[Federal Register Volume 67, Number 251 (Tuesday, December 31, 2002)]
[Rules and Regulations]
[Pages 79965-80184]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-32503]



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Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services



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42 CFR Parts 410, 414, and 485



Medicare Program; Revisions to Payment Policies Under the Physician Fee 
Schedule for Calendar Year 2003 and Inclusion of Registered Nurses in 
the Personnel Provision of the Critical Access Hospital Emergency 
Services Requirement for Frontier Areas and Remote Locations; Final 
Rule

Federal Register / Vol. 67, No. 251 / Tuesday, December 31, 2002 / 
Rules and Regulations

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 410, 414, and 485

[CMS-1204-FC]
RIN 0938-AL21


Medicare Program; Revisions to Payment Policies Under the 
Physician Fee Schedule for Calendar Year 2003 and Inclusion of 
Registered Nurses in the Personnel Provision of the Critical Access 
Hospital Emergency Services Requirement for Frontier Areas and Remote 
Locations

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Final rule with comment period.

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SUMMARY: This final rule with comment period refines the resource-based 
practice expense relative value units (RVUs) and makes other changes to 
Medicare Part B payment policy. In addition, as required by statute, we 
are announcing the physician fee schedule update for CY 2003.
    The update to the physician fee schedule occurs as a result of a 
calculation methodology specified by law. That law required the 
Department to set annual updates based in part on estimates of several 
factors. Although subsequent after-the-fact data indicate that actual 
increases were different to some degree from earlier estimates, the law 
does not permit those estimates to be revised. A subsequent law 
required estimates to be revised for FY 2000 and beyond.
    Although we have exhaustively examined opportunities for a 
different interpretation of law that would allow us to correct the flaw 
in the formula administratively, current law does not permit such an 
interpretation. Accordingly, without Congressional action to address 
the current legal framework, the Department is compelled to announce 
herein a physician fee schedule update for CY 2003 of -4.4 percent.
    Because the Department would adopt a change in the formula that 
determines the physician update if the law permitted it, we have 
examined how proper adjustments to past data could result in a positive 
update. The Department believes that revisions of estimates used to 
establish the sustainable growth rates (SGR) for fiscal years (FY) 1998 
and 1999 and Medicare volume performance standards (MVPS) for 1990-1996 
would, under present calculations, result in a positive update.
    The Department intends to work closely with Congress to develop 
legislation that could permit a positive update, and hopes that such 
legislation can be passed before the negative update takes effect. 
Because the Department wishes to change the update promptly in the 
event that Congress provides the Department legal authority to do so, 
we are requesting comments regarding how physician fee schedule rates 
could and should be recalculated prospectively in the event that 
Congress provides the Department with legal authority to revise 
estimates used to establish the sustainable growth rates (SGR) and for 
1998 and 1999 and the NVPS for 1990-1996.
    The other policy changes concern: the pricing of the technical 
component for positron emission tomography (PET) scans, Medicare 
qualifications for clinical nurse specialists, a process to add or 
delete services to the definition of telehealth, the definition for ZZZ 
global periods, global period for surface radiation, and an endoscopic 
base for urology codes. In addition, this rule updates the codes 
subject to physician self-referral prohibitions. We are expanding the 
definition of a screening fecal-occult blood test and are modifying our 
regulations to expand coverage for additional colorectal cancer 
screening tests through our national coverage determination process. We 
also make revisions to the sustainable growth rate, the anesthesia 
conversion factor, and the work values for some gastroenterologic 
services.
    We are making these changes to ensure that our payment systems are 
updated to reflect changes in medical practice and the relative value 
of services.
    This final rule also clarifies the enrollment of physical and 
occupational therapists as therapists in private practice and clarifies 
the policy regarding services and supplies incident to a physician's 
professional services. In addition, this final rule discusses physical 
and occupational therapy payment caps and makes technical changes to 
the definition of outpatient rehabilitation services.
    In addition, we are finalizing the calendar year (CY) 2002 interim 
RVUs and are issuing interim RVUs for new and revised procedure codes 
for calendar year (CY) 2003.
    As required by the statute, we are announcing that the physician 
fee schedule update for CY 2003 is -4.4 percent, the initial estimate 
of the sustainable growth rate for CY 2003 is 7.6 percent, and the 
conversion factor for CY 2003 is $34.5920.
    This final rule will also allow registered nurses (RNs) to provide 
emergency care in certain critical access hospitals (CAHs) in frontier 
areas (an area with fewer than six residents per square mile) or remote 
locations (locations designated in a State's rural health plan that we 
have approved.) This policy applies if the State, following 
consultation with the State Boards of Medicine and Nursing, and in 
accordance with State law, requests that RNs be included, along with a 
doctor of medicine or osteopathy, a physician's assistant, or a nurse 
practitioner with training or experience in emergency care, as 
personnel authorized to provide emergency services in CAHs in frontier 
areas or remote locations.

DATES: Effective date: This rule is effective on March 1, 2003.
    Comment date: We will consider comments on the definition of a 
screening fecal-occult blood test, the critical access hospital 
emergency services requirement, the physician self-referral designated 
health services identified in Table 10, the interim work RVUs for 
selected procedure codes identified in Addendum C, the practice expense 
direct cost inputs, and on how physician fee schedule rates could and 
should be recalculated prospectively in the event that Congress 
provides the Department with legal authority to revise estimates used 
to establish SGRs for 1998 and 1999 and the MVPS for 1990-1996, if we 
receive them at the appropriate address, as provided in the addresses 
section, no later than 5 p.m. on March 3, 2003.

ADDRESSES: In commenting, please refer to file code CMS-1204-FC. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission. Mail written comments (one original and 
two copies) to the following address ONLY: Centers for Medicare & 
Medicaid Services, Department of Health and Human Services, Attention: 
CMS-1204-FC, P.O. Box 8013, Baltimore, MD 21244-8013.
    Please allow sufficient time for us to receive mailed comments on 
time in the event of delivery delays.
    If you prefer, you may deliver (by hand or courier) your written 
comments (one original and two copies) to one of the following 
addresses: Room 445-G, Hubert H. Humphrey Building, 200 Independence 
Avenue, SW., Washington, DC 20201, or Room C5-14-03, 7500 Security 
Boulevard, Baltimore, MD 21244-8013.
    (Because access to the interior of the HHH Building is not readily 
available to persons without Federal Government identification, 
commenters are

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encouraged to leave their comments in the CMS drop slots located in the 
main lobby of the building. A stamp-in clock is available if you wish 
to retain proof of filing by stamping in and retaining an extra copy of 
the comments being filed.)
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and could be considered late.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Marc Hartstein, (410) 786-4539, or 
Stephanie Monroe (410) 786-6864 (for issues related to resource-based 
practice expense relative value units).
    Jim Menas, (410) 786-4507 (for issues related to anesthesia).
    Marc Hartstein, (410) 786-4539 (for issues related to the 
sustainable growth rate).
    Gail Addis, (410) 786-4522 (for issues related to PET scans).
    Craig Dobyski, (410) 786-4584 (for issues related to telehealth).
    Terri Harris, (410) 786-6830 or Pam West, (410) 786-2302 (for 
issues related to physical and occupational therapy).
    William Larson, (410) 786-4639 (for issues related to fecal-occult 
blood test).
    Regina Walker-Wren, (410) 786-9160 (for issues related to clinical 
nurse specialists).
    Dorothy Shannon, (410) 786-3396 (for issues related to services and 
supplies incident to a physician's professional services).
    Joanne Sinsheimer, (410) 786-4620 (for issues related to updates to 
the list of certain services subject to the physician self-referral 
prohibitions).
    Mary Collins, (410) 786-3189 (for issues related to the critical 
access hospital emergency services requirement).
    Diane Milstead, (410) 786-1101 (for all other issues).

SUPPLEMENTARY INFORMATION: Inspection of Public Comments: Comments 
received timely will be available for public inspection as they are 
recorded and processed, generally beginning approximately 4 weeks after 
the publication of the document, at the headquarters of the Centers for 
Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, 
Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 
p.m. To schedule an appointment to view public comments, phone (410) 
786-7197.
    Copies: To order copies of the Federal Register containing this 
document, send your request to: New Orders, Superintendent of 
Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Specify the date 
of the issue requested and enclose a check or money order payable to 
the Superintendent of Documents, or enclose your Visa or Master Card 
number and expiration date. Credit card orders can also be placed by 
calling the order desk at (202) 512-1800 (or toll-free at 1-888-293-
6498) or by faxing to (202) 512-2250. The cost for each copy is $10. As 
an alternative, you can view and photocopy the Federal Register 
document at most libraries designated as Federal Depository Libraries 
and at many other public and academic libraries throughout the country 
that receive the Federal Register.
    This Federal Register document is also available from the Federal 
Register online database through GPO Access, a service of the U.S. 
Government Printing Office. The Web site address is: http://www.access.gpo.gov/nara/index.html.
    Information on the physician fee schedule can be found on our 
homepage. You can access this data by using the following directions:
    1. Go to the CMS homepage (http://www.cms.hhs.gov).
    2. Click on ``Medicare.''
    3. Select Medicare Payment Systems.
    4. Select Physician Fee Schedule.
    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 is not exclusively in section XIII.

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
    E. Delay in the Effective Date
II. Specific Provisions for Calendar Year 2003
    A. Resource-Based Practice Expense Relative Value Units
    B. Anesthesia Issues
    C. Pricing of Technical Components (TC) for Positron Emissions 
Tomography (PET) Scans
    D. Enrollment of Physical and Occupational Therapists as 
Therapists in Private Practice
    E. Clinical Social Worker Services
    F. Medicare Qualifications for Clinical Nurse Specialists
    G. Process to Add or Delete Services to the Definition of 
Telehealth
    H. Definition for ZZZ Global Periods
    I. Change in Global Period for CPT Code 77789 (Surface 
Application of Radiation Source)
    J. Technical Change for Sec.  410.61(d)(1)(iii) Outpatient 
Rehabilitation Services
    K. New HCPCS G-Codes From June 28, 2002 Proposed Rule
    L. Endoscopic Base for Urology Codes
    M. Physical Therapy and Occupational Therapy Caps
III. Other Issues
    A. Definition of a Screening Fecal-Occult Blood Test
    B. Clarification of Services and Supplies Incident To a 
Physician's Professional Services: Conditions
    C. Five-Year Review of Gastroenterology Codes
    D. Critical Access Hospital Emergency Services Requirements
IV. Refinement of Relative Value Units for Calendar Year 2003 and 
Response to Public Comments on Interim Relative Value Units for 2002
V. Update to the Codes for Physician Self-Referral Prohibition
VI. Physician Fee Schedule Update for Calendar Year 2003
VII. Allowed Expenditures for Physicians' Services and the 
Sustainable Growth Rate
    A. Medicare Sustainable Growth Rate
    B. Physicians' Services
    C. Provisions Related to the Sustainable Growth Rate
    D. Preliminary Estimate of the Sustainable Growth Rate for 2003
    E. Sustainable Growth Rate for 2002
    F. Sustainable Growth Rate for 2001
    G. Calculation of 2003, 2002, and 2001 Sustainable Growth Rates
VIII. Anesthesia and Physician Fee Schedule Conversion Factors for 
CY 2003
IX. Provisions of the Final Rule
X. Waiver of Proposed Rulemaking for Definition of a Screening 
Fecal-Occult Blood Test and Critical Access Hospital Emergency 
Services Requirement
XI. Collection of Information Requirements
XII. Response to Comments
XIII. Regulatory Impact Analysis
Addendum A--Explanation and Use of Addendum B
Addendum B--2003 Relative Value Units and Related Information Used 
in Determining Medicare Payments for 2003
Addendum C--Codes with Interim RVUs
Addendum D--2003 Geographic Practice Cost Indices by Medicare 
Carrier and Locality
Addendum E--Updated List of CPT/HCPCS Codes Used to Describe Certain 
Designated Health Services Under the Physician Self-Referral 
Provision
Addendum F--Codes Refined by the PEAC for 2003

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

      AMA   American Medical Association
      BBA   Balanced Budget Act of 1997

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     BBRA   Balanced Budget Refinement Act of 1999
      CAH   Critical Access Hospitals
       CF   Conversion factor
      CFR   Code of Federal Regulations
      CMS   Centers for Medicare & Medicaid Services
      CNS   Clinical Nurse Specialist
      CPT   [Physicians'] Current Procedural Terminology [4th Edition,
             2002, copyrighted by the American Medical Association]
     CPEP   Clinical Practice Expert Panel
     CRNA   Certified Registered Nurse Anesthetist
      E/M   Evaluation and management
     GPCI   Geographic practice cost index
    HCPCS   Healthcare Common Procedure Coding System
      HHA   Home health agency
      HHS   [Department of] Health and Human Services
    IDTFs   Independent Diagnostic Testing Facilities
      MCM   Medicare Carrier Manual
   MedPAC   Medicare Payment Advisory Commission
      MEI   Medicare Economic Index
      MSA   Metropolitan Statistical Area
      NCD   National Coverage Decision
       PC   Professional Component
     PEAC   Practice Expense Advisory Committee
      PET   Positron Emission Tomography
      PPS   Prospective payment system
      RUC   [AMA's Specialty Society] Relative [Value] Update Committee
      RVU   Relative value unit
      SGR   Sustainable growth rate
      SMS   [AMA's] Socioeconomic Monitoring System
      SNF   Skilled Nursing Facility
       TC   Technical Component
 

I. Background

A. Legislative History

    Since January 1, 1992, Medicare has paid for physicians' services 
under section 1848 of the Social Security Act (the Act), ``Payment for 
Physicians'' Services.'' This section provides for three major 
elements--(1) A fee schedule for the payment of physicians' services; 
(2) limits on the amounts that nonparticipating physicians can charge 
beneficiaries; and (3) a sustainable growth rate for the rates of 
increase in Medicare expenditures for physicians' services. 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 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 adjustments to RVUs cause 
expenditures to change by more than $20 million, we must make 
adjustments to preserve budget neutrality.

B. Published Changes to the Fee Schedule

    In the July 2000 proposed rule, (65 FR 44177), we listed all of the 
final rules published through November 1999. In the August 2001 
proposed rule (66 FR 40372) we discussed the November 2000 final rule 
relating to the updates to the RVUs and revisions to payment policies 
under the physician fee schedule.
    In the November 2001 final rule with comment period (66 FR 55246), 
we revised the policy for--resource-based practice expense RVUs; 
services and supplies incident to a physician's professional service; 
anesthesia base unit variations; recognition of CPT tracking codes; and 
nurse practitioners, physician assistants, and clinical nurse 
specialists performing screening sigmoidoscopies. We also addressed 
comments received on the June 8, 2001 proposed notice (66 FR 31028) for 
the 5-year review of work RVUs and finalized these work RVUs. In 
addition, we acknowledged comments received in response to a discussion 
of modifier-62, which is used to report the work of co-surgeons. The 
November 2001 final rule also updated the list of services that are 
subject to the physician self-referral prohibitions in order to reflect 
CPT and Healthcare Common Procedure Coding System (HCPCS) code changes 
that were effective January 1, 2002. These revisions ensure that our 
payment systems are updated to reflect changes in medical practice and 
the relative value of services.
    The Medicare, Medicaid, and State Child Health Insurance Program 
(SCHIP) Benefits Improvement and Protection Act of 2000 (Pub. L. 106-
554) (BIPA) modernized the mammography screening benefit and authorized 
payment under the physician fee schedule effective January 1, 2002. It 
provided for biennial screening pelvic examinations for certain 
beneficiaries and expanded coverage for screening colonoscopies to all 
beneficiaries effective July 1, 2001. It provided for annual glaucoma 
screenings for high-risk beneficiaries and established coverage for 
medical nutrition therapy services for certain beneficiaries effective 
January 1, 2002. It expanded payment for telehealth services effective 
October 1, 2001; required certain Indian Health Service providers to be 
paid for some services under the physician fee schedule effective July 
1, 2001; and revised the payment for certain physician pathology 
services effective January 1, 2001. This final rule conformed our 
regulations to reflect these statutory provisions.
    The final rule also announced the calendar year 2002 physician fee 
schedule conversion factor (CF) of $36.1992.

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 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 (CY) 2003 appears in section VIII. The 
RVUs for CY 2003 are in Addendum B. The GPCIs for CY 2003 can be found 
in Addendum D.
    Section 1848(e) of the Act requires us 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. In accordance with the statute, 
however,

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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 System

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. A research team at the 
Harvard School of Public Health developed the original work RVUs for 
most codes in a cooperative agreement with us. In constructing the 
vignettes for the original RVUs, Harvard worked with expert panels of 
physicians and obtained input from physicians from numerous 
specialties.
    The RVUs for radiology services were based on the American College 
of Radiology (ACR) relative value scale, which we integrated into the 
overall physician fee schedule. The RVUs for anesthesia services were 
based on RVUs from a uniform relative value guide. We established a 
separate CF for anesthesia services, and 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 required that the practice expense 
and malpractice expense RVUs equal the product of the base allowed 
charges and the practice expense and malpractice percentages for the 
service. Base allowed charges are defined as the national average 
allowed charges for the service furnished during 1991, as estimated 
using the most recent data available. For most services, we used 1989 
charge data aged to reflect the 1991 payment rules, since those were 
the most recent data available for the 1992 fee schedule.
    Section 121 of the Social Security Act Amendments of 1994 (Pub. L. 
103-432), enacted on October 31, 1994, 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 
required us to implement resource-based malpractice RVUs for services 
furnished beginning in 2000.

E. Delay in the Effective Date

    On November 5, 2002 we published a notice (67 FR 67319), delaying 
the publication of this final rule due to concerns about the data used 
to establish the physician fees and the need to further assess the 
accuracy of the data. We have concluded our review and are moving 
forward with our proposals unless otherwise indicated in this preamble. 
This rule is effective on March 3, 2003.

II. Specific Provisions for Calendar Year 2003

    In response to the publication of the June 28, 2002 proposed rule, 
(67 FR 43846), and the interim final rule, (67 FR 43555), we received 
approximately 236 comments. We received comments from individual 
physicians, health care workers, and professional associations and 
societies. The majority of comments addressed the proposals related to 
the enrollment of therapists, anesthesia services and the SGR.
    The proposed rule discussed policies that affected 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 would 
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 2003. We discuss in detail the 
effects of these changes in the Regulatory Impact Analysis in section 
XIII.
    For the convenience of the reader, the headings for the policy 
issues correspond to the headings used in the June 28, 2002 proposed 
rule. More detailed background information for each issue can be found 
in the June 2002 interim final rule with comment period and the June 
2002 proposed rule.

A. Resource-Based Practice Expense Relative Value Units

1. Resource-Based Practice Expense Legislation
    Section 121 of the Social Security Act Amendments of 1994 (Pub. L. 
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. In 
developing the methodology, we were to consider the staff, equipment, 
and supplies used in providing medical and surgical services in various 
settings. The legislation specifically required that, in implementing 
the new system of practice expense RVUs, we apply the same budget-
neutrality provisions that we apply to other adjustments under the 
physician fee schedule.
    Section 4505(a) of the Balanced Budget Act of 1997 (BBA) (Pub. L. 
105-33), enacted on August 5, 1997, amended section 1848(c)(2)(ii) of 
the Act and delayed the effective date of the resource-based practice 
expense RVU system until January 1, 1999. In addition, section 4505(b) 
of the BBA provided for a 4-year transition period from charge-based 
practice expense RVUs to resource-based RVUs. Further legislation 
affecting resource-based practice expense RVUs was included in the 
Medicare, Medicaid and State Child Health Insurance Program (SCHIP) 
Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106-113), 
enacted on November 29, 1999. Section 212 of the BBRA amended section 
1848(c)(2)(ii) of the Act by directing us to establish a process under 
which we accept and use, to the maximum extent practicable and 
consistent with sound data practices, data collected or developed by 
entities and organizations. These data would supplement the data we 
normally collect in determining the practice expense component of the 
physician fee schedule for payments in CY 2001 and CY 2002. (In the 
1999 final rule (64 FR 59380), we extended, for an additional 2 years, 
the period during which we would accept supplementary data.)
2. Current Methodology for Computing the Practice Expense Relative 
Value Unit System
    Effective with services furnished on or after January 1, 1999, we 
established a new methodology for computing resource-based practice 
expense RVUs that used 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) Socioeconomic 
Monitoring System (SMS) data. The methodology was based on an 
assumption that current aggregate specialty practice costs are a 
reasonable way to establish initial estimates of relative resource 
costs for physicians' services across specialties. The methodology 
allocated these aggregate specialty practice costs to specific 
procedures and, thus, is commonly called a ``top-down'' approach.

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a. Major Steps

    A brief discussion of the major steps involved in the determination 
of the practice expense RVUs follows. (Please see the November 1, 2001 
final rule (66 FR 55249) for a more detailed explanation of the top-
down methodology.)
    Step 1--Determine the specialty specific practice expense per hour 
of physician direct patient care. We used the AMA's SMS survey of 
actual aggregate cost data by specialty to determine the practice 
expenses per hour for each specialty. We calculated the practice 
expenses per hour for the specialty by dividing the aggregate practice 
expenses for the specialty by the total number of hours spent in 
patient care activities. For the CY 2000 physician fee schedule, we 
also used data from a survey submitted by the Society of Thoracic 
Surgeons (STS) in calculating thoracic and cardiac surgeons' practice 
expenses per hour. (Please see the November 1999 final rule (64 FR 
59391) for additional information concerning acceptance of these data.) 
For 2001, we used these STS data, as well as survey data submitted by 
the American Society of Vascular Surgery and the Society of Vascular 
Surgery. (Please see the November 2000 final rule (65 FR 65385) for 
additional information on the acceptance of these data.)
    Step 2--Create a specialty specific practice expense pool of 
practice expense costs for treating Medicare patients. To calculate the 
total number of hours spent treating Medicare patients for each 
specialty, we used the physician time assigned to each procedure code 
and the Medicare utilization data. We then calculated the specialty 
specific practice expense pools by multiplying the specialty practice 
expenses per hour by the total physician hours.
    Step 3--Allocate the specialty specific practice expense pool to 
the specific services performed by each specialty. For each specialty, 
we divided the practice expense pool into two groups based on whether 
direct or indirect costs were involved and used a different allocation 
basis for each group.
    (i) Direct costs--For direct costs (which include clinical labor, 
medical supplies, and medical equipment), we used the procedure 
specific CPEP data on the staff time, supplies, and equipment as the 
allocation basis.
    (ii) Indirect costs--To allocate the cost pools for indirect costs, 
including administrative labor, office expenses, and all other 
expenses, we used the total direct costs combined with the physician 
fee schedule work RVUs. We converted the work RVUs to dollars using the 
Medicare CF (expressed in 1995 dollars for consistency with the SMS 
survey years).
    Step 4--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.

b. Other Methodological Issues

    (i) Non-Physician Work Pool--For services with physician work RVUs 
equal to zero (including those services with a technical and 
professional component), we created a separate practice expense pool 
using the average clinical staff time from the CPEP data and the ``all 
physicians'' practice expense per hour.
    We then used the adjusted 1998 practice expense RVUs to allocate 
this pool to each service. Also, for all radiology services that are 
assigned physician work RVUs, we used the adjusted 1998 practice 
expense RVUs for radiology services as an interim measure to allocate 
the direct practice expense cost pool for radiology.
    (ii) Crosswalks for Specialties Without Practice Expense Survey 
Data--Since many specialties identified in our claims data did not 
correspond exactly to the specialties included in the SMS survey data, 
it was necessary to crosswalk these specialties to the most appropriate 
SMS specialty.
    Because we believe that most physical therapy services furnished in 
physicians' offices are performed by physical therapists, we cross-
walked all utilization for therapy services in the CPT 97000 series to 
the physical and occupational therapy practice expense pool.
    Comment: We received several comments objecting to our policy of 
cross-walking all utilization for therapy services in the CPT 97000 
series to the physical and occupational therapy practice expense pool. 
One commenter stated that we are currently employing an arbitrary 
utilization crosswalk methodology to determine the resource-based 
practice expense RVUs for physical and occupational therapy. Commenters 
also indicated that this departure from the standard methodology has 
not been previously published for review and comment. In addition, one 
commenter challenged our assumption that most therapy services billed 
by physicians are furnished by therapists and stated that it is neither 
supported by explanatory text nor accompanying data. The commenter 
indicates that if we did not employ this assumption to change the 
resource-based practice expense methodology only for therapy services, 
payments for these services would be as much as 18 percent higher. 
Other commenters stated that use of the ``altered methodology'' has 
resulted in inappropriate reductions in payments for physical and 
occupational therapy services. One commenter expressed concern that the 
adjustment affects SNFs, home health agencies, outpatient hospital 
departments and CORFs in addition to therapists in private practice. 
Other commenters also objected to use of a crosswalk for physical and 
occupational therapy services stating that the policy is inconsistent 
with the ``top-down'' methodology that bases the final RVUs for a 
service on a weighted average of the practice expenses of the 
specialties that bill Medicare. Another commenter indicated that there 
is no evidence to suggest that practice expenses for therapy services 
provided by physicians are any different from the practice expenses of 
all other services they provide. This commenter indicated that 
physician specialties were also disadvantaged because all therapy 
services that a specialty billed were not included in calculating the 
practice expense pool for that specialty, thus decreasing the dollars 
that could be allocated to the services performed by that specialty. 
The commenters strongly recommended that we discontinue use of the 
crosswalk and employ the standard top down methodology for computing 
the 2003 PERVUs for the 97000 CPT code series.
    Response: We carefully reviewed comments on this issue. As 
indicated in our proposed rule, we do not believe that physicians 
provide most therapy services that are billed by physicians. We believe 
that the practice expenses for therapy services provided in physicians' 
offices by therapists are more likely to be comparable to those of 
therapists than physicians. For this reason, we crosswalked utilization 
for the therapy codes (CPT codes 97010 through 97750) to the physical 
and occupational therapy practice cost pools. We used the physician 
utilization data for the therapy evaluation codes (CPT codes 97001 
through 97004) since we believe these services would be much more 
likely to be performed by the billing physician. In the meantime, we 
welcome further public comments on this issue. We note that physical 
therapy was the only specialty for which we used their supplemental 
survey data (as noted below). Use of

[[Page 79971]]

such survey data increases payments for physical therapy by 2 percent.
3. Practice Expense Provisions for Calendar Year 2003

a. Supplemental Practice Expense Surveys Criteria for Acceptance of 
Supplemental Practice Expense Surveys From the June 28, 2002 Interim 
Final Rule with Comment Period

    On June 28, 2002 we published an interim final rule with comment 
period (67 FR 43555) in the Federal Register, which made revisions to 
the criteria that we apply to supplemental survey information supplied 
by physician, non-physician, and supplier groups for use in determining 
practice expense RVUs under the physician fee schedule. While this rule 
was effective upon publication, we provided a comment period on the 
revision to the criteria and are responding to the comments received in 
this final rule.
    The following criteria had been in effect:
    [sbull] Physician groups must draw their sample from the AMA 
Physician Masterfile to ensure a nationally representative sample that 
includes both members and non-members of a physician specialty group. 
Physician groups must arrange for the AMA to send the sample directly 
to their survey contractor to ensure confidentiality of the sample; 
that is, to ensure comparability in the methods and data collected, 
specialties must not know the names of the specific individuals in the 
sample.
    [sbull] Non-physician specialties not included in the AMA's SMS 
must develop a method to draw a nationally representative sample of 
members and non-members. At a minimum, these groups must include former 
members in their survey sample. The sample must be drawn by the non-
physician group's survey contractor, or another independent party, in a 
way that ensures the confidentiality of the sample; that is, to ensure 
comparability in the methods and data collected, specialties must not 
know the names of the specific individuals in the sample.
    [sbull] A group (or its contractors) must conduct the survey based 
on the SMS survey instruments and protocols, including administration 
and follow-up efforts and definitions of practice expense and hours of 
direct patient care. In addition, any cover letters or other 
information furnished to survey sample participants must be comparable 
to the information previously supplied by the SMS contractor to its 
sample participants.
    [sbull] Physician groups must use a contractor that has experience 
with the SMS or a survey firm with experience successfully conducting 
national multi-specialty surveys of physicians using nationally 
representative random samples.
    [sbull] Physician groups or their contractors must submit raw 
survey data to us, including all complete and incomplete survey 
responses as well as any cover letters and instructions that 
accompanied the survey, by August 1, 2002 for data analysis and editing 
to ensure consistency. All personal identifiers in the raw data must be 
eliminated.
    [sbull] The physician practice expense data from surveys that we 
use in our code-level practice expense calculations are the practice 
expenses per physician hour in the six practice expense categories--
clinical labor, medical supplies, medical equipment, administrative 
labor, office overhead, and other. Supplemental survey data must 
include data for these categories.
    In addition to the above survey criteria, we required a 90-percent 
confidence interval with a range of plus or minus 10 percent of the 
mean (that is, 1.645 times the standard error of the mean, divided by 
the mean should be equal to or less than 10 percent of the mean).
    Based on a review of these criteria and concern that the this 
language had created confusion, in the June 2002 interim final rule we 
revised this language to indicate that we will accept surveys that 
achieve a sampling error of 0.15 or less at a confidence level of 90 
percent. We noted that this change refines both the measurement of 
precision and the level of precision we will accept and could result in 
our acceptance of more surveys than the past criteria. In addition, we 
stated that we would allow specialties that have submitted surveys 
previously rejected under the present criteria to resubmit these 
surveys to be evaluated under the revised criterion.
    We also amended Sec.  414.22(b)(6) to reflect the 2-year extension 
in the deadline for submitting supplemental data. Specifically, we will 
accept supplemental data that meet the established criteria that we 
received by August 1, 2002 to determine CY 2003 practice expense RVUs 
and by August 1, 2003 to determine CY 2004 practice expense RVUs.
    Comment: We received comments from several specialty organizations 
on the change in the precision criteria for supplemental surveys. 
Specialty organizations representing audiologists, physical therapists 
and radiologists expressed support for the revised precision criterion. 
The American Academy of Audiology indicated that the revised rule makes 
it easier for specialty groups to submit information for our 
consideration. The American College of Radiology (ACR) supported the 
proposed change by suggesting that the previous requirements were not 
reasonable. The ACR indicated that radiology and radiation oncology did 
not conduct surveys previously because of concerns about the strictness 
of the original criteria. The ACR also indicated concerns about 
averaging the supplemental survey data with existing SMS survey data 
and the requirement that the survey sample would have to be selected 
from the AMA Masterfile. According to the ACR, the AMA Masterfile does 
not adequately represent radiologists and radiation oncologists that 
own and operate their own centers and equipment. The American Physical 
Therapy Association (APTA) supported the new criterion and our decision 
to allow previously completed surveys to be resubmitted and considered 
using the new precision standard. The American Society Clinical 
Oncology (ASCO) objected to the use of any precision criteria and 
outlined a number of reasons why they opposed the use of this test. The 
ASCO indicated that there may be wide variation in oncology practice 
patterns (for example, hospital based versus non-hospital based, or 
differentials in provision of chemotherapy) that could lead to wide 
variation in practice expenses among surveyed practices. They suggested 
that ``at least in the case of oncologists, a survey that is conducted 
in accordance with the CMS rules should not be excluded from 
consideration because of failure to meet the precision criteria.''
    Response: If the data from physician and practitioner surveys is to 
be used as the basis for physician payment, it is necessary that we 
have assurance that the survey is both representative and reliable. 
Applying numerical criteria for the statistical concepts of confidence 
and precision give some basis for believing that the data accurately 
represent practice costs for the specialty nationwide. We set the 
criteria for precision and confidence after lengthy consultation with 
our contractor, the Lewin Group, and agency experts on statistical 
surveys. We believe the levels set are both fair and reasonable. In 
addition, as indicated in the proposed rule, we are attempting to be as 
flexible as possible consistent with our goal of obtaining new surveys 
of practice expense that are scientifically sound and methodologically 
consistent with

[[Page 79972]]

our existing estimates. We indicated that a specialty may include 
different types of physician practices that exhibit different patterns 
of practice expenses. We welcome stratified sampling of these different 
types of practices and, would, as appropriate, apply the precision 
criteria to subgroups of surveyed practices.
    We considered the comment that suggests the AMA Masterfile may not 
adequately represent radiologists and radiation oncologists that own 
and operate their own equipment. However, since the AMA Masterfile is 
the most comprehensive listing of physicians that practice in the 
United States, we still believe it should be the best source of 
information for selecting a representative sample of physicians. We do 
acknowledge that there may be special issues related to diagnostic and 
radiation oncology services. For instance, radiologists and radiation 
oncologists that predominantly practice in hospitals may have 
fundamentally different practice expenses than those providing services 
in free-standing clinics and private offices where they likely incur 
far higher costs for staff, supplies, equipment and indirect costs. In 
addition, office-based radiologists and radiation oncologists may have 
substantial but irregular expenses associated with medical equipment. 
That is, they may purchase equipment one year and amortize the costs 
over several years. It is possible that modification to the survey 
instrument may be necessary to accurately identify annual equipment 
costs for some specialties. Further, independent diagnostic testing 
facilities also bill Medicare for diagnostic services affected by the 
non-physician work pool calculations. A sample of physicians selected 
from the AMA Masterfile is unlikely to include independent diagnostic 
testing facilities. We believe that all of these issues can be 
addressed in a supplemental survey with stratified sampling, relevant 
modifications to the survey instrument and augmentation of the AMA 
Masterfile with a listing of independent diagnostic testing facilities. 
As we indicated in our supplemental survey interim final rule, we are 
attempting to be flexible to achieve our goal of incorporating the best 
possible practice expense survey information into our methodology. We 
believe all of these issues should be considered carefully. We advise 
any party interested in conducting a supplemental survey to consult the 
Lewin Group and us before proceeding with a survey.
    Comment: We also received comments from two organizations 
representing emergency medicine. The Emergency Department Practice 
Management Association (EDPMA) is concerned that the requirement that 
supplemental surveys be based on the SMS survey instrument will 
preclude us from obtaining data on uncompensated care and emergency 
physician practice expenses. The EDPMA suggests that we extend the 
criteria to include data regarding indirect emergency medicine practice 
expense or uncompensated care cost. The American College of Emergency 
Physicians (ACEP) stated that we have failed to recognize the 
legitimate practice costs associated with uncompensated care pursuant 
to requirements imposed by the Emergency Medical Treatment and Active 
Labor Act (EMTALA) and that these costs should be recognized by us. 
Despite our acknowledgement of these costs, the commenter argues that 
we have not made any movement in making payment for EMTALA's 
uncompensated care costs.
    Response: As we indicated in the November 2, 1998 final rule (63 FR 
58821), we made an adjustment in the practice expense per hour for 
emergency medicine because of our concern that emergency medicine 
physicians could spend a significantly higher proportion of time than 
other physicians providing uncompensated care to patients. We are 
currently using a practice expense per hour of $33.00 for emergency 
medicine. If we had not made the adjustment for uncompensated care, the 
practice expense per hour for emergency medicine would be $14.90. Our 
adjustment assumes that 55 percent ($14.9/(1-0.55)=$33.00) of emergency 
physicians' time spent treating patients is uncompensated. This has the 
effect of raising the practice expense per hour to reflect only the 
physician's time spent in revenue-generating activities. If emergency 
physicians believe that they spend more than 55 percent of their time 
treating patients for which they are not compensated, we would welcome 
specific data on this subject from a supplemental survey.
    Comment: The American College of Cardiology (ACC) and the AMA, who 
wrote in support of the ACC, indicated they are aware that we would 
like data on practice expenses that shows the six categories of 
practice expenses used in the practice expense methodology. However, 
the ACC indicated that the AMA no longer collects data in this 
disaggregated fashion and suggested that this data limitation can be 
overcome by simply apportioning practice expense reported in the most 
recent survey to the separate pools based on historical distribution 
patterns.
    Response: We will continue to require disaggregated data from 
supplemental surveys because apportionment based on historical 
distribution patterns might not reflect actual or current cost 
patterns. Further, to accept this data would be inconsistent with our 
clearly stated rule. In both the original interim final rule published 
on May 3, 2000 (65 FR 25666) and in the interim final rule published on 
June 28, 2002 (67 FR 43556), we indicated that ``* * * code-level 
practice expense calculations are the practice expense per physician 
hour in the six practice expense categories-clinical labor, medical 
supplies, medical equipment, administrative labor, office overhead and 
other. Supplemental survey data must include data for these 
categories.''
Result of Evaluation of Comments
    We are retaining the change to the precision and confidence levels 
for supplemental surveys to reflect a confidence level of 90 percent 
and a precision level of 0.15, as stated in our interim final rule.
    (ii) Submission of Supplemental Surveys--We received surveys from 
the American Physical Therapy Association (APTA), the American Society 
of Clinical Oncology (ASCO), the American College of Cardiology (ACC), 
and the American Academy of Pediatrics (AAP). The National Association 
of Portable X-Ray Providers (NAPXP) also provided us with cost data for 
their industry. Our contractor, the Lewin Group, has evaluated the data 
submitted by each organization and recommends that we use the survey 
information from APTA. We reviewed and agree with their analysis; 
therefore, we are using the APTA survey to determine practice expense 
RVUs for CY 2003 and subsequent years. The data supplied to the Lewin 
Group reflects a 1999 cost year. As indicated in our June 2002 interim 
final rule (67 FR 43556), we are deflating the figures by the MEI to 
reflect a 1995 cost year. The revised practice expense per hour figures 
that we are using for physical therapy (specialty code 65) and 
occupational therapy (specialty code 67) are as follows:

[[Page 79973]]



                                                     Table 1
----------------------------------------------------------------------------------------------------------------
                                                     Admin.    Office
                  Clinical staff                      staff    expense   Supplies  Equipment    Other     Total
----------------------------------------------------------------------------------------------------------------
10.4..............................................       6.5      13.4        2.4        2.2       7.7      42.5
----------------------------------------------------------------------------------------------------------------

    The Lewin Group raised significant concerns about the data received 
from ASCO. Specifically, the Lewin Group is concerned about 
extraordinarily high expenses associated with clinical and clerical 
staff and a more than 300 percent increase in ``other'' practice 
expenses compared to the SMS value for oncology. As a result, the Lewin 
Group carefully examined the underlying data. They report that 
compensation (including salaries and fringe benefits) would average out 
to $71,014 for clinical staff and $87,253 for clerical staff. They 
believe it is unlikely that the average annual salary for clerical 
staff would be higher than for clinical staff. Further, the Lewin Group 
indicates that the average clerical compensation from the ASCO survey 
is approximately 400 percent higher than the figure reported by the 
Bureau of Labor Statistics for ``Office Clerks, General.'' While the 
Lewin Group indicates that the high payroll expense for clinical staff 
may be explained, in part, by recent changes in labor markets, we 
remain concerned that the compensation reported in the survey is far 
higher than independent information on oncology nursing salaries 
provided to us by the Oncology Nursing Society. The Lewin Group also 
indicated that ``other professional expenses'' increased more than 349 
percent from the SMS to the supplemental survey and the contribution of 
this category to total practice expenses increased from 9.4 percent to 
22.3 percent. They believe that such a large increase in practice 
expense per hour needs further examination. The Lewin Group believes 
that we should confer with ASCO and request a rationale for the high 
values found in the survey results or validate the data in some other 
fashion. Therefore, at this time, we are not using the supplemental 
survey received from ASCO. However, we would like to further examine 
the data with the Lewin Group and discuss the survey results with ASCO 
and will consider using the data in the future if our concerns are 
addressed.
    In the June 2002 proposed rule (67 FR 43850), we discussed an 
adjustment made to the medical supplies practice expense per hour for 
oncology. We made this adjustment because of a concern that the 
inordinately high practice expense per hour includes expenses 
associated with separately billable drugs. We expressed an interest in 
reconsidering the adjustment consistent with a recommendation made by 
the GAO in their October 2001 report. If we resolve concerns about the 
oncology survey data, the adjustment for medical supplies will no 
longer be necessary since the supplemental survey collects information 
on medical supplies practice expenses net of separately billable drugs.
    The Lewin Group indicated that the surveys from the ACC and the AAP 
do not meet requirements established in regulations for supplemental 
surveys. As a result, we will not be incorporating data from the ACC or 
the AAP into the practice expense methodology. We will be making the 
Lewin Group's full recommendations available on our website. The 
National Association of Portable X-ray Providers (NAPXP) did not 
provide us with data as part of the supplemental survey process. 
However, they requested that we use their data to develop practice 
expense RVUs for the physician fee schedule services they provide. 
Since we were provided with survey information, we asked the Lewin 
Group to evaluate the data using the same standards of review applied 
to other specialty survey data. The Lewin Group evaluated whether the 
cost information supplied by NAPXP meets our criteria for acceptance of 
supplemental surveys. The Lewin Group found that (1) More information 
is required to determine if the data are broadly representative of the 
portable x-ray industry and (2) the data as presented are not 
adequately detailed to support a practice expense per hour based on the 
current practice expense methodology.
    Comment: Health Trac, a supplier of portable x-rays and other 
imaging services, commented that the practice costs associated with 
set-up of portable x-ray equipment are not included in the SMS and 
there are sufficient differences among geographic regions in the 
performance of this procedure that warrant reclassifying this service 
as carrier-priced.
    Response: At this time, we are not making portable x-ray set-up 
(Q0092) a carrier-priced service. However, we will continue to work 
with the suppliers of portable x-ray services to find the best ways of 
developing payment rates for these services.

b. CPEP Data

    (i) 2001 PEAC/RUC Recommendations on CPEP inputs
    In the November 2001 final rule (66 FR 55256), we responded to the 
PEAC/RUC recommendations for the refinement to all or part of the CPEP 
inputs for over 1,100 codes. These included refinements of large 
numbers of orthopedic, dermatology, pathology, physical medicine, and 
ophthalmology services. In addition, these recommendations confirmed 
that there were no inputs for over 150 ZZZ-global procedures that are 
performed only in a facility and no supply or equipment inputs for 
almost 700 facility-only services with an XXX or 0-day global period.
    We accepted almost all of the recommendations with only minor 
revisions. We received the following comments on our responses and 
modifications to the RUC recommendations on the CPEP inputs.
    Comment: Specialty societies representing radiology and orthopedic 
surgery both expressed appreciation about our willingness to work with 
the RUC and PEAC on practice expense refinement, as well as for our 
implementation of the refinements already submitted by the PEAC. Both 
societies agreed with our establishment of revised practice expense 
values as ``interim'' until the refinement process is complete.
    Response: We are also pleased with the progress of the refinement 
of the CPEP inputs and thank the PEAC, RUC and all the involved 
specialty societies for the hard work and dedicated commitment that has 
led to a successful refinement process.
    Comment: A specialty society representing surgeons expressed 
support for our decisions on CPEP revisions in general and commended 
our staff for our efforts to develop appropriate and acceptable inputs 
for a large number of codes. The commenter also agreed with the use of 
the refined evaluation and management (E/M) inputs to refine post-
surgical visits, but recommended that the process should allow for 
exceptions.
    Response: We understand that the PEAC has developed a standard

[[Page 79974]]

approach to estimating the clinical staff time involved in post-
surgical visits in which the times associated with the assigned E/M 
visits are applied to the post-surgical clinical staff times. It is 
also our understanding that, as with all the standards and packages 
that the PEAC has developed, a specialty would be free to argue that 
something other than the standard should be applied to a given service.
    Comment: One commenter representing family physicians noted that we 
had accepted most of the practice expense recommendations submitted by 
the PEAC/RUC and commended us for our willingness to accept these 
recommendations. The commenter also suggested that the PEAC 
recommendations for the fine needle aspiration CPT codes 88170 and 
88171, which were deleted CPT codes for 2002, should be applied to CPT 
codes 10021 and 10022 that replace these deleted codes.
    Response: We agree with this suggestion. When CPT codes 10021 and 
10022 were originally valued by the RUC, the practice expense inputs 
were crosswalked from the then unrefined inputs for CPT codes 88170 and 
88171. Now that these inputs have been refined, it is appropriate for 
us to crosswalk the inputs for CPT codes 10021 and 10022 from this 
updated CPEP data.
    Comment: A commenter representing dermatologists was pleased with 
our acceptance of PEAC revisions for the phototherapy codes. However, 
the commenter expressed concern about the decrease in the practice 
expense RVUs for the code for the application of an Unna boot, CPT code 
29580, and for the cryotherapy code, CPT code 17340 and requested that 
we explain the decrease. A specialty society representing podiatrists 
agreed with decision to retain the Unna boot in the list of supplies 
for CPT code 29580.
    Response: Both CPT codes 29580 and 17340 were refined by the PEAC 
in October 2001 and were included in the PEAC/RUC recommendations for 
2002. We accepted these recommendations without change, except that we 
retained an Unna boot in the supply list for CPT code 29580. The 
recommendations contained lower direct cost inputs than the original 
CPEP panel data, which explains the decrease in payment for these 
services.
    Comment: A specialty society representing urologists requested an 
explanation of why the bougie a boule was deleted from the equipment 
list for the cystourethroscopy code, CPT code 52281 and requested that 
it be added as a supply.
    Response: Since the inception of resource-based practice expense, 
the supply list has been used for disposable items and we have only 
included as equipment those items that are more than $500. The bougie a 
boule is not a disposable item, and at a cost of $105 it does not meet 
the definition of equipment. These definitions have applied across the 
spectrum of physician fee schedule services and, therefore, we do not 
believe that any specialty has been disadvantaged. If we did include a 
$100 item in our equipment list with a five-year expected life, it 
would add only $0.0004 per minute of use to the input costs of any 
associated procedure and, thus, would have no effect on the practice 
expense RVUs for that service.
    Comment: Two organizations representing physical and occupational 
therapists argued strongly that the revisions we made to the PEAC 
recommendations on the practice expense inputs for the physical 
medicine and rehabilitation (PM&R) codes were inappropriate. The 
physical therapy comment commended the specialty societies 
participating in the PEAC, as well as AMA and our staff, for their time 
and assistance as the clinical inputs for the therapy codes were 
developed. However, the commenter also expressed concern that we did 
not accept the PEAC's recommendations in their entirety despite the 
fact that we state in the rule that the PEAC refinement process is 
working. The comment from the occupational therapists shared this 
concern and both commenters urged us to revisit our decision and accept 
the PEAC recommendations for the CPT codes in the 97000 series without 
revisions.
    Specifically, both commenters objected to the deletion of the PEAC 
approved clinical staff time for obtaining vital signs and 
measurements, patient education and phone calls. One commenter 
contended that our decision is contrary to the standardized times that 
we have allowed for physicians' clinical staff and to the survey data 
presented which demonstrated that clinical staff do perform these 
services in therapy practices. The other commenter argued that, because 
we have allowed such clinical staff time for other specialties, our 
revisions disrupt the resource-based relative value scale on which the 
physician fee schedule is based. Further, the occupational therapy 
comment states that the addition of 7 minutes only in the evaluation 
and reevaluation codes for aide services is insufficient to counteract 
the deletion of the physical therapy assistant time, and that this has 
created anomalies in the practice expense RVUs within the PM&R family 
of services.
    Response: We deleted the times assigned to the physical therapy 
assistant for taking vital signs, and for phone calls and patient 
education because we were concerned that there could be an overlap 
between the work of the physical therapist, which is reflected in the 
work RVUs, and the work of the assistant, which is considered as 
practice expense. However, the commenters are correct that we have 
allowed such tasks to be considered as practice expense for other 
services, even though there could also be some potential overlap 
between practitioner and clinical staff work. We still believe that 
this can be more problematic with therapy services because of the broad 
range of clinical activities that the physical therapy assistant can 
share with the therapist, but also believe that this issue might be 
better addressed as a general issue across all specialties. Therefore, 
we are revising the clinical staff times for all codes in the CPT 97000 
series to reflect the 2001 PEAC recommendations for these services.
    Comment: The specialty society representing physical therapy 
commented that the relatively high practice expense of 0.45 RVUs for 
CPT code 97530, therapeutic activities, cause a rank order anomaly with 
other codes in the CPT 97000 series. For example, therapeutic exercise 
(CPT code 97110) only has a PE value of 0.25. The commenter speculated 
that this might be due to inclusion of the environmental module in the 
equipment list for this code.
    Response: On analyzing the differences in CPEP inputs between these 
two codes, it became apparent that the major contributor to the 
possible anomalous practice expense values lies not with the equipment 
for CPT code 97530, but with the supplies. For the timed codes that are 
billed in 15-minute increments, the PEAC recommendations generally 
assumed that two 15-minute sessions would be performed during one 
visit. Therefore, for all of these codes, including CPT code 97110, the 
PEAC recommendations divided the supplies by half because they would 
not have to be replaced for the second 15-minute session. However, 
inadvertently, the recommendation for the therapeutic activities code, 
CPT code 97530, did not make this adjustment, and the full cost of the 
relatively expensive woodworking kit was assigned to the code. In 
addition, it seems unlikely that a supply like a $13 woodworking kit 
would necessarily be discarded after one visit. Therefore, we are

[[Page 79975]]

apportioning the cost of this kit over four sessions, and are assigning 
one-fourth of a kit to CPT code 97530.
    Comment: The comment from the physical therapy specialty society 
raised the concern that there may be an inadvertent error in the 
printing of the values of physical therapy and occupational therapy 
evaluation and reevaluation CPT codes in the final rule. First, the 
values for the occupational therapy codes are significantly higher than 
values for the physical therapy codes, which did not change from the 
2001 values, despite the refinement of these codes. Second, the 
practice expense RVUs for the occupational therapy evaluation and re-
evaluation codes are the same, which appears inappropriate.
    Response: The practice expense RVUs for the occupational therapy 
evaluation and re-evaluation codes are higher than those for physical 
therapy because the PEAC recommendations, which were based on the 
specialty societies' presentation and which we later accepted, assigned 
higher cost supplies and equipment to the occupational therapy codes 
than to the physical therapy evaluation and re-evaluation services. In 
addition, although the occupational therapy evaluation code had higher 
cost equipment than the re-evaluation code, the opposite was true for 
supplies. We would certainly consider information that might point to 
specific problems in any inputs assigned to these codes, but, at this 
point, have no basis for making any changes in the direct cost inputs.
    Comment: A medical electronics manufacturer commented that the 
practice expense RVUs assigned to short wave diathermy treatment (CPT 
code 97024) may not take into account all of the resources required to 
provide the service, because the cost of the equipment alone is not 
covered by the practice expense reimbursement. The commenter suggested 
that the cost of the diathermy machine has increased greatly since 
1995, when the equipment was last priced, and stated that the current 
price is between $18,000 and $30,000. The commenter urged us to 
reevaluate and increase the 2002 fee schedule reimbursement to ensure 
that diathermy continues to be available for beneficiaries.
    Response: We accepted the PEAC recommendations for the direct cost 
inputs for CPT code 97024, except for the deletion of one minute of 
physical therapy assistant time. The PEAC recommendation was based on a 
presentation that was made by the physical therapy specialty society. 
The current CPEP inputs consist of 2 minutes for a physical therapy 
aide and 3 minutes of physical therapy assistant time and 15 minutes of 
a low mat table and diathermy machine. There were no supplies assigned 
because the supplies are included in the procedures that are typically 
delivered with this modality. We have seen no evidence that would 
indicate that any of these inputs are incorrect. Therefore, we will 
make no revisions to the inputs at this time. However, we have two 
diathermy machines in our CPEP input database. We currently have 
assigned the machine priced at $2850 to the diathermy code, but will 
substitute the higher priced machine, which we have priced at $3120, 
until we have more definitive information regarding the typical cost of 
the equipment. We have a contractor who is currently updating the 
prices of all the supplies and equipment listed in the CPEP database, 
and will soon be proposing updated prices for all the CPEP inputs, 
including the diathermy equipment.

(ii) PEAC/RUC Recommendations on CPEP Inputs for 2003

    We have received recommendations from the PEAC on the refinement to 
the CPEP direct practice expense inputs for over 1200 codes. (A list of 
these codes can be found in Addendum F.) These include refinements to 
codes from almost every major specialty. In addition, the PEAC has 
continued to standardize inputs to streamline the refinement process. 
Previously, the PEAC created standardized inputs for 90-day global 
services as well as supply packages for evaluation and management, 
neurosurgery, gynecology services, ophthalmology and postoperative 
services. The PEAC has also established standard times for certain 
clinical staff tasks, such as greeting and gowning the patient, the 
taking of vital signs and post-service phone calls. These current 
recommendations include standardized times for office-based clinical 
staff for services provided during a patient's hospitalization and for 
discharge day management services, as well as pre-service clinical 
staff time data for 323 neurosurgery procedures. At an early PEAC 
meeting a list was drawn up of the codes most in need of refining. Of 
the 122 codes on this list, only seven have not yet been refined, which 
is one important measure of the success of the PEAC's efforts.
    As stated above, we are very pleased with the progress that the 
PEAC has made so far and appreciate greatly the contributions that have 
been made to our refinement effort by the PEAC members, as well as by 
the staff from the AMA and the specialty societies. We have reviewed 
the submitted PEAC recommendations and are also pleased that, because 
of the expertise gained by the PEAC in evaluating the practice expense 
inputs, we are able to accept all of the recommendations without any 
revision. The complete PEAC recommendations and the revised CPEP 
database can be found on our Web site. (See the SUPPLEMENTARY 
INFORMATION section of this rule for directions on accessing our Web 
site.)

(iii) Other Comments on the Refinement of the CPEP Inputs

    Comment: We received comments from specialty societies representing 
vascular surgery, radiation oncology, rheumatology, physical therapy 
and internal medicine agreeing with the update we made to the clinical 
staff categories and to the revised salary data. Several of these 
commenters also thanked us for our analysis and use of the additional 
data that was supplied by the specialty societies.
    Response: We appreciate the positive response to our repricing of 
clinical staff salaries.
    Comment: The specialty society representing radiology expressed 
appreciation for the establishment of new clinical wage rates for CT 
technologist, MRI technologist, medical physicist, and dosimetrist. 
However, the comment expressed disagreement with our decision to merge 
the x-ray technician and radiation technologist staff types under the 
title of ``radiologic technologist,'' because the education and scope 
of practice for these staff types are different and merging them will 
reduce the radiation technologists wage rate. The specialty society 
also opposed the decision to blend the staff types of RN and 
sonographers because they are trained to provide different services and 
are not interchangeable.
    Response: The original CPEP data listed both ``x-ray technician'' 
and ``radiation technologist'' and seemingly made no distinction 
between these two staff types because the same wage rate was assigned 
to both. We used the Bureau of Labor Statistics' salary data to 
determine the wage rate for the ``radiologic technologist.'' Therefore, 
we do not believe that the salary assigned has been reduced in any way. 
If some of the radiology procedures typically use staff that are paid 
at a lower rate than the radiologic technologist, this information 
should be provided by the specialty society when the practice expense 
inputs for the services are refined. Regarding the second concern, we 
did not make a decision to blend the staff types, ``RN'' and 
``diagnostic

[[Page 79976]]

medical sonographer.'' This blend currently exists in the original CPEP 
data and has also been contained in several PEAC recommendations. Both 
staff types are priced separately and we were merely listing what the 
pricing would be when such a blend was applied to any service.
    Comment: Three specialty societies, representing surgeons, thoracic 
surgeons and ophthalmologists, commented on the issue of our previous 
exclusion from the CPEP data of all claimed time associated with staff 
brought to the hospital by the physician. The commenters from the 
surgical and the thoracic surgery specialty societies claimed that a 
recent report by the Office of the Inspector General (OIG) confirms 
that over 70 percent of cardiac surgeons bring staff to the hospital, 
but that only 19 percent are being reimbursed by the hospital. The 
commenters further argued that this is an inequitable arrangement that 
requires corrective action by us. The commenter from the ophthalmology 
society claimed that ophthalmologists bring their staff to the facility 
setting 50 percent of the time and some cost for this should be built 
into their practice expense.
    Response: In the November 2, 1999 final rule (64 FR 59399), we 
adopted a policy to exclude all clinical staff time in the facility 
setting from the input data used to develop practice expense RVUs. 
Among other arguments, we indicated that Medicare should not pay twice 
for the same service. That is, Medicare's payment to the hospital 
includes payment for clinical staff and we should not also compensate a 
physician for using their own staff in the hospital. In addition, we 
argued that we also pay for physician-extender staff used in the 
facility setting, such as physician assistants and nurse practitioners, 
through the physician work RVUs, and we pay physician assistants 
directly when performing as an assistant-at-surgery. In response to 
this argument, thoracic surgeons contended that hospitals are no longer 
providing the staff to furnish adequate care. While we did not change 
our policy, we asked the Office of Inspector General (OIG) to conduct 
an independent assessment of staffing arrangements between hospitals 
and thoracic surgeons (see November 1, 2000 final rule 65 FR 65395). In 
April, 2002 (OEI-09-01-00130, page ii), OIG concluded:
    Medicare pays for non-physician staff even though surgeons do not 
receive additional payment for some of the staff they bring to the 
hospital. Instead, services of these staff are paid to either 
physicians through the work relative value units, to the mid-level 
practitioners directly, or to the hospital through Part A or the 
Ambulatory Payment Classification system for outpatient services. 
Recognizing this, some hospitals and cardiothoracic surgeons have 
entered into arrangements whereby hospitals provide some compensation 
to surgeons who bring their own staff.
    We believe the OIG report clearly supports our position to exclude 
the costs of clinical staff brought to the hospital from the practice 
expense calculations. While it may be common for thoracic surgeons to 
bring staff to hospitals, the OIG report makes clear that Medicare pays 
for these costs either directly to physicians or the hospital. Since 
the OIG report supports our position, we are not making any revisions 
to our policy to exclude practice expense inputs associated with 
bringing clinical staff to hospitals.
    Comment: One commenter representing an independent diagnostic 
testing facility commented that a review of the practice expense inputs 
for the 24-hour cardiac monitoring HCPCS codes G0005, G0006 and G0007 
and the corresponding CPT codes 93270, 93271, and 93272 revealed the 
CPEP input lists contain items that are not needed to perform these 
services. The commenter suggested the following deletions: G0005 and 
CPT code 93270 (for the hookup of the equipment)--delete the ECG 
electrodes, laser paper, king of hearts-20, computer, life receiving 
center; G0006 and CPT code 93721 (for the monitoring and transmission 
of data)-delete the razor, gloves, alcohol swab, and tape and exam 
table; G0007 (interpretation and report)-delete all the supplies (G0007 
currently has no equipment and CPT code 93272 currently has no 
equipment or supplies assigned.
    Response: We agree that the changes to the practice expense inputs 
suggested above divide the inputs more appropriately between the two TC 
codes and the PC code for this cardiac monitoring service. However, as 
discussed in section IV, we are deleting the referenced G-codes for CY 
2003 and these services will be reported using the CPT codes. On an 
interim basis, until these codes are refined, we will make the 
recommended revisions to the CPEP data for the CPT codes for these 
services. It should be noted, however, that the TC codes are currently 
in the non-physician work pool and that the CPEP data is not currently 
used to calculate their practice expense RVUs. In addition, we do not 
assign direct cost inputs to PC codes. Therefore, these changes will 
not at this time have any effect on the payment for these codes.
    Comment: A specialty society representing radiology commented that 
the review cycle for pricing ``high tech'' equipment and supplies may 
need to be reviewed more frequently than every 5 years and suggested a 
3-year cycle.
    Response: We plan to propose current pricing for all the supplies 
and equipment in our CPEP database in next year's proposed rule. We 
have made no final decision on how often this pricing update should be 
done and will consult with the medical community on how best to ensure 
that we have appropriate pricing for all of our direct cost inputs.

(iv) Proposed Changes from June 28, 2002 Proposed Rule

(A) Ophthalmology Services--Rank Order Anomalies

    Based on a request from the American Academy of Ophthalmology we 
proposed revisions to the CPEP data for five ophthalmology services: 
For CPT code 67820, Revise eyelashes, we proposed to remove ophthane 
from the supply list. For CPT code 67825, Revise eyelashes, we proposed 
to remove the bipolar handpiece from the supply list. For CPT code 
65220, Removal foreign body from eye, we proposed using the supply list 
and clinical staff time assigned to CPT code 65222. The exam lane is 
the only equipment assigned. For CPT codes 92081 and 92083, Visual 
field examination(s), we proposed to assign the same supplies and 
equipment as CPT code 92082 and to assign 35 minutes of clinical staff 
time to 92081 and 70 minutes to 92083.
    Comment and Response: Commenters were supportive of the proposed 
revision to the CPEP inputs for the ophthalmology codes and we are 
finalizing the revisions as proposed.

(B) Practice Expense Inputs for Thermotherapy Procedures

    There are three CPT codes for transurethral destruction of prostate 
tissue: CPT 53850, by microwave therapy, CPT 53852, by radiofrequency 
thermotherapy, and CPT 53853, by water-induced thermotherapy (WIT). 
Based on concerns expressed by a manufacturer of WIT equipment that 
practice expense inputs were underestimated for CPT code 53853 relative 
to the other two codes, we made a comparison and agreed that the WIT 
procedure had not been assigned many of the basic supply and equipment 
inputs that were included in the CPEP inputs for the other two 
procedures. Therefore, we proposed to add, on an interim basis, the 
following inputs: Power table, ultrasound unit, mayo stand, endoscopy 
stretcher, light source,

[[Page 79977]]

chux, sani-wipe, patient education book, sterile towel, sterile gloves, 
specimen cup, alcohol swab, gauze, tape, lidocaine, betadine, 10 cc 
syringe, 30 cc syringe, sterile water, leg bag.
    We also proposed to change on an interim basis the staff type for 
CPT code 53853 from the RN/LPN/MTA blend to RN in order to make the 
staff type consistent among these three similar procedures. In 
addition, we corrected, for all three procedures, the minutes assigned 
to each piece of equipment to reflect the intra- and post-clinical 
staff times only, rather than the total clinical staff times.
    We have also requested that these three procedures be reexamined by 
the PEAC at the same time in order to ensure that there is a consistent 
approach to the assignment of direct cost inputs.
    Based on questions we received regarding the large disparity in 
prices used for the three different thermotherapy machines and 
indications that the prices have decreased dramatically since these 
were initially priced in 1999, we proposed to set the price for 
thermotherapy equipment at $60,000 for CPT code 53850 and $30,000 for 
CPT code 53852. We also requested any additional available price 
documentation that would assist us in ensuring assigned prices 
accurately reflect actual costs.
    Comment: Commenters were generally supportive of the proposed 
revisions and in agreement that the PEAC should review the CPEP inputs 
for these procedures. A specialty society representing urology agreed 
that the best way to handle the CPEP inputs for these services is to 
have the PEAC review the direct cost inputs for all the heat therapy 
procedures concurrently and the comment from the RUC stated that it 
plans to review these codes in time for inclusion in the physician fee 
schedule for 2004. However, a few commenters also suggested that the 
review be extended to other codes for treatment for benign prostatic 
hypertrophy, such as the code for transurethral resection of the 
prostate, CPT code 52612, and for laser coagulation of the prostate, 
CPT code 52647.
    Response: We agree that it would be advantageous to have the PEAC 
review the CPEP inputs for all codes pertaining to the treatment of 
benign prostatic hypertrophy at the same time. This would help ensure 
that the same standards are applied to developing the direct cost 
inputs for these codes so that the resulting practice expense RVUs 
appropriately reflect the relative costs of each service. We will 
request that the PEAC include for review all the codes suggested by the 
commenters.
    Comment: One commenter, representing a manufacturer, also indicated 
that, as part of any review, it is imperative that cost data for all 
medical devices that fall within the CPT code should be evaluated. The 
commenter suggested that we work with the specialty groups to obtain 
pricing information rather than using invoices for pricing. The comment 
from the specialty society argued that we should maintain all the 
proposed input changes unless we receive compelling data from 
urologists or manufacturers that varies from the proposed inputs. 
Another commenter stated that, while there has been a reduction in the 
price of the thermotherapy control unit over the past few years, the 
proposed price of $60,000 for thermotherapy equipment for CPT code 
53850 was not representative. The commenter included an invoice that 
indicated that the current price is closer to $80,000, after the 
application of discounts.
    Response: We will finalize the revisions to the CPEP inputs as 
proposed with the exception of the price for the thermotherapy 
equipment that we will increase to $80,000 on an interim basis. As part 
of the practice expense refinement process we have awarded a contract 
to update the pricing for both the supplies and equipment represented 
in the CPEP inputs and we anticipate that the proposed pricing 
revisions to the inputs will be included in next year's proposed rule. 
Pricing of the thermotherapy equipment will be included in these 
proposed changes and we will be seeking input from the specialty 
society to help us in this endeavor.

(C) Revision to Inputs for Iontophoresis

    It had been brought to our attention that the electrodes assigned 
to the supply list for CPT code 97033, Iontophoresis, were not the type 
required for this procedure. We proposed to substitute two electrodes 
with a medication vesicle as the appropriate supply for iontophoresis.

(D) Correction to Price for Sterile Water

    We proposed to change the price for 1000 ml of sterile water from 
$40.00 to $3.00.
    Comments and Responses: No comments were received on our proposals 
to substitute two electrodes with a medication vesicle as the 
appropriate supply for iontophoresis or to correct the price of sterile 
water. Therefore, we are finalizing these as proposed.

b. Non-Physician Work Pool For Practice Expense

    Comment: We received a comment objecting to use of the phrase 
``zero work pool.'' The comment acknowledges that our preamble refers 
to ``zero physician work pool'' but stated that the vernacular used by 
the agency, Congressional staff and other stakeholders is ``zero work 
pool.'' While acknowledging that we do not intend to connote a zero 
value for oncology nurses' contributions, oncology nurses, social 
workers, radiology technicians and others take offense to the use of 
``zero work pool'' because it suggests that the work done by oncology 
nurses and other clinical staff is without value. The comment suggested 
four appropriate alternative titles: Non-physician clinical staff time, 
Non-physician work components, Non-physician work pool or Non-physician 
health professional pool.
    Response: We did not intend to devalue the contribution of clinical 
staff involved in providing physician fee schedule services. In fact, 
we created the special methodology to value services that are provided 
by clinical staff without a physician because of our concern that these 
services could be valued inappropriately low under the top down 
methodology. Nevertheless, it is clear that there are objections to the 
nomenclature we have used. We appreciate the suggestions for 
alternative nomenclature and will refer to the special methodology as 
the ``Non-physician work pool.''

(i) Discussion of Alternatives to the Non-Physician Work Pool

    In our June 2002 proposed rule (67 FR 43850) we summarized 
alternatives to the non-physician work pool that have been included in 
reports prepared by our contractor, the Lewin Group. Included in the 
alternatives were: elimination of the non-physician work pool; 
development of specialty specific non-physician work pools; making the 
TC equal to the global less the PC RVUs; and, development of proxy 
physician work RVUs for physician fee schedule services provided by 
clinical staff without physicians. While we included a discussion of 
each alternative and their feasibility, we did not propose eliminating 
or replacing the non-physician work pool. We indicated that specialties 
whose services are affected by the non-physician work pool may conduct 
supplemental practice expense surveys if they believe there are 
shortcomings in the practice expense per hour information that we use 
as part of the basic methodology. We referenced

[[Page 79978]]

the interim final rule also published June 28, 2002 in the Federal 
Register. The interim final rule modified the criteria for acceptance 
of supplemental data. (See section II.A.3.(a) of this rule for a 
summary of the interim final rule, the public comments, and our 
responses.) We also noted that while the non-physician work pool is of 
benefit to many of the services that were originally included, we have 
allowed specialties to request that their services be removed.
    As part of our analysis of alternatives to the non-physician work 
pool, we proposed a change in the computation of practice expense RVUs 
for some PC and TC services. Since it is far more common to receive a 
global bill than a TC only bill, we believe that using the global to 
value the TC service will result in a payment that is more typical of 
the relative actual practice expense associated with the service. 
Therefore, we proposed to make the TC value equal the difference 
between the global and the PC for procedure codes that are not included 
in the non-physician work pool. That is, we used the practice expense 
value produced by the methodology for the global and subtracted the PC 
to derive the TC practice expense RVU. As a result of concerns that we 
had about the impact of this change on services that are affected by 
the non-physician work pool calculations, we proposed continuing to 
make the global value equal to the sum of the professional and the TC 
values for non-physician work pool services.
    Comment: One commenter, representing oncologists, argued that the 
``normal top-down methodology discriminates against [non-physician work 
pool] services * * * by assuming, without any basis, that indirect 
costs are lower than comparable services that do involve physician 
work.'' The commenter stated that both the GAO and Lewin reports 
provide support for the conclusion that the indirect cost allocation is 
biased against non-physician work services. According to the commenter, 
our assertion that ``the indirect cost allocation must be correct 
because not all of the services without a physician work component are 
disadvantaged by its use is not a sound basis for maintaining the 
current methodology.'' The commenter argues that estimates of practice 
expense per hour and physician time may be overstated for some non-
physician work services resulting in an advantage outside of the non-
physician work pool. Furthermore, the comment argues that an increase 
in payment resulting from services being ``withdrawn from the [non-
physician work pool] does not demonstrate that the normal top-down 
methodology results in an appropriate payment amount for services that 
do not have physician work components.'' The commenter also objected to 
our rejection of the Lewin Group's idea to develop specialty-specific 
non-physician work pools on the basis that a single methodology must 
apply to all services. According to the commenter, our refusal would 
only be appropriate if the methodology was not biased against non-
physician work pool services. Another comment suggested that we 
allocated indirect costs by deeming direct costs as 33.2 percent of 
total costs. Indirect costs would then be added to direct costs to 
determine a total practice expense RVU.
    Response: We do not believe the practice expense methodology is 
biased against non-physician work services. The methodology allocates 
indirect costs based on physician work and direct costs. While the 
comment suggests the use of physician work in the indirect cost 
allocation is biased against services that do not have physician work, 
it ignores that direct costs are also used. Most services that do not 
have physician work have significant direct expenses. Thus, any bias 
against non-physician work services in the indirect cost allocation is 
offset by the use of direct costs. Similarly, the use of physician work 
in the indirect cost allocation will offset any bias against services 
predominantly performed in facilities where the physician will have 
few, if any, direct costs associated with the services. For example, 
surgical services furnished in a hospital have few direct expenses, 
thus the allocation of indirect expenses according to both work and 
direct expenses helps offset any bias against surgical services.
    We also disagree with the comment that suggests ``deeming'' direct 
costs to be 33.2 percent of total costs for purposes of developing 
practice expense RVUs. The proportion of costs attributable to direct 
and indirect costs will be different for each service. Such a proposal 
would be inherently unfair to services that have few direct costs (and 
impossible to use for services that have no direct costs) and would 
create a significant bias in favor of services that have high direct 
expenses.
    We further examined the assertion in the comment and in the Lewin 
Group and GAO reports that the indirect cost allocation is a possible 
explanation for the adverse payment impact that would occur under the 
top-down methodology for some non-physician work pool services. It is 
important to distinguish between the different types of services that 
are affected by the non-physician work pool calculations. Professional/
TC services are the largest category of services included in the non-
physician work pool. While many professional/TC services were not 
adversely affected by the adoption of the top-down methodology, the 
ones remaining in the pool are the services that would be most 
adversely affected by its elimination. Some ``Incident to'' services 
are also included in the non-physician work pool. Elimination of the 
non-physician work pool may cause payments for these services to go up 
or down depending on the specialty that provides them.
    Based on 2000 utilization data, the specialties with the largest 
amount of Medicare allowed charges affected by the non-physician work 
pool calculations are: radiology ($2.8 billion), cardiology ($2.1 
billion), internal medicine ($568 million), radiation oncology ($465 
million), multi-specialty clinics ($313 million), independent 
diagnostic testing facilities ($309 million) and oncology ($226 
million). Radiology receives 87 percent of its Medicare revenues from 
services that are affected by the non-physician work pool calculations. 
The figures are 47 percent for cardiology, 9 percent for internal 
medicine, 65 percent for radiation oncology, 17 percent for multi-
specialty clinics, 86 percent for independent diagnostic testing 
facilities and 26 percent for oncology. There are other smaller 
specialties that also receive a significant proportion of their 
revenues from services in the non-physician work pool (portable x-ray 
suppliers, 100 percent, interventional radiology, 63 percent, allergy/
immunology 35 percent). The specialties that receive the highest 
proportion of their revenues from professional/TC services remaining in 
the non-physician work pool would be most adversely affected by its 
elimination (independent diagnostic testing facilities, portable x-ray 
suppliers, radiology, radiation oncology and interventional radiology). 
Cardiology also receives substantial Medicare revenues from 
professional/TC services remaining in the non-physician work pool but 
would be less adversely affected by its elimination. Allergy/immunology 
receives substantial revenues from ``incident to'' services in the non-
physician work pool and would experience a more modest decline in 
payment under the top-down methodology. Payments to oncology for 
``incident to'' services would increase if the non-physician work pool 
were eliminated.
    Radiology, radiation oncology and certain other diagnostic services 
with professional and technical components

[[Page 79979]]

are likely to be the services most adversely affected by elimination of 
the non-physician work pool. We do not believe the allocation of either 
direct or indirect costs explains the effect of the top-down 
methodology on these services. We examined this issue further by 
modifying the indirect cost allocation using an idea suggested by the 
Lewin Group that would retain work and direct expenses to allocate 
indirect costs but create proxy physician work values for services that 
do not have physician work (the Lewin Group, pages 22-23). As indicated 
earlier, we proposed to modify the practice expense methodology to 
calculate the TC practice expense RVU as the difference between the 
global and the PC RVU for services unaffected by the non-physician work 
pool. To analyze the Lewin idea, we followed this same approach for all 
services. However, we further modified the methodology to use proxy 
work RVUs for the TC (or non-physician work portion) of the global 
service for the allocation of indirect costs. (We did this for TC 
services as well, but it makes no difference whether a proxy physician 
work RVU is used for the indirect cost allocation since the RVU 
produced by the practice expense methodology for the TC is not used). 
By developing a proxy work RVU for the global, in effect, we imputed 
physician work RVUs for the technical portion of the global service and 
added it to the existing work RVUs for the physician interpretation. If 
such an approach were adopted, the indirect cost allocation would favor 
the global service at the expense of professional component. That is, 
the practice expense RVUs would increase for the global and decrease 
for the PC but the overall impact for the specialty would be about the 
same. Modifying the indirect cost allocation in this way would not 
offset large decreases in payment for radiology, radiation oncology and 
other specialties most adversely affected by elimination of the non-
physician work pool. In fact, such a methodological change would not 
even raise payments to these specialties.
    As we indicated in the June 2002 proposed rule, we believe a 
relatively low practice expense per hour, and not the indirect cost 
allocation, explains the adverse impact on diagnostic services that 
would occur from eliminating the non-physician work pool. We encourage 
radiology, radiology oncology and other diagnostic service providers 
affected by the non-physician work pool to undertake a survey of the 
practice expenses. Since practice expense methodology uses a weighted 
average of the practice expenses of the specialties that bill Medicare, 
we believe there are significant advantages to the survey being 
undertaken with collaboration among the different providers of 
diagnostic services. As indicated earlier, we advise any party 
interested in conducting a supplemental survey to consult the Lewin 
Group and us before proceeding.
    Comment: Most comments we received supported making the TC practice 
expense RVUs equal to the difference between the global and PC practice 
expense RVUs. We received a number of comments from pathologists and 
organizations representing independent laboratories, pathologists, 
dermatologists, and others expressing concern about the effect of the 
proposal on payment for pathology services. Some of the commenters 
indicated that we did not provide an explanation of the necessity for 
the change or indicate why a simple arithmetic change should result in 
such a large difference in the proposed fee for TC services. Several of 
these commenters stated that practice expenses for physician pathology 
services are increasing, not decreasing. According to some of these 
commenters, it is inequitable to apply the methodology to certain 
specialties or groups of services that would experience significant 
reductions while sparing other specialties or services that would 
experience reductions under the same change. There were also comments 
indicating that the reduction in payment for pathology services was 
related to the mix of specialties that bill for global services; 
specifically, there is concern that independent laboratories bill for a 
higher proportion of global than TC services. The commenters noted that 
we do not have a practice expense per hour for independent laboratories 
and use a crosswalk practice expense per hour from ``all physicians.'' 
While this comment acknowledges our need to use a crosswalk when we do 
not have a practice expense per hour, the comment indicated that there 
is no reason to conclude that independent laboratories that provide 
pathology services have practice expenses per hour similar to the all 
physician average. The comments expressing concern about the impact of 
the proposal on pathology services requested a one-year moratorium on 
its implementation to allow for a survey of independent laboratory 
practice expenses under the supplemental survey process. There were a 
number of comments indicating that organizations representing 
pathologists would undertake a survey of practice expenses for 
independent laboratories that could be used to develop 2004 physician 
fee schedule rates.
    Response: We agree with the comments that suggest a one-year 
moratorium on implementation of the proposed change for pathology 
services paid under the physician fee schedule. Based on a consultation 
with the College of American Pathologists, we will continue to 
determine the global practice expense RVUs as the sum of the 
professional plus TC for all of the global codes in the CPT 80000 
series that are paid using the physician fee schedule, as well as the 
following HCPCS and CPT codes:

                                 Table 2
------------------------------------------------------------------------
               CPT/HCPCS                           Description
------------------------------------------------------------------------
G0141..................................  Screening c/v, autosys, interp
P3001..................................  Screening c/v, interp
10021..................................  FNA w/o image
10022..................................  FNA w/image
36430..................................  Blood transfusion service
36440..................................  Blood transfusion service
36450..................................  Blood transfusion service
36455..................................  Exchange transfusion service
36460..................................  Transfusion service, fetal
36520..................................  Plasma and/or cell exchange
38220..................................  Bone marrow aspiration
38221..................................  Bone marrow biopsy
38230..................................  Bone marrow collection
38231..................................  Stem cell collection
------------------------------------------------------------------------

    CPT codes and descriptions only are copyright 2002 American Medical 
Association.
    As we indicate in the background part of this preamble, the 
practice expense methodology essentially takes a weighted average of 
different specialty practice expenses to determine a practice expense 
RVU. The methodology will independently produce a value for the global, 
professional and technical components. For instance, CPT code 88305 
(Tissue exam by pathologist) is a commonly provided pathology service. 
The methodology produces a value of 1.60 for the global, 0.34 for the 
PC and 1.39 for the technical component. The sum of the professional 
and TC RVUs (0.34 + 1.39 = 1.73) is not equal to the global RVU (1.60). 
The values are not equal because the mix of specialties that provide 
the global and the TC are different and each specialty has a different 
practice expense per hour. The specialties that bill CPT code 88305 to 
Medicare for the global service most frequently have the following 
practice expense per hour:

[[Page 79980]]



                                 Table 3
------------------------------------------------------------------------
                                    Practice  expense   Percent of total
             Specialty                   per hour            volume
------------------------------------------------------------------------
Independent Lab...................             $69.00                 56
Pathology.........................              66.30                 29
Dermatology.......................             119.40                 13
------------------------------------------------------------------------

    The specialties that bill Medicare most frequently for the TC are:

                                 Table 4
------------------------------------------------------------------------
                                     Practice expense   Percent of total
             Specialty                   per hour            volume
------------------------------------------------------------------------
Independent Lab...................             $69.00                 47
Dermatology.......................             119.40                 33
Pathology.........................              66.30                 16
------------------------------------------------------------------------

    As shown in the tables above, dermatology has a very high practice 
expense per hour relative to independent laboratories and pathology. 
However, dermatologists bill Medicare for a smaller portion of the 
global services. As a result, dermatology contributes less weight to 
the global value than the TC value. Our practice has been to make the 
global RVUs equal the sum of the PC and TC values. If the methodology 
results in PC and TC values that do not sum to the global value, we 
must change either the global or TC value. To date, we have used the PC 
(0.34) and the TC value (1.39) to determine the global value (1.74). 
However, in the proposed rule, we used the global value (1.60) minus 
the PC (0.34) to obtain the TC (1.26). Using the TC to value the global 
component for this code (88305) produces a higher RVU for both the 
technical and the global components than using the global component to 
value the TC.
    As we have previously indicated, it is far more common for Medicare 
to receive a global than technical-component-only bill. For this 
reason, we believe it is valid to rely on the global to produce a value 
for the technical rather than use the technical to value the global. 
Nevertheless, since independent laboratories predominantly bill the 
global for pathology services and we are using a crosswalk for the 
practice expense per hour, we believe it makes sense to allow for a 
one-year moratorium on implementation of this provision for pathology 
services to allow for use of a supplemental survey that provides us 
with specific data on practice expenses for independent laboratories.
    Final Decision: We are not adopting the proposed change for 
pathology services paid using the physician fee schedule at this time. 
For all professional/TC services not included in the non-physician work 
pool, excluding pathology services, we will make the TC value equal the 
difference between the global and the professional component. We will 
continue with the current practice for pathology services and non-
physician work pool services and sum the professional and TC values to 
determine the global.
    (ii) Other Proposals for Changes to the Non-Physician Work Pool

(A). Change to Staff Time Used To Create the Pool

    In the November 2, 1998 final rule (63 FR 58841), we indicated that 
average clinical staff time was used in the creation of the non-
physician work pool. Since the cost pools are created using physician 
time and, by definition, services provided by clinical staff have no 
physician time, we need staff time to create the non-physician cost 
pool. If our database indicates that multiple staff types are typically 
involved in the service, we have used an average of the different 
clinical staff times. We proposed to create the non-physician cost pool 
using the highest staff time in place of average staff time.
    Comment: We received many comments that supported using the highest 
staff time to create the non-physician work pool. Some comments 
suggested that we should consider using ``total'' staff time especially 
if we will use the clinical staff times being provided by the Practice 
Expense Advisory Committee (PEAC). The comment indicates that the PEAC 
has been particularly careful to avoid duplications of time. If the 
PEAC has limited or eliminates concurrent staff time, the comment 
suggests that ``total'' rather ``maximum'' staff time should be use to 
determine the non-physician work pool. A number of comments expressed 
concern about PEAC refinements of clinical staff times associated with 
codes included in the non-physician work pool. These comments requested 
that we not incorporate any PEAC revised clinical staff times for non-
physician work services until there has been an opportunity for public 
notice and comment. There were two comments objecting to this proposal. 
One comment indicated that the maximum staff time is not the 
``typical'' time associated with provision of the service and urged us 
not to implement the proposal. We received another comment that noted 
that physician times used to establish practice expense cost pools for 
physician work services use average or median times from RUC or Harvard 
surveys. The comment indicates that the proposal to use maximum staff 
time represents a step away from the stated goal of developing a 
consistent method for all services. According to this commenter, the 
proposal will penalize specialties that do not perform a large volume 
of services in the non-physician work pool.
    Response: We disagree with the comment that suggests we are not 
using a time that is typical of the service and the one that implies 
our staff time proposal is inconsistent with how we determine physician 
time. For a physician's service, we develop time based on surveys. 
While the comment is correct that we generally use average or median 
time estimates from surveys to determine the typical time, the time 
reflects the service of a single physician.

[[Page 79981]]

For non-physician work pool services, we are also using estimated 
average staff times to represent the typical service. However, multiple 
clinical staff are frequently involved in performing non-physician work 
pool services. The staff may be working concurrently, consecutively or 
overlapping time. Given the special circumstances associated with non-
physician work pool services that do not apply to physicians' services, 
it was necessary for us to select among multiple time estimates to 
develop the pool. We are currently using an average of the estimated 
staff times but proposed to use the maximum. Once we address issues 
related to the non-physician work pool, this will no longer be an issue 
since we will use a single methodology for all physician fee schedule 
services and staff time will not be used to create cost pools.
    In response to the comment that refined clinical staff times not be 
used at this time for non-physician work pool services, we agree that 
there are special circumstances that apply to these services. Because 
the clinical staff times are used to create the pool and can result in 
RVU changes across all services, even those where no refinements have 
been made, we are not using the revised clinical staff time to create 
the non-physician work pool at this time. However, as indicated above, 
this will no longer be an issue once we address other issues related to 
the non-physician work pool.

(B). Removal of Non-Invasive Vascular Diagnostic Study Codes From the 
Non-Physician Work Pool

    We proposed to remove the non-invasive vascular diagnostic study 
codes (CPT codes 93875-93990) from the non-physician work pool based on 
a request from the American Association for Vascular Surgery (AAVS) and 
the Society for Vascular Surgery (SVS).
    Comment: We received support from vascular surgeons and others for 
removing the non-invasive vascular diagnostic studies from the non-
physician work pool. These comments requested that AAVS/SVS should be 
able to modify the request if CMS does not finalize its proposal to 
calculate the TC practice expense RVU as the difference between the 
global and professional components. We also received a number of 
comments requesting that we remove other codes from the non-physician 
work pool. The Society of Vascular Technology and Society of Diagnostic 
Medical Sonography) requested that we remove 26 ultrasound codes in the 
CPT code range 76506 through 76977. The American Society of 
Neuroimaging also requested that some of these codes be removed. The 
American Urological Association (AUA) also requested that we remove CPT 
codes 76857, 76872, 76942 and 96400 from the non-physician work pool. 
While there were no objections to removing the non-invasive vascular 
diagnostic study codes, we received many comments that suggested 
limiting the financial impact that removing codes from the non-
physician work pool have on the remaining codes. In particular, many of 
these commenters expressed concern about the impact of removing 
chemotherapy administration codes from the non-physician work pool. 
Some comments provided suggestions for modifications to the non-
physician work pool (for example, using a different practice expense 
per hour) that could be used if adverse impacts result from codes being 
removed. One commenter suggested that we maintain the existing RVUs and 
provide a downward adjustment to the CF to ensure no increase in 
aggregate payment results from removing chemotherapy administration 
services from the non-physician work pool.
    Response: At this time, we have not received any requests to remove 
chemotherapy administration from the non-physician work pool. 
Nevertheless, if there are sound suggestions that could be adopted 
consistent with changes in the composition of the non-physician work 
pool that will improve the practice expense methodology, we may 
consider adopting them in the future. Of course, as stated elsewhere, 
our goal is to eliminate the non-physician work pool and apply a single 
methodology to all physician fee schedule services so further 
adjustments will be unnecessary. We expect this to be a top priority in 
CY 2003 for determining CY 2004 physician fee schedule rates.
    We have reviewed the comments to remove specific services from the 
non-physician work pool. While our general policy has been that 
``families'' of procedure codes should be removed from the non-
physician work pool (see the July 22, 1999 proposed rule (64 FR 
39620)), we will allow individual codes to be removed if the requesting 
specialty predominantly performs the requested code and other 
specialties predominantly perform the other codes in the family. We 
have reviewed 2001 utilization for the codes requested by the AUA. 
Since urologists predominantly perform the requested codes and other 
codes in the family are predominantly performed by other specialties, 
we are removing the following codes from the non-physician work pool: 
CPT codes 76857, 76872, 76942 and 96400. We are not removing other 
codes requested in the comments because they are predominantly 
performed by radiology, neurology or obstetrics-gynecology and the 
specialty societies representing these physicians have not requested 
that the codes be removed from the non-physician work pool.
    Comment: The American College of Rheumatology (ACR) acknowledged 
that the current average wholesale price (AWP) methodology provides for 
a ``healthy margin overall'' in the provision of these services 
[infusion agents and infusion therapy] through ``cross-subsidization.'' 
However, they indicated that payments for infusion therapy services are 
``woefully insufficient.'' The comments from ACR and many 
rheumatologists expressed concern about reductions in payment for 
infusion agents in combination with maintaining the current payment 
amounts for infusion therapy (CPT codes 90780 and 90781). The comments 
indicated that a reduction in payment for infusion agents without an 
increase in the payment for infusion therapy services will likely 
result in Medicare beneficiaries being unable to receive infusion 
services in physicians' offices. One commenter from a society 
representing gastroenterologists indicated that we should consider 
increasing the payment for non-chemotherapy infusion services. Other 
comments suggested that we should use the rulemaking process to 
establish HCPCS G codes to increase payment for non-chemotherapy drug 
administration to a more appropriate level.
    Response: We currently determine the practice expense RVUs for CPT 
codes 90780 and 90781 using the non-physician work pool methodology. 
One commenter suggested establishing a G code for non-chemotherapy 
infusion services. While this option would allow infusion therapy to be 
valued outside of the non-physician work pool, we want to avoid 
establishment of G codes for services that are already described by 
existing CPT codes. Another option for addressing these comments would 
be to remove infusion therapy from the non-physician work pool and 
allow for resource-based pricing under the top-down methodology. 
However, oncologists predominantly perform these services and have not 
requested removing the codes from the non-physician work pool. We are 
reluctant to remove infusion therapy services from the non-physician 
work pool without a request from the specialty that predominates the 
data. As we previously noted, oncologists provided

[[Page 79982]]

us with a supplemental practice expense survey. At this time, we are 
not incorporating the survey into the practice expense methodology 
because of concerns raised by our contractor, the Lewin Group, about 
the validity of some of the data. However, we hope to work with the 
Lewin Group and ASCO to either get an explanation of the survey results 
or use alternative data to validate the results. As we work to resolve 
issues related to the ASCO survey, we will consider removing the 
infusion therapy codes from the non-physician work pool.
    In the interim, we note that Medicare pays for drugs based on 95 
percent of AWP. This system has been widely criticized for paying 
physicians for drugs at far higher rates than prices paid to obtain 
them. Oncologists receive more than 70 percent of their Medicare 
revenues from drugs. While we would prefer a statutory change to 
address Medicare's drug pricing methodology, we are contemplating 
administrative actions that may be taken under current law to address 
this issue. As we consider options for changing Medicare's drug payment 
methodology, we will continue examining the ASCO survey to determine 
whether the data can be used to calculate the practice expense per hour 
for oncology.

