... ............. A Artery bypass graft... 18.71 NA NA 8.94 14.00 2.27 NA NA 29.92 34.98 090
35612.......... ............. A Artery bypass graft... 15.76 NA NA 7.81 13.00 1.90 NA NA 25.47 30.66 090
35616.......... ............. A Artery bypass graft... 15.70 NA NA 7.67 12.95 1.93 NA NA 25.30 30.58 090
35621.......... ............. A Artery bypass graft... 14.54 NA NA 7.57 12.46 1.74 NA NA 23.85 28.74 090
35623.......... ............. A Bypass graft, not vein 16.62 NA NA 8.22 8.49 2.00 NA NA 26.84 27.11 090
35626.......... ............. A Artery bypass graft... 23.63 NA NA 11.85 17.06 2.98 NA NA 38.46 43.67 090
35631.......... ............. A Artery bypass graft... 24.60 NA NA 11.36 15.38 3.00 NA NA 38.96 42.98 090
35636.......... ............. A Artery bypass graft... 22.46 NA NA 10.28 12.47 2.70 NA NA 35.44 37.63 090
35641.......... ............. A Artery bypass graft... 24.57 NA NA 11.93 17.12 3.00 NA NA 39.50 44.69 090
35642.......... ............. A Artery bypass graft... 17.98 NA NA 7.51 9.36 2.16 NA NA 27.65 29.50 090
35645.......... ............. A Artery bypass graft... 17.47 NA NA 8.52 10.31 1.85 NA