(C). Removal of Immunization CPT Codes 90471 and 90472 From the Non-
Physician Work Pool

    We proposed to remove immunization administration services from the 
non-physician work pool. We indicated this change would nearly double 
payment for CPT code 90471 and slightly reduce payment for CPT code 
90472. Procedure CPT code 90471 is used for immunization administration 
of one vaccine and CPT code 90472 is used for the administration of 
each additional vaccine. Since CPT code 90472 must be billed in 
conjunction with CPT code 90471, the total payment for these procedures 
would increase when billed together.
    We also explained that we have not assigned immunization 
administration physician work RVUs because this service does not 
typically involve a physician. The nurse that administers the vaccine 
typically provides the necessary counseling to the patient and this 
time is accounted for in the practice expense RVU.
    In addition, we noted that not all services represented by CPT 
codes 90471 and 90472 are covered by Medicare. For example, medically 
necessary administrations of tetanus toxoid (such as following a severe 
injury) would be covered whereas preventive administration of this 
vaccine would not be covered. We also indicated we would consider 
whether coding changes might be appropriate to reflect the differences 
in counseling of the patient and/or family for childhood immunizations.
    Comment: Commenters supported our proposal to remove CPT codes 
90471 and 90472 from the non-physician work pool. However, commenters 
indicated elderly patients are at higher risk to acquire pathogens and 
viruses and are in greater need of vaccinations. Medicare must 
recognize that as part of their practice of medicine, physicians take 
the time and responsibility to explain to their patients the benefits 
of vaccination and the potential side effects. Physicians question the 
patient about previous reactions to the vaccine and provide information 
material. These comments indicated that we should assign work RVUs of 
0.17 for the administration of vaccines as recommended by the RUC.
    Response: The RUC has recommended that we both establish a work RVU 
for CPT code 90471 and include 13 minutes of clinical staff time to 
value the practice expense RVU. Further, our understanding from the RUC 
is that these immunization services are also provided in conjunction 
with a separately billable visit. We believe the clinical staff time 
for these services is intended to account for patient counseling and 
some of the activities described in the comment. Other activities 
attributed to the physicians are likely being provided as part of a 
separately billable office visit. For these reasons, we continue to 
believe that these codes should not be assigned physician work RVUs.
    Comment: Several commenters expressed concern that we did not 
propose any change in the payment rate for the administration of 
influenza (G0008), pneumonia (G0009), and hepatitis B (G0010) vaccines. 
The commenters are concerned that we continue to link payment for the 
administration of Medicare covered vaccines to a therapeutic injection 
CPT code (90782) that pays at half of the proposed rate for CPT code 
90471. Other commenters recommended that Medicare use the CPT codes 
90471 and 90472 in place of the Medicare-only alphanumeric codes 
(G0008, G0009, G0010). These comments indicated that if we are to 
retain the G codes, we should publish RVUs for them that match CPT code 
90471.
    Response: We considered the comment to eliminate use of the G codes 
and allow use of the CPT codes for the administration of Medicare 
covered vaccines. However, we have decided that we will maintain these 
G codes at this time. It is important that we be able to closely 
monitor patient access to these important preventive services. However, 
since CPT has established similar codes for immunization administration 
that can be covered by Medicare, we will consider this issue further in 
2003.
    With respect to payment, we agree with the commenters. Rather than 
link payment for procedures codes G0008, G0009, and G0010 to a service 
paid under the physician fee schedule, we will develop practice expense 
RVUs for these codes. Using the top-down methodology to develop 
practice expense RVUs will nearly double payment for these codes and 
make Medicare's payment for vaccine administration using the G codes 
more consistent with the rates paid for the CPT codes. Since the 
statute does not include the administration of pneumonia, influenza, 
and hepatitis B vaccines within the definition of physicians' services 
in section 1848(j) of the Act, the increased payment for these services 
will not result in reductions to the practice expense RVUs associated 
with physician fee schedule services. That is, there is no budget-
neutrality adjustment to be made for revisions in payments for the 
administration of pneumonia, influenza, and hepatitis B vaccines.
    Comment: One commenter indicated that Medicare does not pay for the 
administration of influenza and pneumonia vaccines provided on the same 
day as another physician's service.
    Response: The commenter is incorrect. Medicare will pay separately 
for the administration of these vaccines and other physicians' services 
on the same day.

(D) Utilization Data

    Medicare utilization is an important data source used in 
determining the practice expense RVUs. Our current policy has been to 
use the latest utilization data to develop each successive year's fully 
implemented practice expense RVUs during each year of the transition. 
While substituting the latest year's utilization data into the practice 
expense methodology generally made little difference on total Medicare 
payments per specialty, there has been a larger impact on services 
affected by the non-physician work pool. Based on suggestions made by 
specialty organizations, we proposed to use the CYs 1997 through 2000 
utilization data to develop the CY 2003 practice expense RVUs and not 
to update further the utilization data in this year's final rule

[[Page 79983]]

to incorporate the CY 2001 utilization data. Further, we proposed to 
continue using the CYs 1997 through 2000 utilization data in the 
practice expense methodology until we undertake the 5-year review of 
practice expense RVUs.
    Comment: We received comments both supporting and opposing use of 
multi-year utilization data in the practice expense methodology. The 
comments that ``applauded CMS's efforts to ensure the stability'' of 
the practice expense RVUs largely came from organizations affected by 
the non-physician work pool methodology. We also received support from 
specialties that are largely unaffected by the proposal because of its 
potential to provide more year-to-year stability in the practice 
expense RVUs. Other commenters indicated that use of new utilization 
data with a different ``mix'' of services produces unpredictable 
changes in RVUs even though resource costs have not changed. There were 
comments that indicated use of multi-year utilization data will restore 
the unanticipated and extraordinary reductions experienced by 
diagnostic imaging centers in CY 2002. These commenters urged that we 
adopt our proposal in the final rule. One comment stated that 
``utilization data adjustments should not change annually until the 
[non-physician work pool] is eliminated and/or CMS undertakes the 5-
year review of practice expense RVUs.''
    One commenter stated that it is unclear whether the multi-year 
utilization will be used to develop practice expense RVUs for all 
services or only those in the non-physician work pool. Another 
commenter stated it is difficult to assess the impact of the proposal 
and urged the agency ``not to make such a change, at least until it has 
conducted extensive impact comparisons'' that can be evaluated by 
physicians and other stakeholders. Other commenters suggested that we 
should not update the practice expense methodology with new utilization 
data without giving an opportunity for public notice and comment. A 
number of commenters argued that application of a 10-percent payment 
reduction in CY 1998 and the per beneficiary per facility payment cap 
of $1500 cap in CY 1999 (in settings other than outpatient hospital 
departments) make utilization data unreliable for therapy services 
during the CYs 1997 through 2000 period. Commenters also noted that 
outpatient physical and occupational therapy services provided in 
facility settings were paid under cost-based reimbursement before CY 
1999. The commenters questioned the accuracy of the utilization data 
for Part B therapy services from CYs 1997 through 2000 and suggested 
that the utilization data during this period would be biased by the 
implementation of policy changes. One commenter recommended that we use 
the most current available data as the base for examining therapy 
utilization and should commit to an annual review of the data until it 
can be established that a longer time horizon accurately reflects 
utilization. Other comments requested clarification of how we use data 
from this period for physical and occupational therapy.
    Response: With respect to therapy services, we do not use claims of 
institutional providers (rehabilitation agencies and comprehensive 
outpatient rehabilitation facilities) in developing payment rates for 
therapy services paid using the physician fee schedule. We only use the 
claims for therapy services from physical and occupational therapists 
in private practice. The proposal was intended to apply to all 
physician fee schedule services, not just those in the non-physician 
work pool. We are finalizing our proposal to use the CYs 1997 through 
2000 utilization data to develop the practice expense RVUs for all 
services. However, we believe the comments raise important issues about 
policy changes that were occurring from CYs 1997 through 2000 that 
could lead to changes in utilization patterns during this time. We may 
analyze this issue further. In the interim, we welcome public comment 
about using the latest utilization data in the practice expense 
methodology.

(E) Site of Service

    As part of our resource-based practice expense methodology, we make 
a distinction between the practice expense RVUs for the non-facility 
and the facility setting. This distinction is needed because of the 
higher resource costs to the physician in the non-facility setting 
where the practitioner typically bears the cost of the resources 
associated with the service. In addition, the distinction ensures that 
we do not make a duplicate payment for any of the practice expenses 
incurred in performing a service for a Medicare beneficiary. Currently, 
we have designated only hospitals, skilled nursing facilities (SNFs), 
and community mental health centers (CMHCs) as facilities for purposes 
of calculating practice expense. An ambulatory surgical center (ASC) is 
designated as a facility if it is the place of service for a procedure 
on the ASC list. All other places of service are currently considered 
non-facility.
    We proposed site-of-service designations for several new places of 
service as well as revisions to the site-of-service designation for 
several existing places of service. We proposed to assign a facility 
site-of-service when a facility or other payment will be made, in 
addition to the physician fee schedule payment to the practitioner, to 
reflect the practice expenses incurred in providing a service to a 
Medicare patient. We proposed to designate all other places of service 
as non-facilities.
    The following lists the place of service numerical code, the place 
of service and the proposed site of service designations:

04 Homeless Shelter--Non-facility
15 Mobile Unit--Non-facility, however, if a mobile unit provides a 
service to a facility patient, the appropriate place-of-service code 
for the facility should be used.)
20 Urgent Care Facility--Non-facility
26 Military Treatment Facility--Facility
41 Ambulance-Land--Facility
42 Ambulance Air or Water--Facility
52 Psychiatric Facility Partial Hospitalization--Facility
56 Psychiatric Residential Treatment Facility--Facility (NOTE: the 
chart included in the June 28, 2002 proposed rule at 67 FR 43854 
incorrectly listed this as ``NF''--nonfacility)

    We would also clarify two items in the chart published at 67 FR 
43854:

61 Comprehensive Inpatient Rehabilitation Facility was listed as a non-
facility. This is currently considered a facility setting and we did 
not propose changing this designation. The reference to non-facility 
was in error.

    We also made reference to four place of service codes for Indian 
Health Service and Tribal 638 facilities and clinics. We were 
considering these place of service codes to implement section 432 of 
the BIPA that authorizes physician fee schedule payments to Indian 
Health Service and Tribal 638 facilities and clinics. At this time, we 
do not believe these place of service codes will be needed for 
implementation of these provisions and do not expect them to be in use. 
We are implementing section 432 of BIPA by using specialty codes, not 
place of service codes to identify HIS providers.
    Comment: One organization expressed appreciation for our efforts to 
update the list and had no comments. Others commented requesting 
clarification of site-of-service designations for the provision of Part 
B therapy services in nursing facilities. One commenter expressed 
particular concern about the use of place of service

[[Page 79984]]

code 32 (Nursing facility) in conjunction with outpatient therapy 
services in nursing facilities. This commenter suggested we reiterate 
in the final rule the current policy that fee schedule payments for 
Part B therapy services delivered in a nursing home are classified as 
``non-facility.'' They also suggested we redefine ``site-of-service'' 
for physicians services to non-Part A patients in nursing centers as 
``non-facility,'' thereby applying the higher PERVUs to those services. 
We received one comment from a carrier medical director that indicated 
that physician practice costs for treating patients in skilled nursing 
facilities (POS 31) and nursing facilities (POS 32) are the same and 
that both should be designated as either facility or non-facility. This 
comment also suggested deleting the POS 32 designation (NH), or 
changing its meaning to a ``SNF or NF stay not covered by Medicare.'' A 
physician who practices in nursing facilities also argued that our 
current policy makes no sense because physician practice costs are the 
same regardless of whether Medicare makes a payment to the SNF for 
institutional services. This physician would like us to pay at the 
higher non-facility rate for physicians' services in both entities, but 
acknowledged that using the lower facility rate would be more 
consistent with the practice expense methodology.
    Response: We regret any ambiguity or concern that we may have 
created in our proposed rule. In general, for purposes of the physician 
fee schedule, we will consider a site to be a facility if the site also 
receives a Medicare payment for institutional services (that is, a 
payment under the inpatient prospective payment system (PPS), 
outpatient PPS, and SNF PPS). Thus, since there is a payment for 
institutional services to a hospital when a beneficiary receives care 
in an inpatient or outpatient setting, we consider the site to be a 
facility site and make a payment under the physician fee schedule using 
the facility rate. For entities other than those that receive a payment 
for institutional services, we consider the site a non-facility site 
and pay under the physician fee schedule using the higher non-facility 
rate. However, there are special provisions with respect to outpatient 
physical and occupational therapy services. These services are paid 
under the physician fee schedule even when provided in institutional 
sites like skilled nursing facilities. For this reason, for these 
services we calculate only a non-facility rate. Since there is no 
facility payment under Medicare, we use a non-facility rate to 
determine payment.
    Place of service code 32--Nursing facility--was designated as non-
facility in our June 2002 proposed rule. Place of service code 31--
Skilled nursing facility--is designated as facility. We have instructed 
physicians to use place of service code 31 for patients who are in an 
inpatient stay in a skilled nursing facility. Since Medicare is making 
a payment for institutional services that includes compensation for 
staff, supplies, and equipment, we are paying physicians using the 
lower facility rate when place of service code 31 is used. If the 
patient exhausts eligibility for SNF benefits and Medicare is no longer 
making payment to the SNF for institutional services, we have 
instructed physicians to use place of service code 32--Nursing 
facility, to allow Medicare to provide compensation to the physician 
for the costs of staff, supplies and equipment that would otherwise not 
be included in our payment. However, since it may be burdensome to the 
physician to determine when a patient is entitled to SNF Part A 
benefits, we always allow the physician to use place of service 31 and 
receive the lower facility payment for physicians' services.
    While we acknowledge the arguments of those who have written and 
contacted us both prior to and as part of the rulemaking process, we 
are reluctant to make any further changes in our policy at this time. 
We believe existing policy is equitable in that it does not overly 
burden physicians to have to determine whether a patient is in a Part A 
SNF inpatient stay. Physicians can always bill using place of service 
code 31 and be paid at the facility rate. Further, we allow use of 
place of service code 32 and our payment will be at the higher non-
facility rate that includes compensation for staff, equipment, and 
supplies that would not otherwise be paid since there is no payment for 
the institutional services. In response to the request that we change 
the nomenclature describing place of service code 32, we will consider 
this further as updates are made to place of service coding. However, 
we note that Medicaid uses the place of service codes as well and the 
needs of this program will also need to be considered.
    Comment: One commenter suggested the descriptor for place of 
service code 23, ``emergency room-hospital,'' should be changed to 
``emergency department.''
    Response: We will consider this comment when further updates are 
made to place of service codes.
    Comment: One commenter expressed concern about the proposed 
designation change of site of service from non-facility to facility for 
both psychiatric facility partial hospitalization and psychiatric 
residential treatment facility. The commenter felt this would 
negatively impact physician reimbursement and could provide 
disincentive for psychiatrists to treat patients in these settings.
    Response: By developing practice expense RVUs that differ by site, 
we intend to reflect the relativity of resource costs incurred by 
physicians between sites. Our policies are not intended to provide 
financial incentives for a physician to select one site over another. 
Physicians should make these decisions based on the clinical needs of 
the patient. We believe that both psychiatric residential treatment 
facilities and psychiatric partial hospitalization programs are 
institutional sites that provide staff, equipment and supplies used in 
providing medical services and physicians will not incur these resource 
costs when providing services in these settings.

(F). Other Practice Expense Issues

(1) Budget Neutrality

    We received several comments suggesting that budget neutrality for 
changes in practice expense RVUs be applied to the physician fee 
schedule conversion factor. The comments indicated that payment for CPT 
codes with significant practice expense RVUs are reduced when there are 
aggregate increases in work RVUs but services that are predominantly 
composed of work RVUs are not significantly affected by aggregate 
increases in practice expense RVUs. According to the comments, such a 
modification would ``help assure more year-to-year stability in the 
practice expense RVUs.'' Since affected professional groups have not 
had an opportunity to consider and comment on this important issue, one 
comment suggests that we include this issue in the proposed notice for 
the CY 2004 physician fee schedule.
    Response: We will consider this idea for the future.

(2) Computerized Tomographic Angiography

    Comment: We received a number of comments about Computed 
Tomographic Angiography (CTA). The comments indicated that, before CY 
2001, CTA services were billed as a CT scan of an anatomical region 
plus an add-on code for 3-D image reconstruction. New codes 
specifically for CTA that incorporated the image reconstruction were 
developed for use

[[Page 79985]]

in 2001. The comments indicated that the TC RVUs for CTA established in 
the November 1, 2000 final rule appear as though they were calculated 
by cross-walking the RVUs from the anatomically analogous existing CT 
procedure codes without accounting for the 3-D image reconstruction.
    Response: Based on this comment, we have adjusted the current CTA 
codes to incorporate image reconstruction.

(3) TC for Cardiac Catheterization

    Comment: We received several comments that noted the TC RVU for 
cardiac catheterization declined in the notice of proposed rulemaking 
even though the codes are included in the non-physician work pool. 
These comments noted that the practice expense RVUs for all other non-
physician work pool services increased in the proposed rule. One 
comment expressed concern over our proposal to derive the TC RVU from 
the global RVU service. The comment indicated that we currently have no 
direct cost inputs for these services and it is unlikely that the PEAC 
will be able to provide them since cardiac catheterization is generally 
provided in hospital settings. According to the commenter, there are 
only 80-100 non-hospital facilities that provide cardiac 
catheterization services. It is unlikely that we will have physician 
survey information that reflects the costs of these providers since 
they normally bill for the TC service and not the global service. The 
comment stated the cardiologist normally bills independently for 
professional services.
    Response: We have addressed the comment regarding the TC for the 
cardiac catheterization. The TC RVUs for these services are changing by 
the same percentage as all other non-physician work pool services. We 
understand that the PEAC may consider providing inputs for cardiac 
catheterization services. This will address one aspect of the 
commenter's concern. With respect to valid SMS data for cardiac 
catheterization services, we will consider this issue along with others 
as we address issues related to the non-physician work pool in CY 2003.

B. Anesthesia Issues

1. Five-Year Review of Anesthesia Work
    Section 1848(b)(2)(B) of the Act indicates that, to the extent 
practicable, we will use the anesthesia relative value guide with 
appropriate adjustment of the anesthesia conversion factor (CF) in a 
manner to assure that the fee schedule amounts for anesthesia services 
are consistent with the fee schedule amounts for other services. The 
statute also requires us to adjust the CF by geographic adjustment 
factors in the same manner as for other physician fee schedule 
services. Unlike other physician fee schedule services, anesthesia 
services are paid using a system of base and time units. The base and 
time units are summed and multiplied by a CF. The base unit is fixed 
depending on the type of anesthesia procedure performed, and the time 
units vary based on the length of the anesthesia time associated with 
the surgical procedure. Thus, our payment will increase as anesthesia 
time lengthens. The same anesthesia service provided in two different 
surgeries will be paid different amounts if the associated anesthesia 
time is different. This system differs from other physician fee 
schedule services for which RVUs for physician work, practice expense, 
and malpractice are summed and multiplied by a CF to determine payment. 
Payment for these non-anesthesia procedures will not vary based on the 
length of time it takes to perform the procedure in a specific 
instance.
    In the June 2002 proposed rule (67 FR 43855) we explained that the 
law requires that we review RVUs no less often than every 5 years. 
There is a fundamental difference in how the 5-year review applies to 
anesthesia services versus medical and surgical services. In general, 
for medical and surgical services, the relevant physician specialty 
society and the AMA's RUC review the current and proposed work RVUs on 
a code-by-code basis. The RUC will make recommendations to us on work 
values for specific codes and, if we accept or modify them, the new 
physician work RVUs will be used to determine payment. However, each 
anesthesia service does not have a work RVU. Therefore, adjustments for 
anesthesia work (and practice expense) are made to the anesthesia CF 
and payment for all anesthesia services is affected.
    The second 5-year review (with the exception of anesthesia 
services) was completed and revised work RVUs were implemented in 2002. 
For the second 5-year review, the American Society of Anesthesiologists 
(ASA) contended that the work of anesthesia services remained 
undervalued by almost 31 percent. They subsequently argued for a 26 
percent increase in work RVUs based on additional discussions with the 
RUC. More recently, based on their further analysis and discussion with 
the RUC, the ASA asked for a 13.6 percent increase in work.
    The ASA derived a work value for an anesthesia code by dividing the 
anesthesia service into five uniform components. The five components 
are preoperative evaluation, equipment and supply preparation, 
induction period, postinduction period, and postoperative care and 
visits. These components were assigned work RVUs based on a comparison 
to non-anesthesia services paid under the physician fee schedule. The 
work of these components is then summed. Using this method, the ASA 
proposed new work values for 19 high volume anesthesia codes. These 
work values can be compared to imputed work values derived from current 
anesthesia payments for these services.
    Under the CPT coding system, anesthesia for various common surgical 
procedures is reported under a single anesthesia code. For example, CPT 
code 00790 is used to report anesthesia for over 250 intraperitoneal 
procedures in the upper abdomen.
    The ASA studied one surgical procedure for each of the anesthesia 
codes. The 19 codes represent a range of surgical procedure types, 
including general surgery, vascular surgery, neurosurgery, urology, 
orthopedics, cardiac surgery, and ophthalmology. The 19 procedures 
reviewed account for about 35 percent of Medicare allowed charges for 
anesthesia services.
    During the second 5-year review of work, several RUC workgroups 
reviewed the ASA comments and received supplemental information from 
them through presentations. Most of these workgroups expressed concerns 
about some of the work intensity values the ASA assigned to the 
individual anesthesia components, most notably, the induction and post 
induction time periods. For about 50 percent of the codes, the RUC was 
confident that the anesthesia work value of the surveyed service was 
similar to the anesthesia work values for all of the other surgical 
services assigned to the given anesthesia code. For the remaining 
codes, the RUC was not confident that the work values of the surveyed 
code could be applied to other anesthesia services that would be 
reported under that anesthesia code.
    The workgroups also expressed concern about extrapolating the 
results from the 19 surveyed codes to all anesthesia services. At its 
April 2002 meeting, the final meeting addressing anesthesia work values 
for the second 5-year review, the RUC concluded it was unable to make a 
recommendation regarding modification to the physician work values for 
anesthesia services. Specifically, the RUC stated:
    The RUC, having carefully considered the information presented, and 
having a

[[Page 79986]]

reasonable level of confidence in the data, which was presented and 
developed by the ASA, is unable to make a recommendation to CMS 
regarding modification to the physician work valuation of anesthesia 
services.
    While the RUC did not make a recommendation to us regarding 
extrapolation, it forwarded its analysis to us for review.
    In the June 2002 proposed rule (67 FR 43856), we indicated our 
intent to review the information forwarded by the RUC and all comments 
we received during the comment period.
    Comment: The ASA commented that, based on work values accepted by 
the RUC anesthesia workgroup, the final RUC data show that anesthesia 
services are undervalued by a weighted average of 13.57 percent. The 
ASA urged us to adjust the anesthesia CF accordingly. The American 
Association of Nurse Anesthetists (AANA) endorsed the ASA's comments 
and provided similar comments. Several certified registered nurse 
anesthetists and anesthesiologists also wrote in support of an increase 
in the anesthesia CF. We also received several comments alleging that 
the ratio of Medicare payment to private payer payments for anesthesia 
services is considerably less than the analogous ratio for medical and 
surgical services.
    Response: The ASA and the AANA have requested that we apply the 
RUC's analysis of the 19 codes to all anesthesia codes. They believe 
that the weighted average increase in anesthesia work values that 
results from the RUC's analysis is representative of work values for 
all other anesthesia codes.
    For some codes, the RUC seemed confident that the anesthesia work 
value of the surveyed code was similar to the anesthesia work values 
for all of the other surgical services assigned to the given anesthesia 
code. However, for almost half of the surveyed codes, the RUC did not 
have confidence that the work values of the surveyed code could be 
applied to any other anesthesia services that would be reported under 
that anesthesia code.
    Due to the uncertainty of the RUC with regard to extrapolation, 
even within the family of surgical procedures assigned to a single 
anesthesia code, we have weighted each of the 19 anesthesia codes only 
by the anesthesia allowed charges associated with the single surveyed 
surgical procedure. Using this methodology, anesthesia for the surveyed 
surgical codes account for approximately 23 percent of all anesthesia 
allowed charges. This results in an increase in anesthesia work for the 
19 codes of 9.13 percent. However, because we will apply a payment 
increase only to these codes, we are increasing the physician work 
portion of the anesthesia conversion factor by 2.10 percent which 
reflects a 9.13 percent increase in payment applied to the 23 percent 
of total anesthesia charges represented by the 19 codes. We provide 
more detail on how this increase is applied to the anesthesia 
conversion factor in the section VIII of this final rule.

Final Decision

    We are increasing the physician work component of the anesthesia 
conversion factor by 2.10 percent to reflect a 9.13 percent increase in 
payment applied to 23 percent of anesthesia allowed charges. This as an 
interim adjustment that is subject to comment.
2. Add-On Anesthesia Codes
    Payment for anesthesia services is based on the sum of an 
anesthesia code-specific base unit value plus anesthesia time units 
multiplied by an anesthesia CF. Under our current policy at Sec.  
414.46(g), if the physician is involved in multiple anesthesia services 
for the same patient during the same operative session, payment is 
based on the base unit assigned to the anesthesia service having the 
highest base unit value and anesthesia time that encompasses the 
multiple services.
    Claims processing manuals instruct the carrier on the method for 
handling anesthesia associated with multiple or bilateral surgical 
procedures. Under the Medicare Carrier Manual (MCM) 4830 D, the 
physician reports the anesthesia procedure with the highest base unit 
value with the multiple procedures modifier-51 and total time of 
anesthesia for all surgical procedures. Thus, the carrier is 
recognizing payment for one anesthesia code.
    In CYs 2001 and 2002, the CPT included new add-on anesthesia codes. 
The objective is that the add-on code would be billed with a primary 
code, each code having base units. We believe that anesthesia add-on 
codes should be priced differently from other multiple anesthesia 
codes. We proposed to revise the regulations at Sec.  414.46(g) to 
include an exception to the usual multiple anesthesia services policy 
for add-on codes.
    Comment: The ASA, AANA and the AMA expressed support for our 
adopting a payment policy for add-on anesthesia codes. The ASA asked 
that we clarify the policy for recognition of base or time units or 
both for add-on anesthesia codes.
    Response: Of the 259 anesthesia codes, there are two codes, called 
primary codes that may have add on codes, under certain circumstances. 
These are:

Primary code: CPT code 01967
Add-on code: CPT code 01968 or 01969
Primary code: CPT code 01952
Add-on code: CPT code 01953

    Based on comments received, we understand that the ASA is seeking 
to bill only the base unit of the add-on code (01953) when it is billed 
with the primary code 01952. The time of the add-on code is to be 
included in the time of the primary code. Thus, all anesthesia time is 
attributable to the primary code.
    The ASA is seeking to bill both the base and time of the add-on 
code, 01968 or 01969, when either is billed with the primary code 
01967. Thus, the anesthesia provider would report the base and time 
units of both the primary and the add-on code.
    We recognize that the general policy for add-on codes is that the 
carrier should allow only the base unit of the add-on code. As with 
multiple anesthesia services, the anesthesia time of the add-on code 
would be reported with the time of the primary code. In other words, 
anesthesia time is reported for all the underlying surgical services.
    However, in discussions with the ASA, we have learned that many 
third party payors have more restrictive time units policies for 
obstetrical anesthesia codes than for other anesthesia codes. If the 
time of the add-on code, such as 01968 or 01969, were reported with the 
primary code, the time units of the add-on code might be undervalued. 
To prevent this result, we are requiring that (for the two obstetrical 
anesthesia add-on codes) the anesthesia time be separately reported 
with each of the primary and the add-on code based on the amount of 
time appropriately associated with either code.
    Further, we think the policy on multiple procedure codes as well as 
add-on codes is an operational policy and should be addressed only in 
program operating instructions. As a result, we are revising the 
regulation text at Sec.  414.46(g) accordingly.

Final Decision

    We are allowing the carriers to recognize the base unit of the add-
on codes. However, for the obstetrical add-on codes, the carrier may 
recognize both the base unit and the anesthesia time associated with 
the add-on code.

C. Pricing of Technical Components (TC) for Positron Emission 
Tomography (PET) Scans

    Currently, all components of HCPCS code G0125, Lung image PET scan, 
are

[[Page 79987]]

nationally priced. However, the TC and the global value for all other 
PET scans are carrier-priced. To keep pricing consistent with other PET 
scans, we proposed to have carriers price the TC and global values of 
HCPCS code G0125.
    Comment: We received comments from one specialty organization in 
support of carrier pricing. We received comments from another specialty 
organization and a few providers stating that they were concerned that, 
contrary to our stated purpose, this change would lead to inconsistent 
payment by carriers. The commenters believe that some carriers use the 
nationally-established TC RVUs for G0125 as a reference for payment for 
the other PET scans.
    Response: While we understand the commenter's concerns, we believe 
the RVUs assigned before CY 2003 for the TC of G0125 do not accurately 
reflect the resources used for furnishing this service, which is why we 
proposed carrier pricing. Thus, using G0125 as a reference code for 
pricing could lead to inappropriate pricing for all services. We 
believe that adopting carrier-pricing, instead of a national fee 
schedule amount, for the TC of G0125 will result in more appropriate 
pricing for the TC of all PET scans. Carriers have a variety of methods 
that they use to establish payment for codes. We believe using some of 
these alternative methods will lead to more accurate pricing for this 
service.

Final Decision

    We will finalize our proposal to allow carriers to price the TC and 
global values of code G0125.

D. Enrollment of Physical and Occupational Therapists as Therapists in 
Private Practice

    In the November 2, 1998 final rule (63 FR 58814), we defined 
private practice for physical therapists (PTs) or occupational 
therapists (OTs) to include a therapist whose practice is in an--
    [sbull] Unincorporated solo practice;
    [sbull] Unincorporated partnership; or
    [sbull] Unincorporated group practice.
    The term ``private practice'' also includes an individual who is 
furnishing therapy services as an employee of one of the above, a 
professional corporation, or other incorporated therapy practice. Some 
carriers and fiscal intermediaries have interpreted the regulation to 
mean that OTs and PTs employed by physicians cannot be enrolled as 
therapists in private practice. In these carrier areas, therapy 
services provided in a physician's office must instead be billed as 
incident to a physician's service.
    A specialty society representing OTs has requested that carriers be 
able to enroll OTs in physician-directed groups as OTs in private 
practice. A group representing PTs believes that provider numbers 
should be issued only to PTs working as employees in practices owned 
and operated by therapists.
    We proposed to clarify national policy and revise Sec. Sec.  410.59 
and 410.60 to state we would allow enrollment of therapists as PTs or 
OTs in private practice when employed by physician groups. We believe 
that this reflects actual practice patterns, will permit more flexible 
employment opportunities for therapists and will also increase 
beneficiaries' access to therapy services, particularly in rural areas.
    Comments: We received many comments from associations, specialty 
groups, therapists, and the public that strongly support the proposed 
clarification that would allow carriers and fiscal intermediaries to 
enroll therapists as PTs or OTs in private practice when they are 
employed by physician groups. However, one association urged us to 
confirm that this policy extends to therapists employed by a non-
professional corporation.
    Response: We agree and will change the regulation to reflect that 
carriers and fiscal intermediaries can enroll therapists as PTs or OTs 
in private practice when the therapist is employed by physician groups 
or groups that are not professional corporations, if allowed by State 
law.
    Comments: Several commenters suggested that we state clearly that 
carriers and fiscal intermediaries are required to enroll physician-
employed therapists, who are otherwise qualified, and that carriers and 
fiscal intermediaries may not refuse to enroll therapists simply on the 
basis of employment. They requested that the regulation state 
specifically that Medicare contractors must enroll therapists as PTs or 
OTs in private practice when they are employed or under contractual 
relationships with physician groups or groups that are not professional 
corporations.
    Response: We agree and will change the Medicare Carriers and Fiscal 
Intermediaries Manuals' to reflect that carriers and fiscal 
intermediaries ``will'' enroll Medicare therapists as PTs or OTs in 
private practice for purposes of Medicare when the therapists are 
employed by physician groups or groups that are not professional 
corporations. However, we do not believe that we need to specify 
further employee-employer relationships, which are detailed in the 
Medicare Carriers Manual, Part 3, Chapter III.
    Comment: One commenter believed that we should not enroll PTs who 
are employees of physicians' offices as PTs or OTs in private practice 
but, instead, should establish a separate section of the regulations 
that would govern the issuance of provider numbers to PTs who are 
employees in physicians' offices, and give these therapists a different 
designation. The commenter suggested we also include protections that 
currently exist when a non-physician practitioner provides services in 
a physician's office and the physician bills for these services under 
the physician's Medicare provider number.
    Response: We disagree with this comment. We have established 
procedures for issuing provider numbers that we believe are adequate. 
The proposed changes to the regulations reflect actual practice 
patterns, will permit more flexible employment opportunities for all 
therapists, and also increase beneficiary access to therapy services, 
particularly in rural areas. Therapists still have the flexibility of 
providing outpatient therapy services incident to a physicians service 
if they so choose. However, the services must meet the incident to 
requirements at Sec.  410.26.

Final Decision

    We will finalize our proposal to revise Sec. Sec.  410.59 and 
410.60 with the modifications noted above.

E. Clinical Social Worker Services

    In the June 28, 2002 proposed rule, (67 FR 43846), we indicated we 
would be addressing comments received on the October 19, 2000 proposed 
rule entitled, ``Clinical Social Worker Services,'' (65 FR 62681), in 
this final rule. Upon further review, we have determined that we will 
not include this issue in this final rule, but will address it in 
future rulemaking.

F. Medicare Qualifications For Clinical Nurse Specialists

    Currently, the qualifications for a clinical nurse specialist (CNS) 
include a requirement that a CNS must be certified by the American 
Nurses Credentialing Center (ANCC). We proposed to revise this 
particular requirement under the CNS qualifications because of concerns 
expressed that the ANCC does not provide certification for CNSs who 
specialize in fields such as oncology, critical care, and 
rehabilitation. Additionally, we noted that the proposed revision of 
the certification requirement for CNSs is consistent with

[[Page 79988]]

the certification requirement under the nurse practitioner (NP) 
qualifications. Accordingly, we proposed specifically to revise section 
Sec.  410.76(b)(3) to read as follows:
    ``Be certified as a clinical nurse specialist by a national 
certifying body that has established standards for clinical nurse 
specialists and that is approved by the Secretary.''
Comments and Responses
    We received comments on the proposed revision to the CNS 
certification requirement from professional nursing societies, a 
specialty nursing certification corporation, a college of radiology, a 
major nurses association, a provider of health care and elder care and, 
several independent clinical nurse specialists.
    Comment: We received comments indicating that the current CNS 
certification requirement poses a serious threat to ensuring Medicare 
beneficiary access to quality care because it restricts CNSs who are 
not certified by the ANCC from qualifying for Medicare payment. The 
ANCC does not certify CNSs in oncology, rehabilitation, acute care or 
critical care. Since the current CNS certification requirement 
inherently precludes CNSs who are certified in oncology from Medicare 
payment, the number of nurses available to care for Medicare 
beneficiaries with cancer is limited. The proposed change to the CNS 
qualifications is more inclusive, and it will enable the 415 oncology 
CNSs who hold Advanced Oncology Nursing Certification (AOCN) provided 
by the Oncology Nursing Certification Corporation (ONCC) to meet the 
certification criteria for CNSs and therefore, qualify for Medicare 
payment. An independent CNS stated that as a palliative care CNS, her 
institution required advanced certification that is not offered by the 
ANCC in many specialty areas of practice. However, the American Board 
of Nursing Specialties is the credentialing board for the ONCC, which 
is the only national certification that an advanced practice nurse can 
obtain specific to his or her field of expertise. All of the commenters 
support the proposed revision to the CNS certification requirement 
because they stated that overall, the certification criteria for CNSs 
will be consistent with the certification criteria for NPs and the 
requirement will ensure that Medicare beneficiaries receive services 
from advanced practice nurses who are certified by a national 
certifying body.
    Response: It has not been our intention to be overly restrictive in 
our program requirements and consequently prevent qualified CNSs who 
specialize in areas of medicine other than those certified by the ANCC 
from participating under the Medicare program's CNS benefit and 
rendering care to patients in need of specialized services. The intent 
of the revised CNS certification requirement is to recognize all 
appropriate national certifying bodies for CNSs as the program does for 
NPs.
Result of Evaluation of Comments
    We are implementing the proposed revision to the CNS certification 
requirement under the CNS qualifications at Sec.  410.76.

G. Process To Add or Delete Services to the Definition of Telehealth

    In the June 2002 proposed rule (67 FR 43862), we proposed to 
establish a process for adding or deleting services from the list of 
telehealth services, and to add specific services to the list of 
telehealth services for CY 2003.
    We stated that we would accept proposals from any interested 
individuals or organizations from either the public or the private 
sectors, for example, from medical specialty societies, individual 
physicians or practitioners, hospitals, and State or Federal agencies. 
We also mentioned that we might internally generate proposals for 
additions or deletions of services.
    We stated that we would post instructions on our website outlining 
the steps necessary to submit a proposal. Please see the June 2002 
proposed rule for the items that were to be addressed, the assignment 
of categories, and the outcomes.
    We proposed to remove a service from the telehealth list of 
services if, upon review of the available evidence, we determine that a 
telehealth service is not safe, effective, or medically beneficial when 
performed as a telehealth service.
    We proposed to make additions or deletions to the list of 
telehealth services effective on a CY basis. We proposed to use the 
annual physician fee schedule proposed rule published in the summer and 
the final rule published by November 1 each year as the vehicle for 
making these changes. Requests must be received no later than December 
31 of each CY to be considered for the next proposed rule.
    Based upon further review of the comments submitted in response to 
the proposed rule for CY 2002, we believe that the psychiatric 
diagnostic interview is similar to the telehealth services listed in 
the statute. Specifically, we believe this service would meet the 
criteria set forth in Category 1 of the proposed process for adding 
services. Therefore, we proposed to add psychiatric diagnostic 
interview examination as represented by CPT code 90801 to the list of 
telehealth services and proposed to revise Sec. Sec.  410.78 and 414.65 
to reflect the proposed addition to the list of telehealth services.
    Comment: We received many comments expressing support for our 
proposed process for adding and deleting telehealth services. The 
commenters indicated that our proposed criteria for reviewing submitted 
requests are reasonable and provide a viable mechanism for adding 
existing services to the list of telehealth services. However, as part 
of our review, one specialty college suggested that the CPT editorial 
panel be an integral part of our process. The commenter stressed that 
reviewing codes and determining how these services can be furnished is 
the CPT editorial panel's area of expertise. With regard to deletion of 
services, one association urged us to consult with the appropriate 
medical society members to obtain clinical evidence based on peer-
reviewed information and medical journal articles before deleting 
services from the list of telehealth services.
    Response: Section 1834(m) of the Act requires us to develop a 
process specifically for adding or deleting telehealth services on an 
annual basis. The mandate for this statutory provision is separate and 
distinct from the role of the AMA CPT editorial panels in developing 
new codes and/or defining services for the CPT compendia. It would not 
be appropriate to make the CPT editorial panel an integral part of the 
process to add or delete services from the list of telehealth services. 
We will review submitted requests for addition and deletion based on 
the criteria discussed in this final rule and welcome input from 
medical professionals with expertise in the service being reviewed as 
part of the rulemaking process.
    We are clarifying from the proposed rule that a decision to remove 
a service from the list of telehealth services would be made using 
evidence-based, peer-reviewed data which indicate that a specific 
telehealth service is not safe, effective, or medically beneficial. 
Such determination would not be made under section 1862(a)(1)(A) of the 
Act. Therefore, a decision to delete a service under this process would 
only apply to the list of Medicare telehealth services.
    Comment: One commenter suggested that we publish a summary of any 
requests that are rejected.
    Response: As stated in the proposed rule, we will use the annual 
physician fee schedule as a vehicle to make changes to the list of 
telehealth services.

[[Page 79989]]

As part of the rulemaking process, we will publish a summary in the 
proposed rule of the requests that we receive with an explanation as to 
why a service is added, deleted, or a request is rejected.
    Comment: One commenter requested that, if possible, we look for 
ways to shorten the time frame between the submittal of a request and 
the actual implementation. The commenter stated that actual 
implementation of an additional telehealth service could take a year or 
more from the date of the request.
    Response: The statute requires us to establish a process that 
provides for the addition or deletion of telehealth services on an 
annual basis. We understand that in some cases our review and 
subsequent implementation of a decision to accept a request may take up 
to and possibly more than a full year. However, we believe that using 
the annual physician fee schedule rulemaking schedule would be the most 
efficient and time sensitive mechanism for publishing changes to the 
list of telehealth services.
    A national coverage determination (NCD) is a possible alternative 
to the rulemaking process for adding or deleting telehealth services. 
In formulating the proposed process to add services to the list of 
telehealth services, we considered using the NCD process. For instance, 
under this option, all requests for addition, whether the request is 
considered an existing or new service, would be required to complete 
the requirements for an NCD. We rejected this option because we believe 
that many telehealth applications are existing services provided 
through a different delivery mechanism. We believe that subjecting all 
requests for addition to the evidence-based requirements of an NCD 
would be unnecessary, and would be contrary to the public interest.
    Comment: A large number of commenters applauded the addition of the 
psychiatric diagnostic interview examination to the list of telehealth 
services. Commenters generally agreed that the psychiatric diagnostic 
interview includes components that are comparable to an initial office 
visit or consultation, which are currently telehealth services.
    Response: We agree with the comment.
    Comment: We received two comments regarding general telehealth 
policy. One commenter urged us to expand the definition of an 
originating site. For example, the commenter believes that hospitals 
with inadequate physician ratios relative to the treatment of acute 
ischemic stroke patients should be considered as an originating site, 
regardless of geographic location or whether the hospital is located in 
a designated health professional shortage area. The other comment 
pertained to the physician or practitioner who provides the telehealth 
service at the distant site. In this regard, one association encouraged 
us to support the addition of speech language pathologists and 
audiologists to the list of practitioners that may provide and receive 
payment for telehealth services.
    Response: The statute permits hospitals to serve as originating 
sites for any Medicare telehealth service as long as the hospital is 
located in a rural HPSA or in a non-MSA county. Thus, the commenter 
would be able to serve as an originating site for the treatment of 
acute ischemic stroke patients if the hospital is located in these 
geographic areas. The statute is explicit regarding the types of 
practitioners who can provide and receive payment for telehealth 
services. Speech language pathologists and audiologists are not 
included within the list of medical professionals that may provide and 
or receive payment for telehealth services at the distant site. We are 
reviewing these issues as part of a report to the Congress as required 
by the BIPA.
Result of Evaluation of Comments
    We are adopting the process to add or delete telehealth services 
and adding the psychiatric diagnostic interview examination to the list 
of telehealth services as stated in the proposed rule. Additionally, we 
are referencing the process to add or delete services at new Sec.  
410.78(f).

H. Definition for ZZZ Global Periods

    Services with ZZZ global periods are add-on services that can be 
billed only with another service. Before CY 2003, we paid only the 
incremental intraservice work and practice expense RVUs associated with 
the add-on service for a code with a global indicator of ZZZ. Any pre-
service or post-service work associated with a service with a global 
indicator of ZZZ is considered accounted for in the base procedure with 
which these add-on services must be billed. However, based on comments 
from the RUC and specialty societies that some add-on services contain 
separately identifiable post-service work and practice expense RVUs, we 
proposed to revise the current definition of a ZZZ global period as 
follows:
    ``ZZZ = Code related to another service and is always included in 
the global period of the other service (Note: Physician work is 
associated with intra-service time and in some instances the post-
service time).''
    Comments: The commenters supported this change. However, several 
specialty organizations, as well as the RUC, stated that there are 
instances when pre-service time should be considered, and they 
recommended that we amend the definition to include pre- and post-
service time.
    Response: We agree with the commenters and will revise the 
definition to consider pre-service time as well post-service time. 
However, when a code with a ZZZ global indicator is considered by the 
RUC or PEAC, we will require that all base codes with which the ZZZ 
codes are billed are also considered by the RUC and PEAC to assure that 
both physician work and practice expense RVUs are appropriate for the 
base and add-on codes and to assure that no duplicate payment is made.
Result of Evaluation of Comments
    The definition of a ZZZ global period will be revised as follows:
    ``ZZZ = Code related to another service and is always included in 
the global period of the other service (Note: Physician work is 
associated with intra-service time and in some instances the pre- and 
post-service time).''

I. Change in Global Period for CPT Code 77789 (Surface Application of 
Radiation Source)

    Based on a suggestion from the RUC, we proposed to change the 
global period for CPT code 77789 (surface application of radiation 
source) from a 90-day global period to a 000-day global period. We 
stated that we did not need to adjust the current work values or the 
practice expense inputs for supplies and equipment, but we would adjust 
the clinical staff practice expense inputs to reflect that there is no 
post-procedure visit.
    Comment: The commenters supported this change and noted that the 
PEAC attributed clinical times for this CPT code of 34 minutes for the 
registered nurse and 6 minutes for the physicist. The commenters did 
not believe the practice expense RVUs should change significantly, if 
at all, as a result of this adjustment in the global period.
    Response: We had not received the PEAC recommendations at the time 
the proposed rule was written, and we proposed a change to the original 
CPEP inputs that included time for a post-procedure visit. We have 
reviewed and accepted the above PEAC recommended clinical staff times.

[[Page 79990]]

Result of Evaluation of Comments
    We are changing the global period for CPT code 77789 (surface 
application of radiation source) from a 90-day global period to a 000-
day global period as proposed.

J. Technical Change for Sec.  410.61(d)(1)(iii) Outpatient 
Rehabilitation Services

    Based on comments received that Sec.  410.61(d)(1)(iii) incorrectly 
references ``physical'' therapy when it should reference 
``occupational'' therapy, we proposed to revise Sec.  410.61(d)(1)(iii) 
to correct this error.

Final Decision

    No comments were received on this proposed technical correction. We 
will correct Sec.  410.61(d)(1)(iii) by replacing the word ``physical'' 
with ``occupational'' as proposed.

K. HCPCS G-Codes From June 28, 2002 Proposed Rule

    In the June 28, 2002 rule we proposed the following new HCPCS G 
codes.
1. Codes for Treatment of Peripheral Neuropathy
    Effective for services furnished on or after July 1, 2002, Medicare 
will cover an evaluation (examination and treatment) of the feet every 
six months for individuals with a documented diagnosis. This policy is 
a national coverage determination.
    G0245: Initial physician evaluation of a diabetic patient with 
diabetic sensory neuropathy resulting in a loss of protective sensation 
(LOPS) which must include the procedure used to diagnose LOPS; a 
patient history; and a physical examination that consists of at least 
the following elements--
    (a) Visual inspection of the forefoot, hindfoot and toe-web spaces;
    (b) Evaluation of protective sensation;
    (c) Evaluation of foot structure and biomechanics;
    (d) Evaluation of vascular status and skin integrity;
    (e) Evaluation and recommendation of footwear; and
    (f) Patient education.
    We proposed to crosswalk work and malpractice RVUs and the practice 
expense inputs from CPT code 99202, a level two, new patient office 
visit code. We proposed to revalue the practice expense RVUs using the 
practice expense methodology once we have utilization data for these 
codes.
    G0246: Follow-up evaluation of a diabetic patient with diabetic 
sensory neuropathy resulting in a loss of protective sensation (LOPS) 
to include at least the following, a patient history and physical 
examination that includes--
    (a) Visual inspection of the forefoot, hindfoot and toe-web spaces;
    (b) Evaluation of protective sensation;
    (c) Evaluation of foot structure and biomechanics;
    (d) Evaluation of vascular status and skin integrity;
    (e) Evaluation and recommendation of footwear; and
    (f) Patient education.
    We proposed to crosswalk the work and malpractice RVUs from CPT 
code 99212, a level two, established-patient office visit code. We also 
proposed to crosswalk the practice expense inputs from CPT code 99212 
and to revalue the practice expense RVUs using the practice expense 
methodology once we have utilization data for these codes.
    G0247: Routine foot care of a diabetic patient with diabetic 
sensory neuropathy resulting in a loss of protective sensation (LOPS) 
to include if present, at least the following--
    (a) Local care of superficial wounds;
    (b) Debridement of corns and calluses; and
    (c) Trimming and debridement of nails.
    We proposed to crosswalk the work and malpractice RVUs and the 
practice expense inputs from CPT code 11040, Debridement; skin; partial 
thickness. We would revalue the practice expense RVUs using the 
practice expense methodology once we have utilization data for this 
code.
    Comment: The American Podiatric Medical Association (APMA) believes 
that the RVUs assigned to HCPCS codes G0245 and G0246 are too low. They 
do not believe that the assigned RVUs account for the physician work 
and practice expense required to perform those services. They 
recommended that we crosswalk the RVUs from CPT codes 99203 and 99213 
to these codes instead of the crosswalk we actually used, from CPT 
codes 99202 and 99212. They also commented that the RVUs assigned for 
G0247 were too low and should be increased as the assigned RVUs did not 
account for the required physician work. Alternatively, they 
recommended that we delete G0247 and allow a physician to report CPT 
codes that described similar services. A large medical clinic commented 
that they were not sure why CMS had implemented these codes. They 
believe that if the only reason for creating codes was to permit us to 
track the services, this reason is insufficient because the codes cause 
significant administrative burden to physician practices. They believe 
that providers could use other CPT codes to report these services 
instead of the G codes. A carrier medical director familiar with these 
services commented that G0247 is overvalued because the most common 
service provided using this code will be toe nail trimming and 
debridement and that the CPT code for toe nail trimming and debridement 
is valued much lower then G0247.
    Response: These G codes were created to implement a national 
coverage determination (NCD). The coverage determination was very 
specific with regard to the required components of each service. 
Furthermore, the NCD specifically allowed these services to be 
performed no more than every six months and allowed the initial visit 
to be performed only once per physician for the lifetime of a 
beneficiary. Creation of these G codes allows us to implement the 
coverage decision, especially with regard to the required frequency 
limitation and to track the utilization of these services while 
minimizing provider burden. Reporting these services with CPT 
evaluation and management (E/M) codes and procedure codes would have 
resulted in numerous post-pay audits while creation of a modifier to be 
used in conjunction with such CPT codes would have been quite 
burdensome and resulted in just as many post pay audits. Therefore, we 
plan to continue requiring these G codes for reporting of these 
services.
    With regard to the valuation of these services we will finalize the 
proposed RVUs. This service is provided to those diabetic beneficiaries 
who are ``at risk'' for foot-care problems but who do not have an 
injury or illness of the foot. Any service provided to a diabetic 
beneficiary with an illness or injury to the foot (for example, foot 
pain, foot ulcer, foot infection) should be reported using the 
appropriate CPT codes (for example, E/M service, debridement service). 
Furthermore, the requirements for provision of care to LOPS patients 
are clearly set forth in the NCD. Nothing beyond those requirements 
need be performed in order to report a LOPS HCPCS code. Careful 
scrutiny of the requirements for provision of initial LOPS services 
shows that they are most similar to the requirements of a level 2 E/M 
service. The lack of illness, injury, or deformity in these patients 
and the requirements that the practitioners need only to take a history 
and to examine the foot are quite similar to the requirements of CPT 
code 99202: an expanded problem focused history, an expanded problem 
focused examination, and straightforward medical decision making. For 
follow-up patients who do not have an illness, injury, or deformity, 
the requirements of

[[Page 79991]]

the NCD are quite similar to the requirements of CPT code 99212: a 
problem focused history, a problem focused examination, and 
straightforward medical decision making. With regard to G0247, we agree 
with the carrier medical director who stated that the most commonly 
performed procedure would be toenail trimming and or debridement. 
However, review of the work RVUs for CPT codes 11719 (0.17), 11720 
(0.32), 11721 (0.54), 11055 (0.43), 11056 (0.61), 11057 (0.79), and 
11040 (0.50) shows that we have properly valued this service. We 
believe that a work value of 0.50 RVUs appropriately accounts for what 
is likely to be the typical combination of services provided to 
eligible beneficiaries.
Result of Evaluation of Comments
    We will continue requiring these G codes for reporting of these 
services and are finalizing the RVUs as proposed.
    2. Current Perception Sensory Nerve Conduction Threshold Test 
(SNCT)
    G0255: Current Perception Threshold/Sensory Nerve Conduction Test, 
(SNCT) per limb, any nerve
    We proposed a G-code that represents SNCT as a diagnostic test used 
to diagnose sensory neuropathies. This test is noninvasive and uses a 
transcutaeous electrical stimulus to evoke a sensation. However, we 
determined that there is insufficient scientific or clinical evidence 
to consider the use of this device as reasonable and necessary within 
the meaning of section 1862(a)(1)(A) of the Act and indicated Medicare 
will not pay for this type of test.
    Comment: One commenter requested that the descriptor for this code 
be revised, as the current descriptor ``Current Perception Threshold/
Sensory Nerve Conduction Test'' is very similar to other codes for 
example, the short descriptor for CPT code 95904 is ``Sense Nerve 
Conduction Test''. The commenter recommended changing the descriptor 
for this G code to ``Current Perception Threshold Test''.
    Response: We appreciate the commenters bringing this to our 
attention and have revised the short descriptor for this G code to 
address the concern they raised. The short descriptor for this G code 
will be ``Current perception threshold test''.
    Result of Evaluation of Comments: We will finalize our proposal for 
G0255 but will revise the short descriptor as discussed above.
3. Positron Emission Tomography (PET) Codes for Breast Imaging
    Medicare has expanded the coverage indications for PET scanning to 
include imaging for breast cancer, and we have created codes that 
describe staging and restaging after or prior to the course of 
treatment of breast cancer. We also created a PET scan code to evaluate 
the response to treatment of breast cancer.
    PET imaging for initial diagnosis of breast cancer and/or surgical 
planning for breast cancer are described by a CPT code, but Medicare 
will not cover the procedure for this diagnosis.
    G0252: PET imaging for initial diagnosis of breast cancer and /or 
surgical planning for breast cancer (for example, initial staging of 
axillary lymph nodes), not covered by Medicare.
    We stated that this code is not covered by Medicare because there 
is a national non-coverage determination for the use of PET imagery for 
the initial diagnosis of breast cancer and initial staging of axillary 
lymph nodes.
    G0253: PET imaging for breast cancer, full and partial-ring PET 
scanners only, staging/restaging after or prior to course of treatment.
    G0254: PET imaging for breast cancer, full and partial-ring PET 
scanners only, evaluation of response to treatment, performed during 
course of treatment.
    We proposed that the TC and global for both of these codes be 
carrier-priced. For the PC for codes G0253 and G0254, we proposed to 
make the PC work RVU equal to 1.87 and use practice expense RVUs of 
0.58 and malpractice RVUs of 0.07 since there are no direct inputs for 
PC services.
    Comments: Commenters expressed appreciation for creation of these G 
codes; however, one commenter was concerned that the TC and global 
component of these codes will be carrier-priced which, the commenter 
contended, could lead to widely varying and unjustifiably low payment 
rates, particularly if there is no national benchmark.
    Response: Carriers use a variety of methods and resources when 
developing payment rates for services that they are responsible for 
pricing. We do not believe that having the carriers price these codes 
will lead to unjustifiably low payment rates.
    Result of Evaluation of Comments: We are adopting the proposals for 
these G codes; however, we have made editorial revisions to the 
descriptors for G0252 and G0253 to more accurately describe the service 
provided. The revised descriptors are as follows:
    G0252: PET imaging, full and partial-ring PET scanners only, for 
initial diagnosis of breast cancer and /or surgical planning for breast 
cancer (for example, initial staging of axillary lymph nodes).
    G0253: PET imaging for breast cancer, full and partial-ring PET 
scanners only, staging/restaging of local regional recurrence or 
distant metastases (that is, staging/restaging after or prior to course 
of treatment).
4. Home Prothrombin Time International Normalized Ratio (INR) 
Monitoring for Anticoagulation Management
    For services furnished on or after July 1, 2002, Medicare will 
cover the use of home prothrombin time or INR monitoring in a patient's 
home for anticoagulation management for patients with mechanical heart 
valves. A physician must prescribe the testing. The patient must have 
been anticoagulated for at least three months prior to use of the home 
INR device, and the patient must undergo an education program. The 
testing with the device is limited to a frequency of once per week.
    G0248: Demonstration, at initial use, of home INR monitoring for a 
patient with mechanical heart valve(s) who meets Medicare coverage 
criteria, under the direction of a physician; includes: demonstration 
use and care of the INR monitor, obtaining at least one blood sample 
provision of instructions for reporting home INR test results and 
documentation of a patient's ability to perform testing.
    We proposed that this code be assigned no work RVUs and .01 
malpractice RVUs. For the practice expense inputs, we proposed 75 
minutes of RN/LPN/MTA staff time; a supply list including four test 
strips, lancets and alcohol pads, a patient education booklet, and 
batteries for the monitor; and equipment consisting of a home INR 
monitor. These proposed inputs result in an estimated practice expense 
RVU of 2.92.
    G0249: Provision of test materials and equipment for home INR 
monitoring to patient with mechanical heart valve(s) who meets Medicare 
coverage criteria. Includes provision of materials for use in the home 
and reporting of test results to physician; per 4 tests.
    We proposed this code be assigned no work RVUs and .01 malpractice 
RVUs. For the practice expense inputs, we proposed 13 minutes of RN/
LPN/MTA staff time; a supply list including four test strips, lancets 
and alcohol pads, and equipment consisting of a home INR monitor. These 
resulted in an estimated practice expense RVU of 2.08.
    G0250: Physician review/interpretation and patient management of 
home INR test for a patient with mechanical heart valve(s) who meets 
other coverage criteria; per 4 tests (does not require face-to face 
service)

[[Page 79992]]

    We proposed this code be assigned 0.18 work RVUs and .01 
malpractice RVUs. We stated that there would be no direct practice 
expense inputs for this code, and the use of the practice expense 
methodology to develop the indirect practice expense of the physician 
performing this service resulted in an estimated practice expense RVU 
of 0.07. Note: Subsequent to the publication of the proposed rule, we 
updated the payment rates for home PT/INR monitoring via Program 
Memorandum AB-02-112 (July 31, 2002). Based on a correction in the 
practice expense methodology used to calculate the practice expense 
RVUs issued in the Program Memorandum AB-02-064 on May 2, 2002 and 
included in the June 28, 2002 proposed rule there was an increase in 
practice expense RVUS for G0248 to 3.06 and to 3.28 for G0249 effective 
for services performed after October 1, 2002.
    Comment: A manufacturer of equipment used to perform INR monitoring 
at home was concerned that the proposed RVUs for the HCPCS codes used 
to report Home INR monitoring services were inconsistent with the RVUs 
published in Program Memorandum AB-02-112 issued on July 31, 2002. 
(This program memorandum was issued to correct an error that had 
resulted in the original RVUs for these codes being too low.) The 
commenter also requested that we clarify the descriptor for the HCPCS 
code used to report provision of Home INR materials to assure that 
Medicare only paid for properly controlled INR tests that were 
consistent with FDA labeling.
    Response: The aforementioned program memorandum was issued after 
the Proposed Rule (NPRM) was published. We agree with the commenter 
that the physician fee schedule for 2003 should reflect the RVUs as 
published in the July 31, 2002 program memorandum and will make this 
change.
    With regard to changing the descriptors for the HCPCS code used to 
report provision of home INR test materials, we will review this issue 
and, if appropriate, clarify the descriptor as requested for CY 2004.
    Comment: Several commenters asked CMS to expand the covered 
indications for home INR monitoring.
    Response: We direct these commenters to the published process for 
requesting a national coverage determination. In order for the covered 
indications to be expanded on a national level this process must be 
followed.
    Comment: A manufacturer of equipment used for home INR monitoring 
pointed out that there were several companies who manufacture test 
strips. Producing a test result may require one or three test strips 
depending on the manufacturer. Additionally, the cost of test strips 
from each manufacturer is different and Medicare based its payment on 
the cost of a test strip from only one manufacturer.
    Response: We agree that there are several types of test strips 
available. However, we also understand that not all manufacturers are 
currently providing new home INR monitoring equipment and that the 
market share for each product is in flux. We will review the 
appropriate payment for this service, including the appropriate amount 
to include for test strips, after we have sufficient experience paying 
for this service. The earliest time that we could consider proposing a 
change in payment rate would be for the 2005 physician fee schedule; at 
that time, we would have 18 months worth of payment data upon which we 
could base a proposal.
Result of Evaluation of Comments
    As indicated above, payment for CY 2003 for these services will 
reflect the corrections made in the Program Memorandum AB-02-112 issued 
on July 31, 2002.
5. Bone Marrow Aspiration and Biopsy on the Same Date of Service
    We proposed a new G code (GXXXX) that reflects a bone marrow biopsy 
and aspiration procedure that is performed on the same date, at the 
same encounter, through the same incision, based on our understanding 
that the typical case involves an aspiration and biopsy through the 
same incision.
    We proposed physician work RVUs of 1.56 and malpractice RVUs of 
0.04. We also proposed to crosswalk the practice expense inputs from 
CPT code 38220, Bone marrow aspiration, with the assignment of an 
additional five minutes of clinical staff time. These proposed inputs 
in the practice expense methodology resulted in an estimated practice 
expense RVU of 3.32 in the nonfacility setting and 0.60 in the facility 
setting.
    We also noted that if the two procedures, aspiration and biopsy, 
are performed at different sites (for example, contralateral illiac 
crests, sternum/illiac crest, two separate incisions on the same iliac 
crest or two patient encounters on the same date of service), the CPT 
codes for aspiration and biopsy would each be used along with the -59 
modifier.
    Comment: Two commenters, one representing a provider and the other 
a specialty organization, agreed with the proposal to create a G code 
for bone marrow aspiration and biopsy on the same date of service. 
However, another specialty organization and the AMA did not agree with 
the creation of this new G code and felt its creation was unnecessary. 
These commenters indicated that CPT currently has sufficient and 
accurate coding for these services that is, CPT codes 38220 and 38221 
which when performed through the same incision could both be reported 
with the modifier 51 (used in reporting of multiple procedures 
performed in the same incision) appended. In addition, the commenters 
stated that the descriptor for this code does not adequately describe 
the procedure for which it is intended as it does not specifically 
state ``through the same incision.'' This could lead to a denial of 
services of all bone marrow aspiration and biopsies performed on the 
same date of service.
    Response: After review of the comments, we agree that this code 
should go through the CPT process. Therefore, we are withdrawing our 
proposal to create this code. We will submit a code for ``Bone Marrow 
Biopsy and Aspiration performed in the same bone'' to CPT in time for 
the 2004 CPT cycle.
Result of Evaluation of Comments
    We will not proceed with a separate G code for bone marrow biopsy 
and aspiration procedure that is performed on the same date, at the 
same encounter.
Creation of G Codes
    Comment: Several commenters expressed concern about the increasing 
frequency of G codes being issued by us. Commenters believed that, in 
the interest of coding standardization, accuracy, and clarity, G codes 
should only be developed as a last resort and should be temporary. 
Commenters believed that an annual meeting with us to discuss codes 
that may be necessary to accommodate new payment and coverage policies 
would help reduce the number of G codes. Some commenters also asked for 
greater physician involvement in the HCPCS editorial process (for 
example, direct representation of the physician community on the 
panel).
    Response: We agree that, where appropriate, G codes should be 
temporary. Unfortunately, it is sometimes necessary to develop G codes 
to accommodate changes in legislation, regulation, coverage, and 
payment policy. The timetable for such changes

[[Page 79993]]

is not necessarily consistent with the timetable for CPT publication 
and frequently these changes must be made on a quarterly basis.
    In 2002 CMS and CPT staff, working together, reviewed all existing 
G codes and agreed to transition over 20 of them to CPT codes. 
Therefore, for 2003 many G codes are being deleted in favor of newly 
created CPT codes. (See section IV for a discussion of deleted G 
codes). We believe that an annual review of G codes by CMS and CPT 
staff is the best way to determine which G codes should be transitioned 
to CPT codes and the process to use for such a transition. Therefore, 
we plan to continue working with CPT staff on an annual basis to 
continue transitioning existing G codes to CPT codes. We believe such 
an annual comprehensive review will address the commenters' concerns. 
However, we do wish to emphasize that we, when appropriate, does 
consult with interested providers prior to the creation of G codes in 
order to facilitate coding clarity and minimize physician burden.

L. Endoscopic Base For Urology Codes

    Cystoscopy and treatment CPT codes 52234, 52235, and 52240 were 
inadvertently identified in the Medicare Physician Fee Schedule 
Database as services subject to the reductions for multiple procedures 
as opposed to the procedural reduction rules specific to endoscopic 
services. This has resulted in our overpaying for these services. We 
proposed applying the endoscopic reduction rules to these services and 
identified CPT code 52000 as the endoscopic base code for these 
services.
    Comment: The American Urological Association was in agreement with 
our proposal to apply the endoscopic reduction rules to CPT codes 
52234, 52235, and 52240.
    Final Decision: The endoscopic reduction rules will be applied to 
these three codes as proposed.

M. Physical Therapy and Occupational Therapy Caps

    Section 4541(c) of the Balanced Budget Act of 1997 required 
application of a payment limitation to all rehabilitation services 
provided on or after January 1, 1999. The limitation was an annual per 
beneficiary limit of $1500 on all outpatient physical therapy (PT) 
services (including speech-language pathology services). A separate 
$1500 limit was applied to all occupational therapy (OT) services. (The 
limitation amounts were to be increased to reflect medical inflation.) 
The annual limitation did not apply to services furnished directly or 
under arrangement by a hospital to an outpatient or to an inpatient who 
is not in a covered Part A stay.
    Section 221 of the Balanced Budget Refinement Act of 1999 (BBRA) 
(Pub. L. 106-113, enacted on November 29, 1999) placed a moratorium on 
the application of the payment limitation for two years from January 1, 
2000 through December 31, 2001. Section 421 of the Medicare, Medicaid, 
and SCHIP Beneficiary Improvement and Protection Act of 2000 (BIPA) 
(Pub. L. 106-554, enacted on December 21, 2000), extended the 
moratorium on application of the limitation to claims for outpatient 
rehabilitation services with dates of service January 1, 2002 through 
December 31, 2002. As we explained in the June 28, 2002 proposed rule, 
outpatient rehabilitation claims for services rendered on or after 
January 1, 2003 will be subject to the payment limitation unless the 
Congress acts to extend the moratorium.
    Comments: We received comments from associations and societies 
urging us to support the permanent repeal of the $1500 financial 
limitation on PT, including speech language pathology, and a separate 
$1500 financial limitation on OT. All commenters stated that this 
financial limitation would adversely affect nursing home beneficiaries 
who receive Part B therapy services.
    Response: As stated before, we will implement the outpatient 
rehabilitation therapy financial limitation via a Program Memorandum to 
Carriers and Fiscal Intermediaries, unless the Congress acts to extend 
the moratorium or repeals the legislation.

III. Other Issues

A. Definition of a Screening Fecal-Occult Blood Test

    One commenter suggested that the current definition of a screening 
fecal-occult blood test at Sec.  410.37(a)(2) that limits coverage to 
guaiac-based tests should be expanded to permit coverage of another 
test. The commenter suggested that this change be made in the final 
rule because the June 2002 proposed rule added a variety of new HCPCS G 
codes similar to the G code for which the commenter has requested for 
its new fecal-occult blood test.
    Based on our analysis of the preliminary information we have on the 
new test, we believe that it may have the potential for effective 
screening for colorectal cancer, and thus, we have agreed with the 
commenter to broaden the definition in Sec.  410.37(a)(2) to permit 
coverage of non-guaiac based tests. However, in order to establish 
national coverage of the new test under the Medicare colorectal cancer 
screening benefit we must first compare the clinical utility of the 
test to the existing guaiac-based test. If, for instance, the test is 
not as effective as the currently covered test, it would not make sense 
to authorize coverage as permitted by section 1861(pp)(1)(D) of the 
Act.
    To facilitate our consideration of future coverage of other new 
types of fecal-occult blood tests, we have decided to amend Sec.  
410.37(a)(2) to provide that in addition to the guaiac-based screening 
test, other types of fecal-occult blood tests may be covered under the 
screening benefit, if we determine that this is appropriate through a 
national coverage determination (NCD). This change will allow us to 
conduct a more timely assessment of other new types of fecal-occult 
blood tests that may have been approved or cleared for marketing by the 
Food and Drug Administration (FDA) than is possible under the standard 
rulemaking process. We intend to use the NCD process, which includes an 
opportunity for public comments, for evaluating the medical and 
scientific issues relating to the coverage of additional tests that may 
be brought to our attention in the future. Use of an NCD to establish a 
change in the scope of benefits is authorized by section 1871(a)(2) of 
the Act.
    In accordance with section 1861(pp)(1)(D) of the Act, we have 
discretion to determine that additional tests or procedures are 
appropriate and can be used for the early detection of colorectal 
cancer. This authority is currently reflected in Sec.  410.37(a)(1)(v). 
We are amending that section to announce that approval of any new tests 
or procedures for use in early detection of colorectal cancer will be 
made through an NCD. The use of an NCD, authorized by section 
1871(a)(2) of the Act, will permit public participation. The NCD 
process, however will allow Medicare to expand coverage for additional 
tests or procedures when warranted more rapidly than the notice and 
comment procedures of the Administrative Procedure Act would normally 
permit.

B. Clarification of Services and Supplies Incident to a Physician's 
Professional Services: Conditions

    In the November 2001 final rule (66 FR 55238) we revised 
regulations on services and supplies furnished incident to a 
physician's professional services. In the revised regulations at Sec.  
410.26(a)(7) we defined such services and supplies as `` * * * any 
services and supplies * * * that are included in section

[[Page 79994]]

1861(s)(2)(A) of the Act and are not specifically listed in the Act as 
a separate benefit included in the Medicare program.''
    We are clarifying that services having their own statutory benefit 
category are covered under that category rather than as incident to 
services. This means that they are subject to manual and other program 
operating instructions pertaining to their specific statutory benefit 
category. In addition, they are not required to meet incident to 
implementing instructions such as those in section 2050 of Part III of 
the Medicare Carriers Manual (MCM). For example, diagnostic tests are 
covered under section 1861(s)(3) of the Act and are subject to the 
requirements for diagnostic tests in MCM section 2070. Depending on the 
particular test, the supervision requirement in section 2070 may be 
more or less stringent than that in section 2050 for incident to 
services. When diagnostic tests are furnished, the requirements for 
diagnostic tests apply, and not those for incident to services. 
Likewise, pneumococcal, influenza, and hepatitis B vaccines are covered 
under section 1861(s)(10) of the Act and do not need to meet incident 
to requirements.
    While we believe our regulations are clear on this point, one of 
the comments and responses published in our November 2001 final rule 
has caused some confusion on this issue. The comment and response were 
as follows:
    Comment: ``Many commenters wanted us to re-emphasize that incident 
to services set forth in section 1861(s)(2)(A) of the Act do not 
include Medicare benefits separately and independently listed in the 
Act, such as diagnostic services set forth in section 1861(s)(3). Some 
requested that we not permit these separately and independently listed 
services to be furnished as incident to services.''
    Response: ``We realize, as did the Congress with the enactment of 
section 4541(b) of the BBA, that many services--even those that are 
separately and independently listed--can be furnished as incident to 
services. However, this fact of medical practice is not inconsistent 
with our policy. We maintain that a separately and independently listed 
service can be furnished as an incident to service but is not required 
to be furnished as an incident to service. Furthermore, even if a 
separately and independently listed services is provided as an incident 
to service, the specific requirements of that separately and 
independently listed service must be met. For instance, a diagnostic 
test under section 1861(s)(3) of the Act may be furnished as an 
incident to service. Nevertheless, it must also meet the requirements 
of the diagnostic test benefit set forth in Sec.  410.32. Specifically, 
the test must be ordered by the treating practitioner, and it must be 
supervised by a physician. Thus, if a test requires a higher level of 
physician supervision than direct supervision, then that higher level 
of supervision must exist even if the test is furnished as an incident 
to service. Accordingly, we decline to prohibit a separately and 
independently listed service from being furnished as an incident to 
service. Instead, we reiterate that a separately and independently 
listed service need not meet the requirements of an incident to 
service.''
    The intent of the above response was to state that for a service 
having its own separately and independently listed statutory benefit 
category, Medicare carriers should apply the requirements of that 
separately listed benefit category and not also apply the incident to 
requirements. We interpret Sec.  410.26(a)(7) literally. That is, 
incident to services and supplies covered under 1861(s)(2)(A) of the 
Act means services and supplies not having their own independent and 
separately listed statutory benefit category.
    Perhaps it could be argued that any service provided under the 
direct supervision of a physician could be considered an incident to 
service. However, the Congress specifically provided for the many 
separate benefit categories of medical and health services in the Act. 
We believe that the Congress intended for incident to services to be a 
catch-all category to allow payment for certain services and supplies 
commonly furnished in a physician's office and not having their own 
separate benefit category. The billing of services with their own 
separate and independent coverage benefit categories as incident to may 
circumvent the coverage and payment rules applicable to those other 
categories. Therefore, only services that do not have their own benefit 
category are appropriately billed as incident to a physician service. 
Examples of benefit categories are diagnostic X-ray tests (section 
1861(s)(3) of the Act) and influenza vaccine and its administration 
(section 1861(s)(10)(A) of the Act).
    However, since section 4541(b) of the BBA allows certain services 
with their own benefit category (that is, outpatient physical therapy 
services (including speech-language pathology services) and outpatient 
occupational therapy) to also be provided as incident to services, we 
cannot prohibit physicians and practitioners from billing these 
services as incident to. However, when these services are billed 
incident to, requirements in Medicare Carriers Manual section 2050 must 
also be met. Note that the personal (in-the-room) supervision 
requirements for physical and occupational therapy assistants apply 
only to the private practice setting. The services of nurse 
practitioners, clinical nurse specialists and physician's assistants 
may be billed as incident to a physician's service if the incident to 
requirements are met, or those practitioners may bill their services 
separately under their own benefit.

C. Five-Year Review of Gastroenterology Codes

    In the November 2001 final rule, (66 FR 55246), we finalized work 
RVUs for several gastrointestinal endoscopy codes that were reviewed by 
the RUC during the five-year review of physician work. However, we 
asked the RUC to review several families of gastrointestinal endoscopy 
codes to ensure that no rank order anomalies existed within those 
families. The procedures for gastrointestinal stent placement were 
among those families. Although we have not received further RUC 
recommendations for any gastrointestinal endoscopy codes, several 
specialty societies have submitted further information regarding the 
physician work required to perform gastrointestinal stent placement 
services. We have reviewed this information and are making several 
adjustments to the RVUs for these services. These adjustments are 
interim and we will respond to comments concerning these adjustments in 
next year's final rule.
    CPT code 43219 Esophagoscopy, rigid or flexible; with insertion of 
plastic tube or stent
    Based on the information we have reviewed (including physician 
intraservice time data), there is no compelling evidence that the 
physician work of this procedure is inappropriate. The work increment 
(1.21 work RVUs) beyond the base procedure CPT code 43200, 
Esophagoscopy, rigid or flexible; with or without collection of 
specimen(s) by brushing or washing (separate procedure) is appropriate. 
Therefore we are maintaining 2.8 work RVUs for CPT code 43219.
    CPT code 43256 Upper gastrointestinal endoscopy including 
esophagus, stomach, and either the duodenum and/or jejunum as 
appropriate; with transendoscopic stent placement (includes 
predilation)
    This code currently has 4.60 work RVUs. We reviewed physician time 
data for this service and believe that it is overvalued compared to the 
value of

[[Page 79995]]

other stent placement procedures. Therefore, to place it in the proper 
rank order to other stent placement codes, we are assigning it 4.35 
work RVUs. This makes the incremental work (1.96 work RVUs) above the 
base procedure CPT code 43235, Upper gastrointestinal endoscopy 
including esophagus, stomach and either the duodenum and/ or jejunum as 
appropriate; diagnostic, with or without collection of specimen(s) by 
brushing or washing (separate procedure), in line with other stent 
placement codes.
    CPT code 44383 Ileoscopy, through stoma; with transendoscopic stent 
placement (includes predilation)
    This code currently has 3.26 work RVUs. We reviewed physician time 
data for this code and compared it to other stent placement codes. The 
incremental work value (2.21 work RVUs) above the base procedure CPT 
code 44380, Ileoscopy, through stoma; diagnostic, with or without 
collection of specimen(s) by brushing or washing (separate procedure), 
is high. Therefore, we are reducing the work RVUs to 2.94. This gives 
it an incremental work value of 1.89 work RVUs which is similar to the 
incremental work value of CPT code 44397, Colonoscopy through stoma; 
with transendoscopic stent placement (includes predilation), and places 
it in the proper rank order with other stent placement codes.

D. Critical Access Hospital Emergency Services Requirements

    Section 1820 of the Act provides for a nationwide Medicare Rural 
Hospital Flexibility Program (MRHF). The Act also provides that certain 
rural providers may be designated as critical access hospitals (CAHs) 
under the MRHF program if they meet qualifying criteria and the 
conditions for designation specified in the statute. Implementing 
regulations for section 1820 of the Act are located at 42 CFR part 485, 
subpart F.
    Section 1820(c)(2)(B) of the Act implements specific conditions of 
participation (CoPs) that a facility must meet to be designated a CAH. 
The statutory criteria for State designation as a CAH require, in part, 
that the facility makes available 24-hour emergency care services that 
a State determines are necessary for ensuring access to emergency care 
services in each area served by a CAH. To help protect the health and 
safety of Medicare patients who seek emergency medical care at a CAH, 
our regulations at Sec.  485.618 require CAHs to provide emergency care 
necessary to meet the needs of its patients.
    In 2002, we received letters requesting a special waiver from the 
current emergency services personnel requirement (specified in Sec.  
485.618(d)) for CAHs in frontier areas and remote locations. The 
requests included the following comments; (1) A number of remote CAHs 
have been struggling to comply with the current CAH requirement; (2) 
the personnel requirement places a hardship on isolated frontier 
communities that have only one medical practitioner; and (3) often 
these remote facilities have a very low volume of patients which makes 
it difficult to recover all of their costs and to recruit other 
practitioners.
    As of September 2002, the Cecil G. Sheps Center for Health Services 
Research at Chapel Hill, North Carolina has identified approximately 
173 CAHs that are located in frontier areas (identified as having six 
individuals per square mile). The average population for a frontier CAH 
community is 7,024. We have no empirical data to indicate which of 
these 173 CAHs are currently experiencing workforce issues that create 
a hardship for the facility or any sole provider. However, the 
University of Washington conducted a survey of CAHs in May 2001 and 
learned that, of the 388 CAHs that responded to the survey, 146 
facilities are in an isolated small rural census tract. Of these 
facilities, 10 have no physicians, 24 have only 1 physician, 39 have 2 
physicians, and 26 have 3 physicians. Of the CAHs with no doctors, 6 
have only 1 mid-level provider (4 of these are in Montana), and 3 have 
2 mid-level providers (1 apparently had no physician or mid-level 
provider at the time of the survey). Of the 39 CAHs that had 2 
physicians, 3 had no mid-level providers, and 12 had only 1 mid-level 
provider.
    The Rural Health Research Center at the University of Washington, 
through its CAH National Tracking Project, reported that CAHs 
frequently cite problems with recruitment and retention of emergency 
medical personnel. Based on 2002 data, more than half of the designated 
CAHs are serving counties dually designated as both a Medically 
Underserved Area (MUA) and a Health Professional Shortage Area (HPSA). 
Less than 1 in 10 CAHs are located in counties without a HPSA or an MUA 
designation.
    The delicate balance of providing access to care in very rural and 
remote areas without jeopardizing quality of care continues to be 
challenging. We believe that if a small CAH is forced to close because 
of the lack of qualified personnel, adding RNs to the list of approved 
personnel would greatly help CAHs with nogreater than 10 beds, in 
frontier areas or remote locations to serve the emergency health care 
needs of residents of these areas. Often CAHs in frontier or remote 
areas are located 50 miles or farther from the nearest health care 
facility. We believe that allowing RNs, as needed on a temporary basis, 
to work in CAHs with no greater than 10 beds, with training or 
experience in emergency care to be included in the list of personnel to 
be on call and immediately available within 60 minutes is the best 
means of ensuring that patients in frontier or remote areas will 
continue to have access to high-quality emergency health care services. 
However, we are requesting comments on other viable alternatives on how 
CAHs that are currently experiencing workforce issues can provide 
emergency care in frontier and remote areas.
    Our regulations at Sec.  485.618(d) require a doctor of medicine or 
osteopathy, a physician's assistant, or a nurse practitioner with 
training or experience in emergency care to be on call and immediately 
available by telephone or radio and to be available on site within 30 
minutes, or 60 minutes if the CAH is located in a designated frontier 
area or a remote location designated by the State in its rural health 
plan. In addition, Sec.  485.618(e) requires that the CAH must 
coordinate with the emergency response system in the area and ensure 
the 24-hour telephone or radio availability of a doctor of medicine or 
osteopathy to receive emergency calls, provide information on treatment 
of patients, and refer patients to the CAH or other appropriate 
locations for treatment.
    We understand that it may be difficult for small CAHs in frontier 
areas or remote locations to meet the personnel requirements set forth 
in Sec.  485.618(d). However, section 1820(c)(2)(B)(ii) of the Act 
requires a qualifying CAH to make available the 24-hour emergency care 
services that a State determines are necessary for ensuring access to 
emergency care services in each area served by a CAH. Although the 
statute does not provide authority to waive the requirement for 
continuous emergency care services, we believe that the statute 
provides the flexibility for States to assess their emergency care 
service needs and permit small CAHs that experience the absence of 
emergency personnel required by Sec.  485.618(d) to nonetheless provide 
emergency services. Accordingly, this final rule with comment provides 
a mechanism for States with CAHs with no greater than 10 beds, in 
frontier areas and remote locations to include registered nurses (RNs), 
with training or

[[Page 79996]]

experience in emergency care, as authorized emergency services 
personnel under our current general emergency service personnel 
requirements at Sec.  485.618(d). Therefore, in this final rule with 
comment we are revising Sec.  485.618(d) to add the possibility for 
States to include RNs among authorized personnel, at Sec.  
485.618(d)(3). This will permit State Governors, following consultation 
on the issue of using RNs on a temporary basis as part of their State 
rural healthcare plan with the State Boards of Medicine and Nursing, 
and in accordance with State laws, to request in writing the inclusion 
of RNs to our current personnel requirements, so that RNs may fulfill 
the emergency personnel requirements of Sec.  485.618 for frontier area 
or remote location CAHs with no greater than 10 beds. The letter from 
the Governor must attest that he or she has consulted with State Boards 
of Medicine and Nursing about issues related to access to and the 
quality of emergency services in the State. The letter from the 
Governor must also describe the circumstances and duration of the 
temporary request to include the RN on a list of emergency personnel 
specified in Sec.  485.618(d)(1). The request for such inclusion, and 
any withdrawal of a request for this inclusion, may be submitted at any 
time, and will be effective on the date we receive the request. In 
addition, once a State submits a letter to us signed by the Governor 
requesting that an RN be included in the list of specified personnel 
for CAHs with no greater than 10 beds, a CAH must submit documentation 
to the State survey agency demonstrating that it has not been able, 
despite reasonable attempts, to hire a sufficient number of physicians, 
physician assistants, or nurse practitioners to provide 24-hour 
emergency services on-call coverage. In a frontier or remote area when 
a CAH has only one physician or mid-level provider, we would expect the 
facility to provide relief to the sole provider by using an RN with 
training or experience in emergency services to provide emergency on-
call services.

IV. Refinement of Relative Value Units for Calendar Year 2003 and 
Response to Public Comments on Interim Relative Value Units for 2002

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

    Section IV.B of this final rule describes the methodology used to 
review the comments received on the RVUs for physician work and the 
process used to establish RVUs for new and revised CPT codes. Changes 
to codes on the physician fee schedule reflected in Addendum B are 
effective for services furnished beginning January 1, 2003.

B. Process for Establishing Work Relative Value Units for the 2003 
Physician Fee Schedule

    Our November 1, 2001 final rule (66 FR 55294) announced the final 
work RVUs for Medicare payment for existing procedure codes under the 
physician fee schedule and interim RVUs for new and revised codes. The 
RVUs contained in the final rule applied to physician services 
furnished beginning January 1, 2002. We announced that we considered 
the RVUs for the interim codes to be subject to public comment under 
the annual refinement process. In this section, we summarize the 
refinements to the interim work RVUs published in the November 2001 
final rule and our establishment of the work RVUs for new and revised 
codes for the 2003 physician fee schedule.
Work Relative Value Unit Refinements of Interim and Related Relative 
Value Units
    1. Methodology (Includes Table titled ``Work Relative Value Unit 
Refinements of the 2002 Interim and Related Relative Value Units'')
    Although the RVUs in the November 2001 final rule were used to 
calculate 2002 payment amounts, we considered the RVUs for the new or 
revised codes to be interim. We accepted comments for a period of 60 
days. We received substantive comments from many individual physicians 
and several specialty societies on approximately 19 CPT codes with 
interim work RVUs. Only comments on codes listed in Addendum C of the 
November 2001 final rule were considered.
    To evaluate these comments we used a process similar to the process 
used in 1997. (See the October 31, 1997 final rule (62 FR 59084) for 
the discussion of refinement of CPT codes with interim work RVUs.) We 
convened a multispecialty panel of physicians to assist us in the 
review of the comments. The comments that we did not submit to panel 
review are discussed at the end of this section, as well as those that 
were reviewed by the panel. We invited representatives from the 
organization from which we received substantive comments to attend a 
panel for discussion of the code on which they had commented. The panel 
was moderated by our medical staff, and consisted of the following 
voting members:
    [sbull] One or two clinicians representing the commenting 
organization.
    [sbull] Two primary care clinicians nominated by the American 
Academy of Family Physicians and the American College of Physicians/
American Society of Internal Medicine.
    [sbull] Four carrier medical directors.
    [sbull] Four clinicians with practices in related specialties, who 
were expected to have knowledge of the service under review.
    The panel discussed the work involved in the procedure under review 
in comparison to the work associated with other services under the 
physician fee schedule. We assembled a set of reference services and 
asked the panel members to compare the clinical aspects of the work of 
the service a commenter believed was incorrectly valued to one or more 
of the reference services. In compiling the set, we attempted to 
include--(1) Services that are commonly performed whose work RVUs are 
not controversial; (2) services that span the entire spectrum from the 
easiest to the most difficult; and (3) at least three services 
performed by each of the major specialties so that each specialty would 
be represented. The set listed approximately 300 services. Group 
members were encouraged to make comparisons to reference services. The 
intent of the panel process was to capture each participant's 
independent judgement based on the discussion and his or her clinical 
experience. Following the discussion, each participant rated the work 
for the procedure. Ratings were individual and confidential, and there 
was no attempt to achieve consensus among the panel members.
    We then analyzed the ratings based on a presumption that the 
interim RVUs were correct. To overcome this presumption, the inaccuracy 
of the interim RVUs had to be apparent to the broad range of physicians 
participating in each panel.
    Ratings of work were analyzed for consistency among the groups 
represented on each panel. In general, we used statistical tests to 
determine whether there was enough agreement among the groups of the 
panel and whether the agreed-upon RVUs were significantly different 
from the interim RVUs published in Addendum C of the November 2001 
final rule. We did not modify the RVUs unless there was a clear 
indication for a change. If there was agreement across groups for 
change, but the groups did not agree on what the new RVUs should be, we 
eliminated the outlier group and looked for agreement among the 
remaining groups as the basis for new RVUs. We used the same 
methodology in analyzing the ratings

[[Page 79997]]

that we first used in the refinement process for the 1993 physician fee 
schedule. The statistical tests were described in detail in the 
November 25, 1992 final rule (57 FR 55938).
    Our decision to convene multispecialty panels of physicians and to 
apply the statistical tests described above was based on our need to 
balance the interests of those who commented on the work RVUs against 
the redistributive effects that would occur in other specialties.
    We also received comments on RVUs that were interim for 2002, but 
which we did not submit to the panel for review for a variety of 
reasons. These comments and our decisions on those comments are 
discussed in further detail below.
    The table below lists the interim code reviewed during the 
refinement process described in this section. This table includes the 
following information:
    [sbull] CPT Code. This is the CPT code for a service.
    [sbull] Description. This is an abbreviated version of the 
narrative description of the code.
    [sbull] 2002 Work RVU. The work RVUs that appeared in the November 
2001 rule are shown for each reviewed code.
    [sbull] Requested Work RVU. This column identifies the work RVUs 
requested by commenters.
    [sbull] 2003 Work RVU. This column contains the final RVUs for 
physician work.

                      Table 5.--Work RVU Refinement of 2002 Interim Codes and Related RVUs
----------------------------------------------------------------------------------------------------------------
  CPT code                                                                   Requested  work
    \1\                      Description                   2002 Work  RVU          RVU           2003 Work  RVU
----------------------------------------------------------------------------------------------------------------
      53853  Transurethral destruction of prostate                    4.14               8.75              5.24
              tissue; by water-induced thermotherapy...
----------------------------------------------------------------------------------------------------------------
\1\ All CPT codes and descriptions copyright 2003 American Medical Association.

    2. Interim 2002 Codes
    CPT Code 00797 Anesthesia for Intraperitoneal Procedures in Upper 
Abdomen Including Laparoscopy; Gastric Restrictive Procedure for Morbid 
Obesity CPT Code 01968 Cesarean Delivery Following Neuraxial Labor 
Analgesia/Anesthesia (List Separately in Addition to Code for Primary 
Procedure
    The RUC recommended that 9 base units be assigned to CPT code 00797 
and 3 base units be assigned to the add-on code CPT code 01968. We did 
not accept the RUC recommended values for these two anesthesia services 
and assigned 8 base units to CPT code 00797 and 2 base units to the 
add-on code CPT code 01968.
    The AMA and the RUC disagreed with the reductions we made to the 
base units and the reasoning as stated in the November 1, 2001 final 
rule behind these reductions. No other comments were received on these 
codes.
    Final Decision: Given that the only comments received were from the 
AMA and RUC and these provided no additional information, we are 
maintaining the base units of 8 for CPT code 00797 and 2 base units for 
the CPT code 01968.
    CPT code 47382 Ablation, one or more liver tumor(s), percutaneous, 
radiofrequency
    We had not received recommendations from the RUC for this procedure 
and assigned work RVUs of 12.00 to this service.
    Specialty organizations indicated that the value assigned was 
inappropriately low and that this would be revisited by the RUC in 
February 2002. They recommended that we take the RUC values into 
consideration for the 2003 Medicare fee schedule.
    Final Decision: We did receive a RUC recommendation of 15.19 for 
CPT code 47382 and are in agreement with the recommended work RVU.
    CPT code 52001 Cystourethroscopy with irrigation and evacuation of 
clots.
    The RUC recommended 5.45 work RVUs based on a comparison to certain 
reference procedures. We had concerns about the descriptor associated 
with this code and based on the descriptor of this CPT code for 2002 
assigned 2.37 RVUs to this procedure. We felt the time and intensity of 
the physician work for this procedure as described was comparable to 
CPT Code 52005. Commenters acknowledged that the descriptor was being 
revised and felt that this would enable us to accept the original RUC 
recommendation of 5.45.
    Final decision: The descriptor for CPT code 52001 has been revised 
for 2003 and the RUC provided a new recommended work RVU of 5.45. We 
agree with the RUC recommended work RVU of 5.45 for CPT code 52001.
    CPT code 53853 Transurethral destruction of prostatic tissue; by 
water induced thermotherapy).
    The RUC recommended 6.41 work RVUs for this procedure. We did not 
agree with the RUC recommendation and based on an analysis of 
intraservice activities, we believed it more appropriate to compare CPT 
code 53853 to 90-day global procedures with less than 30 minutes of 
intraservice time. Based on this we assigned a work RVU of 4.14 to this 
code.
    Commenters disagreed with the RVUs assigned. One commenter provided 
detailed information in support of an increase in work RVUs. Based on 
these comments we referred this code to the multispecialty validation 
panel for review.
    Final decision: As a result of the statistical analysis of the 2002 
multispecialty validation panel ratings, we have assigned 5.24 work 
RVUs to CPT code 53853.
    CPT code 76490 Ultrasound guidance for, and monitoring of, tissue 
ablation
    We did not receive a recommendation from the RUC for this 
procedure. We compared the time and intensity of this procedure to 
other radiologic guidance codes and to radiologic supervision and 
interpretation codes and assigned work RVUs of 2.00 to this code. Two 
specialty groups expressed concern that the assigned RVUs were not 
appropriate and indicated the RUC would be revisiting work RVUs for 
this service in February 2002. They recommended that we take the RUC 
values into consideration for the 2003 Medicare fee schedule.
    Final Decision: We did receive a RUC work RVU recommendation of 
4.00 for this service and are in agreement with this recommendation.
    CPT code 90471 Immunization administration (includes percutaneous, 
intradermal, subcutaneous, intramuscular and jet injections); one 
vaccine (single or combination vaccine/toxoid) and CPT code 90472 
Immunization administration (includes percutaneous, intradermal, 
subcutaneous, intramuscular and jet injections); each additional 
vaccine/toxoid (List separately in addition to code for primary 
procedure) one vaccine
    We disagreed with the RUC recommended work RVU of .17 for CPT code 
90471 and .15 work RVUs for CPT code 90472. To the extent the physician

[[Page 79998]]

performs any counseling related to this service, it is considered part 
of the work of the preventive medicine visit during which the 
immunization was administered. If the vaccine is administered during a 
visit other than a preventive medicine service, any physician 
counseling should be billed separately as an E/M service. Commenters 
disagreed that there is no physician work associated with this service 
particularly in light of the required counseling that must be provided 
by the physician concerning possible reactions to vaccines. Commenters 
also continue to be concerned that Medicaid and private payors will 
base their payment amounts on the ``incomplete'' RVUs established under 
the physician fee schedule, which do not include physician work for 
these services.
    Final Decision: We have addressed the issue of immunization 
administration in a separate section of this rule. We continue to 
believe that there is no physician work associated with this service. 
Please see Section A.(3)(c) (Practice Expense provisions for CY 2003) 
for discussion of this issue.
    CPT code 90473 Immunization administration by intranasal or oral 
route; one vaccine (single or combination vaccine/toxoid); and, CPT 
code 90474 Immunization administration by intranasal or oral route each 
additional vaccine/toxoid (List separately in addition to code for 
primary procedure)
    The RUC recommended a work RVU of .17 for CPT code 90473 and .15 
work RVUs for CPT code 90474. Medicare does not cover self-administered 
vaccines. We did not assign work RVUs to these services as these are 
noncovered services. Commenters disagreed with our assessment that 
there is no physician work associated with these codes.
    Final Decision: As we had previously indicated, Medicare does not 
cover self-administered vaccines. Since these services are not covered 
under Medicare, RVUs are not listed under the physician fee schedule.
    CPT code 93609 Intraventricular and/or intra-atrial mapping of 
tachycardia site(s) with catheter manipulation to record from multiple 
sites to identify origin of tachycardia
    We did not receive a recommendation from the RUC for this service. 
The descriptor for this service did not change, but the AMA CPT 
editorial panel changed the global period for this service from a zero 
day global to a ZZZ global. This means that this is now an ``add-on'' 
code and the physician work RVUs no longer include any pre- or 
postservice work. (It previously had a work RVU of 10.07.) To 
appropriately value this add-on service, we compared it to several 
other electrophysiology services and assigned a work RVU of 4.81 to CPT 
code 93609. Commenters disagreed with the assigned work RVUs and stated 
that this code would be presented at the February 2002 RUC meeting. 
Commenters encouraged us to reconsider the work RVUs for this code 
based on the forthcoming RUC recommendation.
    Final Decision: We have received a RUC recommendation of 5.00 for 
CPT code 93609 for 2003 and are in agreement with this recommendation.
    CPT code 93613 Intracardiac electrophysiologic 3-dimensional 
mapping
    This was a new add-on code for 2002 for which we did not receive a 
recommendation from the RUC. This is a service that does not include 
any pre-or postservice work. Based on a comparison to similar services, 
we believed the intraservice time and intensity of 93613 was slightly 
less than that of CPT code 93619 and therefore assigned 7.00 work RVUs 
to CPT code 93613. Commenters disagreed with our rationale and stated 
that this code would be presented at the February 2002 RUC meeting. 
Commenters encouraged us to reconsider the work RVUs for this code.
    Final Decision: We have received a RUC recommendation of 7.00 for 
CPT code 93613 for 2003 and are in agreement with this recommendation.
    CPT code 93701 Bioimpedence, thoracic, electrical
    We did not accept the RUC recommendation of 0.00 work RVUS but 
assigned this service 0.17 work RVUs based on the value assigned to 
HCPCS code M0302 which is the code used to pay for this service in 
2001. We did indicate that we would consider the RUC recommendation but 
that, if we considered revising the work RVUs, we would discuss any 
proposed change in a future proposed rule. Commenters expressed concern 
that we would revisit this issue as we had addressed valuing of this 
service through rulemaking in 2000. While we retained the work RVUs 
that had been assigned based on rulemaking in 2000 for this service, we 
did want to indicate that, in consideration of the RUC recommendation, 
should we determine that any revisions to the RVUs are necessary, we 
would address revisions in future rulemaking.
    Final Decision: We are retaining the work RVU of 0.17.
    CPT code 95250 Glucose monitoring for up to 72 hours by continuous 
recording and storage of glucose values from interstitial tissue fluid 
via a subcutaneous sensor (includes hook-up, calibration, patient 
initiation and training, recording, disconnection, downloading with 
printout of data)
    We agreed with the RUC recommendation that the physician work value 
for this service was 0.00. Though the physician can bill an E/M code 
for the physician review and interpretation associated with this 
service, commenters believe that use of the E/M code to reflect the 
physician work is not adequate and that the present reimbursement for 
this code will discourage its use.
    Final Decision: The CPT descriptor for this code indicates that it 
is for the ``TC'' only and that, to report the physician review, 
interpretation and written report associated with this code, the 
practitioner should use the E/M service codes. Based on this, we 
believe that the assignment of 0.00 work RVUs is appropriate.
    CPT code 97602 Removal of devitalized tissue from wound(s); non-
selective debridement, without anesthesia (e.g., wet-to-moist 
dressings, enzymatic, abrasion), including topical applications(s), 
wound assessment and instruction(s) for ongoing care, per session
    The HCPAC recommended a work RVU of 0.32 for this service. We 
disagreed with this recommendation and stated that the services of this 
code are bundled into CPT code 97601 and did not establish work RVUs 
for this service. Commenters disagreed with our determination that this 
service should be bundled. Commenters felt that, despite the fact that 
there may be some elements of the service that are common to both 
codes, these codes describe distinct services that are not used 
simultaneously. We have re-examined our determination but have not 
changed our decision. As we explained in last year's final rule, CPT 
code 97602 describes services that typically involve placement of a 
wound covering, for example, wet-to-dry gauze or enzyme-treated 
dressing. It also includes nonspecific removal of devitalized tissue 
that is an inherent part of changing a dressing. This service is 
already included in the work and practice expenses of CPT code 97601. 
In the typical service described by CPT code 97601, the patient has a 
dressing placed over the wound. We would add that the services 
described by CPT code 97602 are also included in the work and practice 
expenses of the whirlpool code, CPT code 97022. For this reason, we 
consider this a bundled service that is not paid separately.

[[Page 79999]]

    Final Decision: As discussed above we will continue to consider 
this a bundled service that is not paid separately.
    CPT code 99091 Collection and interpretation of physiologic data 
(e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or 
transmitted by the patient and/or caregiver to the physician or other 
qualified health care professional, requiring a minimum of 30 minutes 
of time
    The RUC recommended work RVUs of 1.10 for this code. We disagreed 
since this work is considered part of the pre- and post-service work of 
an E/M service and payment for this code is bundled into payment for 
the E/M service. Commenters objected to our bundling of this code and 
believed that the work associated with this service is not captured in 
other services, as this is not a face-to-face service. Some commenters 
felt that the work involved in this code was similar to care plan 
oversight codes, for which we provide separate payment.
    Final Decision: Some portion of both the pre- and post-service work 
of an evaluation and management visit will not be face-to-face. We 
still conclude, as discussed above, that this a bundled service that is 
not paid separately.
    CPT codes 99289 Physician constant attention of the critically ill 
or injured patient during an interfacility transport; first 30-74 
minutes, and 99290, each additional 30 minutes (List separately in 
addition to code for primary service)
    We did not agree with the RUC recommended values of 4.8 work RVUs 
for CPT code 99289 and 2.4 work RVUs for CPT code 99290. We also had 
concerns as to whether the code descriptors for these two new codes, as 
written, met the requirements for critical care. Based on the concerns 
outlined in the November 1, 2001 rule, we decided not to recognize 
these codes for Medicare purposes and created two HCPCS Level II codes 
for use in CY 2002 to describe critical care services provided to 
patients during inter-facility transport. These codes (G0240--Critical 
Care Service delivered by a physician; face-to-face, during inter-
facility transport of a critically ill or critically injured patient: 
first 30-74 minutes of active transport and G0241--each additional 30 
minutes (list separately in addition to G0240) were valued at 4.00 work 
RVUs and 2.00 work RVUs, respectively. Commenters indicated that the 
descriptors for the CPT codes were being revised and requested that we 
reconsider the work relative values for these codes in light of the 
changes that CPT will be making to these codes.
    Final Decision: Based on the changes the CPT Editorial Panel has 
made to the descriptors for CPT codes 99289 and 99290, we are in 
agreement with the RUC recommended work RVUs of 4.80 for 99289 and 2.40 
for 99290 and will use these CPT codes for Medicare purposes. We are 
also eliminating HCPCS codes G0240 and G0241 that had previously been 
used to report these services.
RUC Recommendations on Practice Expense Inputs for 2002 New and Revised 
Codes
    In the November 2001 final rule (66 FR 55310), we responded to the 
RUC recommendations on the practice expense inputs for the new and 
revised CPT codes for CY 2002. We have received two comments on this 
issue.
    Comment: The AMA commented that it was pleased that we accepted 
nearly all of the RUC's recommendations for direct practice expense 
inputs for new and revised codes for CPT 2002.
    Response: We are also pleased that we are receiving recommendations 
on the practice expense inputs that need no modification and thank the 
RUC for the time and effort expended on developing appropriate 
recommendations.
    Comment: Two organizations representing radiation oncologists were 
opposed to the reduction of the recommended clinical staff time for a 
radiation therapist from 123 to 60 minutes for CPT code 77418, 
intensity modulated treatment delivery. One of the comments argued that 
there is no overlap of clinical staff time with other services and that 
the typical time is over 60 minutes for this procedure. Both comments 
contend that for quality of care purposes two therapists are required.
    Response: In the November 2001 final rule (66 FR 55310), we 
accepted, as interim, the RUC's recommendations for practice expense 
inputs for CPT code 77418, except that we reduced the staff time from 
120 minutes (60 minutes for each of two radiation technologists) to 60 
minutes (for one radiation technologist). We still believe that this 
reduction in staff time is appropriate. IMRT is currently delivered in 
multiple fractions on a daily basis and is usually administered to 
patients with prostate cancer or tumors of the head and neck. Most of 
the treatments take considerably less than 60 minutes and only one 
technologist is required to actually deliver the treatment, as the 
parameters are preprogrammed into a computer. Further, any time spent 
adjusting the radiation fields using ultrasound or computed tomography 
is separately payable. We believe that 60 minutes of staff time 
adequately accounts for the pre-, intra-, and post-service staff 
resources used to provide this service.
    We received the following comments on HCPCS codes established in 
the November 1, 2001 final rule.
    [sbull] Respiratory Therapy Codes
    G0237 Therapeutic Procedures To Increase Strength or Endurance of 
Respiratory Muscles, Face-to-Face, One-on-One, Each 15 Minutes 
(Includes Monitoring); G0238 Therapeutic Procedures To Improve 
Respiratory Function, Other Than Described by G0237, One-on-One, Face-
to-Face, per 15 Minutes (Includes Monitoring); and G0239 Therapeutic 
Procedures To Improve Respiratory Function, Two or More Patients 
Treated During the Same Period, Face-to-Face (Includes Monitoring).
    Note that we have revised the descriptor for G0239 for clarity, and 
discussed this in section IV(C).
    While several organizations expressed appreciation for the 
establishment of these codes, they requested clarification on the 
following points:
    Comment: Commenters asked whether nurses could also use these 
codes.
    Response: Physicians can use these codes if nurses are providing 
services ``incident to'' a physician's service, with the physician in 
the suite in his or her office, and the codes may be used in a 
comprehensive outpatient rehabilitation facility (CORF) or a hospital 
outpatient department. Since there is no respiratory therapy or 
pulmonary rehabilitation benefit, respiratory therapists can provide 
these services only in a CORF or under the ``incident to'' provision in 
a physician's office or in the hospital outpatient setting.
    Comment: Commers requested clarification of the term ``monitoring'' 
used in all three of these code descriptions.
    Response: Monitoring provides physiologic or other data about the 
patient during the period before, during, and after the activities. It 
can represent, for example, pulse oximetry readings, 
electrocardiography data, pulmonary testing measurements, or 
measurements of strength or endurance performed to assess the status of 
the patient before, during, and after the activities. An example would 
be pursed-lip breathing which involves nasal inspiration followed by 
slow exhalations through partially closed pursed lips to create 
positive pressure in upper respiratory tract, and improve respiratory 
muscles action. If, after this training, the practitioner were to check 
the patient's oxygen saturation level (via pulse oximetry), peak 
respiratory flow, or

[[Page 80000]]

other respiratory parameters, then this would be considered 
``monitoring.'' Payment for this monitoring is bundled into G0237 and 
not paid separately as a diagnostic test.
    Comment: Another asked about the differences between the G codes.
    Response: G0237 involves therapeutic procedures specifically 
targeted at improving the strength and endurance of respiratory 
muscles. Examples include pursed-lip breathing, diaphragmatic 
breathing, and paced breathing (strengthening the diaphragm by 
breathing through tubes of progressively increasing resistance to 
flow). G0238 involves a variety of activities including teaching 
patients strategies for performing tasks with less respiratory effort 
and the performance of graded activity programs to increase endurance 
and strength of upper and lower extremities. G0238 does not include 
demonstration of the use of nebulizer or inhaler or chest percussions 
because these services are described by other CPT codes (94664 and 
94667, respectively). G0239 represents situations in which two or more 
patients are receiving services simultaneously (such as those described 
above in G0237 or G0238) during the same time period. The practitioners 
must be in constant attendance but need not be providing one-on-one 
contact. For example, a therapist provides medically necessary 
therapeutic procedures to two patients (A and B) in the same gym, for a 
30-minute period. Both are performing different graded activities 
(described by G0238) to increase endurance of their upper and lower 
extremities while the therapist divides his/her time--in intermittent, 
brief episodes--between patients A and B. In this scenario the 
therapist would bill each patient for group therapy (G0239) because the 
treatment was provided simultaneously to two patients, and not one-on-
one, as required by G0238.
    Comment: Commers requested clarification concerning use of G0237, 
G0238, and G0239 codes and whether these codes can be billed more than 
once a day.
    Response: G0237 and G0238 are timed codes, reported for each 15 
minutes of one-on-one face-to-face treatment. They can be reported with 
more than one unit per patient per day, depending upon the duration of 
treatment. G0239 is not a timed code and thus should be reported only 
once a day for each patient in the group.
    Comment: Clarification was also requested about whether the 
physician must certify the services every 30 days.
    Response: The 30-day certification and recertification of the plan 
of care requirement applies to the services of physical therapists, 
occupational therapists, and speech language pathologists as described 
in section 1861(p) of the Act. Since we expected G0237, G0238, and 
G0239 typically to be provided by respiratory therapists, the 30-day 
certification and recertification of the plan of care requirement does 
not generally apply. If the services are performed by either a physical 
or occupational therapist (or by a therapy assistant under his or her 
direction), the requirement for the 30-day certification and 
recertification applies. Additionally, all services provided in the 
CORF setting including G0237, G0238, and G0239 require 60-day 
certification and recertification of the plan of care.
    Comment: One commenter asked whether the ``NA'' in the facility 
total column indicated that these codes are not for use in the hospital 
outpatient setting.
    Response: As stated above, these codes are appropriate for use in 
the hospital outpatient setting. The ``NA'' refers to the fact that in 
the hospital outpatient setting, these codes are paid under the 
hospital outpatient prospective payment system and are assigned to an 
APC, rather than being paid on the physician fee schedule.
    Comment: Commenters also asked for the specific clinical situations 
in which the use of these codes is appropriate.
    Response: All services must meet the test of being ``reasonable and 
necessary'' pursuant to section 1862(a)(1)(A) of the Act. 
Determinations of medical necessity have been made by carriers and 
intermediaries on a claim-by-claim basis in their local medical review 
policies. We believe that this is the appropriate manner to address 
these questions, and many of our contractors have already developed 
these policies. We note however, there is no explicit pulmonary 
rehabilitation benefit.
    Comment: Commenters asked whether respiratory therapists would be 
precluded from using additional CPT codes to bill for their pulmonary-
rehabilitation related services.
    Response: We reiterate that codes G0237, G0238, and G0239 were 
developed to provide more specificity about the services being 
delivered. Thus, CPT codes 97000 to 97799 are not to be billed by 
professionals involved in treating respiratory conditions, unless these 
services are delivered by physical or occupational therapists and meet 
the other requirements for physical and occupational therapy services. 
Also CPT code 99211, (office or other outpatient visit for evaluation 
and management), should not be used by practitioners providing 
outpatient respiratory or pulmonary therapy services.
Revisions to Malpractice RVUs for New and Revised CPT Codes for 2002
    Malpractice RVUs are calculated using the methodology described in 
detail at Addendum G of our November 1, 2000 final rule (65 FR 65589). 
Because of the timing of the release of new and revised CPT codes each 
year, the malpractice RVUs for the first year of these codes are 
extrapolated from existing similar codes based on the advice of our 
medical consultants and are considered interim subject to public 
comment and our revision. The following year, these codes are given 
values based on our malpractice RVU methodology and a review of any 
comments received.
    The malpractice RVUs for new and revised codes for CY 2002 
published in Addendum B of the November 2001 final rule, were 
extrapolated from existing similar codes. The malpractice RVUs for 
these codes in this year's Addendum B were calculated by our 
consultant, KPMG, using the same methodology used for all other codes. 
Likewise, the malpractice RVUs for new and revised codes for CY 2003 
are being extrapolated from existing similar codes and will be 
calculated using the malpractice RVU methodology next year.
    Comment: The American College of Radiology continues to be 
concerned about the increasing liability costs for radiology and 
radiation oncology. They would like us to explore and ultimately 
implement a change in the malpractice methodology. They stated that 
radiologists and radiation oncologists bear the majority of costs for 
liability insurance; therefore, the larger proportion of malpractice 
value should be included in the PC and the smaller portion in the TC.
    Response: While we can understand the concern about rising 
liability costs, we do not believe that radiology and radiation 
oncology are the only specialties facing such increases. We also do not 
agree that the larger proportion of malpractice values should be 
associated with the PC component of the service. As we have explained 
in previous physician fee schedule rules, 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 insurance) represent only

[[Page 80001]]

the interpretation of the test by the physician. Generally, the TC RVUs 
for radiology services are significantly higher than the PC RVUs 
because of the very expensive equipment and supplies. The malpractice 
RVUs are generally split in similar proportion between PC and TC as are 
the practice expense RVUs. In cases when 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 (which would include 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: The American Occupational Therapy Association indicated 
that for computing malpractice RVUs, occupational therapy was 
incorrectly crosswalked to occupational medicine (Insurance Service 
Office (ISO) code 80233). They suggested the appropriate crosswalk is 
to physical medicine and rehabilitation (ISO 80235).
    Response: We agree with the commenter that a more appropriate 
crosswalk for occupational therapy is to physical medicine and 
rehabilitation as opposed to occupational medicine. The original data 
that were used to calculate malpractice RVUs were based upon 1993 to 
1995 malpractice premium data. These data were replaced with more 
recent premium data (1996 to 1998). The resulting risk factors are 
published in the November 2000 final rule (65 FR 65594). These more 
recent premium data place occupation medicine, occupational therapy, 
and physical medicine and rehabilitation into the same risk 
classification. Due to this update to the risk classifications, 
revising the crosswalk for occupational therapy will have no effect; 
nonetheless, for purposes of accuracy, we will change the occupational 
therapy crosswalk at the next scheduled update to malpractice premium 
data in CY 2005.
Establishment of Interim Work Relative Value Units for New and Revised 
Physician's Current Procedural Terminology (CPT) Codes and New 
Healthcare Common Procedure Coding System Codes (HCPCS) for 2003 
(Includes Table titled American Medical Association Specialty Relative 
Value Update Committee and Health Care Professionals Advisory Committee 
Recommendations and CMS's Decisions for New and Revised 2003 CPT Codes)
    One aspect of establishing RVUs for 2003 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 physician fee 
schedule (57 FR 55983) and in section III.B. of the 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 
249 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 had 
previously been established, 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 the 
relative relationships reflected in the RUC values. In some instances, 
when we agreed with the relationships, we nonetheless revised the work 
RVUs 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 will be the 
same as the sum of the current work RVUs (weighted by projected 
frequency of use). For approximately 96 percent of the RUC 
recommendations, proposed work RVUs were reviewed and accepted, and, 
for approximately 4 percent, we disagreed with the RUC recommended 
values. In the majority of these instances, we agreed with the 
relativity established by the RUC, but needed to adjust work RVUs to 
retain budget neutrality.
    There were also 22 CPT codes for which we did not receive a RUC 
recommendation. After a review of these CPT codes by our staff and 
medical officers, we established interim work RVUs for the majority of 
these services. For those services for which we could not arrive at 
interim work RVUs, we have assigned a carrier-priced status until such 
time as the RUC provides work RVU recommendations.
    We received 22 recommendations from the Health Care Professionals 
Advisory Committee (HCPAC). We agreed with approximately 86 percent of 
the HCPAC recommendations and disagreed with approximately 14 percent 
of the HCPAC recommendations.
    We have also included, in Table 6, 34 codes for which the RUC has 
submitted revisions to their original 2002 recommendations. These CPT 
codes are identified with an ``L'' in Table 6.
    Table 6, titled ``AMA RUC and HCPAC Recommendations and CMS 
Decisions for New and Revised 2003 CPT Codes'', lists the new or 
revised CPT codes, and their associated work RVUs, that will be interim 
in 2003. This table includes the following information:
    [sbull] A ``'' identifies a new code for 2003.
    [sbull] CPT code. This is the CPT code for a service.
    [sbull] Modifier. A ``26'' in this column indicates that the work 
RVUs are for the professional component of the code.
    [sbull] Description. This is an abbreviated version of the 
narrative description of the code.
    [sbull] RUC recommendations. This column identifies the work RVUs 
recommended by the RUC.
    [sbull] HCPAC recommendations. This column identifies the work RVUs 
recommended by the HCPAC.
    [sbull] CMS decision. This column indicates whether we agreed with 
the RUC recommendation (``agree'') or we disagreed with the RUC 
recommendation (``disagree''). Codes for which we did not accept the 
RUC recommendation are discussed in greater detail following this 
table. An ``(a)'' indicates that no RUC recommendation was provided.
    [sbull] 2003 Work RVUs. This column establishes the 2003 work RVUs 
for physician work.

[[Page 80002]]



                                                                         Table 6
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                            RUC               HCPAC
 *CPT code               Mod                     Description           recommendation     recommendation          CMS decision           2003 Work RVU
--------------------------------------------------------------------------------------------------------------------------------------------------------
      11400  ..........................  Exc tr-ext b9+marg 0.5 <                 0.85  .................  Agree.....................               0.85
                                          cm.
      11401  ..........................  Exc tr-ext b9+marg 0.6-1                 1.23  .................  Agree.....................               1.23
                                          cm.
      11402  ..........................  Exc tr-ext b9+marg 1.1-2                 1.51  .................  Agree.....................               1.51
                                          cm.
      11403  ..........................  Exc tr-ext b9+marg 2.1-3                 1.79  .................  Agree.....................               1.79
                                          cm.
      11404  ..........................  Exc tr-ext b9+marg 3.1-4cm               2.06  .................  Agree.....................               2.06
      11406  ..........................  Exc tr-ext b9+marg  4.0 cm.
      11420  ..........................  Exc h-f-nk-sp b9+marg 0.5                0.98  .................  Agree.....................               0.98
                                          <.
      11421  ..........................  Exc h-f-nk-sp b9+marg 0.6-               1.42  .................  Agree.....................               1.42
                                          1.
      11422  ..........................  Exc h-f-nk-sp b9+marg 1.1-               1.63  .................  Agree.....................               1.63
                                          2.
      11423  ..........................  Exc h-f-nk-sp b9+marg 2.1-               2.01  .................  Agree.....................               2.01
                                          3.
      11424  ..........................  Exc h-f-nk-sp b9+marg 3.1-               2.43  .................  Agree.....................               2.43
                                          4.
      11426  ..........................  Exc h-f-nk-sp b9+marg  4 cm.
      11440  ..........................  Exc face-mm b9+marg 0.5 <                1.06  .................  Agree.....................               1.06
                                          cm.
      11441  ..........................  Exc face-mm b9+marg 0.6-1                1.48  .................  Agree.....................               1.48
                                          cm.
      11442  ..........................  Exc face-mm b9+marg 1.1-2                1.72  .................  Agree.....................               1.72
                                          cm.
      11443  ..........................  Exc face-mm b9+marg 2.1-3                2.29  .................  Agree.....................               2.29
                                          cm.
      11444  ..........................  Exc face-mm b9+marg 3.1-4                3.14  .................  Agree.....................               3.14
                                          cm.
      11446  ..........................  Exc face-mm b9+marg  4 cm.
      11600  ..........................  Exc tr-ext mlg+marg 0.5 <                1.31  .................  Agree.....................               1.31
                                          cm.
      11601  ..........................  Exc tr-ext mlg+marg 0.6-1                1.80  .................  Agree.....................               1.80
                                          cm.
      11602  ..........................  Exc tr-ext mlg+marg 1.1-2                1.95  .................  Agree.....................               1.95
                                          cm.
      11603  ..........................  Exc tr-ext mlg+marg 2.1-3                2.19  .................  Agree.....................               2.19
                                          cm.
      11604  ..........................  Exc tr-ext mlg+marg 3.1-4                2.40  .................  Agree.....................               2.40
                                          cm.
      11606  ..........................  Exc tr-ext mlg+marg  4 cm.
      11620  ..........................  Exc h-f-nk-sp mlg+marg 0.5               1.19  .................  Agree.....................               1.19
                                          <.
      11621  ..........................  Exc h-f-nk-sp mlg+marg 0.6-              1.76  .................  Agree.....................               1.76
                                          1.
      11622  ..........................  Exc h-f-nk-sp mlg+marg 1.1-              2.09  .................  Agree.....................               2.09
                                          2.
      11623  ..........................  Exc h-f-nk-sp mlg+marg 2.1-              2.61  .................  Agree.....................               2.61
                                          3.
      11624  ..........................  Exc h-f-nk-sp mlg+marg 3.1-              3.06  .................  Agree.....................               3.06
                                          4.
      11626  ..........................  Exc h-f-nk-sp mlg+mar  4 cm.
      11640  ..........................  Exc face-mm malig+marg 0.5               1.35  .................  Agree.....................               1.35
                                          <.
      11641  ..........................  Exc face-mm malig+marg 0.6-              2.16  .................  Agree.....................               2.16
                                          1.
      11642  ..........................  Exc face-mm malig+marg 1.1-              2.59  .................  Agree.....................               2.59
                                          2.
      11643  ..........................  Exc face-mm malig+marg 2.1-              3.10  .................  Agree.....................               3.10
                                          3.
      11644  ..........................  Exc face-mm malig+marg 3.1-              4.03  .................  Agree.....................               4.03
                                          4.
      11646  ..........................  Exc face-mm mlg+marg  4 cm.
    L 11981  ..........................  Insert drug implant device               1.48  .................  Agree.....................               1.48
    L 11982  ..........................  Remove drug implant device               1.78  .................  Agree.....................               1.78
    L 11983  ..........................  Remove/insert drug implant               3.30  .................  Agree.....................               3.30
      17304  ..........................  1 stage mohs, up to 5 spec               7.60  .................  Agree.....................               7.60
      17305  ..........................  2 stage mohs, up to 5 spec               2.85  .................  Agree.....................               2.85
      17306  ..........................  3 stage mohs, up to 5 spec               2.85  .................  Agree.....................               2.85
      17307  ..........................  Mohs addl stage up to 5                  2.85  .................  Agree.....................               2.85
                                          spec.
      17310  ..........................  Mohs any stage                0.95  .................  Disagree..................               0.62
                                          5 spec each.
    L 20526  ..........................  Ther injection, carp                     0.94  .................  Agree.....................               0.94
                                          tunnel.
    L 20550  ..........................  Inj tendon sheath/ligament               0.75  .................  Agree.....................               0.75
    L 20551  ..........................  Inject tendon origin/                    0.75  .................  Agree.....................               0.75
                                          insert.
    L 20552  ..........................  Inject trigger point, 1 or               0.66  .................  Agree.....................               0.66
                                          2.
    L 20553  ..........................  Inject trigger points, =/                0.75  .................  Agree.....................               0.75
                                           3.
    L 20600  ..........................  Drain/inject, joint/bursa.               0.66  .................  Agree.....................               0.66
     L20605  ..........................  Drain/inject, joint/bursa.               0.68  .................  Agree.....................               0.68
    # 20612  ..........................  Aspirate/inj ganglion cyst               0.70  .................  Agree.....................               0.70
      21030  ..........................  Excise max/zygoma b9 tumor                (a)  .................   (a)......................               3.89
      21034  ..........................  Excise max/zygoma mlg                   16.17  .................  Agree.....................              16.17
                                          tumor.
      21040  ..........................  Removal of jaw bone lesion                (a)  .................   (a)......................               3.89
    # 21046  ..........................  Remove mandible cyst                    13.00  .................  Agree.....................              13.00
                                          complex.
    # 21047  ..........................  Excise lwr jaw cyst w/                  18.75  .................  Agree.....................              18.75
                                          repair.
    # 21048  ..........................  Remove maxilla cyst                     13.50  .................  Agree.....................              13.50
                                          complex.
    # 21049  ..........................  Excise uppr jaw cyst w/                 18.00  .................  Agree.....................              18.00
                                          repair.
      21740  ..........................  Reconstruction of sternum.              16.50  .................  Agree.....................              16.50
    # 21742  ..........................  Repair sternum/nuss w/o                   (a)  .................  (a).......................            carrier
                                          scope.
    # 21743  ..........................  Repair sternum/nuss w/                    (a)  .................  (a).......................            carrier
                                          scope.
      23410  ..........................  Repair rotator cuff, acute              12.45  .................  Agree.....................              12.45
      23412  ..........................  Repair rotator cuff,                    13.31  .................  Agree.....................              13.31
                                          chronic.
    L 24344  ..........................  Reconstruct elbow lat                   14.00  .................  Agree.....................              14.00
                                          ligmnt.
    L 24346  ..........................  Reconstruct elbow med                   14.00  .................  Agree.....................              14.00
                                          ligmnt.
      25320  ..........................  Repair/revise wrist joint.              10.77  .................  Agree.....................              10.77
      27425  ..........................  Lat retinacular release                  5.22  .................  Agree.....................               5.22
                                          open.
      27730  ..........................  Repair of tibia epiphysis.               7.41  .................  Agree.....................               7.41
      27732  ..........................  Repair of fibula epiphysis               5.32  .................  Agree.....................               5.32
      27734  ..........................  Repair of lower leg                      8.48  .................  Agree.....................               8.48
                                          epiphysis.

[[Page 80003]]

 
      27870  ..........................  Fusion of ankle joint,                  13.91  .................  Agree.....................              13.91
                                          open.
      29806  ..........................  Shoulder arthroscopy/                   14.37  .................  Agree.....................              14.37
                                          surgery.
    # 29827  ..........................  Arthroscop rotator cuff                 15.36  .................  Agree.....................              15.36
                                          repr.
    # 29873  ..........................  Knee arthroscopy/surgery..               6.00  .................  Agree.....................               6.00
    # 29899  ..........................  Ankle arthroscopy/surgery.              13.91  .................  Agree.....................              13.91
    # 33215  ..........................  Reposition pacing-defib                  4.44  .................  Disagree..................               4.76
                                          lead.
      33216  ..........................  Insert lead pace-defib,                  5.39  .................  Disagree..................               5.78
                                          one.
      33217  ..........................  Insert lead pace-defib,                  5.75  .................  Agree.....................               5.75
                                          dual.
    # 33224  ..........................  Insert pacing lead &                     9.05  .................  Agree.....................               9.05
                                          connect.
    # 33225  ..........................  L ventric pacing lead add-               8.34  .................  Agree.....................               8.34
                                          on.
    # 33226  ..........................  Reposition L ventric lead.               8.69  .................  Agree.....................               8.69
    # 33508  ..........................  Endoscopic vein harvest...               0.31  .................  Agree.....................               0.31
  \L\ 33979  ..........................  Insert intracorporeal                   46.00  .................  Agree.....................              46.00
                                          device.
  \L\ 33980  ..........................  Remove intracorporeal                   56.25  .................  Agree.....................              56.25
                                          device.
      34812  ..........................  Xpose for endoprosth,                    6.75  .................  Agree.....................               6.75
                                          femorl.
      34825  ..........................  Endovasc extend prosth,                 12.00  .................  Agree.....................              12.00
                                          init.
      34826  ..........................  Endovasc extend prosth,                  4.13  .................  Agree.....................               4.13
                                          addl.
    # 34833  ..........................  Xpose for endoprosth,                   12.00  .................  Agree.....................              12.00
                                          iliac.
    # 34834  ..........................  Xpose, endoprosth,                       5.35  .................  Agree.....................               5.35
                                          brachial.
    # 34900  ..........................  Endovasc iliac repr w/                  16.38  .................  Agree.....................              16.38
                                          graft.
    # 35572  ..........................  Harvest femoropopliteal                  6.82  .................  Agree.....................               6.82
                                          vein.
      36415  ..........................  Routine venipuncture......               0.00  .................  Agree.....................               0.00
    # 36416  ..........................  Capillary blood draw......               0.00  .................  Agree.....................               0.00
    # 36511  ..........................  Apheresis wbc.............                (a)  .................  (a).......................               1.74
    # 36512  ..........................  Apheresis rbc.............                (a)  .................  (a).......................               1.74
    # 36513  ..........................  Apheresis platelets.......                (a)  .................  (a).......................               1.74
    # 36514  ..........................  Apheresis plasma..........                (a)  .................  (a).......................               1.74
    # 36515  ..........................  Apheresis, adsorp/reinfuse                (a)  .................  (a).......................               1.74
    # 36516  ..........................  Apheresis, selective......                (a)  .................  (a).......................               1.74
    # 36536  ..........................  Remove cva device obstruct               3.60  .................  Agree.....................               3.60
    # 36537  ..........................  Remove cva lumen obstruct.               0.75  .................  Agree.....................               0.75
      36540  ..........................  Collect blood venous                     0.00  .................  Agree.....................               0.00
                                          device.
    # 37182  ..........................  Insert hepatic shunt                    17.00  .................  Agree.....................              17.00
                                          (tips).
    # 37183  ..........................  Remove hepatic shunt                     8.00  .................  Agree.....................               8.00
                                          (tips).
    # 37500  ..........................  Endoscopy ligate perf                   11.00  .................  Agree.....................              11.00
                                          veins.
      37760  ..........................  Ligation, leg veins, open.              10.47  .................  Agree.....................              10.47
    # 38204  ..........................  Bl donor search management               2.00  .................  Disagree..................               0.00
    # 38205  ..........................  Harvest allogenic stem                   1.50  .................  Agree.....................               1.50
                                          cells.
    # 38206  ..........................  Harvest auto stem cells...               1.50  .................  Agree.....................               1.50
    # 38207  ..........................  Cryopreserve stem cells...                (a)  .................  (a).......................               0.00
    # 38208  ..........................  Thaw preserved stem cells.                (a)  .................  (a).......................               0.00
    # 38209  ..........................  Wash harvest stem cells...                (a)  .................  (a).......................               0.00
    # 38210  ..........................  T-cell depletion of                       (a)  .................  (a).......................               0.00
                                          harvest.
    # 38211  ..........................  Tumor cell deplete of                     (a)  .................  (a).......................               0.00
                                          harvest.
    # 38212  ..........................  Rbc depletion of harvest..                (a)  .................  (a).......................               0.00
    # 38213  ..........................  Platelet deplete of                       (a)  .................  (a).......................               0.00
                                          harvest.
    # 38214  ..........................  Volume deplete of harvest.                (a)  .................  (a).......................               0.00
    # 38215  ..........................  Harvest stem cell                         (a)  .................  (a).......................               0.00
                                          concentrte.
    # 38242  ..........................  Lymphocyte infuse                        1.71  .................  Agree.....................               1.71
                                          transplant.
    # 43201  ..........................  Esoph scope w/submucous                  2.09  .................  Agree.....................               2.09
                                          inj.
    # 43236  ..........................  Uppr gi scope w/submuc inj               2.92  .................  Agree.....................               2.92
      43245  ..........................  Uppr gi scope dilate                     3.18  .................  Agree.....................               3.18
                                          strictr.
    # 44206  ..........................  Lap part colectomy w/stoma              27.00  .................  Agree.....................              27.00
    # 44207  ..........................  L colectomy/                            30.00  .................  Agree.....................              30.00
                                          coloproctostomy.
    # 44208  ..........................  L colectomy/                            32.00  .................  Agree.....................              32.00
                                          coloproctostomy.
    # 44210  ..........................  Laparo total                            28.00  .................  Agree.....................              28.00
                                          proctocolectomy.
    # 44211  ..........................  Laparo total                            35.00  .................  Agree.....................              35.00
                                          proctocolectomy.
    # 44212  ..........................  Laparo total                            32.50  .................  Agree.....................              32.50
                                          proctocolectomy.
    # 44701  ..........................  Intraop colon lavage add-                3.10  .................  Agree.....................               3.10
                                          on.
    # 45335  ..........................  Sigmoidoscope w/submuc inj               1.46  .................  Disagree..................               1.36
    # 45340  ..........................  Sig w/balloon dilation....               1.96  .................  Disagree..................               1.66
    # 45381  ..........................  Colonoscope, submucous inj               4.30  .................  Disagree..................               4.20
    # 45386  ..........................  Colonoscope dilate                       4.58  .................  Agree.....................               4.58
                                          stricture.
    # 46706  ..........................  Repr of anal fistula w/                  2.95  .................  Disagree..................               2.39
                                          glue.
  \L\ 47370  ..........................  Laparo ablate liver tumor               19.69  .................  Agree.....................              19.69
                                          rf.
  \L\ 47371  ..........................  Laparo ablate liver                     19.69  .................  Agree.....................              19.69
                                          cryosurg.
  \L\ 47380  ..........................  Open ablate liver tumor rf              23.00  .................  Agree.....................              23.00
  \L\ 47381  ..........................  Open ablate liver tumor                 23.27  .................  Agree.....................              23.27
                                          cryo.
  \L\ 47382  ..........................  Percut ablate liver rf....              15.19  .................  Agree.....................              15.19
    # 49419  ..........................  Insrt abdom cath for                     6.65  .................  Agree.....................               6.65
                                          chemotx.
    # 49904  ..........................  Omental flap, extra-abdom.              20.00  .................  Agree.....................              20.00

[[Page 80004]]

 
      49905  ..........................  Omental flap, intra-abdom.               6.55  .................  Agree.....................               6.55
    # 50542  ..........................  Laparo ablate renal mass..              20.00  .................  Agree.....................              20.00
    # 50543  ..........................  Laparo partial nephrectomy              25.50  .................  Agree.....................              25.50
    # 50562  ..........................  Renal scope w/tumor resect              10.90  .................  Agree.....................              10.90
    # 55866  ..........................  Laparo radical                          30.74  .................  Agree.....................              30.74
                                          prostatectomy.
    # 51701  ..........................  Insert bladder catheter...               0.50  .................  Agree.....................               0.50
    # 51702  ..........................  Insert temp bladder cath..               0.50  .................  Agree.....................               0.50
    # 51703  ..........................  Insert bladder cath,                     1.47  .................  Agree.....................               1.47
                                          complex.
    # 51798  ..........................  Us urine capacity measure.               0.38  .................  Disagree..................               0.11
      53440  ..........................  Male sling procedure......              13.62  .................  Agree.....................              13.62
      53442  ..........................  Remove/revise male sling..              11.57  .................  Agree.....................              11.57
    # 56820  ..........................  Exam of vulva w/scope.....               1.50  .................  Agree.....................               1.50
    # 56821  ..........................  Exam/biopsy of vulva w/                  2.05  .................  Agree.....................               2.05
                                          scope.
    # 57420  ..........................  Exam of vagina w/scope....               1.60  .................  Agree.....................               1.60
    # 57421  ..........................  Exam/biopsy of vag w/scope               2.20  .................  Agree.....................               2.20
    # 57452  ..........................  Exam of cervix w/scope....               1.50  .................  Agree.....................               1.50
    # 57454  ..........................  Bx/curett of cervix w/                   2.33  .................  Agree.....................               2.33
                                          scope.
    # 57455  ..........................  Biopsy of cervix w/scope..               1.99  .................  Agree.....................               1.99
    # 57456  ..........................  Endocerv curettage w/scope               1.85  .................  Agree.....................               1.85
    # 57460  ..........................  Bx of cervix w/scope, leep               2.83  .................  Agree.....................               2.83
    # 57461  ..........................  Conz of cervix w/scope,                  3.44  .................  Agree.....................               3.44
                                          leep.
      58140  ..........................  Myomectomy abdom method...              14.60  .................  Agree.....................              14.60
      58145  ..........................  Myomectomy vag method.....               8.04  .................  Agree.....................               8.04
    # 58146  ..........................  Myomectomy abdom complex..              19.00  .................  Agree.....................              19.00
      58260  ..........................  Vaginal hysterectomy......              12.98  .................  Agree.....................              12.98
      58262  ..........................  Vag hyst including t/o....              14.77  .................  Agree.....................              14.77
      58263  ..........................  Vag hyst w/t/o & vag                    16.06  .................  Agree.....................              16.06
                                          repair.
      58267  ..........................  Vag hyst w/urinary repair.              17.04  .................  Agree.....................              17.04
      58270  ..........................  Vag hyst w/enterocele                   14.26  .................  Agree.....................              14.26
                                          repair.
    # 58290  ..........................  Vag hyst complex..........              19.00  .................  Agree.....................              19.00
    # 58291  ..........................  Vag hyst incl t/o, complex              20.79  .................  Agree.....................              20.79
    # 58292  ..........................  Vag hyst t/o & repair,                  22.08  .................  Agree.....................              22.08
                                          compl.
    # 58293  ..........................  Vag hyst w/uro repair,                  23.06  .................  Agree.....................              23.06
                                          compl.
    # 58294  ..........................  Vag hyst w/enterocele,                  20.28  .................  Agree.....................              20.28
                                          compl.
    # 58545  ..........................  Laparoscopic myomectomy...              14.60  .................  Agree.....................              14.60
    # 58546  ..........................  Laparo-myomectomy, complex              19.00  .................  Agree.....................              19.00
      58550  ..........................  Laparo-asst vag                         14.19  .................  Agree.....................              14.19
                                          hysterectomy.
    # 58552  ..........................  Laparo-vag hyst incl t/o..              14.19  .................  Agree.....................              14.19
    # 58553  ..........................  Laparo-vag hyst, complex..              19.00  .................  Agree.....................              19.00
    # 58554  ..........................  Laparo-vag hyst w/t/o,                  19.00  .................  Agree.....................              19.00
                                          compl.
    # 61316  ..........................  Implt cran bone flap to                  1.39  .................  Agree.....................               1.39
                                          abdo.
    # 61322  ..........................  Decompressive craniotomy..              29.50  .................  Agree.....................              29.50
    # 61323  ..........................  Decompressive lobectomy...              31.00  .................  Agree.....................              31.00
      61340  ..........................  Subtemporal decompression.              18.66  .................  Agree.....................              18.66
    # 61517  ..........................  Implt brain chemotx add-on               1.38  .................  Agree.....................               1.38
    # 61623  ..........................  Endovasc tempory vessel                  9.96  .................  Agree.....................               9.96
                                          occl.
      61624  ..........................  Transcath occlusion, cns..              20.15  .................  Agree.....................              20.15
    # 62148  ..........................  Retr bone flap to fix                    2.00  .................  Agree.....................               2.00
                                          skull.
    # 62160  ..........................  Neuroendoscopy add-on.....               3.00  .................  Agree.....................               3.00
    # 62161  ..........................  Dissect brain w/scope.....              20.00  .................  Agree.....................              20.00
    # 62162  ..........................  Remove colloid cyst w/                  25.25  .................  Agree.....................              25.25
                                          scope.
    # 62163  ..........................  Neuroendoscopy w/fb                     15.50  .................  Agree.....................              15.50
                                          removal.
    # 62164  ..........................  Remove brain tumor w/scope              27.50  .................  Agree.....................              27.50
    # 62165  ..........................  Remove pituit tumor w/                  22.00  .................  Agree.....................              22.00
                                          scope.
      62201  ..........................  Brain cavity shunt w/scope              14.86  .................  Agree.....................              14.86
      62263  ..........................  Epidural lysis mult                      6.14  .................  Agree.....................               6.14
                                          sessions.
    # 62264  ..........................  Epidural lysis on single                 4.43  .................  Agree.....................               4.43
                                          day.
      64415  ..........................  N block inj, brachial                    1.48  .................  Agree.....................               1.48
                                          plexus.
    # 64416  ..........................  N block cont infuse, b                   3.50  .................  Agree.....................               3.50
                                          plex.
      64445  ..........................  N block inj, sciatic, sng.               1.48  .................  Agree.....................               1.48
    # 64446  ..........................  N blk inj, sciatic, cont                 3.25  .................  Agree.....................               3.25
                                          inf.
    # 64447  ..........................  N block inj fem, single...               1.50  .................  Agree.....................               1.50
    # 64448  ..........................  N block inj fem, cont inf.               3.00  .................  Agree.....................               3.00
      64450  ..........................  N block, other peripheral.               1.27  .................  Agree.....................               1.27
    # 66990  ..........................  Ophthalmic endoscope add-                1.51  .................  Agree.....................               1.51
                                          on.
    # 75901  26........................  Remove cva device obstruct               0.49  .................  Agree.....................               0.49
    # 75902  26........................  Remove cva lumen obstruct.               0.39  .................  Agree.....................               0.39
      75953  26........................  Abdom aneurysm endovas rpr               1.36  .................  Agree.....................               1.36
    # 75954  26........................  Iliac aneurysm endovas rpr               2.93  .................  Disagree..................               1.36
      76070  26........................  Ct bone density, axial....               0.25  .................  Agree.....................               0.25
    # 76071  26........................  Ct bone density,                         0.22  .................  Agree.....................               0.22
                                          peripheral.

[[Page 80005]]

 
    L 76085  26........................  Computer mammogram add-on.               0.06  .................  Agree.....................               0.06
   L 76362E  26........................  CAT scan for tissue                      4.00  .................  Agree.....................               4.00
                                          ablation.
    L 76394  26........................  MRI for tissue ablation...               4.25  .................  Agree.....................               4.25
    L 76490  26........................  US for tissue ablation....               4.00  .................  Agree.....................               4.00
    # 76801  ..........................  Ob us < 14 wks, single                   0.99  .................  Agree.....................               0.99
                                          fetus.
    # 76802  ..........................  Ob us < 14 wks, addl fetus               0.83  .................  Agree.....................               0.83
      76805  ..........................  Ob us = 14 wks,               0.99  .................  Agree.....................               0.99
                                          sngl fetus.
      76810  ..........................  Ob us = 14 wks,               0.98  .................  Agree.....................               0.98
                                          addl fetus.
    # 76811  ..........................  Ob us, detailed, sngl                    1.90  .................  Agree.....................               1.90
                                          fetus.
    # 76812  ..........................  Ob us, detailed, addl                    1.78  .................  Agree.....................               1.78
                                          fetus.
      76815  ..........................  Ob us, limited, fetus(s)..               0.65  .................  Agree.....................               0.65
      76816  ..........................  Ob us, follow-up, per                    0.85  .................  Agree.....................               0.85
                                          fetus.
    # 76817  ..........................  Transvaginal us, obstetric               0.75  .................  Agree.....................               0.75
    # 92601  ..........................  Cochlear implt f/up exam <  .................               0.00  Agree.....................               0.00
                                          7.
    # 92602  ..........................  Reprogram cochlear implt <  .................               0.00  Agree.....................               0.00
                                          7.
    # 92603  ..........................  Cochlear implt f/up exam 7  .................               0.00  Agree.....................               0.00
                                          .
    # 92604  ..........................  Reprogram cochlear implt 7  .................               0.00  Agree.....................               0.00
                                          .
    # 92605  ..........................  Eval for nonspeech device   .................               0.00  Agree.....................               0.00
                                          rx.
    # 92606  ..........................  Non-speech device service.  .................               0.00  Agree.....................               0.00
    # 92607  ..........................  Ex for speech device rx,    .................               0.00  Agree.....................               0.00
                                          1hr.
    # 92608  ..........................  Ex for speech device rx     .................               0.00  Agree.....................               0.00
                                          addl.
    # 92609  ..........................  Use of speech device        .................               0.00  Agree.....................               0.00
                                          service.
    # 92610  ..........................  Evaluate swallowing         .................               0.00  Agree.....................               0.00
                                          function.
    # 92611  ..........................  Motion fluoroscopy/swallow  .................               0.00  Agree.....................               0.00
    # 92612  ..........................  Endoscopy swallow tst       .................               1.27  Agree.....................               1.27
                                          (fees).
    # 92613  ..........................  Endoscopy swallow tst       .................               0.99  Disagree..................               0.00
                                          (fees).
    # 92614  ..........................  Laryngoscopic sensory test  .................               1.27  Agree.....................               1.27
    # 92615  ..........................  Eval laryngoscopy sense     .................               0.88  Disagree..................               0.00
                                          tst.
    # 92616  ..........................  Fees w/laryngeal sense      .................               1.88  Agree.....................               1.88
                                          test.
    # 92617  ..........................  Interprt fees/laryngeal     .................               1.10  Disagree..................               0.00
                                          test.
    # 93580  ..........................  Transcath closure of asd..              18.00  .................  Agree.....................              18.00
    # 93581  ..........................  Transcath closure of vsd..              24.43  .................  Agree.....................              24.43
    L 93609  26........................  Map tachycardia, add-on...               5.00  .................  Agree.....................               5.00
    L 93613  ..........................  Electrophys map 3d, add-on               7.00  .................  Agree.....................               7.00
    L 93619  26........................  Electrophysiology                        7.32  .................  Agree.....................               7.32
                                          evaluation.
    L 93620  26........................  Electrophysiology                       11.59  .................  Agree.....................              11.59
                                          evaluation.
    L 93621  26........................  Electrophysiology                        2.10  .................  Agree.....................               2.10
                                          evaluation.
    L 93622  26........................  Electrophysiology                        3.10  .................  Agree.....................               3.10
                                          evaluation.
    # 95990  ..........................  Spin/brain pump refil &                   (a)  .................  (a).......................               0.00
                                          main.
    L 96000  ..........................  Motion analysis, video/3d.  .................               1.80  Agree.....................               1.80
    L 96001  ..........................  Motion test w/ft press      .................               2.15  Agree.....................               2.15
                                          meas.
    L 96002  ..........................  Dynamic surface emg.......  .................               0.41  Agree.....................               0.41
    L 96003  ..........................  Dynamic fine wire emg.....  .................               0.37  Agree.....................               0.37
    L 96004  ..........................  Phys review of motion       .................               2.14  Agree.....................               2.14
                                          tests.
      96530  ..........................  Syst pump refill & main...               0.00  .................  Agree.....................               0.00
    # 96920  ..........................  Laser tx, skin < 250 sq cm               1.15  .................  Agree.....................               1.15
    # 96921  ..........................  Laser tx, skin 250-500 sq                1.17  .................  Agree.....................               1.17
                                          cm.
    # 96922  ..........................  Laser tx, skin                2.10  .................  Agree.....................               2.10
                                          500 sq cm.
    # 99026  ..........................  In-hospital on call                       (a)  .................  (a).......................               0.00
                                          service.
    # 99027  ..........................  Out-of-hosp on call                       (a)  .................  (a).......................               0.00
                                          service.
      99289  ..........................  Ped crit care transport...               4.80  .................  Agree.....................               4.80
      99290  ..........................  Ped crit care transport                  2.40  .................  Agree.....................               2.40
                                          addl.
    # 99293  ..........................  Ped critical care, initial              16.00  .................  Agree.....................              16.00
    # 99294  ..........................  Ped critical care, subseq.               8.00  .................  Agree.....................               8.00
      99295  ..........................  Neonate crit care, initial              18.49  .................  Agree.....................              18.49
      99296  ..........................  Neonate critical care                    8.00  .................  Agree.....................               8.00
                                          subseq.
      99298  ..........................  Neonatal critical care....               2.75  .................  Agree.....................               2.75
    # 99299  ..........................  Ic, lbw infant 1500-2500                 2.50  .................  Agree.....................              2.50
                                          gm.
--------------------------------------------------------------------------------------------------------------------------------------------------------
(a) No Final RUC recommendation provided.
# New CPT codes.
*All CPT codes copyright 2002 American Medical Association.
L Revised 2002 RUC recommendations.

    Table 7, which is titled ``AMA RUC ANESTHESIA RECOMMENDATIONS AND 
CMS DECISIONS FOR NEW AND REVISED 2003 CPT CODES'', lists the new or 
revised CPT codes for anesthesia and their base units that will be 
interim in 2003. This table includes the following information:
    [sbull] CPT code. This is the CPT code for a service.
    [sbull] Description. This is an abbreviated version of the 
narrative description of the code.

[[Page 80006]]

    [sbull] RUC recommendations. This column identifies the base units 
recommended by the RUC.
    [sbull] CMS decision. This column indicates whether we agreed with 
the RUC recommendation (``agree'') or we disagreed with the RUC 
recommendation (``disagree''). Codes for which we did not accept the 
RUC recommendation are discussed in greater detail following this 
table.
    [sbull] 2003 Base Units. This column establishes the 2003 base 
units for these services.

                                                     Table 7
----------------------------------------------------------------------------------------------------------------
                                                    RUC
 *CPT code             Description             recommendation            CMS decision           2003 base units
----------------------------------------------------------------------------------------------------------------
     #00326  Anesth, larynx/trach, < 1 yr..                  7  Agree........................                  7
     #00539  Anesth, trach-bronch reconst..                 18  Agree........................                 18
     #00540  Anesth, chest surgery.........                 12  Agree........................                 12
     #00541  Anesth, one lung ventiliation.                 15  Agree........................                 15
     #00640  Anesth, spine manipulation....                  3  Agree........................                  3
     #00834  Anesth, hernia repair < 1 yr..                  5  Agree........................                  5
     #00836  Anesth hernia repair, preemie.                  6  Agree........................                  6
     #00921  Anesth, vasectomy.............                  3  Agree........................                  3
     #01829  Anesth, dx wrist arthroscopy..                  3  Agree........................                  3
     #01991  Anesth, nerve block/inj.......                  3  Agree........................                  3
     #01992  Anesth, nerve block/inj, prone                  5  Agree........................                 5
----------------------------------------------------------------------------------------------------------------
*All CPT codes copyright 2003 American Medical Association.# New CPT codes.

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 or base unit 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 or base units.
New and Revised Codes for 2003
    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 histopathological preparation 
including the first routine stain (e.g., hematoxylin and eosin, 
toluidine blue); each additional specimen after the first 5 specimens, 
fixed or fresh tissue, any stage (List separately in addition to code 
for primary procedure).
    This add-on code is used to report specimens generated during Mohs 
surgery. Prior to the changes made for 2003, the code was reported once 
for all specimens over five, generated during a particular stage of 
Mohs surgery. In 2003, the code will be used to report each specimen 
over five during a particular stage of Mohs surgery. The RUC 
recommended maintaining 0.95 work RVUs for this code as an interim 
value. We disagree. We share the concerns of the RUC that the specialty 
society recommendation was based on a survey that did not take into 
account the ZZZ global period of this code. Additionally, in order to 
determine whether the current work RVU for 17310 was appropriate, we 
analyzed the current work RVU for 17310 in the context of the work RVUs 
for other Mohs surgery CPT codes. Mohs surgery work RVUs are based on 
Harvard data which is depicted in Table 8 below (all codes have 000 
global periods for 2002):

                                                                         Table 8
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                    Histotechnician Time
      CPT code           2002 Work RVUs           Total time       Intra-service time   Work intensity (work    RN Time (minutes)      (minutes) (CPEP
                                                  (minutes)             (minutes)          RVU/total time)         (CPEP data)              data)
--------------------------------------------------------------------------------------------------------------------------------------------------------
              17304                   7.6                    89                    50                  .085                   202                    50
              17305                  2.85                    62   ....................                 .046                   101                    25
              17306                  2.85                    62   ....................                 .046                   101                    25
              17307                  2.85                    62   ....................                 .046                   101                    25
              17310                  0.95                    31   ....................                 .031                    32                     8
--------------------------------------------------------------------------------------------------------------------------------------------------------

    These data clearly show that the Harvard data appropriately rank 
these services in terms of intensity. We note that, because intra-
service times are not given for all codes, it is impossible to 
calculate intra-service work intensity. The RUC recommendation of 0.95 
work RVUs which is based on a median time of 20 minutes yields a work 
intensity of 0.047 which is higher than the work intensities for CPT 
codes 17305-17307. This would create a rank order anomaly in this 
family of codes.
    We also note that the 2002 descriptor for CPT code 17310 says that 
this code should be reported only once for all specimens more than five 
for a given stage of Mohs. Therefore, we believe that the current work 
RVU represents the total work required for the typical number of 
specimens obtained (beyond five) per stage of Mohs.
    We compared CPT code 17310 with CPT codes 88331 Pathology 
consultation during surgery; first tissue block, with frozen 
section(s), single specimen, and 88332 Pathology consultation during 
surgery; each additional tissue block with frozen section(s). CPT code 
88332 has a work RVU of 0.59 and total physician time of 15 minutes. We 
note that if the RUC survey time (20 minutes) for CPT code 17310 is 
multiplied by the Harvard

[[Page 80007]]

intensity (.031) that a work value of 0.62 is obtained.
    Therefore, we are assigning a work value of 0.62 work RVUs to CPT 
code 17310 pending further recommendations from the RUC. We believe 
this value is appropriate for the new descriptor, which allows 
reporting of CPT code 17310 for each specimen rather than once for all 
specimens. We also believe this work value places this code in correct 
rank order with CPT codes 17304-17307 and with CPT codes 88331 and 
88332.
    We also note that a work value of 0.62 RVUs will not require any 
work neutrality adjustment because it already takes our claims data for 
CPT code 17310 into account.
    CPT Codes 21030, Excision of benign tumor or cyst of maxilla or 
zygoma, by enucleation and curettage, and 21040, Excision of benign 
tumor or cyst of mandible, by enucleation or curettage.
    CPT changed the descriptors for these codes to make the procedure 
more specific, and we have not yet received RUC recommendations for 
these codes. We compared these services to CPT Codes 21555, Excision 
tumor, soft tissue of neck or thorax; subcutaneous (work RVU of 4.35), 
28043, Excision, tumor, foot; subcutaneous tissue (work RVU 3.54), 
28108, Excision or curettage of bone cyst or benign tumor, phalanges of 
foot (work RVU 4.16), 21501, Incision and drainage, deep abscess or 
hematoma, soft tissues of neck or thorax (work RVU 3.81), 26115 
Excision, tumor or vascular malformation, soft tissue of hand or 
finger; subcutaneous (work RVU 3.86), and 24075 Excision, tumor, soft 
tissue of upper arm or elbow area; subcutaneous (work RVU 3.92). We 
believe that 21030 and 21040 are most similar to 24075 and 26115 in 
terms of physician work and are assigning interim RVUs of 3.89 for both 
of these procedures. We are crosswalking the malpractice RVUs from 
current CPT Code 21030 (0.60 RVUs) to these procedures.
    CPT Codes 21740 Reconstructive repair of pectus excavatum or 
carinatum; open and 21742 Reconstructive repair of pectus excavatum or 
carinatum; minimally invasive approach (Nuss procedure) with 
thoracoscopy
    We have not received the final recommendation from the RUC on these 
services and carriers will price these services in 2003.
    CPT codes 33215 Repositioning of previously implanted transvenous 
pacemaker or pacing cardioverter-defibrillator (right atrial or right 
ventricular) electrode and 33216 Insertion of transvenous electrode; 
single chamber (one electrode) permanent pacemaker or single chamber 
pacing cardioverter-defibrillator
    We received a RUC recommendation of 4.44 work RVUs for CPT code 
33215 and a RUC recommendation of 5.39 work RVUs for CPT code 33216. 
Previously, both the insertion and repositioning of the electrodes were 
billed under CPT code 33216. Effective January 1, 2003, CPT code 33215 
will be used to report the repositioning of a previously implanted 
transvenous pacemaker or pacing cardioverter-defibrillator electrode, 
while CPT 33216 will be used to report the insertion of a transvenous 
electrode. Although we agree with the relativity established by the 
RUC, in order to retain work neutrality between these two services, we 
have scaled the total relative values that will be paid in 2003 to what 
would have been paid in 2003 if CPT code 33215 had not been 
established. This results in work RVUs of 4.76 for CPT code 33215 and 
5.78 work RVUs for CPT code 33216.
    CPT Codes 36511 Therapeutic apheresis; for white blood cells, 36512 
Therapeutic apheresis; for red blood cells, 36513 Therapeutic 
apheresis; for platelets, 36514 Therapeutic apheresis; for plasma 
pheresis, 36515 Therapeutic apheresis; with extracorporeal 
immunoadsorption and plasma reinfusion, and 36516 Therapeutic 
apheresis; with extracorporeal adsorption or selective filtration and 
plasma reinfusion
    We have not yet received the RUC recommendations for these CPT 
codes. We are assigning 1.74 work RVUs to all these procedures. This is 
the work RVU for both CPT codes 36520 and 36521 (deleted for CPT 2003) 
which are currently being used to report these procedures. We are also 
crosswalking the malpractice RVUs for CPT code 36520 to these 
procedures (0.06 RVU).
    CPT Codes 38204 Management of recipient hematopoietic progenitor 
cell donor search and cell acquisition, 38205 Blood-derived 
hematopoietic progenitor cell harvesting for transplantation, per 
collection; allogenic, 38206 Blood-derived hematopoietic cell 
harvesting for transplantation, per collection; autologous, 38207 
Transplant preparation of hematopoietic progenitor cells; 
cryopreservation and storage, 38208 Transplant preparation of 
hematopoietic progenitor cells; thawing of previously frozen harvest, 
38209 Transplant preparation of hematopoietic progenitor cells; washing 
of harvest, 38210 Transplant preparation of hematopoietic progenitor 
cells; specific cell depletion within harvest, T-cell depletion, 38211 
Transplant preparation of hematopoietic progenitor cells; tumor cell 
depletion, 38212 Transplant preparation of hematopoietic progenitor 
cells; red blood cell removal, 38213 Transplant preparation of 
hematopoietic progenitor cells; platelet depletion, 38214 Transplant 
preparation of hematopoietic progenitor cells; plasma (volume) 
depletion, 38215 Transplant preparation of hematopoietic progenitor 
cells; cell concentration in plasma, mononuclear, or buffy coat layer, 
38242 Bone marrow or blood-derived peripheral stem cell 
transplantation; allogeneic donor lymphocyte infusions
    We agree with the RUC work recommendations for CPT codes 38205, 
38206, and 38242. We disagree with the RUC recommendations for the CPT 
code 38204. CPT codes 38207 through 38215 were reviewed at the April 
RUC meeting but final work RVUs were not established. We did not 
receive final recommendations on work RVUs for these services in time 
for publication in this final rule, but will review any RUC 
recommendations for next year.
    CPT code 38204 is reported by the physician managing a search for 
potential hematopoietic progenitor cell donors. We are giving this code 
a status indicator ``B,'' meaning that we will not make separate 
payment for this service. We believe we are already making payment for 
any physician work associated with this service as part of our payment 
for other bone marrow transplant codes (that is, CPT codes 38205, 
38206, 38240, 38241, and 38242). Furthermore, we have significant 
concerns about how this code would be used in actual practice. Would 
beneficiaries be billed for failed donor searches, and, if so, how 
many? How would beneficiaries be able to determine whether one or more 
searches had actually been conducted? This problem is compounded by the 
fact that the beneficiary would probably never meet the physician 
conducting the search. Additionally, it is unclear from the specialty 
society vignette what is actually physician work and what is the work 
of clinical and administrative staff. It would seem most appropriate 
that any payment would be made to the physician who is performing the 
cell harvesting or bone marrow transplant services (that is, CPT codes 
38205, 38206, 38240, 38241, and 38242). We welcome RUC's further review 
of these codes to determine whether any physician work associated with 
a cell donor search is already included. If the RUC determines that 
such work is not included, we would review

[[Page 80008]]

recommendation for changing the RUC values of these codes to include 
such work.
    CPT codes 38207, 38208, 38209. These codes represent an unbundling 
of CPT codes 88240 Cryopreservation, freezing and storage of cells, 
each cell line, and 88241 Thawing and expansion of frozen cells, each 
aliquot. Both codes 88240 and 88241 are paid under the laboratory fee 
schedule. We also note that CPT 2003 has added a parenthetical note 
under 88240 and 88241, which implies that, starting in January 2003, 
they should be used only for diagnostic services, and codes 38207, 
38208, and 38209 should be used for therapeutic services.
    [sbull] It is unclear from the specialty vignettes whether any 
physician work is typically required to perform these services. The 
descriptions of typical physician involvement in these procedures 
indicate that the only physician services are laboratory oversight or 
quality management services for which we do not make separate payment 
to physicians.
    [sbull] We also believe these services will be reported on a ``per 
aliquot'' basis. However, even though blood-derived stem cells are 
usually stored in aliquots, the processes of freezing, thawing, and 
washing are done in batches. This means that the physician oversight of 
these processes does not occur on a ``per aliquot'' basis and 
therefore, it does not seem appropriate to pay for physician services 
on a ``per aliquot'' basis.
    [sbull] We believe that the analysis the RUC was using to arrive at 
its interim recommendation for assigning physician work to CPT codes 
38207, 38208, and 38209 was flawed. The RUC discussed assigning 
physician work to these services based on its review of 38210 which it 
compared to CPT code 86077 Blood bank physician services; difficult 
cross match and/or evaluation of irregular antibody(s), interpretation 
and written report (work RVU 0.94). The RUC then used the specialty 
societies' relative ranking of services 38207-38215 as the basis for 
recommending work values for CPT codes 38207-38209 and 38211-38215. 
With regard to this analysis, we note: (1) the descriptor for CPT code 
86077 requires a physician service and an ``interpretation and written 
report,'' while CPT code 38210 is not described as a physician service, 
nor does it require an ``interpretation and written report.'' 
Therefore, we believe it is inappropriate to compare 38210 with 86077, 
(2) 38210 is currently reported as CPT code 86915, Bone Marrow or 
peripheral stem cell harvest, modification or treatment to eliminate 
cell types (e.g., T cells, metastatic carcinoma) which is paid under 
the laboratory fee schedule, and (3) 38207, 38208, and 38209 describe 
entirely different services from 38210, 86077, and 86915, thus making 
it difficult to understand how a work value for 38210 could be 
extrapolated to 38207-38209.
    At this time we are assigning status indicator ``I'' to 38207-38209 
making them not valid for Medicare purposes. We are creating two G 
codes, G0265 Cryopreservation, freezing and storage of cells for 
therapeutic use, each cell line, and G0266 Thawing and expansion of 
frozen cells for therapeutic use, each aliquot. These codes will be 
paid under the laboratory fee schedule at the same rate as CPT codes 
88240 and 88241 respectively. The descriptors will allow us to continue 
to recognize CPT codes 88140 and 88141 as described in CPT 2003 for 
diagnostic use, thus making it unnecessary for us to change the status 
indicators for these services. The G codes will also enable us to track 
the utilization of these services. We believe that continuing the 
status quo with regard to these procedures will not affect beneficiary 
access to transplantation services and will give us more time to 
analyze the services and recommendations.
    CPT codes 38210-38215. Currently CPT codes 38210-38213 are 
described by CPT code 86915, Bone Marrow or peripheral stem cell 
harvest, modification or treatment to eliminate cell types (for 
example, T cells, metastatic carcinoma). Currently, CPT code 86915 is 
paid under the laboratory fee schedule. With regard to CPT codes 38210-
38215, we have many of the same concerns as we have for CPT codes 
38207-38209.
    [sbull] It is unclear from the specialty vignettes whether any 
physician work is typically required to perform these services. The 
descriptions of typical physician involvement in these procedures 
indicate that a significant portion of the physician work is procedure 
oversight or quality management services for which we do not make 
separate payment to physicians. In fact, the only references in the 
specialty society vignettes for these procedures to services paid under 
the physician fee schedule are references to performance of flow 
cytometry. Therefore, if there is any physician work associated with 
these services it is currently payable under the CPT code 88180 Flow 
cytometry; each cell surface, cytoplasmic or nuclear marker.
    [sbull] We do not believe that unbundling of these services is 
warranted because CPT codes 38210, 38212, 38213, 38214, and 38215 may 
be performed together on a single harvest of stem cells during an 
allogeneic transplant. Further, when these services are performed 
together, if there is any physician work associated with these 
activities, it must be allocated to each service and it is not clear 
that this can be accomplished.
    [sbull] As discussed above, we have concerns about the RUC's 
preliminary discussions for work RVUs for these codes. CPT code 86077 
to which 38210 was compared requires physician services, an 
interpretation and report, and has forty minutes of intra-service time 
associated with it. In contrast 38210 has no requirement for physician 
work, and it is stated that the physician will only perform this 
service in an emergency. Further, there is no requirement for 
interpretation of data or a written report, and the intra-service time 
is 23 minutes. We do not believe the stress involved with these 
procedures is any greater than the stress involved with 86077 or other 
pathology services that require correct interpretation of clinical 
laboratory data or surgical specimens to make a correct diagnosis 
essential in determining appropriate treatment. Furthermore, we know 
the RUC is continuing to review these codes and we also require further 
time to review them.
    Therefore, we are assigning status indicator ``I'' to CPT codes 
38210-38215, making them invalid for Medicare purposes. We are creating 
G0267, Bone marrow or peripheral stem cell harvest, modification or 
treatment to eliminate cell type(s) (for example, T-cells, metastic 
carcinoma). This G code will replace deleted code CPT code 86915, and 
it will be paid under the laboratory fee schedule.
    We welcome any comments from the RUC or other interested parties 
concerning these codes and ask that such comments specifically address 
the concerns discussed above. We will continue to review these codes 
internally, obtain payment and utilization data for CPT code 86915, and 
track utilization of all three G codes.
    CPT code 45335 Sigmoidoscopy, flexible; with directed submucosal 
injection(s) any substance and 45381 Colonoscopy, flexible, proximal to 
splenic flexure; with directed submucosal injection(s) any substance
    The RUC recommended work RVUs of 1.46 for CPT code 45335 and 4.30 
for CPT code 45381. For CPT code 45335, the RUC used CPT code 45330 as 
the base code (0.96 work RVUs) and added an increment of 0.50 work RVUs 
based upon the increased pre-, intra-, and post-service work associated 
with CPT code 45335 as compared to CPT code 45330. For CPT code 45381, 
the RUC

[[Page 80009]]

used CPT code 45378 (3.70 work RVUs) as the base code and added an 
increment of 0.60 work RVUs based upon the increased pre-, intra-, and 
post-service work associated with CPT code 45381 as compared to CPT 
code 45378.
    In order to review the RUC recommended values for CPT code 45335 
and 45381, we compared these services to the analysis and 
recommendations provided by the RUC for CPT codes 43201 and 43236. We 
agree with the RUC recommendations for CPT codes 43201 and 43236, which 
are also new submucosal injection codes. We further note that the 
intra-service intensities of CPT codes 43201 and 43236 should be higher 
than the intra-service intensities of CPT codes 45335 and 45381 because 
of the increased risk of complications, and the fact that several sites 
are being injected instead of one.
    In reviewing the pre-, intra-, and post-service times for CPT codes 
43201, 43236, 45335, and 45381, we are unsure why these times vary so 
much. The pre-service time for CPT code 45381 is 25 minutes longer than 
the pre-service time for CPT code 45378 and there is nothing in the RUC 
vignette to indicate the reason for the increased pre-service time. 
Moreover, it is unclear why the post-service time for CPT code 45381 is 
9 minutes less than the post-service time for CPT code 45378. 
Interestingly, less than 10 minutes of extra pre- and post-service time 
(beyond the base codes) was allotted for the incremental work of CPT 
codes 43201 and 43236 that we believe are more intensive procedures 
than CPT codes 45335 and 45381. Therefore, we believe that the pre- and 
post-service time increment for CPT codes 45335 and 45381 should be 
less than for CPT codes 43201 and 43236. In short, we had a great deal 
of difficulty interpreting the RUC time data.
    In assigning work values to CPT codes 45335 and 45381, we compared 
them to the incremental work values and times for CPT codes 43201 and 
43236 because we agreed with the RUC recommendations and times for 
those codes. The intra-service intensities for CPT codes 43201 and 
43236 are 0.05 RVU per minute and 0.035 RVU per minute, respectively. 
We believe the intra-service intensity of CPT code 45335 is less than 
the intensity of CPT code 43201. After accounting for a few minutes of 
extra post-service time and an intra-service intensity of 0.04 RVU per 
minute, we are left with an incremental work value of 0.4 work RVUs for 
CPT code 43201, which is what we will apply to CPT code 45335. We also 
believe the intensity of CPT code 45381 is less than the intensity of 
CPT code 43201. Therefore, accounting for approximately 10 minutes of 
extra pre- and post-service time, and assigning an intra-service 
intensity of 0.04 RVU per minute leaves an incremental work value of 
0.5 work RVUs, which is what we will apply to CPT code 45381. 
Therefore, we are assigning work RVUs of 1.36 and 4.20 to CPT codes 
45335 and 45381, respectively.
    CPT code 45340 Sigmoidoscopy, flexible; with dilation by balloon, 
each stricture
    The RUC recommended a work RVU of 1.96 for this CPT code. This 
includes 1.00 for the incremental work based on the need for conscious 
sedation to perform this procedure (other flexible sigmoidoscopies do 
not require conscious sedation). This means the incremental work for 
CPT code 45340 is greater than the incremental work for other 
endoscopic dilation codes (CPT codes 43245 and 45386) because those 
codes have base procedures that include use of conscious sedation. The 
RUC has been considering the issue of conscious sedation in general for 
some time and has not been able to conclude that there is any 
incremental physician work associated with conscious sedation. In the 
absence of a specific RUC recommendation affirmatively stating that 
specific physician work is associated with conscious sedation, we do 
not believe it is appropriate to assign a work RVU for CPT code 45340 
that is based on the presumption that a portion of the work value is 
for using conscious sedation. Therefore, we compared the RUC 
recommendations for work and physician time for CPT code 45386 to the 
incremental times for CPT code 45340. We believe that the intra-service 
intensity of CPT code 45340 should be no greater than the intra-service 
intensity for CPT code 45386. Therefore, we calculated the increment in 
pre- and post-service work (.341 work RVUs) and the intra-service 
intensity (0.036 RVU per minute) of CPT code 45386. We multiplied this 
intensity by 10 minutes to arrive at an intra-service work of .36 RVU 
for CPT code 45340 and added .341 RVUs for pre- and post-service work 
to arrive at an RVU of 0.7 for the total incremental work of CPT code 
45340. Therefore, we are assigning an interim work RVU of 1.66 to CPT 
code 45340.
    CPT code 46706 Repair of Anal Fistula with fibrin glue. The RUC 
recommended 2.95 work RVUs for this service based on a comparison to 
CPT codes 46020, Placement of Seton (work RVU 2.90) and 46940, 
Curettage or Cautery of Anal Fissure, including dilation of anal 
sphincter (separate procedure); initial (work RVU 2.32). The intra-
service time for CPT code 46706 is less than the intra-service time for 
CPT code 46940 and requires similar physician work to CPT code 46612, 
Anoscopy with removal of multiple tumors, polyps, or other lesions by 
hot biopsy forceps, bipolar cautery or snare technique (work RVU 2.34). 
The post-service work for CPT code 46706 is comparable to that of CPT 
code 46940. Therefore, we are assigning a work RVU of 2.39 to CPT code 
46706. Malpractice RVUs are crosswalked from CPT code 46940 at 0.17 
RVUs.
    CPT code 51798 Measurement of post-voiding residual urine and/or 
bladder capacity by ultrasound, nonimaging. The RUC recommended 0.38 
work RVUs based on a comparison of this procedure to CPT code 76857, 
Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image 
documentation; complete. The RUC recommended 0.38 work RVUs based on a 
urology survey that reported that this procedure is performed 75 
percent of the time by the physician and based on a comparison of this 
procedure to CPT code 76857, Ultrasound, pelvic (nonobstetric, B-scan 
and/or real time with image documentation; complete. We disagree. This 
code has been a HCPCS level two code that was assigned 0.00 work RVUs 
because we believe that it is typically performed by a nurse or other 
clinical staff. We continue to believe that this is a non-physician 
service and are assigning 0.00 work RVUs to this service. We will 
accept the practice expense inputs recommended by the RUC and will 
crosswalk the malpractice RVUs from G0050. It is not appropriate to 
bill CPT code 51798 in a SNF, hospital, or other setting in which 
nursing care is provided by the facility, since it is a routine nursing 
service, not really a diagnostic test.
    CPT code 75954 Endovascular graft placement for repair of iliac 
artery (for example, aneurysm, pseudoaneurysm, ateriovenous 
malformation, trauma) radiological supervision and interpretation.
    The RUC agreed with the specialty societies and recommended a value 
of 2.93 work RVUs based on comparing this code to CPT code 75952, 
Endovascular repair of infrarenal abdominal aortic anuerysm or 
dissection, radiological supervision and interpretation (work RVU of 
4.5) and CPT code 75953, Placement of proximal or distal extension 
prosthesis for endovascular repair of infra renal abdominal aortic 
aneurysm, radiological supervision and

[[Page 80010]]

interpretation (work RVU or 1.36). The recommended RVUs are midway 
between the RVUs of the reference procedures. The specialty societies 
presented the following to the RUC: ``Unlike many of the other 
radiological supervision and interpretation (S&I) codes, 75954 includes 
all routine supervision and interpretation of the endovascular iliac 
graft placement procedure with the only exception being that 75953 is 
added if an extension prosthesis is required. This more inclusive 
approach makes 75954 very similar in concept to the inclusive S&I for 
endovascular aortic aneurysm repair CPT 75952.'' The specialties go on 
to say that survey respondents believed that the code should be valued 
less than CPT code 75952 but more than CPT code 75953. We disagree. 
First, we note that CPT code 75953, which was reviewed by the RUC in 
February of 2001, is not an ``add-on'' code. It is a stand-alone code 
that is billed with a stand-alone surgical procedure. Furthermore, 
total procedure time for CPT code 75954 (85 minutes) is less than the 
total procedure time for CPT code 75953 (95 minutes), and the intra-
service times of CPT codes 75954 and 75953 are identical (45 minutes). 
This is consistent with the specialty societies' description of the 
work of CPT code 75954, which is virtually identical to the description 
of the work for CPT code 75953. Therefore, in order to maintain correct 
rank order in this family of codes we are assigning a work RVU of 1.36 
to CPT code 75954.
    CPT codes 92605 Evaluation for prescription of non-speech 
generating augmentative and alternative communication device and 92606 
Therapeutic service(s) for the use of non-speech generating device, 
including programming and modification
    We will consider CPT codes 92605 and 92606 bundled for Medicare 
payment purposes. The RUC's evaluation of these services implied that 
they are similar to the new CPT codes for speech generating devices. We 
believe that CPT codes 92605 and 92606 typically do not involve the 
same type of highly specialized equipment as the codes for speech 
generating devices. We believe that the work associated with these 
services is already contained in CPT codes 92506 Evaluation of speech, 
language, voice communication, auditory processing, and/or aural 
rehabilitation status and 92507 Treatment of speech, language, voice 
communication, auditory processing disorder (includes aural 
rehabilitation); individual, and will consider CPT codes 92605 and 
92606 bundled.
    We note that CPT also created new codes to describe programming and 
analysis of cochlear implants. These CPT codes are 92601 Diagnostic 
analysis of cochlear implant, patient under 7 years of age; with 
programming; 92602 Diagnostic analysis of cochlear implant, patient 
under 7 years of age; subsequent reprogramming; 92603 Diagnostic 
analysis of cochlear implant, age 7 years or older, with programming; 
and 92604 Diagnostic analysis of cochlear implant, age 7 years or 
older, subsequent reprogramming. Codes 92601 and 92603 describe post-
operative analysis and fitting of previously placed external devices, 
connection to the cochlear implant, and programming of the stimulator. 
CPT Codes 92602 and 92604 describe subsequent sessions for measurements 
and adjustment of the external transmitter and re-programming of the 
internal stimulator.
    An existing CPT code, 92510 Aural rehabilitation following cochlear 
implant (includes evaluation of aural rehabilitation status and 
hearing, therapeutic services) with or without speech processor 
programming, will no longer be used for Medicare services since it 
represents services which have considerable overlap with the services 
described by the new CPT codes, 92601, 92602, 93603, and 92604. For the 
remaining services that do not involve reprogramming of the cochlear 
implant, CPT code 92507 Treatment of speech, language, voice, 
communication, and/or auditory processing disorder (includes aural 
rehabilitation); individual describes the services, so a code specific 
to cochlear implant patients is no longer needed. The use of CPT code 
92507 for this service is consistent with the note in the CPT manual 
under CPT code 92602.
    CPT codes 92613 Flexible fiberoptic endoscopic evaluation of 
swallowing by cine or video recording; physician interpretation and 
report only, 92615 Flexible fiberoptic endoscopic evaluation, laryngeal 
sensory testing by cine or video recording; physician interpretation 
and report only, and 92617 Flexible fiberoptic endoscopic evaluation of 
swallowing and laryngeal sensory testing by cine or video recording; 
physician interpretation and report only.
    Effective January 1, 2003, CPT created several codes to describe 
fiberoptic endoscopic evaluation services that are currently described 
by temporary G-codes. For specific information related to both the 
former G-codes and the new CPT codes that will replace the deleted G-
codes, refer to the end of this section. We agreed with the RUC 
recommended values for all of the fiberoptic endoscopic evaluation 
services (CPT codes 92612, 92614, and 92616) with the exception of CPT 
codes 92613, 92615, and 92617. For these three services that refer only 
to a separately identified physician review and interpretation of the 
fiberoptic endoscopic evaluation, we consider the physician 
interpretation and report bundled into an evaluation and management 
service. We believe the physician who does not perform the testing 
should only bill the patient when performing an evaluation and 
management service, not as the supervisor of another professional 
performing and reviewing the initial fiberoptic endoscopic evaluation. 
The interpretation of this test is an integral part of the testing 
itself. If a nonphysician professional has the credentials and 
experience to perform this testing, then that professional should also 
provide the interpretation of the findings.
    CPT codes 93784 Ambulatory blood pressure monitoring, utilizing a 
system such as magnetic tape and/or computer disk, for 24 hours or 
longer; including recording, scanning analysis, interpretation and 
report, 93786 Ambulatory blood pressure monitoring, utilizing a system 
such as magnetic tape and/or computer disk, for 24 hours or longer; 
recording only, 93788 Ambulatory blood pressure monitoring, utilizing a 
system such as magnetic tape and/or computer disk, for 24 hours or 
longer; scanning analysis with report, and 93790 Ambulatory blood 
pressure monitoring, utilizing a system such as magnetic tape and/or 
computer disk, for 24 hours or longer; physician review with 
interpretation and report.
    We have not yet received RUC recommendations for these codes. We 
established RVUs for these services during this past year in response 
to a national coverage determination. We will maintain these RVUs until 
we receive a RUC recommendation.
    CPT code 95990 Refilling and maintenance of implantable pump or 
reservoir for drug delivery; spinal (intrathecal, epidural) or brain 
(intraventricular).
    We understand that performance of CPT code 95990 requires the use 
of an expensive kit, the cost of which may not be reflected in the RVUs 
for CPT code 96530, the code under which it was previously reported. 
CPT code 96530 has practice expense RVUs of 1.01 and malpractice RVUs 
of 0.05. We are assigning 1.50 practice expense RVUs because we 
estimate that the practice expense for CPT code 95990 is 50 percent 
higher than it is for CPT code

[[Page 80011]]

96530. We are crosswalking the malpractice RVUs from CPT code 96530 to 
CPT code 95990.
    We are not assigning work RVUs to CPT code 95990 for 2003 since we 
believe that this procedure is typically (greater than 50 percent of 
the time) performed by a nurse. We understand that there has been 
discussion with the CPT Editorial Committee about revising this code so 
that it would be billed only when performed in the presence of a 
physician. If the code were to be so revised, we would consider any RUC 
recommendations regarding work RVUs for this service.
    These values are interim for 2003 and we will address comments 
about the RVUs for this code in next year's final rule.
    CPT codes 99026 Mandated On-call service; in hospital and 99027 
Mandated physician on call services
    No RUC recommendation was received for these codes. Note that 
stand-by and on-call services are not covered by Medicare and we would 
not pay for these services billed using these codes.
Establishment of Interim Practice Expense RVUs for New and Revised 
Physician's Current Procedural Terminology (CPT) Codes and New 
Healthcare Common Procedure Coding System (HCPCS) Codes for 2003
    We have developed a process for establishing interim practice 
expense RVUs for new and revised codes that is similar to that used for 
work RVUs. Under this process, the RUC recommends the practice expense 
direct inputs, that is, the staff time, supplies and equipment, 
associated with each new code. We then review the recommendations in a 
manner similar to our evaluation of the recommended work RVUs.
    The RUC recommendations on the practice expense inputs for the new 
and revised 2003 codes were submitted to us as interim recommendations. 
We, therefore, consider that these recommendations are still subject to 
further refinement by the PEAC, or by us, if it is determined that such 
future review is needed. We may also revisit these inputs in light of 
future decisions of the PEAC regarding supply and equipment packages 
and standardized approaches to pre- and post-service clinical staff 
times.
    We have accepted, in the interim, all of the practice expense 
recommendations submitted by the RUC for the codes listed in the 
following table titled ``AMA RUC and HCPAC RVU Recommendations and CMS 
Decisions for New and Revised 2003 CPT Codes.''

C. Other Changes to the 2003 Physician Fee Schedule

    We are establishing the following HCPCS codes for CY 2003.
    GO262 Small intestinal imaging; intraluminal, from ligament of 
Treitz to the ileo cecal valve, includes physician interpretation and 
report
    We are creating this code to describe a new diagnostic test for 
which we will make separate payment under the physician fee schedule 
and the Hospital Outpatient Prospective Payment System (OPPS). The 
procedure involves ingesting a small camera through the mouth. As the 
camera traverses the gastrointestinal tract, it produces two images per 
second and transmits those images to a receiver worn by the patient. 
After eight hours (the battery life of the camera) the belt containing 
the receiver is removed from the patient. The images are then developed 
and reviewed by a physician who interprets them and makes a written 
report. The capsule is excreted in the patient's stool and discarded. 
Images taken in the esophagus, stomach and large intestine (colon) are 
hard to interpret; therefore, current use of this imaging modality is 
limited to evaluation of the small intestine. The G-code descriptor is 
designed to ensure accurate reporting of this diagnostic test. Although 
this test has been referred to as ``capsule endoscopy'', the term 
``endoscopy'' is a misnomer because ``endoscopy'' refers to physician-
controlled viewing the gastrointestinal tract through an endoscope.
Physician Work
    We understand from recently published clinical studies that the 
average small intestine transit time was 257 minutes and the transit 
time from ingestion to the cecum was 302 minutes. Review of the images 
includes a first pass overview to mark areas of special interest, a 
review of the entire video recording, and a focused review of 
abnormalities, if any are found. The average time to review the capsule 
images in two recently published studies was 50 and 56 minutes. 
Therefore, we believe that, typically, 53 minutes of physician time 
will be spent reviewing the video. To assign a work value, we compared 
the work of this code to the work of other diagnostic tests and 
procedures that require review of significant amounts of data. 
Specifically, we reviewed the work RVUs and intra-service times for 
electroencephalography (EEG) reading and interpretation, magnetic 
resonance angiography (MRA), computed tomographic angiography (CTA), 
Holter monitor reading and interpretation, prolonged esophageal acid 
reflux testing, echocardiography, duplex scanning of the carotid 
arteries, and anorectal manometry. Based on these comparisons, we are 
assigning a work value of 2.12 RVUs. This results in an intensity of 
.04 RVU per minute and places it in correct rank order with the 
procedures to which it was compared. We note that this assumes that a 
complete study from the ligament of Treitz to the ileocecal valve was 
performed and that the camera functioned normally throughout the 
procedure and produced two images per second. If an incomplete 
evaluation of the small intestine is accomplished, this code should be 
billed with a CPT code 52-modifier indicating reduced services, and the 
payment amount would also be reduced. The amount of reduction is 
determined by the carrier. Until such time as we make a NCD for this 
service, coverage is at the discretion of carriers and intermediaries.
Malpractice
    We are crosswalking the value from CPT code 74230 with the same PC/
TC split because they have similar physician times and intensities.
Practice Expense
    For the physician fee schedule we are assigning the following 
inputs for practice expense:
    [sbull] Staff Time--RN/LPN/MA mix--90 minutes--includes pre-service 
education, attachment of the receiver, administration of the camera, 
removal of the receiver, and processing of the images
    [sbull] Supplies--Single use camera; Razor
    [sbull] Equipment--Workstation
    GO268 Removal of impacted cerumen (one or both ears) by physician 
on same date of service as audiologic function testing
    This code was created in order to allow payment to a physician who 
removes impacted cerumen on the same date as his or her employed 
audiologist performs audiologic function testing. We will assign the 
same physician work RVUs, practice expense inputs, and malpractice RVUs 
to this code as are assigned to CPT code 69210, Removal impacted 
cerumen (separate procedure), one or both ears.
    First, we emphasize that routine removal of cerumen is not paid 
separately. It is considered to be part of the procedure with which it 
is billed (for example, audiologic function testing). To assure the 
appropriate reporting of this code, we note that it

[[Page 80012]]

should only be used in those unusual circumstances when an employed 
audiologist who bills under a physician UPIN number performs audiologic 
function testing on the same day as removal of impacted cerumen 
requiring physician expertise for removal. This code should not be used 
when the audiologist removes cerumen, because removal of cerumen is 
considered to be part of the diagnostic testing and is not paid 
separately.
    GO269 Placement of occlusive device into either a venous or 
arterial access site, post surgical or interventional procedure (for 
example, angioseal plug, vascular plug)
    We are creating this G code to assure proper reporting of this 
service. It has come to our attention that this service is being 
inappropriately reported with codes for such procedures as ``blood 
vessel repair'' and ``repair of arterial pseudoaneurysm.'' We are 
assigning a status indicator of ``B'' (payment bundled into payment for 
other services) to this service, as the work, practice expense, and 
malpractice risk of closing an arteriotomy or venotomy site at the 
conclusion of an invasive percutaneous procedure, whether by manual 
compression, suture, or use of a closure device, is included in the 
main invasive procedure. Therefore, there is no separate payment for 
this procedure.
    GO270 Medical nutrition therapy; reassessment and subsequent 
intervention(s) following second referral in same year for change in 
diagnosis, medical condition, or treatment regimen (including 
additional hours needed for renal disease), individual, face-to-face 
with the patient, each 15 minutes and
    GO271 Medical nutrition therapy, reassessment and subsequent 
intervention(s) following second referral in same year for change in 
diagnosis, medical condition, or treatment regimen (including 
additional hours needed for renal disease) group (2 or more 
individuals), each 30 minutes
    In our NCD dated May 1, 2002, we established basic coverage for 
medical nutrition therapy billed under CPT codes 97802 through 97804 as 
3 hours per year for beneficiaries with either diabetes or renal 
disease. However, we also pay for additional hours if a physician makes 
a second referral in the same year based on a change in the 
beneficiary's medical condition, diagnosis, or treatment regimen. These 
new codes allow us to edit for basic coverage and reimburse for 
additional coverage when appropriate.
    We are crosswalking the RVUs from CPT code 97803 to G0270 and CPT 
code 97804 to G0271 because these are the corresponding CPT medical 
nutrition codes.
    GO272 Naso/oro gastric tube placement, requiring physician's skill 
and fluoroscopic guidance (includes fluoroscopy, image documentation 
and report)
    We are creating this code for one year until an identical CPT code 
becomes effective.
Physician Work
    We compared this code to other gastroenterology and radiologic 
procedures including CPT codes 91105 Gastric intubation, and aspiration 
or lavage for treatment (e.g, for ingested poisons) (work RVU of 0.37); 
44500 Introduction of long gastrointestinal tube (e.g., Miller-Abbott) 
(separate procedure) (work RVU of 0.49); 74340 Introduction of long 
gastrointestinal tube (e.g., Miller-Abbott), including multiple 
fluoroscopies and films, radiological supervision and interpretation 
(work RVU of 0.54), and 76000 Fluoroscopy (separate procedure), up to 
one hour physician time, other than 71023 or 71034 (e.g., cardiac 
fluoroscopy) (work RVU of 0.17).
    This procedure is most similar to CPT code 91105 (16 minutes of 
physician time), but requires less work because it is done in a 
controlled setting with fluoroscopy to aid in placement. It is not 
similar to CPT codes 44500 and 74340 because placement of Miller-Abbott 
tubes is a more lengthy and involved procedure than placement of naso/
oro gastric tubes. In fact, the physician time for placement of Miller-
Abbott tubes is over 30 minutes, while placement of a naso/oro gastric 
tube takes about 15 minutes. We are assigning this G code a work RVU of 
0.32, which is the sum of the work RVU for CPT code 76000 and the work 
intensity of CPT code 44500 times 15 minutes.
Malpractice
    We are assigning 0.02 malpractice RVUs to this procedure.
Practice Expense
    We believe this procedure will only be performed in facilities, so 
we are not assigning any practice expense inputs to this code.
    GO273 Radiopharmaceutical biodistribution, single or multiple scans 
on one or more days, pre-treatment planning for radiopharmaceutical 
therapy of non-Hodgkin's lymphoma, includes administration of 
radiopharmaceutical (e.g., radiolabeled antibodies).
    We are creating this code to describe radionuclide scanning to 
determine the biodistribution of Zevalin. The procedure encompasses 
administration of Indium labeled Zevalin followed by whole body 
radionucliide scanning 2-24 hours and 48-72 hours after the 
administration of Zevalin. Rarely, a third scan is necessary. The 
purpose of the scanning is to ensure that the biodistribution of 
Zevalin is normal, thus decreasing the risk of toxic effects from the 
administration of a therapeutic dose. The published criteria for 
determining appropriate biodistribution involve making a qualitative 
comparison of isotope uptake in several organ systems between the two 
scans. Therefore, these scans cannot be read in isolation, and this 
code should only be reported once, no matter how many scans are 
performed.
Physician Work
    We are assigning 0.86 work RVUs to this code which is equivalent to 
the work for CPT code 78802, Radiopharmaceutical localization of tumor; 
whole body. We believe the total physician time of 41 minutes for CPT 
code 78802, and the intensity are similar to the time and intensity 
required for this service.
Malpractice
    We are assigning 0.28 RVU to the global procedure, 0.25 RVU to the 
technical component, and 0.03 RVU to the professional component. These 
are identical values to CPT code 78802.
Practice Expense
    The TC of this code is being priced in the nonphysician work pool, 
where we crosswalked it to the charge-based practice expense RVUs for 
CPT code 78802, taking into account that the radiopharmaceutical is 
administered once, but that there are two scans obtained.
    We wish to emphasize that this code is only reported once and 
includes the administration of the radiopharmaceutical and performance 
and interpretation of all scans. We also note that the infusion of 
rituxumab prior to the administration of Zevalin is separately payable.
    GO274 Radiopharmaceutical therapy, non-Hodgkin's lymphoma, includes 
administration of radiopharmaceutical (e.g., radiolabeled antibodies)
    We are establishing this code to allow appropriate reporting of 
this new service. Radiopharmaceutical therapy using radiolabeled 
monoclonal antibodies is a new form of treatment for non-Hodgkins 
lymphoma and is not currently described by any existing HCPCS code.

[[Page 80013]]

    After review of information regarding this service, we are 
assigning the following RVUs:
Physician Work
    We believe that physicians typically take 60 minutes to perform 
this service on the day of the procedure. Of this time, 45 minutes is 
spent counseling the patient and family, while 15 minutes are spent 
setting up and infusing the radiopharmaceutical. Additionally, there is 
post-procedure time spent reviewing platelet counts, which requires 
calling the patient or another physician 25 percent of the time. We 
compared this procedure to the physician work RVUs, physician times, 
and intensity (RVU per minute) of other nuclear medicine and radiation 
oncology procedures CPT codes 79400, 77790, 79030, 79035, and 79100; 
infusion procedures CPT codes 36520, 36521, 37201, and 37202; 
hemodialysis CPT codes 90935, and 90937; evaluation and management CPT 
codes 99214 and 99215.
    Based on this comparison we are assigning a work RVU of 2.07 to 
this code. This represents the work of CPT code 99214 (counseling a 
complex patient), 15 minutes for infusion at an intensity of 0.05 RVU 
per minute (similar to the intensity of CPT code 77790), and 10 minutes 
of post service work (at an intensity of 0.022 RVU per minute). This 
also places the code in the correct rank order with all of the above 
procedures.
Malpractice
    We are assigning malpractice RVUs of 0.20 to this procedure, with 
0.12 assigned to the technical component and 0.08 assigned to the 
professional component. These are identical to the RVUs for CPT code 
79400.
Practice Expense
    The TC of this code is being priced in the nonphysician workpool 
where we crosswalked it to the charge-based practice expense RVUs for 
CPT code 79400.
    GO275 Renal angiography (unilateral or bilateral) performed at the 
time of cardiac catheterization, includes catheter placement in the 
renal artery, injection of dye, flush aortogram and radiologic 
supervision and interpretation and production of images (List 
separately in addition to primary procedure) and
    GO278 Iliac artery angiography performed at the same time of 
cardiac catheterization, includes catheter placement in the iliac 
artery, injection of dye, radiologic supervision and interpretation and 
production of images (List separately in addition to primary procedure)
    We are creating these add-on codes to assure proper reporting of 
and payment for renal and iliac angiography performed at the time of 
cardiac angiography. These procedures are performed frequently on 
Medicare patients and are currently reported using codes that describe 
placement of a catheter in the renal and/or iliac artery(s) (CPT codes 
36245 and 36246) and radiological supervision and interpretation of 
renal and/or iliac angiography (CPT codes 75710, 75716, 75722, and 
75724).
Physician Work
    Based on the information we reviewed, the typical performance of 
these procedures involves the use of a pigtail catheter positioned in 
the aorta (not the renal or iliac artery(s)), injection of a minimal 
dye load (because of the heavy dye load already used for cardiac 
angiography), and viewing the dye run off into the proximal main renal 
or iliac arteries under fluoroscopy. We determined work values for 
these procedures by using the work values for CPT codes 75625, 
Aortography, abdominal, by serialography, radiological supervision and 
interpretation (1.14 work RVUs with 22 minutes of physician time) and 
93544, Injection procedure during cardiac catheterization; for 
aortography (0.25 work RVUs and 5 minutes of physician time) and 
adjusting for a procedure time of approximately two and one half 
minutes. This process yields a value of 0.25 work RVUs, which is what 
we are assigning to these two add-on procedures.
Malpractice
    We are crosswalking the 0.01 malpractice RVUs for CPT code 93544 to 
these procedures.
Practice Expense
    We are not assigning any practice expense inputs to these 
procedures because the incremental increase in staff and room time to 
perform these procedures is negligible.
    GO279 Extracorporeal shock wave therapy; involving elbow 
epicondylitis.
    GO280 Extracorporeal shock wave therapy; involving other than elbow 
epicondylitis or plantar fascitis.
    CPT code 0020T Extracorporeal Shock Wave Therapy; involving plantar 
fascia
    We are creating and establishing a national payment amount for two 
G-codes describing extracorporeal shock wave therapy for the 
musculoskeletal system and establishing a national payment amount for 
CPT code 0020T. We are doing this in response to multiple requests from 
our contractors to establish a national payment amount, though creation 
of these codes does not imply that services will be covered by 
Medicare. We also note that this form of therapy was recently approved 
by the Food and Drug Administration for treatment of lateral 
epicondylitis. Our staff has reviewed the method of treatment and we 
are establishing work, practice expense, and malpractice RVUs for these 
codes.
    We believe these services are similar to other physical therapy 
modalities and are designating it to be paid on the therapy fee 
schedule. Based on the information we reviewed, these services are 
typically performed by a technician similar to a physical therapy aide 
and take about 20 minutes to perform.
Physician Work
    We compared these services to other physical therapy services and 
believe they are most similar to unattended physical therapy modalities 
such as diathermy. We are assigning a work RVU of 0.06 for these 
procedures in order to place them in proper rank order with other 
unattended physical therapy services.
Malpractice
    We are crosswalking the malpractice RVUs (0.01) from CPT code 
97024, Application of a modality to one or more areas; diathermy, to 
these procedures.
Practice Expense
    We are assigning the following practice expense inputs:
    [sbull] Staff/Time: Physical therapy aide; 30 minutes.
    [sbull] Supplies: Ultrasound Gel.
    [sbull] Equipment: Shock wave machine.
    We note that, for lateral epicondylitis, the typical treatment 
regimen is up to 3 total treatments at weekly intervals.
Electrical Stimulation for Wound Care
    GO281 Electrical stimulation, (unattended), to one or more areas, 
for chronic stage III and stage IV pressure ulcers, arterial ulcers, 
diabetic ulcers, and venous stasis ulcers not demonstrating measurable 
signs of healing after 30 days of conventional care, as part of a 
therapy plan of care; and
    GO282 Electrical stimulation, (unattended), to one or more areas, 
for wound care other than described in G0281 and
    GO283 Electrical stimulation, (unattended), to one or more areas, 
for indication(s) other than wound care, as part of a therapy plan of 
care.

[[Page 80014]]

    These three new G codes have been created to implement the coverage 
determination on use of electrical stimulation for wound care.
    The work, practice expense, and malpractice values for CPT code 
97014 Application of a modality to one or more areas; electrical 
stimulation (unattended) will be crosswalked to these new G codes, but 
G0282 will not be covered by Medicare. In addition, CPT code 97032, 
Application of a modality to one or more areas: electrical stimulation 
(manual), each 15 minutes, should not be utilized for any wound care.
    The coverage determination that allowed coverage for the use of 
electrical stimulation for certain types of wound care also stated that 
another similar modality, electromagnetic stimulation, would not be 
covered. A G code, ``G0295: Electromagnetic stimulation, to one or more 
areas'' will be created to describe this service, since this service 
would otherwise have been coded using CPT code 97039 and would have 
required manual claims review. The new code, G0295, will be listed as 
non-covered by Medicare.
    GO288 Reconstruction, computed tomographic angiography of aorta for 
surgical planning for vascular surgery.
    We are creating this code to assure accurate reporting of this 
service by independent diagnostic testing facilities (IDTFs) that 
perform this service. Facilities that perform this service (either at 
the facility or under arrangement) report this service through the use 
of a ``C'' code specific to hospital reporting.
    This code is a technical component code only since the service 
provided by the IDTF includes receipt of a Computed Tomographic 
Angiogram (CTA), post CTA processing using specialized software, and 
burning the 3D model onto a CD and returning it to the operating 
surgeon. This 3D model is used to assist vascular surgeons in planning 
for, or monitoring the results of, endovascular aneurysm repair. The 
service is a technical service provided under the general supervision 
of a physician according to the supervision requirements for IDTFs. We 
compared this procedure to CPT codes 74175, Computed tomagraphic 
angiography, abdomen, without contrast material(s), followed by 
contrast material(s) and further sections, including image post-
processing and 76375, Coronal, sagital, multiplanar, oblique, 3-
dimensional and/or holographic reconstruction of computerized axial 
tomography, magnetic resonance imaging, or other tomographic modality. 
Based on this review, we developed practice expense RVUs using the 
nonphysician workpool methodolgy. The malpractice RVUs will be 
crosswalked from CPT code 76375 directly and will be set at 0.15 RVUs.
    GO289 Arthroscopy, knee, surgical, for removal of loose body, 
foreign body, debridement/shaving of articular cartilage 
(chrondroplasty) at the time of other surgical knee arthroscopy in a 
different compartment of the same knee.
    We are creating this code to permit appropriate reporting of 
arthroscopic procedures performed in different compartments of the same 
knee during the same operative session. This is an add-on code and 
should be added to the knee arthroscopy code for the major procedure 
being performed. This code is only to be reported once per extra 
compartment, even if both chondroplasty, loose body removal, and 
foreign body removal are performed. The code may be reported twice (or 
with a unit of two) if the physician performs these procedures in two 
compartments in addition to the compartment where the main procedure 
was performed.
    This code should only be reported if the physician spends at least 
15 minutes in the additional compartment performing the procedure. It 
should not be reported if the reason for performing the procedure is 
due to a problem caused by the arthroscopic procedure itself. This code 
is to be used when a procedure is performed in the lateral, medial, or 
patellar compartments in addition to the main procedure. However, CPT 
codes 29874, Arthroscopy, knee, surgical; for removal of loose body or 
foreign body (e.g., osteochrondritis dissecans fragmentation, chondral 
fragmentation) and 29877 Arthroscopy, knee, surgical; debridement/
shaving of articular cartilage (chrondroplasty) may not be billed with 
other arthroscopic procedures on the same knee.
Physician Work
    We examined the work RVUs, the intra-operative work intensity, and 
the intra-operative times for CPT codes 29874 and 29877. We also 
compared these intensities and times to those for CPT code 29870, the 
base procedure for this family. We determined a work value using the 
intra-operative intensity for CPT code 29874 (which is higher than for 
CPT code 29877) and the mean intra-operative times (for CPT codes 29874 
and 29877) beyond the time required for CPT code 29870 (14 minutes for 
CPT code 29874 and 27 minutes for CPT code 29877). This code represents 
approximately 20 minutes of extra work at a high level of intensity. 
Therefore, the work value we are assigning to this code is 1.48 RVUs.
Malpractice
    We are assigning 0.27 malpractice RVUs to this procedure. This is 
the sum of the malpractice RVUs for CPT codes 29874 and 29877 beyond 
the malpractice RVUs for CPT code 29870, divided by two.
Practice Expense
    We are not assigning any practice expense inputs to this code 
because it is an add-on code that will only be performed in the 
facility setting.
Revisions to G Codes
    We are also revising the descriptors for the following existing G 
codes as follows:
    G0179 Physician recertification services for Medicare-covered 
services provided by a participating home health agency (patient not 
present) including review of subsequent reports of patient status, 
review of patient's responses to the OASIS assessment instrument, 
contact with the home health agency to ascertain the follow-up 
implementation plan of care, and documentation in the patient's office 
record, per certification period and
    G0180 Physician certification services for Medicare-covered 
services provided by a participating home health agency (patient not 
present), including review of initial or subsequent reports of patient 
status, review of patient's responses to the OASIS assessment 
instrument, contact with the home health agency to ascertain the 
initial implementation plan of care, and documentation in the patient's 
office record, per certification period
    Comment: Individuals have requested clarification as to whether a 
review of OASIS data is required when a physician bills for the 
certification and re-certification of home health plans of care.
    Response: The review of OASIS data, although not required for the 
performance of either a certification or re-certification of a home 
health plan of care, is considered a valuable tool to be utilized in 
the performance of both a certification or re-certification of a home 
health plan of care. We agree that the current HCPCS code(s) 
descriptors are unclear and will revise the descriptors to identify the 
review of OASIS as an option as opposed to a requirement. The 
descriptors are being revised as follows:
    G0179 Physician re-certification for Medicare-covered home health 
services under a home health plan of care (patient not present), 
including contacts with home health agency and review of reports of 
patient status required by physicians to affirm the initial

[[Page 80015]]

implementation of the plan of care that meets patient's needs, per re-
certification period.
    G0180: Physician certification for Medicare-covered home health 
services under a home health plan of care (patient not present), 
including contacts with home health agency and review of reports of 
patient status required by physicians to affirm the initial 
implementation of the plan of care that meets patient's needs, per 
certification period.
    G0236 Digitization of film radiographic images with computer 
analysis for lesion detection and further physician review for 
interpretation, diagnostic mammography (list separately in addition to 
code for primary procedure)
    Comment: Individuals have requested that we establish additional G-
codes that would specify the use of computer-aided detection with 
direct digital image mammograms. Currently, the descriptors associated 
with HCPCS code G0236 (diagnostic) and CPT code 76085 (screening) refer 
not only to the application of computer-aided detection but also to the 
conversion of film images to digital images.
    Response: When the computer-aided detection codes were originally 
assigned, we intended that they would be used for the application of 
computer-aided detection to both direct digital images and to standard 
film images that were converted to digital images. The current 
descriptors of both HCPCS code G0236 and CPT code 76085 do not 
explicitly state that the code can be billed in conjunction with either 
direct digital images or standard film images converted to digital 
images. We have revised the descriptor associated with the application 
of computer-aided detection to diagnostic images (HCPCS code G0236) to 
incorporate both direct digital images and standard film images 
converted to digital images. Additionally, we will request that the CPT 
editorial panel review the current definition associated with the 
screening computer-aided detection code (CPT code 76085) for future 
revision. Until such time as a revision is made to CPT code 76085, 
physicians should use CPT code 76085 for both direct digital screening 
images as well as for standard film screening images that are converted 
to digital images.
    G0236 is revised to read as follows: Digitization of film 
radiographic images with computer analysis for lesion detection, or 
computer analysis of digital mammogram for lesion detection, and 
further physician review for interpretation, diagnostic mammography 
(List separately in addition to code for primary procedure).
    G0239 Therapeutic procedures to improve respiratory function, other 
than services described by G0237, two or more (includes monitoring).
    For clarity, and to address concerns expressed by individuals about 
how to code group treatment of patients with procedures described in 
G0237, we are revising the descriptor for G0239 to read as follows:
    G0239 Therapeutic procedures to improve respiratory function or 
increase strength or endurance of respiratory muscles, two or more 
(includes monitoring).

Deletion of G Codes

    We will be deleting the following G codes for CY 2003: G0002 Office 
procedure, insertion of temporary indwelling catheter, foley type 
(separate procedure)
    Services formerly billed under G0002 will be billed under CPT codes 
51702 Insertion of temporary indwelling bladder catheter; simple (e.g., 
Foley) or 51703 Insertion of temporary indwelling bladder catheter; 
complicated (e.g., altered anatomy, fractured catheter/balloon).
    G0004 Patient demand single or multiple event recording with pre-
symptom memory loop and 24 hour attended monitoring, per 30 day period; 
includes transmission, physician review and interpretation; G0005 
Patient demand single or multiple event recording with pre-symptom 
memory loop and 24 hour attended monitoring, per 30 day period; 
recording (includes hook-up, recording and disconnection); G0006 
Patient demand single or multiple event recording with pre-symptom 
memory loop and 24 hour attended monitoring, per 30 day period; 24 hour 
attended monitoring, receipt of transmissions, and analysis; and G0007 
Patient demand single or multiple event recording with pre-symptom 
memory loop and 24 hour attended monitoring, per 30 day period; 
physician review and interpretation only.
    Services formerly billed under G0004 will be billed using CPT code 
93268, Patient demand single or multiple event recording with 
presymptom memory loop, 24-hour attended monitoring, per 30 day period 
of time; includes transmission, physician review and interpretation; 
services billed using G0005 will be billed using CPT code 93270, 
Patient demand single or multiple event recording with presymptom 
memory loop, 24-hour attended monitoring, per 30 day period of time; 
recording (includes hook-up, recording and disconnection); services 
billed using G0006 will be billed using CPT code 93271, Patient demand 
single or multiple event recording with presymptom memory loop, 24-hour 
attended monitoring, per 30 day period of time; monitoring, receipt of 
transmissions and analysis; services billed using G0007 will be billed 
using CPT code 93272 Patient demand single or multiple event recording 
with presymptom memory loop, 24-hour attended monitoring, per 30 day 
period of time; physician review and interpretation only, and services 
billed using G0015 will be billed using CPT code 93012 Telephonic 
transmission of post-symptom electrocardiogram rhythm strip(s), per 30 
day period of time, tracing only. Unattended monitoring of patient 
demand single or multiple event recording with presymptom memory loop, 
per 30 day period of time and unattended telephonic transmission of 
post symptom electrocardiogram rhythm strip(s), per 30 day period of 
time should be billed using CPT code 93799, Unlisted cardiovascular 
service or procedure.
    G0050 Measurement of post-voiding residual urine and/or bladder 
capacity by ultrasound
    Services formerly billed under G0050 will be billed using CPT code 
51798.
    G0131 Computerized tomography bone mineral density study, one or 
more sites; axial skeleton (e.g., hips, pelvis, spine) and G0132 
Computerized tomography bone mineral density study, one or more sites; 
appendicular skeleton (peripheral) (e.g., radius, wrist, heel).
    Services formerly billed under G0131 will be billed using CPT code 
76070, and those billed under G0132 will be billed using CPT code 
76071.
    G0185 Destruction of localized lesion of choroids for example, 
choroidal neovascularization; transpupillary thermotherapy (one or more 
sessions) and G0186 Destruction of localized lesion of choroids for 
example, choroidal neovascularization; photocoagulation, feeder vessel 
technique (one or more sessions).
    Services formerly billed under G0185 will be billed using CPT code 
0016T, Destruction of localized lesion of choroids (e.g., choroidal 
revascularization), transpupillary thermotherapy, and G0186 will be 
billed using CPT code 0017T, Destruction of macular drusen, 
photocoagulation.
    G0193 Endoscopic study of swallowing function (also fiberoptic 
endoscopic evaluation of swallowing (FEEST)), G0194 Sensory testing 
during endoscopic study of (add-on code) referred to as fiberoptic 
endoscopic evaluation of swallowing

[[Page 80016]]

with sensory (FEEST), G0195 Clinical evaluation of swallowing function 
(not involving interpretation of dynamic radiological studies or 
endoscopic study of swallowing), and G0196 Evaluation of swallowing 
involving swallowing of radio-opaque materials.
    Services formerly billed under G0193 will be billed using new CPT 
code 92612; services billed using G0194 will be billed using new CPT 
code 92614; services billed using G0195 will be billed using new CPT 
code 92610; and G0196 should be billed using new CPT code 92611.
    G0197 Evaluation of patient for prescription of speech generating 
devices, G0198 Patient adaptation and training for use of speech 
generating devices, G0199 Re-evaluation of patient using speech 
generating devices, G0200 Evaluation of patient for prescription of 
voice prosthetic, and G0201 Modification or training in use of voice 
prosthetic.
    Services formerly billed under G0197 will be billed using CPT code 
92607 Evaluation for prescription for speech-generating augmentative 
and alternative communication device, face-to-face with the patient; 
first hour, and, if appropriate, CPT code 92608, Evaluation for 
prescription for speech-generating augmentative and alternative 
communication device, face-to-face with the patient; each additional 30 
minutes; services billed using G0198 will be billed using CPT code 
92609 Therapeutic services for the use of speech-generating device, 
including programming and modification; services billed using G0199 
will be billed using CPT code 92607, using the -52 modifier if the 
service is less than 1 hour; services billed using G0200 will be billed 
using revised CPT code 92597 Evaluation for use and/or fitting of voice 
prosthetic device to supplement oral speech; and services billed using 
G0201 will be billed using CPT code 92507.
    G0240 Critical Care Service delivered by a physician; face-to-face, 
during inter-facility transport of a critically ill or critically 
injured patient: first 30-74 minutes of active transport, and G0241--
each additional 30 minutes (list separately in addition to G0240)
    Services formerly billed under G0240 and G0241 will be billed using 
CPT codes 99289 and 99290.

V. Update to the Codes for Physician Self-Referral Prohibition

A. Background

    On January 4, 2001 we published in the Federal Register a final 
rule with comment period, ``Medicare and Medicaid Programs; Physicians' 
Referrals to Health Care Entities With Which They Have Financial 
Relationships'' (66 FR 856). That final rule incorporated into 
regulations the provisions in paragraphs (a), (b) and (h) of section 
1877 of the Act. Section 1877 of the Act prohibits a physician from 
referring a Medicare beneficiary for certain ``designated health 
services'' to a health care entity with which the physician (or a 
member of the physician's immediate family) has a financial 
relationship, unless an exception applies. In the final rule, we 
published an attachment listing all of the CPT and HCPCS codes that 
defined the entire scope of the following designated health services 
for purposes of section 1877 of the Act: clinical laboratory services; 
physical therapy services (including speech-language pathology 
services); occupational therapy services; radiology and certain other 
imaging services; and radiation therapy services and supplies.
    In the January 2001 final rule, we stated that we would update the 
list of codes used to define these designated health services in an 
addendum to the annual physician fee schedule final rule. The purpose 
of the update is to conform the code list to the most recent 
publications of CPT and HCPCS codes. An updated all-inclusive list of 
codes was included in the November 1, 2001 physician fee schedule final 
rule in Addendum E and was subsequently corrected in a notice that was 
published in the Federal Register (66 FR 20681) on April 26, 2002.
    The updated all-inclusive list of codes effective for January 1, 
2003 is presented in Addendum E in this final rule. It is our intent to 
always use Addendum E of the annual physician fee schedule final rule 
for the physician self-referral update. The updated all-inclusive list 
of codes will also be available on our Web site at http://cms.hhs.gov/medlearn/refphys.asp.

B. Response to Comments

    We received three comments regarding the code list. The comments 
and our responses are stated below.
    Comment: One commenter agreed with the additions and deletions to 
the list of designated health services as published in the November 1, 
2001 physician fee schedule final rule (66 FR 55312). The commenter 
expressed the understanding that we would address the comments 
regarding the original list of designated health services (published in 
the January 4, 2001 final rule) in a second final rule on the physician 
self-referral prohibition. A second commenter raised concerns about our 
decision (announced in the January 4, 2001 final rule) to exclude 
nuclear medicine from the definition of ``radiology and certain other 
imaging services.''
    Response: The first commenter is correct in understanding that we 
intend to address substantive comments on the designated health 
services that are defined by reference to HCPCS and CPT codes in a 
second final rule concerning the physician self-referral prohibition. 
We will also address the second commenter's concerns regarding nuclear 
medicine in that final rule. As noted above, this update to the code 
list merely reflects changes to the most recent publications of HCPCS 
and CPT codes.
    Comment: One commenter noted that we post on our Web site (http://www.hcfa.gov/stats/cpt/rvudown.htm) an Excel spreadsheet file 
containing all of the CPT/HCPCS codes with accompanying RVUs. The 
commenter suggested that we add a column indicating whether a code is 
considered a designated health service for purposes of the physician 
self-referral law, as well as in which category of designated health 
services it would be included. The commenter stated that, as changes 
are made, they would be scattered throughout several physician fee 
schedules.
    Response: We believe that the commenter was concerned that updates 
to the list of designated health services under the physician self-
referral law would be published in various fee schedules throughout the 
course of a year. This is not the case. We publish the annual update 
and the entire list of CPT/HCPCS codes in the physician fee schedule 
final rule. (Addendum E contains the updated all-inclusive list of 
codes.) We have no plans to publish an updated list of codes for 
physician self-referral purposes in any other fee schedule. We chose 
the physician fee schedule, as opposed to one of the other fee 
schedules, because we believe that physicians would be more likely to 
see it. We maintain a current list of codes used to define certain 
designated health services for purposes of the physician self-referral 
law on our Web site at http://cms.hhs.gov/medlearn/refphys.asp. We have 
decided not to make any changes to the RVU website at this time because 
we believe the updated all-inclusive list of codes used for purposes of 
physician self-referral is readily available to all physicians.

C. Revisions Effective for 2003

    Table 9, below, identifies the additions and deletions to the 
comprehensive list of physician self-referral codes published in 
Addendum

[[Page 80017]]

E of the November 2001 physician fee schedule final rule and 
subsequently corrected in the April 26, 2002 correction notice (66 FR 
20681). Table 9 also identifies the additions, deletions and revisions 
to the lists of codes used to identify the items and services that may 
qualify for the exceptions in Sec.  411.355(g) (regarding EPO and other 
dialysis-related outpatient prescription drugs furnished in or by an 
end-stage renal dialysis (ESRD) facility) and in Sec.  411.355(h) 
(regarding preventive screening tests, immunizations and vaccines).
    We will consider comments with respect to the codes listed in Table 
9 below, if we receive them by the date specified in the DATES section 
of this final rule.

 Table 9.--Additions and Deletions to the Physician Self-Referral Codes
------------------------------------------------------------------------
            HCPCS                          CPT \1\/Descriptor
------------------------------------------------------------------------
Additions:
51798........................  Us urine capacity measure
76070........................  Ct bone density, axial
76071........................  Ct bone density, peripheral
76801........................  Ob us < 14 wks, single fetus
76802........................  Ob us < 14 wks, addl fetus
76811........................  Ob us, detailed, sngl fetus
76812........................  Ob us, detailed, addl fetus
92601........................  Cochlear implt f/up exam < 7
92602........................  Reprogram cochlear implt < 7
92603........................  Cochlear implt f/up exam 7 
92604........................  Reprogram cochlear implt 7 
92607........................  Ex for speech device rx, 1hr
92608........................  Ex for speech device rx addl
92609........................  Use of speech device service
92610........................  Evaluate swallowing function
92611........................  Motion fluoroscopy/swallow
92612........................  Endoscopy swallow tst (fees)
92614........................  Laryngoscopic sensory test
92616........................  Fees w/laryngeal sense test
0010T........................  TB test, gamma interferon
0019T........................  Extracorp shock wave tx, ms
0020T........................  Extracorp shock wave tx, ft
0023T........................  Phenotype drug test, HIV 1
0026T........................  Measure remnant lipoproteins
0028T........................  Dexa body composition study
0029T........................  Magnetic tx for incontinence
0030T........................  Anitprothrombotin antibody
0041T........................  Detect UR infect agnt w/cpas
0042T........................  Ct perfusion w/contrast, cbf
0043T........................  Co expired gas analysis
G0256........................  Prostate brachy w palladium
G0261........................  Prostate brachytherapy w/rad
G0262........................  Sm intestinal image capsule
G0274........................  Radiopharm tx, non-Hodgkins
G0279........................  Excorp shock tx, elbow epi
G0280........................  Excorp shock tx other than
G0281........................  Elec stim unattend for press
G0283........................  Elec stim other than wound
G0288........................  Recon, CTA for surg plan
J0636........................  Inj calcitriol per 0.1 mcg
J1756........................  Iron sucrose injection
J2501........................  Paricalcitol
J2916........................  Na ferric gluconate complex
Q3021........................  Ped hepatitis b vaccine inj
Q3022........................  Hepatitis b vaccine adult ds
Q3023........................  Injection hepatitis Bvaccine
Deletions:
76830........................  Us, exam transvaginal
76872........................  Echo exam, transrectal
76873........................  Echograp trans r, pros study
86915........................  Bone marrow/stem cell prep
90744........................  Hepb vacc ped/adol 3 dose im
90746........................  Hep b vaccine, adult, im
90747........................  Hepb vacc, ill pat 4 dose im
92510........................  Rehab for ear implant
97014........................  Electric stimulation therapy
G0026........................  Fecal leukocyte examination
G0027........................  Semen analysis
G0050........................  Residual urine by ultrasound
G0131........................  CT scan, bone density study
G0132........................  CT scan, bone density study
G0193........................  Endoscopicstudyswallowfunctn

[[Page 80018]]

 
G0194........................  Sensorytestingendoscopicstud
G0195........................  Clinicalevalswallowingfunct
G0196........................  Evalofswallowingwithradioopa
G0197........................  Evalofptforprescipspeechdevi
G0198........................  Patientadapation&trainforspe
G0199........................  Reevaluationofpatientusespec
G0200........................  Evalofpatientprescipofvoicep
G0201........................  Modifortraininginusevoicepro
J0635........................  Calcitriol injection
J1755........................  Iron sucrose injection
J2915........................  NA Ferric Gluconate Complex
Revisions:
76085........................  Computer mammogram add-on [when used in
                                conjunction with 76092]
------------------------------------------------------------------------
\1\ CPT codes and descriptions only are copyrighted in the 2002 American
  Medical Association. All rights are reserved and applicable FARS/DFARS
  clauses apply.

    The ``Additions'' section of Table 9 generally reflects new CPT and 
HCPCS codes that become effective January 1, 2003. The one exception is 
the addition of the following emerging technology codes, referred to as 
Category III codes, which the AMA first included in the CPT effective 
January 1, 2002: 0010T, 0019T, 0020T, 0023T, and 0026T. CPT codes 
0010T, 0023T, and 0026T represent clinical laboratory services while 
CPT codes 0019T and 0020T are therapy codes. These codes were addressed 
in the November 2001 physician fee schedule final rule with the 
clarification that coverage and payment of these services is generally 
at the discretion of the carrier. However, the portion of the November 
2001 final rule that concerned the list of codes for physician self-
referral purposes failed to address these new codes. Thus, we are 
adding the Category III codes that should have been included in last 
year's update. We also are adding the following new Category III codes 
issued for 2003 to which the physician self-referral prohibition 
applies: 0028T, 0029T, 0030T, 0041T, 0042T, and 0043T. CPT codes 0028T 
and 0042T are radiology services; CPT code 0029T is a physical therapy 
service; and, CPT codes 0030T, 0041T and 0043T are clinical laboratory 
services.
    Table 9 also reflects the addition of 4 new codes (J0636, J1756, 
J2501 and J2916) to the list of dialysis-related outpatient 
prescription drugs that may qualify for the exception described in 
Sec.  411.355(g) regarding those items. The physician self-referral 
prohibition will not apply to these drugs if they meet the conditions 
set forth in Sec.  411.355(g). Table 9 also reflects the addition of 3 
vaccine codes (Q3021, Q3022 and Q3023) to the list that identifies 
preventive screening tests, immunizations and vaccines that may qualify 
for the exception described in Sec.  411.355(h) for such items and 
services. The physician self-referral prohibition will not apply to 
these vaccines if they meet the conditions set forth in Sec.  
411.355(h) concerning the exception for preventive screening tests, 
immunizations, and vaccines.
    With the exception of CPT codes 76830, 76872 and 76873 for 
ultrasounds, the ``Deletions'' section of Table 9 reflects changes 
necessary to conform the code list to the most recent publications of 
CPT and HCPCS codes. We are deleting CPT code 76830 for transvaginal 
ultrasound and CPT codes 76872 and 76873 for transrectal ultrasounds 
because these codes should never have appeared on the list of 
designated health services. Our definition of ``radiology and certain 
other imaging services'' published in the January 2001 final rule (66 
FR 956) specifically excludes any ultrasonic procedure that requires 
``the insertion of a needle, catheter, tube, or probe''. Thus, although 
the deletion of these codes is not a change to conform to an annual 
change in CPT or HCPCS codes, we are making the change at this time so 
that the list of codes will accurately reflect the regulatory 
definition for ``radiology and certain other imaging services.''
    Table 9 includes one revised CPT code. That is CPT code 76085, 
``Computer mammogram add-on.'' In the CPT publication effective January 
1, 2003, the CPT long descriptor was changed to delete the word 
``screening'' so that the digitization no longer refers only to 
screening mammography. Because our exception under Sec.  411.355(h) 
applies to preventive screening tests, we have revised the list of 
codes that may qualify for that exception to indicate that CPT code 
76085 may qualify for the exception only when it is used in conjunction 
with CPT code 76092, ``Mammogram screening.''

VI. Physician Fee Schedule Update for Calendar Year 2003

A. Physician Fee Schedule Update

    The physician fee schedule update is determined under a calculation 
methodology that is specified by statute. Under section 1848(d)(4) of 
the Act, the update is equal to the product of 1 plus the percentage 
increase in the Medicare Economic Index (MEI) (divided by 100) and 1 
plus the update adjustment factor. For CY 2002, the MEI is equal to 3.0 
percent (1.030). The update adjustment factor is equal to -7.0 percent 
(0.930). Section 1848(d)(4)(F) of the Act requires an additional -0.2 
percent (0.998) reduction to the update for 2003. Thus, the product of 
the MEI (1.030), the update adjustment factor (0.930), and the 
statutory adjustment factor (0.998) equals the CY 2003 update of -4.4 
percent (0.956).
    The Department believes that the negative update is inappropriate 
because the current update system does not reflect actual, after the 
fact, data from earlier years. Instead, the Act requires the Department 
to rely upon estimates made in past years, even though the Department 
now has actual data for these particular years. Even though after-the-
fact data show that for certain years actual increases differed to some 
degree from earlier estimates, the Department is unable to revise 
estimates without congressional action. We have exhaustively searched 
for a different interpretation of law that would allow us to revise 
estimates for earlier years administratively, but unfortunately, we had 
to conclude that current law does not permit such an interpretation.
    Without congressional action to address the current legal 
framework, the Department is compelled to announce a

[[Page 80019]]

physician fee schedule update for CY 2003 of -4.4 percent. The 
Department's calculations are explained below.
    We have, however, also identified reasonable adjustments that could 
result in a positive update in physician fee schedule rates if the 
Department were permitted by law to make those adjustments. Revisions 
of estimates used to establish the sustainable growth rates (SGR) for 
fiscal years (FY) 1998 and 1999 and Medicare volume performance 
standards (MVPS) for 1990 through 1996 could, under present 
estimations, result in an increase in the update.
    The Department intends to work closely with the Congress to develop 
legislation that could permit a positive update, and hopes that such 
legislation can be passed before the negative update takes effect. 
Because the Department wishes to take action immediately in the event 
that Congress provides the Department legal authority to make the 
corrections, we are requesting comments regarding how physician fee 
schedule rates could and should be recalculated prospectively in the 
event that Congress provides the Department with legal authority to 
revise estimates used to establish the sustainable growth rates (SGR) 
for FYs 1998 and 1999 and the MVPS for 1990-1996.

B. The Percentage Change in the Medicare Economic Index

1. Medicare Economic Index (MEI) Productivity Adjustment
    In the June 28, 2002 proposed rule, we reviewed the history of the 
MEI productivity adjustment, described the current MEI productivity 
adjustment, identified and evaluated possible alternative MEI 
productivity adjustments based on the individual contributions we 
solicited from experts on this topic, and proposed changing the MEI 
productivity adjustment to reflect an economy-wide multifactor 
productivity adjustment. In this final rule, we repeat this research 
information, respond to public comments on the MEI, and determine the 
CY 2003 MEI using the proposed methodological change.

a. History of MEI Productivity Adjustment

    The MEI is required by section 1842(b)(3)(L) of the Act which 
states that prevailing charge levels beginning after June 30, 1973 may 
not exceed the level from the previous year except to the extent that 
the Secretary finds, on the basis of appropriate economic index data, 
that such higher level is justified by year-to-year economic changes. 
S. Rep. No. 92-1230, at 191 (1972) provides slightly more detail on 
that index, stating that:
    Initially, the Secretary would be expected to base the proposed 
economic indexes on presently available information on changes in 
expenses of practice and general earnings levels combined in a manner 
consistent with available data on the ratio of the expenses of practice 
to income from practice occurring among self-employed physicians as a 
group.
    Consistent with section 1842(b)(3)(L) and legislative intent, in 
1975, we determined that the MEI would be based on a broad wage measure 
reflecting overall earnings growth, rather than direct inclusion of 
physicians' net income. We used average weekly earnings of 
nonagricultural production (non-supervisory) workers, net of worker's 
productivity, as the wage proxy in the initial MEI. We included the 
productivity adjustment because it avoided double counting of gains in 
earnings resulting from growth in productivity and produced an MEI that 
approximated an economy-wide output price index similar to the Consumer 
Price Index (CPI). The productivity adjustment we used was the annual 
change in economy-wide private non-farm business labor productivity, 
applied only to the physicians' earnings portion of the MEI (then 60 
percent).
    As noted, the productivity adjustment in the MEI serves to avoid 
the double counting of productivity gains. Absent the adjustment, 
productivity gains from producing additional outputs (procedures) with 
a given amount of inputs would be included in both the earnings 
component of the MEI (reflecting growth in overall economy-wide wages) 
and in the additional procedures that are billed (reflecting 
physicians' own productivity gains). Therefore, general economic labor 
productivity growth is removed from the labor portion of the MEI.
    Although the basic structure of the MEI remained relatively 
unchanged from its effective date (July 1, 1975) until 1992, its 
weights were updated periodically and a component was added for 
professional liability insurance. Section 9331 of the Omnibus Budget 
Reconciliation Act of 1986 (Pub. L. 99-509) (OBRA 86) mandated that we 
conduct a study of the structure of the MEI and prepare a notice and 
offer the public an opportunity to comment before we revise the 
methodology for calculating the MEI. Based on this requirement, we held 
a workshop with experts on the MEI in March 1987 to discuss topics 
ranging from the specific type of index to use (Laspeyres versus 
Paasche) to revising the method of reflecting productivity changes. 
Participants included the Federal government, the Physician Payment 
Review Commission (PPRC), the Congressional Budget Office, the AMA, and 
several private consulting firms. The meeting participants concluded 
that a productivity adjustment in the MEI was appropriate and that an 
acceptable measure of physician-specific productivity did not currently 
exist. Many alternative approaches were discussed, including the use of 
a policy-based ``target'' measure and several existing economic 
productivity measures.
    Using recommendations from the meeting participants, we revised the 
MEI and the productivity adjustment with the implementation of the 
physician fee schedule as discussed in the November 1992 final rule (57 
FR 55896). While we retained an adjustment for economy-wide labor 
productivity, this adjustment was applied to all of the direct labor 
categories of the MEI (70.448 percent), not just physicians' earnings, 
and was based on the 10-year moving average percent change (instead of 
annual percent changes). This form of the index has been used since 
that time, and was most recently discussed in the November 1998 final 
rule (63 FR 58845) when the MEI weights were rebased to a 1996 base 
year.
    The BBA replaced the Medicare Volume Performance Standard (MVPS) 
with a Sustainable Growth Rate (SGR). The SGR is an annual growth rate 
that applies to physicians' services paid for by Medicare. The use of 
the SGR is intended to control growth in aggregate Medicare 
expenditures for physicians' services. Payments for services are not 
withheld if the percentage increase in actual expenditures exceeds the 
SGR. Rather, the physician fee schedule update, as specified in section 
1848(d)(4) of the Act, is adjusted based on a comparison of allowed 
expenditures (determined using the SGR) and actual expenditures. If 
actual expenditures exceed allowed expenditures, the update is reduced. 
If actual expenditures are less than allowed expenditures, the update 
is increased. Specifically, the SGR is calculated on the basis of the 
weighted average percentage increase in fees for physicians' services, 
growth in fee-for-service Medicare enrollment, growth in real per 
capita Gross Domestic Product (GDP), and the change in expenditures on 
physicians' services resulting from changes in law or regulations.

[[Page 80020]]

    When the SGR was enacted, the Congress specified continued use of 
the MEI. By 1997, the MEI, including its productivity adjustment, had 
been used in updating Medicare payments to physicians for over twenty 
years. We did not propose any changes to the productivity adjustment 
used in the MEI when the SGR system was enacted because its continued 
use was consistent with the newly mandated formula. If we did not make 
a productivity adjustment in the MEI, general economic productivity 
gains would be reflected in two of the SGR factors, the MEI and real 
per-capita GDP (which reflects real GDP per hour worked, or labor 
productivity, and hours worked per person). We believe it is reasonable 
to remove the effect of general economic productivity from one of these 
factors (the MEI) to avoid double counting.
    As noted previously, since its original development, the MEI 
productivity adjustment has been based on economy-wide productivity 
changes. This practice arose from the fact that the physicians' 
compensation portion of the MEI is proxied to grow at the same rate as 
general earnings in the overall economy, which reflect growth in 
overall economy-wide productivity. Removing labor productivity growth 
reflected in general earnings from the labor portion of the MEI 
produces an index that is consistent with other economy-wide output 
price indexes, like the CPI.

b. Research on Alternative MEI Productivity Adjustments

    In the June 2002 proposed rule we presented the research we 
completed on evaluating the most appropriate productivity adjustment 
for the MEI. This research included evaluating the currently available 
productivity estimates produced by the BLS to develop a better 
understanding of the strengths and weaknesses of these measures and 
reviewing the theoretical foundation of the MEI to understand how labor 
and multifactor productivity relate to the current physician payment 
system. We also studied the limited publicly available data to begin to 
develop preliminary estimates of trends in physician-specific 
productivity to better understand the current market conditions facing 
physicians. Finally, we solicited the individual contributions of 
academic and other professional economic experts on prices and 
productivity. These experts included individuals from the MedPAC, the 
AMA, the Office of Management and Budget (OMB), Dr. Uwe Reinhardt from 
Princeton University, Dr. Joe Newhouse from Harvard University, Dr. 
Ernst Berndt from MIT, and Dr. Joel Popkin from Joel Popkin and 
Company. Below we repeat the findings on each of the six options we 
investigated and detailed in the proposed rule:
    [sbull] Option 1--Using a physician-specific productivity 
adjustment.
    This option would entail using an estimate of physician-specific 
productivity to adjust the MEI. This option may have some theoretical 
attractiveness, but there are major problems in obtaining accurate 
measures of physician-specific productivity. First, no published 
measure of physician-specific productivity is available. The Federal 
agency that produces the official government statistics on 
productivity, BLS, does not calculate or publish productivity measures 
for any health sector. Nor are there alternative measures of physician-
specific productivity that would conform to the BLS methodology for 
measuring productivity. Second, it is not clear that using physician-
specific productivity within the current structure of the MEI would be 
appropriate. Because we believe the MEI appropriately uses an economy-
wide wage measure as the proxy for physician wages, using physician 
specific productivity could overstate or understate the appropriate 
wage increases in the MEI.
    We do believe, however, that it is important to understand the rate 
of change in physician-specific productivity. Toward this end, we have 
performed our own preliminary analysis of physician-specific 
productivity, using the limited available data on physician outputs and 
inputs. Our analysis attempted to simulate the methodology the BLS 
would use to measure productivity. To help achieve this we have been in 
contact with experts at the BLS to obtain their feedback on our 
methodology. While this information cannot be interpreted as an 
official measure of physician productivity, we do believe it provides a 
rough indication of the current market conditions facing physicians. We 
used this information to aid in forming our determination of the most 
appropriate productivity adjustment to incorporate in the MEI, fully 
recognizing its preliminary nature and other limitations of our 
analysis. The results of our preliminary analysis suggest that long-run 
physician-specific productivity growth is currently near the level of 
economy-wide multifactor productivity growth. Prior to the recent 
period, however, our preliminary estimates suggested that physician 
productivity gains were generally significantly greater than general 
economy-wide multifactor productivity gains and more in line with 
economy-wide labor productivity.
    As we have emphasized, our rough estimates are inadequate for 
establishing a formal basis for the productivity adjustment to the MEI. 
In addition, the underlying economic theory is not sufficiently 
compelling, at this time, to adopt a physician-specific productivity 
measure, even if a suitable one were available. We conclude, however, 
that economy-wide multifactor productivity growth appears to be roughly 
comparable to our estimates of current physician-specific productivity 
growth.
    Comment: A few commenters urged us to develop a measure of 
productivity that more accurately reflects the conditions facing 
physicians. The commenters suggested that we consider issues like 
increased regulatory burden on physicians and the service-oriented 
nature of physician services.
    Response: As we stated in the June 2002 proposed rule and repeated 
above, no publicly available measure of physician productivity exists. 
In addition, no publicly available measure of service-sector 
productivity exists. Because of this it is not possible at this time to 
incorporate a productivity adjustment in the MEI that explicitly 
reflects physician marketplace characteristics.
    However, we do believe that it is important that the productivity 
adjustment included in the MEI be consistent with the market conditions 
facing physicians. As we have discussed in this final rule, we 
attempted to understand the trends in physician productivity by 
researching and making the most optimal use of the sparse data 
available. We will continue to refine this research, including 
soliciting contributions both from experts at BLS and outside experts 
on measuring productivity. In addition, we encourage the commenters to 
work with BLS to pursue the development of official measures of 
physician and health sector productivity.
    [sbull] Option 2--Using economy-wide labor productivity applied to 
the labor portion of the MEI.
    We have applied economy-wide labor productivity growth to a portion 
of the MEI in some form since the inception of the index in 1975. For 
the 2002 update, we applied the 10-year moving average percent change 
in economy-wide labor productivity to the labor portion of the MEI. 
This adjustment was developed based on the contributions of a 1987 
expert panel. That panel concluded that applying labor productivity 
data to the labor portion of the index was a technically sound way to 
account for

[[Page 80021]]

productivity in the physician update. This method made optimal use of 
the available data because labor productivity data were, and are, 
available on a more-timely basis than economy-wide multifactor 
productivity. By applying this measure to the labor portion of the 
index, the mix of physician-specific labor and non-labor inputs is 
reflected. Also, the use of a 10-year moving average percentage change 
reduces the volatility of annual labor productivity changes.
    Our research, however, has indicated that using multifactor 
productivity applied to the entire index is a superior method to using 
an economy-wide labor productivity measure applied only to the labor 
portion of the index. The experts with whom we consulted believed it 
was more appropriate to reflect the explicit contribution to output 
from all inputs. The current measure explicitly reflects the changes in 
economy-wide labor inputs but does not reflect the actual change in 
non-labor inputs. Instead, it implicitly assumes that non-labor inputs 
would grow at a rate necessary to produce an economy-wide multifactor 
measure that is equivalent to the current MEI productivity adjustment. 
That implicit assumption is less precise than a direct, explicit 
calculation.
    In addition, while the implicit approach produced an MEI 
productivity adjustment in most years that was reasonably consistent 
with overall multifactor productivity growth, it now appears less 
consistent with the actual change in non-labor inputs in the economy. 
In recent years, economy-wide labor productivity has grown very 
rapidly. This acceleration is partly the result of major investments in 
non-labor inputs that have helped to create a more productive work 
force. Also, the Bureau of Economic Analysis (BEA) adopted 
methodological changes in accounting for computer software purchases in 
measuring GDP. These changes have significantly increased the measured 
historical growth rates in real GDP and labor productivity. As a result 
of these developments, the current MEI productivity adjustment, 
applying labor productivity only to the labor portion of the MEI, has 
increased very rapidly. Because the multifactor definition is an 
explicit calculation of the change in economic output relative to the 
change in both labor and non-labor inputs, it better reflects the 
overall productivity trend changes.
    Finally, as noted previously, our preliminary estimates of 
physician-specific productivity suggest a current growth pattern that 
is similar to growth in multifactor productivity in the economy 
overall. In consideration of the economic theory underlying 
productivity measurement, especially in view of the recent developments 
in labor versus non-labor economic input growth trends, we concluded 
that using a multifactor productivity adjustment is superior to the 
current methodology for adjusting for productivity in the MEI.
    [sbull] Option 3--Change to using economy-wide multifactor 
productivity.
    The option we proposed in the June 2002 proposed rule was to adjust 
for productivity gains in the MEI using economy-wide multifactor 
productivity applied to the entire index, instead of labor productivity 
applied to the labor portion of the MEI. This option would better 
satisfy the theoretical requirements of an output price, in this case 
the MEI, by explicitly reflecting the productivity gains from all 
inputs. In addition, the use of economy-wide multifactor productivity 
would still be consistent with the MEI's use of economy-wide wages as a 
proxy for physician earnings. While annual multifactor productivity can 
fluctuate considerably, though usually less than labor productivity, 
using a moving-average would produce a relatively stable and 
predictable adjustment.
    Each expert with whom we consulted believed that using a 
multifactor productivity measure was theoretically superior to the 
previous methods used to adjust the MEI because it reflects the actual 
changes in non-labor inputs instead of reflecting an implicit 
assumption about those changes. These experts also believed that the 
lack of timely data on multifactor productivity was not as important as 
would have appeared initially. Instead, they believed it was more 
appropriate that the adjustment be based on a long-run average that was 
stable and predictable rather than on annual changes in productivity. 
Thus, if a long-run average were used, the increased lag time 
associated with the availability of published data on multifactor 
productivity becomes less significant. Finally, one expert believed 
that changing to economy-wide multifactor productivity applied to the 
entire MEI would make it easier to understand the magnitude of the 
productivity adjustment.
    However, use of multifactor productivity to adjust the MEI poses 
two concerns. First, multifactor productivity is much harder to measure 
than labor productivity. Economic inputs other than labor hours can be 
very difficult to identify and calculate properly. The experts at BLS, 
however, have adequately overcome these difficulties, and we are 
satisfied that their official published measurements are sound for the 
purpose at hand. Moreover, use of a 10-year moving average increase 
helps to mitigate any remaining measurement variation from year to 
year.
    The second concern relates to the timeliness of the data. BLS 
publishes multifactor productivity levels and changes annually (as 
opposed to the quarterly release of labor productivity data) and with 
an extended time lag (about 1\1/2\ years). These timeframes arise 
unavoidably from the difficulties of measuring non-labor input as 
mentioned above, but would result in a misalignment of the data periods 
for the data used to adjust the MEI and of the historical data on wages 
and prices underlying the MEI. For the CY 2003 physician payment 
update, for example, we would use data on wages and prices through the 
second quarter of CY 2002, but would have to use multifactor 
productivity data through CY 2000. Although the misalignment of data 
periods is a concern, we believe it is a reasonable trade-off in view 
of the improvement offered by an explicit measurement of non-labor 
inputs. Also, because use of a 10-year moving average is intended to 
reduce fluctuations and provide a more stable level of the productivity 
adjustment, availability of the most recent data is of less importance.
    The 10-year moving average percent change in economy-wide 
multifactor productivity that would be used for the CY 2003 update 
(historical data through CY 2000) is estimated at 0.8 percent. Our 
preliminary internal analysis of physician-specific productivity gains 
suggests that these economy-wide multifactor measures are consistent 
with those trends. Thus, using economy-wide multifactor productivity 
for MEI productivity adjustment theoretically would be superior to 
using labor productivity growth applied to the labor portion of the 
MEI.
    [sbull] Option 4--Change to using economy-wide multifactor 
productivity with physician-specific input weights
    Another option we explored was using economy-wide labor and capital 
productivity measures (which, when weighted together, produce 
multifactor productivity), but with physician-specific input weights. 
This method would better reflect the proportion of labor and capital 
inputs used by physicians, and reflect the explicit contribution to 
productivity of labor and non-labor inputs. The experts with whom we 
discussed this option thought it was theoretically consistent with a 
measure of multifactor productivity, even though different productivity

[[Page 80022]]

measures would be applied to different components of the MEI.
    A weakness of this method is that the BLS capital productivity 
series is not widely used or cited; therefore, we are unsure of the 
accuracy and reliability of this measure. This method also adds another 
layer of complexity to the formula, making it more difficult to 
understand the adjustment. We would prefer that any method we choose be 
straightforward so that it can be readily understood. Moreover, the 
labor and capital shares for the overall economy do not appear to vary 
enough from the physician-specific shares in the MEI to result in a 
significantly different measure. Overall, we believe that this method 
does not provide enough of a technical improvement to justify the added 
complexity that would be required to implement it.
    [sbull] Option 5--Adjusting productivity using a ``Policy 
Standard''.
    In its March 2002 Report to the Congress, MedPAC suggested 
establishing a policy target for the productivity adjustment. Under 
this methodology, the level of the policy target would be based on the 
productivity gains that physicians could reasonably be expected to 
attain. This level would be set through policy and would likely be 
based on a long-run average of either economy-wide labor or multifactor 
productivity (but could reflect other, possibly judgmental, factors). 
Generally, the level of the policy standard would remain constant for 
several years, and periodically would be reviewed and adjusted as 
needed.
    Some of the experts we consulted believed that a policy target 
would lessen the volatility of the adjustment because the target would 
not be changed often. Conversely, others noted the large, abrupt 
changes that could result if actual economic performance deviated from 
the policy standard requiring subsequent adjustments to the standard. 
Some believed that this method adjusts for the problem of precisely 
measuring productivity. If we used a policy standard we could avoid 
having to develop an exact measure. Using a policy target, however, may 
appear arbitrary without a theoretical basis to support its use.
    The policy target recommended by the MedPAC was 0.5 percentage 
points per year. The MedPAC's justification for this number was that 
the long-run average of economy-wide multifactor productivity was close 
to 0.5 percent (the most recent 10-year average is now 0.8 percent). We 
do not believe this is a preferred option for adjusting the MEI for 
productivity improvements. Our preference is to use a data based 
approach that automatically reflects changes in actual economic 
performance over time, and not through abrupt periodic, possibly large 
adjustments. Thus, we conclude that a policy target does not provide an 
improvement over any of the data based methodologies.
    Comment: One commenter recommended the productivity adjustment be 
removed from the MEI to make the index more consistent with our other 
market baskets.
    Response: Since its inception in 1975 the MEI has included a 
productivity adjustment. By including the productivity adjustment in 
the MEI and using a general earnings proxy for physician wages, the 
index approximated an economy-wide output price index like the CPI. 
This original intent was different from that for the other market 
baskets, which are defined to reflect pure price changes in inputs 
associated with providing care. Thus, the MEI appropriately includes an 
adjustment for productivity changes.
    As we described earlier, practically it makes no difference whether 
productivity is adjusted for within or outside the MEI, as long as an 
adjustment is present. However, given the historical precedent 
regarding the definition of the MEI, the apparent legislative intent 
behind recent legislation that did not prescribe a change to the MEI 
definition, and the specific update formula that must be used under the 
SGR, we do not believe it would be appropriate for the productivity 
adjustment to be made outside the MEI.
    [sbull] Option 6--Eliminate Productivity Adjustment from the MEI.
    Questions are raised occasionally as to the possibility of 
eliminating the productivity adjustment from the MEI. We did not 
consider this to be a viable option. Our research concluded that 
adjusting for productivity in the MEI is necessary in order to have a 
technically correct measure of an output price increase, free from 
double-counting of the impact of productivity. Every expert with whom 
we consulted agreed that a productivity adjustment is appropriate. They 
believed that the important question is which measure is the most 
appropriate for the adjustment.

c. Use of a Forecasted MEI and Productivity Adjustment

    In a March 2002 Report to the Congress, the MedPAC recommended the 
use of a forecasted MEI value, rather than the current historical 
increase. However, implementation of this option raises several legal 
as well as practical issues. The 1972 Senate Finance Committee report 
language reflects the intent of the Congress that the MEI should 
``follow rather than lead'' overall inflation. As a result, updates to 
the physician fee schedule have always been based on historical, rather 
than forecasted, MEI data. In this way, increases in the MEI do not 
lead the current measures of inflation but follow them based on 
historical trends. Furthermore, at the time of implementation of the 
SGR system, the Congress specified that the SGR system should use the 
MEI that existed at the time, which was based on historical data 
measures. The law did not recommend or specify a change in the MEI 
methodology. Thus, the assumption is that the Congress was satisfied 
that the MEI was functioning as designed. If we were to use a 
forecasted MEI and productivity adjustment, there are several practical 
issues that would need to be addressed. One issue is that a change from 
a historical-based MEI to a projected MEI would cause transitional 
problems because there would be a period of data that would not be 
accounted for in the year of implementation. For example, the CY 2002 
MEI update was based on historical data through the second quarter of 
2001. If we were to use a forecasted MEI in the update for CY 2003, any 
changes between the second quarter of 2001 and the first quarter of 
2003 would not be accounted for in the update. Additionally, changing 
to a forecasted MEI and productivity adjustment raises additional 
questions about correcting for forecast errors. Based on these 
problems, we will continue to use historical data to make updates under 
the physician fee schedule.
    Comment: One commenter urged us to use a forecast of the MEI change 
for the update in the upcoming year. The commenter believed that we had 
the legal authority to make such a change and that the transition 
issues cited in the proposed rule were not relevant.
    Response: We do not believe that it would be appropriate to use a 
forecast of the MEI for the 2003 update. Since the inception of the 
MEI, and more recently the implementation of the physician fee 
schedule, the MEI increase for the upcoming year's update has been 
based on as much historical data as is available when the update is 
determined. For the 2003 update this means using data that is available 
through June 2002.
    Our interpretation of the legislative intent is for the MEI update 
to be based on historical data, and does not contemplate a MEI based on 
projections.

[[Page 80023]]

As we stated above, the MEI update has always been based on historical 
data and we believe that the legislative intent when the SGR system was 
implemented was to continue using this methodology. In addition, we 
believe that the transition and forecast error issues described above 
are legitimate concerns that, at this time, would outweigh the benefits 
of making such a change. Therefore, we will continue to use historical 
data in developing the MEI used for the 2003 fee schedule update.

d. Productivity Adjustment to the MEI

    Based on the research we conducted on this issue, we are changing 
the methodology for adjusting for productivity in the MEI. The MEI used 
for the CY 2003 physician payment update will reflect changes in the 
10-year moving average of private non-farm business (economy-wide) 
multifactor productivity applied to the entire index. Several 
commenters agreed with this methodological change.
    We made this change because--(1) It is theoretically more 
appropriate to explicitly reflect the productivity gains associated 
with all inputs (both labor and nonlabor); (2) the recent growth rate 
in economy-wide multifactor productivity appears more consistent with 
the current market conditions facing physicians, and (3) the MEI still 
uses economy-wide wage changes as a proxy for physician wage changes. 
We believe that using a 10-year moving average change in economy-wide 
multifactor productivity produces a stable and predictable adjustment 
and is consistent with the moving-average methodology used in the 
existing MEI. Thus, the productivity adjustment will be based on the 
latest available actual historical economy-wide multifactor 
productivity data, as measured by the BLS.
    We currently estimate the MEI to increase 3.0 percent for CY 2003. 
This is the result of a 3.8 percent increase in the price portion of 
the MEI, adjusted downward by a 0.8 percent increase in the 10-year 
moving average change in economy-wide multifactor productivity. Table 
10 shows the detailed cost categories of the MEI update for CY 2003.

 Table 10.--Increase in the Medicare Economic Index Update for Calendar
                              Year 2003 \1\
------------------------------------------------------------------------
                                                              CY 2003
   Cost categories and price measures      1996 Weights       percent
                                                \2\           changes
------------------------------------------------------------------------
Medicare Economic Index Total,                       n/a             3.0
 productivity adjusted..................
    Productivity: 10-year moving average             n/a             0.8
     of multifactor productivity,
     private nonfarm business sector....
Medicare Economic Index Total, without             100.0             3.8
 productivity adjustment................
    1. Physician's own time \3\.........            54.5             3.9
        a. Wages and Salaries: Average              44.2             3.7
         hourly earnings private nonfarm
        b. Fringe Benefits: Employment              10.3             5.0
         Cost Index, benefits, private
         nonfarm........................
    2. Physician's practice expense \3\.            45.5             3.6
        a. Nonphysician employee                    16.8             4.2
         compensation...................
            1. Wages and Salaries:                  12.4             3.7
             Employment Cost--Index,
             wages and salaries,
             weighted by occupation.....
            2. Fringe Benefits:                      4.4             5.5
             Employment Cost--Index,
             fringe benefits, white
             collar.....................
        b. Office Expense: Consumer                 11.6             2.8
         Price Index for urban consumers
         (CPI-U), housing...............
        c. Medical Materials and                     4.5             2.0
         Supplies: Producer Price Index
         (PPI), ethical drugs/PPI,
         surgical appliances and
         supplies/CPI-U, medical
         equipment and supplies (equally
         weighted)......................
        d. Professional Liability                    3.2            11.3
         Insurance: CMS professional
         liability insurance survey \4\.
        e. Medical Equipment: PPI,                   1.9             1.5
         medical instruments and
         equipment......................
        f. Other professional expense...             7.6             1.8
            1. Professional Car: CPI-U,              1.3             2.3
             private transportation.....
            2. Other: CPI-U, all items               6.3            2.6
             less food and energy.......
------------------------------------------------------------------------
\1\ The rates of historical change are estimated for the 12-month period
  ending June 30, 2002, which is the period used for computing the
  calendar year 2003 update. The price proxy values are based upon the
  latest available Bureau of Labor Statistics data as of September 19,
  2002.
\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 measures of productivity, average hourly earnings, Employment
  Cost Indexes, as well as the various Producer and Consumer Price
  Indexes can be found on the Bureau of Labor Statistics Web site http://stats.bls.gov.
\4\ Derived from a CMS survey of several major insurers (the latest
  available historical percent change data are for the period ending
  second quarter of 2002).
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.

    Comment: Several commenters requested that we ensure that the costs 
of medical liability insurance are adequately reflected in the MEI by 
making available all information that is the basis for measuring 
medical liability costs in the MEI.
    Response: We agree with the commenters that it is vital that the 
MEI accurately reflect the price changes associated with professional 
liability costs. Accordingly, we continue to incorporate into the MEI a 
price proxy that accomplishes this goal by making the maximum use of 
available data on professional liability premiums. Below we describe in 
more detail the annual CMS data collection from commercial insurance 
carriers, which are designed to maximize the use of publicly available 
data.
    Each year, we solicit professional liability premium data for 
physicians from a small sample of commercial carriers. This information 
is not collected through a survey form, but instead is requested from a 
few national commercial carriers via letter. The carriers provide 
information on a voluntary basis, and generally between 5 and 8 
carriers volunteer this information.
    As we require for our other price proxies, the professional 
liability price proxy must reflect the pure price change associated 
with this particular cost category. Thus, it should not capture changes 
in the mix or level of liability coverage. To accomplish this result, 
we

[[Page 80024]]

 obtain premium information from commercial carriers for a fixed level 
of coverage, currently $1 million per occurrence and a $3 million 
annual limit. This information is collected for every state by 
physician specialty and risk class. Finally, the state-level, 
physician-specialty data is aggregated by effective premium date to 
compute a national total using counts of physicians by state and 
specialty as provided in the AMA publication ``Physician 
Characteristics and Distribution in the U.S.''
    The resulting data provides a quarterly time series, indexed to a 
base year consistent with the MEI, which reflects the national trend in 
the average professional liability premium for a given level of 
coverage. From this series, quarterly and annual percent changes in 
professional liability insurance are estimated for inclusion in the 
MEI. This data produced an 11.3 percent increase for professional 
liability insurance in the MEI for the 2003 update. We believe that, 
given the limited timely data available on professional liability 
premiums, this methodology adequately reflects the price trends facing 
physicians.
    Comment: One commenter urged CMS to use the most current 
professional liability insurance data available when developing the MEI 
update.
    Response: The professional liability data used to develop the 2003 
MEI update was based on premium rates effective as of June 2002. We 
believe our methodology ensures that the MEI update includes the most 
recent data available. In the spring of 2002 we collected professional 
liability insurance premiums from commercial insurers as described in 
the previous comment. These data included both the premium amount and 
effective date, which we use to create a quarterly time series. Thus, 
the professional liability insurance component of the 2003 MEI update 
includes effective premium rates through the 2nd quarter of 2002, which 
is consistent with the timeliness of other data used in determining 
this update.
    The most comprehensive data on professional liability costs exist 
with the state insurance commissioners. However, these data are 
available only with a substantial lag. For instance, when we developed 
this final rule the most recent professional liability data available 
from the state insurance commissioners were for 2000. Hence, the data 
currently incorporated into the MEI are much more timely.
    Comment: Several commenters requested that we make an ad hoc 
adjustment to the MEI to account for recent increases in medical 
liability insurance.
    Response: We disagree with the commenters that an ad hoc adjustment 
should be made to the MEI to account for recent increases in 
professional liability insurance. As detailed above, the current 
methodology reflects recent data collected directly from commercial 
insurance carriers and specifically reflects the conditions facing 
physicians. Thus, the MEI adequately accounts for the recent increases 
in professional liability insurance prices, much the same way it 
reflects the price changes associated with other inputs, such as office 
expenses, wages or benefits. Thus, we believe the MEI appropriately 
reflects the price changes as measured by reliable and relevant data 
sources, and should not be adjusted through an ad hoc mechanism.
    Comment: Several commenters suggested that physicians' earnings 
more closely follow the wage changes faced by professional and 
technical occupations. The commenters suggested that we use the 
employment cost index (ECI) for professional and technical workers as 
the physicians' wage proxy in the MEI.
    Response: As we stated in the November 2, 1998 final rule (63 FR 
58848), we believe that the current price proxy for physicians' 
earnings, average hourly earnings (AHE) in the non-farm business 
economy, is the most appropriate proxy to use in the MEI. The AHE for 
the non-farm business economy reflects the impacts of supply, demand 
and economy-wide productivity for the average worker in the economy. 
Using the AHE as the proxy for physician earnings captures the parity 
in the rate of change in wages for the average worker and for 
physicians. In addition, use of this proxy is consistent with the 
original legislative intent that the change in the physicians' earnings 
portion of the MEI parallel the change in general earnings for the 
economy.
    The suggestion to use the ECI for professional and technical 
workers has a major shortcoming in that, in many instances, 
occupations, such as engineers, computer scientists, nurses, etc., have 
unique characteristics that are not reflective of the overall economy 
or the physician market. Specifically, wage changes for these types of 
occupations can be influenced by excess supply or demand for these 
types of workers. We do not believe it would be appropriate to proxy 
the physician earnings portion of the MEI with a wage proxy that 
reflects these unique characteristics.

C. The Update Adjustment Factor

    Section 1848(d) of the Act provides that the physician fee schedule 
update is equal to the product of the MEI and an ``update adjustment 
factor.'' The update adjustment factor is applied to make actual and 
target expenditures (referred to in the law as ``allowed 
expenditures'') equal. Allowed expenditures are equal to actual 
expenditures in a base period updated each year by the SGR. The SGR 
sets the annual rate of growth in allowed expenditures and is 
determined by a formula specified in section 1848(f) of the Act.
    Since the inception of the physician fee schedule in 1992, 
physician payment rates have been updated using two different systems. 
From 1992 to 1998, physician fee schedule rates were updated using the 
Medicare Volume Performance Standard (MVPS). From 1999 to the present, 
physician fee schedule rates have been updated using the sustainable 
growth rate (SGR). While there are significant and important 
differences between the MVPS and SGR, both use the same general concept 
that expenditures for physicians' services should grow by a limited 
percentage amount of allowed expenditures each year. If expenditures 
exceed the amount in a year, the physician fee schedule update is 
reduced. If expenditures are less than the amount of allowed 
expenditures in a year, the physician fee schedule update is increased.
    We determined the annual percentage increase in expenditures using 
the formulas specified in the statute. One important feature of both 
the MVPS and the SGRs for fiscal years (FYs) 1998 and 1999 was that the 
percentage increase was based on estimates of the four factors 
specified in the law, made before the beginning of the year. Under the 
MVPS and the SGRs for FYs 1998 and 1999, the statute did not permit us 
to revise the estimates used to set the annual percentage increase. 
Beginning with the FY 2000 SGR, the statute specifically requires us to 
use actual, after the fact, data to revise the estimates used to set 
the SGR.
    For some of the component factors of both the MVPS and the SGR, 
there have been differences between the estimates used to set the 
annual MVPS and SGR and the actual increase based on actual, after the 
fact, data. For instance, under both the MVPS and the SGR, we are 
required to account for increases in Medicare beneficiary fee-for-
service enrollment. There have been differences between our estimates 
of the increase in fee-for-service enrollment and the actual, after the 
fact increase because it

[[Page 80025]]

is difficult to predict, before the beginning of the year, beneficiary 
enrollment in Medicare + Choice plans (or Medicare managed care plans 
as they were known under the MVPS). Under the MVPS, we generally 
estimated higher growth in beneficiary fee-for-service enrollment than 
actually occurred. For the FY 1998 and FY 1999 SGRs, we estimated lower 
growth in beneficiary fee-for-service enrollment than actually 
occurred. (For subsequent years, the statute has required us to revise 
our estimates.)
    Under the SGR, the statute also requires us to account for the 
increase in real per capita gross domestic product (GDP) to determine 
the annual percentage increase in expenditures for physicians' 
services. In both FY 1998 and FY 1999, we estimated lower real per 
capita GDP growth than actually occurred. Because the statute did not 
permit us to revise estimates for these years, the SGRs for FYs 1998 
and 1999 are lower than if we were authorized to revise estimates as 
required under current law for the FY 2000 SGR and all subsequent SGRs.
    Because the physician fee schedule CF has been affected by a 
comparison of the actual increase in expenditures to the level of 
allowed expenditures calculated using the MVPS and the SGRs for FYs 
1998-1999, revision of our estimates would have resulted in different 
CFs than those we actually determined. Revision of the estimates used 
to set the MVPS would have made the physician fee schedule CFs 
established under the MVPS lower than those we have actually 
determined. As a result, higher expenditures in 1997 were higher than 
if we had revised estimates with actual after the fact data. The actual 
amount of expenditures in 1997 forms the basis for the calculation of 
allowed expenditures under the SGR.
    In contrast, revision of the estimates used to set the SGRs for FYs 
1998 and 1999 would have resulted in higher physician fee schedule CFs 
for CY 2000 and all subsequent years than those we have actually 
determined. If the statute authorized revisions of the estimates used 
to establish both the MVPS and the SGRs for FYs 1998 and 1999, the 
physician fee schedule CF would be higher than it is currently.
    We have analyzed the effect that revision of the estimates used to 
set the MVPS from FY 1990 through 1996 and the SGRs for FYs 1998 and 
1999 would have on the physician fee schedule update for CY 2003 and 
subsequent years. The Department believes that a positive update could 
result if the statute authorized revisions of the estimates used to 
establish both the SGR for FYs 1998 and 1999 and MVPS for 1990 to 1996.
    As noted above, however, current law does not permit the Department 
to adopt the positive update for 2003. In the event that Congress 
enacts legislation permitting the Department to make such an 
adjustment, the Department wishes to make the adjustment as promptly as 
possible. We therefore are soliciting public comments regarding the 
proper adjustments in the event that Congress authorizes the Department 
to make such an adjustment.
1. Calculation Under Current Law
    Under section 1848(d)(4)(A) of the Act, the physician fee schedule 
update for a year is equal to the product of-- (1) 1 plus the 
Secretary's estimate of the percentage increase in the MEI for the 
year, divided by 100 and (2) 1 plus the Secretary's estimate of the 
update adjustment factor for the year. Under section 1848(d)(4)(B) of 
the Act, the update adjustment factor for a year beginning with 2001 is 
equal to the sum of the following--
    [sbull] Prior Year Adjustment Component. An amount determined by--

--Computing the difference (which may be positive or negative) between 
the amount of the allowed expenditures for physicians' services for the 
prior year (the year prior to the year for which the update is being 
determined) and the amount of the actual expenditures for such services 
for that year;
--Dividing that difference by the amount of the actual expenditures for 
such services for that year; and
--Multiplying that quotient by 0.75.
    [sbull] Cumulative Adjustment Component. An amount determined by--

--Computing the difference (which may be positive or negative) between 
the amount of the allowed expenditures for physicians' services from 
April 1, 1996, through the end of the prior year and the amount of the 
actual expenditures for such services during that period;
--Dividing that difference by actual expenditures for such services for 
the prior year as increased by the sustainable growth rate for the year 
for which the update adjustment factor is to be determined; and
--Multiplying that quotient by 0.33.
    Section 1848(d)(4)(E) of the Act requires the Secretary to 
recalculate allowed expenditures consistent with section 1848(f)(3) of 
the Act. Section 1848(f)(3) specifies that the SGR (and, in turn, 
allowed expenditures) for the upcoming calendar year (2003 in this 
case), the current calendar year (2002) and the preceding calendar year 
(2001) are to be determined on the basis of the best data available as 
of September 1 of the current year. Allowed expenditures are initially 
estimated and subsequently revised twice. The second revision occurs 
after the calendar year has ended (that is, we are making the final 
revision to 2001 allowed expenditures in this final rule). Once the SGR 
and allowed expenditures for a year have been revised twice, they are 
final.
    Table 11 shows annual and cumulative allowed expenditures for 
physicians' services from April 1, 1996 through the end of the current 
calendar year, including the transition period to a calendar year 
system that occurred in 1999.

                                                                        Table 11
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                               Cumulative allowed expenditures
              Period                Annual allowed expenditures (Dollars)                 (Dollars)                             FY or CY SGR
--------------------------------------------------------------------------------------------------------------------------------------------------------
4/1/96-3/31/97...................  48.9 billion                            48.9 billion                            N/A
4/1/97-3/31/98...................  49.6 billion                            98.5 billion                            FY 1998=1.5%
4/1/98-3/31/99...................  49.4 billion                            147.9 billion                           FY 1999=-0.3%
1/1/99-3/31/99...................  12.5 billion                            Included in 147.9 above                 FY 1999=-0.3%
4/1/99-12/31/99..................  39.6 billion                            Included in 187.6 below                 FY 2000=6.9%
1/1/99-12/31/99..................  52.1 billion                            187.6 billion                           FY 1999/FY 2000 (see note)
1/1/00-12/31/00..................  55.9 billion                            243.5 billion                           CY 2000=7.3%
1/1/01-12/31/01..................  58.4 billion                            301.9 billion                           CY 2001=4.5%
1/1/02-12/31/02..................  63.5 billion                            365.4 billion                           CY 2002=8.8%
1/1/03-12/31/03..................  68.3 billion                            433.8 billion                           CY 2003=7.6%
--------------------------------------------------------------------------------------------------------------------------------------------------------



[[Page 80026]]

    *Note: Allowed expenditures for the first quarter of 1999 are 
based on the FY 1999 SGR and allowed expenditures for the last three 
quarters of 1999 are based on the FY 2000 SGR. Allowed expenditures 
in the first year (April 1, 1996-March 31, 1997) are equal to actual 
expenditures. All subsequent figures are equal to quarterly allowed 
expenditure figures increased by the applicable SGR. Cumulative 
allowed expenditures are equal to the sum of annual allowed 
expenditures. We provide more detailed quarterly allowed and actual 
expenditure data on our Web site under the Medicare Actuary's 
publications at the following address: http://www.cms.hhs.gov/statistics/actuary/. We expect to update the web site with the most 
current information later this month.

    Consistent with section 1848(d)(4)(E) of the Act, table 12 includes 
our final revision of allowed expenditures for 2001, a recalculation of 
allowed expenditures for 2002, and our initial estimate of allowed 
expenditures for 2003. To determine the update adjustment factor for 
2003, the statute requires that we use cumulative allowed expenditures 
from April 1, 1996 through December 31, 2002, actual expenditures 
through December 31, 2002, and the SGR for 2003, as well as annual 
allowed and actual expenditures for 2002. We are using estimates of 
allowed expenditures for 2002 and 2003 that will subsequently be 
revised consistent with section 1848(d)(4)(E) of the Act. Because we 
have incomplete expenditure data for 2002, we are using an estimate for 
this period. Any difference between current estimates and final figures 
will be taken into account in determining the update adjustment factor 
for future years.
    We are using figures from table 12 in the statutory formula 
illustrated below:
[GRAPHIC] [TIFF OMITTED] TR31DE02.000

UAF = Update Adjustment Factor.
Target02 = Allowed Expenditures for 2002 or $63.5 billion.
Actual02 = Estimated Actual Expenditures for 2002 = $69.1 
billion.
Target 4/96-12/02 = Allowed Expenditures from 4/1/1996-12/
31/2002 = $365.4 billion.
Actual 4/96-12/02 = Estimated Actual Expenditures from 4/1/
1996-12/31/2002 = $381.9 billion.
SGR03 = 7.6 percent (1.076).
[GRAPHIC] [TIFF OMITTED] TR31DE02.001

    Section 1848(d)(4)(D) of the Act indicates that the update 
adjustment factor determined under section 1848(d)(4)(B) of the Act for 
a year may not be less than -0.07 or greater than 0.03. Because the 
calculated update adjustment factor of -0.134 is less than the 
statutory limit of -0.07, the update adjustment factor for 2003 will be 
-0.07.
    Section 1848(d)(4)(A)(ii) of the Act indicates that 1 should be 
added to the update adjustment factor determined under section 
1848(d)(4)(B) of the Act. Thus, adding 1 to -0.070 makes the update 
adjustment factor equal to 0.930.

VII. Allowed Expenditures for Physicians' Services and the Sustainable 
Growth Rate

A. Medicare Sustainable Growth Rate

    The SGR is an annual growth rate that applies to physicians' 
services paid for by Medicare. The use of the SGR is intended to 
control growth in aggregate Medicare expenditures for physicians' 
services. Payments for services are not withheld if the percentage 
increase in actual expenditures exceeds the SGR. Rather, the physician 
fee schedule update, as specified in section 1848(d)(4) of the Act, is 
adjusted based on a comparison of allowed expenditures (determined 
using the SGR) and actual expenditures. If actual expenditures exceed 
allowed expenditures, the update is reduced. If actual expenditures are 
less than allowed expenditures, the update is increased.
    Section 1848(f)(2) of the Act specifies that the SGR for a year 
(beginning with 2001) is equal to the product of the following four 
factors:
    (1) The estimated change in fees for physicians' services.
    (2) The estimated change in the average number of Medicare fee-for-
service beneficiaries.
    (3) The estimated projected growth in real GDP per capita.
    (4) The estimated change in expenditures due to changes in law or 
regulations.
    In general, section 1848(f)(3) of the Act requires us to publish 
SGRs for 3 different time periods, no later than November 1 of each 
year, using the best data available as of September 1 of each year. 
Under section 1848(f)(3)(C)(i) of the Act, the SGR is estimated and 
subsequently revised twice (beginning with the FY and CY 2000 SGRs) 
based on later data. Under section 1848(f)(3)(C)(ii) of the Act, there 
are no further revisions to the SGR once it has been estimated and 
subsequently revised in each of the 2 years following the preliminary 
estimate. In this final rule, we are making our preliminary estimate of 
the 2003 SGR, a revision to the 2002 SGR, and our final revision to the 
2001 SGR.

B. Physicians' Services

    Section 1848(f)(4)(A) of the Act defines the scope of physicians' 
services covered by the SGR. The statute indicates that the term 
``physicians' services'' includes other items and services (such as 
clinical diagnostic laboratory tests and radiology services), specified 
by the Secretary, that are commonly performed or furnished by a 
physician or in a physician's office, but does not include services 
furnished to a Medicare+Choice plan enrollee. We published a definition 
of physicians' services for use in the SGR in the Federal Register (66 
FR 55316) on November 1, 2001. We defined ``physicians' services'' to 
include many of the medical and other health services listed in section 
1861(s) of the Act. For purposes of determining allowed expenditures, 
actual expenditures, and SGRs through December 31, 2002, we have 
specified that ``physicians' services'' include the following medical 
and other health services if bills for the items and services are 
processed and paid by Medicare carriers:
    [sbull] Physicians' services.

[[Page 80027]]

    [sbull] Services and supplies furnished incident to physicians' 
services.
    [sbull] Outpatient physical therapy services and outpatient 
occupational therapy services.
    [sbull] Antigens prepared by or under the direct supervision of a 
physician.
    [sbull] Services of physician assistants, certified registered 
nurse anesthetists, certified nurse midwives, clinical psychologists, 
clinical social workers, nurse practitioners, and clinical nurse 
specialists.
    [sbull] Screening tests for prostate cancer, colorectal cancer, and 
glaucoma.
    [sbull] Screening mammography, screening pap smears, and screening 
pelvic exams.
    [sbull] Diabetes outpatient self-management training services.
    [sbull] Medical nutrition therapy services.
    [sbull] Diagnostic x-ray tests, diagnostic laboratory tests, and 
other diagnostic tests.
    [sbull] X-ray, radium, and radioactive isotope therapy.
    [sbull] Surgical dressings, splints, casts, and other devices used 
for the reduction of fractures and dislocations.
    [sbull] Bone mass measurements.
    In the June 2002 proposed rule (67 FR 43861), we announced a change 
to our methodology for determining the ``weighted average percentage 
increase in fees for all physicians' services'' for the 2001 and 
subsequent year SGRs. We use a weighted average of the price indices 
that are used to increase payment for services included in the SGR to 
determine the percentage increase in fees for physicians' services. 
Physicians' services are updated using the MEI. Clinical diagnostic 
laboratory services are updated using the CPI. Drugs furnished 
``incident to'' a physician's service under section 1861(s)(2)(A) of 
the Act, are also included in the calculation of the SGR. Under section 
1842(o) of the Act, payments for drugs are based on 95 percent of 
average wholesale prices. We are currently using the MEI as a proxy for 
growth in drug prices. In the proposed rule, we indicated that, rather 
than using the MEI as proxy for growth in drug prices, we would use 
growth in actual drug prices to determine the weighted average 
percentage increase in fees for all physicians' services. In response, 
we received many comments suggesting that ``incident to'' drugs should 
not be included in the definition of physicians' services.
    Comment: Comments indicated that the administration of a drug is a 
physician's service that, by statute, must be included in the 
definition of physicians' services. The drug itself, however, argued 
the comments, is not a physician service and should not be included in 
the SGR. A number of comments indicated that rising Medicare 
expenditures for drugs are due in large part to the introduction of 
costly new cancer drugs and not to the failure of physicians to control 
their use. Many of these comments stated that the increase in drug 
spending is due to government policies that encourage the rapid 
development of new drugs, as well as government efforts to urge 
Americans to be tested and seek early treatment for cancer and other 
diseases. Some comments indicated that physicians should not be forced 
to pay for the rising cost of drugs covered by Medicare through reduced 
fees. Other comments stated that including drugs in the SGR has not led 
to controls on drug spending and, as a result, removing them would not 
lead to increased spending. Other comments indicated that the SGR has 
not been increased to reflect the growing cost of drugs. These comments 
indicated that the SGR should either account for the growing cost of 
drugs or exclude them completely. One comment indicated that the SGR 
should account for the cost of new drugs approved by the FDA and 
covered by Medicare during the prior year and the cost of covered drugs 
that have the same biologic effect as non-covered drugs. Several 
comments indicated that the Secretary does not have the legal authority 
to include ``incident to'' drugs in the SGR because the section 1848(f) 
of the Act refers to physicians' services and not ``medical and other 
health services.'' Others provided copies of a detailed legal opinion 
arguing that drugs may be included in the SGR under section 1848(f) of 
the Act but cannot be included in the definition of physicians' 
services for purposes of determining the update adjustment factor under 
section 1848(d) of the Act.
    Response: The statute provides the Secretary with clear authority 
to specify the services that are included in the SGR. Section 
1848(f)(4)(A) of the Act indicates ``the term `physicians' services' 
includes other items and services (such as clinical diagnostic 
laboratory tests and radiology services) specified by the Secretary, 
that are commonly performed or furnished by a physician or in a 
physician's office''. We disagree with the comments suggesting that the 
Secretary does not have the authority to include drugs in the 
definition of physicians' services for purposes of determining allowed 
expenditures, actual expenditures and the SGR. In reviewing section 
1861(s) of the Act, we decided to include items and services in the SGR 
that are commonly furnished by physicians or in physicians' offices. 
Since ``incident to'' drugs covered under section 1861(s) of the Act 
are commonly furnished in physicians' offices, we are including these 
items in the SGR.

C. Provisions Related to the Sustainable Growth Rate

    Section 211(b)(1) of the BBRA amended section 1848(f)(1) of the Act 
to require that three SGR estimates be published in the Federal 
Register not later than November 1 of every year. In this final rule, 
we are publishing our preliminary estimate of the SGR for 2003, a 
revised estimate of the SGR for 2002, and our final determination of 
the SGR for 2001. Consistent with section 1848(f)(3)(C) of the Act, we 
are using the best data available to us as of September 1, 2002 for all 
of the figures.

D. Preliminary Estimate of the Sustainable Growth Rate for 2003

    Our preliminary estimate of the 2003 SGR is 7.6 percent. We first 
estimated the 2003 SGR in March and made the estimate available to the 
Medicare Payment Advisory Commission and on our website. Table 12 shows 
our March estimates and our current estimates of the factors included 
in the SGR:

                                Table 12
------------------------------------------------------------------------
        Statutory factors           March estimate     Current estimate
------------------------------------------------------------------------
Fees............................        1.7% (1.017)        2.9% (1.029)
Enrollment......................        1.3% (1.013)        1.2% (1.012)
Real per capita GDP.............        2.9% (1.029)        3.3% (1.033)
Law and regulation..............        0.0% (1.000)        0.0% (1.000)
                                 ---------------------
    Total.......................        6.0% (1.060)        7.6% (1.076)
------------------------------------------------------------------------



[[Page 80028]]

    Note: Consistent with section 1848(f)(2) of the Act, the 
statutory factors are multiplied, not added, to produce the total 
(that is, 1.029 x 1.012 x 1.033 x 1.000 = 1.076.) A more detailed 
explanation of each figure is provided below in section H.1.

E. Revised Sustainable Growth Rate for 2002

    Our current estimate of the 2002 SGR is 8.8 percent. Table 13 shows 
our preliminary estimate of the 2002 SGR that was published in the 
Federal Register on November 1, 2001 (66 FR 55317) and our current 
estimate:

                                Table 13
------------------------------------------------------------------------
        Statutory factors          11/1/01 estimate    Current estimate
------------------------------------------------------------------------
Fees............................         2.3 (1.023)        2.5% (1.025)
Enrollment......................         0.7 (1.007)        2.8% (1.028)
Real per capita GDP.............         1.7 (1.017)        2.3% (1.023)
Law and regulation..............         0.8 (1.008)        0.9% (1.009)
                                 ---------------------
    Total.......................         5.6 (1.056)        8.8% (1.088)
------------------------------------------------------------------------

    A more detailed explanation of each figure is provided below in 
section H.2.

F. Final Sustainable Growth Rate for 2001

    The SGR for 2001 is 4.5 percent. Table 14 shows our preliminary 
estimate of the SGR published in the Federal Register on November 1, 
2000 (65 FR 65433), our revised estimate published in the Federal 
Register on November 1, 2001 (66 FR 55317) and the final figures 
determined using the latest available data:

                                                    Table 14
----------------------------------------------------------------------------------------------------------------
                  Statutory factors                    11/1/00 estimate    11/1/01 estimate    Current estimate
----------------------------------------------------------------------------------------------------------------
Fees................................................         1.9 (1.019)         1.9 (1.019)        2.1% (1.021)
Enrollment..........................................         0.9 (1.009)         3.0 (1.030)        3.0% (1.030)
Real per capita GDP.................................         2.7 (1.027)         0.7 (1.007)       -0.7% (0.993)
Law and regulation..................................         0.0 (1.000)         0.4 (1.004)        0.1% (1.001)
                                                     ---------------------
    Total...........................................         5.6 (1.056)         6.1 (1.061)        4.5% (1.045)
----------------------------------------------------------------------------------------------------------------

    A more detailed explanation of each figure is provided below in 
section H.2.

G. Calculation of 2003, 2002, and 2001 Sustainable Growth Rates

1. Detail on the 2003 SGR
    A more detailed discussion of our preliminary estimates of the four 
elements of the 2003 SGR follows. We note that all of the figures used 
to determine the 2003 SGR are estimates that will be revised based on 
subsequent data. Any differences between these estimates and the actual 
measurement of these figures will be included in future revisions of 
the SGR and incorporated into subsequent physician fee schedule 
updates.

Factor 1--Changes in Fees for Physicians' Services (Before Applying 
Legislative Adjustments) for CY 2003

    This factor was calculated as a weighted average of the 2002 fee 
increases for the different types of services included in the 
definition of physicians' services for the SGR. Medical and other 
health services paid using the physician fee schedule account for 
approximately 83.5 percent of total allowed charges included in the SGR 
and are updated using the MEI. The MEI for 2003 is 3.0 percent. 
Diagnostic laboratory tests represent approximately 8.0 percent of 
Medicare allowed charges included in the SGR and the costs of these 
tests are typically updated by the CPI-U. The CPI-U for 2003 that will 
be used to update clinical diagnostic laboratory tests is 1.1 percent. 
Drugs represent 8.5 percent of Medicare allowed charges included in the 
SGR. Medicare pays for drugs based on 95 percent of AWP under section 
1842(o) of the Act. We calculated the weighted average fee increase for 
drugs to be included in the SGR, we estimate a weighted average fee 
increase for drugs of 3.3 percent in 2002. Table 15 shows the weighted 
average of the MEI, laboratory and drug price increases for 2003:

                                Table 15
------------------------------------------------------------------------
                                              Weight          Update
------------------------------------------------------------------------
Physician...............................           0.835             3.0
Laboratory..............................           0.080             1.1
Drugs...................................           0.085             3.3
Weighted Average........................           1.000             2.9
------------------------------------------------------------------------

    After taking into account the elements described in table 16, we 
estimate that the weighted-average increase in fees for physicians' 
services in 2002 under the SGR (before applying any legislative 
adjustments) will be 2.9 percent.

Factor 2--The Percentage Change in the Average Number of Part B 
Enrollees From 2002 to 2003

    This factor is our estimate of the percent change in the average 
number of

[[Page 80029]]

fee-for-service enrollees from 2002 to 2003. Services provided to 
Medicare+Choice (M+C) plan enrollees are outside the scope of the SGR 
and are excluded from this estimate. Our actuaries estimate that the 
average number of Medicare Part B fee-for-service enrollees will 
increase by 1.2 percent from 2002 to 2003. Table 16 illustrates how 
this figure was determined:

                                Table 16
------------------------------------------------------------------------
                                               2002            2003
------------------------------------------------------------------------
Overall.................................  37.986 million  38.321 million
Medicare+Choice.........................   5.070 million   5.012 million
Net.....................................  32.916 million  33.309 million
Percent Increase........................  ..............     1.2 percent
------------------------------------------------------------------------

    An important factor affecting fee-for-service enrollment is 
beneficiary enrollment in Medicare+Choice plans. Because it is 
difficult to estimate the size of the Medicare+Choice enrollee 
population before the start of a calendar year, at this time, we do not 
know how actual enrollment in Medicare+Choice plans will compare to 
current estimates. For this reason, there may be substantial changes to 
this estimate as actual Medicare fee-for-service enrollment for 2003 
becomes known.

Factor 3--Estimated Real Gross Domestic Product Per Capita Growth in 
2003

    We estimate that the growth in real per capita GDP from 2002 to 
2003 will be 3.3 percent. Our past experience indicates that there have 
also been large changes in estimates of real per capita GDP growth made 
before the year begins and the actual change in GDP computed after the 
year is complete. Thus, it is likely that this figure will change as 
actual information on economic performance becomes available to us in 
2003.

Factor 4--Percentage Change in Expenditures for Physicians' Services 
Resulting From Changes in Law or Regulations in CY 2003 Compared With 
CY 2002

    As indicated below, section 101-104 of the BIPA added Medicare 
coverage for a variety of new services. We estimate no additional costs 
for these services in 2003 relative to 2002. We will continue to 
monitor utilization of all of the new benefits provided in BIPA and 
modify our estimates (up or down) and the SGRs accordingly.
    Comment: We received many comments indicating that we should adjust 
the SGR to account for the addition of the psychiatric diagnostic 
interview to the list of covered telehealth services.
    Response: We agree that the addition of the psychiatric diagnostic 
interview is a change in regulation that should be accounted for in the 
SGR. However, since there is such low utilization of the telehealth 
benefit, we believe the addition of the psychiatric diagnostic 
interview to the list of covered telehealth services will have no 
impact on the SGR.
    Comment: Several comments noted that section 112 of BIPA changed 
Medicare's drug payment policy. Prior to the enactment of the BIPA, 
section 1861(s)(2) of the Act allowed Medicare to pay for ``drugs and 
biologicals, which cannot, as determined in accordance with 
regulations, be self-administered.'' The BIPA amended the Act to allow 
Medicare to pay for drugs which ``are not usually administered by the 
patient.'' The commenters believe that this new drug payment policy 
will result in an increase in expenditures that should be accounted for 
in the SGR.
    Response: The amendments to Medicare's drug payment policy 
contained in section 112 of the BIPA constitute a change in law or 
regulation that is taken into account in determining the SGR. We 
estimate a 2002 cost for this policy change that will be accounted for 
in the 2002 SGR described below. At this time, we are not estimating 
additional Medicare costs in 2003 relative to 2002 for drugs not 
usually self-administered by patients.
    Comment: We received many public comments that argued for adjusting 
the SGR for changes in expenditures resulting from NCDs. According to 
these comments, any changes in national Medicare coverage policy that 
are adopted by us pursuant to a formal or informal rulemaking, such as 
a Program Memorandum or a national Medicare coverage determination, 
constitute a regulatory change for purposes of computing factor 4 of 
the SGR. The comments indicate that our authority to make any 
regulatory change is derived from law--whether it is a law specifically 
authorizing Medicare coverage of a new service or a law that provides 
general rulemaking authority. According to these comments, any new 
coverage initiative is a direct implementation, by regulation, of a law 
that should be taken into account in determining the SGR. One commenter 
indicated that we effectively compare actual expenditure data that 
include additional utilization resulting from NCDs with a spending 
target that does not include this additional utilization, making it 
more likely that the target will be exceeded.
    Response: We carefully considered this comment. If the Congress 
adds a new statutory benefit (for example, medical nutrition therapy), 
we are required by law to increase the target. Medicare does not have 
authority to pay for a service lacking a defined statutory benefit 
listed in section 1861(s) of the Act (for example, prior to January 1, 
2002, there was no authority for Medicare to pay for medical nutrition 
therapy). However, we do have the authority to establish national 
coverage policies for items and services that are included in a benefit 
category listed in section 1861(s) of the Act. Further, we contract 
with Medicare carriers who may establish local coverage policies for 
items and services that have a statutory benefit category.
    The statute requires that real GDP per capita be used in setting 
the SGR target. We believe that use of real GDP per capita was intended 
as a proxy for a number of factors that may increase the volume and 
intensity of physicians' services (other than beneficiary enrollment 
and statutory changes that increase expenditures, which are separately 
accounted for by the statute), such as those associated with coverage 
of new items or services and other miscellaneous factors that cannot be 
specifically identified, such as any spending associated with NCDs.
    The large majority of Medicare spending is for services that are 
covered at local carrier discretion. While we may establish national 
coverage (or non-coverage) for a new item or service with a defined 
statutory benefit category, this NCD does not necessarily increase 
Medicare spending to the extent that the service has or would have been 
covered at local carrier discretion in the absence

[[Page 80030]]

of a NCD. For instance, there was widespread publicity in 2000 about 
ocular photodynamic therapy (OPT), a new treatment for macular 
degeneration, a common cause of blindness in the elderly. Prior to our 
NCD, Medicare carriers had the authority to cover OPT at local carrier 
discretion as a physician's service under section 1861(s)(1) of the 
Act. Given the widespread publicity about the effectiveness of this new 
treatment, it is likely that, in the absence of a NCD, OPT would have 
been covered at local carrier discretion. That is, application of 
existing Medicare law and regulations would have allowed Medicare 
coverage for OPT at local carrier discretion. Because it seems likely 
that Medicare would covered this procedure in any event, it is unclear 
whether there are any additional costs associated with the NCD. Indeed 
the NCD limited the coverage of OPT to a defined subpopulation of 
Medicare beneficiaries. The local contractor determinations may not 
have done so, and therefore, the NCD may actually have resulted in a 
net savings to Medicare. Moreover, we did not change the law or 
regulations by making a national coverage decision for OPT. Rather, we 
applied existing law and regulations to a new service to make a 
national statement about coverage where one did not previously exist.
    We may also issue a NCD to clarify Medicare coverage for existing 
items or services. Such a decision may establish national policy that 
replaces differing local practices. In such a case, there may not have 
been consistency among Medicare carriers as to whether an item or 
service qualified for coverage based on existing law or regulation. 
Thus, our NCD would not change law or regulation, but replaces 
differing local practices with a national determination that, based on 
existing law and regulations, clarifies Medicare coverage for an item 
or service. Spending may increase or decrease depending upon the degree 
to which the particular item or service is currently being covered by 
Medicare carriers and whether the decision is to establish coverage or 
non-coverage of the item or service.
    For the reasons previously discussed, it would be very difficult to 
estimate any costs or savings associated with specific coverage 
decisions. Further, we believe any adjustment to the target would 
likely be of such a small magnitude that it would have little effect on 
future projected updates.
1. Detail on the 2002 SGR
    A more detailed discussion of our revised estimates of the four 
elements of the 2002 SGR follows.

Factor 1--Changes in Fees for Physicians' Services (Before Applying 
Legislative Adjustments) for 2002

    This factor was calculated as a weighted average of the 2002 fee 
increases that apply for the different types of services included in 
the definition of physicians' services for the SGR.
    Services paid using the physician fee schedule account for 
approximately 84.5 percent of total allowed charges included in the 
SGR, and are updated using the MEI. The MEI for 2002 is 2.6 percent. 
Diagnostic laboratory tests represent approximately 7.5, and the costs 
of these tests are typically updated by the CPI-U. However, the BBA 
required a 0.0 percent update in 2002 for laboratory services. Drugs 
represent 8.0 percent of Medicare allowed charges included in the SGR. 
Pursuant to section 1842(o) of the Act, Medicare pays for drugs based 
on 95 percent of AWP. Using wholesale pricing information and Medicare 
utilization for drugs included in the SGR, we estimate a weighted 
average fee increase for drugs of 3.3 percent in 2002. Table 17 shows 
the weighted average of the MEI, laboratory and drug price increases 
for 2002:

                                Table 17
------------------------------------------------------------------------
                                              Weight          Update
------------------------------------------------------------------------
Physician...............................           0.845             2.6
Laboratory..............................           0.075             0.0
Drugs...................................           0.080             3.3
Weighted Average........................           1.000             2.5
------------------------------------------------------------------------

    After taking into account the elements described in table 18, we 
estimate that the weighted-average increase in fees for physicians' 
services in 2002 under the SGR (before applying any legislative 
adjustments) will be 2.5 percent.

Factor 2--The Percentage Change in the Average Number of Part B 
Enrollees from 2001 to 2002

    Our actuaries estimate that the average number of Medicare Part B 
fee-for-service enrollees (excluding beneficiaries enrolled in M+C 
plans) increased by 2.8 percent in 2002. Table 18 illustrates how we 
determined this figure:

                                Table 18
------------------------------------------------------------------------
                                               2001            2002
------------------------------------------------------------------------
Overall.................................  37.633 million  37.986 million
Medicare+Choice.........................   5.608 million   5.070 million
Net.....................................  32.025 million  32.916 million
Percent Increase........................  ..............     2.8 percent
------------------------------------------------------------------------

    Our actuaries' estimate of the 2.8 percent change in the average 
number of fee-for-service enrollees, net of Medicare+Choice enrollment 
for 2002, compared to 2001 is different from our preliminary estimate 
(0.7 percent for 2002 from the November 1, 2001 final rule (66 FR 
55318)) because the historical base from which our actuarial estimate 
is made has changed. We now have complete information on Medicare fee-
for-service enrollment for 2001 that is different than the figure we 
used one year ago. Further, we now have information on actual fee-for-
service

[[Page 80031]]

enrollment for the first 8 months of 2002. We would caution that our 
estimate of fee-for-service enrollment for 2002 may change again once 
we have complete information for the entire year.

Factor 3--Estimated Real Gross Domestic Product Per Capita Growth in 
2002

    We estimate that the growth in real per capita GDP will be 2.3 
percent in 2002. Our past experience indicates that there have also 
been large differences between our preliminary estimates of real per 
capita GDP growth and the actual change in this factor. Thus, it is 
likely that this figure will change further as actual information on 
economic performance becomes available to us in 2003.

Factor 4--Percentage Change in Expenditures for Physicians' Services 
Resulting From Changes in Law or Regulations in 2002 Compared With 2001

    As indicated earlier, sections 101 through 104 of the BIPA added 
Medicare coverage for a variety of new services that will affect the 
2002 SGR. We included an adjustment in the 2002 SGR based on previous 
estimates of the costs of these new benefits, but are reducing our 
estimate of the costs of the new telehealth and medical nutrition 
therapy benefits based on lower utilization of these services than we 
had originally anticipated. This change will have little effect on this 
factor and we are not changing our estimate of the costs of any of the 
other provisions described earlier. In addition, as explained above, 
section 112 of BIPA made changes that will result in additional 
Medicare coverage for certain drugs. Prior to the enactment of the 
BIPA, Medicare only paid for drugs that cannot be self-administered by 
the patient. BIPA allows Medicare to pay for drugs that can be but are 
not usually self-administered. Accordingly, we are accounting for the 
increased Medicare drug expenditures that will result from 
implementation of section 112 of the BIPA. After taking these 
provisions into account, the percentage change in expenditures for 
physicians' services resulting from changes in law or regulations is 
estimated to be 0.9 percent for 2002.
3. Detail on the 2001 SGR
    A more detailed discussion of our current estimates of the four 
elements of the 2001 SGR follows. Pursuant to section 1848(f)(3)(C) of 
the Act, we will be making no further revisions to these figures.

Factor 1--Changes in Fees for Physicians' Services (Before Applying 
Legislative Adjustments) for 2001

    We are using a weighted average of the fee increases that apply to 
the different services included in the SGR for 2001. Services that are 
updated by the MEI represent 85.7 percent of allowed charges included 
in the SGR. The 2001 MEI was 2.1 percent. Pursuant to the BBA, 
laboratory services were updated by 0.0 percent in 2001 and represent 
7.0 percent of allowed charges included in the SGR. The weighted 
average percentage increase in average wholesale prices for drugs 
included in the SGR in 2001 was 3.4 percent. Drugs represent 7.3 
percent of allowed charges included in the SGR. Using these figures, 
the weighted average percentage increase in fees for physicians' 
services is illustrated in table 19:

                                Table 19
------------------------------------------------------------------------
                                              Weight          Update
------------------------------------------------------------------------
Physician...............................           0.857             2.1
Laboratory..............................           0.070             0.0
Drugs...................................           0.073             3.4
Weighted Average........................           1.000             2.1
------------------------------------------------------------------------

Factor 2--The Percentage Change in the Average Number of Fee-for-
Service Part B Enrollees From 2000 to 2001

    We estimate the increase in the average number of fee-for-service 
enrollees (excluding Medicare+Choice enrollees) from 2000 to 2001 was 
3.0 percent. Table 20 illustrates the calculation of this factor:

                                Table 20
------------------------------------------------------------------------
                                               2000            2001
------------------------------------------------------------------------
Overall.................................  37.330 million  37.633 million
Medicare+Choice.........................   6.233 million   5.608 million
Net.....................................  31.098 million  32.205 million
Percent Increase........................  ..............     3.0 percent
------------------------------------------------------------------------

    Our calculation of this factor is based on complete data from 2001.

Factor 3--Estimated Real Gross Domestic Product Per Capita Growth in 
2001

    We estimate that the growth in real per capita GDP was -0.7 percent 
in 2001. This is a final figure based on complete data for 2001.

Factor 4--Percentage Change in Expenditures for Physicians' Services 
Resulting From Changes in Law or Regulations in CY 2001 Compared With 
CY 2000

    As described above, the BIPA makes changes to the Act that affect 
Medicare expenditures for services included in the SGR. Some of these 
provisions had no effect on Medicare expenditures in 2001 because they 
did not go into effect until 2002. Other provisions became effective at 
some time during 2001. These provisions relate to coverage of new 
technology mammography, coverage changes for screening pap smears, 
screening pelvic exams, screening colonoscopy, expanded access to 
telehealth services, and Medicare payment for services provided in 
Indian Health Service hospitals and clinics. After taking these 
provisions into

[[Page 80032]]

account, the percentage change in expenditures for physicians' services 
resulting from changes in law or regulations is estimated to be 0.1 
percent for 2001.

VIII. Anesthesia and Physician Fee Schedule Conversion Factors

    The 2003 physician fee schedule CF will be $34.5920. The 2003 
national average anesthesia conversion factor is $16.0353.
    The specific calculations to determine the physician fee schedule 
and anesthesia CFs for 2003 are explained below.

Detail on Calculation of the 2003 Physician Fee Schedule Conversion 
Factor

[sbull] Physician Fee Schedule Conversion Factor

    Under section 1848(d)(1)(A) of the Act, the physician fee schedule 
CF is equal to the CF for the previous year multiplied by the update 
determined under section 1848(d)(4) of the Act. In addition, section 
1848(c)(2)(B)(ii)(II) of the Act requires that changes to RVUs cannot 
cause the amount of 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 CF. There is one 
change that will require us to make an adjustment to the conversion 
factor to comply with the budget neutrality requirement in section 
1848(c)(2)(B)(ii)(II) of the Act. We are making a 0.04 percent 
reduction (0.9996) in the CF to account for the increase in anesthesia 
work resulting from the 5-year review.
    We are illustrating the calculation for the 2003 physician fee 
schedule CF in table 21:

                                Table 21
------------------------------------------------------------------------
 
------------------------------------------------------------------------
2002 Conversion Factor..................................        $36.1992
2003 Update.............................................          0.9560
Budget-Neutrality Adjustment: Increase in Anesthesia              0.9996
 Work...................................................
2003 Conversion Factor..................................         34.5920
------------------------------------------------------------------------

[sbull] Anesthesia Fee Schedule Conversion Factor

    Because anesthesia services do not have RVUs like other physician 
fee schedule services, we are accounting for the increase in anesthesia 
work through an adjustment to the anesthesia fee schedule conversion 
factor. As indicated earlier, we are increasing the physician work 
component of the anesthesia conversion factor by 2.10 percent to 
reflect a 9.13 percent increase in payment applied to 23 percent of 
anesthesia allowed charges. The 2002 anesthesia CF is $16.60. The 
physician work portion of the anesthesia conversion factor is 78 
percent. We applied a 1.6 percent (1.016) increase to this part of the 
anesthesia conversion factor. Similarly, we also simulated the effect 
of practice expense refinements on the practice expense portion of the 
anesthesia conversion factor. The refinements reduced this portion of 
the anesthesia conversion factor by 4.04 percent (0.9596). In addition, 
we are also applying the physician fee schedule update and the budget 
neutrality adjustment for the increase in anesthesia work that that 
also apply to the physician fee schedule CF. To determine the 
anesthesia fee schedule CF for 2003, we used the following figures:

                                Table 22
------------------------------------------------------------------------
 
------------------------------------------------------------------------
2002 Anesthesia Conversion Factor.......................        $16.6055
Adjustments for work and practice expense...............          1.0106
2003 Update.............................................          0.9560
Budget-Neutrality Adjustment: Increase in Anesthesia              0.9996
 Work...................................................
2003 Conversion Factor..................................         16.0353
------------------------------------------------------------------------

IX. Provisions of the Final Rule

    This final rule adopts the provisions of the June 2002 proposed 
rule, except as noted elsewhere in the preamble. The following is a 
highlight of the changes made from the proposed rule.
    For immunization administration, we are developing practice expense 
RVUs for influenza, pneumonia, and hepatitis B vaccine G codes. This 
will increase the payment for these codes and make Medicare's payment 
for vaccine administration more consistent with the rates paid for the 
CPT codes.
    For anesthesia, we are revising the regulations text at Sec.  
414.46(g) to incorporate that the policy on multiple procedure codes as 
well as add-on codes.
    For enrollment of PTs and OTs as therapists in private practice, we 
are revising our regulations text at Sec.  410.59 and Sec.  410.60 to 
reflect that carriers and fiscal intermediaries can enroll therapists 
as PTs or OTs in private practice when the therapist is employed by 
physician groups or groups that are not professional corporations.
    We are adopting the process to add or delete telehealth services 
and adding the psychiatric diagnostic interview examination to the list 
of telehealth services. In addition, we are referencing the process to 
add or delete services at new Sec.  410.78(f).
    For the definition of a ZZZ global period, we are revising the 
definition to show that physician work is associated with intraservice 
time and, in some instances, the pre- and postservice time.
    For the definition of a screening fecal-occult blood test, we are 
revising the definition at Sec.  410.37(a)(2) to permit coverage of 
non-guaiac based tests.
    For the critical access hospital emergency services requirement we 
are modifying Sec.  485.618(d) to include RNs.

X. Waiver of Proposed Rulemaking for Definition of a Screening Fecal-
Occult Blood Test and Critical Access Hospital Emergency Services 
Requirement

    We ordinarily publish a notice of proposed rulemaking in the 
Federal Register and invite public comment on proposed rules. The 
notice of proposed rulemaking includes a reference to the legal 
authority under which the rule is proposed and the terms and substances 
of the proposed rule or a description of the subjects and issues 
involved. This procedure can be waived, however, if an agency finds 
good cause that notice-and-comment procedure is impracticable, 
unnecessary, or contrary to the public interest and incorporates a 
statement of the finding and its reasons in the rule issued.
    In our proposed rule, we did not propose to modify Sec.  410.37. 
Still, we received a comment seeking to modify coverage for one 
particular type of colorectal cancer test, a fecal-occult blood test. 
As explained earlier in this preamble, we have agreed to modify this 
regulation in a manner that would permit broader Medicare coverage if 
that is determined to be appropriate. Consistent with this change, we 
are modifying Sec.  410.37(a)(1)(v) to announce that we will consider 
approving new tests or procedures for use in the early detection of 
colorectal cancer through our process for making national coverage 
determinations.
    The Congress has authorized the Secretary to cover additional tests 
or procedures that can be used for the early detection of colorectal 
cancer under the Colorectal Cancer Screening Test benefit in under part 
B in section 1861(pp)(1)(D) of the Act. The Secretary may determine 
that coverage of other tests or procedures are appropriate, in 
consultation with appropriate organizations. We are aware that new 
colorectal cancer screening tests are

[[Page 80033]]

being developed. To determine whether it is appropriate to expand 
coverage to provide Medicare payment for additional tests or 
procedures, it will be necessary to compare the new tests to tests that 
are already covered. We are modifying Sec.  410.37(a)(1)(v) to permit 
determinations on whether to cover (or not cover) additional tests or 
procedures to be made through NCDs.
    Expanding Medicare coverage of additional, effective, and 
appropriate screening tests would be in the public interest because the 
tests may discover patients with cancer at an earlier stage, increasing 
the chances that the patient will obtain proper medical treatment. An 
NCD, authorized by section 1869(a)(2) of the Act, can be used to 
develop a national policy regarding the scope of benefits. Moreover, 
the process for making an NCD will permit public participation, as well 
as the participation of appropriate groups, as the agency determines 
whether or not expanded coverage for additional tests or procedures is 
appropriate. This process offers advantages to the public because it 
could permit an expansion in the scope of the colorectal cancer 
screening benefit more rapidly than the notice and comment procedures 
of the Administrative Procedure Act would normally permit.
    In addition, we did not propose to modify Sec.  485.618(d). A delay 
in implementation of this provision would hinder the ability of small 
CAHs (with no greater than 10 beds) in some frontier areas or remote 
locations to provide the necessary critical access hospital emergency 
services. It was brought to our attention that, in recent months, a 
number of small CAHs in very remote frontier areas have been struggling 
to comply with the CAH standard in Sec.  485.618(d) that requires CAHs 
to have either a doctor of medicine or osteopathy, a physician's 
assistant, or a nurse practitioner, with training or experience in 
emergency care to ensure emergency coverage 24-hours-a-day, seven-days-
a-week. These CAHs have 10 or less beds. In order to provide additional 
flexibility for other CAHs of virtually the same size, we believe 10 
beds is an appropriate size limit for facilities that may be in the 
same situation and require potential relief from the existing staffing 
requirements. These facilities, located in isolated frontier 
communities, have only one medical practitioner and see a low volume of 
patients. For these providers the requirement referenced above results 
in a significant personal hardship to the sole practitioner who must be 
on call 24-hours-a-day, 52-weeks-a-year. In addition, it is a financial 
hardship for the facility to find a replacement for the currently 
required emergency services personnel because frequently the 
replacement costs far exceed what is recovered through the services 
provided. We believe that by allowing States to include RNs in the 
current critical access hospital emergency services personnel 
requirement, so that RNs may be on call for small CAHs in frontier 
areas or remote locations, we will help ensure that frontier 
communities will have continued access to CAH services. In addition, if 
small CAHs in frontier areas or remote locations close their doors 
there would be no access to care in these communities.
    Accordingly, we find good cause for waiving the prior notice-and-
comment procedures as unnecessary and contrary to the public interest. 
In addition, we note that rules of agency procedure are exempt from the 
notice and comment requirements of 5 U.S.C. 553.

XI. Collection of Information Requirements

    Under the Paperwork Reduction Act of 1995, we are required to 
provide 60-days notice in the Federal Register and solicit public 
comment before a collection of information requirement is submitted to 
the Office of Management and Budget (OMB) for review and approval. In 
order to fairly evaluate whether an information collection should be 
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act 
of 1995 requires that we solicit comment on the following issues:
    [sbull] The need for the information collection and its usefulness 
in carrying out the proper functions of our agency.
    [sbull] The accuracy of our estimate of the information collection 
burden.
    [sbull] The quality, utility, and clarity of the information to be 
collected.
    [sbull] Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
    We are soliciting public comment on each of these issues for the 
following sections of this document that contain information collection 
requirements:
    Section 485.618 permits a CAH located in an area designated as a 
frontier area or remote location described in paragraph (d)(1)(i) to 
include in the personnel requirement in paragraph (d) a RN, if the 
State in which the small CAH is located submits a letter to us, signed 
by the Governor, following consultation with the State Boards of 
Medicine and Nursing, and in accordance with State law, requesting that 
a RN be included temporarily in the list of personnel that must be on 
call and available on site within 60 minutes.
    Since we anticipate that we will receive approximately five 
requests for an inclusion of RNs on an annual basis, this collection 
requirement is not subject to the PRA as stipulated under 5 CFR 
1320.3(c).
    If you comment on these information collection and recordkeeping 
requirements, please mail copies directly to the following:
    Centers for Medicare & Medicaid Services, Office of Strategic 
Operations & Regulatory Affairs, RDIG, Attn.: John Burke, Room N2-14-
26, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    Office of Information and Regulatory Affairs, Office of Management 
and Budget, Room 10235, New Executive Office Building, Washington, DC 
20503, Attn: Brenda Aguilar, CMS Desk Officer.

XII. 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 major comments in the preamble to that 
document.

XIII. Regulatory Impact Analysis

    We have examined the impact of this rule as required by Executive 
Order 12866 (September 1993, Regulatory Planning and Review), the 
Regulatory Flexibility Act (RFA) (September 16, 1980 Pub. L. 96-354), 
section 1102(b) of the Social Security Act, the Unfunded Mandates 
Reform Act of 1995 (Pub. L. 104-4), and Executive order 13132.
    Executive Order 12866 (as amended by Executive Order 13258, which 
reassigns responsibility of duties) directs agencies to assess all 
costs and benefits of available regulatory alternatives and, when 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, distributive impacts, and equity). A 
regulatory impact analysis must be prepared for final rules with 
economically significant effects (that is, a final rule that would have 
an annual effect on the economy of $100 million or more in any 1 year, 
or would adversely affect in a material way the economy, a sector of 
the economy, productivity, competition, jobs, the environment, public 
health or safety, or State, local, or tribal governments or

[[Page 80034]]

communities). We have simulated the effect of increases in payment for 
anesthesia work and the changes to practice expense RVUs described 
earlier. The net effect of the changes will not materially increase or 
decrease Medicare expenditures for physicians' services because the 
statute requires that these changes cannot increase or decrease 
expenditures more than $20 million. Since increases in payments 
resulting from the 5-year review anesthesia work and practice expense 
RVU changes cannot increase or decreases expenditures by more than $20 
million, any increases or decreases in payment will result in a 
redistribution of payments among physician specialties. The proposed 
changes to the MEI would result in increases in Medicare expenditures 
for physicians' services of $150 million in fiscal year (FY) 2003, $340 
million in FY 2004, and $550 million in FY 2005. Therefore, this rule 
is considered to be a major rule because it is economically 
significant, and, thus, we have prepared a regulatory impact analysis.
    The RFA requires that we analyze regulatory options for small 
businesses and other 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 concerning the reason 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 with 
less significant adverse economic impact on the small entities.
    Section 1102(b) of the Act requires us to prepare a regulatory 
impact analysis for any proposed rule that may have a significant 
impact on the operations of a substantial number of small rural 
hospitals. 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 a 
Metropolitan Statistical Area and has fewer than 100 beds.
    For purposes of the RFA, physicians, non-physician practitioners, 
and suppliers, are considered small businesses if they generate 
revenues of $8.5 million or less. Approximately 96 percent of 
physicians are considered to be small entities. There are about 700,000 
physicians, other practitioners and medical suppliers that receive 
Medicare payment under the physician fee schedule. In addition, CAHs 
are considered small entities, either by nonprofit status or by having 
revenues of $6 to $29 million in any one year.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule that may result in expenditure in any 1 year by State, 
local, or tribal governments, in the aggregate, or by the private 
sector, of $110 million. We have determined that this proposed rule 
will have no consequential effect on State, local, or tribal 
governments.
    We have examined this final rule in accordance with Executive Order 
13132 and have determined that this regulation would not have any 
negative impact on the rights, roles, or responsibilities of State, 
local, or tribal governments.
    We have prepared the following analysis, which together with the 
rest of this preamble, meets all assessment requirements. It explains 
the rationale for, and purposes of, the rule, details the costs and 
benefits of the rule, analyzes alternatives, and presents the measures 
we are using to minimize the burden on small entities. As indicated 
elsewhere, we are making changes to the Medicare Economic Index, 
refining resource-based practice based practice expense RVUs, and 
making a variety of other changes to our regulations, payments, or 
payment policies to ensure that our payment systems are updated to 
reflect changes in medical practice and the relative value of services. 
We provide information for each of the policy changes in the relevant 
sections in this rule. In large part, the provisions of this rule are 
changing only Medicare payment rates for physician fee schedule 
services. While this rule allows physical and occupational therapists 
that are employed by physicians to separately enroll in the Medicare 
program, it does not impose reporting, recordkeeping, and other 
compliance requirements. We are unaware of any relevant Federal rules 
that duplicate, overlap, or conflict with this rule. The relevant 
sections of this contain a description of significant alternatives.

A. Resource-Based Practice Expense Relative Value Units

    Under section 1848(c)(2) of the Act, adjustments to RVUs may not 
cause the amount of expenditures to differ by more than $20 million 
from the amount of expenditures that would have resulted without such 
adjustments. We are proposing several changes that would result in a 
change of expenditures that would exceed $20 million if we made no 
offsetting adjustments to either the CF or RVUs.
    With respect to practice expense, our policy has been to meet the 
budget-neutrality requirements in the statute by incorporating a 
rescaling adjustment in the practice expense methodology. That is, we 
estimate the aggregate number of practice expense RVUs that would be 
paid under current policies and under the policies we will be using in 
2003. We apply a uniform adjustment factor to make the aggregate number 
of proposed practice expense relative values equal the number estimated 
that would have been paid under current policy. Consistent with section 
1848(c)(2)(B)(ii)(II) of the Act, we ensure that changes to practice 
expense RVUs do not increase or decrease payments more than $20 
million. We are also applying a 0.49 percent (0.9951) reduction to the 
practice expense RVUs to account for an anticipated increase in the 
volume and intensity of services in response to payment reductions from 
refinement of practice expense RVUs.
    Table 23 shows the specialty level impact of RVU changes on payment 
in 2003. As indicated in the June 2002 proposed rule (67 FR 43869), we 
are showing more specialty categories in our impact tables in this 
final rule than we have in the past. This change was well-received by 
the public, and we will continue to show impacts for the more detailed 
list of physician specialties, non-physician practitioners and medical 
suppliers. As indicated in the proposed rule, it is important to note 
that the payment impacts reflect averages for each specialty based on 
Medicare utilization. The payment impact for an individual physician 
would be different from the average, based on the mix of services the 
physician provides. The average change in total revenues would be less 
than the impact displayed here since physicians furnish services to 
both Medicare and non-Medicare patients and certain specialties may 
receive substantial Medicare revenues for services that are not paid 
under the physician fee schedule. For instance, independent 
laboratories receive more than 80 percent of their Medicare revenues 
from clinical laboratory services that are not paid under the physician 
fee schedule. Table 23 shows only the payment impact on physician fee 
schedule services.
    We modeled the impact of several changes that will affect payment 
for physician fee schedule services in CY 2003. The column labeled 
``NPRM'' shows the impacts of our proposed rule policies and reflects 
the figures shown in the June 28, 2002 proposed rule (67 FR 43867). The 
remaining columns show additional impacts that will result from changes 
made in this final rule in response to comments. The column labeled 
practice expense refinements

[[Page 80035]]

shows the impact on payment resulting from changes to practice expense 
inputs that are described in section II.A. As indicated earlier, we are 
making refinements to over 1,100 procedure codes. These changes result 
in little or no impact for most specialties. Dermatology, nephrology, 
and audiology will experience an approximate reduction in payment of 3 
percent as a result of these changes. Payment will decline by an 
estimated 2 percent for others (clinical social workers, independent 
diagnostic testing facilities) while reductions in payments will be 
more modest for a few other specialties (cardiac surgery, neurosurgery, 
clinical psychology, orthopedic surgery and physician assistants). 
Payment will increase by an estimated 4 percent for independent 
laboratories as a result of these changes and by 2 percent for plastic 
surgery. Other specialties will experience smaller increases in 
payments from the practice expense refinements (endocrinology, family 
practice, general practice, obstetrics, gynecology, pediatrics, 
physical medicine, rhematology, urology, chiropractor, and optometry).
    The column labeled ``5-Year Review'' shows the impact revisions to 
payments for anesthesia services resulting from the 5-year review of 
physician work. As expected, the increase in anesthesia work results in 
a 1-percent increase in payment to anesthesiologists and a 2-percent 
increase to certified registered nurse anesthetists (CRNAs) that bill 
Medicare for anesthesia services. CRNAs bill Medicare almost 
exclusively for anesthesia services. Anesthesiologists bill Medicare 
for anesthesia services and other physician fee schedule services. The 
net increase in payment is slightly less for anesthesia services 
because it reflects the average increase in payment for anesthesia 
services and other physician fee schedule services that are not 
increasing as a result of the 5-year review
    The column labeled ``All Other Changes'' reflects all changes that 
affect practice expense RVUs described in section II. A. These changes 
include: (1) As requested by the American Urology Association (AUA), 
removing several codes From the non-physician work pool; (2) 
incorporating supplemental data from the American Physical Therapy 
Association (APTA) and; (3) continuing to determine the global practice 
expense RVUs as the sum of the PC and TC practice expense RVUs for 
pathology services. While removing the codes requested by the AUA will 
increase payments to urologists, it will result in a somewhat smaller 
increase in payment than proposed for the services remaining in the 
non-physician work pool. As expected, incorporating supplemental survey 
data will increase payment to physical and occupational therapists. 
Payment reductions to pathology and independent laboratories resulting 
from determining the TC value as the difference between the global and 
PC will not occur in CY 2003 since we are not making this change for 1 
year for pathology services paid using the physician fee schedule.
    The column labeled ``Total'' shows the combined effect of all RVU 
changes on average Medicare payments for the specialties shown. The net 
effect of our final rule will continue to benefit several types of 
suppliers that provide services that are affected by the non-physician 
work pool methodology. Payments to Independent Diagnostic Testing 
Facilities will increase by approximately 4 percent. Portable x-ray 
suppliers will also receive an approximate increase of 4 percent in 
payments for services paid under the physician fee schedule. However, 
we note that only about 47 percent of Medicare revenues received by 
portable x-ray suppliers are attributable to physician fee schedule 
services. The other Medicare revenues received by portable x-ray 
suppliers are attributed to the transportation of x-ray equipment paid 
at rates determined by the Medicare carrier. Any change to the rates 
for carrier-priced services would be made at local carrier discretion. 
We recently asked our Medicare carriers to analyze payment for portable 
x-ray transportation since it has been a number of years since payment 
for this service has been reviewed.

      Table 23.--Impact of Work and Practice Expense Changes on Total Medicare Allowed Charges by Physician,
                                      Practitioner and Supplier Subcategory
----------------------------------------------------------------------------------------------------------------
                                                                   Practice
                                   Medicare allowed     NPRM        expense       5-year   All other     Total
            Category                charges  ($ in   (percent)    refinements     review     changes   (percent)
                                      billions)                    (percent)    (percent)  (percent)
----------------------------------------------------------------------------------------------------------------
Physicians:
ALLERGY/IMMUNOLOGY..............               0.14         2                0          0          0           1
ANESTHESIOLOGY..................               1.24        -1                0          1          0           1
CARDIAC SURGERY.................               0.28         0               -1          0          0          -1
CARDIOLOGY......................               4.75         1                0          0         -1           1
CLINICS.........................               2.57         0                0          0          0           0
DERMATOLOGY.....................               1.55        -2               -3          0          1          -4
EMERGENCY MEDICINE..............               1.17         0                0          0          0           0
ENDOCRINOLOGY...................               0.21         0                1          0         -1           0
FAMILY PRACTICE.................               3.43         0                1          0          0           0
GASTROENTEROLOGY................               1.34        -1                0          0          0          -1
GENERAL PRACTICE................               0.84         0                1          0          0           0
GENERAL SURGERY.................               1.98        -1                0          0          0          -1
GERIATRICS......................               0.08         0                0          0          0           0
HEMATOLOGY/ONCOLOGY.............               0.95         1                0          0          0           1
INFECTIOUS DISEASE..............               0.28        -1                0          0          0          -1
INTERNAL MEDICINE...............               6.77         0                0          0          0           0
INTERVENTIONAL RADIOLOGY........               0.14         1                0          0         -2          -1
NEPHROLOGY......................               1.09        -1               -3          0          0          -4
NEUROLOGY.......................               0.91         2                0          0          0           2
NEUROSURGERY....................               0.38        -1               -1          0          0          -1
OBSTETRICS/GYNECOLOGY...........               0.48         0                1          0          0           1
OPHTHALMOLOGY...................               3.86        -1                0          0          0          -1
ORTHOPEDIC SURGERY..............               2.40         0               -1          0          0          -2
OTOLARNGOLOGY...................               0.66         0                0          0         -1          -1

[[Page 80036]]

 
PATHOLOGY.......................               0.69        -2                0          0          2           0
PEDIATRICS......................               0.05         0                1          0          0           1
PHYSICAL MEDICINE...............               0.49         1                1          0          0           2
PLASTIC SURGERY.................               0.25        -1                2          0          0           0
PSYCHIATRY......................               1.00         0                0          0          0          -1
PULMONARY DISEASE...............               1.12         0                0          0          0           0
RADIATION ONCOLOGY..............               0.81         3                0          0         -2           1
RADIOLOGY.......................               3.47         2                0          0         -1           1
RHEUMATOLOGY....................               0.30         0                1          0         -1           0
THORACIC SURGERY................               0.43         0                0          0          0          -1
UROLOGY.........................               1.36        -1                1          0          2           2
VASCULAR SURGERY................               0.37         2                0          0          0           1
Other Practitioners:
AUDIOLOGIST.....................               0.02         8               -3          0         -2           2
CHIROPRACTOR....................               0.50        -1                1          0          0          -1
CLINICAL PSYCHOLOGIST...........               0.40         1               -1          0          0           0
CLINICAL SOCIAL WORKER..........               0.23         0               -2          0          0          -1
NURSE ANESTHETIST...............               0.38        -1                0          2          0           1
NURSE PRACTITIONER..............               0.30         0                0          0          0           0
OPTOMETRY.......................               0.54        -2                1          0         -1          -1
PHYSICAL/OCCUPATIONAL THERAPY...               0.61         0                0          0          3           2
PHYSICIANS ASSISTANT............               0.23         0               -1          0          0          -1
PODIATRY........................               1.17        -1                0          0          0           0
Suppliers:
DIAGNOSTIC TESTING FACILITY.....               0.51         9               -2          0         -4           3
INDEPENDENT LABORATORY..........               0.43        -8                4          0          8           3
PORTABLE X-RAY SUPPLIER.........               0.07         8                0          0         -3           4
ALL OTHER.......................               0.29         0               -1          0          0          -1
                                 --------------------
    ALL PHYSICIAN FEE SCHEDULE..              53.53         0                0          0          0           0
----------------------------------------------------------------------------------------------------------------

    Table 24 shows the combined impact of changes in payment due to 
RVUs and the physician fee schedule update. As described in section V, 
section 1848(d)(4) of the Act requires the physician fee schedule 
update to be -4.4 percent. We do not have the authority to change the 
physician fee schedule update formula specified in the statute. Table 
24 shows the estimated change in average payments by specialty based on 
the provisions of this final rule and the physician fee schedule 
update.

            Table 24.--Estimated Impact of All Changes on Total Medicare Allowed Charges by Specialty
----------------------------------------------------------------------------------------------------------------
                                                                                5 Year    Physician
                                                            Medicare allowed   review/       fee
                         Category                            charges  ($ in      RVU       schedule      Total
                                                               billions)       changes      update      percent
                                                                               percent     percent
----------------------------------------------------------------------------------------------------------------
Physicians:
ALLERGY/IMMUNOLOGY.......................................               0.14          1         -4.4          -3
ANESTHESIOLOGY...........................................               1.24          1         -4.4          -3
CARDIAC SURGERY..........................................               0.28         -1         -4.4          -6
CARDIOLOGY...............................................               4.75          1         -4.4          -4
CLINICS..................................................               2.57          0         -4.4          -5
DERMATOLOGY..............................................               1.55         -4         -4.4          -8
EMERGENCY MEDICINE.......................................               1.17          0         -4.4          -5
ENDOCRINOLOGY............................................               0.21          0         -4.4          -5
FAMILY PRACTICE..........................................               3.43          0         -4.4          -5
GASTROENTEROLOGY.........................................               1.34         -1         -4.4          -5
GENERAL PRACTICE.........................................               0.84          0         -4.4          -4
GENERAL SURGERY..........................................               1.98         -1         -4.4          -5
GERIATRICS...............................................               0.08          0         -4.4          -5
HEMATOLOGY/ONCOLOGY......................................               0.95          1         -4.4          -3
INFECTIOUS DISEASE.......................................               0.28         -1         -4.4          -5
INTERNAL MEDICINE........................................               6.77          0         -4.4          -5
INTERVENTIONAL RADIOLOGY.................................               0.14         -1         -4.4          -5
NEPHROLOGY...............................................               1.09         -4         -4.4          -8
NEUROLOGY................................................               0.91          2         -4.4          -2
NEUROSURGERY.............................................               0.38         -1         -4.4          -6

[[Page 80037]]

 
OBSTETRICS/GYNECOLOGY....................................               0.48          1         -4.4          -3
OPHTHALMOLOGY............................................               3.86         -1         -4.4          -5
ORTHOPEDIC SURGERY.......................................               2.40         -2         -4.4          -7
OTOLARNGOLOGY............................................               0.66         -1         -4.4          -5
PATHOLOGY................................................               0.69          0         -4.4          -5
PEDIATRICS...............................................               0.05          1         -4.4          -4
PHYSICAL MEDICINE........................................               0.49          2         -4.4          -3
PLASTIC SURGERY..........................................               0.25          0         -4.4          -4
PSYCHIATRY...............................................               1.00         -1         -4.4          -5
PULMONARY DISEASE........................................               1.12          0         -4.4          -4
RADIATION ONCOLOGY.......................................               0.81          1         -4.4          -3
RADIOLOGY................................................               3.47          1         -4.4          -4
RHEUMATOLOGY.............................................               0.30          0         -4.4          -4
THORACIC SURGERY.........................................               0.43         -1         -4.4          -5
UROLOGY..................................................               1.36          2         -4.4          -3
VASCULAR SURGERY.........................................               0.37          1         -4.4          -3
Other Practitioners:
AUDIOLOGIST..............................................               0.02          2         -4.4          -2
CHIROPRACTOR.............................................               0.50         -1         -4.4          -5
CLINICAL PSYCHOLOGIST....................................               0.40          0         -4.4          -4
CLINICAL SOCIAL WORKER...................................               0.23         -1         -4.4          -5
NURSE ANESTHETIST........................................               0.38          1         -4.4          -4
NURSE PRACTITIONER.......................................               0.30          0         -4.4          -5
OPTOMETRY................................................               0.54         -1         -4.4          -5
PHYSICAL/OCCUPATIONAL THERAPY............................               0.61          2         -4.4          -3
PHYSICIANS ASSISTANT.....................................               0.23         -1         -4.4          -6
PODIATRY.................................................               1.17          0         -4.4          -5
Suppliers:
DIAGNOSTIC TESTING FACILITY..............................               0.51          3         -4.4          -1
INDEPENDENT LABORATORY...................................               0.43          3         -4.4          -1
PORTABLE X-RAY SUPPLIER..................................               0.07          4         -4.4           0
ALL OTHER................................................               0.29         -1         -4.4          -6
                                                          --------------------
    ALL PHYSICIAN FEE SCHEDULE...........................              53.53          0         -4.4          -5
----------------------------------------------------------------------------------------------------------------

    Table 25 shows the impact of all of the changes previously 
discussed on payments for selected high volume procedures. This table 
shows the combined impact of changes in RVUs and the physician fee 
schedule update on total payment for the procedure. There are separate 
columns that show the change in the facility rates and the nonfacility 
rates. For an explanation of facility and non-facility practice expense 
refer to Sec.  414.22(b)(5)(i).

      Table 25.--Impact of Proposed Rule and Physician Fee Schedule Update on Medicare Payment for Selected
                                                   Procedures
----------------------------------------------------------------------------------------------------------------
                                                              Non-Facility                    Facility
 HCPCS    MOD                   DESC                 -----------------------------------------------------------
                                                         Old       New    % Change     Old       New    % Change
----------------------------------------------------------------------------------------------------------------
  11721  .....  Debride nail, 6 or more.............    $36.92    $35.28        -4    $28.96    $27.33        -6
  17000  .....  Destroy benign/premlg lesion........     62.62     57.77        -8     32.94     31.13        -5
  27130  .....  Total hip arthroplasty..............       N/A       N/A       N/A  1,452.31  1,263.30       -13
  27236  .....  Treat thigh fracture................       N/A       N/A       N/A  1,113.85  1,005.24       -10
  27244  .....  Treat thigh fracture................       N/A       N/A       N/A  1,137.38  1,086.53        -4
  27447  .....  Total knee arthroplasty.............       N/A       N/A       N/A  1,514.21  1,359.47       -10
  33533  .....  CABG, arterial, single..............       N/A       N/A       N/A  1,827.34  1,691.89        -7
  35301  .....  Rechanneling of artery..............       N/A       N/A       N/A  1,061.36  1,009.74        -5
  43239  .....  Upper GI endoscopy, biopsy..........    354.75    317.55       -10    154.93    146.67        -5
  45385  .....  Lesion removal colonoscopy..........    571.22    513.00       -10    287.78    273.28        -5
  66821  .....  After cataract laser surgery........    229.50    215.51        -6    213.94    200.29        -6
  66984  .....  Cataract surg w/iol, 1 stage........       N/A       N/A       N/A    669.32    630.61        -6
  67210  .....  Treatment of retinal lesion.........    603.08    568.35        -6    546.61    515.77        -6
  71010     26  Chest x-ray.........................      9.05      8.65        -4      9.05      8.65        -4
  71020     26  Chest x-ray.........................     11.22     10.38        -7     11.22     10.38        -7
  76091  .....  Mammogram, both breasts.............     90.50     88.21        -3       N/A       N/A       N/A
  76091     26  Mammogram, both breasts.............     43.44     41.51        -4     43.44     41.51        -4
  76092  .....  Mammogram, screening................     81.81     77.83        -5       N/A       N/A       N/A
  76092     26  Mammogram, screening................     35.48     33.90        -4     35.48     33.90        -4
  77427  .....  Radiation tx management, 5..........    167.96    158.09        -6    167.96    158.09        -6
  78465     26  Heart image (3d), multiple..........     74.93     70.91        -5     74.93     70.91        -5
  88305     26  Tissue exam by pathologist..........     40.54     38.40        -5     40.54     38.40        -5
  90801  .....  Psy dx interview....................    144.80    140.10        -3    137.19    132.14        -4
  90806  .....  Psytx, off, 45-50 min...............     95.93     90.63        -6     91.22     87.17        -4

[[Page 80038]]

 
  90807  .....  Psytx, off, 45-50 min w/e&m.........    103.53     96.51        -7     98.82     94.09        -5
  90862  .....  Medication management...............     51.04     47.74        -6     46.33     44.97        -3
  90921  .....  ESRD related services, month........    273.30    246.64       -10    273.30    246.64       -10
  90935  .....  Hemodialysis, one evaluation........       N/A       N/A       N/A     76.38     67.11       -12
  92004  .....  Eye exam, new patient...............    123.44    116.23        -6     87.96     83.02        -6
  92012  .....  Eye exam established pat............     61.18     57.77        -6     35.84     33.90        -5
  92014  .....  Eye exam & treatment................     91.22     85.44        -6     58.64     55.35        -6
  92980  .....  Insert intracoronary stent..........       N/A       N/A       N/A    788.06    752.72        -4
  92982  .....  Coronary artery dilation............       N/A       N/A       N/A    582.45    559.01        -4
  93000  .....  Electrocardiogram, complete.........     25.34     24.91        -2       N/A       N/A       N/A
  93010  .....  Electrocardiogram report............      9.05      8.30        -8      9.05      8.30        -8
  93015  .....  Cardiovascular stress test..........     99.91     97.55        -2       N/A       N/A       N/A
  93307     26  Echo exam of heart..................     48.14     45.32        -6     48.14     45.32        -6
  93510     26  Left heart catheterization..........    230.59    217.58        -6    230.59    217.58        -6
  98941  .....  Chiropractic manipulation...........     35.48     33.55        -5     31.13     29.40        -6
  99202  .....  Office/outpatient visit, new........     61.54     58.81        -4     45.61     43.24        -5
  99203  .....  Office/outpatient visit, new........     91.95     87.17        -5     69.50     66.07        -5
  99204  .....  Office/outpatient visit, new........    130.68    124.19        -5    102.81     97.55        -5
  99205  .....  Office/outpatient visit, new........    166.15    158.43        -5    136.47    129.37        -5
  99211  .....  Office/outpatient visit, est........     20.27     19.37        -4      8.69      8.30        -4
  99212  .....  Office/outpatient visit, est........     36.20     34.25        -5     23.17     21.79        -6
  99213  .....  Office/outpatient visit, est........     50.32     48.08        -4     34.03     32.52        -4
  99214  .....  Office/outpatient visit, est........     78.91     75.06        -5     56.11     53.27        -5
  99215  .....  Office/outpatient visit, est........    115.84    110.00        -5     90.50     85.79        -5
  99221  .....  Initial hospital care...............       N/A       N/A       N/A     65.16     61.92        -5
  99222  .....  Initial hospital care...............       N/A       N/A       N/A    108.24    102.74        -5
  99223  .....  Initial hospital care...............       N/A       N/A       N/A    150.95    142.86        -5
  99231  .....  Subsequent hospital care............       N/A       N/A       N/A     32.58     30.79        -5
  99232  .....  Subsequent hospital care............       N/A       N/A       N/A     53.57     50.85        -5
  99233  .....  Subsequent hospital care............       N/A       N/A       N/A     76.38     72.30        -5
  99236  .....  Observ/hosp same date...............       N/A       N/A       N/A    214.66    203.75        -5
  99238  .....  Hospital discharge day..............       N/A       N/A       N/A     66.24     65.03        -2
  99239  .....  Hospital discharge day..............       N/A       N/A       N/A     90.86     88.21        -3
  99241  .....  Office consultation.................     47.06     44.62        -5     33.30     31.13        -7
  99242  .....  Office consultation.................     87.24     83.02        -5     68.05     64.00        -6
  99243  .....  Office consultation.................    115.84    109.66        -5     90.14     85.10        -6
  99244  .....  Office consultation.................    164.34    156.01        -5    133.58    126.26        -5
  99245  .....  Office consultation.................    212.85    202.36        -5    177.01    167.08        -6
  99251  .....  Initial inpatient consult...........       N/A       N/A       N/A     34.75     32.86        -5
  99252  .....  Initial inpatient consult...........       N/A       N/A       N/A     69.86     66.07        -5
  99253  .....  Initial inpatient consult...........       N/A       N/A       N/A     95.20     90.29        -5
  99254  .....  Initial inpatient consult...........       N/A       N/A       N/A    136.83    129.72        -5
  99255  .....  Initial inpatient consult...........       N/A       N/A       N/A    188.60    178.49        -5
  99261  .....  Follow-up inpatient consult.........       N/A       N/A       N/A     21.72     20.76        -4
  99262  .....  Follow-up inpatient consult.........       N/A       N/A       N/A     43.44     41.16        -5
  99263  .....  Follow-up inpatient consult.........       N/A       N/A       N/A     64.80     61.23        -6
  99282  .....  Emergency dept visit................       N/A       N/A       N/A     26.43     25.25        -4
  99283  .....  Emergency dept visit................       N/A       N/A       N/A     59.37     56.73        -4
  99284  .....  Emergency dept visit................       N/A       N/A       N/A     92.67     88.56        -4
  99285  .....  Emergency dept visit................       N/A       N/A       N/A    144.80    138.02        -5
  99291  .....  Critical care, first hour...........    208.87    197.52        -5    198.37    188.18        -5
  99292  .....  Critical care, addl 30 min..........    108.24    101.35        -6     98.82     94.09        -5
  99301  .....  Nursing facility care...............     70.23     66.76        -5     60.09     57.42        -4
  99302  .....  Nursing facility care...............     95.57     90.98        -5     80.72     76.45        -5
  99303  .....  Nursing facility care...............    118.73    112.77        -5    100.27     95.13        -5
  99311  .....  Nursing fac care, subseq............     40.18     38.40        -4     30.05     28.71        -4
  99312  .....  Nursing fac care, subseq............     61.90     58.81        -5     49.95     47.39        -5
  99313  .....  Nursing fac care, subseq............     84.34     80.60        -4     70.95     67.45        -5
  99348  .....  Home visit, est patient.............     73.85     69.88        -5       N/A       N/A       N/A
  99350  .....  Home visit, est patient.............    166.52    157.74        -5       N/A       N/A       N/A
  G0008  .....  Admin influenza virus vac...........      3.98      7.26        82       N/A       N/A       N/A
  G0009  .....  Admin pneumococcal vaccine..........      3.98      7.26        82       N/A       N/A       N/A
  G0010  .....  Admin hepatitis b vaccine...........      3.98      7.26        82       N/A       N/A       N/A
----------------------------------------------------------------------------------------------------------------

B. Proposed Productivity Adjustment to the MEI

    As indicated in section VI.B. of this final rule, we are adopting 
the proposed change to the methodology for adjusting for productivity 
in the MEI. We will use the 10-year moving average of private nonfarm 
business (economy-wide) multifactor productivity applied to the entire 
index to calculate the MEI beginning in CY 2003. The prior method 
accounted for productivity by adjusting the labor portion of the MEI by 
the 10-year moving average change in private nonfarm business (economy-
wide) labor productivity. Our reasons for proposing this change and the 
alternatives we considered are discussed in detail in section VI.
    We believe that we have developed a revised MEI methodology that is 
technically superior to the current MEI and more adequately reflects 
annual changes in the cost of furnishing services in efficient 
physicians' practices. The change to the MEI will

[[Page 80039]]

raise the index by 0.7 percentage points from 2.3 percent to 3.0 
percent for 2003. We estimate that this change will increase Federal 
expenditures by $150 million in FY 2003. The outyear impact is a 
function of numerous economic variables that fluctuate unpredictably. 
Our estimate of the impact beyond FY 2003 is based on projections of 
both the current and revised index. We estimate the change would 
increase Federal expenditures by $340 million in FY 2004 and $550 
million in FY 2005.

C. Site of Service

    Relative values for practice expense are determined for both 
``facility'' and ``non-facility'' settings. (See Addendum B.) We are 
clarifying whether a given place of service is either a facility or 
non-facility site for purposes of determining Medicare payment. This 
clarification should benefit physicians, providers, and Medicare 
contractors by making the payment rules clearer. We are updating the 
facility and non-facility designations for several new place-of-service 
codes and changing the designations for several already in existence. 
The update for the new place-of-service codes will have no effect on 
Medicare spending. The place-of-service codes in which we are changing 
the designation are infrequently used for physician fee schedule 
services. This rule could result in a minor redistribution in payment 
among physician fee schedule services through the practice expense 
budget-neutrality adjustments.

D. Pricing of Technical Components (TC) for Positron Emission 
Tomography (PET) Scans

    As stated earlier, to keep pricing consistent with the manner in 
which other PET scan services are paid, we are changing from national 
pricing to carrier pricing for the TC and global value for HCPCS code 
G0125 Lung Image PET scans. The budgetary impact on the Medicare 
program and providers would be uncertain since we do not know the 
payment amounts that carriers would use for this service.

E. Medicare Qualifications for Clinical Nurse Specialists (CNSs)

    As previously stated, we are revising regulations regarding 
qualifications for CNSs by allowing flexibility as to certifying 
bodies. We believe this change will make the Medicare requirements more 
consistent with criteria for nurse practitioners. We also believe there 
will be additional enrollment of CNSs that will qualify for Medicare 
enrollment. We expect that this policy will have little effect on 
Medicare expenditures.

F. Process To Add or Delete Services to the Definition of Telehealth

    We are finalizing a process for adding or deleting services from 
the list of telehealth services. In addition, we are adding psychiatric 
diagnostic interview examinations, CPT code 90801, to the list of 
Medicare telehealth services. We believe this will have little effect 
on Medicare expenditures.

G. Change in Global Period for CPT code 77789 (Surface Application of 
Radiation Source

    We are changing the global period for CPT code 77789 (surface 
application of radiation source) from a 90-day global period to a 000-
day global period. We believe physicians that furnish these services 
will benefit from this change because it will simplify their billing 
processes. We do not expect it will have a significant impact on the 
Medicare program because the change will reflect current practices.

H. New HCPCS G-Codes

    In section K we discuss new G-codes for--treatment of peripheral 
neuropathy; current perception sensory nerve conduction threshold 
tests; PET codes for breast imaging; and home prothrombin time INR 
monitoring for anticoagulation management. We have withdrawn our 
proposal for a new G code for bone marrow aspiration and biopsy on the 
same date of service. All G codes except for the G code for bone marrow 
aspiration and biopsy on the same date of service have been implemented 
during CY 2002 through Program Memoranda as a result of national 
coverage decisions or the need to clarify payment policy. As stated, we 
are not proceeding with a G code for bone marrow aspiration and biopsy 
on the same date of service.

I. Endoscopic Base For Urology Codes

    We are correcting the pricing of certain endoscopic services. As we 
previously indicated, we will use CPT procedure code 52000 as the 
endoscopic base code for CPT procedure codes 52234, 52235, and 52240. 
This will result in a reduction in payment in instances when these 
codes are billed in conjunction with either CPT procedure code 52000 or 
other codes that have CPT procedure code 52000 as the endscopic base 
code. We expect the savings will be negligible.

J. Physical Therapy and Occupational Therapy Caps

    There were no proposals made in this area. The imposition of the 
physical and occupational therapy caps will occur as a result of 
application of section 4541(c) of the BBA. While section 221 of the 
BBRA and section 421 of BIPA placed a moratorium on application of 
these caps, the moratorium expires for physical and occupational 
therapy services furnished after December 31, 2002. We estimate that 
application of the caps will reduce Medicare expenditures for physical 
and occupational therapy services by $240 million in CY 2003.

K. Enrollment of Physical and Occupational Therapists as Therapists in 
Private Practice

    This change will provide flexibility for therapists by allowing 
therapists that meet the enrollment criteria to enroll in Medicare 
without regard to how they are organized to provide services. We do not 
expect this will have a significant effect on Medicare expenditures 
because Medicare pays the same amount for these therapy services 
whether they are billed directly by a therapist or by a physician as an 
incident to service.

L. Screening Fecal Occult Blood Tests

    As discussed in section II.N (1) of the preamble, we are modifying 
our regulations to allow us to expand coverage when appropriate for (1) 
screening fecal-occult blood tests for the early detection of 
colorectal cancer, and (2) additional colorectal cancer screening tests 
through our national coverage determination process. These changes will 
allow us to conduct more timely assessments of new types of colon 
cancer screening tests than is normally possible under the standard 
rulemaking process. There are no costs or savings to the Medicare 
program associated with this regulation change.

M. Add-on Anesthesia Codes

    The add-on codes, two for obstetrical anesthesia (CPT codes 01968 
and 01969) and one for burn excisions (CPT code 01953), represent low 
volume codes for the Medicare population. We believe the new policy for 
add-on codes will have a negligible impact on total anesthesia 
payments.

N. Physician Self-Referral Prohibitions

    As discussed in section IV of this preamble, we are updating the 
list of codes used to define certain designated health services for the 
purposes of section 1877 of the Act. We are not making any substantive 
change to the description of any designated health

[[Page 80040]]

service as set forth in the January 4, 2001 physician self-referral 
final rule (66 FR 856). Instead, we are merely updating our list of 
codes to conform to coding changes in the most recent publication of 
CPT and HCPCS codes.
    For this reason, we certify that the changes we are making will not 
have a significant economic effect on a substantial number of small 
entities or on the operations of a substantial number of small rural 
hospitals.

O. Critical Access Hospital Emergency Services Requirement

    We anticipate that this rule will reduce cost for small CAHs. 
Frontier area and remote location CAHs will no longer be limited to 
hiring only a physician, nurse practitioner or physician assistant to 
provide emergency coverage in the absence of the sole practitioner. 
This rule will provide relief to small CAHs in meeting the current 
emergency staffing requirement by allowing them to utilize a registered 
nurse to provide emergency care services once the State submits a 
letter to us, signed by the Governor, following consultation with the 
State Boards of Medicine and Nursing, and in accordance with State law, 
requesting that RNs be included as emergency personnel in Sec.  
485.618(d).

P. Alternatives Considered

    This final rule contains a range of policies. The preamble 
identifies those policies when discretion has been exercised and 
presents rationale for our decisions, including a presentation of 
nonselected options (except for the critical access hospital emergency 
services requirement which is provided separately).
Critical Access Hospitals Emergency Services Personnel Requirement
    We considered allowing each CAH in a frontier area or remote 
location to individually request a waiver of the requirements at Sec.  
485.618(a) and (d). The statute does not provide authority to waive the 
requirement for continuous emergency room coverage. Section 
1820(c)(B)(ii) requires a qualifying CAH to make available the 24-hour 
emergency care services that a State determines are necessary for 
ensuring access to emergency care services in each area served by a 
CAH. However, we believe States may interpret emergency care services 
to allow CAHs to use a RN in order to comply with the emergency 
services personnel requirement stated in the regulations at Sec.  
485.618. This change is consistent with our policy of respecting State 
oversight of health care professions by deferring to State law to 
regulate professional practice.

Q. Impact on Beneficiaries

    Although changes in physicians' payments were large when the 
physician fee schedule was implemented in 1992, we detected no problems 
with beneficiary access to care. We do not believe that there would be 
any problem with access to care as a result of the changes in this 
rule. While it has been suggested that the negative update for CY 2003 
may affect beneficiary access to care, we note that the formula to 
determine this update is set by statute and this regulation cannot, and 
does not, change it.
    As indicated above, the imposition of the physical and occupational 
therapy caps will occur as a result of application of section 4541(c) 
of the BBA. It is possible that application of physical and 
occupational therapy caps will have an impact on Medicare beneficiaries 
either through increased liability for services exceeding the cap or 
fewer services being provided. We contracted with the Urban Institute 
to perform analyses related to the implementation of the therapy caps, 
based on an analysis of a sample of therapy services provided from CYs 
1998 through 2000. The draft reports are available on the CMS website. 
The contractor report indicated that in CY 2000, about 12 percent of 
patients who received therapy services would have exceeded the caps. 
The caps are more likely to be exceeded in skilled nursing facilities, 
comprehensive outpatient rehabilitation facilities, and other 
rehabilitation facility settings. The caps do not apply to outpatient 
therapy services provided in an outpatient hospital. The report does 
not make assumptions about changes in behavior in response to the caps. 
Without more experience with the caps, it is difficult to predict the 
precise impact on beneficiaries.
    In addition, CAHs in frontier areas and remote locations will be 
able to satisfy the CAH emergency services personnel requirement, 
through the addition of RNs to our personnel requirements and 
beneficiaries will have greater access to care through the utilization 
of RNs providing emergency care services to patients.
    In accordance with the provisions of Executive Order 12866, the 
Office of Management and Budget reviewed this regulation.

List of Subjects

42 CFR Part 410

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

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 485

    Grant programs-health, Health facilities, Medicaid, Medicare, 
Reporting and recordkeeping requirements.
    For the reasons set forth in the preamble, the Centers for Medicare 
& Medicaid Services amends 42 CFR chapter IV as follows:

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS

    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.  410.37, paragraphs (a)(1)(v) and (a)(2) are revised to 
read as follows:


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

    (a) * * *
    (1) * * *
    (v) Other tests or procedures established by a national coverage 
determination, and modifications to tests under this paragraph, with 
such frequency and payment limits as CMS determines appropriate, in 
consultation with appropriate organizations
    (2) Screening fecal-occult blood test means--
    (i) A guaiac-based test for peroxidase activity, testing two 
samples from each of three consecutive stools, or,
    (ii) Other tests as determined by the Secretary through a national 
coverage determination.
* * * * *

    3. Section 410.59 is amended as follows:
    A. Paragraph (c)(1)(ii)(C) is revised.
    B. A new paragraph (c)(1)(ii)(D) is added.
    C. A new paragraph (c)(1)(ii)(E) is added.
    The revision and additions read as follows:


Sec.  410.59  Outpatient occupational therapy services: Conditions.

* * * * *

[[Page 80041]]

    (c) * * *
    (1) * * *
    (ii) * * *
    (C) An unincorporated solo practice, partnership, or group 
practice, or a professional corporation or other incorporated 
occupational therapy practice.
    (D) An employee of a physician group.
    (E) An employee of a group that is not a professional corporation.
* * * * *

    4. Section 410.60 is amended as follows:
    A. Paragraph (c)(1)(ii)(C) is revised.
    B. A new paragraph (c)(1)(ii)(D) is added.
    C. A new paragraph (c)(1)(ii)(E) is added
    The revision and additions read as follows:


Sec.  410.60  Outpatient physical therapy services: Conditions

* * * * *
    (c) * * *
    (1) * * *
    (ii) * * *
    (C) An unincorporated solo practice, partnership, or group 
practice, or a professional corporation or other incorporated physical 
therapy practice.
    (D) An employee of a physician group.
    (E) An employee of a group that is not a professional corporation.
* * * * *

    5. Section 410.61 is amended by revising paragraph (d)(1)(iii) to 
read as follows:


Sec.  410.61  Plan of treatment requirements for outpatient 
rehabilitation services.

    (d) * * *
    (1) * * *
    (iii) The occupational therapist that furnishes the occupational 
therapy services.
* * * * *

    6. Section 410.76 is amended by revising paragraph (b)(3) to read 
as follows:


Sec.  410.76  Clinical nurse specialists' services.

* * * * *
    (b) * * *
    (3) Be certified as a clinical nurse specialist by a national 
certifying body that has established standards for clinical nurse 
specialists and that is approved by the Secretary.
* * * * *

    7. Section 410.78 is amended as follows:
    a. Revise the heading of the section.
    b. Revise the introductory text of paragraph (b).
    c. Revise paragraph (b)(1).
    d. Add a new paragraph (f).
    The revisions and additions read as follows:


Sec.  410.78  Telehealth services.

* * * * *
    (b) General rule. Medicare Part B pays for office and other 
outpatient visits, professional consultation, psychiatric diagnostic 
interview examination, individual psychotherapy, and pharmacologic 
management furnished by an interactive telecommunications system if the 
following conditions are met:
    (1) The physician or practitioner at the distant site must be 
licensed to furnish the service under State law. The physician or 
practitioner at the distant site who is licensed under State law to 
furnish a covered telehealth service described in this section may 
bill, and receive payment for, the service when it is delivered via a 
telecommunications system.
* * * * *
    (f) Process for adding or deleting services. Changes to the list of 
Medicare telehealth services are made through the annual physician fee 
schedule rulemaking process.

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

    1. The authority citation for part 414 continues to read as 
follows:

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

    2. Section 414.46 is amended by revising paragraph (g) to read as 
follows:


Sec.  414.46  Additional rules for payment of anesthesia services.

* * * * *
    (g) Physician involved in multiple anesthesia services. If the 
physician is involved in multiple anesthesia services for the same 
patient during the same operative session, the carrier makes payment 
according to the base unit associated with the anesthesia service 
having the highest base unit value and anesthesia time that encompasses 
the multiple services. The carrier makes payment for add-on anesthesia 
codes according to program operating instructions.

    3. Section 414.65, is amended as follows:
    a. Revise the heading of the section.
    b. Revise paragraph (a)(1).
    c. Revise paragraph (b) introductory text.
    The revisions read as follows:


Sec.  414.65  Payment for telehealth services.

    (a) * * *
    (1) The Medicare payment amount for office or other outpatient 
visits, consultation, individual psychotherapy, psychiatric diagnostic 
interview examination, and pharmacologic management furnished via an 
interactive telecommunications system is equal to the current fee 
schedule amount applicable for the service of the physician or 
practitioner.
* * * * *
    (b) Originating site facility fee. For telehealth services 
furnished on or after October 1, 2001:
* * * * *

PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS

    Part 485 is amended as set forth below:
    1. The authority citation for 485 continues to read as follows:

    Authority: Secs. 1102 and 1871 of the Act (42 U.S.C. 1302 and 
1396hh).

    2. Section 485.618 is amended by revising paragraph (d) to read as 
follows:


Sec.  485.618  Condition of participation: Emergency services.

* * * * *
    (d) Standard: Personnel. (1) Except as specified in paragraph 
(d)(2) of this section, there must be a doctor of medicine or 
osteopathy, a physician assistant, or a nurse practitioner, with 
training or experience in emergency care on call and immediately 
available by telephone or radio contact, and available on site within 
the following timeframes:
    (i) Within 30 minutes, on a 24-hour a day basis, if the CAH is 
located in an area other than an area described in paragraph (d)(1)(ii) 
of this section; or
    (ii) Within 60 minutes, on a 24-hour a day basis, if all of the 
following requirements are met:
    (A) The CAH is located in an area designated as a frontier area 
(that is, an area with fewer than six residents per square mile based 
on the latest population data published by the Bureau of the Census) or 
in an area that meets the criteria for a remote location adopted by the 
State in its rural health care plan, and approved by CMS, under section 
1820(b) of the Act.
    (B) The State has determined, under criteria in its rural health 
care plan, that allowing an emergency response time longer than 30 
minutes is the only feasible method of providing emergency care to 
residents of the area served by the CAH.

[[Page 80042]]

    (C) The State maintains documentation showing that the response 
time of up to 60 minutes at a particular CAH it designates is justified 
because other available alternatives would increase the time needed to 
stabilize a patient in an emergency.
    (2) A registered nurse satisfies the personnel requirement 
specified in paragraph (d)(1) of this section for a temporary period 
if--
    (i) The CAH has no greater than 10 beds;
    (ii) The CAH is located in an area designated as a frontier area or 
remote location as described in paragraph (d)(1)(ii)(A) of this 
section;
    (iii) The State in which the CAH is located submits a letter to CMS 
signed by the Governor, following consultation on the issue of using 
RNs on a temporary basis as part of their State rural healthcare plan 
with the State Boards of Medicine and Nursing, and in accordance with 
State law, requesting that a registered nurse with training and 
experience in emergency care be included in the list of personnel 
specified in paragraph (d)(1) of this section. The letter from the 
Governor must attest that he or she has consulted with State Boards of 
Medicine and Nursing about issues related to access to and the quality 
of emergency services in the States. The letter from the Governor must 
also describe the circumstances and duration of the temporary request 
to include the registered nurses on the list of personnel specified in 
paragraph (d)(1) of this section;
    (iv) Once a Governor submits a letter, as specified in paragraph 
(d)(2)(ii) of this section, a CAH must submit documentation to the 
State survey agency demonstrating that it has been unable, due to the 
shortage of such personnel in the area, to provide adequate coverage as 
specified in this paragraph (d).
    (3) The request, as specified in paragraph(d)(2)(ii) of this 
section, and the withdrawal of the request, may be submitted to us at 
any time, and are effective upon submission.
* * * * *

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

    Dated: November 26, 2002.
Thomas A. Scully,
Administrator, Centers for Medicare & Medicaid Services.

    Approved: December 12, 2002.
Tommy G. Thompson,
Secretary.

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

Addendum A--Explanation and Use of Addenda B

    The addenda on the following pages provide various data pertaining 
to the Medicare fee schedule for physicians' services furnished in 
2003. 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.
    In previous years, we have listed many services in Addendum B that 
are not paid under the physician fee schedule. To avoid publishing as 
many pages of codes for these services, we are not including clinical 
laboratory codes and most alpha-numeric codes (Healthcare Common 
Procedure Coding System (HCPCS) codes not included in CPT) in Addendum 
B.

Addendum B--2003 Relative Value Units and Related Information Used in 
Determining Medicare Payments for 2003

    This addendum contains the following information for each CPT code 
and alphanumeric HCPCS code for services that may be paid under the 
physician fee schedule as well as all G codes
    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.
    F = Deleted/discontinued codes. Code not subject to a 90-day grace 
period.
    G = Code not valid for Medicare purposes. Medicare does not 
recognize codes assigned this status. Medicare uses another code for 
reporting of, and payment for, these services.
    H = Deleted modifier. Either the TC or PC component shown for the 
code has been deleted, and the deleted component is shown in the data 
base with the H status indicator. (Code subject to a 90-day grace 
period.)
    I = Not valid for Medicare purposes. Medicare uses another code for 
the reporting of, and the payment for these services. (Code NOT subject 
to a 90-day grace period.)
    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).
    --If the item or service is covered as other than incident to a 
physician's

[[Page 80043]]

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 thisservice in 2003. Codes that are not used for Medicare payment 
are identified with a ``+.''
    6. Facility practice expense RVUs. These are the fully implemented 
resource-based practice expense RVUs for facility settings. An ``NA'' 
in the facility column means that we do not pay for the service in a 
facility setting. For instance, we do not pay using the physician fee 
schedule for the global or technical component of a radiology service 
or other diagnostic test in a facility setting. Also, there is no 
payment in a facility setting for ``incident to'' services (services 
that do not have physician work RVUs). Payment is included in our 
payment for institutional services.
    7. Non-facility practice expense RVUs. These are the fully 
implemented resource-based practice expense RVUs for non-facility 
settings. An ``NA'' in the nonfacility column means that the service is 
generally not provided outside of hospitals and we do not have 
information upon which to determine a price. In most cases, these are 
major surgical services.
    8. Malpractice expense RVUs. These are the RVUs for the malpractice 
expense for the service for 2003.
    9. Facility total. This is the sum of the work, fully implemented 
facility practice expense, and malpractice expense RVUs.
    10. Non-facility total. This is the sum of the work, fully 
implemented non-facility practice expense, and malpractice expense 
RVUs.
    11. 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 = Code related to another service and is always included in the 
global period of the other service. (Note: Physician work is associated 
with intra service time and in some instances the pre- and post-service 
time.)




[[Page 80044]]





    --------------------
\1\ CPT codes and descriptions only are copyright 2002 American Medical 
Association. All Rights Reserved. Applicable FARS/DFARS Apply.

\2\ Copyright 2002 American Dental Association. All rights reserved.

\3\ + Indicates RVUs are not used for Medicare payment.

[[Page 80044]]



                                            Addendum B.--Relative Value Units (RVUS) and Related Information
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                             Physician     Non-                  Mal-       Non-
  CPT \1\/  HCPCS         MOD            Status            Description          Work     Facility   Facility   Practice   Facility   Facility    Global
        \2\                                                                   RVUs\3\    PE RVUs    PE  RVUs     RVUs      Total      Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
0001T.............  ..............  C                Endovas repr abdo ao         0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      aneurys.
0002T.............  ..............  C                Endovas repr abdo ao         0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      aneurys.
0003T.............  ..............  C                Cervicography.........       0.00       0.00       0.00       0.00       0.00       0.00        XXX
0005T.............  ..............  C                Perc cath stent/brain        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      cv art.
0006T.............  ..............  C                Perc cath stent/brain        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      cv art.
0007T.............  ..............  C                Perc cath stent/brain        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      cv art.
0008T.............  ..............  C                Upper gi endoscopy w/        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      suture.
0009T.............  ..............  C                Endometrial                  0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      cryoablation.
0010T.............  ..............  C                Tb test, gamma               0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      interferon.
0012T.............  ..............  C                Osteochondral knee           0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      autograft.
0013T.............  ..............  C                Osteochondral knee           0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      allograft.
0014T.............  ..............  C                Meniscal transplant,         0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      knee.
0016T.............  ..............  C                Thermotx choroid vasc        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      lesion.
0017T.............  ..............  C                Photocoagulat macular        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      drusen.
0018T.............  ..............  C                Transcranial magnetic        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      stimul.
0019T.............  ..............  C                Extracorp shock wave         0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      tx, ms.
0020T.............  ..............  A                Extracorp shock wave         0.06       1.46       0.02       0.01       1.53       0.09        XXX
                                                      tx, ft.
0021T.............  ..............  C                Fetal oximetry,              0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      trnsvag/cerv.
0023T.............  ..............  C                Phenotype drug test,         0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      hiv 1.
0024T.............  ..............  C                Transcath cardiac            0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      reduction.
0025T.............  ..............  C                Ultrasonic pachymetry.       0.00       0.00       0.00       0.00       0.00       0.00        XXX
0026T.............  ..............  C                Measure remnant              0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      lipoproteins.
0027T.............  ..............  C                Endoscopic epidural          0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      lysis.
0028T.............  ..............  C                Dexa body composition        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      study.
0029T.............  ..............  C                Magnetic tx for              0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      incontinence.
0030T.............  ..............  C                Antiprothrombin              0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      antibody.
0031T.............  ..............  C                Speculoscopy..........       0.00       0.00       0.00       0.00       0.00       0.00        XXX
0032T.............  ..............  C                Speculoscopy w/direct        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      sample.
0033T.............  ..............  C                Endovasc taa repr incl       0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      subcl.
0034T.............  ..............  C                Endovasc taa repr w/o        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      subcl.
0035T.............  ..............  C                Insert endovasc              0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      prosth, taa.
0036T.............  ..............  C                Endovasc prosth, taa,        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      add-on.
0037T.............  ..............  C                Artery transpose/            0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      endovas taa.
0038T.............  ..............  C                Rad endovasc taa rpr w/      0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      cover.
0039T.............  ..............  C                Rad s/i, endovasc taa        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      repair.
0040T.............  ..............  C                Rad s/i, endovasc taa        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      prosth.
0041T.............  ..............  C                Detect ur infect agnt        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      w/cpas.
0042T.............  ..............  C                Ct perfusion w/              0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      contrast, cbf.
0043T.............  ..............  C                Co expired gas               0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      analysis.
0044T.............  ..............  C                Whole body photography       0.00       0.00       0.00       0.00       0.00       0.00        XXX
10021.............  ..............  A                Fna w/o image.........       1.27       2.37         NA       0.07       3.71         NA        XXX
10022.............  ..............  A                Fna w/image...........       1.27       2.66         NA       0.05       3.98         NA        XXX
10040.............  ..............  A                Acne surgery..........       1.18       1.10       0.71       0.05       2.33       1.94        010
10060.............  ..............  A                Drainage of skin             1.17       1.49       0.67       0.08       2.74       1.92        010
                                                      abscess.
10061.............  ..............  A                Drainage of skin             2.40       1.88       1.41       0.17       4.45       3.98        010
                                                      abscess.
10080.............  ..............  A                Drainage of pilonidal        1.17       2.13       0.73       0.09       3.39       1.99        010
                                                      cyst.
10081.............  ..............  A                Drainage of pilonidal        2.45       2.90       1.55       0.19       5.54       4.19        010
                                                      cyst.
10120.............  ..............  A                Remove foreign body...       1.22       1.54       0.36       0.10       2.86       1.68        010
10121.............  ..............  A                Remove foreign body...       2.69       2.96       1.79       0.25       5.90       4.73        010
10140.............  ..............  A                Drainage of hematoma/        1.53       1.49       0.87       0.15       3.17       2.55        010
                                                      fluid.
10160.............  ..............  A                Puncture drainage of         1.20       0.77       0.42       0.11       2.08       1.73        010
                                                      lesion.
10180.............  ..............  A                Complex drainage,            2.25       1.48       1.27       0.25       3.98       3.77        010
                                                      wound.
11000.............  ..............  A                Debride infected skin.       0.60       0.64       0.24       0.05       1.29       0.89        000
11001.............  ..............  A                Debride infected skin        0.30       0.38       0.11       0.02       0.70       0.43        ZZZ
                                                      add-on.
11010.............  ..............  A                Debride skin, fx......       4.20       2.40       1.96       0.45       7.05       6.61        010
11011.............  ..............  A                Debride skin/muscle,         4.95       3.83       2.60       0.53       9.31       8.08        000
                                                      fx.
11012.............  ..............  A                Debride skin/muscle/         6.88       5.51       4.23       0.89      13.28      12.00        000
                                                      bone, fx.
11040.............  ..............  A                Debride skin, partial.       0.50       0.52       0.21       0.05       1.07       0.76        000
11041.............  ..............  A                Debride skin, full....       0.82       0.66       0.33       0.06       1.54       1.21        000
11042.............  ..............  A                Debride skin/tissue...       1.12       0.97       0.47       0.09       2.18       1.68        000
11043.............  ..............  A                Debride tissue/muscle.       2.38       3.57       2.64       0.24       6.19       5.26        010
11044.............  ..............  A                Debride tissue/muscle/       3.06       4.73       3.91       0.34       8.13       7.31        010
                                                      bone.
11055.............  ..............  R                Trim skin lesion......       0.43       0.51       0.18       0.02       0.96       0.63        000
11056.............  ..............  R                Trim skin lesions, 2         0.61       0.58       0.26       0.03       1.22       0.90        000
                                                      to 4.
11057.............  ..............  R                Trim skin lesions,           0.79       0.65       0.33       0.04       1.48       1.16        000
                                                      over 4.
11100.............  ..............  A                Biopsy of skin lesion.       0.81       1.24       0.38       0.04       2.09       1.23        000
11101.............  ..............  A                Biopsy, skin add-on...       0.41       0.38       0.20       0.02       0.81       0.63        ZZZ
11200.............  ..............  A                Removal of skin tags..       0.77       1.23       0.31       0.04       2.04       1.12        010
11201.............  ..............  A                Remove skin tags add-        0.29       0.56       0.12       0.02       0.87       0.43        ZZZ
                                                      on.
11300.............  ..............  A                Shave skin lesion.....       0.51       0.99       0.22       0.03       1.53       0.76        000
11301.............  ..............  A                Shave skin lesion.....       0.85       1.10       0.39       0.04       1.99       1.28        000

[[Page 80045]]

 
11302.............  ..............  A                Shave skin lesion.....       1.05       1.30       0.48       0.05       2.40       1.58        000
11303.............  ..............  A                Shave skin lesion.....       1.24       1.59       0.54       0.06       2.89       1.84        000
11305.............  ..............  A                Shave skin lesion.....       0.67       0.84       0.27       0.04       1.55       0.98        000
11306.............  ..............  A                Shave skin lesion.....       0.99       1.10       0.43       0.05       2.14       1.47        000
11307.............  ..............  A                Shave skin lesion.....       1.14       1.29       0.50       0.05       2.48       1.69        000
11308.............  ..............  A                Shave skin lesion.....       1.41       1.45       0.61       0.07       2.93       2.09        000
11310.............  ..............  A                Shave skin lesion.....       0.73       1.11       0.33       0.04       1.88       1.10        000
11311.............  ..............  A                Shave skin lesion.....       1.05       1.23       0.50       0.05       2.33       1.60        000
11312.............  ..............  A                Shave skin lesion.....       1.20       1.43       0.57       0.06       2.69       1.83        000
11313.............  ..............  A                Shave skin lesion.....       1.62       1.81       0.74       0.09       3.52       2.45        000
11400.............  ..............  A                Exc tr-ext b9+marg 0.5       0.85       2.08       0.96       0.06       2.99       1.87        010
                                                      < cm.
11401.............  ..............  A                Exc tr-ext b9+marg 0.6-      1.23       2.12       1.08       0.09       3.44       2.40        010
                                                      1 cm.
11402.............  ..............  A                Exc tr-ext b9+marg 1.1-      1.51       2.28       1.14       0.12       3.91       2.77        010
                                                      2 cm.
11403.............  ..............  A                Exc tr-ext b9+marg 2.1-      1.79       2.50       1.35       0.16       4.45       3.30        010
                                                      3 cm.
11404.............  ..............  A                Exc tr-ext b9+marg 3.1-      2.06       2.84       1.42       0.18       5.08       3.66        010
                                                      4 cm.
11406.............  ..............  A                Exc tr-ext b9+marg  4.0 cm.
11420.............  ..............  A                Exc h-f-nk-sp b9+marg        0.98       1.81       1.00       0.08       2.87       2.06        010
                                                      0.5 <.
11421.............  ..............  A                Exc h-f-nk-sp b9+marg        1.42       2.12       1.18       0.11       3.65       2.71        010
                                                      0.6-1.
11422.............  ..............  A                Exc h-f-nk-sp b9+marg        1.63       2.30       1.38       0.14       4.07       3.15        010
                                                      1.1-2.
11423.............  ..............  A                Exc h-f-nk-sp b9+marg        2.01       2.66       1.49       0.17       4.84       3.67        010
                                                      2.1-3.
11424.............  ..............  A                Exc h-f-nk-sp b9+marg        2.43       2.93       1.64       0.21       5.57       4.28        010
                                                      3.1-4.
11426.............  ..............  A                Exc h-f-nk-sp b9+marg        3.78       3.75       2.15       0.34       7.87       6.27        010
                                                       4 cm.
11440.............  ..............  A                Exc face-mm b9+marg          1.06       2.27       1.41       0.08       3.41       2.55        010
                                                      0.5 < cm.
11441.............  ..............  A                Exc face-mm b9+marg          1.48       2.40       1.59       0.11       3.99       3.18        010
                                                      0.6-1 cm.
11442.............  ..............  A                Exc face-mm b9+marg          1.72       2.66       1.66       0.14       4.52       3.52        010
                                                      1.1-2 cm.
11443.............  ..............  A                Exc face-mm b9+marg          2.29       3.04       1.90       0.18       5.51       4.37        010
                                                      2.1-3 cm.
11444.............  ..............  A                Exc face-mm b9+marg          3.14       3.64       2.28       0.25       7.03       5.67        010
                                                      3.1-4 cm.
11446.............  ..............  A                Exc face-mm b9+marg          4.49       4.26       2.88       0.30       9.05       7.67        010
                                                       4 cm.
11450.............  ..............  A                Removal, sweat gland         2.73       4.12       0.98       0.26       7.11       3.97        090
                                                      lesion.
11451.............  ..............  A                Removal, sweat gland         3.95       4.98       1.43       0.39       9.32       5.77        090
                                                      lesion.
11462.............  ..............  A                Removal, sweat gland         2.51       4.10       0.95       0.23       6.84       3.69        090
                                                      lesion.
11463.............  ..............  A                Removal, sweat gland         3.95       5.60       1.57       0.40       9.95       5.92        090
                                                      lesion.
11470.............  ..............  A                Removal, sweat gland         3.25       4.54       1.23       0.30       8.09       4.78        090
                                                      lesion.
11471.............  ..............  A                Removal, sweat gland         4.41       5.69       1.72       0.40      10.50       6.53        090
                                                      lesion.
11600.............  ..............  A                Exc tr-ext mlg+marg          1.31       2.53       0.99       0.09       3.93       2.39        010
                                                      0.5 < cm.
11601.............  ..............  A                Exc tr-ext mlg+marg          1.80       2.60       1.24       0.12       4.52       3.16        010
                                                      0.6-1 cm.
11602.............  ..............  A                Exc tr-ext mlg+marg          1.95       2.73       1.29       0.13       4.81       3.37        010
                                                      1.1-2 cm.
11603.............  ..............  A                Exc tr-ext mlg+marg          2.19       2.96       1.35       0.16       5.31       3.70        010
                                                      2.1-3 cm.
11604.............  ..............  A                Exc tr-ext mlg+marg          2.40       3.27       1.41       0.18       5.85       3.99        010
                                                      3.1-4 cm.
11606.............  ..............  A                Exc tr-ext mlg+marg          3.43       3.96       1.76       0.28       7.67       5.47        010
                                                       4 cm.
11620.............  ..............  A                Exc h-f-nk-sp mlg+marg       1.19       2.49       0.97       0.09       3.77       2.25        010
                                                      0.5 <.
11621.............  ..............  A                Exc h-f-nk-sp mlg+marg       1.76       2.60       1.27       0.12       4.48       3.15        010
                                                      0.6-1.
11622.............  ..............  A                Exc h-f-nk-sp mlg+marg       2.09       2.87       1.42       0.15       5.11       3.66        010
                                                      1.1-2.
11623.............  ..............  A                Exc h-f-nk-sp mlg+marg       2.61       3.22       1.62       0.20       6.03       4.43        010
                                                      2.1-3.
11624.............  ..............  A                Exc h-f-nk-sp mlg+marg       3.06       3.61       1.81       0.25       6.92       5.12        010
                                                      3.1-4.
11626.............  ..............  A                Exc h-f-nk-sp mlg+mar        4.30       4.56       2.44       0.35       9.21       7.09        010
                                                       4 cm.
11640.............  ..............  A                Exc face-mm malig+marg       1.35       2.54       1.14       0.10       3.99       2.59        010
                                                      0.5 <.
11641.............  ..............  A                Exc face-mm malig+marg       2.16       2.92       1.57       0.15       5.23       3.88        010
                                                      0.6-1.
11642.............  ..............  A                Exc face-mm malig+marg       2.59       3.30       1.77       0.18       6.07       4.54        010
                                                      1.1-2.
11643.............  ..............  A                Exc face-mm malig+marg       3.10       3.70       2.01       0.24       7.04       5.35        010
                                                      2.1-3.
11644.............  ..............  A                Exc face-mm malig+marg       4.03       4.63       2.56       0.33       8.99       6.92        010
                                                      3.1-4.
11646.............  ..............  A                Exc face-mm mlg+marg         5.95       5.73       3.60       0.46      12.14      10.01        010
                                                       4 cm.
11719.............  ..............  R                Trim nail(s)..........       0.17       0.25       0.07       0.01       0.43       0.25        000
11720.............  ..............  A                Debride nail, 1-5.....       0.32       0.34       0.13       0.02       0.68       0.47        000
11721.............  ..............  A                Debride nail, 6 or           0.54       0.44       0.21       0.04       1.02       0.79        000
                                                      more.
11730.............  ..............  A                Removal of nail plate.       1.13       0.81       0.44       0.09       2.03       1.66        000
11732.............  ..............  A                Remove nail plate, add-      0.57       0.30       0.23       0.05       0.92       0.85        ZZZ
                                                      on.
11740.............  ..............  A                Drain blood from under       0.37       0.82       0.14       0.03       1.22       0.54        000
                                                      nail.
11750.............  ..............  A                Removal of nail bed...       1.86       1.72       0.77       0.16       3.74       2.79        010
11752.............  ..............  A                Remove nail bed/finger       2.67       2.11       1.76       0.33       5.11       4.76        010
                                                      tip.
11755.............  ..............  A                Biopsy, nail unit.....       1.31       1.11       0.56       0.06       2.48       1.93        000
11760.............  ..............  A                Repair of nail bed....       1.58       1.80       1.25       0.17       3.55       3.00        010
11762.............  ..............  A                Reconstruction of nail       2.89       2.24       1.88       0.32       5.45       5.09        010
                                                      bed.
11765.............  ..............  A                Excision of nail fold,       0.69       1.13       0.49       0.05       1.87       1.23        010
                                                      toe.
11770.............  ..............  A                Removal of pilonidal         2.61       2.98       1.23       0.24       5.83       4.08        010
                                                      lesion.
11771.............  ..............  A                Removal of pilonidal         5.74       5.50       3.91       0.56      11.80      10.21        090
                                                      lesion.
11772.............  ..............  A                Removal of pilonidal         6.98       6.41       4.36       0.68      14.07      12.02        090
                                                      lesion.
11900.............  ..............  A                Injection into skin          0.52       0.75       0.22       0.02       1.29       0.76        000
                                                      lesions.
11901.............  ..............  A                Added skin lesions           0.80       0.72       0.36       0.03       1.55       1.19        000
                                                      injection.
11920.............  ..............  R                Correct skin color           1.61       2.16       0.80       0.17       3.94       2.58        000
                                                      defects.
11921.............  ..............  R                Correct skin color           1.93       2.52       1.00       0.21       4.66       3.14        000
                                                      defects.
11922.............  ..............  R                Correct skin color           0.49       0.38       0.26       0.05       0.92       0.80        ZZZ
                                                      defects.
11950.............  ..............  R                Therapy for contour          0.84       1.22       0.42       0.06       2.12       1.32        000
                                                      defects.
11951.............  ..............  R                Therapy for contour          1.19       1.61       0.52       0.10       2.90       1.81        000
                                                      defects.
11952.............  ..............  R                Therapy for contour          1.69       1.97       0.70       0.17       3.83       2.56        000
                                                      defects.

[[Page 80046]]

 
11954.............  ..............  R                Therapy for contour          1.85       2.59       0.93       0.19       4.63       2.97        000
                                                      defects.
11960.............  ..............  A                Insert tissue                9.08         NA      10.94       0.88         NA      20.90        090
                                                      expander(s).
11970.............  ..............  A                Replace tissue               7.06         NA       4.98       0.77         NA      12.81        090
                                                      expander.
11971.............  ..............  A                Remove tissue                2.13       6.33       3.86       0.21       8.67       6.20        090
                                                      expander(s).
11975.............  ..............  N                Insert contraceptive        +1.48       1.44       0.58       0.14       3.06       2.20        XXX
                                                      cap.
11976.............  ..............  R                Removal of                   1.78       1.62       0.70       0.17       3.57       2.65        000
                                                      contraceptive cap.
11977.............  ..............  N                Removal/reinsert            +3.30       2.30       1.28       0.31       5.91       4.89        XXX
                                                      contra cap.
11980.............  ..............  A                Implant hormone              1.48       1.07       0.56       0.10       2.65       2.14        000
                                                      pellet(s).
11981.............  ..............  A                Insert drug implant          1.48       1.59       0.58       0.14       3.21       2.20        XXX
                                                      device.
11982.............  ..............  A                Remove drug implant          1.78       1.71       0.70       0.17       3.66       2.65        XXX
                                                      device.
11983.............  ..............  A                Remove/insert drug           3.30       2.30       1.28       0.31       5.91       4.89        XXX
                                                      implant.
12001.............  ..............  A                Repair superficial           1.70       2.16       0.44       0.13       3.99       2.27        010
                                                      wound(s).
12002.............  ..............  A                Repair superficial           1.86       2.23       0.92       0.15       4.24       2.93        010
                                                      wound(s).
12004.............  ..............  A                Repair superficial           2.24       2.51       1.03       0.17       4.92       3.44        010
                                                      wound(s).
12005.............  ..............  A                Repair superficial           2.86       3.07       1.22       0.23       6.16       4.31        010
                                                      wound(s).
12006.............  ..............  A                Repair superficial           3.67       3.69       1.53       0.31       7.67       5.51        010
                                                      wound(s).
12007.............  ..............  A                Repair superficial           4.12       4.16       1.83       0.37       8.65       6.32        010
                                                      wound(s).
12011.............  ..............  A                Repair superficial           1.76       2.34       0.44       0.14       4.24       2.34        010
                                                      wound(s).
12013.............  ..............  A                Repair superficial           1.99       2.49       0.96       0.16       4.64       3.11        010
                                                      wound(s).
12014.............  ..............  A                Repair superficial           2.46       2.77       1.08       0.18       5.41       3.72        010
                                                      wound(s).
12015.............  ..............  A                Repair superficial           3.19       3.38       1.27       0.24       6.81       4.70        010
                                                      wound(s).
12016.............  ..............  A                Repair superficial           3.93       3.81       1.55       0.32       8.06       5.80        010
                                                      wound(s).
12017.............  ..............  A                Repair superficial           4.71         NA       1.90       0.39         NA       7.00        010
                                                      wound(s).
12018.............  ..............  A                Repair superficial           5.53         NA       2.27       0.46         NA       8.26        010
                                                      wound(s).
12020.............  ..............  A                Closure of split wound       2.62       2.55       1.42       0.24       5.41       4.28        010
12021.............  ..............  A                Closure of split wound       1.84       1.70       1.02       0.19       3.73       3.05        010
12031.............  ..............  A                Layer closure of             2.15       2.29       0.77       0.15       4.59       3.07        010
                                                      wound(s).
12032.............  ..............  A                Layer closure of             2.47       2.98       1.28       0.15       5.60       3.90        010
                                                      wound(s).
12034.............  ..............  A                Layer closure of             2.92       3.21       1.44       0.21       6.34       4.57        010
                                                      wound(s).
12035.............  ..............  A                Layer closure of             3.43       3.15       1.67       0.30       6.88       5.40        010
                                                      wound(s).
12036.............  ..............  A                Layer closure of             4.05       5.26       2.46       0.41       9.72       6.92        010
                                                      wound(s).
12037.............  ..............  A                Layer closure of             4.67       5.62       2.80       0.49      10.78       7.96        010
                                                      wound(s).
12041.............  ..............  A                Layer closure of             2.37       2.48       0.83       0.17       5.02       3.37        010
                                                      wound(s).
12042.............  ..............  A                Layer closure of             2.74       3.17       1.41       0.17       6.08       4.32        010
                                                      wound(s).
12044.............  ..............  A                Layer closure of             3.14       3.26       1.60       0.24       6.64       4.98        010
                                                      wound(s).
12045.............  ..............  A                Layer closure of             3.64       3.58       1.87       0.34       7.56       5.85        010
                                                      wound(s).
12046.............  ..............  A                Layer closure of             4.25       5.53       2.55       0.40      10.18       7.20        010
                                                      wound(s).
12047.............  ..............  A                Layer closure of             4.65       6.15       2.89       0.41      11.21       7.95        010
                                                      wound(s).
12051.............  ..............  A                Layer closure of             2.47       3.16       1.41       0.16       5.79       4.04        010
                                                      wound(s).
12052.............  ..............  A                Layer closure of             2.77       3.12       1.38       0.17       6.06       4.32        010
                                                      wound(s).
12053.............  ..............  A                Layer closure of             3.12       3.26       1.54       0.20       6.58       4.86        010
                                                      wound(s).
12054.............  ..............  A                Layer closure of             3.46       3.60       1.64       0.25       7.31       5.35        010
                                                      wound(s).
12055.............  ..............  A                Layer closure of             4.43       4.60       2.19       0.35       9.38       6.97        010
                                                      wound(s).
12056.............  ..............  A                Layer closure of             5.24       6.62       3.05       0.43      12.29       8.72        010
                                                      wound(s).
12057.............  ..............  A                Layer closure of             5.96       6.14       3.73       0.50      12.60      10.19        010
                                                      wound(s).
13100.............  ..............  A                Repair of wound or           3.12       3.50       1.84       0.21       6.83       5.17        010
                                                      lesion.
13101.............  ..............  A                Repair of wound or           3.92       3.76       2.29       0.22       7.90       6.43        010
                                                      lesion.
13102.............  ..............  A                Repair wound/lesion          1.24       0.76       0.58       0.10       2.10       1.92        ZZZ
                                                      add-on.
13120.............  ..............  A                Repair of wound or           3.30       3.60       1.88       0.23       7.13       5.41        010
                                                      lesion.
13121.............  ..............  A                Repair of wound or           4.33       3.99       2.39       0.25       8.57       6.97        010
                                                      lesion.
13122.............  ..............  A                Repair wound/lesion          1.44       0.89       0.65       0.12       2.45       2.21        ZZZ
                                                      add-on.
13131.............  ..............  A                Repair of wound or           3.79       3.88       2.21       0.25       7.92       6.25        010
                                                      lesion.
13132.............  ..............  A                Repair of wound or           5.95       4.72       3.25       0.32      10.99       9.52        010
                                                      lesion.
13133.............  ..............  A                Repair wound/lesion          2.19       1.22       1.05       0.17       3.58       3.41        ZZZ
                                                      add-on.
13150.............  ..............  A                Repair of wound or           3.81       5.29       2.64       0.29       9.39       6.74        010
                                                      lesion.
13151.............  ..............  A                Repair of wound or           4.45       5.27       3.08       0.28      10.00       7.81        010
                                                      lesion.
13152.............  ..............  A                Repair of wound or           6.33       6.01       3.98       0.38      12.72      10.69        010
                                                      lesion.
13153.............  ..............  A                Repair wound/lesion          2.38       1.37       1.16       0.18       3.93       3.72        ZZZ
                                                      add-on.
13160.............  ..............  A                Late closure of wound.      10.48         NA       6.33       1.19         NA      18.00        090
14000.............  ..............  A                Skin tissue                  5.89       7.60       4.65       0.46      13.95      11.00        090
                                                      rearrangement.
14001.............  ..............  A                Skin tissue                  8.47       8.94       5.96       0.65      18.06      15.08        090
                                                      rearrangement.
14020.............  ..............  A                Skin tissue                  6.59       8.10       5.35       0.50      15.19      12.44        090
                                                      rearrangement.
14021.............  ..............  A                Skin tissue                 10.06       9.53       7.12       0.69      20.28      17.87        090
                                                      rearrangement.
14040.............  ..............  A                Skin tissue                  7.87       8.77       7.05       0.55      17.19      15.47        090
                                                      rearrangement.
14041.............  ..............  A                Skin tissue                 11.49      11.01       8.91       0.71      23.21      21.11        090
                                                      rearrangement.
14060.............  ..............  A                Skin tissue                  8.50       9.48       7.84       0.59      18.57      16.93        090
                                                      rearrangement.
14061.............  ..............  A                Skin tissue                 12.29      12.05       9.77       0.75      25.09      22.81        090
                                                      rearrangement.
14300.............  ..............  A                Skin tissue                 11.76      11.44       9.36       0.88      24.08      22.00        090
                                                      rearrangement.
14350.............  ..............  A                Skin tissue                  9.61         NA       6.36       1.09         NA      17.06        090
                                                      rearrangement.
15000.............  ..............  A                Skin graft............       4.00       3.66       2.22       0.37       8.03       6.59        000
15001.............  ..............  A                Skin graft add-on.....       1.00       1.26       0.42       0.11       2.37       1.53        ZZZ
15050.............  ..............  A                Skin pinch graft......       4.30       5.12       3.99       0.46       9.88       8.75        090
15100.............  ..............  A                Skin split graft......       9.05      11.70       8.09       0.94      21.69      18.08        090
15101.............  ..............  A                Skin split graft add-        1.72       3.27       1.48       0.18       5.17       3.38        ZZZ
                                                      on.
15120.............  ..............  A                Skin split graft......       9.83      10.23       8.03       0.90      20.96      18.76        090

[[Page 80047]]

 
15121.............  ..............  A                Skin split graft add-        2.67       4.19       1.85       0.27       7.13       4.79        ZZZ
                                                      on.
15200.............  ..............  A                Skin full graft.......       8.03       9.60       5.54       0.73      18.36      14.30        090
15201.............  ..............  A                Skin full graft add-on       1.32       1.05       0.64       0.14       2.51       2.10        ZZZ
15220.............  ..............  A                Skin full graft.......       7.87       9.74       6.18       0.68      18.29      14.73        090
15221.............  ..............  A                Skin full graft add-on       1.19       0.93       0.58       0.12       2.24       1.89        ZZZ
15240.............  ..............  A                Skin full graft.......       9.04       9.25       7.01       0.80      19.09      16.85        090
15241.............  ..............  A                Skin full graft add-on       1.86       1.47       0.94       0.17       3.50       2.97        ZZZ
15260.............  ..............  A                Skin full graft.......      10.06       9.91       8.90       0.63      20.60      19.59        090
15261.............  ..............  A                Skin full graft add-on       2.23       2.91       1.60       0.17       5.31       4.00        ZZZ
15342.............  ..............  A                Cultured skin graft,         1.00       2.06       0.75       0.09       3.15       1.84        010
                                                      25 cm.
15343.............  ..............  A                Culture skn graft addl       0.25       0.26       0.10       0.02       0.53       0.37        ZZZ
                                                      25 cm.
15350.............  ..............  A                Skin homograft........       4.00       8.44       4.34       0.42      12.86       8.76        090
15351.............  ..............  A                Skin homograft add-on.       1.00       0.95       0.41       0.11       2.06       1.52        ZZZ
15400.............  ..............  A                Skin heterograft......       4.00       4.84       4.84       0.40       9.24       9.24        090
15401.............  ..............  A                Skin heterograft add-        1.00       1.25       0.46       0.11       2.36       1.57        ZZZ
                                                      on.
15570.............  ..............  A                Form skin pedicle flap       9.21       8.16       6.07       0.96      18.33      16.24        090
15572.............  ..............  A                Form skin pedicle flap       9.27       7.75       5.80       0.93      17.95      16.00        090
15574.............  ..............  A                Form skin pedicle flap       9.88       8.32       6.84       0.92      19.12      17.64        090
15576.............  ..............  A                Form skin pedicle flap       8.69       8.91       6.29       0.72      18.32      15.70        090
15600.............  ..............  A                Skin graft............       1.91       6.13       2.34       0.19       8.23       4.44        090
15610.............  ..............  A                Skin graft............       2.42       3.39       2.62       0.25       6.06       5.29        090
15620.............  ..............  A                Skin graft............       2.94       6.74       3.39       0.28       9.96       6.61        090
15630.............  ..............  A                Skin graft............       3.27       6.19       3.66       0.28       9.74       7.21        090
15650.............  ..............  A                Transfer skin pedicle        3.97       6.17       3.73       0.36      10.50       8.06        090
                                                      flap.
15732.............  ..............  A                Muscle-skin graft,          17.84         NA      12.70       1.50         NA      32.04        090
                                                      head/neck.
15734.............  ..............  A                Muscle-skin graft,          17.79         NA      12.73       1.91         NA      32.43        090
                                                      trunk.
15736.............  ..............  A                Muscle-skin graft, arm      16.27         NA      11.81       1.78         NA      29.86        090
15738.............  ..............  A                Muscle-skin graft, leg      17.92         NA      12.25       1.95         NA      32.12        090
15740.............  ..............  A                Island pedicle flap         10.25       9.00       7.05       0.62      19.87      17.92        090
                                                      graft.
15750.............  ..............  A                Neurovascular pedicle       11.41         NA       8.20       1.16         NA      20.77        090
                                                      graft.
15756.............  ..............  A                Free myo/skin flap          35.23         NA      20.85       3.11         NA      59.19        090
                                                      microvasc.
15757.............  ..............  A                Free skin flap,             35.23         NA      21.96       3.37         NA      60.56        090
                                                      microvasc.
15758.............  ..............  A                Free fascial flap,          35.10         NA      22.00       3.52         NA      60.62        090
                                                      microvasc.
15760.............  ..............  A                Composite skin graft..       8.74       9.10       6.62       0.72      18.56      16.08        090
15770.............  ..............  A                Derma-fat-fascia graft       7.52         NA       6.08       0.78         NA      14.38        090
15775.............  ..............  R                Hair transplant punch        3.96       2.87       1.35       0.43       7.26       5.74        000
                                                      grafts.
15776.............  ..............  R                Hair transplant punch        5.54       5.75       2.89       0.60      11.89       9.03        000
                                                      grafts.
15780.............  ..............  A                Abrasion treatment of        7.29       6.61       6.58       0.41      14.31      14.28        090
                                                      skin.
15781.............  ..............  A                Abrasion treatment of        4.85       5.07       4.80       0.27      10.19       9.92        090
                                                      skin.
15782.............  ..............  A                Abrasion treatment of        4.32       4.30       4.15       0.21       8.83       8.68        090
                                                      skin.
15783.............  ..............  A                Abrasion treatment of        4.29       4.72       3.57       0.26       9.27       8.12        090
                                                      skin.
15786.............  ..............  A                Abrasion, lesion,            2.03       1.77       1.29       0.11       3.91       3.43        010
                                                      single.
15787.............  ..............  A                Abrasion, lesions, add-      0.33       0.32       0.16       0.02       0.67       0.51        ZZZ
                                                      on.
15788.............  ..............  R                Chemical peel, face,         2.09       3.14       1.03       0.11       5.34       3.23        090
                                                      epiderm.
15789.............  ..............  R                Chemical peel, face,         4.92       6.17       3.51       0.27      11.36       8.70        090
                                                      dermal.
15792.............  ..............  R                Chemical peel,               1.86       2.96       2.17       0.10       4.92       4.13        090
                                                      nonfacial.
15793.............  ..............  A                Chemical peel,               3.74         NA       3.50       0.17         NA       7.41        090
                                                      nonfacial.
15810.............  ..............  A                Salabrasion...........       4.74       3.73       3.73       0.42       8.89       8.89        090
15811.............  ..............  A                Salabrasion...........       5.39       6.09       4.73       0.52      12.00      10.64        090
15819.............  ..............  A                Plastic surgery, neck.       9.38         NA       6.67       0.77         NA      16.82        090
15820.............  ..............  A                Revision of lower            5.15       7.12       5.25       0.30      12.57      10.70        090
                                                      eyelid.
15821.............  ..............  A                Revision of lower            5.72       7.47       5.41       0.31      13.50      11.44        090
                                                      eyelid.
15822.............  ..............  A                Revision of upper            4.45       6.06       4.23       0.22      10.73       8.90        090
                                                      eyelid.
15823.............  ..............  A                Revision of upper            7.05       8.06       6.13       0.32      15.43      13.50        090
                                                      eyelid.
15824.............  ..............  R                Removal of forehead          0.00       0.00       0.00       0.00       0.00       0.00        000
                                                      wrinkles.
15825.............  ..............  R                Removal of neck              0.00       0.00       0.00       0.00       0.00       0.00        000
                                                      wrinkles.
15826.............  ..............  R                Removal of brow              0.00       0.00       0.00       0.00       0.00       0.00        000
                                                      wrinkles.
15828.............  ..............  R                Removal of face              0.00       0.00       0.00       0.00       0.00       0.00        000
                                                      wrinkles.
15829.............  ..............  R                Removal of skin              0.00       0.00       0.00       0.00       0.00       0.00        000
                                                      wrinkles.
15831.............  ..............  A                Excise excessive skin       12.40         NA       7.69       1.30         NA      21.39        090
                                                      tissue.
15832.............  ..............  A                Excise excessive skin       11.59         NA       7.68       1.21         NA      20.48        090
                                                      tissue.
15833.............  ..............  A                Excise excessive skin       10.64         NA       7.06       1.17         NA      18.87        090
                                                      tissue.
15834.............  ..............  A                Excise excessive skin       10.85         NA       6.95       1.18         NA      18.98        090
                                                      tissue.
15835.............  ..............  A                Excise excessive skin       11.67         NA       6.93       1.13         NA      19.73        090
                                                      tissue.
15836.............  ..............  A                Excise excessive skin        9.34         NA       6.18       0.95         NA      16.47        090
                                                      tissue.
15837.............  ..............  A                Excise excessive skin        8.43       7.40       6.42       0.78      16.61      15.63        090
                                                      tissue.
15838.............  ..............  A                Excise excessive skin        7.13         NA       5.68       0.58         NA      13.39        090
                                                      tissue.
15839.............  ..............  A                Excise excessive skin        9.38       7.21       5.75       0.88      17.47      16.01        090
                                                      tissue.
15840.............  ..............  A                Graft for face nerve        13.26         NA       9.75       1.15         NA      24.16        090
                                                      palsy.
15841.............  ..............  A                Graft for face nerve        23.26         NA      14.51       2.65         NA      40.42        090
                                                      palsy.
15842.............  ..............  A                Flap for face nerve         37.96         NA      22.78       3.99         NA      64.73        090
                                                      palsy.
15845.............  ..............  A                Skin and muscle             12.57         NA       8.47       0.80         NA      21.84        090
                                                      repair, face.
15850.............  ..............  B                Removal of sutures....      +0.78       1.44       0.30       0.04       2.26       1.12        XXX
15851.............  ..............  A                Removal of sutures....       0.86       1.64       0.34       0.05       2.55       1.25        000
15852.............  ..............  A                Dressing change,not          0.86       1.75       0.36       0.07       2.68       1.29        000
                                                      for burn.

[[Page 80048]]

 
15860.............  ..............  A                Test for blood flow in       1.95       1.30       0.81       0.13       3.38       2.89        000
                                                      graft.
15876.............  ..............  R                Suction assisted             0.00       0.00       0.00       0.00       0.00       0.00        000
                                                      lipectomy.
15877.............  ..............  R                Suction assisted             0.00       0.00       0.00       0.00       0.00       0.00        000
                                                      lipectomy.
15878.............  ..............  R                Suction assisted             0.00       0.00       0.00       0.00       0.00       0.00        000
                                                      lipectomy.
15879.............  ..............  R                Suction assisted             0.00       0.00       0.00       0.00       0.00       0.00        000
                                                      lipectomy.
15920.............  ..............  A                Removal of tail bone         7.95         NA       5.49       0.83         NA      14.27        090
                                                      ulcer.
15922.............  ..............  A                Removal of tail bone         9.90         NA       7.31       1.06         NA      18.27        090
                                                      ulcer.
15931.............  ..............  A                Remove sacrum pressure       9.24         NA       5.56       0.95         NA      15.75        090
                                                      sore.
15933.............  ..............  A                Remove sacrum pressure      10.85         NA       7.98       1.14         NA      19.97        090
                                                      sore.
15934.............  ..............  A                Remove sacrum pressure      12.69         NA       8.29       1.35         NA      22.33        090
                                                      sore.
15935.............  ..............  A                Remove sacrum pressure      14.57         NA       9.96       1.56         NA      26.09        090
                                                      sore.
15936.............  ..............  A                Remove sacrum pressure      12.38         NA       8.79       1.32         NA      22.49        090
                                                      sore.
15937.............  ..............  A                Remove sacrum pressure      14.21         NA      10.25       1.51         NA      25.97        090
                                                      sore.
15940.............  ..............  A                Remove hip pressure          9.34         NA       5.92       0.98         NA      16.24        090
                                                      sore.
15941.............  ..............  A                Remove hip pressure         11.43         NA       9.80       1.23         NA      22.46        090
                                                      sore.
15944.............  ..............  A                Remove hip pressure         11.46         NA       8.59       1.21         NA      21.26        090
                                                      sore.
15945.............  ..............  A                Remove hip pressure         12.69         NA       9.51       1.38         NA      23.58        090
                                                      sore.
15946.............  ..............  A                Remove hip pressure         21.57         NA      13.95       2.32         NA      37.84        090
                                                      sore.
15950.............  ..............  A                Remove thigh pressure        7.54         NA       5.15       0.80         NA      13.49        090
                                                      sore.
15951.............  ..............  A                Remove thigh pressure       10.72         NA       7.99       1.14         NA      19.85        090
                                                      sore.
15952.............  ..............  A                Remove thigh pressure       11.39         NA       7.39       1.19         NA      19.97        090
                                                      sore.
15953.............  ..............  A                Remove thigh pressure       12.63         NA       8.79       1.38         NA      22.80        090
                                                      sore.
15956.............  ..............  A                Remove thigh pressure       15.52         NA      10.40       1.64         NA      27.56        090
                                                      sore.
15958.............  ..............  A                Remove thigh pressure       15.48         NA      10.72       1.66         NA      27.86        090
                                                      sore.
15999.............  ..............  C                Removal of pressure          0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      sore.
16000.............  ..............  A                Initial treatment of         0.89       1.07       0.27       0.06       2.02       1.22        000
                                                      burn(s).
16010.............  ..............  A                Treatment of burn(s)..       0.87       1.19       0.36       0.07       2.13       1.30        000
16015.............  ..............  A                Treatment of burn(s)..       2.35       1.89       0.94       0.22       4.46       3.51        000
16020.............  ..............  A                Treatment of burn(s)..       0.80       1.13       0.26       0.06       1.99       1.12        000
16025.............  ..............  A                Treatment of burn(s)..       1.85       1.88       0.67       0.16       3.89       2.68        000
16030.............  ..............  A                Treatment of burn(s)..       2.08       3.05       0.91       0.18       5.31       3.17        000
16035.............  ..............  A                Incision of burn scab,       3.75         NA       1.50       0.36         NA       5.61        090
                                                      initi.
16036.............  ..............  A                Incise burn scab, addl       1.50         NA       0.62       0.11         NA       2.23        ZZZ
                                                      incis.
17000.............  ..............  A                Destroy benign/premlg        0.60       1.04       0.27       0.03       1.67       0.90        010
                                                      lesion.
17003.............  ..............  A                Destroy lesions, 2-14.       0.15       0.12       0.07       0.01       0.28       0.23        ZZZ
17004.............  ..............  A                Destroy lesions, 15 or       2.79       2.45       1.27       0.12       5.36       4.18        010
                                                      more.
17106.............  ..............  A                Destruction of skin          4.59       4.77       3.21       0.28       9.64       8.08        090
                                                      lesions.
17107.............  ..............  A                Destruction of skin          9.16       7.30       5.37       0.53      16.99      15.06        090
                                                      lesions.
17108.............  ..............  A                Destruction of skin         13.20       9.35       7.66       0.89      23.44      21.75        090
                                                      lesions.
17110.............  ..............  A                Destruct lesion, 1-14.       0.65       1.71       0.45       0.04       2.40       1.14        010
17111.............  ..............  A                Destruct lesion, 15 or       0.92       1.75       0.56       0.04       2.71       1.52        010
                                                      more.
17250.............  ..............  A                Chemical cautery,            0.50       1.23       0.34       0.04       1.77       0.88        000
                                                      tissue.
17260.............  ..............  A                Destruction of skin          0.91       1.37       0.41       0.04       2.32       1.36        010
                                                      lesions.
17261.............  ..............  A                Destruction of skin          1.17       1.62       0.55       0.05       2.84       1.77        010
                                                      lesions.
17262.............  ..............  A                Destruction of skin          1.58       1.89       0.75       0.07       3.54       2.40        010
                                                      lesions.
17263.............  ..............  A                Destruction of skin          1.79       2.07       0.82       0.08       3.94       2.69        010
                                                      lesions.
17264.............  ..............  A                Destruction of skin          1.94       2.25       0.86       0.08       4.27       2.88        010
                                                      lesions.
17266.............  ..............  A                Destruction of skin          2.34       2.57       0.96       0.11       5.02       3.41        010
                                                      lesions.
17270.............  ..............  A                Destruction of skin          1.32       1.70       0.60       0.06       3.08       1.98        010
                                                      lesions.
17271.............  ..............  A                Destruction of skin          1.49       1.79       0.71       0.06       3.34       2.26        010
                                                      lesions.
17272.............  ..............  A                Destruction of skin          1.77       2.00       0.85       0.07       3.84       2.69        010
                                                      lesions.
17273.............  ..............  A                Destruction of skin          2.05       2.23       0.96       0.09       4.37       3.10        010
                                                      lesions.
17274.............  ..............  A                Destruction of skin          2.59       2.61       1.18       0.11       5.31       3.88        010
                                                      lesions.
17276.............  ..............  A                Destruction of skin          3.20       3.03       1.42       0.15       6.38       4.77        010
                                                      lesions.
17280.............  ..............  A                Destruction of skin          1.17       1.61       0.53       0.05       2.83       1.75        010
                                                      lesions.
17281.............  ..............  A                Destruction of skin          1.72       1.92       0.82       0.07       3.71       2.61        010
                                                      lesions.
17282.............  ..............  A                Destruction of skin          2.04       2.17       0.98       0.09       4.30       3.11        010
                                                      lesions.
17283.............  ..............  A                Destruction of skin          2.64       2.58       1.23       0.11       5.33       3.98        010
                                                      lesions.
17284.............  ..............  A                Destruction of skin          3.21       2.99       1.49       0.14       6.34       4.84        010
                                                      lesions.
17286.............  ..............  A                Destruction of skin          4.44       3.78       2.18       0.22       8.44       6.84        010
                                                      lesions.
17304.............  ..............  A                1 stage mohs, up to 5        7.60       8.09       3.66       0.31      16.00      11.57        000
                                                      spec.
17305.............  ..............  A                2 stage mohs, up to 5        2.85       3.81       1.37       0.12       6.78       4.34        000
                                                      spec.
17306.............  ..............  A                3 stage mohs, up to 5        2.85       3.81       1.38       0.12       6.78       4.35        000
                                                      spec.
17307.............  ..............  A                Mohs addl stage up to        2.85       3.82       1.40       0.12       6.79       4.37        000
                                                      5 spec.
17310.............  ..............  A                Mohs any stage  5 spec each.
17340.............  ..............  A                Cryotherapy of skin...       0.76       0.38       0.26       0.04       1.18       1.06        010
17360.............  ..............  A                Skin peel therapy.....       1.43       1.59       0.72       0.06       3.08       2.21        010
17380.............  ..............  R                Hair removal by              0.00       0.00       0.00       0.00       0.00       0.00        000
                                                      electrolysis.
17999.............  ..............  C                Skin tissue procedure.       0.00       0.00       0.00       0.00       0.00       0.00        YYY
19000.............  ..............  A                Drainage of breast           0.84       1.20       0.29       0.07       2.11       1.20        000
                                                      lesion.
19001.............  ..............  A                Drain breast lesion          0.42       0.82       0.14       0.03       1.27       0.59        ZZZ
                                                      add-on.
19020.............  ..............  A                Incision of breast           3.57       6.81       3.39       0.35      10.73       7.31        090
                                                      lesion.
19030.............  ..............  A                Injection for breast x-      1.53       3.56       0.52       0.07       5.16       2.12        000
                                                      ray.
19100.............  ..............  A                Bx breast percut w/o         1.27       1.43       0.44       0.10       2.80       1.81        000
                                                      image.
19101.............  ..............  A                Biopsy of breast, open       3.18       5.02       1.89       0.20       8.40       5.27        010

[[Page 80049]]

 
19102.............  ..............  A                Bx breast percut w/          2.00       4.86       0.68       0.13       6.99       2.81        000
                                                      image.
19103.............  ..............  A                Bx breast percut w/          3.70      12.31       1.27       0.16      16.17       5.13        000
                                                      device.
19110.............  ..............  A                Nipple exploration....       4.30       8.62       4.43       0.44      13.36       9.17        090
19112.............  ..............  A                Excise breast duct           3.67       9.15       3.08       0.38      13.20       7.13        090
                                                      fistula.
19120.............  ..............  A                Removal of breast            5.56       4.92       3.09       0.56      11.04       9.21        090
                                                      lesion.
19125.............  ..............  A                Excision, breast             6.06       5.05       3.26       0.61      11.72       9.93        090
                                                      lesion.
19126.............  ..............  A                Excision, addl breast        2.93         NA       1.02       0.30         NA       4.25        ZZZ
                                                      lesion.
19140.............  ..............  A                Removal of breast            5.14       9.35       3.65       0.52      15.01       9.31        090
                                                      tissue.
19160.............  ..............  A                Removal of breast            5.99         NA       4.52       0.61         NA      11.12        090
                                                      tissue.
19162.............  ..............  A                Remove breast tissue,       13.53         NA       7.88       1.38         NA      22.79        090
                                                      nodes.
19180.............  ..............  A                Removal of breast.....       8.80         NA       5.93       0.88         NA      15.61        090
19182.............  ..............  A                Removal of breast.....       7.73         NA       4.98       0.79         NA      13.50        090
19200.............  ..............  A                Removal of breast.....      15.49         NA       9.07       1.51         NA      26.07        090
19220.............  ..............  A                Removal of breast.....      15.72         NA       9.12       1.56         NA      26.40        090
19240.............  ..............  A                Removal of breast.....      16.00         NA       8.74       1.62         NA      26.36        090
19260.............  ..............  A                Removal of chest wall       15.44         NA       9.13       1.64         NA      26.21        090
                                                      lesion.
19271.............  ..............  A                Revision of chest wall      18.90         NA      11.31       2.27         NA      32.48        090
19272.............  ..............  A                Extensive chest wall        21.55         NA      12.24       2.54         NA      36.33        090
                                                      surgery.
19290.............  ..............  A                Place needle wire,           1.27       2.89       0.43       0.06       4.22       1.76        000
                                                      breast.
19291.............  ..............  A                Place needle wire,           0.63       1.69       0.21       0.03       2.35       0.87        ZZZ
                                                      breast.
19295.............  ..............  A                Place breast clip,           0.00       2.65         NA       0.01       2.66         NA        ZZZ
                                                      percut.
19316.............  ..............  A                Suspension of breast..      10.69         NA       7.57       1.15         NA      19.41        090
19318.............  ..............  A                Reduction of large          15.62         NA      11.72       1.69         NA      29.03        090
                                                      breast.
19324.............  ..............  A                Enlarge breast........       5.85         NA       4.25       0.63         NA      10.73        090
19325.............  ..............  A                Enlarge breast with          8.45         NA       6.25       0.90         NA      15.60        090
                                                      implant.
19328.............  ..............  A                Removal of breast            5.68         NA       4.54       0.61         NA      10.83        090
                                                      implant.
19330.............  ..............  A                Removal of implant           7.59         NA       5.20       0.81         NA      13.60        090
                                                      material.
19340.............  ..............  A                Immediate breast             6.33         NA       3.19       0.68         NA      10.20        ZZZ
                                                      prosthesis.
19342.............  ..............  A                Delayed breast              11.20         NA       7.83       1.21         NA      20.24        090
                                                      prosthesis.
19350.............  ..............  A                Breast reconstruction.       8.92      13.45       6.80       0.95      23.32      16.67        090
19355.............  ..............  A                Correct inverted             7.57      13.63       5.41       0.80      22.00      13.78        090
                                                      nipple(s).
19357.............  ..............  A                Breast reconstruction.      18.16         NA       9.82       1.96         NA      29.94        090
19361.............  ..............  A                Breast reconstruction.      19.26         NA      10.27       2.08         NA      31.61        090
19364.............  ..............  A                Breast reconstruction.      41.00         NA      25.22       3.91         NA      70.13        090
19366.............  ..............  A                Breast reconstruction.      21.28         NA      10.27       2.27         NA      33.82        090
19367.............  ..............  A                Breast reconstruction.      25.73         NA      17.47       2.78         NA      45.98        090
19368.............  ..............  A                Breast reconstruction.      32.42         NA      21.08       3.51         NA      57.01        090
19369.............  ..............  A                Breast reconstruction.      29.82         NA      20.65       3.24         NA      53.71        090
19370.............  ..............  A                Surgery of breast            8.05         NA       6.08       0.86         NA      14.99        090
                                                      capsule.
19371.............  ..............  A                Removal of breast            9.35         NA       7.15       1.01         NA      17.51        090
                                                      capsule.
19380.............  ..............  A                Revise breast                9.14         NA       7.05       0.98         NA      17.17        090
                                                      reconstruction.
19396.............  ..............  A                Design custom breast         2.17       6.25       1.02       0.23       8.65       3.42        000
                                                      implant.
19499.............  ..............  C                Breast surgery               0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
20000.............  ..............  A                Incision of abscess...       2.12       2.16       1.18       0.17       4.45       3.47        010
20005.............  ..............  A                Incision of deep             3.42       3.03       2.21       0.34       6.79       5.97        010
                                                      abscess.
20100.............  ..............  A                Explore wound, neck...      10.08       5.82       4.37       0.99      16.89      15.44        010
20101.............  ..............  A                Explore wound, chest..       3.22       2.90       1.50       0.24       6.36       4.96        010
20102.............  ..............  A                Explore wound, abdomen       3.94       3.39       1.75       0.35       7.68       6.04        010
20103.............  ..............  A                Explore wound,               5.30       4.26       3.02       0.57      10.13       8.89        010
                                                      extremity.
20150.............  ..............  A                Excise epiphyseal bar.      13.69         NA       8.96       0.96         NA      23.61        090
20200.............  ..............  A                Muscle biopsy.........       1.46       1.70       0.61       0.17       3.33       2.24        000
20205.............  ..............  A                Deep muscle biopsy....       2.35       3.87       0.96       0.23       6.45       3.54        000
20206.............  ..............  A                Needle biopsy, muscle.       0.99       3.15       0.35       0.06       4.20       1.40        000
20220.............  ..............  A                Bone biopsy, trocar/         1.27       4.87       2.93       0.06       6.20       4.26        000
                                                      needle.
20225.............  ..............  A                Bone biopsy, trocar/         1.87       4.37       3.02       0.11       6.35       5.00        000
                                                      needle.
20240.............  ..............  A                Bone biopsy,                 3.23         NA       4.22       0.33         NA       7.78        010
                                                      excisional.
20245.............  ..............  A                Bone biopsy,                 7.78         NA       6.91       0.44         NA      15.13        010
                                                      excisional.
20250.............  ..............  A                Open bone biopsy......       5.03         NA       4.37       0.50         NA       9.90        010
20251.............  ..............  A                Open bone biopsy......       5.56         NA       4.92       0.79         NA      11.27        010
20500.............  ..............  A                Injection of sinus           1.23       5.89       3.82       0.10       7.22       5.15        010
                                                      tract.
20501.............  ..............  A                Inject sinus tract for       0.76       3.14       0.26       0.03       3.93       1.05        000
                                                      x-ray.
20520.............  ..............  A                Removal of foreign           1.85       5.60       3.59       0.17       7.62       5.61        010
                                                      body.
20525.............  ..............  A                Removal of foreign           3.50       6.84       4.38       0.40      10.74       8.28        010
                                                      body.
20526.............  ..............  A                Ther injection, carp         0.94       0.77       0.41       0.06       1.77       1.41        000
                                                      tunnel.
20550.............  ..............  A                Inj tendon sheath/           0.75       0.76       0.24       0.06       1.57       1.05        000
                                                      ligament.
20551.............  ..............  A                Inject tendon origin/        0.75       0.70       0.34       0.06       1.51       1.15        000
                                                      insert.
20552.............  ..............  A                Inject trigger point,        0.66       0.66       0.30       0.06       1.38       1.02        000
                                                      1 or 2.
20553.............  ..............  A                Inject trigger points,       0.75       0.75       0.34       0.06       1.56       1.15        000
                                                      =/ 3.
20600.............  ..............  A                Drain/inject, joint/         0.66       0.66       0.36       0.06       1.38       1.08        000
                                                      bursa.
20605.............  ..............  A                Drain/inject, joint/         0.68       0.78       0.37       0.06       1.52       1.11        000
                                                      bursa.
20610.............  ..............  A                Drain/inject, joint/         0.79       0.97       0.42       0.08       1.84       1.29        000
                                                      bursa.
20612.............  ..............  A                Aspirate/inj ganglion        0.70       0.77       0.28       0.06       1.53       1.04        000
                                                      cyst.
20615.............  ..............  A                Treatment of bone cyst       2.28       4.87       2.69       0.19       7.34       5.16        010
20650.............  ..............  A                Insert and remove bone       2.23       5.08       3.29       0.28       7.59       5.80        010
                                                      pin.
20660.............  ..............  A                Apply, rem fixation          2.51         NA       2.28       0.48         NA       5.27        000
                                                      device.

[[Page 80050]]

 
20661.............  ..............  A                Application of head          4.89         NA       6.91       0.92         NA      12.72        090
                                                      brace.
20662.............  ..............  A                Application of pelvis        6.07         NA       6.27       0.81         NA      13.15        090
                                                      brace.
20663.............  ..............  A                Application of thigh         5.43         NA       5.58       0.77         NA      11.78        090
                                                      brace.
20664.............  ..............  A                Halo brace application       8.06         NA       8.62       1.49         NA      18.17        090
20665.............  ..............  A                Removal of fixation          1.31       2.14       1.30       0.17       3.62       2.78        010
                                                      device.
20670.............  ..............  A                Removal of support           1.74       6.09       3.55       0.23       8.06       5.52        010
                                                      implant.
20680.............  ..............  A                Removal of support           3.35       5.37       5.37       0.46       9.18       9.18        090
                                                      implant.
20690.............  ..............  A                Apply bone fixation          3.52         NA       1.82       0.47         NA       5.81        090
                                                      device.
20692.............  ..............  A                Apply bone fixation          6.41         NA       3.05       0.60         NA      10.06        090
                                                      device.
20693.............  ..............  A                Adjust bone fixation         5.86         NA      13.20       0.85         NA      19.91        090
                                                      device.
20694.............  ..............  A                Remove bone fixation         4.16       9.45       6.56       0.57      14.18      11.29        090
                                                      device.
20802.............  ..............  A                Replantation, arm,          41.15         NA      27.57       5.81         NA      74.53        090
                                                      complete.
20805.............  ..............  A                Replant forearm,            50.00         NA      43.16       3.95         NA      97.11        090
                                                      complete.
20808.............  ..............  A                Replantation hand,          61.65         NA      49.60       6.49         NA     117.74        090
                                                      complete.
20816.............  ..............  A                Replantation digit,         30.94         NA      46.54       3.01         NA      80.49        090
                                                      complete.
20822.............  ..............  A                Replantation digit,         25.59         NA      42.54       3.07         NA      71.20        090
                                                      complete.
20824.............  ..............  A                Replantation thumb,         30.94         NA      45.41       3.48         NA      79.83        090
                                                      complete.
20827.............  ..............  A                Replantation thumb,         26.41         NA      45.08       3.21         NA      74.70        090
                                                      complete.
20838.............  ..............  A                Replantation foot,          41.41         NA      28.58       5.85         NA      75.84        090
                                                      complete.
20900.............  ..............  A                Removal of bone for          5.58       6.60       6.39       0.77      12.95      12.74        090
                                                      graft.
20902.............  ..............  A                Removal of bone for          7.55         NA       9.17       1.06         NA      17.78        090
                                                      graft.
20910.............  ..............  A                Remove cartilage for         5.34       8.85       6.69       0.50      14.69      12.53        090
                                                      graft.
20912.............  ..............  A                Remove cartilage for         6.35         NA       7.49       0.55         NA      14.39        090
                                                      graft.
20920.............  ..............  A                Removal of fascia for        5.31         NA       5.57       0.54         NA      11.42        090
                                                      graft.
20922.............  ..............  A                Removal of fascia for        6.61       8.97       6.40       0.88      16.46      13.89        090
                                                      graft.
20924.............  ..............  A                Removal of tendon for        6.48         NA       7.16       0.82         NA      14.46        090
                                                      graft.
20926.............  ..............  A                Removal of tissue for        5.53         NA       6.42       0.73         NA      12.68        090
                                                      graft.
20930.............  ..............  B                Spinal bone allograft.       0.00       0.00       0.00       0.00       0.00       0.00        XXX
20931.............  ..............  A                Spinal bone allograft.       1.81         NA       0.96       0.34         NA       3.11        ZZZ
20936.............  ..............  B                Spinal bone autograft.       0.00       0.00       0.00       0.00       0.00       0.00        XXX
20937.............  ..............  A                Spinal bone autograft.       2.79         NA       1.49       0.43         NA       4.71        ZZZ
20938.............  ..............  A                Spinal bone autograft.       3.02         NA       1.59       0.52         NA       5.13        ZZZ
20950.............  ..............  A                Fluid pressure, muscle       1.26         NA       2.24       0.16         NA       3.66        000
20955.............  ..............  A                Fibula bone graft,          39.21         NA      29.76       4.35         NA      73.32        090
                                                      microvasc.
20956.............  ..............  A                Iliac bone graft,           39.27         NA      28.79       5.77         NA      73.83        090
                                                      microvasc.
20957.............  ..............  A                Mt bone graft,              40.65         NA      21.19       5.74         NA      67.58        090
                                                      microvasc.
20962.............  ..............  A                Other bone graft,           39.27         NA      28.28       5.19         NA      72.74        090
                                                      microvasc.
20969.............  ..............  A                Bone/skin graft,            43.92         NA      32.14       4.34         NA      80.40        090
                                                      microvasc.
20970.............  ..............  A                Bone/skin graft, iliac      43.06         NA      30.05       4.64         NA      77.75        090
                                                      crest.
20972.............  ..............  A                Bone/skin graft,            42.99         NA      18.39       6.07         NA      67.45        090
                                                      metatarsal.
20973.............  ..............  A                Bone/skin graft, great      45.76         NA      28.24       4.65         NA      78.65        090
                                                      toe.
20974.............  ..............  A                Electrical bone              0.62       0.42       0.33       0.09       1.13       1.04        000
                                                      stimulation.
20975.............  ..............  A                Electrical bone              2.60         NA       1.38       0.42         NA       4.40        000
                                                      stimulation.
20979.............  ..............  A                Us bone stimulation...       0.62       0.73       0.35       0.04       1.39       1.01        000
20999.............  ..............  C                Musculoskeletal              0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      surgery.
21010.............  ..............  A                Incision of jaw joint.      10.14         NA       7.16       0.54         NA      17.84        090
21015.............  ..............  A                Resection of facial          5.29         NA       7.09       0.52         NA      12.90        090
                                                      tumor.
21025.............  ..............  A                Excision of bone,           10.06       7.35       6.87       0.79      18.20      17.72        090
                                                      lower jaw.
21026.............  ..............  A                Excision of facial           4.85       5.39       5.08       0.40      10.64      10.33        090
                                                      bone(s).
21029.............  ..............  A                Contour of face bone         7.71       6.96       6.15       0.74      15.41      14.60        090
                                                      lesion.
21030.............  ..............  A                Excise max/zygoma b9         3.89       4.36       3.64       0.60       8.85       8.13        090
                                                      tumor.
21031.............  ..............  A                Remove exostosis,            3.24       3.35       2.17       0.28       6.87       5.69        090
                                                      mandible.
21032.............  ..............  A                Remove exostosis,            3.24       3.32       2.29       0.27       6.83       5.80        090
                                                      maxilla.
21034.............  ..............  A                Excise max/zygoma mlg       16.17      10.67      10.64       1.37      28.21      28.18        090
                                                      tumor.
21040.............  ..............  A                Excise mandible lesion       3.89       3.76       2.58       0.19       7.84       6.66        090
21041.............  ..............  D                Removal of jaw bone          0.00       0.00       0.00       0.00       0.00       0.00        090
                                                      lesion.
21044.............  ..............  A                Removal of jaw bone         11.86         NA       7.96       0.87         NA      20.69        090
                                                      lesion.
21045.............  ..............  A                Extensive jaw surgery.      16.17         NA      10.29       1.20         NA      27.66        090
21046.............  ..............  A                Remove mandible cyst        13.00         NA      10.42       1.01         NA      24.43        090
                                                      complex.
21047.............  ..............  A                Excise lwr jaw cyst w/      18.75         NA       9.87       1.53         NA      30.15        090
                                                      repair.
21048.............  ..............  A                Remove maxilla cyst         13.50         NA      10.63       1.01         NA      25.14        090
                                                      complex.
21049.............  ..............  A                Excis uppr jaw cyst w/      18.00         NA       9.55       1.01         NA      28.56        090
                                                      repair.
21050.............  ..............  A                Removal of jaw joint..      10.77         NA      11.63       0.84         NA      23.24        090
21060.............  ..............  A                Remove jaw joint            10.23         NA      10.09       1.16         NA      21.48        090
                                                      cartilage.
21070.............  ..............  A                Remove coronoid              8.20         NA       5.98       0.67         NA      14.85        090
                                                      process.
21076.............  ..............  A                Prepare face/oral           13.42       9.49       7.13       1.36      24.27      21.91        010
                                                      prosthesis.
21077.............  ..............  A                Prepare face/oral           33.75      23.88      17.94       3.43      61.06      55.12        090
                                                      prosthesis.
21079.............  ..............  A                Prepare face/oral           22.34      16.88      12.41       1.59      40.81      36.34        090
                                                      prosthesis.
21080.............  ..............  A                Prepare face/oral           25.10      18.97      13.94       2.55      46.62      41.59        090
                                                      prosthesis.
21081.............  ..............  A                Prepare face/oral           22.88      17.28      12.71       1.87      42.03      37.46        090
                                                      prosthesis.
21082.............  ..............  A                Prepare face/oral           20.87      14.77      11.10       1.46      37.10      33.43        090
                                                      prosthesis.
21083.............  ..............  A                Prepare face/oral           19.30      14.58      10.72       1.96      35.84      31.98        090
                                                      prosthesis.
21084.............  ..............  A                Prepare face/oral           22.51      17.01      12.51       1.57      41.09      36.59        090
                                                      prosthesis.
21085.............  ..............  A                Prepare face/oral            9.00       6.37       4.79       0.65      16.02      14.44        010
                                                      prosthesis.
21086.............  ..............  A                Prepare face/oral           24.92      18.83      13.84       1.86      45.61      40.62        090
                                                      prosthesis.

[[Page 80051]]

 
21087.............  ..............  A                Prepare face/oral           24.92      17.63      13.24       2.22      44.77      40.38        090
                                                      prosthesis.
21088.............  ..............  C                Prepare face/oral            0.00       0.00       0.00       0.00       0.00       0.00        090
                                                      prosthesis.
21089.............  ..............  C                Prepare face/oral            0.00       0.00       0.00       0.00       0.00       0.00        090
                                                      prosthesis.
21100.............  ..............  A                Maxillofacial fixation       4.22       5.93       4.05       0.18      10.33       8.45        090
21110.............  ..............  A                Interdental fixation..       5.21       5.31       4.32       0.28      10.80       9.81        090
21116.............  ..............  A                Injection, jaw joint x-      0.81       7.71       0.29       0.05       8.57       1.15        000
                                                      ray.
21120.............  ..............  A                Reconstruction of chin       4.93       9.80       6.08       0.29      15.02      11.30        090
21121.............  ..............  A                Reconstruction of chin       7.64       7.94       6.21       0.56      16.14      14.41        090
21122.............  ..............  A                Reconstruction of chin       8.52         NA       7.63       0.59         NA      16.74        090
21123.............  ..............  A                Reconstruction of chin      11.16         NA       8.08       1.16         NA      20.40        090
21125.............  ..............  A                Augmentation, lower         10.62       9.53       8.07       0.72      20.87      19.41        090
                                                      jaw bone.
21127.............  ..............  A                Augmentation, lower         11.12       9.80       7.50       0.76      21.68      19.38        090
                                                      jaw bone.
21137.............  ..............  A                Reduction of forehead.       9.82         NA       8.03       0.53         NA      18.38        090
21138.............  ..............  A                Reduction of forehead.      12.19         NA       9.40       1.47         NA      23.06        090
21139.............  ..............  A                Reduction of forehead.      14.61         NA       9.78       1.02         NA      25.41        090
21141.............  ..............  A                Reconstruct midface,        18.10         NA      10.79       1.63         NA      30.52        090
                                                      lefort.
21142.............  ..............  A                Reconstruct midface,        18.81         NA      12.16       1.16         NA      32.13        090
                                                      lefort.
21143.............  ..............  A                Reconstruct midface,        19.58         NA      11.10       0.90         NA      31.58        090
                                                      lefort.
21145.............  ..............  A                Reconstruct midface,        19.94         NA      11.25       2.09         NA      33.28        090
                                                      lefort.
21146.............  ..............  A                Reconstruct midface,        20.71         NA      11.92       2.13         NA      34.76        090
                                                      lefort.
21147.............  ..............  A                Reconstruct midface,        21.77         NA      12.15       1.52         NA      35.44        090
                                                      lefort.
21150.............  ..............  A                Reconstruct midface,        25.24         NA      16.33       1.09         NA      42.66        090
                                                      lefort.
21151.............  ..............  A                Reconstruct midface,        28.30         NA      19.93       1.98         NA      50.21        090
                                                      lefort.
21154.............  ..............  A                Reconstruct midface,        30.52         NA      19.84       4.86         NA      55.22        090
                                                      lefort.
21155.............  ..............  A                Reconstruct midface,        34.45         NA      20.75       5.48         NA      60.68        090
                                                      lefort.
21159.............  ..............  A                Reconstruct midface,        42.38         NA      25.58       6.74         NA      74.70        090
                                                      lefort.
21160.............  ..............  A                Reconstruct midface,        46.44         NA      26.69       4.39         NA      77.52        090
                                                      lefort.
21172.............  ..............  A                Reconstruct orbit/          27.80         NA      15.82       1.91         NA      45.53        090
                                                      forehead.
21175.............  ..............  A                Reconstruct orbit/          33.17         NA      20.06       5.16         NA      58.39        090
                                                      forehead.
21179.............  ..............  A                Reconstruct entire          22.25         NA      17.84       2.48         NA      42.57        090
                                                      forehead.
21180.............  ..............  A                Reconstruct entire          25.19         NA      18.59       2.15         NA      45.93        090
                                                      forehead.
21181.............  ..............  A                Contour cranial bone         9.90         NA       8.34       0.97         NA      19.21        090
                                                      lesion.
21182.............  ..............  A                Reconstruct cranial         32.19         NA      21.89       2.53         NA      56.61        090
                                                      bone.
21183.............  ..............  A                Reconstruct cranial         35.31         NA      23.87       2.75         NA      61.93        090
                                                      bone.
21184.............  ..............  A                Reconstruct cranial         38.24         NA      24.30       4.12         NA      66.66        090
                                                      bone.
21188.............  ..............  A                Reconstruction of           22.46         NA      15.62       1.85         NA      39.93        090
                                                      midface.
21193.............  ..............  A                Reconst lwr jaw w/o         17.15         NA      10.78       1.53         NA      29.46        090
                                                      graft.
21194.............  ..............  A                Reconst lwr jaw w/          19.84         NA      12.72       1.39         NA      33.95        090
                                                      graft.
21195.............  ..............  A                Reconst lwr jaw w/o         17.24         NA      12.35       1.20         NA      30.79        090
                                                      fixation.
21196.............  ..............  A                Reconst lwr jaw w/          18.91         NA      12.91       1.62         NA      33.44        090
                                                      fixation.
21198.............  ..............  A                Reconstr lwr jaw            14.16         NA      11.66       1.05         NA      26.87        090
                                                      segment.
21199.............  ..............  A                Reconstr lwr jaw w/         16.00         NA       9.29       1.26         NA      26.55        090
                                                      advance.
21206.............  ..............  A                Reconstruct upper jaw       14.10         NA       9.72       1.01         NA      24.83        090
                                                      bone.
21208.............  ..............  A                Augmentation of facial      10.23       9.69       8.36       0.92      20.84      19.51        090
                                                      bones.
21209.............  ..............  A                Reduction of facial          6.72       7.97       5.79       0.60      15.29      13.11        090
                                                      bones.
21210.............  ..............  A                Face bone graft.......      10.23       8.99       8.14       0.88      20.10      19.25        090
21215.............  ..............  A                Lower jaw bone graft..      10.77       8.90       7.08       1.04      20.71      18.89        090
21230.............  ..............  A                Rib cartilage graft...      10.77         NA      10.06       0.96         NA      21.79        090
21235.............  ..............  A                Ear cartilage graft...       6.72      12.21       8.03       0.52      19.45      15.27        090
21240.............  ..............  A                Reconstruction of jaw       14.05         NA      11.30       1.15         NA      26.50        090
                                                      joint.
21242.............  ..............  A                Reconstruction of jaw       12.95         NA      11.07       1.40         NA      25.42        090
                                                      joint.
21243.............  ..............  A                Reconstruction of jaw       20.79         NA      13.76       1.85         NA      36.40        090
                                                      joint.
21244.............  ..............  A                Reconstruction of           11.86         NA       9.17       0.95         NA      21.98        090
                                                      lower jaw.
21245.............  ..............  A                Reconstruction of jaw.      11.86      12.18      10.18       0.88      24.92      22.92        090
21246.............  ..............  A                Reconstruction of jaw.      12.47      10.33      10.33       1.21      24.01      24.01        090
21247.............  ..............  A                Reconstruct lower jaw       22.63         NA      16.39       2.21         NA      41.23        090
                                                      bone.
21248.............  ..............  A                Reconstruction of jaw.      11.48       8.99       7.76       1.01      21.48      20.25        090
21249.............  ..............  A                Reconstruction of jaw.      17.52      11.51      10.20       1.39      30.42      29.11        090
21255.............  ..............  A                Reconstruct lower jaw       16.72         NA      11.44       1.13         NA      29.29        090
                                                      bone.
21256.............  ..............  A                Reconstruction of           16.19         NA      13.27       1.04         NA      30.50        090
                                                      orbit.
21260.............  ..............  A                Revise eye sockets....      16.52         NA      10.71       1.25         NA      28.48        090
21261.............  ..............  A                Revise eye sockets....      31.49         NA      20.59       2.20         NA      54.28        090
21263.............  ..............  A                Revise eye sockets....      28.42         NA      12.98       2.16         NA      43.56        090
21267.............  ..............  A                Revise eye sockets....      18.90         NA      14.48       1.35         NA      34.73        090
21268.............  ..............  A                Revise eye sockets....      24.48         NA      16.12       0.79         NA      41.39        090
21270.............  ..............  A                Augmentation, cheek         10.23       9.54       9.54       0.73      20.50      20.50        090
                                                      bone.
21275.............  ..............  A                Revision, orbitofacial      11.24         NA      10.78       1.03         NA      23.05        090
                                                      bones.
21280.............  ..............  A                Revision of eyelid....       6.03         NA       6.07       0.27         NA      12.37        090
21282.............  ..............  A                Revision of eyelid....       3.49         NA       5.15       0.21         NA       8.85        090
21295.............  ..............  A                Revision of jaw muscle/      1.53         NA       4.35       0.13         NA       6.01        090
                                                      bone.
21296.............  ..............  A                Revision of jaw muscle/      4.25         NA       4.55       0.30         NA       9.10        090
                                                      bone.
21299.............  ..............  C                Cranio/maxillofacial         0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      surgery.
21300.............  ..............  A                Treatment of skull           0.72       2.73       0.26       0.09       3.54       1.07        000
                                                      fracture.
21310.............  ..............  A                Treatment of nose            0.58       2.68       0.15       0.05       3.31       0.78        000
                                                      fracture.
21315.............  ..............  A                Treatment of nose            1.51       3.43       1.27       0.12       5.06       2.90        010
                                                      fracture.

[[Page 80052]]

 
21320.............  ..............  A                Treatment of nose            1.85       4.83       2.03       0.15       6.83       4.03        010
                                                      fracture.
21325.............  ..............  A                Treatment of nose            3.77         NA       3.67       0.31         NA       7.75        090
                                                      fracture.
21330.............  ..............  A                Treatment of nose            5.38         NA       5.51       0.48         NA      11.37        090
                                                      fracture.
21335.............  ..............  A                Treatment of nose            8.61         NA       7.16       0.64         NA      16.41        090
                                                      fracture.
21336.............  ..............  A                Treat nasal septal           5.72         NA       5.55       0.45         NA      11.72        090
                                                      fracture.
21337.............  ..............  A                Treat nasal septal           2.70       5.23       3.25       0.22       8.15       6.17        090
                                                      fracture.
21338.............  ..............  A                Treat nasoethmoid            6.46         NA       5.96       0.53         NA      12.95        090
                                                      fracture.
21339.............  ..............  A                Treat nasoethmoid            8.09         NA       6.70       0.76         NA      15.55        090
                                                      fracture.
21340.............  ..............  A                Treatment of nose           10.77         NA       9.09       0.85         NA      20.71        090
                                                      fracture.
21343.............  ..............  A                Treatment of sinus          12.95         NA       9.77       1.06         NA      23.78        090
                                                      fracture.
21344.............  ..............  A                Treatment of sinus          19.72         NA      13.44       1.72         NA      34.88        090
                                                      fracture.
21345.............  ..............  A                Treat nose/jaw               8.16       9.73       7.91       0.60      18.49      16.67        090
                                                      fracture.
21346.............  ..............  A                Treat nose/jaw              10.61         NA      10.05       0.85         NA      21.51        090
                                                      fracture.
21347.............  ..............  A                Treat nose/jaw              12.69         NA       9.50       1.14         NA      23.33        090
                                                      fracture.
21348.............  ..............  A                Treat nose/jaw              16.69         NA      10.93       1.50         NA      29.12        090
                                                      fracture.
21355.............  ..............  A                Treat cheek bone             3.77       4.40       2.28       0.29       8.46       6.34        010
                                                      fracture.
21356.............  ..............  A                Treat cheek bone             4.15         NA       3.23       0.36         NA       7.74        010
                                                      fracture.
21360.............  ..............  A                Treat cheek bone             6.46         NA       5.63       0.52         NA      12.61        090
                                                      fracture.
21365.............  ..............  A                Treat cheek bone            14.95         NA      11.31       1.30         NA      27.56        090
                                                      fracture.
21366.............  ..............  A                Treat cheek bone            17.77         NA      11.90       1.41         NA      31.08        090
                                                      fracture.
21385.............  ..............  A                Treat eye socket             9.16         NA       7.53       0.64         NA      17.33        090
                                                      fracture.
21386.............  ..............  A                Treat eye socket             9.16         NA       7.97       0.76         NA      17.89        090
                                                      fracture.
21387.............  ..............  A                Treat eye socket             9.70         NA       8.22       0.78         NA      18.70        090
                                                      fracture.
21390.............  ..............  A                Treat eye socket            10.13         NA       8.47       0.70         NA      19.30        090
                                                      fracture.
21395.............  ..............  A                Treat eye socket            12.68         NA       9.79       1.09         NA      23.56        090
                                                      fracture.
21400.............  ..............  A                Treat eye socket             1.40       3.12       1.05       0.12       4.64       2.57        090
                                                      fracture.
21401.............  ..............  A                Treat eye socket             3.26       4.83       3.11       0.34       8.43       6.71        090
                                                      fracture.
21406.............  ..............  A                Treat eye socket             7.01         NA       6.75       0.59         NA      14.35        090
                                                      fracture.
21407.............  ..............  A                Treat eye socket             8.61         NA       7.75       0.67         NA      17.03        090
                                                      fracture.
21408.............  ..............  A                Treat eye socket            12.38         NA      10.01       1.24         NA      23.63        090
                                                      fracture.
21421.............  ..............  A                Treat mouth roof             5.14       7.44       6.09       0.42      13.00      11.65        090
                                                      fracture.
21422.............  ..............  A                Treat mouth roof             8.32         NA       7.49       0.69         NA      16.50        090
                                                      fracture.
21423.............  ..............  A                Treat mouth roof            10.40         NA       8.02       0.95         NA      19.37        090
                                                      fracture.
21431.............  ..............  A                Treat craniofacial           7.05         NA       6.68       0.58         NA      14.31        090
                                                      fracture.
21432.............  ..............  A                Treat craniofacial           8.61         NA       7.74       0.55         NA      16.90        090
                                                      fracture.
21433.............  ..............  A                Treat craniofacial          25.35         NA      17.10       2.46         NA      44.91        090
                                                      fracture.
21435.............  ..............  A                Treat craniofacial          17.25         NA      12.56       1.66         NA      31.47        090
                                                      fracture.
21436.............  ..............  A                Treat craniofacial          28.04         NA      17.16       2.32         NA      47.52        090
                                                      fracture.
21440.............  ..............  A                Treat dental ridge           2.70       5.68       3.64       0.22       8.60       6.56        090
                                                      fracture.
21445.............  ..............  A                Treat dental ridge           5.38       7.04       5.17       0.55      12.97      11.10        090
                                                      fracture.
21450.............  ..............  A                Treat lower jaw              2.97       6.87       2.74       0.23      10.07       5.94        090
                                                      fracture.
21451.............  ..............  A                Treat lower jaw              4.87       6.63       5.65       0.39      11.89      10.91        090
                                                      fracture.
21452.............  ..............  A                Treat lower jaw              1.98       9.39       4.20       0.14      11.51       6.32        090
                                                      fracture.
21453.............  ..............  A                Treat lower jaw              5.54       7.52       6.40       0.49      13.55      12.43        090
                                                      fracture.
21454.............  ..............  A                Treat lower jaw              6.46         NA       5.78       0.55         NA      12.79        090
                                                      fracture.
21461.............  ..............  A                Treat lower jaw              8.09       9.26       7.94       0.73      18.08      16.76        090
                                                      fracture.
21462.............  ..............  A                Treat lower jaw              9.79      10.56       8.08       0.80      21.15      18.67        090
                                                      fracture.
21465.............  ..............  A                Treat lower jaw             11.91         NA       7.87       0.84         NA      20.62        090
                                                      fracture.
21470.............  ..............  A                Treat lower jaw             15.34         NA       9.93       1.36         NA      26.63        090
                                                      fracture.
21480.............  ..............  A                Reset dislocated jaw..       0.61       1.58       0.18       0.05       2.24       0.84        000
21485.............  ..............  A                Reset dislocated jaw..       3.99       3.85       3.39       0.31       8.15       7.69        090
21490.............  ..............  A                Repair dislocated jaw.      11.86         NA       7.57       1.31         NA      20.74        090
21493.............  ..............  A                Treat hyoid bone             1.27         NA       3.38       0.10         NA       4.75        090
                                                      fracture.
21494.............  ..............  A                Treat hyoid bone             6.28         NA       5.06       0.44         NA      11.78        090
                                                      fracture.
21495.............  ..............  A                Treat hyoid bone             5.69         NA       5.00       0.41         NA      11.10        090
                                                      fracture.
21497.............  ..............  A                Interdental wiring....       3.86       4.75       3.97       0.31       8.92       8.14        090
21499.............  ..............  C                Head surgery procedure       0.00       0.00       0.00       0.00       0.00       0.00        YYY
21501.............  ..............  A                Drain neck/chest             3.81       4.39       3.59       0.36       8.56       7.76        090
                                                      lesion.
21502.............  ..............  A                Drain chest lesion....       7.12         NA       7.44       0.79         NA      15.35        090
21510.............  ..............  A                Drainage of bone             5.74         NA       7.16       0.67         NA      13.57        090
                                                      lesion.
21550.............  ..............  A                Biopsy of neck/chest..       2.06       2.33       1.22       0.13       4.52       3.41        010
21555.............  ..............  A                Remove lesion, neck/         4.35       4.26       2.44       0.41       9.02       7.20        090
                                                      chest.
21556.............  ..............  A                Remove lesion, neck/         5.57         NA       3.21       0.51         NA       9.29        090
                                                      chest.
21557.............  ..............  A                Remove tumor, neck/          8.88         NA       7.68       0.85         NA      17.41        090
                                                      chest.
21600.............  ..............  A                Partial removal of rib       6.89         NA       7.57       0.81         NA      15.27        090
21610.............  ..............  A                Partial removal of rib      14.61         NA      11.24       1.85         NA      27.70        090
21615.............  ..............  A                Removal of rib........       9.87         NA       8.07       1.20         NA      19.14        090
21616.............  ..............  A                Removal of rib and          12.04         NA       9.27       1.31         NA      22.62        090
                                                      nerves.
21620.............  ..............  A                Partial removal of           6.79         NA       8.04       0.77         NA      15.60        090
                                                      sternum.
21627.............  ..............  A                Sternal debridement...       6.81         NA      12.58       0.82         NA      20.21        090
21630.............  ..............  A                Extensive sternum           17.38         NA      13.52       1.95         NA      32.85        090
                                                      surgery.
21632.............  ..............  A                Extensive sternum           18.14         NA      12.17       2.16         NA      32.47        090
                                                      surgery.
21700.............  ..............  A                Revision of neck             6.19       9.22       7.25       0.31      15.72      13.75        090
                                                      muscle.
21705.............  ..............  A                Revision of neck             9.60         NA       7.62       0.92         NA      18.14        090
                                                      muscle/rib.
21720.............  ..............  A                Revision of neck             5.68       7.95       7.01       0.80      14.43      13.49        090
                                                      muscle.

[[Page 80053]]

 
21725.............  ..............  A                Revision of neck             6.99         NA       7.45       0.90         NA      15.34        090
                                                      muscle.
21740.............  ..............  A                Reconstruction of           16.50         NA      12.48       2.03         NA      31.01        090
                                                      sternum.
21742.............  ..............  C                Repair stern/nuss w/o        0.00       0.00       0.00       0.00       0.00       0.00        090
                                                      scope.
21743.............  ..............  C                Repair sternum/nuss w/       0.00       0.00       0.00       0.00       0.00       0.00        090
                                                      scope.
21750.............  ..............  A                Repair of sternum           10.77         NA       9.85       1.35         NA      21.97        090
                                                      separation.
21800.............  ..............  A                Treatment of rib             0.96       2.38       1.08       0.09       3.43       2.13        090
                                                      fracture.
21805.............  ..............  A                Treatment of rib             2.75         NA       4.71       0.29         NA       7.75        090
                                                      fracture.
21810.............  ..............  A                Treatment of rib             6.86         NA       7.06       0.60         NA      14.52        090
                                                      fracture(s).
21820.............  ..............  A                Treat sternum fracture       1.28       2.92       1.56       0.15       4.35       2.99        090
21825.............  ..............  A                Treat sternum fracture       7.41         NA      10.26       0.84         NA      18.51        090
21899.............  ..............  C                Neck/chest surgery           0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
21920.............  ..............  A                Biopsy soft tissue of        2.06       2.45       0.75       0.12       4.63       2.93        010
                                                      back.
21925.............  ..............  A                Biopsy soft tissue of        4.49      11.93       4.68       0.44      16.86       9.61        090
                                                      back.
21930.............  ..............  A                Remove lesion, back or       5.00       4.60       2.62       0.49      10.09       8.11        090
                                                      flank.
21935.............  ..............  A                Remove tumor, back....      17.96         NA      13.01       1.87         NA      32.84        090
22100.............  ..............  A                Remove part of neck          9.73         NA       8.38       1.55         NA      19.66        090
                                                      vertebra.
22101.............  ..............  A                Remove part, thorax          9.81         NA       8.57       1.51         NA      19.89        090
                                                      vertebra.
22102.............  ..............  A                Remove part, lumbar          9.81         NA       8.77       1.46         NA      20.04        090
                                                      vertebra.
22103.............  ..............  A                Remove extra spine           2.34         NA       1.24       0.37         NA       3.95        ZZZ
                                                      segment.
22110.............  ..............  A                Remove part of neck         12.74         NA      10.66       2.20         NA      25.60        090
                                                      vertebra.
22112.............  ..............  A                Remove part, thorax         12.81         NA      10.54       1.96         NA      25.31        090
                                                      vertebra.
22114.............  ..............  A                Remove part, lumbar         12.81         NA      10.45       1.98         NA      25.24        090
                                                      vertebra.
22116.............  ..............  A                Remove extra spine           2.32         NA       1.19       0.40         NA       3.91        ZZZ
                                                      segment.
22210.............  ..............  A                Revision of neck spine      23.82         NA      17.10       4.23         NA      45.15        090
22212.............  ..............  A                Revision of thorax          19.42         NA      14.61       2.78         NA      36.81        090
                                                      spine.
22214.............  ..............  A                Revision of lumbar          19.45         NA      15.09       2.78         NA      37.32        090
                                                      spine.
22216.............  ..............  A                Revise, extra spine          6.04         NA       3.21       0.98         NA      10.23        ZZZ
                                                      segment.
22220.............  ..............  A                Revision of neck spine      21.37         NA      15.50       3.65         NA      40.52        090
22222.............  ..............  A                Revision of thorax          21.52         NA      13.08       3.08         NA      37.68        090
                                                      spine.
22224.............  ..............  A                Revision of lumbar          21.52         NA      15.72       3.20         NA      40.44        090
                                                      spine.
22226.............  ..............  A                Revise, extra spine          6.04         NA       3.17       1.01         NA      10.22        ZZZ
                                                      segment.
22305.............  ..............  A                Treat spine process          2.05       3.40       2.82       0.29       5.74       5.16        090
                                                      fracture.
22310.............  ..............  A                Treat spine fracture..       2.61       5.04       4.44       0.37       8.02       7.42        090
22315.............  ..............  A                Treat spine fracture..       8.84         NA       8.64       1.37         NA      18.85        090
22318.............  ..............  A                Treat odontoid fx w/o       21.50         NA      14.63       4.26         NA      40.39        090
                                                      graft.
22319.............  ..............  A                Treat odontoid fx w/        24.00         NA      17.14       4.76         NA      45.90        090
                                                      graft.
22325.............  ..............  A                Treat spine fracture..      18.30         NA      13.88       2.61         NA      34.79        090
22326.............  ..............  A                Treat neck spine            19.59         NA      15.00       3.54         NA      38.13        090
                                                      fracture.
22327.............  ..............  A                Treat thorax spine          19.20         NA      14.24       2.75         NA      36.19        090
                                                      fracture.
22328.............  ..............  A                Treat each add spine         4.61         NA       2.33       0.66         NA       7.60        ZZZ
                                                      fx.
22505.............  ..............  A                Manipulation of spine.       1.87       4.80       3.19       0.27       6.94       5.33        010
22520.............  ..............  A                Percut vertebroplasty        8.91         NA       3.98       0.99         NA      13.88        010
                                                      thor.
22521.............  ..............  A                Percut vertebroplasty        8.34         NA       3.81       0.93         NA      13.08        010
                                                      lumb.
22522.............  ..............  A                Percut vertebroplasty        4.31         NA       1.73       0.33         NA       6.37        ZZZ
                                                      addl.
22548.............  ..............  A                Neck spine fusion.....      25.82         NA      16.22       4.98         NA      47.02        090
22554.............  ..............  A                Neck spine fusion.....      18.62         NA      12.63       3.51         NA      34.76        090
22556.............  ..............  A                Thorax spine fusion...      23.46         NA      14.89       3.78         NA      42.13        090
22558.............  ..............  A                Lumbar spine fusion...      22.28         NA      13.40       3.18         NA      38.86        090
22585.............  ..............  A                Additional spinal            5.53         NA       2.87       0.98         NA       9.38        ZZZ
                                                      fusion.
22590.............  ..............  A                Spine & skull spinal        20.51         NA      13.62       3.81         NA      37.94        090
                                                      fusion.
22595.............  ..............  A                Neck spinal fusion....      19.39         NA      13.12       3.62         NA      36.13        090
22600.............  ..............  A                Neck spine fusion.....      16.14         NA      11.40       2.89         NA      30.43        090
22610.............  ..............  A                Thorax spine fusion...      16.02         NA      11.56       2.66         NA      30.24        090
22612.............  ..............  A                Lumbar spine fusion...      21.00         NA      14.36       3.28         NA      38.64        090
22614.............  ..............  A                Spine fusion, extra          6.44         NA       3.44       1.04         NA      10.92        ZZZ
                                                      segment.
22630.............  ..............  A                Lumbar spine fusion...      20.84         NA      14.01       3.79         NA      38.64        090
22632.............  ..............  A                Spine fusion, extra          5.23         NA       2.74       0.90         NA       8.87        ZZZ
                                                      segment.
22800.............  ..............  A                Fusion of spine.......      18.25         NA      13.02       2.71         NA      33.98        090
22802.............  ..............  A                Fusion of spine.......      30.88         NA      19.99       4.42         NA      55.29        090
22804.............  ..............  A                Fusion of spine.......      36.27         NA      23.15       5.23         NA      64.65        090
22808.............  ..............  A                Fusion of spine.......      26.27         NA      16.72       4.36         NA      47.35        090
22810.............  ..............  A                Fusion of spine.......      30.27         NA      18.75       4.49         NA      53.51        090
22812.............  ..............  A                Fusion of spine.......      32.70         NA      20.27       4.67         NA      57.64        090
22818.............  ..............  A                Kyphectomy, 1-2             31.83         NA      19.49       5.01         NA      56.33        090
                                                      segments.
22819.............  ..............  A                Kyphectomy, 3 or more.      36.44         NA      20.58       5.20         NA      62.22        090
22830.............  ..............  A                Exploration of spinal       10.85         NA       8.32       1.73         NA      20.90        090
                                                      fusion.
22840.............  ..............  A                Insert spine fixation       12.54         NA       6.67       2.03         NA      21.24        ZZZ
                                                      device.
22841.............  ..............  B                Insert spine fixation        0.00       0.00       0.00       0.00       0.00       0.00        XXX
                                                      device.
22842.............  ..............  A                Insert spine fixation       12.58         NA       6.69       2.04         NA      21.31        ZZZ
                                                      device.
22843.............  ..............  A                Insert spine fixation       13.46         NA       6.78       2.10         NA      22.34        ZZZ
                                                      device.
22844.............  ..............  A                Insert spine fixation       16.44         NA       8.99       2.42         NA      27.85        ZZZ
                                                      device.
22845.............  ..............  A                Insert spine fixation       11.96         NA       6.24       2.22         NA      20.42        ZZZ
                                                      device.
22846.............  ..............  A                Insert spine fixation       12.42         NA       6.51       2.26         NA      21.19        ZZZ
                                                      device.
22847.............  ..............  A                Insert spine fixation       13.80         NA       7.21       2.36         NA      23.37        ZZZ
                                                      device.
22848.............  ..............  A                Insert pelv fixation         6.00         NA       3.27       0.88         NA      10.15        ZZZ
                                                      device.

[[Page 80054]]

 
22849.............  ..............  A                Reinsert spinal             18.51         NA      13.75       2.87         NA      35.13        090
                                                      fixation.
22850.............  ..............  A                Remove spine fixation        9.52         NA       8.50       1.51         NA      19.53        090
                                                      device.
22851.............  ..............  A                Apply spine prosth           6.71         NA       3.45       1.11         NA      11.27        ZZZ
                                                      device.
22852.............  ..............  A                Remove spine fixation        9.01         NA       8.26       1.40         NA      18.67        090
                                                      device.
22855.............  ..............  A                Remove spine fixation       15.13         NA      11.24       2.74         NA      29.11        090
                                                      device.
22899.............  ..............  C                Spine surgery                0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
22900.............  ..............  A                Remove abdominal wall        5.80         NA       4.29       0.58         NA      10.67        090
                                                      lesion.
22999.............  ..............  C                Abdomen surgery              0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
23000.............  ..............  A                Removal of calcium           4.36       8.97       7.38       0.50      13.83      12.24        090
                                                      deposits.
23020.............  ..............  A                Release shoulder joint       8.93         NA      10.95       1.23         NA      21.11        090
23030.............  ..............  A                Drain shoulder lesion.       3.43       6.24       4.54       0.42      10.09       8.39        010
23031.............  ..............  A                Drain shoulder bursa..       2.74       6.00       4.34       0.33       9.07       7.41        010
23035.............  ..............  A                Drain shoulder bone          8.61         NA      15.81       1.19         NA      25.61        090
                                                      lesion.
23040.............  ..............  A                Exploratory shoulder         9.20         NA      12.15       1.28         NA      22.63        090
                                                      surgery.
23044.............  ..............  A                Exploratory shoulder         7.12         NA      11.01       0.97         NA      19.10        090
                                                      surgery.
23065.............  ..............  A                Biopsy shoulder              2.27       2.71       1.33       0.14       5.12       3.74        010
                                                      tissues.
23066.............  ..............  A                Biopsy shoulder              4.16       7.96       6.49       0.50      12.62      11.15        090
                                                      tissues.
23075.............  ..............  A                Removal of shoulder          2.39       5.36       3.21       0.25       8.00       5.85        010
                                                      lesion.
23076.............  ..............  A                Removal of shoulder          7.63         NA       8.42       0.87         NA      16.92        090
                                                      lesion.
23077.............  ..............  A                Remove tumor of             16.09         NA      14.26       1.81         NA      32.16        090
                                                      shoulder.
23100.............  ..............  A                Biopsy of shoulder           6.03         NA       9.13       0.81         NA      15.97        090
                                                      joint.
23101.............  ..............  A                Shoulder joint surgery       5.58         NA       9.14       0.77         NA      15.49        090
23105.............  ..............  A                Remove shoulder joint        8.23         NA      10.55       1.13         NA      19.91        090
                                                      lining.
23106.............  ..............  A                Incision of collarbone       5.96         NA       9.25       0.82         NA      16.03        090
                                                      joint.
23107.............  ..............  A                Explore treat shoulder       8.62         NA      10.74       1.19         NA      20.55        090
                                                      joint.
23120.............  ..............  A                Partial removal,             7.11         NA       9.97       0.99         NA      18.07        090
                                                      collar bone.
23125.............  ..............  A                Removal of collar bone       9.39         NA      11.08       1.27         NA      21.74        090
23130.............  ..............  A                Remove shoulder bone,        7.55         NA      10.20       1.06         NA      18.81        090
                                                      part.
23140.............  ..............  A                Removal of bone lesion       6.89         NA       8.64       0.82         NA      16.35        090
23145.............  ..............  A                Removal of bone lesion       9.09         NA      12.05       1.24         NA      22.38        090
23146.............  ..............  A                Removal of bone lesion       7.83         NA      11.37       1.11         NA      20.31        090
23150.............  ..............  A                Removal of humerus           8.48         NA      10.37       1.14         NA      19.99        090
                                                      lesion.
23155.............  ..............  A                Removal of humerus          10.35         NA      12.62       1.20         NA      24.17        090
                                                      lesion.
23156.............  ..............  A                Removal of humerus           8.68         NA      10.74       1.18         NA      20.60        090
                                                      lesion.
23170.............  ..............  A                Remove collar bone           6.86         NA      11.17       0.84         NA      18.87        090
                                                      lesion.
23172.............  ..............  A                Remove shoulder blade        6.90         NA      10.70       0.95         NA      18.55        090
                                                      lesion.
23174.............  ..............  A                Remove humerus lesion.       9.51         NA      12.19       1.30         NA      23.00        090
23180.............  ..............  A                Remove collar bone           8.53         NA      16.82       1.18         NA      26.53        090
                                                      lesion.
23182.............  ..............  A                Remove shoulder blade        8.15         NA      16.90       1.08         NA      26.13        090
                                                      lesion.
23184.............  ..............  A                Remove humerus lesion.       9.38         NA      17.08       1.24         NA      27.70        090
23190.............  ..............  A                Partial removal of           7.24         NA       8.72       0.97         NA      16.93        090
                                                      scapula.
23195.............  ..............  A                Removal of head of           9.81         NA      11.11       1.38         NA      22.30        090
                                                      humerus.
23200.............  ..............  A                Removal of collar bone      12.08         NA      14.52       1.48         NA      28.08        090
23210.............  ..............  A                Removal of shoulder         12.49         NA      14.47       1.61         NA      28.57        090
                                                      blade.
23220.............  ..............  A                Partial removal of          14.56         NA      15.73       2.03         NA      32.32        090
                                                      humerus.
23221.............  ..............  A                Partial removal of          17.74         NA      17.13       2.51         NA      37.38        090
                                                      humerus.
23222.............  ..............  A                Partial removal of          23.92         NA      21.02       3.37         NA      48.31        090
                                                      humerus.
23330.............  ..............  A                Remove shoulder              1.85       5.75       3.77       0.18       7.78       5.80        010
                                                      foreign body.
23331.............  ..............  A                Remove shoulder              7.38         NA      10.06       1.02         NA      18.46        090
                                                      foreign body.
23332.............  ..............  A                Remove shoulder             11.62         NA      12.40       1.62         NA      25.64        090
                                                      foreign body.
23350.............  ..............  A                Injection for shoulder       1.00       7.30       0.34       0.05       8.35       1.39        000
                                                      x-ray.
23395.............  ..............  A                Muscle                      16.85         NA      14.27       2.29         NA      33.41        090
                                                      transfer,shoulder/arm.
23397.............  ..............  A                Muscle transfers......      16.13         NA      14.61       2.24         NA      32.98        090
23400.............  ..............  A                Fixation of shoulder        13.54         NA      14.58       1.91         NA      30.03        090
                                                      blade.
23405.............  ..............  A                Incision of tendon &         8.37         NA       9.69       1.12         NA      19.18        090
                                                      muscle.
23406.............  ..............  A                Incise tendon(s) &          10.79         NA      11.89       1.48         NA      24.16        090
                                                      muscle(s).
23410.............  ..............  A                Repair rotator cuff,        12.45         NA      12.81       1.72         NA      26.98        090
                                                      acute.
23412.............  ..............  A                Repair rotator cuff,        13.31         NA      13.32       1.86         NA      28.49        090
                                                      chronic.
23415.............  ..............  A                Release of shoulder          9.97         NA      10.45       1.39         NA      21.81        090
                                                      ligament.
23420.............  ..............  A                Repair of shoulder....      13.30         NA      14.31       1.86         NA      29.47        090
23430.............  ..............  A                Repair biceps tendon..       9.98         NA      11.50       1.40         NA      22.88        090
23440.............  ..............  A                Remove/transplant           10.48         NA      11.82       1.47         NA      23.77        090
                                                      tendon.
23450.............  ..............  A                Repair shoulder             13.40         NA      13.30       1.86         NA      28.56        090
                                                      capsule.
23455.............  ..............  A                Repair shoulder             14.37         NA      13.88       2.01         NA      30.26        090
                                                      capsule.
23460.............  ..............  A                Repair shoulder             15.37         NA      14.46       2.17         NA      32.00        090
                                                      capsule.
23462.............  ..............  A                Repair shoulder             15.30         NA      14.13       2.16         NA      31.59        090
                                                      capsule.
23465.............  ..............  A                Repair shoulder             15.85         NA      14.31       1.61         NA      31.77        090
                                                      capsule.
23466.............  ..............  A                Repair shoulder             14.22         NA      13.84       2.00         NA      30.06        090
                                                      capsule.
23470.............  ..............  A                Reconstruct shoulder        17.15         NA      12.42       2.40         NA      31.97        090
                                                      joint.
23472.............  ..............  A                Reconstruct shoulder        21.10         NA      14.64       2.37         NA      38.11        090
                                                      joint.
23480.............  ..............  A                Revision of collar          11.18         NA      12.16       1.56         NA      24.90        090
                                                      bone.
23485.............  ..............  A                Revision of collar          13.43         NA      13.35       1.84         NA      28.62        090
                                                      bone.
23490.............  ..............  A                Reinforce clavicle....      11.86         NA      12.24       1.11         NA      25.21        090
23491.............  ..............  A                Reinforce shoulder          14.21         NA      13.76       2.00         NA      29.97        090
                                                      bones.
23500.............  ..............  A                Treat clavicle               2.08       4.08       2.60       0.26       6.42       4.94        090
                                                      fracture.

[[Page 80055]]

 
23505.............  ..............  A                Treat clavicle               3.69       6.20       4.12       0.50      10.39       8.31        090
                                                      fracture.
23515.............  ..............  A                Treat clavicle               7.41         NA       8.43       1.03         NA      16.87        090
                                                      fracture.
23520.............  ..............  A                Treat clavicle               2.16       4.12       2.68       0.26       6.54       5.10        090
                                                      dislocation.
23525.............  ..............  A                Treat clavicle               3.60       6.00       3.98       0.44      10.04       8.02        090
                                                      dislocation.
23530.............  ..............  A                Treat clavicle               7.31         NA       8.20       0.85         NA      16.36        090
                                                      dislocation.
23532.............  ..............  A                Treat clavicle               8.01         NA       8.60       1.13         NA      17.74        090
                                                      dislocation.
23540.............  ..............  A                Treat clavicle               2.23       4.68       2.57       0.24       7.15       5.04        090
                                                      dislocation.
23545.............  ..............  A                Treat clavicle               3.25       5.26       3.69       0.39       8.90       7.33        090
                                                      dislocation.
23550.............  ..............  A                Treat clavicle               7.24         NA       8.37       0.94         NA      16.55        090
                                                      dislocation.
23552.............  ..............  A                Treat clavicle               8.45         NA       9.03       1.18         NA      18.66        090
                                                      dislocation.
23570.............  ..............  A                Treat shoulder blade         2.23       4.06       2.77       0.29       6.58       5.29        090
                                                      fx.
23575.............  ..............  A                Treat shoulder blade         4.06       6.41       4.37       0.53      11.00       8.96        090
                                                      fx.
23585.............  ..............  A                Treat scapula fracture       8.96         NA       9.58       1.25         NA      19.79        090
23600.............  ..............  A                Treat humerus fracture       2.93       5.91       3.74       0.39       9.23       7.06        090
23605.............  ..............  A                Treat humerus fracture       4.87       8.79       6.83       0.67      14.33      12.37        090
23615.............  ..............  A                Treat humerus fracture       9.35         NA      10.47       1.31         NA      21.13        090
23616.............  ..............  A                Treat humerus fracture      21.27         NA      16.24       2.98         NA      40.49        090
23620.............  ..............  A                Treat humerus fracture       2.40       5.62       3.47       0.32       8.34       6.19        090
23625.............  ..............  A                Treat humerus fracture       3.93       7.75       5.75       0.53      12.21      10.21        090
23630.............  ..............  A                Treat humerus fracture       7.35         NA       8.44       1.03         NA      16.82        090
23650.............  ..............  A                Treat shoulder               3.39       5.74       3.58       0.31       9.44       7.28        090
                                                      dislocation.
23655.............  ..............  A                Treat shoulder               4.57         NA       4.38       0.52         NA       9.47        090
                                                      dislocation.
23660.............  ..............  A                Treat shoulder               7.49         NA       8.24       1.01         NA      16.74        090
                                                      dislocation.
23665.............  ..............  A                Treat dislocation/           4.47       7.93       5.99       0.60      13.00      11.06        090
                                                      fracture.
23670.............  ..............  A                Treat dislocation/           7.90         NA       8.93       1.10         NA      17.93        090
                                                      fracture.
23675.............  ..............  A                Treat dislocation/           6.05       8.66       6.87       0.83      15.54      13.75        090
                                                      fracture.
23680.............  ..............  A                Treat dislocation/          10.06         NA      10.06       1.39         NA      21.51        090
                                                      fracture.
23700.............  ..............  A                Fixation of shoulder..       2.52         NA       3.65       0.35         NA       6.52        010
23800.............  ..............  A                Fusion of shoulder          14.16         NA      14.66       1.97         NA      30.79        090
                                                      joint.
23802.............  ..............  A                Fusion of shoulder          16.60         NA      13.91       2.34         NA      32.85        090
                                                      joint.
23900.............  ..............  A                Amputation of arm &         19.72         NA      15.69       2.47         NA      37.88        090
                                                      girdle.
23920.............  ..............  A                Amputation at shoulder      14.61         NA      14.02       1.92         NA      30.55        090
                                                      joint.
23921.............  ..............  A                Amputation follow-up         5.49         NA       6.90       0.78         NA      13.17        090
                                                      surgery.
23929.............  ..............  C                Shoulder surgery             0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
23930.............  ..............  A                Drainage of arm lesion       2.94       6.19       4.05       0.32       9.45       7.31        010
23931.............  ..............  A                Drainage of arm bursa.       1.79       5.97       3.88       0.21       7.97       5.88        010
23935.............  ..............  A                Drain arm/elbow bone         6.09         NA      13.61       0.84         NA      20.54        090
                                                      lesion.
24000.............  ..............  A                Exploratory elbow            5.82         NA       6.17       0.77         NA      12.76        090
                                                      surgery.
24006.............  ..............  A                Release elbow joint...       9.31         NA       8.70       1.27         NA      19.28        090
24065.............  ..............  A                Biopsy arm/elbow soft        2.08       5.87       3.35       0.14       8.09       5.57        010
                                                      tissue.
24066.............  ..............  A                Biopsy arm/elbow soft        5.21       8.94       6.82       0.61      14.76      12.64        090
                                                      tissue.
24075.............  ..............  A                Remove arm/elbow             3.92       8.20       6.14       0.43      12.55      10.49        090
                                                      lesion.
24076.............  ..............  A                Remove arm/elbow             6.30         NA       7.34       0.70         NA      14.34        090
                                                      lesion.
24077.............  ..............  A                Remove tumor of arm/        11.76         NA      13.78       1.32         NA      26.86        090
                                                      elbow.
24100.............  ..............  A                Biopsy elbow joint           4.93         NA       5.79       0.62         NA      11.34        090
                                                      lining.
24101.............  ..............  A                Explore/treat elbow          6.13         NA       6.96       0.84         NA      13.93        090
                                                      joint.
24102.............  ..............  A                Remove elbow joint           8.03         NA       7.95       1.09         NA      17.07        090
                                                      lining.
24105.............  ..............  A                Removal of elbow bursa       3.61         NA       5.38       0.49         NA       9.48        090
24110.............  ..............  A                Remove humerus lesion.       7.39         NA      10.13       0.99         NA      18.51        090
24115.............  ..............  A                Remove/graft bone            9.63         NA      10.52       1.15         NA      21.30        090
                                                      lesion.
24116.............  ..............  A                Remove/graft bone           11.81         NA      12.57       1.66         NA      26.04        090
                                                      lesion.
24120.............  ..............  A                Remove elbow lesion...       6.65         NA       6.95       0.87         NA      14.47        090
24125.............  ..............  A                Remove/graft bone            7.89         NA       7.28       0.88         NA      16.05        090
                                                      lesion.
24126.............  ..............  A                Remove/graft bone            8.31         NA       8.03       0.90         NA      17.24        090
                                                      lesion.
24130.............  ..............  A                Removal of head of           6.25         NA       7.05       0.87         NA      14.17        090
                                                      radius.
24134.............  ..............  A                Removal of arm bone          9.73         NA      16.46       1.31         NA      27.50        090
                                                      lesion.
24136.............  ..............  A                Remove radius bone           7.99         NA       6.55       0.85         NA      15.39        090
                                                      lesion.
24138.............  ..............  A                Remove elbow bone            8.05         NA       8.03       1.12         NA      17.20        090
                                                      lesion.
24140.............  ..............  A                Partial removal of arm       9.18         NA      17.56       1.23         NA      27.97        090
                                                      bone.
24145.............  ..............  A                Partial removal of           7.58         NA      11.64       1.01         NA      20.23        090
                                                      radius.
24147.............  ..............  A                Partial removal of           7.54         NA      11.64       1.04         NA      20.22        090
                                                      elbow.
24149.............  ..............  A                Radical resection of        14.20         NA      11.19       1.90         NA      27.29        090
                                                      elbow.
24150.............  ..............  A                Extensive humerus           13.27         NA      15.23       1.81         NA      30.31        090
                                                      surgery.
24151.............  ..............  A                Extensive humerus           15.58         NA      16.96       2.19         NA      34.73        090
                                                      surgery.
24152.............  ..............  A                Extensive radius            10.06         NA       9.83       1.19         NA      21.08        090
                                                      surgery.
24153.............  ..............  A                Extensive radius            11.54         NA       7.06       0.64         NA      19.24        090
                                                      surgery.
24155.............  ..............  A                Removal of elbow joint      11.73         NA       9.42       1.42         NA      22.57        090
24160.............  ..............  A                Remove elbow joint           7.83         NA       6.95       1.07         NA      15.85        090
                                                      implant.
24164.............  ..............  A                Remove radius head           6.23         NA       5.95       0.84         NA      13.02        090
                                                      implant.
24200.............  ..............  A                Removal of arm foreign       1.76       5.73       3.35       0.15       7.64       5.26        010
                                                      body.
24201.............  ..............  A                Removal of arm foreign       4.56       8.91       7.06       0.56      14.03      12.18        090
                                                      body.
24220.............  ..............  A                Injection for elbow x-       1.31      11.02       0.46       0.07      12.40       1.84        000
                                                      ray.
24300.............  ..............  A                Manipulate elbow w/          3.75         NA       5.53       0.49         NA       9.77        090
                                                      anesth.
24301.............  ..............  A                Muscle/tendon transfer      10.20         NA       9.22       1.30         NA      20.72        090
24305.............  ..............  A                Arm tendon lengthening       7.45         NA       7.79       0.98         NA      16.22        090

[[Page 80056]]

 
24310.............  ..............  A                Revision of arm tendon       5.98         NA       8.53       0.74         NA      15.25        090
24320.............  ..............  A                Repair of arm tendon..      10.56         NA      11.05       1.00         NA      22.61        090
24330.............  ..............  A                Revision of arm              9.60         NA       8.87       1.21         NA      19.68        090
                                                      muscles.
24331.............  ..............  A                Revision of arm             10.65         NA       9.48       1.41         NA      21.54        090
                                                      muscles.
24332.............  ..............  A                Tenolysis, triceps....       7.45         NA       5.21       0.77         NA      13.43        090
24340.............  ..............  A                Repair of biceps             7.89         NA       7.86       1.08         NA      16.83        090
                                                      tendon.
24341.............  ..............  A                Repair arm tendon/           7.90         NA       7.86       1.08         NA      16.84        090
                                                      muscle.
24342.............  ..............  A                Repair of ruptured          10.62         NA       9.44       1.48         NA      21.54        090
                                                      tendon.
24343.............  ..............  A                Repr elbow lat ligmnt        8.65         NA       7.89       1.13         NA      17.67        090
                                                      w/tiss.
24344.............  ..............  A                Reconstruct elbow lat       14.00         NA      11.18       1.83         NA      27.01        090
                                                      ligmnt.
24345.............  ..............  A                Repr elbw med ligmnt w/      8.65         NA       7.89       1.13         NA      17.67        090
                                                      tissu.
24346.............  ..............  A                Reconstruct elbow med       14.00         NA      11.18       1.83         NA      27.01        090
                                                      ligmnt.
24350.............  ..............  A                Repair of tennis elbow       5.25         NA       6.44       0.72         NA      12.41        090
24351.............  ..............  A                Repair of tennis elbow       5.91         NA       6.93       0.82         NA      13.66        090
24352.............  ..............  A                Repair of tennis elbow       6.43         NA       7.19       0.90         NA      14.52        090
24354.............  ..............  A                Repair of tennis elbow       6.48         NA       7.15       0.88         NA      14.51        090
24356.............  ..............  A                Revision of tennis           6.68         NA       7.33       0.90         NA      14.91        090
                                                      elbow.
24360.............  ..............  A                Reconstruct elbow           12.34         NA       9.65       1.69         NA      23.68        090
                                                      joint.
24361.............  ..............  A                Reconstruct elbow           14.08         NA      10.64       1.95         NA      26.67        090
                                                      joint.
24362.............  ..............  A                Reconstruct elbow           14.99         NA      12.41       1.92         NA      29.32        090
                                                      joint.
24363.............  ..............  A                Replace elbow joint...      18.49         NA      11.53       2.52         NA      32.54        090
24365.............  ..............  A                Reconstruct head of          8.39         NA       7.31       1.11         NA      16.81        090
                                                      radius.
24366.............  ..............  A                Reconstruct head of          9.13         NA       7.69       1.28         NA      18.10        090
                                                      radius.
24400.............  ..............  A                Revision of humerus...      11.06         NA      12.99       1.53         NA      25.58        090
24410.............  ..............  A                Revision of humerus...      14.82         NA      14.11       1.89         NA      30.82        090
24420.............  ..............  A                Revision of humerus...      13.44         NA      17.27       1.82         NA      32.53        090
24430.............  ..............  A                Repair of humerus.....      12.81         NA      13.18       1.80         NA      27.79        090
24435.............  ..............  A                Repair humerus with         13.17         NA      14.37       1.84         NA      29.38        090
                                                      graft.
24470.............  ..............  A                Revision of elbow            8.74         NA       8.50       1.23         NA      18.47        090
                                                      joint.
24495.............  ..............  A                Decompression of             8.12         NA      10.28       0.92         NA      19.32        090
                                                      forearm.
24498.............  ..............  A                Reinforce humerus.....      11.92         NA      12.68       1.67         NA      26.27        090
24500.............  ..............  A                Treat humerus fracture       3.21       5.31       3.38       0.41       8.93       7.00        090
24505.............  ..............  A                Treat humerus fracture       5.17       9.31       7.10       0.72      15.20      12.99        090
24515.............  ..............  A                Treat humerus fracture      11.65         NA      11.58       1.63         NA      24.86        090
24516.............  ..............  A                Treat humerus fracture      11.65         NA      12.14       1.63         NA      25.42        090
24530.............  ..............  A                Treat humerus fracture       3.50       6.52       4.97       0.47      10.49       8.94        090
24535.............  ..............  A                Treat humerus fracture       6.87       9.14       6.89       0.96      16.97      14.72        090
24538.............  ..............  A                Treat humerus fracture       9.43         NA      10.85       1.25         NA      21.53        090
24545.............  ..............  A                Treat humerus fracture      10.46         NA      10.37       1.47         NA      22.30        090
24546.............  ..............  A                Treat humerus fracture      15.69         NA      13.83       2.18         NA      31.70        090
24560.............  ..............  A                Treat humerus fracture       2.80       5.10       3.16       0.35       8.25       6.31        090
24565.............  ..............  A                Treat humerus fracture       5.56       8.24       6.05       0.74      14.54      12.35        090
24566.............  ..............  A                Treat humerus fracture       7.79         NA      10.34       1.10         NA      19.23        090
24575.............  ..............  A                Treat humerus fracture      10.66         NA       8.43       1.44         NA      20.53        090
24576.............  ..............  A                Treat humerus fracture       2.86       4.85       3.31       0.38       8.09       6.55        090
24577.............  ..............  A                Treat humerus fracture       5.79       8.47       6.32       0.81      15.07      12.92        090
24579.............  ..............  A                Treat humerus fracture      11.60         NA      11.31       1.62         NA      24.53        090
24582.............  ..............  A                Treat humerus fracture       8.55         NA      10.77       1.20         NA      20.52        090
24586.............  ..............  A                Treat elbow fracture..      15.21         NA      11.05       2.12         NA      28.38        090
24587.............  ..............  A                Treat elbow fracture..      15.16         NA      10.88       2.14         NA      28.18        090
24600.............  ..............  A                Treat elbow                  4.23       7.12       5.11       0.49      11.84       9.83        090
                                                      dislocation.
24605.............  ..............  A                Treat elbow                  5.42         NA       5.09       0.72         NA      11.23        090
                                                      dislocation.
24615.............  ..............  A                Treat elbow                  9.42         NA       7.97       1.31         NA      18.70        090
                                                      dislocation.
24620.............  ..............  A                Treat elbow fracture..       6.98         NA       6.71       0.90         NA      14.59        090
24635.............  ..............  A                Treat elbow fracture..      13.19         NA      16.64       1.84         NA      31.67        090
24640.............  ..............  A                Treat elbow                  1.20       3.54       1.84       0.11       4.85       3.15        010
                                                      dislocation.
24650.............  ..............  A                Treat radius fracture.       2.16       4.81       2.92       0.28       7.25       5.36        090
24655.............  ..............  A                Treat radius fracture.       4.40       7.66       5.41       0.58      12.64      10.39        090
24665.............  ..............  A                Treat radius fracture.       8.14         NA       9.72       1.13         NA      18.99        090
24666.............  ..............  A                Treat radius fracture.       9.49         NA      10.48       1.32         NA      21.29        090
24670.............  ..............  A                Treat ulnar fracture..       2.54       4.71       3.13       0.33       7.58       6.00        090
24675.............  ..............  A                Treat ulnar fracture..       4.72       7.86       5.68       0.65      13.23      11.05        090
24685.............  ..............  A                Treat ulnar fracture..       8.80         NA      10.08       1.23         NA      20.11        090
24800.............  ..............  A                Fusion of elbow joint.      11.20         NA       9.94       1.41         NA      22.55        090
24802.............  ..............  A                Fusion/graft of elbow       13.69         NA      11.56       1.89         NA      27.14        090
                                                      joint.
24900.............  ..............  A                Amputation of upper          9.60         NA      11.21       1.18         NA      21.99        090
                                                      arm.
24920.............  ..............  A                Amputation of upper          9.54         NA      12.82       1.22         NA      23.58        090
                                                      arm.
24925.............  ..............  A                Amputation follow-up         7.07         NA       9.68       0.95         NA      17.70        090
                                                      surgery.
24930.............  ..............  A                Amputation follow-up        10.25         NA      11.78       1.23         NA      23.26        090
                                                      surgery.
24931.............  ..............  A                Amputate upper arm &        12.72         NA       9.23       1.56         NA      23.51        090
                                                      implant.
24935.............  ..............  A                Revision of amputation      15.56         NA      12.63       1.58         NA      29.77        090
24940.............  ..............  C                Revision of upper arm.       0.00       0.00       0.00       0.00       0.00       0.00        090
24999.............  ..............  C                Upper arm/elbow              0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      surgery.
25000.............  ..............  A                Incision of tendon           3.38         NA       7.59       0.45         NA      11.42        090
                                                      sheath.
25001.............  ..............  A                Incise flexor carpi          3.38         NA       4.37       0.45         NA       8.20        090
                                                      radialis.

[[Page 80057]]

 
25020.............  ..............  A                Decompress forearm 1         5.92         NA      11.38       0.76         NA      18.06        090
                                                      space.
25023.............  ..............  A                Decompress forearm 1        12.96         NA      17.36       1.52         NA      31.84        090
                                                      space.
25024.............  ..............  A                Decompress forearm 2         9.50         NA       8.08       1.24         NA      18.82        090
                                                      spaces.
25025.............  ..............  A                Decompress forarm 2         16.54         NA      11.75       2.18         NA      30.47        090
                                                      spaces.
25028.............  ..............  A                Drainage of forearm          5.25         NA      10.17       0.61         NA      16.03        090
                                                      lesion.
25031.............  ..............  A                Drainage of forearm          4.14         NA      10.14       0.50         NA      14.78        090
                                                      bursa.
25035.............  ..............  A                Treat forearm bone           7.36         NA      16.87       0.98         NA      25.21        090
                                                      lesion.
25040.............  ..............  A                Explore/treat wrist          7.18         NA       9.48       0.96         NA      17.62        090
                                                      joint.
25065.............  ..............  A                Biopsy forearm soft          1.99       2.58       2.58       0.12       4.69       4.69        010
                                                      tissues.
25066.............  ..............  A                Biopsy forearm soft          4.13         NA       8.42       0.49         NA      13.04        090
                                                      tissues.
25075.............  ..............  A                Removel forearm lesion       3.74         NA       7.39       0.40         NA      11.53        090
                                                      subcu.
25076.............  ..............  A                Removel forearm lesion       4.92         NA      12.88       0.59         NA      18.39        090
                                                      deep.
25077.............  ..............  A                Remove tumor, forearm/       9.76         NA      15.51       1.10         NA      26.37        090
                                                      wrist.
25085.............  ..............  A                Incision of wrist            5.50         NA      11.29       0.71         NA      17.50        090
                                                      capsule.
25100.............  ..............  A                Biopsy of wrist joint.       3.90         NA       7.66       0.50         NA      12.06        090
25101.............  ..............  A                Explore/treat wrist          4.69         NA       8.02       0.60         NA      13.31        090
                                                      joint.
25105.............  ..............  A                Remove wrist joint           5.85         NA      11.25       0.77         NA      17.87        090
                                                      lining.
25107.............  ..............  A                Remove wrist joint           6.43         NA      11.62       0.82         NA      18.87        090
                                                      cartilage.
25110.............  ..............  A                Remove wrist tendon          3.92         NA       8.62       0.48         NA      13.02        090
                                                      lesion.
25111.............  ..............  A                Remove wrist tendon          3.39         NA       6.67       0.42         NA      10.48        090
                                                      lesion.
25112.............  ..............  A                Reremove wrist tendon        4.53         NA       7.49       0.54         NA      12.56        090
                                                      lesion.
25115.............  ..............  A                Remove wrist/forearm         8.82         NA      17.36       1.11         NA      27.29        090
                                                      lesion.
25116.............  ..............  A                Remove wrist/forearm         7.11         NA      16.36       0.90         NA      24.37        090
                                                      lesion.
25118.............  ..............  A                Excise wrist tendon          4.37         NA       8.09       0.55         NA      13.01        090
                                                      sheath.
25119.............  ..............  A                Partial removal of           6.04         NA      11.54       0.80         NA      18.38        090
                                                      ulna.
25120.............  ..............  A                Removal of forearm           6.10         NA      15.31       0.81         NA      22.22        090
                                                      lesion.
25125.............  ..............  A                Remove/graft forearm         7.48         NA      16.39       1.02         NA      24.89        090
                                                      lesion.
25126.............  ..............  A                Remove/graft forearm         7.55         NA      15.93       1.00         NA      24.48        090
                                                      lesion.
25130.............  ..............  A                Removal of wrist             5.26         NA       8.44       0.66         NA      14.36        090
                                                      lesion.
25135.............  ..............  A                Remove & graft wrist         6.89         NA       9.27       0.89         NA      17.05        090
                                                      lesion.
25136.............  ..............  A                Remove & graft wrist         5.97         NA       8.50       0.58         NA      15.05        090
                                                      lesion.
25145.............  ..............  A                Remove forearm bone          6.37         NA      15.73       0.82         NA      22.92        090
                                                      lesion.
25150.............  ..............  A                Partial removal of           7.09         NA      12.28       0.96         NA      20.33        090
                                                      ulna.
25151.............  ..............  A                Partial removal of           7.39         NA      16.28       0.93         NA      24.60        090
                                                      radius.
25170.............  ..............  A                Extensive forearm           11.09         NA      17.76       1.52         NA      30.37        090
                                                      surgery.
25210.............  ..............  A                Removal of wrist bone.       5.95         NA       8.84       0.73         NA      15.52        090
25215.............  ..............  A                Removal of wrist bones       7.89         NA      12.52       1.02         NA      21.43        090
25230.............  ..............  A                Partial removal of           5.23         NA       8.35       0.66         NA      14.24        090
                                                      radius.
25240.............  ..............  A                Partial removal of           5.17         NA      11.07       0.69         NA      16.93        090
                                                      ulna.
25246.............  ..............  A                Injection for wrist x-       1.45      10.27       0.50       0.07      11.79       2.02        000
                                                      ray.
25248.............  ..............  A                Remove forearm foreign       5.14         NA      10.23       0.54         NA      15.91        090
                                                      body.
25250.............  ..............  A                Removal of wrist             6.60         NA       6.19       0.84         NA      13.63        090
                                                      prosthesis.
25251.............  ..............  A                Removal of wrist             9.57         NA       8.08       1.15         NA      18.80        090
                                                      prosthesis.
25259.............  ..............  A                Manipulate wrist w/          3.75         NA       5.46       0.50         NA       9.71        090
                                                      anesthes.
25260.............  ..............  A                Repair forearm tendon/       7.80         NA      17.12       0.97         NA      25.89        090
                                                      muscle.
25263.............  ..............  A                Repair forearm tendon/       7.82         NA      16.99       0.94         NA      25.75        090
                                                      muscle.
25265.............  ..............  A                Repair forearm tendon/       9.88         NA      17.71       1.19         NA      28.78        090
                                                      muscle.
25270.............  ..............  A                Repair forearm tendon/       6.00         NA      16.17       0.76         NA      22.93        090
                                                      muscle.
25272.............  ..............  A                Repair forearm tendon/       7.04         NA      16.74       0.89         NA      24.67        090
                                                      muscle.
25274.............  ..............  A                Repair forearm tendon/       8.75         NA      17.17       1.14         NA      27.06        090
                                                      muscle.
25275.............  ..............  A                Repair forearm tendon        8.50         NA       7.44       1.13         NA      17.07        090
                                                      sheath.
25280.............  ..............  A                Revise wrist/forearm         7.22         NA      16.29       0.91         NA      24.42        090
                                                      tendon.
25290.............  ..............  A                Incise wrist/forearm         5.29         NA      18.62       0.66         NA      24.57        090
                                                      tendon.
25295.............  ..............  A                Release wrist/forearm        6.55         NA      15.93       0.86         NA      23.34        090
                                                      tendon.
25300.............  ..............  A                Fusion of tendons at         8.80         NA      10.06       1.07         NA      19.93        090
                                                      wrist.
25301.............  ..............  A                Fusion of tendons at         8.40         NA       9.98       1.08         NA      19.46        090
                                                      wrist.
25310.............  ..............  A                Transplant forearm           8.14         NA      16.74       1.01         NA      25.89        090
                                                      tendon.
25312.............  ..............  A                Transplant forearm           9.57         NA      17.49       1.22         NA      28.28        090
                                                      tendon.
25315.............  ..............  A                Revise palsy hand           10.20         NA      18.31       1.26         NA      29.77        090
                                                      tendon(s).
25316.............  ..............  A                Revise palsy hand           12.33         NA      19.71       1.74         NA      33.78        090
                                                      tendon(s).
25320.............  ..............  A                Repair/revise wrist         10.77         NA      11.50       1.32         NA      23.59        090
                                                      joint.
25332.............  ..............  A                Revise wrist joint....      11.41         NA       9.34       1.46         NA      22.21        090
25335.............  ..............  A                Realignment of hand...      12.88         NA      14.95       1.66         NA      29.49        090
25337.............  ..............  A                Reconstruct ulna/           10.17         NA      13.85       1.31         NA      25.33        090
                                                      radioulnar.
25350.............  ..............  A                Revision of radius....       8.78         NA      16.98       1.17         NA      26.93        090
25355.............  ..............  A                Revision of radius....      10.17         NA      17.60       1.44         NA      29.21        090
25360.............  ..............  A                Revision of ulna......       8.43         NA      16.89       1.17         NA      26.49        090
25365.............  ..............  A                Revise radius & ulna..      12.40         NA      18.51       1.67         NA      32.58        090
25370.............  ..............  A                Revise radius or ulna.      13.36         NA      18.42       1.88         NA      33.66        090
25375.............  ..............  A                Revise radius & ulna..      13.04         NA      19.42       1.84         NA      34.30        090
25390.............  ..............  A                Shorten radius or ulna      10.40         NA      17.69       1.38         NA      29.47        090
25391.............  ..............  A                Lengthen radius or          13.65         NA      19.37       1.73         NA      34.75        090
                                                      ulna.
25392.............  ..............  A                Shorten radius & ulna.      13.95         NA      18.37       1.73         NA      34.05        090
25393.............  ..............  A                Lengthen radius & ulna      15.87         NA      20.63       1.87         NA      38.37        090
25394.............  ..............  A                Repair carpal bone,         10.40         NA       8.29       1.40         NA      20.09        090
                                                      shorten.

[[Page 80058]]

 
25400.............  ..............  A                Repair radius or ulna.      10.92         NA      18.22       1.50         NA      30.64        090
25405.............  ..............  A                Repair/graft radius or      14.38         NA      20.48       1.95         NA      36.81        090
                                                      ulna.
25415.............  ..............  A                Repair radius & ulna..      13.35         NA      19.39       1.87         NA      34.61        090
25420.............  ..............  A                Repair/graft radius &       16.33         NA      21.34       2.20         NA      39.87        090
                                                      ulna.
25425.............  ..............  A                Repair/graft radius or      13.21         NA      26.80       1.61         NA      41.62        090
                                                      ulna.
25426.............  ..............  A                Repair/graft radius &       15.82         NA      20.12       2.23         NA      38.17        090
                                                      ulna.
25430.............  ..............  A                Vasc graft into carpal       9.25         NA       7.62       1.07         NA      17.94        090
                                                      bone.
25431.............  ..............  A                Repair nonunion carpal      10.44         NA       6.38       0.56         NA      17.38        090
                                                      bone.
25440.............  ..............  A                Repair/graft wrist          10.44         NA      11.25       1.41         NA      23.10        090
                                                      bone.
25441.............  ..............  A                Reconstruct wrist           12.90         NA      10.14       1.83         NA      24.87        090
                                                      joint.
25442.............  ..............  A                Reconstruct wrist           10.85         NA       9.00       1.24         NA      21.09        090
                                                      joint.
25443.............  ..............  A                Reconstruct wrist           10.39         NA       8.89       1.30         NA      20.58        090
                                                      joint.
25444.............  ..............  A                Reconstruct wrist           11.15         NA       9.17       1.43         NA      21.75        090
                                                      joint.
25445.............  ..............  A                Reconstruct wrist            9.69         NA       8.18       1.26         NA      19.13        090
                                                      joint.
25446.............  ..............  A                Wrist replacement.....      16.55         NA      12.17       2.20         NA      30.92        090
25447.............  ..............  A                Repair wrist joint(s).      10.37         NA       8.76       1.34         NA      20.47        090
25449.............  ..............  A                Remove wrist joint          14.49         NA      10.89       1.77         NA      27.15        090
                                                      implant.
25450.............  ..............  A                Revision of wrist            7.87         NA      13.09       0.88         NA      21.84        090
                                                      joint.
25455.............  ..............  A                Revision of wrist            9.49         NA      14.28       1.07         NA      24.84        090
                                                      joint.
25490.............  ..............  A                Reinforce radius......       9.54         NA      16.71       1.19         NA      27.44        090
25491.............  ..............  A                Reinforce ulna........       9.96         NA      17.58       1.41         NA      28.95        090
25492.............  ..............  A                Reinforce radius and        12.33         NA      18.06       1.62         NA      32.01        090
                                                      ulna.
25500.............  ..............  A                Treat fracture of            2.45       4.37       2.93       0.28       7.10       5.66        090
                                                      radius.
25505.............  ..............  A                Treat fracture of            5.21       8.04       5.81       0.69      13.94      11.71        090
                                                      radius.
25515.............  ..............  A                Treat fracture of            9.18         NA      10.00       1.22         NA      20.40        090
                                                      radius.
25520.............  ..............  A                Treat fracture of            6.26       8.23       6.43       0.85      15.34      13.54        090
                                                      radius.
25525.............  ..............  A                Treat fracture of           12.24         NA      11.92       1.68         NA      25.84        090
                                                      radius.
25526.............  ..............  A                Treat fracture of           12.98         NA      15.40       1.80         NA      30.18        090
                                                      radius.
25530.............  ..............  A                Treat fracture of ulna       2.09       4.42       2.92       0.27       6.78       5.28        090
25535.............  ..............  A                Treat fracture of ulna       5.14       7.81       5.86       0.68      13.63      11.68        090
25545.............  ..............  A                Treat fracture of ulna       8.90         NA      10.14       1.23         NA      20.27        090
25560.............  ..............  A                Treat fracture radius        2.44       4.41       2.90       0.27       7.12       5.61        090
                                                      & ulna.
25565.............  ..............  A                Treat fracture radius        5.63       8.28       6.02       0.76      14.67      12.41        090
                                                      & ulna.
25574.............  ..............  A                Treat fracture radius        7.01         NA       9.05       0.96         NA      17.02        090
                                                      & ulna.
25575.............  ..............  A                Treat fracture radius/      10.45         NA      10.98       1.46         NA      22.89        090
                                                      ulna.
25600.............  ..............  A                Treat fracture radius/       2.63       4.75       3.11       0.34       7.72       6.08        090
                                                      ulna.
25605.............  ..............  A                Treat fracture radius/       5.81       8.51       6.27       0.81      15.13      12.89        090
                                                      ulna.
25611.............  ..............  A                Treat fracture radius/       7.77         NA      10.37       1.08         NA      19.22        090
                                                      ulna.
25620.............  ..............  A                Treat fracture radius/       8.55         NA       9.91       1.17         NA      19.63        090
                                                      ulna.
25622.............  ..............  A                Treat wrist bone             2.61       4.70       3.08       0.33       7.64       6.02        090
                                                      fracture.
25624.............  ..............  A                Treat wrist bone             4.53       7.73       5.49       0.61      12.87      10.63        090
                                                      fracture.
25628.............  ..............  A                Treat wrist bone             8.43         NA       9.95       1.14         NA      19.52        090
                                                      fracture.
25630.............  ..............  A                Treat wrist bone             2.88       4.86       3.14       0.37       8.11       6.39        090
                                                      fracture.
25635.............  ..............  A                Treat wrist bone             4.39       7.68       4.75       0.39      12.46       9.53        090
                                                      fracture.
25645.............  ..............  A                Treat wrist bone             7.25         NA       9.47       0.93         NA      17.65        090
                                                      fracture.
25650.............  ..............  A                Treat wrist bone             3.05       4.91       3.21       0.37       8.33       6.63        090
                                                      fracture.
25651.............  ..............  A                Pin ulnar styloid            5.36         NA       5.69       0.72         NA      11.77        090
                                                      fracture.
25652.............  ..............  A                Treat fracture ulnar         7.60         NA       6.85       1.02         NA      15.47        090
                                                      styloid.
25660.............  ..............  A                Treat wrist                  4.76         NA       5.49       0.59         NA      10.84        090
                                                      dislocation.
25670.............  ..............  A                Treat wrist                  7.92         NA       9.73       1.07         NA      18.72        090
                                                      dislocation.
25671.............  ..............  A                Pin radioulnar               6.00         NA       6.02       0.81         NA      12.83        090
                                                      dislocation.
25675.............  ..............  A                Treat wrist                  4.67       7.52       5.43       0.57      12.76      10.67        090
                                                      dislocation.
25676.............  ..............  A                Treat wrist                  8.04         NA       9.78       1.10         NA      18.92        090
                                                      dislocation.
25680.............  ..............  A                Treat wrist fracture..       5.99         NA       6.48       0.61         NA      13.08        090
25685.............  ..............  A                Treat wrist fracture..       9.78         NA      10.44       1.25         NA      21.47        090
25690.............  ..............  A                Treat wrist                  5.50         NA       7.21       0.78         NA      13.49        090
                                                      dislocation.
25695.............  ..............  A                Treat wrist                  8.34         NA       9.86       1.07         NA      19.27        090
                                                      dislocation.
25800.............  ..............  A                Fusion of wrist joint.       9.76         NA      10.92       1.30         NA      21.98        090
25805.............  ..............  A                Fusion/graft of wrist       11.28         NA      11.81       1.51         NA      24.60        090
                                                      joint.
25810.............  ..............  A                Fusion/graft of wrist       10.57         NA      11.34       1.37         NA      23.28        090
                                                      joint.
25820.............  ..............  A                Fusion of hand bones..       7.45         NA       9.68       0.96         NA      18.09        090
25825.............  ..............  A                Fuse hand bones with         9.27         NA      10.66       1.20         NA      21.13        090
                                                      graft.
25830.............  ..............  A                Fusion, radioulnar jnt/     10.06         NA      17.12       1.27         NA      28.45        090
                                                      ulna.
25900.............  ..............  A                Amputation of forearm.       9.01         NA      14.48       1.08         NA      24.57        090
25905.............  ..............  A                Amputation of forearm.       9.12         NA      15.75       1.06         NA      25.93        090
25907.............  ..............  A                Amputation follow-up         7.80         NA      15.19       1.01         NA      24.00        090
                                                      surgery.
25909.............  ..............  A                Amputation follow-up         8.96         NA      15.62       1.07         NA      25.65        090
                                                      surgery.
25915.............  ..............  A                Amputation of forearm.      17.08         NA      23.14       2.41         NA      42.63        090
25920.............  ..............  A                Amputate hand at wrist       8.68         NA       9.91       1.06         NA      19.65        090
25922.............  ..............  A                Amputate hand at wrist       7.42         NA       9.06       0.93         NA      17.41        090
25924.............  ..............  A                Amputation follow-up         8.46         NA      10.25       1.07         NA      19.78        090
                                                      surgery.
25927.............  ..............  A                Amputation of hand....       8.80         NA      14.18       1.02         NA      24.00        090
25929.............  ..............  A                Amputation follow-up         7.59         NA       7.83       0.89         NA      16.31        090
                                                      surgery.
25931.............  ..............  A                Amputation follow-up         7.81         NA      15.09       0.88         NA      23.78        090
                                                      surgery.
25999.............  ..............  C                Forearm or wrist             0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      surgery.

[[Page 80059]]

 
26010.............  ..............  A                Drainage of finger           1.54       5.97       1.78       0.14       7.65       3.46        010
                                                      abscess.
26011.............  ..............  A                Drainage of finger           2.19      12.48       2.48       0.25      14.92       4.92        010
                                                      abscess.
26020.............  ..............  A                Drain hand tendon            4.67         NA       5.31       0.59         NA      10.57        090
                                                      sheath.
26025.............  ..............  A                Drainage of palm bursa       4.82         NA       5.18       0.60         NA      10.60        090
26030.............  ..............  A                Drainage of palm             5.93         NA       5.85       0.72         NA      12.50        090
                                                      bursa(s).
26034.............  ..............  A                Treat hand bone lesion       6.23         NA       6.04       0.79         NA      13.06        090
26035.............  ..............  A                Decompress fingers/          9.51         NA       7.99       1.12         NA      18.62        090
                                                      hand.
26037.............  ..............  A                Decompress fingers/          7.25         NA       6.48       0.87         NA      14.60        090
                                                      hand.
26040.............  ..............  A                Release palm                 3.33         NA       3.75       0.45         NA       7.53        090
                                                      contracture.
26045.............  ..............  A                Release palm                 5.56         NA       5.30       0.74         NA      11.60        090
                                                      contracture.
26055.............  ..............  A                Incise finger tendon         2.69      15.46       3.59       0.36      18.51       6.64        090
                                                      sheath.
26060.............  ..............  A                Incision of finger           2.81         NA       3.28       0.35         NA       6.44        090
                                                      tendon.
26070.............  ..............  A                Explore/treat hand           3.69         NA       3.32       0.35         NA       7.36        090
                                                      joint.
26075.............  ..............  A                Explore/treat finger         3.79         NA       3.67       0.40         NA       7.86        090
                                                      joint.
26080.............  ..............  A                Explore/treat finger         4.24         NA       4.58       0.52         NA       9.34        090
                                                      joint.
26100.............  ..............  A                Biopsy hand joint            3.67         NA       3.90       0.45         NA       8.02        090
                                                      lining.
26105.............  ..............  A                Biopsy finger joint          3.71         NA       3.93       0.45         NA       8.09        090
                                                      lining.
26110.............  ..............  A                Biopsy finger joint          3.53         NA       3.80       0.44         NA       7.77        090
                                                      lining.
26115.............  ..............  A                Removel hand lesion          3.86      14.42       4.43       0.48      18.76       8.77        090
                                                      subcut.
26116.............  ..............  A                Removel hand lesion,         5.53         NA       5.66       0.69         NA      11.88        090
                                                      deep.
26117.............  ..............  A                Remove tumor, hand/          8.55         NA       6.94       1.01         NA      16.50        090
                                                      finger.
26121.............  ..............  A                Release palm                 7.54         NA       6.72       0.94         NA      15.20        090
                                                      contracture.
26123.............  ..............  A                Release palm                 9.29         NA       8.65       1.17         NA      19.11        090
                                                      contracture.
26125.............  ..............  A                Release palm                 4.61         NA       2.51       0.57         NA       7.69        ZZZ
                                                      contracture.
26130.............  ..............  A                Remove wrist joint           5.42         NA       5.12       0.65         NA      11.19        090
                                                      lining.
26135.............  ..............  A                Revise finger joint,         6.96         NA       6.20       0.87         NA      14.03        090
                                                      each.
26140.............  ..............  A                Revise finger joint,         6.17         NA       5.75       0.76         NA      12.68        090
                                                      each.
26145.............  ..............  A                Tendon excision, palm/       6.32         NA       5.78       0.77         NA      12.87        090
                                                      finger.
26160.............  ..............  A                Remove tendon sheath         3.15      18.94       3.86       0.39      22.48       7.40        090
                                                      lesion.
26170.............  ..............  A                Removal of palm              4.77         NA       4.72       0.60         NA      10.09        090
                                                      tendon, each.
26180.............  ..............  A                Removal of finger            5.18         NA       5.10       0.64         NA      10.92        090
                                                      tendon.
26185.............  ..............  A                Remove finger bone....       5.25         NA       5.62       0.67         NA      11.54        090
26200.............  ..............  A                Remove hand bone             5.51         NA       5.14       0.71         NA      11.36        090
                                                      lesion.
26205.............  ..............  A                Remove/graft bone            7.70         NA       6.69       0.95         NA      15.34        090
                                                      lesion.
26210.............  ..............  A                Removal of finger            5.15         NA       5.12       0.64         NA      10.91        090
                                                      lesion.
26215.............  ..............  A                Remove/graft finger          7.10         NA       6.07       0.77         NA      13.94        090
                                                      lesion.
26230.............  ..............  A                Partial removal of           6.33         NA       5.68       0.84         NA      12.85        090
                                                      hand bone.
26235.............  ..............  A                Partial removal,             6.19         NA       5.62       0.78         NA      12.59        090
                                                      finger bone.
26236.............  ..............  A                Partial removal,             5.32         NA       5.17       0.66         NA      11.15        090
                                                      finger bone.
26250.............  ..............  A                Extensive hand surgery       7.55         NA       6.23       0.92         NA      14.70        090
26255.............  ..............  A                Extensive hand surgery      12.43         NA       9.26       1.05         NA      22.74        090
26260.............  ..............  A                Extensive finger             7.03         NA       5.98       0.83         NA      13.84        090
                                                      surgery.
26261.............  ..............  A                Extensive finger             9.09         NA       6.22       0.84         NA      16.15        090
                                                      surgery.
26262.............  ..............  A                Partial removal of           5.67         NA       5.18       0.70         NA      11.55        090
                                                      finger.
26320.............  ..............  A                Removal of implant           3.98         NA       4.50       0.49         NA       8.97        090
                                                      from hand.
26340.............  ..............  A                Manipulate finger w/         2.50         NA       4.64       0.30         NA       7.44        090
                                                      anesth.
26350.............  ..............  A                Repair finger/hand           5.99         NA      20.03       0.73         NA      26.75        090
                                                      tendon.
26352.............  ..............  A                Repair/graft hand            7.68         NA      20.50       0.93         NA      29.11        090
                                                      tendon.
26356.............  ..............  A                Repair finger/hand           8.07         NA      21.49       0.99         NA      30.55        090
                                                      tendon.
26357.............  ..............  A                Repair finger/hand           8.58         NA      21.19       1.02         NA      30.79        090
                                                      tendon.
26358.............  ..............  A                Repair/graft hand            9.14         NA      21.74       1.07         NA      31.95        090
                                                      tendon.
26370.............  ..............  A                Repair finger/hand           7.11         NA      20.67       0.90         NA      28.68        090
                                                      tendon.
26372.............  ..............  A                Repair/graft hand            8.76         NA      22.00       1.06         NA      31.82        090
                                                      tendon.
26373.............  ..............  A                Repair finger/hand           8.16         NA      21.56       0.98         NA      30.70        090
                                                      tendon.
26390.............  ..............  A                Revise hand/finger           9.19         NA      16.75       1.09         NA      27.03        090
                                                      tendon.
26392.............  ..............  A                Repair/graft hand           10.26         NA      22.55       1.26         NA      34.07        090
                                                      tendon.
26410.............  ..............  A                Repair hand tendon....       4.63         NA      16.30       0.57         NA      21.50        090
26412.............  ..............  A                Repair/graft hand            6.31         NA      17.39       0.80         NA      24.50        090
                                                      tendon.
26415.............  ..............  A                Excision, hand/finger        8.34         NA      15.90       0.77         NA      25.01        090
                                                      tendon.
26416.............  ..............  A                Graft hand or finger         9.37         NA      18.56       1.20         NA      29.13        090
                                                      tendon.
26418.............  ..............  A                Repair finger tendon..       4.25         NA      16.13       0.50         NA      20.88        090
26420.............  ..............  A                Repair/graft finger          6.77         NA      17.69       0.83         NA      25.29        090
                                                      tendon.
26426.............  ..............  A                Repair finger/hand           6.15         NA      17.16       0.77         NA      24.08        090
                                                      tendon.
26428.............  ..............  A                Repair/graft finger          7.21         NA      18.24       0.84         NA      26.29        090
                                                      tendon.
26432.............  ..............  A                Repair finger tendon..       4.02         NA      13.36       0.48         NA      17.86        090
26433.............  ..............  A                Repair finger tendon..       4.56         NA      14.27       0.56         NA      19.39        090
26434.............  ..............  A                Repair/graft finger          6.09         NA      14.67       0.71         NA      21.47        090
                                                      tendon.
26437.............  ..............  A                Realignment of tendons       5.82         NA      14.40       0.74         NA      20.96        090
26440.............  ..............  A                Release palm/finger          5.02         NA      18.87       0.62         NA      24.51        090
                                                      tendon.
26442.............  ..............  A                Release palm & finger        8.16         NA      20.31       0.94         NA      29.41        090
                                                      tendon.
26445.............  ..............  A                Release hand/finger          4.31         NA      18.71       0.54         NA      23.56        090
                                                      tendon.
26449.............  ..............  A                Release forearm/hand         7.00         NA      20.02       0.84         NA      27.86        090
                                                      tendon.
26450.............  ..............  A                Incision of palm             3.67         NA       8.57       0.46         NA      12.70        090
                                                      tendon.
26455.............  ..............  A                Incision of finger           3.64         NA       8.45       0.47         NA      12.56        090
                                                      tendon.
26460.............  ..............  A                Incise hand/finger           3.46         NA       8.20       0.44         NA      12.10        090
                                                      tendon.

[[Page 80060]]

 
26471.............  ..............  A                Fusion of finger             5.73         NA      14.06       0.73         NA      20.52        090
                                                      tendons.
26474.............  ..............  A                Fusion of finger             5.32         NA      14.31       0.69         NA      20.32        090
                                                      tendons.
26476.............  ..............  A                Tendon lengthening....       5.18         NA      13.80       0.62         NA      19.60        090
26477.............  ..............  A                Tendon shortening.....       5.15         NA      14.01       0.60         NA      19.76        090
26478.............  ..............  A                Lengthening of hand          5.80         NA      14.65       0.77         NA      21.22        090
                                                      tendon.
26479.............  ..............  A                Shortening of hand           5.74         NA      14.65       0.76         NA      21.15        090
                                                      tendon.
26480.............  ..............  A                Transplant hand tendon       6.69         NA      19.94       0.84         NA      27.47        090
26483.............  ..............  A                Transplant/graft hand        8.29         NA      20.43       1.03         NA      29.75        090
                                                      tendon.
26485.............  ..............  A                Transplant palm tendon       7.70         NA      20.34       0.94         NA      28.98        090
26489.............  ..............  A                Transplant/graft palm        9.55         NA      17.04       0.98         NA      27.57        090
                                                      tendon.
26490.............  ..............  A                Revise thumb tendon...       8.41         NA      15.54       1.05         NA      25.00        090
26492.............  ..............  A                Tendon transfer with         9.62         NA      16.15       1.19         NA      26.96        090
                                                      graft.
26494.............  ..............  A                Hand tendon/muscle           8.47         NA      16.14       1.13         NA      25.74        090
                                                      transfer.
26496.............  ..............  A                Revise thumb tendon...       9.59         NA      15.87       1.17         NA      26.63        090
26497.............  ..............  A                Finger tendon transfer       9.57         NA      16.32       1.17         NA      27.06        090
26498.............  ..............  A                Finger tendon transfer      14.00         NA      18.71       1.74         NA      34.45        090
26499.............  ..............  A                Revision of finger....       8.98         NA      17.02       0.94         NA      26.94        090
26500.............  ..............  A                Hand tendon                  5.96         NA      14.98       0.66         NA      21.60        090
                                                      reconstruction.
26502.............  ..............  A                Hand tendon                  7.14         NA      15.27       0.87         NA      23.28        090
                                                      reconstruction.
26504.............  ..............  A                Hand tendon                  7.47         NA      15.08       0.84         NA      23.39        090
                                                      reconstruction.
26508.............  ..............  A                Release thumb                6.01         NA      14.59       0.76         NA      21.36        090
                                                      contracture.
26510.............  ..............  A                Thumb tendon transfer.       5.43         NA      14.30       0.71         NA      20.44        090
26516.............  ..............  A                Fusion of knuckle            7.15         NA      15.07       0.90         NA      23.12        090
                                                      joint.
26517.............  ..............  A                Fusion of knuckle            8.83         NA      16.41       0.96         NA      26.20        090
                                                      joints.
26518.............  ..............  A                Fusion of knuckle            9.02         NA      16.12       1.13         NA      26.27        090
                                                      joints.
26520.............  ..............  A                Release knuckle              5.30         NA      18.85       0.65         NA      24.80        090
                                                      contracture.
26525.............  ..............  A                Release finger               5.33         NA      19.02       0.66         NA      25.01        090
                                                      contracture.
26530.............  ..............  A                Revise knuckle joint..       6.69         NA       6.04       0.86         NA      13.59        090
26531.............  ..............  A                Revise knuckle with          7.91         NA       6.95       1.01         NA      15.87        090
                                                      implant.
26535.............  ..............  A                Revise finger joint...       5.24         NA       3.69       0.66         NA       9.59        090
26536.............  ..............  A                Revise/implant finger        6.37         NA      10.32       0.80         NA      17.49        090
                                                      joint.
26540.............  ..............  A                Repair hand joint.....       6.43         NA      14.89       0.81         NA      22.13        090
26541.............  ..............  A                Repair hand joint with       8.62         NA      16.25       1.12         NA      25.99        090
                                                      graft.
26542.............  ..............  A                Repair hand joint with       6.78         NA      14.78       0.87         NA      22.43        090
                                                      graft.
26545.............  ..............  A                Reconstruct finger           6.92         NA      15.52       0.79         NA      23.23        090
                                                      joint.
26546.............  ..............  A                Repair nonunion hand..       8.92         NA      16.15       1.14         NA      26.21        090
26548.............  ..............  A                Reconstruct finger           8.03         NA      16.02       0.98         NA      25.03        090
                                                      joint.
26550.............  ..............  A                Construct thumb             21.24         NA      23.47       1.80         NA      46.51        090
                                                      replacement.
26551.............  ..............  A                Great toe-hand              46.58         NA      36.90       6.57         NA      90.05        090
                                                      transfer.
26553.............  ..............  A                Single transfer, toe-       46.27         NA      28.16       1.99         NA      76.42        090
                                                      hand.
26554.............  ..............  A                Double transfer, toe-       54.95         NA      38.79       7.76         NA     101.50        090
                                                      hand.
26555.............  ..............  A                Positional change of        16.63         NA      22.51       2.13         NA      41.27        090
                                                      finger.
26556.............  ..............  A                Toe joint transfer....      47.26         NA      34.27       6.67         NA      88.20        090
26560.............  ..............  A                Repair of web finger..       5.38         NA      12.99       0.60         NA      18.97        090
26561.............  ..............  A                Repair of web finger..      10.92         NA      16.12       0.69         NA      27.73        090
26562.............  ..............  A                Repair of web finger..      15.00         NA      19.37       0.98         NA      35.35        090
26565.............  ..............  A                Correct metacarpal           6.74         NA      14.95       0.84         NA      22.53        090
                                                      flaw.
26567.............  ..............  A                Correct finger               6.82         NA      14.88       0.84         NA      22.54        090
                                                      deformity.
26568.............  ..............  A                Lengthen metacarpal/         9.08         NA      20.41       1.10         NA      30.59        090
                                                      finger.
26580.............  ..............  A                Repair hand deformity.      18.18         NA      15.87       1.46         NA      35.51        090
26587.............  ..............  A                Reconstruct extra           14.05       6.36         NA       1.12      21.53         NA        090
                                                      finger.
26590.............  ..............  A                Repair finger               17.96         NA      17.46       1.32         NA      36.74        090
                                                      deformity.
26591.............  ..............  A                Repair muscles of hand       3.25         NA      13.80       0.37         NA      17.42        090
26593.............  ..............  A                Release muscles of           5.31         NA      13.78       0.64         NA      19.73        090
                                                      hand.
26596.............  ..............  A                Excision constricting        8.95         NA       9.86       0.87         NA      19.68        090
                                                      tissue.
26600.............  ..............  A                Treat metacarpal             1.96       4.36       2.83       0.25       6.57       5.04        090
                                                      fracture.
26605.............  ..............  A                Treat metacarpal             2.85       6.33       4.45       0.38       9.56       7.68        090
                                                      fracture.
26607.............  ..............  A                Treat metacarpal             5.36         NA       8.46       0.70         NA      14.52        090
                                                      fracture.
26608.............  ..............  A                Treat metacarpal             5.36         NA       9.07       0.73         NA      15.16        090
                                                      fracture.
26615.............  ..............  A                Treat metacarpal             5.33         NA       8.49       0.70         NA      14.52        090
                                                      fracture.
26641.............  ..............  A                Treat thumb                  3.94       6.70       4.86       0.42      11.06       9.22        090
                                                      dislocation.
26645.............  ..............  A                Treat thumb fracture..       4.41       7.51       5.35       0.54      12.46      10.30        090
26650.............  ..............  A                Treat thumb fracture..       5.72         NA       9.24       0.77         NA      15.73        090
26665.............  ..............  A                Treat thumb fracture..       7.60         NA       9.52       0.97         NA      18.09        090
26670.............  ..............  A                Treat hand dislocation       3.69       6.53       4.75       0.36      10.58       8.80        090
26675.............  ..............  A                Treat hand dislocation       4.64       6.66       4.57       0.56      11.86       9.77        090
26676.............  ..............  A                Pin hand dislocation..       5.52         NA       9.30       0.76         NA      15.58        090
26685.............  ..............  A                Treat hand dislocation       6.98         NA       9.14       0.95         NA      17.07        090
26686.............  ..............  A                Treat hand dislocation       7.94         NA       9.73       1.05         NA      18.72        090
26700.............  ..............  A                Treat knuckle                3.69       5.13       2.96       0.35       9.17       7.00        090
                                                      dislocation.
26705.............  ..............  A                Treat knuckle                4.19       6.47       4.41       0.50      11.16       9.10        090
                                                      dislocation.
26706.............  ..............  A                Pin knuckle                  5.12         NA       5.98       0.64         NA      11.74        090
                                                      dislocation.
26715.............  ..............  A                Treat knuckle                5.74         NA       8.65       0.75         NA      15.14        090
                                                      dislocation.
26720.............  ..............  A                Treat finger fracture,       1.66       3.22       1.69       0.20       5.08       3.55        090
                                                      each.
26725.............  ..............  A                Treat finger fracture,       3.33       5.47       3.28       0.43       9.23       7.04        090
                                                      each.

[[Page 80061]]

 
26727.............  ..............  A                Treat finger fracture,       5.23         NA       9.18       0.69         NA      15.10        090
                                                      each.
26735.............  ..............  A                Treat finger fracture,       5.98         NA       8.91       0.77         NA      15.66        090
                                                      each.
26740.............  ..............  A                Treat finger fracture,       1.94       4.01       2.67       0.24       6.19       4.85        090
                                                      each.
26742.............  ..............  A                Treat finger fracture,       3.85       7.41       5.28       0.49      11.75       9.62        090
                                                      each.
26746.............  ..............  A                Treat finger fracture,       5.81         NA       8.98       0.74         NA      15.53        090
                                                      each.
26750.............  ..............  A                Treat finger fracture,       1.70       3.82       2.41       0.19       5.71       4.30        090
                                                      each.
26755.............  ..............  A                Treat finger fracture,       3.10       5.25       3.10       0.37       8.72       6.57        090
                                                      each.
26756.............  ..............  A                Pin finger fracture,         4.39         NA       8.89       0.56         NA      13.84        090
                                                      each.
26765.............  ..............  A                Treat finger fracture,       4.17         NA       7.97       0.51         NA      12.65        090
                                                      each.
26770.............  ..............  A                Treat finger                 3.02       4.98       2.71       0.27       8.27       6.00        090
                                                      dislocation.
26775.............  ..............  A                Treat finger                 3.71       6.25       4.06       0.43      10.39       8.20        090
                                                      dislocation.
26776.............  ..............  A                Pin finger dislocation       4.80         NA       9.01       0.63         NA      14.44        090
26785.............  ..............  A                Treat finger                 4.21         NA       7.94       0.54         NA      12.69        090
                                                      dislocation.
26820.............  ..............  A                Thumb fusion with            8.26         NA      16.22       1.11         NA      25.59        090
                                                      graft.
26841.............  ..............  A                Fusion of thumb.......       7.13         NA      15.46       0.97         NA      23.56        090
26842.............  ..............  A                Thumb fusion with            8.24         NA      16.24       1.10         NA      25.58        090
                                                      graft.
26843.............  ..............  A                Fusion of hand joint..       7.61         NA      14.93       0.99         NA      23.53        090
26844.............  ..............  A                Fusion/graft of hand         8.73         NA      16.20       1.12         NA      26.05        090
                                                      joint.
26850.............  ..............  A                Fusion of knuckle.....       6.97         NA      14.89       0.89         NA      22.75        090
26852.............  ..............  A                Fusion of knuckle with       8.46         NA      15.84       1.05         NA      25.35        090
                                                      graft.
26860.............  ..............  A                Fusion of finger joint       4.69         NA      13.75       0.60         NA      19.04        090
26861.............  ..............  A                Fusion of finger jnt,        1.74         NA       0.96       0.22         NA       2.92        ZZZ
                                                      add-on.
26862.............  ..............  A                Fusion/graft of finger       7.37         NA      15.38       0.92         NA      23.67        090
                                                      joint.
26863.............  ..............  A                Fuse/graft added joint       3.90         NA       2.17       0.51         NA       6.58        ZZZ
26910.............  ..............  A                Amputate metacarpal          7.60         NA      14.07       0.90         NA      22.57        090
                                                      bone.
26951.............  ..............  A                Amputation of finger/        4.59         NA      13.06       0.56         NA      18.21        090
                                                      thumb.
26952.............  ..............  A                Amputation of finger/        6.31         NA      14.25       0.74         NA      21.30        090
                                                      thumb.
26989.............  ..............  C                Hand/finger surgery...       0.00       0.00       0.00       0.00       0.00       0.00        YYY
26990.............  ..............  A                Drainage of pelvis           7.48         NA      16.35       0.92         NA      24.75        090
                                                      lesion.
26991.............  ..............  A                Drainage of pelvis           6.68      11.94       9.87       0.85      19.47      17.40        090
                                                      bursa.
26992.............  ..............  A                Drainage of bone            13.02         NA      20.25       1.75         NA      35.02        090
                                                      lesion.
27000.............  ..............  A                Incision of hip tendon       5.62         NA       7.78       0.76         NA      14.16        090
27001.............  ..............  A                Incision of hip tendon       6.94         NA       8.52       0.95         NA      16.41        090
27003.............  ..............  A                Incision of hip tendon       7.34         NA       9.52       0.93         NA      17.79        090
27005.............  ..............  A                Incision of hip tendon       9.66         NA      10.84       1.36         NA      21.86        090
27006.............  ..............  A                Incision of hip              9.68         NA      10.84       1.33         NA      21.85        090
                                                      tendons.
27025.............  ..............  A                Incision of hip/thigh       11.16         NA      10.70       1.38         NA      23.24        090
                                                      fascia.
27030.............  ..............  A                Drainage of hip joint.      13.01         NA      12.69       1.81         NA      27.51        090
27033.............  ..............  A                Exploration of hip          13.39         NA      12.81       1.87         NA      28.07        090
                                                      joint.
27035.............  ..............  A                Denervation of hip          16.69         NA      17.51       1.70         NA      35.90        090
                                                      joint.
27036.............  ..............  A                Excision of hip joint/      12.88         NA      14.25       1.80         NA      28.93        090
                                                      muscle.
27040.............  ..............  A                Biopsy of soft tissues       2.87       6.16       3.97       0.21       9.24       7.05        010
27041.............  ..............  A                Biopsy of soft tissues       9.89         NA       8.60       1.01         NA      19.50        090
27047.............  ..............  A                Remove hip/pelvis            7.45       9.54       7.15       0.79      17.78      15.39        090
                                                      lesion.
27048.............  ..............  A                Remove hip/pelvis            6.25         NA       8.06       0.73         NA      15.04        090
                                                      lesion.
27049.............  ..............  A                Remove tumor, hip/          13.66         NA      13.54       1.60         NA      28.80        090
                                                      pelvis.
27050.............  ..............  A                Biopsy of sacroiliac         4.36         NA       7.42       0.53         NA      12.31        090
                                                      joint.
27052.............  ..............  A                Biopsy of hip joint...       6.23         NA       8.71       0.85         NA      15.79        090
27054.............  ..............  A                Removal of hip joint         8.54         NA      11.05       1.17         NA      20.76        090
                                                      lining.
27060.............  ..............  A                Removal of ischial           5.43         NA       7.63       0.60         NA      13.66        090
                                                      bursa.
27062.............  ..............  A                Remove femur lesion/         5.37         NA       7.59       0.74         NA      13.70        090
                                                      bursa.
27065.............  ..............  A                Removal of hip bone          5.90         NA       9.09       0.76         NA      15.75        090
                                                      lesion.
27066.............  ..............  A                Removal of hip bone         10.33         NA      12.88       1.42         NA      24.63        090
                                                      lesion.
27067.............  ..............  A                Remove/graft hip bone       13.83         NA      14.91       1.95         NA      30.69        090
                                                      lesion.
27070.............  ..............  A                Partial removal of hip      10.72         NA      18.36       1.36         NA      30.44        090
                                                      bone.
27071.............  ..............  A                Partial removal of hip      11.46         NA      19.32       1.51         NA      32.29        090
                                                      bone.
27075.............  ..............  A                Extensive hip surgery.      35.00         NA      25.82       2.22         NA      63.04        090
27076.............  ..............  A                Extensive hip surgery.      22.12         NA      20.29       2.86         NA      45.27        090
27077.............  ..............  A                Extensive hip surgery.      40.00         NA      29.14       3.18         NA      72.32        090
27078.............  ..............  A                Extensive hip surgery.      13.44         NA      15.81       1.67         NA      30.92        090
27079.............  ..............  A                Extensive hip surgery.      13.75         NA      15.34       1.86         NA      30.95        090
27080.............  ..............  A                Removal of tail bone..       6.39         NA       7.66       0.80         NA      14.85        090
27086.............  ..............  A                Remove hip foreign           1.87       5.13       3.97       0.17       7.17       6.01        010
                                                      body.
27087.............  ..............  A                Remove hip foreign           8.54         NA       9.19       1.09         NA      18.82        090
                                                      body.
27090.............  ..............  A                Removal of hip              11.15         NA       8.95       1.55         NA      21.65        090
                                                      prosthesis.
27091.............  ..............  A                Removal of hip              22.14         NA      14.22       3.11         NA      39.47        090
                                                      prosthesis.
27093.............  ..............  A                Injection for hip x-         1.30      12.50       0.50       0.09      13.89       1.89        000
                                                      ray.
27095.............  ..............  A                Injection for hip x-         1.50      11.47       0.54       0.10      13.07       2.14        000
                                                      ray.
27096.............  ..............  A                Inject sacroiliac            1.40      10.28       0.34       0.08      11.76       1.82        000
                                                      joint.
27097.............  ..............  A                Revision of hip tendon       8.80         NA       9.44       1.22         NA      19.46        090
27098.............  ..............  A                Transfer tendon to           8.83         NA       9.88       1.24         NA      19.95        090
                                                      pelvis.
27100.............  ..............  A                Transfer of abdominal       11.08         NA      13.03       1.57         NA      25.68        090
                                                      muscle.
27105.............  ..............  A                Transfer of spinal          11.77         NA      12.72       1.66         NA      26.15        090
                                                      muscle.
27110.............  ..............  A                Transfer of iliopsoas       13.26         NA      13.59       1.38         NA      28.23        090
                                                      muscle.
27111.............  ..............  A                Transfer of iliopsoas       12.15         NA      12.43       1.48         NA      26.06        090
                                                      muscle.

[[Page 80062]]

 
27120.............  ..............  A                Reconstruction of hip       18.01         NA      12.05       2.45         NA      32.51        090
                                                      socket.
27122.............  ..............  A                Reconstruction of hip       14.98         NA      11.19       2.08         NA      28.25        090
                                                      socket.
27125.............  ..............  A                Partial hip                 14.69         NA      10.75       2.05         NA      27.49        090
                                                      replacement.
27130.............  ..............  A                Total hip arthroplasty      20.12         NA      13.58       2.82         NA      36.52        090
27132.............  ..............  A                Total hip arthroplasty      23.30         NA      15.87       3.26         NA      42.43        090
27134.............  ..............  A                Revise hip joint            28.52         NA      18.20       3.97         NA      50.69        090
                                                      replacement.
27137.............  ..............  A                Revise hip joint            21.17         NA      14.24       2.97         NA      38.38        090
                                                      replacement.
27138.............  ..............  A                Revise hip joint            22.17         NA      14.72       3.11         NA      40.00        090
                                                      replacement.
27140.............  ..............  A                Transplant femur ridge      12.24         NA      12.27       1.67         NA      26.18        090
27146.............  ..............  A                Incision of hip bone..      17.43         NA      16.51       2.27         NA      36.21        090
27147.............  ..............  A                Revision of hip bone..      20.58         NA      17.71       2.61         NA      40.90        090
27151.............  ..............  A                Incision of hip bones.      22.51         NA      12.83       3.12         NA      38.46        090
27156.............  ..............  A                Revision of hip bones.      24.63         NA      20.37       3.48         NA      48.48        090
27158.............  ..............  A                Revision of pelvis....      19.74         NA      16.00       2.60         NA      38.34        090
27161.............  ..............  A                Incision of neck of         16.71         NA      14.57       2.32         NA      33.60        090
                                                      femur.
27165.............  ..............  A                Incision/fixation of        17.91         NA      15.11       2.51         NA      35.53        090
                                                      femur.
27170.............  ..............  A                Repair/graft femur          16.07         NA      14.30       2.20         NA      32.57        090
                                                      head/neck.
27175.............  ..............  A                Treat slipped                8.46         NA       7.39       1.19         NA      17.04        090
                                                      epiphysis.
27176.............  ..............  A                Treat slipped               12.05         NA      10.20       1.68         NA      23.93        090
                                                      epiphysis.
27177.............  ..............  A                Treat slipped               15.08         NA      11.88       2.11         NA      29.07        090
                                                      epiphysis.
27178.............  ..............  A                Treat slipped               11.99         NA       9.63       1.68         NA      23.30        090
                                                      epiphysis.
27179.............  ..............  A                Revise head/neck of         12.98         NA      11.01       1.84         NA      25.83        090
                                                      femur.
27181.............  ..............  A                Treat slipped               14.68         NA      11.17       1.74         NA      27.59        090
                                                      epiphysis.
27185.............  ..............  A                Revision of femur            9.18         NA      10.51       1.29         NA      20.98        090
                                                      epiphysis.
27187.............  ..............  A                Reinforce hip bones...      13.54         NA      13.81       1.89         NA      29.24        090
27193.............  ..............  A                Treat pelvic ring            5.56       7.39       5.47       0.77      13.72      11.80        090
                                                      fracture.
27194.............  ..............  A                Treat pelvic ring            9.65       9.40       7.71       1.32      20.37      18.68        090
                                                      fracture.
27200.............  ..............  A                Treat tail bone              1.84       3.25       1.83       0.22       5.31       3.89        090
                                                      fracture.
27202.............  ..............  A                Treat tail bone              7.04         NA      22.21       0.69         NA      29.94        090
                                                      fracture.
27215.............  ..............  A                Treat pelvic                10.05         NA      10.59       1.37         NA      22.01        090
                                                      fracture(s).
27216.............  ..............  A                Treat pelvic ring           15.19         NA      14.82       2.15         NA      32.16        090
                                                      fracture.
27217.............  ..............  A                Treat pelvic ring           14.11         NA      13.07       1.95         NA      29.13        090
                                                      fracture.
27218.............  ..............  A                Treat pelvic ring           20.15         NA      14.41       2.85         NA      37.41        090
                                                      fracture.
27220.............  ..............  A                Treat hip socket             6.18       7.73       5.82       0.85      14.76      12.85        090
                                                      fracture.
27222.............  ..............  A                Treat hip socket            12.70         NA      10.44       1.77         NA      24.91        090
                                                      fracture.
27226.............  ..............  A                Treat hip wall              14.91         NA      10.98       2.07         NA      27.96        090
                                                      fracture.
27227.............  ..............  A                Treat hip fracture(s).      23.45         NA      17.40       3.24         NA      44.09        090
27228.............  ..............  A                Treat hip fracture(s).      27.16         NA      19.68       3.77         NA      50.61        090
27230.............  ..............  A                Treat thigh fracture..       5.50       8.01       6.44       0.73      14.24      12.67        090
27232.............  ..............  A                Treat thigh fracture..      10.68         NA       9.48       1.45         NA      21.61        090
27235.............  ..............  A                Treat thigh fracture..      12.16         NA      11.34       1.71         NA      25.21        090
27236.............  ..............  A                Treat thigh fracture..      15.60         NA      11.28       2.18         NA      29.06        090
27238.............  ..............  A                Treat thigh fracture..       5.52         NA       6.55       0.76         NA      12.83        090
27240.............  ..............  A                Treat thigh fracture..      12.50         NA      10.52       1.69         NA      24.71        090
27244.............  ..............  A                Treat thigh fracture..      15.94         NA      13.24       2.23         NA      31.41        090
27245.............  ..............  A                Treat thigh fracture..      20.31         NA      15.64       2.85         NA      38.80        090
27246.............  ..............  A                Treat thigh fracture..       4.71       7.73       6.19       0.66      13.10      11.56        090
27248.............  ..............  A                Treat thigh fracture..      10.45         NA      10.25       1.45         NA      22.15        090
27250.............  ..............  A                Treat hip dislocation.       6.95         NA       6.49       0.68         NA      14.12        090
27252.............  ..............  A                Treat hip dislocation.      10.39         NA       8.43       1.37         NA      20.19        090
27253.............  ..............  A                Treat hip dislocation.      12.92         NA      11.14       1.81         NA      25.87        090
27254.............  ..............  A                Treat hip dislocation.      18.26         NA      14.04       2.52         NA      34.82        090
27256.............  ..............  A                Treat hip dislocation.       4.12         NA       4.45       0.49         NA       9.06        010
27257.............  ..............  A                Treat hip dislocation.       5.22         NA       4.77       0.56         NA      10.55        010
27258.............  ..............  A                Treat hip dislocation.      15.43         NA      14.26       2.06         NA      31.75        090
27259.............  ..............  A                Treat hip dislocation.      21.55         NA      17.51       2.99         NA      42.05        090
27265.............  ..............  A                Treat hip dislocation.       5.05         NA       6.25       0.65         NA      11.95        090
27266.............  ..............  A                Treat hip dislocation.       7.49         NA       7.69       1.04         NA      16.22        090
27275.............  ..............  A                Manipulation of hip          2.27         NA       3.75       0.31         NA       6.33        010
                                                      joint.
27280.............  ..............  A                Fusion of sacroiliac        13.39         NA      14.60       1.98         NA      29.97        090
                                                      joint.
27282.............  ..............  A                Fusion of pubic bones.      11.34         NA      12.54       1.14         NA      25.02        090
27284.............  ..............  A                Fusion of hip joint...      23.45         NA      18.80       2.36         NA      44.61        090
27286.............  ..............  A                Fusion of hip joint...      23.45         NA      19.33       2.37         NA      45.15        090
27290.............  ..............  A                Amputation of leg at        23.28         NA      17.03       2.94         NA      43.25        090
                                                      hip.
27295.............  ..............  A                Amputation of leg at        18.65         NA      14.46       2.35         NA      35.46        090
                                                      hip.
27299.............  ..............  C                Pelvis/hip joint             0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      surgery.
27301.............  ..............  A                Drain thigh/knee             6.49      16.43      14.49       0.80      23.72      21.78        090
                                                      lesion.
27303.............  ..............  A                Drainage of bone             8.28         NA      15.57       1.14         NA      24.99        090
                                                      lesion.
27305.............  ..............  A                Incise thigh tendon &        5.92         NA       9.50       0.77         NA      16.19        090
                                                      fascia.
27306.............  ..............  A                Incision of thigh            4.62         NA       7.93       0.62         NA      13.17        090
                                                      tendon.
27307.............  ..............  A                Incision of thigh            5.80         NA       8.53       0.78         NA      15.11        090
                                                      tendons.
27310.............  ..............  A                Exploration of knee          9.27         NA      10.40       1.29         NA      20.96        090
                                                      joint.
27315.............  ..............  A                Partial removal, thigh       6.97         NA       4.45       0.79         NA      12.21        090
                                                      nerve.
27320.............  ..............  A                Partial removal, thigh       6.30         NA       4.68       0.78         NA      11.76        090
                                                      nerve.
27323.............  ..............  A                Biopsy, thigh soft           2.28       6.01       3.57       0.17       8.46       6.02        010
                                                      tissues.

[[Page 80063]]

 
27324.............  ..............  A                Biopsy, thigh soft           4.90         NA       7.14       0.59         NA      12.63        090
                                                      tissues.
27327.............  ..............  A                Removal of thigh             4.47       8.59       6.51       0.50      13.56      11.48        090
                                                      lesion.
27328.............  ..............  A                Removal of thigh             5.57         NA       7.28       0.66         NA      13.51        090
                                                      lesion.
27329.............  ..............  A                Remove tumor, thigh/        14.14         NA      14.74       1.68         NA      30.56        090
                                                      knee.
27330.............  ..............  A                Biopsy, knee joint           4.97         NA       6.61       0.66         NA      12.24        090
                                                      lining.
27331.............  ..............  A                Explore/treat knee           5.88         NA       7.83       0.81         NA      14.52        090
                                                      joint.
27332.............  ..............  A                Removal of knee              8.27         NA       9.06       1.15         NA      18.48        090
                                                      cartilage.
27333.............  ..............  A                Removal of knee              7.30         NA       8.59       1.03         NA      16.92        090
                                                      cartilage.
27334.............  ..............  A                Remove knee joint            8.70         NA       9.97       1.21         NA      19.88        090
                                                      lining.
27335.............  ..............  A                Remove knee joint           10.00         NA      10.83       1.41         NA      22.24        090
                                                      lining.
27340.............  ..............  A                Removal of kneecap           4.18         NA       6.26       0.58         NA      11.02        090
                                                      bursa.
27345.............  ..............  A                Removal of knee cyst..       5.92         NA       7.70       0.81         NA      14.43        090
27347.............  ..............  A                Remove knee cyst......       5.78         NA       7.45       0.76         NA      13.99        090
27350.............  ..............  A                Removal of kneecap....       8.17         NA       9.17       1.15         NA      18.49        090
27355.............  ..............  A                Remove femur lesion...       7.65         NA      10.74       1.07         NA      19.46        090
27356.............  ..............  A                Remove femur lesion/         9.48         NA      11.74       1.29         NA      22.51        090
                                                      graft.
27357.............  ..............  A                Remove femur lesion/        10.53         NA      12.24       1.48         NA      24.25        090
                                                      graft.
27358.............  ..............  A                Remove femur lesion/         4.74         NA       2.59       0.67         NA       8.00        ZZZ
                                                      fixation.
27360.............  ..............  A                Partial removal, leg        10.50         NA      18.97       1.42         NA      30.89        090
                                                      bone(s).
27365.............  ..............  A                Extensive leg surgery.      16.27         NA      14.68       2.26         NA      33.21        090
27370.............  ..............  A                Injection for knee x-        0.96      11.98       0.33       0.06      13.00       1.35        000
                                                      ray.
27372.............  ..............  A                Removal of foreign           5.07       8.64       6.69       0.62      14.33      12.38        090
                                                      body.
27380.............  ..............  A                Repair of kneecap            7.16         NA       8.67       1.00         NA      16.83        090
                                                      tendon.
27381.............  ..............  A                Repair/graft kneecap        10.34         NA      10.37       1.44         NA      22.15        090
                                                      tendon.
27385.............  ..............  A                Repair of thigh muscle       7.76         NA       9.02       1.09         NA      17.87        090
27386.............  ..............  A                Repair/graft of thigh       10.56         NA      11.17       1.49         NA      23.22        090
                                                      muscle.
27390.............  ..............  A                Incision of thigh            5.33         NA       8.20       0.69         NA      14.22        090
                                                      tendon.
27391.............  ..............  A                Incision of thigh            7.20         NA       9.33       0.99         NA      17.52        090
                                                      tendons.
27392.............  ..............  A                Incision of thigh            9.20         NA      11.43       1.23         NA      21.86        090
                                                      tendons.
27393.............  ..............  A                Lengthening of thigh         6.39         NA       8.74       0.90         NA      16.03        090
                                                      tendon.
27394.............  ..............  A                Lengthening of thigh         8.50         NA      11.13       1.17         NA      20.80        090
                                                      tendons.
27395.............  ..............  A                Lengthening of thigh        11.73         NA      14.02       1.63         NA      27.38        090
                                                      tendons.
27396.............  ..............  A                Transplant of thigh          7.86         NA      11.02       1.11         NA      19.99        090
                                                      tendon.
27397.............  ..............  A                Transplants of thigh        11.28         NA      12.48       1.58         NA      25.34        090
                                                      tendons.
27400.............  ..............  A                Revise thigh muscles/        9.02         NA      11.20       1.18         NA      21.40        090
                                                      tendons.
27403.............  ..............  A                Repair of knee               8.33         NA       9.19       1.16         NA      18.68        090
                                                      cartilage.
27405.............  ..............  A                Repair of knee               8.65         NA      10.04       1.21         NA      19.90        090
                                                      ligament.
27407.............  ..............  A                Repair of knee              10.28         NA      10.74       1.38         NA      22.40        090
                                                      ligament.
27409.............  ..............  A                Repair of knee              12.90         NA      12.29       1.75         NA      26.94        090
                                                      ligaments.
27418.............  ..............  A                Repair degenerated          10.85         NA      11.28       1.51         NA      23.64        090
                                                      kneecap.
27420.............  ..............  A                Revision of unstable         9.83         NA      10.02       1.38         NA      21.23        090
                                                      kneecap.
27422.............  ..............  A                Revision of unstable         9.78         NA      10.04       1.37         NA      21.19        090
                                                      kneecap.
27424.............  ..............  A                Revision/removal of          9.81         NA      10.00       1.38         NA      21.19        090
                                                      kneecap.
27425.............  ..............  A                Lat retinacular              5.22         NA       7.58       0.73         NA      13.53        090
                                                      release open.
27427.............  ..............  A                Reconstruction, knee..       9.36         NA       9.64       1.29         NA      20.29        090
27428.............  ..............  A                Reconstruction, knee..      14.00         NA      12.86       1.95         NA      28.81        090
27429.............  ..............  A                Reconstruction, knee..      15.52         NA      13.68       2.18         NA      31.38        090
27430.............  ..............  A                Revision of thigh            9.67         NA      10.08       1.35         NA      21.10        090
                                                      muscles.
27435.............  ..............  A                Incision of knee joint       9.49         NA       9.91       1.33         NA      20.73        090
27437.............  ..............  A                Revise kneecap........       8.46         NA       7.31       1.18         NA      16.95        090
27438.............  ..............  A                Revise kneecap with         11.23         NA       8.71       1.56         NA      21.50        090
                                                      implant.
27440.............  ..............  A                Revision of knee joint      10.43         NA       6.23       1.42         NA      18.08        090
27441.............  ..............  A                Revision of knee joint      10.82         NA       6.90       1.49         NA      19.21        090
27442.............  ..............  A                Revision of knee joint      11.89         NA       9.09       1.68         NA      22.66        090
27443.............  ..............  A                Revision of knee joint      10.93         NA       8.85       1.52         NA      21.30        090
27445.............  ..............  A                Revision of knee joint      17.68         NA      12.52       2.49         NA      32.69        090
27446.............  ..............  A                Revision of knee joint      15.84         NA      11.50       2.22         NA      29.56        090
27447.............  ..............  A                Total knee                  21.48         NA      14.82       3.00         NA      39.30        090
                                                      arthroplasty.
27448.............  ..............  A                Incision of thigh.....      11.06         NA      12.41       1.51         NA      24.98        090
27450.............  ..............  A                Incision of thigh.....      13.98         NA      14.20       1.96         NA      30.14        090
27454.............  ..............  A                Realignment of thigh        17.56         NA      16.02       2.46         NA      36.04        090
                                                      bone.
27455.............  ..............  A                Realignment of knee...      12.82         NA      12.70       1.78         NA      27.30        090
27457.............  ..............  A                Realignment of knee...      13.45         NA      11.87       1.88         NA      27.20        090
27465.............  ..............  A                Shortening of thigh         13.87         NA      14.06       1.86         NA      29.79        090
                                                      bone.
27466.............  ..............  A                Lengthening of thigh        16.33         NA      16.39       1.92         NA      34.64        090
                                                      bone.
27468.............  ..............  A                Shorten/lengthen            18.97         NA      16.56       2.68         NA      38.21        090
                                                      thighs.
27470.............  ..............  A                Repair of thigh.......      16.07         NA      16.45       2.24         NA      34.76        090
27472.............  ..............  A                Repair/graft of thigh.      17.72         NA      17.33       2.49         NA      37.54        090
27475.............  ..............  A                Surgery to stop leg          8.64         NA       9.62       1.13         NA      19.39        090
                                                      growth.
27477.............  ..............  A                Surgery to stop leg          9.85         NA      10.08       1.31         NA      21.24        090
                                                      growth.
27479.............  ..............  A                Surgery to stop leg         12.80         NA      12.35       1.81         NA      26.96        090
                                                      growth.
27485.............  ..............  A                Surgery to stop leg          8.84         NA       9.79       1.24         NA      19.87        090
                                                      growth.
27486.............  ..............  A                Revise/replace knee         19.27         NA      13.67       2.70         NA      35.64        090
                                                      joint.
27487.............  ..............  A                Revise/replace knee         25.27         NA      16.83       3.54         NA      45.64        090
                                                      joint.
27488.............  ..............  A                Removal of knee             15.74         NA      11.83       2.21         NA      29.78        090
                                                      prosthesis.

[[Page 80064]]

 
27495.............  ..............  A                Reinforce thigh.......      15.55         NA      16.19       2.18         NA      33.92        090
27496.............  ..............  A                Decompression of thigh/      6.11         NA       8.25       0.77         NA      15.13        090
                                                      knee.
27497.............  ..............  A                Decompression of thigh/      7.17         NA       8.28       0.84         NA      16.29        090
                                                      knee.
27498.............  ..............  A                Decompression of thigh/      7.99         NA       8.67       0.97         NA      17.63        090
                                                      knee.
27499.............  ..............  A                Decompression of thigh/      9.00         NA       9.28       1.18         NA      19.46        090
                                                      knee.
27500.............  ..............  A                Treatment of thigh           5.92      10.40       7.84       0.80      17.12      14.56        090
                                                      fracture.
27501.............  ..............  A                Treatment of thigh           5.92      11.65       9.09       0.83      18.40      15.84        090
                                                      fracture.
27502.............  ..............  A                Treatment of thigh          10.58         NA      11.60       1.49         NA      23.67        090
                                                      fracture.
27503.............  ..............  A                Treatment of thigh          10.58         NA      11.64       1.49         NA      23.71        090
                                                      fracture.
27506.............  ..............  A                Treatment of thigh          17.45         NA      14.57       2.33         NA      34.35        090
                                                      fracture.
27507.............  ..............  A                Treatment of thigh          13.99         NA      12.74       1.95         NA      28.68        090
                                                      fracture.
27508.............  ..............  A                Treatment of thigh           5.83       7.42       5.52       0.80      14.05      12.15        090
                                                      fracture.
27509.............  ..............  A                Treatment of thigh           7.71         NA       9.50       1.08         NA      18.29        090
                                                      fracture.
27510.............  ..............  A                Treatment of thigh           9.13         NA       7.39       1.26         NA      17.78        090
                                                      fracture.
27511.............  ..............  A                Treatment of thigh          13.64         NA      13.34       1.91         NA      28.89        090
                                                      fracture.
27513.............  ..............  A                Treatment of thigh          17.92         NA      15.66       2.51         NA      36.09        090
                                                      fracture.
27514.............  ..............  A                Treatment of thigh          17.30         NA      14.78       2.41         NA      34.49        090
                                                      fracture.
27516.............  ..............  A                Treat thigh fx growth        5.37       8.20       6.00       0.74      14.31      12.11        090
                                                      plate.
27517.............  ..............  A                Treat thigh fx growth        8.78       9.86       7.97       1.22      19.86      17.97        090
                                                      plate.
27519.............  ..............  A                Treat thigh fx growth       15.02         NA      13.83       2.09         NA      30.94        090
                                                      plate.
27520.............  ..............  A                Treat kneecap fracture       2.86       5.79       3.90       0.38       9.03       7.14        090
27524.............  ..............  A                Treat kneecap fracture      10.00         NA       9.05       1.40         NA      20.45        090
27530.............  ..............  A                Treat knee fracture...       3.78       6.31       4.45       0.51      10.60       8.74        090
27532.............  ..............  A                Treat knee fracture...       7.30       7.79       5.87       1.02      16.11      14.19        090
27535.............  ..............  A                Treat knee fracture...      11.50         NA      12.23       1.61         NA      25.34        090
27536.............  ..............  A                Treat knee fracture...      15.65         NA      12.09       2.19         NA      29.93        090
27538.............  ..............  A                Treat knee fracture(s)       4.87       7.97       5.73       0.67      13.51      11.27        090
27540.............  ..............  A                Treat knee fracture...      13.10         NA      10.55       1.80         NA      25.45        090
27550.............  ..............  A                Treat knee dislocation       5.76       7.57       5.83       0.68      14.01      12.27        090
27552.............  ..............  A                Treat knee dislocation       7.90         NA       8.23       1.10         NA      17.23        090
27556.............  ..............  A                Treat knee dislocation      14.41         NA      14.69       2.01         NA      31.11        090
27557.............  ..............  A                Treat knee dislocation      16.77         NA      15.93       2.37         NA      35.07        090
27558.............  ..............  A                Treat knee dislocation      17.72         NA      16.13       2.51         NA      36.36        090
27560.............  ..............  A                Treat kneecap                3.82       6.20       3.99       0.40      10.42       8.21        090
                                                      dislocation.
27562.............  ..............  A                Treat kneecap                5.79         NA       5.85       0.69         NA      12.33        090
                                                      dislocation.
27566.............  ..............  A                Treat kneecap               12.23         NA      10.20       1.73         NA      24.16        090
                                                      dislocation.
27570.............  ..............  A                Fixation of knee joint       1.74         NA       3.45       0.24         NA       5.43        010
27580.............  ..............  A                Fusion of knee........      19.37         NA      16.57       2.70         NA      38.64        090
27590.............  ..............  A                Amputate leg at thigh.      12.03         NA      12.59       1.35         NA      25.97        090
27591.............  ..............  A                Amputate leg at thigh.      12.68         NA      14.63       1.63         NA      28.94        090
27592.............  ..............  A                Amputate leg at thigh.      10.02         NA      12.18       1.17         NA      23.37        090
27594.............  ..............  A                Amputation follow-up         6.92         NA       9.10       0.82         NA      16.84        090
                                                      surgery.
27596.............  ..............  A                Amputation follow-up        10.60         NA      12.65       1.24         NA      24.49        090
                                                      surgery.
27598.............  ..............  A                Amputate lower leg at       10.53         NA      11.61       1.24         NA      23.38        090
                                                      knee.
27599.............  ..............  C                Leg surgery procedure.       0.00       0.00       0.00       0.00       0.00       0.00        YYY
27600.............  ..............  A                Decompression of lower       5.65         NA       7.85       0.68         NA      14.18        090
                                                      leg.
27601.............  ..............  A                Decompression of lower       5.64         NA       7.79       0.69         NA      14.12        090
                                                      leg.
27602.............  ..............  A                Decompression of lower       7.35         NA       8.13       0.85         NA      16.33        090
                                                      leg.
27603.............  ..............  A                Drain lower leg lesion       4.94      16.03      10.71       0.56      21.53      16.21        090
27604.............  ..............  A                Drain lower leg bursa.       4.47      11.74       8.69       0.54      16.75      13.70        090
27605.............  ..............  A                Incision of achilles         2.87      10.88       4.01       0.38      14.13       7.26        010
                                                      tendon.
27606.............  ..............  A                Incision of achilles         4.14      13.17       5.24       0.57      17.88       9.95        010
                                                      tendon.
27607.............  ..............  A                Treat lower leg bone         7.97         NA      14.85       1.08         NA      23.90        090
                                                      lesion.
27610.............  ..............  A                Explore/treat ankle          8.34         NA      10.90       1.15         NA      20.39        090
                                                      joint.
27612.............  ..............  A                Exploration of ankle         7.33         NA       8.61       1.01         NA      16.95        090
                                                      joint.
27613.............  ..............  A                Biopsy lower leg soft        2.17       5.93       3.16       0.16       8.26       5.49        010
                                                      tissue.
27614.............  ..............  A                Biopsy lower leg soft        5.66      11.55       7.39       0.62      17.83      13.67        090
                                                      tissue.
27615.............  ..............  A                Remove tumor, lower         12.56         NA      16.85       1.39         NA      30.80        090
                                                      leg.
27618.............  ..............  A                Remove lower leg             5.09      11.86       6.86       0.54      17.49      12.49        090
                                                      lesion.
27619.............  ..............  A                Remove lower leg             8.40      13.36       9.46       1.01      22.77      18.87        090
                                                      lesion.
27620.............  ..............  A                Explore/treat ankle          5.98         NA       8.48       0.83         NA      15.29        090
                                                      joint.
27625.............  ..............  A                Remove ankle joint           8.30         NA      10.10       1.16         NA      19.56        090
                                                      lining.
27626.............  ..............  A                Remove ankle joint           8.91         NA      10.79       1.23         NA      20.93        090
                                                      lining.
27630.............  ..............  A                Removal of tendon            4.80      11.52       7.24       0.60      16.92      12.64        090
                                                      lesion.
27635.............  ..............  A                Remove lower leg bone        7.78         NA      11.58       1.06         NA      20.42        090
                                                      lesion.
27637.............  ..............  A                Remove/graft leg bone        9.85         NA      12.91       1.38         NA      24.14        090
                                                      lesion.
27638.............  ..............  A                Remove/graft leg bone       10.57         NA      13.24       1.47         NA      25.28        090
                                                      lesion.
27640.............  ..............  A                Partial removal of          11.37         NA      18.94       1.54         NA      31.85        090
                                                      tibia.
27641.............  ..............  A                Partial removal of           9.24         NA      16.89       1.22         NA      27.35        090
                                                      fibula.
27645.............  ..............  A                Extensive lower leg         14.17         NA      18.70       1.98         NA      34.85        090
                                                      surgery.
27646.............  ..............  A                Extensive lower leg         12.66         NA      17.64       1.55         NA      31.85        090
                                                      surgery.
27647.............  ..............  A                Extensive ankle/heel        12.24         NA      11.52       1.64         NA      25.40        090
                                                      surgery.
27648.............  ..............  A                Injection for ankle x-       0.96       9.75       0.34       0.05      10.76       1.35        000
                                                      ray.
27650.............  ..............  A                Repair achilles tendon       9.69         NA       9.79       1.35         NA      20.83        090
27652.............  ..............  A                Repair/graft achilles       10.33         NA      10.02       1.45         NA      21.80        090
                                                      tendon.

[[Page 80065]]

 
27654.............  ..............  A                Repair of achilles          10.02         NA      10.51       1.41         NA      21.94        090
                                                      tendon.
27656.............  ..............  A                Repair leg fascia            4.57      12.84       6.76       0.48      17.89      11.81        090
                                                      defect.
27658.............  ..............  A                Repair of leg tendon,        4.98      13.20       9.52       0.68      18.86      15.18        090
                                                      each.
27659.............  ..............  A                Repair of leg tendon,        6.81      14.89      10.27       0.96      22.66      18.04        090
                                                      each.
27664.............  ..............  A                Repair of leg tendon,        4.59      15.00       9.66       0.63      20.22      14.88        090
                                                      each.
27665.............  ..............  A                Repair of leg tendon,        5.40      14.63       9.79       0.75      20.78      15.94        090
                                                      each.
27675.............  ..............  A                Repair lower leg             7.18         NA       8.63       1.01         NA      16.82        090
                                                      tendons.
27676.............  ..............  A                Repair lower leg             8.42         NA       9.68       1.15         NA      19.25        090
                                                      tendons.
27680.............  ..............  A                Release of lower leg         5.74         NA       8.48       0.80         NA      15.02        090
                                                      tendon.
27681.............  ..............  A                Release of lower leg         6.82         NA       8.98       0.92         NA      16.72        090
                                                      tendons.
27685.............  ..............  A                Revision of lower leg        6.50      10.50       8.74       0.91      17.91      16.15        090
                                                      tendon.
27686.............  ..............  A                Revise lower leg             7.46      15.11      10.39       1.05      23.62      18.90        090
                                                      tendons.
27687.............  ..............  A                Revision of calf             6.24         NA       8.90       0.88         NA      16.02        090
                                                      tendon.
27690.............  ..............  A                Revise lower leg             8.71         NA       9.75       1.22         NA      19.68        090
                                                      tendon.
27691.............  ..............  A                Revise lower leg             9.96         NA      11.37       1.40         NA      22.73        090
                                                      tendon.
27692.............  ..............  A                Revise additional leg        1.87         NA       0.95       0.26         NA       3.08        ZZZ
                                                      tendon.
27695.............  ..............  A                Repair of ankle              6.51         NA       9.63       0.90         NA      17.04        090
                                                      ligament.
27696.............  ..............  A                Repair of ankle              8.27         NA       9.97       1.16         NA      19.40        090
                                                      ligaments.
27698.............  ..............  A                Repair of ankle              9.36         NA       9.72       1.31         NA      20.39        090
                                                      ligament.
27700.............  ..............  A                Revision of ankle            9.29         NA       5.81       1.24         NA      16.34        090
                                                      joint.
27702.............  ..............  A                Reconstruct ankle           13.67         NA      10.57       1.92         NA      26.16        090
                                                      joint.
27703.............  ..............  A                Reconstruction, ankle       15.87         NA      11.36       2.24         NA      29.47        090
                                                      joint.
27704.............  ..............  A                Removal of ankle             7.62         NA       5.75       0.61         NA      13.98        090
                                                      implant.
27705.............  ..............  A                Incision of tibia.....      10.38         NA      11.94       1.44         NA      23.76        090
27707.............  ..............  A                Incision of fibula....       4.37         NA       8.83       0.60         NA      13.80        090
27709.............  ..............  A                Incision of tibia &          9.95         NA      11.93       1.39         NA      23.27        090
                                                      fibula.
27712.............  ..............  A                Realignment of lower        14.25         NA      14.10       2.00         NA      30.35        090
                                                      leg.
27715.............  ..............  A                Revision of lower leg.      14.39         NA      15.50       2.00         NA      31.89        090
27720.............  ..............  A                Repair of tibia.......      11.79         NA      14.12       1.66         NA      27.57        090
27722.............  ..............  A                Repair/graft of tibia.      11.82         NA      13.88       1.65         NA      27.35        090
27724.............  ..............  A                Repair/graft of tibia.      18.20         NA      17.61       2.10         NA      37.91        090
27725.............  ..............  A                Repair of lower leg...      15.59         NA      16.06       2.20         NA      33.85        090
27727.............  ..............  A                Repair of lower leg...      14.01         NA      14.96       1.84         NA      30.81        090
27730.............  ..............  A                Repair of tibia              7.41      21.22      10.17       0.75      29.38      18.33        090
                                                      epiphysis.
27732.............  ..............  A                Repair of fibula             5.32      14.21       8.71       0.63      20.16      14.66        090
                                                      epiphysis.
27734.............  ..............  A                Repair lower leg             8.48         NA       9.91       0.85         NA      19.24        090
                                                      epiphyses.
27740.............  ..............  A                Repair of leg                9.30      23.90      11.76       1.31      34.51      22.37        090
                                                      epiphyses.
27742.............  ..............  A                Repair of leg               10.30      16.69      10.97       1.55      28.54      22.82        090
                                                      epiphyses.
27745.............  ..............  A                Reinforce tibia.......      10.07         NA      12.05       1.38         NA      23.50        090
27750.............  ..............  A                Treatment of tibia           3.19       5.93       4.10       0.43       9.55       7.72        090
                                                      fracture.
27752.............  ..............  A                Treatment of tibia           5.84       8.53       6.34       0.82      15.19      13.00        090
                                                      fracture.
27756.............  ..............  A                Treatment of tibia           6.78         NA      11.38       0.94         NA      19.10        090
                                                      fracture.
27758.............  ..............  A                Treatment of tibia          11.67         NA      12.42       1.52         NA      25.61        090
                                                      fracture.
27759.............  ..............  A                Treatment of tibia          13.76         NA      13.74       1.93         NA      29.43        090
                                                      fracture.
27760.............  ..............  A                Treatment of ankle           3.01       5.69       3.91       0.39       9.09       7.31        090
                                                      fracture.
27762.............  ..............  A                Treatment of ankle           5.25       7.99       5.87       0.71      13.95      11.83        090
                                                      fracture.
27766.............  ..............  A                Treatment of ankle           8.36         NA       8.68       1.17         NA      18.21        090
                                                      fracture.
27780.............  ..............  A                Treatment of fibula          2.65       5.61       3.71       0.33       8.59       6.69        090
                                                      fracture.
27781.............  ..............  A                Treatment of fibula          4.40       6.84       4.69       0.57      11.81       9.66        090
                                                      fracture.
27784.............  ..............  A                Treatment of fibula          7.11         NA       8.92       0.98         NA      17.01        090
                                                      fracture.
27786.............  ..............  A                Treatment of ankle           2.84       5.66       3.83       0.37       8.87       7.04        090
                                                      fracture.
27788.............  ..............  A                Treatment of ankle           4.45       6.92       4.75       0.61      11.98       9.81        090
                                                      fracture.
27792.............  ..............  A                Treatment of ankle           7.66         NA       8.40       1.07         NA      17.13        090
                                                      fracture.
27808.............  ..............  A                Treatment of ankle           2.83       6.81       4.62       0.38      10.02       7.83        090
                                                      fracture.
27810.............  ..............  A                Treatment of ankle           5.13       8.08       5.88       0.71      13.92      11.72        090
                                                      fracture.
27814.............  ..............  A                Treatment of ankle          10.68         NA      11.19       1.50         NA      23.37        090
                                                      fracture.
27816.............  ..............  A                Treatment of ankle           2.89       6.27       4.63       0.37       9.53       7.89        090
                                                      fracture.
27818.............  ..............  A                Treatment of ankle           5.50       8.22       6.02       0.74      14.46      12.26        090
                                                      fracture.
27822.............  ..............  A                Treatment of ankle          11.00         NA      13.50       1.29         NA      25.79        090
                                                      fracture.
27823.............  ..............  A                Treatment of ankle          13.00         NA      14.56       1.65         NA      29.21        090
                                                      fracture.
27824.............  ..............  A                Treat lower leg              2.89       6.73       4.63       0.39      10.01       7.91        090
                                                      fracture.
27825.............  ..............  A                Treat lower leg              6.19       8.70       6.50       0.85      15.74      13.54        090
                                                      fracture.
27826.............  ..............  A                Treat lower leg              8.54         NA      12.17       1.19         NA      21.90        090
                                                      fracture.
27827.............  ..............  A                Treat lower leg             14.06         NA      15.23       1.96         NA      31.25        090
                                                      fracture.
27828.............  ..............  A                Treat lower leg             16.23         NA      15.93       2.27         NA      34.43        090
                                                      fracture.
27829.............  ..............  A                Treat lower leg joint.       5.49         NA       8.94       0.77         NA      15.20        090
27830.............  ..............  A                Treat lower leg              3.79       5.77       4.31       0.44      10.00       8.54        090
                                                      dislocation.
27831.............  ..............  A                Treat lower leg              4.56         NA       5.53       0.61         NA      10.70        090
                                                      dislocation.
27832.............  ..............  A                Treat lower leg              6.49         NA       8.61       0.91         NA      16.01        090
                                                      dislocation.
27840.............  ..............  A                Treat ankle                  4.58         NA       6.11       0.47         NA      11.16        090
                                                      dislocation.
27842.............  ..............  A                Treat ankle                  6.21         NA       5.25       0.76         NA      12.22        090
                                                      dislocation.
27846.............  ..............  A                Treat ankle                  9.79         NA      10.58       1.36         NA      21.73        090
                                                      dislocation.
27848.............  ..............  A                Treat ankle                 11.20         NA      11.92       1.55         NA      24.67        090
                                                      dislocation.
27860.............  ..............  A                Fixation of ankle            2.34         NA       3.76       0.31         NA       6.41        010
                                                      joint.
27870.............  ..............  A                Fusion of ankle joint,      13.91         NA      14.08       1.95         NA      29.94        090
                                                      open.

[[Page 80066]]

 
27871.............  ..............  A                Fusion of tibiofibular       9.17         NA      11.36       1.29         NA      21.82        090
                                                      joint.
27880.............  ..............  A                Amputation of lower         11.85         NA      11.88       1.38         NA      25.11        090
                                                      leg.
27881.............  ..............  A                Amputation of lower         12.34         NA      13.55       1.59         NA      27.48        090
                                                      leg.
27882.............  ..............  A                Amputation of lower          8.94         NA      12.97       1.03         NA      22.94        090
                                                      leg.
27884.............  ..............  A                Amputation follow-up         8.21         NA      10.83       0.95         NA      19.99        090
                                                      surgery.
27886.............  ..............  A                Amputation follow-up         9.32         NA      11.37       1.13         NA      21.82        090
                                                      surgery.
27888.............  ..............  A                Amputation of foot at        9.67         NA      11.23       1.26         NA      22.16        090
                                                      ankle.
27889.............  ..............  A                Amputation of foot at        9.98         NA      10.58       1.19         NA      21.75        090
                                                      ankle.
27892.............  ..............  A                Decompression of leg..       7.39         NA       8.26       0.86         NA      16.51        090
27893.............  ..............  A                Decompression of leg..       7.35         NA       8.11       0.90         NA      16.36        090
27894.............  ..............  A                Decompression of leg..      10.49         NA       9.56       1.25         NA      21.30        090
27899.............  ..............  C                Leg/ankle surgery            0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
28001.............  ..............  A                Drainage of bursa of         2.73       5.63       3.23       0.31       8.67       6.27        010
                                                      foot.
28002.............  ..............  A                Treatment of foot            4.62       6.93       4.33       0.56      12.11       9.51        010
                                                      infection.
28003.............  ..............  A                Treatment of foot            8.41      11.29      10.81       1.03      20.73      20.25        090
                                                      infection.
28005.............  ..............  A                Treat foot bone lesion       8.68         NA      10.68       1.14         NA      20.50        090
28008.............  ..............  A                Incision of foot             4.45       8.11       6.33       0.56      13.12      11.34        090
                                                      fascia.
28010.............  ..............  A                Incision of toe tendon       2.84       7.56       5.29       0.39      10.79       8.52        090
28011.............  ..............  A                Incision of toe              4.14       9.37       7.07       0.58      14.09      11.79        090
                                                      tendons.
28020.............  ..............  A                Exploration of foot          5.01       9.32       6.74       0.64      14.97      12.39        090
                                                      joint.
28022.............  ..............  A                Exploration of foot          4.67       8.13       6.33       0.62      13.42      11.62        090
                                                      joint.
28024.............  ..............  A                Exploration of toe           4.38       8.30       6.56       0.50      13.18      11.44        090
                                                      joint.
28030.............  ..............  A                Removal of foot nerve.       6.15         NA       3.46       0.85         NA      10.46        090
28035.............  ..............  A                Decompression of tibia       5.09       9.32       5.50       0.71      15.12      11.30        090
                                                      nerve.
28043.............  ..............  A                Excision of foot             3.54       7.53       5.21       0.45      11.52       9.20        090
                                                      lesion.
28045.............  ..............  A                Excision of foot             4.72       8.14       5.91       0.62      13.48      11.25        090
                                                      lesion.
28046.............  ..............  A                Resection of tumor,         10.18      12.35      10.95       1.13      23.66      22.26        090
                                                      foot.
28050.............  ..............  A                Biopsy of foot joint         4.25       7.78       6.03       0.55      12.58      10.83        090
                                                      lining.
28052.............  ..............  A                Biopsy of foot joint         3.94       8.10       6.14       0.51      12.55      10.59        090
                                                      lining.
28054.............  ..............  A                Biopsy of toe joint          3.45       8.01       5.96       0.45      11.91       9.86        090
                                                      lining.
28060.............  ..............  A                Partial removal, foot        5.23       8.76       6.63       0.69      14.68      12.55        090
                                                      fascia.
28062.............  ..............  A                Removal of foot fascia       6.52       9.62       6.52       0.85      16.99      13.89        090
28070.............  ..............  A                Removal of foot joint        5.10       7.95       6.12       0.68      13.73      11.90        090
                                                      lining.
28072.............  ..............  A                Removal of foot joint        4.58       8.50       7.07       0.64      13.72      12.29        090
                                                      lining.
28080.............  ..............  A                Removal of foot lesion       3.58       7.89       5.68       0.50      11.97       9.76        090
28086.............  ..............  A                Excise foot tendon           4.78      11.42       7.64       0.66      16.86      13.08        090
                                                      sheath.
28088.............  ..............  A                Excise foot tendon           3.86       9.48       6.95       0.52      13.86      11.33        090
                                                      sheath.
28090.............  ..............  A                Removal of foot lesion       4.41       8.05       5.73       0.57      13.03      10.71        090
28092.............  ..............  A                Removal of toe lesions       3.64       8.48       6.17       0.46      12.58      10.27        090
28100.............  ..............  A                Removal of ankle/heel        5.66      11.90       7.91       0.76      18.32      14.33        090
                                                      lesion.
28102.............  ..............  A                Remove/graft foot            7.73         NA       9.27       0.97         NA      17.97        090
                                                      lesion.
28103.............  ..............  A                Remove/graft foot            6.50      10.07       7.46       0.89      17.46      14.85        090
                                                      lesion.
28104.............  ..............  A                Removal of foot lesion       5.12       8.79       6.99       0.69      14.60      12.80        090
28106.............  ..............  A                Remove/graft foot            7.16         NA       6.84       1.01         NA      15.01        090
                                                      lesion.
28107.............  ..............  A                Remove/graft foot            5.56      10.01       7.09       0.74      16.31      13.39        090
                                                      lesion.
28108.............  ..............  A                Removal of toe lesions       4.16       7.42       5.44       0.52      12.10      10.12        090
28110.............  ..............  A                Part removal of              4.08       8.95       7.08       0.49      13.52      11.65        090
                                                      metatarsal.
28111.............  ..............  A                Part removal of              5.01      10.65       7.86       0.63      16.29      13.50        090
                                                      metatarsal.
28112.............  ..............  A                Part removal of              4.49       9.66       7.66       0.60      14.75      12.75        090
                                                      metatarsal.
28113.............  ..............  A                Part removal of              4.79       9.24       7.32       0.63      14.66      12.74        090
                                                      metatarsal.
28114.............  ..............  A                Removal of metatarsal        9.79      14.07      11.12       1.36      25.22      22.27        090
                                                      heads.
28116.............  ..............  A                Revision of foot......       7.75       8.88       6.83       1.03      17.66      15.61        090
28118.............  ..............  A                Removal of heel bone..       5.96       9.52       7.26       0.79      16.27      14.01        090
28119.............  ..............  A                Removal of heel spur..       5.39       8.54       6.23       0.74      14.67      12.36        090
28120.............  ..............  A                Part removal of ankle/       5.40      12.72      10.02       0.69      18.81      16.11        090
                                                      heel.
28122.............  ..............  A                Partial removal of           7.29      11.28       9.68       0.96      19.53      17.93        090
                                                      foot bone.
28124.............  ..............  A                Partial removal of toe       4.81       9.52       7.87       0.65      14.98      13.33        090
28126.............  ..............  A                Partial removal of toe       3.52       8.27       7.11       0.49      12.28      11.12        090
28130.............  ..............  A                Removal of ankle bone.       8.11         NA       9.03       1.11         NA      18.25        090
28140.............  ..............  A                Removal of metatarsal.       6.91      10.80       7.99       0.84      18.55      15.74        090
28150.............  ..............  A                Removal of toe........       4.09       8.94       7.33       0.52      13.55      11.94        090
28153.............  ..............  A                Partial removal of toe       3.66       8.27       5.96       0.49      12.42      10.11        090
28160.............  ..............  A                Partial removal of toe       3.74       8.58       7.50       0.51      12.83      11.75        090
28171.............  ..............  A                Extensive foot surgery       9.60         NA       8.48       1.13         NA      19.21        090
28173.............  ..............  A                Extensive foot surgery       8.80      11.13       8.87       1.04      20.97      18.71        090
28175.............  ..............  A                Extensive foot surgery       6.05       9.58       6.90       0.75      16.38      13.70        090
28190.............  ..............  A                Removal of foot              1.96       6.41       3.42       0.16       8.53       5.54        010
                                                      foreign body.
28192.............  ..............  A                Removal of foot              4.64       8.20       5.59       0.52      13.36      10.75        090
                                                      foreign body.
28193.............  ..............  A                Removal of foot              5.73       8.77       6.70       0.63      15.13      13.06        090
                                                      foreign body.
28200.............  ..............  A                Repair of foot tendon.       4.60       8.41       6.53       0.59      13.60      11.72        090
28202.............  ..............  A                Repair/graft of foot         6.84      11.55       7.11       0.86      19.25      14.81        090
                                                      tendon.
28208.............  ..............  A                Repair of foot tendon.       4.37       8.15       6.10       0.59      13.11      11.06        090
28210.............  ..............  A                Repair/graft of foot         6.35       9.60       6.56       0.77      16.72      13.68        090
                                                      tendon.
28220.............  ..............  A                Release of foot tendon       4.53       7.94       6.29       0.63      13.10      11.45        090
28222.............  ..............  A                Release of foot              5.62       8.34       7.12       0.77      14.73      13.51        090
                                                      tendons.

[[Page 80067]]

 
28225.............  ..............  A                Release of foot tendon       3.66       7.72       5.83       0.50      11.88       9.99        090
28226.............  ..............  A                Release of foot              4.53       7.99       6.80       0.62      13.14      11.95        090
                                                      tendons.
28230.............  ..............  A                Incision of foot             4.24       8.10       7.09       0.59      12.93      11.92        090
                                                      tendon(s).
28232.............  ..............  A                Incision of toe tendon       3.39       8.14       6.78       0.48      12.01      10.65        090
28234.............  ..............  A                Incision of foot             3.37       8.22       6.25       0.46      12.05      10.08        090
                                                      tendon.
28238.............  ..............  A                Revision of foot             7.73      10.31       7.61       1.08      19.12      16.42        090
                                                      tendon.
28240.............  ..............  A                Release of big toe....       4.36       8.05       6.67       0.61      13.02      11.64        090
28250.............  ..............  A                Revision of foot             5.92       9.00       7.08       0.81      15.73      13.81        090
                                                      fascia.
28260.............  ..............  A                Release of midfoot           7.96       9.47       7.73       1.08      18.51      16.77        090
                                                      joint.
28261.............  ..............  A                Revision of foot            11.73      11.02       9.66       1.66      24.41      23.05        090
                                                      tendon.
28262.............  ..............  A                Revision of foot and        15.83      17.31      15.44       2.22      35.36      33.49        090
                                                      ankle.
28264.............  ..............  A                Release of midfoot          10.35      11.28      11.28       1.46      23.09      23.09        090
                                                      joint.
28270.............  ..............  A                Release of foot              4.76       8.70       7.46       0.67      14.13      12.89        090
                                                      contracture.
28272.............  ..............  A                Release of toe joint,        3.80       7.59       5.63       0.52      11.91       9.95        090
                                                      each.
28280.............  ..............  A                Fusion of toes........       5.19       9.25       7.16       0.72      15.16      13.07        090
28285.............  ..............  A                Repair of hammertoe...       4.59       8.76       6.85       0.64      13.99      12.08        090
28286.............  ..............  A                Repair of hammertoe...       4.56       8.62       6.80       0.64      13.82      12.00        090
28288.............  ..............  A                Partial removal of           4.74       9.14       8.50       0.65      14.53      13.89        090
                                                      foot bone.
28289.............  ..............  A                Repair hallux rigidus.       7.04      11.61       9.63       0.96      19.61      17.63        090
28290.............  ..............  A                Correction of bunion..       5.66       9.89       9.25       0.79      16.34      15.70        090
28292.............  ..............  A                Correction of bunion..       7.04       9.86       7.77       0.98      17.88      15.79        090
28293.............  ..............  A                Correction of bunion..       9.15       8.28       5.99       1.28      18.71      16.42        090
28294.............  ..............  A                Correction of bunion..       8.56      10.47       7.96       1.16      20.19      17.68        090
28296.............  ..............  A                Correction of bunion..       9.18      10.94       8.74       1.28      21.40      19.20        090
28297.............  ..............  A                Correction of bunion..       9.18      11.96      10.51       1.31      22.45      21.00        090
28298.............  ..............  A                Correction of bunion..       7.94      10.07       8.40       1.12      19.13      17.46        090
28299.............  ..............  A                Correction of bunion..      10.58      11.36       9.11       1.24      23.18      20.93        090
28300.............  ..............  A                Incision of heel bone.       9.54      15.04       9.59       1.31      25.89      20.44        090
28302.............  ..............  A                Incision of ankle bone       9.55      14.76       9.53       1.15      25.46      20.23        090
28304.............  ..............  A                Incision of midfoot          9.16      10.31       7.89       1.00      20.47      18.05        090
                                                      bones.
28305.............  ..............  A                Incise/graft midfoot        10.50      14.76       9.73       0.55      25.81      20.78        090
                                                      bones.
28306.............  ..............  A                Incision of metatarsal       5.86       9.21       6.48       0.81      15.88      13.15        090
28307.............  ..............  A                Incision of metatarsal       6.33      13.36       8.20       0.71      20.40      15.24        090
28308.............  ..............  A                Incision of metatarsal       5.29       7.88       5.45       0.74      13.91      11.48        090
28309.............  ..............  A                Incision of                 12.78         NA      10.66       1.64         NA      25.08        090
                                                      metatarsals.
28310.............  ..............  A                Revision of big toe...       5.43       9.14       6.99       0.76      15.33      13.18        090
28312.............  ..............  A                Revision of toe.......       4.55       8.87       7.70       0.62      14.04      12.87        090
28313.............  ..............  A                Repair deformity of          5.01       9.36       9.36       0.68      15.05      15.05        090
                                                      toe.
28315.............  ..............  A                Removal of sesamoid          4.86       7.91       5.75       0.66      13.43      11.27        090
                                                      bone.
28320.............  ..............  A                Repair of foot bones..       9.18         NA       9.14       1.27         NA      19.59        090
28322.............  ..............  A                Repair of metatarsals.       8.34      11.91       8.67       1.17      21.42      18.18        090
28340.............  ..............  A                Resect enlarged toe          6.98       9.40       6.86       0.98      17.36      14.82        090
                                                      tissue.
28341.............  ..............  A                Resect enlarged toe...       8.41       9.50       7.14       1.18      19.09      16.73        090
28344.............  ..............  A                Repair extra toe(s)...       4.26       8.82       5.99       0.60      13.68      10.85        090
28345.............  ..............  A                Repair webbed toe(s)..       5.92       9.33       7.70       0.84      16.09      14.46        090
28360.............  ..............  A                Reconstruct cleft foot      13.34         NA      13.96       1.88         NA      29.18        090
28400.............  ..............  A                Treatment of heel            2.16       6.16       4.90       0.29       8.61       7.35        090
                                                      fracture.
28405.............  ..............  A                Treatment of heel            4.57       7.06       6.09       0.63      12.26      11.29        090
                                                      fracture.
28406.............  ..............  A                Treatment of heel            6.31         NA       9.13       0.87         NA      16.31        090
                                                      fracture.
28415.............  ..............  A                Treat heel fracture...      15.97         NA      15.68       2.24         NA      33.89        090
28420.............  ..............  A                Treat/graft heel            16.64         NA      16.03       2.29         NA      34.96        090
                                                      fracture.
28430.............  ..............  A                Treatment of ankle           2.09       5.58       4.27       0.27       7.94       6.63        090
                                                      fracture.
28435.............  ..............  A                Treatment of ankle           3.40       5.82       4.89       0.47       9.69       8.76        090
                                                      fracture.
28436.............  ..............  A                Treatment of ankle           4.71         NA       8.17       0.66         NA      13.54        090
                                                      fracture.
28445.............  ..............  A                Treat ankle fracture..      15.62         NA      14.08       1.29         NA      30.99        090
28450.............  ..............  A                Treat midfoot                1.90       5.53       4.16       0.25       7.68       6.31        090
                                                      fracture, each.
28455.............  ..............  A                Treat midfoot                3.09       5.46       5.08       0.43       8.98       8.60        090
                                                      fracture, each.
28456.............  ..............  A                Treat midfoot fracture       2.68         NA       6.50       0.36         NA       9.54        090
28465.............  ..............  A                Treat midfoot                7.01         NA       8.48       0.87         NA      16.36        090
                                                      fracture, each.
28470.............  ..............  A                Treat metatarsal             1.99       4.77       3.44       0.26       7.02       5.69        090
                                                      fracture.
28475.............  ..............  A                Treat metatarsal             2.97       5.37       4.59       0.41       8.75       7.97        090
                                                      fracture.
28476.............  ..............  A                Treat metatarsal             3.38         NA       7.01       0.46         NA      10.85        090
                                                      fracture.
28485.............  ..............  A                Treat metatarsal             5.71         NA       8.18       0.80         NA      14.69        090
                                                      fracture.
28490.............  ..............  A                Treat big toe fracture       1.09       2.86       2.18       0.13       4.08       3.40        090
28495.............  ..............  A                Treat big toe fracture       1.58       2.96       2.31       0.19       4.73       4.08        090
28496.............  ..............  A                Treat big toe fracture       2.33      10.94       5.26       0.32      13.59       7.91        090
28505.............  ..............  A                Treat big toe fracture       3.81      11.49       6.99       0.50      15.80      11.30        090
28510.............  ..............  A                Treatment of toe             1.09       2.55       2.17       0.13       3.77       3.39        090
                                                      fracture.
28515.............  ..............  A                Treatment of toe             1.46       2.80       2.26       0.17       4.43       3.89        090
                                                      fracture.
28525.............  ..............  A                Treat toe fracture....       3.32      11.14       6.62       0.44      14.90      10.38        090
28530.............  ..............  A                Treat sesamoid bone          1.06       3.07       2.81       0.13       4.26       4.00        090
                                                      fracture.
28531.............  ..............  A                Treat sesamoid bone          2.35      11.17       4.20       0.33      13.85       6.88        090
                                                      fracture.
28540.............  ..............  A                Treat foot dislocation       2.04       3.82       3.82       0.24       6.10       6.10        090
28545.............  ..............  A                Treat foot dislocation       2.45       4.11       4.11       0.33       6.89       6.89        090
28546.............  ..............  A                Treat foot dislocation       3.20       9.17       6.25       0.46      12.83       9.91        090

[[Page 80068]]

 
28555.............  ..............  A                Repair foot                  6.30      13.38       8.67       0.88      20.56      15.85        090
                                                      dislocation.
28570.............  ..............  A                Treat foot dislocation       1.66       4.23       4.00       0.22       6.11       5.88        090
28575.............  ..............  A                Treat foot dislocation       3.31       6.02       5.69       0.45       9.78       9.45        090
28576.............  ..............  A                Treat foot dislocation       4.17      11.89       6.88       0.56      16.62      11.61        090
28585.............  ..............  A                Repair foot                  7.99       9.70       8.46       1.13      18.82      17.58        090
                                                      dislocation.
28600.............  ..............  A                Treat foot dislocation       1.89       4.58       4.15       0.24       6.71       6.28        090
28605.............  ..............  A                Treat foot dislocation       2.71       5.24       5.20       0.35       8.30       8.26        090
28606.............  ..............  A                Treat foot dislocation       4.90      16.53       7.41       0.68      22.11      12.99        090
28615.............  ..............  A                Repair foot                  7.77         NA       9.71       1.09         NA      18.57        090
                                                      dislocation.
28630.............  ..............  A                Treat toe dislocation.       1.70       2.39       2.39       0.17       4.26       4.26        010
28635.............  ..............  A                Treat toe dislocation.       1.91       2.60       2.60       0.24       4.75       4.75        010
28636.............  ..............  A                Treat toe dislocation.       2.77       7.15       3.21       0.39      10.31       6.37        010
28645.............  ..............  A                Repair toe dislocation       4.22       6.72       4.42       0.58      11.52       9.22        090
28660.............  ..............  A                Treat toe dislocation.       1.23       3.15       2.47       0.11       4.49       3.81        010
28665.............  ..............  A                Treat toe dislocation.       1.92       2.63       2.63       0.24       4.79       4.79        010
28666.............  ..............  A                Treat toe dislocation.       2.66       7.78       2.94       0.38      10.82       5.98        010
28675.............  ..............  A                Repair of toe                2.92       9.64       5.13       0.41      12.97       8.46        090
                                                      dislocation.
28705.............  ..............  A                Fusion of foot bones..      18.80         NA      15.42       2.13         NA      36.35        090
28715.............  ..............  A                Fusion of foot bones..      13.10         NA      12.85       1.84         NA      27.79        090
28725.............  ..............  A                Fusion of foot bones..      11.61         NA      11.67       1.63         NA      24.91        090
28730.............  ..............  A                Fusion of foot bones..      10.76         NA      11.03       1.51         NA      23.30        090
28735.............  ..............  A                Fusion of foot bones..      10.85         NA      10.81       1.51         NA      23.17        090
28737.............  ..............  A                Revision of foot bones       9.64         NA       9.45       1.36         NA      20.45        090
28740.............  ..............  A                Fusion of foot bones..       8.02      13.73       9.19       1.13      22.88      18.34        090
28750.............  ..............  A                Fusion of big toe            7.30      14.99       9.59       1.03      23.32      17.92        090
                                                      joint.
28755.............  ..............  A                Fusion of big toe            4.74       9.24       6.76       0.66      14.64      12.16        090
                                                      joint.
28760.............  ..............  A                Fusion of big toe            7.75      10.17       7.89       1.07      18.99      16.71        090
                                                      joint.
28800.............  ..............  A                Amputation of midfoot.       8.21         NA       9.11       0.98         NA      18.30        090
28805.............  ..............  A                Amputation thru              8.39         NA       9.05       0.97         NA      18.41        090
                                                      metatarsal.
28810.............  ..............  A                Amputation toe &             6.21         NA       7.96       0.70         NA      14.87        090
                                                      metatarsal.
28820.............  ..............  A                Amputation of toe.....       4.41      11.19       7.26       0.51      16.11      12.18        090
28825.............  ..............  A                Partial amputation of        3.59      10.58       7.11       0.43      14.60      11.13        090
                                                      toe.
28899.............  ..............  C                Foot/toes surgery            0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
29000.............  ..............  A                Application of body          2.25       3.08       1.74       0.30       5.63       4.29        000
                                                      cast.
29010.............  ..............  A                Application of body          2.06       3.07       1.72       0.27       5.40       4.05        000
                                                      cast.
29015.............  ..............  A                Application of body          2.41       2.97       1.60       0.21       5.59       4.22        000
                                                      cast.
29020.............  ..............  A                Application of body          2.11       3.27       1.44       0.16       5.54       3.71        000
                                                      cast.
29025.............  ..............  A                Application of body          2.40       3.16       1.86       0.26       5.82       4.52        000
                                                      cast.
29035.............  ..............  A                Application of body          1.77       3.10       1.53       0.24       5.11       3.54        000
                                                      cast.
29040.............  ..............  A                Application of body          2.22       2.48       1.54       0.35       5.05       4.11        000
                                                      cast.
29044.............  ..............  A                Application of body          2.12       3.42       1.83       0.29       5.83       4.24        000
                                                      cast.
29046.............  ..............  A                Application of body          2.41       3.12       2.01       0.34       5.87       4.76        000
                                                      cast.
29049.............  ..............  A                Application of figure        0.89       1.10       0.57       0.12       2.11       1.58        000
                                                      eight.
29055.............  ..............  A                Application of               1.78       2.54       1.44       0.24       4.56       3.46        000
                                                      shoulder cast.
29058.............  ..............  A                Application of               1.31       1.36       0.76       0.14       2.81       2.21        000
                                                      shoulder cast.
29065.............  ..............  A                Application of long          0.87       1.15       0.70       0.12       2.14       1.69        000
                                                      arm cast.
29075.............  ..............  A                Application of forearm       0.77       1.09       0.64       0.11       1.97       1.52        000
                                                      cast.
29085.............  ..............  A                Apply hand/wrist cast.       0.87       1.13       0.62       0.11       2.11       1.60        000
29086.............  ..............  A                Apply finger cast.....       0.62       0.72       0.55       0.06       1.40       1.23        000
29105.............  ..............  A                Apply long arm splint.       0.87       1.08       0.51       0.11       2.06       1.49        000
29125.............  ..............  A                Apply forearm splint..       0.59       0.91       0.40       0.06       1.56       1.05        000
29126.............  ..............  A                Apply forearm splint..       0.77       1.13       0.47       0.06       1.96       1.30        000
29130.............  ..............  A                Application of finger        0.50       0.44       0.17       0.05       0.99       0.72        000
                                                      splint.
29131.............  ..............  A                Application of finger        0.55       0.71       0.24       0.03       1.29       0.82        000
                                                      splint.
29200.............  ..............  A                Strapping of chest....       0.65       0.80       0.36       0.04       1.49       1.05        000
29220.............  ..............  A                Strapping of low back.       0.64       0.75       0.40       0.07       1.46       1.11        000
29240.............  ..............  A                Strapping of shoulder.       0.71       0.88       0.39       0.05       1.64       1.15        000
29260.............  ..............  A                Strapping of elbow or        0.55       0.77       0.34       0.04       1.36       0.93        000
                                                      wrist.
29280.............  ..............  A                Strapping of hand or         0.51       0.81       0.34       0.04       1.36       0.89        000
                                                      finger.
29305.............  ..............  A                Application of hip           2.03       2.91       1.65       0.29       5.23       3.97        000
                                                      cast.
29325.............  ..............  A                Application of hip           2.32       3.09       1.83       0.31       5.72       4.46        000
                                                      casts.
29345.............  ..............  A                Application of long          1.40       1.55       1.02       0.19       3.14       2.61        000
                                                      leg cast.
29355.............  ..............  A                Application of long          1.53       1.53       1.07       0.20       3.26       2.80        000
                                                      leg cast.
29358.............  ..............  A                Apply long leg cast          1.43       1.80       1.04       0.19       3.42       2.66        000
                                                      brace.
29365.............  ..............  A                Application of long          1.18       1.44       0.90       0.17       2.79       2.25        000
                                                      leg cast.
29405.............  ..............  A                Apply short leg cast..       0.86       1.07       0.67       0.12       2.05       1.65        000
29425.............  ..............  A                Apply short leg cast..       1.01       1.08       0.70       0.14       2.23       1.85        000
29435.............  ..............  A                Apply short leg cast..       1.18       1.37       0.89       0.17       2.72       2.24        000
29440.............  ..............  A                Addition of walker to        0.57       0.63       0.27       0.07       1.27       0.91        000
                                                      cast.
29445.............  ..............  A                Apply rigid leg cast..       1.78       1.64       0.95       0.24       3.66       2.97        000
29450.............  ..............  A                Application of leg           2.08       1.39       1.08       0.13       3.60       3.29        000
                                                      cast.
29505.............  ..............  A                Application, long leg        0.69       1.06       0.47       0.06       1.81       1.22        000
                                                      splint.
29515.............  ..............  A                Application lower leg        0.73       0.80       0.47       0.07       1.60       1.27        000
                                                      splint.
29520.............  ..............  A                Strapping of hip......       0.54       0.88       0.44       0.02       1.44       1.00        000
29530.............  ..............  A                Strapping of knee.....       0.57       0.82       0.35       0.04       1.43       0.96        000

[[Page 80069]]

 
29540.............  ..............  A                Strapping of ankle and/      0.51       0.39       0.32       0.04       0.94       0.87        000
                                                      or ft.
29550.............  ..............  A                Strapping of toes.....       0.47       0.40       0.27       0.05       0.92       0.79        000
29580.............  ..............  A                Application of paste         0.57       0.60       0.35       0.05       1.22       0.97        000
                                                      boot.
29590.............  ..............  A                Application of foot          0.76       0.49       0.30       0.06       1.31       1.12        000
                                                      splint.
29700.............  ..............  A                Removal/revision of          0.57       0.81       0.29       0.07       1.45       0.93        000
                                                      cast.
29705.............  ..............  A                Removal/revision of          0.76       0.74       0.39       0.10       1.60       1.25        000
                                                      cast.
29710.............  ..............  A                Removal/revision of          1.34       1.41       0.71       0.17       2.92       2.22        000
                                                      cast.
29715.............  ..............  A                Removal/revision of          0.94       1.08       0.41       0.08       2.10       1.43        000
                                                      cast.
29720.............  ..............  A                Repair of body cast...       0.68       1.00       0.39       0.10       1.78       1.17        000
29730.............  ..............  A                Windowing of cast.....       0.75       0.73       0.35       0.10       1.58       1.20        000
29740.............  ..............  A                Wedging of cast.......       1.12       1.04       0.50       0.15       2.31       1.77        000
29750.............  ..............  A                Wedging of clubfoot          1.26       1.00       0.59       0.16       2.42       2.01        000
                                                      cast.
29799.............  ..............  C                Casting/strapping            0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
29800.............  ..............  A                Jaw arthroscopy/             6.43         NA       9.06       0.84         NA      16.33        090
                                                      surgery.
29804.............  ..............  A                Jaw arthroscopy/             8.14         NA       8.53       0.66         NA      17.33        090
                                                      surgery.
29805.............  ..............  A                Shoulder arthroscopy,        5.89         NA       7.85       0.84         NA      14.58        090
                                                      dx.
29806.............  ..............  A                Shoulder arthroscopy/       14.37         NA      11.17       2.00         NA      27.54        090
                                                      surgery.
29807.............  ..............  A                Shoulder arthroscopy/       13.90         NA      10.93       1.94         NA      26.77        090
                                                      surgery.
29819.............  ..............  A                Shoulder arthroscopy/        7.62         NA       6.87       1.07         NA      15.56        090
                                                      surgery.
29820.............  ..............  A                Shoulder arthroscopy/        7.07         NA       6.39       0.99         NA      14.45        090
                                                      surgery.
29821.............  ..............  A                Shoulder arthroscopy/        7.72         NA       6.89       1.08         NA      15.69        090
                                                      surgery.
29822.............  ..............  A                Shoulder arthroscopy/        7.43         NA       6.77       1.04         NA      15.24        090
                                                      surgery.
29823.............  ..............  A                Shoulder arthroscopy/        8.17         NA       7.32       1.15         NA      16.64        090
                                                      surgery.
29824.............  ..............  A                Shoulder arthroscopy/        8.25         NA       7.46       1.15         NA      16.86        090
                                                      surgery.
29825.............  ..............  A                Shoulder arthroscopy/        7.62         NA       6.86       1.06         NA      15.54        090
                                                      surgery.
29826.............  ..............  A                Shoulder arthroscopy/        8.99         NA       7.63       1.26         NA      17.88        090
                                                      surgery.
29827.............  ..............  A                Arthroscop rotator          15.36         NA      11.55       1.86         NA      28.77        090
                                                      cuff repr.
29830.............  ..............  A                Elbow arthroscopy.....       5.76         NA       5.47       0.79         NA      12.02        090
29834.............  ..............  A                Elbow arthroscopy/           6.28         NA       5.96       0.86         NA      13.10        090
                                                      surgery.
29835.............  ..............  A                Elbow arthroscopy/           6.48         NA       6.02       0.88         NA      13.38        090
                                                      surgery.
29836.............  ..............  A                Elbow arthroscopy/           7.55         NA       6.83       1.06         NA      15.44        090
                                                      surgery.
29837.............  ..............  A                Elbow arthroscopy/           6.87         NA       6.27       0.96         NA      14.10        090
                                                      surgery.
29838.............  ..............  A                Elbow arthroscopy/           7.71         NA       6.98       1.07         NA      15.76        090
                                                      surgery.
29840.............  ..............  A                Wrist arthroscopy.....       5.54         NA       5.49       0.69         NA      11.72        090
29843.............  ..............  A                Wrist arthroscopy/           6.01         NA       5.74       0.82         NA      12.57        090
                                                      surgery.
29844.............  ..............  A                Wrist arthroscopy/           6.37         NA       5.96       0.86         NA      13.19        090
                                                      surgery.
29845.............  ..............  A                Wrist arthroscopy/           7.52         NA       6.61       0.84         NA      14.97        090
                                                      surgery.
29846.............  ..............  A                Wrist arthroscopy/           6.75         NA       6.19       0.89         NA      13.83        090
                                                      surgery.
29847.............  ..............  A                Wrist arthroscopy/           7.08         NA       6.33       0.91         NA      14.32        090
                                                      surgery.
29848.............  ..............  A                Wrist endoscopy/             5.44         NA       5.69       0.72         NA      11.85        090
                                                      surgery.
29850.............  ..............  A                Knee arthroscopy/            8.19         NA       5.27       0.74         NA      14.20        090
                                                      surgery.
29851.............  ..............  A                Knee arthroscopy/           13.10         NA       9.94       1.81         NA      24.85        090
                                                      surgery.
29855.............  ..............  A                Tibial arthroscopy/         10.62         NA       8.79       1.50         NA      20.91        090
                                                      surgery.
29856.............  ..............  A                Tibial arthroscopy/         14.14         NA      10.74       2.00         NA      26.88        090
                                                      surgery.
29860.............  ..............  A                Hip arthroscopy, dx...       8.05         NA       7.06       1.14         NA      16.25        090
29861.............  ..............  A                Hip arthroscopy/             9.15         NA       7.48       1.29         NA      17.92        090
                                                      surgery.
29862.............  ..............  A                Hip arthroscopy/             9.90         NA       8.58       1.39         NA      19.87        090
                                                      surgery.
29863.............  ..............  A                Hip arthroscopy/             9.90         NA       8.53       1.40         NA      19.83        090
                                                      surgery.
29870.............  ..............  A                Knee arthroscopy, dx..       5.07         NA       5.00       0.67         NA      10.74        090
29871.............  ..............  A                Knee arthroscopy/            6.55         NA       5.98       0.88         NA      13.41        090
                                                      drainage.
29873.............  ..............  A                Knee arthroscopy/            6.00         NA       6.56       0.73         NA      13.29        090
                                                      surgery.
29874.............  ..............  A                Knee arthroscopy/            7.05         NA       6.27       0.87         NA      14.19        090
                                                      surgery.
29875.............  ..............  A                Knee arthroscopy/            6.31         NA       5.98       0.88         NA      13.17        090
                                                      surgery.
29876.............  ..............  A                Knee arthroscopy/            7.92         NA       7.12       1.11         NA      16.15        090
                                                      surgery.
29877.............  ..............  A                Knee arthroscopy/            7.35         NA       6.81       1.03         NA      15.19        090
                                                      surgery.
29879.............  ..............  A                Knee arthroscopy/            8.04         NA       7.21       1.13         NA      16.38        090
                                                      surgery.
29880.............  ..............  A                Knee arthroscopy/            8.50         NA       7.46       1.19         NA      17.15        090
                                                      surgery.
29881.............  ..............  A                Knee arthroscopy/            7.76         NA       7.04       1.09         NA      15.89        090
                                                      surgery.
29882.............  ..............  A                Knee arthroscopy/            8.65         NA       7.34       1.09         NA      17.08        090
                                                      surgery.
29883.............  ..............  A                Knee arthroscopy/           11.05         NA       9.16       1.33         NA      21.54        090
                                                      surgery.
29884.............  ..............  A                Knee arthroscopy/            7.33         NA       6.76       1.03         NA      15.12        090
                                                      surgery.
29885.............  ..............  A                Knee arthroscopy/            9.09         NA       7.98       1.27         NA      18.34        090
                                                      surgery.
29886.............  ..............  A                Knee arthroscopy/            7.54         NA       6.94       1.06         NA      15.54        090
                                                      surgery.
29887.............  ..............  A                Knee arthroscopy/            9.04         NA       7.95       1.27         NA      18.26        090
                                                      surgery.
29888.............  ..............  A                Knee arthroscopy/           13.90         NA      10.42       1.95         NA      26.27        090
                                                      surgery.
29889.............  ..............  A                Knee arthroscopy/           16.00         NA      12.48       2.11         NA      30.59        090
                                                      surgery.
29891.............  ..............  A                Ankle arthroscopy/           8.40         NA       7.50       1.17         NA      17.07        090
                                                      surgery.
29892.............  ..............  A                Ankle arthroscopy/           9.00         NA       7.77       1.26         NA      18.03        090
                                                      surgery.
29893.............  ..............  A                Scope, plantar               5.22         NA       3.88       0.74         NA       9.84        090
                                                      fasciotomy.
29894.............  ..............  A                Ankle arthroscopy/           7.21         NA       5.61       1.01         NA      13.83        090
                                                      surgery.
29895.............  ..............  A                Ankle arthroscopy/           6.99         NA       5.60       0.97         NA      13.56        090
                                                      surgery.
29897.............  ..............  A                Ankle arthroscopy/           7.18         NA       6.04       1.01         NA      14.23        090
                                                      surgery.
29898.............  ..............  A                Ankle arthroscopy/           8.32         NA       6.28       1.14         NA      15.74        090
                                                      surgery.
29899.............  ..............  A                Ankle arthroscopy/          13.91         NA      10.58       1.95         NA      26.44        090
                                                      surgery.
29900.............  ..............  A                Mcp joint arthroscopy,       5.42         NA       5.92       0.75         NA      12.09        090
                                                      dx.

[[Page 80070]]

 
29901.............  ..............  A                Mcp joint arthroscopy,       6.13         NA       6.30       0.85         NA      13.28        090
                                                      surg.
29902.............  ..............  A                Mcp joint arthroscopy,       6.70         NA       6.61       0.93         NA      14.24        090
                                                      surg.
29999.............  ..............  C                Arthroscopy of joint..       0.00       0.00       0.00       0.00       0.00       0.00        YYY
30000.............  ..............  A                Drainage of nose             1.43       2.52       1.47       0.10       4.05       3.00        010
                                                      lesion.
30020.............  ..............  A                Drainage of nose             1.43       2.71       1.56       0.08       4.22       3.07        010
                                                      lesion.
30100.............  ..............  A                Intranasal biopsy.....       0.94       1.33       0.52       0.06       2.33       1.52        000
30110.............  ..............  A                Removal of nose              1.63       2.80       0.87       0.12       4.55       2.62        010
                                                      polyp(s).
30115.............  ..............  A                Removal of nose              4.35         NA       4.49       0.31         NA       9.15        090
                                                      polyp(s).
30117.............  ..............  A                Removal of intranasal        3.16       4.97       3.15       0.22       8.35       6.53        090
                                                      lesion.
30118.............  ..............  A                Removal of intranasal        9.69         NA       8.17       0.66         NA      18.52        090
                                                      lesion.
30120.............  ..............  A                Revision of nose......       5.27       5.97       5.97       0.41      11.65      11.65        090
30124.............  ..............  A                Removal of nose lesion       3.10         NA       3.31       0.20         NA       6.61        090
30125.............  ..............  A                Removal of nose lesion       7.16         NA       6.42       0.54         NA      14.12        090
30130.............  ..............  A                Removal of turbinate         3.38         NA       3.94       0.22         NA       7.54        090
                                                      bones.
30140.............  ..............  A                Removal of turbinate         3.43         NA       4.58       0.24         NA       8.25        090
                                                      bones.
30150.............  ..............  A                Partial removal of           9.14         NA       8.56       0.76         NA      18.46        090
                                                      nose.
30160.............  ..............  A                Removal of nose.......       9.58         NA       8.47       0.78         NA      18.83        090
30200.............  ..............  A                Injection treatment of       0.78       1.21       0.44       0.06       2.05       1.28        000
                                                      nose.
30210.............  ..............  A                Nasal sinus therapy...       1.08       2.15       0.59       0.08       3.31       1.75        010
30220.............  ..............  A                Insert nasal septal          1.54       2.51       0.84       0.11       4.16       2.49        010
                                                      button.
30300.............  ..............  A                Remove nasal foreign         1.04       2.60       0.38       0.07       3.71       1.49        010
                                                      body.
30310.............  ..............  A                Remove nasal foreign         1.96         NA       1.88       0.14         NA       3.98        010
                                                      body.
30320.............  ..............  A                Remove nasal foreign         4.52         NA       5.24       0.36         NA      10.12        090
                                                      body.
30400.............  ..............  R                Reconstruction of nose       9.83         NA       8.81       0.80         NA      19.44        090
30410.............  ..............  R                Reconstruction of nose      12.98         NA      10.50       1.08         NA      24.56        090
30420.............  ..............  R                Reconstruction of nose      15.88         NA      12.20       1.24         NA      29.32        090
30430.............  ..............  R                Revision of nose......       7.21         NA       7.14       0.62         NA      14.97        090
30435.............  ..............  R                Revision of nose......      11.71         NA      10.22       1.10         NA      23.03        090
30450.............  ..............  R                Revision of nose......      18.65         NA      13.82       1.53         NA      34.00        090
30460.............  ..............  A                Revision of nose......       9.96         NA       9.12       0.85         NA      19.93        090
30462.............  ..............  A                Revision of nose......      19.57         NA      14.40       1.92         NA      35.89        090
30465.............  ..............  A                Repair nasal stenosis.      11.64         NA       8.64       0.97         NA      21.25        090
30520.............  ..............  A                Repair of nasal septum       5.70         NA       5.85       0.41         NA      11.96        090
30540.............  ..............  A                Repair nasal defect...       7.75         NA       6.43       0.53         NA      14.71        090
30545.............  ..............  A                Repair nasal defect...      11.38         NA       9.58       0.80         NA      21.76        090
30560.............  ..............  A                Release of nasal             1.26       2.33       1.50       0.09       3.68       2.85        010
                                                      adhesions.
30580.............  ..............  A                Repair upper jaw             6.69       4.97       4.97       0.50      12.16      12.16        090
                                                      fistula.
30600.............  ..............  A                Repair mouth/nose            6.02       4.93       4.93       0.70      11.65      11.65        090
                                                      fistula.
30620.............  ..............  A                Intranasal                   5.97         NA       6.54       0.45         NA      12.96        090
                                                      reconstruction.
30630.............  ..............  A                Repair nasal septum          7.12         NA       7.08       0.51         NA      14.71        090
                                                      defect.
30801.............  ..............  A                Cauterization, inner         1.09       2.55       2.30       0.08       3.72       3.47        010
                                                      nose.
30802.............  ..............  A                Cauterization, inner         2.03       3.10       2.84       0.15       5.28       5.02        010
                                                      nose.
30901.............  ..............  A                Control of nosebleed..       1.21       1.40       0.33       0.09       2.70       1.63        000
30903.............  ..............  A                Control of nosebleed..       1.54       3.14       0.51       0.12       4.80       2.17        000
30905.............  ..............  A                Control of nosebleed..       1.97       3.79       0.78       0.15       5.91       2.90        000
30906.............  ..............  A                Repeat control of            2.45       4.19       1.23       0.17       6.81       3.85        000
                                                      nosebleed.
30915.............  ..............  A                Ligation, nasal sinus        7.20         NA       7.03       0.50         NA      14.73        090
                                                      artery.
30920.............  ..............  A                Ligation, upper jaw          9.83         NA       8.48       0.69         NA      19.00        090
                                                      artery.
30930.............  ..............  A                Therapy, fracture of         1.26         NA       2.16       0.09         NA       3.51        010
                                                      nose.
30999.............  ..............  C                Nasal surgery                0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
31000.............  ..............  A                Irrigation, maxillary        1.15       2.43       0.64       0.08       3.66       1.87        010
                                                      sinus.
31002.............  ..............  A                Irrigation, sphenoid         1.91         NA       2.03       0.14         NA       4.08        010
                                                      sinus.
31020.............  ..............  A                Exploration, maxillary       2.94       4.30       3.64       0.20       7.44       6.78        090
                                                      sinus.
31030.............  ..............  A                Exploration, maxillary       5.92       4.77       4.60       0.42      11.11      10.94        090
                                                      sinus.
31032.............  ..............  A                Explore sinus, remove        6.57         NA       6.06       0.47         NA      13.10        090
                                                      polyps.
31040.............  ..............  A                Exploration behind           9.42         NA       6.97       0.71         NA      17.10        090
                                                      upper jaw.
31050.............  ..............  A                Exploration, sphenoid        5.28         NA       5.04       0.39         NA      10.71        090
                                                      sinus.
31051.............  ..............  A                Sphenoid sinus surgery       7.11         NA       6.51       0.55         NA      14.17        090
31070.............  ..............  A                Exploration of frontal       4.28         NA       5.00       0.30         NA       9.58        090
                                                      sinus.
31075.............  ..............  A                Exploration of frontal       9.16         NA       8.16       0.64         NA      17.96        090
                                                      sinus.
31080.............  ..............  A                Removal of frontal          11.42         NA       8.78       0.78         NA      20.98        090
                                                      sinus.
31081.............  ..............  A                Removal of frontal          12.75         NA       9.73       1.84         NA      24.32        090
                                                      sinus.
31084.............  ..............  A                Removal of frontal          13.51         NA      10.49       0.96         NA      24.96        090
                                                      sinus.
31085.............  ..............  A                Removal of frontal          14.20         NA      10.73       1.18         NA      26.11        090
                                                      sinus.
31086.............  ..............  A                Removal of frontal          12.86         NA      10.42       0.90         NA      24.18        090
                                                      sinus.
31087.............  ..............  A                Removal of frontal          13.10         NA      10.43       1.15         NA      24.68        090
                                                      sinus.
31090.............  ..............  A                Exploration of sinuses       9.53         NA       8.89       0.66         NA      19.08        090
31200.............  ..............  A                Removal of ethmoid           4.97         NA       5.70       0.25         NA      10.92        090
                                                      sinus.
31201.............  ..............  A                Removal of ethmoid           8.37         NA       7.76       0.58         NA      16.71        090
                                                      sinus.
31205.............  ..............  A                Removal of ethmoid          10.24         NA       8.39       0.58         NA      19.21        090
                                                      sinus.
31225.............  ..............  A                Removal of upper jaw..      19.23         NA      15.01       1.38         NA      35.62        090
31230.............  ..............  A                Removal of upper jaw..      21.94         NA      16.66       1.57         NA      40.17        090
31231.............  ..............  A                Nasal endoscopy, dx...       1.10       1.99       0.59       0.08       3.17       1.77        000
31233.............  ..............  A                Nasal/sinus endoscopy,       2.18       2.63       1.19       0.16       4.97       3.53        000
                                                      dx.
31235.............  ..............  A                Nasal/sinus endoscopy,       2.64       2.90       1.45       0.18       5.72       4.27        000
                                                      dx.

[[Page 80071]]

 
31237.............  ..............  A                Nasal/sinus endoscopy,       2.98       3.17       1.61       0.21       6.36       4.80        000
                                                      surg.
31238.............  ..............  A                Nasal/sinus endoscopy,       3.26       3.71       1.82       0.23       7.20       5.31        000
                                                      surg.
31239.............  ..............  A                Nasal/sinus endoscopy,       8.70         NA       6.51       0.46         NA      15.67        010
                                                      surg.
31240.............  ..............  A                Nasal/sinus endoscopy,       2.61         NA       1.55       0.18         NA       4.34        000
                                                      surg.
31254.............  ..............  A                Revision of ethmoid          4.65         NA       2.71       0.32         NA       7.68        000
                                                      sinus.
31255.............  ..............  A                Removal of ethmoid           6.96         NA       4.01       0.49         NA      11.46        000
                                                      sinus.
31256.............  ..............  A                Exploration maxillary        3.29         NA       1.95       0.23         NA       5.47        000
                                                      sinus.
31267.............  ..............  A                Endoscopy, maxillary         5.46         NA       3.16       0.38         NA       9.00        000
                                                      sinus.
31276.............  ..............  A                Sinus endoscopy,             8.85         NA       5.05       0.62         NA      14.52        000
                                                      surgical.
31287.............  ..............  A                Nasal/sinus endoscopy,       3.92         NA       2.30       0.27         NA       6.49        000
                                                      surg.
31288.............  ..............  A                Nasal/sinus endoscopy,       4.58         NA       2.67       0.32         NA       7.57        000
                                                      surg.
31290.............  ..............  A                Nasal/sinus endoscopy,      17.24         NA      11.56       1.20         NA      30.00        010
                                                      surg.
31291.............  ..............  A                Nasal/sinus endoscopy,      18.19         NA      11.87       1.73         NA      31.79        010
                                                      surg.
31292.............  ..............  A                Nasal/sinus endoscopy,      14.76         NA      10.05       0.99         NA      25.80        010
                                                      surg.
31293.............  ..............  A                Nasal/sinus endoscopy,      16.21         NA      10.76       0.97         NA      27.94        010
                                                      surg.
31294.............  ..............  A                Nasal/sinus endoscopy,      19.06         NA      12.32       1.04         NA      32.42        010
                                                      surg.
31299.............  ..............  C                Sinus surgery                0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
31300.............  ..............  A                Removal of larynx           14.29         NA      17.26       0.99         NA      32.54        090
                                                      lesion.
31320.............  ..............  A                Diagnostic incision,         5.26         NA      12.98       0.40         NA      18.64        090
                                                      larynx.
31360.............  ..............  A                Removal of larynx.....      17.08         NA      19.03       1.20         NA      37.31        090
31365.............  ..............  A                Removal of larynx.....      24.16         NA      22.76       1.72         NA      48.64        090
31367.............  ..............  A                Partial removal of          21.86         NA      23.63       1.57         NA      47.06        090
                                                      larynx.
31368.............  ..............  A                Partial removal of          27.09         NA      28.25       1.90         NA      57.24        090
                                                      larynx.
31370.............  ..............  A                Partial removal of          21.38         NA      23.28       1.51         NA      46.17        090
                                                      larynx.
31375.............  ..............  A                Partial removal of          20.21         NA      20.86       1.43         NA      42.50        090
                                                      larynx.
31380.............  ..............  A                Partial removal of          20.21         NA      20.88       1.40         NA      42.49        090
                                                      larynx.
31382.............  ..............  A                Partial removal of          20.52         NA      22.86       1.44         NA      44.82        090
                                                      larynx.
31390.............  ..............  A                Removal of larynx &         27.53         NA      28.42       1.95         NA      57.90        090
                                                      pharynx.
31395.............  ..............  A                Reconstruct larynx &        31.09         NA      34.27       2.27         NA      67.63        090
                                                      pharynx.
31400.............  ..............  A                Revision of larynx....      10.31         NA      15.66       0.72         NA      26.69        090
31420.............  ..............  A                Removal of epiglottis.      10.22         NA      15.35       0.71         NA      26.28        090
31500.............  ..............  A                Insert emergency             2.33         NA       0.67       0.15         NA       3.15        000
                                                      airway.
31502.............  ..............  A                Change of windpipe           0.65       1.98       0.26       0.04       2.67       0.95        000
                                                      airway.
31505.............  ..............  A                Diagnostic                   0.61       0.67       0.23       0.04       1.32       0.88        000
                                                      laryngoscopy.
31510.............  ..............  A                Laryngoscopy with            1.92       2.83       0.98       0.15       4.90       3.05        000
                                                      biopsy.
31511.............  ..............  A                Remove foreign body,         2.16       3.12       0.75       0.16       5.44       3.07        000
                                                      larynx.
31512.............  ..............  A                Removal of larynx            2.07       3.07       1.07       0.16       5.30       3.30        000
                                                      lesion.
31513.............  ..............  A                Injection into vocal         2.10         NA       1.28       0.15         NA       3.53        000
                                                      cord.
31515.............  ..............  A                Laryngoscopy for             1.80       2.39       0.85       0.12       4.31       2.77        000
                                                      aspiration.
31520.............  ..............  A                Diagnostic                   2.56         NA       1.38       0.17         NA       4.11        000
                                                      laryngoscopy.
31525.............  ..............  A                Diagnostic                   2.63       2.91       1.48       0.18       5.72       4.29        000
                                                      laryngoscopy.
31526.............  ..............  A                Diagnostic                   2.57         NA       1.54       0.18         NA       4.29        000
                                                      laryngoscopy.
31527.............  ..............  A                Laryngoscopy for             3.27         NA       1.71       0.21         NA       5.19        000
                                                      treatment.
31528.............  ..............  A                Laryngoscopy and             2.37         NA       1.26       0.16         NA       3.79        000
                                                      dilation.
31529.............  ..............  A                Laryngoscopy and             2.68         NA       1.55       0.18         NA       4.41        000
                                                      dilation.
31530.............  ..............  A                Operative laryngoscopy       3.39         NA       1.75       0.24         NA       5.38        000
31531.............  ..............  A                Operative laryngoscopy       3.59         NA       2.12       0.25         NA       5.96        000
31535.............  ..............  A                Operative laryngoscopy       3.16         NA       1.82       0.22         NA       5.20        000
31536.............  ..............  A                Operative laryngoscopy       3.56         NA       2.09       0.25         NA       5.90        000
31540.............  ..............  A                Operative laryngoscopy       4.13         NA       2.40       0.29         NA       6.82        000
31541.............  ..............  A                Operative laryngoscopy       4.53         NA       2.64       0.32         NA       7.49        000
31560.............  ..............  A                Operative laryngoscopy       5.46         NA       3.05       0.38         NA       8.89        000
31561.............  ..............  A                Operative laryngoscopy       6.00         NA       3.26       0.42         NA       9.68        000
31570.............  ..............  A                Laryngoscopy with            3.87       4.16       2.23       0.24       8.27       6.34        000
                                                      injection.
31571.............  ..............  A                Laryngoscopy with            4.27         NA       2.45       0.30         NA       7.02        000
                                                      injection.
31575.............  ..............  A                Diagnostic                   1.10       2.07       0.57       0.08       3.25       1.75        000
                                                      laryngoscopy.
31576.............  ..............  A                Laryngoscopy with            1.97       2.45       1.02       0.13       4.55       3.12        000
                                                      biopsy.
31577.............  ..............  A                Remove foreign body,         2.47       2.93       1.25       0.17       5.57       3.89        000
                                                      larynx.
31578.............  ..............  A                Removal of larynx            2.84       3.19       1.24       0.20       6.23       4.28        000
                                                      lesion.
31579.............  ..............  A                Diagnostic                   2.26       2.94       1.20       0.16       5.36       3.62        000
                                                      laryngoscopy.
31580.............  ..............  A                Revision of larynx....      12.38         NA      16.18       0.87         NA      29.43        090
31582.............  ..............  A                Revision of larynx....      21.62         NA      21.69       1.52         NA      44.83        090
31584.............  ..............  A                Treat larynx fracture.      19.64         NA      18.64       1.42         NA      39.70        090
31585.............  ..............  A                Treat larynx fracture.       4.64         NA       8.94       0.30         NA      13.88        090
31586.............  ..............  A                Treat larynx fracture.       8.03         NA      12.77       0.56         NA      21.36        090
31587.............  ..............  A                Revision of larynx....      11.99         NA      14.23       0.88         NA      27.10        090
31588.............  ..............  A                Revision of larynx....      13.11         NA      17.11       0.92         NA      31.14        090
31590.............  ..............  A                Reinnervate larynx....       6.97         NA      12.52       0.50         NA      19.99        090
31595.............  ..............  A                Larynx nerve surgery..       8.34         NA      11.32       0.62         NA      20.28        090
31599.............  ..............  C                Larynx surgery               0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
31600.............  ..............  A                Incision of windpipe..       7.18         NA       3.05       0.34         NA      10.57        000
31601.............  ..............  A                Incision of windpipe..       4.45         NA       2.15       0.39         NA       6.99        000
31603.............  ..............  A                Incision of windpipe..       4.15         NA       1.75       0.35         NA       6.25        000
31605.............  ..............  A                Incision of windpipe..       3.58         NA       1.21       0.33         NA       5.12        000
31610.............  ..............  A                Incision of windpipe..       8.76         NA      10.79       0.69         NA      20.24        090

[[Page 80072]]

 
31611.............  ..............  A                Surgery/speech               5.64         NA      10.19       0.40         NA      16.23        090
                                                      prosthesis.
31612.............  ..............  A                Puncture/clear               0.91       1.49       0.42       0.06       2.46       1.39        000
                                                      windpipe.
31613.............  ..............  A                Repair windpipe              4.59         NA       8.88       0.37         NA      13.84        090
                                                      opening.
31614.............  ..............  A                Repair windpipe              7.12         NA      12.24       0.51         NA      19.87        090
                                                      opening.
31615.............  ..............  A                Visualization of             2.09       3.74       1.17       0.14       5.97       3.40        000
                                                      windpipe.
31622.............  ..............  A                Dx bronchoscope/wash..       2.78       3.44       1.15       0.14       6.36       4.07        000
31623.............  ..............  A                Dx bronchoscope/brush.       2.88       3.18       1.14       0.14       6.20       4.16        000
31624.............  ..............  A                Dx bronchoscope/lavage       2.88       2.89       1.14       0.13       5.90       4.15        000
31625.............  ..............  A                Bronchoscopy w/              3.37         NA       1.30       0.16         NA       4.83        000
                                                      biopsy(s).
31628.............  ..............  A                Bronchoscopy/lung bx,        3.81       3.36       1.40       0.14       7.31       5.35        000
                                                      each.
31629.............  ..............  A                Bronchoscopy/needle          3.37         NA       1.27       0.13         NA       4.77        000
                                                      bx, each.
31630.............  ..............  A                Bronchoscopy dilate/fx       3.82         NA       1.97       0.30         NA       6.09        000
                                                      repr.
31631.............  ..............  A                Bronchoscopy, dilate w/      4.37         NA       2.01       0.31         NA       6.69        000
                                                      stent.
31635.............  ..............  A                Bronchoscopy w/fb            3.68         NA       1.67       0.21         NA       5.56        000
                                                      removal.
31640.............  ..............  A                Bronchoscopy w/tumor         4.94         NA       2.34       0.37         NA       7.65        000
                                                      excise.
31641.............  ..............  A                Bronchoscopy, treat          5.03         NA       2.13       0.30         NA       7.46        000
                                                      blockage.
31643.............  ..............  A                Diag bronchoscope/           3.50         NA       1.32       0.15         NA       4.97        000
                                                      catheter.
31645.............  ..............  A                Bronchoscopy, clear          3.16         NA       1.22       0.13         NA       4.51        000
                                                      airways.
31646.............  ..............  A                Bronchoscopy, reclear        2.72         NA       1.09       0.12         NA       3.93        000
                                                      airway.
31656.............  ..............  A                Bronchoscopy, inj for        2.17         NA       0.93       0.10         NA       3.20        000
                                                      x-ray.
31700.............  ..............  A                Insertion of airway          1.34       2.34       0.69       0.07       3.75       2.10        000
                                                      catheter.
31708.............  ..............  A                Instill airway               1.41         NA       0.60       0.06         NA       2.07        000
                                                      contrast dye.
31710.............  ..............  A                Insertion of airway          1.30         NA       0.71       0.06         NA       2.07        000
                                                      catheter.
31715.............  ..............  A                Injection for bronchus       1.11         NA       0.61       0.06         NA       1.78        000
                                                      x-ray.
31717.............  ..............  A                Bronchial brush biopsy       2.12       3.40       0.88       0.09       5.61       3.09        000
31720.............  ..............  A                Clearance of airways..       1.06       1.86       0.33       0.06       2.98       1.45        000
31725.............  ..............  A                Clearance of airways..       1.96         NA       0.60       0.10         NA       2.66        000
31730.............  ..............  A                Intro, windpipe wire/        2.85       2.42       1.10       0.15       5.42       4.10        000
                                                      tube.
31750.............  ..............  A                Repair of windpipe....      13.02         NA      16.00       1.02         NA      30.04        090
31755.............  ..............  A                Repair of windpipe....      15.93         NA      19.11       1.15         NA      36.19        090
31760.............  ..............  A                Repair of windpipe....      22.35         NA      12.34       1.48         NA      36.17        090
31766.............  ..............  A                Reconstruction of           30.43         NA      16.11       3.16         NA      49.70        090
                                                      windpipe.
31770.............  ..............  A                Repair/graft of             22.51         NA      14.25       2.27         NA      39.03        090
                                                      bronchus.
31775.............  ..............  A                Reconstruct bronchus..      23.54         NA      15.35       2.91         NA      41.80        090
31780.............  ..............  A                Reconstruct windpipe..      17.72         NA      12.85       1.55         NA      32.12        090
31781.............  ..............  A                Reconstruct windpipe..      23.53         NA      14.74       2.04         NA      40.31        090
31785.............  ..............  A                Remove windpipe lesion      17.23         NA      12.68       1.36         NA      31.27        090
31786.............  ..............  A                Remove windpipe lesion      23.98         NA      15.62       2.20         NA      41.80        090
31800.............  ..............  A                Repair of windpipe           7.43         NA       6.79       0.67         NA      14.89        090
                                                      injury.
31805.............  ..............  A                Repair of windpipe          13.13         NA      10.71       1.45         NA      25.29        090
                                                      injury.
31820.............  ..............  A                Closure of windpipe          4.49       8.08       7.96       0.35      12.92      12.80        090
                                                      lesion.
31825.............  ..............  A                Repair of windpipe           6.81      11.16      11.16       0.50      18.47      18.47        090
                                                      defect.
31830.............  ..............  A                Revise windpipe scar..       4.50       7.97       7.97       0.36      12.83      12.83        090
31899.............  ..............  C                Airways surgical             0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
32000.............  ..............  A                Drainage of chest.....       1.54       3.11       0.50       0.07       4.72       2.11        000
32002.............  ..............  A                Treatment of collapsed       2.19         NA       0.85       0.11         NA       3.15        000
                                                      lung.
32005.............  ..............  A                Treat lung lining            2.19         NA       0.87       0.17         NA       3.23        000
                                                      chemically.
32020.............  ..............  A                Insertion of chest           3.98         NA       1.44       0.36         NA       5.78        000
                                                      tube.
32035.............  ..............  A                Exploration of chest..       8.67         NA       7.97       1.02         NA      17.66        090
32036.............  ..............  A                Exploration of chest..       9.68         NA       8.69       1.20         NA      19.57        090
32095.............  ..............  A                Biopsy through chest         8.36         NA       8.13       0.99         NA      17.48        090
                                                      wall.
32100.............  ..............  A                Exploration/biopsy of       15.24         NA      10.39       1.45         NA      27.08        090
                                                      chest.
32110.............  ..............  A                Explore/repair chest..      23.00         NA      12.89       1.63         NA      37.52        090
32120.............  ..............  A                Re-exploration of           11.54         NA       9.49       1.42         NA      22.45        090
                                                      chest.
32124.............  ..............  A                Explore chest free          12.72         NA       9.42       1.51         NA      23.65        090
                                                      adhesions.
32140.............  ..............  A                Removal of lung             13.93         NA       9.97       1.68         NA      25.58        090
                                                      lesion(s).
32141.............  ..............  A                Remove/treat lung           14.00         NA       9.87       1.72         NA      25.59        090
                                                      lesions.
32150.............  ..............  A                Removal of lung             14.15         NA       9.84       1.60         NA      25.59        090
                                                      lesion(s).
32151.............  ..............  A                Remove lung foreign         14.21         NA      10.50       1.49         NA      26.20        090
                                                      body.
32160.............  ..............  A                Open chest heart             9.30         NA       6.31       1.01         NA      16.62        090
                                                      massage.
32200.............  ..............  A                Drain, open, lung           15.29         NA      10.04       1.46         NA      26.79        090
                                                      lesion.
32201.............  ..............  A                Drain, percut, lung          4.00         NA       5.54       0.18         NA       9.72        000
                                                      lesion.
32215.............  ..............  A                Treat chest lining....      11.33         NA       9.44       1.34         NA      22.11        090
32220.............  ..............  A                Release of lung.......      24.00         NA      13.45       2.39         NA      39.84        090
32225.............  ..............  A                Partial release of          13.96         NA      10.11       1.70         NA      25.77        090
                                                      lung.
32310.............  ..............  A                Removal of chest            13.44         NA       9.75       1.65         NA      24.84        090
                                                      lining.
32320.............  ..............  A                Free/remove chest           24.00         NA      13.18       2.50         NA      39.68        090
                                                      lining.
32400.............  ..............  A                Needle biopsy chest          1.76       1.86       0.57       0.07       3.69       2.40        000
                                                      lining.
32402.............  ..............  A                Open biopsy chest            7.56         NA       8.06       0.91         NA      16.53        090
                                                      lining.
32405.............  ..............  A                Biopsy, lung or              1.93       2.38       0.65       0.09       4.40       2.67        000
                                                      mediastinum.
32420.............  ..............  A                Puncture/clear lung...       2.18         NA       0.85       0.11         NA       3.14        000
32440.............  ..............  A                Removal of lung.......      25.00         NA      12.43       2.56         NA      39.99        090
32442.............  ..............  A                Sleeve pneumonectomy..      26.24         NA      14.04       3.12         NA      43.40        090
32445.............  ..............  A                Removal of lung.......      25.09         NA      13.48       3.11         NA      41.68        090
32480.............  ..............  A                Partial removal of          23.75         NA      12.47       2.24         NA      38.46        090
                                                      lung.

[[Page 80073]]

 
32482.............  ..............  A                Bilobectomy...........      25.00         NA      12.50       2.35         NA      39.85        090
32484.............  ..............  A                Segmentectomy.........      20.69         NA      10.93       2.54         NA      34.16        090
32486.............  ..............  A                Sleeve lobectomy......      23.92         NA      12.63       3.00         NA      39.55        090
32488.............  ..............  A                Completion                  25.71         NA      13.20       3.18         NA      42.09        090
                                                      pneumonectomy.
32491.............  ..............  R                Lung volume reduction.      21.25         NA      11.97       2.66         NA      35.88        090
32500.............  ..............  A                Partial removal of          22.00         NA      11.79       1.77         NA      35.56        090
                                                      lung.
32501.............  ..............  A                Repair bronchus add-on       4.69         NA       1.54       0.56         NA       6.79        ZZZ
32520.............  ..............  A                Remove lung & revise        21.68         NA      10.87       2.71         NA      35.26        090
                                                      chest.
32522.............  ..............  A                Remove lung & revise        24.20         NA      11.71       2.84         NA      38.75        090
                                                      chest.
32525.............  ..............  A                Remove lung & revise        26.50         NA      12.42       3.25         NA      42.17        090
                                                      chest.
32540.............  ..............  A                Removal of lung lesion      14.64         NA       9.12       1.84         NA      25.60        090
32601.............  ..............  A                Thoracoscopy,                5.46         NA       3.61       0.63         NA       9.70        000
                                                      diagnostic.
32602.............  ..............  A                Thoracoscopy,                5.96         NA       3.76       0.70         NA      10.42        000
                                                      diagnostic.
32603.............  ..............  A                Thoracoscopy,                7.81         NA       4.19       0.76         NA      12.76        000
                                                      diagnostic.
32604.............  ..............  A                Thoracoscopy,                8.78         NA       4.74       0.97         NA      14.49        000
                                                      diagnostic.
32605.............  ..............  A                Thoracoscopy,                6.93         NA       4.26       0.86         NA      12.05        000
                                                      diagnostic.
32606.............  ..............  A                Thoracoscopy,                8.40         NA       4.57       0.99         NA      13.96        000
                                                      diagnostic.
32650.............  ..............  A                Thoracoscopy, surgical      10.75         NA       6.50       1.25         NA      18.50        090
32651.............  ..............  A                Thoracoscopy, surgical      12.91         NA       7.05       1.50         NA      21.46        090
32652.............  ..............  A                Thoracoscopy, surgical      18.66         NA       9.74       2.30         NA      30.70        090
32653.............  ..............  A                Thoracoscopy, surgical      12.87         NA       6.78       1.55         NA      21.20        090
32654.............  ..............  A                Thoracoscopy, surgical      12.44         NA       7.20       1.51         NA      21.15        090
32655.............  ..............  A                Thoracoscopy, surgical      13.10         NA       7.07       1.53         NA      21.70        090
32656.............  ..............  A                Thoracoscopy, surgical      12.91         NA       7.53       1.61         NA      22.05        090
32657.............  ..............  A                Thoracoscopy, surgical      13.65         NA       7.42       1.64         NA      22.71        090
32658.............  ..............  A                Thoracoscopy, surgical      11.63         NA       7.01       1.47         NA      20.11        090
32659.............  ..............  A                Thoracoscopy, surgical      11.59         NA       7.12       1.39         NA      20.10        090
32660.............  ..............  A                Thoracoscopy, surgical      17.43         NA       9.05       2.09         NA      28.57        090
32661.............  ..............  A                Thoracoscopy, surgical      13.25         NA       7.47       1.66         NA      22.38        090
32662.............  ..............  A                Thoracoscopy, surgical      16.44         NA       8.51       2.01         NA      26.96        090
32663.............  ..............  A                Thoracoscopy, surgical      18.47         NA      10.22       2.28         NA      30.97        090
32664.............  ..............  A                Thoracoscopy, surgical      14.20         NA       7.48       1.70         NA      23.38        090
32665.............  ..............  A                Thoracoscopy, surgical      15.54         NA       8.02       1.79         NA      25.35        090
32800.............  ..............  A                Repair lung hernia....      13.69         NA       9.82       1.51         NA      25.02        090
32810.............  ..............  A                Close chest after           13.05         NA      10.08       1.55         NA      24.68        090
                                                      drainage.
32815.............  ..............  A                Close bronchial             23.15         NA      13.56       2.84         NA      39.55        090
                                                      fistula.
32820.............  ..............  A                Reconstruct injured         21.48         NA      13.98       2.31         NA      37.77        090
                                                      chest.
32850.............  ..............  X                Donor pneumonectomy...       0.00       0.00       0.00       0.00       0.00       0.00        XXX
32851.............  ..............  A                Lung transplant,            38.63         NA      20.19       4.90         NA      63.72        090
                                                      single.
32852.............  ..............  A                Lung transplant with        41.80         NA      21.70       5.17         NA      68.67        090
                                                      bypass.
32853.............  ..............  A                Lung transplant,            47.81         NA      23.60       6.13         NA      77.54        090
                                                      double.
32854.............  ..............  A                Lung transplant with        50.98         NA      24.25       6.41         NA      81.64        090
                                                      bypass.
32900.............  ..............  A                Removal of rib(s).....      20.27         NA      12.20       2.42         NA      34.89        090
32905.............  ..............  A                Revise & repair chest       20.75         NA      12.57       2.54         NA      35.86        090
                                                      wall.
32906.............  ..............  A                Revise & repair chest       26.77         NA      14.61       3.30         NA      44.68        090
                                                      wall.
32940.............  ..............  A                Revision of lung......      19.43         NA      11.85       2.47         NA      33.75        090
32960.............  ..............  A                Therapeutic                  1.84       2.15       0.57       0.12       4.11       2.53        000
                                                      pneumothorax.
32997.............  ..............  A                Total lung lavage.....       6.00         NA       1.93       0.55         NA       8.48        000
32999.............  ..............  C                Chest surgery                0.00       0.00       0.00       0.00       0.00       0.00        YYY
                                                      procedure.
33010.............  ..............  A                Drainage of heart sac.       2.24         NA       0.98       0.13         NA       3.35        000
33011.............  ..............  A                Repeat drainage of           2.24         NA       1.02       0.13         NA       3.39        000
                                                      heart sac.
33015.............  ..............  A                Incision of heart sac.       6.80         NA       4.52       0.64         NA      11.96        090
33020.............  ..............  A                Incision of heart sac.      12.61         NA       8.01       1.50         NA      22.12        090
33025.............  ..............  A                Incision of heart sac.      12.09         NA       7.88       1.50         NA      21.47        090
33030.............  ..............  A                Partial removal of          18.71         NA      12.30       2.40         NA      33.41        090
                                                      heart sac.
33031.............  ..............  A                Partial removal of          21.79         NA      13.57       2.78         NA      38.14        090
                                                      heart sac.
33050.............  ..............  A                Removal of heart sac        14.36         NA      10.31       1.73         NA      26.40        090
                                                      lesion.
33120.............  ..............  A                Removal of heart            24.56         NA      16.05       3.06         NA      43.67        090
                                                      lesion.
33130.............  ..............  A                Removal of heart            21.39         NA      12.74       2.51         NA      36.64        090
                                                      lesion.
33140.............  ..............  A                Heart revascularize         20.00         NA      10.67       2.27         NA      32.94        090
                                                      (tmr).
33141.............  ..............  A                Heart tmr w/other            4.84         NA       1.57       0.55         NA       6.96        ZZZ
                                                      procedure.
33200.............  ..............  A                Insertion of heart          12.48         NA       9.72       1.17         NA      23.37        090
                                                      pacemaker.
33201.............  ..............  A                Insertion of heart          10.18         NA       9.71       1.21         NA      21.10        090
                                                      pacemaker.
33206.............  ..............  A                Insertion of heart           6.67         NA       5.69       0.50         NA      12.86        090
                                                      pacemaker.
33207.............  ..............  A                Insertion of heart           8.04         NA       6.23       0.57         NA      14.84        090
                                                      pacemaker.
33208.............  ..............  A                Insertion of heart           8.13         NA       6.43       0.54         NA      15.10        090
                                                      pacemaker.
33210.............  ..............  A                Insertion of heart           3.30         NA       1.28       0.17         NA       4.75        000
                                                      electrode.
33211.............  ..............  A                Insertion of heart           3.40         NA       1.34       0.17         NA       4.91        000
                                                      electrode.
33212.............  ..............  A                Insertion of pulse           5.52         NA       4.62       0.44         NA      10.58        090
                                                      generator.
33213.............  ..............  A                Insertion of pulse           6.37         NA       5.06       0.46         NA      11.89        090
                                                      generator.
33214.............  ..............  A                Upgrade of pacemaker         7.75         NA       6.19       0.52         NA      14.46        090
                                                      system.
33215.............  ..............  A                Reposition pacing-           4.76         NA       3.15       0.36         NA       8.27        090
                                                      defib lead.
33216.............  ..............  A                Insert lead pace-            5.78         NA       5.32       0.36         NA      11.46        090
                                                      defib, one.
33217.............  ..............  A                Insert lead pace-            5.75         NA       5.58       0.36         NA      11.69        090
                                                      defib, dual.
33218.............  ..............  A                Repair lead pace-            5.44         NA       4.68       0.40         NA      10.52        090
                                                      defib, one.

[[Page 80074]]

 
33220.............  ..............  A                Repair lead pace-            5.52         NA       4.69       0.39         NA      10.60        090
                                                      defib, dual.
33222.............  ..............  A                Revise pocket,               4.96         NA       4.08       0.39         NA       9.43        090
                                                      pacemaker.
33223.............  ..............  A                Revise pocket, pacing-       6.46         NA       5.41       0.44         NA      12.31        090
                                                      defib.
33224.............  ..............  A                Insert pacing lead &         9.05         NA       3.92       0.36         NA      13.33        090
                                                      connect.
33225.............  ..............  A                L ventric pacing lead        8.34         NA       3.11       0.36         NA      11.81        ZZZ
                                                      add-on.
33226.............  ..............  A                Reposition l ventric         8.69         NA       3.79       0.36         NA      12.84        000
                                                      lead.
33233.............  ..............  A                Removal of pacemaker         3.29         NA       4.12       0.22         NA       7.63        090
                                                      system.
33234.............  ..............  A                Removal of pacemaker         7.82         NA       5.66       0.56         NA      14.04        090
                                                      system.
33235.............  ..............  A                Removal pacemaker            9.40         NA       6.50       0.68         NA      16.58        090
                                                      electrode.
33236.............  ..............  A                Remove electrode/           12.60         NA       9.38       1.49         NA      23.47        090
                                                      thoracotomy.
33237.............  ..............  A                Remove electrode/           13.71         NA       9.78       1.57         NA      25.06        090
                                                      thoracotomy.
33238.............  ..............  A                Remove electrode/           15.22         NA       9.27       1.56         NA      26.05        090
                                                      thoracotomy.
33240.............  ..............  A                Insert pulse generator       7.60         NA       5.77       0.53         NA      13.90        090
33241.............  ..............  A                Remove pulse generator       3.24         NA       3.71       0.21         NA       7.16        090
33243.............  ..............  A                Remove eltrd/               22.64         NA      10.90       2.53         NA      36.07        090
                                                      thoracotomy.
33244.............  ..............  A                Remove eltrd, transven      13.76         NA       8.43       1.05         NA      23.24        090
33245.............  ..............  A                Insert epic eltrd pace-     14.30         NA      11.02       1.28         NA      26.60        090
                                                      defib.
33246.............  ..............  A                Insert epic eltrd/          20.71         NA      14.36       2.22         NA      37.29        090
                                                      generator.
33249.............  ..............  A                Eltrd/insert pace-          14.23         NA       9.27       0.80         NA      24.30        090
                                                      defib.
33250.............  ..............  A                Ablate heart dysrhythm      21.85         NA      14.42       1.01         NA      37.28        090
                                                      focus.
33251.............  ..............  A                Ablate heart dysrhythm      24.88         NA      14.53       2.41         NA      41.82        090
                                                      focus.
33253.............  ..............  A                Reconstruct atria.....      31.06         NA      16.79       3.68         NA      51.53        090
33261.............  ..............  A                Ablate heart dysrhythm      24.88         NA      14.79       2.82         NA      42.49        090
                                                      focus.
33282.............  ..............  A                Implant pat-active ht        4.17         NA       4.91       0.39         NA       9.47        090
                                                      record.
33284.............  ..............  A                Remove pat-active ht         2.50         NA       4.39       0.23         NA       7.12        090
                                                      record.
33300.............  ..............  A                Repair of heart wound.      17.92         NA      12.08       1.91         NA      31.91        090
33305.............  ..............  A                Repair of heart wound.      21.44         NA      13.53       2.68         NA      37.65        090
33310.............  ..............  A                Exploratory heart           18.51         NA      12.43       2.26         NA      33.20        090
                                                      surgery.
33315.............  ..............  A                Exploratory heart           22.37         NA      13.74       2.90         NA      39.01        090
                                                      surgery.
33320.............  ..............  A                Repair major blood          16.79         NA      11.44       1.66         NA      29.89        090
                                                      vessel(s).
33321.............  ..............  A                Repair major vessel...      20.20         NA      12.72       2.70         NA      35.62        090
33322.............  ..............  A                Repair major blood          20.62         NA      13.32       2.51         NA      36.45        090
                                                      vessel(s).
33330.............  ..............  A                Insert major vessel         21.43         NA      12.93       2.49         NA      36.85        090
                                                      graft.
33332.............  ..............  A                Insert major vessel         23.96         NA      13.18       2.45         NA      39.59        090
                                                      graft.
33335.............  ..............  A                Insert major vessel         30.01         NA      16.23       3.79         NA      50.03        090
                                                      graft.
33400.............  ..............  A                Repair of aortic valve      28.50         NA      15.00       3.09         NA      46.59        090
33401.............  ..............  A                Valvuloplasty, open...      23.91         NA      13.33       2.71         NA      39.95        090
33403.............  ..............  A                Valvuloplasty, w/cp         24.89         NA      13.71       2.48         NA      41.08        090
                                                      bypass.
33404.............  ..............  A                Prepare heart-aorta         28.54         NA      13.94       3.31         NA      45.79        090
                                                      conduit.
33405.............  ..............  A                Replacement of aortic       35.00         NA      17.52       3.86         NA      56.38        090
                                                      valve.
33406.............  ..............  A                Replacement of aortic       37.50         NA      18.31       4.07         NA      59.88        090
                                                      valve.
33410.............  ..............  A                Replacement of aortic       32.46         NA      16.00       4.11         NA      52.57        090
                                                      valve.
33411.............  ..............  A                Replacement of aortic       36.25         NA      17.97       4.16         NA      58.38        090
                                                      valve.
33412.............  ..............  A                Replacement of aortic       42.00         NA      19.77       4.66         NA      66.43        090
                                                      valve.
33413.............  ..............  A                Replacement of aortic       43.50         NA      20.10       4.26         NA      67.86        090
                                                      valve.
33414.............  ..............  A                Repair of aortic valve      30.35         NA      17.98       3.79         NA      52.12        090
33415.............  ..............  A                Revision, subvalvular       27.15         NA      16.05       3.25         NA      46.45        090
                                                      tissue.
33416.............  ..............  A                Revise ventricle            30.35         NA      16.41       3.85         NA      50.61        090
                                                      muscle.
33417.............  ..............  A                Repair of aortic valve      28.53         NA      17.51       3.58         NA      49.62        090
33420.............  ..............  A                Revision of mitral          22.70         NA      10.12       1.48         NA      34.30        090
                                                      valve.
33422.............  ..............  A                Revision of mitral          25.94         NA      13.03       3.30         NA      42.27        090
                                                      valve.
33425.............  ..............  A                Repair of mitral valve      27.00         NA      12.58       3.00         NA      42.58        090
33426.............  ..............  A                Repair of mitral valve      33.00         NA      16.42       3.87         NA      53.29        090
33427.............  ..............  A                Repair of mitral valve      40.00         NA      18.59       4.30         NA      62.89        090
33430.............  ..............  A                Replacement of mitral       33.50         NA      16.54       3.95         NA      53.99        090
                                                      valve.
33460.............  ..............  A                Revision of tricuspid       23.60         NA      14.13       3.02         NA      40.75        090
                                                      valve.
33463.............  ..............  A                Valvuloplasty,              25.62         NA      14.87       3.17         NA      43.66        090
                                                      tricuspid.
33464.............  ..............  A                Valvuloplasty,              27.33         NA      15.47       3.47         NA      46.27        090
                                                      tricuspid.
33465.............  ..............  A                Replace tricuspid           28.79         NA      15.80       3.61         NA      48.20        090
                                                      valve.
33468.............  ..............  A                Revision of tricuspid       30.12         NA      20.10       4.00         NA      54.22        090
                                                      valve.
33470.............  ..............  A                Revision of pulmonary       20.81         NA      13.67       2.81         NA      37.29        090
                                                      valve.
33471.............  ..............  A                Valvotomy, pulmonary        22.25         NA      12.72       3.00         NA      37.97        090
                                                      valve.
33472.............  ..............  A                Revision of pulmonary       22.25         NA      15.25       2.92         NA      40.42        090
                                                      valve.
33474.............  ..............  A                Revision of pulmonary       23.04         NA      13.42       2.84         NA      39.30        090
                                                      valve.
33475.............  ..............  A                Replacement, pulmonary      33.00         NA      18.87       2.64         NA      54.51        090
                                                      valve.
33476.............  ..............  A                Revision of heart           25.77         NA      14.07       2.40         NA      42.24        090
                                                      chamber.
33478.............  ..............  A                Revision of heart           26.74         NA      15.15       3.56         NA      45.45        090
                                                      chamber.
33496.............  ..............  A                Repair, prosth valve        27.25         NA      17.18       3.44         NA      47.87        090
                                                      clot.
33500.............  ..............  A                Repair heart vessel         25.55         NA      13.86       2.80         NA      42.21        090
                                                      fistula.
33501.............  ..............  A                Repair heart vessel         17.78         NA      10.55       2.05         NA      30.38        090
                                                      fistula.
33502.............  ..............  A                Coronary artery             21.04         NA      17.04       2.51         NA      40.59        090
                                                      correction.
33503.............  ..............  A                Coronary artery graft.      21.78         NA      14.05       1.42         NA      37.25        090
33504.............  ..............  A                Coronary artery graft.      24.66         NA      16.92       3.04         NA      44.62        090
33505.............  ..............  A                Repair artery w/tunnel      26.84         NA      18.36       1.52         NA      46.72        090
33506.............  ..............  A                Repair artery,              35.50         NA      19.69       3.19         NA      58.38        090
                                                      translocation.

[[Page 80075]]

 
33508.............  ..............  A                Endoscopic vein              0.31         NA       0.11       0.03         NA       0.45        ZZZ
                                                      harvest.
33510.............  ..............  A                CABG, vein, single....      29.00         NA      15.52       3.13         NA      47.65        090
33511.............  ..............  A                CABG, vein, two.......      30.00         NA      16.21       3.34         NA      49.55        090
33512.............  ..............  A                CABG, vein, three.....      31.80         NA      16.75       3.70         NA      52.25        090
33513.............  ..............  A                CABG, vein, four......      32.00         NA      16.91       3.99         NA      52.90        090
33514.............  ..............  A                CABG, vein, five......      32.75         NA      17.16       4.37         NA      54.28        090
33516.............  ..............  A                Cabg, vein, six or          35.00         NA      17.91       4.62         NA      57.53        090
                                                      more.
33517.............  ..............  A                CABG, artery-vein,           2.57         NA       0.84       0.32         NA       3.73        ZZZ
                                                      single.
33518.............  ..............  A                CABG, artery-vein, two       4.85         NA       1.58       0.61         NA       7.04        ZZZ
33519.............  ..............  A                CABG, artery-vein,           7.12         NA       2.31       0.89         NA      10.32        ZZZ
                                                      three.
33521.............  ..............  A                CABG, artery-vein,           9.40         NA       3.05       1.18         NA      13.63        ZZZ
                                                      four.
33522.............  ..............  A                CABG, artery-vein,          11.67         NA       3.79       1.48         NA      16.94        ZZZ
                                                      five.
33523.............  ..............  A                Cabg, art-vein, six or      13.95         NA       4.50       1.78         NA      20.23        ZZZ
                                                      more.
33530.............  ..............  A                Coronary artery,             5.86         NA       1.90       0.73         NA       8.49        ZZZ
                                                      bypass/reop.
33533.............  ..............  A